Mrs Patel came in for her diabetes review with her foot all bandaged up. I asked her what has happened and she explained that she stood on a pin walking around her house barefoot. She had been told to wear shoes in the house but was not given an information sheet and so her family, who support her, did not know that wearing shoes in the house would protect her feet from damage as she has minor sensory neuropathy.
The Quality, Innovation, Productivity and Prevention (QIPP) programme is a national Department of Health strategy involving all NHS staff, patients, clinicians and the voluntary sector in England. It aims to improve the quality and delivery of NHS care at the same time as reducing costs to make £20 billion efficiency savings by 2014/15 (see www.evidence.nhs.uk/qipp for more information). The above scenario illustrates that pretty much every day, people working in the NHS see things that could have been done better, often saving inconvenient and expensive consequences by reducing avoidable use of NHS resources.
On a small scale, we have started using e-consultations to avoid outpatient appointments for opinions where the benefit of having a consultant face-to-face with an individual is minimal (Bradford Teaching Hospitals NHS Foundation Trust, 2011). E-consultations using a shared electronic record resulted in a reduction in hospital visits. The outcome (results and opinions) are returned promptly to the GP who then communicates them to the individual and appropriate action is taken (such as initiating insulin, reducing metformin or adding another blood pressure drug). Savings of about £25 million a year have been realised in one trust, achieved by the differing unit cost between first outpatient appointments and the much lower e-consultation tariff, not to mention much reduced inconvenience to patients and reduced transport costs.
On a bigger scale, a project by Heart of England NHS Foundation Trust (2011) on reorganising diabetes renal services was designed to reduce the rate of loss of kidney function in people with diabetes so that fewer people develop kidney failure and need dialysis treatment. Essentially, they have started weekly identification by a nephrologist of individuals with a low estimated glomerular filtration rate (eGFR) or deteriorating trend in eGFR and relay the information to the individual’s own GP with a management plan including a patient education and self-management tool. Monitoring of these people, and picking out the ones with falling eGFR despite appropriate interventions, has removed the waiting list for diabetes renal consultations and reduced the number of people with diabetes needing dialysis, with a saving of £48800 per 100000 population.
There are things we can do in our surgeries and clinics, like making sure diagnoses are accurate, reducing medication wastage through better communication and agreed care plans and having an effective footcare strategy, which starts with every member of the team knowing how to do a basic foot examination (Karet, 2009).
It is important, however, that before we implement such changes, we make some attempt to quantify the problem and the potential costs of the intervention balanced against potential savings. Each practice or group of practices will decide upon its QIPP agenda by looking at several areas. All staff should be involved, not only in data collection but also in suggesting areas that might be amenable to QIPP changes based on our own daily experience. We can pick areas from the NICE (2011) quality standards, all of which have quality statements and quality measures defining what they mean. As we have to implement these anyway, it is a good place to start. If we do, maybe Mrs Patel won’t tread on any more pins.