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At the heart of general practice since 1960

Benefits of a GP PBC Co-Op

Dr Charles Alessi explains how a pioneering PBC co-operative in his area has got both GPs and the PCT on a mission to make PBC work

Dr Charles Alessi explains how a pioneering PBC co-operative in his area has got both GPs and the PCT on a mission to make PBC work

Our organisation is about ensuring GPs grasp the opportunities that PBC offers.

We are a not-for-profit limited company funded by the DES and LES money from our 27 constituent practices and have an sPMS contract with our PCT.

The individual practices in our co-op retain control and autonomy of their practice budgets.

We are the overseers of PBC, if you like. We educate and support practices, we manage PBC data collection tools and we manage referrals across the PCT including those made by consultant to consultants.

We came about because GPs understood the Department of Health wanted all GPs to be involved in PBC but realised that if practices didn't take on a PBC role the door would be open for another organisation to do it instead. The alternative organisation could be another GP practice, an NHS organisation, private company or the PCT.

We felt strongly that GPs should be the ones making the commissioning decisions.

Kingston Co-operative Initiative, the name of our organisation, represents 170,000 patients and 100 GPs.

It has two medical directors, seven other board members, an office manager, 27 council members representing each of the 27 practices, and a significant back-room staff to enable us to function.

There are fortnightly board meetings, and quarterly council meetings. I will now look in more detail at some of the functions we perform.

GP education and support

Kingston Education and Support Services (KESS) is a branch of our work that involves assisting practices in the formulation of their PBC plans. We run dedicated training days on PBC. We also represents practices' views and intentions to the PCT and in turn feed back PCT commissioning information to practices.

We also assist the PCT in the audit of activity signalled by secondary care providers to ensure activity generated and presented for settlement via payment by results is properly validated.

Our aim is not to supplant the practice in matters related to PBC but to augment, refine and translate.

We do not performance-manage GPs as we see that as a role for the PCT. However,

if practices want us to, we can support them in the process of performance management and assist in implementing any changes they need to make as a result of being performance-managed.

Gp-led referral management

Kingston Clinical Assessment Service (KCAS) is a central system that collects and processes referrals from the GP practices before they go through the normal Choose and Book system. Exceptions include the two-week cancer rule and rapid access chest pain clinics. We electronically assess the referral for quality and the KCAS doctor decides the most appropriate next step in the patient's care. We then direct the referral to the appropriate department and it is only then that it is passed on to Kingston Choose and Book service for processing with the patient who is contacted to discuss their choice of service and to finalise the appointment.

We are not a demand management service but a support service to practices for the process of referral and we ensure local GPSI services are used where possible.

This triage process is turned around within 48 hours and the service is manned by a rota of contracted GPs.

PRODIGY has been the basis for the triage protocols but these have been adapted to suit local needs.

The service also oversees hospital referrals in the following ways:

• all consultant-to-consultant referrals require KCAS approval

• all conversions from A&E to outpatients require KCAS approval

• all referrals from other health professionals – health visitors, therapists – have to go through KCAS.

We have put in place a well-defined appeal process, which can be triggered by either a patient or professional. To date we have seen a 10% reduction in GP referral activity. In total we have already saved at least £1m by weeding out about 15% of the total number of referrals to secondary care.

Some of the themes on referrals that have emerged are summarised at the bottom of this article.

Keeping it individual

GP-led referral management schemes are now common throughout England and Wales. I believe they are a useful transitional step in the journey around practice-based commissioning. As they mature, more practices will take fuller responsibility for managing referrals within their PBC unit.

A management system is only as good as the individuals managing the process and relies on the practices co-operating within the process. It should not tell GPs what to do, but assist and facilitate referrals, often signposting alternatives to treatment the originating practitioner was not aware of.

Care and sensitivity in managing colleagues' referrals is an essential prerequisite and some recent PCT-imposed models, whereby the assessment is performed by individuals who lack a clinical background, could be extremely dangerous for the PCT in terms of litigation, to the practitioner and to the patient in terms of safety.

The budget belongs to the practices and the referral management system is only there to help and assist. Thus the process of referral needs to remain and be strengthened at practice level.

The next steps

A further aim of the co-operative is to develop provider services in the community under our Kingston Provider and Treatment Service (KPTS) branch. This will be an ideal vehicle to provide the infrastructure for some out-of-hospital services.

All GPSI services currently provided by the PCT – covering dermatology, vasectomy, headache clinic, musculoskeletal care and minor surgery – could be folded into KPTS.

A diabetes service is also being developed in conjunction with Kingston Hospital and the PCT and the potential for an anticoagulant service is being explored.

Dr Charles Alessi is a GP in Kingston, Surrey, and medical director of Kingston Co-operative Initiative

60 second summary

Initiative Not-for-profit limited company overseeing PBC on behalf of 27 practices (100 GPs). Runs an education and support service and a GP-led referral management scheme. Also developing a service provider arm.

Contract Funded by DES and LES money from constituent practices, working under an sPMS contract with the PCT.

Policy link Enables PBC to become a reality because clinical control retained over referral process. 18-week referral-to-treatment target.

Staffing Two medical directors and one office manager plus sessional part-time staff to effect referral bookings (about 15 hours

a day). Supported by board and council, which has a representative from each practice.

Outcomes 15% reduction in secondary care referrals.

Savings £1m.


Spotlight on GP referrals

The mainstay of managing elective activity is by managing GP referrals. They are, after all, the first in a series of steps that patients go through to receive secondary care.

A typical referral would involve a first consultation in outpatients followed by

an indeterminate number of follow-up appointments and in some cases inpatient and/or operative interventions and further follow-up. The implications of making a first referral can therefore be considerable both to the patient and to the budget of the practice-based commissioner.

GPs refer patients for a variety of reasons and managing this process starts individually at the consultation.

As a GP working on the KCAS team and now having looked at thousands of referrals, I have found that the number of referrals made by locums and registrars is totally out of proportion to their number. Locums inevitably do not know patients as well as their regular doctors and registrars manage risk (the mainstay of general practice) in a different way from the established practitioner. A referral to an outpatient department is an easy way to assuage patient request, close a consultation, maintain a relationship with a patient that is not known to you, maintain your popularity among patients and so on.

For GPs who want to start to challenge their individual referral patterns, the following three questions are useful.

1. Why am I really making this referral?

Is it because you are unsure of how to proceed? In which case, have you considered asking one of your colleagues within

the practice how they manage this presentation? Referral rates between GPs, even GPs within the same practice, vary enormously and all too often practitioners practise in isolation although they nominally form part of a practice or partnership.

2. Is it because I am being influenced by patient demand to get the condition ‘treated'?

Again, consider sharing this with colleagues prior to making a final decision to refer. Different referrers have developed different ways of managing patient expectations

and some seem to be able to manage expectations far better than others, without the need for an outpatient referral. If you are in a group practice, consider an interpractice referral to the practitioner that seems

to have the most success in managing expectations. Again there are approaches that can be adopted to manage this aspect of care better.

3. Is it because I am not really quite sure how to proceed in the management of an ongoing medical condition?

Have you ever thought of asking all other doctors within the practice (and colleagues outside) how they manage a particular presentation? You would be surprised by the number of times alternative pathways or forms of treatment to outpatient request become apparent after discussion.

we have already saved £1m by weeding out about 15% of referrals to secondary care we have already saved £1m by weeding out about 15% of referrals to secondary care we have already saved £1m by weeding out about 15% of referrals to secondary care

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