When our PBC consortium was first established in 2006 there was an initial excitement among the practices about the commissioning changes. Within months however GP members were losing interest as the rate of change was so slow. As consortium chair, I felt an innovative ‘quick-win’ project was needed. We needed a service based on grassroots experience that would resonate with the GPs and show them immediately the benefits of working together in a way that would impact on their day-to-day working patterns.
We knew that urgent care was the top priority for change both nationally and locally, and our PCT told us that if we came up with a scheme that addressed problems with emergency admissions and the urgent care agenda they would support it.
We looked at the data which confirmed what we had long suspected: emergency admissions for all ages were going up. St Helens was one of the highest PCTs in the SHA for emergency admissions and a local service utilisation review showed that 43% of patients occupying hospital beds did not need to be there if community alternatives were available.
Reasons behind admissions
We held discussions with colleagues and patient groups about the reasons which led to an emergency admission. These discussions suggested that many patients were admitted for assessment because of three main reasons.
The first was to do with primary care capacity – GPs were already working to saturation in many practices and were generally able to spend less than 10 minutes with a patient on home visits. This was not enough time for detailed evaluation of other alternatives and frequently resulted in admission as the safest option.
The second cause was patient and carer expectations – most of those requesting a home visit were genuinely concerned about the seriousness of the medical condition, or because of the 24/7 lifestyle many people now lead needed rapid access to healthcare to allay their concerns. If the GP could not visit within the timeframe to suit their expectations, then the risk of the patient or carer dialling 999 or attending A&E was high and often resulted in an emergency admission.
Finally, many admissions were the result of increasingly defensive practice – initiated because GPs felt unable to disrupt planned work for fear of complaints and so felt unable to risk delay attendance for home visits in case of deterioration of the clinical situation. This dilemma frequently resulted in admission as a safer option for the patient.
General Practice has evolved in such a way that to expect practices to deal with planned and urgent care at the same time is not sustainable. We needed to look at how to separate them to make them both more efficient and effective and this led to the idea of the Acute Visiting Service (AVS). It was implemented within eight weeks of the idea being proposed.
What we did
The AVS was implemented for 12 practices which covered 60,000 patients. The aim was to provide a rapid access doctor for acute care at home, thus reducing the need to access urgent hospital care.
We aimed to:
• Reduce emergency admissions
• Improve access
• Use the patient/carer definition of ‘urgent’ rather than a clinical interpretation, remembering always that symptoms can be alarming for patients and the reason they are asking for a medical opinion is because they are worried.
• Achieve better patient satisfaction with home visit assessment, further reducing risk of subsequent admission
• Release capacity in GP surgeries for planned care
The PCT (now the CCG) commissioned the service from our local out of hours cooperative which provides the driver and vehicle and manages the calls. We have a mobile, community-based doctor available between 9:00 am and 6:30 pm. The doctors who make the visits are all local GPs employed on a sessional basis by the provider so they are familiar with local services and care pathways. Increasing numbers of doctors are retiring early or going part time in their own practices and this has helped us as they are available for this work. They find it very satisfying – there is no QOF work, no tick box exercises, no prompts to achieve targets, they are just seeing the patient and can spend twenty minutes with them to more fully explore the options for integrated and community care, helping the patient to mak ea safer choice to stay at home. We are essentially assessing-to-admit rather than admitting-to-assess.
They aim to visit within 60 minutes, ideally within 30 and have access to basic clinical history and information including the following:
• Direct access telephone number for practice with named contact in case of queries
• Presenting complaint
• Relevant history
• Repeat medication list
We decided that it was vital that referral came via the patient’s own practice. The GPs there know the patient and their circumstances and can make a safe decision about their needs and the appropriateness of their request. It also means that the patient has confidence in the decision about whether they should receive a visit as they have spoken to the practice with which they are registered and familiar.
If the patient referred themselves into the service there is a risk of inappropriate self-referral as well as the risk that the patient would still end up contacting their own practice for reassurance.
The GP or nurse at the patient’s own practice uses a standard form to triage and refer into the service and tells the patient that, although they are unable to visit at the moment, their colleague is working within the local area and is able to visit within the next hour. The AVS GP is described as part of the practice team and introduces him or herself as from the practice at each visit so the patient is more accepting of the service.
A completed visit sheet is sent to practice at end of each session and the OOH co-ordinates relay of information. If there is a quiet patch we have a cold case load for the visiting doctors to work on, carrying out reviews in all our care homes and re-visits or telephone reviews for those at higher risk of admission or readmission.
Outcomes
During the initial pilot, in the first six months 370 visits were made, resulting in only four hospital admissions. A detailed analysis of 118 of these visits revealed that referral into the AVS avoided approximately 30% of admissions. This figure resonates with national statistics which suggest that 30% of patients in hospital are admitted for less than 24hours (Dr Foster 2012), suggesting that perhaps they should not have been admitted at all. The AVS outcomes strongly indicate that these ‘zero day’ admissions can be avoided in many cases by having appropriate rapid access in the community.
The two main reasons identified for the successful outcomes achieved by the AVS were the speed with which patients were seen and assessed and the time the AVS doctor was able to spend with each patient. Patients felt reassured because anxiety about their illness was quickly allayed and the extended consultation allowed time to ask questions and discuss options other than hospital admission.
Chest pain, collapse and dyspnoea or other respiratory problems accounted for approximately 30% of the ‘AVS’ visits.
We now carry out on average around 3,000 visits per year. We employ a clinical lead to audit and monitor the scheme on a sessional basis. Regular audits include quarterly review of 10% of visits done, we have monthly review of response times and time spent with each patient and annual review of unplanned admissions.
We have seen reductions in emergency admissions, zero day admissions and re-admissions. Peer review of case notes suggests on average a 30% reduction for emergency admissions in the hours that the service is in operation. Based on an average complex admission at PBR of approximately £2,500 this equates to a projected saving of around £0.5million for a population of 50,000.
Zero day admissions - an area of great concern nationally – accounted for just 0.6% of all AVS admissions last year.
For the first few years admissions rates following visits were hovering at around 5%. In the last 12 to 18 months our clinical lead has reviewed all the admissions, particularly areas such as IV antibiotics for cellulitis and DVT rapid access assessments, to see what else could be done in the community. As a result we have managed to further reduce admission rates to 3.8% using existing community services but integrating them better with our service.
The service has never had a clinically significant event and surveys show 90% patient satisfaction. Practices have reported no increase in requests for re-visits. Monitoring peaks and troughs has been very useful and we have emphasised the use of revisits or telephone reviews for patients who are still at high risk of admission following their initial contact.
An unexpected benefit has been increased capacity for planned appointments. GPs no longer have to leave unexpectedly for urgent home visits which can take up to 20-30 minutes once travel time is included, so on average each surgery can now offer two additional appointments per day. This is clearly a better and more productive use of existing clinical resources and equates to an extra fulltime GP across the CCG without any additional funding.
The clinical engagement gained from the success of the Acute Visiting Service has been resolute and has been fundamental to the CCG’s progress. Practices trust commissioning decisions based on grassroot experiences which have a relevance to daily primary care.
At a cost of just £6 per patient per year the AVS is self-funding for a population of 50,000 patients, if two complex elderly admissions are avoided per week.
The future
The scheme is due to be rolled out to all 37 practices in the borough and I believe this model could easily be replicated across the country with great results. Based on our costs and savings I have calculated it could save well in excess of £500 million per year nationally. Over 15 CCGs across the country have so far requested workshops to roll out the service in their areas and an event I recently hosted in St Helens to share good practice as part of the philosophy of ‘Innovation Health and Wealth: Accelerating adoption and diffusion in the NHS’ generated huge interest from all parts of England.
The AVS has challenged traditional models of working in General Practice. Its success has persuaded patients, GPs and commissioners that innovative methods of delivering traditional care can have benefits at multiple levels.
Traditionally there has been a rigid definition of core GMS work. ‘The AVS’ demonstrates that it is possible to work across these barriers and integrate core GMS services with new care pathways to deliver an enhanced service which provides outstanding patient care and has a genuine impact on local and national targets.
It is perceived that patients traditionally express a preference to see their usual GP because he or she knows their history, background and circumstances. However, the AVS demonstrates that a suitably trained doctor with access to only basic clinical information can provide excellent quality care and gain high levels of patient satisfaction, even if the doctor is not the ‘usual GP’.
Dr Shikha Pitalia is a GP board member and lead for innovation, St Helens CCG, Merseyside
