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How an interface service can halve the costs of care

An interface service set up in Somerset has created a high-quality, cost-effective scenario for GPs, patients, surgeons and budget-holders, says Dr Donal Hynes

An interface service set up in Somerset has created a high-quality, cost-effective scenario for GPs, patients, surgeons and budget-holders, says Dr Donal Hynes

The concept of forcing a patient to attend on multiple occasions, at different times, to secure a health service, is a historical deficit from the time that the patient had to fit the service. Practice-based commissioning gives the opportunity to change things so that the service fits the patient.

Orthopaedics is one of the areas where patients have the longest wait to secure a treatment, partly caused by multiple outpatient visits and delays in investigation .In Somerset it was agreed that contracting these visits into a single session was in everyone's interest and would make sense financially.

Setting up the service

In setting up any service under the new commissioning paradigm, it is necessary first to outline the commissioning plan that describes the service that should be provided for the patient group, including defined clinical pathways and acceptable time intervals.

This must then be matched by a provider plan, outlining the provider's mechanism for meeting the commissioning plan, including processes and costs.

The commissioning plan

Although the service was formed prior to PBC, it used the same principles. The plan was to be developed between primary and secondary care so securing engagement of both groups was important.

GPs felt the system needed to be uncomplicated, consistent with current practice and responsive to their requirements. It had to fit the traditional model of referring patients into a single point of access and the patient would need to receive a comprehensive treatment service.

From the outset it was clear that the service should not be a ‘referral bounce service', under which GPs referrals judged as inappropriate are returned to the practice, nor was the concept of triaging referrals into multiple different services attractive.

An interface service – a multidisciplinary clinic where patients were seen, investigated and treated – was agreed. We identified a small number of practices and offered them the opportunity of using the service for all orthopaedic referrals for the relevant body area.

To initiate the service in a phased manner, it was agreed to initially limit the clinics to dealing with back, shoulder or knee pain. Back pain was considered appropriate as most patients should be managed without seeing a surgeon. Similarly shoulder pain could often be treated with accurate diagnosis and interventions such as corticosteroid infiltration before involving a surgeon.

Finally knee pain was considered appropriate as it crossed many diagnoses, frequently required complex investigations such as MRI scanning, and also gave the opportunity to explore issues surrounding direct surgical listing from the clinic.

A GPSI and an extended scope physiotherapist (ESP) worked with the orthopaedic department to agree pathways for the correct investigation and management of the most common problems in these areas. In effect, these pathways represented more of a building of trust between the surgeons and other clinicians.

These pathways constituted the commissioning plan and the PCT then took on the work of developing a provision plan. As the PBC agenda becomes more developed, the commissioning plan can be circulated for tender by different providers.

The provision plan

The PCT looked at the costs of setting up the service. It based its figures on the numbers of referrals to orthopaedics for these conditions in the previous year. This determined the number of clinics plus the estimated number of investigations, including MRI scans.

The clinics took place in the community hospital. MRI scans were purchased from a private provider as, at the time the service was set up, the radiology department felt their own waiting lists for the test precluded the interface services' specification that the scan be completed and reported within seven days of request.

The PCT's professional executive committee agreed to fund the service as a pilot on the understanding that should it be successful, its further rollout depended on identifying resources released from secondary care.

Implementation

The PCT used its own referral management service to direct every referral from the agreeing practice to the interface clinic, even if the referring doctors sometimes forgot! As there was commitment from the orthopaedic department to the scheme, they identified any errant patients who appeared within the hospital service and redirected them to the interface clinic.

The service was immediately identified as a success. GPs had a single point of referral; patients were being rapidly seen and treated with success; and orthopaedic surgeons were freed to concentrate on complex cases. In fact the difficulty arose in attempting to restrict the service to the pilot practices, as their neighbouring colleagues had patients complaining that they could not have accelerated access to treatments.

Current arrangement

The interface service now takes all orthopaedic referrals, with the exception of ‘red flag' emergency or post-operative complications. Patients who request a particular surgeon have that reflected in their choice of surgeon after the interface clinic has completed the agreed work-up of the patient to the point of listing.

There are approximately 65 clinics per year to serve a population of 100,000. ESPs lead the clinics, which are classified by major anatomical area: backs; shoulders; upper limbs including hands, knees and hips; and lower limbs, including feet.

This classification ensures that the appropriately skilled ESP is present at the relevant clinic. The patient is seen by the ESP or GPSI, who has full access to investigations and therapies including biomechanical assessment, orthotists and podiatrists.

Some of the clinics are held in premises that do not have instant access to X-ray. In these cases, the referral letter is looked at prior to appointment and the investigation requested before they attend clinic.

Cost

Set-up costs will vary according to local circumstances. Holding clinics in a community hospital obviates the need for rental and other costs, but the clinics do require their own administration and personnel.

Employment of GPSIs can be either through direct contract, direct payment to their practice, or through secondment. In the present service there is a mixture, with some being full-time and others who work across different organisations.

Provider costs: Current estimates are £112 per new patient seen and £56 per follow-up. This includes the set-up costs, investigations and all personnel and estates. Costs diminish by having a greater number of clinics supported by the same administration unit.

Commissioner savings: The service is clearly quicker and more patient friendly than the traditional service. It is also comparatively cost efficient. The average saving of sending 1,000 patients through this system is in the region of £584,000 (see box above).

Savings lie predominantly in two areas. The first is the low new-to-follow-up ratio. The structure of the interface clinic is such that there is an expectation that the management package offered to the patient will work. So, for example, a patient with knee pain who chooses a pain management programme will not be given a return appointment to monitor the success of the programme. If the patient requires further consultation they will do so through their GP, who then promptly gets them seen in the clinic, without waiting many weeks. This means that those who require follow-up are self-selecting based on their need.

The other saving is from the lower conversion rate to surgery. As the interface service has been running for more than seven years we have accumulated enough information to confirm that the clinic is not just ‘postponing' a patient's operation. The truth is that when a patient is given a broad range of choices (such as orthotics, pain control, joint injection and surgical procedure) they will often opt for a less-invasive treatment when they understand that they can have rapid access to surgery if they should need it in the future.

This prevents the common situation of a patient opting to go on the waiting list as insurance in case their condition further deteriorates in the future months. As we know from studies in osteoarthritis, the natural history of the condition is stabilisation following exacerbation rather than inevitable deterioration.

Conclusion

The service now covers the whole of the PCT in which it was originally conceived and is being extended further. It takes all orthopaedic referrals and provides access to operation listing for patients across a number of different provider trusts.

Apart from being clinically a success both with patients and clinicians, the interface service has proven to be a much more cost-effective way of providing a high-quality service to the population.

Dr Donal Hynes is a GP in Bridgwater, Somerset; interim chair of Somerset PCT's professional executive committee; and a founder member of the Primary Care Rheumatology Society


Lessons

• Engage all parties first

• Agree clinical pathways, mainly to build up trust

• Have a universal system rather than triaging or re-directing

• Count patient movement through the system

• Make it simple

• Demonstrate cost-efficiency to commissioners

Contact Dr Donal Hynes, email donmorhyn@aol.com

COST COMPARISON

Costs per 1,000 patients

Musculoskeletal interface service

First appointment at interface clinic 1,000 x £112

Plus

Follow-up appointments at interface clinic 500 x £56 £140,000

1st orthopaedic department appointment 133 x £144 £19,152

Follow-up orthopaedic appointment (1:2) 266 x £71 £18,886

2° care surgery 173 x £2300 £397,900

Total £575,938

Orthopaedic department

1st orthopaedic appointment 1000 x £144 £144,000

Follow-up appointment (1:2) 2000 x £71 £142,000

2° care surgery 380 x £2,300 £874,000

Total £1,160,000

Savings are made mostly from the low new-to-follow-up ratio and low conversion rate to surgery

60 second summary 60 second summary

Initiative The development of a musculoskeletal interface clinic, offering assessment, investigations, treatments, and direct surgery listings
Staffing GPs with special interests and extended scope physiotherapists on direct contracts or secondments
Results Patients gain rapid access and choice of treatments at local clinics; GPs have a single referral point and rapid feedback on cases; orthopaedic surgeons freed to concentrate on complex cases

Results

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