WHSSCREFERRAL

MANAGEMENT

• Aims and objectives of referral management

• Guidance to using directory

Guidance

• On behalf of the Local Health Boards WHSSC manages thirty four healthcare contracts, with English providers to the value of £100m.

• Approximately 16,000 new out-patient referrals made to these contracts per annum.

Background Information

To introduce a formal process of approving all new outpatient referrals for all patients requiring treatment at a defined list of English NHS provider organisations contracted through the Welsh Health Specialised Services Committee (WHSSC).

Aim

• Where appropriate patients from Wales are treated in Wales and at established centres close to the border;

• Local services are engaged whenever possible, and referrals into England specialist centres are robustly managed;

• Requests for specialist and non-specialist services are considered by the appropriate commissioner ensuring equity of access;

• Patients receiving specialist care in England are treated in the preferred providers;

• The specialist and tertiary centres that serve the population of Wales are sustained;

Principles - 1

• There is an improvement in intelligence with regards to new outpatient referrals;

• Arrangements and mechanisms that would improve service and commissioning planning, both in Wales and outside, are in place; and

• Clinical Governance arrangements are in place through contract mechanisms which will allow for the audit the quality of care and outcomes for patients.

• There will be no undue delay to patient care as a result of the introduction of referral management;

• Clinical gateways are empowered to make referrals into England where the service cannot be provided within Wales

Principles - 2

Phase one Providers (Specifically non border):

• Cambridge University Hospital NHS Foundation Trust (Addenbrooke's)• Great Ormond Street Hospital NHS Trust • Guy's and St Thomas' Hospital Trust• Imperial College Healthcare (Hammersmith)• Kings Healthcare NHS Trust (King's College Hospital NHS Foundation Trust)• Leeds Teaching Hospitals NHS Trust• Papworth Hospital NHS Trust• Royal Brompton and Harefield NHS Trust• Royal Free Hampstead NHS Trust• Royal Marsden NHS Trust• Royal Orthopaedic Hospital NHS Trust• Sheffield Teaching Hospitals NHS Trust• University Hospital North Staffordshire NHS Trust • University College London Hospitals NHS Trust

Phase One Providers

Referrals will be managed using one of three discrete gateway points:

 • Clinical gateways – Clinically informed decisions made regarding

the appropriate management of referrals in accordance with current policies.

• WHSSC Prior Approval gateway - Where no a clinical gateway is in place for a particular specialised service, the WHSSC prior approval team will provide the necessary authorisation.

• LHB Prior Approval - Where a referral is for a non specialist service within a WHSSC contract, the relevant LHBs prior approval team will provide the necessary authorisation

Process of Referral Management - 1

• Every clinical gateway /prior approval team is registered with WHSSC and issued with a gateway number and WHSSC approval stamp.

• All new out-patient referrals into the first phase English providers must be stamped in order for the receiving Trust to process the referral.

• Any referral that is not stamped will be returned to the referrer.• Unless the secondary care consultant/GP transfers the care of the

patient to the clinical gateway, clinical care and responsibility remains with the secondary care consultant/GP.

Process of Referral Management - 2

• If the clinical gateway does not authorise the referral and the secondary care consultant / GP disagrees with this opinion, the secondary care consultant can apply to WHSSC for authorisation on an exceptional basis in accordance with the All Wales policy on making individual decisions.

• It is a requirement that any urgent referrals are processed within 2 working days and routine referrals processed within 10 working days.

Process of Referral Management - 3

• None of the above should result in a delay to patient care. Where the position is unclear, the default position will always be for the referral to be considered by the WHSSC Prior Approval team.

Process of Referral Management - 4

To support the process WHSSC has produced a comprehensive service directory which will inform referrers of the following:

 • Definitions of services • Relevant policies and or service specifications

relating to services• Specific inclusions/exclusions where appropriate• Authorised gateways and gatekeepers• Preferred providers

Process of Referral Management -5

Referral Management Service Directory

WHSSC

• Developed to support the tertiary referral management project.

• Single point of information including:– Services commissioned through WHSSC– List of local tertiary providers– Referral management arrangements– AGNSS services– WHSSC commissioning policies

Objective

• Excel spreadsheet• Index page with 8 subsections

– Guidance on using document– Service Definitions– Local Tertiary Providers– Referral Management– AGNSS Services– AGNSS Providers– Commissioning Policies– DH Specialised Services Definition

Structure

High level definitions of specialised services commissioned by WHSSC

Unique reference number. Definition group – Broad level definition. Specific service area – service specific definition. Commissioning arrangements since 2009/10 Planning exclusions and inclusions Funding exclusions and inclusions Referral management Services which are highlighted in light grey are not

delegated to WHSSC, and as such are planned and funded locally by each Health Board.

Service Definitions

• Current local service provision for each of the services identified in the previous section

• Clinicians should consult this section to identify the arrangements for provision of this care within the existing contractual arrangements held by NHS Wales

Local Tertiary Providers

• Clinicians should consult this section once all levels of local services have been exhausted, in order to identify the clinical gatekeeping arrangements.

• If the diagnosis or required procedure is not included, then the clinician will need to liaise with appropriate IPFR team.

Referral Management 1

Diagnosis ICD code – where available Procedure OPCS4 code – where available Health Board – these are the health board populations

which are covered by the referral management arrangements

Clinical gatekeeper – the name of the designated gatekeeper

Provider – the provider which provides the care or specific procedure for the identified diagnosis

Sub specialty – the subspecialty at the provider which patients are referred to through the gatekeeper

Gateway number – the assigned number for each gateway

Referral Management 2

• Two sections– Services– Providers

AGNSS

• List of WHSSC policies• Links to DH Specialised Definitions

Set

Additional Resources

• Directory is designed to be used sequentially

• Buttons on the index sheet link to the relevant section

How to use Directory 1

• For example, clicking on the service definition button, as below

How to use Directory 2

• Will open the Service Definition Section as illustrated below

How to use Directory 3

• Clicking on the return to Index button, will return to the Index sheet

How to use Directory 4

• Directory will be available on WHSSC website• Updates will be uploaded as further

gatekeeping arrangements are established• All queries relating to the Directory should be

directed to WHSSC.GeneralEnquiries@wales.nhs.uk

Support