Delivering improvements in diagnostic services 31st March 2010

Survive and Thrive

Direct primary care access to imaging Plain films, ultrasound, bariums CT – CT brain – All CT MRI – MRI lumbar spine

Aim of direct access Improve patient pathways Improve patient experience Enhance doctor-patient relationship Reduce whole journey waiting times

“ There is still a lingering perception among patients that their journey remains littered with barriers, pitfalls, duplication and delay”. Kerr Report, 2005

Imaging in patient journey Imaging is one part of the journey Imaging interfaces with other steps Redesigning interface processes can improve the whole patient journey

Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management

Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management

Effect of opening access Consultation in primary care Imaging arranged Primary care ongoing management

Referral should be based on clinical criteria not referral source

Process to open direct access to CT and MRI Context of formalising co-operative radiology/primary care working in 2004 Established regular radiology and primary care meetings

Radiology/primary care liaison group CHP leads, GP sub-committee secretary, GP care fellow Radiology clinical and managerial staff Developed open team culture - honest - supportive - challenging

CT brain direct access pilot Referral criteria agreed for chronic headache Educational events arranged Information packs distributed Pilot from April 2005 – April 2006

Chronic headache Commonest GP referral to neurology 4.4 consultations per 100 patients per year 18,700 headache consultations in Tayside per year

Outcome from 1 year CT brain direct access pilot 82% of practices referred 45% of individual GPs referred 215 patients had CT brain scans 1.2% referral rate from headache consultations

Questionnaires returned from 189 referrals Initial Outcome 88% of scans stopped a secondary care referral Longer term (1-2 years post-scan) 18 (8%) from 215 patients were referred to neurology

Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management

Conclusion from CT brain direct access pilot Good primary care utilisation Adherence to referral guidance Improved patient pathway 88% of scans stopped secondary care referral Adopted into routine practice in 2006

Process to open access to all CT Referral criteria agreed during 2006 Patients with a non-acute condition that CT may assist in diagnosing with CT being indicated on currently accepted Royal College of Radiologists imaging guidance

Primary care direct access to all CT Educational events arranged Information packs distributed Pilot started February 2007 First 6 months – 28 non brain referrals Adopted into routine practice in 2007

CT referrals in 2009 Total CT – 23,272 referrals GP CT – 1,375 (6%) referrals

Process to open direct access to MRI Discussions at radiology/primary care liaison group Agreed to consider MRI lumbar spine pilot Orthopaedic and neurosurgery input

Referral criteria agreed Indications Sciatica Spinal claudication Developing motor deficit – simultaneous clinical and MRI referral Exclusions acute cauda equina syndrome mechanical back pain

Implementation process Educational event, EPASS accredited Referral criteria and flowchart sent to practices Advice to radiologists on reporting format Questionnaires sent to referrer with report

Data from 6 months pilot April to September 2009 on primary care direct access to lumbar spine MRI

179 Referrals Number of GPs referring /309 GPs (35%) Number of practices referring /72 practices (82%)

Referrals by practice April – September 2009

Referrals by practice October – December 2009

Impact on MRI MRI lumbar spine referrals Year Sept-Sept Out patient MRI lumbar spine 2006/ / /

Monthly total GP/out-patient MRI lumbar spine referrals

Monthly % GP referrals of total out- patient/GP MRI referrals

MRI waits from receipt of referral to verified report April 2009 – 6 weeks October 2009 – 6 weeks

Data summary Good GP utilisation Impact on total referrals uncertain MRI waiting times unaltered

Responses to distributed questionnaires 173 questionnaires distributed 146 questionnaires returned (84%) 134 questionnaires analyzed (77%)

Did access to MRI lumbar spine stop a referral to secondary care? Yes- 46 (34%) No - 88 (66%)

Was the patient referred to secondary care after the result of the MRI was known? Yes - 68 (51%)

Was the patient referred to secondary care at the same time as the referral for the MRI? Yes - 20 (15%) Did you mention MRI in the referral letter? Yes - 20 (100%)

Was the report useful to you in managing the patient? Yes (98%) No- 2

Questionnaire summary 34% stopped a secondary care referral When patients were referred, MRI was always noted

Would secondary care have arranged an MRI on these patients? Clinical details on 134 request cards were reviewed by Mr. Eric Ballantyne, consultant neurosurgeon 125 (93%) would have had MRI 9 (7%) would not have had MRI

Patient journey Before direct access GP OPMRI OP After direct access GPMRI34% GPMRIOP66%

Patient journey times in weeks Before direct access GP OPMRI OP = 24 After direct access GPMRI 4 = 4 GPMRIOP 4 8 = 12

Outpatient clinic attendances Before direct access GP OPMRI OP After direct access GPMRI GPMRIOP 88 88

Outpatient clinic attendances Reduction in referrals equivalent to 1.5 weeks off neurosurgical departmental W/T for all new patients Reduction in reviews equivalent to 2.5 weeks off neurosurgical departmental W/T for all review patients

Whole year impact 1,400 MRI lumbar spines per year 40% (560 patients) use direct GP access Annual reduction in OP visits 750 Without direct access 1,120 With direct access 34% (190) 0 visits 68% (370) 1 visit 370

Primary care perspective General practitioners views Patient experience

Overall summary Good primary care utilisation Adherence to referral criteria essential MRI waiting times maintained 34% stopped a secondary care referral Improves patient journey - improves patient experience - shorter journey times - fewer outpatient attendances

Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management

Discussion on pilot interpretation to determine future direction GP/Radiology liaison group Diagnostics, radiology and neurosciences group Open evening meeting for GPs Adopted into routine practice in 2009

Next steps Direct primary care access to knee MRI Similar process, but add physiotherapy input Aim to commence pilot in mid-2010

Direct primary care access to imaging Improves patient experience Reduces whole journey waiting times Releases resource through reducing waste Requires to be developed in close collaboration between primary care, imaging and secondary care staff