Point of Care Testing

This article first appeared on 22.9.15 on digitalhealth.net

You will hopefully know by now that I’m always keen to find ways to make the life of a GP easier and more productive – while, hopefully, improving the service to patients at the same time.

Here’s an idea I’ve been playing with over the past couple of weeks. I don’t claim any particular originality with it. In fact, I’m sure others are working on much the same thing. I also need help in delivering it – so if you are interested in helping, get in touch.

Testing a big data idea

We have been using online order communications for years. Locally we use Anglia ICE. Every GP request for the past ten years must be in the system.

Do we ever get a report? No. I’d love to get a really hot data person to look at it with me. Let’s throw the whole lot into some “big data” engine and see what it comes up with.

I suspect it will show a load of inconsistency. I suspect that there are GPs and practices who order at the high end and those that order at the low end.

We are used to this in medicines management, where we have become adept at behaviour modification. For example, my practice did an antibiotic prescribing audit.

It turns out we are average to below average prescribers with some internal variation. Three months later, when we retested, and although we were low we had gone lower.

How? We create league tables, do educational sessions, discuss pathways and so on. There isn’t any naming and shaming. Ultimately, the Hawthorn effect (individuals modifying their behaviour in response to being observed) plays a big part.

As well as looking at doctors, we could also look at the patients. Why do some diabetics get 15 tests a year, while others get just two?

Do those getting 15 tests need all of them? Do we concentrate on the “wanty” not the “needy”? Should we look at outliers in terms of investigations, just as we look at high users of salbutamol (an asthma medication, for my non-clinical readers)?

I’m convinced that if we really looked at ordering – whether of back x-rays or bloods – we could save money. That money I’d invest in point of care testing.

Blocks to point of care testing   

One of the things our federation is looking at is how we reduce variation between the practices involved. We are looking at starting a nurse bank for locums.

I’ve said out loud that I’d like to explore centrally employing all practice nurses. I think it would give them career development opportunities, unified and better T&Cs, and help to standardise protocols and procedures.

I think it would also reduce waste; instead of18 practices all writing their own protocols for a new vaccine, why not just write one?

If we had all of our practices working in roughly the same way, using a common bank of nurses, couldn’t we look at how to make what they were doing more efficient?

At the moment, most chronic disease clinics make you come in a few days before an appointment to have your bloods done. This is so they have the results to go through with you. Much better this than: “I’ll give you a ring in a few days…” because you can actually discuss treatment changes.  

However, it is inefficient. It means at least two visits to the surgery – two appointments made with reception, queuing twice, two days off work.  

Why not have the bloods done on arrival and have the results available immediately? Let’s face it, table top analysers exist; we just need to be confident they are accurate and work out how we pay for them.

The problem, as always, is the second bit, because of how GPs and other services are funded. The local clinical commissioning group pays local labs to deliver a bloods service on cost and volume or on a block contract.

The labs will say they have huge machines, quality assurance and – hopefully – low unit costs. But they can deliver no quicker than overnight results.

If general practice bought its own machines, it would see none of the CCG contract cash. So any GPs that went down this route would take home less money. And frankly I’m not going to pay out of my pocket unless it’s going to save me money somewhere else.

Think like Amazon

I noticed recently that Amazon is delivering on a Sunday for no extra cost to the person who has ordered their goods. Thinking it through, it was obvious why Amazon has done this.

Even though – I hope – the company has to pay its drivers more money to work on a Sunday, it saves overall. The roads are quieter and therefore the drivers can do more drops per day, while using less fuel sitting in jams.

Crucially, the chances of catching people in are presumably much higher. Consumers might well like Sunday deliveries. But really, there’s a simple economic argument for doing them.

Compare this with general practice and my POCT idea. Improve the service to the patient, and it costs more for the practice; unless it can tap into that CCG budget for testing or fund it in a different way.

While the cost of bloods is paid for by the CCG, there is no benefit to me to do the work instead. If I don’t use the local labs, I don’t make a saving. Instead, I bear the cost of the machine and test. I don’t use less nurse time, as it’s my nurse that would be doing more work.

If I was a private business, then I might charge more for a one stop shop than a two stop one to cover these costs. But as it stands, I can’t do this.

Show me the money

Personally, I think the CCG should give us the budget after doing a deal with us on risk sharing any saving or overspend.

If I thought I could save £30,000, then I would consider hiring a new nurse. If I thought that I could be more efficient by ordering fewer bloods, I might concentrate on doing that.

We also need to transfer some of the phlebotomist time built into the lab contracts into POCT equipment. Now, I don’t want to sack anyone, but the good news here is the posts are often unfilled and there is loads of natural wastage.

In addition, most phlebotomists make great healthcare assistants; and there are plenty of other things they can do.

So, in summary, give me the tools to spend money in different ways, cut costs, and improve the service for patients.