OOHCareMAPPING CASEMIX AND PLANNING

SKILLMIX

Dr Jeremy Lade

REDDOCReading Doctors On Call

An ISO 9001-2000

Company

REDDOCThe ISO LOGO awarded by Systeme General Surveillance of Switzerland

Management Quality Standards and Protocols approved every 6 months

REDDOCREDDOC Ltd

• A private company, non profit-making.• Employs 50 staff:• Office staff• Operators• Nurses• Drivers• Turnover £750,000 pa• Mainly financed by the GPs themselves and not by the NHS.• ISO 9001 2000 certificate awarded in 2001

REDDOC

• REDDOC opened in April 1996

• 120 GP Members

• 225,000 patients covered each night

• Reading and Wokingham PCTs

• 40,000 calls per year.

NEWDOC

REDDOC

SEBDOC

BEDROCK

Berkshire OOH Providers 2003

REDDOCCALL FLOW

PATIENT

REDDOCOPERATORS AND DISPATCHERS

TRIAGE DOCTOR

ADVICE39%

VISIT20%

PRIMARYCARE CENTRE

39%

DISTRICTNURSES

2%

RoyalBerkshireHospital

MinorAilments

WOKINGHAMHOSPITAL

The Present Situation

• The PCTs now have the opportunity to set up and provide a fully integrated system for providing OOH and unscheduled care across their areas.

• What should they be doing or have done by now??

PCT preparation tasks• 1 ASSESS THE DEMAND:

• Look at call volumes and casemix of:

• OOH services.

• Community Nursing IH and OOH

• Ambulance Trusts

• A&E and Minor Injuries

• Palliative Care

• Social Services/Homecare

• Major Incident Planning

PCT preparation tasks• 2 PLAN:

• The types of service and resources available to meet the demand :

• ie Premises, Transport, Organisational and Technical Networks for:

• Primary Care Centres

• Walk in centres

• A&E

• Minor Injuries Units

• Ambulance/PTS

• District Nurses, Social Services, Homecare Services.

PCT preparation tasks

• 3 ESTIMATE COSTS

• Bearing in mind that:

• Many funding streams in Emergency Care will overlap.

• Redesign of OOH services will need setup funding initially that should not be borne by existing providers.

West Berkshire

• 251 GPs

• OOH care provided by five Co-operatives Majority of 178 with REDDOC and NEWDOCS

• Future Provider pattern not yet decided by PCTs who are waiting until January 2004

West Berkshire Provider REDDOC/NEWDOCS

465000 patients

East Berkshire Provider Bedrock

415000 patients

REDDOC/NEWDOCS Berkshire OOH provision proposal

REDDOC/NEWDOC planning across NHS departments includes: • Accurate workforce/skillmix design.

• A&E and CDU sessions for OOH doctors

• Integrating with District Nursing OOH

• Integrating with Social Services OOH

• Working with Palliative Care OOH

• Working with Mental Health Services

• Working with Hospital Outpatient Services

• Working with PCTs to provide Central Operations Role In and Out Of Hours

• Major Incident Planning and Co-ordination

Planning Casemix and Skillmix

• It has been said that after April 2004 OOH Doctors will be few and expensive and much of their current OOH work can perhaps be done by First Contact Clinicians (Nurse or Paramedic)

• Question: What is the current OOH Workload?

• Question: How much of it can be done by FCCs and where are they to be found?

Present REDDOC Nursing Staff

• 12 nurses• None yet trained as FCC• None do Redeye shifts• All wish to continue routine work at PCC• ALL wish to train for Triage• 4 wish to train for FCC

• All have family and work commitments

• Conclusion: There are very few (if any) FCC nurses available in West Berkshire at present.

Data Collection at REDDOC

• 100% of encounter forms examined the followingday since 1996.

• Fixed Read codes used since Aug 2000.

• All office staff are clinically experienced and havehad lengthy training.

• Only the same staff work input data.

• Data is stable and reliable.

• Labour intensive but essential for planning.

• Clinical Governance implications are important.

Demography of Reading/Wokingham

• Reading:

• Urban, mixed leafy affluent suburbs, inner city and deprived areas.

• Centre for teenage drinking. Gun crime common.

• Wokingham:

• More rural, villages, “happiest” place in England in 2002. Second healthiest in 2003.

• High 3 car per family area.

• Patients know their rights, highest OOH demand per patient in UK.

Reading & Wokingham Population by Age Group 2001

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2000

4000

6000

8000

10000

12000

14000

16000

18000

0-4 5-9 10-14

15-19

20-24

25-29

30-34

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50-54

55-59

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70-74

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85-89

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95-99

100and >

Age Group

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M F

PCT Population Age Groups 2001

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M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

0-4 0-4 5-9 5-9 10-14 10-14 15-19 15-19 20-24 20-24 25-29 25-29 30-34 30-34 35-39 35-39 40-44 40-44 45-49 45-49 50-54 50-54 55-59 55-59 60-64 60-64 65-69 65-69 70-74 70-74 75-79 75-79 80-84 80-84 85-89 85-89 90-94 90-94 95-99 95-99 100 and >100 and >

Age Group

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Reading

Wokingham

TRIAGE CALLS TO

REDDOC

Number: 15,100 per annum

40% of calls

The commonest advice call typesare spread across all age groups

• Advice about prescriptions: 1164

• Intestinal problems, gastroenteritis: 1166

• URTIs: 803

• Symptoms, signs, ill defined conditions 1308

• Injuries, burns, poisoning, allergies: 1237

• TOTAL 6960

• (46%)

Nurse Triage

• Should they use a CAS system? It may slow call handling down.

• Problem areas:

• Age 0-2 may be difficult.

• Multiple pathology.

• Multiple or complicated prescriptions.

• Mental Health problems.

• However

• Self-assessment suggests 50-90% could be managed, ie 8,000 plus now and 16,000 plus per annum in the future.

• This will be a major contribution to OOH

Visits by REDDOCNumber: 8095 per annum

21% of calls

Visits by Day & Age Group June 2003

0

10

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80

0 - 2 yrs 2 - 5 yrs 5 - 10 yrs 10 - 15yrs

15 - 20yrs

20 - 25yrs

25 - 30yrs

30 - 35yrs

35 - 40yrs

40 - 45yrs

45 - 50yrs

50 - 55yrs

55 - 60yrs

60 - 65yrs

65 - 70yrs

70 - 75yrs

75 - 80yrs

80 yrs or>

Age Group

Nu

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Vis

its

SundayMondayTuesdayWednesdayThursdayFridaySaturday

Visits by Day & Age Group December 2002

0

10

20

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80

0 - 2 yrs 2 - 5 yrs 5 - 10 yrs 10 - 15yrs

15 - 20yrs

20 - 25yrs

25 - 30yrs

30 - 35yrs

35 - 40yrs

40 - 45yrs

45 - 50yrs

50 - 55yrs

55 - 60yrs

60 - 65yrs

65 - 70yrs

70 - 75yrs

75 - 80yrs

80 yrs or>

Age Group

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Vis

its

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Most Frequent reasons for visiting (not in order)

• Heart Failure

• Circulatory system

• Strokes and TIAs

• Chest Infections

• Pyrexia/UTIs in elderly

• Abdominal pain (all ages)

• Ill defined problems in elderly

• Injuries in elderly

• Gastroenteritis (all ages)

Visits in 75 and over : 2731

Visits in 65-75: 997

Visiting 65 and over: 3728 = 46% of annual calls

These are clinically the most challenging calls and will need GP assessment

Visiting older patients

Problems with Visiting the Elderly

Diagnosis often uncertain until patient is seen - Who to send?

Elderly have multiple pathology and polypharmacy.

There are often Social Services and home care problems.

Consultation time available is usually short.

Experience, confidence and the authority to make rapid and effective management decisions including hospital admission are essential.

OOH services can only afford a single consultation, double visits are not efficient.

First Contact Clinicians and Home Visiting

Elderly visits needing GP assessment 46%

The other 54% more likely to need GP assessment (perhaps 50%) ie up to 70%.

Hence FCCs attending all visits would need to request 70% doctor follow up call rate.

This would be expensive and inefficient

This problem is avoided by sending GPs in the first place

(However District Nurses do have a very important role in managing chronic conditions at home and should become part of the OOH team if hours on call can be extended as they are already out on duty).

Problems with bringing patients into PCC/hospital for assessment in West Berkshire

• Shortage of ambulance facilities • Co-op transport not safe• PCC not equipped, staffed or large enough• Acute Trust already stacking patients at home• Elderly patients tend to be admitted• Confusion in elderly• A&E 4 hour target figures• Process delays run over into morning• Hospital bed occupancy around 98%

OOH Attendance at the

REDDOC PCC

Number: 14259 per annum

38% of calls

Disorder Number Ages

Gastroenteritis 519 0-2, 2-10, 10-35

Viral + rash 154 0-2, 2-10

Other viral 662 0-2, 2-10

Conjunctivitis 371 0-2, 2-10

Otitis media 1012 0-2, 2-10

Tonsillitis 752 0-2, up to 50

URTIs 1314 0-10, up to 50

LRTIs 540 Any

Asthma 533 Any

UTIs 726 2-10, 20-50

Injuries/burns 710 Any

Total 6654 = 47% of 14061

PRIMARY CARE CENTRE PATIENTS MOST SUITABLE FOR MANAGEMENT BY FIRST CONTACT CLINICIANS

FCCs working in the Primary Care Centre

• Majority of work involves children

• Doctor back up always available

• This work is ideal for FCCs who could probably deal with 75% of the workload (depending upon day of week and time)

• This work is clinically interesting and fulfilling for FCCs

Mental Health Statistics

FCCs working in West Berkshire in the future:

FCCs could manage 60% of the workload of 80,000 calls per year:

Triage 25,000 patients

PCC 21,000 patients

BUT Visits would be only approx 1,000 (less than 2 per week night).

Conclusion:

For West Berkshire it will more efficient to employ FCCs on Triage and PCC shifts

BUT District Nurses already on shift may be very helpful when integrated into the system. Their job specification may have to be altered to allow for long shifts.

CONCLUSIONS

1 First Contact Clinicians (Nurses or Paramedics) should be employed for Triage and Primary Care centre work with doctor back up

2 Training of FCC nurses is a priority.( If they start with Triage they will be able to work sooner)

3 Home visits are often clinically challenging but essential given the current NHS organisation and low bed capacity.

4 Experienced GPs are the most effective clinicians to carry out Home Visits at present

Doctors working OOH

REDDOC REGULAR DOCTOR SHIFTS

Day/Shift ET EP EME NME EMW NMW AT AP AME AMW MT WS MP1 MP2 AP1 AP2 MME MMW

Sunday F G A A B B F G H H

Monday H G A A B B

Tuesday E G A A B B

Wednesday E H C C D D

Thursday E F C C D D

Friday E F C C D D

Saturday G H E E F F G H

Making OOH work attractive for GPs

• Full time OOH GP

• Practice contract GP

• Weekend sessions GP

• A&E and CDU Hospital GP shifts

• Include:

• On going Training, Team working, Appraisal, Re-validation, Clinical Governance.

West Berkshire OOH SkillmixShort Term provision

• Triage GPs and FCCs

• PCC GPs and FCCs

• Mobile GPs

• A&E and CDU GPs

• Mobile DNs

• Social Services and CPNs when required

• Palliative care when required

West Berkshire OOH Future development to improve cross-service integration

• New building next to Hospital to include:

• Walk-in centre

• Minor Injuries Unit/XR

• PCC and GP technical links

• 24 hr Pharmacy

• 24 hr Dental Services

• Hospital patient management systems and services to include SS, DN, Transport, Mental Health

• In and OOH Operations Room, PCT services, single point of access for community services