Although it may not be widely appreciated yet, the publication of the Commission for Quality and Innovation incentives (CQUIN 2017-19: https://www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/) in November 2016 has the potential to create a step change in the way primary and secondary care interact, to the benefit of all.
As a reminder, CQUINs allows Trusts and other providers to receive central payments for innovations and activities that have the potential to improve patient care; this can be as much as 0.25% of the annual commissioned contract if all CQUIN targets are met. While providing advice and guidance to GPs won’t give them all the CQUINs they need it certainly contributes and actively encourages provider trusts to offer this kind of service to their primary care colleagues.
As the provider of the leading Clinical Advice & Guidance solution to the NHS we are obviously very interested in the inclusion of a CQUIN element for advice and guidance related to “non-urgent GP referrals”. In our experience, this is a great step…
“enabling GPs to have better access to consultants to determine the best course of action for their patients and make it easier for GPs to access appointments for their patients”
As background, Kinesis has been in active use since 2011 (and in pilot since 2010), with hundreds of GP Practices over 7 CCGs. To date our users have avoided more than 13,000 hospital attendances through use of effective advice and guidance. One of the key benefits is that it is a system that matches their work practices and ensures that the advice and guidance process is rapid and assured; this both reduces the time to treatment and drives up regular use through confidence and a willingness to adopt the technology. Today there are over 50 specialties offering advice from almost a dozen trusts; GPs predominately get advice from the consultants at their local providers.
To date our users have avoided more than 13,000 hospital attendances through use of effective advice and guidance
However… One of the biggest hurdles CCGs face is persuading Trusts to release time for their consultants to provide this important service. It takes a degree of persuasion and negotiation between the parties and, to date, this has been led by the CCG’s.
On one hand hospital consultants are obviously very busy and do not have sessions set aside for such an activity. On the other the data clearly shows that use of effective advice and guidance avoids unnecessary referrals at outpatient clinics, which means that the specialties see a higher proportion of patients with significant clinical needs. Furthermore, there is good evidence that the process of A&G actively improves GP knowledge, leading to better referral decision without going through an A&G process. It is also thought that it results in fewer patients with an outpatient clinic referral attending A&E during their appointment wait time. This is all good news for the specialists and their trusts.
The active introduction of CQUINs as a reward for providing advice and guidance as to immediate effects
- it raises the profile of effective advice and guidance as a key process in managing non-urgent care
- it provides a centrally funded financial reward which helps justify trusts releasing specialist time and setting up the process for dealing with advice and guidance requests.
“The scheme requires providers to set up and operate A&G services for non-urgent GP referrals, allowing GPs to access consultant advice prior to referring patients in to secondary care”
To be effective at the health system level, we believe there are a number of key considerations:
- The Advice and Guidance process needs to be applied consistently across all specialties so that GPs have the same process and experience regardless of who they are requesting advice from. In fact, the process ideally needs to be consistent across all providers serving the GP community. Fragmented systems and differences in process will serve to undermine the success of any advice and guidance programme.
- Sufficient specialties need to be available to address the most frequently required clinical needs from primary care. In practice, the CQUIN target addresses this in part by requiring the provider to offer advice and guidance against the highest volume elective specialties.
- Response to advice and guidance requests needs to be assured and rapid; the GPs need to know that they will get an answer and that it will arrive within a clinically meaningful period of time. The CQUIN guidance on this suggests trusts should be able to respond within two days. It is worth noting that ad hoc arrangements such as email show average response times and rates of around nine working days and less than 50% response rates, so there is a considerable improvement to be made and this requires effective management, reporting and monitoring and whatever technologies employed to actively drive response rates within a period of time specified in a service level agreement.
- Active adoption across all parts of the clinical spectrum. This means that its insufficient to simply make available technologies that enable advice and guidance requests and responses; it must be delivered as part of a programme of work that changes practice at both primary and secondary operational levels.
- It’s not enough to use a blunt tool. Clinicians and the environment they work in are complex and whatever the process adopted is needs to reflect this. Our experiences that there are dozens of subtle business rules that need to be embedded in the process to address things like individual versus group response to advice requests, leave and absence, delegation, legal access to advice, feedback and outcomes tracking, working days and much more. Introduction of advice and guidance processes that lack this has been seen to flounder rather rapidly as users reject the process as unworkable in their real-world situation.
- Simplicity for the users is essential. There’s no getting away from this being yet another thing that they have to do, so it needs to be as un-intrusive as possible, very simple to understand and use and have a minimal impact on their time. It must be fast, it must be easy, it must do the job.
- Any system needs to allow for a dialogue between the clinicians, not just a question-and-answer. Most of the time, that dialogue doesn’t need to happen in real-time; for non-urgent GP referrals, it is sufficient for GP to be able to act on advice given within a day or two, with the opportunity for the clinicians involved to continue to liaise to ensure the advice is:
- specific to the patient
- avoids a referral where appropriate
“A&G in the context of this CQUIN refers to structured, non-urgent, electronic A&G provided via telephone, email, or an online system. CCGs may agree with trusts how the local programme of A&G will operate”
It is our view that email is not a workable technology. It lacks any of the business rules and drivers to adoption that will be required. There is no shortage of advice and guidance being given via email, but this is always on a non-programmatic basis, not at scale and not provided consistently. Response rates tend to be poor. The telephone is highly useful in specific, urgent cases; but most of the time, the immediacy of a call isn’t required and requires clinical experts to be on call 24×7. Telephone-based services and email both tend to suffer a lack of governance, reporting and management.
Well-designed online systems, though more complex under the hood, can be simple enough to quickly roll out and drive to adoption at scale. This would allow achievement of the CQUIN milestone dates. As we are living in a modern world, the implication is that a hosted or cloud solution, running through a browser rather than anything installed locally and which requires no IT effort is a good choice.
“Agree local quality standard for provision of A&G, including that 80% of asynchronous responses are provided within 2 working days”
Our data has clearly shown that the target of 80% response within two working days can be achieved reliably. It won’t happen by itself; it needs support at both primary and secondary care level to monitor and act on slow responses. The concept of two working days also needs to be actively addressed; clinicians are often not available and the people requesting advice need to have visibility of this and be allowed a choice of who to request the advice from accordingly; this also means systems need to be in place for users to set their out of office, working days and leave periods. There needs to be recognition that staff change and leavers and starters need to be accommodated or risk degrading trust in the system.
Quarterly milestones require “quality standards for provision of A&G met”
Obviously, we believe that our system, Kinesis Advice and Guidance, ticks all the boxes; that’s why we have written this article of course. There are other approaches out there, including some highly professional telephone-based options which survey useful purpose, as well as the advice and guidance module built into NHS eRS (electronic Referral System, the replacement for Choose and Book). The important thing is for providers wishing to offer advice and guidance, in order to qualify for CQUIN’s, to think hard about what will make it work as a failed rollout with poor adoption will not only fail to attract the desired payments will be costly in terms of implementation effort and clinical staff confidence.
Find out More
If you’d like to know more about Kinesis Advice and Guidance please contact us at firstname.lastname@example.org
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