Scottish Emergency Care

8/8/2019 Scottish Emergency Care

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Primary Care Foundation

Reviewing

Urgent Care in

General Practice


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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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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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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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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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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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Will patients get through?Using data to benchmark existing service


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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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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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What do we find?


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Reminder of the Key Questions

Will theyget

through?

Will they be

spotted?

Will they beseen rapidly?


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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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Benchmarking

Proper comparison

Move beyond anecdote and rumor being turned into fact

ot many examples of benchmarking at scale


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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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Cost per call compared to calls

per head of population


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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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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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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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Referral towards hospital

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Referral towards Hospital


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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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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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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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Other Parts of the World

Tasmania


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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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Scotland

Edinburgh


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Urban Semi Rural


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Very Rural


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Highlands Islands


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Discussion


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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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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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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

Documents

Scottish Emergency Care