How Scottish Health Boards embrace prof-to-prof advice to reduce unnecessary attendances

Published: 28th June 2021
NHS Tayside, NHS Lanarkshire and the Scottish Ambulance Service share how their use of prof-to-prof advice or Advice & Guidance is playing a key part in their response to the national goal of redesigning unscheduled care.

Consultant Connect changes the way clinicians interact with colleagues in hospitals and other secondary care services, improves patient care, and reduces unnecessary referrals. In Scotland NHS Greater Glasgow & Clyde, NHS Tayside and NHS Lanarkshire are all using Consultant Connect for rapid prof-to-prof advice to support clinical decision making, reduce unnecessary attendances, and to navigate patients to the most appropriate place, first time.

The conversations between clinicians and specialists, result in between 30% – 60% of patients avoiding an unnecessary hospital appointment.

If you missed our recent webinar on the topic, the article below summarises the three case studies shared by the speaker panel. 

NHS Tayside Case Study

  • The journey of how prof-to-prof advice developed in Tayside, to what the service covers today

Dr Ron Cook

“Prof-to-prof started in Tayside just over 15 years ago to provide safe remote discharge. Back then it was used to support junior doctors in our smaller departments, when there wasn’t immediately an Emergency Department (ED) senior doctor available on the floor. The junior doctors would call the senior doctor phone. Shortly after that, we made the line available to regional ambulance crews for remote clinician decision support, to both help decide where patients in the region should come to between Perth and Ninewells, but also to support access to alternative care – enabling them to determine whether a patient needed an emergency transfer to hospital or not. 

It started initially with us just carrying a handset from an old-fashioned landline, but we came across the issue of documentation and recording what the outcome of calls were. Although our ED staff always had a notepad to hand, the use of this, to document calls was pretty unreliable as you can imagine. So, we used mobile phone apps to try and record calls, but then came across further problems with mobile phone reception, calls dropping out and recording of calls. Despite these issues, the line was very well used, and very popular and we got to the point in 2016 that we were sort of looking at 7,000-8,000 calls a day. This made us really realise the value of the prof-to-prof services, whenever we did an audit and looked at outcomes of the calls, 30% of the ambulance calls resulted in a patient not being immediately brought to an emergency department and accessing care in the community.

 At that point our colleagues in acute medicine had also started a prof-to-prof service and they found that if a referral into acute medicine from the regional GP was answered by a consultant or senior doctor, then 20% could access alternative care. 

 In 2018 we were taking around 11,000 calls a day, and we realised we needed to address the issues in terms of resources and clinical governance. So, we started our relationship with Consultant Connect. By using Consultant Connect we immediately had the benefits of call recordings, call loggings, and getting the volumes, getting a much more detailed feel of how many calls we were actually taking, where they were coming from (for example, were they coming from GPs or the ambulance service).

Consultant Connect and the use of prof-to-prof advice really did provide us with a good platform for when a couple of years later COVID hit, and we were able to use that resource to support our COVID activity as well.”

 

  • Impact of COVID/ rapid redesign of front doors/ impact during COVID peak

Dr Ron Cook

“I don’t think I need to tell anyone here that COVID presented a particular challenge in how to run unscheduled care, and in an emergency department! When it hit, we made an early decision that we thought all COVID activity apart from those patients requiring immediate resuscitation, needed to come through a completely separate entrance from the emergency department, straight into a unit being run by infectious diseases and respiratory medicine and acute medicine. To enable that we needed to give access to the ambulance service, to be able to notify the unit that they were coming in with a COVID patient. Overnight we were able to turn on a dedicated prof-to-prof line to support that activity. Susan was heavily involved in that.”

Susan Bean

“Covid  was such an unknown quantity at the beginning, that being able to provide really quick access to senior clinical decision makers, even just from an advice perspective, for ambulance crews on scene with these patients, and also to primary care out-of-hours was really valuable. We were able to put that in place extremely quickly over the course of an afternoon.  As well as clinical advice, prof to prof discussions could provide destination support as well. This meant that critically unwell patients would be directed to the Emergency Department and other patients accessed the most appropriate entry point. –This  was key to  safely managing access to hospital, so that we weren’t holding patients anywhere, and we were minimising footfall in as many parts of the hospital as possible while ensuring access to definitive care as quickly as possible.”

Dr Ron Cook

“Adding to that, I think it gave the opportunity for COVID patients to either identify that cohort that needed to be straight to resus, have a team waiting for them, a cohort that could go straight into a ward environment, or even have a level two type of machine waiting for their arrival, or the patient who needed to come for assessment in hospital but could potentially be turned around and be assessed in a more COVID ambulatory style setting.

 As the COVID year progressed we developed those three streams pretty effectively and kept a lot of that activity away from the emergency department front door and handled it through these dedicated COVID units.  We also had redesign of urgent care programme in Scotland, launching well into the COVID year around August/September 2020. Those established prof-to-prof lines were brought into our flow navigation centre and used to further support the ambulance service. We’ve seen a 300% increase in ambulance service use of prof-to-prof, and key to that with that huge increase in use the outcomes were sustained.

We still maintained that 30% of calls, patients were able to access care alternate to that, just coming to hospital. So much so when we did the figures and looked at the prof-to-prof calls taken, looked at the patients that accessed direct COVID, accessed direct AMU from ambulance service, doing the calculations we’d have seen 15% at least, maybe 20% more traditional unscheduled attendances through our ED front door, with the whole scheduling which redesign of urgent care enabled on top of that, so it made a huge difference to our managing of it.”

 

  • Beyond A&E approach

 Susan Bean

“We’ve expanded on our medical specialties, started with diabetes in Tayside, who are now providing just an in-hours prof-to-prof service. This is not designed to replace an outpatient referral, these are patients who the GP may have considered sending up to the medical assessment, or medical admissions unit, in Ninewells, or in Perth, to be seen there. Via Consultant Connect they are able to access a senior clinical decision maker in that patient’s own specialty where there’s a patient with a chronic condition, and possibly also the supporting specialist nursing team. It’s just enabling them to access as many alternative pathways for patients as possible – for example, a diabetic or a patient with COPD may have had to come up to hospital to be assessed before, actually being able to speak to their own consultant can enable them to have the care they need closer to him (for example, arrange an urgent hot clinic review, changes over the phone to their management plan etc).

It’s all about care as close to home as possible, and whether that is, ambulance service crews being able to speak to our consultants to arrange alternative models of care, or GPs being able to do the same. You have to ask yourself what value you’re adding with an admission.”

NHS Lanarkshire Case Study

  • Ramping up prof-to-prof in 2020, in the context of national redesign work

 Dr Gordon McNeish

“Every Health Board has complexities, ours is fairly unique with three similar sized hospitals with three Emergency Departments (EDs), each seeing around about 1,200 to 1,300 patients a week (pre-COVID). 

We first started to look at prof-to-prof based on a couple of things:

  • First of all, we’d had a GP out-of-hours pilot where ED consultants were working in GP out-of-hours and working alongside GPs. They started to tell us about how they didn’t really have alternatives to referrals other than through our existing Emergency Response Centre (ERC) which has been in place in Lanarkshire for about 15 years. The ERC is the in hours call handling of GP unscheduled care referrals.
  • The emergency medical consultants within Monklands, (one of the hospitals in Lanarkshire), told us about the variability in the type of patients being sent in. Sometimes we would have frustration about whether there was an active alternative

So, in August 2019 we set up a short life working group where we tried to gather in representatives from primary care, secondary care, across all three sites, to try and put something together in terms of what we could do to look at unscheduled care referrals and Consultant Connect was mentioned as an option. Hearing from experience in Tayside and Greater Glasgow & Clyde certainly set the ball rolling to look at that in a bit more detail.”

  • Front door and back door approach

 Dr Gordon McNeish

“Through contact with Consultant Connect and a conversation with Dr Ron Cook and a representative from Greater Glasgow & Clyde, we got the notion of Tayside’s front door approach with their paramedics being at the forefront of calls, and Greater Glasgow & Clyde’s, at the time, back door approach, where the specialty consultants were taking calls similar to what Susan was describing earlier. We were keen to push ahead with both of these approaches.

We were about five months into planning when COVID arrived. The redesign of urgent care and unscheduled care approach which came from the Scottish Government included a press for a prof-to-prof communication, and scheduling of unscheduled care. That gave the spur to finish off the business case that we were developing and present it to the board for funding of Consultant Connect.

While we were waiting for an answer on the business case for Consultant Connect, we started trying out a prof-to-prof link with the Scottish Ambulance Service at Monklands with an initial focus on for patients with potential COVID. As Tayside found, it was a challenge trying to keep track of these conversations. We went through different recording solutions with paper, we put a database together, but each of them failed to really have a reliable capture of the amount of calls we were taking and the outcomes, and similarly any governance towards any non-favourable outcomes about patients ending up with us anyway. 

So, when we got agreement for funding for Consultant Connect, we went two-pronged. We looked at eight specialties in the first instance, to be able to take calls directly from primary care, initially to gauge this advice for patients that you would otherwise have sent via the ERC, to the acute hospitals before, for unscheduled care referrals. This was to see, if there were any patients that were on the borderline of requiring acute referral, if a discussion with a specialist would maybe offset that. Then, having ED as one of those options for GPs, but also giving that ED option, and other options, such as medicine for the elderly, to paramedics across Lanarkshire, and then scaling it up right across Lanarkshire, so that all three EDs and the specialists across Lanarkshire.

 At the same time our ERC developed into our Flow Navigation Centre, which was another one of the asks of the redesign of urgent care programme. We had an existing structure of an ERC, but we needed to scale it up, so we could operate 24/7, and as well as taking GP calls, as we did previously, and also have Consultant Connect as an option.

  • Flow centre and Patient Connect approach

 Dr Gordon McNeish

“Patient Connect is part of our flow navigation centre strategy. We were looking to provide some senior decision maker support to the nursing staff who operated within the flow navigation centre, so we created a rota which covered peak times between 12pm and 8pm, seven days a week. We have around ten ED consultants across the three sites in Lanarkshire who cover these shifts.  We have some variability in it but a reasonable pickup rate for these shifts as additional shifts to ED shifts. 

They were initially done within the flow centre at Hairmyres, so we were sitting in amongst the staff to be able to see the setup of it all, but more latterly we’ve been able to do that remotely from a laptop, either at home, or within the office, so that makes it a bit easier for consultants to sign up to these shifts and provide that support.”

  • So, what is the support we’re providing? 

Dr Gordon McNeish

“Different Health Boards are all doing things a bit differently, but with our flow navigation centre the calls from NHS 24 to ED are getting booked onto the Adastra system and displaying on the Trakcare systems of the individual acute site across Lanarkshire.

We’re able to see these calls coming through and pretty much phone back the patient immediately using Consultant Connect’s Patient Connect to do that. 

With Patient Connect, we use the Consultant Connect App, and are able to dial out to patients. Via Consultant Connect all calls are recorded in the same way that they are when it is a clinician-to-clinician call via the system, outcomes can be recorded by the consultants, enabling us to capture accurate data of what the call outcomes are. Data shows that with about 30-35% of calls we make we’re able to divert patients away from ED. I think we’re approaching about 1,800 consultant to patient calls since we started doing this the end of December 2020/beginning of January 2021 and we’re hoping that the national messaging campaign from Scottish Government about calls going via NHS 24 we can hopefully redirect even more patients away from ED.”

Scottish Ambulance Service Case Study

  • The magic in prof-to-prof conversation” in action, across the Scottish Ambulance service

Jonathon Will, Clinical Effectiveness Lead, SAS Specialist Paramedic & Tayside Mountain Rescue Officer, Scottish Ambulance Service

Below Jonathon shares with us a patient care example:

“One example of prof-to-prof conversations working incredibly well was a 74-year-old gentleman I attended earlier this year. He had been reported to the police as a ‘wandering dementia patient’, and when they found him, it was clear he was somewhat unstable on his feet; in fact, he already had some minor injuries consistent with a fall.

Despite the patient being somewhat confused, they managed to find out where he lived, and got him home. At home, he was in a place of safety, but the Police were concerned about the likelihood of repeat wandering, and possible subsequent fall. From a duty of care they felt forced to call the Scottish Ambulance Service.

We attended the scene and discovered that the police had managed to contact the patient’s brother who also arrived. Unfortunately, the brother was a poor historian, and was also displaying early signs of cognitive decline; he was also the sole carer for his wife which meant he couldn’t stay and look after his brother – it was a really complex situation.

The brother shared a muddled conversation about the patient having a urinary tract infection and recent hospital admission. The patient really didn’t want to go back to hospital, but also recognised that he wasn’t able to look after himself.

We called the prof-to-prof line and the Senior Clinical Decision Support who informed us that he had indeed been in hospital for two days being treated for acute confusion and a UTI. There were also notes to the effect that the confusion was suspected to be more chronic in nature.

On the advice of the consultant, we then contacted the patient’s own GP for a further prof-to-prof conversation. It turned out that the patient was booked for a five-day residential dementia assessment the following week. Given the history and our observations, the GP completed a remote consultation and prescribed further antibiotics. A prescription was sent to the local pharmacy, and we arranged for this to be collected by the patient’s own care company. The GP also managed to provide details of the assessment centre and the patient’s social worker.

A conversation with the assessment centre highlighted that they could not accept the patient early, but a further conversation with his social worker enabled us to arrange emergency rest bite at a nearby care home to bridge the gap until his assessment.

Although we were on scene for a long time, our overall service time was not increased because we avoided a long convey and hand over at hospital.

The patient had been quite anxious about the prospect of returning to hospital, and so he was very grateful for this alternative plan.

“We avoided an unnecessary ED attendance and a probable hospital admission, we reduced our travel impact, and we collaborated with our Primary Care, Hospital, and Health and Social Care colleagues to provide a very patient centred plan.”

In summary then, utilising multidisciplinary prof-to-prof conversation along with shared decision making, resulted in the police being reassured about their duty of care, it provided a more efficient use of NHS resources, and most importantly, we absolutely got the right care for our patient. It was a great outcome for everybody.”

 

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