Learning from practice

Westwood Park diagnostic and treatment centre (DTC) in Bradford has been up and running for six years and takes 30,000 referrals a year.

It is a purpose-built building with a large recovery area which provides a range of clinical services and diagnostics, including gastroscopy, cystoscopy, cataract surgery and more recently gynaecology services.

The DTC’s ENT service offers procedures such as nasal endoscopies and is delivered by a team of six GPwSIs who have worked as independent practitioners for between 18 months and five years. They clinically triage all GP ENT referrals - over 100 a week at present - most of whom are new patients.

The service retains about 60 per cent of these referrals for further care, assessment or diagnosis and the remaining 40 per cent are offered choice and referred directly to secondary care. In all cases the team is supported by regular ‘joint clinics’ attended by consultants from Bradford Royal Infirmary. Set up six years ago as part of a PCT-led initiative to move more care into community settings, the initial vision came from a PCT chief executive.

Although the start-up costs were considerable, including capital outlay on equipment and the training of clinicians, the PCT was fortunate that there was a lot of momentum and enthusiasm to make it work, backed up by significant investment. Says Dr Andy McElligott, “The main benefits to patients are that they can often be seen closer to their home and more quickly, although neither of these is true in every case. The environment of the community hospital is infinitely more pleasant than that of the acute trust and patients can park for free

Another plus is that appointments are very rarely cancelled by us and rearranged as happens all too often in hospitals.” The team feels that working closely with both secondary care colleagues and the PCT was and continues to be essential. Continues Dr McElligott; “This type of service needs to be led by clinicians and supported by the PCT rather than the other way around. The support of consultants is also essential, the GPwSI service was never designed to replace their work; we need the express support of consultant colleagues, and in our case we’re lucky to have a particularly strong relationship.” Dr McElligott feels that there is a danger of GPwSIs becoming isolated and has been putting some thought into how this can be addressed; “Unlike junior hospital doctors, GPwSI can sometimes feel that they don’t have anyone looking out for them. I recently started thinking that perhaps we should, as a general rule, work alongside consultant colleagues.

This would mean that senior advice is always at hand, an improvement on the present situation where we do our clinics alone and bring difficult cases back to a consultant clinic for review.”

The service undergoes regular reappraisal by the PCT. This includes a Bradford-wide accreditation panel which has representation from acute and primary care and clinical governance. The panel meets monthly and is a comprehensive and central way of managing the governance of GPwSI services. GPwSIs have to demonstrate their training, experience and background and are accredited every couple of years.

The PCT has established what it feels are mutually beneficial contractual arrangements for their GPwSIs, which allow time for training and audit and professional development. The team is currently considering taking over the running of the service from the PCT and it is hoped that there will be scope for expansion. Tips for other PCTs wanting to put a similar service in place:

• Be prepared to put in the necessary level of investment at the outset. The start up costs can be considerable and equipment does not last forever.

• Consider asking groups of practices to form provider companies to run these services with PCT support.

Make sure that robust succession planning is part of the business plan because GPwSIs take a long time to train but only one day to move elsewhere!

The Care Closer to Home Demonstration Project has been set up to consider how care can be shifted and delivered in innovative ways to make it more convenient for patients. The project is evaluating care pathways and models of care in six specialities - dermatology, orthopaedics, gynaecology, urology, ENT and general surgery. DH web page gives more details at http://digbig.com/4nken