general paediatric service: future developments

General Paediatric

Service: Future Developments

Dr Gary Ruiz9 January 2008

Government policies• 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

Strategy for Child Health1. Provide more

focused, efficient & effective general services

2. Develop our specialist services

3. Radically improve our shared services

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.”

Appropriateness of hospital care

• General Paediatric Outpatient Clinic

• Acute Paediatric Ward

Audit of General Paediatric Clinic referrals

• 92 referral letters of children attending 6 KCH clinics in November 2005

• Categorized to:1. “Must see”2. Potential to be seen in community or primary

care (if facilities / expertise existed)3. Potential to be dealt with by telephone4. Inappropriate for General Paediatric Clinic

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

Breakdown of “must sees”

12

5

2

84

5

15

n = 51

Urology

Growth

Lymphadenopathy

G.I.

Abdo pain

Neurol.

Misc.

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

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)

Necessity for in-patient treatment• Pressure on

hospital beds / Emergency targets

• Facilitating early discharge: Nurse-led home care

• Avoiding need for admission: ambulatory facility

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

Home investigation / monitoring

• Overnight oxygen saturation

• 24 hour oesophageal pH

• Blood pressure• Urinanalysis• Capillary glucose

Electronic patient records• All pathology

results, clinic records held on EPR

• Obstacles to giving access to primary care:– Security/

confidentiality– Accountability

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