This article describes how a primary care trust’s low clinical priority procedures were implemented by a clinical health psychologist working across primary and acute settings. 

The low clinical priority procedures policy is a local policy developed by Tower Hamlets Primary Care Trust (now the commissioning branch, NHS Tower Hamlets) to manage resources in the context of patients seeking procedures deemed to be of low clinical priority. 

The policy contains a number of procedures relevant to the plastic surgery department at Barts and the London Trust, such as breast reduction and excess skin excision. The policy was informed by Action on Plastic Surgery, Information for Commissioners of Plastic Surgery Services – Referrals and Guidelines in Plastic Surgery and an update of the North East Sector Inner London Primary Care Trusts’ Service Constraints Document – Guidance for GPs and Consultants 2001.  PCTs local to the acute trust have similar policies and all will be referred to as LCPPP.

The presenting problem

As a result of a commissioning led service improvement initiative, in May 2008 a clinical health psychologist was appointed by Tower Hamlets Primary Care Trust (now the provider branch, Tower Hamlets Community Health Service) to streamline the pathway of care for patients requesting bilateral breast reduction surgery at the Royal London Hospital. 

The post was hosted by Barts and the London Trust and the clinical health psychologist was integrated into the plastic surgery department, operating as a clinician with a remit to review service delivery. 

From the vantage point of being a clinician and fostering links with neighbouring PCTs, the clinical health psychologist reviewed the limited implementation of the LCPPP at both a community and acute trust level.  

Suboptimal implementation of the policy resulted in inadequate gate keeping by GPs and a high volume of poor quality referrals to the acute trust plastic surgery department for restricted procedures. 

Referrals often did not show evidence of reference to the LCPPP, nor outline exceptionality or availability of funding. Outpatient clinics were overbooked, and patients listed for surgery without reference to funding. Theatre capacity exceeded demand resulting in extra surgical lists organised in the private sector in order for NHS treatment targets to be met. Patients’ expectations were raised inappropriately by inconsistent management approaches. 

Confusion regarding the policy was evident at all levels. Some patients were being treated without the proper funding route being followed, resulting in an inequity of service delivery.  Due to the absence of a feedback loop, funding panels in neighbouring PCTs had a limited awareness of these difficulties.

On assessment, the limited policy implementation appeared to be due to multiple factors including: policy ambiguity; the policy not being linked to the reality of clinical practice; poor compatibility with relevant operational guidelines such as 18 week referral to treatment targets and patient choose and book systems; low level understanding of the policy by clinicians at both community and acute trust level; an over-reliance on clinicians saying “no” to distressed patients in time pressed consultations and no audit infrastructure to ensure policy adherence.

The intervention

The ProblemsThe Intervention
The policy involved multiple disconnected health systems.
  • Links were created between the multiple systems ie: acute trust, local PCTs and the exceptions treatment panel.
There was no audit to assess policy adherence.
  • Audit processes were instigated.
  • Administrative systems were adjusted to promote effectiveness.
Funding panels were “out of the loop”.
  • A transparent referral screening system was implemented in the plastic surgery department, redirecting GP referrals to the funding panel in the first instance.
There was a lack of supporting resources for clinicians and administrators.
  • An easy reference guide about the policy was created with agreement from the funding panels.
  • A reference guide was made available in clinic settings.

The outcome

Within the plastic surgery department there was an increased understanding of the policy and a clarification of roles and responsibilities of implementation. Where difficulties existed the clinical health psychologist was available to provide clarity or a direct link to the funding panel. Audit processes were initiated from which the results below are drawn.

As a result of the referral screening system and internal process policy, in a five month period 80 inappropriate referrals were redirected back to GPs to approach their funding panel.  Premature outpatient contact was prevented in 56 per cent of cases (n = 49 x £128 = £6272 cost saving), and partially in 30 per cent of cases. This reduced outpatient clinic burden, reduced the risk of inappropriately raised patient expectations and was cost saving.

Clinicians and administrators made good use of the easy reference guide, and consistency in patient management was improved. A comparison was made between the management of new patients presenting for low clinical priority procedures in May 2008 and May 2009. This reflected patient management before and after the change in practice. Those patients identified had their care tracked forwards and backwards to assess their total management burden. Graph 1 (right) shows the results.

Total first patient attendances differed by 40 per cent, with a lower frequency of initial appointments being offered in May 2009. Follow-up appointments differed by 93 per cent with a lower frequency being offered in May 2009.  New patients presenting in May 2008 for low priority procedures were offered 74 follow-up appointments, had 46 non attendances or cancellations, 14 hospital admissions, 34 nights in hospital and evidence of PCT funding was found in just one case. 

In contrast, follow-up appointments were minimal for patients presenting in May 2009, admissions were minimal with no associated nights in hospital and where a funding application was appropriate this was indicated in discharge letters to patients’ GPs. In time it is expected that any hospital admissions associated with low priority procedures will be accompanied by evidence of funding approval. 

The service manager for plastic surgery has confirmed that the match between theatre capacity and theatre demand is much improved with targets being met and no additional lists have been arranged to date.


At an acute trust level the implementation of the LCPPP has resulted in increased theatre capacity, increased clinic capacity, a decrease in patient non-attendance rates, consistent patient management, the containing of patient expectations and health economic benefits. The referral screening system ensures that the correct funding route is adhered to across all PCTs. 

While great gains have been made in the acute trust which result in positive knock-on effects in the community, still more improvements could be made at a community level to improve the management of patients seeking surgery for low clinical priority procedures. This work is now in progress.

Related files/tables