Andy Newton explains how practice-based commissioning helped achieve effective service redesign at Bath and North East Somerset.primary care trust

Andy Newton explains how practice-based commissioning helped achieve effective service redesign at Bath and North East Somerset.primary care trust

At Bath and North East Somerset.primary care trust,.the lower gastrointestinal scopes project is a good example of engaging with GPs and secondary care to address a capacity problem and redesign a pathway.

We have reduced the waiting list from more than.800 patients waiting for more than.nine months to around 70 over six weeks. This has been achieved in seven months with considerable support from GPs, practices and secondary care.

To address a significant backlog for colonoscopies at the Royal United Hospital in.Bath, the PCT included service redesign and clinical validation for colonoscopies in the practice-based commissioning plan for 2006-07. GPs worked closely with secondary care consultants to develop a clinical validation process and redesign the pathway for referral into secondary care.

GPs, the PCT and secondary care are hugely encouraged by the progress that has been made with this project, using PBC to provide an incentive for service redesign. Much has been thanks to the learning that has taken place through discussing the issues in depth between primary and secondary care, and the willingness of GPs to support the project through PBC.

In addition to.getting most patients who had been subjected to long waiting times.treated and ensuring that waiting times at the acute trust are significantly reduced, the project has given valuable information to allow GPs to change the pathway for this group of patients.

Changing circumstances

Around half of the validated patients were removed from the list for either administrative or clinical reasons. Considering that the list was validated administratively 12 months ago, this was a surprisingly high number. It suggests that there are a significant number of patients whose symptoms improve over time without requiring a colonoscopy. Of the half who still required a procedure, 40 per cent had their scope undertaken at Shepton Mallet treatment centre in August 2006, thanks to the speedy return of the GP validation forms in July.

Many of the patients still requiring a procedure are surveillance patients. Half of the non-surveillance patients were suitable for a flexible sigmoidoscopy or barium enema rather than a colonoscopy, although they had originally been listed for a colonoscopy.

This has opened up options for alternative ways to manage these patients. The project has demonstrated one of the things we had discovered in discussion with the gastroenterologists - that GPs, with their broad knowledge of patients' symptoms, circumstances and history, can be better placed to make some of the initial management decisions than secondary care specialists..

The current system of referring patients with some indicated symptoms for triage by the gastroenterologists has led to a tendency towards intervention, when sometimes an opinion is really what is required. So we have taken the learning from the project to make changes to the current referral process and pathway for lower GI scopes.

Treatment options

GPs are now directly involved in triaging patients and identifying preferred tests before referral into secondary care. This gives GPs and patients a choice of procedures and providers. GPs, in discussion with patients, now indicate either the required procedure or outpatient consultation. Some patients who wish to be seen at Shepton Mallet treatment centre and are clinically suitable will be offered this choice, providing a minimal wait for patients..

Other patients are added to the Royal United Hospital waiting list. This also allows us to understand the demand for the various diagnostic lower GI scopes and plan for any alternative community services that might be required in the future.

The results of the audit also indicate that it would be best practice to audit all patients who are still waiting after a certain period of time to ensure that they still require a scope, thereby avoiding.the dangers of unnecessary intervention.

We are therefore establishing a system of validation to ask GPs to confirm that the patient still requires a procedure after they have been on the list for six weeks..Initial work indicates that 15 per cent of patients can be removed with clinical validation six to eight weeks after referral for a scope. This raises interesting questions as the health community seeks to understand the effects of reduced waiting lists in preparation for 18 weeks.

Andy Newton is commissioning manager at Bath and North East Somerset primary care trust.