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

2. The Foundation
● Benchmark 100+ PCT GP O t of Ho rs Ser ices
Out Hours Services
● Report on urgent care in general practice
● 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

3. The real issue is not in the hospital!
3 Hours 2 Hours 2 often 4 Hours
8.30 11.30 13.30 17.30
15 Minutes 1 Hour 1 Hour
8.30 8.45 09.45 10.45
© The Primary Care Foundation

4. Objective behind the use of primary
care

5. What were the objectives for using primary
care staff?
The 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 following
a) 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
much examination
h i ti
c) attempting to see all walking patients including those that clearly need hospital
facilities, eg Xray
d) reducing the number of p
) g patients admitted (
(but not seeing ambulance p
g patients,
,
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
(which was difficult as the hospital ran out of beds for prolonged periods).
© The Primary Care Foundation

6. Reasons for working together
●An a f l lot were about cost and admission red ction
An awful ere abo t 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 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 gu de pa e s
s p e p ocess o guide patients
© The Primary Care Foundation

7. Operational model – Initial reception

8. 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
making own decision
● Three main types of process:
● R
Receptionist quick d i i ( ft using simple protocols). Thi i not
ti i t i k decision (often i i l t l ) This is t
“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 sent
p
● 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 Primary Care Foundation

9. 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 demand
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 arrive.
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.
© The Primary Care Foundation

10. Operational model – model of service
There appear to be four main types of model

11. Four main types
1. Situated alongside the Emergency department running
separate reception and operational processes
2. Situated alongside the Emergency department and
running common reception and separate operational
i i d i l
processes
3.
3 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.
5 GPs employed as part of acute team working within the
team
© The Primary Care Foundation

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

13. 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
other primary care clinical staff – much b tt if not sessional
th i li i l t ff h better t i l
● Around half of services expect the GPs to see a considerably wider
range of cases than would be seen in General practice (which
implies f hi training
i li refreshing t i i around such thi
d h things as X rays and th
d the
interpretation of some tests)
● Very few services use primary care staff during the ‘red-eye’ period.
Most
M t services that are using primary care staff d so f
i th t i i t ff do from 8 till l t
late
7 days a week.
© The Primary Care Foundation

14. 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
● 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 g
practice). 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
different skill groups
diff t kill
● 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’ patients
walk-in
● 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))
© The Primary Care Foundation

15. 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
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
© The Primary Care Foundation

16. Conclusion – primary care staff can see
C l i i t ff
somewhere between 10 and 30% of cases
depending 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
© The Primary Care Foundation

17. Responsibility for audit, operational and
clinical governance
li i l

18. In many services there is a lack of
clarity over responsibility for important
y p y p
aspects of the service
In services that we visited questions such as
as….
● Who has overall responsibility for the clinical governance in respect of
patients that attend A&E?
● 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?
● 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?
…often exposed this lack of clarity
f d hi l k f l i
© The Primary Care Foundation

19. Conclusion – making sure that there is
clear responsibility f clinical and
l ibilit for li i l d
operational governance is important!
© The Primary Care Foundation

20. Funding and cost-effectiveness

21. Adding more staff and an additional service
option is rarely cheaper
ti i l h
● Fail re to compare like with like (often looking at the
Failure ith
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 (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
© The Primary Care Foundation

22. Conclusion
● It is possible to incl de primar care staff in a way that
include primary a
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.
© The Primary Care Foundation