Retaining dermatology patients in primary care using dialogues with secondary care: A service evaluation (preprint)

Summary Background Wait list sizes for specialist secondary care have soared in recent years. Dermatology is a good candidate service for retaining patients in primary care and avoiding unnecessary waits to see a specialist. A dermatology dialogue service between primary and secondary care (DDPS) was developed in Norfolk and Waveney, eastern England. The service involved primary care referrers uploading patient images of skin complaints for review by and dialogue with secondary specialists to see if the patient could be retained in primary care, or should be referred to secondary care routinely, urgently or on the two week wait cancer pathway. Objectives To evaluate service performance with respect to specific targets including reduction in secondary care wait list growth in the period March 2021-March 2022 inclusive. Methods Service activity was summarized with respect to speed of resolution, case counts and dispositions. Clinician and patient satisfaction were canvased with structured questionnaires. Actual new referral counts were compared to projections based on historical data. Wait list growth was compared to other specialisms and other areas. Wait times to receive first treatment at start and end of monitoring period were monitored. Results Over 3600 patients were enrolled in the DDPS system. Over 98% of cases were reported by the dermatologists within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Wait list growth to see dermatology in the commissioning area was smaller for dermatology than other large specialisms, and mostly smaller growth than dermatology wait lists commissioned by other NHS commissioners. Negative impact on the urgent priority (cancer pathway) wait list could not be observed. Conclusions The DDPS was satisfactory to clinicians and patients and coincided with smaller dermatology wait list growth than might otherwise have been expected.

Feasibility and evaluation of an emergency department-based GP streaming and treatment service (preprint)

BACKGROUND Emergency departments (EDs) are under ever-increasing pressure. The General Practitioner Streaming and Treatment (GPST) service implemented at a large ED in England UK aimed to identify and treat patients who attended an ED but who might effectively be managed in primary care to reduce pressure on ED services. METHODS Patients attending ED were met by a GP nurse practitioner who ‘streamed’ them to the GPST service or usual ED care. Routinely collected electronic records, satisfaction questionnaires and interviews were used to evaluate patient outcomes, staff experiences, service outcomes and impacts on usual ED services. RESULTS Approximately 96% of GPST patients were seen by a clinician within one hour and all within 87 minutes. Routinely collected ED datasets indicate statistically significant reductions in patients streamed to usual ED care who had to wait > 4 hours for disposition (p=<0.005). Of 769 patients with GPST consultation (approximately 10% of all walk-in patients) 421 (55%) needed no further intervention by ED. The speed at which GPST patients were managed exceeded patients’ expectations and was a major determinant of their satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in patient eligibility criteria and built environment design features. CONCLUSIONS Concurrent provision of GPST correlated with shorter waits for ED attenders to receive health care. Patient and staff experiences of GPST were positive. A robust assessment of safety and health economic outcomes would be useful to refine eligibility criteria and cost effectiveness.

Testing for SARS-CoV-2 in care home staff and residents in English care homes: A service evaluation (preprint)

Background COVID-19 has especially affected care home residents. Aim To evaluate a nurse-led Enhanced Care Home Team (ECHT) enhanced SARS-CoV-2 testing strategy. Design and setting Service evaluation in care homes in Norfolk UK. Method Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0-14 after test and mortality to 13 July 2020. Results Residents (n=518) in 44 homes and staff (n=340) in 10 care homes were tested. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in seven homes. Of 103 SARS-CoV-2+ residents, just 38 had typical symptom(s) at time of test (new cough and/or fever). Amongst 54 residents who were completely asymptomatic when tested, 12 (22%) developed symptoms within 14 days. Compared to SARS-CoV-2 negative residents, SARS-CoV-2+ residents were more likely to exhibit typical symptoms (new cough (n=26, p=0.001); fever (n=24, p=<0.001)) or as generally-unwell (n=18, p=0.001). Of 38 resident deaths, 21 (55%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One death not initially attributed to SARS-CoV-2 also tested positive. Conclusion Testing identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being generally-unwell was common amongst symptomatic residents and may indicate SARS-CoV-2 infection in older people in the absence of more typical symptoms. Where a resident appears generally unwell SARS-CoV-2-infection should be suspected. Protocols for testing involved integrated health and social care teams.