Giving care in the right place, first time

The Director of NHS England’s Elective Care Transformation Programme explains why practical handbooks published this week can help the NHS address a steady rise in referrals for hospital treatment while benefitting patients:

Some pundits like to suggest that the NHS is doomed to collapse under the growing weight of public expectations.

At the NHS England Elective Care Transformation Programme we beg to differ.

But there is a real challenge: since 2005-06 total outpatient appointments have nearly doubled, from 60.6million to 118.6million. This means patients are waiting longer for hospital appointments when they could be seen in the community by a clinician, such as a clinical nurse specialist or physiotherapist.

We are working with local GPs, nurses, consultants and allied health professionals to test out new ways that patients can access health services. And this week we published the first fruits of that initial work.

We focused on two specialties that are among the busiest in the NHS – musculoskeletal (MSK)/orthopaedic and gastroenterology.

Clinicians supported by local NHS managers and my team have tested a variety of new options for people affected by joint or muscle pain, or experiencing some form of bowel problems.

These new approaches were tested in four health communities over a 100 day period. Now we’re asking the wider NHS to look at how they can adopt them, adapting each intervention to meet local circumstances.

The new approaches are aimed at making sure that GPs only refer to hospital those people who will benefit from seeing a hospital consultant. Our testing suggests this will shorten waiting times – both for patients who are referred to a hospital consultant and those who can actually see another health professional. In MSK that could mean an advanced practice physiotherapist; in gastroenterology it might mean a dietitian or clinical nurse specialist.

Each of the new approaches is aimed at ensuring the patient sees the right person in the right place, first time.

What does that mean in practice for patients?

One of the new approaches tested out for patients with MSK/orthopaedic problems was educating them in managing their own conditions. This can give patients greater control over their own health – including chronic conditions. Such education can be provided in face-to-face groups or through webinars. These programmes include clear advice on both healthy lifestyles and when to seek professional help – for example, if symptoms change.

In Stockport, a range of health professionals with MSK expertise ran three knee workshops to educate and support patients to manage their condition better, promote early intervention and help them become more involved in decisions about their own treatment. Between 30 and 40 people aged over 50 with osteoarthritis attended each workshop.

Among the 83 people who filled in the feedback questionnaires, the number who said they felt confident about self-managing their condition soared from 8 to 61.

In Somerset, local clinicians tested out a telephone ‘advice and guidance’ service for GPs who had patients with gastroenterology problems sitting in front of them. While a GP will usually know how to help the patient, often they find it useful to have a specialist from the local hospital at the end of the phone to confirm whether they need to refer the patient. Four gastroenterology consultants in Somerset are available during working hours to advise on whether they should refer a patient where the GP would welcome extra reassurance.

In the trial, 54% of calls from GPs to those specialists resulted in no referral – meaning patients avoided hospital appointments that are often inconvenient, and were diagnosed and treated in the community without waiting to see a consultant. The GP, following the consultant’s advice, diagnosed and treated the problem for some patients; other patients were seen by other health professionals such as a dietitian or a clinical nurse specialist.

To address long waiting times for patients with suspected Inflammatory Bowel Disease (IBD), Stockport clinicians changed how such people access the gastroenterology service. They established a rapid access clinic for people with suspected IBD and a ‘flare up’ service through which patients have direct telephone access to the IBD specialist nurse when their condition deteriorates. The specialist nurse provides advice and can book an urgent clinic appointment if necessary.

Some Stockport people had previously been waiting longer than the 18 week referral-to-treatment target for gastroenterology services. By early 2017 the average wait time was down to 13.7 weeks. For patients following the new IBD pathway, that figure had dropped to 8.8 weeks by June – mainly due to quick access to an initial appointment and referral for tests.

These are the sorts of rapid results that make us confident we can work together to make the NHS better for everyone.

Download handbooks for Gastroenterology and Musculoskeletal and Orthopaedic.

Dr Linda Charles-Ozuzu

Linda Charles-Ozuzu is NHS England’s Director of Commissioning in the North West.

She was previously NHS England’s Director of the Elective Care Transformation Programme, and Assistant Director/Associate Medical Director in NHS England Midlands and East.

Her other senior healthcare management roles include extending the Department of Health’s Improving Access to Psychological Therapies (IAPT) Programme to people with long term conditions, severe mental illness and medically unexplained symptoms.

Linda is a member of the Royal Society for Public Health; a recipient of the NHS Leadership Academy Award in Executive Healthcare Leadership and an alumnus of the Global Health Leadership Forum.

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