What it's like to run an urgent care centre
Dr Peter Rudge answers questions on how he set up and manages NHS Plymouth’s Acute GP Service
Dr Peter Rudge answers questions on how he set up and manages NHS Plymouth's Acute GP Service
How did you get involved in urgent care work?
I got interested after an elderly patient I had sent to hospital told me how she had to wait on a plastic chair for hours and then was moved from ward to ward in the early hours before treatment was started.
What had been the point in sending her in that night? Then in 2003 a chance came up to provide GP cover for an intermediate care home and we were successful in our tender.
Unfortunately our funding was withdrawn but the acute trust asked me to work on the medical assessment unit of the hospital.
How did you set up the Acute GP Service?
A I wrote a report criticising the assessment unit. It concluded that telephone reviews of requests for adult admissions could improve the standard of referrals and reduce non-elective admission rates.
We made a business case and in October 2005 the service was launched.
What does the service actually do?
The service opens from 9am to 7pm Monday to Friday, working from the medical assessment unit of the acute hospital. Two GPs are available every day, working eight-hour shifts.
They take all calls for acute adult medical admissions from GPs, and increasingly from emergency care practitioners, specialist community nurses and other healthcare practitioners.
If admission is needed, we take details, hand over to the on-call medical team and make arrangements for the patient to come in. Or we give telephone advice, often with supported decision-making, allowing the patient to stay at home.
We may direct patients to an alternative service such as an intermediate care team, a two-week wait pathway, an arranged outpatient slot or treatment by community nursing.
There is also the option of managing the patient directly within the Acute GP Service. This is what happens most often and about 91% of these patients are then discharged.
Referring GPs are always kept informed with a fax sent the same day.
What do you do as the person who manages the service?
As clinical lead, I work with our operational manager to ensure we offer a consistently high-quality service with appropriate clinical governance. I am also responsible for strategic development.
Governance strategies include significant event reviews for learning and support, and audits and review of unexpected returns within seven and 28 days of contact.
Our unexpected return rate for the patients we managed in 2007/8 was 1.1% – well below the usual rates for acute medical units.
Patients and GPs are surveyed from time to time.
This year overall ratings were very high, with 94% of all ratings good, very good or excellent. Interestingly, despite being told explicitly, many patients were unaware they were seeing a GP, not a hospital doctor.
Is it a private company? What is its business status?
A The service is commissioned by NHS Plymouth and also by the surrounding PCTs – Devon and Cornwall and Isles of Scilly.
It is provided by the salaried GP service, with most GPs dividing their time between general practice and the Acute GP Service.
What sort of patients do you see?
The patient profile is typical of acute medical intake except that our patients tend to be a little younger. In 2007/8, 62% were aged between 18 and 64. The graph below shows the case types.
What would be a typical few hours working for the Acute GP Service?
The cornerstones for the service are dialogue with community colleagues and senior-led decision-making for patients who arrive on the ward.
Mornings are dominated by arrival of follow-up patients booked by the previous day's GP, after which we address calls from community GPs from about 11am.
This follows the pattern of GP surgeries, with a mid-afternoon lull and then a subsequent rise.
There is a great mixture of hands-on medicine and dialogue and learning between professionals. As well as GP colleagues, we work closely with nurses, junior doctors, medical consultants and imaging departments.
What are the benefits to the NHS of setting up a service like this?
The service provides patients with choice about where and when to access urgent care.
We have also achieved savings from reducing non-elective admissions, and the cost of seeing one of our GPs is less than the short-stay Payment by Results rate. There are also savings in follow-up costs and pharmacy.
The real key to savings is our peer-to-peer discussion, which identifies the needs of the referrer and their patient and delivers this with senior-led decision-making.
It contrasts with the junior-led services that generally prevail within secondary care.
Can you give an estimate of how substantial these savings will be?
It is hard to exactly quantify our savings but our estimates suggest up to £1.1m for 2007/8. The calculations to prove this are crude but are based on short-stay and average admission tariffs.
Our running cost is £484,000 a year and for 2007/8 we think there were 899 avoided admissions.
Are there any downsides to working for the Acute GP Service?
The downsides are few and most have been overcome. Initially the acute trust was concerned its non-elective income would be reduced, but the service is now considered an integral part of the hospital.
The biggest downside is the risk of losing that elusive, hard-to-measure skill of a GP – the ability to remain a community-centred generalist and manage risk in a way that is entirely different from the methods used by our hospital colleagues.
This is learned from the way we work and is sometimes hard to retain when working in a hospital environment. It's the one reason the GPs in the service are required to retain some mainstream general practice work.
As with all portfolio posts, there is also the risk of losing continuity with your practice's patients. This can never be truly overcome, but we will be bringing an extension of our practices' clinical systems into the medical assessment unit, which will mitigate some of these issues.
What do you enjoy about the work?
I enjoy the challenging mix of medical practice right at the interface between primary care and secondary care, with enormous opportunities to make a real difference for patients.
For me, there have been few jobs so satisfying.
What is the future of the service in your view?
A We plan to start work on developing a hospital outpatient treatment clinic jointly with acute physicians on the medical assessment unit.
This will reframe what we think of as inpatients so we start treating them as outpatients.
We will also link the clinical systems of our practices with the medical assessment unit, emergency department and out-of-hours provider, and develop a single point of access for urgent and emergency care.
These changes will redraw the interface between primary and secondary care and lead to enormous benefits for patients.
Dr Peter Rudge is a GP in Plymouth and clinical lead for the Acute GP ServiceGuest editor Urgent care