Providing rapid-access diagnostics in primary care
Dr Agnelo Fernandes explains how his practice is part of a pilot improving community access to ultrasound, MRI and echocardiography
With most practices experiencing falling profits, it may be tempting just to focus on the services your local primary care organisation provides funding for, or those contained in the GP contract. But by doing this, you are missing an opportunity to serve your practice population better.
For three years, our practice has been part of a pilot programme to offer diagnostic services closer to people's homes in GP surgeries. The pilot has been a tremendous success, with estimated savings – in terms of avoided hospital appointments – running into millions of pounds.
As well as the financial benefits, we have seen that offering rapid-access diagnostics in our surgery has boosted patient satisfaction and improved the quality of care we provide. We also have the indirect benefit that patients see the services we are providing and want to stay with us.
Our patients are our best advocates, and with the increased emphasis on choice we need to ensure we are thinking of new and innovative ways of improving the service we offer. With a registered patient list of around 13,100 in the north of Croydon, Parchmore Medical Centre serves a highly ethnically diverse population. The practice has the largest population of people with diabetes in the borough and an excess of cardiovascular-related conditions.
With this disease burden on our doorstep, patients were used to experiencing lengthy waits for diagnostic appointments in hospital – for ultrasound in particular – and the process for hospital referral was time-consuming and complex. Patients were often having to travel too far to attend multiple appointments for diagnostics, with the attendant costs in time and money, and those with cars were paying a lot for hospital parking.
This contributed to delays in diagnoses and ineffective monitoring of treatments. We decided as a practice to look at accelerating patient access to diagnostic services, with faster results and treatment. Provision of routine diagnostics at the surgery or outside hospital was therefore the natural path to follow.
What we did
As a practice, we already had a policy of reinvesting our resources in the practice to develop the services we offer. Because of this, we now offer an operating theatre and provide other services for our own patients and those of other local practices, such as community phlebotomy, anticoagulation and GPSI rheumatology services, which are funded via local enhanced services.
We have also developed in-house capability for conducting ECG, spirometry and 24-hour ambulatory blood pressure monitoring for our patients.
In addition, our practice is part of the Croydon Federation of General Practices that began a trial in November 2007 looking at providing diagnostic procedures closer to people's homes.
The project was run in conjunction with NHS London and diagnostic equipment provider InHealth, and was designed to offer patients more choice, accelerate the speed of service delivery and reduce travel time and costs – improving patient access and enhancing clinical outcomes for all sections of the community.
As part of this, we began to offer local GPs direct access to ultrasound in our surgery. Other practices within the Croydon Federation offered specialist ultrasound and echocardiography that we also had direct access to, and direct-access MRI became available with a choice of locations locally and throughout London.
How we did it
For the Croydon pilot, the cost of investigations was equivalent to hospital tariff, so there was no additional cost to the NHS. We felt that this development was of such importance that we project-managed the pilot without any funding ourselves, working with InHealth and NHS London. The GP surgeries chosen as diagnostic sites fulfilled certain criteria, including additional space, capacity and capability.
The concept of community-based scans was new to GPs and patients alike, and strict governance principles (in the form of ultrasound, echocardiography and MRI guidelines and pre- and post-referral governance) were introduced to ensure that patients were referred appropriately.
At the point of referral by their local GP, via Choose and Book, patients could choose between several locations in the area. In many cases they opted for an appointment at their local practice.
There was flexibility in terms of choice of date and time (including evenings and weekends) to fit in with personal preference.
With regards to the other services our practice offers, the ECG machine was obtained from the British Heart Foundation and electronic spirometers and 24-hour ambulatory blood pressure monitors were purchased using incentive monies from prescribing savings.
GPs and nurses both received training on ECG interpretation. Healthcare assistants were also trained on doing ECGs and highlighting seriously abnormal readings, as well as in conducting accurate spirometry and 24-hour ambulatory blood pressure investigations.
The introduction of these services at the surgery has paid dividends. They have contributed to better patient care and maximised return on QOF incentives. In 2010, we were awarded the RCGP Quality Practice Award in recognition of the quality improvement systems that we have developed, including this project.
Developing our staff skill mix to include experienced healthcare assistants has meant that nursing capacity for direct patient care has been greatly enhanced, making more appropriate use of nursing skills and expertise.
The wider Croydon pilot has been phenomenally successful – winning national awards for improving patient access to diagnostics.
The diagnostics in the community project was expanded to all practices in Croydon, and between February 2010 and January 2011 there were nearly 3,000 MRI scans, 5,193 ultrasound scans and 1,200 echocardiograms conducted through the programme.
During this period, the estimated savings from prevented outpatient follow-up appointments has been in the region of £1.6m.
Having a diagnosis much earlier has been the greatest gain for our patients, with an average ‘referral to report time' for all diagnostics of 18 days and a high rate of patient satisfaction.
Direct access to MRI and specialist joint ultrasound has significantly shortened the musculoskeletal pathway – now, a diagnosis and treatment in-house or reassurance by excluding pathology takes place in less than three weeks instead of waiting three months before even a diagnostic test.
Direct access to echocardiography in GP surgeries allowed creation of a heart failure pathway that did not always involve a cardiologist, allowing patients to receive faster diagnoses and management in the community by heart failure nurses.
Audits conducted showed that, supported by guidelines, the vast majority of referrals for diagnostics were appropriate, with a high pick-up rate of clinically relevant abnormalities – such as an MRI of knees, where the detection of clinically relevant pathology was over 95%.
As well as the comforting familiarity of their local surroundings, patients saved a great deal of time and money by never having to travel for more than 30 minutes to their appointment.
Further audits are needed to show the reductions in GP consultation rates and analgesic prescribing that we might expect from earlier access to diagnostics.
Patients in pain inevitability also seek second opinions with A&E departments – so the impact of earlier direct access to diagnostics on A&E attendance and emergency admissions needs further study, as does the impact on cancer diagnosis.
Rapid direct access to diagnostics has had a multifaceted impact on GP referral behaviour, as well as on the quality of patients lives, in our area. During the coming financial year, these services for patients of local practices will be further expanded to include a wider range of cardiac diagnostics, such as ECG, holter monitoring and 24-hour ambulatory blood pressure monitoring.
As this is rolled out, we hope to continue as a practice to expand the range of diagnostics we provide for our patients.
Dr Agnelo Fernandes is a GP in Croydon, chair of the Croydon Healthcare Consortium and RCGP lead for urgent and emergency care
Dr Agnelo Fernandes