Like many CCGs, Gloucestershire has been challenged by an ever-increasing burden on unscheduled care. We have looked at many aspects of the system with a view to managing and ideally reducing this trend. This has included the ambulance service, ambulatory day units, improved radiology access, paediatric hot clinics and rapid response community teams.
There is evidence to suggest that continuity of care in general practice is a significant factor in reducing emergency admissions and that lower satisfaction with practice telephone access is associated with higher A&E attendance rates. We decided to take a look at the whole picture: why were these patients going out of primary care and into A&E?
We decided to look at our systems to see if there was any way of reducing these numbers. This led us to employ the Primary Care Foundation in May 2012 to identify whether changing the way patients access services might reduce A&E attendances.
The Primary Care Foundation would engage with all practices in Gloucestershire to review their internal systems, help them understand how they provide access and support them to consider improvements where required. Attendance at workshops and collection of data was funded through a LES.
We then had to decide how we were going to engage the practices, but in fact they were keen. We presented it as a win for everyone – the patients would get better access, practices would get an independent opinion on their systems from someone very experienced and would get paid for changing their model. It’s also a win for the commissioners as, if this process prevents even one admission per practice per year, that’s a total saving of around £150,000.
As well as helping to reduce the pressures on secondary care, the process was also an opportunity to create time for GPs to look at their systems and consider improvements to them. The Primary Care Foundation’s approach is about working less hard to get the job done. The process also gave the practices a clear way to achieve their QOF QP indicators 12-14, which relate to unscheduled care admissions.
Dr David Carson from the Primary Care Foundation gave a presentation about the process and set up workshops for one GP and the practice manager from each surgery. Each practice then selected four weeks to look at a range of data such as phone calls – what times they came in, how many people were answering the phone, whether patients were waiting too long to get through and the number of staff and GPs available.
There was around three hours’ extra work for each practice manager for which they were paid, plus some extra work, mainly for the reception team, during the data collection week.
The figures were analysed by the Primary Care Foundation and a bespoke report produced for each practice manager covering a number of key factors, including ease of access by phone, consultation rate, patient experience, balance of same-day and book-ahead appointments, use of telephone consultations, home visits, workload by staff group, and variation in response by reception team.
GP visit waits
Much of the data collected focused on the consultation rate and we saw vast variation across the CCG’s practices. One might see each patient two or three times a year, another eight or nine times. We also looked at when visit calls were coming in, how they were triaged and when the patients requesting visits were actually seen.
Dr Carson showed the detrimental effect of patients having to wait too long for a visit. So for example if the patient calls the surgery at eight in the morning, the GP visits between one and two in the afternoon, and if the GP then calls an ambulance the patient turns up at A&E at about five. So they hit A&E at the busiest time and have waited eight or nine hours to get there. And if all the other GPs have done their visits at the same time, the ambulances have to queue. Many patients who attend A&E don’t need to be admitted, but trying to get waiting times down to four hours at busy times has the knock-on effect of more unnecessary admissions. Identifying this led to a lot of practices discussing what time to do their visits.
Each practice had an internal discussion about their reports and then met David Carson and their peers from four or five practices. This was a good experience – everyone was opening up and discussing what did and didn’t work for each practice. Dr Carson, who has worked with about 500 practices across the country, then gave his experienced view, suggested models that might work without telling anyone what to do, and each practice selected plans for how they could improve access for patients with urgent need.
Practices who felt they needed more help, or whose data suggested they did, were offered a one-to-one session with him.
Some surgeries were identified as beacons of good practice: their plans did not involve many changes, although every practice has made at least one change.
Many of the changes included scheduling a one-hour visiting slot in the morning so GPs could get to the urgent cases earlier. A lot of practices decided to spread the urgent appointments so each doctor took some every day – we found patients were calling to see a particular doctor, given an appointment with whoever was on call but then ringing back the next day for another appointment to see their ‘favourite’. What could have been dealt with in one go ended up being a telephone call, an urgent appointment and another appointment the next day.
Opening up appointments for up to three months ahead could also help prevent a bottleneck. A patient may see a GP and be asked to re-attend in three months’ time. When the patient leaves the surgery they may want to book this. But if they can book only four weeks ahead they may do that instead, seeing the GP much sooner than intended and then probably again after another month.
Cultures and attitudes
Our colleagues in secondary care are pleased we are taking this approach. Traditionally they have been blamed for the problems but we were taking some responsibility for not managing the patients as well as we could in primary care.
The staff in my practice were all keen to make the changes. The reception staff in particular were interested to see the figures for incoming calls as they had often complained that these were not being dealt with well, but the analysis showed there was pressure at all points in the system. The Primary Care Foundation went through scenarios with them about when a patient needed to see a doctor immediately. They enjoyed it, and we realised we’d never done that with them. There was very positive feedback from practice managers who are now highly motivated and expect the work to deliver improvements to working life.
It is too early to see the full effects of what we have done, but the Primary Care Foundation has seen reductions in acute admissions in some cases of between 20 and 40% as a result of good general practice management of urgent care. Their work suggests we will see the following benefits as almost all our practices have made significant changes:
⦁ reduced attendances and more staggered arrivals at A&E
⦁ reduced emergency admissions as a result of improved continuity of care
⦁ improved continuity of care and timely access to a clinician, ensuring a smooth pathway for the acutely ill
⦁ better working life for practice staff in a more efficient environment
⦁ identification of good practice and potential peer support.
We intend to review all practices in a year’s time and provide extra help to those that need it.
It will be hard to isolate what benefits we can attribute to this process as there are other changes to urgent care happening at the same time but I believe we will find the process to have been very worthwhile. Our neighbours in Swindon have employed the Primary Care Foundation to carry out the same process for them. Anecdotally, one of the first changes my practice made was to add the urgent morning visiting slot and in the first two weeks I saw a lot of anxious patients who were not actually very ill, but if left for another hour would have panicked and dialled 999. It’s an incredibly simple idea and we should have done it ages ago.
Dr Jeremy Welch is a GP in Tewkesbury, Gloucestershire and Gloucestershire CCG board member
How the costs broke down
Practice manager/administration 8,160
time funded at £16 per hour for
6 hours for data collection (LES)
Introductory workshops, data 26,400
analysis, practice reports
(Facilitated by Primary Care Foundation)
Practice vists to discuss reports 11,600
(Facilitated by Primary Care Foundation)
⦁ Initiative Changing the way patients access primary care to have a positive impact on A&E attendances. Primary Care Foundation contracted to work with practices to analyse patterns in relation to patient access, GP home visit times and effects on A&E
⦁ Changes made Practices chose how to react to the findings, with some changing GP visit times to the morning
⦁ Costs £46,100
⦁ Outcomes not yet available but work by Primary Care Foundation with other practices suggests admissions could be cut by up to 40% as a result of changes made in general practice
⦁ Contact Jeremy.Welch@glos.nhs.uk
What information was collected?
Three types of information were collected from each practice:
1 How the practice works
A set of 14 questions provides an important description of the practice that helps suggest ways the practice can improve the way they manage access and urgent care.
2 Data for a sample week
The samples cover ‘opening hours’, ‘telephony’, ‘walk-in appointments’, ‘consultations’ and ‘additional information’. These each require the staff to enter data about one week that they select as reasonably typical for the practice.
3 The reception quiz
This is designed as a support tool for everyone who carries out reception duties in the practice, either taking calls or speaking to patients who walk into the surgery. It looks at the level of confidence in managing urgent cases and asks how staff would deal with patients presenting with potentially urgent problems. The quiz
is intended to be the basis for a follow-up session, preferably with the practice manager and one of the GPs.
Results from the General Practice Patient Survey were used to assess how patient experience links to all the other information collected.