In the face of increasing financial constraints, all clinical commissioning groups (CCGs) are seeking ways to reduce unnecessary referrals while ensuring patient care is not compromised. Some have employed third-party solutions to manage referrals – so-called referral management centres. Personally, I feel very strongly that the best people to make decisions about referrals are an informed GP in discussion with an informed patient.
I cannot see that receiving advice after the event, which leads to an about-turn in a decision a GP has made in good faith days or weeks earlier, will lead to appropriate or patient-centred care. And even if a referral management centre is effective in telling a GP what they should not do, it is equally important to be guided as to what one should do. I therefore thought it was important to develop a system that would always advise GPs on alternative pathways of care in circumstances where their patient did not meet the criteria advised by the service provider.
Our proposed solution
I have been a GP in Rushden, Northamptonshire, for 24 years and have a long-standing interest in the use of IT to support clinicians. Since the inception of Nene Commissioning, I have worked as its clinical governor and adviser on care pathways. Although clinical guidance was already available on the web – for example, Map of Medicine and GP Notebook – I felt an interactive system was needed, which supported appropriate referral decision making and promoted consistent communication of clinical information to other services and providers of care.
I spoke with Ben Gowland, who had just been appointed chief executive of Nene Commissioning, and asked him if he would support the development of a web-based decision support tool to bring clinical guidelines to life on the GP’s desktop and assist with decisions about referrals – a tool we later called PathFinder.
What we did
The PathFinder system we developed provides referral information across a wide variety of clinical areas, conditions and scenarios, including the two-week wait pathways for suspected cancer.
We started by using an Excel spreadsheet to demonstrate proof of concept, and with the support of an excellent systems trainer, over the next year PathFinder was introduced to surgeries throughout Northamptonshire. GPs were enthusiastic about the concept of PathFinder because they saw it as a resource that could make their lives easier by replacing paper guidelines, which were often out of date, with electronic versions all held in one place. By 2009, the project had gathered enough momentum for local GPs to agree via Nene Commissioning to fund the second phase, which was web-based and hosted on the PCT’s server. The PathFinder system contains referral pro forma, clinical documents including NICE and SIGN guidance, patient information leaflets and links to other authoritative websites. Each of the pro forma has a similar structure and function, and:
• lists the inclusion criteria for a care pathway
• lists the exclusion criteria for a care pathway
• signposts alternative pathways when exclusion criteria apply
• prompts clinical details advised by the service provider
• mandates clinical details required by the service provider
• mandates key pre-referral investigations.
Referral pro forma are quick and easy to complete and form part of the GP record. Direct-access investigations such as for ambulatory ECG, echocardiography and MRI were also added to facilitate more appropriate use of investigations.
NHS Northamptonshire’s enthusiastic prescribing team were invited to contribute their regular bulletins to the PathFinder website, together with their medicines formulary and shared-care monitoring protocols.
What we learned
The web version was quickly rolled out, and by the end of 2009 the website statistics were recording over 4,000 visits per month, with an average of 10 pages viewed per visit.
An evaluation by the University of Northampton produced favourable results, as well as some learning points that we acted on: the need for a faster system with more frequent updates and for a greater range of conditions to be covered, advice on Choose and Book options and contact details for consultants. Feedback from local GPs indicated that they valued having authoritative guidance on when to make referrals. Local hospitals also started to buy into the idea of PathFinder as they saw an improvement in the quality of referrals and information provided from primary care. Consultants approached me as the editor, and jointly we began to use PathFinder to support the commissioning of new services.
DXA scans were now requested with a FRAX score based on NOGG guidance, and patients with new-onset atrial fibrillation with a high CHADS2 score were fast-tracked for anticoagulation because the referrals contained this key information.
GPSIs who were providing minor surgery were able to use PathFinder to advise their colleagues on appropriate referrals. For example, the PCT commissioned vasectomy within primary care and a pro forma was designed to assist the referring GP with counselling and patient selection – which is so important because of the potential medicolegal implications.
GPs also valued the information provided about community services – such as for smoking cessation and weight management – and the providers of these services were equally pleased with the increase in number of people attending their clinics.
Importantly, through PathFinder GPs could demonstrate to patients why sometimes a referral was not necessary – which in today’s climate of savings and efficiency was appreciated by the patient and certainly helped protect the relationship with their GP.
Over the past three years that Nene Commissioning has used PathFinder, referrals to hospital have increased much more slowly than in surrounding areas. Between 2007/8 and 2009/10, referrals rose by 11.1% across Nene Commissioning, but by 26.3% over the rest of the East Midlands. We have assessed the cost of PathFinder as approximately £200 per 1,000 population, or around £1 per referral. The system has no effect on GP consultation time, reduces staff and administrative time and has enhanced patient satisfaction.
During 2010, other GP consortia from the West Midlands contacted Nene Commissioning asking about the possibility of having their own version of PathFinder.
We were also keen to improve the functionality of the website and the breadth of content, and to progress integration with GP clinical systems. In late 2010, Nene Commissioning started discussions with Plain Healthcare, a software company with an excellent track record for delivering decision-support software – including Odyssey, which is used by out-of-hours providers and a number of GP practices. As a result, a generic and customisable version of PathFinder has been developed. I started working on extending the conditions covered with the aim that PathFinder will provide at least 100 common referral pro forma by the end of 2011.
The new version called PathFinderRF (RF stands for referral facilitation) is released this month and will be customisable by each consortium that chooses to use it. With the support of other CCGs, Plain Healthcare and Nene Commissioning will in turn continue to develop PathFinderRF through a user forum, while adding other decision support tools to assist with the management of long-term conditions.
Commissioning groups face huge challenges in the coming years while the complexity of guidelines and service provision will continue to increase. Bringing care into the community must be done safely or there will be no savings. Primary care deserves to be supported and clinicians at the coalface must be empowered through IT. If the last decade was the decade of clinical guidelines, then this has to be the decade of decision support.
Dr James Findlay is a GP in Rushden, Northamptonshire, and clinical governor and adviser on care pathways at Nene Commissioning