David Carson: Primary care in emergency departments (A&E)

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David Carson: Primary care in emergency departments (A&E)

  1. 1. Primary Care in EmergencyDepartments (A&E)An outline of the report structure and findings
  2. 2. The Foundation● Benchmark 100+ PCT GP O t of Ho rs Ser ices Out Hours Services● Report on urgent care in general practice● Report on A&E and Primary Care● Completed a study of Urgent Care Centers for the DH● Working with a number of systems on whole system g y y change © The Primary Care Foundation
  3. 3. The real issue is not in the hospital! 3 Hours 2 Hours 2 often 4 Hours8.30 11.30 13.30 17.30 15 Minutes 1 Hour 1 Hour8.30 8.45 09.45 10.45 © The Primary Care Foundation
  4. 4. Objective behind the use of primarycare
  5. 5. What were the objectives for using primarycare staff?The assumption seems to be that its so obviously a good idea that the underlying principles cant be questioned.At various times the objects of our scheme have included the following a) redirecting patients to their own GPs surgery without treatment (sometimes less than 1 a day) b) seeing and treating simple problems that need no investigation and not much examination h i ti c) attempting to see all walking patients including those that clearly need hospital facilities, eg Xray d) reducing the number of p ) g patients admitted ( (but not seeing ambulance p g patients, , which account for almost all admissions) e) reducing number of 4 hour breaches (which are also almost all in ambulance patients). f) general desire to ensure that the coming winter will be better than the last (which was difficult as the hospital ran out of beds for prolonged periods). © The Primary Care Foundation
  6. 6. Reasons for working together●An a f l lot were about cost and admission red ction An awful ere abo t reduction●There is a poor link between overall attendances andadmissions ●Admissions rise when its busy due to shortcomings in A&E process ●The answer is to fix this●The emphasis was very much on: ●Working together (not a solution that is imposed by one party) ●To provide prompt, safe care to the full range of patients ●Making effective use of both primary and secondary care skills ●A simple process to gu de pa e s s p e p ocess o guide patients © The Primary Care Foundation
  7. 7. Operational model – Initial reception
  8. 8. Clinical Triage is used to prioritise patients whohave to sit in a queue. What was interestingwere the services where this is not necessary.● Quite firm views found on triage versus simple guidance or patient making own decision● Three main types of process: ● R Receptionist quick d i i ( ft using simple protocols). Thi i not ti i t i k decision (often i i l t l ) This is t “clinical assessment” so tends to meet with opposition from clinical staff. Sometimes this may be followed by clinical triage at the second point where the patient is sent p ● Very rapid clinician assessment – typically by a nurse and taking < 2 minutes ● Full clinical assessment process (perhaps taking 2 to 15 minutes) and then seen after waiting © The Primary Care Foundation
  9. 9. The majority of services accept that a queue isinevitable, the innovative ones staff up to avoidthis and find that it is better for patients andcheaper. This is the lesson that manufacturing learned inthe 1970s!● Clinical triage is the solution adopted by services that cannot staff up to meet predictable peaks in demand demand.● Really good services manage to avoid this by having enough clinical staff to carry out a proper consultation of all patients very soon after they arrive. arrive● In these services clinical triage is reserved as part of an emergency plan if the A&E department is overrun following some major disaster● This may be hard to sell to many clinicians!● But those who can make it work avoid the waste associated with the double consultation and provide a significantly more responsive and patient friendly service. © The Primary Care Foundation
  10. 10. Operational model – model of serviceThere appear to be four main types of model
  11. 11. Four main types1. Situated alongside the Emergency department running separate reception and operational processes2. Situated alongside the Emergency department and running common reception and separate operational i i d i l processes3.3 Fully integrated with common reception and operational processes4. Primary care staff attempting to extract patients already booked into the Emergency Department to find alternative treatment/options5.5 GPs employed as part of acute team working within the team © The Primary Care Foundation
  12. 12. Proportion of servicesusing primary care staffand proportion seen byprimary care clinicians
  13. 13. Most services that have primary care in the Emergency Department use GPs, from 8 till late and about half ask them to take on a wider case mix than typical in General Practice● Vast majority use GPs, usually sessional. Relatively few involve other primary care clinical staff – much b tt if not sessional th i li i l t ff h better t i l● Around half of services expect the GPs to see a considerably wider range of cases than would be seen in General practice (which implies f hi training i li refreshing t i i around such thi d h things as X rays and th d the interpretation of some tests)● Very few services use primary care staff during the ‘red-eye’ period. Most M t services that are using primary care staff d so f i th t i i t ff do from 8 till l t late 7 days a week. © The Primary Care Foundation
  14. 14. There are a number of reasons for thevariation in proportion of cases seen byprimary care● Variations in the hours primary care clinicians are available● Variation in the skills and range of cases that clinicians are asked and willing to take on (and variation in the investment in refresher training for GPs being asked to undertake a wider range of tasks than are typical in general g yp g practice). Examples include interpretation of Xrays and the wider range of diagnostic tests available in hospital● The different operating models and protocols around steering patients to different skill groups diff t kill● Whether the figure is calculated as a proportion of all cases that attend A&E (including ‘majors’ and ‘resuscitation’ patients) or as a proportion of ‘minors’ or ‘walk-in’ patients walk-in● And there are frequently very significant variation depending on the individual clinicians on duty (which increases the difficulty in planning a consistent and reliable service)) © The Primary Care Foundation
  15. 15. There are also some wildly different claims forthe percentage of cases that could be seen bya general practitioner● From 60% derived from a study in London asking GPs which cases they could have seen● To around 15% from a survey of opinion by the college of emergency medicine.But is this really the right question? ● After 7 years of training doctors are equally well-positioned to become specialists in emergency departments or GPs ● Reductio ad absurdem leads one to conclude there is no reason why with training the percentage that could be seen by a GP is 100% ● Clearly this would not be the way to develop a first class group of experienced emergency cliniciansThe right question is perhaps:● If primary care clinicians are used alongside A&E at the busier times (when there is enough work for all) what proportion can they usefully see?● Some example case studies give some indication of what this proportion might be © The Primary Care Foundation
  16. 16. Conclusion – primary care staff can see C l i i t ff somewhere between 10 and 30% of casesdepending on the set-up – more ambitious targets are likely to lead to poorly utilised A&E staff that need to be on stand-by for the urgent cases? y g © The Primary Care Foundation
  17. 17. Responsibility for audit, operational and clinical governance li i l
  18. 18. In many services there is a lack ofclarity over responsibility for important y p y paspects of the serviceIn services that we visited questions such as as….● Who has overall responsibility for the clinical governance in respect of patients that attend A&E? ● Who audits the cases? ● Who reviews the decisions made? ● Who feeds information back to the clinicians involved, who is responsible for identifying any concerns or training needs? ● Who would be responsible if something went wrong?● Who has operational responsibility? ● Who will make the hour to hour decisions to reallocate resources or patients to other clinicians when necessary? ● Who is it who looks at the overall utilisation of clinical and other staff seeing patients that have come to A&E to make sure that best use is made of the total resource?…often exposed this lack of clarity f d hi l k f l i © The Primary Care Foundation
  19. 19. Conclusion – making sure that there is clear responsibility f clinical and l ibilit for li i l d operational governance is important! © The Primary Care Foundation
  20. 20. Funding and cost-effectiveness
  21. 21. Adding more staff and an additional serviceoption is rarely cheaper ti i l h● Fail re to compare like with like (often looking at the Failure ith marginal cost of the additional cases referred to an existing primary care against the tariff which includes on- costs)● Failure to recognise the cost that the Emergency Department had to bear of providing a back up (for example when the primary care service was unable to provide the staff to deliver the promised service)● There are some examples where they have developed a local approach (block for both services) that overcomes some of the financial perverse incentives © The Primary Care Foundation
  22. 22. Conclusion● It is possible to incl de primar care staff in a way that include primary a benefits the system and is cost effective – but you need to be sure that you count it right and should NOT expect massive savings – the aim should be to treat patients faster and better with primary care staff and marginal savings can be expected if this is set up well. © The Primary Care Foundation

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