P56 Integrating primary care within paediatric rheumatology: does it work?
Authors: Bloxham Erin , Denman Graeme , Jandial Sharmila 
Published: September 2019

Abstract

Background
Delay in accessing specialist care is well recognised in childhood musculoskeletal conditions including juvenile idiopathic arthritis (JIA). Patients often describe circuitous routes within healthcare prior to diagnosis. In the UK, primary care is the gatekeeper to specialist services; review by a general practitioner (GP) is the first point of contact for the majority of non-emergency health concerns.
The paediatric rheumatology service at the Great North Children’s Hospital is the sole provider of paediatric rheumatology care in the North-East of England and North Cumbria seeing >600 new patients per year. Since 2012 the department has hosted an innovative GP integrated training post with a focus on new patient assessment and diagnosis. The success of this led to the appointment of a substantive GP post in 2017, providing independent new patient assessment for one clinic per week. The aim of this service evaluation was to review patient outcomes from this.

Methods
A mixed-methods approach was used. Quantitative data collected over a 12-month period included number of new patients assessed, time to first appointment, investigations, referrals, diagnosis and follow-up. Qualitative data was collected from patients (patient and parent satisfaction) and the multi-disciplinary paediatric rheumatology team (anonymised).

Results
150 patients were assessed over the 12-month period, accounting for 25% of the new patient referrals to the service overall. Management included no investigations (29%), blood tests only (18%), blood tests and imaging (21%) and imaging only (32%). 87% of diagnoses made were non-inflammatory: Hypermobility (35%), mechanical pain (25%) and others (27%). 12% were inflammatory: JIA (4%), suspected connective tissue disease (3%), idiopathic uveitis (1%) and others (4%). 1 patient (1%) was unaccounted for as they failed to attend further appointments. Referrals were made for 59% of patients, the majority to physiotherapy. Mean waiting time to first appointment was 38 days (range 4 – 75). 67% of patients were discharged, with only 1 re-referral which resulted in the same diagnosis and repeated discharge. No complaints were received.
Patient satisfaction (n = 19) was very good, excellent or outstanding in all domains and 100% were happy to be seen by a GP who works as a specialty doctor in paediatric rheumatology. Multi-disciplinary team (MDT) feedback was received from medical (n = 5), nursing (n = 2), physiotherapy (n = 1) and administrative staff (n = 2). The majority of domains were rated as excellent to outstanding with unanimously positive additional comments about the GP and trainees working within the service.

Conclusion
Integrating a GP into the paediatric rheumatology team has provided a significant contribution to new patient assessment and is highly rated by patients and the MDT. Unsurprisingly, the majority of new patient assessments are not diagnosed with inflammatory disease, and by providing our GP with appropriate training and support, such patients are able to be diagnosed and discharged appropriately.

Conflicts of Interest
The authors declare no conflicts of interest.