Endocrinology

Reduce unnecessary duplication of diagnostic tests to streamline initial referral and avoid wastage. Appropriate information sharing is an essential part of the provision of safe and effective care. a GIRFT and the Society for Endocrinology to provide guidance on which diagnostic tests are appropriate to be carried out or commissioned by GPs prior to referral to secondary or specialist care, and which should follow or be conducted at an initial outpatient visit or arranged between referrer and referee. b GIRFT to ensure guidelines on diagnostic testing at appropriate point in patient journey inform Choose and Book criteria. c In line with new NHS Digital's Data and Technology Standards Framework, providers should look to improve digital interoperability to enable clearer visibility in both directions on the electronic patient record around which tests have been conducted/requested, as well as any which follow after diagnosis and treatment.

Expedite prompt referral to specialised care where indicated (in this recommendation we support the work of the NHS Neuroscience Transformation Programme and the work currently being undertaken by NHS England to rewrite the specification for specialised adult endocrinology services). a GIRFT to ensure proposed list of endocrine conditions which indicate a need for specialised care are fed into NHS England review of specifications for specialised endocrinology services. b Trusts to declare compliance with service specifications for treating these conditions through the Quality Surveillance Information System (QSIS). c Trusts to agree referral and repatriation criteria and record these consistently to ensure that referrals between centres include a clear rationale for the need for specialist input in a standardised way.

Deliver networked service models so that patients can be referred to the most appropriate surgeon and the correct level of care. a Trusts to establish service-level agreements to facilitate and deliver recommended network service arrangements and models (see recommendation 8) including for: i. treatment of medullary thyroid cancer; ii. adrenalectomies (and to ensure within each network there is a hub for adrenal cancer and phaeochromocytomas); iii. pituitary surgery.

Consider options to accelerate urgent treatment for patients with serious non-cancer endocrine conditions. a GIRFT to work closely with NHS England and trusts to review referral pathways for life-threatening endocrine conditions or conditions which have risks of major complications (listed below) to ensure that patients can access urgent treatment without unnecessary delay once diagnosis is confirmed: i. phaeochromocytoma; ii. severe hypercalcaemia; iii. severe pressure symptoms of enlarged thyroid; iv. Cushing's syndrome; v. severe Graves' disease.

Ensure that where clinically appropriate, lengths of stay for surgical procedures are reduced. a Trusts to review their patient pathways with a view to achieving the following targets for elective admissions: i. 90% of patients having parathyroid surgery for primary hyperparathyroidism to be discharged with zero night stay (day case); ii. 90% of patients undergoing thyroid lobectomy to be discharged with no more than one night's stay; iii. 90% of patients undergoing total thyroidectomy to be discharged with no more than two nights' stay.

Improve audit and availability of data relating to all endocrine operations. a All surgeons carrying out thyroid surgery, as well as those carrying out parathyroid or adrenal surgery should participate in the British Association of Endocrine and Thyroid Surgeons (BAETS) electronic UK Registry of Endocrine and Thyroid Surgery (UKRETS) to allow for accurate auditing of services. b Trusts to include data capture for national audit as part of job descriptions and job planning for consultants, with time allocated as required.

Agree clearer definitions and protocols for surgical complications. a GIRFT to work with patient groups and professional societies to review and agree clearer definitions of surgical complications e.g. deficient calcium post thyroidectomy, damage to the recurrent laryngeal nerve post-thyroidectomy and hypopituitarism post hypophysectomy (removal of the pituitary gland). b GIRFT to work with professional societies to share exemplar protocols for conditions where surgery involves a known risk of life-changing complications or post-operative issues, e.g. thyroid bleed protocols.

Trusts should work collaboratively in networks or amalgamate services to concentrate surgical expertise. Direct patients requiring surgery to appropriately trained surgeons performing the recommended volume of procedures. a Optimise specialist endocrinology care and ensure a safe service is provided, as recommended in national service specifications and international guidelines. In particular: i. Centres carrying out very few adrenalectomies (under six adrenalectomies per surgeon per year or under 20 if they are operating on patients with adrenal cancer and phaeochromocytoma) should stop doing so. These centres should refer patients to surgeons within their network who perform this procedure at higher volumes. ii. Centres carrying out thyroid surgery should ensure surgeons are carrying out a minimum number of 20 thyroid operations each per annum or that patients are being referred to surgeons within their network who perform these procedures at higher volumes. iii. Centres carrying out parathyroid surgery should ensure surgeons are operating on at least 20 patients per annum or that their patients are being referred to surgeons within their network who perform these procedures at higher volumes. iv. Centres carrying out pituitary surgery should ensure surgeons are operating on 20 patients per annum, aspiring to 50 operations per department per year or their patients should be referred to surgeons within their network who perform these procedures at higher volumes. b Endocrinology departments should work with regional vascular and radiology networks to optimise numbers regionally and improve success rates of adrenal venous sampling (AVS) and petrosal sinus sampling. c GIRFT to work with the NHS pricing team to ensure that commissioning models encourage best practice by only funding adrenalectomies and pituitary surgery where these are carried out at a specialist centre.

Review appropriate triage and pre-investigation for outpatient referrals to improve patient flow, address capacity challenges and enable innovative practice. a Trusts to review current protocols around pre-investigation diagnostic blood/urine tests prior to first outpatient appointment, to enable between 30-50% of patients to be pre-investigated and triaged. b Trusts, with input from the Society for Endocrinology, to develop protocols for the implementation of clinical/referral assessment services to support appropriate triage of outpatient referrals and increase the likelihood of discharge at first appointment.

Review management of follow-up appointments. a Society for Endocrinology to develop follow-up protocols to ensure that endocrinology departments can benchmark performance against approved pathways for each endocrine condition. b GIRFT to work with the National Outpatient Transformation Programme to look at increasing availability of remote appointments/virtual clinics, especially for follow-ups. c Trusts to explore options to advance to a core level of digitisation by 2024, as set out in the NHS Long Term Plan. d GIRFT to work with the NHS pricing team and the National Outpatient Transformation Programme to review current pricing arrangements and incentives for video versus telephone appointments.

Ensure all surgeons and wider team members involved in endocrine activity have access to the latest information and training to maintain their competence. a GIRFT and Joint Committee on Surgical Training (working with the specialty and subspecialty Specialist Advisory Committees) to jointly produce a cross-specialty endocrine surgery module for pre- or post-certificate training. b Trusts should endeavour to facilitate and support endocrinology-specific training for the wider endocrinology team, including Society for Endocrinology training for nurses.

Ensure the endocrinology department is fully optimised to release clinicians' time to care in line with associated NHS People Plan programmes. a To enable better workforce planning and support service delivery, trusts should review the resourcing of their endocrinology MDTs and relevant surgical services considering in particular: i. Employing at least one but ideally two specialist nurses (dependent on department workload/demand) to carry out pre-investigation assessments for outpatients, lead clinics and support pre/post-operative care. The specialist nurse support for the surgical service may be the same or separate from that for the endocrinology service. Trusts would need to make a business case to ascertain the value of this action. ii. Increasing administrative and clerical resource to provide support for clinics. b GIRFT to work with NHS England and Improvement People Directorate to action specialist nursing workforce needs in endocrinology and encourage uptake of Society for Endocrinology training courses for specialist nurses.

Improve access to weight assessment and management services for patients with complex obesity. a Endocrinology units should appoint a dedicated obesity lead in their team (where they have not already). b Trusts should work with integrated care systems to implement Tier 3 obesity services, with a specialist multidisciplinary team in place to assess and manage patients (where they have not already). These actions are also endorsed by the GIRFT clinical leads for diabetes.

Accurately assign main specialty and treatment function codes to ensure endocrinology activity is appropriately captured. a Trusts to ensure all endocrinology activity is coded using treatment function code 302, and either main specialty code 300 (general medicine) or 302 (endocrinology), according to the job plan of the consultant who undertook the activity.

Ensure there is clear and consistent delineation between outpatient and day case endocrine activity and that pricing arrangements reflect this. a Society for Endocrinology, in collaboration with GIRFT, to produce clear guidelines around which endocrinology procedures should be conducted as day cases (using proposed list - see page 70). b GIRFT endocrinology team to feed into the GIRFT coding workstream with insight on procedures which require more time/resource than a standard outpatient appointment, but less than day case activity. c GIRFT to work with NHS England and NHS Improvement to review pricing arrangements for outpatient and day case procedures to standardise funding and incentivise best practice.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a Use sources of procurement data, such as the NHS Spend Comparison Service and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c Use Category Towers (CTs) to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per unit of activity. b Clinicians and trust management to regularly discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS resolution of any claims that are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified, clinicians and trust management to further review claims in detail, including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims manager needs additional assistance with this, each trust's panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SIs)/Patient Safety Incidents (PSIs) and, where a claim has not already been reviewed as SI/PSI, we recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clerical staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional teams to follow up and support trusts in the steps taken to learn from claims. Clinical leads and regional team directors will also be able to share examples of good practice with trusts.