IMG 1901

Community-based sleep services can improve access and reduce waiting times

Wednesday, November 25, 2020

We spoke to Dr Swapna Mandal and Dr Nikesh Devani of the Royal Free London about their very successful pilot which took a sleep clinic out of the hospital and closer to the community, working closely with primary care colleagues.

In 2016, our hospital decided to grow its sleep services with the appointment of a new consultant (Swapna) and as a result of this drive we moved from having 700 referrals per year to close to 2000, most of which were for cases of suspected Obstructive Sleep Apnoea (OSA). The increase in numbers, unfortunately, came with longer waiting times, something that was very frustrating for both patients and staff. The system felt inefficient, and it was clear that we needed to do something differently.

Taking stock of patients’ views

We reached out to patients and, using a survey, we asked them what we could do to improve the service, and specifically what they perceived to be the barriers as users of our sleep clinic. People found it difficult travelling to the hospital, could not find parking spaces nearby, were upset by the parking charges but also felt that they needed to go through far too many appointments before receiving a diagnosis.

A sleep study is one of the key diagnostic tools for OSA. One of the things we did straight away was to try and streamline the service by reducing the number of appointments needed before a patient was offered a sleep study, and we kept thinking how we could move even further.

The turning point was when we realised that as long as the clinical expertise was there, it didn’t matter where you had your consultation, and mattered even less to patients where they picked up their sleep study equipment; that was when we began to think about working in partnership with GP practices.

Designing the new pilot service was a collaborative effort

Our plan was to cut down waiting times by bringing the sleep clinic closer to the patient, and to reduce the number of appointments it took for them to be referred and assessed. We initially devised a model whereby a sleep specialist would hold the sleep clinic directly at the GP practices, assess the patient and prescribe a sleep study if required, with the patient able to pick up the equipment straight from the practice.

However, this model had the drawback that the sleep team member would have to hold a number of clinics across several practices and would only be available for a very limited period of time in each locality. So instead, we moved to a “hub and spoke” model, where the sleep specialist would hold the clinic in a central practice (the “hub”) and see referrals from all the spoke practices in the area.

We designed this pathway in collaboration with local GPs and with input from local commissioners and next, we moved on to recruit practices for a pilot of the new pathway. We organised several meetings with seven local practices, during which we discussed the new proposed pathway and offered insight into OSA and other sleep disorders. As part of the roll out of the project we delivered teaching sessions on sleep disordered breathing to GPs to give them a better insight into the disease process and management options.

We came up with a solid proposition that addressed some of the most common concerns. It was time limited, it didn’t require GPs to make big changes to their procedures, it offered specialist support to GPs on demand, it wasn’t reliant on practice staff to be delivered and there was a clear plan to seek funding for the service from commissioners at the end of the process, to properly embed and spread it into the local community, if successful.
As a result all seven practices agreed to take part, and in 2018 we were ready to start a year-long pilot.

How the service pilot works in practice

We held a once monthly, half-day clinic in the “hub” practice, staffed by a sleep and ventilation clinical fellow with capacity to review eight patients face-to-face. To refer patients, GPs based in any of the spoke practices were required to complete an electronic referral proforma, embedded within their Electronic Patient Record (EPR), which was sent directly to the sleep team at the Royal Free where it was triaged. The team would then approve the referral to the monthly clinic or provide specialist commentary to support the GP in their decision.

At the clinic, after a brief assessment from the specialist and completion of a sleep questionnaire, patients were given the sleep study equipment and provided with training on how to use it. Once the devices were returned and the data uploaded and interpreted, a diagnosis was reached via a Multidisciplinary team meeting (MDT) run by the sleep and ventilation team of the Royal Free. Results were, immediately communicated to GP and patient. Patients requiring treatment or further review were automatically scheduled to attend a secondary care clinic.

A very successful experiment

There were many positive outcomes, some of which can’t be measured in a conventional way. For example, the educational sessions we ran for the various practices and the specialist advice via the referral system have up-skilled our primary care colleagues in sleep medicine, which in turn has reduced the number of referrals turned down by the service. It has also made us in secondary care more aware of the complexities of the referral process, something we are not quite exposed to in our daily job. I would say coupled with increased and better communication, this has created a strong sense of trust between the hospital and our local practices.

The evaluation of the pilot showed very positive changes, with comparable outcomes. The non-attendance rate was considerably lower than in the hospital pathway, and most importantly, the waiting time from referral to diagnosis was on average 6 weeks, versus the 32 weeks in the old hospital pathway. Furthermore, the community pathway meant that patients attended, on average, fewer appointments before being told their diagnosis or starting their treatment (where required) and an assessment of costs suggested a saving of around £290 could be achieved for each patient.

Patients preferred the community settings of the clinic and the way it was structured, citing among the benefits, the reduced number of appointments and not needing to visit the hospital often, which for some was a source of anxiety. By using the existing primary care infrastructure, we did not require patients to be visited at home by a healthcare practitioner, instead they were more able to attend a GP practice within their local neighbourhood which they found more comfortable.

GPs were also happy with the new arrangement, praising the responsiveness and convenience of the pathway, the simple referral and rapid communication with secondary care which forged stronger relationships between hospital trust and primary care providers.

We submitted our pilot work for peer review, and it was recently published in BMJ Open Respiratory Research, but the initiative also received wider praise as the winner of a BMJ award in 2019 and we were named as a regional finalist for the Sir Peter Carr Award, in 2019.

Rolling out the service more widely

Armed with data demonstrating the indisputable success of this pilot in reducing waiting times and costs to the Health Service, we approached the local CCG to begin consulting on how to roll out the service across the whole of the North Central London Sustainability and Transformation Plan. Initially we looked to embed this across the entire London Borough of Camden and with the support of the CCG we began to consult with local providers to determine the best course of action. Once the clinical framework was set, the CCG wrote a business case to support the roll out. Negotiations were ongoing but then unfortunately COVID-19 hit and the process was stopped.

We very much hope that this will be picked up again following COVID and believe that the pandemic has highlighted even more how important it is to move care away from a hospital setting.
The pilot has proved very successful and implementing this more widely will require more innovative and sustainable ways of working. , In turn, we can work to optimise patient attendance to healthcare institutions, whilst maintaining high quality care.