The NW London NHS Financial Recovery Plan will come under close scrutiny at the Community and Wellbeing Scrutiny Committee on Wednesday. The plan aims to tackle the deficit in a variety of ways but the fear is that it will impact on patients.
The full document with the financial background and overall stratgey can be found HERE but of most importance for residents will be the actions that are planned that will affect patients. Committee members will need to look beyond the jargon and probe deeply to find out what the real implications are for patients.
Fortunately Cllr Mary Daly has provided a commentary via Twitter:
6. How These Changes Will Affect Brent Patients
6.1.The section below provides further detail on how specific recovery schemes are likely to affect Brent patients, as requested by the Community Wellbeing Scrutiny Committee.
6.2.Elective hospital services and bringing some elective hospital services back to local North West London providers
This programme will focus on “repatriating” elective procedures begin referred by General Practitioners and Trusts to providers outside North West London back into the North West London sector. The project aims to change referral patterns where NWL GPs consider using NW London providers and only refer outside of the sector if there is no capacity or if the patient requires intervention provided by specialist centres out of area.
North West London NHS has an agreement with local NHS Trusts that specific quantities of activity will be delivered in each trust. Any activity above a set threshold is paid at 70% of the Payment by Results Tariff. This means that if more activity is referred to North West London providers, then approximately 30% of the tariff will be saved on each procedure. This is not true of providers external to North West London or to private sector providers.
The total amount of activity that we could bring back into the sector amounts to around 15% of all secondary care activity.
For Brent patients, they should see no change in the healthcare that they receive, except that they are more likely to be referred to a local provider rather than a provider external to the North West London health economy such as Royal Free Hospitals NHS Trust, for example. This is likely to be a benefit to patients in not having to travel longer distances across the city.
It should be noted that patients and GPs will always retain the right under the NHS Constitution to be referred to a provider of their choice and that GP retain the right to make decisions for the wellbeing of their patients.
6.3. Outpatient services and changes to outpatient appointments
NWL CCGs have reached agreement with providers that all activity in Quarters 3 and 4 of 2019/20 will be at contracted (planned) levels of activity, unless this puts waiting list commitments at risk. It was agreed that there will be no rise in 52 week waiters.
Additionally, our providers have agreed to adhere an existing consultant to consultant referral policy. The key principle behind this is that referrals relating to the original complaint can be referred on directly to another consultant. However, if an entirely different complaint comes to the attention of the consultant (unrelated to the original referral) this should be referred back to the patient’s GP first.
We have an outpatient transformation programme in North West London which has developed standardised referral guidelines. Consultants are currently triaging GP referrals against these guidelines when the referrals arrive at the hospital. Any referrals which do not adhere to the guidelines will be sent back to the referring GP with advice. In this way, unnecessary outpatient appointments can be avoided and patients may receive their care from their local GP practice.
6.4. Reducing spending on over the counter medicine prescriptions
Using the NHS London published guidance, we are working with secondary and primary care to reduce the volume of over the counter medication (for example paracetamol or ibuprofen) prescribed to patients. We have in place a communication plan for clinicians, patients and the wider public to support roll out. We will work with secondary care colleagues to support the programme and ensure that advice to patients is consistent across primary and secondary care.
Patients who are considered to be particularly vulnerable and are in receipt of free prescriptions may still receive these over the counter medications on prescription, at the discretion of their GP.
6.5. Standardising assessments for patient transport
This programme involves the renegotiation of the price on the LNWHT patient transport contract and a consistent application of current eligibility criteria. Discussions are currently underway with LNWHT with regard to the first element of the programme. Patient care will not be affected and those patients who require patient transport will still be able to receive it.
6.6.Home Oxygen and Enteral Feeds
This programme is made up of 3 elements. The first is the benefit of a pricing change following national procurement for home oxygen. The next is a clinical review of patients on home oxygen, prioritising those patients who have not been reviewed in the last 12 months and/or those patients where the data shows they are using less oxygen than prescribed. This review process will ensure that patients are not receiving a higher dosage of oxygen than they need, and that oxygen is not being wasted where it is no longer required. It will not change the criteria for patients to receive oxygen.
The enteral feeds procurement provides commissioners with a saving by reducing the costs of consumables and securing a better deal with the NHS’s external providers. It does not alter the care pathway and patients will not experience any change.
6.7.Unscheduled Care
A&E attendances and unplanned emergency admissions to hospital continue to rise in an unsustainable way. These are one of the biggest drivers of the deficit to the NWL financial system. There are a number of workstreams to address this. These schemes are divided up into “front door demand”, which is about reducing the number of patients turning up at the front door of A&E/ Urgent Care Centres, and “short stay flow”, which is about getting senior level clinician input at the start of patients’ journeys into the A&E department so that they can be turned around more quickly. This in turn means that they are less likely to be admitted to an inpatient bed.
Clinicians from LNWHUT and Brent and Harrow CCGs are currently participating in a “6As audit”. Emergency admission to hospital is a major event in people’s lives. It should never happen because it is easy to admit or to access services that could be available as an out-patient or to administer treatment that may be available closer to home or to get a specialist opinion. All of these are spurious reasons for an emergency admission. To transform emergency healthcare we need to understand why we put patients through this process when alternatives exist and operate effectively across the country but haven’t been widely implemented.
Emergency admission implies a patient is sick and requires a high level of intervention. As such, all proposed emergency admissions should prompt a clinical conversation between senior doctors, ideally consultants.
The 6 As audit is about establishing whether patients are currently going to the optimal place, or whether improvements could be made to better utilise community care pathways. The audit involves asking whether the following alternatives could have been used:
6.8. High Intensity Users
This programme is about pro-active case finding of high intensity users (5 or more A&E attendances or admissions within the last 12 months) and to ensure that members of the frequent attenders forum are fully informed. The forum aims to identify other services and resources that may help the patient address their needs e.g. housing, drug and alcohol treatment programmes,psychological interventions etc. As part of this process, the patient’s GP is consistently informed of their registered patient’s interactions with the ambulance/ hospital/ urgent care services. A care plan is formulated and stored on the Co-ordinate My Care system, which means that it is then accessible to hospital clinicians who need to access it as part of any future re- attendance. The aim of the programme is to reduce future unnecessary re- attendances. It will improve patient care in Brent as patients will receive pro- active care that is better tailored to their needs, rather than turning up in an A&E department, which may not be best suited to the type of expertise that the patient needs.
6.9.LAS Demand
This scheme is about supporting the London Ambulance Service (LAS) to book into extended access hub appointments based in GP practices, where this would be the most appropriate course of action for the patient’s needs.
Where appropriate, the 999 service will also be able to book into the access hub appointments.
To support the LNWUHT system Brent, Harrow, and Ealing CCGs have been selected for rollout in phase 1 of GP in-hours and Extended Access booking from LAS Clinical Hub (known as CHUB). Clinical engagement is underway for opening these slots to the CHUB.
6.10. LAS Walk-In Demand
The Brent category of the LAS has some of the highest rates of conveyance to A&E of all categories. This may be due to higher than average vacancy rates in the service, and a less experienced cohort of incoming paramedics that may be more risk averse in their assessment of patients. This should improve over time as staff become more experienced, but a programme of shadowing is taking place so that LAS staff understand what is available in the community and can refer patients to community pathways where a conveyance to A&E is not deemed to be required.
6.11. Same Day Emergency Care (SDEC)
SDEC is the provision of same day care for emergency patients who would otherwise be admitted to hospital.Under this care model, patients presenting at hospital with relevant conditions can be rapidly assessed, diagnosed and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.
When a patient comes to hospital, an SDEC service (which may operate under the name of ambulatory emergency care unit) means patients with some medical concerns can be assessed, diagnosed, treated and safely discharged home the same day, rather than being admitted.
SDEC services treat a wide range of common conditions including headaches, deep vein thrombosis, pulmonary embolus, pneumonia, cellulitis, and diabetes. The types of conditions that can be managed through SDEC will vary depending on the hospital and needs of the local population.
We aim to expand the usage of SDEC as part of our financial recovery programme, which will reduce overnight non-elective admissions (1-2 days length of stay) and A&E attendances by increasing activity through the SDEC pathways and optimising the ambulatory emergency care units. Shorter lengths of stay attract a lower tariff for the CCGs and therefore reduce costs.
6.12. Front Door Frailty
The aim of this programme is to implement proactive frailty services which will avoid admissions by providing a holistic response for frail older people in the community and during time of crisis. Frailty practitioners will screen patients who are 75 or over and for those who have a high score, a consultant geriatrician at the front end of A&E will provide a comprehensive geriatric assessment. This means that we are usually able to turn the patient around more quickly so that they get the care they need and may never need an admission to an inpatient bed. This is safer for the patient, as they are likely to stay more mobile at home and not pick up hospital acquired infections.
6.13. Admission conversion rates
This programme is about the rates of which A&E attendances ‘convert’ into unplanned admissions to hospital beds. We are using benchmarking data to compare our local hospitals to national averages and London averages so that hospitals who are above the average try to bring their conversion rates down to the average. This means that more patients will benefit from being able to stay out of hospital and reduce their risk of hospital acquired infections. It is a financial benefit to the system because it means that we are not funding unnecessary numbers of hospital beds or opening new beds. It also allows those patients who are most seriously ill to access a bed when they need it.
6.14. Demand Management
We have a comprehensive review programme of primary care variation. Across Brent, the amount of secondary care activity and prescribing spend that are attributed to individual GP practices varies significantly, and this does not always correlate with deprivation levels of the demographics of the GP practice. We intend to reduce this unwarranted variation in practice and to enable GP practices to learn from each other to ensure that best practice care pathways are being followed.
The programme includes:
The meeting begins at 6pm on Thursday 24th October at Brent Civic Centre. The meeting will be in the Conference Hall and is open to the press and public.
The full document with the financial background and overall stratgey can be found HERE but of most importance for residents will be the actions that are planned that will affect patients. Committee members will need to look beyond the jargon and probe deeply to find out what the real implications are for patients.
Fortunately Cllr Mary Daly has provided a commentary via Twitter:
The managers bemoan the increased use of emergency service doesn’t seem able to link it to cuts to out of hours primary care across the area or CMH urgent care centre. There is no plan for primary or community care.There appears to be no equalities impact assessment. No meaningful consultation with residents and certainly no contact with local councillors. yet we are told £98.9m.....£8m saved by denying brent residents over the counter medicines. This affects the most vulnerable refugees, low income residents. this is not to improve the service but to save money...,£6m saving by stopping new and follow up outpatient appointments denying specialist to thousands......
Admit fewer emergency patients including those with pulmonary embolus and pneumonia no reference to community services social care ......£4.6m saved by refusing referral for elective surgery if the money runs out unless you are waiting more than a year YES a year
6. How These Changes Will Affect Brent Patients
6.1.The section below provides further detail on how specific recovery schemes are likely to affect Brent patients, as requested by the Community Wellbeing Scrutiny Committee.
6.2.Elective hospital services and bringing some elective hospital services back to local North West London providers
This programme will focus on “repatriating” elective procedures begin referred by General Practitioners and Trusts to providers outside North West London back into the North West London sector. The project aims to change referral patterns where NWL GPs consider using NW London providers and only refer outside of the sector if there is no capacity or if the patient requires intervention provided by specialist centres out of area.
North West London NHS has an agreement with local NHS Trusts that specific quantities of activity will be delivered in each trust. Any activity above a set threshold is paid at 70% of the Payment by Results Tariff. This means that if more activity is referred to North West London providers, then approximately 30% of the tariff will be saved on each procedure. This is not true of providers external to North West London or to private sector providers.
The total amount of activity that we could bring back into the sector amounts to around 15% of all secondary care activity.
For Brent patients, they should see no change in the healthcare that they receive, except that they are more likely to be referred to a local provider rather than a provider external to the North West London health economy such as Royal Free Hospitals NHS Trust, for example. This is likely to be a benefit to patients in not having to travel longer distances across the city.
It should be noted that patients and GPs will always retain the right under the NHS Constitution to be referred to a provider of their choice and that GP retain the right to make decisions for the wellbeing of their patients.
6.3. Outpatient services and changes to outpatient appointments
NWL CCGs have reached agreement with providers that all activity in Quarters 3 and 4 of 2019/20 will be at contracted (planned) levels of activity, unless this puts waiting list commitments at risk. It was agreed that there will be no rise in 52 week waiters.
Additionally, our providers have agreed to adhere an existing consultant to consultant referral policy. The key principle behind this is that referrals relating to the original complaint can be referred on directly to another consultant. However, if an entirely different complaint comes to the attention of the consultant (unrelated to the original referral) this should be referred back to the patient’s GP first.
We have an outpatient transformation programme in North West London which has developed standardised referral guidelines. Consultants are currently triaging GP referrals against these guidelines when the referrals arrive at the hospital. Any referrals which do not adhere to the guidelines will be sent back to the referring GP with advice. In this way, unnecessary outpatient appointments can be avoided and patients may receive their care from their local GP practice.
6.4. Reducing spending on over the counter medicine prescriptions
Using the NHS London published guidance, we are working with secondary and primary care to reduce the volume of over the counter medication (for example paracetamol or ibuprofen) prescribed to patients. We have in place a communication plan for clinicians, patients and the wider public to support roll out. We will work with secondary care colleagues to support the programme and ensure that advice to patients is consistent across primary and secondary care.
Patients who are considered to be particularly vulnerable and are in receipt of free prescriptions may still receive these over the counter medications on prescription, at the discretion of their GP.
6.5. Standardising assessments for patient transport
This programme involves the renegotiation of the price on the LNWHT patient transport contract and a consistent application of current eligibility criteria. Discussions are currently underway with LNWHT with regard to the first element of the programme. Patient care will not be affected and those patients who require patient transport will still be able to receive it.
6.6.Home Oxygen and Enteral Feeds
This programme is made up of 3 elements. The first is the benefit of a pricing change following national procurement for home oxygen. The next is a clinical review of patients on home oxygen, prioritising those patients who have not been reviewed in the last 12 months and/or those patients where the data shows they are using less oxygen than prescribed. This review process will ensure that patients are not receiving a higher dosage of oxygen than they need, and that oxygen is not being wasted where it is no longer required. It will not change the criteria for patients to receive oxygen.
The enteral feeds procurement provides commissioners with a saving by reducing the costs of consumables and securing a better deal with the NHS’s external providers. It does not alter the care pathway and patients will not experience any change.
6.7.Unscheduled Care
A&E attendances and unplanned emergency admissions to hospital continue to rise in an unsustainable way. These are one of the biggest drivers of the deficit to the NWL financial system. There are a number of workstreams to address this. These schemes are divided up into “front door demand”, which is about reducing the number of patients turning up at the front door of A&E/ Urgent Care Centres, and “short stay flow”, which is about getting senior level clinician input at the start of patients’ journeys into the A&E department so that they can be turned around more quickly. This in turn means that they are less likely to be admitted to an inpatient bed.
Clinicians from LNWHUT and Brent and Harrow CCGs are currently participating in a “6As audit”. Emergency admission to hospital is a major event in people’s lives. It should never happen because it is easy to admit or to access services that could be available as an out-patient or to administer treatment that may be available closer to home or to get a specialist opinion. All of these are spurious reasons for an emergency admission. To transform emergency healthcare we need to understand why we put patients through this process when alternatives exist and operate effectively across the country but haven’t been widely implemented.
Emergency admission implies a patient is sick and requires a high level of intervention. As such, all proposed emergency admissions should prompt a clinical conversation between senior doctors, ideally consultants.
The 6 As audit is about establishing whether patients are currently going to the optimal place, or whether improvements could be made to better utilise community care pathways. The audit involves asking whether the following alternatives could have been used:
· Advice - suggest a clinical management plan that allows the patient to be managed in primary care
· Access to out-patient services - suggest an outpatient referral for specialist assessment
· Ambulatory Emergency Care - clinically stable patients appropriate for same day discharge
· Acute Frailty Unit - to provide comprehensive geriatric assessment for frail older patients
· Acute Assessment Units - to diagnose and stabilise patients likely to need admission
· Admission to specialty ward directly - for agreed clinical pathways and specialised clinical presentations
Once the conclusions of the audit are received, we will aim to optimise our referral pathways so that patients are seen in the most appropriate service and location.
This programme is about pro-active case finding of high intensity users (5 or more A&E attendances or admissions within the last 12 months) and to ensure that members of the frequent attenders forum are fully informed. The forum aims to identify other services and resources that may help the patient address their needs e.g. housing, drug and alcohol treatment programmes,psychological interventions etc. As part of this process, the patient’s GP is consistently informed of their registered patient’s interactions with the ambulance/ hospital/ urgent care services. A care plan is formulated and stored on the Co-ordinate My Care system, which means that it is then accessible to hospital clinicians who need to access it as part of any future re- attendance. The aim of the programme is to reduce future unnecessary re- attendances. It will improve patient care in Brent as patients will receive pro- active care that is better tailored to their needs, rather than turning up in an A&E department, which may not be best suited to the type of expertise that the patient needs.
6.9.LAS Demand
This scheme is about supporting the London Ambulance Service (LAS) to book into extended access hub appointments based in GP practices, where this would be the most appropriate course of action for the patient’s needs.
Where appropriate, the 999 service will also be able to book into the access hub appointments.
To support the LNWUHT system Brent, Harrow, and Ealing CCGs have been selected for rollout in phase 1 of GP in-hours and Extended Access booking from LAS Clinical Hub (known as CHUB). Clinical engagement is underway for opening these slots to the CHUB.
6.10. LAS Walk-In Demand
The Brent category of the LAS has some of the highest rates of conveyance to A&E of all categories. This may be due to higher than average vacancy rates in the service, and a less experienced cohort of incoming paramedics that may be more risk averse in their assessment of patients. This should improve over time as staff become more experienced, but a programme of shadowing is taking place so that LAS staff understand what is available in the community and can refer patients to community pathways where a conveyance to A&E is not deemed to be required.
6.11. Same Day Emergency Care (SDEC)
SDEC is the provision of same day care for emergency patients who would otherwise be admitted to hospital.Under this care model, patients presenting at hospital with relevant conditions can be rapidly assessed, diagnosed and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.
When a patient comes to hospital, an SDEC service (which may operate under the name of ambulatory emergency care unit) means patients with some medical concerns can be assessed, diagnosed, treated and safely discharged home the same day, rather than being admitted.
SDEC services treat a wide range of common conditions including headaches, deep vein thrombosis, pulmonary embolus, pneumonia, cellulitis, and diabetes. The types of conditions that can be managed through SDEC will vary depending on the hospital and needs of the local population.
We aim to expand the usage of SDEC as part of our financial recovery programme, which will reduce overnight non-elective admissions (1-2 days length of stay) and A&E attendances by increasing activity through the SDEC pathways and optimising the ambulatory emergency care units. Shorter lengths of stay attract a lower tariff for the CCGs and therefore reduce costs.
6.12. Front Door Frailty
The aim of this programme is to implement proactive frailty services which will avoid admissions by providing a holistic response for frail older people in the community and during time of crisis. Frailty practitioners will screen patients who are 75 or over and for those who have a high score, a consultant geriatrician at the front end of A&E will provide a comprehensive geriatric assessment. This means that we are usually able to turn the patient around more quickly so that they get the care they need and may never need an admission to an inpatient bed. This is safer for the patient, as they are likely to stay more mobile at home and not pick up hospital acquired infections.
6.13. Admission conversion rates
This programme is about the rates of which A&E attendances ‘convert’ into unplanned admissions to hospital beds. We are using benchmarking data to compare our local hospitals to national averages and London averages so that hospitals who are above the average try to bring their conversion rates down to the average. This means that more patients will benefit from being able to stay out of hospital and reduce their risk of hospital acquired infections. It is a financial benefit to the system because it means that we are not funding unnecessary numbers of hospital beds or opening new beds. It also allows those patients who are most seriously ill to access a bed when they need it.
6.14. Demand Management
We have a comprehensive review programme of primary care variation. Across Brent, the amount of secondary care activity and prescribing spend that are attributed to individual GP practices varies significantly, and this does not always correlate with deprivation levels of the demographics of the GP practice. We intend to reduce this unwarranted variation in practice and to enable GP practices to learn from each other to ensure that best practice care pathways are being followed.
The programme includes:
· Reviewing A&E and UCC attendances, and contacting patients within 2 days of discharge where attendance was inappropriate;
· Practices promoting self-care management and continue to improve patient access. 40 practices currently offering E-consultations with a further going live imminently;
· Ensuring visible display of GP Access Hub, NHS 111 and Online Services Posters;
· Conducting internal and external peer reviews with CCG and PCN/network leads;
· Locum, GP trainees and associates referrals to be triaged by the lead clinician/GP partner
· Educational sessions for all GPs and clinical staff. Inter-practice referrals optimising skill mix at PCN level
· Kilburn Locality has a low outpatient referral activity - learning shared with other PCNs (advice and guidance at Imperial and MDT programme)
The meeting begins at 6pm on Thursday 24th October at Brent Civic Centre. The meeting will be in the Conference Hall and is open to the press and public.