Clinical commissioning groups have only been statutory organisations for a few months, yet GPs are already aware of the large scale changes they can bring about to benefit patients and make the system more efficient and sustainable, says Dr Howard Stoate
In the past, a GP would try to find a service that best met the needs of their patient; you would see a patient with a problem and hunt around for a service that might be right for them.
Compare that to the new health world, where we’ve turned this process on its head: now, GPs work with consultants and patients to design the service tailored to the patient’s need.
This is making the system much more efficient. As a GP I spend less time scouring around to find a suitable service for my patient and my patient receives a more holistic package of care. In Bexley, more than 25 per cent of GPs are using their clinical skills to improve patient care.
The co-commissioning triangle
Clinical input into redesigning services is crucial because if we do not get it right, the whole system can fall apart. I think of the co-commissioning process as a triangle.
The three parts are clinical need, affordability and capacity. As clinical commissioners we have to balance the triangle to ensure that the clinical need is matched with resources and capacity, in order to deliver patient centred services. If we do not, it can lead to instability, unaffordability and patient dissatisfaction.
A true partnership is that of patient, commissioner and provider, all working together to improve outcomes.
‘It is imperative that we encourage GPs to become clinical leaders’
Take our musculoskeletal pathway − it is fragmented, disjointed and multiple providers deliver different parts of the service. We believe we can make this service more efficient and meet the needs of our patients in a more joined up way.
Two GPs in Bexley are leading the redesign of the MSK service. It is a big responsibility. We spend about £15m annually on inpatient electives, outpatients and community based MSK services. MSK is also the clinical commissioning group’s largest quality innovation productivity and prevention scheme.
Using their insight of the MSK pathway with patients, our GPs have established that services need to be more integrated and provided by a single organisation. This way the patient is directed automatically to the right part of the service. It joins everything up.
Everybody gains, the GPs get a better service, the patients get a far more rapid and better outcome and the system saves money on wasted appointments.
‘Clinical leads are redesigning the cardiology pathway with a focus on outcomes rather than activity’
It is imperative that we encourage GPs to become clinical leaders. I’m not saying all GPs should become commissioners or managers; this is about GPs being GPs and being clinical leaders, supported by commissioners and contractors. GPs will design what the service will look like − how that is translated into a contract is not their responsibility.
Heart of change
Another example of a service redesign being led by our GPs in Bexley is cardiology. Cardiology is our second biggest QIPP scheme − we spend around £12m on cardiology services annually.
We currently have a multitude of services − community cardiology clinics, rapid access chest pain clinics, consultant referrals in secondary care and accident and emergency and urgent care. We also have patients in hospital for other reasons and it transpires they have a cardiac problem and are referred within the hospital.
Our clinical leads are redesigning the cardiology pathway with a focus on outcomes rather than activity. Patients with a cardiac problem will be put into one system and directed to the right part of it.
‘I am optimistic about the future. Knowing my fellow colleagues are willing to sign up to the clinical commissioning challenge is promising’
This approach will not impact any elements of the service that already work well and are valued by patients and GPs.
Local GP surgeries offer weekly specialist cardiology clinics and a rehabilitation scheme is also provided in the community. Patients are seen within a week of being referred, rather than having to wait at least eight weeks. Patients are sent for a CT scan instead of angiography − those with normal results return home and patients in need of intervention are treated promptly.
The service is improving patient outcomes, with satisfaction levels approaching 100 per cent, as a result of the service being more convenient, accessible and quicker than previous referrals.
The clinic also acts as a one stop shop for residents and reduces pressure on local hospitals. It has already resulted in significant savings against traditional outpatient angiogram pathways, more accurate diagnosis where patients are prevented from having an unnecessary angiogram, misdiagnosis and the prevention of further consultant visits.
The redesign of cardiology services using this approach will improve the community cardiology scheme. Instead of inappropriate secondary care referrals, or inappropriate access to accident and emergency, patients will be directed back to the community cardiology scheme.
In the last three months we have learnt a lot about the work our clinical leads are undertaking, and now we want to make sure we support them more in the future.
I am optimistic about the future. As chair of NHS Bexley Clinical Commissioning Group, knowing my fellow colleagues are willing to sign up to the clinical commissioning challenge is promising.
Dr Howard Stoate is chair at Bexley Clinical Commissioning Group