iain a pretty professor of public health dentistry...referral management for minor oral surgery iain...

Referral Management for Minor Oral SurgeryIain A Pretty

Professor of Public Health DentistryUniversity of Manchester

A celebration of those ‘ light bulb moments ’ that are transforming patient experience and care across the North West

Overview

• What is the issue?• How did it come about• How did we address it?• Why undertake research?• The NIHR programme• Challenges

Statement of Disclosure

I have a financial interest in referral management systems.

I am working with the current pilot in NHS Greater Manchester as one of a number of Consultants

delivering the service under a SLA.

What’s the issue?• Minor oral surgery referrals increased year on

year since 2006• Other dental referrals into secondary care

followed same pattern• Significant issues for

– PCTs– Acute trusts

• Cost profile between primary and secondary care (£150 vs £650 – £1200)

• Need for a single operating framework

How did it come about?• 2006 saw the introduction of a new dental

contract• Same payment for referral as for undertaking the

procedure (NHS Band II – 3 UDAs at £25 per UDA)

• Acute trusts welcomed additional activity• Investment into staff grade positions• 18 week issues began to emerge• Performance issues in the primary care

contracts• No simple intelligence on referral patterns

What did we do?• Started in NHS Manchester• Pilot work• Central capture system developed• Initially with basic IT systems (lack of N3)• Developed into a rolling programme• N3 connectivity developed• Enhanced the NHS NET provision• Currently in 7 out of 10 GM PCTS• All PCTs by year end

How does it work?

The ProcessCentral Capture• Referrals received by post, email (NHS NET),

fax or direct entry to website• Each has a URN

The ProcessAdmin Triage• Each referral is assessed for completeness• Rejected if areas not completed• Then automatically sent to:Consultant Triage• Assesses for case complexity• Assigns to appropriate service• Provides clinical advice and supportSent to Provider / Referrer• System automatically sends via NHS NET

The RMS IT• Hosted on CfH approved servers• Web based – access using 2FA• All referral details stored securely• Sent from NHS NET onwards• Governance enables referrals to be reviewed,

reports issued and issues tracked

Impact 1• Significant improvement in the quality of referrals

within 2 months of implementation• Reduction of “inappropriate referrals” seen within 3

months • 58% of cases of minor oral surgery identified as

suitable for primary care in first 3 months• 33% of cases identified as such from month 4• Savings achieved on MOS referrals• Clinical quality and advice on peads & restorative

Impact 2• Cost savings• £250,000 saving per month in GM using system

based on MOS on average• Service costs circa £35,000 per month for GM

currently• Not taking advantage of all possible savings as not

all PCTs have primary care services• Quality and governance of system enhanced• Provides rich health needs assessment data

Risks• Promotes referrals by stimulating demand• De-stabilises acute trust departments• Risk to training and learning • Case complexity issues may not be adequately

recognised by tariff• Leakage practices• Industrialisation• Quality of care

Research• Anecdotal evidence suggests the system is

great!• Lets roll out across England!• NHSCB a great opportunity to do this with new

care pathways and secondary care commissioning

• The NHS way of implementation

Research• Anecdotal evidence suggests the system is

great!• Lets roll out across England!• NHSCB a great opportunity to do this with new

care pathways and secondary care commissioning

• The NHS way of implementation

NIHR SDO / HSD&R• Research bid to SDO workstream• Described a robust research approach to

evaluating the referral management system• Applicable to all schemes with primary care

diversions• Aims to assess impact across the whole system,

and for all stakeholders• Take a virgin site (in terms of MOS and referral

management) and undertake staged implementation

RefTon Project• Based in NHS Sefton with electronic only

submission• Will assess impact on

– Practices– Patients (in terms of quality)– Acute trusts– Commissioners

• Will consider– Cost– Quality– Whole service impact

Conclusions• Intelligent, clinically led referral management

can drive quality care• There are cost savings to be made• Not without risk or consequence and

engagement is key • RMS likely to be a key recommendation of the

NHSBC• CCGs are developing RMS – need to ensure

approach is evidence based• Kernow CCG is excellent example

ThanksNHS• Colette Bridgman• Ben Squires• Lesley Gough• Gina Lawrence• Anne Lamb

University of Manchester• Martin Tickle• Caroline Sanders• Stephen Birch• Tanya Walsh• Joanna Goldthorpe

iain.pretty@manchester.ac.uk

Q&A