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How a roving GP can cut unplanned admissions

Dr Shikha Pitalia’s brainchild to use a dedicated GP for inhours home visits will save her consortium £1m next year. Here she explains how

Dr Shikha Pitalia's brainchild to use a dedicated GP for inhours home visits will save her consortium £1m next year. Here she explains how

The League was formed in April 2006 as a practice-based commissioning consortium in St Helens, Merseyside. We are nine practices, four of whom were singlehanded at the outset, covering 42,000 patients.
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There was an initial buzz of excitement about the potential of PBC but sadly, by October,GPs were wondering if PBC had a future because implementation of schemes was delayed by prolonged processes.

As consortium chair I felt an innovative, simple,‘quick-win'project was needed to regain clinical engagement and confidence in PBC. I devised an acute visiting scheme whose key objective was to reduce unplanned hospital admissions.

Experience suggested urgent home visit requests from patients for conditions such as dyspnoea, chest pain and collapse were likely to result in admission unless seen within an hour by GPs. The white paper Our Health, Our Care, Our Say also suggests 50% of patients taken to A&E by ambulance can be cared for by appropriate community services.

CHALLENGING TRADITION

The acute visiting scheme required us to:

•recruit a ‘floating'GP with a driver/navigator
•use the local out-of-hours co-operative service to act as conduit for calls
•use a standard form for GPs to triage and refer into the service those patients requesting urgent visits
•ensure these patients were seen ideally within 60 minutes
•audit the impact on unplanned admission.

However,the scheme faced some obstacles. It challenged:

•traditional working practice,given that the visiting GP would be seeing patients with only basic clinical information
•the PCT's perception that all daytime visits were core GMS work
•patients'perceptions that only their ‘own' doctor should deal with daytime visits.

After holding detailed discussions with the PCT on how the scheme would demonstrate value for money, the trust took the bold decision to approve a three-month pilot.

But the only funds available were the PBC management allowance,so the deputy chair of the consortium and I decided to forego a share of the allowance to pump prime the project.

The cost was £1,500 a week, covering the visiting doctor's sessions, transport and administration.

We recruited a highly experienced GP via the out-of-hours co-op to work with us on a sessional basis. He is a professional locum, familiar with local services and care pathways,and initially worked four hours daily (9am-1pm).

HOW FLOATING GP SCHEME WORKS

When a patient rings their own surgery to request an urgent home visit they are offered a telephone consultation with a clinician to assess the urgency. This is crucial,given that the practice has access to the patient's history and can make an accurate assessment of needs.

Evidence also suggests that if a patient's own practice recommends another NHS service, then the patient's confidence in that service is higher.

The practice then faxes the visit request to the out-of-hours co-op's central control, and telephones them to ensure it has been received. The co-op records all calls.


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The scheme's GP is then sent to the patient's home. All nine practices in the consortium were covered from the start, and travelling time to patients is no longer than 20 minutes. At the end of each session,the GP completes a standard feedback form that is faxed backed to practices. The GP also has ex-directory direct numbers for all practices.

If there is a quiet day we have a list of ‘cold cases'– such as elderly residents in care homes – for whom the visiting doctor carries out routine reviews,so his time is always fully used. In the scheme's pilot three-month period there was an admission rate of only 1% from the scheme,compared with 5% of visits done by the patient's own GP. This initial success spurred the PCT to continue the scheme for a further three months while a detailed audit was undertaken.

In the first six months 370 visits carried out by the scheme's GP resulted in only four hospital admissions.We did a detailed analysis of 118 of these visits,which revealed that referral into the scheme avoided about 30% of admissions. Nearly a third (31%) of visits were for chest pain, collapse, or dyspnoea or other respiratory problems. Admissions were avoided chiefly because of the speed with which patients were seen and th length of a visit (20 minutes on average).

Patient anxiety about their illness was quickly allayed and the extended consultation allowed time to ask questions and discuss options other than hospital admission. A follow-up patient survey indicated 90% satisfaction with the quality of the scheme.

WHOLE CONSORTIUM BENEFITS

An additional benefit has been improved surgery access. Each visit passed to the scheme releases about 30 minutes of GP time. On average this equates to three additional appointments, that is 27 additional appointments daily, across the consortium.This is equivalent to one whole-time equivalent GP providing two standard GP surgeries per day.

Reducing admissions also lessens risk of hospital-acquired infections and impacts on the 18-week referral-to-treatment target by releasing secondary care capacity. There is no evidence that the scheme has resulted in a rising demand for home visits from patients generally,or an expectation from acute patients of a home visit every time they contact the surgery.

Our insistence that practices triage initial calls ensures the appropriateness of referral to the scheme, or the alternative options of telephone advice or a surgery consultation.

We analysed admission rates post-visit to assess if admissions had just been delayed by the scheme rather than actually avoided and found there was a 1% admission rate, for unrelated conditions,rather than an exacerbation of the same condition.

SIGNIFICANT SAVINGS

Significant savings have been made on our consortium's unscheduled care budget, a substantial part of which the PCT believes is directly related to the success of the scheme.

The net annual savings demonstrated were £500,000 based on admissions avoided. Projected savings are due to rise next year to more than £1m,as the PCT has agreed to provide funding to extend the scheme so it operates 9am-6.30pm.

We plan to retain our existing doctor for two sessions per day and are now recruiting another GP to carry out the rest. We prefer to continue employing them on a sessional basis as this maximises use of our fundingand reduces risk to the service.

LESSONS LEARNED

The scheme owes much of its success to outstanding clinical engagement.The majority of the consortium's practices are small or singlehanded so attendance at meetings can be onerous on clinical time, but the potential benefits of a project encouraged GPs to make time to be involved.

GP feedback about the scheme includes such praise as:

•‘We wonder how we ever managed before the acute visiting scheme.'
•‘I can now attend meetings such as prescribing and develop new services, because the scheme releases time.'
•‘It's the best thing to happen in my 37 years of general practice experience.'

As a result of the scheme's effectiveness, ongoing support for PBC is phenomenal and GPs have great confidence in the abilities of our executive board to deliver on other innovative ideas. The scheme is eminently replicable and I am keen to share best practice and support organisations wishing to set up a similar scheme.

Lessons learned along the way include:

•The driving ethos for any scheme should be a desire to improve patient services.
•The four-week timescale from idea to inception was ambitious but we wanted to put it in place to cope with winter pressures to reduce maximum numbers of avoidable admissions.
•The project management requires intensive efforts of a dedicated individual.
•It is essential to demonstrate benefits to GPs,the PCT,patient group representatives and patients.
•Patient representatives can be useful allies to promote your scheme.
•Remember to involve key frontline reception staff who are vital to the success of many new schemes.
•Key performance indicators should be used to measure success objectively (using standard forms and recording systems) and subjectively (such as patient surveys) in order to demonstrate value for money.

The acute visiting scheme has been recognised as a success nationally as well as locally. We won the NHS Alliance Acorn award in November and we were also shortlisted in the ‘improving patient access' category of another national awards programme last month.

Our scheme has challenged traditional models of working that rigidly define core GMS work,and patients'previous preference to see their own GP.

The scheme demonstrates that it is possible to work across these barriers and integrate core GMS services with new care pathways.

A suitably trained doctor using only basic clinical information on referrals can provide excellent quality care and gain high levels of patient satisfaction,even if the doctor is not the patient's usual GP.

Overall the scheme exemplifies a simple yet effective way of delivering quality services while still providing value for money and making practice-based commissioning a success.

Dr Shikha Pitalia is a GP in St Helens, Merseyside, and chair of The League PBC consortium

How scheme improves 60 second summary Gave up part of management pay to pump-prime scheme Dr Shikha Pitalia Dr Poochi Muthuvel Bagirathan is the scheme's floating GP, carrying out urgent visits Dr Poochi Muthuvel Bagirathan is the scheme's floating GP, carrying out urgent visits 60 second summary

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