In New Zealand the number of referrals by GPs often overloads secondary or specialist care.
A lack of resources is one issue impacting on timely specialist review, including the people power for investigations such as CT scans and angiograms etc. A lack of information – due mostly to the evolution in primary practice of rapid assessment – is another issue impacting on prioritising investigations.
In practice this means it is very difficult to meet the government mandate of treating all patients with an urgent health problem within four months. Politically it is also a way of shifting the focus to the medical profession, who are deemed to be the only ones who can determine urgency.
A small country means limited public resources, and the reality that patients have to wait sometimes many months to even be investigated, let alone diagnosed. Adding to this is a growing understanding at a primary care level that listing a problem as ‘urgent’ may decrease a patient’s waiting time for specialist review – albeit the urgent referral may be based on a rapid assessment and often without adequate information to make this decision.
Knowing, or assessing, what is really truly urgent would theoretically make the system more efficient by allowing truly urgent problems to be prioritised for specialist review, and subsequently treatment, while still acknowledging the impact of limited public resources.
Pilot of free specialist review clinic
To try and address some of these issues, and to help patient’s increase their understanding of their health problems, I offered to trial a Specialist Review Clinic in the town of Whakatane.
The Specialist Review Clinic was established in a local GP practice offering free half-hour appointments to patients as part of a pilot study.
The primary objective of the pilot study was for a specialist, myself an Upper Gastrointestinal Hepatobiliary and Bariatric surgeon, to offer the local community access to a review assessment when a patient, or their GP, was concerned about the urgency of investigating their health problem and subsequently their access to treatment.
The trial clinic was offered for half a day a week and involved completely reviewing each patient case to determine urgency. The local community formed a working group and collected donations that allowed me to order privately-funded investigations – such as ultrasounds, MRIs and echocardiograms (ECGs) – if I deemed such investigations were necessary to determine the urgency of the patient’s health concern.
The secondary objectives of the trial were to see if there was a permanent community need for such a service, whether it would be supported and sustained by the community, and whether a review clinic contributed to more efficient patient treatment. These objectives were then evaluated six weeks after the month-long trial got underway. The trial was heavily promoted by one of the local radio stations and the local newspaper also ran a feature article.
Pilot a success for patients
During the trial 25 patients were seen, with four follow-up appointments. The age range was from 21 to 84 years and the ratio of male to female patients was 15:10.
Eight patients had pathology discovered because of privately-funded diagnostic investigations, resulting in an urgent referral directly to the public system. One example was a woman with low grade abdominal pain for over 12 months. Examination revealed lower abdominal tenderness and an ultrasound revealed metastatic ovarian cancer. Public chemotherapy was arranged within two weeks.
Four patients were identified with pathology which was deemed urgent and referred for specialist review. The remaining 13 patients were deemed non-urgent and not investigated privately, but a full referral was submitted electronically into the public system and to their GP.
An evaluation questionnaire indicated all twenty-five patients found the atmosphere for discussion with the specialist relaxing, information easy to understand, and all were extremely satisfied that their queries had been dealt with. In addition they reported that they had a much better understanding of their health problems. All twenty-five patients stated that they would not hesitate to recommend such a clinic to their friends.
As a result the Specialist Review Clinic was established permanently in Kawerau, an area of social and economic need. Community members created a permanent charity, the Emergency Assessment Fund (www.eaFund.org.nz) to fund private investigative tests.
After 12 months, 342 patients have been reviewed, 30 undiscovered pathologies identified, and 60 patients have had their health problems upgraded to urgent. During this 12-month period, several personal consultations were carried out and dealt with within the GP practice.
Review clinics: a model that could make a real difference?
A Specialist Review Clinic can improve patient care by establishing which cases are truly urgent, through investigation. This can lead to prioritisation of truly urgent patients. Such a clinic arguably has other specific benefits.
The medical profession is sometimes criticised for poor communication. Several studies have shown a positive correlation between effective communication and improved outcomes.
A relaxed half hour consultation with a motivated specialist has the potential to contribute to not only better informed and less anxious patients, but potentially better surgical/medical outcomes.
The Specialist Review Clinic is an innovative approach to improving patient care, which could be replicated elsewhere, it could even be centrally funded with specialist spending half a day a week in selected primary health care practices.
Specialists looking to contribute back to the community could even donate half a day. Such a development may also contribute to a reduction in the estimated 170,000 patients , who are not even on waiting lists, and reduce the waiting time from an average of 304 days for specialist review.
On a personal level, the Specialist Review Clinic, provided great mental stimulation, social interaction and a genuine feeling of meeting a community need, accepting the bias that a free consultation may have influenced the positivity of patient response.
There is also great satisfaction in having the time to give information to patients in this setting.
There are also challenges, not to be understated, in convincing the primary health care providers that this is about better patient outcomes, and not usurping their authority. That is still a work in progress – but achieving greater acceptance as the positive results of integrating primary and secondary healthcare are observed.
Paul Anderson, MBChB FRACS/FRCS (Edin) MA, PhD Dip Tch MBChB FRACS JLA MBBS is an Upper Gastrointestinal Hepatobiliary and Bariatric surgeon. He is also a lecturer at Te Whare Wānanga o Awanuiārangi’s nursing school, offers the free Specialist Review Clinic to the Eastern Bay of Plenty (www.aeFund.org.nz) and is the founding Chairman of Specialists without Borders (www.specialistswithoutborders.org).
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