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Primary Care and Out of Hours. David Carson david.carson@primarycarefoundation.co.uk 07703025775. Reviewing Urgent Care in General Practice. Urgent Care in General practice. Our experience so far suggests that most general practice has a limited focus on dealing with people with urgent needs
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Primary Care andOut of Hours David Carson david.carson@primarycarefoundation.co.uk 07703025775
Urgent Care in General practice Our experience so far suggests that most general practice has a limited focus on dealing with people with urgent needs In general, there is an inverse care law, with those with the greatest needs being left until last Our approach • Capturing both the normal range of current practice as well as best practice • A pre-tested questionnaire to identify current performance on managing same day care across 5 PCT demonstration sites • Working with 8 pilot practices • Developing practices to make practical and realistic changes
A web based questionnaire Access to practice No of lines for patients Access by phone Access by internet or email Appointment capacity No of planned ‘extra’ slots? Assessment Use of protocols Training for staff Use of computerised decision support systems Triaging patients – clinicians & receptionists Regular triage or only when full? How are requests for home visits assessed? Response How long does it take to respond to home visit requests? Is there a duty doctor or doctor of the day system? Are they free to respond rapidly without leaving a clinic? Do you work with others practices to assess or respond? Will Patients get through? Is there capacity to see them? Will the tiny number of potentially urgent cases be spotted? Will they be seen with the necessary urgency?
Principles • The response and system is safe • How urgent the problem is – Defined by patient • Only defined by patient until assessment by the practice • Life Threatening - Practice has a system which reliably identifies those patients with acute urgent problem • Pathways developed for these cases • Pathways are in place for high impact cases ( Palliative, Respiratory, Cardiac, Frequent) • Adequate balanced capacity is in place to meet the demand • Balance 30% same day 70% book ahead • Telephone consultation can increase capacity • Response to visit requests is timely • Practices set their own standards!
Developing the principles for urgent cases presenting to General Practice Primary principle The system must be safe for the patient Secondary principles Which implies Must deal with patients wherever they present Minimal delay reacting to a patient that presents Must avoid long queues (for initial phone call, assessment or face to face) Receptionists have adequate training/ process to identify potentially urgent cases Urgent is defined by patient until assessed Potentially urgent cases should be assessed by a clinician as early as is practical Must have adequate receptionists for calls and face to face Plans and capacity to respond as needed Must have ‘duty clinician’ or other arrangement for early assessment Must have capacity and plans to react if patient needs to be seen Build ‘safety netting’ (advising callers what to do if the condition worsens/does not improve) into the process In cases of doubt, then err on the side of safety In cases of doubt ensure that the patient is assessed or seen sooner rather than later
There is a very wide variation in the number of appointments and the proportion of slots that can be booked for same day treatment The % available for same day appointments (red bar) varies from a few % to close to 100% There is a significant variation in number of appointments each week per 10,000 patients from perhaps 700 to 1700
Will patients get through? Using data to benchmark existing service
Telephone Capacity • Based on 85% of calls being answered within 30 seconds and an average call length of 90 seconds then the peak numbers of calls that can be handled are: • One agent – 7 calls per hour • Two agents – 31 calls per hour • Three agents – 60 calls per hour • Four agents – 92 calls per hour • Five agents – 126 calls per hour • Six agents – 160 calls per hour • Eight agents – 232 calls per hour
Telephone triage • Dreadful concept • No choice • “I” the nurse/doctor know best • Reduces choice • Huge waste of resources • Practices who gave patients no choice • 50 – 60 % had to be seen following “Triage” • Patients offered CHOICE of coming in or telephone consultation • 80% of telephone episodes did not need to be seen
Establishing a national benchmark for out of hours services “At last there is a real hope that we will soon be able to accurately compare services across all out of hours providers and drive up the quality of care for patients” David Colin-Thomé, National Clinical Director for Primary Care “A successful benchmark will help us celebrate the success of a service that supports over 8 million people a year and could offer fresh ideas for extending access in primary care and delivering consistent high quality care around the clock – key drivers for world class commissioning of the future”. Michael Dixon, Chairman, NHS Alliance
Benchmarking Proper comparison Move beyond anecdote and rumor being turned into fact Not many examples of benchmarking at scale
12 headline indicators Cost Cost per head Cost per case Productivity Number cases per clinician per hour Outcomes Referrals to hospital (if possible, sub-divided between referrals to A&E and referral to a hospital bed) Overall breakdown of dispositions (advice/PC Centre/home visit) % Calls classified Urgent on receipt Process The quality of clinical governance systems and processes Performance Time to clinical assessment for all calls as a %age Time to face to face consultations for urgent calls (including % urgent after assessment) Patient Experience Patient experience of receiving telephone advice Patient experience of treatment at a centre Patient experience of home visits
Time to assessment of urgent cases compared with % urgent on receipt
Cases per clinician hour at peak times (weekend mornings) Cases per clinician hour at peak times (Weekend Mornings)
Outcome of Patient Contacts (Dispositions) PCT A Table of all Out of Hours Providers (total of 27 providers)
Referral towards hospital Referral towards Hospital
Clinical Governance:Providers scored themselves, generally low on coding and prescribing
What lessons for Out of Hours in the future • Current standards are stifling innovation • Leading edge services are moving away from “triage” • Why assess everyone? • Give patient choice • Telephone consultation • Base consultation • Walk in base consultation!!! (Radical stuff) • Home visit • Not the same model everywhere • Urban and rural (Highlands, Islands)
Service Model – Some radical thinking • The population are not Idiots • They do not require staff to • Direct • Triage • Manage Demand
