Peer Review of Referrals and Evidence based Medicine - the Gwent Experience

1. Peer Review of Referrals and Evidence based Medicine - the Gwent Experience

2. Discussion in practices on Quality Indicators, on the letters sent to hospital consultants in the last week • Consensus 1 Is there enough information in the letter letter or were important things omitted? • C1 increased from 89% to 95% over the year • Consensus 2 Was there enough work up before referral or could the GPs have done more to address the question themselves • C2 increased from 86% to 94% • Consensus 3 use of recognised guideline before referral • C3 decreased from 64% to 58% • Use of Map of Medicine increased from 3.4% to 6% • Alternative Pathway might be available-- up to 25%

3. Data • Data was collected, analysed and discussed on • HospitalDept. / Specialty • NHS / Private • Urgent or Routine • Objective or Reason for Referral • Initial Diagnosis • Alternative Path • Date of 1st Appointment • Result of OPD Appointment • Consultant Feedback • No of Days from Referral to 1st Appointment

4. Peer review of Referrals • Between July 2007 and March 2010 • Torfaen and then the other localities • Well received - GPs and consultants both enjoyed the experience of discussing referrals • Showed that a consensus could usually be reached as to which were the most effective • Variation in referral rates between individual GPs was reduced • Showed that a reduction in referrals in certain specialities was possible

5. Use of guidelines for referral from primary care • Patients’views have to be considered • Often ambiguous or unclear, obvious or too abstruse • Often no relevant guidelines anyway • too many different presentations of the same illness • No time • Junior doctors - had to do what they were told • Evidence not enough • Resources not available • All say refer anyway if not completely sure • If you really need a guideline there probably isn’t one

6. Variation • As much within practices as between practices • No reasons – not gender, not part time/full time, not area (degree of deprivation, or wealth) • May be slight tendency for older GPs to refer less • Locums and registrars referred more • Some differences in Gynae, Urology • The only conclusion is that differences must in some way be related to the training, personality, and mind set of the referrer • It seems self evident that the lack of feedback to GPs from their colleagues and the consultants to whom they refer must have a big effect in allowing such large variation to go unchecked.

7. Up or Down? • As a result of peer review, referrals could theoretically go up or down. • High referrers may note alternative ways of dealing with a problem, or gain more confidence in managing problems they previously would have referred • Low referrers may realise after discussion that they should be referring more patients

8. 22 Practices over whole of Gwent showing variation in referral rate Q1 2009

11. Referrals were often redirected rather than not made • Orthopaedics –alternatives were Podiatry, MDT, Physio, pain management, sometimes Rheumatology • Ophthalmology went to Optometrists, sometimes orthoptists or dermatology • Dermatology went to Nurse-led clinics, for p e a, some interest in tele-dermatology • Cardiology – Care-net clinics, ECHO clinics (inequitable service) • Neurology – Urology! Specialist nurses • General Surgery went to Podiatry. • Urology – continence nurse, lots of discussion on guidelines • Rheumatology – some went to Orthopaedics or MDT • Emergency Admissions - ACAT • Pathways were sometimes streamlined – cholecystectomy, urology

12. Some went in house • Importance of early mobilization and patient self-management (Orthopaedics) • Injections for orthopaedic conditions • More minor surgery • Some went to a partner with more expertise • Some may have been managed by doctors who now had more confidence

13. The results we got were achieved • By improving the work up beforehand • By improving the content of the letters • By discussing the referrals with peers within the practice • By discussing with colleagues in other disciplines, especially consultants in hospital • Not necessarily by explicitly following guidelines • And certainly not by using Map of Medicine

14. What did GP’s think of the scheme?Short Questionnaire • Peer review was useful 84% • Will discussion of referrals continue? 76% • * in a less structured way 30% • Would you attend meeting with consultants? 61% • Comments on hand out sheet

15. What did Consultants think of the scheme? • Tremendous amount of help from some • Orthopaedics – mostly positive at the beginning, some reservations towards the end. • There were some difficulties – had to have very large central meetings rather than smaller more intimate ones, and the learning was not as good • Some were very helpful, but there were some who resisted transfer of patients to primary care colleagues (physio’s, podiatrists, optometrists, nurses) and always wanted to be in control, for very understandable reasons

16. Table showing increase in referrals after practices leave the scheme (rebound) (from Trust figures)

17. Other suggestions • Politicians to admit rationing is necessary • Patients to reduce demand • More consultant feedback • Guidelines appropriate to primary care • Consultants to follow guidelines

18. Recommendations for ensuring quality standards of referrals and implementationof evidence-based medicine • Facilitate meetings (without Pharma input) within and between practices, for general discussion e g of referrals • Ensure good dialogue between GPs and consultants • Try to balance the flow of health business guidelines with local guidelines promoting community based services • Facilitate meetings of all interested clinicians in multi- disciplinary communities for discussion of referrals • More use of well trusted opinion leaders in general practice and less of “experts” • Use discussion fora in non peer reviewed publications,

19. Recommendations for ensuring quality standards of referrals and implementationof evidence-based medicine • Facilitate meetings (without Pharma input) within and between practices, for general discussion e g of referrals • Ensure good dialogue between GPs and consultants • Try to balance the flow of health business guidelines with local guidelines promoting community based services • Facilitate meetings of all interested clinicians in multi- disciplinary communities for discussion of referrals • More use of well trusted opinion leaders in general practice and less of “experts” • Use discussion fora in non peer reviewed publications,

20. Quality and Productivity Domains of the QOF (note: do not involve consultants) • Rewardsthereviewofcurrentpractice by GPs bothwithinthepractice and withexternal peers • It usesactivitydata, collectednationally, whichwill be practicespecific and comparativebetweenthesmallgroupsofpractices (5-10) • An InternalReviewmeeting is held withas many relevant personnel as possible e.g. referrers and includingsessional staff • Shouldreviewabsolute and relative activitywithinthepractice and shouldcomparewithotherpractices. • Discussion should explore the possible internal (practice) or external factorsthereasons for and, ifappropriate, addressoutlierperformance by a practice in three areas; emergencyadmissions, outpatientreferrals and prescribing • Externalreviews must be attended by at least 2 representatives (including 1 GP), from eachpractice. • Theywilldiscuss3 pathwaysofcare. • Thesemeetingswill be convened and facilitated by the LHB. • Report to be sent to theHealth Board