Charlotte Levitt, a GP based in south London, faced a dilemma. One of her patients was taking a drug that had just come onto the market and his kidney function had started deteriorating. Should she refer the patient to a consultant, or take him off the drug?
Whereas many GPs might automatically make a referral, Levitt, referral management lead at Wandsworth clinical commissioning group (CCG), was able to resolve the question quickly. She logged on to Kinesis, web-based software from Cloud2 that enables GPs to confer with local hospital consultants. In this case, the consultant advised further blood tests: if they were abnormal, the patient should be referred. If not, the drug was likely to be the problem.
Last year, there were 13.6m GP referrals in England, a 5% rise on the previous year, representing an increasing cost burden on CCGs. A 2009 report from theNHS Institute for Innovation and Improvement found that up to 65% of patients referred to outpatient specialty clinics were discharged with “no significant pathology detected”, meaning many were unnecessary.
Four years ago, Wandsworth CCG implemented Kinesis across its 43 GP practices as part of a wider plan to manage referrals more effectively. If a GP isn’t sure whether to refer a patient, or simply wants to ask a consultant for advice, they log on to the Kinesis website and choose the consultant or specialism they are interested in. The GP submits their question, attaching any relevant documents, ECGs, photographs or videos, which the consultant receives via the NHS’s secure N3 network (though the software can also run on Microsoft’s Azure cloud platform).
The first local hospital to come on board was St George’s, but since then Chelsea and Westminster, Guy’s and St Thomas’s and Kingston have also joined. Consultants are not obliged to take part, but at St George’s, most specialties are represented on the system. As part of hospitals’ agreement with the CCG, the consultant is required to reply within 24 hours. If a consultant is off sick or on holiday, it won’t be possible to message them.
In 2015/16, Wandsworth GPs sent 3,993 requests via Kinesis. Of those, 48% did not lead to a referral, saving the CCG £276,730, if we assume that without the ability to confer with the consultant, the GP would have referred the patient.
So what are the advantages for consultants? Simon Hudson, founder director of Cloud2, says the most immediate benefit is that, because routine cases can now be dealt with over Kinesis, they have “slightly more interesting and more complex patients turning up at outpatient appointments”. Longer term, he says, the hospitals save money and see patients more quickly.
Some consultants worry that they will be overwhelmed with requests, but Sarah Thurlbeck, a paediatric consultant at St George’s and an early adopter of Kinesis, says she receives, on average, one request a day and it takes about 10 minutes to respond. “It’s usually borderline cases,” she says.
“If the child has something obviously wrong, they’re going to be sent up, but if it’s just some niggling thing, I might advise the child is watched, or I might advise some simple tests.”
Thurlbeck, who does some GP teaching, has also found that it gives her a sense of what local GPs are concerned about and where they would like more training. She also likes the fact that Kinesis keeps an audit trail of questions and answers. “What you see is what was said. When you have a telephone conversation, what you say and what is heard may be two different things.”
Levitt agrees that Kinesis has been good for building relationships between hospital consultants and GPs, as well as for improving her own practice. “I might ask a weird and wonderful question,” she says. “It’s amazing how often you see that again in the future, and I don’t ask the question again because I now know the answer.”
Two years ago, Sutton CCG in south-west London implemented Kinesis, enabling GPs to confer with consultants at St Helier hospital and St George’s. Dino Pardhanani, clinical lead for Sutton CCG, uses Kinesis about twice a week and says that GPs are also using it to request MRI and CT scans from radiologists, who can authorise the request without the patient having to see a consultant. The ability to receive a quick response to a query benefits the patients too, he says. “You can reassure the patient that they’re getting input from an expert, but it’s much more streamlined.”
Hudson believes that as Kinesis is more widely adopted, its potential will grow. It could be extended to allow access to international experts, for example, while the stored anonymised conversations could be analysed to identify trends such as an emerging epidemic. Already, he says, Wandsworth CCG has noted a surprisingly high incidence of gout being discussed on Kinesis, resulting in the introduction of a dedicated gout pathway. “That’s had a direct patient impact because they get access to the care they want more rapidly,” he says.
This article originally appeared on Guardian Health Professionals on 09/08/2016← Other news articles