Taking the leading 50 clinical pathways and making them as good as they can be is how Northamptonshire GP Dr James Findlay describes the task facing GPs as clinical commissioners.
“That’s a huge ask for any group of people,” he says. However, his emerging clinical commissioning group has already made progress with the help of a web-based referral management and clinical communication system written by Dr Findlay himself.
Called PathFinder, the system came out of Dr Findlay’s longstanding interest in decision support and his recognition that practice-based commissioning would be much more difficult without some sort of IT support for those working at the coalface.
The system is used on a daily basis by the 76 GP practices in Northamptonshire that make up the award-winning Nene Commissioning Community Interest Company. It is beginning to take on some elements of the local commissioning budget, and hopes to be authorised as one of the first CCGs next year.
Helping the coalface
“I became clinical governor of Nene Commissioning, and in 2008 I went to the chief executive and told him that with the rate of change in the NHS we would need something that went straight to the GP desktop that enabled us to share information with GPs and take them with us,” Dr Findlay explains.
With the group’s backing, he began work on PathFinder, beginning with a template for two week cancer referrals. Since then, the system has developed and now includes data on between 60 and 80 clinical pathways.
At the heart of the system are referral templates and accompanying guidelines that provide GPs with information on each available clinic, individual inclusion and exclusion criteria, and the information the receiving consultant would like to get from the referring GP.
The template is a Word document that can be merged with data from the GP system, whether that software is provided by EMIS, INPS or TPP. The Word document is then available for GPs to send as the referral document.
Each speciality can also specify how it would prefer to receive the information, which might be via email or as a Choose and Book attachment.
PathFinder also provides additional information for GP and patient including flowcharts, leaflets and share care protocols.
A prescribing section provides the latest drug-related information, including the local formulary, and there are web links to Prodigy’s clinical knowledge summaries and other useful websites.
Dr Findlay says: “It is very simple and intuitive and GPs can get the information they need in just two or three clicks.”
The PathFinder site now has more than 6,000 hits every month and more than 800 users a month – not just the 300 plus GPs in the commissioning group, but other staff in GP surgeries such as nurses and medical secretaries.
A recent survey conducted by Nene Commissioning asked GPs to rate how useful they found PathFinder on a scale of one (no use) to five (very useful). In response, 50% of GPs gave PathFinder a five and a further 23% a four.
Dr Findlay says the service has also proved popular with the clinicians running services in secondary care. “I found that after a year or two the consultants were coming to me because they had heard that if they wanted to get something to work they needed to get it on PathFinder.”
Dr Findlay argues that the tool also offers clear benefits for patients. “I think it’s really important for patients that GPs are not making an assessment on their whim, but that decision making belongs to a considered guideline they can use time after time. It means there’s less variance between doctors.”
The tool is also an effective part of the commissioning strategy for Nene Commissioning. One of the group’s original aims was to redesign clinical pathways.
By 2009, its achievements included reducing GP referrals for first outpatient attendances by 9.4% in September to November, in comparison to the same three month period in 2008.
It also made savings of £1.8m to reinvest in services identified as priorities by GPs, and increased the number of patients assessed and treated in primary care rather than secondary care.
Dr Findlay can also point to some specific examples of where PathFinder has been involved in improving care over the past 18 months (see box).
He says: “It is not a diagnostic tool but once you know what the diagnosis is it is really helpful in getting the patient the right service, removing the need for unnecessary outpatient appointments and making procedures like radiology more effective.”
The commissioning group also has some impressive figures on referral activity. Dr Findlay says that in 2008-9, GP referrals to hospital and community services rose by 3%, while they rose by an average of 13% in primary care trusts throughout the Midlands.
Dr Findlay adds: “While you can’t say that was completely down to PathFinder – and I don’t think anyone could put an exact figure on it – if we were responsible for 50% of that 10% it would still be a success.”
Working with Plain Healthcare
In the last few months, Nene Commissioning has set up a partnership with decision support specialists Plain Healthcare to develop PathFinder and offer the system to other clinical commissioning groups.
Dr Findlay is continuing to work on the system and a new website for PathFinder. Other plans include adding better reporting for commissioning, closer integration with GP systems, functionality to enable GPs to use the system as part of their appraisal process and developing the system to cover care of patients with long term conditions.
He adds that such IT support can not only enable CCGs to disseminate clinical pathways that they have commissioned, but to receive rapid feedback from providers and commissioners on what works and does not work, which can then be reflected in reworked referral templates.
“I think a shared understanding is key,” Dr Findlay says. “I always feel that 99.9% of people in the NHS want to do the best for their patients and often it are the system that lets us down. My own feeling on IT is that it has to bring people together.”
Providing safer care for AF patients
Dr Findlay says: “I was contacted by Kettering Hospital, which was keen to set up a one-stop atrial fibrillation (abnormal heart rhythm) service.
During subsequent discussion, we identified [that] patients found to have atrial fibrillation, who also had other co-morbidities such as diabetes, were at a high risk of having a stroke if not anticoagulated. We wanted to make sure that this group was seen urgently, to avoid the disastrous scenario of a patient having a stroke whilst waiting to go on warfarin.
The cardiologist identified a risk scoring system called CHADS2 and this was incorporated into the referral proforma on PathFinder. Not only was the new service commissioned, but the risk to patients was also reduced.”
Supporting a GP-led vasectomy service
GPs with Special Interest (GPwSI) have taken over the local contract for carrying out vasectomies. PathFinder prompts and records that all appropriate counselling has taken place and demonstrates that the patient has been selected according to best practice.
This reduces the risk of subsequent patient regret - and also the risk of a challenge to the local health system by a patient; who might otherwise claim, for example, that the permanence of the procedure was never explained by their GP.
“PathFinder is not about practising defensive medicine, but is a tool to help GPs document the decisions they make with patients,” Dr Findlay argues.
Ensuring appropriate use of DEXA scans
Dr Findlay says: “I was contacted by the radiologist who manages the DEXA scan service used to asses if a person was at risk of osteoporosis.
He was concerned that this resource was being taken up by patients who were actually at low risk and that the service was not reaching those at risk.
We incorporated a link to the FRAX score and made this a condition for requesting a DEXA scan so that referrals now matched best evidence and best practice.”