Why not find out why a process risks wasting money rather than add another process to try to check it, says Andrew Castle

Twice in the past few weeks I have been confronted by something that just does not make sense to me. The first was an explanation of how a clinical assessment service works.

Broadly speaking, the way it works is that a patient attends an appointment with their GP, who explains that they are being referred to a specialist in an acute hospital.

The patient is likely to believe that the 18-week clock is now ticking, unless it is explained that actually the clock does not start until the referral leaves a clinical assessment service.

The referral is forwarded from the GP to the clinical assessment service to be reviewed for appropriateness. From there it is forwarded to the acute provider.

The purpose of the clinical assessment, as it was explained to me, is to prevent inappropriate referrals. This is obviously a reasonable result, so on the face of it the service seems a good idea.

Delays and expense

But a few things make me wonder. The first is the cost, the second the delay, and the third is whether inappropriate referrals are such a problem that they warrant a third party inspecting every acute referral.

The problems highlighted to me related specifically to the fact that some GPs batch their referrals and send them over once a week. Once at clinical assessment they can take several days to turn around, and that delays the patient's journey.

That is even more undesirable if the service gets a decision wrong so that a very sick patient is not referred. Clearly it is better to send a well patient inappropriately than not to send a sick one.

The problems as I see it are the delay and the cost of preventing inappropriate referrals.

The people I was discussing this with thought that the level of inappropriate referrals was about 3-5 per cent.

Let's say the cost of processing a referral from the GP's office to the clinical assessment service and on to the acute is£100 in various people's time. If a service deals with 100,000 referrals a year the cost is around£10m; if both the cost and volume were halved the cost would still be£2.5m a year.

So we are spending between£2.5-£10m to save perhaps 10 per cent of referrals which are inappropriate.

If an outpatient appointment costs£100 and the referral that was inappropriate could be picked up there, we are spending£2.5m-£10m to save between 5,000 and 10,000 inappropriate referrals, which would cost between£500,000 and£1m in outpatient appointments.

This does not seem a particularly cost effective way of reducing the demand placed on acute organisations.

Pointless intervention

This brings me to the second thing I could not see the sense in: an organisation I came across that has implemented a strict purchasing procedure which will not allow anyone to place an order without it first having been countersigned by a manager who does not work in the area.

This new procedure was put in place in the past six weeks and the net result has been a 40 per cent increase in spend.

The underlying root causes to address in these issues are, in the first instance, inappropriate referrals due to a lack of training, competence, or other more complex factors, and in the second instance an inadequate process. Instead, we have put in a process at an exorbitant cost to address a problem that does not warrant a response of that level.

Perhaps problems, whether as big as these examples or something simpler, warrant eliminating their root causes rather than putting in place systems that cost time and money but add little or no value to the end user: in this case the patient or the balance sheet of an organisation.