6th June 2024
By Dr Alex Harborne (Clinical Director) and Clarissa Sørlie (Improvement Advisor)
When Dr Alex Harborne joined Tower Hamlets Community Health Services (CHS) as Clinical Director in 2022, she heard the same story from every team she met: a “tangible disconnect” between primary care and CHS, and a high proportion of rejected referrals. As an example, almost 40% of all GP referrals received for the continence service were rejected due to being inappropriate, leading to delays for patients in accessing appropriate services.
Figure 1. Alex Hadayah (Lead Therapist) and Dr Alex Harborne (Clinical Director)
Recognising the complexity of this challenge, Alex formed a team of staff and service users to begin to understand the problem and identify changes that could lead to an improvement. Salima Khatun, one of the service users on the project, reflected, “I found my input as a service user was valued, my voice was heard, and I felt like an important team member amongst a group of leads and clinicians. I was able to question the process and be part of finding solutions.”
Together, the team sought feedback from multiple system partners to understand the problem. They used this learning to generate change ideas and develop a driver diagram (see Figure 2) to outline their strategy for tackling this complex problem.
Figure 2. Driver diagram illustrating the team’s theory of change
After a year of testing various change ideas, the team have distilled their key learning into the mnemonic ‘A, B, C, D, E’:
To fully understand the problem, the team sought feedback from system partners in a variety of ways. For example, they shadowed GPs as they completed referrals, sent a survey to all GP practices in Tower Hamlets, attended locality and London Medical Council (LMC) meetings to discuss challenges, sought feedback via e-mail, and met with GPs who had a particular interest in technology.
Every GP practice has a telephone number for the public, and a separate bypass number for healthcare professionals such as ambulances or district nurses in a patient’s home who urgently needs medication or advice. Staff reported that they were sometimes unable to get through on the bypass line, or that there were very long waits that caused delays in patient care. The admin team called the bypass number for every surgery and recorded how long it took for the call to be answered. In the first audit, there were 14 GP practices where they either were unable to get through or waited more than 5 minutes for the line to be answered. In her role as clinical director, Alex e-mailed practice managers to inform them of the audit results and checked whether CHS held the correct number. They learned that some practices had merged or changed their number, and others were experiencing telephony problems. The team repeated this audit every 3 months and when most recently tested, every number was answered within seconds. Now they keep an up-to-date list of bypass numbers on MS Teams, and staff can access a copy on their phones when they go on visits. The team continue to audit the bypass numbers every 6 months, and with 33 GP practices, this takes less than an hour.
From the outset, Alex prioritised attendance at any meetings where GPs would be present. She gave several presentations about the purpose of the QI project and the problems they were experiencing. Through these meetings, Alex met likeminded people in the system who also experienced a sense of disconnect. Together, they started a small monthly meeting with five representatives from primary care, Barts Health, GP Care Group and CHS. The group have met for half an hour every month for two years, and value the informal space to share blockages in communication and work together to find solutions. Reflecting on the meetings, Alex said, “It’s a good place to go when you don’t know who to approach about an issue. We all know our own systems, so we can solve problems for each other.”
The team tested several change ideas related to digital solutions. These involved updating service information on the ELFT website, making changes to the electronic referral form, and recording a podcast about their services.
When they reviewed the ‘I’m a GP in Tower Hamlets’ ELFT website, the team discovered that the limited information available was out-of-date, and referral criteria were not clear. They developed a process for updating and monitoring the website (see Figure 3) and have seen a sustained increase in average monthly views from 50 to 235 on their webpage (see Figure 4), which gives them confidence that GPs are regularly referring to this resource.
After identifying that important information was missing from GP referrals, the team made changes to the referral template and added a direct link to referral criteria on the updated ELFT webpage. The template was tested on a small scale, with twice-weekly huddles and online feedback forms, before the improved template was implemented. A ‘Control Group’ representing all partners has been formed to oversee future template changes and to continue to monitor functionality.
Finally, the team have recorded short podcasts for GPs, with a focus on different CHS services and which patients would benefit most from a referral. Each podcast features interviews with colleagues and patients, offering insightful tips for GPs. Dr Roberto Tamsanguan, a GP interviewed on the podcast, said: “So great to spend time learning about the amazing teams supporting patients!”, and Dr Claire Davies, also a GP, reflected, “I learned so much from Chinny [continence lead] and came away actually INSPIRED by continence. Just feel so enthused!”
In addition to connectivity meetings, Alex has prioritised attendance at place-based events to engage with primary care and system partners. Through her work on this project, Alex has forged stronger relationships with neighbourhood and locality work led by the Integrated Care Board.
Alex recently co-led a GP learning event with her ICB colleagues at the Town Hall sharing the QI work and thinking together about integrated neighbourhood teams.
Alex also led ELFT first ever learning event for GPs in October 2023. GPs were invited to ‘Reconnect’ with the frontline staff in attendance, learning who they are and what they do, ‘Rediscover’ CHS services, and learn how the QI project team are ‘Reforming’ the referral process.
Figure 3. High-level flow chart for improving ‘I am a GP’ webpage [Click here for the PDF version]
Figure 4. Control Chart showing a sustained increase in webpage views
The relationship building that has taken place as part of this project has created a firm foundation for further improvement work. For example, the electronic referrals working group are now turned their attention to how to learn from patient safety incidents across Barts Health, CHS, North East London Integrated Care Board and primary care to improve patient care in Tower Hamlets. They are testing a new process for sharing learning from incidents, and their work is being presented at the Patient Safety Forum. Reflecting on this outcome, Alex said: “To build a culture of learning, people need to trust you to know that you aren’t blaming them. Now that we’ve forged relationships through the GP Communications project, we’re in a position to build clarity of process, a place to connect, and ultimately change the safety culture between primary care and CHS”.
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