Reducing referral costs
Dr Ian Trimble
NHS Nottingham City is responsible for ensuring appropriate care for a population of 305,000 people. In a review at the end of 2009, Nottingham University Hospital (NUH) Trust reported a year on year increase in the number of referrals received by the Spinal Surgical Unit to treat patients with low back pain. This put greater pressure on the orthopaedic directorate and resulted in approximately 100 patients being unable to book appointments via the Choose and Book system, due to slot shortages. Further analysis revealed that only 25% of all referrals required interventional procedures, whereas 75% of referrals were appropriate for non-interventional care, which could be administered via the Community Pain Service.
NHS Nottingham City decided to develop a local pathway that would clearly outline all the community services available for the management of patients with low back pain and identify the criteria for referring patients to the Spinal Surgical Unit. The pathway also needed to include the latest evidence to help improve the clinical effectiveness and cost efficiency of the multiservice approach.
Role of the Map of Medicine
NHS Nottingham City used the Map of Medicine as the system of choice for receiving, understanding and following guidelines, services and referral criteria as specified in the locally-customised low back pain pathway.
The local pathway on the Map is available online and visible across different organisations, helping to establish a benchmark for clinical practice and to improve patient outcomes.
Milestones
- The clinical pathway development work was undertaken by the already established pathway steering group including a commissioning lead, representatives from primary care led services including a Specialist Physiotherapist, GP, Consultant in Pain Management from NUH Community Pain Service, two nurses from the Nottingham Back Team, and a Consultant Spinal Surgeon.
- Low back pain pathways from other local communities on the Map of Medicine were reviewed to reach a consensus on the final format of the pathway for NHS Nottingham City.
- The clinical lead and the commissioning lead worked together on the implementation of the local low back pain pathway.
- The pathway was then published in the Nottinghamshire view on the Map and promoted during a launch event, attended by approximately 50% of GPs in the area.
Challenges
- There had been numerous unsuccessful attempts over the preceding years to develop the pathway because of the challenge of pulling together the already established services independently involved in the management of adult patients with low back pain.
- Another challenge was reaching consensus on the vision of a pathway and getting it signed off by the appropriate stakeholders.
Results
Since the launch of the pathway in June 2010, there has already been a 70% reduction in the number of referrals received by secondary care spinal services in Nottingham City. This has resulted in a saving of over £30,000 in the first two months, based on known expenditure from the previous year and on the cost of referrals after the pathway was published, which dropped significantly. This has been reflected in a parallel increase in the number of referrals received by the Community Pain Service in primary care, containing more relevant information.
The implementation of the locally developed evidence-based low back pain pathway outlining all services available means that the patient journey is streamlined and patients receive the appropriate care faster.
Because the screening process in the pathway directs patients more accurately to the right services, those requiring surgery can be taken to a monthly multidisciplinary case conference where, if deemed appropriate, the surgeon will prioritise them to be seen in their pre-operative clinic rather than a traditional outpatient clinic.
The relationships between primary, secondary, and community care services are considerably enhanced by a greater understanding of each service, and as a result, healthcare professionals are providing a consistent message to patients about the available treatment options.
The pathway steering group is planning to explore methods of disseminating further information and updates with regards to the progress of the pathway to all Nottingham City GPs. The pathway has already been promoted in the monthly GP newsletter, and NHS Nottingham City is in the process of organising another awareness event for GPs.