Clinical Commissioning effectively

Vertical Patient Pathways with proactive leaders
Supportive Referral systems
Access to experienced advice
Feedback

If the Clinical commissioning for patient care is truly responsive to those working in primary care there is great potential to make the NHS more efficient and safer. The risk is that there is a shuffling of management without true links being made with those working day to day with patients. Those people organising clinical commissioning need day to day feedback from those working in primary care and secondary care about problems in the system and how these can be resolved.

Care pathways, referral routes and resources for expert advice are three areas where large strides forward can be made to improve patient care

Vertical Patient Pathways with proactive leaders

One of the biggest concerns within primary and secondary care is how to help the patient through each step in the pathway of their care in a seamless, rapid and safe way. It is a source of embarrassment and risk that this does not yet occur. It is also a waste of resources

When things work well there is usually a clear pathway already mapped out and a co-ordinating person who is easy to identify and access. An example is the improvements in stroke care with a named stroke care co-ordinator who can trouble shoot and smooth a patient through the care pathway.

Horizontal teams refer to the groups of healthcare workers who provide care for each part of the pathway. They are often relatively cohesive groups who work well together. However the patient sees only the vertical teams as they pass from one setting to another. For example the A&E team then the Xray team then the medical team then the ward team. These provide the patient pathway and it is the co-ordination of this route, which is core.

Supportive Referral systems

The introduction of national computer systems for referrals has been a technological step forward, but could be more effective if it focused more on the needs of the doctors making the referral.

Doctors need clear information on the current management of presenting problems as well as the best route to obtain advice, and comparative information on the quality of care provided by each specialist.

Unfortunately referral systems have previously funnelled patients towards specialists who have lower demand to be seen within a lower cost settings. This has taken choice away from the referrer and may have led to longer term care costs.

Systems which gain the support of doctors and review each referral so that it is handled most appropriately can be more efficient and save resources. An example is the Sentinal referral system set up by Dr Peter Rudge in NHS Plymouth.

Access to experienced advice

Every referral does not need to see a specialist, but those that do should see the specialist who can address the problem most effectively.

Access to written, internet or phone advice can resolve the need to refer. Most people working in primary care are already experienced so it is focused expert advice that is needed. A regular known time to access the specialist by phone with access to results of investigations and quick routes to arranging further investigations is required.

Focused relevant local knowledge databases  can speed management, investigation and treatment. An example is the LLAMA database (Local Linked Addresses Management and Advice see “downloads“). The internet is a rich information source, but more focused, specific bits of immediately retrievable and relevant knowledge are required during each face to face consultation.

Feedback

Routes of feedback on services will help inform improvements. These routes need to be simple and easy to access. The pattern of feedback can guide commissioners on the priority and which area to focus on.

If you want to see how confusing the NHS can be go to this great Kings fund cartoon to explain the new NHS in 2013

http://www.youtube.com/watch?v=8CSp6HsQVtw