What is it?
Bassetlaw Commissioning Organisation is a clinical commissioning group (CCG) which shares boundaries with NHS Bassetlaw. Working with PCT managers at NHS Bassetlaw, CCG members designed a programme to drive efficiency in primary care using funds from the 2010-11 practice-based commissioning local enhanced service. The scheme was rolled out across all Bassetlaw GP practices, and has already resulted in more efficient referrals, reducing the number of unnecessary journeys patients make to hospital and making more efficient use of NHS resources.
How does it work?
With the agreement of local GPs, CCG leaders created an incentive scheme for practices which meet efficiency targets. The scheme is broad in scope, covering areas such as appropriateness of referrals, prescribing spend and emergency admissions. Each practice has produced its own strategy for implementing the programme and when goals specified under the scheme are achieved, savings are released.
The programme is supported by an information database designed by the CCG members and the PCT’s information management team. This report is provided to practices on a monthly basis and covers referrals, emergency admissions and prescribing data. The CCG decided that using an incentive scheme was appropriate as in implementing the efficiencies, practices would be taking on significant additional work.
The element of the scheme which focuses on referral quality was designed in response to comparatively high rates of referral to secondary care in the Bassetlaw area. Inappropriate referrals are inconvenient for patients and can result in NHS resources being spent on unneeded hospital consultations instead of being used to pay for necessary patient 
care. Crucially, the scheme does not “block” referrals, meaning that patients who need to see a secondary care clinician are still referred. Instead, behaviours in practices have changed to ensure that referrals are appropriate and follow clinical best practice. For instance, GPs with expertise in particular clinical areas have increased their availability to colleagues, and practices have ensured that doctors can seek a second opinion from a GP colleague within the practice if they require one. There has also been increased emphasis on using community services where appropriate rather than referring patients to acute trusts. GPs feel that the scheme has led to greater clarity about when it is appropriate to refer a patient to hospital and when this is not appropriate. This has been achieved through providing a better system for aiding decision making about referral, rather than applying restrictions.
The GPs view the high levels of clinical engagement which they have achieved as critical to the success of the scheme. GPs recognised the need to ensure referrals were appropriate and agreed that the work was necessary to protect services for patients. The local acute trust has been supportive of the CCG's work and GPs have made a point of being transparent about their plans and sharing proposals at an early stage.
What has it achieved?
The scheme’s initial focus has been on ensuring that patients are only referred to hospital where clinically appropriate. As a result , there has been a 12 per cent reduction in first outpatient referrals over six months across the area. This has already meant that Bassetlaw has moved from the third quartile nationally for referral rates to the second quartile. In addition to the work around referral quality, pathways for dermatology and orthopaedics have been redesigned and work on a glaucoma pathway is now underway, with input from ophthalmologists and community based opticians. Work to tackle emergency admissions, prescribing and additional pathways is also ongoing.