Our panel of experts answer questions about written Advice & Guidance through e-RS and telephone Advice & Guidance in this blog. The experts are:
- NHSE: Dr Linda Charles-Ozuzu, Head of Elective Care Transformation Programme at NHS England
- e-RS: Sarah Hayden, NHS Sunderland CCG and Christine Powell, NHS Greater Huddersfield, Calderdale and North Kirklees CCGs
- CC: Jonathan Patrick, CEO, Consultant Connect
Webinar Recording available to watch on demand:
We held a webinar on the topic and attendees were also able to ask questions to our panel live. You can view a recording of the webinar by clicking here.
The speakers at the webinar included:
- Prof. Sir Muir Gray, Director at the Oxford Centre for Triple Value Healthcare, Adviser to Public Health England, and Author
- Sarah Hayden, Locality Commissioning Manager, NHS Sunderland CCG;
- Christine Powell, Senior Relationship Manager, NHS Greater Huddersfield, Calderdale and North Kirklees CCGs
- Jonathan Patrick, CEO, Consultant Connect.
1. ‘BIG PICTURE’ QUESTIONS
Why should we implement Advice & Guidance?
NHSE: Patients should receive the care and treatment they need in primary care wherever possible. Unnecessary hospital visits should be avoided and they should feel more confident and supported to manage their condition. Primary care clinicians should be able to manage patients more effectively and avoid unnecessary referrals into secondary care. Where a referral does need to be made, advice and guidance can improve the quality of information that accompanies the referral. This means that specialist expertise can be directed to those patients who need it most. Advice and guidance is a great opportunity for shared learning. As practitioners’ confidence and proficiency increases, the overall number of referrals made may reduce, along with waiting times for specialist input.
e-RS: It improves care for patients, who can be seen and looked after by primary care, and do not need to attend secondary care but would historically have had an outpatient appointment.
Does it definitely work?
CC : Yes! If you think about it, it’s not difficult to see how a GP speaking with a specialist will be able to come up with a plan for that patient that doesn’t require hospital. Many of the tests that a hospital clinician might want to run are available to GPs, and both are prescribing professionals, meaning the GP has the same right to prescribe a treatment that the specialist might recommend. Consultant Connect’s data shows that 66% of calls about a patient result in the patient’s care being kept with their GP. On the other side of the coin, we also have evidence of patients being sent to hospital urgently when the specialist has recognised a severe condition, saving lives in the process.
e-RS: Electronic A&G via e-RS works only with the agreement of the local Trust, cooperation from the lead clinician within each specialty, with the backing of the team, plus an agreed process with clear monitoring.
Who should be able to access Advice & Guidance?
NHSE: A&G is designed to support GPs in the decision making process and as such, it occurs prior to any referral. Once the GP has received advice and intends to refer onwards, they should discuss the choices available to the patient when agreeing ongoing treatment.
e-RS: All clinicians in General Practice who can refer should be able to access Advice and Guidance via e-RS. It should be accessible to any clinician and admin staff to ensure the immediacy and continuity of care for patients, then the responses should be added to the clinical record by admin staff.
Who should answer Advice & Guidance queries?
CC: Whoever is answering the phone or written request needs to be in a position to advise the requester. As many requests will come from experienced clinicians, this normally means a senior hospital clinician. Most commonly, this will be a consultant in the specialty. Sometimes, though, a specialist nurse, such as a diabetes nurse or neurology nurse, may have considerable experience and be able to advise GPs on a patient’s treatment.
e-RS: Consultant/Registrar in the specialty. Some written A&G requests via e-RS have been printed and shown to consultants to aid of a prompt response.
When should clinicians use Advice & Guidance?
NHSE: Advice and Guidance should be used by GPs in management of non-urgent patients whom they may be considering referring to secondary care. The types of advice that may be requested include, but are not limited to, treatment plans, interpretation of results and/or advice on appropriateness of referrals/tests.
2. OPTIONS AND COSTS
What different options are available for getting Advice & Guidance?
NHSE: There are several methods of obtaining Advice and Guidance. For example, the NHS e-Referral Service enables GPs to actively request advice from identified specialists. Clinicians in primary care can also use email or telephone services using ‘chase’ systems, which call secondary care clinicians in turn until the call is picked up.
What is the best option for my area?
CC: We get asked this a lot. As you would expect, we think telephone Advice & Guidance is a great approach as it is extremely quick and you can cover a huge amount of ground in a 3-minute conversation. You can also cover urgent queries that can’t wait for a written response, sometimes avoiding admissions the same day. Having said that, for queries that aren’t urgent, email and e-RS allow a responding clinician to reply when they are able, meaning you don’t have to have clinicians available as the queries come in. e-RS and email don’t cost anything extra and this is obviously an important consideration! Ultimately, we recommend giving GPs a choice. The easier it is to use for their particular patient query, the more likely a GP is to use it. All of our projects sit alongside e-RS and email. We see some GPs who use only telephone, some who prefer written and the majority who use both.
Is Advice & Guidance a good investment?
NHSE: Yes, it allows GPs to access timely and specialist advice at tariff lower than standard outpatient levels. This is in addition of course to good patients experience due to timely decision making, which is an investment in quality.
Who pays for what? Does the Trust get a tariff for Advice?
CC: For an email or e-RS Advice & Guidance service, the only cost is a tariff payment. These are normally agreed locally and we have seen tariffs ranging from £15 to £35 from area to area. The latest non-compulsory tariffs from NHSE recommend £30 for advice received within 48 hours (which includes all phone advice, of course), £20 if it’s received within a week and £10 for anything that takes longer. It shows the NHS policy that advice should have a value, but also recognises that the value is increased if it is received in a timely fashion. If you’re using a paid-for service, such as Consultant Connect, this is normally funded by the commissioner and, sometimes, central funding such as the recent Vanguard program. Commissioners paying by results (i.e. not paying a block contract) make significant savings from avoided referrals or admissions, so it is economically attractive to them to pay for a service that reduces activity. We supply a basic Excel model that allows commissioners to test their assumptions and work out if Advice & Guidance is going to pay back – please get in touch if you’d like to have a look at it.
3. MAKING IT HAPPEN
How long does it take to set up a service?
NHSE: It is straightforward to set up and can be developed in a short time frame if all parties are committed to delivery and the obvious benefits to patients and all stakeholders. It is about making good use of current resources.
e-RS: Once the GPs are happy to use the proposed system, and the secondary care clinicians have agreed to read the A&G requests alongside their daily or weekly (or however they decide to manage) e-RS triage of referrals, then promotion of the service can begin with the GPs, then go live on an agreed date. The process is still ongoing – we are looking to get practices to focus on usage and feedback issues/barriers.
How can I get started?
NHSE: Make use of available resources. Don’t get held up by technical concerns. Testing a simple, low tech solution (such as using email and phone) is an easy way to generate interest and buy-in. This gives opportunities to understand what is needed, what will work locally and any potential issues or challenges.
CC: We tend to focus on the enthusiasm of individual specialties at the beginning – aiming to push at an open door! We have a list of the most used specialties nationally and will ask each of them whether they would like to try offering Advice & Guidance over the phone. At the beginning we expect to get 2 or 3 out of our top 5 specialties by usage to try it out, which will then mean a useful service for GPs. If the service is useful for GPs it tends to be straightforward to build usage and start seeing results.
e-RS: 1) Develop a task and finish group with representation from both primary and secondary care, 2) Review secondary care information to identify which specialties will go online first – also look at consultant capacity, 3) Develop training for both clinicians and secretaries on how the system works.
Do I need to do a pilot to start with?
NHSE: Start small and scale up. Invite consultants to join the advice and guidance rota on a trial basis. People may prefer to take part in a trial first before committing long term. This also allows initial benefits to be observed and helps to make the case for scaling up the service.
e-RS: Pilot from both sides is a good way to start – pilot specialties in secondary care with interested practices in primary care.
Who needs to be involved?
NHSE: The following list isn’t exhaustive, but you may wish to include many of these people from the start:
- Practice nurses
- Practice managers
- Primary care relationship managers
- Specialty business managers
- Booking team
- Finance team (if purchasing a new solution)
- IT support (including app developers, if applicable)
- NHS Digital (for e-Referral service support)
- Administrative support in secondary care to help review and monitor advice and guidance requests and responses.
Do job plans at the Trust need to change to accommodate Advice & Guidance?
CC: That depends. For written advice, such as via email or through e-RS, we frequently see clinician time set aside for responding to requests. This obviously allows for backlogs to be cleared regularly and effectively. For telephone advice, we are not aware of job plans ever having been changed. This is because our approach is to look for a consultant who has three and a half minutes to take a call. They can be doing anything, for example they might be doing ward rounds, between clinics or walking between different bits of the Trust. The typical consultant spends 12 – 16 minutes on the phone per week on one of our projects, which many feel doesn’t need to be job planned.
NHSE: Ensure job planning implications are worked through to secure ongoing involvement. Build dedicated time into schedules and ensure there is capacity to provide the service consistently.
e-RS: We do our best to convince clinicians that it should be part of their normal triage time.
What sort of communications plan do I need?
NHSE: Promote the service and available resources to GPs and practice managers. Using various means (face-to-face, email communication, flyers, etc.) is most effective. Link in with practice education sessions and use local networks where possible. Provide information and training for clinicians. Consider developing a quick reference guide for consultants and GPs to refer to. This is useful as they start to use the service. Consider developing an information video to promote and explain the service. Liaise with your local communications leads to gain support and advice on filming and editing. Invite clinicians and patients to take part and share their positive experiences.
e-RS: We communicated the launch with practices via our ‘Time Out’ education sessions and also during education sessions. Regular communication with practices around usage and new specialties as they come on board is important. Also plan for face to face training and a feedback mechanism for issues.
What technical support do I need?
NHSE: If you are looking to use e-RS this is already live in all GP practices to support referrals and will not be a block, however you should include this in set up conversations with secondary care partners.
4. MEASURING SUCCESS
How do I measure success?
NHSE: Think about how you are going to provide evidence of the impact you are having. Ultimately, your metrics need to paint a picture that reflect whether you are unlocking the main intended benefits of Advice & Guidance:
- Earlier access to specialist advice and reduced patient waiting times;
- Increase in quality of referrals to secondary care;
- Reduction in unnecessary referrals to secondary care.
This is not an exhaustive list, but the following metrics could be used to help demonstrate impact:
- Length of time between referral and appointment in secondary care
- Number of consultant to consultant referrals
- Number of practitioners using the service (broken down by where they work)
- Number of advice and guidance requests
- Outcome of Advice and Guidance – e.g. refer to secondary care/rejected/advice and guidance to enable patient to remain under primary care
- Length of time taken for a response to be received
- Feedback from referrers:
- Knowledge, ability and confidence to manage patients in primary care with support from the advice and guidance service (self-reported)
- Effectiveness of communication and relationships with colleagues providing advice and guidance
- Feedback from secondary care:
- Quality of referrals and accompanying information received
- Feedback from patients and the public:
- What was their experience? (case studies)
Finally, don’t forget to take advantage of the huge educational opportunity of Advice & Guidance. Collate common themes and use these to inform local educational programmes for primary care (protected learning events, learning bulletin etc). An optimally effective advice and guidance service should up-skill all those with the same learning need as the GP seeking advice, whether or not they are aware of their own needs or whether they would have asked for the same advice themselves. Information about the implementation of Advice and Guidance as part of our Wave 1 Elective Care Development Collaborative is included in the Gastroenterology Elective Care Specialty Handbook: https://www.england.nhs.uk/publication/transforming-gastroenterology-elective-care-services/
e-RS: With regard to feedback from referrers (via e-RS), quality and clarity or response, and not a blanket “Please refer” response is important. We measure success by number of advice and guidance requests sent and number of specialties on board. Communicating actual figures each month helps users to see that requests do not fall into an email black hole.
What are the biggest risks to the project?
CC: There are only two ways a project can fail: either the GPs don’t use the service or the consultants don’t answer the requests (either at all or in a timely fashion). If you get these two elements right, the project can’t fail. The bigger challenge of the two is getting the Trust clinicians to answer queries. This can be a stiff task if the clinicians are not enthusiastic. GPs will quickly abandon a project if their advice requests go unanswered. It’s essential that you take the time to engage with the different clinical teams, understand their concerns and address them as well as you can. You may not win everybody over, but you may not have to if the enthusiastic team members are willing to cover the task themselves. Ultimately, though, if a team is reluctant to participate, that’s a matter that needs to be addressed by Trust management. GP participation is crucial but is, in some ways, easier. If the service is easy to access and includes useful, high-volume specialties, the GPs will want to use it – you just need to tell them that it’s there, so effective communications are central. There are, of course, exceptions to this. We have come across a couple of areas where GPs are low users of Advice & Guidance and prefer to refer if they have any queries. Again, this is a matter for CCG management. We are participating in some projects where usage of Advice & Guidance has been made compulsory for certain pathways with good results and, ultimately, positive feedback from GPs.
e-RS: Responses not received in a timely manner and GPs choosing not to use the system.
How many Advice & Guidance queries should I expect?
NHSE: It depends on the size of service Advice & Guidance links with and buy-in from GP practices. It is likely to start small and grow as the service becomes more embedded. Start with a pilot and build from there would be a sensible approach.
e-RS: There is no way of anticipating the demand.
What if it goes wrong?
NHSE: Provided all partners are signed up to this and can see the benefits for patients and the local health economy this should not happen.
e-RS: Ensure that there is a mechanism for two-way feedback and that the feedback is shared.
CC: In the words of Bruce Lee, “Don’t fear failure. Not failure, but low aim, is the crime. In great attempts it is glorious even to fail.” The truth is, the Long Term Plan puts Advice & Guidance front and centre in the NHS and the only reason it can fail is lack of engagement from clinicians. Most clinicians are extremely open to improving patient care in this way, which means that your project already has a good chance of success. Don’t be deterred if you have had similar projects fail in the past – you were probably ahead of your time, the environment now is conducive to success!
Email us at firstname.lastname@example.org with your questions, we’ll update the FAQs with more answers as more questions come in. And don’t forget to access the recording of our recent webinar click HERE.