Facing the Future Together for Child Health: Working with General Practitioners (GPs)
Below are several practice examples of working with General Practitioners in a variety of different ways:
Children and Young People's Health Partnership - Evelina Children's Hospital
Learning Together - UCL Partners
Paediatric Unscheduled CarePilot (PuC) - North of Scotland Planning Group
Rapid access clinic - Rotherham Hospital, Rotherham NHS Foundation Trust
Salford Children’s Community Partnership
Senior telephone advice - Nottingham Children's Hospital
Supporting Primary Care - King's College Hospital, London
Up-skilling GPs and nurses - Partners in Paediatrics
Children and Young People's Health Partnership - Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust
The Children and Young People’s Health Partnership is a coalition of clinical commissioning groups, local authorities, acute providers, third sector and family and patient representatives, funded by the Guy’s and St Thomas’ Charity and focused on improving the everyday health needs of children in Southwark and Lambeth. A three-pronged strategy was developed to ensure that general children’s services worked closely with primary care to develop better care pathways.
Firstly, a series of guidance covering the most commonly seen conditions in primary care, for example, asthma, fever, constipation and mental health conditions was developed. These consisted of one page flow charts of how to identify conditions, what to look out for (red flags) and top tips. Each piece of guidance was localised with specific information on when to refer and where. The guidance was designed with primary care to ensure they are user friendly and the information sits within the IT system of primary care, making it accessible and functional.
Secondly, a hotline service was developed at the Evelina and King’s to ensure there was a strong link to the general paediatric service. This service enables primary care to access real time advice via email or telephone from a consultant paediatrician. Outcomes of a call or email are advice, transfer to the Emergency Department, booking into the next available outpatient slot or a hot clinic appointment. This service helped build a strong relationship between primary care and the hospital and provides a mechanism by which concerns can be directed to the relevant guidance.
Thirdly, by doing in-reach clinics with GPs, a further opportunity to guide people to the new guidance has been created. During in-reach clinics a consultant paediatrician sees children alongside a GP. These children are a mix of children about whom the GP has concerns, those who attend the Emergency Department frequently or those who would otherwise have been referred to the hospital.
Learning Together is an educational intervention that aims to improve outcomes for children and young people. A paediatric registrar and a GP registrar see children or young people in a joint clinic based in a GP surgery, sitting in the same consultation, seeing patients together. The intervention is inter-speciality and has key multidisciplinary team elements.
Twenty-five percent of children in Scotland live in remote and rural settings which present challenges in providing safe, sustainable paediatric care. The PuC pilot trialled a dedicated on-call paediatric consultant model, providing 14 rural general and community hospitals with single point of contact access to paediatric consultants, 24 hours a day, seven days a week, via videoconference with project management being provided by NHS24.
Sixteen on-call consultants were recruited; all were within 10 minutes of secure broadband access and standardised SBAR documentation was used. Within individual rural hospitals, following initial nurse triage, there are two models in place:
Assessment by a trainee (foundation year/GP trainee). Many children are then referred on to regional paediatric services, without further evaluation. Rural (adult) physicians have clinical responsibility for the care of the child whilst in hospital until the child reaches definitive care but, in practice, rarely get involved.
- Evaluation by experienced rural practitioners, who may carry out investigation or initiate active management, prior to referral for advice/transfer.
Two hundred and thirty referrals were made to PuC (152 managed locally, 21 retrieved and 57 transferred). An independent evaluation by the Centre for Rural Health noted that videoconferencing enhances clinical assessment and decision support of children in remote locations, with rapid-access to senior advice being valuable in this setting. Parents and carers find videoconferencing helpful which helps improve further the outcome for children. Even in children requiring transfer, early assessment and management adds value. External Expert Review by a rural GPnoted that 33 percent of cases showed improved outcome: ‘PuC added value and security to the children seen’. A paediatric intensive care consultant statedimproved outcome in 20 to 25 percent of cases: ‘PuC avoids unnecessary admission/transfer/retrieval and offers significant support to remote and rural locations.’
Further details: Dr Donald MacGregor, Consultant Paediatrician, firstname.lastname@example.org
A rapid-access clinic was set up in Rotherham Hospital 20 years ago with the aim of providing an immediate consultant appointment for GP and emergency department referrals of children less than 16 years old who are not acute emergencies but who cannot wait for a routine outpatient appointment.
The rapid-access clinic is located within a children’s clinic on the hospital site with full access to pharmacy, laboratory and imaging services and to inpatient facilities if these are required. The clinic is run by a consultant paediatrician who is rostered to the clinic on a 1:7 basis. This is identified in the job plan as two hours clinic time with an hour administration time associated with the outcomes from the clinic. Clinics run from Tuesday to Friday between 1.30pm and 3.30pm, with four 30 minute appointments available. Referrals are made by telephoning a dedicated number in the Children’s Clinic and bookings are only made 48 hours in advance. If there are no slots, the clinic staff re-direct the GP or referrer to the on-call paediatric registrar who discusses alternatives, for example, children’s assessment unit, routine clinic appointment or specialist nurses. The rapid-access clinic has been used to give feedback and complete a mini-Clinical Examination Exercise (CEX) for trainee registrars with the trainee doing the clinic and the consultant observing.
In July 2013, 38 case notes of children referred to the rapid-access clinic were reviewed retrospectively. Of children seen, 55 percent were under 12 months of age and 29 percent were between one and five years old. Children were mostly seen for medical conditions; 79 percent of referrals were from GPs and 8 percent of referrals were from the emergency department. The rest came from consultants, asthma nurses or other sources, for example, health visitors. The outcome of the consultation was that two children were admitted, seven were discharged, 23 were investigated and/or given medication and 25 had follow-up arranged.
Recommendations for consideration in setting up a rapid-access clinic:
- Consult with stakeholders (GPs/commissioners/clinic staff/consultants/trainees)
- Identify availability of clinic rooms and scheduling
- Write a set of simple guidelines for referral (why, what, where, when and how)
- Ensure a 48 hour booking rule; otherwise the clinic ceases to function as a rapid-access clinic
- Monitor, evaluate, audit, implement change and re-audit
- Consider conducting patient satisfaction surveys to gain feedback on the service
Further details: Dr Sanjay Suri, Consultant Paediatrician, email@example.com
The Salford Children’s Community Partnership (SCCP) is the first of its kind in the UK, funded for three years by the Department of Health. The service sits between the GP practice and the hospital. It’s a dedicated children’s nursing service in the Little Hulton surgery of Salford Health Matters GP practices, aimed to help children get well at home, a preferable alternative to putting them in hospital on a short term basis. The team consists of highly trained, specialist children’s nurses.
A project team working on improving the pathway for emergency medical admissions identified that when a GP called with concerns about a child the call was taken by a junior doctor and always resulted in the GP being advised to send the child into the Children’s Assessment Unit. The Project Team hypothesised that if the calls were taken by someone senior, with more extensive paediatric knowledge than the GP making the call, it might be possible to have a more proactive discussion and identify some appropriate options that did not involve an on-the-day attendance.
Nottingham already had a ‘hotweek’ consultant rota for emergency admissions, so the group proposed a trial of having the hotweek consultant take the GP calls to see how many could be diverted from the hospital. Simple paperwork was developed using the Situation, Background, Assessment and Recommendation (SBAR) format.
The trial ran for one week and found that 30 percent of patients did not need to attend; some were diverted to routine outpatient or rapid-access clinics and some were managed by the GP with advice from a consultant. There was an additional, unexpected, outcome of two patients being escalated as a result of the call and a 999 ambulance called. In some practices, the clinical discussion prompted the GP to change practice or purchase equipment such as a saturation monitor.
The initial trial identified that the idea was worth pursuing and further trials confirmed this. The change in process was fully implemented and has also been rolled out for other specialties. Analysis of the paediatric calls has shown that the outcomes are: 63 percent sent to the Children’s Assessment Unit; 13 percent referred to a rapid-access clinic; 4 percent referred to routine outpatients; 15 percent managed by GP with advice from the consultant; and 4 percent escalated.
‘I sometimes send people in - particularly children, because I am being cautious. Discussion with a senior paediatrician may give me confidence to keep at home.’ GP using the telephone advice service.
Further details: Please email firstname.lastname@example.org
Service development in Ambulatory Paediatrics at King’s has evolved over a period of years. The overall vision is to deliver high quality healthcare for children, streamlining their patient journey and thereby optimise their patient experience. This approach has enabled the development of a comprehensive portfolio of clinical services targeted at meeting the needs of children and their families.
GP Education: An annual paediatric GP conference is convened at King’s College Hospital. This utilises the expertise of the wide variety of paediatric subspecialties represented at King’s to deliver interactive lectures on clinical topics of importance to GPs. The GP feedback collated is proactively utilised to refine the programme content in subsequent years in order to ensure ongoing relevance to a primary care audience. By forging collaborative relationships with colleagues at Evelina Children’s Hospital and Lambeth and Southwark CCGs, we also deliver education at CCG organised annual paediatric educational events. This therefore provides 3 dedicated, free, events per annum for formal paediatric learning for local GPs.
Paediatric Phone Line: A phone line has been in operation since July 2014, whereby GPs can speak directly to a paediatric consultant between 0800-2200 on weekdays and 0800-1730 at weekends. The aim is to optimise patient care by facilitating timely, reciprocal communication with the most appropriate hospital based paediatrician. This enables acutely unwell children and outpatient referrals to be directed appropriately. It has streamlined the outpatient referral pathway, reduced the numbers of inappropriate paediatric emergency department (PED) attendances and serves to strengthen professional relationships between primary and secondary care. A supplementary function of the phone-line is that it is also used as a means of communication for junior doctors seeking senior advice from the duty paediatric consultant within the hospital. This has facilitated more timely decision making in the paediatric emergency department (PED) and improved clinical care, as well as directly preventing 26 hospital admissions within the first year of operation.
Rapid Access Clinic: This clinic has been operational for 6 years. In July 2014, there was expansion to facilitate rapid access clinic provision every weekday. Primary care referrals are accepted by phone, email or fax. The aim is to see every patient within two weeks of referral, although this can be expedited on clinical grounds as required.
Email advice: Utilising the facility contained within the established ‘choose and book’ system, local GPs can send email enquiries for clinical advice to a consultant paediatrician. There is a 24 hour response time during weekdays.
Outreach Clinics: Working in partnership has also facilitated the delivery of paediatric outreach clinics in primary care. A consultant paediatrician delivers a monthly primary care clinic alongside a GP partner. Together, they see patients who would otherwise have been referred to a hospital based general paediatric clinic. Each clinic is preceded by a lunchtime teaching session with the wider primary care team. There is also an opportunity for discussion of specific patients’ management following the clinic. These clinics provide reciprocal learning opportunities for both clinicians as consultant paediatricians develop an increased appreciation of the clinical challenges faced in primary care. The patient feedback is overwhelmingly positive.
Further details: Dr Omowunmi Akindolie email@example.com
Up-skilling General Practitioners (GPs) and Nurses in the clinical management of children with acute health problems - Partners in Paediatrics (PiP)
In October 2010, research at University Hospital North Staffordshire (now known as University Hospitals of North Midlands) identified that the number of children with acute health problems admitted to paediatric wards was about twice the admission rate of other hospitals in similar communities. It also identified the top 10 conditions where children referred into the hospital by a GP were discharged within four hours without active clinical intervention.
An interactive up-skilling programme for primary care was developed through a business case model. The work was supported by Partners in Paediatrics. The main objectives of the programme were to:
- Increase the competence and confidence of GPs and nurses in the clinical management of children with acute health problems
- Reverse the year-on-year rise in inappropriate referrals to the Paediatric Assessment Unit by primary care clinicians
- Improve the patient experience, particularly providing services closer to patient homes
Ten master-class sessions, run by paediatric consultants, were held in spring and summer 2011 to increase competence and confidence in managing acute paediatric conditions in primary care. Approximately 250 clinicians took part, including 114 GPs (40 percent of the GP cohort), 79 nurses and participants from other clinical backgrounds, including student doctors, clinical educators and community midwives.
Master-class topics included respiratory problems, failure to thrive, gastroenteritis, abdominal pain, constipation, fever management/febrile child, fits, faints and funny turns, mixture of acute admissions, rashes and skin problems. Paediatric pre-referral guidelines and urgent care referral guidelines were produced and made readily available to all clinicians in primary care.
The overall response to the programme was extremely positive. Participants welcomed the wide range of practical tips for managing conditions in the community working with parents and many rated the explanation of the NICE and locally developed urgent care guidelines particularly highly. After 18 months, GPs and nurses who took part in the up-skilling project indicated that they felt more competent and confident in the clinical management of children with acute health problems, that they are retaining more care within general practice and that they are referring more appropriately. They also felt better able to advise and support parents and carers. Of the 28 GPs who responded to the post master-class evaluation, most believed that the master-classes had increased their ability and confidence in the clinical care of children, particularly those with acute health problems. Specific changes in practice identified from attending the master-classes included use of saturation probes to check oxygen saturations in respiratory paediatric cases and use of pulse oximetry for children.