Paediatric outpatient referrals from primary care have changed. More than 80% attend for one appointment and are discharged without follow up or investigation. This is as a result of many different issues not least that the majority of primary care clinicians no longer have any exposure to paediatric training.There are more than 30 steps involved in a child or young person (CYP) attending a hospital to be seen by a paediatrician. Of all these steps there are two steps with added value - the face to face consultation with the clinician in primary care and the face to face consultation with the consultant paediatrician. The paediatric first outpatient tariff is £240 of which only 5-10% relates to the cost of this added value step. The rest is used to pay for all the processes and procedures around that outpatient appointment.
The ambition of this project was to create a pathway for CYP to be seen in primary care by paediatricians without the unnecessary process steps that added cost, time and inconvenience to the pathway for families, clinicians and the healthcare economy. By creating closer relationships between primary and secondary care clinicians we hoped that many CYP could be managed with a bespoke management plans that were shared between primary and secondary care so that a child was no longer in primary or secondary care but was having a medical care plan wrapped around them with expertise from the whole health care system.
We began by looking retrospectively at patients referred, the conditions that they were referred with and the number that needed investigation or follow up. It soon became apparent that our referrals were increasing by 20% year on year. In addition where historically CYP were referred with diagnoses eg asthma, constipation, coeliac disease etc, more recently these referrals have changed to become symptom based: abdominal pain, wheezy, diarrhoea. We involved our GP, CCG and executive teams in developing shared measure of success that were designed to fit with the sustainability and transformation plan. Prior to embarking on the pilot we carried out a survey in our outpatient department about where families would prefer to be seen.
The first pilot clinic was carried out in a GP practice with an annual referral rate of 80 each year. Bimonthly clinics were designed with a capacity for 8 patients (30 minute appointments each as occurs in hospital). All referrals were emailed to a named paediatric consultant who had the freedom to manage the referrals in one of three ways:
1. Provide a bespoke written management plan describing the diagnosis, investigation and red flags with copied provided to the family and other relevant health care professionals.
2. Ask for the patient to be added to the next primary care paediatric list for a face to face appointment
3. Referred to a specialist as the condition required specialist input or investigations.Those that were allocated to the clinic would be seen by that same consultant in primary care accompanied by a member of that GP Practice. In some cases this was a nurse practitioner, in others a GP or GP trainee.
Information was accessed directly from the GP record and inputted directly onto that EPR preventing the need for dictation, transcription, sending and uploading of letters to the GP system. Is also allowed all those within the practice to immediately see the paediatric opinion. At the end of clinic a meeting is held with the clinicians in practice to discuss referrals over the last 8 weeks and any CYP that they have vague concerns about ‘case finding’. On leaving the practice the next 8 week cycle begins. As the clinics took place other practices became aware of the initiative and wanted to implement a similar service. It was seen as a service that added quality, motivation and efficiency to all parts of the health care pathway. As this became established and proof of concept became the operational gold standard it became apparent that we needed to renegotiate a local tariff so that the health economy could also benefit.
We therefore after some discussion came to an agreement between the acute trust and CCG to agree 50% new patient tariff for CYP seen in this way. This recognised the reduced overheads for the acute trust in terms of premises and admin work but allowed profit margin to remain in order to prevent destabilisation of the peadiatric service. For every 100 referrals managed in this way the health economy therefore saved £12000. This service is currently running for about 30% of referrals (over 500/year) and therefore represents significant value for the health economy - before it has even been rolled out to cover the entire patch.
Improved patient care: This initiative has allowed for the CYP to be managed by the most expert specialist within the primary care setting. This has therefore allowed ‘wrap around care ’ of the patient whether they are in primary or secondary care. In cases where a management plan is developed this is returned to the young person’s family within 5 working days preventing their need to attend a hospital appointment. 40-50% of all referrals as managed in this way. Where a specialist paediatric appointment is needed this is immediately arranged rather than prolonging the patient pathway with a general paediatric appointment first - this is arranged for 20% of referrals. Where the CYP needs a face to face general paediatric appointment this is carried out in general practice and information directly entered into patient record so that there is no need for typing or dictation of letters and the primary care team are immediately aware of the expert opinion.
Improved paediatric training: Most GPs now receive no or very little paediatric training. Those that so have a paediatric job as part of their training program do not in general get to see the outpatient referrals that will be their bread and butted as GPs. This system allows a GP trainee to sit in on clinic and receive bespoke paediatric training for the common GP presenting conditions.
Improved patient experience: Families are able to receive an expert opinion without travelling large distances to their district general hospital. With our rural geography this can mean preventing the need for a 1 hour journey to and from the clinic - acceptable it you have a serious conditions - not acceptable if it simply to reassure the family that they do not need to be worried.
Improved value for money: By shortening the patient pathway and excluding process steps to that pathway the process becomes much cheaper to deliver. We have therefore agreed a tariff with our CCG for 50% of the standard new patient tariff. This has been calculated to equate to a £1000 saving for every 8 children referred. Although this reduces the overall income to the trust it maintains the profit margin - preventing destabilisation of the acute trust services. The longer term aim is that by working closer with our primary care teams we can prevent the increasing referral rates seen elsewhere.The system is not rocket science - it is basically reestablishing the relationships that have been lost between primary and secondary care - working together to look after their children and families to allow expertise to be at the front end of patient pathways. The prevention of unnecessary steps allows the system to be delivered far more efficiently for the health economy.
We began this project with just one primary care practice. Very quickly surrounding practices wanted to be included in the work. We are growing every week but currently manage a third of all referrals with this system. Surrounding trusts are aware of the project and I have had enquiries from Exeter,Torbay, Bristol and Cornwall about how they might trial a similar model of care. I met and explained the model to a team in Cardiff who have instituted it for one of their city centre GP clusters.The advantage of this model is that there is no finance or operational change needed in order to try it for an 8 week block - simply a desire for clinicians in primary and secondary care to give it a go.
Running this model has resulted in interest from both primary and secondary care in wondering whether it could be utilised in other specialities. The specialities that could consider this model are those where there are first patient appointments that require little or no specialist investigation or follow up. Other specialities that have shown interest locally are cardiology and the frail elderly team.