We reviewed our referrals across the clinical commissioning group to look for areas where they were high – and gynaecology came out near the top of our list.
Local patient participation groups had expressed difficulty in accessing gynaecological services due to the cultural sensitivities surrounding such issues within the local community.
In our area of Greet, in Birmingham, there are a large number of ethnic minorities from Asian communities – mainly Pakistani, Bangladeshi, Muslim Punjabi and Hindi.
The patient participation group explained that women from these backgrounds were often reluctant to see a male GP about a women's health issue, and that if the patient didn't have English as a first language there could be communication problems at the hospital.
The group also flagged the distance between home and hospital and the cost of car parking as reasons for the high number of DNAs after gynaecology referrals.
Furthermore, every time a patient needed an ultrasound scan they had to be sent to the hospital as there was no community facility available, and reports generally took around a week or 10 days to come back to the GP.
Gynaecology is within the top five high-cost specialties for GP commissioners at the SmartCare CCG – now part of Birmingham South Central CCG – and it would be impossible to perform well in relation to the QIPP programme without addressing the overspend.
What we did
We worked with our local patient groups and local women's groups to redesign gynaecology services so the end product would be a better-quality service for patients, while supporting delivery of some of the financial challenges around delivering QIPP within our CCG. We wanted to reduce DNAs and referrals by offering better access to female gynaecologists. We wanted to bring the service into the community, which would make it easier to attend and reduce costs such as car parking. We also wanted to reduce the time it took consultants to report back to GPs and give GPs more control over service design.
Following support for our plans from the PCT, we went out to procurement. Around six or seven bids were made, some of which came from two local PCTs.
In the end, we implemented the new service through a company called Health Harmonie in October 2009.
We didn't want to discriminate, but Health Harmonie were able to offer us the chance to work with female consultants – something our patient group had indicated as a key factor in reducing referral costs.
The clinic was staffed by a team of consultant gynaecologists and sonographers provided by Health Harmonie – the six consultants have substantive NHS posts.
It was hosted at an underused community centre that was just four years old, and made available to referrals from 20 surgeries in Smartcare CCG – originally part of Heart of Birmingham PCT, now part of Birmingham South Central CCG. The community centre has good car parking facilities and public transport, and is near many patients' homes, which makes it more practical for patients to attend.
The centre runs three clinics a week with new and follow-up patients, and each clinic has 12 patients. Appointments are available until 8pm to cater to patients in full-time work, and the centre also has the facility for Saturday clinics. Between 2010/11 consultants saw an excess of 500 new patients.
Referrals at the centre are triaged within 24 hours. Initial consultations with a gynaecologist were available within four weeks of a GP's referral by email or fax.
Direct-access ultrasound scans were available within two weeks of referral and reports were sent out from the clinic to GPs within 48 hours of consultation.
Referrals on to the hospital would always copy the GP in so that the patient continued to maintain contact with her doctor throughout the referral.
The clinic has the ability to prescribe to patients, and can also provide minor surgical procedures such as fitting the Mirena coil – in effect, running a one-stop-shop for blood tests, ultrasound and associated services.
It is open five days a week and typically has four or five staff working together, including one consultant gynaecologist, one sonographer, one nurse and a co-ordinator.
The biggest learning curve for us was finding ways of allowing GPs and patients to work together to create a solution that meets everyone's requirements.
Giving GPs the autonomy to lead the establishment of a service and performance-manage providers directly has led to much closer working relationships between commissioners and providers. Now issues are discussed directly between GPs and the provider and resolved quickly – this would not have been possible through the routine PCT contract-monitoring processes.
This model has provided the basis for a range of community services that have since been commissioned by the SmartCare CCG, such as direct-access diagnostics, ophthalmology, cardiology and rheumatology.
Health Harmonie reports that onward referral rates from the clinic are less than 10%, and DNAs are less than 5%.
The new service has improved both GP and patient satisfaction. A recent patient survey revealed that 96% of patients rated the care they received within the service as either ‘beyond their expectation', ‘excellent' or ‘very good'.
Furthermore, 100% of GPs said they would recommend the service to their colleagues.
GPs were happy with the service because they felt they had ownership of it and had a good relationship with Health Harmonie.
When a GP needs an urgent appointment they can now speak directly to the consultants on the same or next day, whereas working with the hospital had traditionally been more difficult and took longer.
During its first year of operation GPs experienced a reduction of 1,070 gynaecology outpatient attendances to secondary care, saving around £150,000 in GP commissioning budgets. The service was run at 80% of payment by results costs, which we were happy with.
In addition, we have found an overall reduction of new to follow-up ratios. We have also been able to improve the capacity for new patients, as the new to follow-up ratio dropped to 0.5.
The SmartCare CCG has recently merged to form a much larger group – Birmingham South Central CCG.
We are now working to replicate this model across the CCG – which represents around 250,000 patients – so that more patients can benefit from these improvements in quality and efficiency.
We negotiated on the cost of the service initially and we are happy paying 80% of payment by results. If the volume of the contract increases we anticipate that the cost of the contract will go down.
Dr Sharad Pandit is the deputy chair and Dr Aman Mann the QIPP and commissioning lead of Birmingham South Central CCG. Both are GPs in Birmingham.