That’s the way to do it?
Posted: 25 July, 2010 by Andrew Craig
A debate is ramping up in the GP press – Pulse online is required viewing – about how (or even if) GP commissioners can make savings by doing things better vis a vis secondary care (aka hospitals) than PCTs generally manage to achieve. Everyone knows that acute trusts are past masters at maximising income. And the games some play would put a chess grand master to shame.
That’s how they’ll do it
I was taken by this contribution on the subject from Dr Michelle Drage, joint CEO of Londonwide LMCs . As GP professional bodies, they know a thing or three about the system and its perversities. This is how she said GPs would do it, meaning reduce expenditure on secondary care and improve primary care:
The first thing GPs will do is put a stop the tricks that NHS trusts play to generate more income from the same episode. And the coding games.
Then they’ll stop unnecessary admissions through A&E and other revolving doors.
Then they’ll work with clinicians to help them get the admin support they need to prevent patients coming back to GPs with no information so they get referred back unnecessarily.
And they’ll help consultants who use 85% of the budget manage their systems and workload in context with that of GPs who see 90% of patients with only 15% of the funding.
And services will be commissioned based on primary care need, not hospital income generation or colleagues’ favourite types of procedures.
And then they’ll make better use of the funds released so that patients in general practice get the best holistic general practice possible, not a service which only allows 10 minutes per patient, and that in turn will mean more appropriate referrals to hospital, greater patient satisfaction, and less unnecessary work for hospitals.
That’s how they’ll do it.
Hospital charivari
At this point an observing Mr Punch would squawk “That’s the way to do it!” And it sounds good I admit. But hang on. The more switched on GPs in practice based commissioning clusters have been trying these things already with strong PCT encouragement. Have referrals to A&E and demand for secondary care generally gone down? It doesn ‘t look like it from national data and our own local experience in London.
The Nuffield Trust’s recent analysis of the rising trend in emergency admissions highlights how costly and largely preventable many admissions are especially for older people. Big variations exist between areas and there is no clear link with deprivation. That suggests the phenomenon has something to do with variations in the clinical knowledge, skills, attitudes and behaviour of the referrers - in other words this trend is linked to what GPs do (or more accurately what many don’t do to prevent these admissions).
The perils of success
Dr Drage and her progressive colleagues have their work cut out turning that around. And here’s the sting that may scupper success. If all of this prescription worked (and we sincerely hope it does because we have waited far too long for it), then the inevitable, inescapable, inevitable and incontrovertible consequence will be a drop in hospital income. Possibly a significant and sustained one.
When demand drops and stays down, secondary care providers will have to respond with reduced capacity and prices (fewer wards, people, procedures and lower costs). That could put the rising stars of GP commissioning on a collision course with local defenders of well-loved but threatened institutions. They both can’t succeed. We back the GPs.
Is that the way to do it? Our crystal ball is a bit blurry about that. But whatever happens, a ringside seat is advised.
With PCTs in London facing stiff challenges to shift activity away from secondary care (and hoping to save mega£££s), the Kings Fund has a timely report out on what works best in Referral Management.
This is all about GP behaviour because they initiate the referrals. It bears out many of the things that we know locally about the poor quality and inappropriateness of many referral letters, but it doesn’t answer the question about why the demand for secondary care is rising at such a rate. No one seems to know and there isn’t one single answer at least in London.
The KF report concludes “A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective.” Which is all well and good, but the snag is there is no incentive either contractual or cultural for referring clinicians to behave like this. Indeed, the built-in motivation is to go on doing what they think is needed for each patient in the name of clinical freedom and underpinned by the present GP contract. The contractual part may have to change soon.
Even if GPs did start exercising a moderating role in referrals (rationing access to secondary care by any other name)it would be time consuming and could increase costs and perhaps even clinical risks if only done to get the numbers down. And yet that is just what GP commissioning consortia will have to do very soon.
Locally our out patient activity shift plans depend on controlling referrals, but the KF report says that even PCT’s operating what they believe are effective demand management systems are not getting the demand control they think they are. They concluded: “Although half the PCTs studied believed that their referral management schemes had managed to curtail demand, the evidence from the quantitative analysis suggests that PCTs with active referral management were, in fact, no more likely to curtail demand than were other PCTs.” That is the really worrying part. We are relying on something for which we have no assurance that it will deliver the goods.
If GP referral levels to secondary care are any indication of success or failure at reducing demand, then we are definitely experiencing the latter according to the Quarter 1 figures for 2010-11 released by DH last week.
As Pulse summarised the situation today:
Unless this is controlled it will tear apart consortia commissioning. If aspiring GP commissioners have a plan to get a grip on this – meaning their colleagues referral behaviour – now would be a good time to share it with the rest of us (please).