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Watch out for the referral ref

In the latest instalment of the PBC diaries our protagonist, having made inroads on emergency care, turns to tackling the beast of elective care

In the latest instalment of the PBC diaries our protagonist, having made inroads on emergency care, turns to tackling the beast of elective care

The story so far

Dr Peter Weaving is a GP in north Cumbria and former chair of a PBC consortium. He is now a locality lead for Cumbria PCT, sandwiched between clinicians and managers as they attempt to implement practice-based commissioning and service reforms. His latest task is to look at plans to bring in clinical information managers to analyse practice referral behaviour – a move that needs careful handling...

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Are you an Outlier? Have you ever been an Outlier? Have you knowingly collaborated with Outliers?

You know what I mean – GPs are familiar with seeing their performance, whether it is prescribing or how much they use Choose and Book, shown on bar charts comparing them with other practices and with a depressingly unattainable line, usually red, that represents the national average.

My deputy says that the red line doesn't matter – what GPs want is to be in the middle of the pack, the centre bar on the chart, attracting no attention for under- or overperformance. Or, in management speak: peer pressure induces behaviour normalisation.

In Cumbria we have had some great success in keeping a lid on prescribing costs by applying these and other measures to medicines management.

Now we are taking this approach to PBC's perennial problem – demand management or referral support, whatever you want to call it.

Having made some inroads into our emergency care overspend we need to tackle elective care – referrals to outpatient clinics and the hugely expensive procedures that follow.

My practice is involved in piloting some basic data assessment and educational feedback to the referring docs in a non-confrontational way.

The plan for Cumbria is a scheme where each practice has a clinical interface manager, or CIM (no reference to the computer game) either newly appointed or internally promoted.

The CIM has training and support from the PCT to analyse the practice's referral behaviour and, with a designated GP, feed the information back to the referring docs.

Now just a dog-gone minute!

You mean some clerk is going to tell me when and when not to refer my patient for a specialist opinion, procedure or investigation?

That's interfering with my clinical freedom and the doctor-patient relationship – it sounds like a man with a clipboard and a stopwatch standing over me in the consulting room.

Yes, the introduction of the CIMs needs to be handled carefully – and can we justify them over and above our financial targets?

But our pilot suggests there is a powerful clinical argument for looking carefully at what we do and why.

In one simple area – low back pain – 20 patients with this condition were referred to an orthopaedic surgeon, and only one needed surgery.

Then we focused in on patients with dizziness, and again about 20 ENT referrals with this condition were analysed. Here the evidence was even stronger for us to put our house in order – what happened to these

20 patients? Nothing at all. Two patients had a scan; some were given exercise sheets that you can download if you Google ‘dizziness' and nobody had any procedure undertaken.

With my PBC hat on I can give you nearly two million reasons why I want you to meet the CIMs.

But I believe there are good clinical reasons, too.

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