NHS Alliance focuses on CCGs’ best practice
The NHS Alliance has published a best practice guide focusing on the success of 12 different CCGs across England.
The guide – Clinical Commissioning in Action – outlines how commissioning projects have helped increase standards of patient care whilst meeting financial targets.
The document outlines how CCGs hold the “key to the future of the NHS” and many clinical commissioners are “already demonstrating their potential to make a real difference”.
“Where real progress has happened, it was only possible through meaningful partnerships combined with willingness and determination from those involved in bringing about change,” the guide says.
“These clinical commissioners have tackled issues head on, drawing on experience of front line staff, their knowledge of the local community and working with local managers.
“Was it easy? Mostly not. Was it worth it? Absolutely. Patients were placed at the heart of the health care system and services were designed to meet their needs.”
The guide states how doctors have often known how to tackle local health issues but have “lacked the mechanisms” to bring about change. But CCGs have given GPs “that leverage” and the opportunity to improve local services has been “seized with both hands”.
NHS Newcastle West and Newcastle North and East CCGs aimed to reduce hospital admissions by providing staff at care homes across the city training, support and input from local GPs.
The scheme was initiated after a hospital doctor found care home residents were admitted as emergencies at an average cost of £8,225 per day. A third of patients were discharged the same day and half within two days. But nearly a fifth (18%) died – many within five days of admission.
To tackle this, the CCGs allocated a link GP who would make regular visits to care homes and build relationships. Staff were also given training on topics such as wound management, falls and also care planning to support individuals who wished to die in their own homes.
The new measures resulted in a 9% reduction in unplanned admissions from care homes, same day discharges being reduced by a quarter and 27% fewer patients dying within a day of being admitted to hospital.
The cost of the project - £250,000 in the first year – was funded by practice-based commissioning savings with ongoing costs expected to be lower as the scheme continues. But savings are “at least as substantial”, the guide said.
David Thorne, Chief Operating Officer, Newcastle West CCG, said the engagement of the GPs had been “vital” to develop the scheme. “GPs instinctively ‘get it’,” he said. “I have not met a GP yet who doesn’t say that this is really important work.”
Bridging the gulf
Collaborative working between NHS South Devon and Torbay CCG and secondary care clinicians aimed to provide safe follow up care to men who have raised prostate specific antigen levels which need monitoring.
The CCG was keen to avoid visits to outpatient clinics and a worrying six month wait for results for often elderly patients. It has now adopted a model first pioneered in Bath enabling patients to have blood tests locally, who are then contacted with their results. Visits to hospitals are only required if tests are outside the expected range or if patients are concerned about their symptoms.
It is estimated that the new model may save up to 1,500 outpatient appointments annually and generate “substantial potential financial savings,” the guide says.
The scheme was designed by secondary care doctors and GPs working in partnership in a clinical pathway group for urology. Firstly, a consultant decides if a patient is suitable for monitoring. If so, the details are entered into a PSA computer system. Using this information, a urology nurse ensures patients are contacted when they need a check up – which is conducted at a GP surgery. The nurse then contacts the patient again to tell them whether additional tests are required.
Dr Derek Greatorex, CCG co-chair, said the project was a “no brainer”: “It was by far the most convenient robust approach and it meets the needs of the patient.
“The whole impetus of our clinical pathway groups is to improve collaboration and get over the gulf between primary and secondary care. Sometimes it does not take much of a change to make a difference.”
Reducing prescribing costs
NHS Bassetlaw CCG introduced new prescribing practices in an attempt to become more efficient whilst improving standards of care. Ensuring that best practice is followed in prescribing is a difficult and complex task. However, the CCG was able to improve prescribing practice and reduce costs.
Working in tandem with constituent practices, commissioners were able to reduce prescription costs by nearly 10% and create savings of £1.5 million. Despite the savings, patients were never denied required medication. In fact, prescribing rates for certain drugs actually increased during the efficiency drive.
CCG Chair Dr Stephen Kell said that clinical engagement played a major part in meeting set targets. “Comparing ourselves with where we should be really got our hearts and minds together,” he said.
“Having a meaningful practice-led discussion was really important. By meeting together and sharing good practice we have been able to drive down prescribing costs. Unnecessary prescribing is inefficient prescribing and not beneficial for patients.”
Dr Kell also pointed towards the relatively small size of the CCG in helping make the scheme a success. “Size is always an issue in terms of running costs but it does enable change,” he added. “The key driver for GPs is undoubtedly patients. Everything they do should be with that in mind.”
Joint working between a pharmaceutical company and Rushcliffe CCG aimed to improve COPD pathways for long-term sufferers. The project aimed to develop an integrated COPD service which covers patients from screening and diagnosis through management in the community to hospital care.
The pharmaceutical company provided a specialist COPD nurse who worked in GP practices across the region with a high rate of COPD-related emergency admissions. The nurse provided support and improved management of patients identified as high risk, whilst working alongside practice colleagues.
The CCG also introduced a number of new measures including distributing self-management booklets to patients, a subscription to Metcheck so individuals can be forewarned of any adverse weather that may affect their condition, and a commissioned clinic at a primary care centre to keep patients out of hospital.
Also, patients had access to exercise classes at a local leisure centre to improve fitness levels and increased access to pulmonary rehabilitation services that meet NICE guidelines.
The outcome of the new services saw emergency hospital admissions for COPD sufferers in the area fall below 700 in 2011/12. The year before there were more than 800 emergency admissions, with more than 900 cases in 2009/10.
Dr Neil Fraser, long-term conditions lead for the CCG, said the introduction of new services has also seen the total cost of COPD treatment fall. “The expensive thing is often the thing that is bad for the patient as well,” he said.
“GPs have championed the improvements to services and have worked closely with specialist nurses. There has been a debate and conversation with GPs about how it has developed.”