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At the heart of general practice since 1960

How our PBC group overhauled out-of-hours care

With the new Government planning to make GPs responsible for commissioning out-of-hours services, Dr Yvonne Owen’s scheme in East Lincolnshire could prove to be a prototype

With the new Government planning to make GPs responsible for commissioning out-of-hours services, Dr Yvonne Owen's scheme in East Lincolnshire could prove to be a prototype

When East Lindsey PBC Cluster was established in 2006, it was based around Louth District General Hospital which provided acute services – A&E and mainly acute inpatient care.

We knew these services had been under threat for some time and the fear was the acute hospital trust would withdraw them, leaving the nearest acute hospital 20 miles away.

As this is a very rural area with a high elderly population, poor public transport and a challenging road network we felt it was important to keep services local.

At the time, most GPs in the 14 practices that made up the cluster had opted out of providing out-of-hours care under the new GP contract.

East Lincolnshire PCT had set up a service to cover the East Lindsey cluster area of 90,000 patients , but the standard was low and most GPs were not satisfied. The level of patient complaints was high and GPs often had to pick up the pieces in the next day's surgery.

It began to become clear to us that redesigning and commissioning out-of-hours could form the basis to maintain and develop our local A&E and acute services.

Four years on, there is now a 24/7 walk-in service for A&E and urgent primary care alongside acute onsite inpatient beds on the site of the DGH.

The inpatient beds are no longer provided by the acute trust but through the PCT provider arm, which sub-contracts a GP-led company to provide the A&E and inpatient beds/services.

The key is integration. When a patient walks through the door it doesn't matter whether they are classified as A&E or out-of-hours, we work as a team to look after their needs.

How we did it

We had discussions with West Lincolnshire PCT who were at that point proposing that they would take over out-of-hours cover for the whole county. This probably meant we would not get the fully manned primary care centre at Louth that we felt was needed.

The PCT was supportive of the idea of the cluster taking over out-of-hours for the East Lindsey area and could see the cluster's potential for transforming care and worked well with us.

The first thing we did was to commission an emergency care practitioner (ECP) service from the East Midlands Ambulance Service (EMAS) to provide both onsite primary care services at Louth and a home visiting service. At that time EMAS provided an ECP and a vehicle to cover the out-of-hours period, with additional cover when necessary, for example on bank holidays. The ECPs primarily carried out home visits and also worked in the primary care centre/ A&E based at Louth DGH.

At around the same time we got together local GPs and stimulated their enthusiasm to become involved in out-of-hours care again and worked with the PCT who were to provide the call handling and triaging service.

For the first year this was a cluster- commissioned service. We did our own thing while a single Lincolnshire service covered the rest of the county. Then in 2007 I was approached by the PCT to become out-of-hours lead for East Lincolnshire.

The East Lindsey out-of-hours service is now an integrated part of out-of-hours care across the whole county covering 700,000 patients. I work closely with a colleague covering the west of the county to ensure we have a seamless service. Being registered with a particular practice no longer means you have to go to a particular out-of-hours centre – we take a county-wide approach.

GPs providing A&E and inpatient care

Our vision of a local clinical model in Louth has always had the hospital at its core. We wanted it to have:

• a 24/7 walk-in service, whether for an A&E patient, a primary care patient with urgent needs or an out-of-hours patient

• a service anyone could refer into – patients could self-refer or be referred by GPs, community nurses, intermediate care, social services, mental health team, ECPs/ambulance service, out-of-hours or NHS Direct.

Having accessed our service we wanted patients from this one point of contact to have direct access to any other services they needed such as inpatient beds, secondary care beds on other acute hospital sites, outpatient services, diagnostics, social care and community nursing.

The acute trust was finding it increasingly difficult to provide an acute medical inpatient service that was remote from on-site critical and intensive care and acute surgery. So it was happy when we suggested we look at an alternative model with a view to commissioning services from a different provider.

To fully ensure patients' needs could be met by the new provider we analysed nearly 3,000 of the previous year's admissions and 18,000 walk-in A&E patients so we were very clear about what care patients were given at Louth hospital.

The proposal we developed in partnership with the PCT and the acute trust was that the A&E and inpatient care be provided by the PCT provider arm, Lincolnshire Community Health Services (LCHC) and a public consultation was held.

LCHS has the overall contract to provide out-of-hours services across the county and acute medical services on the Louth site.

The provider arm subcontracts a GP-led company, Louth and District Medical Services (LADMS), which includes GPs from the PBC cluster to provide the medical input in the A&E department, the primary care access centre and the 55 inpatient beds.

The public and all our partners were overwhelmingly in favour of these changes.

There was no resistance to this idea from anywhere, although the PCT needed persuading that we could provide the service. They then employed an experienced project manager who worked with the cluster executive, the PCT and everyone else involved and brought it all together.

The aim was always for this to be cost neutral – the money that the PCT would have paid the acute hospital trust now goes to run the hospital. There was no investment required apart from the management and development costs.

The business plan went through very smoothly. There were clearly identified roles (I led on the clinical side) and the PCT hosted a monthly development board to review progress and keep driving forward, which stopped things slipping.

Transferring staff

New management staff were brought in and a new consultant physician was employed while other staff were transferred to work for LCHS from the acute trust.

LADMs also employ staff grades, particularly for working within the hospital. We've found it good to have physicians with extensive hospital-based experience working on the wards and within the A&E departments. Combining their skills with those of the GPs gives a holistic approach.

Doctors have transferred from LCHS to LADMS. GPs from practices in the area take part in the LADMS rota.

GPs are mostly very excited about working within this set-up. It gives them the opportunity to practise medicine in a much broader setting.

We have doctors who work in their own practices then come up to the hospital to work in the A&E department and on the wards doing things they don't get the chance to do in primary care.

We have a rigorous competency framework involving training and assessment, which was designed to meet the needs of the 3,000 admissions we analysed.

Training involves knowledge of acute care pathways, NICE and other therapeutic guidelines, gained through reading, practical training, shadowing more experienced doctors and then a final assessment.

Results

In April 2009 A&E transferred to the GP-led, PCT-provided service although this had already been gradually happening for about a year as we had been encouraging a greater sense of integration.

Since then we've seen an increase in attendances but not in the transfer of patients to other A&E departments – if anything there's been a decrease as the doctors in the department are comfortable managing a wide range of patients.

The inpatient beds transferred in August 2009 and that's worked very well too. We predicted that an extra 10 patients per week would have to be transferred, for example those with heart attacks or strokes, as we wouldn't have the facilities on site to deal with them, but we continue to take the vast majority of the patients previously admitted when it was run by the acute trust.

We also actively repatriate patients who have been admitted elsewhere for the acute, specialist part of their care.

The average length of stay has been reduced so turnover of patients is better than it was before. This is partly because previously, although there were three consultants, ward rounds were done only twice a week so patients had to wait for the next ward round before they could be discharged.

LCHS has a full-time employed consultant and there is a ward round every day so patients can be discharged daily once they are medically fit enough.

There's now a much better feeling of integrated working and team working – we don't have pockets of healthcare professionals working in isolation.

Because it's a PCT-provided service there's greater communication and integration with case managers who will be taking on responsibility for patients when they're discharged. Everyone's aware of what patients' potential needs are after discharge.

Out-of-hours standards

Within a year we saw the transformation of a service that was underperforming to one that consistently met national quality requirements for out-of-hours. There was a big drop in patient complaints and within the service we saw the practitioners go through huge professional development because they were much more supported.

Hospital services

Activity in the A&E department has increased. We're now setting up a primary care access centre that allows extended primary care access. There has been a drop in the average inpatient length of stay.

The future

At the outset West Lincolnshire PCT didn't believe the cluster could take on out-of-hours. We had to prove ourselves and we did that without a doubt.

In the process of the PCTs merging and taking over out-of-hours for the whole county that scepticism has disappeared completely.

As far as out-of-hours goes we continuously strive to keep performance up, improve quality and patient experience where possible.

From a hospital and cluster perspective we're now looking to develop services on site to try to bring as much as possible to the patient. We're looking at various providers to get as many specialist outpatient services as possible on site such as children's services, maternity services and diagnostics – MRI and CT scanning. We can't provide acute specialist care or critical care and are never likely to be able to.

I believe this is the way forward for out-of-hours services. PBC recognises that one size doesn't fit all and for something like out-of-hours, which has huge variation across the UK, it enables us to look at what

is being provided and ways of improving that by working together in an integrated way.

Dr Yvonne Owen is PBC executive member and out-of-hours GP lead for East Lincolnshire PCT

Coalition policy on out-of-hours

• New health secretary Andrew Lansley has already made it clear he plans to pass responsibility for commissioning
out-of-hours care to GPs.
• The coalition wants to see GP out-of-hours services integrated within a 24/7 urgent care service, with a single phone number providing access to all types of urgent care.

60 second summary

Initiative: Creation of an integrated out-of-hours model at local hospital that has led to a GP provider company now supplying A&E services and inpatient bed care

Investment required: Cost-neutral for PCT

Policy Link: The Coalition: our Programme for Government

Staffing: Consultant physician employed, staff transferred across from acute trust to PCT provider arm, local GPs now working shifts on local hospital wards

Results: Out-of-hours care standards now met, seamless care for patients. Looking to commission outpatient services on same hospital site

Contact: Via susan.mcnulty@ubm.com

Dr Yvonne Owen

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