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The motivation behind avoiding outpatient appointments

This month’s Focus On…shows how practices can connect with consultants without sending patients for a costly hospital outpatient appointment. Dr Tony Brzezicki explains the motivation for such schemes

This month's Focus On…shows how practices can connect with consultants without sending patients for a costly hospital outpatient appointment. Dr Tony Brzezicki explains the motivation for such schemes

Given the chance to redesign from fresh our healthcare system, the first institution to go would surely be outpatients. They are not patient friendly and often have no added value for the patient. They are convenient for trusts but each visit comes with a cheque attached – the PbR tariff.

Outpatients activity rose 15% last year yet the NHS plan includes a target to shift 10 million outpatient appointments to primary care in an attempt to free up hospital staff and secure 18-week waits.

Many PCTs and PBC groups have set up schemes to ‘manage' outpatient referrals. These are usually primary care-led and often increase the pressure on GPs to reduce the use of hospitals and so reduce the money spent on their patients. Many GPs not surprisingly feel uncomfortable doing this.

There are many reasonable areas to target to reduce activity and these should be those which add no value for the patients, for example:

- appointments to be told results are normal and the person can be discharged

- routine follow-up already carried out in primary care

- attending just to be told results

- attendance because this is the only way a hospital can be reassured it has managed the patient correctly

Consultant-to-consultant referrals are another obvious target - and may account for as much as 50% of a practice's outpatient activity.

There has to be another way of working together to provide care for patients that is better for them as well as better for GPs and consultants. To round off the win-win scenario, these schemes should also save money (known as VFM or Value for Money schemes).

This series of articles looks at case histories where exactly that is happening. Is it always necessary for patients to travel to hospital to get specialist advice, especially when the patient does not need to be examined?

Dr John Havard has designed a software package to risk assess patients who may need warfarin With input from his cardiology colleagues, a high-quality assessment is delivered without the need for patients to travel or take time out of their lives. The tariff for this service is also much lower.

I introduced a scheme to obtain consultant advice by email on how to manage patients with stable prostate cancer in general practice. The hospital is paid a set annual fee to advise what to do next if PSA results start to go awry, rather than patients attending hospital.

In Hackney an advice service has created a timetable where consultants in different specialties are available at certain times of the week to deal with GP queries about patients via fax, telephone or email.

Dr Compitus with her consultant colleagues has developed a system whereby patients can have their skin lesions photographed in a GP practice and assessed by a specialist. Again this joint working has reduced waits, given patients a faster response time and spared them a hospital journey. Clearly this is patient-focused, with NHS institutions working together on the behalf of the patient rather than to generate income.

All of these schemes can apply to each and every practice within a PBC group, making life easier for the GP, better for the patient and freeing up resources (both staff and money) to be reinvested in patient care. PBC has its critics, but projects like these justify primary care clinicians taking the lead on improving services.

Dr Tony Brzezicki is founding chair of C4 consortium group and interim vice chair of the Pan Croydon PBC group.

Dr Tony Brzezicki: There are many reasonable areas to target to reduce activity Dr Tony Brzezicki: There are many reasonable areas to target to reduce activity

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