The following article in Healthcare Manager magazine tells the story of our project with Stockport Together from the perspective of the CCG management’s contribution.
You can download a pdf of the article here: Healthcare Manager CC Article
“When I first started here 15 years ago, we had a lot of formal and informal meetings with GPs,” recalls Dr Ngai Kong, a consultant at Stepping Hill Hospital in Stockport. “We weren’t as stressed out as we are now, and GPs could phone consultants to discuss patients. We’re so time-pressured these days, there’s no time to have a natter. So those easy connections were broken, and nowadays I don’t know the GPs and they don’t know me.”
Dr Kong’s experience chimes with that of Julie Ryley, head of primary care development at Stockport Clinical Commissioning Group. Investigating variable referral rates among the CCG’s GP practices, she identified a “disconnect between the consultants and GPs which had been there for quite a few years”. CCG doctors expressed a “need for advice and guidance – not only for the GP, but also to reassure patients”.
With informal communication channels between primary and secondary care clinicians weakened by ever-growing workloads and structural reorganisations, GPs were dependent on formal referral systems – piling patients onto growing waiting lists for a consultant appointment. Many patients waited months for an appointment and then, on arrival, found they were in the wrong queue and were referred on for tests or passed to a different specialism.
As Kong says, in the “binary system – to refer or not to refer – there’s no room for resolving uncertainty in the grey areas”. So Ryley set out to find a way of reconnecting GPs with consultants – and thus of addressing those uncertainties and ensuring that each patient receives the right care.
A few months on, consultants at Stockport NHS Foundation Trust and GPs at the CCG’s practices are directly linked via a telephone advice service; and the early results are impressive. In the eight weeks to 15 April, GPs calling into the service reported that speaking with a consultant had avoided a referral in 59% of cases. In a further 11% they had requested diagnostics – ensuring that consultants had essential test results at hand when outpatients arrive at hospital.
“Now patients can get some reassurance without waiting 12 weeks to be seen,” comments Ryley. “And the people who do need to be seen will be seen quicker, because the waiting list isn’t full of people whose referral could have been avoided. So far, I can’t find a negative side to it.”
The new system, explains Dr Simon Woodworth – a GP in Stockport’s Chadsfield Medical Practice – has been introduced under Stockport Together, a major change programme designed to integrate health and social care, with funding from the Vanguard scheme. “So there’s a background which is about trying to improve interconnectivity and communications, and a strong management drive to not put barriers up,” he says. “There’s an appetite to do things differently.”
Woodworth became involved in the project when Ryley recruited him to test a system developed by a company called Consultant Connect. Each GP practice has a dedicated number they can call. Once they have entered the patient’s NHS number and the specialism required, the system calls the consultants listed on the day’s rota, so GPs can explain a patient’s symptoms and seek guidance on how to proceed.
“As a GP, it’s time-efficient. Rather than dictating a letter, I make a call – and we save time on administration,”
says Woodworth. “It’s also efficient for the patient: they don’t have to attend hospital for an appointment they wouldn’t gain anything from.” Kong adds that consultants can suggest diagnostic tests to ensure that patients are referred to the right specialism, and give GPs the confidence to prescribe specific treatments – shortening the wait until patients receive treatment by many weeks.
The system also asks GPs to record the outcome of each call, logs performance metrics, and saves a recording of each call into the patient’s records. “When you’re talking about the care of a patient, it’s very important to have clarity about what is being said between consultants and GPs,” comments Gill Burrows, the trust’s deputy medical director. “It was important that Consultant Connect store all those calls.”
Though both trust and CCG staff could see the potential benefits of Consultant Connect, it would never have got off the ground if health managers hadn’t identified and addressed people’s worries about the new system. “A GP’s concern is that they’re very busy, and if they’re going to make a call it’s important that it’s likely to be answered,” explains Jonathan Patrick, a director at Consultant Connect. “The consultants’ concern is that they might be inundated with calls. And it’s all very well talking about the theory, but does a call really help you to avoid an unnecessary referral?
“This is where management comes in, because they have to perform a very skilful dance,” he continues. “Everybody’s interested in people getting the right healthcare at the right time, but the trust wants to make sure its consultants aren’t overworked.”
Ryley adds that when the project was first mooted, the trust was on a payment-by-results contract – raising fears that if the system did indeed reduce referrals, the hospital’s income might fall. “The answer was: yes, it could,” she comments. “But consultants already take phone calls from GPs, they receive letters asking for advice – and that time’s not logged.” Using the new system, this kind of advice can be recorded and recognised; and soon the trust moved onto a block-booking contract, giving it a stronger financial interest in dealing with each patient as effectively and as efficiently as possible.
To address such practical concerns, Ryley and Burrows recruited a group of clinicians to test and pilot the system – checking its operation, and generating the evidence and confidence to get other medics on board. “Managers can win people’s minds by going through the procedures, doing their business cases, but to win hearts they have to convince everybody that it’s a good idea,” comments Patrick. “Even when you have a good story, that doesn’t mean it’s easy to communicate, and it’s the managers’ job to do that.”
These clinical leads included Dr Kong, a specialist in diabetes and endocrinology, fellow endocrinologist Richard Bell and GP Dr Woodworth. Then Ryley and Burrows organised meetings bringing consultants and GPs together: “And we could recount our own experience and reassure people,” recalls Kong. “My colleagues were worried about the time it could take, but it’s only a few minutes and you don’t have to take the call; if you’re busy, it gets passed on to the next person. It’s about finding those little windows of opportunity. A lot of work was needed in the run-up [to the launch] to demonstrate the system and make sure people understood what it’s about.”
With the system up and running for four trust specialisms, the performance metrics are reassuring: 76% of GPs are put through to a consultant on their first attempt, with an average wait of 40 seconds, and the average call time is just three minutes 45 seconds. Ryley is, though, trying to persuade GPs to stay on the line after their call to log the outcome. Currently, around half ring off as soon as they’ve received advice. “But unless I’ve got evidence that it’s a useful system, I might not get further funding,” she says.
Summing up, Patrick points to benefits on all sides. “For the CCG, there’s less unnecessary referrals so they spend less money. For the trust, the only people on the waiting list are people who need to be there. Consultants have less paperwork. And patients get the right care first time, with no unnecessary trips to hospital.”
Dr Woodworth adds that the system has exceeded his expectations and those of his patients: “Waiting two months for a letter to come back drives people daft,” he comments. “Patients want quick, effective communica
tions that tell them what they should be doing and when, and that’s difficult to achieve through the traditional models.”
Less tangibly, the system has begun to rebuild those crucial links between consultants and GPs. “There’s a softer benefit: a recognition between GPs and secondary consultants that the relationships that used to exist have been eroded,” says the trust’s Burrows. “It may be more difficult to prove the benefits of reconnecting those two groups, but there’s a clear feeling that renewing those links will ultimately give much better patient care”.
The Stockport Together programme, she adds, will “require a lot more integration across the whole of health and social care. And here we’ve seen a real willingness to work differently and across traditional boundaries that has been very encouraging; a much more open attitude from all clinicians to working differently.”
Ultimately, this kind of project only produces benefits when clinicians – of different disciplines, specialisms and organisations – come together in the interests of better patient care. But as Jonathan Patrick points out, it would never have been conceived, developed, piloted, tested or delivered without visionary, ambitious and pragmatic leadership by health managers within the CCG and trust.
“Without the managers, this project simply wouldn’t have happened, because all the clinicians are far too busy – and God knows how busy they’d be if they didn’t have the managers supporting them,” he says. “They could have let life carry on as normal, but they took the step and are now sitting on what looks like a very successful project. They are the unexpected heroes of the story.”
Asked to name the key figures behind this project, Dr Woodworth replies that the trust’s medical directors “drove it through the business managers within the hospital environment. It was incredibly important to have the foundation trust’s commitment to the idea.”
At the CCG, “Julie [Ryley] was the driver behind the project,” he adds. She developed it, championed it, produced the business case, took it to the board. And I sat on her coat tails, as any clinician will with a good manager.”
“The best year for the NHS, in terms of hitting all its targets, was 2006,” Woodworth concludes. “And that’s when it had the most managers – so I’m certainly not a convert to the idea that less managers equals a better NHS. And I’m a clinician, not a manager.”.