A&E and GP Access

Another week of headlines.

Millions 'wrongly attending' A&E.  GP access needs to improve.  GPs could do more to ease the burden on hospitals. 

'Winter is coming.'

So what would happen if a practice opened the doors and allowed walk in access to its patients for urgent conditions? No triage. No need to ring.  Partners and nurse practitioners  working as a team, average wait 30 minutes.  The ability to phone if you want to speak to someone.

This is my practice.  The model has been described in another blog: http://clinicalcommissioning.blogspot.co.uk/2013/01/opening-doors.html?m=1

The practice

We have a large practice, across 4 sites, looking after over 27,000 patients.  14 partners, 3 nurse practitioners.  Separate entrances and waiting rooms for the urgent care service, based at the main site with 15,500 patients.  We have just started a walk in service at one of the branch surgeries this summer.  We have tried most systems over the years including telephone triage and traditional on call models.  There is no additional contract for the service, it’s simply our model for our patients.

The main site is a few hundred yards from A&E.  There are areas of significant deprivation and high levels of chronic disease, obesity and substance misuse including alcohol.

We have partners with a high level of training and experience in a number of areas including dermatology, orthopaedics, palliative care, substance misuse, diabetes, ophthalmology and ENT.

The effect on the practice staff

The service (known as LUCS – Larwood Urgent Care Service) has been extremely popular. Routine surgeries are no longer overbooked and receptionists now have no frustration finding appointments for patients wanting to be seen urgently. 

Staff work extremely hard, and are proud of the service they help deliver.

Attendance levels

We opened the service in November 2010 - at the start of a flu epidemic.  We coped well with up to 140 contacts per session that winter.  As the service has become established we have more stable numbers attending, less inappropriate use and numbers have dropped slightly from 24,000 per year in 2010/11 and 11/12.

We are able to predict attendance numbers and adjust staffing levels with higher numbers attending on Monday, Tuesday and Fridays.

Patient satisfaction levels are high, and we have seen and diagnosed a significant amount of serious illnesses in the walk in service.  Patients are asked their main problem as they attend to ensure they do not have symptoms of a myocardial infarction or a stroke.

A&E attendances

The practice is situated next to A&E and has a high level of morbidity and deprivation.  A&E attendance is therefore higher than most other practices in the CCG with more rural locations.  A&E attendance overall has reduced slightly, but less than we expected with a difference of 2-3%.  We have seen an increase in complex conditions in A&E and a reduction in minor illness attendances requiring no investigations.

2012 Attendances By Day (in-hours)

2012 Attendances by Month (in-hours)

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Pressure on appointments

Routine surgeries now have no extras, and visits seem to have reduced due to the ability to be seen quickly at the surgery.  There is still a pressure on appointments and we continue to work on this.  We see a lot of patients, do extended hours and have a large team of highly trained nursing staff.  The service has improved the efficiency of the practice and for a large urban practice the ability to separate acute and planned care has undoubtedly been beneficial.

Wasted appointments

Despite enabling online booking and texting reminders to patients before appointments we had just under 10,000 appointments wasted last year due to DNAs.  We are working with the patient group and local media in an attempt to reduce this.

Conclusions

There are many reasons why the walk-in service is better for the staff and our patients.  Reducing A&E attendance was not a key driver in an area where inequalities are significant and comorbidities common.  Reducing inappropriate A&E attendance was a driver, and we have had some success with this.

Patients attend A&E ‘inappropriately’ for many reasons.  Primary care access may be one, but deprivation, family culture, free prescriptions and distance from A&E are key factors.  We know that the ‘frequent attenders’ at A&E have mainly alcohol or mental health problems, and it is essential that practices and CCGs ensure services are commissioned to deal with these problems in an appropriate setting. 

There is little evidence that we can prevent inappropriate A&E attendance through education.  We should focus on making A&E safe, focus on staffing and pathways, and look to integrate services (including primary care) where possible. 

Blaming GPs for not doing enough, or patients for attending, is not the answer.