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Create an acute GP unit to reduce emergency admissions

Cornish GP Dr Rob White explains how his PBC group set up a countywide acute GP unit that has drastically reduced non-elective hospital admissions

Cornish GP Dr Rob White explains how his PBC group set up a countywide acute GP unit that has drastically reduced non-elective hospital admissions

Hospital admissions are on the rise nationally. But here in the South West we have set up a pioneering acute GP service that typically reduces emergency medical admissions by 30%, saving Cornwall and the Isles of Scilly PCT (CIOSPCT) hundreds of thousands of pounds a year in the process.

The service has GPs based in the medical admissions unit at the Royal Cornwall Hospital in Treliske, Truro, taking referral calls from 74 GP practices across the county.

Because the GPs on duty in the acute unit are well acquainted with the community and social services on offer within the NHS locally, they can often recommend an alternative to admission that the referring GP didn't know about or hadn't thought of. This could be anything ranging from setting up a visit from the hospital-at-home team, to sending them to a ‘hot' clinic to see the cardiologist of the week, to reassuring the GP their patient management plan is sound – depending on the case.

Preparatory work on the scheme began around two years ago when our local commissioning group, the Carrick Commissioning Consortium, was launched. The consortium covers 10 practices in the centre of Cornwall serving a total of nearly 95,000 patients.

One of the aims we shared with CIOSPCT from the very start was to reduce hospital admissions – something I'd also been interested in independently for a while.

Eureka moment

I read an article in Pulse (pulsetoday.co.uk) about Dr Peter Rudge, a Plymouth GP who had been asked by his acute trust in Devon to look at what happens in an admissions unit. So Dr Rudge literally went and sat in the medical admissions unit (MAU) at his local hospital and looked at what came in. He found that reviewing requests for adult admissions could improve the standard of referrals and reduce non-elective admissions rates.

Dr Rudge started a pilot scheme employing two salaried GPs working eight-hour shifts in the medical admissions unit of the local hospital from 9am to 7pm every Monday to Friday. Figures from the scheme's first year suggested he had prevented an estimated 900 admissions, saving about £1m based on short-stay and average admission tariffs. That's with a running cost of less than £500,000 a year.

I thought we might be able to achieve a similar thing here and have GPs answering the phone, seeing the patients who were referred and reviewing the alternatives. It makes sense to keep people at home where the risks to health are lower with less chance of coming into contact with C. difficile or MRSA. Also, it's sometimes overlooked that GPs are extremely well-trained in risk management.

So I took the idea to the other five GP commissioning groups that use the Royal Cornwall Hospital. At first they were a little suspicious. There was an attitude of ‘if I want patients to go to hospital, I want them to go to hospital'.

But I basically badgered them over a period of abut six months and I was able to convince them to give it a try.

What really won the day were the figures Dr Rudge had arrived at. Broadly, if you save one admission, you save up to £1,000. If you save five a day, that's £5,000 a day and with running costs of around a £1,000 a day that results in £4,000 of freed-up resources every day – 70% of which can go back into commissioning care.

Getting going

The next stage was to get the PCT on board. Donna Chapman, senior primary care manager and PBC locality lead, and Karen Reeves, senior commissioning manager, have been particularly supportive from the start.

Our new model has incorporated a service that the PCT already had in place. This service is manned by call handlers who take the details for each medical admission and organise the transport, where this is needed. Having this service already in post would prove really helpful to getting the current scheme off the ground.

Before the acute GP service started, all medical admissions were simply ‘barn door' with no filter, and to handle this, the MAU introduced its own triage system with an SHO filtering GPs' referral calls.

When we introduced the acute GP scheme we used the same phone number that GPs were used to calling and gradually educated them to talk to the acute GP instead of having calls triaged by the SHO.

CIOSPCT helped write a business case, which it took to the relevant PCT committees and provided an initial £100,000 to prime the pumps for the countywide service. It was agreed the PCT would host the service on behalf of the PBC group. Since April, it has been under the PCT's commissioning arm although mechanisms are in place to transfer it to the provider arm.

GP Dr Simon Barton is our full-time clinical lead employed to develop the service. Simon puts together a monthly newsletter to educate GPs about admission alternatives and also to encourage GPs to use assessment tools such as Wells (scoring system probability for PE/DVT) and CURB scores (for pneumonia). He also includes latest findings on things such as antibiotic regimes that can reduce hospital admissions.

Simon is also developing ‘hot' clinics. For example, in cardiology there will be a ‘cardiologist of the week' to discuss potential admissions with or come down to the unit and see patients. These have existed in some departments for some years – but GPs are not connected with them.

A year's pilot scheme was launched in October 2008 and we employed part-time GPs Dr Janine Glazier and Dr Frank Davey to man the unit – both experienced local GPs with good local knowledge.

Working at the primary-secondary care interface means it is their job to have better knowledge of alternatives and so they ‘specialise' in seeking out and developing such services.

Day-to-day running

The scheme – which has just been given the go-ahead by the PCT for another financial year (2010/11) – now employs five GPs on a salaried basis (2.25 whole-time equivalent).

They are based in three rooms at the entrance to the medical admissions corridor with a shared waiting room, a clinical room and a small office. Instead of working a formal rota, they arrange their early and late shifts (8.30am-4.30pm or 10.30am-6.30pm) between themselves.

We learned very quickly that to be most effective and safe, we needed two GPs together at busy times so there are two GPs on duty to cover the busiest time of day between 10.30 and 4.30. One of the GPs sees referred patients in a clinic from 10.30am to 4.30pm while the other takes calls.

Calls from GPs around the county are taken by the call handlers who are based in the out-of-hours unit nearby. First of all, they record demographic details, addresses and any transport requirements the patient may have on a specially adapted Adastra system. They transfer the call to one of the acute GPs who can watch the same Adastra page on their screen and there then follows a GP-to-GP conversation. If the patient is being admitted, the system will fax the decision and details to whichever service needs them. A copy of the patient's notes is always faxed back to the GP. The acute GP may also decide the patient should be seen at the acute GP clinic described above.

The call handlers drastically shorten the amount of time the acute GP has to spend gathering information as they can basically do the ‘clerical' bit – gather information such as the address and GP phone numbers, and tie it into previous data if the patient has used the service before or used out-of-hours.

The software by Adastra was part of the IT set-up costs for phones and computers of £3,000-£4,000. The acute GPs are employed as salaried GPs by the PCT. They are not GPSIs and need no extra qualifications.

Costings

The costings for the current financial year (2009/10) are as follows:

GP salaries £224,000

Locum fund (for holidays, £49,000

training days, study leave and so on)

Administration (stationery and £5,000

some administrative time)

Prescribing budget £2,000

Total allocation £280,000

The cost for the accommodation is currently under discussion between the PCT and the Hospitals Trust.

Outcomes

Monitoring is carried out using several key indicators related to activity rates. Among other things we look at acute GP activity, analyse the outcomes of avoided admissions and check on readmissions within seven days of admission being avoided to satisfy ourselves patients are not coming back and being admitted three/four days later.

The headline benefits so far are that patient care has hugely benefited, we're saving money and reducing admissions. This of course means that we are also taking pressure off acute medical beds.

The table attached also shows a number of admissions are attempted that are not necessary.

The large number referred back to the GP includes those who come up to the clinic and a diagnosis made or excluded, and are then managed by the GP. So, for example, the GP has a patient with pleuritic sounding chest pain, but is well and cannot find cause. The acute GP can exclude PE and order bloods and CXR. It transpires the patient has a viral infection so a life-threatening condition is excluded – but under the old system that patient would have been ‘in', on a ward waiting to be seen by a chest consultant.

The patient still requires management by the GP and it was correct to make the initial referral, but the result is that the patient has not had to go into hospital to have a condition excluded because of the access to tests the acute GP has.

GPs are trained to manage risk of serious illness much better than secondary care doctors. So access to a few simple rapid tests has prevented admissions. The bottom line is that well patients can be safely managed at home, sick patients need hospital – and this service can sort wheat from chaff.

We plan to do a patient satisfaction survey and also to do a survey of GPs. Our monthly to six-weekly team meetings involve the GPs, call handlers and administrators and discuss the general running of the scheme as well as reviewing any significant events.

On our best day so far we have ‘turned around' – found an alternative to admission for – 16 cases out of 30 calls. Normally we find alternatives for about five patients a day.

Savings

We have been very conservative in estimating the savings the service has produced. We estimated a cost of £560 for a short-stay admission and used that as a basis for calculations even though we know longer stays cost considerably more. Using that figure, over the six months of March to August 2009 we estimate a gross saving of £418,320, which is £2,208 per working day net of budgeted costs.

This forms part of the PBC groups' freed-up resources and some will be reinvested to expand the service next year. The FURs we've made have also paid back the initial £100,000 the PCT paid to start up the service.

Future expansion

I think if we had our time over again we'd opt for better premises to triage the telephone calls from the start. The current office space does not meet health and safety standards – an issue that is now being addressed.

We continue to have frequent meetings with the hospital consultants at the medical admissions unit. We are gradually building relationships and breaking down historical barriers.

In the future, the service could be extended to operate out-of-hours. Taking on some surgical admissions such as biliary colic, low abdominal pain in women, rectal bleeding and falls is also possible. This would be a separate piece of work and would only add an extra seven or so calls a day to the workload. A scheme in the A&E is also being considered.

My tips for anyone else wanting to do this would be to get on board with your PCT, start small if you can and use the figures to win round the doubters. They should speak for themselves.

The bottom line is that GPs have spent a lot of time in hospitals. We've all worked in medical admissions units. We also know our patients. That's the reason this works. GPs know both sides of the coin.

Dr Rob White is a GP in St Agnes, Cornwall

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