Taking the isolation out of referral decisions
As one of the most deprived areas of the country, referrals posed a real challenge for Corby CCG in Northamptonshire. Dr Peter Wilczynski explains how GPs joined forces to rise to the challenge
We are the smallest CCG in the country – and very proud to be – comprising six practices covering 67,000 patients.
Originally part of one of the largest commissioning organisations, when we decided to form an independent group we knew we had one of the most deprived populations in the country, with extremely high levels of morbidity and mortality.
We also have one of the fastest-growing populations, and figures show more than 13,000 of the 55,000 people living in Corby town are classified in the most deprived 20% nationally. Life expectancy in the most deprived wards is 10.3 years lower for men and 6.7 years lower for women, compared with those in the least deprived areas.
With high levels of smoking and alcohol abuse, a high number of our patients have heart disease, diabetes and COPD and as a direct result of this we had some of the highest referral rates in the county.
Because of our small size, we knew we would have to change our behaviour as GPs if we were to address how many patients were being sent to secondary care. As part of our QIPP agenda, each practice had an individual QIPP target. Improving the quality of referrals would be key to achieving this.
We had also agreed to move £1m
towards the new fair-share funding allocation level, something that could not be achieved without cutting the referrals budget. This has since changed and we will be funded on the basis of historic activity, but we had thrown down the gauntlet and believed we could make a large difference to our referral activity.
Referral management through an external team or process is expensive, and is not something we felt had been proven to be consistently effective despite being tried by many PCTs over the past decade. We wanted a long-term, sustainable solution.
Our practice-led approach
Our data showed that although we had one of the highest referral rates in the county, many patients did not end up having a procedure when they saw the specialist.
One of the practices in our CCG had trialled a process of ‘prospective review', which over a three-month period was shown to have a significant impact on reducing their referrals. In late 2010/early 2011, prospective review was gradually introduced across all six practices – although the approach each practice took varied depending on its size and circumstances.
One practice of 8,000 patients put in place a policy where all referrals, with the exception of urgent referral for suspected cancer and termination of pregnancy, were peer reviewed once a week.
Patients are advised during the consultation that a referral to a specialist might be necessary, but that the GP would like to discuss the best option for them with their colleagues and would contact them at the end of the week.
In this training practice of four partners, a couple of salaried doctors and GP registrars, there are about 40 to 50 referrals a week. Over a Friday lunchtime educational meeting – with food – the registrars each present a couple of referrals on a specific topic with the aim of increasing the level of understanding within the practice. Referrals are peer reviewed and a decision is made as to whether there is more that can be done within the practice, whether there is expertise that can be used elsewhere within primary care or whether the referral needs to go ahead.
If it is decided that the patient does not require a referral or that a referral should be delayed while further care is provided in primary care, the GP contacts the patient to explain the decision and care plan.
If the referral has been agreed, the secretary contacts the patient to go through the Choose and Book process and get the ball rolling.
For our largest practice of 45,000 patients that manages 700-800 referrals a month a different approach was needed, as it would be impossible to peer review 200 referrals in a weekly lunchtime meeting. Instead, each partner has been designated a disease area for monitoring.
Once a referral has been raised, an internal email is sent to the appropriate doctor asking them to review the clinical record and determine the next best options for that patient, which may be to be seen internally or it may indeed be a referral. This process must happen within two to three days.
These approaches ensure the referral is appropriate, enables GPs and registrars to learn from their colleagues, provides support for difficult decisions and makes better use of the expertise we already have within primary care.
In 2011/12, the number of referrals was cut by a quarter compared with the previous year – we are still maintaining that level.
Despite an increase in consultant-to-consultant referrals over that time period, this produced a cost saving for the CCG of £300,000 in the referrals budget.
We are funding this at a cost of £1 per patient per year, which has a return of £4 for every £1 spent – this is far cheaper than many referral management centres that have been set up to monitor GP referrals.
The three-month comparison between February to April 2011 and February to April 2012 on page 34 shows how this 25% reduction in referrals breaks down.
The huge drop in maxillo-facial referrals is likely to be a bit of an aberration because we have so few referrals to this speciality, but many of the others are related to better use of the expertise within primary care.
For example, urology referrals – which have been in decline since we started prospective review – have now fallen by more than half after using the experience of a local GP/urologist. We put in place a GP practice-based lower urinary tract service to see patients with frequency and dysuria (men with normal PSA) who require flow studies and ultrasound bladder scans.
Diabetes is another example of where we have made a large impact.
By commissioning a county-wide service with Nene Commissioning, we now have a diabetes-specific, community-based multidisciplinary team for patients who need more expert care than routine GP appointments can provide but who do not need to see a consultant.
Patient feedback shows they like having their case discussed by the practice team. They value that you care enough about their case to spend time discussing the best option for them with your colleagues and they don't want to spend several weeks waiting for an appointment when it is not appropriate and more can be done for them within primary care.
An important aspect is also the number of patients who save themselves the time and costs associated with a trip to hospital.
This approach is not about ‘rejecting' referrals, but about supporting GPs to make difficult decisions.
General practice can be a very lonely life, and having the support of your colleagues and being able to call on expertise within primary care is important to the quality of care we provide.
Through this approach, if the course of action is not to refer but manage the patient in general practice, if something goes wrong you can stand up and say: ‘We spent time talking about the best thing we could do for you and several of us agreed this was the path to take.'
The educational aspect of the prospective review approach is the most important factor in all of this.
Even in the practice where referrals are looked at by partners before a final decision is made, there is a weekly meeting to discuss those referrals where an alternative option was recommended, with registrars presenting the case.
We issue CPD certificates with these meetings, so instead of becoming a chore it is part of GPs' career development.
And although it may seem a trivial point, the practice that has had the greatest impact is the one that makes it a weekly educational meeting over a meal. The draw of a social element should not be underestimated.
The doctor-patient relationship is also important. You have to start by explaining to the patient that you have got as far as you can in helping them and it may be that a referral is worthwhile, but there may be other options you have not considered and you would like to discuss it with your team.
Patients know their GP cannot do everything, but they welcome their problems being taken seriously.
That is a big difference from having a third-party team determine whether the referral ticks the right box.
Of course, if a patient absolutely demands a referral after we have explained our decision, we will provide them with one – but that is a rare occurrence.
And the patient will probably learn a few months down the line that it was a waste of time.
I am often asked if this has been so successful in Corby because of our size – that maybe this is something only a small CCG can implement.
But I do not agree with that. Yes, it has perhaps helped that we are small and it may be easier to share learning between our six practices.
However, I think as long as it is done on a locality basis – that practices take ownership of it – it is replicable by any CCG in the country.
I believe that external forms of referral management are costly and doomed to fail, mainly because GPs and other practice staff have little opportunity to learn from the experience. This is purely about changing people's behaviour and having a discussion about the best option for a patient's care, whether that is primary or secondary care.
We have made great strides in cutting referrals, but the figures show there is much more we can do.
Even with prospective review, around 40% of patients seen by hospital consultants do not end up having a procedure.
One way we hope to improve these figures is by employing consultants to assist in the review process on a sessional basis for ophthalmology, ENT, gynaecology and trauma and orthopaedics.
We are in the process of putting a business case together, and options include GPs and consultants inviting the patient for a joint appointment or a phone call if more information is needed. By involving consultants in the peer-review process, it changes the way we use expertise within the hospital.
This could also help us to better select those cases where the patient might need an initial investigation that could be organised within primary care.
We have also decided to move to one IT system across all our practices, which will improve our ability to do GP-to-GP referrals.
Dr Peter Wilczynski is chair of Corby CCG in Northamptonshire
Referral peer-review processes developed by practices appropriate to their size. Smaller practices hold weekly meetings to discuss best options for patients, larger practices have a designated GP responsible for particular disease referrals that colleagues send referrals to. CPD certificates issued when meetings held to discuss referrals.
Each practice is given an individual QIPP target. Improving quality of referrals key to achieving this.
A 25% reduction in referrals in the first year, saving the CCG some £300,000. Now looking at how to introduce joint consultations with consultants to ensure best outcomes for patients.
Our GP referrals reduction (%)
Maxillo-facial surgery -133.3
Trauma and orthopaedics -54.2
Plastic surgery -47.1
Diabetic medicine -41.7
Breast surgery -19.0
General surgery -8.3
*Three-month comparison. February to April 2011 compared with February to April 2012