Abstract

Background  The COVID-19 pandemic called for significant restructuring of healthcare system in the United Kingdom to overcome the burden on emergency services and restore elective activities. This study aims to discuss the development of a new triage system of reviewing gynaecology e-referrals to secondary care and analyse the sustainability of this service beyond the pandemic. The streamlining of primary care referrals was conceptualised on the framework of Clinical Assessment Service (CAS) as recommended by NHS Long-Term Plan.

Method CAS was implemented in our gynaecology department as a response to COVID-19 pandemic. E-referrals triaged using CAS in phase 1 were reviewed and areas of improvement identified. A second review was carried out in phase 2 after implementing changes to ensure improved services. The outcomes of interest were appropriateness of referrals, destination appointments and percentage of virtual appointments.

Results 185 e-referrals in phase 1 and 85 e-referrals in phase 2 were analysed. Training and education of relevant stakeholders and a more efficient CAS in phase 2 resulted in significant reduction in inappropriate referrals from 14% to 3% [RR-0.17 (95% CI - 0.04-0.72); p=0.02]. For every 9 e-referral reviewed in CAS, 1 inappropriate referral was avoided. The number of virtual appointments increased by 16% (45% in Group 1, 61% in Group 2).

Conclusion CAS framework provides a sustainable strategy to overcome disruptions in the provision of elective outpatient services caused by COVID-19 pandemic. It reduces inappropriate secondary care e-referrals, allows management of eligible patients digitally, shortens patient care pathway and creates a dynamic link between the primary care providers and specialist care.

Keywords Continuous quality improvement, COVID-19, General Practice, Healthcare quality improvement, Women’s Health

Introduction

The COVID-19 pandemic has created unprecedented changes in the delivery of gynaecological services in the United Kingdom leading to a cancellation of outpatient and theatre appointments. Elective gynaecological work had to be cancelled to enable capacity for sick patients of COVID-19.¹ During initial phases of the pandemic, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by COVID-19 patients and much of the disaster planning involved addressing overcrowded urgent care facilities and decompressing these locations.² This has led to significant waiting lists and frustration for patients as well as clinicians involved in elective activity. As we moved into the next phase of the pandemic, rapid implementation of restoration and recovery strategies to restart elective gynaecological work became a clinical priority. Looking beyond the immediate challenge of restoring services due to disruption in patient care as a result of the pandemic, the learning achieved from this experience offered a unique opportunity to focus on the required changes in healthcare structure in order to create a better and fairer health organisation in the long term. The challenge was to grasp this opportunity while restoring services to achieve both recovery and renewal as the pandemic continued to plague the nation.

The approach to renewal was built on the direction set out in the National Health Service (NHS) Long-Term Plan.³The NHS Long-Term Plan, also known as the NHS 10-Year Plan, published by NHS England on 7 January 2019 set out priorities for healthcare over the next 10 years and showed how the NHS funding settlement could be used.³ The five major changes proposed by the document included boosting ‘out of hospital’ care, reducing pressure on emergency services, creating a more digitally enabled outpatient care, promoting personal health and improving population health.³ The Clinical Assessment Service (CAS) is part of the service model conceptualised by digital NHS to streamline and triage primary care referrals to the most appropriate onward care pathway.⁴ It is an intermediate service that allows for greater level of clinical expertise in assessing and investigating patients than would normally be expected of the referring clinician. It would ensure the most cost-effective commissioning as patients are seen in the right place at the first attempt, hence reducing cancellations and rejected referrals.⁴

The objective of this single-institutional study was to analyse the implementation of a new triage system of reviewing gynaecological referrals for secondary care. We identified the structural and logistic challenges to a new service, implemented recommendations and issued action plans to reduce the number of hospital attendances without compromising patient care.

Methods

The manuscript was written in accordance with SQUIRE guidelines.⁵

The study was conducted in two phases:

Phase 1 discussed the conceptualisation of CAS framework. A retrospective analysis of e-referrals in the first eight CAS clinics conducted biweekly was performed. Areas of improvement were identified from this pilot project and action plans implemented using a Plan-Do-Study-Act approach.⁶ CAS framework was implemented in our unit to expand access to secondary care during the restoration phase of the COVID-19 pandemic. Prompt development of the CAS protocol was proposed at the end of March 2020 during the first lockdown. The protocol was established in May 2020. All gynaecology e-referrals between 1 February 2020 and 30 April 2020 were reviewed in the CAS clinic starting 20 May 2020. The results of Phase 1 were reviewed and audited to assess the newly developed service and areas of improvement identified.

Phase 2 involved collection of a second round of data between 12 August 2020 and 20 September 2020 to assess the same metrics as the phase 1 study, with a view to assess the change in practice by comparing the two cohorts.

Development of CAS team

The hospital booking team received e-referrals from Primary Care Physicians (PCP), either a General Practitioner (GP) or Advanced Healthcare Professionals (AHP). A team was nominated to review and triage these e-referrals. Two week wait referrals, early pregnancy problems, and unscheduled consultations between primary care and on-call gynaecology team were excluded from the CAS review. The team included senior clinicians who could provide expert opinions and engage the right stakeholders in order to ensure implementation of a change of practice that was essential to transform elective care services in the COVID-19 context. The staff involved in streamlining the e-referrals included a GP with special interest in Gynaecology, Clinical Director of Gynaecology, a senior consultant gynaecologist, administrative staff from outpatient services.

Multidisciplinary triage of e-referrals enabled team members to gain insight into challenges and issues in primary and secondary care domains, identify learning themes based on referrals patterns, and focus on areas where it became apparent that there was a knowledge gap. Overall, this enabled collaborative working pattern between primary and secondary care clinicians and help bridge the gap between the two. The administrative staff played a vital role in putting together CAS clinic templates and ensuring all the information required was available to the clinical team on electronic patient record (Cerner Millenium, UK^TM). The team met virtually on Microsoft Teams^TM twice a week with appropriate IT support and access to audio-visual equipment. 20-25 e-referrals were analysed in each CAS clinic that ran for 120-150 minutes. On an average, 5-10 minutes were spent on each e-referral.

Development and Implementation of the Triage Process

Following early implementation of CAS framework, a CAS proforma was created to capture the CAS clinical review outcomes in a uniform and consistent manner for all patients. The proforma covered the following aspects – indication of the e-referral, urgency of referral, investigations required before first appointment in secondary care, acceptance or rejection of the referral and the onward care pathway(Online supplementary material 1) . Figure 1 shows the onward care pathway from the time the e-referral was generated. Patients were routinely informed of the CAS process which improved patient satisfaction and added multidisciplinary value to the clinical care they received.

Phases of the project

Phase 1

A data collection tool was created to record details of the source of referrals, CAS outcomes, appropriateness of referrals, destination appointments, and proportion of virtual appointments (Online supplementary material 2) . Analysis of data from the CAS clinics between 20 May 2020 and 26 June 2020 was performed. Data was extracted retrospectively from electronic patient records. A validated data input spreadsheet (Microsoft Excel®, Microsoft Corporation, USA^TM) was created for the collection of anonymised data. The results from the first phase were presented in the gynaecology Clinical Governance Meeting (CGM). The action plan from the project was disseminated across primary and secondary care, with a tight schedule for implementation of change, with a quick turnaround time. The action plan included education and design of treatment pathways for common gynaecological presentations, increasing uptake of advice and guidance, educating the PCPs on the information to be included in referrals letters and giving positive feedback on the receipt of good quality referrals. In addition, the action plan also included training other clinicians to perform CAS triages and virtual clinics to increase throughput.

Phase 2

CAS clinic framework was subsequently restructured and training was provided to more staff members in the department to conduct the reviews. Data collection and analysis for Phase 2 was performed using the same parameters and Excel spreadsheet. Analysis of CAS clinic outcomes between 12 August and 20 September 2020 was performed and presented at the gynaecology CGM. Phase 2 results were compared with those of phase 1.

Statistical Analysis

Statistical analysis was performed using SPSS (V25) (IBM Corporation) and the magnitude of experimental effect calculated using chi square test for significance and relative risk with confidence intervals set to 95% to reflect a significance level of 0.05.⁷ Data was represented using descriptive statistics and results expressed in absolute numbers and percentages. Tables, clustered bar chart and stacked column charts were used when appropriate for a diagrammatic representation of data.

Results

Data from 185 e-referrals was analysed in the first phase (Group 1) and 85 e-referrals were analysed in the second phase (Group 2). The number of e-referrals was higher in Group 1 as the CAS clinic reviewed all pending e-referrals from the preceding months that were deferred due to clinic cancellations as a result of the Covid-19 pandemic and lockdown.

Source of e-referrals

Majority of the e-referrals were from General Practitioners [Group 1 - 139/185 (75%); Group 2 -76/85 (89%)]. The remaining were from Advanced Nurse Practitioners [Group 1 - 42/185 (23%); Group 2 - 8/85 (10%)], Advanced Pharmacist Practitioners [Group 1 - 4/185 (2%); Group 2 -1/85 (1%)] from the community who had privileges to request secondary care referrals.

Referral indications

Referral indications for patients in Group 1 and 2 are enumerated inTable 1 . Reasons for referral encompassed a wide range of conditions. However some of these referrals were made mainly to seek advice for diagnostic and therapeutic interventions that would be feasible in primary care. Some examples include advice around the initiation, continuation, discontinuation or change of medication, guidance on whether to perform radiological investigations and the need for further diagnostic tests.

Appropriateness of e-referrals

76% (140/185) of e-referrals in Group 1 and 89% (76/85) in Group 2 were deemed appropriate for secondary care (Table 2) . Among the rejected referrals, common themes were menstrual disorders and pelvic pain that could be managed in primary care. These e-referrals were rejected with advice on investigations or treatment that could be initiated in primary care and secondary care referral to be considered if they failed.

Implementation of CAS was found to reduce the inappropriateness of e-referrals significantly from 14% in Group 1 to 3% in Group 2 [RR-0.17 (95% CI - 0.04-0.72); p=0.02]. For every 9 patients reviewed in CAS clinic, 1 patient was found to have a reduced risk of rejection due to an inappropriate e-referral.

Destination appointments following CAS review

Destination appointments for each accepted e-referral was organised immediately after review in CAS clinic and the appointments were sent out to patients. (Table 3) . Majority of the appointments were for review in the General Gynaecology Clinic [71/140 (51%) in Group 1; 46/76 (61%) in Group 2]. The proportion of virtual appointments was calculated after excluding referrals to hysteroscopy, colposcopy and urogynaecology clinics that were arranged as face-to-face. Implementation of action plan after phase 1 and training of other clinicians was found to reduce face-to-face contact by 16% [55 %(39/71) in Group 1; 39%(18/46) in Group 2) (Figure 2) .

Discussion

This study establishes the advantages of the CAS framework. It is a useful tool with joint ownership between primary and secondary care clinicians, and helps to reduce inappropriate referrals, through triage and enhances patient care. Our study showed that sharing mutually beneficial learning themes from CAS clinics reduced inappropriate e-referrals significantly from 14% to 3% [RR-0.17 (95% CI - 0.04-0.72); P=0.02] and for every 9 patients discussed in CAS clinics, 1 inappropriate e-referral was avoided. This has a positive impact on healthcare through efficient utilisation of resources to deliver patient-centred care from the outset in a multidisciplinary environment. It would be reasonable to assume that minimising the duration of patients’ journey by avoiding unnecessary clinical consults and investigations would reduce the cost of secondary services provided to patients. Experience gathered from this study also confirms that CAS promises to enhance the quality of patient care by providing them with a comprehensive assessment, diagnosis, and treatment in primary care and ensures they are referred for secondary care only when there is a definite need for hospital-based specialist services. It also provides a means to give feedback to GPs and AHPs by educating them about appropriate indications for referral for specialist advice, thereby reducing inappropriate e-referrals to secondary care.

CAS was envisaged to be a collaboration initiative with joint primary and secondary care responsibility to review, prioritise and triage referrals to help overcome the backlog of cancelled elective appointments during first peak of COVID-19. This fulfils the criteria for implementation of the service model of digital NHS as recommended in the NHS Long-Term Plan.⁴

Several published studies and audits^8-11 have discussed about bridging the gap between primary and secondary care but there is a paucity of literature on implementation of a structured triage system such as CAS to expand access to secondary care. It is well established that the referral process and communication across primary and secondary care interface has a potential to affect patient care.^8-11 A survey analysis conducted in England and Wales concluded that audit activity at the primary-secondary care interface is an enjoyable experience for a majority of doctors.⁹

Quality improvement interventions like designing treatment pathways for different gynaecological conditions, providing advice and guidance to primary care physicians, giving feedback about missing information in e-referrals, and applauding PCPs for a good quality e-referral in a multidisciplinary environment helps to improve the quality of patient care.

One of the important reasons behind successful implementation of CAS was involvement of experienced clinicians from both primary and secondary sectors. Advanced clinical skills are required for assessing the information in e-referrals and making the right decision for patients. This new service facilitated discussion of management plans for complex patients in a multidisciplinary environment. Literature suggests that attending these multidisciplinary clinics provide training opportunities for GPs and career-grade trainees.¹² Designing flow charts and ‘pathways on a page’ for managing common gynaecological conditions is an area we would like to explore through clinical interface engagement sessions with PCPs.

Telemedicine has transformed the way healthcare service is delivered in the NHS that is severely burdened due to COVID-19 pandemic.¹³ The Royal College of Obstetricians and Gynaecologists has made recommendations that women should be managed by remote communication in outpatient antenatal and gynaecology appointments whenever possible.¹⁴ A systematic review on the use of telemedicine in gynaecological practice showed remote consultations to be promising with regards to clinical effectiveness and gynaecological training.¹⁵ Another study on the use of telemedicine in the management of urogynaecological conditions showed that many first line treatments can be commenced virtually with similar levels of patient satisfaction as face to face appointments.¹⁶ Telemedicine is also useful when following up post-operative patients who have had no complications.¹⁶ This study adds further evidence that telemedicine plays an important role in reviewing patients referred as first attendance, provided there are robust pathways that streamline patients to the correct consultation.¹⁶

Although there are many advantages of virtual clinics, careful planning is sought when care is provided to vulnerable groups such as those at a higher risk of domestic violence, depression and sexually transmitted infections.¹⁷ Prioritising hospital appointments for ethnic minorities should be considered as social distancing requirements can further exacerbate an already underlying racial and minority disparities in care and health outcomes.¹⁷ Additional measures such as the use of 3-way telephone interpreting service may mitigate lapses in communication but can be challenging to conduct. A recent study conducted in Boston, USA found that differences in telemedicine access have the potential to compound existing racial, ethnic, and language-based disparities in chronic disease outcomes, and careful monitoring of telemedicine use across patient demographics is advised.¹⁸

This study has shown a reduction in face-to-face appointments from 61% to 45% for new patient consultations by following interventions adopted as per the action plans advocated after the first phase. One of the interventions included training of consultants and junior doctors in conducting tele-consultations. The general feeling among doctors was that training and education led to an increase in confidence in conducting these consultations. A retrospective review of 4738 gynaecology e-referrals showed that 21.4% of the referrals could be managed by e-consult that involved writing a management plan to the referrer.¹⁹ The increase in virtual appointments by 16% in our study is comparable to a Commonwealth Fund Review that reported a reduction in face-to-face visits across a wide variety of specialties by 9-51% as a result of adoption of telemedicine.²⁰ Another study from Canada found that traditional consult could be avoided in 34.3% of referrals with the use of telemedicine between GPs and gynaecologists.²¹

This study has many strengths. With COVID-19 expected to create barriers in provision of elective activity in healthcare in the near future, triage pathways and remote consultations will continue to be of significant importance. To the best of our knowledge, this is the first study on the use of CAS in gynaecology as recommended in the NHS Long-Term Plan.

This study has the limitation that it is a single institution study, Therefore the results may not be representative of practices at a national level. This is best assessed with multi-centre studies on a larger cohort of patients. Furthermore, while this study has specifically validated the use of CAS in the field of gynaecology, there is paucity of literature for evidencing implementation of a similar framework in other specialities with equal efficacy. Cost-benefit analysis was not performed in this study, however, it would be reasonable to assume that CAS would help in cutting costs by reducing inappropriate referrals and unnecessary consultations through appropriate triage of e-referrals enabling efficient capacity and demand management, which would automatically release efficiencies. Increase in virtual appointments had the advantage of reducing estates and staffing costs.

Conclusion

CAS framework provides a sustainable strategy to overcome disruptions in provision of elective outpatient services caused by COVID-19 pandemic and beyond. It promises a better future with enhanced access to specialist advice and guidance for PCPs. CAS clinics reduce inappropriate secondary care e-referrals and allow management of eligible patients virtually avoiding unnecessary visits to the hospital. It shortens patient care pathway and creates a dynamic link between the primary care providers and specialist secondary care.

Declarations

Disclosure of interests

The authors declare that they have no competing interests. Completed disclosure of interest forms are available to view online as supporting information.

Funding

We declare that any organisation, government or university did not fund us materially or financially.

Contribution to authorship

RR and ST were involved in the conception of the study. CT, TN and ST were involved in triage of referrals in Phase 1 and CT, TN, ST, RR and TV in Phase 2. RR, LF, TV and ST involved in extraction of data. RR and MTA were involved in the analysis of the data. RR and LF were involved in review of literature. RR wrote the manuscript with mentoring from ST, TN. All authors were involved in the finalisation and approval of the manuscript.

Ethical approval

The Quality Improvement Project protocol was approved by the Audit Committee of Family and Specialty Services, Calderdale and Huddersfield NHS Foundation Trust. Approvals to undertake phase 1 and phase 2 were granted separately (Phase 1- CWF054; date of approval 13/05/2020 and Phase 2- CWF069; date of approval 01/08/2020)

Acknowledgements

The authors are grateful to Dr Elizabeth Loney and Mr Ranadeb Acharyya, Audit Committee leads of Calderdale and Huddersfield NHS Foundation Trust, United Kingdom for the support received to undertake this project.

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