GI Direct and Complete Advice Guidance & Proceed

1. 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

2. 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

3. 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 Advice Guidance & Proceed

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

5. 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 Advice Guidance & Proceed

6. 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 Consultant Case review Long-term condition programme Advice Guidance & Proceed

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

8. Advice Guidance & Proceed

9. 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

10. Preliminary outcomes: first 350 patients Advice Guidance & Proceed

11. 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 Advice Guidance & Proceed

12. 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 Advice Guidance & Proceed

13. 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 Advice Guidance & Proceed

14. Next 12 months: Advice Guidance & Proceed

15. Questions? Advice Guidance & Proceed

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

17. GI direct and complete – What next? GP referral Case Reivew • Additional assessment • Non face to face contact • 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 Pre referral Pre-assessment community clinic (CAS managed) LTC Surveillance Programme (CAS managed) • Direct access diagnostics • Guidance and template for referral to diagnostics • Minimum standard for direct access e.g. attendance at course • 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 • 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 Refer back to GP Outpatient appointment Choice of provider • Advice on appropriateness of referral • Advice on management of patient i.e. care plan Community Pre-assessment and Case review • Clinic setting • Nurse led clinics Advice Guidance & Proceed