CLINICAL IT
The Gatekeeper A
ll PCTs have been trying to manage demand for healthcare to cope with
budget pressures – but simply rationing care is not the only way forward, and many have used referral gateway systems to try to triage care more appropriately.
In Manchester, ever more sophisticated referral gateway systems have been implemented over the last few years, the newest of which has been in place since April and offers instant access to data.
Across the UK, referral gateways and referral management centres have been controversial among GPs and were criticised in an infl uential King’s Fund report in 2010, as they are felt to reduce patient choice, undermine and inhibit GPs’ professional decisions, create barriers to care and tend not to be cost effective.
But Manchester’s experience has been different, according to project leader Simon Wootton, now the chief offi cer at North Manchester CCG, who said that to understand the system now in place, a little history lesson is needed.
Peer review
When Wootton joined NHS Manchester, originally as an Associate Director of Commissioning, four years ago, activity was just beginning to outstrip budget – and it was at that stage that the PCT decided to put more pressure on GPs to improve and reduce referrals.
A peer review incentive scheme for referrals was instigated – as recommended by the King’s Fund – and had some success in educating doctors, but it ultimately had “very little effect” on reducing demand for secondary care in Manchester, Wootton told us.
He explained: “Practices were paid and incentivised to reduce referrals, and were to review their referrals – which often came two months later because it was based on hospital
46 | national health executive Jul/Aug 12
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SUS data. Often it was too late – the referral had been done – and though the practices may have looked at what came and thought, ‘yes I could have sent it there instead’, when the next referral came along, they didn’t do that. So the peer review didn’t have the effect that we wanted.”
That trial had two components – using the hospital data in combination with the NHS number to fi nd out what had happened to referrals, and also trying to reduce outpatient demand by using alternative and Tier 2 services.
Following that nine-month trial in 2009/10, the city’s three Practice Based Commissioning Consortia (PBCs) and the PCT began to discuss other methods to manage demand.
Gateway trial
After extensive discussion, four practices in the South Manchester PBC decided to trial a referral gateway scheme and did so for fi ve months, with referrals going through the existing booking team in Manchester.
The trial data looked good from a demand management point of view: 13% of activity was diverted, either to the CATS (Clinical Assessment & Treatment Services mobile units, provided by Care UK), to Tier 2 primary care services, to the former Greater Manchester Surgical Centre, discharged back to the GP, or re-referred as suspected cancer.
Wootton said it was particularly important at the time to get better use out of the CATS vans: “We had to pay for it whether we used it or not, and we were utilising only about 35% of capacity – so it was important to get better value for money out of it. It was clear that some of the community services we had in place weren’t actually being used.”
The results of the gateway trial were discussed at a high level among the city’s health leaders, and a decision was made to look at a proper referral gateway for all of Manchester.
Wootton, who offered to lead the project, said: “At that point, we looked at using the Manchester booking team to do it for us – but thought we lacked the software to do what we wanted, because we wanted to divert activity but also do advice and guidance back to GPs. Often, on a lot of the referrals that were being looked at, more could be done in primary care.”
He said the quality of referrals also left much to be desired and needed to be improved: “The clear feedback from hospitals was that poor referrals were coming in. I’ve seen some horrifying letters to hospital consultants over the years: ‘Dear doctor, this patient has hypertension, please see’. No history – nothing.”
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