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Getting the complex cases to consultants



Our local hospital offers a good outpatient service but lacks the capacity to provide the service local GPs really want for their large and growing elderly population.

The GPs’ ‘wants’ are short waiting times, patients managed quickly and clinics that aren’t cancelled at short notice.

In 2006, local GPs Dr Mark Gaffney and Dr Jörg Bruuns, decided to try to offer an additional service to increase choice.

Beginning with very little funding, the East Sussex Outpatient Services (ESOPS) has grown to become
a successful, consultant-led Any Qualified Provider (AQP) service that has earned the support of the PCT along the way.

Patients are seen in a building that belongs to charity The Chaseley Trust, that has a pleasant, well-managed outpatient area.

ESOPS has a unique role in the area. Outpatients are initially seen and assessed by a consultant so they miss out the lower echelon of hospital staff and go straight to the top person’s opinion, resulting in a very efficient service. The right decisions are made in the first place, cutting out unnecessary appointments and reducing follow-up.

The pathway is as follows: if a patient needs specialist referral, the GP, together with the patient, can choose to refer straight to the district general hospital (DGH) or refer to ESOPS to see a consultant in the community setting.

If the patient and GP choose ESOPS, the service receives all the patient’s referral information and can access results of investigations that have been done. The case is then triaged by a clinician and put through to the relevant consultant.

Once the consultant has seen the patient, they will then either send them back to the GP, manage them, or schedule them for treatment or an operation, which can be done either at the local hospital or at an independent hospital.

The ESOPS clinic provides all the information to the hospital and follow-up is done back in the community clinic which oversees the whole process right up to discharge.

Some GPs send roughly equal numbers of patients to ESOPS and the DGH. ESOPS’ only exclusions are under-18s and two-week-wait cancer referrals. For more complex cases, where it is not so evident what is needed, it is good to have them seen in the first instance by a consultant and this can also be reassuring to GPs that a potentially complex case will be seen by a senior member of staff.

Nuts and bolts

ESOPS employs the consultants directly and subcontracts the hospital inpatient work to the independent sector or DGH. It is paid at tariff by the PCT for the outpatient work and the inpatient money goes to the subcontracting hospital. ESOPS has responsibility for the whole patient pathway and monitors the patient for the entire journey, making sure everything is happening on time, all the results are in, and so on.

ESOPS is licensed to provide patient services in:

⦁ Musculoskeletal medicine

⦁ Orthopaedic surgery

⦁ General surgery

⦁ Colorectal surgery

⦁ Urology

⦁ Gynaecology

⦁ Gastroenterology

⦁ Dermatology

⦁ ENT

⦁ Ophthalmology

⦁ Maxillofacial surgery

⦁ Pain Management

X-rays and MRI scans are undertaken at the DGH or the Esperance, a local private hospital. ESOPS is connected to the local DGH via the secure N3 NHS net, which allows consultants to see  X-rays, scans and blood tests in the clinic while with the patient.

Outcomes

The advantage of always seeing a consultant in the first instance is that it cuts down a lot of the investigative and follow-up work. Turnaround of patients is quick. Consultants can make clear decisions about investigations and management whereas junior staff may have to get a second opinion or do investigations which may sometimes be unnecessary. Junior staff also tend to refer to other specialities more, which the consultant may not feel is necessary, thus reducing internal referrals. Consultants create fewer follow-up appointments than junior staff.

Patients are seen within four weeks for a routine problem. They  always see a consultant and decisions are made at the first appointment. If the patient has seen a particular consultant previously they will be seen by the same consultant again.

The doctors who work for the service are all specialists in their field; they are senior decision makers so do not have to check decisions. Consultants ask for fewer and more appropriate investigations than juniors in the hospital systems.

ESOPS only sees people who really need to be seen by a consultant. Inappropriate referrals go back to the GP to discuss treatment alternatives with the patient, instead of being told later it was unnecessary to refer. 

Although tariffs are the same as the DGH it costs less in total because of lower rates of follow-up and investigations.

The consultants are given a calm, efficient working environment without people coming in and out all the time. They have full IT support and maximum clinical time to focus on the patient with 20-minute consultations. While they still obviously comply with all the guidelines, working in this environment takes the pressure off them which often means better decisions are made. The consultants enjoy working this way and some have approached the service to see if they can join.

They are all local, well-recognised consultants. Some, but not all, work for the DGH, but this ESOPS work is private. The founders of ESOPS have known the consultants for many years, and this creates a working environment that makes it easier to influence the behaviour of the consultants, for example in adhering to agreed treatment thresholds.

There is a higher conversion rate, but the consultants only see those patients who actually need to see them, so more patients are listed for operations per clinic.

GP referral letters are seen by the consultant so they are aware which cases are more urgent and those that are inappropriate referrals. We employ five full time administration staff.

To refer is straightforward, with access through Choose and Book or direct referral letters. 

The future

ESOPS provides competition for the local DGH in that referrals would previously have gone to the hospital, but this is not destabilising. The hospital has so much to do that it has been a help rather than a hindrance and is helping them manage their waiting times.

In the early days, the service had a close working relationship with the DGH as the chief executive at the time was keen to have more consultant time that wasn’t in its core NHS time. ESOPS would do the outpatient work and the DGH would do the inpatient work, so it worked for everyone. As time has gone on, ESOPS has started to use some smaller independent providers so there is not quite such a close relationship with the DGH.

Once patients have been seen as outpatients at ESOPS much of the inpatient work is done in the independent sector, taking pressure off DGH beds.

We hope the funding will continue and we will be providing our services in two new community settings shortly. Our AQP accreditation runs until April 2015. ESOPS is still growing and consultants are still joining, which is evidence of its success.

Drs Mark Gaffney and Jörg Bruuns founded ESOPS and are practising GPs in Eastbourne, East Sussex, and
Dr Steve Dickson is a GP in Polegate, East Sussex and is the practice’s CCG representative

60-second summary

⦁ Start-up costs 50k

⦁ Staffing Start-up: two office staff, two consultants per speciality (1,000 consultations in first year)

⦁ Savings Normal tariff rate applies. Savings result from less activity, reduced follow-up ratio and senior clinicians using resources efficiently

⦁ Outcomes Improved patient experience (short wait, seeing consultant, closer to home), value for money (efficient use of resources)

⦁ Contact information@esops.co.uk

The commissioner’s view

Dr Matt Jackson is GP vice chair of Eastbourne, Hailsham and Seaford CCG

The ESOPS service is an efficient way of treating many of our patients. Of course, the choice of provider rests with the patient but for patients where ESOPS is an appropriate option, it can be convenient, timely and cost effective for us in terms of a typically shorter pathway.

This doesn’t lessen the challenge for the CCG, of course, in ensuring that referral thresholds are appropriate and adhered to; and that there is robust governance around our contracting of ESOPs (supported by our commissioning support provider), given the potential for a perceived conflict of interest.

There are some challenges for this model of service going forward; while we appreciate the seniority of the clinicians our patients see, they will need to play a larger part in training in the future; and although ‘competing’ with their local acute, they have a part to play in ensuring that we have a financially sustainable system where money really can follow the patient.’