GPs in Bolton have pioneered an urgent care clinical dashboard and seen reductions in non-elective and A&E admissions. Bolton GP Dr Anne Talbot, now the national clinical lead for the QIPP project, explains how it works.
The urgent care clinical dashboard is a web-delivered application that can be accessed by GP practice staff from any desktop, and in Bolton's case using the NHS smartcard.
It collates all the previous day's activity data from A&E, hospital admissions, discharges, out-of-hours care and walk-in centres and brings it all together in one place. Previously, A&E information took 48 hours to reach us and admissions data only came after the patient had been discharged.
The dashboard means you can see the raw data around any of the patients in your practice who have accessed unscheduled care. If you click on the dial representing A&E activity, you see a list of patients who have attended A&E in the previous 24 hours The information we now receive isn't anything we didn't have access to previously. The difference is the information is available quickly and in a very easy to understand format.
Each practice can tailor their dashboard using the indicators they find most useful. It can be linked with practice disease registers to show which patients accessing urgent care have diabetes, asthma or COPD, for example. In practice you can use this feature to flag other information against the patient – for example, you could use it to identify a register of patients in nursing homes.
Data reaction
It's up to practices how they use the information the dashboard provides. For instance, they could invite an asthma patient who has repeatedly accessed unscheduled care to the practice for a treatment review. Our active case managers are now able to identify when their patients get admitted, and link in with the acute hospital team to support their discharge.
The dashboard is very adaptable and allows you to interrogate data over time – for example over a week or 14 days, or by type of unscheduled care service – and enables you to identify trends. When I first used the dashboard it was like suddenly having the blinkers taken off. I was quite shocked by the fragmentation and duplication in the system.
Where dashboards came from
A number of clinical dashboards were developed as part of the NHS Next Stage Review. Lord Darzi recommended the use of dashboards presenting selected nationally and locally developed measures to drive forward improvements in patient care. The recommendation followed NHS medical director Professor Sir Bruce Keogh seeing them in use in the US and elsewhere.
We were first asked to develop a dashboard and assess the use as a ‘proof of concept' in 2008. I simply wanted a better idea of where my patients were in the system and what was happening to them.
The dashboard was refined and rolled out across NHS Bolton in 2009 as part of the NHS Connecting for Health Clinical Dashboard pilot, and has developed continuously and organically ever since. We have a user group led by a local GP which meets every two months and provides feedback on how our local practices would like the dashboard to develop.
We all have our favourite screens on the dashboard that provides us with an insight into where our patients are. I particularly like to drill down to patients with the highest unscheduled care activity. We now have enough accumulated data to look at timelines of our activity and make comparisons, which also feeds back into service development.
Nearly all GP practices in Bolton now have the dashboard. We have active case managers shared between practices, who are able to access and use the dashboard to identify patients that may benefit from active case management. The smart card allows them secure access to data from each of the practices they work with.
GPs find the system intuitive to use and our project lead says that while training GPs and other practice staff to use it only takes 10 minutes, the session tends to last an hour or more, because the information it provides GPs with is so relevant to their daily work.
Outcomes
The dashboard is an important part of the QIPP urgent and emergency care workstream, which aims to support the introduction of a system into the NHS to guide patients to the right care in the right place and to help to cut A&E admissions nationally by 10% by 2015.
Our figures so far suggest that across NHS Bolton, the dashboard has contributed to a 3.14% reduction in A&E admissions over 12 months.
It has also contributed to a reduction of 4.19% in non-elective admissions in the same period, equating to an estimated efficiency saving of £600,000.
Some practices have demonstrated more dramatic changes. In my own practice, for example, which has a population of just under 17,000 patients, non-elective admissions have reduced by 16.9% over the past two years.
Once the dashboard system is set up, all the daily data flows are automated and the system requires very little human intervention, keeping operational costs low.
We were using active case managers prior to this work – however, the dashboard now allows them to work more proactively and identify patients to whose care they can make a real difference. We have redesigned the service as a result.
Lessons
My advice for others would be that it worked well in Bolton because it was clinically led. And although teamwork with the IT and informatics specialists is very important, clinical leadership is key. The dashboard was designed by clinicians for clinicians.
It's also important to remember that the dashboard is a tool, not a solution – and for me, it's very important to get the message out that it is something that can be used in conjunction with other improvement initiatives to reduce inappropriate A&E attendances and non-elective admissions.
More pioneers
The dashboard approach is being implemented further via a network of pioneers. We had expressions of interest in January from 45 PCTs and GP consortia. We've chosen 12 as pioneer sites and invited them to work with the initiative.
There's one in each region of England, with two in the North West and two in London. There are also a number of associate pioneer sites, including Liverpool and Gateshead, where we felt they were well on their way already to developing their own dashboards but could benefit from being part of the wider pioneer stage.
There is no pre-developed dashboard software solution provided as part of the project, and most of the pioneers have an existing business intelligence capability that they plan to extend. There is, however, a focus on standards and on making each dashboard deployment as replicable as possible. To support the implementations, a comprehensive toolkit is being provided to each pioneer, and interoperability toolkit (ITK) data feed specifications created for the key information flows.
In June, we will be asking for further expressions of interest, and hope to expand to a further 20 pioneer sites.
Dr Anne Talbot is a GP in Bolton
Dr Anne Talbot: the dashboard means you can see the raw data about which patients have accessed unscheduled care Dr Anne Talbot: the dashboard means you can see the raw data about which patients have accessed unscheduled care
