Our GP commissioner at the coalface has been discussing how to avoid routine referrals and hit upon a novel plan with private provider.
Since the Government backtracked on price competition we have been asked to fight a growing financial deficit with one arm tied behind our back - whilst hopping. Obviously quality is a prerequisite, a sine qua non , but quality could have been written into the Key Performance Indicators of any service auction.
Nevertheless, the new ground rules have been established, so it looks like we are going to have to be inventive to reduce elective procedure costs.
One way is not to refer in the first place and another is to evolve a different pathway. Peer review is proving useful in both of these as well as giving some paid time for GPs to sit together and discuss clinical issues in the context of commissioning and the financial environment. It brings the fight to the pit-face and is to be recommended. Ours is done retrospectively in a non-confrontational formative environment that gets assertive debate going amidst the cheeky banter. New pathways of in-house management are refined and suggestions made for new secondary care pathways.
A corollary of choice and competition is a plethora of alternative referral routes. How on earth can a GP manage to retain the best one to pick? One way could be improved Choice and Book software , another is the utilisation of localised Map of Medicine where the pathways available in your area are revealed.
My suggestion to our consortium is to introduce in to that local MAP a printable Patient Advice Leaflet which highlights the pros and cons of any intervention. An informed patient may choose to limp away from a hip replacement referral if they were made aware of a 1% mortality risk. Thus , informed consent could justifiably and with better patient care, reduce referrals.
Another way to reduce NHS referrals has been highlighted to me on a visit to a local private provider. They estimate between 8% to 10% of patients undergoing NHS surgery in our region have private health insurance they are failing to use. Oddly, I don't see many children of families paying for our local private school attending the nearby comprehensive! We will need to explore the reasons why, which may include offsetting any ‘excess payment'. A basis for a scheme will be proposed whereby the private provider rewards the consortium if a greater uptake of pre-existing insurance policies are utilised. The NHS saves money, the private provider gets its private patients at a tariff in excess of NHS reimbursement and the patient gets surgery outside the vicissitudes of an acute hospital setting. That sounds fair enough. The downside may be having to ask all patients ‘do you have private insurance?' as a prelude to booking the NHS appointment. Some would see that as pressuring or introducing an expectation that people should consider getting insurance next time round, undermining confidence in the NHS.
I think the end justifies the means. Complex times.
dr clive henderson
