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Shared care - a better way of working

Shared care prostate clinic at Colchester Hospital, a model of clinical research and development

Why was the initiative launched?
What steps were taken?
Setting up a pilot clinic
Building on early success
What were the benefits?
From referral to discharge
Tips for success
For more information contact

Why was the initiative launched?

In the early 1990s the Department of Urology at Colchester Hospital was facing pressures. There was growing patient demand when the focus for funded development work was in primary care, not in hospitals. Creative thinking and action was required. Because of pressure on resources in the Trust solutions would have to be found elsewhere. The Department decided to use research funds made available through donations and collaborative research.

What steps were taken?

To retain control over research the Urology Department sought external funding from Colchester Catalyst Charity to help them set up an organisation to manage their research activities. With a substantial grant (£20,000) they set up their own charitable company, URINE: Urology Research in North Essex. URINE had three objectives: to research new technology, to development new technology and to develop the role of specialist urology nurses.

Since URINE was founded it has developed an extensive research programme. From an ImpAct perspective the attraction is the work undertaken to develop the role of specialist urology nurses, and a model for shared-care prostate clinics. To meet growing demand the aim was to find ways to use skills of GPs, the specialist nurse and consultant to the best effect: could a practical way be found to share the necessary tasks? A team led by Urologist Chris Booth decided that they needed a means to test their ideas for a shared-care, nurse-led, consultant-backed, prostate clinic.

Setting up a pilot clinic

A pilot service was based at Clacton Hospital, a large cottage hospital in the Trust. The unit dealt with 44 GPs serving an elderly population where there was a high level of demand. Another attraction was that it was the base for two nurses keen to develop a new role for nurses in urology. Preparation for the pilot involved the design of a structured referral protocol for use by local GPs and a structured interview schedule for use in the prostate clinic. The team also arranged training sessions so that nurses running the clinic had the knowledge and skills necessary.

The ideas for a shared care clinic were presented to GPs in 1993. GPs were encouraged to use the referral protocol instead of the traditional referral letter. To minimise workload on GPs no prior investigation was required and GPs were asked only to indicate the predominant urological symptom, relevant history and drugs prescribed. A specialist nurse would see patients and complete a full assessment, including necessary investigations. The results of this assessment would be discussed with the Urologist and a patient management plan formulated and put into action. The aim was for nurses to investigate and for doctors to treat. Details of assessment and plan were passed to the GP. With the support of GPs the pilot clinic started in November 1993. A synopsis of the assessments completed in the first six months was sent to GPs who were pleased with the new arrangement.

Building on early success

Despite the success of the pilot, problems arose when the Department wanted to adopt the approach at the main general hospital in Colchester. The Trust was unwilling to fund the development of a new clinic. The progress of the independent URINE charity weighed against the Department because it seemed to be too successful in raising funds that were outside of the control of the Trust. The initiative was also happening in the middle of a nursing grading review, apparently to reduce costs. Creation of a new nursing specialist role did not sit well with these plans!

It was not a comfortable time but the team were determined to press ahead because the new approach was right. They funded a urology research nurse from URINE to spend part of her time running a prostate clinic at Colchester. As at Clacton, procedures were explained to GPs and the new clinic was soon a success. After a year the value of the clinic was accepted by the Trust as an important, successful part if the Urology Department, and the Trust took over the costs of the new clinics.

What were the benefits?

In the first year of operation at Clacton, 330 patients were assessed, about six patients at each weekly clinic. Assessments took about 25 minutes. The Urologist's review of the previous week's assessments took about 20 minutes before the regular urology clinic (Table 1). The average delay from a patients' appointment with his GP to the GP's receipt of the assessment was one month. Under the old system this could have taken up to four months. GPs preferred the new approach and said that the overwhelming response from patients was favourable. Patients welcomed the thoroughness of the assessment.

Table 1: Shared care prostate clinic, Clacton. Results of first year’s assessment

  Number %
To GP with no treatment recommended 19 6
To GP with drugs recommended 71 22
To Urologist: urgent appointment 94 28
To Urologist: routine appointment 117 36
Further assessment for drug trial 15 4
Further Investigation 14 4
Total patients 330 100

Shared-care has become the preferred model for patients, GPs, specialist nurses and urologists. Nurses like the responsibility the new system gives them. The protocols have proved robust: a gold standard service. Shared care prostate clinics are now based at the main hospital (Colchester) and at three other sites. The work has strengthened working relationships between the Department and GPs. Relationships within the Trust have also improved as the success of the clinic has become known further afield through national and international publications and presentations.

Audits have echoed the detailed findings from the initial assessment at Clacton. A cost effectiveness study in 1999 showed that the cost of nurse-led clinics (£44 per patient) compared favourably with medical outpatient costs (about £50; Table 2). This is important since the nurse, without medical intervention, can deal with between 30% and 50% of patients.

Table 2: Shared Care Prostate Clinic: comparative costs (£)

  Nurse Consultant Staff Grade Registrar
Salary 5.12 14.17 7.16 6.44
Consumables 1.00 1.00 1.00 1.00
Investigations 23.38 23.38 23.38 23.38
Total direct costs 29.50 38.55 31.54 30.82
Add 20% indirect costs 5.90 7.71 6.31 6.16
Add 30% for overheads 8.85 11.57 9.46 9.25
Total cost per patients 44.25 57.83 47.31 46.23
Note: Costs assume that a nurse spends 30 minutes per patient and a doctor 15 minutes per patient.

From referral to discharge

Patients no longer return to an out patient clinic for follow-up after uncomplicated endoscopic prostatic surgery. A protocol-based, nurse-led telephone service has been introduced instead. Patients are contacted by telephone 4-6 weeks after surgery to check that all is well. The protocol is designed to assess residual symptoms using a scoring system. It has proved to be safe and convenient for patients, who appreciate the reminder of advice given on discharge. Of 100 patients, only two said they would have preferred to attend a regular follow-up out patient clinic. The protocol indicated that 15 should be seen again by their GP and the remainder required no further follow-up.

Shared care and specialist nursing clinics are developing in other areas, particularly for benign prostatic hyperplasia, prostate cancer and continence. In BPH management the shared care clinic's assessment techniques are now being taken up entirely within primary care by GPs and practice nurses. URINE has continued to play a pivotal role by funding the necessary training of nurses through conference attendance and BSc and MSc courses.

Tips for success

√ Find imaginative ways to support your ideas: creation of an independent charity can be effective but time-consuming to set up.
√ Build on the skills of individual members of the team: look for hidden talent.
√ Establish a clear model for what you want to achieve before you start detailed work: make sure you can see the wood in the trees!
√ Use pilots and evaluate them so that you can convince sceptics about the value of you ideas.
√ Don't let the ink dry on your protocols: keep making them better!
√ Don't be deterred by organisational inertia: management involvement might help open some doors but it may not be essential.
√ Make the service so good that ways have to be found to keep it going.
√ Take time to persuade those involved of the benefits of your plans: not everyone will turn up to seminars!
√ Provide educational opportunities for all levels of staff.

For more information contact

Dr Chris Booth, Consultant Urologist
Department of Urology, Essex Rivers Healthcare Trust
Colchester General Hospital, Colchester CO4 5JL

Tel 01206 742450 Fax 01206 742039

The following material is available:

Prostate referral, interview and investigation protocol
Post-TURP telephone follow-up protocol
Haematuria referral/investigation protocol
Suspected urological malignancy referral proforma
Shared-care continence clinic protocol
Setting up a charitable company form

ImpAct bottom line

Determination is a must: don't expect others to share your enthusiasm for your ideas.


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