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Why we relaunched our urgent care plan to boost outcomes

Dr Chris Peterson shares valuable lessons learned when setting up an urgent care scheme within A&E

Dr Chris Peterson shares valuable lessons learned when setting up an urgent care scheme within A&E

Patients with minor conditions who attend A&E in Liverpool are being diverted back to general practice, in a scheme devised by practice-based commissioners to save resources in both secondary and primary care.

A pilot scheme was launched in January 2008 but progress has been far from straightforward.

The numbers being seen under the original scheme soon diminished and not all of the A&E department staff have fully engaged. We've now relaunched the scheme and are exploring a number of options to boost participation.

The original scheme

Our acute trust, the Royal Liverpool and Broadgreen University Hospitals, had seen a 4% increase in A&E attendance year-on-year and was struggling to meet the four-hour waiting time in the emergency department. We made it clear to the trust that consortium GPs were willing to offer a prompt, same-day appointment to patients being referred back to general practice.

The pilot scheme was commissioned as a LES, based on a joint bid from two practices and the PCT's provider arm to provide two nurses to staff the scheme (one on duty at

a time). A&E reception clerks would, before full booking-in, identify patients with minor ailments who might be suitable for diversion to in-hours primary care.

Nurses were based in a room in the emergency department where suitable patients could be seen. If, after assessing the patient, the nurse deemed they could be diverted to primary care, they would contact the GP surgery to arrange a prompt appointment, either via an electronic system or, as a fallback, by telephone.

Concerns

The original concerns staff had about the scheme were:

• The numbers of patients referred back and the effect on GP workload
• Possible confrontation with patients
• How the IT infrastructure would work.

We envisaged using the EMIS web system so nurses had access to patient records from general practice and could book appointments directly, with back up via dedicated phone lines or mobile phones.

Early on in the project we discussed our plans 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.

We've offered patients what we believe to be a more efficient service: ‘You can choose to wait here for four hours or Dr Bloggs will see you at 2.10pm.'

Falling numbers

Initially it was a success, but over a few weeks the numbers dwindled to just one or two patients and the nurses became demoralised.

There was a variety of reasons for the lack of patients:

• Confusion by hospital receptionists about which patients were eligible (originally not all city practices were involved, just the 19 in the Liverpool South Central PBC consortium)

• There was no out-of-hours diversion provided. The nurses worked 9am to 5pm and these limited hours added to confusion among receptionists.

• We asked practices to commit to offering prompt appointments and answering calls from nurses rapidly, either on a dedicated phone line or via a mobile, but this didn't always happen so the nurses became demoralised.

• A&E staff felt the system was being forced on them. It stood in front of A&E, with patients being diverted by receptionists before being seen by A&E nurses, so it was never embedded into the routine work of the department.

Conversations

The hospital held a winter pressures workshop in June last year. The view of the PBC group was that the whole project was dead in the water unless A&E took it on.

The trust said it wanted it to work so we looked at how to get it going again.

We wanted to rule out any fears the hospital might have had about loss of income. With the four-hour wait target to meet, they would also be losing the patients that would be the easiest to see quickly.

In response to this we said: ‘We want to investigate whether this works, and you keep the money even if patients are diverted. Let us see if there is any mileage in it and then at some point in the future we will discuss finances.'

Making progress

The medical director of the emergency floor backed us and encouraged the A&E nurses to get on board. We altered the project so these A&E triage nurses would divert patients back to GP practices rather than asking receptionists to identify patients who could be seen by our own nurses based in a side room.

Some 80-90% of GPs are now signed up, not just from our consortium but from 85 of the 100 practices across the city, which has made it an option for more patients.

We relaunched the project in November last year and since then some 134 patients have gone through the diversion service, of whom 67 were successfully diverted back to primary care.

But as the department sees 110,000 patients a year there is clearly a long way to go.

We now know the system can work when used. However, significant diversion attempts have only come from two of the 70 nurses in the department.

Our challenge now is how to embed this system into the A&E department. To aid this we are looking at carrying out close scrutiny of the kinds of patients being seen to give us an idea of where we might go in the future, so we can have a meaningful dialogue with A&E.

Any concerns that some patients might resist being diverted, or even become aggressive, have proved unfounded. Most seem happy to have been referred to the primary care nurse. However, about 45% of patients have turned down the opportunity to go back to their own practices. We need to evaluate why this is. Early feedback suggests a range of reasons, including:

• Wanting a second opinion

• The hospital location is convenient to their work or home

• Availability of appointments.

We plan to address some of these issues and learn from them.

Concerns about IT also proved unfounded as it has worked very well.

Originally we planned for the practice nurse in A&E to have an integrated computer system to allow access to a summary of the patient's medical records and to book an immediate appointment online. This summary includes any diagnoses, medications, allergies and a general health summary about the patient. It can only be accessed with the patient's permission.

We developed the clinical record and appointment booking system with our main GP primary care system supplier, EMIS. As the scheme evolved, PCT IM&T staff went into the emergency department and trained all senior doctors and nurses in the system. They were given passwords and access to summary records and appointments, all of which was done with explicit consent from the patients for the clinicians to view their records.

The IT infrastructure worked – A&E staff have access to the patient's record from general practice. But it isn't being used effectively to divert patients back to primary care. A&E staff need to be persuaded that this aspect of the scheme is reliable and easy to use.

Keeping going

There is a growing feeling among our cluster that we are paying hospital prices for primary care activity, which is not a good use of resources in a health economy that is going to become increasingly tight.

We wouldn't pay for orthopaedics in a gynaecology facility and this is the kind of thinking we need to motivate among A&E staff.

It costs us £56 per episode in A&E for the simplest cases – those who could easily be diverted back to primary care.

I think a lot of this is about cultural change. Things can't carry on as they always have. The Royal's emergency floor is a massive department so changing hearts and minds is not easy, but I don't believe they should continue to see patients with routine conditions who could be more effectively managed in primary care.

Dr Chris Peterson is chair of Liverpool South Central PBC Consortium

My top tips for relaunching a scheme

1 Step back and be honest about what the weaknesses are.
Remember: the weak spots might not be the the ones you originally anticipated.
Initially we thought IT or adverse patient behaviour could be the main obstacles but neither proved to be problematic.


2Make sure everyone still wants to do it.
It sounds obvious but having such conversations with the people at the top will empower you to move to the next stage, and means you can go back to them later on to discuss specific problems.


3Consider taking money out of the equation.
We told the emergency floor director we wanted to see if the scheme worked before discussing finances or moving towards a diversion tariff. We wanted to first get the system embedded into A&E although ultimately money will be a key driver.


4 Don't underestimate what you have learned.
Why did half the patients not want to go back to their GP?
Did patients really believe it was okay to go to A&E in their lunch hour because it was more convenient?
Even though the scheme itself hasn't gone as far as we would have liked, it has taught us some valuable lessons and we are now considering these issues.


5. Keep going
If the powers that be and the PBC group believe there is value in a scheme and want to make something happen, then you should stick with it.
We are satisfied that almost all our local GPs are involved even though A&E staff are yet to be convinced. But we don't see our efforts as wasted. We've learned some valuable lessons that have helped to motivate us and drive this project forward.

Dr Christopher Peterson

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