Abstract
Introduction: Waiting lists for children’s hospital outpatient appointments are long and appointments in hospital result in children missing valuable time in school. Diverting paediatric patients from hospital appointments to Child Health General Practice Hubs (joint clinics and multidisciplinary team meetings (MDTs) with a paediatrician and the child’s primary care team), can provide more holistic, patient-centred, quality care and reduce time missed at school.
Connecting Care for Children (CC4C), an integrated care collaborative working within Imperial College Healthcare NHS Trust, London, run well established child health GP Hub clinics and MDTs.
Methods: Two junior doctors within the CC4C team screened all referrals to St Mary’s hospital general paediatric department from GP surgeries in their child health GP Hubs every two weeks over a four-month period. Cases identified were discussed with a paediatric consultant to assess suitability to be seen in Hub clinics or discussed in the MDT. If suitable for clinic, the parents of the patient were contacted and offered the Hub appointment. If parents agreed, the patient was booked into a Hub clinic appointment. If suitable for MDT discussion, the referring GP was contacted and asked to attend for discussion.
Results: Over four months, 243 referrals to general paediatrics were screened. 37 patients were deemed appropriate to be seen or discussed in a Hub clinic or MDT, of which 31 patients accepted a Hub appointment (14 for MDT, 17 for clinic). Of those diverted into Hubs, ten patients were successfully treated in Hub clinic. For these ten patients the average waiting time reduction was 42 days (19-80 day interval). For patients not successfully discharged from their hospital appointment, the most common reason was that patients forgot to attend their Hub appointment.
The MDTs had attendance from multiple professionals, including GPs, dieticians, school nurses, health visitors, practice nurses, Child Adolescent Mental Health representatives, and paediatricians; case discussion often yielded a plan, without needing face to face patient assessment.
Conclusions: Integrated MDTs and clinics between GPs and Paediatricians offer a rich opportunity to improve patient-centred, quality care. Once the infrastructure to screen paediatric hospital appointments is in place, we have shown that diverting paediatric patients from hospital appointments to integrated-care, monthly MDTs and clinics reduces waiting times and allows patients to receive care in a collaborative way with their primary care team, with potential for shared professional learning.
Implications for transferability, sustainability, and limitations: Limitations to successfully booking patients into Hub MDTs and clinics included whether there was space in the Hub clinic or MDT, whether the patient was deemed appropriate for clinic, and whether the patient’s parents agreed to the appointment. Patients were deemed inappropriate for Hub clinics if they were likely to require tests that would need to be done in hospital or were already being followed up in hospital, whereby a hub clinic would disrupt their continuity of care.
We strongly believe that other Primary Care networks should divert patients from hospital to community clinics. Our next steps will be to gather further patient experience data on this work.