In 2011, Maryhill Practice, in Morayshire, Scotland, took the unusual step of recruiting a paramedic to join our duty team as an 'emergency care practitioner'
This clinician (who had previously worked as a first responder in the out-of-hours GP service) initially worked with duty doctors, responding to daily, unplanned calls and visiting patients to make a baseline assessment.
They would monitor a patient's oxygen levels, for example, or assess whether they needed a blood test; do all the checks as if it were an emergency. All the information would be reported back to the duty team back at the practice so decisions could be made about the patient's care.
Virtual medical ward
It began to feel like the practice, which has six GP partners and two GP assistants, was running a mini hospital ward; we found ourselves clerking patients and planning care for them.
So we decided to introduce a virtual medical ward, led by our in-house team, to deliver the same kind of care to (appropriate) patients at home, as they might receive in hospital.
Our first aim in doing this was to allow our team delivering emergency and unplanned care to manage patients more effectively; however, the ultimate goal was to prevent unnecessary hospital admissions.
A typical patient receiving care in our virtual ward might have a long-term condition such as COPD and have developed an infection, or they might be a frail, elderly patient who is unwell and temporarily unable to look after themselves.
Previously, patients such as these would have been admitted to hospital. However, we know from feedback that patients prefer to be looked after at home, if possible, so this is about changing the way we deliver care to match patients' needs.
When we started the scheme, the duty team comprised a GP; emergency care practitioner; five practice nurses; two practice-attached district nurses; and one practice-attached health visitor. Since then we have taken on an additional emergency care practitioner.
Admission to the virtual medical ward can be made by any of the duty team as well as our pharmacy team. Patient details are entered on a white board in the duty team area and on the practice clinical system.
A meeting is held each morning by the duty team to plan care for all the cases. And the GP rostered to the virtual medical ward on a particular day works only on that; they are not expected to hold routine surgeries.
Prior to developing this project the only option for patients needing advice or follow-up was to receive this from the GPs. Where necessary, this is still the case.
However, with our extended team, there is better continuity of care, more robust checks in place for monitoring patients and follow-up is clearly managed and defined.
Patients who previously may have had contact with a different duty doctor each day now have a single point of contact: the duty team. This provides the team with a clearer picture of the patient journey and appropriate intervention at the appropriate time.
The training we have put in place to be able to run this virtual medical ward has been high quality. Our GP team had previously trained some of the practice nurses in treating minor conditions so they could take appointments for a restricted group of conditions.
We needed to build on that, so we approached Aberdeen's Robert Gordon University to provide 'in-house' training for our staff so they could avoid the 120- mile round trip to Aberdeen for training at the university.
The university agreed to provide two lecturers who came to the practice each week for six months to train the practice nurses, emergency care practitioner, district nurses and health visitor in advanced clinical examination skills.
This gave us an appropriately-trained team across all disciplines, able to assist with house visits, telephone triage and even consultations. The team is also able to provide daily surgeries for those conditions appropriate to their advanced skills training. A GP is still available as part of the duty team for those patients who have more complex needs.
By providing effective support and mentorship, the duty team is even able to take responsibility for house visits and follow up visits on a daily basis. This offers continuity of care and has relieved some of the GP workload arising from home visits, enabling them to offer more in-surgery appointments to those patients needing to see a GP.
The virtual medical ward incorporating the duty team has led to more focused discussion between members of the primary care team, resulting in improved communication and better patient care that helps reduce possible risk in the future.
Most admissions tend to be short-stay; anything from 48 hours to five days. For those patients that have lengthier stays of around a few weeks we are now looking to introduce an intensive care virtual ward.
The model we have trialled has generated quite a lot of interest from practices in our locality and it has brought about tangible benefits. The Community Health Partnership (CHP) has since offered funding to assist other practices interested in training staff for similar projects.
We calculated it saved 149 hospital days from April 2012 to March 2013. Although we estimate the potential cost of a hospital bed to be around £1,000 a day, we appreciate the money we save is not necessarily equivalent, because these beds are still used by other patients. However, we have reduced the frequency of stays in hospital for patients and patient feedback has been positive because they prefer to be cared for at home.
Funding the new scheme and staff training
Funding for the scheme was found in-house, by the practice. When a GP assistant was leaving to take up post in another area - and since GP recruitment was proving difficult - the doctors opted to take on a locum GP to cover some sessions, but to invest the remainder of the GP assistant's salary in this initiative.
Subsequently, we received help with the training staff have required. In line with what the CHP has offered other practices, it agreed to reimburse us 50 per cent of training costs for practice-employed staff and 100 per cent for NHS Grampian-employed staff.
The virtual ward did require us to look at staff resourcing. But we had already discussed with our district nursing team the need to extend cover (not just for the virtual ward, but for other reasons) and the team responded positively to changing cover from 9am to 5pm to 8am to 6pm. The district nurse team leader case manages the district nurse team's workload to enable capacity adn ensure we have the appropriate team members available to assist with the project.
Ultimately, however, the aim of the virtual ward is not about saving money but about delivering a better patient experience.
Key tips for running a 'virtual ward'
- Ensure communication is effective within the practice team and especially between everybody in the duty team and across all the different specialties.
- Have a good plan for patients. Know from the beginning what care you want to put in place and be prepared to revise it if necessary. Be aware that patients may still require hospital admission.
- Be confident in what you are asking members of the team to do and use their skills appropriately to the task-in-hand.
- Eileen Rae is practice manager at the Maryhill Practice, a training practice in Elgin, Scotland.
- This initiative was shortlisted in this year's GP Enterprise Awards