Commissioning priorities: the case for clear rules

CCGs are being forced to manage demand for services in a more proactive way.  Hardly a week goes by without a CCG announcing restrictions on procedures available to patients.  Most recently three West Midlands CCGs changed the eligibility threshold for hip and knee replacements, expecting to save £2 million per year by reducing activity volume by 12% and 19%, respectively (reported by the HSJ)

Demand for secondary care is growing rapidly and the key drivers are well documented – an aging population and new expensive treatment options.  Technology is likely to compound this growth.  GPs now face demanding patients armed with Google facts.  But more importantly, the whole system is configured to facilitate patient choice (think Choose & Book).  The scary prospect for CCGs is that a paperless NHS and a well-functioning e-RS (electronic referral service) will reduce friction and almost certainly accelerate demand.

CCGs have no choice but to prioritise.  But in order to maintain fairness and avoid litigation, Commissioners will have to develop and enforce clear rules for what is funded and what is not funded by the NHS; this includes local rules that drive take-up of lower cost, out-of-hospital services.

Software from psHEALTH is designed to ‘intercept’ referrals and provide cost-effective management:  “Does a lower cost pathway exist?”, “Is this a procedure of limited clinical value?”.  Core to our solution is a high degree of automation using machine learning and a sophisticated triage engine that is configured to local rules.  The output of course is an enormous amount of data on referral demand.  We have already demonstrated success in reducing demand for CCGs and ACOs and now have data on over 500,000 referrals.  Our long-term vision is to connect referral demand with clinical outcomes and the associated invoices.  Check out this short video.