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There is a well recognised need to shift a significant proportion of hospital-based care to the community,1 and a corresponding increase in out-of-hospital specialist presence is needed to facilitate this.2 Potentially avoidable paediatric hospital referrals indicate the need for further support for primary care health professionals,3 especially given that many have limited formal paediatric training.4
Connecting Care for Children (http://www.cc4c.imperial.nhs.uk), an integrated child health programme, brings specialist expertise and support into primary care. One component of the service is ‘open access’, which includes an email advice line for community health professionals to contact paediatricians for advice and guidance on patients presenting to primary care.
Email advice lines have been explored in other specialties, and in international rural paediatric settings.5 Paediatric email services are available elsewhere but to our knowledge, this is the first reported evaluation performed in the UK. We set out to evaluate service usage, effect on the workforce and advice outcomes.
This evaluation reviewed 451 emails sent over a 10-month period. 62.7% of emails were responded to within the target of one working day, and 80.7% within two working days. The outcome of each email was categorised independently by three reviewers with a paediatric consultant providing input where a consensus could not be reached (figure 1).
In over half of the replies the paediatricians provided advice and guidance to support the GP's management of the patient in primary care. A further 35.2% of the responses guided referral to an appropriate specialist, supporting the concept of the patient getting to see the right professional, first time; 7.2% were deemed to avert a potentially ‘unnecessary referral’ although this is likely to be a conservative estimate, as this was only counted when GPs explicitly asked if the patient should be referred. Emails were anonymised meaning it was not possible to measure further patient-level health service interactions or referrals.
A random sample of approximately 10% of service users were asked to provide feedback with a 55.0% response rate. Of the responders 81.8% agreed that the service has reduced the frequency of hospital referrals and all surveyed individuals were satisfied with the responses received.
Paediatric registrars answered the emails with consultant review before sending. Six registrars gave feedback on this experience. Five out of six responded that it took them less than 25 min/day to answer the two to three emails sent on average per day. All of these also appreciated the educational benefits of enhancing their understanding of the issues faced by their colleagues in primary care.
With regards to further development of the service, tailored educational interventions for GPs and trainees will be designed using the common queries highlighted by the evaluation. The model is also highly transferrable to other localities and specialties, being relatively cheap and easy to implement. Phone advice via a consultant-manned hotline is a further aspect of our service.6 However, email has several advantages including flexibility of time and location, ease of inputting into healthcare records and ability for the responder to easily draft, research and discuss responses before sending.
Our evaluation demonstrates the positive impact of an email advice service in supporting the management of paediatric patients in the community and empowering GPs to manage patients with more confidence, while also reducing primary care referrals. The email advice line is an effective means of signposting services and directing referrals, so that patients are more likely to be seen by the ‘right person, right place, first time.’ GPs highly valued the ease of access and efficiency of the response and it simultaneously provides a unique learning opportunity for paediatric specialist trainees.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.