Features: May 7th, 2010

By Robbie Hughes

Patients continue to experience significant waiting times when they move from primary, to secondary care. There are bottlenecks in diagnostics and other areas. The author argues that enabling GPs to be more than gatekeepers and secretaries and instead perform minor surgical procedures would make a significant reduction in waiting times. Putting diagnostics, minor ops and groups of complementary clinicians into mini-hospitals would divert pressure from hospitals and improve care.

How do we go about improving and streamlining the patient journey in the NHS? To answer this question it is important to examine how can we improve the management of an organisation so complex, and requiring such depth of knowledge and understanding, that you can spend years training in it and still only be capable of working in one tiny part of it. To suggest that there is a single fix for ‘improving the NHS’ or ‘improving the patient journey’ is to grossly misunderstand the UK healthcare system and the NHS itself.

Technology is looked upon as a solution to many problems across a number of sectors, but attempting to define technology as a single concept within the healthcare industry is nearly impossible. Electronic medical records, Choose & Book, ultrasound machines, MRI scanners, Da Vinci robotic surgeries – where would you even begin?

The fatal mistake made by most participants in this debate, including the government, is attempting to define the NHS as a single entity. The NHS is the largest employer in Europe, with 1.3 million people, and has so many differing priorities, specialties, departments and goals that aligning all these people into a single category is an impossible task. From the point of view of the patient, however, the view is somewhat different and designing the system from this perspective is really the only way that any marginal degree of success will be achieved.
Streamlining and improving the patient experience must be core to any new initiatives employed in the NHS. Top down directives will only work successfully when the data modeled and examined has the patient at its core, as the patient is the only common element to all aspects of the NHS. This seems like an obvious point, but when put into context of what has been delivered over the past few years, it is easy to see where the problems began.

Separate Entities, One Journey

The first problem we encounter is that, the patient will travel from primary into secondary care, two entirely separate entities. The GP (primary care) will examine and triage the patient on behalf of the health system to determine, in a matter of minutes, if further action is required and if so, make arrangements for a referral. Rates of referral vary by diagnosis, region of the country and even social class of the patient but typically are performed either for review by a colleague, for diagnostics, or for both.

The GP is the patient’s first point of contact with the NHS and it is to the GP that the patient will come if they have any further problems or concerns. The GP however sees thousands of patients a year and is tasked with managing all their results and monitoring their care. It is the GP that receives the report back from the consultant or diagnostic unit and the GP that conveys this information back to the patient. The GP is effectively the gatekeeper and secretary of the NHS. The GP is also, despite appearances, one of the most efficient deliverers of care in the healthcare system. Costs in the health service are primarily found in hospitals where thousands of staff provide everything from hotel services to inpatients through to surgical teams and diagnostic machines. In one particularly distasteful scheme, GPs were actually incentivised with cash not to refer patients to hospitals because of the cost differentials.

Despite government targets and incentives, significant waiting times still exist to get into secondary care, often with bottlenecks found in areas such as diagnostics where you may find an appointment with a consultant within days, but have to wait weeks for a scan – without which the consultant cannot see you.

But what would happen if we were to take the hospital out of this equation? What would happen if we were to enable GPs to be more than gatekeepers and secretaries and instead perform minor surgical procedures? What if we took some of the most used diagnostics out of hospitals and trained GPs to use them properly? Naturally I am not suggesting putting a £2m 3T MRI machine in every GP surgery with an operating theatre next door, but there is a middle ground.

The best of intentions…

Despite the incredibly bad press polyclinics received, they were a serious attempt by the government at achieving exactly this. Putting diagnostics, minor ops and groups of complementary clinicians into mini-hospitals to handle day to day cases was a very serious attempt to divert the pressure from hospitals back into the community in an effort to improve access and care.

The mistake made here was that instead of complementing GPs, they were branded as ways of replacing them. Closing ten rural practices and replacing them with a single super-centre seems like a good idea until you step back and remember that the focus must remain on the patients, most of whom would not drive 45 minutes to get to their nearest polyclinic.

Furthermore, by looking at it as a GP replacement system, the original point of the polyclinic (providing services in the community) is lost. There is, however, still a better way of doing this.

Federated Healthcare

The economics of the current primary care market and the proposals put forward by the Conservatives are starting to encourage the formation of groups of GP practices that are linked together. When practices work together in this way, it is possible to achieve and deliver care in ways that are far more efficient than may otherwise have been possible. In a group of five practices with 20 GPs, there may be a blend of specialists and interests ranging from women’s health through to minor surgery. One GP may be trained in mental health, another in vasectomies (previously a surgical procedure that can now be performed by GPs) and be able to accept referrals from his colleagues. One practice may employ an ultrasound service twice a week and now suddenly, rather than having to refer to hospitals for diagnostics, GPs can benefit from the same services in house. These kinds of innovations are small, and largely unincentivised by the government, but when deployed in a co-ordinated and structured way, can have a very tangible benefit on the treatment of patients in the NHS.

By putting more skills and tools in the hands of those who work in the community, we can allow the patient to be treated faster, diagnosed more effectively and decrease the burden on those areas that need more specialised treatments. This small shift in emphasis, if combined with proper incentives from the market, such as voucher systems, or from the government, could not only improve access to quality care for patients, but also empower GPs and dramatically cut the cost of providing care in a climate of decreased spending and funding shortfalls.

Robbie Hughes is Strategy Director at Ascensus