Patient Choice Strategy

Patient Choice Strategy Page 1 of 14

Contents Page 1 Background 4 2 Putting Patients and the Public at the Heart of Health and 5 Healthcare in West Lancashire 3 Where are we now and where do we need to be? 6 4 Choice of Tier 2 Services 7 4.1 Where are we now? 7 4.2 Where do we need to be? 7 5 Choice Discussion at the Point of Referral 7 5.1 Where are we now? 7 5.2 Where do we need to be? 8 6 Choose and Book 8 6.1 Where are we now? 8 6.2 Where do we need to be? 9 7 Referral Management Centre 9 7.1 Where are we now? 9 7.2 Where do we need to be? 9 8 Choice of Maternity Services 9 8.1 Where are we now? 9 8.2 Where do we need to be? 10 9 Mental Health 10 9.1 Where are we now? 10 9.2 Where do we need to be? 10 10 Community Services 11 10.1 Where are we now? 11 10.2 Where do we need to be? 11 Page 2 of 14

11 Long Term Conditions 12 11.1 Where are we now? 12 11.2 Where do we need to be? 12 12 End of Life Care 12 12.1 Where are we now? 12 12.2 Where do we need to be? 13 13 Communications 13 14 Using Health Market Analysis 13 15 Monitoring Patient Choice 13 16 Summary 14 17 Links to Key Documents 14 Page 3 of 14

1. Background Since April 2008, the full roll out of Free Choice has meant that the majority of patients being referred to hospital have been able to choose where they wish to be treated 1 from a national menu of services provided by NHS and nationally appointed Independent Sector providers alongside any primary care services commissioned locally by the Primary Care Trust. However, the NHS Constitution, published on 21 January 2009, established a right to choice and to information to support that choice. The right makes choice a core feature of a responsive NHS in the 21 st century. The Constitution states that: Patients have the right to make choices about their NHS care and to information to support these choices. The options available to them will develop over time and depend on their individual needs. From 1 April 2009 patients 2 will have the right to choose where they have treatment when they are referred for their first outpatient appointment with a service 3 led by consultants and to information to support that choice. The right to choice will develop as choice is extended into other areas. New legally binding Directions from the Secretary of State to primary care trusts support this new right. The Department of Health has issued guidance for primary care trusts to help them with the implementation of the right. The guidance explains what their new duties are and sets out some of the levers for implementing the new duties. Equity and Excellence: Liberating the NHS 4, published in July 2010 set out future plans for the extension of Choice. Further guidance published by the Department of Health in July 2011 entitled Operational Guidance to the NHS, Extending Patient Choice of Provider (Department of Health, July 2011) outlines how this choice should be extended further to include Any Qualified Provider (AQP). This means that when patients are referred (usually by their GP) for a particular service, they should be able to choose from a list of qualified providers who meet NHS service quality requirements, prices and normal contractual obligations. It is intended that a phased implementation of patient choice of Any Qualified Provider is undertaken, treating 2012/13 as a transitional year, starting with a limited set of community and mental health services. Based on discussions with national patient groups and an assessment of deliverability, DH has identified a list of potential services for priority implementation. This Strategy has been developed to support NHS West Lancashire CCG in fulfilling its responsibilities and to outline the plan for improving patient choice and increasing the availability of information to inform that choice across West Lancashire. 1 Introduction of Free Choice at Referral, Important changes affecting Providers (Department of Health, March 2008) 2 Except persons detained under the Mental Health Act 1983, military personnel and prisoners 3 Except services where speed of access to diagnosis and treatment is particularly important, for example emergency attendances/admissions, attendances at a Rapid Access Chest Pain Clinic or Cancer Service under the two-week maximum waiting time, maternity services, mental health services 4 Equity and Excellence: Liberating the NHS (Department of Health, July 2010) Page 4 of 14

2. Putting Patients and the Public at the Heart of Health and Healthcare in West Lancashire This Patient Choice Strategy will be an important step in the development of a world class health system for the people of West Lancashire. It will promote coalitions to improve the quality and outcomes of our health care system. It will ensure that services are commissioned that are personalised to the needs of patients and delivered in the most appropriate environment. It is based on sharing information with the public to help them make decisions about their own clinical needs. NHS West Lancashire CCG has established a number of aims which include: To improve the quality and length of life of the population of West Lancashire To ensure safe and effective services are provided when and where they are needed most, making sure that the quality of those services matches local people s expectations To encourage consistent two-way communication with local people to listen to their needs and views on West Lancashire s health services To provide the population with the information they need to take more control over their health and health services To make the most effective use of technology to improve our effectiveness and efficiency To make best use of evidence based practice to help us to make objective decisions concerning healthcare and health services Guidance 5 places an obligation on the NHS to involve service users in the planning and development of services. It recognises that a user led view of the patient journey is important and that service users can assist in setting standards and promoting patient-centred services. Meaningful engagement with patients, carers and their communities will therefore be absolutely essential for Clinical Commissioning Groups. NHS Central Lancashire, supported by Department of Health funding, has developed A toolkit for health commissioners and partner organisations. This important document is written as a guide for anyone who needs to engage with the public about healthcare and related issues. It provides practical advice about gathering public opinion and how to make it an integral part of the commissioning process. 5 Real Involvement, working with people to improve health services (October 2008) Page 5 of 14

3. Where are we now and where do we need to be? The diagram below summarises NHS West Lancashire CCG s current position in relation to Choice and the expected position once this strategy has been fully implemented. NOW FUTURE Choice of Tier 2 Patients can choose from a limited range of Tier 2 services in addition to secondary care options Choice of Tier 2 Patients will be able to choose from a wider range of Tier 2 services and providers Choice of secondary care Patients are offered a small number of secondary care providers and appointment availability may be limited Choice of secondary care Patients will be offered a wider range of providers and will have a choice of appointments at first booking attempt Choice of mental health Patients are offered appointments at a local clinic unless they request alternative options Choice of community services Patients are offered a choice of clinic site. Choice for Long Term Conditions patients Patients can choose from a number of community based services in addition to secondary care options Health Market Analysis Patient Feedback Public Involvement Choice of mental health Patients will be provided with more information and additional new points of access into mental health will be considered Choice of community services Patients will be offered choice of clinic site for a wider range of services and providers Choice for Long Term Conditions patients Patients will have access to a wider range of community based services Choice of End of Life Care Patients can choose their preferred place of care and have access to information to make informed choices Choice of End of Life Care End of Life care services to be jointly commissioned (with LCC) and reshaped to provide improved care for patients and their families Page 6 of 14

4. Choice of Tier 2 Services 4.1 Where are we now? A number of Tier 2 services are in place which provide an intermediate level of service between traditional primary and secondary care and provide patients with a wider choice of services into which they can be referred. These provide care closer to home and are more appropriate for conditions which GPs are unable to treat but that do not require consultant opinion/treatment. The range of Tier 2 services includes a Minor Surgery service, Orthopaedic Joint Injection GP with Specialist Interest Service, Gastroscopy GP with Specialist Interest service and Ophthalmology service. Information regarding these services is available via Choose and Book and from GPs. 4.2 Where do we need to be? NHS West Lancashire CCG will continually review the way services are provided to ensure that, where possible, they are delivered closer to home to provide better patient care. The development of further Tier 2 services in 2012/13 is currently underway. These will provide patients with expanded and additional services in community-based settings, including Minor Oral Surgery and Dermatology. 5. Choice Discussion at the Point of Referral 5.1 Where are we now? Since 1 April 2009, Primary Care Trusts have had a duty to ensure patients are offered a choice of secondary care provider. Each Primary Care Trust has had to ensure that the necessary processes are in place so that any patient requiring an elective referral is given the choice of any clinically appropriate secondary care provider for their first outpatient appointment with a consultant or a member of the consultant s team. Processes must also be in place to ensure that, where a patient has not been offered a choice and notifies the primary care trust that the person making their referral did not offer them a choice, they are then offered a choice of provider. Services currently exempt from Choice are: accident and emergency services cancer services or services provided at rapid access chest pain clinics which are subject to the 2 week maximum waiting time maternity services mental health services or any other services where it is necessary to provide urgent care Page 7 of 14

Patients to whom the duty does not apply are those: detained under the Mental Health Act 1983(c) detained in or on temporary release from prison or serving as a member of the armed forces. 5.2 Where do we need to be? During 2012/13 a referral gateway is being introduced across West Lancashire CCG, supported by the implementation of an Integrated Care Gateway software solution which is expected to be rolled out by mid October 2012. The software will enable GPs to make referrals through a central point and will support the triage of referrals, where appropriate. Following this, choice will be discussed with the patient by a member of staff at the Referral Management Centre (RMC) who will then book an appointment at the patients preferred provider. The software will enable a systematic approach to the discussion of choice and will ensure that all patients whose referral is sent through the central referral gateway have the same choice discussion. We will ensure that Referral Management Centre call scripts/processes are regularly reviewed to ensure that they enable staff to hold a full choice discussion with patients. 6. Choose & Book 6.1 Where are we now? Choose and Book is an e-booking software application introduced to enable patients needing an outpatient appointment to choose which hospital they are referred to by their GP and to book a convenient date and time for their appointment. To ensure that Choose and Book fulfils its role NHS Central Lancashire ensures that: The Information Management and Technology infrastructure is in place and functioning effectively to ensure e-booking compliance All relevant staff are in possession of and fully trained on the tools required to successfully deliver the Choice agenda, including staff within the Referral Management Centre As of May 2012, Choose and Book utilisation within NHS Central Lancashire was reported as 21% against a target of 90%. Following the cessation of the Choose and Book Local Enhanced Service (LES) in April 2010, which previously incentivised practices to use Choose and Book, many practices reverted back to sending manual referrals. Page 8 of 14

6.2 Where do we need to be? Through the implementation of the Integrated Care Gateway Software, as outlined under point 5.2, the Referral Management Centre will discuss choice and book an appointment at the patient s preferred provider. In order to do this, Referral Management Centre staff will add all referrals sent through the gateway to Choose and Book to facilitate the choice discussion and appointment booking. It is expected that Choose and Book utilisation will therefore increase. We will work closely with our local providers to ensure that all services are directly bookable, including 2 week rule (urgent), Rapid Access and Antenatal referrals. 7. Referral Management Centre 7.1 Where are we now? It is currently GPs responsibility to discuss Choice with patients and offer a range of appropriate providers for their treatment unless there is a Tier 2 based service in place for the specialty. In this instance, GPs refer their patients through the Referral Management Centre to facilitate clinical triage following which Referral Management Centre staff offer the patient choice following assessment. 7.2 Where do we need to be? As outlined under 5.2 and 6.2 above, the Referral Management Centre will manage all referrals sent via the referral gateway, will discuss choice options with patients and negotiate an appointment at a time and date of their choice. The staff at the Referral Management Centre will be fully aware of all information available to them from both NHS Choices and local surveys and will be trained to discuss Choice without influencing the patient. 8. Choice of Maternity Services 8.1 Where are we now? Maternity Matters set out four national guarantees in order to improve choice which are: Choice in how to access to maternity care Choice of type of antenatal care Choice of place of birth Choice of postnatal care In line with the NHS Central Lancashire pledge that patients will be more involved in decisions about healthcare women and their partners are able to access midwifery services directly in order for them to enter the maternity care system in places and at times that suit them and at an earlier and more advantageous stage of their pregnancy. Patients can also access antenatal care via their GP who directly refers them either to secondary care or a midwife linked to the practice. Their antenatal care takes place within their General Practice unless, clinically, the patient requires consultant led care. Page 9 of 14

Choice awareness around place of birth is reliant on discussion between the patient and their GP, midwife or consultant. Post-natal care is provided by midwives via home visits but patients can also choose to make an appointment at their local children s centre or health centre. Support workers are available to provide breastfeeding support or provide advice regarding any specific problems. 8.2 Where do we need to be? The aspiration is that more targeted interventions for vulnerable groups should be in place involving wider communication and more joined up, universal service provision. 9. Mental Health 9.1 Where are we now? Within Central Lancashire, Primary Care Mental health services are in the process of being tendered and the future provider will be in place by November 2012. The specification provides a single point of access to all mental health services across all CCG areas. Currently, following assessment of the referral, patients are contacted and offered a suitable appointment at a clinic local to them. If a patient specifically requests not to attend a local clinic they are offered a choice of clinics across Central Lancashire, however this choice is only offered if patients request it. Advocacy and support services can help service users exercise choice and are available in Central Lancashire. In addition, service users are active participants in all service developments. It is generally agreed that service users have limited choices at present about their mental health care and lifestyle. 9.2 Where do we need to be? Good information is crucial if choices are to be meaningful, along with support for people to help them make often complex choices. With the help of professionals and advocates, people with mental health needs should be able to access good quality information not only about their health care but about all aspects of their lives, such as housing and employment. This information is essential if mental health service users are genuinely to be placed at the centre of a Patient-led NHS, as the government intends. To ensure choice becomes a reality for all client groups, issues of inequality, which affect some groups such as people from minority ethnic groups and those with learning and communication difficulties will need to be addressed. NHS West Lancashire CCG is committed to implementing choice in mental health in line with national guidelines. Page 10 of 14

10. Community Services 10.1 Where are we now? NHS West Lancashire CCG recognises that there is no reason why Choice should only be applicable to consultant-led appointments with secondary care providers. There should be a wider choice across all community based clinics. Guidance entitled Operational Guidance to the NHS, Extending Patient Choice of Provider (Department of Health, July 2011) outlines that PCT clusters, supported by pathfinder clinical commissioning groups, should undertake a phased implementation of patient choice of Any Qualified Provider, treating 2012/13 as a transitional year, starting with a limited set of community and mental health services. The priority areas have been identified as Ophthalmology, Minor Oral Surgery and Adult Hearing Services in the community. This work is in progress. The former NHS Central Lancashire Provider Arm redesigned the referral pathway for the Podiatry and Musculoskeletal services to ensure that patients are seen by the most appropriate clinician at a time and place of their choice by using the Referral Management Centre as a central referral point and triaging all referrals. Following triage, patients are offered a choice of clinic site within Central Lancashire. This often enables patients who are willing to travel access to an earlier appointment. There is also flexibility in the system for the patient to change sites if they prefer their follow up appointment closer to home. The above services are available via Choose and Book. 10.2 Where do we need to be? As further service re-design takes place or new community services are developed, NHS West Lancashire CCG will ensure that, via the booking process, patients have access to a choice of clinic sites and providers appropriate to their condition. Where possible, these choices will be available on Choose and Book. NHS West Lancashire CCG will work with providers to ensure that all closer to home health services are patient-focused and as it is not currently obligatory for community services to offer choice, importance will be placed on engaging stakeholders and patients in the service development process. Commissioning leads will be required to demonstrate that this has taken place prior to business case approval. Where it is apparent that patients have limited choice in treatment types and/or providers we will look at existing service models and, with the results of Health Market Analysis, evaluate the options around expanding/developing existing services, reviewing service models and redesigning services or commissioning alternative providers to provide additional capacity or choice. Page 11 of 14

11. Long Term Conditions 11.1 Where are we now? As part of the development of the Integrated Care Organisation (ICO) work is continuing to ensure that patients are more involved in their care and are able to access services closer to home. Ongoing development of services linked to long term conditions ensures that this can happen. Information regarding these services will be available from GPs and on Choose and Book. Care, support and advice is also available from the patient s community matron. For patients choosing self care/self management options, condition-specific information is available via NHS Choices. 11.2 Where do we need to be? Plans are in place to develop integrated care teams to manage the needs of all patients with long term conditions. A work programme is in place for the development of these teams during 2013/14. 12. End of Life Care 12.1 Where are we now? Patients can currently choose their preferred place of care and this may be at home, in hospital or at a hospice. A hospice at home pilot is currently being carried out and an innovation bid has been submitted to support its development. Information regarding End of Life Care and patient choices is available from a range of professionals including GPs, district nurses, hospital staff and a range of other staff based in hospices. An education programme is currently being delivered aimed at staff within care homes that supports people in their choice of preferred place at end stages of life. Clinical Nurse Specialist services based at Queenscourt Hospice have been expanded over seven days a week and bank holiday coverage to support preferred priorities of care (PPC). A pilot project is currently being developed within Central Lancashire aimed at addressing the difficulties for those in Amber Phase (last three months of life) where funding between health and social care can be better streamlined reducing duplication of assessments and improving choices at end of life. It is anticipated that the learning gained from this pilot will be expanded out to a wider footprint. Page 12 of 14

12.2 Where do we need to be? While patients do have access to a range of end of life care options and information an audit of all national end of life/palliative care tools is currently taking place, including the Gold Standards Framework, Preferred Priorities of Care and Liverpool Care Pathway, to identify in which care settings the tools are and are not currently being used. NHS West Lancashire CCG will ensure that following this audit any areas where the tools are not being fully used will be addressed. Plans have been approved through the CCG Executive and End of Life Care Strategy Group to undertake a whole system review of end of life care and associated service functions (CVD, Respiratory, Renal & Dementia) with a view to developing a joint commissioning strategy and action plan (with Lancashire County Council commissioners) to re-shape end of life care services to provide improved care for patients and their families and carers at this crucial stage of their lives. The timescale for this to be completed is end of March 2013. 13. Communications Patient Awareness of their right to Choice According to The Primary Care Trusts (Choice of Secondary Care Provider) Directions 2009 NHS Central Lancashire has a duty to do the following: Publicise and promote availability of choice of secondary care provider Publicise and promote information about choice of secondary care provider Publicise the complaints procedure (see 4.4.1) A patient information leaflet was developed informing patients of the national and local tools available to assist them with making an informed Choice and this was distributed widely during 2010. Patients are also signposted to the NHS Choices and Choose and Book websites from the NHS Central Lancashire website. 14. Using Health Market Analysis CCGs will use the results of Health Market Analysis to understand whether there is a need to expand existing services and/or develop the market for other services to ensure patients are provided with sufficient choice options. CCGs will provide feedback to GPs and other health professionals, via regular reports, on the outcome of Health Market Analysis to keep them informed regarding the quality of the services provided. 15. Monitoring Patient Choice GP referrals and the choices patients are making will be monitored regularly and this information will be used to inform future commissioning intentions. Page 13 of 14

16. Summary CCGs should ensure that they fulfil their duties in relation to the NHS Constitution, in particular to ensure that: a. Patients are able to exercise their right to make choices about their NHS care b. Patients are able to access information to support their choices c. Patients are made fully aware of the complaints procedure should Choice not be offered or publicised, as outlined in the NHS Constitution While CCG responsibilities currently only relate to secondary care choice, we will ensure that patients are provided with as many choices as possible for their total care pathway. We will also ensure that future contracting decisions are reflective of current guidance in relation to Any Qualified Provider (AQP) and the recently published guidance Code of Conduct: Managing Conflicts of Interest Where GP Practices are Potential Providers of CCG-Commissioned Services (NHS Commissioning Board, July 2012) noting that in general commissioning through competitive tender or AQP will introduce greater transparency and help reduce the scope for conflicts of interest. Where choices are limited NHS West Lancashire CCG will, using patient feedback and the results of health market analysis, expand existing services and/or develop the market for other services. 17. Links to Key Documents This strategy has links with the following key documents/guidance: 1) NHS Constitution (January 2009) 2) The Primary Care Trusts (Choice of Secondary Care Provider) Directions 2009 (January 2009) 3) Introduction of Free Choice at Referral, Important changes affecting Providers (Department of Health, March 2008) 4) Equity and Excellence: Liberating the NHS (Department of Health, July 2010) 5) Operational Guidance to the NHS, Extending Patient Choice of Provider (Department of Health, July 2011) 6) Real Involvement, working with people to improve health services (October 2008) 7) Operating Framework for the NHS in England 2012/13 8) Choice at Referral Supporting Information for 2008/09 (March 2008) 9) Maternity Matters (April 2007) 10) End of Life Care Strategy (July 2008) 11) Code of Conduct: Managing Conflicts of Interest Where GP Practices are Potential Providers of CCG-Commissioned Services (July 2012) Page 14 of 14