New cost-cutting primary and community “care models” to replace hospital services, and a block on GP referrals to hospital of patients with suspected spinal cord compression, are putting patient safety at risk and giving some West Yorkshire GPs pause for thought about the direction of travel in the NHS, which is being driven by the West Yorkshire and Harrogate Sustainability and Transformation Partnership.
At a recent West Yorkshire GP practice peer discussion meeting, it emerged that GPs are realising that patient safety is threatened by West Yorkshire and Harrogate Sustainability and Transformation Partnership’s cost cutting changes to radiology, cataract surgery and bloods.
There was discussion of problems arising from commissioning of outsourced radiology services and changes to management of suspected spinal cord compression, that have been introduced by the Sustainability and Transformation Partnership.
This is something that the West Yorkshire and Harrogate Joint Health Scrutiny Committee should scrutinise without delay. We will be emailing them about this.
GPs can no longer send patients with suspected spinal cord compression into hospital
Spinal cord came up. A patient was sent urgently from the GP to A&E, due to a change in management of suspected spinal cord compression which means that now GPs can no longer send a patient with suspected spinal cord compressions into hospital, where acute would have arranged an urgent scan.
In A&E the patient was assessed with spinal cord compression, possibly by more junior staff, but there was no bed and no medical discipline happy to take admission – for example orthopoedics or oncology.
With this change in management of spinal cord compression, there are issues with getting the urgent image via A&E or being able to get appropriate review by speciality (ie oncology / orthopaedic) accepting the admission and reviewing same day.
The patient was sent back to the GP with advice to fast track a scan – but this is not what GP is able to do. An urgent MRI isn’t something the GP can arrange. They can refer for a routine scan but what if it’s urgent? As it was. Spinal cord compression should be inpatient and sent straight for an urgent scan.
Because if the patient has a spinal cord compression and treatment is delayed this can lead to permanent loss of neurological function and immobility
Problems with radiology follow up
Problems are arising with radiology reporting no longer being automatically referred on to the GP practice or reported in terms of follow up advice. Now only the findings are reported on, without clinical next step advice.
In terms of ultrasound scans there is a choice of about 7 locations on the ultrasound forms, including GP practices that describe themselves as running specialist services, some of which are hospital services that are run in the community rather than at hospital.
An example is at Windhill Green GP practice, which includes an Ultrasound Clinic. Their website says
“We have sonographers working over two sites, four days a week. Our ultrasound service has a short wait time. Your GP will usually have your Ultrasound results within 48 hours of your appointment. We pride ourselves on offering a convenient and professional service.”
In Calderdale they also do scans at Brighouse GP surgery.
Care closer to home/out of hospital services
This is part of the supposedly all-singing all-dancing care closer to home/out of hospital services schemes being set up across England by Sustainability and Transformation Partnerships, that are quickly morphing into Accountable Care Systems (now rebranded Integrated Care Systems by NHS England in order to remove the connotations of the USA’s inefficient, ineffective and costly health service, which is largely privatised with only a limited range of publicly-funded healthcare provided through Medicaid/Medicare, for people who can’t afford private health insurance).
However, radiology in the new scheme of things doesn’t seem to be working as well as the hospital service it’s replaced.
The West Yorkshire GP practice peer discussion meeting heard that problems include who is reporting – whether the scan and report has been overseen just by the sonographer/ radiologist or a consultant – & how the results are reported back. Not as much info is coming back on reports – now they will report findings only, so the GP now has to decide: Is this telling me they have found something and what’s the next step? Has it been redirected already or what do I now do with patient? Reports used to say suggest rescan in x weeks or suggest follow up CT scan or would have been flagged to acute.
A West Yorkshire clinician said,
“This is awful. All this was discussed with patients that had been taken to group peer review, but it shows lots more falling through the net.
It’s a matter in all these cases of oversight and responsibility. If you fall and hurt your arm the x-ray is taken and initially a little break may be missed. Quite often stuff was picked up when the consultant looked at report. I’m not so sure if the same processes occur in the community as would happen in the hospital.
A big thing with safety is all the checks and balances that were in place. Hospital routine can seem a lot of red tape but actually remove a layer and the safety net has gone.”
This seems to tie in with the West Yorkshire and Harrogate Sustainability and Transformation Partnership decision to set up a Yorkshire Radiology Collaborative to provide imaging in hospitals and communities, with patients managing access to and controlling their own data. We will ask the STP about this.
If patients are dying of some horrible illness or suffering a painful fracture or suspected spinal cord compression, are they going to want to have the hassle of managing, accessing and controlling their own data?
Sustainability and Transformation Partnership’s drive to cut 6,042 neurological hospital bed days/year
The Sustainability and Transformation Partnership’s move towards centralisation of hospital services on the one hand and restrictions on GP referrals on the other means that GPs seem unable to refer patients with spinal pain to the hospital neurology department but generally have to refer them to an MSK clinic which may well be privatised, as in Kirklees – or else send them to A&E.
On the basis of an NHS commissioners’ Go Compare-type scheme called Right Care, which uses data of questionable accuracy, West Yorkshire and Harrogate Sustainability and Transformation Partnership has identified that it uses 6, 042 more neurological inpatient bed days/year than it would if Clinical Commissioning Groups in the Sustainability and Transformation Partnership were in line with the average for 10 comparable Clinical Commissioning Groups. And if Clinical Commissioning Groups in the West Yorkshire and Harrogate Sustainability and Transformation Partnership were in line with the average spending on non-elective neurology hospital admissions, the STP would save £2.344m/year.
The Clinical Commissioning Groups in the Sustainability and Transformation Partnership therefore aim to reduce neurological inpatient bed days by cutting both elective and non-elective neurology hospital admissions – although the biggest potential cuts to spending come from reducing non-elective neurology hospital admissions to the average for 10 comparable Clinical Commissioning Groups.
The new form of whole population budget contract that will be used by the new Accountable/Integrated Care Systems that replace the Sustainabilty and Transformation Partnerships will have to align financial and clinical considerations. Translated, this means that patients will no longer be treated on the basis of clinical need, but on the basis of a combination of financial considerations and clinical need, with the aim of “managing demand” for NHS treatments.
Problems with cataract operations follow up
The West Yorkshire GP practice peer discussion meeting discussed similar problems with cataract follow up – again the result of decisions by the West Yorkshire and Harrogate Sustainability and Transformation Partnership, which has decided that Post-op outpatients’ follow up appointments will “no longer be the norm” – but “ will be preserved for those whose clinical needs rely on the technology or skills of the secondary/tertiary care environment.”