Clinical thresholds are one of the tools being use across the country to help transform the approach to care. Often patients are offered pathways that encourage self-care or alternative approaches before further intervention (e.g. surgery) is required.
Clinical threshold policies are evidence-based pathways which are applied to commissioning contracts with providers. The policies are formalised through sign off from CCG governing bodies.
Many of these policies started originally at individual PCT and subsequently CCG level; current development has been at STP, regional and National level for greater impact and reduced variation for the patients involved. Monitoring compliance and the developing of new policies is time consuming and challenging to implement.
Here we explore the challenges and opportunities of clinical thresholds.
What are clinical thresholds?
There are commonly three types of threshold:
Those procedures which may be offered on a routine basis but only for patients who meet defined criteria agreed in a clinical protocol, e.g. cataract surgery. The responsibility for adherence to these policies lies with the referring and accepting clinicians and prior approval is sought from the CCG where this is part of the contracting arrangements.
Those procedures which are not routinely provided by the CCG and where provision is only possible on an individual patient basis. For these procedures, the criteria listed form guidance to referring clinicians and the CCG commissioner. In instances in which eligibility is unclear the final decision is made through the application of an Exceptional Cases process.
Exceptional Clinical Circumstances
These are procedures which are only funded in exceptional circumstances. Applications for these procedures should be made to an Exceptional Case Team [IFR team] and is only made where the patient demonstrates this criteria.
How are clinical thresholds documented?
Clinical thresholds policies have various names and scope across England e.g. Procedures of Low Clinical Value (PolCV), Clinical Priorities Policy, and Commissioning Policy.
What is the Attain approach to clinical thresholds opportunities?
Naturally, we tailor to fit a customer’s needs, but the underlying principles are:
understand monitoring and compliance with existing policy
benchmarking to ascertain initial list of opportunities
engage with Public Health and GP leads re: clinical evidence and practicality of initial list
sense check and engage with providers
consider activity and financial impact
when change is possible engage with relevant patient and public groups
work with commissioners on monitoring arrangements and embedding into contracts
What are the challenges of reviewing and identifying new clinical thresholds?
The volume of activity captured via coding does not necessarily reflect compliance. Compliance is often reviewed by retrospective challenge and/or small sample clinical audit which uses GP, provider clinician and associated commissioning and provider management time to carry out and agree output.
What are the challenges introducing new clinical threshold policies?
Clinical thresholds are perceived as some clinicians and the public as rationing of the care to save money, which can make buy-in difficult; however, the robust development is based on clinical evidence and clinically lead to demonstrate either no value of a procedure or the benefit of conservative treatment and informed patient discussion to potentially avoid an invasive procedure with its associated risks.
Even the best written policy will gather dust in a draw if there is no buy-in by the gatekeepers of the policy. The front line of the majority of pathways is a GP; therefore, ensuring existing communication and education processes are fit for purpose is vital for initial uptake.
What are the challenges to maintaining clinical threshold policies?
Ongoing adherence to the policy where no referral management or pathway guidance is mandated can result in slow initial uptake and sustaining compliance. Considerable effort is required to maintain and review policies on an annual basis to ensure they reflect current thinking.
Who Attain have worked with
Since 2015, we’ve worked with numerous CCGs and STPs on clinical threshold policies across England. We have supported these from standalone benchmarking to the full end to end process. We’ve also provided PMO development, implementation and monitoring for those that need additional support.
We are currently working with a STP refining lines of enquiry with a view to contributing to 19/20 contract rounds, considering national and previous pieces of regional work and providing system wide PMO leadership.
Nationally, NHS England is in process of building some clinical thresholds into the NHS Standard Contract 2019/20 with associated clarification on coding and monitoring arrangements to be defined.
The Healthy London Partnership has established the London Choose Wisely group. The group is aligning with the national work, but also has additional lines of enquiry for consideration.
It will be interesting to see how the impact of the national work will result in a focus on reactive referral management (review of referral) or application of wider pathway/ clinical decision making support systems (such as OSCAR –Online Support and Clinical Advise Resource and further central policy development.
Acknowledgement: Types of threshold- Extract from NEE CCG Clinical Priority Policy