scottish emergency care
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Primary Care Foundation
Reviewing
Urgent Care in
General Practice
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Primary Care Foundation
Urgent Care in General practice
Our experience so far suggests that most general practicehas a limited focus on dealing with people with urgent needs
In general, there is an inverse care law, with those with thegreatest needs being left until last
Our approach
Capturing both the normal range of current practice as well asbest practice
A pre-tested questionnaire to identify current performance onmanaging same day care across 5 PCT demonstration sites
Working with 8 pilot practices
Developing practices to make practical and realistic changes
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Primary Care Foundation
A web based questionnaire
1. Access to practice No of lines for patients
Access by phone
Access by internet or email
Appointment capacity
No of planned extra slots?
2. Assessment Use of protocols
Training for staff
Use of computerised decision support systems
Triaging patients clinicians & receptionists
Regular triage or only when full?
How are requests for home visits assessed?
3. Response How long does it take to respond to home visit requests?
Is there a duty doctor or doctor of the day system?
Are they free to respond rapidly without leaving a clinic?
Do you work with others practices to assess or respond?
Will Patients getthrough?
Is there capacity tosee them?
Will the tiny number ofpotentially urgentcases be spotted?
Will they be seen withthe necessaryurgency?
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Primary Care Foundation
Principles
The response and system is safe How urgent the problem is Defined by patient
Only defined by patient until assessment by the practice
Life Threatening - Practice has a system which reliablyidentifies those patients with acute urgent problem
Pathways developed for these cases Pathways are in place for high impact cases ( Palliative,
Respiratory, Cardiac, Frequent)
Adequate balanced capacity is in place to meet the demand Balance 30% same day 70% book ahead Telephone consultation can increase capacity Response to visit requests is timely
Practices set their own standards!
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Primary Care Foundation
Developing the principles for urgent casespresenting to General Practice
The system must besafe for the patient
Secondary principles
Minimal delay reacting toa patient that presents
Which implies
Urgent is defined bypatient until assessed
Plans and capacity torespond as needed
Must deal with patients wherever they present
Must avoid long queues (for initial phone call,assessment or face to face)
Receptionists have adequate training/ process toidentify potentially urgent cases
Potentially urgent cases should be assessed by aclinician as early as is practical
Must have adequate receptionists for calls and face toface
Must have duty clinician or other arrangement forearly assessment
Must have capacity and plans to react if patient needsto be seen
In cases of doubt, thenerr on the side of safety
Build safety netting (advising callers what to do if thecondition worsens/does not improve) into the process
In cases of doubt ensure that the patient is assessedor seen sooner rather than later
Primary principle
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Primary Care Foundation
There is a very wide variation in the number of
appointments and the proportion of slots that can
be booked for same day treatment
1
1
um o
Num
er o
ee
y a
ointment
er 1
o
u
ation
um o
Num
er o
a
ointment
or
ame day
atient
er 1
o
u
ation
Num
er o
ee
y a
ointment
er 1
o
u
ation
ata
There i a igni icantvariation in num er o
a ointment each ee
er 1 , atient romerha 7 to 17
The % avai a e orame day a ointment(red ar) varie rom a
e % to c o e to 1 %
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Primary Care Foundation
Will patients get through?Using data to benchmark existing service
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Primary Care Foundation
Telephone Capacity
Based on 85% of calls being answered within 30 seconds and an averagecall length of 90 seconds then the peak numbers of calls that can be handledare:
One agent 7 calls per hour Two agents 3 calls per hour
Three agents 60 calls per hour Four agents 92 calls per hour Five agents 26 calls per hour Six agents 60 calls per hour Eight agents 232 calls per hour
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Primary Care Foundation
Telephone triage
Dreadful concept
o choice
I the nurse/doctor know best
Reduces choice
Huge waste of resources
Practices who gave patients no choice
50 60 % had to be seen following Triage
Patients offered CHOICE of coming in or telephoneconsultation
80% of telephone episodes did not need to be seen
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Primary Care Foundation
What do we find?
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Primary Care Foundation
Reminder of the Key Questions
Will theyget
through?
Will they be
spotted?
Will they beseen rapidly?
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Primary Care Foundation
Establishing anational benchmark for
out of hours services
At last there is a real hope that we will soon be able
to accurately compare services across all out of
hours providers and drive up the quality of care for
patientsDavid Colin-Thom, National Clinical Director for
Primary Care
A successful benchmark will help us celebrate the success of a
service that supports over 8 million people a year and could
offer fresh ideas for extending access in primary care and
delivering consistent high quality care around the clock key
drivers for world class commissioning of the future.
Michael Dixon, Chairman, NHS Alliance
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Primary Care Foundation
Benchmarking
Proper comparison
Move beyond anecdote and rumor being turned into fact
ot many examples of benchmarking at scale
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Primary Care Foundation
Cost per head
$0.00
$2.00
$4.00
$6.00
$8.00
$ 0.00
$ 2.00
$ 4.00
$ 6.00
$ 8.00
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Primary Care Foundation
Cost per call compared to calls
per head of population
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Primary Care Foundation
Time to assessment of urgent cases
compared with % urgent on receipt
0.0%
0.0%
20.0%30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
00.0%
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Primary Care Foundation
Cases per clinician hour at peak
times (weekend mornings)
0.00
.00
2.00
3.00
.00
5.00
6.00
7.00
Cases per clinician hour at peak times
(Weekend Mornings)
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Primary Care Foundation
Outcome of Patient Contacts
(Dispositions)
PCT A
Ta le of all Out of ours Pro i ers (total of pro i ers)
36.1%
46.
%
1
.
%
A
ice & refer
Primary Care Centre
ome Visit
Type Your PCT Rank low me ian high
A ice & referral 36.1 6 34.8% 45.8% 65.1%
Base 46. 3= 3.1% 38. % 48.5%
ome Visit 1 . 9 5. % 16.0% 6.8%
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Primary Care Foundation
Referral towards hospital
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Referral towards Hospital
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Primary Care Foundation
Clinical Governance:Providers scored themselves, generally low
on coding and prescribing
Sco es against clinical gove nance indicato s
0
2
3
4
5
67
8
9
0
Initial priorit
Di
po
ition and priorit
Coding and pre
ribingReferral
Produ
ti!
it
Ma"
imum
ore A!
erage
ore Minimum
ore Your PCT
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Primary Care Foundation
What lessons for Out of Hours in thefuture
Current standards are stifling innovation
Leading edge services are moving away from triage
Why assess everyone?
Give patient choice Telephone consultation
Base consultation
Walk in base consultation!!! (Radical stuff)
Home visit
ot the same model everywhere
Urban and rural (Highlands, Islands)
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Primary Care Foundation
Service Model Some radical thinking? not that radical!
The population are not Idiots
They do not require staff to Direct
Triage
Manage Demand
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Primary Care Foundation
Other Parts of the World
Tasmania
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Primary Care Foundation
Some data from GP assist Tasmania
Sef are
Pres ri tion
ura GP
ome isit o art
S ed ini
t er
e orted eat
Pat o o y
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Primary Care Foundation
Scotland
Edinburgh
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Primary Care Foundation
Urban Semi Rural
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Primary Care Foundation
Very Rural
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Primary Care Foundation
Highlands Islands
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Primary Care Foundation
Discussion
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Primary Care Foundation
The evidence
Fast tracking systems in the ED can reduce waits.
Case management for chronic disease and high serviceusers can reduce demand, as can home support and
specialist nurses. Point-of-care testing is faster than centralised laboratory
testing.
Seniority of staffing reduces delays.
Triaging out of the ED can reduce usage but its safety isnot known. US evidence suggests safety issues
Primary care gate-keeping can reduce attendancenumbers. Safety may be an issue
Ref: Towards faster treatment: reducing attendance and waits at emergency departments
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Primary Care Foundation
The evidence
A&E Triage systems cause delay and may be unsafe
Patient education is of unproven advantage in reducingattendances.
The benefits of diverting cases away from EDs by theambulance service are not proven.
There is a lack of evidence about bed management anddelayed discharges.
Priority should be given to further research on the role ofparamedics and on diverting some 999 calls to advicelines since the impact of these innovations on patientsafety is uncertain.
Ref: Towards faster treatment: reducing attendance and waits at emergency departments
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Primary Care Foundation
The evidence primary care
Rapid response in primary care reduces hospital admissions Case management works if function of primary care teams
not one prof group Many admission avoidance statistics doubtful reliability
some are made up Evidence that disease management not linked to GP surgeries
may add cost and admissions Growing body of evidence that General Practice can influence
emergency admissions St Helens 30% reduction Home Visits orfolk 50% reduction Rapid response to acute emergencies Runcorn 50% reduction Primary Care team and proactive
management
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