Clinical advice: Improving access to care

The clinical advice resource is a growing suite of blog posts, advice sheets and resources aimed at helping Pinnacle practices provide high quality clinical care.

Pinnacle's role in advocating alongside practices

Currently GPs in each of our districts get frustrated when they hit barriers when seeking interventions from other providers. There is a perception that hospital services are becoming more difficult to access and that different hospitals have different levels of service available to their communities.

This was abundantly evident in the work we did with GPNZ, Quantifying and understanding the impact of unmet need on New Zealand general practice,    and we continue to hear stories of difficult access every week from across the network and across many specialities form our GP members.

Barriers usually present as a rejection letter from the referred provider, sometimes with explanation and further guidance, sometimes without any solution to support further patient care.

We know GPs do not seek help for a patient without good cause, however "rejection" arises for a number of reasons:

• the provider believes the service / intervention can be provided in primary care
• the intervention is rationed and cannot be provided for someone with this acuity of problem
• there is not enough information for the service provider to prioritise the issue.

Currently the options for GPs is to re-refer, discuss private options with their patients, connect directly with the hospital team and seek support, or support the patient to advocate with local MPs and others for the service to be improved.

GPs from time to time involve Pinnacle support services in their advocacy and find we can help by:

• supporting members to advocate for individual patient care
• seeking system improvement with referred providers
• identifying areas of systematic gaps in care.

We think we can do more to help. We want to support members to:

• effectively to access patient care
• gather information about the services under pressure in the DHB systems.

With more involvement we may be able to add value through strategic services such as extended GP teams and specialist in the community roles to help reduce pressure on services.

The New Zealand Medical Council provide guidance for doctors working in resource constrained environments, as follows.

"As a doctor you have a responsibility to advocate for your patients, to seek the provision of appropriate resources for your patients' care and report any deficiencies to the appropriate authorities. Where these deficiencies are serious, the report should be made in writing."

They also state that when allocated resources

"the prioritisation systems should be fair, systematic, consistent, evidence-based, equitable, sustainable and transparent."

We have therefore developed a system to support your advocacy and to help identify areas where we can support our resource constrained hospital services.

Process flows

For the GP in practice

1. GP sends a referral to a service as normal.
2. Rejection letter received - GP is encouraged to review rejection against 'best practice' and adjust accordingly. (c.f. HealthPathways, referral information complete).
3. Second rejection letter received - GP encouraged to review the reasons for second rejection and discuss alternative options with patient, for example further public health advocacy / private referral / involving the hospital GP liaison if available in supporting the referral.
4. NEW ACTION - Inform the Pinnacle MHN clinical director or your local Pinnacle GP leader in writing (for example by email) of the details and the patient choice - request advocacy if required.

Pinnacle clinical director

1. Receive and register details of second rejection.
2. If GP is seeking advocacy support, check:
   - information provided against 'best practice' clarity of referral and sufficient information to make a priority
   - current known issues with service provider and ability to provide care.
3. Feedback to GP and/or refer onto hospital chief medical officer or GP liaison, depending on the correct mechanism for the location and level of concern.
4. Inform the clinical governance group of the case.
5. Follow up case until resolution.

Pinnacle clinical governance group

1. Monitor rejected referrals for patterns and systemic issues
2. Report concerns to Pinnacle Incorporated executive via the medical director' report
3. Support solution focused advocacy through Pinnacle Incorporated working directly with DHBs.

Timeframes

Here are our expected time frames when you contact us with details of a rejected referral.

• Immediate response to indicate we acknowledge we received your concerns.
• Initial opinion and advice will be provided from our medical director within three working days.
• Clinical governance opinion within two weeks.