Shared learning database

Shire Pharmaceuticals & East & North Hertfordshire NHS Trust
Published date:
March 2015

The toolkit was developed and funded by Shire Pharmaceuticals as a service to medicine. It helped the team in East and North Hertfordshire take a step-by-step approach to implementing NICE Guideline CG72 on ADHD for children and adolescents, including:
- Reviewing current service provision against the recommendations of NICE CG72
- Identifying priority needs
- Making the business case for new activities including an expansion of the role of ADHD nurses, and targeted resources for parent/carer support, and advice for professionals. The resulting new pathway implements NICE Guideline CG72 on ADHD for children and young people, and has reduced waiting times, improved the referral process, and improved access to appropriate care.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The toolkit has a range of aims focused on service improvement in line with NICE CG72. Specifically, its aims included to:
- Help NHS stakeholders to identify local opportunities for developing better services in line with the standards of NICE ADHD guidelines for young people
- Enable NHS stakeholders to involve a wide range of relevant stakeholders, including parents and young people with ADHD, in structured discussions about future service provision
- Remove the sense of isolation for people working in ADHD and people who support patients and carers, through providing a structure for change and development that meets local ADHD needs
- Facilitate and improve multi-agency working through providing a forum for the exchange of ideas with the aim of developing improved local ADHD services
- Enable NHS stakeholders to provide enhanced patient care through the implementation of improved multi-disciplinary working alongside more efficient ADHD service provision
- Provide NHS stakeholders with a series of practical tools that can help them to identify development areas in current ADHD service provision and opportunities to enhance local support
- Enable easy to use benchmarking of current practice against NICE Guideline CG72 criteria
- Prepare a step-by-step case for future development through structured tools and targeted workshops
- Enable NHS stakeholders to feel confident about proposing their business cases and influencing local developments in ADHD local care pathways in order to quickly and effectively roll out implementation of the NICE guidelines.

The initial aims of the project using the toolkit in East and North Hertfordshire included to:
- Identify and confirm the need for a local child and adolescent pathway for ADHD service delivery
- Clarify, simplify and communicate the referral process, using the pathway to map the ideal structure for identification, referral, specialist assessment, intervention and support of a child/young person with ADHD
- Audit current practice and service user and HCP experiences, and identify priorities for improvement
- Reduce waiting times
- Route service users to the most appropriate consultants and resources
- Reduce the number of consultations needed for accurate diagnosis per patient
- Increase cases where diagnosis is made in one consultation because pre-assessment and referral has been carried out completely.

Reasons for implementing your project

The context for the toolkit is based around the development areas in service provision that have been identified and documented in the NICE guidelines. These include:
- Consistency in the approach to recognising and diagnosing ADHD (full guidelines, p29)
- Simplification of referral pathways (full guidelines, p30)
- Aligned provision of treatments and interventions (full guidelines, p29)
- Effectiveness of multi-agency working (full guidelines, p31-32). The toolkit has been widely used by people in a variety of roles within the NHS, including a Community Consultant Paediatrician, who leads an ADHD Joint Working Group across North Hertfordshire. The need for change in East and North Hertfordshire was driven and confirmed by a number of triggers including the launch of the NICE Guideline on ADHD (CG72), the employment of a new Consultant Community paediatrician, and surveys with stakeholders including patients, carers and GPs.

Working systematically with a comprehensive ADHD service improvement toolkit developed and funded as a service to medicine by Shire Pharmaceuticals, the team were able to confirm and demonstrate the need for a local ADHD pathway. For example, combining audit data with survey experience, the team established that there were opportunities to clarify the referral process and the referral criteria used. Importantly, there were improvements to be made around making sure that from a single point of access, a patient would be appropriately and quickly referred to the most appropriate resource. For example, there were delays in the system and wasted consultant time because patients were referred to the wrong local service, or were referred before necessary assessments had been carried out.

There were also opportunities to simplify the process and how it was administered. For example, using standard forms and templates, and switching the focus from a paper trail to more cost effective and trackable electronic communication. It also became clear that the team needed to extend the nurse role to help make sure that the right patient was referred to the right type of support, with the right paperwork. So, the NICE Guideline CG72 set out what the team needed to deliver in ADHD. The comprehensive toolkit helped them to pinpoint the priority gaps between current performance and expectations from the guideline, identify core areas for improvement, identify stakeholders, and plan what they would deliver, and how.

How did you implement the project

The launch of the NICE guideline on ADHD, CG72, provided an opportunity in East and North Hertfordshire to develop a new multi-agency pathway for child and adolescent ADHD. The team used a service improvement toolkit, which was developed and funded by Shire Pharmaceuticals as a service to medicine, to help structure and inform its approach. The toolkit broke the activity over three stages.

- The first stage was identifying priorities for improvement. During this stage they surveyed patient, carers and professionals; this confirmed the need for a pathway, as there was confusion around referral steps and criteria. They also used a spidergram in the toolkit to review current delivery against what is expected at each step on the patient journey in the NICE clinical guideline. The team audited its existing service, which helped to target critical areas for improvement. This confirmed a number of challenges to address, including waiting times for treatment, delays in referring to the right service, and referrals delayed because of incomplete assessment inputs.
- The second stage was about preparing the case for development. The toolkit helped the team to map all the stakeholders, identify who could be on the core team, and critically, identify the benefits for them of taking part. Introducing a new pathway takes group consensus from a wide variety of stakeholders, so it is crucial to identify how they think the pathway can improve the service from their own perspective. The team held a series of meetings to gain group consensus on the need for a pathway, and how to progress it.
- The third stage in the toolkit is about implementing the case for development. This included meetings with stakeholders to build and put into action the steps needed to reach group agreement on the pathway, and plan how to launch and embed it. This included targeted launches for different stakeholders including paediatricians, GPs, CAMHS, school nurses and the voluntary sector, backed up with specialist training for GPs. During the work agreeing the pathway, the team identified a number of specific resources needed. For example, the toolkit helped them to make a number of supporting business cases, including for ADHD nurses, targeted parent and carer training, an email referral advice service for GPs and other professionals, and comprehensive local online support for ADHD.

Key findings

The introduction of the ADHD pathway, and actions for targeted support that arose from its development, is delivering a range of benefits assessed by regular audits and data analysis. All core stakeholders continue to benefit from this project, including the clarity introduced by the launch of the pathway, based on the NICE CG72.

- For patients and parents: Reduction in waiting times for referral and diagnosis. Referral to the most appropriate service for diagnosis and support that is right first time. Comprehensive website giving information and support, and making clear the process. Improved visibility of who they can contact for what type of support. Targeted support workshop run by ADHD specialists.

- For consultants: The ADHD nurse now acts as a single point of contact and quality check on pre-assessment work, so most diagnostic consultations now take one session, down from two or more consultations previously. Before the initial consultation, pre-assessment checks and paperwork are completed in 94% of cases, up from 68% previously. In most cases, the necessary observations at home and school have been made, and in many cases the ADHD nurse has also observed the patient. The consultants gain the information they need to make a fair assessment, without the cost or delay of requesting further data.

- For GPs: Clarity about the referral criteria, referral process and shared care. Support through a single point of access triage system on determining which suspected ADHD cases to refer to CAMHS due to their complexity, associated difficulties and comorbidities, and which cases go to the Community Paediatric Child Development Centre. Training and support, including a dedicated local email advice service to support referral decisions and answer GP questions.

- For ADHD nurses: Expansion of status and responsibilities as a single point of contact for families, coordinating and streamlining the referral process, quality checking referrals, ensuring paperwork is complete and correct before consultant time is taken, troubleshooting. Direct observation and feedback on patients as part of the referral process. Supporting families, GPs and schools during the pre-assessment phase. Planned new prescribing responsibilities.

- For commissioners: Local adherence with NICE CG72. Waiting time breaches at constant level despite significantly increased patient throughput. Simplified, clearer process, with less costly administration.

Key learning points

Utilising a toolkit enabled the team to take a systematic approach, identify key stakeholders and resources and develop a project plan. The tools included a spidergram, which helped them to reach agreement on priorities needed to deliver the NICE Guideline on ADHD, CG72, effectively. When developing a multi-agency, multi-modal pathway in health and social care, it is particularly important to identify and plan how to involve and communicate with all stakeholders. In leading a project such as this, a structured approach is pivotal. It took 18 months to develop the pathway and ensure all stakeholders across the local health economy were in agreement to then launching it locally. The toolkit allowed the team to break the work into steps ensuring stakeholders were kept informed and momentum was in place. In addition, it was crucial to balance the need for consultation and communication with all stakeholder groups, while keeping the project steering group to a manageable size. The core steering group was led by two consultant community paediatricians, and included two nurse specialists, a school health advisor, a school advisor for integrated children's services, a consultant clinical and adolescent psychiatrist, one further consultant community paediatrician, and the clinical lead and service manager for the local early intervention CAMHS.

Beyond the core group, the team involved at each stage, a wider group of stakeholders including patients/service users themselves, the local parent/carer ADHD support group, commissioners, Trust Deputy General Managers, GPs and a GP registrar, a consultant paediatrician specialist registrar, a Senior Matron, a CAMHS clinical manager, and an Early Intervention in Psychosis Services medical lead. It was important throughout to keep the service users at the heart of the project, and bring in all perspectives, embracing both clinical and resourcing perspectives, and bringing together, mental health, well-being, and education.

Contact details

Marie Gray & Dr Susan Ozer
Market Access Marketer & Consultant Community Paediatrician
Shire Pharmaceuticals & East & North Hertfordshire NHS Trust

Is the example industry-sponsored in any way?

Shire Pharmaceuticals developed and funded the toolkit as a service to medicine, provided an unrestricted educational grant to East and North Hertfordshire NHS Trust to support pathway development, its printing and launch.