Musculoskeletal conditions affect around a quarter of the adult population and account for approximately 30% of GP consultations in England (NHS England, 2016). In 2011, musculoskeletal conditions were estimated to account for nearly £4.8 billion of NHS spending (NHS England, 2016). The prevalence of musculoskeletal disorders correlates with population age; consequently, the burden on primary and secondary care resources is predicted to increase as the UK population ages (Arthritis Research UK, 2017).
Nurse-led telephone helplines are increasingly being used to address demands on NHS services, and help fulfil patients' need to access relevant information and advice from health professionals (Twomey, 2000; Hughes et al, 2002; Shah et al, 2013; Shaw et al, 2013). Telephone helpline services may promote patient and caregiver empowerment and disease self-management, and, if used effectively, could help reduce the burden faced by NHS services (McDonald, 2014; Arthritis Research UK, 2017). For example, patients with long-term conditions reported that they would like a named contact for day-to-day queries, and that they thought this would reduce GP visits and hospital admissions (McDonald, 2014).
In response to the significant variation in the provision of telephone helpline services throughout England and Wales, the Royal College of Nursing (RCN) Rheumatology Forum formed a working party to compile a guidance document for nurses providing telephone advice for people with long-term conditions (RCN Rheumatology Forum, 2006; Thwaites et al, 2008; RCN, 2012). The RCN guidance provides a framework for developing or redesigning helplines as telephone advice lines (TALs), with advice on appropriate documentation for patients, audits, adherence to governance and legal issues, and systems to keep clear patient records (RCN Rheumatology Forum, 2006; RCN, 2012).
The Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) rheumatology department established a telephone helpline led by specialist nurses in 1996 to provide patients with information and support with all aspects of disease management, including administration of medication, side effects and flare management. On calling the helpline, users were asked to leave a recorded message with their contact details, allowing a nurse to return the call and provide assistance. The Trust's helpline was not only used by patients, but also by GPs, practice nurses and other health professionals in primary care. These accounted for 13% of all calls, with queries regarding patient management, such as ‘shared care’ (a protocol for shared responsibility between the specialist and a primary care prescriber for managing the prescribing of a medicine) (Khambh and Barnick, 2007).
This article describes an internal review and redesign of the RLBUHT's rheumatology helpline conducted by the specialist nurses running the service. The aim was to ensure that the service was reliable, effective, efficient and safe, and fulfilled the needs of patients, nurses, primary and secondary health professionals, the RLBUHT and the Liverpool Clinical Commissioning Group (CCG). In addition, it is hoped that the process could be used as a framework to evaluate and improve existing service helplines used to support other specialties.
Method
Internal review of the RLBUHT rheumatology helpline
The five rheumatology specialist nurses running the RLBUHT rheumatology department telephone helpline were given time and opportunity to reflect on the current service, share ideas and consider innovative ways of delivering and managing it. Two sessions were used to discuss the limitations and issues with the helpline service.
RCN guidelines (2006) were used by the specialist nurses to inform discussions and to identify solutions to improve the service (Table 1).
Table 1. Use of the Royal College of Nursing Rheumatology Forum (RCNRF) guidance to inform the redesign of the Royal Liverpool and Broadgreen University Hospitals NHS Trust rheumatology telephone advice line service
| Limitation of the original helpline service | Relevant RCNRF guidance* | Action taken |
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Evaluating usage of the new telephone advice line
With approval from the RLBUHT business manager, each call made to a patient was recorded as a telephone appointment for a 12-month period between 1 April 2014 and 1 April 2015 so that patients' usage of the RLBUHT TAL service could be evaluated. Calls made to respond to queries from health professionals in primary or secondary care were not recorded.
Patient/health professional feedback
The nurses requested general feedback on the TAL. Health professionals who had used the service were asked for their feedback by email in February 2018; specific comments on the accessibility and response times of the service were requested. Feedback provided voluntarily by patients in their communications with the nurses were recorded and collated.
Ethical approval
As this was a service evaluation and redesign, review by a research ethics committee was not required. This was confirmed using the NHS Health Research Authority Research Ethics Committee decision tool.
Results
Inadequacies of the RLBUHT rheumatology helpline
There were a number of concerns regarding the reliability and safety of the RLBUHT helpline service. Rheumatology patients can suffer from comorbidities (Sokka et al, 2018) and poor mental health (Matcham et al, 2013), and take medications associated with potential serious side-effects, so a failure to respond quickly could place the patient at risk of harm. The internal review of the service, facilitated by the RCN guidelines, identified concerns in three broad categories:
- The nature of calls received
- Staffing and time management
- The procedure for returning calls and documentation.
The nature of calls received
The original service provided patients with no guidance on appropriate use of the helpline; inappropriate calls were received on a regular basis, with queries concerning occupational therapy, physiotherapy and podiatry, outpatient appointments, and non-rheumatic conditions. The time required to process inappropriate calls slowed the nurses' response time, frustrating helpline users.
The types of queries the new TAL should advise on were discussed; it was agreed that these should include general disease management, medication, and flare-up control. As recommended by the RCN guidelines, the redesign of the service would provide users with verbal and written information on what to expect from the TAL, the type of advice and support they could expect, and other contact points for information and support (Table 1).
Staffing and time management
Helplines require staff with excellent communication skills and expert disease and treatment knowledge. One of the biggest challenges identified was the time required to staff the telephone helpline. In the past, no specific resource time was allocated to the helpline; instead, nurses were expected to provide the service around face-to-face consultations, on an ad hoc, sessional basis, which made it very difficult to guarantee a response within a designated time frame.
The lack of planned time for returning helpline calls was partly due to the absence of this skilled role in the nurse's job description and job plan. Consequently, the Trust did not recognise the helpline as an additional job-specific function the nurses were having to perform and so did not reimburse the rheumatology service for the care that they were providing. Furthermore, as the helpline was not specified in the nurses' job plan, there were no procedures for allocating call responses, which reduced the continuity of care for patients and contributed to delayed response times.
The procedure for returning calls and documentation
The original service had no method of logging calls. Details of all answerphone messages received, and calls made to patients or other users, were recorded by hand using a paper form and stored locally; the records were not linked to patient case notes, potentially putting patients' safety at risk. For example, an internal review of the helpline identified instances where patients had repeatedly called to request a response to their original call, indicating that either there were delays in returning patients' calls or the original call record had been missed.
Redesigning of the RLBUHT rheumatology helpline into a telephone advice line
The RLBUHT rheumatology helpline was re-designed in September 2012 to align the service with RCN recommendations and address the concerns identified through the internal review.
Reducing inappropriate calls
To reduce the proportion of inappropriate queries, changes were implemented to better communicate the scope of the service. First, the service was rebranded from a ‘helpline’ to an ‘advice line’, as recommended by the RCN guidelines. The aim of this change was to associate the TAL with patient disease self-management, aligning patients' expectations of the service with what the nurses could offer. This rebranding was implemented across all communications regarding the TAL.
A patient information leaflet was produced to communicate the details and scope of the new TAL and to advise who to contact for commonly received inappropriate queries. The RCN patient information leaflet template was used to guide the design of the TAL leaflet, which included details on the aims and objectives of the service, clarification that the advice line is not an emergency service, the scope of queries that the nurses can advise on, how the service works, the information that the caller should leave in their recorded message, when patients could expect their call to be returned, and information on other points of contact for commonly received queries not within their scope. To ensure that as many patients being treated at the rheumatology clinic as possible are aware of the TAL service and how it functions, the patient information leaflet is given to every new patient in clinic. Receipt of the patient information leaflet is recorded with a tick box on the patient's electronic record, and this is checked for each patient coming into the clinic for a face-to-face consultation.
To reinforce the guidance provided in the patient information leaflet, the prerecorded answerphone message patients hear when they call the TAL (before they are given the opportunity to record a message with their query) was modified, redirecting all appointment-related queries to the appropriate number.
Ensuring provision of staff and assigning responsibility
To address the resourcing issues associated with the original helpline, ie that nurses were expected to staff the helpline around their face-to-face consultations, time was incorporated into nurses' job plans as half-day blocks, giving the specialist nurses 3.47 days (whole time equivalents) per week to deliver the advice line service. A rota was implemented so that each nurse was allocated one morning and one afternoon session for the days they work to equitably assign responsibility among the five specialist nurses for responding to the messages received. To support continuity of care (Freeman and Hughes 2010), each message received on the advice line would be handled by an individual nurse, who would be the patient's named contact.
Using RCN guidance, a 2-day target was set for responding to all TAL calls, with a maximum of three attempts to contact the patient. These targets were communicated to all TAL users to set clear expectations of the service. To keep track of the calls received and all attempts at responding to these, an electronic call log form was developed with the Trust's electronic records design team, who transferred the form to the patient electronic notes system (PENS) so that patients' use of the TAL service would be linked to their medical records. The electronic form recorded the caller's details as provided in the recorded answerphone message, the number of call-back attempts, and the outcomes of the telephone consultation, should a call-back attempt be successful.
The value of the TAL to key stakeholders
Feedback from patients, the nursing team, consultant rheumatologists and primary caregivers, indicated that the redesign of the helpline to an advice line was effective and gave value to both health professionals and patients (Table 2, Figure 1).
Table 2. Benefits of the redesigned telephone advice line
| The nature of calls received | Staffing, time management | Procedures and documentation | |
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| Key areas of the redesign |
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| Results of the evaluation of the redesigned service |
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Patients
The feedback received from patients indicated that they valued the advice and prompt responses they received from the specialist nurses via the RLBUHT TAL.
The specialist nursing team
The nurses involved in delivering the RLBUHT rheumatology TAL reported a drop in the number of inappropriate calls, which was attributed to the patient information leaflet and the re-recording of the answerphone message. Furthermore, they found that providing each patient with a named contact in the nursing team, incorporating the TAL into their job plans, and introducing a rota system to ensure each TAL clinic was assigned a specific specialist nurse, provided a way of ensuring accountability. The nurses also appreciated having electronic records of all previous patient calls, as this supported clinical decision-making and ensured a record of decisions was kept for future reference.
Primary and secondary care
Health professionals in primary care valued the additional information in patients' records since the redesign of the service linked all calls to patients' records, and appreciated the expert advice provided by the specialist nurse team. Health professionals in secondary care highlighted the potential time saving from reduced clinical appointments as a key advantage of the new TAL (Table 2).
Cost benefits of the new advice line
The number of rheumatology patients recorded within the RLBUHT in 2012 was 4526, which had increased to 5246 in 2017, indicating an increase of around 144 patients per year, or approximately 16%, over 5 years. However, during the same period, no new outpatient slots, requiring further clinical or clerical staffing, nor extra TAL sessions by nurses were created. These data suggest that the redesigned advice line may have contributed to a reduced patient need for face-to-face and telephone consultations between 2012 and 2017.
The TAL nurse team made 2730 calls over 12 months, between April 2014 and April 2015. The Liverpool CCG reimburses the RLBUHT for the telephone-based care provided through the TAL at a tariff of £23 per call, and this would have cost the CCG £62 790 in the 12-month review period. Had the patients who used the TAL service requested face-to-face consultations for advice instead, at the tariff used at the time (£153 per consultation), this would have cost the Liverpool CCG £417 690, suggesting a total saving for the CCG of approximately £354 900 over 12 months.
Discussion
The specialist RLBUHT rheumatology nurses successfully used the RCN guideline, Telephone Advice Lines for People with Long Term Conditions, as a framework to review and implement a redesign of the telephone service they were providing (Table 1). The objective of the redesign was to provide a more reliable, safe, and efficient service, which would bring greater value to all key stakeholders: patients, other health professionals involved in their care, the specialist nurses, and the NHS. The new TAL provides many user benefits:
- A clear description of the service so that all users fully understand the TAL's function
- A clear nurse protocol
- A source of advice for other health professionals managing rheumatology patients
- Support for the ‘shared care’ protocol
- Continuity of care for patients
- Costs savings for the NHS.
A lack of communication with patients regarding the scope of the previous helpline resulted in a large proportion of the calls received falling outside of the service's remit. Communicating the scope of the RLBUHT rheumatology TAL by producing a patient information leaflet, and recording a new answerphone message to communicate the scope of the service, reduced the proportion of inappropriate calls. With fewer inappropriate calls, the nurses were able to provide a more efficient service.
Policy recommendations and published literature on the care of patients with long-term conditions have focused on patient empowerment through supported self-management (Corben and Rosen, 2005; McCorkle et al, 2011; Manchikanti et al, 2017). Patients with chronic rheumatic disease feel they need coaching and support to develop problem-solving skills so that they can self-manage their disease effectively (Been-Dahmen et al, 2017), and yet they have infrequent face-to-face consultations with specialist health professionals (McDonald, 2014). It is predicted that the number of face-to-face clinic slots with consultant rheumatologists per patient will continue to reduce as the patient population rises. The TAL provides patients with an alternative option for support with their disease self-management.
There is a clear link between patient experience and clinical outcomes (Doyle et al, 2013). The RLBUHT rheumatology TAL supports continuity of care, providing advice on treatment protocols, answering questions about side-effects, and providing information and education on patients' conditions. The redesigned service further supports continuity of care by assigning each patient a single nurse to handle all of their queries; this named contact is familiar with the patient's medical history and previous queries. The feedback from health professionals in primary and secondary care also highlights the contribution the service makes to supporting the ‘shared care’ protocol by making the details of the patient's query available on the PENS. Continuity of care, both in terms of having a continuous relationship with a specific clinician, and having consistent clinical management, makes an important, positive contribution to a patient's treatment experience (Freeman and Hughes, 2010).
NHS advice and guidance (A&G) services allow one clinician to seek advice directly from another on a treatment plan, the ongoing management of a patient, for clarification or advice on a patient's test results, whether to refer their patient or choose an alternative care pathway, and, if referring a patient, which service would be most appropriate (NHS Digital, 2017). Since the new RLBUHT rheumatology TAL has proved to be an effective way for specialist nurses to provide A&G to other health professionals in primary and secondary care, additional A&G services have been rolled out across the Trust.
In March 2017, NHS England published Next Steps on the NHS Five Year Forward View, which included the 10-point efficiency plan to reduce waste and increase efficiency within the NHS (Dau et al, 2017). The evaluation of the new TAL, together with the greater numbers of rheumatology patients cared for by the RLBUHT rheumatology service, indicate that the redesigned service has helped reduce treatment costs by reducing face-to-face clinic visits and has made a valuable contribution to the NHS's current drive for efficiency. This was recognised at the 2016 ‘Make a Difference Awards,’ where the RLBUHT specialist nurses were presented with the ‘Quality Improvement and Transformation Award’ (Royal Liverpool and Broadgreen University Hospitals NHS Trust, 2016).
As well as bringing greater value to patients and health professionals in primary and secondary care, and improving efficiency, the redesign of the helpline also aimed to improve the working conditions of the specialist nurses. The new procedures ensure staffing provision for the service and support an equitable division of responsibilities within the specialist nursing team, resulting in a more efficient and effective service, and improved morale.
Limitations
There were several limitations associated with this service evaluation and redesign. Although feedback from the rheumatology patients and staff from the Trust who had used the redesigned service indicates that the service does bring value to all stakeholders, this feedback was requested by email and may therefore be biased, since the responses were not anonymised. Moreover, the feedback requested was unstructured; a survey with questions on various aspects of the TAL service would provide a better understanding of users' experiences, and identify the aspects of the service that are performing well and those requiring further improvement. Feedback was obtained from a relatively small number of users; requesting feedback from a larger sample would provide a better overview of the service. In the future, a formal service evaluation that requests feedback from service users in a way that is structured and timely after service use and ensures the anonymity of respondents is required to reduce the likelihood of receiving biased feedback. Overall, the lack of audits before and after the service redesign prevented the systematic and formal evaluation of the impact of the changes made to the TAL service, which would have also allowed a detailed analysis of cost savings made by the NHS. However, a standard operating procedure for the rheumatology TAL has now been developed in preparation for a formal audit of the service.
Conclusion
The specialist nurses of the RLBUHT rheumatology department successfully used RCN guidance to redesign the Trust's rheumatology telephone helpline. This redesign delivered a reliable, effective, efficient and safe service for patients, improved structures and created clear procedures for the nursing team. It also allowed the nurses to support their colleagues in primary and secondary care, deliver the ‘shared care’ protocol, and provide patients with continuity of care, while making efficiency savings for the NHS. Although this service redesign was specific to a rheumatology service helpline, this described process of evaluation and redesign could be applied to any existing service helpline.
KEY POINTS
- Nurse-led telephone advice lines are increasingly being used to address demands on NHS services, and help fulfil patients' need to access information and advice from health professionals
- Specialist rheumatology nurses providing a telephone advice service within the Royal Liverpool and Broadgreen University Hospitals NHS Trust rheumatology department conducted an internal review of their service
- Before the redesign, problems facing the helpline service included a high number of inappropriate calls, calls not recorded in patients' records, and no formal process for assigning calls to nurses
- Specialist rheumatology nurses used RCN guidance to redesign the telephone advice service and resolve the problems they had identified
- Feedback from patients and other service users showed that the redesigned telephone advice line was valued by patients, supported other health professionals to care for rheumatology patients, provided the nurses with recognition for their clinical activity, and contributed to the NHS drive for efficiency
CPD reflective questions
- Do you provide a telephone advice line or other patient information service? Think about areas of the service that could be improved
- How could you better support your colleagues in primary care with regard to your patient group?
- How do you ensure that patients' queries or problems with their condition or treatment are brought to the attention of appropriate colleagues?