Paediatric Navigation and Referral Guidelines for GPs

1. Paediatric Navigation and Referral Guidelines for GPs • Dr Louise Wells, Dr Anna Mead, Dr Elizabeth Marder • Dr Rosemary Gradwell, Dr Nadya James, Dr Jill Sussens

2. Aim of the Navigation Hub To establish a comprehensive navigation system: - Provide primary care referrers with a timely response - For acute and elective general/community paediatric referrals - Directing children to the most appropriate service Right person Right place Right time 2

3. The Navigation hub offers Consultant paediatrician hot line during peak GP referral hours - Arrange urgent admissions - Divert non urgent admissions - Advice regarding safe management at home Single point of access for all non-urgent general and community referrals - Decide most appropriate time, place and person for appointment - Biweekly consultant led vetting Information resources online - Clear pathways for acute and non acute paediatric problems - Detailed description of services and referrals guidance - Information leaflets for parents and carers - Paediatrician involvement in primary care CPD 2

4. How the Hub is funded 2010: One year pilot project funded by the CCGs with the aim to reduce acute admissions by 5%: - 5 Acute consultant PA sessions to cover the phone line - Navigation coordinator (band 3) 2011: Realism that more consultant sessions required to cover the phone line and to include outpatient referrals to be vetted. CCGs now fund: - 8 Acute consultant PA sessions to cover the phone line - 2 consultant PA sessions to support triage of outpatient referrals - Full time navigation coordinator (band 3) 2

5. Outpatient referral guidelines

6. Background 2012 Concern: Concerns raised from the local Children’s Health Network regarding the quality and variation in outpatient referrals from primary to secondary care 2012 Audit: - 21.6% of referrals classed as not appropriate, but many were still offered outpatient appointment due to lack of clear guidance. - A significant number of children could have been managed in primary care with advice. - A number of children were already under a Paediatrician with the skills to manage the current problem. 2

7. Background 2015: Acute and Community Paediatric teams and senior GPs consulted to determine opinion on conditions suitable for inclusion 2015: Paediatric referral guidelines developed by Acute and Community Paediatricians across both trusts, senior GPs, and multi-agency seminars supported by the CCGs and local Councils November 2015: Launch of the Paediatric referral guidelines including presentations at Nottingham County GP PLT meetings 3

8. Working together Referral guidelines for Paediatric outpatients from primary care has been a collaborative process Initiated by Nottingham City and South of County CCG’s and Nottingham Children’s Hospital Developed in collaboration with GP CCG Childrens leads, community, general and specialist paediatricians at Nottingham Children’s Hospital and Sherwood Forest Hospitals Reviewed and “ Owned “ by Nottingham and Nottinghamshire Children and Young People’s Health Network Implemented at Nottingham Children’s Hospital and Sherwood Forest Hospitals 18

9. Aim • To support GPs to manage more C&YP with non-acute conditions safely & confidently in primary care, including increased use of local / national resources & guidance • To ensure timely referral, to an appropriate outpatient clinic or service, for C&YP that require it • To support paediatric triage of referrals, improving consistency in standards for accepting or redirecting referrals 4

10. The guideline • Over 100 Paediatric presentations/conditions • Hyperlinks to national and/or local guidelines • Hyperlink to patient information leaflets, resources and websites • When to refer • How urgently to refer - including acute pathway • Where to refer • Unable to reassure a parent is always deemed an appropriate reason for referral 5

11. Where can the Guidelines be found? • Nottingham Care Navigator • F12 button • https://nuh.nhs.uk/staff-area/clinical-guidelines/ Under Childrens Hospital – General • http://www.midnottspathways.nhs.uk • Choose and Book front page 5

12. The guideline 6

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15. Example: Constipation and Soiling 9

16. Central appointments re-book child into a suggested clinic Alternative general or community clinic suggested Admin team send letter to GP Advise letter dictated with link to the guideline Referral redirected to specialist service Appropriate clinic already allocated Referral sent to specialty for vetting No change to C&B appointments Agree child needs to be reviewed in secondary care Choose & book appointment allocated. GP should explain that this is a provisional appointment Presentation meets referral criteria Primary care management Vetting of referrals by community and general paediatricians (twice weekly) GP reviews the paediatric outpatient referral guidelines Refer back to GP GP sees child In line with the guidelines: GP refers to general paediatrics/community peadiatrics/specialty service GP unable to reassure parents The pathway in action 17

17. Is the guideline utilised? Re-audit in November 2016: - ‘Rejected’ referrals increased from 8% to 17% - Referred to by paediatricians in the vetting meeting - Concluding low GP usage January 2017: Re-launch of revised guideline including review at the East Midlands Children’s Network meeting May 2017: Presentation at RCPCH Conference September 2017: Presentations at Nottingham City PLTs 9

18. Early Findings from Audit of Referrals into Nottingham Childrens Hospital • Based on 123 referring practices • Only counted those with >10 referrals • Great variability in percentage of referrals accepted between practices 92.3% to 45% • Needs further unpicking- highest 5 County , 5 lowest City . This may represent: • Difference in behaviour pathways • Difference in awareness of Navigation and referral guidelines (County CCG PLT 2015/16, this is 1st for City) 18

19. Some numbers • November 2015 - June 2017 10806 referrals • Referrals Accepted 73% • Rejected 17% • Redirected to a different service (in NUH) 10% • Of the accepted referrals • Accepted to original appt slot64% • Appt changed to sooner inc. rapid access 5% • Rebooked for a different clinic 4% 18

20. IMPORTANTre: referrals via Choose and Book • PLEASE note that all referrals to paediatrics via the Choose and Book system are always PROVISIONAL • They are considered by our consultant vetting team and • approx 17 % are NOT ACCEPTED • approx 20% are CHANGED to different time ,date, service or place. • Please do not tell parents/carers the details for this provisional appointment (or make it clear that it is PROVISIONAL AND STILL TO BE CONFIRMED) nor the information that they can change it (at this stage) • Please do tell Parents/carers that they will receive a confirmed appointment, with correct time, date and place directly from the hospital if the referral is accepted 18

21. IMPORTANT re: referrals via Choose and Book If we do NOT accept the referral we will contact you to explain why and make alternative suggestions We do NOT contact the parent/family (unless the appt is less than a week away) To avoid referrals being rejected please refer to 18

22. Referral Guideline Review 2017 We are in the process of reviewing the guidelines and welcome input in terms of general comment , corrections, omissions or additions. If you would like to contribute please contact Paediatric Navigation Hub at Nottingham Children’s Hospital (Nottingham University Hospital NHS Trust) 0115 9249924 ext. 63475 or email elizabeth.marder@nuh.nhs.uk 18

23. Case Study One 7yr girl Mum found ‘lump’ when brushing hair Present 5 weeks ?bigger Currently 2.3cm Otherwise well

24. Lymphadenopathy Reactive? Infective? Pathological?

25. Case Study Two 14y girl Headaches last 6m ‘Banging’, ‘very bad’ Dark room & analgesia Last several hours 1-2 per fortnight Getting more frequent Misses school Exam – overweight, else NAD

26. Headache ?Migraine ?tension ?other

27. Red Flags Eye exam, BP check, waking/cough headache

28. Case Study Three 13yr boy Height 0.4th cent Weight 2nd cent Parents 5’5” 4’9” Healthy, pre-pubertal Self conscious +++

29. Short Stature / Faltering Growth Normal? Delayed? Illness? Nutritional? Endocrine? Genetic? Psychosocial?

31. Case Study Four 20m boy Restricted eating ++ Eats dirt, paper, clothing… Tired & ‘naughty’ Hb 10.2 Ferr 10 Vit D 40 (treat <50)

32. Diet and Anaemia

33. Acute referral and advice lineSupporting the acute management of patients across the primary/secondary care interface

34. GP phoneline 2010: Trial of consultant paediatricians receiving referrals from primary care. - 30% of patients could be managed without attending at that point - 15% seen in a rapid access clinic - 4% seen in a routine outpatient clinic - 11% managed by a GP in the community following advice from a paediatrician 2017: Consultant +/- senior trainee advice via a direct GP line Seasonal variation in role responsibilities 18

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36. GP phoneline: possible outcomes • Emergency referral to be seen the same day • Urgent outpatient review • Jaundice clinic • Routine outpatient review • Redirected to patient’s known consultant • GP to manage in primary care • We will never refuse to review a patient, but we might suggest an alternative! 18

37. Pathways for common acute presentations Designed and developed with GPs to support consistent management across primary and secondary care 18

38. Example - Gastroenteritis 18

39. GP phoneline: recent audit Audit: January 2017 - Average of 30 phone calls per day - Calls from GPs, midwives and OOH primary care - 58.4% patients seen in Children’s Assessment Unit - 35% advice given to GP, OOH and midwives - 4% seen in Rapid Access Clinic - 2.6% redirected to other specialty or known consultant 41.6% of referrals not seen by paediatrics acutely 18

40. Potential for further development • Electronic record keeping • - Accurate auditing of data • - Documented advice on patient notes (via Medway) • Extended hours of operation of the consultant phone line towards 7 day working • Involvement of other clinical areas including Paediatric specialties 18

41. Summary • Both pathways shown to reduce numbers of children being seen in paediatrics • Need for increased GP awareness • Annual review of guidelines (supported by GP fellows) • Continuous auditing • Right patient, right place, right time 18

42. Thank you • Any questions?