Informatics - Robust data underpins pathfinder

NHS Bexley's focus on patient data analytics aids consortium development, says Dr Sid Deshmukh.

Evidence suggests that, armed with appropriate information management tools, GPs are well placed to deliver the key aims of the NHS reforms.

Over the past year or so, Bexley NHS Care Trust has built on its established principles of practice-based commissioning (PBC) and, with the help of an analytical information program solution, has delivered millions of pounds in NHS cost savings.

The care trust and now in shadow form, our pathfinder GP consortium Bexley Clinical Cabinet, are responsible for approximately 230,000 people.

In 2006/7, the care trust faced a deficit of around £20 million on a turnover of £260 million. Bexley's ageing population had led to a high demand for services for diseases associated with older age and has had a big impact on the local health economy. Consistent overspending in secondary care was largely driving the deficit.

There were high volumes of uncontrolled hospital admissions and acute providers' accounting processes had led to regular instances of overcharging. To address this, the care trust sought to bolster its claims management system, and to give local GPs increased commissioning powers.

  • In April 2010, Bexley NHS Care Trust reported its third successive operating surplus, completing a significant turnaround in its financial performance from the deficits of the previous four years.
  • In 2009/10, £10 million in cost savings were delivered, with the prospect of more to follow.
  • The 'Bexley experience' is compelling evidence that GP consortia can work and impact positively on patient care.

Awash with data
GP consortia represent the best chance of improving services but the right level of support is necessary. The NHS is awash with data, but has generally lacked good information.

Giving clinicians the right information enables them to make appropriate and cost-effective commissioning decisions.

In April 2009, the care trust successfully piloted a performance analysis informatics system with wide-ranging functionality. Key objectives for the project included a reporting and analytics system to support PBC by providing GPs with easy-to-access data on areas such as pharmacy, QOF targets, budgets and inpatient activity.

Alongside this, the system analysed community activity, identifying and monitoring projects designed to move treatment pathways from acute to primary care.

GPs can focus on 'frequent flyers' - patients admitted to hospital more than twice within 12 months - and consider if being treated in the community would be more cost-effective. Referral patterns can be monitored to identify opportunities for service redesign and commissioning new services to alter patient pathways away from expensive acute care.

The demand management group, which was developed to meet the needs of Bexley GPs following comprehensive consultation, has redesigned clinical pathways in cardiology, ambulatory services, COPD, cancer, diabetes and anticoagulation.

Data analysis has also shown that frequent flyers tend to be from certain groups - for example, inpatients who have had falls may need extra support at home and care or occupational therapy on discharge from hospital. This has driven service re-design to save costs.

The intelligence gathered showed that some care homes were sending large numbers of patients to A&E in the middle of the day when GP surgeries are open. To address this, we set up a care homes group where GPs and care home managers met to share ideas, protocols and policies, establishing best practice across the trust.

Identifying and case-managing frequent flyers results in significant cost savings, and just having the ability to identify them is a start.

  • Bexley Clinical Cabinet was one of the first eight pathfinder consortia to be approved in London.
  • Its geographical area is the London Borough of Bexley in south-east London.
  • Membership is 29 practices and patient population is around 230,000, covering the same area as Bexley NHS Care Trust.
  • Local GPs had started working collaboratively with the care trust and Bexley Clinical Cabinet was in existence before the White Paper Liberating the NHS was published in 2010.

Overspending practices
Bexley Care Trust's medicines management team was also able to look at additional prescribing data generated by the informatics program and, if practices are overspending in a particular area, this can be addressed.

Practices were tasked to review the use of liquid preparations. Some GPs were prescribing liquid preparations costing up to 60 times the tablet alternative. Simply reviewing spend on liquid preparations and reducing the prescribing of them could save a substantial sum.

Peer review at practice level is undoubtedly the best way to get GP engagement and GP consortia need to see the detailed activity and expenditure behind it. The system works because it was designed by GPs for GPs.

In an NHS facing a radical overhaul and significantly challenged by the need to find significant efficiencies, time is critical. The emergence of GP consortia to drive NHS commissioning means PCTs must act now to create a legacy of information to help GPs succeed with their new commissioning responsibilities.

  • Dr Deshmukh is a GP in south-east London and clinical lead for Bexley Care Trust

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