Transforming elective care services - dermatology Learning from the Elective Care Development Collaborative - NHS England
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Right person, right place, first time Transforming elective care services dermatology Learning from the Elective Care Development Collaborative
NHS England INFORMATION READER BOX Equality and health inequalities
Directorate Promoting equality and addressing health inequalities are
Medical Operations and Information Specialised Commissioning at the heart of NHS England’s values. Throughout the
Nursing Trans. & Corp. Ops. Strategy & Innovation development of the policies and processes cited in this
Finance document, we have:
• Given due regard to the need to eliminate
Publications Gateway Reference: 08767
discrimination, harassment and victimisation, to
Document Purpose Resources
advance equality of opportunity, and to foster good
Document Name Transforming elective care service: Dermatology relations between people who share a relevant
Author Elective Care Transformation Programme protected characteristic (as cited under the Equality
Publication Date 16th January 2019 Act 2010) and those who do not share it; and
Target Audience CCG Clinical Leaders, Care Trust CEs, Foundation Trust CEs, Medical Directors, NHS • Given regard to the need to reduce inequalities between
Trust Board Chairs, NHS England Regional Directors, NHS England Directors of patients in access to, and outcomes from, healthcare
Commissioning Operations, Allied Health Professionals, GPs, Emergency Care Leads
services and to ensure services are provided in an integrated
Additional CCG Accountable Officers, CSU Managing Directors, Directors of PH, Directors of way where this might reduce health inequalities.
Circulation List Nursing, Communications Leads
Description Information Governance Statement
Cross Reference N/A Organisations needs to be mindful of the need to comply
(if applicable) with the Data Protection Act 2018, the EU General Data
Superseded Docs N/A Protection Regulation (GDPR), the Common Law Duty
Action Required N/A of Confidence and Human Rights Act 1998 (particularly
(if applicable) Article 8 – right to family life and privacy).
Timing/Deadlines N/A
(if applicable)
Contact details for Linda Charles-Ozuzu This information can be made available in
further information Director - National Elective Care Transformation Programme
alternative formats, such as easy read or large print,
Email: england.electivecare@nhs.net
and may be available in alternative languages,
Document Status upon request. Please contact 0300 311 22 33 or
email: england.contactus@nhs.net stating that this
This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet
is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this
document is owned by Elective Care Transformation
document should not be saved onto local or network drives but should always be accessed from the intranet. Team, Operations & Information, NHS England.
2 Right person, right place, first time
Introduction
1. The national context and
Contents click to return to this page
challenges facing elective
care services in England
2. The national Introduction 4
dermatology challenge
3. The Elective Care 1. The national context and challenges facing elective care services in England 5
Development
Collaborative and a
framework for action 2. The national dermatology challenge 6
4. Overview of ideas
included in this 3. The Elective Care Development Collaborative and a framework for action 7
handbook
5. Opportunities
for improvement:
4. Overview of ideas included in this handbook 8
rethinking referrals
a. Shared learning 5. Opportunities for improvement: rethinking referrals
opportunities and
establishing GP a. Shared learning opportunities and establishing GP champions 9
champions
b. Advice and guidance b. Advice and guidance: e-Referral Service and teledermatology 15
via e-Referral Service
and teledermatology
c. T
riage in the
c. Triage in the community (spot clinics) 23
community (spot clinics)
6. Opportunities for 6. Opportunities for improvement: shared decision making
improvement: shared
decision making and
and self-management support
self-management support
a. Self-management a. Self-management education and support 29
education and support
7. Opportunities 7. Opportunities for improvement: transforming outpatients
for improvement:
transforming outpatients
a. One stop clinic 37
a. One stop clinic
8. Common factors
in transforming
8. Common factors in transforming dermatology elective care 43
dermatology elective care
9. Key resources 9. Key resources 44
10. Case studies and further
evidence 10. Case studies and further evidence 45
3 Right person, right place, first time
Introduction
1. The national context and
Introduction
challenges facing elective
care services in England
2. The national This handbook describes what local health and care systems can do to transform dermatology
dermatology challenge
elective care services at pace, why this is necessary and how the impact of this transformation
3. The Elective Care
Development can be measured. Practical guidance for implementing and adopting a range of interventions
Collaborative and a
framework for action
locally is included to help ensure patients see the right person, in the right place, first time.
4. Overview of ideas Interventions and case studies are grouped by theme
included in this
handbook within this handbook. ‘How-to’ guides and suggested
5. Opportunities metrics are included.
for improvement:
rethinking referrals The list of interventions is not exhaustive and reflects
a. Shared learning those tested in the second wave of the Elective Care
opportunities and Development Collaborative, along with further relevant
establishing GP
champions
information.
b. Advice and guidance The success of interventions designed to transform
via e-Referral Service
and teledermatology local elective care services should be measured by
c. T
riage in the
changes in local activity following implementation of
community (spot clinics) the intervention and performance against the Referral
6. Opportunities for to Treatment (RTT) standard. Patient and professional
improvement: shared outcome and satisfaction should also be measured (NHS
decision making and
self-management support Improvement, 2018).
a. Self-management The second wave of the Elective Care Development
education and support
Collaborative included rapid testing in dermatology,
7. Opportunities
for improvement: diabetes and ophthalmology. This handbook is just
transforming outpatients one of the resources to be produced following this
a. One stop clinic wave. Further handbooks, case studies, resources
8. Common factors and discussion can also be found on the Elective Care
in transforming
dermatology elective care
Community of Practice pages.
9. Key resources You can learn about the interventions tested in previous
10. Case studies and further waves (MSK and gastroenterology) and find all the
evidence
handbooks and case studies on our webpages.
4 Right person, right place, first time
Introduction
1. The national context and
1. The national context and challenges
challenges facing elective
care services in England facing elective care services in England
2. The national
dermatology challenge
3. The Elective Care The NHS is experiencing significant pressure The friends and family test results for October 2018
Development
and unprecedented levels of demand for show that overall satisfaction with outpatient services
Collaborative and a
is high, with 94% of 1,401,736 respondents saying that
framework for action elective care.
4. Overview of ideas they would recommend the service to a friend or family
included in this Around 1.7 million patients are referred for elective member; 3% said they would not recommend the service,
handbook with the remaining 3% saying ‘neither’ or ‘don’t know’.
consultant-led treatment each month. Between 2011/12
5. Opportunities It is important to take steps to ensure that patient
for improvement: and 2016/17, referrals rose annually by an average
rethinking referrals of 3.7% per year and since 2005/06, total outpatient satisfaction remains high.
a. Shared learning appointments have nearly doubled from 60.6 million to
opportunities and 118.6 million.
establishing GP
champions
At the end of October 2018 only 87.1% of patients were
b. Advice and guidance
via e-Referral Service
waiting less than 18 weeks to start treatment (thus not
and teledermatology meeting the 92% Constitutional Standard for referral
c. T
riage in the to treatment). 4.2 million patients were waiting to start
community (spot clinics) treatment and of those, 2816 patients were waiting more
6. Opportunities for than 52 weeks.
improvement: shared
decision making and
self-management support Timely access to high quality elective care is a
a. Self-management
education and support
key priority under the NHS Constitution.
7. Opportunities Two key documents: Next Steps on the Five Year Forward
for improvement:
transforming outpatients View and the NHS Operational Planning and Contracting
a. One stop clinic Guidance 2017-19, make the redesign of elective care
8. Common factors services a must-do for every local system. They call for
in transforming better demand management that improves patient care
dermatology elective care
while improving efficiency.
9. Key resources
10. Case studies and further The NHS Long Term Plan clarifies the direction for
evidence health and care over the next ten years, including the
importance of transforming outpatient services.
5 Right person, right place, first time
Introduction
1. The national context and
2. The national dermatology challenge
challenges facing elective
care services in England
2. The national Skin disorders are extremely common. More than half the Dermatology (national data):
dermatology challenge population are affected annually, leading to 13 million
3. The Elective Care consultations in primary care and 880,000 referrals to Number of GP-referred first outpatient attendances
Development specialists. Between 2013/14 and 2017/18 GP referrals for Number of referrals from all sources for a first outpatient appointment
Collaborative and a Number of GP referrals received for a first outpatient appointment
framework for action dermatology increased by 15% to 1.16 million per year. Linear (Number of GP-referred first outpatient attendances)
4. Overview of ideas Causes of this rise in demand are thought to include the
included in this increasingly ageing population, rising expectations of skin 1,400,000
handbook
appearance, improved treatments and the growing
5. Opportunities 1,200,000
for improvement: number of people living with conditions such as skin
rethinking referrals cancer, leg ulcers and atopic eczema. 1,000,000
a. Shared learning
Current challenges include: a shortage of consultant 800,000
892,063
869,602
868,561
opportunities and
847,067
786,240
establishing GP dermatologists and an ageing workforce (King’s Fund, 2015); 600,000
champions
variation in diagnosis and management in primary care 400,000
b. Advice and guidance due to the lack of training for GPs (British Association of
via e-Referral Service 200,000
and teledermatology Dermatologists, 2014); limited and fragmented use of
c. T
riage in the available technology (ABPI, 2018); inadequate triage in both 0
2013/14 2014/15 2015/16 2016/17 2017/18
community (spot clinics) primary and secondary care; limited and inconsistent coding
6. Opportunities for of outpatient activity (King’s Fund, 2015), in particular coding Source: National Commissioning Data Repository
improvement: shared
decision making and for follow-up appointments and treatment (Levell et al, 2013).
self-management support
Opportunities to improve dermatology services include:
a. Self-management pharmacists and GPs with extended roles to ensure that
education and support developing clear multidisciplinary pathways and care models
patients receive the right treatment and care in the most
7. Opportunities that address patients’ physical and psychological needs
appropriate setting (Royal College of General Practitioners,
for improvement: (British Association of Dermatologists, 2014); enabling well
transforming outpatients 2018); and specialised education for both patients and GPs.
supported self-management (Association of the British
a. One stop clinic Pharmaceutical Industry, 2018); better use of teledermatology Not all of the above challenges and opportunities could be
8. Common factors (British Association of Dermatologists, 2014); a clear model tackled by teams during their 100 Day Challenge. However,
in transforming
dermatology elective care for community dermatology (British Association of input from key stakeholders shaped both the challenge
9. Key resources Dermatologists, 2013) including how best to use nurses, framework for Wave 2 and the ideas the teams have tested.
10. Case studies and further
evidence
6 Right person, right place, first time
Introduction
1. The national context and
3. The Elective Care Development Collaborative
challenges facing elective
care services in England
2. The national NHS England’s Elective Care Transformation Programme supports local health and care systems to work together to:
dermatology challenge
Better manage rising demand for elective care services.
3. The Elective Care
Development Improve patient experience and access to care.
Collaborative and a
framework for action Provide more integrated, person-centred care.
4. Overview of ideas
included in this As part of this programme, the Elective Care Development Collaborative has been established to support rapid change
handbook led by frontline teams. In Wave 2 of the Elective Care Development Collaborative, local health and care systems in
5. Opportunities Dorset, Stockport, Norfolk and Lincolnshire formed teams to develop, test and spread innovation in delivering elective
for improvement: care services in just 100 days (the 100 Day Challenge). You can find more about the methodology used here.
rethinking referrals
a. Shared learning The teams used an intervention framework to structure their ideas around three strategic themes:
opportunities and
establishing GP
champions
b. Advice and guidance
Rethinking Shared decision making and Transforming
via e-Referral Service referrals self-management support outpatients
and teledermatology
c. T
riage in the Rethinking referral An all age, whole population approach to personalised Transforming
community (spot clinics) processes to ensure care means that: outpatients means
6. Opportunities for they are as efficient and considering how patient
improvement: shared • People are supported to stay well and are enabled to
decision making and effective as possible make informed decisions and choices when their health pathways and clinic
self-management support means that from the changes. arrangements (including
a. Self-management first time a patient • People with long term physical and mental health processes) ensure that
education and support presents in primary care, patients always receive
conditions are supported to build knowledge, skills and
7. Opportunities patients should always confidence to live well. assessment, treatment
for improvement:
transforming outpatients receive the assessment, and care from the right
treatment and care they • People with complex needs are empowered to manage person, in the right
a. One stop clinic their own condition and the services they use.
8. Common factors
need from the right place, first time. This
in transforming person, in the right This should be considered at every stage of the patient may not be in secondary
dermatology elective care place, first time. pathway and can be achieved through shared decision care. Virtual clinics,
9. Key resources making, personalised care and support planning, social technological solutions
10. Case studies and further prescribing, patient choice, patient activation and personal and treatment closer to
evidence health budgets. home are all possibilities.
7 Right person, right place, first time
Introduction
1. The national context and
4. Overview of ideas included in this handbook
challenges facing elective
care services in England
2. The national Theme Intervention The opportunity
dermatology challenge
3. The Elective Care If learning and knowledge around the appropriate treatment of dermatological conditions
Development Shared learning
is shared between practitioners, then patients should receive effective treatment and
Collaborative and a opportunities
framework for action advice earlier. Primary care practitioners should build their knowledge, confidence and
and establishing GP
4. Overview of ideas expertise reducing the number of referrals into secondary care and improving the quality
champions
included in this of referrals made.
handbook
5. Opportunities If access to specialist advice and guidance is available via e-Referral Service or
for improvement: Rethinking Advice and guidance teledermatology, more patients should receive effective treatment and advice in primary
rethinking referrals
Referrals (via teledermatology care. Primary care practitioners should have improved and more responsive access to
a. Shared learning and e-Referral Service) specialist support. This should reduce the number of referrals into secondary care and
opportunities and
establishing GP improve the quality of referrals made.
champions
If triage in the community that is integrated with secondary care services is implemented,
b. Advice and guidance Triage in the
via e-Referral Service patients should be seen by an appropriate practitioner and spend less time waiting to see
community
and teledermatology them. Practitioners should see the right patients at the right time, reducing the number of
(spot clinics)
c. T
riage in the referrals into secondary care and waiting times associated with these appointments.
community (spot clinics)
6. Opportunities for If self-management resources for GPs and patients are available within primary care
improvement: shared then patients should feel more confident to manage their conditions and be more likely
decision making and
self-management support Self-management to improve their health outcomes. Practitioners’ confidence to manage patients with
Shared Decision resources dermatological conditions in the community should also improve. This should reduce the
a. Self-management
education and support Making number of referrals into primary and secondary care and increase the quality of referrals
7. Opportunities made.
for improvement:
transforming outpatients If a one stop clinic is introduced where assessment, diagnosis, and treatment take place
a. One stop clinic on the same day, then patient satisfaction should increase, waiting times for patients
8. Common factors Transforming One stop clinic referred to secondary care should decrease and the number of outpatient attendances
in transforming Outpatients should be reduced.
dermatology elective care
9. Key resources
10. Case studies and further
evidence
8 Right person, right place, first time
Introduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions
2. The national
dermatology challenge
3. The Elective Care What is this idea?
Development We know it works:
Collaborative and a Shared learning sessions and information packs on key
framework for action Since the start of the one hundred days in Norfolk:
local topics are designed and delivered for primary care
4. Overview of ideas
included in this clinicians to build their knowledge, skills and confidence. • 42 practitioners attended a continuing professional
handbook Topics may include common dermatological conditions development (CPD) shared learning event for
5. Opportunities such as actinic keratosis or new technology such as dermatology where an information pack and
for improvement:
rethinking referrals
teledermatology. These sessions and information packs treatment algorithm were launched and discussed.
a. Shared learning
can be delivered by GPs with an extended role (GPwER) 100% of attendees said that this will change the
opportunities and (Royal College of General Practitioners, 2018) or specialists way they treat patients.
establishing GP from secondary care.
champions • Attendees rated the event 8.4 out of 10 for
b. Advice and guidance GP champions are GPs with an interest in dermatology content and for how helpful it would be in their
via e-Referral Service (who may be GPwERs) and who are supported to develop day-to-day practice.
and teledermatology
their knowledge and skills to act as a local lead in • Estimated net annual cost saving for clinical
c. T
riage in the
community (spot clinics) dermatology (King’s Fund, 2015). commissioning groups (CCGs): £38,200 (at a cost
6. Opportunities for GPwERs are expected to provide support and training of £18,500 for two face-to-face events and two
improvement: shared
decision making and to other GPs and members of the primary healthcare webinars per year). This is a gross saving of £56,700
self-management support team. This process should be supported by commissioning if each ‘event attendance’ saves one referral.
a. Self-management pathways (RCGP, 2018).
education and support
7. Opportunities
for improvement:
transforming outpatients
a. One stop clinic
8. Common factors
in transforming
dermatology elective care
9. Key resources
10. Case studies and further
evidence
9 Right person, right place, first time
Introduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions
2. The national
dermatology challenge
3. The Elective Care Why implement this idea?
Development
Collaborative and a GPs receive very little undergraduate training in dermatology
framework for action
and this training is not compulsory. This means that most GPs
4. Overview of ideas
included in this are not confident in diagnosing or treating many
handbook dermatological conditions (The King’s Fund, 2014).
5. Opportunities
for improvement: If learning and knowledge around the appropriate treatment
rethinking referrals of dermatological conditions is shared between practitioners
a. Shared learning (including GPs, consultants, nurses and pharmacists) and
opportunities and
establishing GP GPwERs are utilised to their full advantage, then:
champions
• Patients should be able to access the care they need earlier
b. Advice and guidance
via e-Referral Service
and have a better experience of support to manage their
and teledermatology condition within a primary and community care setting.
c. T
riage in the • Primary care clinicians should build their knowledge,
community (spot clinics)
confidence and expertise in dermatology, meaning
6. Opportunities for
improvement: shared referrals are made into secondary care only when
decision making and necessary. Improved communication builds trust between
self-management support practitioners and improves patient management across
a. Self-management care settings. Secondary care specialists should spend more
education and support
time seeing those patients who need their expertise.
7. Opportunities
for improvement: • As clinicians in primary care become more confident and
transforming outpatients
proficient at dealing with dermatological conditions and
a. One stop clinic pathways include GPwER services, the number of
8. Common factors unnecessary referrals to secondary care should decrease
in transforming
dermatology elective care and variation in the quality of referrals and prescribing
9. Key resources should improve.
10. Case studies and further
evidence
10 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions
2. The national
dermatology challenge
3. The Elective Care How to achieve success: implementing shared learning sessions
Development
Collaborative and a The sections below include learning from sites in Wave 2 of the Elective Care Development Collaborative:
framework for action
4. Overview of ideas Get the right focus Schedule and cost events in a way that meets
included in this
handbook • Identifying a specific focus for the CPD event can be a participants’ needs
5. Opportunities useful first step towards engaging the right people and • Consider holding CPD/shared learning events on
for improvement:
rethinking referrals
recruiting GP champions. Saturday mornings. Undertake a quick local survey to
a. Shared learning • Through engaging with people from across the system, see whether more people may be able to attend outside
opportunities and you may be able to start having different conversations. of normal working hours.
establishing GP
champions • Share learning and improve the care being delivered. • Keep costs low or free for attendees wherever possible.
b. Advice and guidance • Engage and connect people from across your local
via e-Referral Service Involve people with lived experience system even before developing formal learning
and teledermatology
c. T
riage in the • Hearing from people with lived experience is a powerful opportunities. This enables different conversations and
community (spot clinics) way to influence change. It also means that the patient shared learning to develop and take place organically.
6. Opportunities for perspective is embedded into the new ways of working
improvement: shared
being developed from supporting information. Film events and gather information to share more widely
decision making and
self-management support
• Use the Primary Care Dermatology Society website and • If speakers are happy to be filmed and participants
a. Self-management
resources to help develop your local education offer. are willing to share feedback, their experiences and
education and support
perspectives can be shared online, which may reach a
7. Opportunities
for improvement: wider audience and reduce future costs.
transforming outpatients
a. One stop clinic
8. Common factors People you may wish to involve from the start:
in transforming
dermatology elective care • consultant dermatologist • GPs • nurse consultant
9. Key resources
10. Case studies and further
• GP with an extended role (GPwER) • people with lived experience • practice nurses
evidence
11 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions
2. The national
dermatology challenge
3. The Elective Care Metrics to consider for measuring success
Development The following standards and guidance may be useful:
Collaborative and a Think about how you are going to provide evidence of British Association of Dermatologists e-learning
framework for action
the impact you are having. This is not an exhaustive list.
4. Overview of ideas However, the following metrics could be used to help Guidance and competences to support the accreditation of GPs
included in this with Extended Roles (GPwER): Dermatology and Skin Surgery
handbook demonstrate impact.
(Royal College of General Practitioners, 2018)
5. Opportunities Quantitative
for improvement: Primary Care Dermatology Society: GPwER webpages
rethinking referrals • Number of GPs who have attended/accessed GP shared
a. Shared learning learning events.
opportunities and
establishing GP • Advice and guidance requests for dermatology. Resources required:
champions
• Cost savings: event cost vs. cost per referral. • A venue to hold education sessions.
b. Advice and guidance
via e-Referral Service • Number of referrals made into secondary care (two- • Information resources, including patient testimony.
and teledermatology
week wait, and standard pathway), referrals saved, and • Administrative support to promote and coordinate the event
c. T
riage in the
community (spot clinics)
associated change in waiting times. and pull together the necessary resources.
6. Opportunities for • Number of GPs recruited as champions. If planning to develop a case study video or other
improvement: shared
decision making and • Percentage of patients self-managing. video resource:
self-management support • Filming equipment and editing support.
a. Self-management Qualitative
education and support
• People with lived experience who are willing to share their experience.
• GP impact survey assessing knowledge and confidence levels.
7. Opportunities
for improvement: • GP feedback on the value of shared learning events and
transforming outpatients information resources.
a. One stop clinic
• Feedback from secondary care clinicians about the
Intended benefits:
8. Common factors • Improved access to care in primary care for patients.
in transforming
quality of referrals being made.
dermatology elective care • Feedback from primary and secondary care clinicians • Improved knowledge, confidence and expertise for primary
9. Key resources about their experience of working together throughout care clinicians.
10. Case studies and further the referral process. • Improvement in the quality of referrals made into secondary care.
evidence
• Patient feedback on outcomes and experience.
12 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions:
2. The national
dermatology challenge Norfolk case study
3. The Elective Care
Development
Collaborative and a
framework for action
The challenge – why here and why now? • Prepared talks and teaching materials in advance
including certificates of attendance and participation
4. Overview of ideas
included in this
In Norfolk, actinic keratosis is the largest source of non- questionnaire.
handbook cancer referrals to secondary care (aside from the general
• Identified patients to share their experiences as part
5. Opportunities category of ‘rash’). In north Norfolk, 8% of dermatology
for improvement: of the event, including case study examples from real
referrals were for actinic keratosis (approximately 800 per
rethinking referrals patients, either in person or using a video that patients
year). If actinic keratosis is not treated appropriately it can
a. Shared learning consented to share.
opportunities and result in cancer but overall it is a relatively low-risk
establishing GP condition, with up-to-date guidance available to follow • Publicised the event through CCG networks.
champions
lending itself to self-care (British Association of • Invited stakeholders including GPs, GP vocational
b. Advice and guidance Dermatologists, 2007). The relatively simple advice for
via e-Referral Service trainees, primary care nurses and pharmacists.
and teledermatology treatment of actinic keratosis led the team to believe that
c. T
riage in the they would be able to create significant impact on this
community (spot clinics) issue over the course of 100 days. What did people say?
6. Opportunities for
improvement: shared “[I feel] more confident in treating actinic keratosis
decision making and What was the idea?
self-management support for longer periods and providing reassurance to
a. Self-management To improve primary care practitioners’ knowledge of patients on treatment reactions.”
education and support treating actinic keratosis through a shared learning event. GP, Norfolk.
7. Opportunities
for improvement: “Gives me more confidence to recognise actinic
transforming outpatients The intervention – what did they do and how keratosis and begin treatment knowing I am not
a. One stop clinic did they do it? losing time and can still refer later.”
8. Common factors
in transforming The idea was led by a consultant and a nurse consultant. GP participant.
dermatology elective care They undertook the following: “Excellent day. I will definitely make changes to
9. Key resources
• Identified speakers (including consultants and specialist practice.”
10. Case studies and further
evidence nurse), venue, audience and date. Advanced nurse practitioner.
13 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England a. Shared learning opportunities and establishing GP champions:
2. The national
dermatology challenge Norfolk case study
3. The Elective Care
Development
Collaborative and a
framework for action
The intervention – what did they
4. Overview of ideas do and how did they do it? (continued) Headline achievements in 100 days:
included in this
handbook • Delivered the event on a Saturday to maximise Event turnout was 90% (42 attendees of 47 registered).
5. Opportunities attendance. It was free to attend and counted as two Excellent participant feedback:
for improvement: and a half hours towards continuing professional
rethinking referrals • 100% of respondents said the event will change the way they
development (CPD).
a. Shared learning treat their patients.
opportunities and • Gathered feedback from participants through
establishing GP • Attendees rated the event 8.4 out of 10 for content and for
champions a questionnaire. how helpful it would be in their day-to-day practice.
b. Advice and guidance
via e-Referral Service
Lessons learned Estimated net cost saving for CCG: £38,200 per annum, if an annual
and teledermatology • Demand for this type of event is high, which led the programme of events is rolled out. This assumes that each ‘event
c. T
riage in the team to wonder whether it could be replicated across attendance’ saves one referral. This assumes a tariff of £135 per referral,
community (spot clinics) and 420 annual event attendances (150 at each of two face-to-face
the country as a ‘GP academy’. There is potential to
6. Opportunities for events, and 60 at each of two webinars) leading to a gross saving
improvement: shared deliver some elements of the education session via a
decision making and webinar, which could help with scale and spread, of £56,700 per annum, with a cost of £18,500 for the four events.
self-management support
although feedback on the day was that participants Knowledge quiz pre-event score was 2768.39 points (n=23) for
a. Self-management
education and support
would prefer to attend face-to-face sessions. speed and correct answers and the post-score was 5537.95 (n=20).
The post-event quiz demonstrated correct answers in 97% of cases.
7. Opportunities • Holding shared learning sessions on a Saturday can
for improvement:
transforming outpatients
increase attendance.
a. One stop clinic • Considering payment structures for the sessions is
8. Common factors important when thinking about scale and sustainability. You can find further information about this work,
in transforming as well as other case studies on the Elective Care
dermatology elective care Community of Practice pages. For more information,
9. Key resources please email: england.electivecare@nhs.net
10. Case studies and further
evidence
14 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: e-Referral Service and teledermatology
2. The national
dermatology challenge
3. The Elective Care What is advice and guidance?
Development We know it works:
Collaborative and a An advice and guidance service enables one clinician
framework for action • Utilisation of the NHS e-Referral Service has steadily increased
to seek advice from another, usually a specialist. For across England from 55% in January 2017 to 73% in May 2018.
4. Overview of ideas
included in this example: this could be about a patient’s diagnosis,
handbook treatment plan and ongoing management; or it could be • Patient satisfaction with the e-Referral Service was 80% overall
for clarification of test results and referral pathways. (NHS Digital 2018).
5. Opportunities
for improvement: • 66% of calls regarding high-volume elective specialties resulted
rethinking referrals There are several methods of obtaining advice and in an unnecessary hospital visit being avoided (Consultant
a. Shared learning guidance. For example, the NHS e-Referral Service enables Connect, 2018).
opportunities and GPs to actively request advice from identified specialists.
establishing GP
GPwERs are expected to provide advice and support to • Only 29% of requests through Telederm resulted in a referral to
champions a secondary care specialist (Telederm, 2017).
b. Advice and guidance
other local practitioners to help manage conditions within
via e-Referral Service their expertise (RCGP, 2018). Teledermatology enables GPs Since the start of the one hundred days in Stockport:
and teledermatology to share an image of the affected skin area securely with • Of the 68 advice and guidance requests made via
c. T
riage in the a specialist clinician (such as a GPwER or dermatology teledermatology, 99% were responded to the same day
community (spot clinics) consultant) for advice and review.
6. Opportunities for
(compared to a three or four month waiting list for a face-to-
improvement: shared face outpatient appointment).
decision making and
self-management support
• Only 18% of the 68 requests resulted in a referral to secondary care.
a. Self-management • 12% of the requests had to be repeated due to inadequate images.
education and support
Since the start of the one hundred days in Norfolk:
7. Opportunities
for improvement: • The number of advice and guidance requests increased steadily
transforming outpatients throughout the one hundred days (from 15 per month
a. One stop clinic beforehand to 20 per month at day 100).
8. Common factors
in transforming • Throughout the one hundred days, 80% of referrals were
dermatology elective care responded to within 48 hours, meaning their target was met.
9. Key resources • Only 3% of requests resulted in a referral to secondary care.
10. Case studies and further
evidence • 78% of respondents had a high level of satisfaction with the service.
15 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: e-Referral Service and teledermatology
2. The national
dermatology challenge
3. The Elective Care Why implement this idea?
Development
Collaborative and a If quicker and increased access to specialist advice and
framework for action
guidance is introduced:
4. Overview of ideas
included in this Patients should be able to have their condition diagnosed
handbook
and treated in primary care whenever possible and should
5. Opportunities
for improvement:
be supported to manage their condition. They should
rethinking referrals receive quicker and more convenient access to specialist
a. Shared learning advice and care when necessary.
opportunities and
establishing GP Primary care clinicians should be able to manage
champions patients more effectively and avoid unnecessary referrals
b. Advice and guidance into secondary care. Where a referral does need to be
via e-Referral Service
and teledermatology
made, advice and guidance can improve the quality
c. T
riage in the
of information that accompanies the referral. This
community (spot clinics) means that specialist expertise can be directed to those
6. Opportunities for patients who need it most. Advice and guidance is a
improvement: shared great opportunity for shared learning. As practitioners’
decision making and confidence and proficiency increases, the overall number
self-management support
of referrals made may reduce, along with waiting times
a. Self-management
education and support for specialist input.
7. Opportunities
for improvement:
transforming outpatients
a. One stop clinic
8. Common factors
in transforming
dermatology elective care
9. Key resources
10. Case studies and further
evidence
16 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: e-Referral Service and teledermatology
2. The national
dermatology challenge
3. The Elective Care How to achieve success: implementing advice and guidance services
Development
Collaborative and a The sections below include learning from sites in Wave 2 of the Elective Care Development Collaborative:
framework for action
4. Overview of ideas Involve people from across the system • Install and test the chosen advice and guidance system.
included in this Ensure there are opportunities for continual feedback and
handbook • It is important to achieve buy-in across primary and
secondary care before launching the advice and refinement from users at all stages of implementation.
5. Opportunities
for improvement: guidance service. Without successful buy-in across the Promote the service to GPs and practice managers
rethinking referrals local system, the service is unlikely to be widely used.
a. Shared learning If choosing to develop an information video to promote
opportunities and Engage with consultants and invite them to join the and explain the service:
establishing GP advice and guidance rota
champions • Liaise with your local leads to offer support and advice
b. Advice and guidance • Explain the opportunity and potential benefit of joining on filming and editing.
via e-Referral Service the rota.
and teledermatology • Invite clinicians and patients to take part in the film and
c. T
riage in the • Inviting consultants to take part in a trial may be more share their positive experiences of the system.
community (spot clinics) successful initially.
• Engage the local lead to introduce and explain the
6. Opportunities for
improvement: shared Provide training in relevant equipment (e.g. intervention.
decision making and teledermatology app/e-Referral Service/dermatoscope) • Agree an approach to sharing the film and make sure
self-management support
a. Self-management
• Develop a quick reference guide for consultants and GPs that all relevant agreements and consents are in place.
education and support to refer to as they implement the service.
7. Opportunities
Agree a way of tracking the use and impact of the advice
for improvement:
transforming outpatients and guidance/teledermatology service People you may wish to involve
a. One stop clinic • Agree activity and impact metrics to demonstrate the
from the start:
8. Common factors success of the advice and guidance service against local • consultants • IT support
in transforming priorities, even in the earliest trial stages, to ensure that
dermatology elective care • GPs • app developer/
evidence is there to prove the case for sustainability.
9. Key resources
• administrative support teledermatology
10. Case studies and further • Ascertain the current baseline and ensure there are service provider
evidence processes in place to capture any necessary data as the
service develops.
17 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: e-Referral Service and teledermatology
2. The national
dermatology challenge
3. The Elective Care Start small before scaling
Development
Collaborative and a • Start small and scale up only when users are
framework for action comfortable with the system and technical glitches have
4. Overview of ideas been addressed.
included in this
handbook Don’t get held up by technical concerns
5. Opportunities
for improvement: • Starting off with a low tech advice and guidance offer
rethinking referrals such as an email or phone solution can be an easy way
a. Shared learning of generating interest and buy-in. This also provides an
opportunities and
establishing GP opportunity to better understand what people actually
champions need.
b. Advice and guidance
via e-Referral Service Make use of available resources
and teledermatology
• Consider a trial using existing resources (e.g. email or
c. T
riage in the
community (spot clinics) telephone). This can help achieve buy-in to the system
6. Opportunities for while any IT issues are overcome.
improvement: shared
decision making and
The following standards and guidance may be useful:
self-management support
NHS e-Referral Service: guidance for managing referrals
a. Self-management Resources required:
education and support Offering Advice and Guidance: Supplementary
7. Opportunities • Email address or phone number for each referrer. Guidance for CQUIN Indicator
for improvement:
transforming outpatients • Agreed advice and guidance provider. Key performance indicators are included here:
a. One stop clinic British Association of Dermatologists Quality
• Teledermatology app and training from the provider.
8. Common factors Standards for Teledermatology
in transforming • Dermatoscope (not necessarily vital at first). If this
dermatology elective care is being used as part of teledermatology, clinicians UK guidance on the use of mobile photographic
9. Key resources would need to be formally trained to use this devices in dermatology (British Teledermatology
10. Case studies and further equipment before the intervention is implemented. Society, 2017)
evidence
18 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: e-Referral Service and teledermatology
2. The national
dermatology challenge
3. The Elective Care Metrics to consider for measuring success
Development
Collaborative and a Think about how you are going to provide evidence of the impact you are having. This is not an exhaustive list.
framework for action
However, the following metrics could be used to helpdemonstrate impact.
4. Overview of ideas
included in this Quantitative Qualitative
handbook
5. Opportunities • Number of advice and guidance queries. • Feedback from GPs and secondary care clinicians on
for improvement: quality of care through surveys.
rethinking referrals • Time for response to advice and guidance queries.
a. Shared learning
• Number of teledermatology referrals rejected or • Feedback from patients on experience of advice and
opportunities and guidance.
establishing GP percentage of cases where photos sent through
champions teledermatology were of adequate quality. • Patient case studies capturing outcomes and satisfaction.
b. Advice and guidance
via e-Referral Service • Outcomes of patients referred via advice and guidance
and teledermatology (referral or no referral).
c. T
riage in the
Intended benefits:
community (spot clinics) • Number of GPs using teledermatology.
• Earlier access to specialist advice and reduced
6. Opportunities for • Number of referrals to secondary care avoided.
improvement: shared patient waiting times.
decision making and • Number of additional referrals to secondary care (local • Increase in quality of referrals to secondary care.
self-management support
definition required, but could use number of rejected
a. Self-management
referrals as a proxy). • Reduction in unnecessary referrals to secondary
education and support
care.
7. Opportunities • Number of referrals to secondary care (two week wait
for improvement:
transforming outpatients and standard pathway).
a. One stop clinic • Waiting time on standard pathway.
8. Common factors
in transforming • GP confidence to manage patients via advice and
dermatology elective care guidance time spent on advice and guidance activity
9. Key resources (primary and secondary care).
10. Case studies and further
evidence
19 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: Stockport case study
2. The national
dermatology challenge
3. The Elective Care The challenge – why here and why now?
Development
Collaborative and a
What did people say?
Under the wider ‘Stockport Together’ programme there
framework for action
is an ambition to reduce outpatient attendances by “Just brilliant. Quick advice back. Have managed to defer
4. Overview of ideas
included in this 55% to 65% over the next three years. As part of the four referrals so far from my GP practice by managing
handbook dermatology team’s work towards this, they aimed to in primary care, advice given via teledermatology”.
5. Opportunities redesign the traditional dermatology GP to hospital GP, Stockport.
for improvement:
rethinking referrals
pathway of care, where patients can wait 16 weeks to be
seen at the hospital. With five GP practices already using “It’s working really well. There are situations where
a. Shared learning I’m not sure what the diagnosis is or others where I’ve
opportunities and teledermatology, it was felt that the 100 Day Challenge
establishing GP was an ideal opportunity to roll out this platform further. tried a few treatments and it’s not working – in my
champions experience, it has stopped referrals going to
b. Advice and guidance outpatient departments, which is great for me and my
via e-Referral Service What was the idea? patients. They don’t have to wait several months for
and teledermatology
an appointment and the hassle of going to hospital.”
c. T
riage in the To expand the use of a teledermatology app from five
community (spot clinics) to ten GP practices in Stockport. The platform enables GP, Stockport.
6. Opportunities for photos to be added to referrals easily and securely. These “The teledermatology system has proved very easy
improvement: shared
decision making and referrals are then emailed to a consultant for a clinical to use and we have been able to give GPs advice,
self-management support decision, either: often avoiding hospital appointments.”
a. Self-management
education and support
• Onward referral into secondary care. Dermatologist, Stockport.
7. Opportunities • Advice and guidance. “Our GPs say that the system has altered their
for improvement:
transforming outpatients • Request for more information or an additional image. referral behaviour to secondary care services, as they
a. One stop clinic are using more in-house skills and then using this as
8. Common factors
a secondary care opinion. It’s also excellent in cases
in transforming where the patient is really suffering (with an
dermatology elective care uncomfortable rash, etc.) You can get advice within
9. Key resources hours rather than the patient waiting for weeks.”
10. Case studies and further Commissioner, Stockport.
evidence
20 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: Stockport case study
2. The national
dermatology challenge
3. The Elective Care The intervention – what did they do and how did they do it?
Development
Collaborative and a The team took a whole system approach and involved the • Tested and adapted the referral process in response
framework for action
CCG head of service reform, GP leads, service managers and to feedback from clinicians (e.g. reassessed how much
4. Overview of ideas
included in this dermatologists from Salford Royal NHS Foundation Trust detail they needed to give so advice and guidance was
handbook and a technology provider. They undertook the following: useful for GPs).
5. Opportunities
for improvement: • Ensured that the software used was clinically driven,
rethinking referrals secure and directly integrated with NHS IT systems
a. Shared learning already in place.
opportunities and
establishing GP • Built relationship with the technology provider team
champions who answered any queries relating to system issues like
b. Advice and guidance log-ins, data information, etc.
via e-Referral Service
and teledermatology • Gave demonstrations at GP practices of the
c. T
riage in the teledermatology platform and ran a short group
community (spot clinics)
training session for GPs.
6. Opportunities for
improvement: shared • Met with three dermatologists and a technology
decision making and
self-management support provider to demonstrate teledermatology and secure
a. Self-management their agreement to expand the use of the platform.
education and support
• Communicated updates with the team including when
7. Opportunities
for improvement: GP practices had ‘gone live’ with teledermatology. This
transforming outpatients ensured that dermatologists knew to expect additional
a. One stop clinic referrals.
8. Common factors
in transforming
• Filmed and shared an information video for local
dermatology elective care practitioners explaining teledermatology through
9. Key resources working with the CCG communication lead, including
10. Case studies and further filming a person with lived experience who had
evidence experienced the service.
21 Right person, right place, first timeIntroduction 5. Opportunities for improvement: rethinking referrals
1. The national context and
challenges facing elective
care services in England b. Advice and guidance: Stockport case study
2. The national
dermatology challenge
3. The Elective Care Lessons learned
Development Headline achievements in 100 days:
Collaborative and a • Starting small and upscaling in stages helps to make
framework for action
sure that users are comfortable with the system and • Expanded teledermatology to five new GP practices.
4. Overview of ideas
included in this technical glitches can be addressed before rolling out • 68 referrals made in four month period.
handbook more widely.
5. Opportunities • 18% of referrals required an outpatient appointment.
for improvement:
• Using teledermatology can encourage shared learning
rethinking referrals of specialist knowledge between GPs. When consultants • 99% of referrals were responded to in the same
a. Shared learning reply to GPs with their responses, GPs can share advice day (compared to a three or four month waiting
opportunities and and guidance with colleagues, who can then apply it to list for a face-to-face outpatient appointment).
establishing GP
champions other patients. • Good quality images provided by GPs. Only 12%
b. Advice and guidance • GPs need proper training in dermoscopy. Implementing of referrals were rejected due to inadequate
via e-Referral Service images. Three skin cancer patients were identified
and teledermatology dermatoscopes alongside teledermatology can have an
even greater impact. In Stockport, a GP picked up three via teledermatology, who were then referred and
c. T
riage in the
community (spot clinics) suspicious lesions early through using dermatoscopes treated urgently.
6. Opportunities for and getting an initial assessment via teledermatology.
improvement: shared
decision making and • Using teledermatology can improve relationships and
self-management support communication between primary and secondary care
a. Self-management You can find further information about this work,
colleagues. as well as other case studies on the Elective Care
education and support
7. Opportunities • Meeting regularly as a cross-system team helps to Community of Practice pages. For more information,
for improvement: support successful implementation of ideas. please email: england.electivecare@nhs.net
transforming outpatients
a. One stop clinic
8. Common factors
in transforming
dermatology elective care
9. Key resources
10. Case studies and further
evidence
22 Right person, right place, first timeYou can also read
