8. Making the change happen
Planned Care provision is complex. It involves community and hospital care and back again, it can cross interagency boundaries and it can also involve the independent healthcare sector. The current healthcare system in Scotland does not manage referrals from Primary to Secondary care in the best way possible.
This inefficiency in process is now colliding against the strategic direction to provide services closer to home and the need for a framework to help plan and deliver this change. Evidence from "Making the Shift" (2006) has shown that key success factors in leading this transformation have included:
- The development of strong relationships between GPs and Consultants through facilitated redesign workshops;
- Strong Clinical leadership to overcome resistance to change;
- The development of GP peer review of referrals;
- High quality information management and technology often with local solutions;
- Robust information systems to provide all clinicians with accurate and real time data to support service developments;
- Support of the Royal Colleges to ensure acceptability in service redesign.
The Planned Care Improvement Programme recommends that NHS boards ensure outpatient pathways are utilised and form part of the wider clinical systems redesign to find clinically appropriate outpatient treatment. These pathways should include the following interventions that have been shown to be effective in optimising the use of scarce resources:
- Discharge of outpatients to either no follow up, patient initiated follow up or GP follow up as alternatives to routine follow up in hospital outpatient clinics;
- Use of GPs with special interests;
- Direct access for GPs to hospital based diagnostic tests and investigations or hospital treatments without the prior approval of a specialist in an outpatient clinic;
- Structured referral sheets which prompt GPs to conduct any necessary pre-referral tests or treatments and educational support by specialists in creation of local referral guidelines;
- Transfer of medical care for common chronic conditions such as diabetes from secondary to primary care;
- Development of teams and team leaders that work across primary and secondary care to reduce the need for treatment within acute services;
- Provision of alternative routes of care that are coordinated by means of referral management services.
The Planned Care Improvement Programme will encourage health boards to introduce referral facilitation frameworks that drive the use of referral information and promote redesign of existing service delivery models to incorporate referral management services. This will help in both the strategic shift in the balance of care and the effective utilisation of scarce resources at both local and regional levels.
The Planned Care Improvement Programme will assist boards to share ideas and best practice and facilitate visits and knowledge exchange with healthcare systems outside Scotland. It is recognised that Health Boards will be starting out from different positions, however, key components of plans should include:
- Identified clinical leads and dedicated project management time;
- A commitment to ensure that outpatient pathways in high volume specialties are adopted (or adapted to suit local circumstances) and are integrated into wider clinical systems redesign;
- A clear understanding of current referral patterns for specialties and their associated waiting times and/or degrees of urgency. Boards should be able to measure the volume of patients to whom patient pathways apply and be able to analyse local variation from patient pathways supported by CHI as the unique patient identifier;
- A clear understanding of community based services and the potential shift available from an acute environment and clear evidence of engagement with community health partnerships in the process of service redesign;
- A commitment to implement patient pathways across long wait specialties and the use of health professionals who have undertaken additional training in their chosen specialties (such as extended role Nurse Practitioners) to help promote the spreading and sharing of existing good practice;
- Boards should have a clear view of the possible redesign of services and subsequent alternative referral routes this offers, including referral management services. Boards should be able to promote the effective use of patient pathways and extended role practitioners;
- Identification of local high volume specialties that will implement integrated referral systems;
- A commitment to decrease the requirement for return outpatient appointments in high volume specialties and to maximise follow up at, or close to home;
- A plan to integrate referral management and booking services.