This case study was published prior to the NHS Listening Exercise. The outcomes of this exercise have led to some changes to the policy, and this case study may not reflect the current policy position. More information can be found in our detailed response to the NHS Future Forum.
Commissioning Development: ‘QIPP’ case study
This case study explores how Fortis Healthcare, a first-wave GP Pathfinder that represents 78,409 registered patients, has set up a ‘Referrals Gateway’.
The Gateway has brought numerous benefits to patients, GPs and clinicians across the health system and effectively demonstrates the principles of Quality, Innovation, Productivity and Prevention.
- Being a pathfinder
- What changed?
- Improvements so far
- Who contributed?
- How will patients benefit?
- Next steps
Being a pathfinder
Dr Paul Husselbee, Medical Director at Fortis Healthcare, talks about being a GP pathfinder and how the work of his consortium will make a difference for patients.
Before Fortis Healthcare (based in Leigh-on-Sea) was established three years ago, the outpatient budget used to be held by the PCT and GPs would make referrals without having to take full responsibility for the costs incurred.
Outpatient referrals were increasing and so were the costs that were associated with them that form a significant part of most primary care budgets. This increase in referrals was also leading to clinicians’ time and taxpayer’s money being wasted and patients being inconvenienced, in particular the elderly or frail, their carers and families.
The number of outpatient referrals needed to drop, as did the number of follow-ups. The referral process needed to change: savings needed to be made so the budget could be kept under control and patient care and experience could be monitored and improved.
All referrals – apart from cancer two week waits – are now triaged by a ‘Clinical Gateway’ that has been established by Fortis Healthcare.
The Gateway works in the following way: All referrals are triaged by GPs from within the group (no GP triages their own referral or that from another GP in their practice). The GPs checking the referral ask:
- is this referral reasonable?
- is it clear what the GP expects the patient to get from the referral?
- has the GP done everything to resolve the issue in primary care?
- has the GP considered other routes?
- is there an alternative service to secondary care – for example an appropriate community service where the patient can go?
If all these questions are answered, the referral is approved. Fortis employ staff who are trained in using Choose and Book system and they book the appointment on behalf of the patient. Where appropriate, patients are offered a choice of provider.
Improvements so far
More broadly, this new referral model is a means to improving care for patients, rather than just improving the referral system alone. The benefits of this rigorous approach are apparent on many levels.
- Educational: Doctors get feedback about their referrals. If there is something missing, the doctor is asked for further detail. If the Gateway panel deem the referral unsatisfactory (ie, the referral is not reasonable), it is returned. This means that the doctors learn from the process and the quality of referrals improve.
- Training and development: Monitoring referrals by type help the Gateway team to identify areas where GPs may require extra training. For example, if referrals are being made increasingly to one particular acute service (such as migraines or other headaches) a secondary care clinician from is invited to provide a ‘refresher’ training course to GPs. This ensures GPs have the knowledge and confidence to make appropriate referrals and identify when a referral is unnecessary.
- Information and budget management: Referrals can be tracked more closely and acute costs can be challenged. Subsequently, hospitals have an incentive to prevent unnecessary follow-ups.
- Improving services and care pathways: Through improved data, GPs are made aware of the requirements for a service in real-time. This has led to setting up separate services away from the hospital. These community-based services not only save money and provide more tailored care but also are preferred by patients who frequently request to be referred to them rather than hospital services.
From a financial perspective, Fortis have demonstrated that they can manage their referrals effectively while spending less than the outturn of the 2007/8 outpatient budget that was used as a baseline. In the first year, Fortis reduced their secondary care first attendances and follow-ups by just under 10 percent compared to the baseline.
In the second year, there was a 15 percent reduction from the original baseline.
Currently it looks like Fortis will maintain this 15 percent reduction in the third year. Their plan is to tighten up the Gateway criteria a little more, which will potentially allow them to increase savings further.
Who else has contributed?
Getting buy-in from senior leadership across the health economy has been key to developing these new programmes and ways of working. The PCT Chief Executive was positive about Fortis’ plans and he engaged others to support efforts.
Individuals, such as the Wyvern’s service redesign contact at the PCT, have made a huge difference by providing encouragement, expertise and advice.
In particular, Fortis group members have been strongly committed and have worked hard to advance their agenda. The process has been both demanding and rewarding. There has been a need to balance patient care with commissioning activity. Different members have been able to focus on their niche areas of interest and expertise, therefore making the most of their skills.
One member described how well his colleagues have worked together – so much so that GPs frequently encourage their patients to visit other member GPs who have different skills and equipment so they can receive quicker treatment.
How will patients benefit?
The biggest benefits for patients are the choices that have become available through the services that Fortis has commissioned and the way they are referred to those services. A choice of services means more alternative community-based options, shorter waiting times, fewer trips to the hospital and better quality care.
A Fortis-commissioned Ear Nose and Throat (ENT) service is proof that patients and clinicians experience the benefits of commissioning.
Analysis of the Referral Gateway’s data showed that the number of monthly ENT referrals was higher than other acute referrals but stable. Based on this data and being aware of the associated costs, Fortis identified the need to explore how they could reduce the costs attached to these ENT referrals (and any potential follow-ups). After exploring the options, they commissioned two ENT clinics per week, away from the hospital.
An ENT specialist now holds ENT clinics at a facility set up by a private provider in the community. Patients can see the specialist within two weeks; they will be seen at the time of their appointment (because the specialist will not have a waiting room full of people to see); and the specialist has all the kit that he needs. As the specialist is out of the hospital, he is uninterrupted by phone calls, he has a dedicated nurse helping him and he has time to provide a thorough examination – almost a ‘one-stop shop’. If the patient still requires extra acute treatment – beyond what the specialist can offer in the primary care environment – they are referred appropriately.
What emerged from this new service is that ENT follow-ups fell from approximately 0.7 of a follow up to every new attendance, to approximately 1 follow up to every 15 first attendances – a massive reduction.
The ENT consultant is happy with this more efficient arrangement because he gets to deal with patients faster and more efficiently. It also means he can spend more time on treating the more challenging cases. Patients have also expressed their satisfaction (and often surprise) at being seen in the community and being treated first time, rather than having to attend a succession of appointments.
Overall, this new service means:
- Quality: reduction in waiting times, faster treatment, improved patient experience and quality of care and better patient outcomes
- Innovation: New solutions and ways of working, using new information technology and more joined-up, collaborative and holistic approaches to care
- Productivity: clinicians time is used more effectively and savings are made
- Prevention: a reduction in referrals, fewer acute follow-ups
Due to the success of this model, it has been rolled out and applied to cover gynaecology, urology, endoscopy and colonoscopy. What was once a pilot has now become a range of Any Willing Provider services.
Now that the Health and Social Care Bill has set out the details around structure and requirements for the ‘new world’, Fortis wants to move quickly. They plan to become a sub-committee of the PCT board by April 1 2011 so they can take control of a larger part of their budget and manage it in the best possible way.
This will mean doing things differently and Fortis plan to bring fresh ideas from other healthcare systems – in particular the US. Other countries’ experience and expertise will highlight ways that Fortis may be able to deal with the new challenges they face and improve their existing services and interventions.
Members of Fortis will continue to be open, flexible and work closely together. They’re aware that there will be a lot to learn throughout the next year and beyond, but having built strong foundations over the past three years, they feel fully equipped and confident that they are up to the challenges ahead.