Top tips for moving into diagnostics
Dr Peter Stott gives some advice to practice-based commissioners looking to set up a diagnostics service
Dr Peter Stott gives some advice to practice-based commissioners looking to set up a diagnostics service
1 Make diagnostics part of a bigger pathway redesign
Traditionally, consultants have been somewhat ‘blunderbuss' in their ordering of investigations whereas GPs are much more likely to just order what they think they need. The point of PBC is to get people to think about what they're buying.
If you build the cost of the investigation into the whole pathway, the provider will start to think twice about the diagnostics they carry out because it will affect their profitability.
Working through a whole patient pathway with the consultants will clarify things and change their mindset about ordering investigations. Concentrate on the process rather than on simply providing a new service and it will follow that referrals to the diagnostic service will be made appropriately and on-protocol.
2 Consultants don't have to be from your local trust
If local consultants are not interested then look elsewhere because other consultants will be. We have had consultants who won't even speak to us and others who have worked with us wonderfully and even gone on to set up their own provider companies.
If your local consultants aren't interested then I would advise trying your local foundation trust as these are very keen to find a way into the community whereas acute trusts may often try to block you.
When our local trust wasn't interested in providing a consultant contract for our ENT proposal, we called the neighbouring trust and they had a consultant on the phone to us the next day. This is a business opportunity for the trust and their sights are not on the community or intermediate care – they are looking for the inpatient work because they want to keep their theatres busy.
3 Be clear whether you're a provider or a commissioner
Sometimes practice-based commissioners aren't clear about this even in their own minds. In PBC it seems to be OK to be both provider and commissioner when you are in areas where GPs have normally branched out – for example INR testing or minor surgery.
But when you start to compete with the big boys and you put your service under the any willing provider model and start to advertise yourselves to other commissioners, it becomes more complicated because you will have access to information they don't – not least of all knowing what your competitors' prices are.
Our PCT has always made it very clear to us that we are a provider.
With our Gateway team (see box below), we could have been seen as being either.
There would be major conflicts of interest if GPs simply referred everything to services in which they had a financial interest. So to avoid this, the triagers are tasked solely to achieve the best outcome for the patient – so in this sense the gateway is a commissioner.
But the PCT always maintained it was a product and that has been helpful.
To avoid the conflict of interest we have three arms in our group:
• the commissioning side (GPs commissioning services)
• the providers
• an executive arm which does the procurement and awards the contracts; within this is a governance committee made up of our finance director, PCT contracts manager and a non-exec member who is a member of the public with a commerce non-health background.
These arms reflect another important point which is that commissioning is different from contracting. Only the latter should get into the pounds and pence. The former should be about looking at patient needs and the best way to meet them in a more cost-effective, efficient way.
4 Write off equipment costs over a three-year period
New items usually come with the manufacturer's warranty for one year and where relevant, such as an ultrasound machine, this can be backed up with a service contract. But in general, for moderate-cost items we would tend to write off the cost over a three-year period, including this within the business plan for the individual service.
In our warfarin monitoring (INR) service, for example, we have provided every practice in the area with a Coagucheck XL machine (cost around £800) with a one-year warranty and a three-year write-off period. We are now three years into this project and the machines are beginning to show signs of age.
Our contract with Roche is quite large and it has been generous in its support. The service is remunerated at the same level as Surrey PCT's locally enhanced service level 4b (£200 per patient per year). With consumables, quality assurance and training costing around £50 per year and payments to practices at £160 per year, we are actually over budget.
We manage the governance of this service completely and are pressing the PCT for payment at level 5 (£250). This would enable us to build a contingency fund to replace the machines and pay for our in-house governance arrangements.
We have also purchased nasendoscopes for the ENT clinic. These are quite costly instruments which are sheathed during use, but which need to be sterilised by the manufacturer's agent after every clinic. Every so often they need to be recoated. There are transport costs involved for every sterilisation and extra costs for the coating.
Again we have budgeted for a three-year write-down period and the instruments are bearing up well. Our ENT clinicians tell us that our management of these instruments is at least as good as anywhere else.
5 Do not underestimate the power of patients
To say PBC is GP-driven is wrong – it should be locally driven. Patients are a great way to advertise what you do.
We have been very keen to involve patients in planning services. This has had an unexpected spin-off in that they have been able to contribute to the costs of the equipment. In Elmbridge, the patients group The Friends of Thames Ditton Hospital has contributed to the costs of both ultrasound machines and ENT equipment.
This is reflected in lower sub-contractor prices with the surplus being available to be spent by the commissioners on additional healthcare. More importantly it has given the ‘friends' an involvement in the development of local services.
The gateway organisations each have large patient forums with representatives from PCT patient organisations, friends' groups, local authorities, county council and hospital trusts. At each forum meeting a subcontractor is present to answer questions. Our next meeting for example is scheduled to consider ultrasound and the patients will give us their verdict on the sub-contractor's performance.
Developing local healthcare democracy by involving consumers is an important part of our organisation. In the last resort, patients are not only our most important critics, they can also be our strongest advocates.
6. Certain things will encourage consultants on board.
We tend to contact consultants on a fairly informal basis with an initial email or telephone call.
I always make a point of telling them the following:
- this is to be a clinician-led service and they would be the lead clinician
- the standards would be imposed by themselves
- they can decide to refer onwards
- they would be the mentor for our GPSIs
- we have a very nice minor-ops theatre
7. Make sure consultants are happy with the equipment you buy
It's surprising how idiosyncratic consultants can be. Most people, when putting in local anaesthetics use disposable needles but the consultants in our own service want dental syringes which have very fine needles but are very expensive.
We've given them what them exactly what they want and have done the same for our other clinics.
Consultants will not work unless they are happy with the equipment and the diagnostics because when someone is referred back to hospital they have to be confident the patient has had the same work-up as if they were in hospital.
8. Tell press and patients what you're doing
A fortnight ago the local paper was on the phone advising they'd received an email from someone making defamatory comments about EDICS.
The paper decided not to run the story and the main reason for this was that I was able to put the reporter in touch with one of our patient representatives who was up to date on what we were doing and was able to put the reporter straight.
It also helped that I knew the reporter and had invited the local press to our launch event.
9. Decide how you will manage demand
The NHS is unlike a business marketplace where unlimited demand is a good thing because the NHS has only finite resources.
So while it's all very well to set up a new service bringing in new providers how will you stop the wrong cases getting referred to it?
There has to be a process for assessing referrals.
As already touched on in tip 1, if you concentrate on the process rather then simply providing a new service you will ensure referrals to the diagnostic service are made appropriately and on-protocol
In our case, our Gateway carried out this task and we even encourage clinicians to refer for services that don't exist so we can consider commissioning them. For example our falls service ceased two years ago and now the hospital nurses are saying they miss it, so we are in the process of collating how many referrals we get for it and then will see if there is a case for it.
10. Source your equipment from reliable suppliers
The clinicians involved in creating a clinic are usually well acquainted with the range of diagnostic equipment they like to work with and it is a simple matter to get them to list these and then to obtain comparative prices. In general, because our services are clinician-lead, we get excellent advice.
Given the chance, clinicians tend to want the best, something which is of equal quality if not better than that available in their other NHS practice and which accords with national guidance (eg NICE, Health Care Commission). Our in-house staff have the task of obtaining quotes from suppliers which these days are easily identified from the internet. These suppliers can also be helpful in sourcing unusual items.
Dr Peter Stott is medical director of EDICS LtdNasal examination EDICS background
In East Surrey, 29 GP practices have formed themselves into three federated provider groups covering a population of nearly 250,000.
Each of the three federations is an individual SPMS company using the same logistics and data systems. Their purpose has been to provide outpatient referrals and enhanced diagnostics.
In Southend, there is a fourth associated SPMS group(Fortis)EDICS has a gateway team of GPs to select the most appropriate cases suitable for these community clinics.The range of diagnostics which we provide on our community contracts is shown in the table above.