General Paediatric Service: Future Developments

1. General Paediatric Service: Future Developments Dr Gary Ruiz 9 January 2008

2. GP incentives to provide care without hospital referral £4 billion reallocated from hospitals to primary care development Payment by Results: tariff-based system demands cost efficiency Patient Choice initiative: expect higher referral rate if good Government policies

3. Strategy for Child Health • Provide more focused, efficient & effective general services • Develop our specialist services • Radically improve our shared services

4. 1. More focused, efficient and effective general services “Work as part of the local healthcare network to ensure we deliver the general services that we, as an acute teaching hospital, are best placed to provide and ensure children are cared for in the most appropriate setting.”

5. Appropriateness of hospital care • General Paediatric Outpatient Clinic • Acute Paediatric Ward

6. Audit of General Paediatric Clinic referrals • 92 referral letters of children attending 6 KCH clinics in November 2005 • Categorized to: • “Must see” • Potential to be seen in community or primary care (if facilities / expertise existed) • Potential to be dealt with by telephone • Inappropriate for General Paediatric Clinic

7. Results of referral audit • GPs referred over 80% of new cases • Follow-up after a UTI was the commonest reason for referral, comprising 22% • Inappropriate clinic attendance was rare (3%) (N.B referrals vetted by a consultant beforehand) • Very few referrals (7%) could have been averted by a telephone discussion with the GP. • A third of the children referred could potentially be managed adequately in community or primary care with appropriate facility / expertise

8. Breakdown of “must sees”

9. Potentially seen in primary care • 1st UTI: typical, single, >1yr (n=13) • “Simple constipation • Soft heart murmurs • Simple growth / size concerns • Head shape / posture • Complex child under many specialties • Parental anxiety: • Crying at night • Clumsy, hyperactive • Colicky / gurgly stomach • Poor weight gain • Small head • Small penis

10. 2007 UTI in childrenNICE guidelines • Investigation post-UTI more targeted: vastly decreased indications • Depends on age, response to treatment, atypical features, recurrence • Ought to produce a drastic reduction in UTI referrals (comprised 22% referrals in our audit)

11. Necessity for in-patient treatment • Pressure on hospital beds / Emergency targets • Facilitating early discharge: Nurse-led home care • Avoiding need for admission: ambulatory facility

12. Intravenous antibiotic therapy • Once daily antibiotic (other?) • Reliable IV access • Potential conditions: • Pneumonia • UTI • periorbital cellulitis, abscess, skin infection, etc • Ambulatory facility for starting / monitoring effect of treatment

13. Home investigation / monitoring • Overnight oxygen saturation • 24 hour oesophageal pH • Blood pressure • Urinanalysis • Capillary glucose

14. Electronic patient records • All pathology results, clinic records held on EPR • Obstacles to giving access to primary care: • Security/confidentiality • Accountability

15. Future developments: Summary • Alternatives to Gen Paed Clinic attendance at acute teaching hospital • More “Hospital at Home” for treating and investigating • Better communication between secondary and primary care