Improving the diagnosis and referral process

A key challenge for clinical commissioning groups is how to deliver better, high-quality care for less. Since diagnosis and referral are the core functions of a GP, the Vale of York CCG decided that this should be a key area to address.

Like many clinical commissioning groups, the Vale of York has variation within its referral rates, reflecting differing GPs’ level of experience, knowledge, clinical skills and risk appetite.

Vale of York is a relatively large CCG, covering about 335,000 patients and 35 GP practices and is derived in part from the North Yorkshire and York PCT. For a number of reasons, NYY PCT has always struggled to achieve financial balance and was obliged to declare a deficit for 2011/12. 

‘We believe that medical information technology will act as an enabler and support GPs to make better clinical decisions’

Vale of York will inherit a deficit of at least £5.3m from April 2013, presenting an extremely challenging position.

Improving diagnosis is a complex problem – especially bearing in mind that 50 per cent of referrals are for diagnosis. In the past, PCTs have gone down the route of referral management centres but evidence from The King’s Fund has shown these to be largely ineffective and not representing value for money.

Need for improvement

Vale of York has a strong set of values and vision to achieve the best possible quality of care for its population. Despite having low referral rates compared with the SHA average, we need to improve on our decision and referral behaviours if we are to reduce unnecessary referrals and secondary care activity.

We had heard about the Isabel Diagnosis Checklist system, which had been started in the UK in 1999 after a little girl, called Isabel, had been misdiagnosed. The system has been successfully used in the US both in primary and secondary care. In April 2012, Vale of York CCG purchased a one-year licence for Isabel.

We believe that medical information technology will act as an enabler and support GPs to make better clinical decisions. Medicine is an increasingly complex and demanding career, with rising numbers of medico-legal claims. Medical IT will allow GPs to do their job more effectively and encourage GPs to think more systematically.

Isabel’s main selling point is the diagnosis software, especially in more complex clinical presentations, but it also acts as a rich information resource linking to BMJ best practice and clinical evidence.

We can also configure the software to incorporate locally commissioned clinical pathways so GPs will “remember” to use the new pathways rather than relying on paper-based documents or half-remembered emails. It really is a case of not what you know but where you go to find it out. The system provides a convenient solution to this problem.

Revalidation demands a more rigorous approach to documenting learning. Isabel allows GPs to track and record their use of the software, which can contribute to their continuing professional development.

Some GPs may argue that there is no substitute for clinical experience acquired over years and, though this is true to a certain extent, newer members of the profession value the pattern recognition that the checklist system supports.

Differential approach

Considering a wider differential diagnosis is also important. This is something that is taught to medical students but can become neglected in postgraduate years. The system helps to reinforce the differential approach to problem solving. With more experienced GPs clinical thinking can become entrenched. Isabel offers a way to “think differently”. 

Vale of York CCG holds monthly GP forums to promote clinical engagement with the CCG agenda. The decision to purchase the Isabel software was widely supported by GP colleagues. Evaluation and use of the software is planned for later this year.

An effective IT strategy is key to delivering high-quality healthcare. We believe this system forms an important part of that strategy and will allow GPs to move from very good to excellent in how they deliver care to their patients.

Dr David Hayward is a developmental board member for the Vale of York CCG