CLINICAL IT
“Our local hospital has a caseload now that is far more complex than it was two years ago. Gateways take out the simplest stuff that used to sit in that pathway.”
Can an electronic referral gateway manage demand for secondary care and keep patients who don’t need to be in hospitals out of them? When implemented properly and with the support of GPs, the answer is yes, argues Simon Wootton, interim chief operating offi cer at North Manchester Clinical Commissioning Group, who has led the project to implement a gateway.
Standardisation and a single template
An important aspect of the gateway idea was to use one standard referral letter template – there used to be around 140 to select from – and to insist that the city’s three acute trusts used the one template.
Wootton decided to go out to market for the gateway software, and came across GP- owned Harmoni, based in Southampton, who had done a gateway for Hillingdon – which ultimately abandoned its referral gateway in the face of urgent care pressures, Wootton said, and noted that its own referral levels have gone back up.
Wootton said: “We commissioned Harmoni to do the Choose & Book for us, because the software meant you could use one standard template. Every week, the practice would get a report back on their referrals: what had
happened to them, where they’d gone. That was good for QoF and QP points.”
Clinical triage was subcontracted to Go To Doc (which now calls itself GTD), the local out-of- hours provider, with Manchester-based GP specialists doing the triaging. It was set up on a payment-per-referral basis, with referral letters sent via
NHS.net email with attachments for scans and so on.
Wootton said: “The triager could look at the letter and, assuming it was complete and everything was on it, could make a decision on whether it was suitable for secondary care, or CATS, or if it should go back to the GP with advice and guidance.”
Rejected referrals
About 5% of referrals ended up going back to the GPs, which unsurprisingly created tension. But Wootton said: “The amount of resistance was actually very small.”
He said he thought this was because of the long lead-up to implementing the gateway – having done the peer review and other exercises – as well as getting the LMC to back the idea, to an extent at least. The LMC thought it could improve quality of care, but doubted it would actually achieve any savings.
Wootton said: “It was no ringing endorsement, but we got the support. We couldn’t just enforce it – we needed a carrot not stick approach.”
The gateway was controversial for various reasons – the involvement of a private company, the location of administrative staff in Southampton, and the feeling that the service may have been outsourced unnecessarily.
But over the 18 months of that gateway being in place, from September 2010, it saved about £4-6m, triaging eight specialties, Wootton said. The referrals were screened fi rst for
completeness, then against the PCT’s non- commissioned policy, to ensure patients weren’t being referred for minor or cosmetic procedures that wouldn’t be funded by the PCT. The third stage was the clinical triage, all with a two-day turnaround time.
The new system
But then came the decision to bring the referral gateway back in-house, primarily for reasons of value-for-money and local expertise, rather than any concern with the service itself, Wootton said.
He explained: “Harmoni worked well, but the feedback was that it would be better to have it done locally. Booking staff in Southampton were very good and had a directory of services, but just didn’t know the idiosyncrasies of Manchester.
“I can’t fault them – they were very professional and I’d recommend them to anyone – but the feeling was we could do it cheaper in-house and employ local people to do it.”
He linked up with Accenda, and North Manchester CCG agreed to pay to implement their Integrated Care Gateway software.
He said: “The difference with this software we’ve got now is that you get live data. Under the old system, practices would get a referral report a week later: now, you can click and see exactly where your referrals are in the system.”
The system can automatically convert attachments to PDFs to ensure standardisation, and the software ensures compliance with standard codes and so on: “Practices can no longer just put ‘MRI’ for Manchester Royal Infi rmary, they have to put Central Manchester Trust, for example, so there’s been a jump in quality of letters.
cont. overleaf > national health executive Jul/Aug 12 | 47
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