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Our plan to divert patients from A&E

Patients turning up inappropriately at A&E are being offered same-day GP appointments to save hospital resources, writes Dr Chris Peterson

Patients turning up inappropriately at A&E are being offered same-day GP appointments to save hospital resources, writes Dr Chris Peterson

In May 2007 the executive of the South Central PBC consortium in Liverpool considered how PBC could influence unplanned care.

Local GPs are often told that their patients attend A&E with primary care problems, whether because of poor GP access, geographical convenience for patients, patients wanting a second opinion or uncertainty among patients as to where to get care.

The A&E department at our acute trust, the Royal Liverpool and Broadgreen University Hospitals NHS Trust, is also seeing a 4% increase in A&E attendances year-on-year, as well as the usual annual winter pressures.

We decided to review one month's activity, which identified that about 40% of patients attending A&E during ‘in-hours' potentially had conditions – such as diarrhoea and vomiting, or minor injuries – that could be treated in primary care. This equated to about six patients per day for the 96,000-patient population covered by South Central PBC consortium.

We also considered evidence about other primary care-led A&E schemes from around the country, and then the idea of an A&E diversion project was formed. Our plan was simply to divert patients inappropriately attending back to their GP for prompt attention.

In Liverpool there is close co-operation and collaboration between the PCT and PBC groups and we agreed to take the idea forward together. Even if the pilot did not work, the information gleaned on GP access and patients' perceptions and reasons for A&E attendance would be extremely valuable.

Crucial talks with the trust

By June we floated the idea past the executive of the acute trust. They were keen to consider any scheme that would reduce inappropriate attendances although it is fair to say there was a degree of scepticism among some staff who felt the evidence base on primary care-led A&E initiatives was not strong.

We then held more in-depth talks with the trust's clinical director for medicine, senior management and A&E consultant. We made clear our initiative was not about GPs becoming absorbed into the A&E workforce – there would be no treatment option available, and we would ensure there was willingness for our consortium's GPs to accept patients referred back by the diversion team with a prompt appointment that same day.

We drew up a detailed service specification for the PCT's unplanned care lead. Some refinement was needed, mostly around ensuring that the pilot would be evaluated.

How we got GP buy-in

By the end of June our next key task was to get ‘buy-in' from the consortium's GPs. Our three overriding principles to ease operation of the project were that:

• there would not be confrontation with patients at A&E – they would not be forced back to their own GP if they refused and we wanted to avoid dissatisfaction from patients towards staff

• the patient journey would be as smooth as possible, whatever the treatment needs of the patient

• there would be minimal disruption for the GPs or their staff and A&E staff.

GPs were told the plan was to situate a nurse in A&E in her own room. Any of the patients from the consortium's 19 practices, who attended A&E with minor problems identified under the Manchester triage system, would be identified by the A&E department clerks before being fully booked in, and asked to present to our nurse. She would then assess the patient and if she deemed they were suitable for diversion to primary care, she would contact the GP surgery to arrange a prompt appointment.

Given that practices in our area are open 8am-6.30pm, it was felt that the diversion service should operate 8am-5pm, in order to ensure same-day appointments would be available.

During the practice visits and general meeting with GPs to discuss the plans, some GPs were wary of a potential increase in workload but acknowledged that it is hard to argue against these patients being seen in primary care.

The numbers available to us suggested no more than one patient per 2,000 practice population per week would be diverted back to the practices.

Computer systems adapted

Although telephone and fax were suitable options, we also decided the nurse should use an integrated computer facility to assist her role.

Discussions commenced with the supplier (EMIS) of the majority of GP primary care systems in Liverpool to develop a solution, with the sign-up of GP practices, that allows the primary care A&E nurse to access in one place, via the EMIS web system, our consortium's patients' demographic details and a summary of clinical information from a patient's primary care record.

This summary includes any diagnoses, medications, allergies and a general health summary about the patient, and can be expanded or limited with permission from GPs depending on the needs of the service. This information can only be accessed by the nurse with the patient's consent. The nurse is also able to input their consultation with the patient into the system.

If the patient is suitable for diversion back to their GP, the nurse will either call the practice or book an immediate appointment online straight into the practice's electronic appointment book. The nurse consultation can also be viewed electronically in each practice's EMIS system by the patient's GP when the patient is seen back at the surgery.

The plans were also discussed with the local patients' involvement forum, which was keen to see it implemented, as long as patients still had the choice to attend A&E.

In terms of the practicalities, a small pre-existing room in A&E lent itself perfectly to the project. Some work was necessary, such as fitting secure doors, upgrading lighting and setting up IT and communication links. The cost of this work was about £12,000 and was paid for by the PCT.

A three-pronged provider bid

By October 2007, the service model had been widely approved and the PCT agreed it should be commissioned as a LES from one of the consortium's practices as a six-month pilot, and invited bids.

What eventually transpired was a joint bid from three parties – involving two practices (one of which is my own) and the PCT's provider arm.

Initially the two practices felt their bid would be strong enough on its own but we then recognised that the provider arm had the benefit of wider nursing infrastructure, and they jumped at the idea when we approached them. The PCT received no other bids and we got the green light in November 2007.

A management board was established to oversee the project's implementation, with overall management resting with one of the practice managers.

We decided more than one nurse would be needed, and appointed a practice nurse from one of the practices, and a walk-in centre nurse who had previous experience of working within an A&E department. Both are employed by the PCT (the practice nurse on a temporary basis for the duration of the pilot). Salary costs for the pilot are £36,000.

A service level agreement (SLA) was drawn up and agreed, which included a business continuity plan and an accountability agreement covering any potential governance issues. The SLA also included monthly performance measures that are key to the continued monitoring of this service (see box below).

The nursing staff worked with the A&E clerks to ensure they had details of all the participating practices to check against when patients arrive.

Early results and reflections

The service started on 28 January this year and patients have turned up with a variety of problems such as sore throats, urinary tract infections, and one person even came in with cracked skin on their hands.

However, experience so far suggests our predicted numbers were excessive – instead of six per day, the nurses have seen one or two patients per day.

This is a bit disappointing, but it may suggest that efforts to publicise the scheme to GPs and patients are having an impact already. There has also been pressure on Liverpool GPs more generally over the past year from a local practice league table that measures, among other things, access and number of A&E attendances.

We accepted from the outset that the success of the scheme would eventually lead to its demise as awareness about how best to use A&E grew.

Interestingly, in one case, the nurse herself was unable to get through to the patient's practice; and although there could be a reasonable explanation for this, it shows the project is throwing up valuable information about access.

Another interesting point to note is that our concerns about patient resistance or aggression have proved unfounded, as patients have seemed happy to have been diverted to the nurse.

In order to make full use of the diversion nurses, our plan now is to roll out the service to the city's other consortiums for the rest of the pilot, which we believe would result in 25-30 patients in core hours, Monday to Friday, with minimal additional running costs.

We are now to have talks with a consultant at the paediatric unit of A&E at Alder Hey Hospital, who suspects they also see a lot of patients with primary care problems.

In addition, we are also considering the use of current out-of-hours primary care services to deal with appropriately diverted patients from A&E outside core GP hours.

Advice to others

Commissioners hoping to establish a similar service should:

• set up early discussions with the acute trust, as they must be on board for a harmonious, safe, risk-averse service

• secure GP buy-in, as without their co-operation the service stands no chance.

The service is being fully evaluated, and we are keen that the learning from this in terms of patient attitude and knowledge of services is used to inform future commissioning decisions.

How the service will be monitored How the service will be monitored

• Percentage reduction in South Central consortium patient A&E attendances during core hours (8am-7pm).
• Number of South Central patients presenting at A&E who are referred to the primary care facility.
• Time of assessment in primary care facility to time patient left primary care facility.
• Time of assessment in primary care facility to appointment made in GP practice.
• Number and percentage of patients attending the service who are booked in as A&E patients.
• Number and percentage of patients attending the service who are redirected to their GP.
• Number and percentage of patients offered advice and information to
self-manage their condition.

Nurse Joyce Kennerd and Dr Chris Peterson are set to roll out the service to other consortiums Joyce Kennerd and Dr Chris Peterson

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