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NPCN: Fixing the urgent care crisis

NPCN: Fixing the urgent care crisis
13 November 2013

A wide sprectrum of primary care professionals put forward solutions to ease the pressure on A&E at the inaugural meeting of the National Primary Care Network, supported by publisher of The Commissioning Review, Cogora.
As winter looms it brings the urgent care crisis into sharp focus. Simply too many people are turning up in A&E and then being admitted to hospital, putting pressure on services and increasing costs in the NHS. 

A wide sprectrum of primary care professionals put forward solutions to ease the pressure on A&E at the inaugural meeting of the National Primary Care Network, supported by publisher of The Commissioning Review, Cogora.
As winter looms it brings the urgent care crisis into sharp focus. Simply too many people are turning up in A&E and then being admitted to hospital, putting pressure on services and increasing costs in the NHS. 
Not all these patients need to attend A&E but they clearly feel there is no alternative. The Department of Health and NHS England need to find a solution to this and clearly primary care is a large part of the answer.
A core representative of the National Primary Care Network (NPCN) including nurses, GPs, community pharmacies, dentists and optometrists gathered in London on September 17 to discuss how the problem is being tackled in their area and what possible solutions could look like.   
Telephone triage
This was seen by many as a key way to increase patient access1 to GP surgeries. Harry Longman gave a presentation on Patient Access, his telephone triage system, and Dr Christopher Peterson demonstrated how it worked in his practice. 
Dr Steve Laitner, a GP in Cambridge, spoke about his experience with telephone triage. 
“There are two paths. Regular patients with an ongoing issue go through to the reception, patients with a new problem go on the GPs list and a telephone appointment is made where they are called back in an average of 12 minutes, that might be followed up by a face-to-face appointment or referral elsewhere.
“Demand is finite. We have seen that as you improve access demand does not go up.
“Supporting our practice to be telephone-led has reduced urgent care admissions by 20-40%. By changing the model, which is predicated on face-to-face consultation starting instead with a phone call, improves access. Colleagues in Seattle have shifted channels from phone to email and found they can do more that way.”
Dr Amit Bhargava, chair of Crawley clinical commissioning group (CCG), said: “There is a cost implication with telephone triage as it does require front loading. That is difficult if you have a shortage of GPs. I would agree demand is predictable over the days and weeks. Monday and Fridays are the busiest. Doctor First2 ( a telephone triage system) has given us more control over our workload an more GP satisfaction as a result.”
Mukesh Lad, a community pharmacist and chair of Northamptonshire local pharmaceutical committee (LPC) said: “Using Doctor First improves access for patients. The only issue is that as it’s so intense in the first few hours of the day it can result in people having a ‘jellified’ brain. But this can be addressed with appropriate scheduling and changing GP working practices.
“Pharmacy First can also help with minor ailments. We use the outcomes as a tool to analyse where the patients would have gone if they had not gone to the pharmacy and that has been a useful tool.
“Teleconferencing and webcam technology can be used in care homes where there are certain issues with certain patients where GP time could be used more effectively than making a visit.”
Patient education
Mukesh Lad commented that patient education should take place with patients presenting at A&E or GP surgeries and would include “having an honest discussion about whether that patient should be there or if and alternative pathway could have been chosen. 
“Although we realise that could be quite a difficult conversation, at some point we do need to address this.
“We do need to try and change the psyche of the patients we are seeing.”
Moira Auchterlonie, chief executive of the Family Doctor Association, said that patients could be provided with a handbook about what they can expect from the NHS.
The obligation of dentists to see a patient within 24 hours if they are in pain was highlighted as something which was clearly understood by patients and worked well.
Altering referral patterns
Sue Blakeney, community optometrist, clinical advisor to the College of Optometrists, and advisor to the local area team (LAT) in Kent said: “I’d like to outline what we do locally in Kent to reduce demand on A&E and GP services for ophthalmology referrals.
“There are several schemes which have various acronyms but the most common one is PEARS – the primary eyecare acute referral service. 
“This allow optometrists to see patients who either self-present or are referred by GPs with acute conditions, most of which are not sight-threatening.
“The most common eye conditions are things such as dry eye, conjunctivitis and flashes and floaters, which are always a bit of a headache, probably to GPs, but certainly to optometrists because if you get it wrong the consequences are quite serious. 
“What I’d like you to do is think about how you deal with optometry referrals. 
“Part of conditions of PEARs is that the optometrists which take part have to see patients within a certain timeframe. Most of the optometrists open on Saturdays and some on Sundays so that will help with seven-day access. 
“This is running in Medway and the larger area of Bexley, Bromely and Greenwich.
“In Kent we have the next level up from PEARS as we have two prescribing optometrists in West Kent who see patients with more acute conditions and they are able to see a higher number of patients without referring them to hospital.3
Paul Hitchcock, director of the Allied Health Professions Federation (AHPF), said: “We could redesign pathways that don’t involve A&E – for example, a fractured neck or femur is a fairly obvious thing to spot. Therefore could we not have pathways where the first doctor a patient sees is the consultant orthopedic surgeon who will fix the problem. We know this best practice is happening in some places.
“GPs recognise that patients want to go to their GP practice as a first point of call, not necessarily to see a GP – making better use of the building by employing different professions could help reduce hospital attendance.
“There are some professions, such as physiotherapy, which could benefit from self-referrals. That’s a way of working which is very limited at present. It could reduce pressure if people can go where it’s appropriate as their first point of call.
Nurse Angela Dempsey, on Enfield CCG governing body, is working on an older person assessment unit to try and prevent issues in the first place by working more closely with patients to keep them well and out of hospital.
Stephen Foster, pharmacy national clinical lead for the National Association of Primary Care, said: “There are 438 million community pharmacy interactions a year, that’s 1.2 a day and 44 million more than in every other visit combined. We can’t underestimate the significance that community pharmacy can have.
Mukesh Lad said: “GPs and pharmacists could run joint surgeries. We know that two out of five patients are coming in for minor ailments; perhaps some of that can be seen by the pharmacist, so more joint working could help in this area.
“The prevention agenda uses providers like pharmacies to take off some of the stresses and strains by providing immunisations for things such as flu.
“Give pharmacists some remit over long term conditions in the community and possibly with home visits.”
Robbie Turner, chief executive at Community Pharmacy West Yorkshire, said: “Using community pharmacists in NHS 111 call centres has been done locally in West Yorkshire. We have evaluated it and found it to be really positive and we have avoided call handlers escalating numerous calls to 999 calls.
“We can see the granular detail of the calls coming in. So over the August bank holiday, about 11% of calls were about emergency access to medicine.”
Barbara Parsons, head of pharmacy practice at the Pharmaceutical Services Negotiation Committee (PSNC), said: “I’d like to point out that we work with the Proprietary Association of Great Britain (PAGB) to look at the way workloads can be shifted for minor ailments from GPs to pharmacy. The Department of Health has done work on this and found £300 million in savings so there is a lot of evidence out there. 
“Also we have looked at the emergency supply of medicines in the NHS as lots of emergency consultations are about people who forgot their medicines.’
Paul Hitchcock said: “From a patient’s perspective, very often a patient who gets free prescribing will go to their GP so they can get a prescription so they don’t have to spend money in the pharmacy shop. 
“We are going to have to redesign how money changes hands if we are going to maximise the use of community pharmacy.
“We could also think about extending prescribing rights to a broader range of clinicians, for example paramedics, who see many of the more vulnerable people in society who may not be registered with a GP. Prescribing there may help with the pressure on other services.”
Jenny Aston, chair of the Royal College of General Practitioners (RCGP) nursing group, said: “If you have an advanced nurse prescriber working with care homes, its amazing what preventative care you can do. We are working on that pathway in our practice in Cambridge.”
Urgent care plans
Dr Agnelo Fernandes, chair of Croydon CCG, spoke about work around risk stratification and anticipatory care in Croydon, where self-care is at the top of the strategy.  
They redesigned emergency care with an integrated front-end A&E, with GPs and nurses who are now see 50% of adults and 70% of children who attend.
Croydon was one of the first to see proper implementation of NHS 111 and it saw a 50% fall in demand for GP out-of-hours (OOH) services. This allowed them to commission urgent care services rather than an OOHs service. There is also a rapid response team for the frail elderly.
GPs discussed PRISM which is a risk stratification system that uses multidisciplinary teams to have locality-based proactive care, helping to identify patients who may use urgent care more than others early.
Long-term conditions
Katie Simon, service improvement manager at Diabetes UK, highlighted the roles technology, care plans and the Year of Care will play in the future management of diabetes. She highlighted the need for there to be ‘someone to call’. 
“There is a cliff edge when patients get scared and need someone to call. This could be a GP, a nurse or maybe even a fellow patient or an online expert. There are lots of routes – it’s about reassurance and trust.”
Harry Longman said: “We have no data about what proportion of demand in A&E is from people who come off that cliff edge with chronic conditions and exacerbations. “We do have data on GP demand; 60% is acute, 30% is chronic conditions and 10% is acute exacerbations of chronic conditions.”
Robbie Turner talked about end-of-life care and highlighted the electronic palliative care record similar to Co-ordinate My Care in London as a good example of innovation in this area which has kept people out of hospital. 
He also stressed the need for improved communication between primary and secondary care so there was a shared terminology between the two in this area. 
Fiona Clarke, chief officer at South Sefton CCG, said: “In Southport and Formby we have improved end-of-life care pathways and have seen a 12% reduction in the number of A&E attendances.”
Jenny Aston focused on training: “We need to look at importance of the training of nurses in general practice and attracting them into that area as a career pathway, as it’s widely variable around the country.
“We are trying to develop that with Health Education England and the local education and training boards to ensure the importance of generalism and health prevention in the provision of care.
“There should be minimum standards for training. For example healthcare assistants could be on a Tesco checkout one day and in general practice the next.
“We need to have proper foundation training that is generalist in its nature, as they are not prepared for this in a hospital environment. This requires student nurses having properly-funded placements in general practice, which they don’t have at the moment.” 
Fiona Clark, chief officer at South Sefton CCG, said: “We are working with local university for a dual qualification for nursing and social care to meet future needs.”
Jeanette Martin, the Royal College of Nursing (RCN) regional director for South West England, said: “I’d like to highlight that a lot of care will be delivered by nurses in general practice. I have a background as a practice nurse.
“We are about to realise the retirement bulge in practice nursing and I would suggest it’s really important that it is linked in strategically to workforce planning. Currently not every local education and training board (LETB) is including practice nursing as part of their delivery. They are not thinking about the workforce planning required for general practice.”
Dr Steve Laitner said: “The Health Foundation is a good resource for information on self-care.
“It certainly does work but it needs to work as part of a system. Giving patients resources isn’t enough, they need support and there needs to be services that cater to empower patients.”
Durairaj Jawahar, vice chair of Leicestershire and Rutland local medical committee (LMC), said: “A lot of patients know of self-care, but some patients think a small rash is meningitis or turn up thinking they have a brain tumor because they read about it in the paper.
“These patients increase the workload. The front door of A&E is used by people who think going to hospital will get them better care. We need a cultural change and public education.
“I listen to ministers say they are bringing in 50,000 GPs in the future, but they are not looking at how GP resources are being used. If you have a European model with 900 people on the list and 20 minutes with a patient I am sure GPs in this country can solve a lot of problems, otherwise there are resource issues and whatever you do at primary care level will have problems.”
 3. PEARS. model pathways

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