Thoughts and opinion from the wards
GP Commissioning - Quick wins and tips
There are huge financial pressures facing the NHS and many PCT have large deficits as GP commissioning bodies evolve. In order to be a successful commissioner you need to start with healthy finances.
In City and Hackney, through its GP commissioning arm, ELIC (a social enterprise set up in 2006 covering 30 practices and 220,000 population) there has been an emphasis on using practice based commissioning to influence clinical behaviours. The focus has been on reducing activity in secondary care but doing this in collaboration with secondary care clinicians.
Through our work in City and Hackney for 2010-201, there was a 4% reduction in secondary care referrals (PCT average for England and Wales was a 16-25% increase) and a £2.1 million reduction in spending on outpatient services. These savings have been achieved by the following strategies:
1. Reducing referrals by creating joint clinical pathways and advice services with secondary care.
High referring specialties such as gynaecology were identified. Practices audited referrals and presented their findings at educational support meetings. Clinical pathways were developed jointly with secondary care colleagues on menorrhagia, infertility and polycystic ovarian syndrome. These pathways give GPs confidence in managing more patients in the community and only referring, if all evidence based management and treatment options have been tried. Furthermore when a GP does refer, the appropriate work up has been done.
There are 17 clinical pathways and 10 in development. There are 16 consultant telephone advice services (including cardiology, neurology and paediatrics) set up with our local provider, the Homerton hospital. These advice services also reduce referrals by offering an alternative to an outpatient visit and support GP management.
We are now comparing practice referral rates for specialties, looking for variation, but recognising a need to understand reasons for outliers, both the low and high referrers. Practices who are high referrers have been invited to buddy with those who are low referrers in that specialty and see what can be learned.Practices are also encouraged to review referrals, particularly those made by trainees and locums and to use the clinical skills and knowledge within their practice as an alternative to a hospital referral where possible.
2. Reducing emergency admissions
Audits of recurrent emergency admissions were carried out with meetings to explore whether any of these admissions could have been avoided.In our GP consortia groups, we met with our community geriatrician who had also audited the cases. She identified a vulnerable patient living alone, who lacked mental capacity which had been missed. GPs shared innovative strategies for supporting certain challenging patients. One 80 year old man with a history of ischaemic heart disease and anxiety, frequently phones the ambulance and out of hours services. A management strategy has been put in place to support him and his A and E attendances and admissions have reduced by 50% over the past year.We have identified the need for a special emergency response for patients with sickle cell disease. Our community geriatrician is contactable by phone during working hours for support in avoiding admissions. There is a first response team and community matrons. Practices are allocating vulnerable patients to named GPs, recognising that multiple admissions in frail elderly patients with multiple co morbidity is often a prognostic indicator for end of life care. Improving communication between primary and secondary care so that clinical information is shared, is crucial for admission avoidance. Our hospital has agreed to fax same day discharge summary information. GPs have agreed to provide timely medical information for those patients in A and E.
3. Reducing outpatient activity
Over the past 12 months we have undertaken 15 audits where a GP and consultant have reviewed outpatient follow ups to identify barriers to patient discharge and used these to develop discharge arrangements and new pathways
4. Reducing A and E attendances
Multiple attenders have been flagged at a practice level. In inner city areas, proximity to A and E encourages attendances. In Tower Hamlets, two GP’s stream all walk in A and E patients and are able to triage 50% of patients away. Many patients are simply confused about where to go out of hours, so there is a need to educate patients about appropriate use of services. There are plans for A and E consultant outreach and alcohol support services. These initiatives are quick wins, save money and improve quality of care.
Dr Kate Adams is a GP in Hackney