Winter is here once again, and with it the relentless media focus on ‘crisis’ in accident and emergency (A&E) departments.
Historically, ‘winter resilience funding’ (the extra money given to local areas to cope over winter) has been allocated to clinical commissioning groups (CCGs) in the autumn. This leaves little opportunity to plan how to spend it or often have any real impact in time for the period of greatest pressure. However this year the money went into CCG baselines in April.
As a primary care commissioner working in a CCG, this was good news – giving us longer to think about how best to spend it and come up with a considered plan. Rather than just focus on the acute sector (as is the tradition), our local system resilience group decided to spend a proportion of the money on schemes in primary care.
Our aim was to better support patients in primary care over the winter period. Why? In order to prevent the cost and pressure of unwarranted A&E attendances and hospital admissions, but also – and more importantly – to help the most vulnerable patients by preventing the stress of an unnecessary trip to A&E or a hospital admission, which for frail elderly people in particular can have a seriously detrimental effect on their ability to recover from illness.
This move is supported by the evidence. We know from national analysis carried out by QualityWatch, the joint research programme led by the Health Foundation and the Nuffield Trust, that one in five of all emergency admissions between 2001 and 2013 were from patients with ambulatory-care sensitive conditions where timely access to high quality primary and preventative care can avoid the need for hospital admission in most cases. Research also shows that continuity of care and extended access to general practice in-hours reduces A&E visits and potentially emergency hospital admissions.
So what have we done in Horsham and Mid Sussex?
Working in collaboration with our practices we have introduced a number of schemes across our area:
- Introducing a GP e-consultation and self-help web service
This is hosted on a number of practice websites and enables patients to access symptom checkers, self-care information provided by NHS Choices, and advice on the various places a patient can get help such as local pharmacies or NHS 111. Registered patients can also fill out an e-consultation form available for 100 common general practice scenarios and symptoms which is sent to their practice for review by a GP within 24 hours. Evidence from piloting this in other areas of the country showed there were nine self-help interactions for every e-consult received and a saving of three appointment requests per e-consult. This frees up GP time to deal with more urgent patients. Feedback from 14% of patients who used the pilot said they would have accessed urgent care services if the web service had not been available.
- Focused use of our risk stratification tool
We’re using practice registered patient data to target those patients with ambulatory-care sensitive conditions who are most at risk of A&E attendance and hospital admission and offer additional proactive support. Identified patients are being contacted by their GP practice and asked to come in or have a call for a proactive review, and to develop a care plan (or ensure an existing one is up to date). With permission, these care plans will then be uploaded onto shared systems so they are available for use by A&E or ambulance staff if needed. We hope this may help prevent their admission to hospital. This scheme is not solely focusing on the frail elderly, but also under fives at risk, as some of our practices have a significantly younger population.
- Using advanced nurse practitioners to proactively work with care home patients
Nurse practitioners will ensure care home residents have appropriate care plans in place, promote and enable community alternatives to a hospital admission and support care home staff to manage patients so they can stay at home. This scheme is building on the successful employment of an advanced nurse practitioner by one local practice, as well as successful implementation of similar schemes in neighbouring CCGs or other health economies. It’s backed up by international evidence which suggests this sort of approach can help reduce emergency admission rates and, where patients are admitted, reduce their overall length of stay.
We are evaluating the impact of these schemes during the winter period so by the spring we can assess their value and then refine or replace them for next year.
Given the suggestion that emergency admissions amongst people with ambulatory-care sensitive conditions that could have been managed in primary care cost the NHS £1.42bn annually and this figure could be reduced by 8-18% by investment in primary and community based services, it appears like a cost effective investment worth making.
Clare Allcock is Head of Primary Care & Community Development at Horsham and Mid Sussex and Crawley CCGs, and a Senior Policy Fellow at the Health Foundation.