Realising Realistic Medicine: Chief Medical Officer for Scotland annual report 2015-2016 appendix

NHS Grampian

Initial thoughts

Realistic Medicine impacts on a wide variety of work being undertaken in NHS Grampian. While much of this pre-dates Realistic Medicine it is helpful to have a context to put this work within and for the recognition and support provided by Realistic Medicine.

What have we done so far?

Major work has been undertaken in the area of ENT surgery. It was highlighted that there were concerns about the levels of ENT surgery for snoring. Other departments in Scotland were reviewed along with the literature which showed there was very little evidence for snoring surgery. Based on this alternate pathways were put in place, working closely with local GPs. Patients were still seen in clinic but offered alternatives including advice. There was a significant drop in procedure numbers with no change in patient outcomes. Guidance around tonsil surgery is now being reviewed as it was noted that NHS Grampian was an outlier in this area. A new template was put in place for referrals, based on SIGN guidelines for surgery - from then on referral letters were clearer and the route to surgery for those who needed it became streamlined. The department is now taking part in a multi-centre RCT looking at tonsillectomy.

The Grampian clinical strategy can be described as the realisation of a response to a new healthcare environment. The strategy took a collaborative approach with significant patient input.

Another important project is Early Comprehensive Geriatric Assessment: When the Geriatric Assessment Unit in the ECC opened, the model of care for frail elderly people was changed to provide same-day comprehensive geriatric assessment. The key component is early identification of frailty at the front door using a simple tool developed nationally alongside colleagues from HIS, and specialist senior medical, nursing, physiotherapy and OT input at the very earliest opportunity, even in acutely unwell patients. This provides holistic and person-centred care. Evidence has shown that this novel intervention resulted in dramatic reductions in length of stay in hospital, doubled the capacity of the department to care for frail older people (despite bed reductions), reduced the number of people needing to move to care homes and provided a better patient experience than the previous, more traditional model of care.

In the area of Diabetes, 'outreach' programme has been developed by senior clinicians from the diabetes team in Grampian and Moray. Each primary care practice has been aligned to a consultant/associate specialist in diabetes who can provide advice and support as appropriate. Regular visits are now made to primary care diabetes teams who are willing to invest time into developing joint primary and secondary care outreach. About 50% of primary care diabetes teams in Grampian and Moray now receive regular visits from the multidisciplinary diabetes team. Individual cases are also discussed and management plans reviewed in a 'virtual clinic'.

This development has enabled more complex patients to be managed in primary care minimising the number of visits to secondary care and ensuring that primary care teams are supported and adequately skilled for the delivery of care.

What next?

In the area of ENT, it has been noted that there is also conflicting evidence around the benefit for nasal septal surgery and a literature is planned to investigate this further to establish if a more patient-centred pathway could be put in place.

The projects described above continue to undergo evaluation and improvement. A further proposed project in Acute Psychology addresses Realistic Medicine with the implementation of Shared Decision Making alongside psychological assessment with some specialties. Acute Psychology will be working with ENT, cardio-thoracic and with HPB cancer surgeons to develop processes which help ensure that patients are more fully involved in decisions and unwanted elective surgery is not undertaken. In addition, psychological assessment will be provided in cases where surgeons are unsure whether psychological factors underpin patient requests for surgery and surgery may not be the best solution.

In Rheumatology, a psychologist (and assistant psychologist) have been working within the department to help reshape the patient pathway to ensure that medical consultant reviews can be most effectively employed and time is not wasted in seeing patients who require self-management or psychological support. Patients are offered psychological assessment/treatment and a self-management group will be rolled out. In addition, other resources are being developed including appropriate signposting for community interventions.

Final thoughts

Patient reported outcome measures mean having Realistic Conversations about healthcare - we need to listen to our patients in order to practice realistically.