When NHS Leicester Health Informatics Service (LHIS) was approached by local GPs to develop a referral management system, the idea was enthusiastically backed by the area’s three CCGs, who provided the funding to get the project off the ground. Four years later, the system is used by all 138 GP practices in the Leicester, Leicestershire and Rutland (LLR) area and in 2017/18 supported 110,000 referrals across 130 conditions.
The system, PRISM, ensures that the GP is provided with the relevant referral criteria and service information to create the referral and the consultant receives the appropriate baseline information.
PRISM guides GPs through the referral process with a questionnaire for each condition. It uses the responses to populate referral letters in a consistent manner that can be attached to bookings made through the electronic referral system (eRS) system.
GPs like the system because it reduces the time taken to make referrals and cuts bureaucracy, but also because it provides other resources to enable them to make confident decisions and support their patients. These include clinical information, the latest NICE guidance and information to support patients to manage their own conditions. Local service directories are being added too, so that when GPs don’t refer they can advise the patient what other healthcare or support services are available.
Dr Nick Pulman, IM&T GP lead at West Leicestershire CCG, said “PRISM helps the clinicians understand what they need to do prior to referral. I use it fifteen to twenty times a day. Referral processes and criteria are constantly changing. PRISM puts all that information in one place and allows it to be completed straight away, or if the information is not immediately available it guides the clinician to get the information required, reducing bounce backs.”
Quality referrals benefit patients too. With a shorter, more reliable pathway from the GP to the appropriate specialist in secondary care, they experience fewer delays.
This is particularly important for patients referred for suspected cancer, who are entitled to be seen by a consultant within two weeks of the referral.
Dr Tony Bentley, co-chair, GP and clinical IM&T lead Leicester City CCG, said: “Having access to PRISM has streamlined my referrals in the two-week wait pathway. I know I’m sending the patient to the right service with the right information. As we put more resources onto PRISM, I am confident that this will make the life of the busy GP easier, and patient care will benefit as a result. The patient will be seen in the right clinic by the right clinician first time and everyone will benefit.”
Referral pathways go through a rigorous process which sees them agreed, tested, clinically checked by GPs and service leads and finally signed off for publishing by the PRISM clinical safety officer.
CCGs like the system because it provides them with consistent referral information for every condition, better enabling them to monitor referral patterns. They also have the assurance that all practices are working with the latest guidance and resources. By working together, the Leicester CCGs are conscious of how these benefits could also be enjoyed at STP scale. The local STP appears to agree, recognising that good referrals data and improved referral quality are big factors in its planned care strategy. The system’s growing use as a repository for self-care and signposting resources also appeals to commissioners, who can see its potential contribution to implementation of the GP Forward View. The Leicester, Leicestershire and Rutland planned care workstream clearly see the value of PRISM aligned with their own five year plans and have invested in a programme of builds for PRISM pathways.
Managers at the local trust are also enthusiastic. Claire Brennan, operational manager at the University Hospitals of Leicester cancer centre, credits PRISM with helping improve efficiency, including the achievement of paperless running targets.
“In allowing us to ask GPs to collect a minimum dataset by way of questionnaire which feeds into a PRISM two week wait (2ww) referral letter we are quickly able to view and respond to key information that is presented in a consistent format and therefore easy to process - recognising that our 2ww team processes over 650 referrals a week,” she says.
“In 2017 the three clinical commissioning groups mandated the use of PRISM alongside eRS to send 2ww letters. As a result over 96% of our 2ww referrals are received on PRISM referral letters, providing us with a great platform for our wider consultant led paper switch off later this year. To put this into context we were only receiving 14% of our 2ww’s as PRISM referrals two years ago so this clearly illustrates GP engagement and buy-in. “
There are lots of reasons why NHS organisations shouldn’t grow their own IT locally, including the potential for dozens of different solutions where one would have done.
Sarah Ost, service delivery manager at LHIS, acknowledges this criticism but stands by the decision to continue to develop PRISM’s functionality. “We looked and the alternatives were expensive and didn’t do the job we needed them to do. This GP support tool complements the national programmes of work and as far as we are aware in Leicestershire there is no alternative that offers the features found in this product with the additional facilitation and support that the pathway development service provides.”
She adds that there was a more basic reason why an off-the-shelf commercial solution would have fallen short. “It was soon clear that the real work was not developing the technology but getting the referral pathways agreed. That meant sitting round a table with all the stakeholders including GPs, CCGs and secondary care. As part of the NHS family we’re able to do that, but I find it hard to imagine the same level of collaboration from other IT partners.”
Ost recognises that locally developed solutions can hinder the way in which the NHS shares knowledge and best practice. This is why LHIS are keen to continue to talk to other CCGs about licensing the service. “If other areas were developing and sharing their own pathways we could soon have a comprehensive library covering every condition,” she says.
To find out more about PRISM, contact prismadmin@leicestershire.nhs.uk
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