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Working it out in Woking

Working it out in Woking
23 July 2011

Dr Nicholas Lance
GP Partner and PIMS Medical Director

The NHS as a whole faces a momentous task to balance the books. It has to deliver a sustainable healthcare system while continuing to put the patient first and improve quality of care, a concept that is becoming increasingly difficult in today's economic climate.

Dr Nicholas Lance
GP Partner and PIMS Medical Director

The NHS as a whole faces a momentous task to balance the books. It has to deliver a sustainable healthcare system while continuing to put the patient first and improve quality of care, a concept that is becoming increasingly difficult in today's economic climate.

The NHS as a whole faces a momentous task to balance the books. It has to deliver a sustainable healthcare system while continuing to put the patient first and improve quality of care, a concept that is becoming increasingly difficult in today's economic climate.

GPs in Woking decided to develop a model to reduce the financial burden and improve patient care, a seemingly impossible task. Managing demand on the health service was a key consideration and funding was sought through the demand management incentive scheme, whereby money could be transferred to practices and commissioning groups.

All the practices in Woking then grouped together to create a limited company called Primary care Integrated Medical Services (PIMS). GPs and practice staff were offered shares at two financial levels so as to make purchasing them available to all members of the primary healthcare team. Level A shares were £500 and level B shares were £100. At this level of value each shareholder would have only a small interest in the company, similar to an employee share-ownership scheme. The total population covered by PIMS is now about 125,000. 

The company's first project was to develop a pilot referral management gateway. This initially required triage training for interested GPs within the group and database functions that were designed to create services within the community setting to deliver best value for patients and the taxpayer.

A simple referral management pathway would add costs to an already overstretched system, but PIMS would manage the referrals and ultimately develop community services at a cost that would enable the funding of the pathway to be achieved without added cost to the primary care trust (PCT). Any further savings that could be generated would be used to improve existing services or develop new ones.

All referrals from the practices to secondary care are directed to PIMS and a team of triage GPs work in pairs on a sessional basis, with two doctors working every weekday morning. This helps to ensure transparency and eliminate conflict of interest as the GPs discuss the referrals. Auditable checks can be made to ensure the referrals into the community clinics are appropriate, at the expected activity and not in the interest of the triaging GP.

The triage ensures that the GP intervenes on each referral to check that it is appropriate and complete. If an alternative pathway is thought to be more appropriate then the referring GP is contacted and the patient redirected accordingly. To date the system has worked relatively smoothly and the GPs have accepted this rerouting after discussion as to the reasons why a different service might be more suitable. This process happens before contact with the patient to offer an appointment.

Protocols for each specialty were developed with secondary care input to determine which investigations are necessary for each condition. Referrals that have incomplete work-up are again returned to the referring GP. Sometimes simple investigations have been completed but are not attached to the referral; at other times X-rays or other tests might not have been done, and these are then arranged before appointments are made.

The database also provides supporting information to establish how patients might best be served through community clinics, rather than reliance on secondary care, if their conditions could be managed outside the hospital setting. The database is not designed as a tool to report on the performance of each triage decision but is aimed at generating relevant information to ascertain how many clinics would be required to deal with cases suitable for the community.

Having operated the gateway for a few months, specialities were identified that could support community clinics. The triage doctors had commented on the referrals as to whether each case could or could not be suitable for these new clinics. The activity data analysed showed that 46% of referrals would be suitable. Business cases were then submitted to the PCT and eventually agreed after some discussion. The first wave of clinics that were agreed with the PCT were dermatology, ENT, gynaecology, ophthalmology and orthopaedics.

The basis of the clinics is to have local consultants to lead, working closely with GPs with a Special Interest (GPwSIs). The clinics were to be hosted by local surgeries and the Woking Community Hospital. The nearby hospital trust was then approached and consultants were seconded to these clinics. Contracts were negotiated and agreed.

Once the numbers of patients suitable for community clinics were identified, it was possible to determine achievable savings. This was assuming that the clinics are run at a considerable cost saving when compared with the tarriff charged for activity in secondary care.

Once the full volume of identified episodes are treated in the community as proposed in the business cases, savings to the health economy will be £295,000 per annum, inclusive of all the gateway overhead costs.

There are also savings made from referrals that are returned to primary care and in the first 10 months there were 602 out of a total of 11,908. Thirty-six of these re-entered the system within four weeks of the original referral date but this still resulted in an extra £35,200 of savings, bearing in mind the cost of initial consultation and follow-up with resultant investigations in a hospital secondary care outpatient clinic.

The key purpose of the gateway pilot was to establish a gateway clinical triaging service and associated community clinics for the population of Woking so that the way referrals are dealt with is made more efficient.

There is still patient choice at the point of referral and these referrals can be easily tracked through a booked referral system. It eliminate areas of waste, particularly where non-added value episodes exist, and provides a better provision of service closer to the patient's environment. This in turn frees up hospital waiting lists. PIMS provides services based on an integrated, clinically driven contracting process, which maintains a high-quality patient service.

The PCT has further business cases submitted by PIMS for paediatrics, gastroenterology and cardiology community clinics, and these have still to be finalised. Once this process has been completed further clinics can be set up to enable the savings to be fully realised.

Non-financial benefits must also be considered. The company has been developed by a total of 15 practices, all with unanimous support for the pilot, and has been recognised by surrounding practices as a model for the future.

This has enabled the practices to work together to modify referral patterns to create a background reduction in the number of referrals entering the system and develop existing skills within the area to provide community clinics.

Where referrals could be dealt with at practice level, these have been returned to the referring GP. This has been a learning curve for all concerned, and the number of rejections has reduced as time has gone on. The community clinics have meant that consultants have been brought into the community setting and created a limited number of GPwSI clinics per week.

It has created an effective tool for demand management at practice level and a system by which the figures supplied by the trust can be accurately challenged if necessary to reconcile data that would have been much more difficult in the past.

Other benefits that have emerged include the development and distribution of protocols to reduce new and follow-up activity and enable more efficient use of existing services. PIMS produces a newsletter to inform and educate GPs within the group and has supported the career developments and skill enhancement of personnel. This has been especially the case in enabling GpwSIs to work in the clinics and achieve accreditation. It has also developed pathways and protocols where the gateway has identified gaps in the understanding at GP level, for example the development of an arrhythmia pathway.

GPs and staff working in the service have reported high levels of satisfaction and feel that the gateway is proving to be an effective and useful tool in managing referrals efficiently and safely. It was seen by some at the start as if their work was being scrutinised, however the triage team worked hard to gain their confidence and PIMS is now seen as supporting and directing in making sure that the patient is referred to the most appropriate provider. Patients seen in the community clinics have been impressed in that they are seen by a consultant in a place convenient to them outside a hospital setting – parking is also a lot easier!

The GPs in Woking see PIMS as a model that improves the quality of patient care at a reduced cost to the health economy. By working together on this pilot they have found that these objectives are achievable, but we need the full co-operation of the PCTs and the local hospital trusts. If this occurs then models such as PIMS should help to ensure a sustainable NHS for the future.

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