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Realistic Medicine in Action: ACRT

Realistic Medicine in action: Active Clinical Referral Triage (ACRT)

Traditionally when GPs referred people to hospital teams, referrals were read and prioritised by specialists and individuals were then placed on waiting lists for either urgent or routine review.

COVID-19 has changed everything – and caused us to think differently. Now many teams are successfully adopting a new approach called Active Clinical Referral Triage (ACRT). This is a more person-centred approach which reduces the need for all patients to have face-to-face review giving individuals more choice and reducing waits.

ACRT – by encouraging shared decisions, increasing patient choice and reducing harm and waste – is therefore a great example of Realistic Medicine in action. And patients like it too!

Even before the pandemic, ACRT was being adopted by teams to successfully manage their waiting lists and reduce the time people wait. But safety needs to be our priority. We need to keep Journeys to a minimum. Social distancing has to be maintained. All of this means that teams up and down the country have re-assessed their pathways and are now providing a range of safer alternatives to face to face review.

So what exactly is it? Well, ACRT has some special features to make the referral process much more personalised to each individual. When a referral is received it is carefully assessed by a senior member of the team, who also checks all the available records and test results for that person. Based on the patient history, the clinician goes on to choose the best option.

ACRT

The exact options vary according to the service but commonly include

  • Possible referral directly to advanced investigations (with follow-up discussion of the results, either remotely or face to face)
  • More detailed information is provided to the patient about the suspected condition and an option to opt-in to further clinical assessment.
  • Referral to a more appropriate speciality or advanced practitioner without the need to go back to the GP.
  • Clinical review either by phone or on screen using our NHS Near Me / Attend Anywhere facilities
  • Or – when there is a clear clinical need – by face to face review in a clinic.

Teams who have adopted this approach have found that both waiting times and patient care have been improved. Working ‘smarter’ has freed time, which is re-invested in a higher quality service, more tailored to the individual needs of patients.

This has been a hugely challenging time for all but despite this, some services have managed to reduce their waiting times. In the graph below, the blue dots represent specialties in Health Boards which have reduced the size of their out-patient waiting lists during the pandemic since 20 March 2020. (Fig 1)

Fig 1: Percentage change in the New OPWL numbers for each HB / specialty from 16/3/2020

OPWL

There have been times when patients have waited for unacceptably long times without any information, only to be given lots of different options, all at once when they are seen in a clinic.

Now this information can be provided at the point of receiving the referral, allowing much more time for them to digest the information, and think about the questions they would like to ask at review. In some instances, it can help people decide that the procedure proposed is not for them. Opting in to a virtual or face to face review is not time limited and allows people to choose for themselves whether and when to proceed.

Many of the specialists involved have found that a conversation with a patient shortly after referral has saved the need for a long wait to review or given the opportunity to signpost them to a more appropriate service - saving months of discomfort.

Most of these new services are being continually evaluated and adjusted to bring further improvement. One survey of orthopaedic patients showed that over 90% of people phoned after being sent information about their condition (in response to referral) understood the information provided and over 80% were satisfied with the service.

The neurology service in Glasgow had significant waiting list pressures but when each sub-specialty of neurology reviewed unbooked cases using ACRT methodology, it was evident that significant numbers of those referred could be managed by advice only – either to the patient or the referrer. Being a regional service with patients sometimes travelling many miles for review, an additional benefit to patients was evident. The neurology team and the subspecialities collaborated to produce a comprehensive advice booklet for referrers.

Graham Christie, the clinical service manager leading the change, said that ‘ACRT has been embraced by the specialist teams and has worked very well to have a major impact in terms of patient satisfaction. Complaints have dramatically decreased and, despite the pandemic, there are now no patients waiting longer than 8 weeks for a booking appointment.

Paul Jenkins, (clinical director orthopaedics at GRI and Stobhill) said: “In the past patients would hear nothing until their appointment and then at that appointment were bombarded with information and expected to make decisions. Now we can provide information at every stage of the process which helps patients and efficiently manages referrals at the first point of contact with the system which helps us provide a better service.”

This isn’t just happening in NHSGGC. Across the country teams are seeing great benefits for their patients. Using this approach, the respiratory service in NHS Fife has seen a 59% decrease in their waiting list numbers since the pandemic began and the cardiology team in NHS Forth Valley saw a 55% reduction in their waiting list numbers by providing a range of options for patients.

ACRT doesn’t just apply to new referrals either. Now on discharge from hospital after a procedure, people are given detailed information about what to expect and even after major surgery are now given the option to return for review only if and when necessary.

This is called PIR or Patient Initiated Review and gives people clear guidance on how to self-refer back into the system without the need to go through the GP all over again. And it seems most people don’t need to come back - allowing that time to be used more effectively.

Graham Christie from the neurology team agreed, saying that ‘far from increasing demand, introducing PIR had so far resulted in over 400 appointment slots being freed up, further enabling better access for new referrals’

Some less familiar with the benefits of ACRT and PIR may wish to keep old ways of working; however, people were waiting for many weeks for an appointment - even before COVID 19 came along!

New ways of working are here to stay and provided we can prove that these changes improve outcomes, costs are efficiently reinvested into higher quality care and the people who need to use the service find it beneficial, ACRT should be much more widely adopted as an example of Realistic Medicine in action.

If you or your team want to know more about how to do this the best place to start is here in this NES Turas toolkit.

Turas: Active Clinical Referral Triage (ACRT)

Scottiish Sharepoint: Active Clinical Triage Virtual Patient Management Resource Page

 

 

Last Updated: 01 September 2021