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How a care co-ordination centre has saved £2m

A new service launched by a GP co-op has prevented an acute admission in 17% of cases and helped overcome silo working in the NHS, writes Dr Russell Muirhead

A new service launched by a GP co-op has prevented an acute admission in 17% of cases and helped overcome silo working in the NHS, writes Dr Russell Muirhead

A care co-ordination centre (CCC) is Shropshire's answer to the problem of trying to access services in an NHS that operates in fragmented silos, making it difficult for both patients and health professionals to navigate and use the myriad resources available.

41181062The CCC is run by the local GP co-operative, Shropdoc, and its staff can offer GPs advice on community service alternatives to acute admissions, arrange rapid outpatient or diagnostic appointments, and arrange telephone conference calls with on-call consultants before committing to admission.

The service is commissioned by Shropshire County and Telford and Wrekin PCTs for all of Shropshire – covering nearly 450,000 patients and 70 practices across 1,200 square miles. It launched in 2006 as a pilot and has since been fully commissioned, with Powys local health board joining in April 2007.

The case for change

Clinicians and managers alike had felt local health economy resources were being underused, because of what appeared to be inherent communication difficulties across care boundaries. In 2005 there were also serious local financial issues to be tackled. ‘Admission avoidance' was the phrase of the moment.

The PCTs carried out research, involving PCT staff or a Shropdoc GP sitting in local hospitals' bed bureaux, taking admission calls from GPs in the community. They asked for the patient's diagnosis, where the GP wanted to refer them, and then whether the provision of any other service would enable them to treat their patient differently and thereby avoid an acute admission.

The findings mirrored those of several other studies – up to 40% of patients could be treated appropriately without admission.

So why not the single point of access model?

Local clinicians felt meetings to explore solutions used rather negative terminology – ‘avoidance', ‘single (that is, no alternative) point of access' – leaving a feeling of barriers being put in place.

Shropdoc's ethos was always an enabling one to secure the very best care for clinicians and patients, and we wanted that to be the ethos of the CCC.

As an out-of-hours co-op, we were used to managing the patient journey and we knew we could transfer those skills to the in-hours period.

41181061But we would not just be a call-handling and forwarding service like a traditional bed bureau – we wanted to help the GP to access the most appropriate service in an easy, timely and effective way for the patient, and to co-ordinate that journey.

Cost savings would be a beneficial side-effect rather than the prime objective.

Preparation

The service was quickly designed in collaboration with Shropdoc, the PCTs and the acute trust.

We already had existing co-op facilities and a workforce of call handlers and triage nurses from whom to recruit to the CCC.

The main other preparation carried out was:

• establishing a single dedicated telephone number into the CCC

• customising our out-of-hours IT software to allow a full electronic patient record

• enhancing our existing Electronic Directory of Resources (EDoR), which was added to as new services became known

• spending a significant amount of time going out and talking about the CCC to GPs, nurses, hospital staff and consultants, support services such as diagnostics, community nurses and hospitals, social services and others

• producing an information letter before CCC went live for distribution to all parts of primary and secondary care, and PCT and community services.

Start-up funding was mostly needed for staff costs and a little IT and telephony support.

The PCTs funded the initial pilot ‘at risk' for 18 months. However, our business plan, based on audit data, showed these costs would be recovered with only one or two admission diversions per day.

How does CCC run in practice?

The CCC is a 24/7 operation as we have incorporated the bed bureau into the service, while the admission diversion service is operational 8.30am-7pm, Monday to Friday. On average we receive 50 calls a day, with Monday and Friday inevitably the busiest.

The process is:

• GP phones the dedicated 0845 number.

• Call handler enters patient demographics on to the IT system.

• Call is passed to triage nurse who takes clinical details from GP and discusses further management of patient. The triage nurse has a number of different options to aid this decision-making process:

– direct referral to secondary care

– access to the EDoR to advise on services available locally

– ability to telephone conference with either the admitting hospital team or on-call consultant before committing to admission

– ability to book same-day or urgent outpatient appointments

– access to rapid diagnostics (DVT screening is a good example of a patient care pathway that can be co-ordinated by the CCC to arrange same-day Doppler scanning or tinzaparin treatment and next-day scanning)

– access to community hospital beds, intermediate care or DAART (diagnostic assessment and access to rehabilitation and treatment) units.

• Once the clinical decision has been made, the triage nurse takes responsibility for arranging the patient's further care and also books patient transport if required.

• The call is only completed when the patient is handed over to the next part of the service and information on this disposal is relayed back to the GP.

Finding the right care can take a significant amount of time and negotiation for some patients which, thanks to the CCC, is a task no longer required of the referring GP.

Results

The CCC had an immediate effect (see box below). Figures for 2007 show an average of 17% diversions, mostly in the medical category. This reflects our ability to rapidly develop a DVT pathway and, second, the increased use of local DAART units.

These services were either in existence or easily developed. We originally predicted a potential diversion rate of 40%, which we still feel is achievable in the short to medium term.

In the beginning there was concern that diversion really meant admission delay and patients would ‘bounce back' into secondary care a few days later. Audit has shown this is unfounded, with readmission rates for patients dealt with by CCC at less than 2%.

The reasons for these readmissions were lack of same-day diagnostic capacity and lack of access to consultant opinion or outpatient appointment.

Several GP feedback exercises have shown consistently high satisfaction rates. Many secondary care consultants have also commented on the benefits to their service. We also have many examples from patients and staff of superb care taking place in cases where an acute admission would have been the previous default.

Savings

The vast majority of diverted patients were treated within existing services so any figures are liable to represent true savings to the health economy rather than costs shifting from one service to another. There is an ongoing debate on how savings should be calculated but we have taken a conservative local figure of £1,500 to represent an average short-stay admission.

We estimate that in 2007 about £2m to £2.5m was saved. If the diversion rate rose to 40%, savings would rise to £4.7m to £7m.

The PCTs' costs were recouped within the first few months of operation.

Lessons

The biggest challenge to a successful CCC is the ability to communicate and work across boundaries.

There is no substitute to getting out there and talking to everyone involved in the patient journey. Only by understanding and integrating the way in which people provide their own services can you hope to marry the different parts together and effectively tackle service redesign and implementation.

Data generated by the CCC is a very powerful lever: it informs commissioners and providers of gaps or blocks in their systems, tells providers to change or expand to deal with patient demand, and reveals where time is lost during the journey.

Other advice and lessons we have learned include:

• check that everyone who needs to know has received details about the service before launch; in our case information had not cascaded to frontline personnel in some cases, causing problems in the first few days

• Friday is often the least effective day for diversions as many services are not available over the weekend period

• ensure the clinical discussion with the referrer and handover to the next service is appropriate and efficient

• check back with the referrer that the outcome was satisfactory

• check back with receiving services that appropriate referrals are taking place

• check with patients that the care they received was optimised.

The future

The CCC team have worked extremely hard to build the service into an effective resource and remain highly motivated and enthusiastic to push the service further. They really feel that they are making a difference to the care patients receive.

Commissioners also remain committed to the scheme, thanks to the results we have shown.

We are now planning a range of projects, such as developing a dozen primary care pathways, mapping capacity and activity across the whole operation footprint, and supporting an extending district nursing service in the evenings.

Impact 60 second summary Dr Russell Muirhead Dr Russell Muirhead Dr Russell Muirhead

The CCC team remain highly motivated and enthusiastic to push the service further

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