code of conduct constipation clinic.doc

BRIEFING PAPER – PROPOSAL FOR ADDITIONS TO CODE OF CONDUCT 11/12

Directorate lead Sara DerbyshireFinance Lead Jason TongeVersion control Version 1Date Submitted 25/7/2011

1. Introduction

Within the Directorate of Child Health there is evidence of unrecorded activity. This means that the Trust will not be recording accurate levels of activity and will also not be receiving the appropriate income. This short briefing paper identifies one such area and sets out an options appraisal and recommendation for future practice.

The Directorate of Child Health requests that this area is submitted as part of the 2011/12 Code of Conduct discussions in order to ensure that appropriate payment is received for services delivered.

2. Background

The Paediatric Outreach service was introduced at Lancashire Teaching Hospitals in 1997 and was developed to provide medical nursing care and to support children discharged from the paediatric wards in their own homes. The team is made up of mainly senior nursing staff (band6; 1 band 7) which includes 2 specialist nurses (epilepsy and diabetes).

Over recent years, the demand for this service has increased whilst the staffing levels have remained static. In an attempt to match capacity and demand and maximise the use of staffing resources, a ‘Constipation clinic’ was set up. The constipation clinic takes place twice monthly in two different community venues (Broadoaks Child Development Centre and Brookfield health centre). Both clinics are run by 2 Sisters from the Paediatric Outreach team. The majority of children are referred to the clinic by a Paediatrician, following a referral from the GP. However there are some referrals generated from the Paediatric Assessment Unit (referred by the Paediatrician to the Outreach team). All patients remain nominally under the care of a Paediatrician and the Outreach team for extended periods for this reason, being reviewed at regular intervals as well as on an ad hoc basis (by the Outreach team, not the Paediatrician).

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3. Current Status

Currently data such as total number of patients who regularly attend the constipation clinics is not recorded. Similarly, data relating to length of time between referral from GP to Outreach review and/or Paediatrician to Outreach review is also not collated. Total length of time children remain on the clinic register is also not recorded although anecdotal evidence suggests that some children remain ‘on the books’ for years.

4. Current Workflow

OPTION 1


Child is referred by GP to Paediatric clinic. (18 week pathway rules apply).

New OP tariff received (£275 – figure supplied by PbR team).

Paediatrician refers to Outreach service. Appointment offered in next clinic; generally always appointments available therefore normally always children seen in

constipation clinic within 4 weeks.

For a small minority of children it is more appropriate for to be reviewed in the home (e.g. autistim; Aspergers;

DNA’s) therefore a home visit is arranged, normally within 1 week

Patient seen in Outreach service Constipation clinic numerous times

Not templated; Not recorded on Quadramed; No Tariff charged; no exit strategy

5. Proposed Workflow

OPTION 2

6. Financial Implications

The Trust currently funds the Outreach service in its entirety. Furthermore, the service currently does not generate any income from the services it provides. During the year 10/11 the constipation clinic saw 50 DNA’s and high numbers of cancellations ‘on the day’. This will need to be addressed in order to maximise income generation.


Child is referred by GP to Paediatric clinic.

New OP tariff received (£275)

Paediatrician refers to Outreach service using agreed criteria and referral process

Patient referral added to Quadramed clinic template in line with Trusts booking

requirements/access policy

Patient contacted and invited to attend clinic

Patient attends constipation clinic as arranged; FU OP tariff received (£117). Patient may require more than one FU appointment depending on treatment/medication advised

by Outreach nurses

Patient is discharged to the care of their GP as per exit strategy

Further intervention by Outreach would require re-referral

The table below highlights the potential income, based on 10/11 activity data. Of the total number of children seen, 185 were ‘Follow-ups’ (i.e. already seen by consultant and seen repeatedly by Outreach throughout the year) and 47 were New referrals (i.e. already seen by the consultant; first appointment with Outreach service). It should be noted that currently there is no exit strategy thus the figures may be higher if the number of new out-patient visits is increased. An exit strategy is currently being considered by the Directorate. The Directorate is committed to reducing new to follow-up ratio’s for out-patients.

Month April May June July Aug Sept Oct Nov Dec Jan Feb Mar TOTAL

No of attendances Preston

6 6 12 2 5 13 7 9 9 9 8 12 98

No of attendances Chorley

14 11 9 11 6 11 13 9 12 11 16 11 134

Potential Income

£2,340

£1,989

£2,457

£1,521

£1,287

£2,808

£2,340

£2,106

£2,457

£2,340

£2,808

£2,691

£27,144

Table 1 – 10/11 Attendance stats and potential income

7. Recommendations

Options Appraisal:

Option 1: Do nothing. The service remains unchanged and the Trust continues to fund all elements of service provision and does not generate income.

Option 2: To create a new template on Quadramed for the activity currently being carried out but not formally recorded and to commence appropriate charging for this activity.

Option 3: To disestablish the constipation clinics run by the Outreach Service whereby children would need to be referred back to their GP for further management. It is likely that this would result in an increase in referrals back to LTH for review by Paediatric consultants which would result in an increase in the number of new out-patient referrals and attendances. This option may also result in an increased waiting time for review or GP’s may choose to refer directly to the PAU instead which would impact upon urgent care activity and would be more costly to the PCT.

The preferred option from the information above would be option 2. This allows the Directorate to generate income from the activity already being carried out whilst being more cost-effective for the PCT. Furthermore, this would not result in negative impacts upon the condition or the experience of the patient and their parents/carers.

Sara DerbyshireAssociate General Manager,Child HealthJuly 2011


code of conduct constipation clinic.doc

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