For a recent HTN Now webinar, we welcomed Rebecca Coughlan, therapy manager of outpatient services at Barking, Havering and Redbridge University Hospitals NHS Trust (BHR), to present how the North East London Musculoskeletal Alliance has improved the quality of referrals and significantly reduced waiting times using integrated referral management platform NEC Rego.
Background to Rego implementation at BHR
Rebecca started out by providing some background on musculoskeletal services at BHR, outlining the need for a solution such as Rego to help manage referrals and waiting times at the trust.
“For the last four or five years NHS teams in North East London, consisting of GPs, physios and secondary care consultants, have been working to improve care for patients with MSK conditions,” she said. “It started with implementing an MSK pathway for patients who were referred by their GP into our secondary care services – physiotherapy, rheumatology, pain management, neurosurgery and orthopaedics. In April 2022, these referrals began being received into our single point of access. When they came into the single point of access, they were triaged, and then they were directed to the correct services that would be able to meet the clinical needs of these patients.”
The trust covers a population of around 750,000, with patients served by 116 GPs, and annually, GPs will refer around 50,000 patients a year for MSK-related conditions.
“We found when we introduced our single point of access that we had a number of issues with the referrals that were coming in, including a lot of quality and safety issues,” Rebecca shared. “We were having to reject a lot of referrals because they were illegible, because we didn’t have enough information to be able to triage. For example, we didn’t have investigation results like results of MRI scans or X-rays, and quite often patients were referred for non-MSK conditions.
“This led to lots of inefficiency within the service – we calculated we were losing about eight hours a week of admin and clinical time within the triaging team, because of missing information within our referrals, and because we were having to send them back and then we were chasing GPs to try and get the correct information. Obviously this also posed problems for our primary care colleagues, because they were then having to resubmit these referrals. Patients were then delayed because of their referrals bouncing backwards and forwards between primary care and triage.”
The journey through Rego implementation
Rebecca took us through how the trust’s journey with Rego began.
“Back in November 2020, our then therapy manager won a scholarship on to the Digital Health London Pioneer Fellowship. Her project was to digitise the referrals coming in from primary care into our single point of access. She went through months of product reviews and requirements, had a business case approved in September 2021, and then Rego was procured at the end of 2021, which is when I joined the team.
“We began to set up review groups, consisting of consultants, physios, primary care colleagues, as well as the team from NEC Rego, to start designing the clinical algorithms and the clinical pathways that would eventually sit behind Rego to allow for these referrals to come into the single point of access.”
They went live in July 2022, Rebecca explained, and then had a period of time where they would accept a hybrid of Rego referrals and old paper-based referrals. However, from October 2022, Rego has been mandated for all referrals coming into the single point of access. To date, the trust has received over 40,000 referrals via Rego into the single point of access for triaging.
Before Rego, about 25 percent of referrals were being rejected, Rebecca noted, and patients were being referred to the wrong service for treatment. “It was taking us two minutes on average to process a referral, as we’d have to click in and out of multiple attachments to figure out the correct service for the patient, which meant there were long delays in triaging. Our primary care colleagues would take about five minutes to process a referral, which is a lot of clinical time. We found referrals would often be batched, so they weren’t being sent off straight away, which meant even longer delays.”
Benefits and learnings from Rego implementation
“Rego has definitely changed the way in which we can triage referrals, and how quickly we can triage referrals,” she said. “We now only have to reject about two percent of referrals, so it’s quite a significant reduction. Time to process referrals has decreased by 50 percent, because Rego integrates with our patient administration systems to allow GPs to automatically upload investigation results for their patient, which means that it all comes through in one PDF, so we can review everything all in one attachment. It’s much easier for us to be able to see, from a triaging perspective, what the patient has been referred for and what service the patient should be referred into.
“Referrals are now triaged within one day of receipt, so we’re able to signpost patients to the correct service much more quickly to get their treatment started. From a GP perspective, it’s now only taking them 100 seconds to be able to complete a referral, since Rego integrates with their patient administration systems and pulls across patient information; so it’s not having to be filled in by a person, it’s already all on the form, and they can upload their imaging results straight into Rego. Rego selects the correct service for the patient via ERS, so the GP just has to press ‘submit’, and it will send the referral straight through to the triaging service.”
Rebecca shared that the trust is on target to save around 3000 hours of GP or first contact practitioner time every year – the equivalent of putting one GP back into the system. “We’ve had great feedback from our FCP colleagues, who are finding it much more simple and straightforward to use,” she said, “and it’s aiding them with the decision making process.”
With regards to waiting lists, one aim was to help reduce the discharge to refer at first appointment, along with consultant to consultant referrals. “For our orthopaedic cohort of patients, discharge to refer at first appointments has decreased from 20 percent to 14 percent, which means that the patients are getting to the right service the first time,” Rebecca said. “On consultant to consultant referrals, our aim was to reduce this from 17 percent to 10 percent – we actually achieved a decrease to eight percent, so we’ve already gone above where we were aiming to with the implementation of Rego. That’s without having Rego mandated for every service and GPs still having direct access to these services.”
Neurosurgery colleagues are still tackling their COVID backlog, but even there Rebecca highlighted that the trust is finding that consultant to consultant referrals have reduced with the implementation of Rego. “If patients are referred by Rego, only eight percent of them are sent back to referral at first appointment, versus 21 percent for patients who aren’t coming in via Rego. That tells us it’s doing a good job of signposting these patients to the correct service the first time.”
In terms of financial recovery, the trust’s hope is that as their waiting list decreases, this could lead to a shift of private sector activity back to NHS services. “We’re hoping that this will then lead to a saving of £3 million over the next three years,” Rebecca shared.
“On collaborative innovation – how we’re working better with our colleagues across the MSK pathway – this really has been a collaboration across all parts of our system for our patients. We’re incorporating our community services, our GP colleagues and our secondary care colleagues both have oversight of our pathways and overall clinical algorithms, and everybody does have the voice to be able to make changes. We’re in discussions with other specialties about introducing Rego for them, as we’re hoping to see similar impacts on their consultant times as we have done for our orthopaedic colleagues. All GPs across all three boroughs are now using the same clinical pathways to refer patients, which means that patients have the same level of care and the same level of decision-making whichever GP they go to. Patients can now move seamlessly around the services as needed.”
If they can switch off direct access altogether, Rebecca continued, “we would see even bigger improvements for patients, hopefully, but we do need to start looking at reviewing our workforce across these patient pathways. We’ve actually seen an increase in the demand for these services, which is right for the patient, as they should be coming to these services first. But now we need to look at how the workforce can support these improvements that we’re seeing for patients across these clinical pathways.
“Change isn’t easy, and we still have a few issues from time to time, but we’re getting there. These positive results do really help to be able to give a narrative that this is the best thing for our patient. Engagement is key, having people onside and having those champions within primary care really does make a difference. Our FCP colleagues have been great – they are using Rego more and more, and we’re starting to use them as to help induct new staff into primary care when they come in, to show them how to use Rego. We’ve used multiple forums to engage GPs, FCPs and their admin staff – we’ve been to PCN meetings, we set up lots of MS Teams teaching sessions, and we also produced a video and PDF training guide that can be held within the PCN. So what we’ve learned is that actually, promising improvements can be seen in a short period of time, and what we’re hoping is that with continued future engagement, we can continue to see improvements that we’re seeing already.”
Many thanks to Rebecca for joining us and sharing BHR’s experiences.