Somerset NHS Foundation Trust: advice and guidance case study

Musgrove Park Hospital is a district general hospital providing care to a population of over 340,000. It's part of Somerset NHS Foundation Trust (formally know as Taunton and Somerset NHS Foundation Trust).

The hospital is one of the largest providers of e-RS advice and guidance services in England, responding to over 19,000 requests in 2018.

Paediatrics was the first speciality to open e-RS advice and guidance in 2009, followed by an expansion across a range of specialities. The majority of services provide a 48 hour turnaround for advice and guidance.

The available advice and guidance services are:

• breast  
• clinical pathology
• community paediatrics 
• ear, nose and throat (ENT)
• gastroenterology           
• gynaecology
• haematology    
• neurology
• ophthalmology
• paediatrics
• rheumatology  

The NHS e-Referral Service (e-RS) private providers dashboard can be used to understand national advice and guidance usage across England.

Users should register for access if they wish to view this data.

Across all services, the rapid turnaround of advice and guidance responses has been used to encourage GPs to use this route before considering referral.

If referral is recommended, e-RS allows consultants to specify which clinic GPs should refer to. An application has been developed by the Trust to provide consultants with a pull-down menu of recommended clinics (this application has been developed by the Trust and is not part of the national e-RS system). 

Here are some examples of successful implementations of advice and guidance across different specialities:

Paediatrics

As the first team to set up advice and guidance services, the paediatric team, led by Dr Sarah Bridges, are passionate about continually improving patient care at the primary / secondary care interface.

The team have developed advice and guidance in parallel with community outreach clinics to streamline patient care. Five consultants cover a weekday each in the advice and guidance service, improving direct communication and education between GPs and consultants.

Neurology

Dr Edward Fathers, consultant neurologist, has led further expansion of advice and guidance across the Trust, employing optional digital dictation for some of the longer advice and guidance responses used in neurology to optimise efficiency.

Haematology

Dr Deepak Mannari is part of a team of seven consultants delivering the haematology advice and guidance service, providing a day each of cover and focussing primarily on GP requests for advice about interpretation of patient test results.

Gastroenterology

Dr Dan Pearl and Dr Rudi Matull work in a team of nine Gastroenterologists who rotate to provide a week of advice and guidance services each. If endoscopies are recommended by the consultants in advice and guidance responses, the test is booked by the patient’s GP.

Rheumatology

Dr Luke Gompels and team provide a busy Rheumatology advice and guidance service, and as Chief Clinical information Officer in the Trust he is continuing to develop advice and guidance within the Trust’s digital strategy to streamline patient care.

Gynaecology

Within the surgical directorate, Dr Hadi Haerizadeh and the gynaecology consultant team have found advice and guidance helpful in reducing unnecessary hospital referrals, with five consultants covering a weekday each.

Ear, nose and throat (ENT)

In the ENT department, Dr Edward Chisolm and the team have used advice and guidance to reduce inappropriate outpatient referrals and ensure GPs receive rapid advice to support optimal investigation and treatment of patients in the community.

The teams have worked hard to ensure consistency in the quality of clinical information provided by both referrers and providers.

Some advice and guidance referrals contain insufficient information and require two-way advice and guidance conversation, which is time-consuming for clinicians and can delay patient care.

The quality of advice and guidance responses can vary within or between specialties, requiring regular peer review and close consultant team work to ensure consistency of responses.

Advice and guidance requires consultants to maintain an up-to-date directory of services for both advice and guidance and face-to-face clinics, ensuring any recommendations for referral are in line with directory of service specifications and local commissioning arrangements.

Although e-RS is intended as a single platform for consultants to access both advice and guidance requests and clinic referrals, in this Trust consultants are required to use a separate system for vetting clinic referrals (Maxims), which many consultants find reduces clinical efficiency.

This data shows face-to-face referrals to the same speciality for any condition within six months of the advice and guidance response, for key specialities providing hospital out-patient services.

This data includes patients referred immediately following advice and guidance (on advice of the responding clinician) and patients where the advice and guidance plan was followed but ultimately the patient still required a subsequent referral. This data is based on NHS numbers and does not differentiate between referral for the same or a different condition, and may therefore include some patients referred for another indication unrelated to their advice and guidance.

Across the key out-patient specialities studied, around two-thirds of patients were not referred to out-patients, although this varied widely across speciality services. Feedback from consultants in qualitative interviews suggests that many patients who are referred to clinic following their advice and guidance are further along their treatment or investigation pathway as a result of advice and guidance, and therefore may require less follow-up in secondary care.

This data should be interpreted in the context of the individual services, as waiting times for new referrals to some services may occasionally exceed six months.

The data reflects patients selected by their GP for advice and guidance, rather than referral, and therefore the figures should not be interpreted by commissioners as applying to all patients requiring a specialist opinion. In some services advice and guidance may result in a referral direct to a test (such as approximately 35% of gastroenterology advice and guidance responses recommended endoscopy); although these patients may not require a subsequent clinic appointment, the patients are still seen in the specialist service for their investigation.

*ENT service started May 2018.

**Community Paediatrics service started June 2018.

Breast and Ophthalmology services started after June 2018 so not included.

Clinical Pathology does not offer outpatient services so not included.

Clinicians access e-RS advice and guidance using their NHS Care Records Service smartcard to view the standard e-RS screen and advice and guidance worklist.

An additional application has been developed by the Trust to provide a drop down list of recommended clinics and services to guide GPs if the consultant recommends referral. This application also copies the advice and guidance response into the hospital Electronic Patient Record (EPRO).

Patient referrals and bookings are graded by consultants in IMS Maxims PAS.

Find out more about advice and guidance by reviewing the advice and guidance toolkit and watching the advice and guidance video, found in our document library.