Care pathway - Dermatology pilot is successful

Dr Sarah Heyes describes how going private does not necessarily mean a more expensive service.

Dr Heyes: dermatology meant we ‘could flex our commissioning muscle’
Dr Heyes: dermatology meant we ‘could flex our commissioning muscle’

The borough of Redbridge in north-east London introduced GP commissioning a year ahead of the government's health White Paper with the creation of five area-based 'polysystems'.

We have enjoyed a number of successes, including a dermatology pilot which offers a cheaper, more effective service than its predecessor as well as minimising secondary care referrals and improving the patients' experience.

Skin complaints are a common condition facing GPs and it seemed an appropriate area in which to flex our new-found commissioning muscles.

Finding an alternative
The challenge was finding an alternative to the GPSI-led service, which despite the best of intentions offered slow referrals and an over-reliance on secondary care intervention.

The 12 practices in Wanstead - an area within the borough - had expressed concern about the service and our polysystem offered an ideal pilot.

Many GPs have long held the belief that they can design more effective care pathways than PCTs and this was our chance to put that into practice.

Our goal was simple. We wanted to provide a cost-effective local service delivered by a level three dermatologist.

The capacity to provide more services closer to home is one of the cornerstones of GP commissioning in Redbridge, offering patients the convenience of local treatment, and commissioners a more streamlined and cost-effective solution.

Going private
We employed a private healthcare provider during the three-month pilot, which treated 36 patients at six clinics between July and September 2010.

The company provided an inclusive package, including a dermatologist, administrative support and a detailed cost, performance and patient satisfaction analysis.

We often focus our efforts on clinical input without fully appreciating the role of good administration. It is obvious advice but often a pinch point where problems occur, such as misplaced files.

My initial advice to fledgling commissioning groups is to have a clear picture of what you want to achieve and start with something small and manageable.

The support of local practices is essential along with a solid evidence base of proven results. It's a case of test, consolidate and move forward. This approach has proved successful in Wanstead and the pilot has now been rolled out across the rest of the polysystem, which has a population of 70,000.

It is also important to set parameters and we made it clear that patients could not expect referrals as a matter of course and that the focus was on treatment in a primary care setting in all but the most serious cases.

This was well received and I think patients appreciated the commitment to a neighbourhood-based solution.

The original pilot had a clinical inclusion list of 12 conditions, including eczema, psoriasis, acne and rosacea, while exclusions included melanomas, squamous cell carcinoma and cosmetic surgery.

Every patient was given an appointment within four weeks with no referrals to secondary care, a low DNA rate (8 per cent), minimal prescriptions (15 items totalling £81.76) and minor use of cryotherapy.

Good service
The majority of patients said the service was good or excellent. The pilot was also provided at 75 per cent of the national tariff for new patients and 25 per cent for follow-up appointments. Minor operations cost £150 compared with the hospital charge of around £500, while basal cell carcinoma excisions cost £350 compared with £500-£3,000.

The total cost of the pilot was £6,716 compared with the projected cost of £11,532 if the prior arrangement with the hospital had remained - saving more than 40 per cent.

A further comparative cost saving model that matched the pilot against previous costs for the period from November 2010 to April 2011 found a saving of £33,800 providing evidence that the use of private healthcare doesn't necessarily equate to higher charges.

It certainly challenges preconceptions about the comparative cost of public sector versus private sector healthcare provision.

Mention of the word 'savings' in the same breath as the NHS is akin to an act of heresy in some quarters but it is time we started challenging some archaic preconceptions.

Exciting time
I believe there is enough money in the health system for everyone to receive the right treatment if there is a sea change in both professional and public attitudes.

In Wanstead, we invite secondary care clinicians to meet local GPs on a regular basis and explain the issues they face and how we can work together to better manage patient loads and referrals.

We have found these information sharing events useful and they serve to strengthen the link between primary and secondary physicians. Our GPs also get together to share best practice with one another which strengthens our capacity to problem solve on a local level.

Likewise, the public has to realise that the NHS has finite resources and misuse of services like A&E cannot go unchecked.

In north-east London, we know a high volume of patients turning up at A&E would be better treated at urgent care and walk-in centres yet many continue to use the service. In Wanstead, we have a record of everyone who goes to A&E and ring patients whose attendance is questionable.

We highlight the alternatives and the fact that going to A&E costs £59 per patient irrespective of the treatment.

I have found patients appreciate this personal touch and are often shocked by the cost and the fact that it means less money is spent on local healthcare.

Often I am struck during the commissioning process by the danger of making assumptions of what people do and do not know and the confusion and problems this can cause.

GPs spend a lot of time working in the isolation of a consulting room and we have to learn to share what we know with other providers and the public so we move forward together.

It is an exciting time to be working in the NHS and a great opportunity for positive change if we are bold enough to take it.

  • Dr Heyes is the clinical director of Wanstead polysystem in north-east London

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