The following case studies are drawn from different types of partnerships between primary and secondary care, and from different parts of the country with different challenges. However, they all have in common a commitment to:
- embrace new approaches led by primary care colleagues in community settings, where possible
- improve communications and shared information between staff in cross-organisational teams and in direct support of patients
- champion clinically led and data driven approaches
- embrace digital transformation and new technologies.
Northumbria Healthcare NHS Foundation Trust, Northumberland Clinical Commissioning Group (CCG) and North Tyneside CCG
Using advice and guidance to improve communication between primary and secondary care
Advice and guidance services, by which GPs can request advice from consultants on patients before making a formal referral, have become an increasingly common tool in the management of outpatient care.
The national elective care transformation programme, introduced in March 2017, includes such provision as a central plank. As with so many areas of new practice, however, the pandemic has seen the applications of this sort of model greatly expand.
In Northumbria Healthcare NHS Foundation Trust, covering Northumberland and North Tyneside, an enhanced advice and guidance setup has been an important part of managing waiting lists. It has also helped bolster communication between primary and secondary care.
Under advice and guidance, any GP within Northumberland CCG and North Tyneside CCG is able to request advice from consultants at Northumbria Healthcare NHS Foundation Trust.
Notably, however, there is also the capacity to send images relating to the request. If, for instance, a patient presents with a skin lesion then the GP can take a photo on any smartphone and attach it to an advice and guidance request. To meet information governance requirements, all photos are held in the cloud rather than on the device.
If a plastic surgeon concludes from the photo that the lesion needs removing, they can then directly book the patient into an operative slot. This entirely avoids the need for an initial outpatient consultation, or for GPs to have to perform the difficult task of accurately describing a lesion without visual aids.
Plans for the advice and guidance facility pre-date the pandemic, but it was launched formally in February 2020 just as the first wave of the virus began to hit. Trust leaders say they worked closely with local PCNs and local CCGs on the service, which has now been built into primary care commissioning.
In the first six months alone, there were about 5,000 requests for advice. Consultants' job plans have now been revised to allow dedicated time to review such requests and feedback. Where urgent same day advice is needed, there is a telephone 'hotline' available.
In the first six months alone, there were about 5,000 requests for advice. Consultants' job plans have now been revised to allow dedicated time to review such requests and feedback.
Local leaders emphasise, however, that the purpose of advice and guidance is not to turn consultants into gatekeepers of outpatient referrals. Instead it is considered a way of enabling structured conversation and discussion between GP and specialist.
Consultants are not expected to make a binary decision focused on whether or not the patient simply requires an outpatient appointment. Rather the idea is to progress the patient journey through advice. That might involve giving clarification on which pathway is appropriate, details of which tests need to be performed prior to a referral, specific treatments or reassurance on a ‘watch and wait’ approach. GPs also have the option to ask that the guidance request be immediately transferred to an outpatient department appointment should that be required.
Since the advice generally comes back within three working days, patients do not have long periods of time ‘stuck’ in the system due to lack of clarity over the best care pathway or what to do next. That in turn enables the trust to manage its outpatient capacity in the most effective way possible.
For more information
Alistair Blair, medical director, Northumbria Healthcare NHS Foundation Trust
alistair.blair@northumbria-healthcare.nhs.uk
Modality Partnership and Sandwell and West Birmingham Hospitals NHS Trust
Delivering outpatient services in the community
Modality Partnership have been working with Sandwell and West Birmingham Hospitals NHS Trust to expand outpatient provision in the community in response to the pandemic.
Under the model GPs can choose to refer a patient to a community-based outpatient service for a number of specialties. The system was first established five years ago, but has been extended to help reduce waiting times as hospitals managed the large influx of COVID-19 patients.
GP 'super practice', Modality, is sub-contracted to provide these services, which are generally run in a GP practice or community facility. Consultants travel to these local sites to deliver appointments, leading a team of GPs with extended roles, nurse specialists and allied health professionals.
This allows for much more multi-disciplinary input into a patient's care than might be given via the traditional hospital-based outpatient model. It also means that all healthcare professionals, including consultants, are able to focus on tasks that make the most appropriate use of their expertise.
During the pandemic, the model has given the trust an alternative to relying on acute settings for the delivery of outpatient services. Capacity in many hospital settings has been reduced and subject to redeployment to enable acute providers to manage COVID-19 patients. By having facilities in the community, it has been possible to avoid significantly the lengthened waiting lists that have resulted from pressures on acute facilities.
The specialties covered have been jointly decided between primary and secondary care doctors, and generally are areas in which there had been pressing challenges with their provision in hospital: workforce issues, for instance, or very lengthy waiting times.
Since April 2020, more services have been moved into primary care. For instance, echocardiography can now be performed in community settings. The use of virtualmappointments has also expanded, including for community based outpatient services. This has been particularly valuable for dermatology, where patients can share a photograph of a mole or rash that is concerning them ready for discussion during an appointment. It has also allowed members of staff who needed to shield or self-isolate to continue working.
It is anticipated that this mixed model of online and in-person community outpatient appointments will continue in the future: patients could initially be seen virtually and then face-to-face if needed.
It is anticipated that this mixed model of online and in-person community outpatient appointments will continue in the future: patients could initially be seen virtually and then face-to-face if needed.
As well as reducing pressure on hospitals, the community setup is more convenient for patients. Weekend and evening slots are available, which may not have been possible for hospital-based outpatient care. If a face-to-face appointment is required then, in most cases, the community site is also much closer to a patient’s home than the hospital.
In January 2021, Sandwell and West Birmingham Hospitals NHS Trust had the shortest local waiting times across 10 specialties for which Modality provides community outpatient services (cardiology, dermatology, ear, nose and throat (ENT), gynaecology, neurology, ophthalmology, respiratory, rheumatology, urology, orthopaedics).
In many cases, the difference is a large one. Patients referred to a cardiology outpatient appointment, for example, had a seven week wait at Sandwell and West Birmingham Hospitals. At another local trust, the wait was 42 weeks. In ENT, the wait was 10 weeks. The next shortest local wait was four times that.
In a survey of almost 5,000 patients, 91% said they preferred to be seen at a community site rather than the hospital.
For more information
Vincent Sai, chief executive, and Naresh Rati, executive partner, Modality Partnership
vincent.sai@england.nhs.uk, naresh.rati@nhs.net
Gateshead Health NHS Foundation Trust
Using remote testing to triage patients with symptoms of bowel disease
Waits for tests that diagnose bowel disease have lengthened significantly during the course of the pandemic. Across the country anyone referred for a colonoscopy or flexi sigmoidoscopy should be seen within six weeks, or within two in suspected cancer cases. Yet in May 2020, during the first wave of the pandemic, 67% of all patients referred for these procedures nationally were waiting longer than that.
At Gateshead Health NHS Foundation Trust, the use of faecal immunochemical testing (FIT) – all delivered entirely remotely – has been central to managing waits and appropriately triaging patients who may need a colonoscopy or flexi sigmoidoscopy.
FIT identifies the level of blood in faeces, which can be a sign of lower gastrointestinal disease that requires further investigation. The test is used for the national bowel cancer screening programme, but separately to that GPs in CCGs served by Gateshead Health NHS Foundation Trust can also make referrals for symptomatic testing – where a patient has presented with symptoms which may be indicative of bowel disease. GPs make referrals where they believe the patient may require further investigation through a colonoscopy or flexi sigmoidoscopy.
Since these tests are used to check for a wide range of bowel conditions, including cancer, it is important that local healthcare systems find ways to reliably identify patients who need to be seen most urgently.
Prior to the pandemic, a patient in north east England referred for symptomatic testing would have to attend their GP practice to collect a testing kit, and to drop it off once complete. The test would then be sent to Gateshead Health NHS Foundation Trust for analysis.
Since these tests are used to check for a wide range of bowel conditions, including cancer, it is important that local healthcare systems find ways to reliably identify patients who need to be seen most urgently.
But to support the move to virtual consultations, and the need to reduce patients visiting health settings unnecessarily, a postal setup has been introduced during the pandemic. The GP's referral for a FIT test goes to the trust, which posts out a kit to the patient. Once complete, the patient posts it back for analysis.
The results of FIT tests allow clinicians to appropriately triage patients who require a colonoscopy or flexi sigmoidoscopy, ensuring those whose results are most indicative of possible serious disease are seen first. Where the test does not show a problem, it also allows GPs to give the patient speedy reassurance.
FIT has therefore been important in managing waiting lists and ensuring patients progress along care pathways where they need to. Around 5,000 to 7,000 symptomatic tests are now performed every month, and all entirely managed by post. Prior to the introduction of the postal system, that figure was around 1,000 to 1,200. The growth is such that a new business case is now being constructed for the service, to demonstrate its value over the longer term.
Leaders at the trust say they worked closely with the local cancer alliance to embed FIT testing across the region. That included offering GPs guidance on the introduction of symptomatic testing. The triaging approach used for symptomatic testing in primary care has also informed the approach to the triage of high-risk patients in secondary care.
For more information
Caroline Addison, senior biochemist, Gateshead Health NHS Foundation Trust
Salford Royal NHS Foundation Trust and Salford CCGs and PCNs
Rapidly creating a community diagnostic hub
Cardiorespiratory investigations such as heart rate monitoring are relatively simple and swift to perform. But in over the course of 2020/21, pandemic-related pressure had made it difficult for patients in the Salford area to have these tests rapidly. On average, they were having to wait more than 100 days for tests including heart rate monitoring, spirometry, FeNO testing (used to diagnose asthma) and sleep studies.
To help address all of this, primary and secondary care in the area have worked together to establish a small community diagnostic hub. The steering group, established in late January 2021, included commissioners from the Clinical Commissioning Groups (CCGs), clinical directors from PCNs, and secondary care clinicians.
Local leaders say this integrated approach to working has long been established in the local area, and that it supported the very swift development of the diagnostics hub – it was up and running by early April, within three months of the steering group being convened.
The hub is intended to reduce the number of outpatient appointments and hospital visits needed for diagnostic investigations, so helping reduce pressure on hospitals and offering greater convenience to patients. The hub is based in central Salford, near to the shopping centre and the council offices, and in the same building as the library. For most people, the venue is far easier to travel to than the local hospital as there is parking readily available and the building is located on several bus routes.
There are up to 200 appointment slots available each week at the hub, with the proportion dedicated to each test determined by consultants and GPs.
The hub is intended to reduce the number of outpatient appointments and hospital visits needed for diagnostic investigations, so helping reduce pressure on hospitals and offering greater convenience to patients.
A significant portion of the workforce are band three employees who had previously been hired on fixed term contracts for the local vaccine hub. In some instances, it had become clear that they were not being fully utilised, with many keen to continue working in the NHS and to do more to help. The diagnostics team therefore offered some rapid training, enabling these members of staff to move across to the new diagnostics hub. Extra shifts were also advertised to primary care staff.
More than a third of Salford GP practices have made referrals to the hub in the first two months of its existence. And by the middle of May 2021, patients were waiting between five and 15 days between their referral to the community diagnostics hub and the test taking place – compared with the NHS constitution standard of six weeks.
The hub is seen as part of a broader evolution of approaches to primary and secondary care in Salford. It is designed to support the use of advice and guidance services, triaging of referrals and of virtual consultations. This has all been aided by the use locally of a shared electronic care record, which allows GPs and consultants to see the same information about a patient, and enables test results to always be available to every relevant clinician.
Plans are now in place to create a second community diagnostics hub, to provide further additional capacity for tests which are currently being booked to close to full capacity.
For more information
Sarah Cannon, senior programme manager, integrated care, Salford Royal NHS Foundation Trust
Croydon Health Services NHS Trust and Croydon CCG
Supporting improved ultrasound referrals
In common with the rest of London, waiting times for a non obstetric ultrasound at Croydon Health Services NHS Trust had been steadily lengthening in the years leading up to the pandemic. An annual 2.5% growth in demand from 2016 onwards led to opening extra capacity out of hours and, by the start of 2020, an ability to just about manage demand such that most patients were seen within the six-week target for diagnostic tests.
Then COVID-19 hit. The impact in Croydon was particularly hard. In the first wave more than half of the trust’s hospital beds were needed for patients with the virus. Elective operations came to a halt, and it became very difficult to continue diagnostic procedures and outpatient care. Conversations between primary and secondary care led to an assessment being undertaken of what capacity remained and how best to use it. This looked at what services would continue face to face, what would become virtual, and what had to temporarily stop due to lack of capacity or staff.
For diagnostics, there was a huge list of patients for whom tests had been requested and a need to decide what should happen given the enormous pressures of the pandemic. The trust's clinical lead for diagnostics and support services and the vice-chair at the CCG – who is the south west London GP lead for diagnostics – worked together to help determine the best approach for individual patients on lists and for diagnostics more generally.
Conversations about non-obstetric ultrasound were informed by an audit of 200 routine referrals from GPs. It suggested that 25% of such referrals were made for cases in which it was unlikely an ultrasound would be helpful. The result was that these patients had a long wait for a procedure that would not advance their care, and as a result, patients who did need a scan urgently were less likely to be seen swiftly.
A big part of the problem is that guidance to GPs on when an ultrasound is needed is complicated. Several bodies have published advice, so information available to GPs is disparate and recommendations are sometimes conflicting.
The result was that these patients had a long wait for a procedure that would not advance their care, and as a result, patients who did need a scan urgently were less likely to be seen swiftly.
Secondary and primary care in Croydon have therefore worked together to develop a non-obstetric ultrasound decision support algorithm for GPs, which combines all current guidance and local expertise. It guides GPs on when an ultrasound is likely to make a difference, when a direct referral to a secondary care outpatient appointment is more appropriate, and when it is best to simply adopt a 'wait and watch' approach.
The intention is to integrate the decision support algorithm into the electronic patient record systems used locally in primary care. This will mean that, when a GP goes to make a referral for ultrasound, they will be shown a few short questions to help identify whether the test is likely to help the patient in question.
Since a key aim of this work has been to further increase communication between radiology departments and GPs, there will also be the ability for GPs to contact hospital specialists if they have any questions regarding a particular patient’s management.
The hope is that the algorithm will help reduce the number of patients who have to wait for a non-obstetric ultrasound that may not be helpful for them, and thereby increase the speed with which patients who do need a scan can be seen. Work is continuing on its introduction in Croydon, with plans now in place to roll it out across the whole of London.
For more information
Ketul Patel, consultant radiologist, Croydon Health Services NHS Trust