So my name's Dr Miten Ruparelia, I've been a GP in Corby for the last 10 years.
I'm one of the partners at this practice which is at Woodsend Medical Centre.
I also play a role in the CCG, which is the Clinical Vice Chair for the CCG, and today
we're going to talk about the Clinical Peer Review process or prospective review of routine
outpatient referrals.
So we've been a training practice for the last probably two decades now and I think
one of the biggest things I noticed was the clinical variation we had in terms of the
outpatient referrals as well as the non-elective referrals that we had at the practice.
There was some pressure, in those days during the PCT times, in terms of trying to get some
control on the numbers that were flowing to our acute trusts.
The biggest reason from the practice perspective was we wanted to firstly improve the educational
elements that we give at the practice for our registrar; help to reduce some of the
clinical variation that takes place within the practice so that our patients can get
better quality of care; and thirdly was around the pressure that we had from the PCT in terms
of trying to get some control of outpatient referrals from the practices.
So I think, like most patients, patients will come up in a state of anxiety sometimes when
they have a clinical need.
As GPs we try our best to be the gatekeepers to try and manage some of that as much as
possible in-house, but there are certain times when we have a need to refer them onwards
to a specialist review.
Now that can, in instances, raise anxiety for the patient where they have to firstly
take some time out to attend their appointment, there raises the anxiety about what the specialist
is going to say or do, and thirdly a hospital attendance isn't necessarily where a patient
wants to spend his day along with.
What this process does is it helps the patient to be appropriately firstly worked up as close
to home as possible, and when the need for a specialist referral is required it's absolutely
essential and agreed as the MDT's time within the practice.
For example with certain pathways we could easily now manage those patients in-house
with some of the expertise we have in-house, rather than those patients having to go all
the way to hospital to just be told that X, Y or Z investigation is needed.
Secondly where it helps is it helps to dampen some of that "I saw GP X who said I need to
go to the hospital" compared to "I saw GP Y who said no I don't need to go to the hospital".
So sometimes that can create confusion for the patient as to which advice they should
take.
This standardises that.
There's a patient choice element in this, where patients can choose to say "no I don't
want to go to the MDT, can you please refer me" if you think it's the right thing, so
we consent patients to make sure they are on board with the process that we're following.
Like most GP consultations that we have with our patients, we tried to get a shared understanding
of what the plan is.
I think occasionally the patients can say "by going through this MDT process will this
delay my need which needs a specialist input?"
We try and allay that anxiety by explaining to the patients that the MDT will enhance
the process in terms of sometimes the care could be given more locally, which will prevent
them having to go to the hospital.
But if there is a clinical need for the specialist referral to take place, the MDT will make
sure that that happens in a timely fashion and ensuring there is no delay set in the
pathway, and the administrative team will ensure that the referral takes place and the
patient is informed in a timely way.
So when we started the process, initially some of my partners were not too keen on doing
it, because they saw it as someone "marking their homework", or us marking each other's
homework -- in a way their independence of being an independent clinician being eroded.
I think once we went through the process and started off in a very open fashion, quite
quickly all the clinicians within the practice realised that this wasn't about us trying
to mark each other's homework or trying to gate-keep each other's work.
It was mainly about improving the outcomes for our patients, as we highlighted earlier.
I think we also realised that this was a critical piece that allowed us in our revalidation
process of peer review in its active sense, and also increasing our clinical knowledge
in certain pathways where we were referring patients for specialist input but through
talking and discussing those cases our knowledge of some of those pathways improved over a
period of time.
Also when our registrars were presenting some of the latest evidence around what's going
on in the pathways, it helped us collectively as a team to learn as an organisation and
then to improve the quality of care we were giving to our patients.
I think the biggest benefit is having that open space and time to discuss something that's
relevant to them, i.e. their patient needs.
Secondly, them having that open and honest place where they can raise some of the nitty-gritty
issues or some of the tricky issues that they are trying, not able to in front of the patient
but they can do that in their MDT's time.
Thirdly it helps with the revalidation.
All of us now have three learning points that come out of that MDT or post that MDT, and
that helps us tremendously when we are sitting and doing our appraisals and our revalidation.
And the final point is it's helped us to enhance as a teaching unit as a practice because we've
increased our knowledge of some of the common pathways between each other by sharing that
expertise.