My practice, the Mount View surgery in Fleetwood, has been successful at significantly cutting healthcare costs through practice-based commissioning (PBC).
This is despite commissioning on our own rather than jointly with other practices. We have a PMS contract and 13,000 patients. In 2005/6 we managed to save £500,000 through reduced use of secondary care.
Wyre PCT (now part of North Lancashire PCT) nominated us as a 'pathfinder' practice for PBC. We worked with the PCT to ensure a common-sense approach was adopted on data collection, service developments and financial flows.
All team members were invited to contribute towards the two main areas of our commissioning plan - making savings against the budget and service development. We identified clear savings opportunities in the prescribing budget and in secondary care referrals.
In 2005/6, we reduced prescribing spend, equal to approximately £170,000, by about 8 per cent. This underspend against the prescribing budget continues to date. The saving could have been much greater. However, to implement local and NICE guidelines, we invested about £190,000 in the increased use of medicines for heart failure, COPD and osteoporosis.
PCT data for 2004/5 showed that the practice was already 10 per cent below the local average for outpatient referrals and had the lowest referral rate of any practice in the PCT. We were confident that this could be reduced further and concentrated on three specialities: dermatology, general medicine and orthopaedics.
One of the practice's GPs became an accredited GPSI in dermatology and a skin clinic was commissioned and developed. In the first 12 months, secondary care referrals fell by 32 per cent. The following year saw a 50 per cent reduction.
We used a multi-disciplinary team approach to commission and develop a clinic for improved management of patients with chronic pain. This led to a 10 per cent drop in orthopaedic referrals in the first year and 20 per cent in the second year.
General medicine referrals fell as a result of improvements in nurse-led clinics for diabetes, IHD and COPD.
In 2004/5, we had the lowest emergency admission rate at 12 per cent below the PCT average. The two specialities with the highest emergency admission rates (excluding mental health) were general medicine and orthopaedics.
With general medicine the majority admitted had a pre-existing condition, particularly COPD or/and vascular disease.
Most patients also had a concomitant mental illness, especially depression. Our approach was to optimise management of these conditions within nurse-led practice clinics.
As to the emergency orthopaedic admissions, a significant number of patients were admitted with osteoporotic fractures.
We felt we could reduce these admissions by implementing NICE osteoporosis guidelines and linking them to a falls assessment. In 2005/6, we reduced the rate of admissions by 11 per cent.
Emergency admission rates
We identified the 30 patients with the highest emergency admission rates and put in place practice-based case management of each individual. There was a 3 per cent drop in our general medical admissions compared to PCT-wide increase of 8 per cent and an overall reduction in our secondary care spend of approximately £500,000 for 2005/6.
The savings generated have enabled the practice to commission and develop a primary care mental health service.
Local GPs refer patients to a mental health team which takes on the management of those patients by offering a range of 'talking' therapies. This has led to a 50 per cent reduction in referrals to our care trust as well as a fall of £30,000 a year in antidepressants expenditure.
Our practice is approximately £1.3 million below a 'fair share' budget and the PCT has accepted that the practice will move towards its fair share allocation over the next three years.
This will enable us to add a minor injuries unit, DVT assessment and day-ward facilities for intravenous therapies at the local community hospital.
Dr Spencer is a GP in Fleetwood, Lancashire
Practice snapshot Mount View Practice
13,000 patients in a highly deprived area of Fleetwood, Lancashire
- Seven GPs.
- Other healthcare professionals including a pharmacist and mental health team.
- Life expectancy in males of only 67 years.
- High prevalence of long-term conditions, including vascular disease, chronic respiratory disease, substance misuse and mental illness.
- Took on PBC budget in april 2005.
- Drugs bill cut by 8 per cent per annum.
- Orthopaedic admissions down 11 per cent.
- General medical admissions down 3 per cent (PCT average up 8 per cent).
- £500,000 total saving in 2005/6 by reducing use of secondary care.
Reducing emergency orthopaedic referrals
|Healthcare resources groups*||2005/6 referrals||2006/7 referrals|
|H39 fracture upper limb over 69||10||4|
| H37 fracture lower limb age 70|
| H87 fracture neck of femur (NOF)/hip|
replacement with complications
| H36 fracture lower limb over 69|
| H88 other fracture NOF|
|H40 fracture upper limb under 70||7||9|
|H45 minor fractures||4||6|
|H86 fracture NOF/hip replacement||1||3|
|H82 fracture NOF with fixation||1||0|
|H83 fracture NOF with fixation||1||1|
|H89 other fracture NOF with complications||1||1|
|H53 pathological fracture||1||0|
|H29 hip dislocation/open reduction||1||0|
|H85 intracapsular fracture NOF||0||1|
|H99 complex elderly with musculo-skeletal||8||9|
|*National tariff codes for Payment by Results|