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Independents' Day

How we set up a consultant advice service

Paul Haigh, executive director of PBC social enterprise ELIC, explains how GPs now have easy access to a consultant in a number of specialties.

Paul Haigh, executive director of PBC social enterprise ELIC, explains how GPs now have easy access to a consultant in a number of specialties.

East London Integrated Care (ELIC), a social enterprise in London's City and Hackney, has seen a 17% reduction in new outpatient activity over the last two years.

Although the reasons behind this reduction are multifactorial, and it is hard to identify cause and effect, one of the factors is undoubtedly the consultant advice services we have established for GPs who need help with a patient, interpretation of diagnostic tests or help with development of a patient management plan.

Our approach to PBC has always involved a lot of work around pathways. ELIC has developed an extensive joint clinical leadership programme with Homerton Hospital, the local acute trust. We have always felt that if you put clinicians in a room together they will come up with some really good ideas. This approach resulted in a formal programme of 13 or so ‘pairings' of individual GPs and consultants to look at services and develop pathways. These meetings uncovered a real need for GPs to have access to a consultant.

41228552The pairings have developed in different ways, but most of them have resulted in new pathways for patient management and referral. Each new pathway has been launched with an education session where patient cases are presented to illustrate use of the new pathway.

The 34 practices covered by ELIC are using these pathways well and really seem to value them – the next step is to audit adherence to the pathways across primary and secondary care. We have already done some informal reviews that have resulted in targeted education support from the pairings to individual practices if they appear to be having difficulty in following the pathways.

Some consultants had already made themselves available to GPs in the past with ad-hoc arrangements, but we wanted to formalise the arrangements so all GPs could benefit and also recognise the consultants' time spent on this work.

When GPs follow a pathway they may get to a point where they are not sure about the next step. Previously this would almost inevitably have led to a referral, but we wondered whether there was an alternative. We discussed the idea for an advice service with the PCT commissioners who were very supportive and agreed to fund its development using new PCT growth money, while recognising that reductions in outpatient activity should occur. The first advice service was set up in October 2008.

Putting the service together

We did some research around relative outpatient referral rates to find the specialties with higher-than-average referral rates, and we talked to GPs about which areas they felt were priorities for improvement.

As it was a new idea, we asked each consultant to suggest the easiest way to make the service work from their end, so we have ended up with a wide range of ways

of getting advice (see box, left). This was necessary at the time in order to get the services up and running, but we would now like to make access arrangements more consistent – perhaps one common system and one point of access would make the service a lot easier for GPs to use.

41228555We are also trying to improve arrangements for GPs to get urgent consultant advice (say within 48 hours), particularly in relation to preventing admissions, and we have had some good discussions with the Homerton clinicians about the kind of service that could deliver this. We plan to develop this over the next couple of months as a joint service specification for the PCT commissioners.

To make the service work, consultants need a slightly different mindset from the one they are used to, so there was a bit of work to persuade them this was the way forward. Those in areas such as diabetes were more used to the idea of making themselves available to GPs for advice, whereas it was quite a new concept in specialties such as gynaecology and urology.

The clinical responsibility in the advice services remains with the GP. The advice the consultant gives is only as good as the information provided by the GP.

The next round of pairings discussions will show us what's working and what's not from the consultant's perspective and we are also gathering feedback from our practices.

The PCT was behind the idea of advice services, as was the acute trust. We have always had good clinical and managerial relationships with both of them and the trust management has been very good at getting the services up and running and doing any troubleshooting.

The advice services have come on stream at different times. The first one took the longest to set up – about two months. The others were quicker. It helped that most of the time we were working with the same manager at the acute trust.


The service is currently free for GPs to use. The PCT agreed to pay the hospital via a non-PbR block contract arrangement for each of the specialties rather than paying per piece of advice. The total cost of the nine different advice services is about £60,000 a year, mostly to cover the consultants' time. Set-up costs were covered by the growth money but were not great – just a few dedicated telephone or fax lines. No new staff needed to be employed.

The recurring cost is the consultant's time, which will continue to be funded provided we can demonstrate that it is good value for money.


It can take a while for all GPs in each practice to become aware of these sorts of services. We have publicised the services through educational sessions, by emails and putting details on our website, and we have taken every opportunity to remind GPs about them. On average it looks like each practice uses at least one of the different services about once a week.
We are now starting to look at what sort of value for money the services offer and how much they are used. All the services are being used, though some are used more than others – generally the medical specialties more than the surgical ones. And the two we have piloted with the mental health trust for drug and alcohol problems seem very popular. GPs are also valuing the new knowledge they are obtaining as a side-effect of the advice services.

Anecdotal feedback is that practices find it very useful to know there is a set time to have a discussion with a consultant. GPs do feel they are avoiding outpatient referrals by using the service.

Future plans

We believe more elderly patients could be looked after in the community if advice were more readily available to GPs and community matrons from a care-of-the-elderly consultant. This could have a large impact on emergency admissions. We feel it is important to have access to urgent advice alongside the more routine advice we already have in other specialties.

We have also commissioned some predominantly educational consultant outreach sessions where the hospital consultants visit GPs from a single practice or a group of practices.

These are aimed at helping GPs to work with the consultants to develop specific management plans for individual complex patients and we are piloting these in cardiology, diabetes, COPD, care of the elderly and A&E (focusing on frequent A&E attenders).

We pay the trust a set amount for the outreach sessions – between £5,000 and £7,000 per specialty depending on how many practices are involved.

I feel this type of service is the way of the future. This is one of the ways ELIC has been developing a ‘federated polyclinic' model locally by facilitating as much joined-up working between GPs and consultants as we possibly can.

Paul Haigh is executive director of PBC social enterprise East London Integrated Care

ELIC background 60-second summary The GP's view

Dr Clare Highton is a GP and chair of ELIC

Like most GPs, I have always found it useful to have consultants happy to give advice on particular clinical issues. The advice services we have set up are really just a way of formalising that and ensuring that the consultants get paid for doing it.
We have gone for the model of doctor-to-doctor conversations rather than something like a rapid-access heart failure clinic. I feel GPs should be able to do the basic tests and investigations as well as, if not better than, a specialist nurse – so why put in an extra step?

We are finding that the advice services are helping save unnecessary referrals. Taking cardiology as an example, previously if someone needed an echo or 24-hour tape we had to refer to outpatients. Now we have open access to those investigations so patients don't need to be referred, but quite often there are queries when interpreting the results and deciding what to do next, so it's useful to talk those over with the consultant.

Under the advice service we can send a fax to the consultant with the relevant investigations and the patient's clinical background and then have the conversation with the consultant about that patient. In practice, it runs quite smoothly and often circumvents the most common reasons for referring to cardiology, such as palpitations. I use this service on average once a fortnight.

Another way in which the advice sessions are helpful is that they allow me to tell a patient I have talked their case over with a consultant who agrees what I am doing is the correct management and would have nothing to add if they did see the patient.
Patients like to feel they are getting a high-quality convenient service – and though some do like to see a consultant many just want the fastest, easiest way so they are pleased to get that direct access.

You do have to respect that consultants are also seeing their own patients and I don't feel consultants would ever be willing to be totally on tap. We never have the case where I might ring up the consultant while the patient is with me. There are set times and ways of contacting the consultant – they wouldn't want to be interrupted.

Avoiding a referral often means more work for the GP, and we have the problem that some GPs prefer just to write the referral letter rather than do the investigations, get in touch with the consultant for advice and then continue managing the patient. Luckily our PCT has been generous in recognising the extra clinical time involved with PBC and we can make a claim for some of that. We are paid up to an extra £2 per patient, which we can claim out of any savings. This is for clinical time involved in PBC – including discussing referrals, referring to other GPs or doing referral audits.

Anything that fosters a personal direct relationship between GPs and consultants has to be good for patient care. GPs are not just getting advice on a particular patient's care but also educating themselves. This is good for personal clinical development and helps maintain standards.

Dr Clare Highton and Paul Haigh of ELIC How it works

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