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Having FUN with follow-ups

In the land of simpledom, curbing follow-up costs should be simple, but our diarist is in the real world

The story so far…..
Cumbrian GP Dr Peter Weaving has left his CCG to go and work for the local hospital trust as its GP clinical director.
Where once he preached to North Cumbria hospital colleagues about efficiency and doing more with less, now it’s his turn to
make the rhetoric a reality…


I was looking at my list of phone messages and visits, the usual postscript to morning surgery, when an unexpected item caught
my eye and provoked a variety of emotions:
‘Please phone Professor X at home.’ Was it a coincidence that the day before I had been speaking at the orthopaedic
clinical meeting about its role as breadwinner for the trust with its elective work? I had mentioned that, although I hugely respected the technical expertise
and clinical acumen of one senior member of their number, we had disagreed in a number of public fora over the years on the intricacies of health service finance, the simple fact of money following the patient at a set national rate based on activity, complexity and co-morbidity.
Now he did have a point in some areas - if there is a set national tariff that determines the payment flow, what is the role of the commissioner? Why didn’t we
cut out the middleman, save a shedload of admin costs and give the money directly to the trust? So, dear clinical commissioner, can you defend yourself and prove you add value to the process?
His other point, about commissioners deliberately starving the trust of funds while expecting increased activity, referred to the historic and generous subsidy the trust had received for as long as anyone could remember. This had been variously labelled over the years as ‘PFI support’, ‘winter pressures money’ or, as former Number 10 health policy adviser Professor Paul Corrigan put it, ‘an incentive and reward for inefficiency’.
One area he didn’t tackle us on was the punitive contracting clause about outpatient follow-up appointments and setting a payment cap for these triggered
by the fact our follow-up-to-new (FUN) ratio was at the 75th centile nationally (in other words to lower our FUN rate).
The rationale being that a trust clinician arranges the follow-up and this generates income for the trust in the same way that a consultant-to-consultant referral does.
There is an incentive for the trust to bring patients back.
This logically puts a commissioning incentive in the system to discharge patients back to their GP for ongoing management. However life is never that
simple in anything as complex as a health economy. Our target meant that between a third and half of current follow-ups should be considered as inappropriate. Now you will find, as I did, that some patients can be discharged safely and appropriately, but can we get anywhere near the target? No,
and I will explain why.
If your GPs and other referrers are for want of a better term, rubbish, then they will refer inappropriately and unnecessarily, leading to a higher number
of them being, guess what? Yes, discharged.
But our GPs aren’t rubbish; in fact, most are very good referrers. A better referral is likely to be more complex and need more sorting out and following up. If you add to the mix a DGH that is distant from tertiary centres, with physicians managing hairy-cell leukaemia and hepatitis C, and
prescribing biologicals for dermatology and rheumatology that might in other areas lead to tertiary referrals, you have a further confounder that will drive up your FUN.
I do get it, professor; whichever side I’m on, I’m in the wrong. Time to make that phone call.

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