Primary Care Foundation - Urgent Care - a practical guide to transforming same-day care in general practice - 21 May 09

Source - Primary Care Foundation - www.primarycarefoundation.co.uk

The Primary Care Foundation has been commissioned by the Department of Health to undertake a stocktake/study across England of GPs and GP services working alongside, within, and with A&E Services.

The work consists of a number of components. We will gather information from A&E services, GP providers and PCT commissioners via questionnaire and visits to a number of departments and providers. In addition we are asking the service across England to tell us about good practice.

Urgent Care  - a practical guide to transforming same-day care in general practice
RCGP and GPC Introduction signed by Steve Field and Laurence Buckman

Urgent Care - a practical guide to transforming same-day care in general practice
The Royal College of General Practitioners (RCGP) and the British Medical Association’s General Practitioners Committee (GPC) support the Primary Care Foundation’s report Urgent Care – a practical guide to transforming same-day care in general practice. This report throws a spotlight onto an often neglected but very important aspect of general practice. Urgent care can be managed by practices in a wide variety of ways and we welcome this report’s  acknowledgement that solutions must be locally formulated within the available resources.

The RCGP and GPC support your conclusion that practices should review their access arrangements and their balance of appointment types and staffing. The examples and practical advice contained within your report will help practices to do this. We would certainly encourage all practices to assess their urgent care arrangements and to set themselves achievable goals for improvement where appropriate.

Practice capacity will be critical in determining practices’ ability to improve patients’ experience of urgent care. All too often practices’ desire to improve patient services is frustrated by insufficient capacity, substandard premises and inadequate funding. The ability of practices to implement many of your recommendations depends heavily on Primary Care Organisation (PCO) support and predictable, adequate practice funding. We support your recommendation that PCOs should support practices with resources, expertise and advice.

Executive Summary
Urgent care in general practice matters. It matters to patients, who may be harmed or distressed if diagnosis and treatment is delayed. It matters to the NHS as a whole, because urgent care arrangements which have not kept pace with other operational changes within the NHS place pressure on the rest of the system, driving people towards A&E and avoidable hospital admissions. It matters to practices, where workloads can become unmanageable if urgent care is not handled well. It also affects the reputation of the service - unhappy patients tell their family, friends and colleagues about their experience.

This report shines a spotlight on what actually happens on the ground. It describes our work with practices across five very different PCTs, outlining key lessons for improving urgent care.

The report and recommendations are designed to support all organisations delivering general practice services including GMS, PMS, PCTMS, APMS and the new GP led health centres. Other services, such as walk in centres, that deliver aspects of general practice should look to apply the principles contained in the document within their operating model and framework.

We focused on three simple questions concerning care for patients who contact their practice with an urgent need:

• Will they get through?
• Will they be identified?
• Will they be seen rapidly?

For staff in general practice
This report aims to help practices answer all three questions with an emphatic ‘yes’. We outline tried and tested ways to improve patient safety while reducing workload, with real-life case studies showing what can be achieved. In fact many of the practices featured focused on urgent care in order to tackle an intolerable workload.

Our research led to 10 recommendations across a number of areas listed below. These recommendations are aimed at practices because this is not an area where one size, one approach or one answer can fit all.

The different operational processes within each individual practice will dictate the best way for that practice to achieve these goals.

Recommendations Practices should:

• Address the urgent needs of a patient, whether they choose to access the service by phone or in person.
• Match capacity to demand - both in responding to the initial call or visit from a patient and in recognising the different demand patterns for same day and advance appointments.
• Ensure that the full range of cases that might need urgent attention will reliably be recognised by staff when the patient rings or presents in person and that the process is understood.
• Set deadlines for assessment and intervention and measure performance against these, paying particular attention to the needs of those requesting home visits where the chances are that the case may be more acute or complex.
• Review and audit the processes to refine the way that they operate.

See Recommendations 1 to 10 below, and Chapters 4 to 6, for more details. Practices will also find a useful checklist, ‘The four dimensions of care’, in Chapter 7.

For Primary Care Organisations and the wider NHS
Offering consistent and ongoing resourced support for practices to improve urgent care can bring major benefits across the system. If surgeries can manage urgent care as early as possible in the patient’s journey, the workload and costs for the rest of the NHS will be reduced. Better management of urgent requests can lead to a substantial reduction in attendance at A&E and emergency hospital admissions, as demonstrated by many of our case studies.

The evidence
Our recommendations are the result of intensive work with primary care professionals, including research into best practice, a survey of GP practices, face-to-face interviews and workshops in five very different PCT areas (see Chapter 1 for more details). We have found a number of ways in which different practices operate to meet the principles of good urgent care within the context of their individual circumstances - patient population, skill mix, geography and other factors.

The case studies we have highlighted often describe only one element of the process, a specific aspect of care, or even just provide an illustrative format for practices to use as a basis for developing their own processes. The named practices would not claim to be exemplars of best practice across the board but do show how it is possible to transform the urgent care offered to patients.

High-quality urgent care depends on four factors:

• Access
• Speed of initial response
• Capacity
• Assessment (by receptionists/call handlersand clinicians).

We have not attempted to draw up any narrow definitions of urgent care, not least because no single description could cover the variety of considerations that need to be
taken into account in any individual case. As a result, we have considered any patient that contacts the practice wanting to be seen that day (same-day care) as a
potentially urgent case.

Action points for practices:

Recommendation 1 - Access
Ensure patients with urgent conditions will receive timely care however they access the service. Many practices aim to achieve this but a small number have tried to channel patients so rigidly into one process that barriers are created, increasing the risk that urgent needs may be missed. See Chapter 3 for more details.

Recommendation 2 - Matching capacity to demand
Ensure processes minimise avoidable peaks in demand. Practices should assess the pattern of phone demand and make sure that sufficient staff and telephone lines are available so that patients do not find it difficult to contact the practice. See Chapter 3 for further information.

Recommendation 3 - Reviewing capacity
Make sufficient appointments available to meet demand from patients. Practices should review the number of appointments available each week (across all skill groups and including telephone consultations) to ensure that they meet the needs of their patient population. Capacity should be sufficient to meet the predictable demand without resorting to unplanned extra appointments. See Chapter 4 for more details.

Recommendation 4 - Capacity for same-day and advance appointments
The balance of book ahead to same-day appointments (including other options such as telephone consultation or other responses) should be matched to the pattern of demand. We found two-thirds advance to one-third same-day appointments appears to be the right mix for the normal demand facing many practices as this reflects the character of general practice workload demonstrated in many studies and surveys. See Chapter 4 for further information, which also describes some of the reasons for varying this proportion.

Recommendation 5 - Responding to urgent cases
Review how the practice would identify and respond to a range of urgent cases. Look both at symptoms that might indicate urgency and consider particular groups of patients that may need to be handled differently. See Chapter 5 for more details.

Recommendation 6 - Training
Review receptionist training to ensure these front-line teams understand and use the right processes to identify and handle urgent calls. Where required, practices should run refresher sessions involving both clinical and non-clinical staff. See Chapter 5 for further information.

Recommendation 7 - Deadline for assessment
Define your own practice standard for the length of time from the patient first ringing to assessment by a clinician (telephone or face-to-face). Practices should monitor performance against their standard and review this measure. See Chapter 6 for more details.

Recommendation 8 - Deadline for intervention
Define your own practice standard for the length of time until appropriate clinical intervention or hand-off takes place where a clinician has assessed the case as urgent. Practices should monitor performance against their standard and review this measure. See Chapter 6 for further information.

Recommendation 9 - Quality
Carry out regular audits of the process for urgent care to review the quality and consistency of telephone response, consultations and decision-making. Consider making use of approaches such as those of the Royal College of GP’s practice accreditation scheme. See Chapter 5 for more details.

Recommendation 10 - Home visits
Any patient or carer requesting an urgent home visit should be offered a rapid assessment by a clinician. Normally this will be by phone but in some cases the clinician, knowing the patient’s condition, may choose to plan an early visit. See Chapter 6 and Case Study 8 for further information.

Action point for Primary Care Organisations:
Recommendation 11 - support from PCOs
Primary Care Organisations should support practices (with recurrent resources, expertise and advice) in reviewing and improving their process for handling requests for same-day urgent care, in line with these recommendations. See Chapter 5 for more details.

Action point for suppliers of phone and IT systems:
Recommendation 12 - phone and IT systems
Suppliers of both IT and phone systems to general practice should develop reports that support practices:

• In measuring and monitoring capacity and demand.
• In monitoring the timeliness of response.
• In reporting of outcomes at each stage in handling an episode of care from the initial patient contact to appropriate clinical intervention or hand-off.
• In reviewing the quality of telephone response by non-clinical staff as well as the quality of clinical consultations.

Those involved in selecting and specifying systems should consider these needs as they update or renew systems over the coming years. See Chapter 5 for further information.

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