Advice Guidance & Proceed This text will NOT appear on your slide show. To edit the footer: go to ‘View’ then ‘Slide Master’. Ensure you have the first slide selected Double click ‘First word Second word’ (This is optional for your department, presentation title etc) Click ‘Close Master View’ Proceed as normal Add new slides by clicking on ‘New Slide’ GI Direct and Complete Advice Guidance & Proceed Emilie Wilkes Consultant Hepatologist, NUH

Outline of session: GI direct and complete – what we did at NUH and Why Preliminary outcomes: first 350 patients What we learned The current unknowns What next…? Advice Guidance & Proceed

GI direct and complete – what we did at NUH and Why 2014: 17 Consultants in Gastroenterology & Hepatology at NUH 5 Consultants OP activity at City Campus 12 consultants through Circle Treatment Centre Variety of specialist/academic interests - Tertiary referrals Missing essential information Consultations with no added value Too many referrals Gastro 3 fold Hep 50 % increase Advice Guidance & Proceed

Source of Nottingham City Hospital GI OP referrals Advice Guidance & Proceed

GI direct and complete – what we did at NUH and Why 2014: Nottingham Hospitals Charity Service Improvement Programme to benefit GI out-patients at Nottingham City campus, NUH Transform the initial diagnostic pathway of new referrals to make the consultation (if required) more efficient. Not referral management system Structured investigation “Tiers” with clinician guided exceptions Organisational Learning 50% City CCG GI referrals Advice Guidance & Proceed

GI direct and complete – what we did at NUH and Why C&B Apt Letter received from GP Non-consultant clinic Consultant led structured Pre-assessment of referral Patient attends Clinic Investigations +/- symptom Questionnaire Written advice to patient 50% City CCG GI referrals Consultant Case review Long-term condition programme Advice Guidance & Proceed

Consultant Led Structured Pre-assessment Vetting GP referral letter review Review NoTIS case record If appropriate clinic – Accept Redirect to appropriate Gastro/Hep clinic Request investigations Symptom Questionnaire If inappropriate for Gastro – re-direct Blood work Stool analysis AQP results e.g. Global Dx USS, Woodthorpe OGD... Check for exclusions OPA < 3 weeks Endoscopy Chaotic pts Imaging Translator required Imaging review Significant learning difficulties Template Letter to patient Allocate reason for referral Advice Guidance & Proceed

Advice Guidance & Proceed

Case review All requested results available Referral letter NoTIS Outcome: Ready for clinic Clinic not required – letter to pt and GP, apt cancelled Clinic likely not required – letter to pt & GP inviting pt to call and cancel apt. More investigations needed – requested/letter to pt Advice Guidance & Proceed

Preliminary outcomes: first 350 patients 50% City CCG GI referrals Half of system failure patients did not require clinic 45% of Long-term conditions patients diverted to non-consultant clinic Advice Guidance & Proceed

GI direct and complete – What we learned Challenges around fixed appointments: Patient expectations Set out-patient appointment “to deal with the problem” Confusion from correspondence Co-ordination issues: delays booking investigations Insufficient patient resources & GP guidance Under development 50% City CCG GI referrals Advice Guidance & Proceed

GI direct and complete – What we don’t know yet Effect upon primary care Do patients return to GP with hospital letters Are there other implications? How to share learning and provide integrate care If we miss the point of referral If you don’t do the basics Longer-term outcomes Are the patients re-referred 50% City CCG GI referrals Advice Guidance & Proceed

GI direct and complete – What next? Community Pre-assessment and Case review Allocated Gastroenterologist and Hepatologist to clusters of practices Clinical Assessment Service co-ordination of referrals Basic “Tier 1” investigations booked through primary care Two way feedback Ongoing resource development Organisational learning with pathway development and commissioning 50% City CCG GI referrals Advice Guidance & Proceed

Next 12 months: Advice Guidance & Proceed Phase Activity Timescale City Hospital Campus pilot continues Current 1 Pilot of pre-assessment pilot commences in one CCG: Rushcliffe 31 October 2016 2 Pilot extended to second CCG - Nottingham City or Rushcliffe 1 January 2017 3 Pilot extended to remaining two CCGs – Nottingham North and East and Nottingham West 1 April 2017 4 Risk stratification of follow ups Development phase: current Implementation: 1 April 2017 5 Linked clinician role including Advice and Guidance 24 hour response 6 Location of face to face outpatient clinics moved to community 1 July 2017 Advice Guidance & Proceed

Questions? 50% City CCG GI referrals Advice Guidance & Proceed

sustainable Pathway GP identifies GI symptom Defined algorithm GI consultant advice and support/ Pathway development Tier 1+/- Tier 2 Investigations Self-Management Tools Non-consultant clinic Reassurance Consultant Clinic Discharge Long-term Follow Up Tier 2/3 investigations Surveillance Programme Split based on last 100 patients

Feedback to clinicians GI direct and complete – What next? Pre referral Direct access diagnostics Guidance and template for referral to diagnostics Minimum standard for direct access e.g. attendance at course Pre-assessment community clinic (CAS managed) Ordering of tests (choice of provider) Tracking of tests and results Access to primary care record Patient questionnaire (with reference to languages other than English and those with low reading age) Infrastructure to track diagnostic testing requests and results Choice of provider Case Reivew Additional assessment Non face to face contact LTC Surveillance Programme (CAS managed) Secondary care surveillance with pre-letter to GP if reason not to follow up “Golden ticket” for follow up care required for times of disease flare Patient education, similar to diabetes Outpatient appointment Clinic setting Nurse led clinics GP referral All adult routine and urgent referrals, excluding 2ww Advance choice of provider for diagnostic test if required (included on referral template) Review unwarranted clinical variation in GP referrals Minimum data set Refer back to GP Advice on appropriateness of referral Advice on management of patient i.e. care plan Community Pre-assessment and Case review High quality data Feedback to clinicians Ongoing Education Advice Guidance & Proceed