Wandsworth CCG: Successfully reducing outpatient referrals 2015

Context

This case study focuses on the approach to referral management by Wandsworth CCG, based on a case study they published ( on the NHS England Learning Environment site ( and is then supplemented by data subsequently available from several additional CCGS who adopted the Kinesis element of the programme in 2015.

Wandsworth Clinical Commissioning Group is located in South West London. The CCG consists of 43 GP practices with over 368,000 registered patients. The CCG is responsible for commissioning healthcare services for Wandsworth with a budget of approximately £400m.

In October 2010, the Wandsworth Referral Management GP working group was established to examine how effective referral management could help to improve care, streamline patient pathways and reduce inappropriate referrals. Wandsworth GPs made thousands of referrals to outpatient clinics every year, with significant financial implications. There was also substantial variation in the quality and rate of referral between GPs and GP practices.

The group’s remit was to review national referral schemes, assess feedback from stakeholder groups, develop a proposal for Wandsworth CCG, and to provide clinical input to the referral management process.

Around the same time, many London boroughs were implementing referral management centres. Wandsworth GPs agreed that a new approach to referrals was needed, but decided to explore the development of a programme of education and peer review, rather than a centre, which would enable GPs and patients to maintain control of their referral decisions.

Since then the programme has continued to evolve and the data collected up to March 2015, especially related to use of Kinesis, has been very encouraging. The CCG has since committed to a longer term use of the Kinesis platform, has extended use to further provider trusts and has witnessed neighbouring CCGs adopt the solution.

Analysis

Wandsworth CCG began the roll-out of a comprehensive referral management programme in May 2012, while still in shadow form. The primary aims of the programme were to:

  • Improve the patient experience and pathway by: guaranteeing patient choice; treating patients as individuals and providing a central location for GPs to obtain patient specific information.
  • Support GPs in decision-making by providing: software to obtain clinical expertise within a 24-hour period (working days only); all current referral forms in one central location; a GP peer review process to promote learning and invoke discussion; education sessions; and monthly reports, which contain all GP outpatient referral data (which is searchable by various criteria).
  • Obtain feedback from everyone who uses the process, including: patients; GPs; acute providers; and CCG management.

Solution

The Wandsworth CCG referral management programme is a suite of initiatives, which support GPs in making high quality referrals and aims to improve the patient pathway and experience. The programme is incentivised and has been developed with input from GPs, patients and clinical providers. The programme includes the following work streams:

Educational sessions: Secondary care consultants from St George’s Healthcare NHS Trust – the local acute provider – run educational sessions for GPs on a quarterly basis at the hospital. Topics are selected from GP feedback and focus on areas where there are above average referrals – for instance, recent sessions looked at ophthalmology. These sessions give GPs the opportunity to discuss referral queries with consultants and increase their knowledge. One GP representative from each practice is expected to attend and to take learning back to their practice. GPs gain CPD credits for attendance and for disseminating information to their practice colleagues.

Peer reviews: Peer reviews are GP-led and take place on a quarterly basis at each GP practice. All GPs from the practice attend, each bringing referrals for discussion within the group, so that learning and best practice can be shared. The peer views topics are linked to the education sessions and are directed by GP feedback. Practices are given three months to complete each peer review; they then provide feedback to the CCG’s referral management programme team. Key learning points are written up and shared across all practices in the Borough.

Online advice service: Kinesis is an online advice service, which currently gives GPs access to specialist consultants at three local provider trusts: St George’s Hospital, Chelsea and Westminster Hospital, and Kingston Hospital NHS Trust. The software is a secure (N3 hosted, encrypted) web service, through which GPs can contact consultants to ask for advice on referrals; these are known as conferrals.

Consultants are encouraged by the system to respond within 24-hours and the data shows that over half of these quick requests for advice result in avoided referrals and therefore improve the time to effective treatment. Furthermore, the system encourages learning and a continuum of care between the sectors, improving clinical dialogue relationships. The system is effectively reducing outpatient referrals and providing significant costs savings throughout the health economy.

Monthly reporting: Practices receive a monthly STORM (Strategic Total Referral Management) report, which displays referral activity based on EMIS read code information. The report is searchable via specific referral data (such as GP, specialty and acute provider), enabling practices and GPs to compare themselves with one another. GPs can drill down into the report to review individual referrals. The dashboard also provides valuable aggregate data and targeting information for the Wandsworth Locality Commissioning Groups.

Feedback: The referral management programme is quality-focused. Feedback is collated from the three main stakeholder groups – GPs, consultants and patients – and reviewed to demonstrate measures of success and to assess the level of quality. Feedback is collected at GP peer review meetings, through GP educational session questionnaires, Kinesis feedback forms, patient questionnaires, acute provider questionnaires and GP working group discussions.

Outcomes

Improved relationship between primary and secondary care:

  • A critical factor in the success of the programme has been attributed to the high level of support from St George’s Hospital, other trusts are thereby encouraged to become involved
  • Consultants are keen to participate as they recognise the value the programme adds. They have not found involvement burdensome, with even heavily used specialities receiving only a handful of requests for advice per consultant per week. Consultants have really valued the ability to both aid their primary care colleagues and maintain a dialogue if a patient has been referred.On average, the number of messages sent per conferral is 2.7, though the modal value is 1; the time spent responding to requests and messages by clinical staff is considered to be low.

  • The hospital’s GP liaison officer also plays a key role in keeping consultants informed and taking responsibility for the programme on behalf of the provider.
  • Having a dedicated project manager at the CCG to drive the programme forward has been essential and is a key component in driving uptake, dealing with user issues and administration and with reviewing reports and processes to ensure the overall programme is a success.

Reducing outpatient activity:

  • GPs are benefitting from expert advice quickly, which informs their decision-making and subsequently reduces referrals to outpatient clinics. Anecdotally, GPs using email etc. expect to receive an answer in around 5 working days, if at all. Most conferrals result in a response in around 24 hours, allowing rapid and appropriate care to be offered to patients.
  • All practices are set up to use Kinesis and about 1/3rd of GPs are regular users, sending an average of 1 request per month.
  • Approximately half of all advice requests made via Kinesis result in a ‘saved referral.’ See below.
  • In reality there has not been a noticeable decrease in clinic activity, however the quality of patients and likelihood of them needing consultant time when attending has improved.

Reducing costs:

2012/13

  • Kinesis savings for the financial year 2012/13 were £22,385 (based on five months of activity since the pilot launch date).

2013/14

  • Bythe end of March 2014 there were 2113 advice requests from GPs, with 1074 of these recorded as a ‘saved referral’ - a cost saving of £200 per referral
  • This is approximately 50 per cent of all advice requests, resulting in an achieved cost saving of £183,105 to date (this figure takes into account a £15 tariff per advice request).

2014/15

  • In the April 2014 – March 2015 year there were 2869 requests for advice with 1660 of these saving a referral, 58% of conferrals avoided a referral.
  • Total net savings of the programme were calculated as £239,590, based on a non-face-to-face tariff payment to providers of £15 against a mean referral cost of £204.

Improving patient pathways:

Since the Kinesis service launched the number of specialities online has increased from 5 to around 40

Acute Medicine / Anaesthetics, Pain
Cardiology / Clinical Genetics
Dermatology / Diabetes & Endocrinology
ENT / Gastroenterology
General Surgery / GU Medicine
Gynaecology / Gynaecology — Assisted Conception
Haematology / Infectious Diseases & Medicine
Medical Oncology / Mental Health — Adult Inpatient
Mental Health — General Adult Psychiatry / Mental Health — IAPT
Mental Health — Liaison Psychiatry / Mental Health — Medical Psychiatry
Mental Health — Perinatal Psychiatry / Mental Health — Rehabilitation Psychiatry (Adult)
Musculoskeletal Physiotherapy / Neonatalogy
Neurology / Neurosurgery
Ophthalmology / Orthopaedics — Spine
Paediatric Infectious Diseases, Immunology, Vaccinology / Paediatric Respiratory Medicine
Paediatric Surgery / Paediatrics
Plastic Surgery / Renal
Respiratory Medicine / Rheumatology
Urology / Vascular

  • Consultants continue to offer timely support with most responding to advice requests within 24-hours.
  • Kinesis provides a number of mechanisms to drive this, including text messages to alert users that they have a message in the system and reminders and reports if the target response time is delayed. Further developments have included allowing users to set working days, out of office for holidays etc. to ensure chase ups and requests are appropriate.
  • The CCG has increased access to consultants through contracting with other local providers, with South West London & St Georges Mental Health Trust joining and Guy’s and St Thomas’s NHS Foundation Trust expected to join Kinesis soon.
  • There is potential to expand the Kinesis service to support stable patients with Long Term Conditions more effectively in the community
  • Users rated the system’s ease of use as 4.4 out of 5, with a 96.6% positive rating; this shows an upward trend despite the addition of further features which might have caused undesirable complexity.

Post March 2015 data

Over the course of 2015 several additional CCGs commenced use of Kinesis, all in the neighbourhood of Wandsworth and often influenced by conversations between clinician users of the system.

An ad hoc analysis of Kinesis service usage across 4 active CCGs on 1 September 2015 showed:

  • 1300 users in total
  • 973 Referrers / GPs
  • 310 Advisors / Consultants
  • 17 Admins

Figure 1 Referral Requests per month via Kinesis

Figure 2 Outcomes of making an advice request

Figure 3 Outcomes of using Kinesis for conferrals

Appendix 1 – Further information

Kinesis on the web

ROI estimator

NHS England case study

PDF:
NHS England Case Study site

Articles on referral management

PULSE

Up to one quarter of GP referrals ‘avoidable’

Dept of Health

East of England pilot analysis

Double click to open the embedded report