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Engaging with the outliers

Now commissioning is compulsory for all GPs, Miranda Griffin asks the experts how consortia can ensure all practices are on board with the changes required.

Our expert panel

Dr Michael Dixon (MD) Chair of NHS Alliance

Dr Johnny Marshall (JM) Chair of NAPC

Dr James Kingsland (JK) President of the National Association of Primary Care and national DH clinical commissioning lead

Should you engage now with a practice that has high referrals and prescribing rates – or quietly hope they go to the consortium up the road?

MD If the practice is within your geographical area you should start the ball rolling now. There's a lot of ground to cover between saying ‘you are an outlier, we need to find out why' and whether the statistics are accurate, and getting things sorted.

JM Someone has to engage with them! We shouldn't be shying away from engaging with local colleagues who naturally sit in the same geographical area as us. We should be trying to understand what the issues are, sharing information and seeing if that reduces unwarranted variation, which in any case may be based on genuine need.

JK It partly depends whether you have already formed a group with them or not, but it's never too early to start. At this stage there should be collective responsibility for function. There is time later to sort out structures, what size groups will be and so on, but now you should have a collective view about what you're trying to achieve. Function involves collectively looking at referrals, different pathways into hospital, reducing length of stays, managing urgent care beds and so on. Far too much focus at the moment is on what PCTs do, what the structures are going to be like and what the governance arrangements are. These are important but not at the moment.

How can you motivate such practices to come into the fold?

MD There are soft and hard ways. Hopefully most practices feel best use of resources is important and there is enough goodwill between practices that when GPs realise they are outliers they are motivated to want to look at why.

There are ways of increasing the incentive – financial incentives for people to look into it and make an action plan, or to reward them for a given reduction or for coming in under a certain threshold. This could be a challenge to those who don't want to be seen as having a purely financial reason not to refer patients.

JM Most GPs want to do a good job. If we're talking about variation, rather than fundamentally poor performance, then as you share information with GPs – openly and transparently and with peer support – showing how they compare with other GPs who are in a similar position, they are usually willing to look at what they're doing and reduce unwarranted variation.

It will also depend on how legislation is developed – if everyone has to be part of a consortium, and if an element of your contract is based around not only the quality of primary care you provide but also how it has an impact on use of resources in the wider NHS, that will provide greater incentive for people to get engaged.

JK There's a lot of misunderstanding about how the changes will alter the function of general practice and the quality of the time spent with patients. If the right information is presented and people understand what the policies are trying to deliver, there will be far less resistance.

What are the common reasons for people being outliers?

MD There are many reasons. You need to look at the individual GP figures as you often find wide variation within a practice. Then you need to see if the individual high referrers are higher referrers across all disease areas, in which case it may be due to not tolerating uncertainty, perhaps because of the GP's personality or lack of confidence.

If high referrals are seen only in certain specialities, there may be other factors coming into play. Paradoxically, if someone knows a lot about a certain speciality such as dermatology they tend to refer more as they know more about the possibilities. There may be issues to do with the population – certain populations are keener than others to have a referral.

JK High referrals don't always equal poor practice. They can be the result of very good clinical practice when due to screening, early interventions and so on, but they can also be a consequence of not getting a consultant opinion further up the pathway.

Frequently it is due to workload rather than skill – often the highest referrers have the biggest workload. In many practices there's a massive amount of work going on by GPs that shouldn't be done by a doctor. They don't have time to work the patient up and if they see a problem that could be serious they make an early referral.

You need to create headroom by building different primary care teams around the population, having the right clinician-to-patient ratio which allows longer consultation times, so GPs refer a smaller number of more complex issues.

JM I see unwarranted variation in clinical behaviour as system failure rather than a personal clinician issue. Knowledge needs to be provided to clinicians on their desktop to help them make the right decisions for their patients in the first place. A much more sophisticated desktop support for clinicians will help them quickly see what the good pathways are, what good quality care looks like.

We also need to provide information about referral patterns that they can compare with their peers. The outliers often aren't even aware that they are outliers. GPs are quite a competitive bunch and when you show them information about how they're behaving in respect to their peers, they're usually fairly receptive to how they might improve that.

The important thing is we focus on the quality agenda – not financial control.

What if the outlier simply has more patients needing to see a consultant than other practices?

MD You have to validate this, perhaps by comparing the practice to similar practices in a different geographic area. Then you need to allow the practice to see if they can sort it out – often they will find their own solutions by, say, having a real-time discussion on referrals. You could also match the partner with the most referrals in a particular specialty with the one with the least and see if they can sort it out. You can also get someone in from outside – but a GP rather than consultant as consultants often think all referrals are justified.

JM If patients genuinely need to see a consultant then they need to see a consultant. That's warranted clinical variation and this is where information suddenly becomes really valuable because it will show whether the variation is due to a genuinely less well population, or a more demanding population. A GP with higher cardiology referrals may justify this by saying their population is older, or has more co-morbidity, and accurate information will show whether this is the case.

PCTs seemed rather punitive in tackling variation – how can consortia do it differently?

MD Tackling variation should be seen as a corporate effort where all the practices agree it's about quality of care as much as saving costs rather than the consortium telling the practices what they have to do.

JK What we found with PBC was that peer review was much more effective in tackling variation than an external manager coming in and telling a practice their prescribing was higher than everyone else's. Also, having ownership of the data meant practices would ask themselves why their practice differed from the others. Most GPs given the right tools and environment will tackle variation themselves.

Do you have to accept there will be some ‘freeriders' who agree on paper to the agenda but forget it once back inside their consulting rooms?

MD You must accept some variation and autonomy is important but if a practice is using up twice as many resources per patient as the others then it is depriving other patients of services they need.

In this new world we cannot tolerate someone who is spending vastly more on their patients with no good clinical reason. In most practices you can appeal to the doctor's sense of fairness, their vocation and sense of being part of the medical community but if all these and financial incentives fail then you will have think about less positive action to bring a practice into line.

The ultimate action would be to expel the practice from that consortium and an expelled practice might find it difficult to have its licence renewed. That's why the NHS Alliance believes that contracts for practices should ultimately remain with the NHS Commissioning Board.

Consortia need to be bonding with their practices using positive instruments and not be seen as the police or the person with the guillotine.

JM There will always be those who are less engaged. What is crucial is to ensure that we have all the primary care clinicians working to a sufficiently high level of quality in the service they deliver as clinicians. Not everyone needs to be integrally involved in the more intricate aspects of commissioning but we do need everyone to deliver high-quality primary care. This can be done through financial support and incentives, providing information and support about how they can deliver high-quality care, peer review and constructing systems to take account of the way they work best.

JK There will always be such people but it's not acceptable. If there are outliers who have been encouraged and supported and given the right environment to make change (and they don't) then it's justifiable to show them the door. If they can't find another consortium then they can't run a list and that is a career breaker. I do not expect all the GPs in this country to survive this policy.

Miranda Griffin is a freelance journalist

Engaging with the outliers Engaging with the outliers