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Setting up an SPMS day surgery

Dr Tim Richardson on how his practice set up a day surgery unit and why there are many opportunities for GPs wishing to follow this path

Dr Tim Richardson on how his practice set up a day surgery unit and why there are many opportunities for GPs wishing to follow this path

Our day surgery unit sees 80% of GPs' specialist referrals from our general practice patient list of 25,000 patients.

It was the first independent, fully accredited treatment centre to open in the UK, and consists of two operating theatres, three recovery bays and a five-bed ward and its development has a long history (see panel, page 54). It is managed by a day surgery company called Epsomedical that is majority owned by GPs. The company manages another day surgery unit at another local community hospital under contract with the PCT.

Surgical procedures at our own unit include skin cancer procedures, hernia repair, cataracts, arthroscopy, gastroscopy, colonoscopy, cystoscopy, gynaecology, foot and hand surgery. We provide podiatry, dietetics, audiology and INR services and a wide range of diagnostics from ultrasound, X-ray and direct access endoscopy.

Assuming all patients we see would have gone to the hospital outpatients department, we are saving our PCT £500,000-£600,000 a year as our price is about 70% of the NHS usual tariff. Our day surgery service costs are about 10-12 % less compared with the national tariff cost used in setting PBC budgets.

We have also reduced outpatient and procedure waiting times to within 18 weeks.

How the day surgery unit works

In 2004, Epsom Downs Integrated Care Services was created, as an outpatients provider under sPMS, owned by 16 practices covering their 121,000 patients. The day surgery unit now serves many of these patients but others are sent to secondary care providers. EDICS now triages a further 200,000 patients from local and neighbouring areas. This sPMS company has a £6.8m contract to provide and manage outpatients and direct access diagnostics for the PCT. We also manage the costs that were in excess of £8m when all the practices' referrals were going to acute hospital trusts.

The centre itself is staffed by an integrated team of consultant specialists, anaesthetists, GP specialists and nursing staff.

New ways of working have been developed through this integrated working, with GPs and nurses extending their roles. Consultants have welcomed the flexibility in the contractual and working arrangements the centre offers them.

GPs work in collaboration with their consultant colleagues as clinic assistants helping to work up patients and providing much of the follow-up and continuity of care. A number of GPs have developed and become accredited GPSIs providing services.

Pre-operative assessment is nurse-led, although patients with particular medical problems are seen by the anaesthetists before being scheduled. The majority of operations are done under local anaesthesia but there are also weekly general anaesthetic lists. Very few patients (about five a year) require transfer to the DGH because of slow recovery from anaesthesia or other complications. Some 95% of patients surveyed say they are highly satisfied with their experience at the centre.

An opportunity for GPs

The conditions for GPs to develop their own services, as we did, are better now than they have been for the past 10 years. But there are a few key things to remember (see my top tips at bottom of page).

One reason for this opportunity is that the new independent treatment centres (ISTCs) have not met expectations because they didn't involve GPs in bottom-up planning, unlike what PBC can do.

A bigger reason, though, is that the Government wants to see a reconfiguration of DGHs.

The NHS plan in 2000, reiterated in 2005 and supported by the 2006/7 white paper Out of Hospital Care and the very recent NHS London Review by the new health minister Lord Ara Darzi, point to a clinical requirement to concentrate the major life-threatening illnesses into centres of excellence. This includes much of the high-level care previously but often inappropriately provided in DGHs such as acute cardiovascular disease, strokes, cancer and acute major trauma.

The volumes of these activities are relatively small as most DGH activity is either routine elective, chronic conditions or acute but non-critical elderly care. In the future we can expect to see MIs and strokes and possibly 24-hour paediatric acute admissions, change pathways and a move towards more centralised ‘polyclinics' as envisaged by Lord Darzi's new London NHS Plan.

The most serious critical illnesses are now acknowledged to need fully accredited specialist care on admission and, to achieve this, specialists need to work in bigger teams to provide full 24-hour cover, particularly for technical interventions such as angiography and angioplasty. The standard admission to a DGH by a junior doctor to await a consultant ward round the following day is no longer accepted as safe for patients who are critically ill.

It is also now increasingly unacceptable to train specialists in small population DGHs as they train over a shorter working week (48 hours, where previously it was about 100 hours) and a shorter total training period (four or five years where it was previously eight to 10 years).This shorter specialist training requires a greater concentration of case-mix to develop the experience and competency needed, which has become increasingly difficult to achieve in small DGHs.

It is now accepted that small DGHs covering populations on average of about 200,000 are unable to deliver either safe levels of expert critical care or effective training. In addition they have become much less cost-effective, with costs rising significantly as they try to meet the 48-hour week.

The opportunity now

Although acute and critical illness care needs to be concentrated, routine or elective and non-critical inpatient care, covering about 80% of all patient hospital activity, can and should be provided both closer to patients and through the integration of secondary and community services with general practice in primary care settings.

Commissioning is the process by which these service changes should be assessed, agreed and procured.

GPs now have the best opportunity to take over many hospital-based services in collaboration with their colleagues from secondary and community services. Failure to do so leaves the door open to new healthcare providers who see a massive market opportunity, but it is practices that have the preferred option to bid to extend their patients' local services.

Work is required to analyse and remodel then deliver these new services, which we have shown are both clinically feasible and less expensive than hospital-based care.

I believe the most effective form of commissioning for GPs is as extended, integrated service providers. We now hope to extend our provider contract to cover most if not all of the PBC range, giving our PCT better value for money and capping their financial exposure. In turn, such a contract would give us the level of resources and decision-making responsibility (and freedom) to redesign all our patient care pathways, not just the elective services we have provided so far.

Dr Tim Richardson is a GP in Epsom, Surrey, and a medical director of Epsomedical

My top tips for GPs

1 Be prepared to work with other practices

Working together for big enough populations gives greater certainty and large volumes, encourages new investment and/or allows you to take over existing facilities.

This does not mean you need to integrate to the extent that we did – that is, merging with two other practices.

We merged because we were like-minded and so it made sense.

2 Find out what your PCT wants and needs

I have little doubt the London model with its specialised centres will be replicated across the country. Merging of DGHs is another likely option albeit a political problem for PCTs as these are highly sensitive local issues. This leaves scope for GPs to provide many of the reconfigured services that don't have to be provided in a specialised centre or DGHs.

3 Avoid getting tied into contracts with private companies you later regret

I am hearing of joint ventures of 50-50 splits for an upfront investment of £100,000. GPs are probably giving away an awful lot of value for this relatively small investment. There is no shortage of willing independent investors but practices that do their own planning will achieve a better deal than those that engage too early with such partners.

We took over our day surgery unit without outside help and there is no reason why other GPs can't do the same.

The history: how we established the day surgery centre

Back in 1988 our health authority closed down Old Epsom Cottage Hospital.

At around the same time Mrs Thatcher's NHS review took place, which led to the purchaser/provider split.

The cottage hospital was on our doorstep and GPs had managed both the elderly acute and rehabilitation beds there and looked after pre- and postoperative patients operated on site by their consultant colleagues. GPs would sit in on consultant consultations or, if they knew a particular consultant was there on a certain morning, would meet to discuss their patients. It was a very personal style of care. But the building was very dilapidated and it was sold off to a property developer.

Fundholding was one of the purchasing options created by Mrs Thatcher's NHS review. Our practice of six GPs was immediately interested in taking on a budget so we could directly provide extended services to our then 11,000 patients, rather than just purchase them from existing hospital providers with the inevitable delays and lack of integration.

The late 80s property slump worked in our favour as the new owner of the hospital saw that it made sense to renovate the hospital and sell it to us while keeping some of the land back for house development. So in 1991 we bought the old cottage hospital for in excess of £1m. The building is made up of two floors and we sold our existing surgery premises and with the cost-rent scheme moved our general practice into the ground floor of the hospital in 1991.

For the first three years we settled in to our new practice premises but were also able to provide space for consultant clinics and to private physiotherapists.

We started to look for a partner to create a day surgery on the first floor. In 1993 we struck a deal with a private company (with clinical support from Kingston Hospital Trust). The arrangement was that the private company would provide the management, theatre staff and equipment and we would provide the restructured premises, which they would rent back from us. They would also provide day surgery services to our patients through fundholding.

In 1995 we extended our premises to include X-ray, dedicated physiotherapy and additional consulting rooms.

With fundholding about to be scrapped by the New Labour government, our practice merged with two others to form the Integrated Care Partnership in April 1998.

This new specialist PMS plus practice now had a joint patient population of 25,000.

Moving to a PMS contract allowed us to become integrated providers, whereas fundholding only allowed us to be purchasers/commissioners, not direct providers of secondary care.

We could now contract with our health authority to provide all the secondary care services we had set up under fundholding, including outpatients, diagnostics and the day surgery. This was just as well, as the private day surgery company felt the NHS no longer offered opportunities to the private sector and sold out their day surgery interest to the GPs.

Dr Tim Richardson

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