PCTs and the intermediate tier (Pursuing a primary care led NHS)

1. Future Healthcare Networks PCTs and the intermediate tier(Pursuing a primary care led NHS) Dr Martin Connor Associate Director (Health Reform) Greater Manchester Strategic Health Authority Nov 25 2003

2. CLINICAL GOVERNANCE & PATIENT SAFETY WORKFORCE INFORMATION & TECHNOLOGY CHRONIC DISEASE MGT PUBLIC & PATIENT INVOLVEMENT Modernisation and Performance Improvement: A Strategic Framework for Access (A System Model) 1o/2o Service Interface Elective Care Unscheduled Care Intermediate Care Primary Care Sector Optimise Bed Occupancy Structured Management of Demand Aligning Capacity and Demand Develop Community Infrastructure Advanced Access Strategic Goals Tier 2 Primary Care Streaming Utilisation review EC Networks Network to Develop Elective Re-design & DTCs Policy Possibilities

3. Nested Capacity Community Primary care Outpatients Beds & Theatres

4. Limited Threshold Management Disease Severity Standard Acute Care Management T2 Standard Primary Care Management T1 Management by Self Care and Prevention Progression over time

5. Threshold Management Disease Severity admission Acute Care T3 Primary Care Tier 2 T2 Primary Care Tier 1 “Therapeutic Drive” T1 Management by Self Care and Prevention Progression over time

6. LDP elective strategy(with delivery programmes) • 0% growth in GP referrals to outpatients (RBMS & Tier 2) • 3% growth in elective activity through productivity and efficiency (GM Choice, POA programme, new performance management focus on system measures) • 3/2/1% growth over three year period in new outpatient activity (Combined with 0% growth in referrals, to reduce backlog then bring the system towards balance)

7. Building new capability • Tier2 – developing a broader range of choice closer to the patient • Booking services – managing the referral pathways through primary and secondary care • Greater Manchester Choice Centre – coordinating the capacity in secondary services • Greater Manchester Surgical Centre – providing additional surgical capacity • Clinical networks – involving clinicians in reform of pathways

8. TIER 2: • Proposed further £10m over 3 years - £14m total • Three waves: • £4m Jan 2004 (£1m in year effect) • £4m April 2004 • £2m Jan 2005 • (+ £3m investment in ‘infrastructure’…)

9. Referral Management RBMS and Tier 2

10. PCT Referrals Management Service ProposalThe previous situation Most referrals Booking Capture Conversion Book OP appt Primary Care Request OP Referral Acute Trust based

11. GMEB – Planned process for majority of referrals Capture & Convert Conversion to Outpatient registration on PAS Booking Primary Care Request Book OP appt PCT Based Acute Trust

12. GMEB – RBMS Aims Conversion Booking Capture & convert to electronic document Tier 2 Discussion & Direction Primary Care Request Book OP appt or diagnostic test OP Referral, Diagnostic request, back to GP PCT Based

13. FUNDAMENTAL DISTINCTION WAITING LIST SCHEDULE Patients who have been seen and for whom it is decided further treatment or contact is required Those who are not linked to an agreed future date, time and location Those who are linked to an agreed future date, time and location

14. TREATMENT SCHEDULE HOSPITAL TRUST (Non-standard, unbooked, high cancellations, difficult to monitor) Each Trust operates a treatment schedule Patient flow

15. TREATMENT SCHEDULE HOSPITAL TRUST (Non-standard, unbooked, high cancellations, difficult to monitor) But the WL is typically greater than the schedule can accommodate WAITING LIST [OP/IP/DC] Patient flow

16. Waiting list initiatives, private practice Waiting list initiatives, private practice TREATMENT SCHEDULE HOSPITAL TRUST (Non-standard, unbooked, high cancellations, difficult to monitor) So the Trust ‘flexes’ the schedule via reactive means: WLIs and Private Practice WAITING LIST [OP/IP/DC] Patient flow

17. Waiting list initiatives, private practice Waiting list initiatives, private practice TREATMENT SCHEDULE HOSPITAL TRUST (Non-standard, unbooked, high cancellations, difficult to monitor) But… where are the PCTs in all this, and how could they help tackle waiting lists? WAITING LIST [OP/IP/DC] Patient flow

18. New model of patient flows: patients retained in hospital systems only when schedules can guarantee treatment within waiting times; otherwise, PCT uses referrals management to directly broker choice of alternative provision HOSPITAL TRUST 6 MONTH TREATMENT SCHEDULE PRIMARY CARE TRUST Patient flow EXCESS WAITING EXCESS WAITING TIER 2 TREATMENT SCHEDULE GMSC TREATMENT SCHEDULE DTC TREATMENT SCHEDULE Plural Provision Referrals Management PLURAL PROVISION

19. Benefits of PCT-led choice: Enhances patient experience – not left ‘hanging around’ with no contact Provides means to offer alternative treatment With RBMS, provides PCTs with means to monitor present activity across the whole system and build alternative pathways of care Repersonalises the waiting list – we respond to long waiters more individually Incorporates dynamic, rather than reactive, validation of lists Provides means by which we can work towards zero suspensions Attacks waiting list volume and improves list quality by activating ROTTs (up to 25% in some specialities) before POA Begins to clarify Trust capacity within the three month schedule – the 2008 end point Provides early warning about developing waiting list problems/ gaps in capacity Stimulates development of ‘plural provision’

20. Closing messages • In the NHS Plan, booking replaces waiting lists, and this needs to be in the front of our minds • Successful booking strategies need to tackle the issue of referrals management as a distinct but essential part of the change • A low wait NHS will focus on the rate, and distribution of demand as well as on capacity to meet demand • Because of this, commissioning as a PCT function becomes of paramount importance to build plural provision • The talk is often of the risk to hospital stability of financial flows – but what of the risks to PCTs, where the resource limit lies • We can use new communications technology and patient choice to drive change whilst improving quality