Harrow community outpatient services (review and next steps)

Following the reviews and public feedback we now plan to take forward the following changes:
 

Patients who have already been referred to the community services will be seen in the same location or contacted if their appointment location needs to change.

Children’s

We will change the current children’s community outpatient service and use existing primary and secondary care services to see these patients, these are our reasons:

• Most children (60%) can be seen faster by their GP with advice and guidance from a specialist. This means children will get help within one to two weeks at their own GP practice, rather than waiting up to and over 18 weeks in the community service.
• For children who need hospital help, it would be faster to refer them directly to the hospital and wait for one appointment rather than two.
• There would also be one pathway for referrals for all Harrow GPs, ensuring equity across the borough and one simple referral route for all GPs.

Ear, nose and throat

We will further explore developing a new ear, nose and throat services across NW London. This would be with a view to engage and develop a service that works for residents and builds on learning from the current community services.

• There is a need to provide community support for ear, nose and throat patients as waiting times in secondary care are significant. This is not just a problem in Harrow, but across NW London.
• Community provision will still be available to patients in Harrow while work on a NW London model is undertaken.

Gastroenterology

We will change the current community gastroenterology service and use existing primary and secondary care services to see these patients, these are our reasons:

• The waiting times and clinical support for patients from hospital gastroenterology services are good.
• Small numbers of patients would be added to the current hospital waiting list around 400 a year. – we may not be transferring the waiting list so not sure of the value or accuracy of this?

• More patients could be seen by their GP usually within a week or two, with the use of **advice and guidance, meaning more patients will receive faster treatment (with one to two weeks) and have fewer onward referrals.
• The current service also exacerbates inequalities for patients in the Northwick Park Hospital catchment area, as not all GPs refer into the community service.
• A single referral route for GPs that ensures patients are triaged by a consultant for advice and guidance or directly books them in for a hospital appointment, will provide a better experience for patients, in terms of less appointments to get the help they need.

Headache/neurology

We will change the current community headache/neurology service and use existing primary and secondary care services to see these patients, these are our reasons:

• North West London GP guidelines have been published for managing headaches, supported by the advice and guidance service which responds to GP requests within a short period.
• Advice and guidance is available from our hospital teams, and where a referral is needed this will be through our existing hospital neurology services.
• For the majority of patients they will only have one appointment, with their GP with support from advice and guidance in the community.
• For patients that need hospital support they are referred directly.
• This change will bring the service in Harrow in-line with all other NW London boroughs.

** The advice and guidance service links GPs with specialist hospital clinicians (across NW London) who can provide them with advice and guidance on next steps for treatment and medication, to help support the patient with-in the practice. Meaning the patient does not need to wait to be seen in hospital. This service is continuingly being improved and was not in place when the community outpatient services were established, patient usually receive advice within 3-10 days.

For this engagement we have reached out to Harrow residents and service users through local authority, voluntary sector and NHS channels – including social media, public meetings and a range of community bulletins. This took place from 9 May to 20 June.

The full list of our outreach activities can be found the table below.

Feedback

Feedback from residents and service users has showed that on the whole patients are happy to be seen in community services for convenience, as long as the referral and waiting times are not too long and they are seen by a trained clinical specialist. Where improvements in waiting times can be made, this would be welcomed.

Another theme that has been fed back, is that patients had not realised there were separate community services and that it is for their GP to refer them onto a clinically appropriate professional. Communication about who and where they are seen for onward care is important.

No preference was given as to how we provide community services in the future, as long as local services are available.

Some of the service user comments recieved:

• “I agree with the idea of having a layer between hospital and GP in order to reduce the load on hospitals.”

• “It will be good if patient is seen within 10 weeks after first appointment.”
   
• “The ENT clinic in Alexandra Avenue is more convenient than waiting in the hospital and also much more pleasant experience.”
   
• "The referral system between the GP practice & clinics need to be improved for a quicker seamless transition.”
   
• It needs to be explained if you are going to be seen in a community service. It’s confusing if not explained properly.
   
• It’s for my GP to decide where I go – not for me to decide – just need to get to the right specialist doctor.”
   
• “I would prefer to be seen and have advice from hospital doctor as they are more trained.”

•  “This has been a very good service and again cut down my waiting time and much more convenient to get too, less money paid in car parks and a much more pleasant experience.”
   
• “It is essential that these services continue in the community with more new and different services added I would hope. It clearly relieves the pressure on the hospitals, so it's better all round. As long as qualified doctors and specialists are available at the community hubs then the service is good."
   
• "It takes days and months to get referred to this service. perhaps the number of clinicians and doctors can be increased to reduce the time lag.”

We also have feedback from 199 service users gathered through a survey in February. This tells us:

• More than 80% of service users said the community service has
  helped them manage their health needs.
• More than 65% liked the service due ease of getting there, being close to home/not in hospital.
• Keeping these services local is important, with 86% of patients happy to be seen in their GP practice or in one of the current primary care premises in use.
• 55% drive to their appointment, 28% walk and 14% travel
  by bus.
• The facilities were rated as good.

Channels used to reach Harrow residents to gather feedback May/June 2023:

February survey

Feedback on the services was gathered through the following channels over four weeks in February 2023. In total 199 responses were submitted to our survey - results above.

In Harrow a range of outpatient services are currently being provided in the community through a contract with Harrow Health Community Interest Company (HHCIC). These are in addition to the hospital outpatient services provided for the same needs.

This contract has been in place for ten years and its latest extension is coming to an end on 30 September 2023.

Four services have been individually reviewed by clinicians, that are solely provided in Harrow through this contract.
*There are also three other services that are currently being engaged on as part of other wider NW London reviews.

• Community neurology
• Community gastroenterology     
• Community children’s out-patients (paediatrics)
• Community ear, nose and throat (ENT)  (details for each service are in the boxes below)

(*Ophthalmology, Musculoskeletal and ADHD services are being reviewed separately across NW London.)

The services are mainly provided out of:

• The Pinn Medical Centre
• Alexandra Health and Social Care Centre

A few clinics are provided at Stanmore Medical Centre and Belmont Health Centre and some clinics are also held in other GP practices, depending on space/location needs.

Patient feedback on current community services

In February we asked service users about the current community service they attend.
Overarching feedback (provided through 199 survey responses) from service users for these four services tells us:

• More than 80% of service users said the community service has helped them manage their health needs.
• More than 65% liked the service due ease of getting there, being close to home/not in hospital.
• Keeping these services local is important, with 86% of patients happy to be seen in their GP practice or in one of the current primary care premises in use.
• 55% drive to their appointment, 28% walk and 14% travel by bus.
• The facilities were rated as good.

The service reviews

Reviews of each of the four services have been completed by a clinical lead and the data team.

A key priority in each of these service reviews is to ensure that all patients/residents in Harrow have equitable provision and access to these services - no matter where they live in the borough, or which GP practice they are registered with.

Other key elements of the reviews include:

• Review of referral data and clinical information
• Access/GPs referral routes
• Patient feedback on the current service
• Waiting times, compared to the same service provided local hospitals
• The patient journey (unnecessary appointments)
• Quality and value 

Based on these reviews, this paper shares our initial thoughts (that we would like to talk to Harrow residents about) on how we would like provide these services in future, to provide the best outcomes and waiting times for patients in Harrow.

We will be talking to Harrow residents throughout May and June to gather feedback on how we provide these services going forward.

This work will be in conjunction with working through and complying to outcomes of equality impact assessments for each service.

More information for each service and how you can share your views can be found in the drop down boxes below.

An update on our engagement and the feedback we have recieved so far (10 June) has been shared with Harrow Council's Health Sub Committe. You can read the update here.

Feedback closed on: 20 June 2023.

The service currently sees around 600 patients a year and is run by a GP with specialist expertise (GPwSI) in headaches.

The service was set up to reduce outpatient appointments and waiting times to neurology for adults with headaches.

The service helps patients with migraines, headaches and pain medication management.

Referral route

Patients currently enter this outpatient service through a referral from their GP, following an initial GP appointment. (Note - not all GPs in Harrow refer into the service, as it is one of two referral pathways available, some GPs will refer patients directly to hospital.)

The referral is then triaged by the GPwSI in the community headache clinic and one of three outcomes occurs: The referral is:

• accepted by the community service and the patient is seen, treated and discharged.
• reviewed and fast tracked on to a hospital service to be seen by neurologist.
• seen and sent on to a hospital service following the first assessment, re-joining the hospital waiting list.

Service data

Out of the 600 patient referrals sent to the service in 21/22:

• 47 patients (7.9%) were directly referred to hospital by the community service.
• 548 patient referrals (91.6%) were accepted to be seen in the community service.
• After first assessment in the community service 11 further patients were referred to be seen in hospital.
• Less than 5 (0.5%) referrals were rejected, rejections are for the wrong service or incorrect referral.
• 80% of patients are seen once in the clinic and get the help they need. Just 20% have more than one appointment.
   

Waiting times

• The waiting time for the current community neurology (Headache clinic) is
  10 weeks.
• The current waiting time to be seen for routine headache appointment in hospital is around 26 weeks.
   

Future scenario to further explore and engage service users

We want to hear from service users and residents on how this service should be provided in future. 

Our initial thoughts are that we would like to continue to provide a community headache clinic in Harrow, for the following reasons:

• The waiting times and clinical support for patients from this type of service are good, with few onward referrals to hospital and faster treatment.
• For the majority of patients this means they only have one appointment in the community and get the help and support they need.
• Expertise in the community clinic can be used to avoid hospital referrals, and treat patients with medications which cannot always be started by their GP.

We would like to hear the public’s views on this scenario going forward.

What do you think?

• Share your thoughts by emailing: nhsnwl.healthiernwl@nhs.net 
• Fill in our feedback form

• Feedback closes on 20 June 2023

The service currently sees around 600 patients a year.

The service has eight sessions a month, four run by two GPs with a specialist expertise in gastroenterology and four by a consultant gastroenterologist for four sessions.

The service was set up to increase the number of patients (who can safely) be seen and treated within the community.

Symptoms/conditions the current service helps with:

Some liver and gastro problems, (without urgent specialist need) for example:

• Abdominal pain
• Food intolerance, Coeliac disease
• Rectal bleeding
• Reflux
• Irritable bowel syndrome (IBS), constipation and diarrhoea

Referral route

Patients currently enter this outpatient service through a referral from their GP, following an initial GP appointment. (Note - not all GPs in Harrow refer into the service, as it is one of two referral pathways available, some GPs will refer patients directly to hospital.)

The referral is then triaged by the community gastroenterology team and one of three outcomes occurs: The referral is:

• reviewed and returned to the GP with advice. 
• accepted by the community service and the patient is booked into be seen.
• reviewed and referred to hospital to be seen by gastroenterologist in hospital.

Service data

Out of the 600 patient referrals sent to the service in 21/22:

• All 600 patient referrals were accepted to be seen in the community service.
• 474 patients (79%) were offered a first appointment in the community clinic.
• 120 patients (20%) were referred directly to secondary care (hospital).
   
  • Of the patients referred on again to wait to be seen in hospital - specialist consultants reviewed these cases and advised that 36 patients (30%) could have been seen directly by their GP with advice and guidance, without the need to see the patient in hospital. This generates an assumption that more patients seen by the community service could be been seen faster by their own GP with advice and guidance from a hospital specialist.
     
• The low number of patient referrals triaged and returned to the GP with advice or rejection (1%) suggests limited triage of referrals when received by the community service.

Waiting times

• On average patients are being seen within 10 weeks of for the community outpatient service.
• The average waiting time for a first appointment in hospital is 16 weeks.
• Evidence suggests that around 200 patients (30%) of these patients waiting for 10 weeks or more to be seen either in the community clinic or hospital could get help/treatment within a week or two using advice and guidance to their GP.

Future scenario to further explore and engage service users

We want to hear from service users and residents on how this service should be provided in future. 

Our initial thoughts going forward are that we would like to explore using existing GP practice and hospital services/staff to see these patients, these are our reasons:

• The waiting times and clinical support for patients from hospital gastroenterology services are good.
   
• Small numbers of patients would be added to the current hospital waiting list around 400 a year.
   
• More patients could be seen by their GP within a week or two, with the use of **advice and guidance, meaning more patients will receive faster treatment and have fewer onward referrals.
   
• The current service also exacerbates inequalities for patients in the Northwick Park Hospital catchment area, as not all GPs refer into the community service.
   
• A single referral route for GPs that ensures patients are triaged by a consultant for advice and guidance or directly books them in for a hospital appointment, will provide a better experience for patients, in terms of less appointments to get the help they need.

** The advice and guidance service links GPs with specialist hospital clinicians (across NW London) who can provide them with advice and guidance on next steps for treatment and medication, to help support the patient with-in the practice. Meaning the patient does not need to wait to be seen in hospital. This service is continuingly being improved and was not in place when the community outpatient services were set-up.

We would like to hear the public’s views on this scenario going forward.

• What do you think?
• Share your thoughts by emailing: nhsnwl.healthiernwl@nhs.net
• Fill in our feedback form

• Feedback closes on 20 June 2023

The community service receives 2400 referrals for children a year.

The service is run by GPs with a specialist expertise (GPwSI) in pediatrics, supported by a consultant.

The service was set up to provide support and treatment for children with low level and routine conditions, without families needing to go to hospital for an outpatient appointment.

Symptoms/conditions the current service helps with for children include:

• Breathing problems including asthma
• Rashes, eczema
• Abdominal pain, reflux, diarrhoea, constipation, food intolerance
• Headaches
• Flat feet and gait problems
• Babies feeding problems and support for parents
   

Referral route

Children currently enter this outpatient service through a referral from their GP, following an initial GP appointment. (Note - not all GPs in Harrow refer into the service, as it is one of two referral pathways available, some GPs will refer patients directly to hospital.)

The referral is then triaged by the children’s community outpatient service and one of three outcomes occurs: The referral is:

• sent on to hospital if the child’s need is more than the service can support.
• referred back to the GP if support is not required or advice can be given.
• accepted by the community service and the child is seen.

Clinical audit/review

An independent clinician has reviewed a random sample of patients seen at their first appointment through the current outpatient service.

98 patient cases were looked at (10%) for children’s first community outpatient appointments in 2021/22.

• The data for these 98 children shows that 59 of the 98 children (60%) could have been treated by their GP, with advice and guidance, without needing to refer the child to any other service. Saving the child an additional onward referral and second appointment.
   
• The remaining 39 children could have been referred directly onto a specialist children’s/hospital service and not seen in the community outpatient clinic.
   
• Further analysis of all the 2400 children referred to the children’s outpatient service showed that 576 children (24%) were referred onto a hospital service after a first appointment with the community.
   

This means that these children had two appointments before seeing to a specialist. Waiting up to 18 weeks for each appointment, before getting treatment.

Waiting times

• The community service currently sees 52% of children within 18 weeks.
• The hospital sees 86% of within 18 weeks.

Future scenario to further explore and engage service users

We want to hear from service users and residents on how this service should be provided in future. 

Our initial thoughts going forward are that we would like to explore using existing GP practice and hospital services/staff to see these patients, these are our reasons:

• Most children (60%) can be seen faster by their GP with **advice and guidance from a specialist. This means children will get help within one to two weeks at their own GP practice, rather than waiting up to and over 18 weeks in the community service.
   
• For children who need hospital help, it would be faster to refer them directly to the hospital and wait for one appointment rather than two.
   
• There would also be one pathway for referrals for all Harrow GPs, ensuring equity across the borough and one simple referral route for all GPs.
   

** The advice and guidance service links GPs with specialist hospital clinicians (across NW London) who can provide them with advice and guidance on next steps for treatment and medication, to help support the patient with-in the practice. Meaning the patient does not need to wait to be seen in hospital. This service is continuingly being improved and was not in place when the community outpatient services were set-up

We would like to hear the public’s views on this scenario going forward.

• What do you think?
• Share your thoughts by emailing:nhsnwl.healthiernwl@nhs.net
• Fill in our feedback form

• Feedback closes on 20 June 2023

The service currently sees around 2900 patients a year.

It is a consultant led community ENT service for adults over 18 years old.

The service was set up to treat more patients in the community and reduce referrals to hospital.
 

Symptoms/conditions the current service helps with:

• Obstructions
• Dizziness
• Nose problems including obstruction
• Tonsillitis, sore throat, hoarseness
• Neck swelling
• Other non-urgent ear, nose and throat conditions

Referral route

Patients currently enter this outpatient service through a referral from their GP, following an initial GP appointment. (Note - not all GPs in Harrow refer into the service, as it is one of two referral pathways available, some GPs will refer patients directly to hospital.)

The referral is then triaged by the community ENT team and one of three outcomes occurs: The referral is:

• reviewed and returned to the GP with advice and guidance.
• accepted by the community service and the patient is booked into be seen.
• reviewed and referred to hospital to be seen by ENT specialist in hospital.

Service data

Out of the 2900 patient referrals sent to the service in 21/22:

• 2871 of the patient referrals (99%) to the service were accepted.
• 2610 patients (90%) were offered a first appointment and seen.
• 260 patients (9%) were referred directly to secondary care (hospital).

Waiting times

• Most patients (92%) are seen within 10 weeks in the community outpatient service.
   
• The average waiting time for a first appointment at hospital is 27 weeks, with >2000 patients currently waiting more than 41-52 weeks.

Future scenario to further explore and engage service users

We want to hear from service users and residents on how this service should be provided in future. 

There is a need to provide community support for ear, nose and throat patients as waiting times in secondary care are significant. This is not just a problem in Harrow, but across NW London.

At this point in time, we would like to further explore developing a new ear, nose and throat services across NW London. This would be with a view to engage and develop a service that works for residents and builds on learning from the current community services.

Developing a sector wide service would provide equity in access for all residents and allow us to utilise specialist support from all our hospitals in building and designing something new.

We would like to hear the public’s views on this scenario going forward.

• What do you think?
• Share your thoughts by emailing: nhsnwl.healthiernwl@nhs.net
• Fill in our feedback form

• Feedback closes on 20 June 2023