A symptoms-based approach to ‘funny turns’
A pioneering ‘funny turns’ clinic marks an expansion of the borders of generalism, says Dr Mark Welton.
I often see patients with ‘funny turns' as well as clear-cut TIAs and strokes, and it has become apparent to me that many clinicians struggle to effectively assess and diagnose patients with this set of symptoms.
In my opinion, this is partly because of the wide range of potential pathologies causing these symptoms and partly because specialists seem to be so highly specialised these days.
This results in a diagnosis being excluded, but no diagnosis being positively made. The number of ‘generalists' in secondary care has also reduced significantly.
For example, a patient with funny turns is referred by his GP to cardiology. The cardiologist assesses him and excludes significant cardiac disease, but is unable to further make a diagnosis because the existing diagnostic possibilities are ‘not within his field'.
Additionally, patients can be sent to the wrong specialist by the referring GP – with vertigo episodes being referred to neurology rather than ENT in the first instance, for example.
Some patients go from neurologist to cardiologist to ENT, and can end up with three or four specialist opinions with each not really knowing what the problem is. Everyone is so super-specialised it can fragment the patient journey. That's why the funny turns clinic fits in so well.
What we did
The idea for a triage and assessment portal for patients with funny turns fermented in my head for 12 months or so before I did anything about it. When PBC commissioning clusters began to be formed, our cluster was looking for a project to develop – so I went to our cluster members with my idea, pointing out the significant cost savings to be made by a reduced number of referrals, with fewer investigations, and improved patient care with a diagnosis being made more promptly.
I first spoke to my consultant in TIA, Dr Simon Ellis, about it. He is a consultant neurologist with a special interest in cerebrovascular disease, and he agreed to be my educational mentor.
In 2007, we set up a pilot to see three patients a week, which ran for four months, with all referrals just from our cluster. It seemed to go really well. GPs really liked the clinic and what it did for their patients. In 2009 the wider PCT (NHS Stoke) commissioned the service, and in 2011 an adjoining PCT (NHS North Staffordshire) did likewise.
From the outset, the clinic was set up with clearly defined goals and referral pathways. A proforma for referral was produced, with pre-referral investigations recommended (routine bloods and an ECG).
Standard data was to be collected on patient demographics, speed of appointment, diagnosis, further tests required, onward referral to a specialist and complaints.
A commitment to seek patient and GP feedback on the clinic was made. Funding was ring-fenced.
In terms of staffing the project, it's really just been me as lead clinician, our cluster administrator and the head of the local Choose and Book involved. I do all triage – four appointment slots a week, 44 weeks of the year. Once we'd decided to use Choose and Book, we set up a section for the funny turns clinic and trained operatives to divert appropriate referrals to me.
We also used our own practice secretary to do the admin work for the clinic and gave her more hours so she could fit that in. I use my own consulting room for the clinic. Contracts are directly with the clinical commissioning groups now, although the initial contract was with NHS Stoke.
The main barrier to doing things these days tends to be apathy. It's difficult to change a referral pathway in your head. The way round this was that I bombarded GPs with emails reminding them about the clinic. It was just about getting them to be aware of our existence.
There was not a lot of resistance from the hospital side. However, I do joke with my consultant friend that the clinic means he's lost some of his private income from women having funny turns.
There was some GP resistance to Choose and Book when it first launched, but that had more or less died down once we came along with the funny turns clinic. I got a few faxed referrals at first.
My advice to anyone thinking of doing the same would be simply to look at the savings. It costs £400 for a TIA appointment. Seeing a cardiologist costs £285 and it's £90 to £100 to see me. So if seeing me at the clinic saves £150 and I do four appointments a week, that's £600 a week, £2,400 a month and £28,000 a year – so it soon mounts up. My clinics cost £8,000 a year to run, so it really does bring savings.
A total of 86% of patients are managed entirely in the clinic with no referral or investigation required. Only about 4% of patients need investigations such as CT or ECG, and about 10% are referred to a cardiologist, neurology or ENT. Previously these patients might have had several specialist appointments.
Setting up the clinic has definitely led to much greater awareness of funny turns among GPs. I felt all along it was really important to provide good-quality feedback to GPs about their referrals, so we factored that in. I wanted letters to go out within 48 hours – as a GP, I have been frustrated in the past by long waits. I like to make a point of explaining something I've found. In the old days, a specialist's letter was an education – now they're generally pretty functional. I wanted my letter to set out my thought processes and provide where possible a proper management plan – ‘try this and if that doesn't work, try this'.
We did a GP satisfaction questionnaire after two years. The results were very positive. Colleagues liked the speed of the letter and found the whole thing very helpful. Patients also felt quite happy with their experience and more empowered.
The other clusters are keen to use the service. They've also asked me to do some educational workshops. I don't see why the service shouldn't be rolled out more widely. Trusts could do it too if they had a clear concept of doing it holistically.
I have also thought about setting up chambers. I have colleagues – one is a neurologist and the other is a geriatrician – who would be keen to join me in providing a similar service more widely.
I think the symptoms-based approach could also work for other clinics – you could have a breathlessness clinic, for example. There's certainly room for more of this type of work. There is only one other funny turns clinic in the country.
Dr Mark Welton is a GP in Stoke-on-Trent
A typical case study would be a 30-year-old lady referred by her GP because of episodes of collapse linked to stress.
I'd triage, take a thorough history, note the symptoms and do a full examination – cardiovascular, seated and standing blood pressure, neurological tests and then a hyperventilation test of 15 quick breaths in and out.
Often after six or seven breaths, the patient will experience the exact same symptoms as during her funny turns. I then get her to do controlled breathing to return to normal.
Often, this is the first time anyone's said: ‘I know what the problem is. There's too much adrenaline, you're hyperventilating and we need to work on your breathing.'
I'll teach the patient some breathing exercises and maybe prescribe some medication.
So the patient leaves with her diagnosis, a management plan and a treatment strategy – and no referral is necessary.