York Teaching Hospital NHS Foundation Trust: advice and guidance case study

The York Hospital is a large teaching hospital with over 700 beds, providing care to a population of over 800,000. York e-RS advice and guidance services are consultant-led, with the majority of consultants being based in York Hospital, but some providing advice and guidance from the nearby Scarborough General Hospital. Both hospitals are part of York Teaching Hospital NHS Foundation Trust.

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. The majority of advice and guidance requests are responded to within 48 hours.

The available advice and guidance services are:

• cardiology
• dermatology
• endocrine and Metabolic medicine
• gastroenterology
• geriatric medicine
• gynaecology
• haematology
• nephrology
• neurology
• ophthalmology
• oral and maxillofacial surgery
• orthopaedics
• pain management
• paediatrics
• respiratory medicine
• rheumatology
• sleep medicine surgery (general)
• surgery (breast, plastic, vascular)
• urology

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.

Across all services, the rapid turn-around of advice and guidance responses has been used to encourage GPs to use this route before considering referral.

The service offers advice only and consultants do not upgrade advice requests to face-to-face clinic appointments. In this Trust, e-RS advice and guidance is uploaded daily into the Trust’s Core Patient Database (CPD) system, rather than being accessed directly by consultants using a smart card. The Trust CPD system then allows consultants to redirect advice and guidance requests to other consultants if required; this functionality is not part of the national e-RS system.

Here are some examples of successful advice and guidance implementation:

Cardiology

Dr Nigel Durham and the cardiology team have used advice and guidance to support GP decision-making and referral pathways. The team aim for a 24-hour turnaround for advice and guidance responses. Referrals have continued to increase. Some cardiologists have used speech recognition software (G2 Speech).

Recommended investigations such as 24-hour ECG recordings or echocardiograms can be booked by the cardiologist or more commonly by the referring GP, with the clinician requesting any tests maintaining responsibility for reviewing and acting on the results.

Dermatology

The dermatology department responds to over 100 advice and guidance requests a week, usually with skin photos attached, taken by the referring GP team. The service is led by Dr Kathryn Thomson and Dr Caroline Love, with five consultants providing the majority of responses, aiming for a 48 hour turnaround.

Typical referrals include rashes and skin lesions (usually pre-cancerous lesions suitable for community management). Consultants can provide the service remotely, given the high volume of referrals. When referring for face-to-face consultations, GPs are advised to specify if a patient has had previous advice and guidance as the dermatology team automatically accept referrals from patients who have previously had advice and guidance.

Endocrine and diabetes

Dr Vijay Jayagopal and three consultant colleagues rotate weekly cover for the advice and guidance service, aiming for 24-hour turnaround when possible. Many advice and guidance requests relate to fatigue or lethargy symptoms. Advice and guidance can often reassure GPs and provide a sounding board for investigation and management discussions.

The team have an additional phone-based advice and guidance service, which can be useful for three-way discussion if GPs have a complex patient in the surgery with them.

Ear, nose and throat (ENT)

Mr Andrew Coatesworth and the team rotate cover of the advice and guidance service when on call. They have found the service helpful both to provide management advice and to signpost GPs to established management plans. Occasionally, GPs attach patient images to advice and guidance requests.

Gastroenterology

Dr Prashant Kant is part of a large team of eight consultants providing advice and guidance in York and three consultants in Scarborough. Advice and guidance requests can be directed to appropriate consultant worklists, or to the two hepatology consultants.

Within gastroenterology, advice and guidance is used to redirect patients to radiological tests or endoscopies directly, meaning that patients may not need to come to clinic.

As a result of advice and guidance, the team have found that patients who do need a clinic appointment have often had appropriate tests and are further along their clinical pathway. Advice and guidance also means that clinic referrals are more appropriate and consultants do not often need to return or redirect face-to-face referrals.

Gynaecology

Miss Nicola Dean and the team provide the gynaecology advice and guidance service. She finds the service is most effective for the medical aspects of gynaecology, including advice around hormone imbalances, HRT and menopausal symptoms.

The team have used internal audits to identify variations in consultant thresholds for recommending referral versus advice only, to improve standardisation. The team rotate advice and guidance when on-call, and have highlighted the need for a regular review of advice and guidance figures in job plans to maintain service quality and balance response times against other clinical commitments.

Haematology

Advice and guidance has provided many benefits to service provision in the haematology department. Dr Annika Whittle and the team previously received high volumes of phone calls for advice. Queries now come through e-RS advice and guidance, so consultants have a more flexible response time, and responses are accessible by other health care professionals and recorded for job planning and audit.

The advice and guidance service is provided by the on-call consultant.

Hepatology

Dr Charles Millson was initially cautious about the role of advice and guidance, but is now a convert. The team have used advice and guidance as an excellent educational tool to signpost GPs to existing local and national guidelines (such as abnormal liver function test pathways and dietary advice).

For many patients he is able to provide GPs with an extra level of reassurance. Interpretation of abnormal liver function tests (many related to fatty liver) are a common cause for face-to-face referral. By training GPs to include important information such as body mass index (BMI), advice and guidance can provide an effective alternative to clinic referral for many patients.

The team use local knowledge of GP resources to adapt recommended management advice, emphasising the importance of knowing the local referral area.

Neurology

Dr Giles Elrington provides the neurology advice and guidance service, allowing other consultant colleagues to concentrate on face-to-face clinics and the review of patients with acute neurological symptoms.

He enjoys providing digital diagnosis and management advice, and finds advice and guidance works well for advising on common neurological problems, such as headaches. He feels the advice and guidance service is able to support local GPs, who can feel increasingly isolated in specialist work.

If required, advice and guidance requests can be redirected to colleagues’ worklists in different specialities.

He has also used optional digital dictation for some of the longer advice and guidance responses used in neurology, to optimise efficiency.

Paediatrics

Dr Murray Wheeler is job-planned to provide the majority of advice and guidance, with cover provided by Dr Ianthe Abbey and Dr Liz Baker. The service works well, improving the quality of patient care, and steering patients to the right clinic if required.

The team generally avoids two-way dialogue, but makes the most of all the available information to formulate a useful advice and guidance response. This happens even if the patient is known to another consultant, with close communication between the consultant team.

Urology

The eight urology consultants all take part in the advice and guidance service, with four consultants covering each of the two hospital sites.

The consultants report advice and guidance for a week each, on a 1:4 rota.

A wide variety of requests are received, including:

• interpretation of test results
• implications for the patient
• requests for comments on ultrasound scans

Mr Russ Wilson and team have used advice and guidance to direct GPs to local web-based urology guidelines, including the haematuria pathways.

The urologists receive requests from a range of health care professionals, including primary care nurses, and have highlighted the importance of working with primary care to maximise the appropriateness and quality of advice and guidance requests and responses. As advice and guidance requests have increased, the importance of job planning and time allocation for reporting has been highlighted.

Uploading advice and guidance requests from e-RS into the Trust Core Patient Database has the advantage of allowing consultant access through a single system.

However, it prevents consultants accessing the full functionality of e-RS, such as:

• the option for two-way dialogues with GPs
• access to the e-RS response outcome question
• access to other functionalities in e-RS (clinic referral letters for vetting or directory of service specifications)

Furthermore, as consultants do not access e-RS directly with a smart card, they can only access advice and guidance requests when processed and uploaded by the Patient Access Team; they do not see advice and guidance in real time as the GP sends the request.

Similarly, GP responses are not received back through their e-RS worklists, but via systems outside of e-RS, causing occasional issues for primary care clinical staff joining up advice and guidance replies with requests.

The clinical teams have worked hard to ensure consistency in the quality of clinical information provided by both referrers and providers. Some advice and guidance referrals contain insufficient information, missing attachments (such as ECGs), or scans cannot be accessed easily. The quality of advice and guidance responses can vary within or between specialties, requiring regular peer review and close consultant team work to ensure a consistency of responses.

Some GPs use advice and guidance to try to expedite patients’ appointments, which is an inefficient use of provider clinicians time, although consultants can provide interim advice on management or suggest alternative channels for referral (such as an emergency phone) if a patient's condition has changed since initial referral.

A Referral Management Centre (RMC) is employed in the area, so consultants are required to ensure any recommendations for referral are in line with local commissioning and RMC triage arrangements.

This data 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 where 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, so it may include some patients referred for another indication unrelated to their advice and guidance.

Across the out-patient specialities studied, around 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 an endoscopy).

Although these patients may not require a subsequent clinic appointment, the patients are still seen in the specialist service for their investigation.

York Hospital uses a Core Patient Database (CPD) which clinicians access, including a clinical desktop (showing clinic letters), and consultant notifications (including blood results, X-rays and scan results to acknowledge).

Advice and guidance requests are received and processed by the Patient Access Team and on receipt, are taken out of e-RS and uploaded onto the ‘Notify’ section of CPD (the consultants electronic worklist), where they are assigned to a consultant or speciality.

At this point, a response is sent via e-RS to the sender, confirming receipt of the request and confirming that a response will be sent outside of e-RS. Advice and guidance requests are checked daily by the consultants, and a weekly summary report is produced at speciality and consultant level, showing the number of requests received (by month) and the turnaround time by two, three and five days. Any outstanding requests are also listed.

Consultant advice and guidance responses are sent back to GPs using MESH (Message Exchange for Social care and Health), to GP practices using Systm1 and to secure email for GP practices using EMIS.

e-RS is not accessed directly by consultants using a smartcard. Similarly, clinical letters for face-to-face clinic referrals are scanned into the CPD for vetting (such as accept, return or redirect), rather than being vetted by clinicians in e-RS.

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.