Our CCG, Eastern Federation, felt that we needed to ensure our referrals to Ipswich Hospital Trust were appropriate and had the relevant investigations completed. Consultants tend not to feel comfortable returning referral letters for fear it will damage relations.
What we did
The Advice Letter Listing (ALL) project ensures that every referral letter to Ipswich Hospital is seen by a consultant via Choose and Book, who then responds within three days. The response to the GP may be:
• a traditional outpatient appointment, but in the correct clinic as GPs and their staff often get the clinic wrong – consultants can make the appointment using the ‘allocated rights' facility on Choose and Book
• a community clinic appointment
• a community management plan to support the GP in managing the patient in the community
• a request for further tests or information.
At the practice level, the ALL project is simple and seamless – every appointment in every specialty is made as a Choose and Book request to the hospital. The GP tells the patient that he or she is seeking the help of a specialist who will determine whether an appointment is needed, and if so which type – hospital or community.
GPs write letters as usual, but we have issued pre-referral guidance to follow to ensure the consultant receives the correct information.
A standard template has been produced that populates much of the information automatically. The form also acts as a useful memory aid to ensure all necessary primary care investigations have been done, and as a prompt for the referrer to include all elements of the history that might be relevant.
As the triage is done by consultants and not in a referral management centre, you have the best-qualified person doing the triage.
The pre-referral guidance and community management plans have been limited to seven specialities at first, as this was all the hospital felt it could cope with in terms of amending consultant work plans.
If a community management plan is emailed to me by the consultant, I see the patient and discuss it with them. It is easy to turn the screen and go through the response. Patients really love this and seem to feel that their problem has been more seriously considered than when they attend clinics.
We're actually going back to how things used to be – GPs would write referral letters and consultants would pick up the phone and say: ‘Why not try this, it'll save the patient coming up to the hospital.'
The trust is now paid a sessional payment of £300 on a pro-rata basis, dependant on the number of GP referrals likely for each specialty. Consultants then have extra funded time to compile a community management plan to give to the GP, if they feel the patient can be managed safely in the community.
We initially paid the trust a payment of £33 per referral before deciding to go down to a sessional payment rate of £300 a week per specialty, so our current annual costs are £517,920 plus booking team costs of £129,000.
Lessons learned
There was obviously a question about how the acute trust would benefit, as they would be earning less from referrals. From its point of view, it only saves costs once it could cut clinics – particularly ones that incur extra costs. If the trust has to run the same number of clinics with fewer patients, it loses money. Once it saw that it could run fewer clinics, it was very forward-looking about it.
There is some GP irritation about the referral guidance request, and we need consultants to be on-side about potential defaulters not using Choose and Book. The hospital trust needed to accommodate the time required to write community management plans within consultant work plans.
We know that more plans would have been issued if time had been available – it is easier for a consultant to say ‘send them to clinic' than to write a management plan.
Outcomes
Every speciality in Ipswich hospital is now covered by this service, and a pilot for gynaecology and urology referrals resulted in a 23% reduction in outpatient appointments, with all these patients receiving written community management plans.
As part of the pilot, I also did a remote-advice project using an ENT specialist at the Royal National Throat, Nose and Ear Hospital in London. I found that our referrals dropped by nearly 30% – mostly because GPs were thinking much harder about the referrals they were making, which led to a drop in referrals. It produced the lowest number of community management plans (10%), probably because there was no local knowledge of clinical alternatives, so the plans will now be run from Ipswich.
Some 23% of gynaecology patients and 24% of urology patients were managed in the community by their GPs. Other advantages were that consultants were able to determine if a community clinic costing 80% of tariff was appropriate. The only cost of the service is paying the consultants.
In terms of savings, an average outpatient appointment is £175 – and our gynaecology and urology referrals have dropped by 23%. We were making 1,000 referrals per year in just urology and gynaecology, so that means a saving of around £39,000 in just those specialities. In Suffolk, for the total ALL specialties, GPs make 64,838 referrals totalling some £11,346,825 in outpatient appointments. Assuming a 20% reduction as was achieved in the pilots, the saving in outpatient appointments would be £2,269,365 (less a 5% deflection back to hospital) (20%=12,967 x £175). So after costs of £646,920, we can make a saving of £1,508,977.
We are all encouraged to do prospective peer review now for referrals. We have decided instead to look at the community management plans that consultants are sending back via Choose and Book. If a GP has a lot of community management plans returned, this might identify a learning need. There can be no cries of ‘foul' as you might get with returns from referral management centres since the letter is being read by a fair and respected arbiter.
The future
ALL is being piloted across Suffolk, and I'd like to see it across the whole country. It would be very easy to roll out nationally.
I feel this project will bring GPs closer to consultants and improve our referrals. Ongoing data will help commissioners to identify learning needs in primary care.
Dr John Havard is a GP in Saxmundham, Suffolk, and East Federation executive board member
60-second summary
Initiative Advice Letter Listing (ALL) referral refinement programme. All referrals go to consultant who responds within three days with an appointment at the correct clinic or a community management plan for the patient to be managed in primary care
Start up costs Initial £33 per referral paid to trust, but now funding consultant sessional time at £300 a week per specialty, totally £517,920 a year plus booking team cost of £129,000
Savings In two pilot specialities, urology and gynaecology, savings of £39,000. Potential savings across all specialties of £1.5m
Outcomes 23% reduction in outpatient appointments in the specialties piloted
Contact john.havard@gp-d83053.nhs.uk
East Suffolk CCG
Established East Federation is about to join with Ipscom to form an East Suffolk CCG in shadow form
Number of practices 42
Population 350,000
Pathfinder status First wave
