Health Service Focus

The Gatekeeper

Can an electronic referral gateway manage demand for secondary care and keep patients who don’t need to be in hospitals out of them? When implemented properly and with the support of GPs, the answer is yes, argues Simon Wootton, interim chief operating officer at North Manchester Clinical Commissioning Group, who has led the project to implement a gateway.

All PCTs have been trying to manage demand for healthcare to cope with budget pressures – but simply rationing care is not the only way forward, and many have used referral gateway systems to try to triage care more appropriately.

In Manchester, ever more sophisticated referral gateway systems have been implemented over the last few years, the newest of which has been in place since April and offers instant access to data.

Across the UK, referral gateways and referral management centres have been controversial among GPs and were criticised in an influential King’s Fund report in 2010, as they are felt to reduce patient choice, undermine and inhibit GPs’ professional decisions, create barriers to care and tend not to be cost effective.

But Manchester’s experience has been different, according to project leader Simon Wootton, now the chief officer at North Manchester CCG, who said that to understand the system now in place, a little history lesson is needed.

Peer review

When Wootton joined NHS Manchester, originally as an Associate Director of Commissioning, four years ago, activity was just beginning to outstrip budget – and it was at that stage that the PCT decided to put more pressure on GPs to improve and reduce referrals.

A peer review incentive scheme for referrals was instigated – as recommended by the King’s Fund – and had some success in educating doctors, but it ultimately had “very little effect” on reducing demand for secondary care in Manchester, Wootton told us.

He explained: “Practices were paid and incentivised to reduce referrals, and were to review their referrals – which often came two months later because it was based on hospital SUS data. Often it was too late – the referral had been done – and though the practices may have looked at what came and thought, ‘yes I could have sent it there instead’, when the next referral came along, they didn’t do that. So the peer review didn’t have the effect that we wanted.”

That trial had two components – using the hospital data in combination with the NHS number to find out what had happened to referrals, and also trying to reduce outpatient demand by using alternative and Tier 2 services.

Following that nine-month trial in 2009/10, the city’s three Practice Based Commissioning Consortia (PBCs) and the PCT began to discuss other methods to manage demand.

Gateway trial

After extensive discussion, four practices in the South Manchester PBC decided to trial a referral gateway scheme and did so for five months, with referrals going through the existing booking team in Manchester.

The trial data looked good from a demand management point of view: 13% of activity was diverted, either to the CATS (Clinical Assessment & Treatment Services mobile units, provided by Care UK), to Tier 2 primary care services, to the former Greater Manchester Surgical Centre, discharged back to the GP, or re-referred as suspected cancer.

Wootton said it was particularly important at the time to get better use out of the CATS vans: “We had to pay for it whether we used it or not, and we were utilising only about 35% of capacity – so it was important to get better value for money out of it. It was clear that some of the community services we had in place weren’t actually being used.”

The results of the gateway trial were discussed at a high level among the city’s health leaders, and a decision was made to look at a proper referral gateway for all of Manchester.

Wootton, who offered to lead the project, said: “At that point, we looked at using the Manchester booking team to do it for us – but thought we lacked the software to do what we wanted, because we wanted to divert activity but also do advice and guidance back to GPs. Often, on a lot of the referrals that were being looked at, more could be done in primary care.”

He said the quality of referrals also left much to be desired and needed to be improved: “The clear feedback from hospitals was that poor referrals were coming in. I’ve seen some horrifying letters to hospital consultants over the years: ‘Dear doctor, this patient has hypertension, please see’. No history – nothing.”

Standardisation and a single template

An important aspect of the gateway idea was to use one standard referral letter template – there used to be around 140 to select from – and to insist that the city’s three acute trusts used the one template.

Wootton decided to go out to market for the gateway software, and came across GPowned Harmoni, based in Southampton, who had done a gateway for Hillingdon – which ultimately abandoned its referral gateway in the face of urgent care pressures, Wootton said, and noted that its own referral levels have gone back up.

Wootton said: “We commissioned Harmoni to do the Choose & Book for us, because the software meant you could use one standard template. Every week, the practice would get a report back on their referrals: what had happened to them, where they’d gone. That was good for QoF and QP points.”

Clinical triage was subcontracted to Go To Doc (which now calls itself GTD), the local out-ofhours provider, with Manchester-based GP specialists doing the triaging. It was set up on a payment-per-referral basis, with referral letters sent via NHS.net email with attachments for scans and so on.

Wootton said: “The triager could look at the letter and, assuming it was complete and everything was on it, could make a decision on whether it was suitable for secondary care, or CATS, or if it should go back to the GP with advice and guidance.”

Rejected referrals

About 5% of referrals ended up going back to the GPs, which unsurprisingly created tension. But Wootton said: “The amount of resistance was actually very small.”

He said he thought this was because of the long lead-up to implementing the gateway – having done the peer review and other exercises – as well as getting the LMC to back the idea, to an extent at least. The LMC thought it could improve quality of care, but doubted it would actually achieve any savings.

Wootton said: “It was no ringing endorsement, but we got the support. We couldn’t just enforce it – we needed a carrot not stick approach.”

The gateway was controversial for various reasons – the involvement of a private company, the location of administrative staff in Southampton, and the feeling that the service may have been outsourced unnecessarily.

But over the 18 months of that gateway being in place, from September 2010, it saved about £4-6m, triaging eight specialties, Wootton said. The referrals were screened first for completeness, then against the PCT’s noncommissioned policy, to ensure patients weren’t being referred for minor or cosmetic procedures that wouldn’t be funded by the PCT. The third stage was the clinical triage, all with a two-day turnaround time.

The new system

But then came the decision to bring the referral gateway back in-house, primarily for reasons of value-for-money and local expertise, rather than any concern with the service itself, Wootton said.

He explained: “Harmoni worked well, but the feedback was that it would be better to have it done locally. Booking staff in Southampton were very good and had a directory of services, but just didn’t know the idiosyncrasies of Manchester.

“I can’t fault them – they were very professional and I’d recommend them to anyone – but the feeling was we could do it cheaper in-house and employ local people to do it.”

He linked up with Accenda, and North Manchester CCG agreed to pay to implement their Integrated Care Gateway software.

He said: “The difference with this software we’ve got now is that you get live data. Under the old system, practices would get a referral report a week later: now, you can click and see exactly where your referrals are in the system.”

The system can automatically convert attachments to PDFs to ensure standardisation, and the software ensures compliance with standard codes and so on: “Practices can no longer just put ‘MRI’ for Manchester Royal Infirmary, they have to put Central Manchester Trust, for example, so there’s been a jump in quality of letters.

“It’s instantaneous live data that can be streamed, and at any point in time a practice can review its referrals from even the previous hour.”

A further development of the new system, called the ‘cube’, will allow practices to see how they compare, in the live data, with their peers – if one doctor is doing more outpatient referrals per 1,000, for example, they’ll be able to find out why.

The new system, which went live in April, has a similar basic template to the previous one and works across all the main clinical IT systems used in Manchester.

He said: “We’ve now got an in-house booking team, the Manchester Integrated Care Gateway team, who do the bookings for us.”

That team of around 20 people are based at Burnage, handling around 180,000 referrals a year, and will in the future be employed by the Manchester CCGs.

Teething troubles

It has not all been smooth sailing: moving from the Harmoni system to an in-house NHS one created some security ructions.

Wootton explained: “Under the Harmoni system, our triagers could access it from home, via a password protected VPN. When it came back into the NHS system, everything’s got to be encrypted, so we lost a bit of triage for four weeks, and we’ve seen outpatients numbers go back up again – quite dramatically.

“As soon as you take that gatekeeper out of the way, that number shoots up. We expect it to come back down in the coming months, but it did show the value of the gateway in controlling demand.”

He added: “There comes a point with gateways where you can only squeeze demand so far – otherwise it pops up in urgent care! But certainly in Manchester, it’s had the effect we needed it to have.

“There’s also ongoing education: advice and guidance goes back on a regular basis to those practices that need it. They can use it for CPD, for QoF and QP points, so for the practice, it’s a good local tool they can use. They may initially see it as a bit of a pain, but they’ve got live data coming through now, and the trick with this going forward is that if all of your data is going in, you can do data validation against it from the acutes’ SUS data.

“We can monitor 18-week targets with it. Once you start all the pathways on it, and the GP practices gets, when they use the database, an email once the booking is made to drop back into the patient notes. If the patient rings up the next day, they will know who they’re going to see.”

The software is soon being further upgraded to do more advanced screening of the data inputted to screen out errors: males with a gynaecology referral, for example.

Wootton said: “Everything’s auditable, because it’s all electronic – so you know exactly what’s happened to the referral point-by-point. Eventually we want to link it in with outcomes as well. It’s been an exciting project.”

It could even raise some revenue for the Manchester commissioning team, which invested time, intellectual energy and money in developing it, as now others in the region are interested in it, including the Central Lancashire CCGs and also Bolton, which already has a paper-based referral gateway.

QIPP and savings

Wootton said: “You can see where the efficiencies lie because if you take it away, referrals go back up.

“Where QIPP comes in is, for example, in the first year, we clearly saw from the triage of cardiology referrals that if we had a Tier 2 Cardiology service in place, we could reduce cardiology referrals big-time: 40% or so.

“A lot of what was being referred didn’t need to be, it could be done as a Tier 2 service, which was established, at a lower tariff and run by three senior GPs. So there’s been a tremendous drop-off in cardio referrals, and QIPP comes from setting up alternative services that are cheaper than secondary care, but it’s also about better utilisation of community resources.

“Our local hospital has a caseload now that is far more complex than it was two years ago. Gateways take out the simplest stuff that used to sit in that pathway. They don’t want to see the ‘basics’, which a community or Tier 2 service could do. There’s definitely a case-mix change that occurs.

“We should see, over time, GP variation decreasing, the standard of GP referrals going up, hospitals getting the right information and standards of letters, consultants getting the right mix of patients they should be getting.

“We will get some more savings out of it, and it will pay for itself.”

Asked where he felt Manchester stood in relation to other parts of the country on managing demand, Wootton said: “I believe we’re a pioneer: if you look at all the evidence, the King’s Fund says peer review is the way forward, but it didn’t work for us.

“This, however, pushes the boundaries. Three acute trusts who didn’t believe we’d manage demand, ever, are now having to listen.

“Historically, PCTs have rarely done a good job of managing demand.”

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