Gloucestershire Hospitals NHS Foundation Trust: advice and guidance case study
This case study focuses on the successful implementation of the NHS e-Referral Service (e-RS) advice and guidance functionality at the Gloucestershire Hospitals NHS Foundation Trust.
Background information
Gloucestershire Hospitals NHS Foundation Trust is one of the largest in the country, providing hospital services for a diverse population of over 620,000. The Trust provides services from two District General Hospitals; Gloucestershire Royal Hospital and Cheltenham General Hospital.
The trust is one of the largest providers of e-RS advice and guidance services in England, responding to over 15,000 advice and guidance requests in 2018. Advice and guidance services were first established in 2012/13 in response to the King’s Fund report 'Referral Management – Lessons for success’ (2010).
The service was initially established in dermatology, before being expanded over time to cover:
- nephrology
- endocrinology
- haematology
- rheumatology
- paediatrics
- neurology
- ear, nose and throat (ENT)
Advice and guidance was subsequently expanded across remaining specialties during 2017/18 and 2018/19, in response to the advice and guidance national CQUIN, with some of the new services such as cardiology and gastroenterology rapidly becoming some of the most commonly used by GPs. The majority of services respond to advice and guidance requests within two to five days.
Available advice and guidance services
The available advice and guidance services are:
- cardiology
- dermatology
- diabetic medicine
- endocrine and metabolic medicine
- ear, nose and throat (ENT)
- gastroenterology
- gynaecology
- haematology
- nephrology
- neurology
- ophthalmology
- orthopaedics
- pain management - paediatrics
- respiratory rheumatology
- surgery (breast, vascular)
- urology
Advice and guidance activity data
The NHS e-Referral Service (e-RS) private providers dashboard can be used to understand national advice and guidance usage across England.
Users should register for access if they wish to view this data.
Implementing advice and guidance using e-RS
Gloucestershire does not have a referral management centre and has instead focused on providing GPs with the necessary support to allow them to appropriately manage patients without referral where possible.
Provision of advice and guidance is a central part of this approach, alongside provision of high quality pathway and guidance materials via a local pathways website (G-care). The rapid turnaround of advice and guidance responses has been used to encourage GPs to use this route before considering referral.
Here are some examples of successful implementations of advice and guidance across different specialities:
Cardiology
The cardiology team set up their advice and guidance service in March 2018 and advice and guidance requests have continued to increase, often with ECGs attached.
Of the team of 12 consultants, Dr Nicol Vaidya and three consultant colleagues cover the advice and guidance service. With volumes increasing, the team have highlighted the importance of job planning and time allocation for reporting.
In the past the cardiology team have received large volumes of paper advice and guidance requests. e-RS advice and guidance now provides the option to channel all advice and guidance requests through e-RS.
Dermatology
Dr Tom Millard is part of a team of six dermatology consultants, each providing an hour of advice and guidance a week. The majority of requests have skin images attached. Most responses do not require two way digital dialogues.
The department has developed a bank of commonly used responses, which can be cut and pasted into e-RS from the departmental shared drive.
Endocrinology
The endocrinology advice and guidance service is provided across two hospital sites (Gloucester and Cheltenham), with two consultants covering each site. Dr Sally Thrower and the team provide a 48 hour turnaround service, and use two-way conversations when required to optimise responses.
The majority of patients do not require face-to-face review. Patients with less complex medical problems are increasingly being cared for via advice and guidance; as a result the clinical casemix in clinics is often more complex.
Ear, nose and throat (ENT)
In ENT, advice and guidance is provided by the on-call consultant for the week. Dr Charlie Hall and the team respond to approximately 30 to 50 advice and guidance requests a month, and have used advice and guidance to reduce inappropriate outpatient referrals and support patient care in the community.
Gastroenterology
Dr Coral Hollywood and the consultant team all take part in the advice and guidance service, aiming for a 48-hour turnaround. They have used the service to direct GPs to a local referral and treatment guidelines website (G-Care) to optimise patient care and streamline referral pathways.
Gynaecology
In the gynaecology department, all consultants provide advice and guidance, with two consultants providing the majority of the responses.
Dr Madhavi Vellayan and colleagues have worked hard to remind referring GPs that advice and guidance is a generic rather than named-consultant service. The team have highlighted the need for regular job-planning as advice and guidance requests have continued to increase.
Haematology
Dr Michael Shields and the team respond to over 100 advice and guidance requests a month. The service is split over both hospital sites.
Although e-RS keeps a record of advice and guidance, the team have found it helpful to additionally scan responses into the clinical document manager (InfoFlex®). They have used advice and guidance to link with resources on the G-Care website, set up by the local Clinical Commissioning Group.
Some consultants in the team prefer to convert the advice and guidance to paper and dictate responses, but others respond electronically. The team have historically offered a parallel telephone advice service between 3pm and 5pm, which has been difficult to resource and will be replaced by advice and guidance.
Neurology
Dr Farhad Golestani and the team have found that advice and guidance has reduced the number of outpatient appointments and encouraged more appropriate referrals.
The neurology team provide an ‘excellent service’, with 24-hour turnaround of the majority of advice and guidance requests.
The service is continuing to increase, requiring time-allocation in job plans to maintain quality.
Neurology is the only speciality in the Trust to process advice and guidance outside of e-RS. Requests are transferred to email by the e-RS administrative team, and as a result two-way dialogue is not used.
Paediatrics
Dr Miles Wagstaff and the team have seen paediatric advice and guidance requests rise from approximately 40 to 50 a month to approximately 120 a month.
The team have tested a variety of models of service delivery, with either some or all consultants providing the service. Currently, every consultant provides a day of advice and guidance a week, which they find provides more effective delivery than covering advice and guidance for the whole week when on call.
Respiratory medicine
Eight consultants rotate to provide the respiratory advice and guidance service when on-call as consultant of the week. Dr Charles Sharp and the team find the service is well used by both practice nurses and GPs, with a 48 hour turnaround. The team run a dedicated parallel email service for practice nurses and physiotherapists.
Rheumatology
As one of the longest running advice and guidance services in the Trust, Dr Hilary Johnson and the team recall initial teething problems when advice and guidance was introduced in 2013, but advice and guidance is now a part of the rheumatology service.
Five consultants provide advice and guidance across the two hospital sites (linked with where the consultants provide peripheral clinics), with higher volumes being referred through Gloucester advice and guidance worklists compared to Cheltenham.
A high proportion of advice and guidance requests relate to osteoporosis, which is not currently covered. This may guide future workforce planning.
As advice and guidance is aimed at patients not under hospital follow-up, the team provides a parallel 24 to 48 hour response telephone advice service run by specialist nurses, for patients already under consultant hospital care.
Urology
Advice and guidance in urology started in October 2017, initially with Mr Eaton reviewing all referrals. However, as numbers rapidly increased, these became the responsibility of the on-call consultant for the week. Each of the nine consultants now review between 60 and 80 advice and guidance requests per week.
Approximately 40 to 45% of requests are managed with advice alone. This service has been particularly valuable for the interpretation of PSA values in the comorbid or elderly (over 80 years of age) population. Paediatric urology is also included in the advice and guidance service, and is preventing unnecessary or inappropriate referral for children with tight foreskins.
89% of advice and guidance requests are reviewed within two days and 98% within five days.
Challenges
Hospital teams have worked hard to optimally balance advice and guidance with face-to-face clinical care, and achieving a 48-hour turnaround is not always possible in all specialities.
Most teams are experiencing increasing volumes of advice and guidance requests, highlighting the need for regular job-planning to accommodate service growth. Although advice and guidance can be provided flexibly, consultants who are job-planned to provide advice and guidance when on-call can experience workload pressures as volumes of both work streams can be unpredictable.
Communication and feedback between primary and secondary care clinical teams has focussed on maintaining the quality of clinical information provided by both referrers and providers.
Advice and guidance referrals containing insufficient information or missing attachments can delay patient care. ECGs and scans performed by private healthcare providers are not always accessible to reporting consultants to comment on via advice and guidance. The quality of advice and guidance responses can vary within or between specialties, requiring regular peer review and close consultant team work to ensure consistency of responses.
Use of the advice and guidance service to expedite patient appointments is an ineffective use of clinical time, unless the patient's condition has changed since referral.
Maintaining an up-to-date directory of services for both advice and guidance and face-to-face clinics has been required, to ensure any recommendations for referral are in line with directory of service specifications and local commissioning arrangements.
Although e-RS is intended as a single platform for consultants to access both advice and guidance requests and clinic referrals, in this Trust consultants are required to use a separate system for vetting clinic referrals (InterSystems TrakCare®), which many consultants find reduces clinical efficiency.
Patients requiring clinic review within 6 months of advice and guidance
The data below shows face-to-face referrals to the same speciality for any condition within six months of the advice and guidance response, for key specialities providing hospital out-patient services.
This data includes patients referred immediately following advice and guidance (on advice of the responding clinician) and patients for who the advice and guidance plan was followed but ultimately the patient still required a subsequent referral. This data is based on NHS numbers and does not differentiate between referral for the same or a different condition, and may therefore include some patients referred for another indication unrelated to their advice and guidance.
Across the outpatient specialities studied, over two-thirds of patients were not referred to out-patients, although this varied widely across speciality services. Feedback from consultants in qualitative interviews suggests that many patients who are referred to clinic following their advice and guidance are further along their treatment or investigation pathway as a result of advice and guidance, and therefore may require less follow-up in secondary care.
This data should be interpreted in the context of the individual services, as waiting times for new referrals to some services may occasionally exceed six months. The data reflects patients selected by their GP for advice and guidance rather than referral, and therefore the figures should not be interpreted by commissioners as applying to all patients requiring a specialist opinion. In some services advice and guidance may result in a referral direct to a test (such as endoscopy); although these patients may not require a subsequent clinic appointment the patients are still seen in the specialist service for their investigation.
Gloucestershire Hospitals Trust Specialty |
Total advice and guidance requests received: Jan-June 2018 |
Patients seen in clinic within six months of advice and guidance response | % seen in clinic within six months |
---|---|---|---|
Cardiology* | 242 | 104 | 42.98% |
Dermatology | 1391 | 368 | 26.46% |
Diabetic medicine | 19 | 13 | 68.42% |
ENT | 166 | 45 | 27.11% |
Endocrinology | 432 | 93 | 21.53% |
Gastroenterology | 358 | 91 |
25.42% |
Gynaecology | 315 | 84 | 26.67% |
Haematology | 699 | 66 | 9.44% |
Nephrology | 242 | 69 | 28.51% |
Neurology | 343 | 131 | 38.19% |
Paediatrics | 499 | 172 | 34.47% |
Pain Management | 20 | 5 | 25.00% |
Respiratory Medicine* | 16 | 4 | 25.00% |
Rheumatology | 348 | 94 | 27.01% |
Urology | 327 | 71 | 21.17% |
Total | 5417 | 1410 | 26.03% |
*Cardiology and Respiratory services started March 2018
Orthopaedics, Vascular and Breast surgery services started after June 2018 so not included.
Trust information technology
Clinicians access e-RS advice and guidance using their NHS Care Records Service smartcard to view the standard e-RS screen and advice and guidance worklist. Advice and guidance is not integrated with the electronic patient record. Previous advice and guidance replies are accessed in e-RS if required.
The Trust uses the InterSystems TrakCare® hospital information system, which consultants use to accept, return or redirect patients referred to face-to-face clinics.
Further information
Find out more about advice and guidance by reviewing the advice and guidance toolkit and watching the advice and guidance video, found in our document library.
Last edited: 13 February 2024 5:09 pm