Referral letters are an underutilised source of unique data and information that reflect the quality of care provided by primary care clinicians. We demonstrate a focused approach to analysing these data, using the results to develop information in partnership with consultant colleagues, applying quality markers based on NICE guidance, then feeding back on individual performance to each clinician. This provides the basis for developing focused educational support for clinicians and patients. We have shown a significant reduction in inappropriate referrals, a 39% increase in appropriate referrals, up-to 43% improvement against the top seven quality markers and the potential annual savings of £28,000 across our 16 practices.
Aims and objectives
To improve the quality of decisions made between clinicians in sixteen GP practices in South Norfolk and their patients with lower urinary tract symptoms (LUTS). Our main objective was:
-To test an approach to referral management which is focused upon the quality of decision making between clinician and patient, using peer review of referrals to provide feedback to individual clinicians on their referrals. This objective is supported by education materials developed with consultant colleagues, based on agreed quality markers from NICE guidance.
Additionally, we also wanted to:
-Test this approach to a single pathway and apply the learning and processes across other clinical areas. Reduce the number of inappropriate referrals.
-Demonstrate improved quality of referrals that reflect the implementation of NICE guidance.
-Explore ways to engage patients in the community so they can get the information they need to inform decisions for their health.
By achieving these objectives we hope to show value for money and best use of NHS resources.
Reasons for implementing your project
Past experience shows that evidence based pathways and GP education may be enough for the committed GP but are rarely enough to change clinical behaviour in the less committed. What is needed is an innovative and collaborate way of working to reach out to all clinicians and to engage patients.
With primary care clinicians having an increasing avalanche of evidence based advice, guidance, pathway must-dos and don't-dos; all to be achieved in a working day, it is easy for them to be overwhelmed by information. Crucially the initial decisions made by the patient and clinician in the consulting room drives the mechanisms, pathways and then costs in our NHS. The 'right decisions at the right time to the right place' gives better outcomes and better use of resources for all.
NICE guidance for LUTS was published in May 2010 and Patient Decision Aids for LUTS became available in January 2011. South Norfolk Healthcare CiC (SNH) performed a detailed evaluation of each clinician's referrals for LUTS. The results of which informed an initial audit which identified the doctors' educational needs. We then tested the process of detailed referral evaluation followed by feedback to individual clinician's, based on NICE guidance for LUTS, as a mechanism for addressing these needs.
We also aimed to address patient unmet needs by promoting Shared Decision Making supported by Patient Decisions Aids (PDAs) for prostate problems. To widen our approach and raise public awareness, SNH joined forces with the Norfolk Libraries Service, Norfolk & Waveney Prostate Cancer Support Group and local parish councils. Urology consultants joined the partnership, to ensure best practice and seamless working across healthcare providers.
How did you implement the project
320 LUTS and prostate problem referrals and associated hospital outcome letters, were jointly audited by practice clinicians and urology consultants and assessed for appropriateness. Quality Markers (QMs), based on NICE guidance, were developed. LUTS referrals over a three month period from January-March 2011 were audited using the QMs.
Analysis of the referrals identified doctors educational needs and formed the basis for education and training. Practices, clinicians and patients attended SNH arranged educational events, received education packs and Patient Decision Aids (PDAs). Clinicians' bi-monthly feedback on their referrals, against the agreed QMs, commenced to inform and reinforce behaviour change. Patients and clinicians were able to access materials from the SNH website.
Norfolk County Council launched PDAs within local libraries, advertising the initiative via their online newsletter, posters and plasma screens. Library staff helped patients to access the PDAs. The launch was covered by the local press and 28 Parish Councils raised patient awareness, sign-posting patients to the practice and library initiatives via their newsletters. The Norfolk and Waveney Prostate Cancer Support Group distributed PDAs and raised awareness through its membership.
One year later January- March 2012 we re-audited all LUTS referrals from the 16 practices. The barrier we had to overcome was finding time for everyone to work together across organisations. The key driver was best practice for patients, an aim that was clear to all and kept us focused.
Costs: we were fortunate to be given the PDA's from NHS Direct. The main cost was for clinical time to audit, review and discuss. Over the two years this was £6500 for clinicians. Data analysis and management support was about £2100. (see slide deck for more details)
The value of the educational materials and approach for SDM and PDA's were surveyed with 22 clinicians in mid 2011. The results showed a marked increase in the understanding of both SDM and PDAs and an increase in the likelihood of clinicians using them.
The three month audits showed an overall increase of 39% for appropriate referrals. It also demonstrated a significant improvement in the quality of primary care being delivered.
For Rank 1 (essential) QMs:
- prostate examination prior to referral improved from below 40% to over 70%
- Investigations for U&E's improved by 43% and urinalysis improved by 36%
- Use of PSA testing improved by 2%
- 54% increase in the use of A-blockers
- 23% increase in the use of combined A-blocker and 5 alpha reductase use.
The Rank 2 (highly desirable-give the consultant a happy day) QMs improved by 7% and 17%.
The re-audit showed an overall reduction in referrals made by the 16 practices for LUTs of 11 referrals over three months. The average cost of a LUTs referral from these practices is £644 and when annualised the potential financial saving is £28,336.
The evaluation results exceeded our expectations, demonstrating improvement in the application of NICE guidance in primary care, improvement in the information presented to consultant colleagues, with more appropriate and fewer overall referrals.
(see slide deck for full results and SNH website).
Key learning points
-Embedding Shared Decision Making the use of Patient Decision Aids requires a multi-organisation approach across the entire care pathway.
-Patient groups can act as valuable champions, but the key to clinician behaviour change is constant re-enforcement of key messages and learning.
-Implementing NICE guidance and improving healthcare decision making is more effective if clinicians are provided personalised feedback. Detailed referral review and subsequent feedback is better received if the quality markers used are based on NICE guidance and have local consultant support.
-There appears to be a reluctance to use PSA testing in primary care.
-Referrals are an ideal moment to review clinical care. Referral support and detailed analysis can support implementation of NICE guidance in primary care.
-We plan to move onto other clinical areas where we can apply the learning from this study. We can also share materials and experience with interested colleagues in the NHS.