1. 1 Improving cardiology referrals from primary to secondary care INTERIM PROJECT REPORT - July 2010 Armon Daniels, Lead GP Mags Moss, Cardiac Specialist Nurse Sue Wilshere, Network Manager

2. 2 Background Sponsored by Cardiff & Vale NHS Trust Strategic Implementation Group Drivers: 26 week Referral to Treatment time target increasing referral numbers variation in referral behaviours opportunities for pathway / service improvement Steering Group of interested stakeholders Buy in from LHBs and LMC

3. 3 Methodology Analysis of data from 53 Cardiff LHB practices to identify statistically significant variations in referral practice, using: –Trust reported GP referrals to cardiology at Cardiff and Vale NHST –QOF reported CHD prevalence data by GP practice –Disposal codes (502) by GP practice (i.e. return to GP no further action) –GP List sizes or adjustment of list size data to prescribing units

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7. 7 “We are told not to admit, not to refer, not to investigate, and not to treat. We are told to spend more time with our patients. What are we supposed to do with them?”

8. 8 Process – Qualitative Interviews All GP practices invited to practice wide review of referral and discharge patterns 9 practices agreed and participated in hour long semi-structured interview Interview and notes taken by experienced interviewer and report drafted

9. 9 Case Study A 50 year old female smoker presented with symptoms of breathlessness and cough. No cardiac history, ?quiet systolic murmur. The GP ordered a CXR which revealed a pleural effusion and the report queried malignancy. GP had to choose which speciality to direct the referral to – urgent cancer hotline respiratory referral. Given OPD within 2 weeks but patient did not receive the letter. GP contacted and advised to prescribe diuretic. GP sees patient who now has some ankle oedema. Prescribes diuretic pending assessment. Patient deteriorates and requires hospital admission for HF.

10. 10 Findings - Influences on Referral Referral to cardiology can be multi-factorial and often involves more than presenting symptoms Clinical – investigation and diagnosis Organisational Factors which make referral necessary –QOF drives referral –Access to diagnostics: Access to BNP blood test (indicated in Guidelines) Echocardiography Comparison with Bridgend Confidence and competence of referring clinician Patient pressure – anxiety, previous ‘bad’ experience Social circumstances – e.g. wanting to fly Waiting list anxiety - weighing up time waiting and worsening symptoms

11. 11 Findings - Cardiology Services Cardiology services generally seen as good, but some frustrations with the service: Lack of awareness of services offered within the Cardiff and Vale Cardiology Service Information about Rapid Access Chest Pain Clinic Timely access to specialist advice Restricted access to non invasive investigations Lack of clarity about diagnosis on discharge Timely access to diagnostic results - more information on Clinical Portal - Echo, summary of the result Medication advice especially duration of clopidogrel use More guidance on management in the letters back to GPs

12. 12 Findings – Education and reflection Guidelines useful for reference but unlikely to be used in a busy surgery PCT education sessions provided good learning opportunity –Value of these sessions depended on quality of speaker –Inconsistency in key messages Journal articles used but could be complicated and contradictory, on-line educational resources used inviting cardiologist/GPwSI to practice meeting very useful way of updating and discussing management issues (case studies) Practices learned from reviewing own referral data, most recent referrals and auditing referrals from previous year. Interest in looking at 502 coded patients

13. 13 Findings - Service Improvement Suggestions Regularly up-dated electronic directory of services including a list of consultants and their speciality Efficient Rapid Access Chest Pain Clinic with doctor input and clear criteria for referral Virtual clinics - all GPs would like access to a consultant for advice via telephone or e-mail ECG reading service Consultant or GPwSI problem orientated assessment service offering timely appointment Improved primary care access to non invasive diagnostics

14. 14 Discussion - low referrers More likely to have a GP with an interest More likely to use guidelines for reference Direct access to some investigations Direct access to consultant advice Would value an up to date directory of services Smoother pathways especially for urgent cases

15. 15 Discussion – higher referrers Reduced clinician confidence Perceived need for education Real time access to guidelines and decision making support Specialist advice could replace some referrals and provide timely advice Access to ECG for single handed practice Need clear information on what services are available and how these are accessed

16. 16 Discussion – before jumping to conclusions Small numbers – data varies from year to year – wide confidence limits Intra practice variation as great as inter practice Referral rates are not necessarily a reflection of quality Referral considered from a primary care perspective - what primary care thinks would help may not Service re-design and referral support should take primary care views into account

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18. 18 Conclusions Referral is an important component in solving patients’ problems There is a huge variation in patient referral which needs to be understood Unsupported downward pressure on referral may result in dissatisfied patients and doctors Decisions to refer are complex, involving the interplay of factors relating to the problem, the patient and the practitioner Self-evaluated confidence and competence varies amongst GPs – interventions may need to reflect this variation Multifaceted interventions: –Access to virtual clinics –Educational media with consistent key messages –Improved access to decision making support –Improved access to non invasive investigations –Improved access to smoother patient pathways

19. 19 Recommendations Study the impact of sharing referral data with practices involved in the project Study GP referral from a secondary care perspective Plan service re-design with consideration given to GP views Consider multifaceted support to primary care to improve appropriate referral