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

Primary Care in Emergency Departments (A&E)An outline of the report structure and findings

The Foundation

Benchmark 100+ PCT GP O t of Ho rs Ser ices● Benchmark 100+ PCT GP Out of Hours Services● Report on urgent care in general practice● Report on A&E and Primary Care● 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

The real issue is not in the hospital!

3 Hours 2 Hours 2 often 4 Hours8.30 11.30 13.30 17.30

8.30 8.45 09.45 10.4515 Minutes 1 Hour 1 Hour


Objective behind the use of primary care

What were the objectives for using primary care staff?

The assumption seems to be that its so obviously a good idea that theThe assumption seems to be that its so obviously a good idea that the underlying principles can't be questioned.

At various times the objects of our scheme have included the followingAt various times the objects of our scheme have included the followinga) 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

h i timuch examinationc) attempting to see all walking patients including those that clearly need hospital

facilities, eg Xrayd) reducing the number of patients admitted (but not seeing ambulance patients, ) g p ( g p ,

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


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).

Reasons for working together

An a f l lot ere abo t cost and admission red ction●An awful lot were about cost and admission reduction●There is a poor link between overall attendances and admissions

●Admissions rise when its busy due to shortcomings in A&E process●The answer is to fix this●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 guide patients


s p e p ocess o gu de pa e s

Operational model – Initial reception

Clinical Triage is used to prioritise patients who have to sit in a queue. What was interesting were the services where this is not necessary.

● Quite firm views found on triage versus simple guidance or patient● Quite firm views found on triage versus simple guidance or patient making own decision

● Three main types of process:R ti i t i k d i i ( ft i i l t l ) Thi i t● Receptionist quick decision (often using simple protocols). This is not “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 sentp

● 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 majority of services accept that a queue is inevitable, the innovative ones staff up to avoid this and find that it is better for patients and cheaper. This is the lesson that manufacturing learned in the 1970s!

● Clinical triage is the solution adopted by services that cannot staff up to meet predictable peaks in demandto meet predictable peaks in 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 arrivethey 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.

Operational model – model of service

There appear to be four main types of model

Four main types

1. Situated alongside the Emergency department running1. Situated alongside the Emergency department running separate reception and operational processes

2. Situated alongside the Emergency department and i i d i lrunning common reception and separate operational

processes3 Fully integrated with common reception and operational3. Fully integrated with common reception and operational

processes 4. Primary care staff attempting to extract patients already

booked into the Emergency Department to find alternative treatment/options

5 GPs employed as part of acute team working within the


5. GPs employed as part of acute team working within the team

Proportion of services using primary care staff and proportion seen by primary care clinicians

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 th i li i l t ff h b tt if t i lother primary care clinical staff – much better if not sessional

● Around half of services expect the GPs to see a considerably wider range of cases than would be seen in General practice (which i li f hi t i i d h thi X d thimplies refreshing training around such things as X rays and the interpretation of some tests)

● Very few services use primary care staff during the ‘red-eye’ period. M t i th t i i t ff d f 8 till l tMost services that are using primary care staff do so from 8 till late 7 days a week.


There are a number of reasons for the variation in proportion of cases seen by primary care

● Variations in the hours primary care clinicians are available● 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 gpractice). 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 diff t killdifferent skill groups

● 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’ patientsor walk-in patients

● 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)


)

There are also some wildly different claims for the percentage of cases that could be seen by a general practitioner

● From 60% derived from a study in London asking GPs which cases they could have● 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

clinicians

The 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

C l i i t ffConclusion – primary care staff can see somewhere between 10 and 30% of cases

depending on the set-up – more ambitious targetsdepending 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


Responsibility for audit, operational and li i lclinical governance

In many services there is a lack of clarity over responsibility for important y p y paspects of the service

In services that we visited questions such asIn services that we visited questions such as….● Who has overall responsibility for the clinical governance in respect of

patients that attend A&E?● Who audits the cases?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?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?

f d hi l k f l i


…often exposed this lack of clarity

Conclusion – making sure that there is l ibilit f li i l dclear responsibility for clinical and

operational governance is important!


Funding and cost-effectiveness

Adding more staff and an additional service ti i l hoption is rarely cheaper

Fail re to compare like ith like (often looking at the● Failure to compare like with like (often looking at the 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 (forDepartment 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


some of the financial perverse incentives

Conclusion

It is possible to incl de primar care staff in a a that● It is possible to include primary care staff in a way that 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.savings can be expected if this is set up well.


Health & Medicine

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