Trust places paediatric experts at the forefront to provide better and timely treatment, avoiding 836 referrals and reducing waiting time by 11 weeks

Synopsis

The place based paediatric offer across Tameside and Glossop consists of a number of initiatives that support children and their families being seen and treated by the most appropriate professional, at the right time and in the right place;

• Electronic Advice and Guidance (A&G); a system that allows GPs to request electronic pre-referral advice from consultant paediatricians from the Trust.
• Children’s Community Clinical Meetings; regular forums between secondary care and general practice clinicians to discuss clinical cases and pathways.
• Emergency Department In-Reach; support to the ED to assess acutely unwell children and determine the most appropriate treatment pathway.

Ambition

In accordance with NHS’s vision of primary and secondary care integration, the Trust’s paediatric department wanted to ensure that children were seen by the right professional at the right time and in the right place. Additionally, less than 50% of GP trainees undertake paediatric placements despite children accounting for 25% of patient population for GPs.

Despite unprecedented demands on services, constrained by significant financial pressures, children must receive effective, safe and sustainable care. Placing paediatric expertise at the front end of care pathways helps mitigate rising attendance.

Therefore, the clinical team reviewed the patients’ journeys across primary care and secondary care. A study of GP referral letters revealed that up to 40% did not require an appointment. Following extensive consultation with primary care and user groups, an electronic A&G process was established allowing virtual consultations.

Based on some local and national guidance, along with aspirations identified by the paediatric team, initial goals for the A&G service and direct paediatric consultant attendance in GP practices included:

• All A&G GP referrals reviewed by 4 paediatric consultants daily.
• Consultant advice within 2 working days.
• 20% reduction in clinic appointments.
• Child seen in correct clinic by correct consultant.
• Earlier investigations and treatment prior to any clinic appointment.
• Reduction in clinic waiting times.
• Safety-netting as consultant reviews all referrals.
• Clinics more efficient, redirecting consultant sessions to support and attend primary care.
• Better communication between primary and secondary care with consultant and CCNT teams linked to each GP practice (Standards 3 & 6, Together for Children,
• RCPCH).
• Regular consultant education and clinic sessions in GP practices, including pathway development of most common conditions.
• Deliver community place based care for paediatrics, one of the key ambitions of the NHS Long Term Plan.

However, a small design group was formed to work with key stakeholders to define and implement the solution. The design group consisted of:

• Children and families
• Commissioners
• Primary Care (GPs, GP Practice nurses)
• Secondary Care (Consultants, Managers, Corporate Services; IT etc)
• Paediatric Community Nursing Teams (CCNT)
• RCPCH
• NHS Digital

A number of focus groups were held with children and families to discuss the ideas behind A&G and to gain valuable feedback prior to and during its implementation. This enabled the team to co-design the A&G offer with both our partners and patients.

A 6-month trial in one neighbourhood demonstrated substantial benefits which supported the service to be rolled-out across the whole borough.

Outcome

A&G referrals are reviewed by 4 paediatric consultants ensuring consistency, expertise and annual leave cover. Consultant advice is returned within 48 hours with very positive feedback from user groups and GPs.

Appointment numbers reduced by 30% (exceeding 20% target) creating an average waiting-time reduction: 16 weeks - 5 weeks.

Consultant led A&G ensures patients are directed to appropriate clinics and vital additional information of investigation results and effects of treatment initiation is available, lowering RTT times.

Efficiencies have been generated through A&G (circa 3.5 outpatient clinics at an annual cost saving of £35,000) which have been reinvested to support the new models of care. Consultant PAs have been redirected to children’s community clinical sessions and paediatric ED in-reach (a positive unintended consequence of releasing capacity within the paediatric consultant team), reducing ward admissions and providing support/education to ED multidisciplinary staff.

Consultant paediatricians & Community Children’s Nursing Team are linked to each GP practice (nationally only 7.4%, Standard 3 and 11.2%, Standard 6 respectively, Together for Child Health, RCPCH). Education is bespoke and has included paediatric asthma clinics with GPs, GP nurses and GPST3 trainees (published best practice example in Standard 4 Together for Child Health, RCPCH). The consultant team are aligned to and working closely with each of the borough’s Primary Care Networks.

Difficulties with engagement and GP training have been overcome by utilising “champion GPs” to encourage colleagues, persistent engagement, GP neighbourhood meetings and regular IT bespoke training.

A&G safety-netting has identified serious conditions referred as routine, including brain tumour, pyloric stenosis and safeguarding enabling same-day assessments.

Spread

The success with A&G has now been rolled out to all other acute specialties within the Trust. Tameside and Glossop GPs are familiar with the A&G model and regular communications from the Trust builds upon the ’advice firs? Approach to secondary care referrals.

In line with the implementation of the NHS Long Term Plan, the paediatric A&G operational model will be used as the model of choice across other specialities to increase demand through the A&G service to support a 30% reduction in face-to-face outpatient appointments.

The Trust is often requested to present A&G at regional events and has organised visits / conference calls to answer questions and offer feedback to support our partner organisations across Greater Manchester in their roll out programmes which has started in 2019.

The RCPCH introduced a national audit on their published standards from their two documents. Facing the Future: for acute paediatric services, 2015 and Together for Child Health, 2017.

161 paediatric clinical directors were surveyed in June 2017(70% response) and the Trust’s paediatric department volunteered to be included in a RCPCH site visit, including for the first time the Young Inspector Programme.

Although the national picture demonstrated poor integration between primary care settings and hospital children services, the RCPCH inspection was so impressed with our innovative integration that our initiative has been published nationally as a best practice example in Standard 4 Together for Child Health in Facing the Future Audit 2017. The best practice example also references Standards 3, 6 and 11 of the same audit.

Facing the Future Audit 2017 publication is distributed nationally to all paediatric directors and every DGH works toward achieving these standards. We have been approached by another DGH and are meeting with them to provide detail on what we have achieved, the barriers we encountered and provide advice and support on the best ways forward.

Value

The service started in February 2017, whereby a roll-out programme by neighbourhood was adopted to continually assess the process prior to up-scaling the model further. By March 2018, the service was open to all 37 GP practices across the 5 neighbourhoods. 99% of all GP advice requests are responded to by a paediatric consultant within 2 working days.

From April 2018 to October 2019, 74% of requests were returned to the referrer with advice without the need for a referral into secondary care. This equated to 836 avoided referrals within that time period.

Further benefits of the service;

• Average reduction in general paediatric outpatient waiting times from 16 to 5 weeks.
• Improved patient experience, reduction in cost and time for families to attend appointments by providing advice ‘closer to home’
• Some urgent referrals normally waiting for a routine appointment have been fast-tracked and admitted to hospital the same day.

The requirement for paediatric consultant time allocated to outpatient clinics has reduced since the inception of A&G equating to an annual cost saving of circa £35,000, which has been reinvested to allow the consultant team to redirect their time to other areas across the system

Consultants now facilitate children’s community clinical meetings with each GP neighbourhood group to;

• Develop personal relationships between practitioners.
• Improve communication between secondary, primary and community care.
• Share knowledge and skills.
• Improve confidence in the management of children’s needs in the community.
• Improve the consistency of care delivered by primary and community practitioners.
• Develop a culture of shared decision making.
• Improve outcomes for children and their families.
• Improve the experiences that children and their families have.

Additionally, the consultant team in-reach into paediatric Emergency Department (ED) to provide a rapid response to the acute needs of children in our community. This support provided into the ED supports;

• Faster medical review times for children in ED.
• Quicker decisions on treatment plans for children
• Appropriate, swift admissions to Observation & Assessment / Children’s Unit.
• Children discharged as appropriate with next steps and advice for parents.

Involvement

The most difficult challenge was engagement with all stakeholders including user groups, GPs across neighbourhoods, hospital managers and executives, paediatric teams and IT, because this was a very different way of working with a very limited national evidence base. However, the Design Group was led by two Paediatric Consultants, GP lead for paediatrics, IT team, users and business managers. Plans were designed and GPs were engaged through their educational TARGET meetings (GP and practice nurse training day) by explaining the need for change utilising national documents and data from the RCPCH and RCGP.

A number of focus groups were held with children and families to discuss the ideas behind A&G and to gain valuable feedback prior to and during its implementation. This enabled the team to co-design the A&G offer with both our partners and patients.

An interested neighbourhood piloted A&G and each practice/GP was provided with IT training. Initially, 91 A&G referrals were received across 11/11 practices. 9 referrals were redirected to appropriate clinics, 37% clinic appointments were prevented and safety-netting identified 4 serious cases and the DNA rate improved from 20% to 7%.

Results were relayed through TARGET and Trust Executive Integration Meetings. Safety-netting and user feedback was emphasised as important benefits. Bespoke consultant-delivered educational sessions for every GP practice at the time and date of their choosing were enthusiastically accepted, evidenced by the first ever 100% positive response from GPs!

Tameside and Glossop consist of 5 neighbourhoods and the GP Integrated Neighbourhood Clinical Directors have subsequently supported and championed this initiative across their patches and A&G is now fully established.