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CCGs told to ensure 'no patient' attends A&E because they can't see GP

CCGs are being told by NHS England to commission services to ensure that no patient has to go to A&E because they could not get a GP appointment, as part of a series of interventions to relieve the urgent care crisis.

The diktat from NHS England is one of eight recommendations coming as a result of medical director Sir Bruce Keogh’s urgent and emergency care review aimed at alleviating pressure on urgent care services, and also calls on commissioners to have arrangements in place with primary care for falls prevention and treatment.

There is no indication how CCGs should ensure that no patient attends A&E due to a lack of GP access, but they were told to submit their plans to carry out these requirements by yesterday.

It comes amid a move by the Government to create seven-day GP services, party in a bid to cut down on A&E attendances.

GP leaders criticised the move, stating that linking a lack of GP access to A&E attendance was ‘perpetuating myths’ about urgent care pressures.

In the first part of the Keogh Review to be rolled out, NHS England sent a letter to CCGs on 28 April stating a series of measures CCGs should be implementing, including:

  • Ensuring ‘no patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP’;
  • ‘Each care home should have arrangements with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital’;
  • ‘A common clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be considered’.

The letter said NHS England was ‘now emerging from what has been a very challenging winter for urgent and emergency care’.

It added that it was ‘clear that CCGs need to include year-round resilience planning, with an additional specific focus on winter’ and it is therefore ‘crucial that CCGs commission enough activity to deal with demand’.

NHS England called on CCGs to submit plans, but said that CCGs will be expected to transform urgent care services, adding: ‘Detailed guidance to support this is being developed, and we will write to the system again regarding next steps in due course.’

But GPC urgent care lead Dr Charlotte Jones said that asking CCGs to ensure patients do not go to A&E was ‘perpetuating myths’ about urgent care pressures.

She said: ‘It fails to recognise the sheer volume of work and pressures facing general practice at the minute. It perpetuates the myths that there are significant numbers turning up at A&E who should have accessed their GP. Let’s not forget it is up to practices how they determine how they manage unscheduled care needs of their population.’

However, she added that the clinical hub was an ‘eminently sensible suggestion’, although it must take into account that out-of-hours GPs ‘would normally be working in other parts of out of hours or unscheduled care’, so could affect the workforce.

The Keogh review, which was set up in 2013, previously suggested GPs offer more same-day telephone appointments to handle urgent patient needs.

NHS England’s eight high-impact urgent care actions

  1. No patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP. This means having robust services from GP surgeries in hours, in conjunction with comprehensive out-of-hours services.
  2. Calls categorised as Green calls to the ambulance 999 service and NHS 111 should have the opportunity to undergo clinical triage before an ambulance or A&E disposition is made. A common clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be considered.
  3. The local Directory of Services supporting NHS 111 and ambulance services should be complete, accurate and continuously updated so that a wider range of agreed dispositions can be made.
  4. SRGs should ensure the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support and responsive community services.
  5. Around 20-30% of ambulance calls are due to falls in the elderly, many of which occur in care homes. Each care home should have arrangements with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital where appropriate.
  6. Rapid Assessment and Treatment should be in place, to support patients in A&E and Acute Medical Units to receive safer and more appropriate care as they are reviewed by senior doctors early on.
  7. Daily review of in-patients through morning ward or board rounds, led by a consultant/senior doctor, should take place seven days a week so that hospital discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend.
  8. Many hospital beds are occupied by patients who could be safely cared for in other settings or could be discharged. SRGs will need to ensure that sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the DTOC rate to 2.5%. This will form a stretch target beyond the 3.5% standard set in the planning guidance.

Source: NHS England



Readers' comments (48)

  • And it came to pass that all patients directed themselves to the appropriate services after careful consideration of their needs!

    I will direct my reception staff to send all patients with sprains cuts bruises injuries (and on) to A+E as they were caused by accidents.
    NHSEngland need to put the effort in to find out what we're doing in primary care when not bitching about them on Pulse ;)

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  • This is simply unachievable without a lot more funding for primary care.
    Simply dictating or wishing these results will not make them happen.
    Point 7 can be achieved however by delaying discharges on a friday in order to increase the % discharged at the weekend!

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  • No Patient to request urgent assessment after an inappropriate hospital discharge
    No Care home visit request after patient discharged from hospital with inadequate end of life care
    No Patient to be seen by GP because A&E/Hosp/Urgent Care centres couldn't deal with minor ailments
    No Patient to see their GP because of self limiting minor ailment that has been present for less than 6 hours!
    No Patient to attend GP because their physician cannot possibly tackle hypertension, COPD and osteoporosis combined
    No Patient to attend GP to request expedition of hospital appointments or investigations
    No Patient to attend their GP to explain and follow up investigations ordered by the hospital

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  • My main difficulty is the specific question asked at AED each attendance "did you try to see your GP?"
    Answer "no" and get a bollocking once and you are a ""yes and they could not fit me in" on all future occasions.
    I would take more notice if "did you approach any other NHS service?" was the question.
    The current one is a little bit too much "when did you stop beating your partner?" for my liking.

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  • Consult yesterday. Patient walked into reception with symptoms suggestive of gout. Appointment offered an hour later (not bad I thought), patient unhappy and took himself off to our local A&E.
    5 hours later A&E called asking why we had refused to see him. This was not an isolated incident.

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  • Wrong!

    A+E need to stop seeing patients needing routine care and route them back to more appropriate services.

    Accident and Emergency - the clue is in the name.

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  • NHSE need to create recommendations on protecting GP from unnecessary work:
    1. do not present with minor ailments
    2. do not book appts with GPs to expedite hospital appts/ investigations
    3. if any hospital tests/results not understand, do not ask your GP to explain it to you, ask the consultation /hosp team.
    4. Appropriate discharges. If not done send the work back to hosp. drs.
    5. sick notes after an operation. Hospital team should give right duration of sick note.
    6. start discussing medical insurance for patients as the current funding level isnt adequate. Once payment of some sort comes in most inappropriate presentations will disappear.
    7. Educate all schools, CAB, solicitors, employers: NOT to tell pts/relatives to get letters from GPs and not to block GP appts.

    hope NHSE are reading these comments

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  • Peter Swinyard

    Love @9.58 and @10.56 comments.
    Clearly there is a veracity gap when patients tell A&E that we have no appointments/have refused to see them/they want to see a doctor in pyjamas or whatever. Would patients feel that they had a better deal if we all wore pyjamas (scrubs) instead of neat business dress?
    i regret that Bruce Keogh still thinks that we are sitting around idly waiting for the pleasure of a patient turning up.
    What measures will he put in place to commission enough GP services to cope with demand - or more imaginatively, what will he do with publicity and public health to reduce demand??????

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  • I'm in a CCG seriously below fair shares funding & in very serious deficit.
    According to the article, the demands came in a letter on 28th April with plans needing to be submitted 3 weeks later.
    Is NHS England fit for purpose?
    And what other services & initiatives - especially in CCGs in turnaround - should have been suspended to deal with this crisis?
    Presumably we didn't hear about it sooner because of pre-election purdah?

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  • I had to help fill this out as a CCG lead for primary care contracting (we are fully delegated for all primary care commissioning).

    The total and utter ignorance of how primary care works or even the fact that NHS England were responsible for it until 01 April was staggering.

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