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Four key steps to assessing existing clinical services

Dr Peter Weaving advises GPs on the key points to consider when assessing local provision as the starting point for commissioning

GPs have now begun taking the reins of commissioning services from PCTs, and one of the opening tasks is monitoring the performance of local providers of everything from ophthalmology to out-of-hours.

There is currently an industry around the monitoring of these contracts covering finance, quality and performance. GP commissioners need to ask themselves how they add value over and above the experienced and dedicated financial and performance managers within PCTs.

In this article, I describe the four key criteria I use for assessing clinical services.

1) Quality

The quality of the service is paramount, and there are a host of indicators from re-admission rates, hospital-acquired infections, ‘never' events and more. Some of this data is mandatory for organisations to collect and some is discretionary. Meet your PCT's performance and intelligence team and talk to them. Each week I receive and skim the ‘sitrep', or situation report, that summarises the data local trusts submit centrally.

It covers everything from A&E attendances to ambulance waits, and ITU capacity to cancelled operations. Get on the mailing list – it's a great barometer of how your health economy is performing.

All trusts submit ‘vital signs' data – a raft of measures set centrally, again building up a picture of performance using varied measures such as how long your patients wait for cancer treatment, or how many of them have had retinal screening as part of their diabetes management.

The national Commissioning for Quality and Innovation (CQUIN) programme now enables commissioners to specify locally relevant quality requirements in contracts with providers.

Some services – such as oncology and pathology – are subject to external audit. We recently had the worrying experience of a local screening service that was highly regarded by clinicians and patients being found seriously wanting by an outside review. The service was decommissioned and is now provided by another trust.

Use multiple sources of data and triangulate your findings. Forget the soft stuff at your peril – the evidence that you, as a GP, are exposed to every day in your consulting room by talking with patients and colleagues about their experiences of the clinical services you will be responsible for commissioning. ‘How was it for you?' is a very relevant question.

2) Need

The need for a service will be determined by your consortium's population, its demographics and its morbidity profile. Your public health department will have very detailed statistics that can be enhanced by practice data and experience. Locally, we have high rates of teenage pregnancies – to improve that we need to work with public health, community providers of sexual health services, school nurses, community pharmacists and, the biggest provider of sexual health services, the GPs themselves.

Local pharmacies are commissioned to provide emergency hormonal contraception and are keen to do more – exploit their high-street presence to reach the people you don't see.

We also have high levels of COPD admissions (see case study here at Benchmarking also highlights need for a service – we rank practices against one another to highlight variations in referral and admission rates.

Practices are visited on a regular basis, and we share with them non-anonymised data showing their position compared with local peers looking after demographically similar populations. Feedback from the practices has modified the dataset and way the data are presented.

Sharing of this information provokes discussion around the factors that cause the variation – whether it is the clinical need of the patients, the availability of expertise within the practice or the way a particular hospital deals with its patients.

3) Access

Three questions to ask here are:

• Can your patients gain access to the service?

• Is the service available locally?

• Can the service be provided in primary care or a community setting?

An example we identified was when assessing the treatment for our patients with sleep apnoea. They currently drive from Carlisle to Barrow to be assessed – a round trip of 180 miles. As a result, we have made it a commissioning priority to develop local services closer to home.

Similarly, specialist services such as neurology and interventional cardiology are not currently available in Cumbria.

Access is not just about the physical availability of a service – you may want your patients to use the orthopaedic service locally, but if it consistently has no available appointments on Choose and Book then people quite reasonably choose St Elsewhere's service because they can be seen more quickly.

4) Value for money

In a time of effectively flat funding and rising demand, you have to make every penny go further. Even if the tariff or cost of a procedure, admission or referral is set and fixed nationally, moves to improve efficiency matter because that cost will be varied by length of inpatient stay, rate of follow-up or frequency of consultant-to-consultant referral and you will need to keep an eye on these measures.

You may decide to use, and probably already do, the services of a GPSI or another community provider of a service for whom you can set the tariff.

We generally aim for 50% of the national tariff to reflect the much lower overheads such a service will incur. We have GPs providing services in dermatology, minor surgery (vasectomies, carpal tunnel release, hernia repairs), ENT and ophthalmology, to name a few.

One caveat with these services is to ensure you are not tapping into unmet need, diverting care that was previously provided under GMS or lowering the threshold for referral. GPSI services are only cost-effective if they genuinely reduce secondary care utilisation. We apply the same referral criteria for primary and secondary care providers.

We use a locally determined set of criteria drawn up by local consultants and GPs – our ‘EBR', or evidence-based guidelines.

It specifies, for example, that a patient should not be referred for carpal tunnel surgery unless they have had a trial of a local steroid injection and that surgery for Dupuytren's contracture should only be considered when flexion of ‘x' degrees is present at ‘y' joint.

Its implementation in practices has been supported by staff appointed by each practice to inform referral behaviour – akin to a medicines manager for prescribing.

Finally, I would leave you with two somewhat contradictory maxims:

• If you can't measure it, you can't improve it.

• Don't forget the soft stuff.

Dr Peter Weaving is a GP in Brampton, Cumbria, and commissioning locality lead for NHS Cumbria

Four key steps