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

2. 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

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 children NICE 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