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Not Choose and Book, but Choose and Consult


26 April 2017

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Primary care with capitation funding has a similar budget to outpatients, but an outpatient appointment costs more than four times as much as a GP one. Primary care, with a fixed budget, has a clear incentive to manage a patient in the most efficient way. Outpatients is incentivised to see a patient in person in the department, rather than manage the pathway and use communication systems to minimise the need for an appointment.

So how do we move to a system that encourages everyone to manage the whole population in the most cost-effective way?

Primary care with capitation funding has a similar budget to outpatients, but an outpatient appointment costs more than four times as much as a GP one. Primary care, with a fixed budget, has a clear incentive to manage a patient in the most efficient way. Outpatients is incentivised to see a patient in person in the department, rather than manage the pathway and use communication systems to minimise the need for an appointment.

So how do we move to a system that encourages everyone to manage the whole population in the most cost-effective way?

At present, a GP refers a patient to hospital by booking them into outpatients. Invariably the appointment is a few weeks later. Typically the referral letter is first read when the patient goes to outpatients and the GP’s tests will be repeated. Eventually a GP will get a letter from outpatients, but many weeks will have passed, the disease will have progressed and quite often the patient will have gone to other outpatient appointments, so all the varying advice needs to be managed by the GP.

In Tower Hamlets now, a GP can e-refer to a renal consultant and get advice back within two weeks, with the consultant being able to view the GP notes and blood test results remotely. There is no need for a patient to travel to the hospital. For skin lesions, the GP can take a picture on a phone and within days get advice back.

So here is the plan. No more Choose and Book; instead Choose and Consult. The default position of booking a patient into outpatients is as old-fashioned as going into your bank.

The consultant team will get an e-referral and can choose to send advice back, phone the patient or GP and if needed book an appointment. All GPs and consultants would have access to GP and hospital notes. There would be immediate triage by the hospital, the use of more management options, timely help for the GP and potentially half the visits to outpatients would be saved.

This would be a win for patients – fewer visits to hospital; a win for GPs – timely help; a win for consultants – the recreation of the consultant as an expert adviser. In a recent meeting of American professor Don Berwick and 100 clinicians from east London, one GP suggested putting up a statue to the consultant diabetologist who has already transformed care along this model.

For urgent advice, follow the lead of Barts hospital. All GPs have a direct line and can ask to be put through to a consultant on their mobile.

Payment by activity has no support among policymakers and clinicians. It leads to poor clinical pathways and financial controls. Accountable care organisations will hasten its demise but we can all play a part by stopping the default position of booking patients into outpatients, lifting controls on consultant-to-consultant referrals and putting outpatients on an equitable footing with primary care. It will bring back the close relationship between hospital and primary care clinicians and the focus on resolving patients’ problems as quickly as possible.

Dr Sam Everington is chair of Tower Hamlets clinical commissioning group, NHS England’s adviser on new care models and chair of the Healthcare Leader editorial board

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