Dr Oliver Bernath describes how a group of six practices managed to save a million pounds over a year through working more closely together.
In a tightening financial climate we all need to find ways to deliver our care more cost effectively and continue improving care standards.
To meet this challenge, six practices in Guildford with a combined list of 73,500 came together with the independent company Integrated Health Partners for a one year pilot to try and take control of our PBC budgets while also improving patient care. This is how we did it.
What we did
Instead of picking only one topic for the integrated care pilot, we went for a comprehensive programme that covered most care; only tertiary care, mental health and internal practice processes were left out to avoid overloading the programme.
We looked at improving the management of long-term conditions, end-of-life care and tackled rising GP referrals and prescribing costs.
We started by improving the adoption of GOLD standards framework for end-of-life care and identifying patients at greatest risk of needing an emergency admissions using the Combined Predictive Model.
We also discussed and planned better coordinated care in a multi-disciplinary meeting with the GP, community and social services.
Clinicians developed referral pathways that were standardised across all practices. All referrals were tracked, peer reviewed and referral rates were benchmarked.
We designed and implemented a one year medicines management initiative focussing on ensure medicines are taken appropriately and using more cost effective medications where clinically appropriate
A key element of the initiative was to bring together engaged clinicians to openly discuss their prescribing habits in a ‘safe environment'. These discussions were facilitated by IHP providing real-time data analysis highlighting prescribing trends and differences.
How we resourced it
NHS Surrey provided funding to free up time for GPs, practice staff and others. In return, all savings went back to the PCT, rather than being split according to PBC rules.
In addition, each practice nominated one GP lead and each workstream was lead by a GP or Practice Manager. IHP provided the project and data management with monthly performance meetings at each practice.
A dedicated patient participation group was created to provide patient input to the pilot.
Our results
From January to December 2009 the pilot generated £1.7 million in savings at a cost of £700,000.
Practices shared best practice and joint efforts to improve care and efficiency and working relationships with the local hospital improved significantly.
By achieving greater consistency in GP referral behaviour, we reduced unnecessary referrals and maximised use of out-of-hospital resources (see figure).
About 300 patient medication reviews took place in care homes and patient homes and we reduced our prescribing spend by 3% compared with the previous year. The rest of Surrey increased their prescribing spend by 1.1% over the same time period.
Emergency admissions grew by 2.8% in the observation period of Sept 09 – March 2010, versus Sept 08 – March 09, compared with 6.3% growth for non-pilot practices.
More strikingly, however, was a reduction in medical emergency admission bed-days (same observation period) of 7.8% of the pilot group, versus an increase in 0.3% for our peer group
We doubled the number of patients on the Gold Standards Framework and increased the number of patients who died in their preferred place from 50% to 55%.
Overall, patient feedback was very positive as patients perceived the services as more responsive and more joined up.
The future
We are exploring the details of a joint budget arrangement between practices and hospitals and have started on joint development of more integrated care pathways.
Dr Oliver Bernath is managing director of Integrated Health Partners
