Dr Martin Whiting and Simon Wootton explain how a radical referrals scheme will help GPs achieve the new QOF indicators
The new QOF indicators on peer review of referrals will raise some issues and eyebrows for GPs in 2011/12. As we all know, it can take ages for data on referrals to come from our hospital colleagues – often two or three months after the referral has gone – and as for discharge letters, your guess is as good as ours.
Our story shows how we arrived at a position to help practices with this in addition to improving the quality of the referral process and managing to reduce first outpatient appointment rates.
Why we chose to implement a referral gateway
In Manchester, the three practice based commissioning consortia ran a two component city-wide peer review incentive scheme in 2009/10.
Component one was based on hospital data that we received two months after the event and was supplied by the PCT IT team on software we use called MaGIC. This allowed practices to find out from a patient's NHS number what had happened to specific referrals and identify learning points and possible alternative services.
Manchester had a DH-negotiated independent sector treatment centre (ISTC), various clinical assessment and treatment services and tier-two services. The ISTC especially was underused for referrals.
Based on this feedback, the North Manchester PBC hub developed practice learning events for pain management and respiratory care with secondary care colleagues, areas highlighted for priority by our practices.
The other element to the city-wide scheme was to reduce hospital outpatient activity levels by using alternative services that had been growing over the last few years. But by the end of 2009/10, while education had occurred, generally outpatient referral activity hadn't reduced.
As commissioners, we looked at alternative ways to try to reduce hospital activity as all our budgets were forecasting overspends. The idea of a referral gateway including triage was initially raised with practices by the consortia as early as May 2009, through letters, meetings and newsletters.
It was then developed by local clinicians and piloted in the South Manchester PBC group with four practices for five months towards the end of the year.
The outcome data showed a great potential to affect outpatient activity and all three consortia and the PCT agreed to set up a city-wide referral gateway.
A project leader was appointed and the three PBC boards then met to agree how the gateway would work. The boards discussed who would triage patients, and allied health professionals and consultants were considered.
But all three boards wanted local Manchester GPs to provide triage support in order to gain the goodwill and engagement of practices at the initial stage.
Steady clinical engagement occurred in each consortium and with Manchester LMC throughout this period. A business case was developed and practices voted on using the PBC incentive money to pay for the gateway. Given problems with internal staffing, the commissioners enlisted Harmoni to run the gateway.
The clinical triage work was subcontracted to our local out-of-hours provider – with the proviso that we wanted Manchester GP specialists to do the triaging.
Results to date
The referral gateway went live in September 2010, and since then we have triaged eight specialities – general surgery, ophthalmology, cardiology, ENT, trauma and orthopaedics, gynaecology, urology and dermatology.
Referrals are screened at three stages.
All this is undertaken electronically as we use one standard referral letter template, rather than the 140 that we used to select from.
At the first stage, GP referrals are checked for completeness – NHS number, date of birth and so on – and then they are checked against NHS Manchester's non-commissioned policy. At the second stage, if data is missing or it is a procedure we don't commission, an electronic advice note goes back to the practice.
The third stage is clinical triage, where three courses of action are possible. The referral can continue, it can be diverted to an alternative service or ‘advice and guidance' from the Map of Medicine, NICE or the local commissioner can be sent back to the referring practice to encourage more work-up or increased management in primary care. The turn-around for this is two working days, all done using NHS Net email.
The results to date have shown significant savings – a 1.2% overall reduction in outpatient activity instead of the forecast 3.8% growth – but most importantly, the feedback we've received from GPs has been mainly positive.
It's not 100% positive, of course, but we have a very transparent appeals process for triage: initially a conversation with the referring GP, then referral to a second triager, a referral to the triage governance lead and then finally to the PCT's effective use of resources panel.
The unique selling points for practices have been:
• one referral template
• feedback on referral letter quality
• GPs no longer use Choose and Book as this is handled by the referral management centre
• primary care will not accept the numerous revised hospital proforma referral templates – we have the power to say ‘no', because we act for all Manchester GPs and can dictate policy to the hospital trusts.
How we plan to link the gateway to new QOF targets
Practices receive weekly reports on the referrals they made the previous week showing what has happened to them. This they can use for review, education and learning.
Our intention is to encourage practices to also use this weekly report for the QOF peer review, and for them to annotate their internal peer review on the report (we are amending these weekly reports so practices can do this).
Practices can then link with partner practices for their referral report to be externally peer reviewed, which is all done electronically and securely on NHS Net. We believe this will support the QOF indicators in a structured way and provide a full weekly audit trail.
As you would expect, the triagers are also identifying general practice educational needs and this will be developed this year through monthly educational meetings and case studies, working in partnership with local consultants. These will provide information on best practice and help standardise primary care management.
We have also used the intelligence gained for service redesign.
The three GPSIs in cardiology, after auditing a few months of triage data, calculated that approximately 40% of cardiology referrals could be managed in a tier-two service. This went live in March 2011, and the gateway allows cardiology referrals to be directed to this service. The other triage areas have also identified potential improvements and a service redesign for ophthalmology is being actively pursued.
The consortia would like to encourage more GPSI development in other areas, as dictated by our referral demand. Redesigned pathways will be developed over the year in conjunction with local hospital consultants to help reduce hospital activity and contribute to the GP commissioning consortia's QIPP targets.
We hope we've set up a circle of information, reflection, education and change. We think this will help GPs with QOF, but more importantly it will help our patients and benefit our health economy.
Dr Martin Whiting is chair of the North Manchester GP Commissioning Consortium and a GP in Cheetham, Manchester. Simon Wootton is chief officer of the North Manchester GP Commissioning Consortium
More here: A graph showing How GPs reduced outpatient referrals
Introducing a GP-led referral gateway
