The North Hub continues to reflect an over spend principally derived from NHS
Provider Service Agreements and Prescribing costs.
The Hub is proactively trying to reduce referrals into secondary care and GP
Practices have been encouraged to send referrals to Greater Manchester Surgical
Centre resulting in an increase in North patients being seen at the Centre. The Hub is
undertaking an audit with Practices around the HRG codes that could have been
treated at GMSC but were operated on at Other Hospitals, to identify why these
weren’t referred to the GMSC. The Hub are also currently accessing the Pennine
Hospital PAS system to identify T&O, ENT and General Surgery patients who are at
risk of breaking the 18 week target and could be sent to alternative providers for
It is anticipated that with the provision of a MSK Service in the North, allowing on site
diagnostic of treatment, more patients will be referred to the Fitness for Surgery
Centre. The logistics are currently being arranged for the Service to be available in
the North at the City of Manchester Stadium and Cornerstones.
Progress is currently being made with PSA and phlebotomy and this will further
facilitate in reducing referrals to secondary care. At the same time the under spend
on PBC commissioning will increase. The ECHO service is now operational and
referrals to this are increasing. The ARAS step up service will go live for a 12 month
period to GPs in November to reduce hospital admissions for COPD exacerbations.
Work is being undertaken to understand the increase in activity to Other Providers
and to identify alternative courses of action.
Prescribing costs for the North PBC Hubs is coming under tighter control, with a full
complement of the medicines management team working in practices. This is
ongoing work to manage the risk in this area. SciptSwitch will be implemented from
December 2008 to assist the PBC and practices in this area.
Central hub are aware of the impact of contract overperformance, and seeking to
work together as a hub to manage demand. A workshop has been held with all the
40 Practices in the hub looking at what can be done to manage demand at Practice
level; this involved sharing benchmarked data on referrals and activity, and sharing
good practice models. A hub wide demand management strategy is being worked up
which will form a key component of the PBC scheme in Central for the next year.
Specific PBC developments and initiatives which are planned to impact on demand
include the following:-
Primary care diagnostics – ECGs deflecting referrals to secondary care.
Direct access Echo; service been expanded, and efficiencies applied
Tier 2 service recently been evaluated; impacting on secondary care activity,
so it is proposed to continue the service and look to roll it out citywide.
Enhanced service for heart failure (LVSD) reducing referrals to secondary
Greater Manchester Surgical centre
Referrals to GMSC from Practices in Central are increasing. Further
measures to increase utilisation are being considered, including practice level
benchmarking of referral activity.
Service being developed citywide, should be in place early 2009/10.
Extended primary care service now in place, which it is planned will deflect
activity from secondary care.
Longer term – CATS
5 independent sector Clinical Assessment and treatment services covering
ENT, MSK, General Surgery, Gynaecology and urology to come on stream in
early 2009. Mobilisation currently underway. ’Consenting visits’ should reduce
new to follow up outpatient ratios in the acute sector.
PCT CATS for Dermatology, Ophthalmology and Dental will be in place in mid
There has been a significant fall in non elective excess bed days, as a result
of improved throughput through the acute system, and more capacity in
community alternatives; both in respect of CMMC’s Continuing care and
assessment beds at Trafford, and also the expansion in Intermediate care at
Accident and emergency avoidance – a number of measures are now in
place to deflect activity from A&E; which impact not only on A&E attendances,
but also potential admissions. These include:-
Opening hours for Primary Care Emergency Centre extended.
Emergency clinics; with direct referrals from pilot GP practices to
start from 1st December 2008.
Cold weather system agreed with Met Office and now in place;
designed to reduce emergency admissions of patients with COPD.
Patient information leaflets on appropriate use of urgent care
services, in place by end December 2008.
Social marketing campaign been carried out students during
freshers week, to promote registration with GPs and reduce
inappropriate use of A&E.
Intermediate care to be re-launched as a ‘step up’ service; to
Improved data challenges; increased data validation at Practice level, now
increased to monthly from quarterly.
New contract clauses now applicable from 1st October 2008:-
Revised contract penalties for non receipt of discharge letters.
Agreed system of challenges where outpatient follow up ratios
exceed planned or benchmarked numbers
Planned procedures not carried out no longer paid for, where the
responsibility lies with the hospital.
Pre procedure bed days also no longer paid for where the
responsibility lies with the hospital.”
South hub is in the process of reviewing the assumptions incorporated within the
contract plans for minor surgery against the actual activity. This was an initiative
(Beacon) that commenced in June and assumed diversions from secondary care of
around 1700 minor procedures. UHSMFT are now rejecting referrals they believe
should be sent to the Beacon Service due to pressures on their Dermatology service.
A rectal bleed service to be implemented within the community is currently going
South is also working on a follow up anti-coagulant service where we are negotiating
a reduction in tariff for follow ups and are currently scoping different models of
delivering the service in a community setting. Once this process is complete, a
business case will be prepared.
Work has begun on a business case for further development of the MSK Extended
Primary Care service. This will reduce the number of referrals into secondary care.
Independent Assessment Unit
The PBC consortium is working with University Hospital of South Manchester, NHS
Trafford and Manchester Social Services to redesign assessment services following
A&E attendance. This includes looking at having an Integrated Assessment team
(IAT) that will operate out of the current Acute Medical Receiving Unit and provide
input to patients across front end services, including A&E were necessary.
The IAT will provide dedicated multi-disciplinary team assessment (consultant,
nursing, therapy and social care) at ‘front end’ services reducing unnecessary
hospital admissions and length of stay. A key enabler to achieving this vision will be
the enhanced discharge pathway links into community services, such as intermediate
care, that the service will be able to forge.
Pathology at UHSMFT
At the moment this is currently over performing and can be split into two halves
The budgets only included the original block + 2.3 % uplift. However the PCT were
paying over performance invoices separately from the main contract which was not
taken into account when setting the budget
Budgeted for Actual predicted Over
Pathology £'s performance £'s performance
1,633,282.93 2,491,693 848,410.07
Then there is true over performance using month 3 data the actual over performance
Performance Actual predicted
Pathology in SLAM performance £'s Over performance
2,491,693 2,746,301 254,608
This makes a total over performance off £1.103m for the year.
The hub has validated on a sample basis practice level information and have worked
with contracting to identify areas for investigation. As a result the fact that we are
being charged for multiple tests for 1 liver function test is now being pursued at both
a PCT level and with other PCTs.
Pathology has now moved into part B of SLAM.
Drugs over performance
Budgeted Actual predicted
Drugs for £'s performance £'s Over performance
139,981 959,857 819,876
For those drugs which are not on the PBR Exclusion List, a prior approval form is
being developed so that informed decisions can be made, and data can be collected
to forecast more accurately the year end position.
At the moment no invoices for over performance have been paid.
Consultant to Consultant Referrals:
South hub is currently checking the activity of first out patient attendances which are
referred by consultant to consultant. It was found 22% of first out patient attendance
are referrals from consultant to consultants. The Contracts and commissioning team
has presented a discussion paper to PBC reform group who agreed in principal that
steps should be taken to decrease these referrals. Further work is in progress to
agree a policy.