How a nurse-led GP liaison service has helped to streamline the patient journey
Initially, I was joined by another Band 6 nurse to deliver this service funded by the Primary Care Group as part of our funding contract; now we are an integral part of the Integrated Discharge Team run by Cambridgeshire Community Services NHS Trust. Being based at the Luton and Dunstable Hospital but employed by a community trust is beneficial as the team have a ‘foot in both camps’ with a ‘can do and if not, why not’ attitude.
The journey to this service, which provides a fast and effective pathway through the hospital and back into the community for patients, many with highly complex needs, began in April 2007. Prior to this date, GP referrals for same day acute medicine and general surgical assessments came through the main hospital switchboard and were discussed and accepted by the hospital ward nursing staff. It was recognised, however, that a designated referral process with a broader knowledge of community services and acute pathways may reduce inappropriate hospital attendance.
As a registered District Nurse who had worked within the Integrated Discharge Planning Team (IDT) and in community, it was felt that I had some understanding of what was required and a change could be possible. The GP Liaison Service was born but not without its initial teething problems.
The pilot began with locum GPs supporting the service. It was soon discovered, however, that our local GPs did not want to further discuss their referrals with a medical peer. Discussions with senior nurses were acceptable, however, but they brought their own challenges. To help us make a clinical decision as to where the appropriate place of care should be, we requested details of basic observations, pulse, blood pressure etc. The request for a temperature elicited many excuses for this not being provided such as the ‘thermometer is broken’, ‘the patient feels hot’ or ‘I don’t believe in temperatures’. Today, however, these observations are given readily and without asking on many occasions – in fact sometimes we are reminded we haven’t asked for them!
As the service developed, we received complaints that many GPs were facing long waiting times to get through the hospital switchboard to the team. In desperation, they would advise their patients to attend A&E which, in turn, had an impact on the hospital meeting the Government’s four hour target for treating and admitting or discharging patients. To address this concern, in November 2015, Luton Clinical Commissioning Group commissioned a private communications company, Consultant Connect, to support referrers.
Each Luton GP surgery was given a specific telephone number to dial in directly to mobile phones carried by the team. This allowed the team to respond within 20 seconds on almost 98 per cent of occasions – an average of 550 calls. Five months later, GP surgeries in South Bedfordshire were brought on board along with Acute Trust Paediatric Service. In addition, we handle an extra 100 calls a month coming in from Hertfordshire and Buckinghamshire via the hospital switchboard as these GPs are not yet commissioned to join our telephone system. Advice and guidance from an on call paediatrician and referral to the hospital’s Paediatric Assessment Unit is now available as well.
The GP Liaison Service operates Monday to Friday 8am to 6.30pm mimicking the current GP surgeries’ opening hours. The data we collect is shared monthly with Luton Clinical Commissioning Group and supports the community admission avoidance work. Out of hours referrals, however, continue to be made directly to the on call specialist teams via the hospital switchboard bleep system. The number of referrals received does not currently highlight a need for extending the team’s working hours; this is constantly under review, however.
When I launched this service, we took an average of 250 referrals a month; today the team of three band 6 nurses and a band 7 service lead share the role of Liaison Sister. We have to know about community services in four CCG areas which can be challenging, but this leads to development across our local services and good practice is being shared.
Over the years, the team has developed several pathways including dealing with outpatient blood transfusions and access to a consultant advice line to support nurses. Routinely, on receiving a referral, we consider initially what community services are available, would advice from a consultant be useful? and can we use the day unit to prevent a hospital admission?Continuity of communication is vital when caring for complex patients and being able to share the information in a timely manner is essential for smooth, safe and appropriate discharge planning. Patients highlighted by the GP Liaison Sister are followed up the next day on the ward by the ‘back end’ team. Working as part of the Integrated Team sitting ‘cheek by jowl’ with local authority colleagues, ensures that patients can be discharged as soon as is appropriate and safe to do so.
Streamlining the patient journey was a major factor in developing this service and this is an area that we are constantly reviewing with our CCG, community and acute trust colleagues. Collaborative working across all of our partners has allowed the team to develop close working relationships and to be able to support each other.
Moving forward, we are working with the acute trust to develop single checking of patients. Patients arriving at the hospital’s accident and emergency unit will be seen and assessed by one person. In addition, we have responsibility for adding our referred patients to the ‘on call’ take list recording patient details We will input as much information as we can for the consultants and link in with specialist nurses to let them know patients are being referred to the hospital and back into the community to keep continuity among the services.
We are also supporting the acute trust with the early detection of sepsis so that we can provide an early alert across the system. We are using the NEWS2 tool which supports assessment of sepsis risk. At the same time, we are working with ambulatory care to support the development of their criteria and pathways.
Already this year, we have received two prestigious national awards. We won the Staff and Patient Experience Category and were highly commended in the Improving Outcomes category of the Draper and Dash Leading Healthcare Awards. In 2018 we were shortlisted as a joint entry with Luton Clinical Commissioning Group and our private telephony provider colleagues, Consultant Connect for the Health Service Journal awards in the category The Use of Information Technology to Drive Value in Clinical Services.
The team is committed to providing a professional service but also maintaining its ‘can do’– ‘if not why not attitude’ – therefore our journey continues…..
Service Manager – Lead Nurse – Community Liaison/Continuing Healthcare
Integrated Discharge Team
Cambridgeshire Community Services NHS Trust
This article has been published in the Primary Care Journal, May 2019. If you would like to read the online version and you have a subscription to view, click here.
This article has also been published by Debbie Manning in May 2019 on the news page of Cambridgeshire Community Services NHS Trust website, click here to view it.
The Luton Integrated Discharge and GP Liaison Team have been recognised at the recent ‘Leading Healthcare Awards’ for their outstanding work. Find out more.