CCG IT: Standing Sentinel

Maximising use of Choose and Book may not be the number one priority for all emerging clinical commissioning groups; but for one it has had a transformational impact.

The Sentinel Healthcare clinical commissioning group  in Plymouth began proactively using the e-booking service in 2008 – when it was in its early days as a practice-based commissioning consortium – and has gone on to build it into its wide-ranging strategy to use IT to improve healthcare.

Referrals down, money out?

The consortium‘s initial rationale for use of Choose and Book was to deliver more ownership on elective demand.

GPs were encouraged to send all referrals though Choose and Book to a consortium-run clinical assessment service for peer to peer review.

Since those early days, consultants from Plymouth Hospitals NHS Trust have come on board to assess referrals via Choose and Book and provide advice to referrers if an outpatient review is not considered necessary.

Dr Peter Rudge, chairman of the Sentinel CCG, describes such use of Choose and Book as “a light bulb moment” that enables patients to get the best service and avoid unnecessary trips to hospital while saving money for the health service. Knowledge is shifted from consultants to GPs and ultimately to patients and the public.

He adds: “Consultants feedback electronically to the surgery and might say ‘you need to do x and y’ and ‘here is a back-up plan’. It is about co-management of the patient which can really transform healthcare.”

The figures from Sentinel speak for themselves. In July 2009, about 85% of referrals were being seen in secondary care, but 12 months later that figure had fallen to 80%. At the same time, the percentage of referrals dealt with in primary care increased from 13% to almost 20%.

Dr Rudge says up to 60% of first outpatient requests in some specialties have been cut where the specialities are run by what he describes as “really good, engaged consultants.”

With the cost of managing referrals in primary care often half the cost of the same patient being seen in secondary care, the savings potential is clear. “It gives you an idea of the scale of the waste,” he adds.

Dr Rudge says Sentinel’s clinical assessment service has also shown that demand is not going up. Demand, he says, remains fairly static – contrary to popular belief – although he acknowledges that “it’s very hard to get that message out.”

If outpatient attendances to hospitals fall, the obvious next step is to reduce payments to hospitals. For many, this has been a step too far but Dr Rudge says Sentinel is contemplating this as part of its plans to shift resources from hospital-based care to secondary and primary prevention and self-care.

He adds: “Are we brave enough to do that? I think we are. I think we are going to take the money out.”

He argues that without such a step “people will find a way of generating activity” and points out that, for example, follow-ups remain outside the control of general practice.

Getting patients to the right place

Hand in hand with Choose and Book goes Sentinel’s use of Map of Medicine. The CCG has put Map of Medicine on every GP’s desktop, with localised pathways that are built into hospital contracts.

Clinician groups of GPs and consultants have worked on the development of the localised pathways to improve treatment episodes for the patient from first referral to ongoing management needs.

Dr Rudge highlights the potential of the system to reduce variability and ensure patients get the same service time and again.

He adds: “It’s a single reference point for referrers and receivers who are able to decide together as a clinical community what all the pathways are and which patients should be let through.”

The CCG also plans to incentivise use of Map of Medicine by GPs by giving credit points for revalidation to those who use it.

In addition, the CCG is using a US-devised IT tool called MCAP (Managed Care Appropriateness Protocol) to help make sure that patients are treated in the right place. The tool aims to assess the appropriate level of care for patients and therefore where that care should be provided.

Dr Rudge says an audit run at the acute hospital in Plymouth has already shown that 21% of non-elective or emergency admissions could have been managed elsewhere, including 12% where patients could have been managed in their own home.

Dr Rudge says MCAP has proved a powerful too; particularly for a hospital like Sentinel’s main provider which is in the foundation trust pipeline.

He adds: “It’s been a great catalyst for getting people and things to move on and show that it’s not good enough at the moment. To imagine a fifth less beds and patients out more quickly is a total change in the culture of commissioning and provision.”

The MyPOD generation

Like many other CCGs, Sentinel recognises that sharing information electronically will also be key to its success and plans to go out to tender for a portal in April. Dr Rudge says Sentinel wants a live electronic consulting record that is visible for all those involved in a patient’s care.

Dr Ridge says Plymouth has taken up the Summary Care Record but argues that it is “not a fluid usage clinical tool” although he says it has helped to start the debate with patients about sharing records.

The CCG’s ultimate aim is to develop a patient-held record for its population. Dr Rudge says the group is currently exploring how it might do this as part of the local authority’s online directory, which he describes as “brilliant”.

The Plymouth Online Directory (POD) has been designed as a one-stop shop to make information more accessible and give residents greater choice and control over the services they want to use.

The CCG hopes that patients might ultimately be able to use MyPOD webspace on the online directory to see their GP record, along with health promotion data and whatever else the patient chooses to include – such as personalised budgets, personal care plans and so on.

Other IT plans the CCG has on its list include use of middleware to connect GP practices more intelligently to the laboratories and tests ordered in general practice, use of telehealth and telemedicine for a community-based crisis response service and use of population-based risk stratification tools to identify patients at risk of admission.

While in many ways Sentinel is well advanced on IT. Dr Rudge argues the NHS remains “light years off the pace on IT” so Sentinel’s IT to-do list is unlikely to get shorter any time soon.