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Five-minute guide to clinical decision-making

The seventh of our eight-part guide on the basics of PBC, produced by Michelle Webster and Beverley Slater of the Improvement Foundation

The seventh of our eight-part guide on the basics of PBC, produced by Michelle Webster and Beverley Slater of the Improvement Foundation

Official definition

Practices and GPs undertake individual needs assessments, make referrals and advise patients on choices and treatments available to them. Each referral is effectively a micro-commissioning decision. See Health reform in England: Update and commissioning framework,

Put into layman's terms

Changing referral habits so that newly commissioned pathways are used.

What it involves

Aligning clinical judgement for a particular patient with the services that have been developed for the whole local population.

Important because…

Access to most commissioned services will be through a primary care referrer, usually the GP, who acts as gatekeeper to the service. Similarly, access to tertiary care services is through a secondary care referral decision.

Unless clinical referrers are willing to change their referral practices to take advantage of the redesigned pathways and services, there is a danger that all the commissioning cycle stages up to that point – including health needs assessment, service redesign and shaping the structure of supply –will achieve very little.

How to go about it

Involving clinicians in redesign of services is essential, and will ensure new services are understood and needed by those making referral decisions. Some PCTs use champions to lead clinical input in a designated area and lead engagement with their colleagues.

Once a service has been designed and commissioned, there are ways to help referrers adhere to these pathways:

• Clinical guidelines – national or local. These are most effective if not too complex, have strong local professional support and are well communicated.

• Well-maintained local web-based information that is user-friendly, containing details of alternatives and ‘pre-referral' work-up requirements for local pathways.

• Service pathways should be introduced with excellent communication to referrers.

• Peer review of referrals (retrospective or prospective) organised at practice level to ensure all partners use the most efficient pathways and make use of colleagues' special knowledge within the practice.

• Prior approval schemes or group patient directives for certain clinical conditions, to ensure secondary care clinicians manage a patient according to the commissioned pathway except in special circumstances.

• Blanket bans on consultant-to-consultant referrals (other than for emergencies) to ensure the GP's judgement determines access to other services within the hospital.

• Quality improvement initiatives can assess performance against criteria.

• Referral management centres – but only when they have good clinical support.

Background/relevant policy

World Class Commissioning competency 4 is to ‘collaborate with clinicians'. This covers all the benefits of clinicians making use of their service knowledge to influence effective commissioning in practice.

Pitfalls to avoid

• Introducing services without closing old services will mean efficiencies of the new system will not be realised.

• Failure to appreciate the difficulties of changing habits. There is always a need for lots of communication and support, preferably from a clinical opinion leader.

• Leaving clinical locums to find their own way around the system.

Michelle Webster is national commissioning lead and Beverley Slater is national knowledge management lead for the Improvement Foundation.

The deadline for applications for its third national advanced commissioning course 2009/10 is 22 May

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