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How a GP federation is cutting A&E workload

A federation of London practices is slashing the A&E workload at one of the capital's busiest hospitals thanks to data-sharing technology. Dr Mike Smith explains how the system works.

Haverstock Healthcare, a federation of all 35 GP practices in Camden, north London, has been running a GP surgery at the front door of the Royal Free Hospital’s A&E since 2009.

Because of our local knowledge and the ability to view patients’ own GP records on EMIS Web (with point-of-care patient permission) we are able to carry out safe, rapid assessments on up to 50% of the patients who present for ‘emergency’ care.

We send home half of those with basic health advice – adding up to 26,000 patients a year who do not need to see a doctor at all. The remainder we send to their own GP, or to a GP-staffed urgent care centre (UCC) next to the A&E for further assessment. Only 10% of our ‘front door’ patients now go on to be treated by specialist emergency doctors in A&E.

The GP record

Having the patient’s core GP record at our fingertips to aid clinical decisions has helped us reduce the risk of:

  • starting patients on a care journey that is not needed with unnecessary investigations
  • prescribing inappropriate medications that have already been tried or they’re allergic to and
  • deferring clinical decisions back to the GP who may be best placed to treat the patients’ conditions.

Access to the patients’ records also improves their experience of A&E and saves everyone’s time – there is no need to take a medical history.

Importantly, we are also cutting costs because we are ordering fewer diagnostics like X-rays and blood tests. In the traditional A&E model, patients often see a junior doctor first, who is not as experienced as a GP in diagnosing and treating minor illness and injury, and will often carry out expensive tests ‘just in case’.

Most importantly of all, we are freeing up emergency clinicians who are able to deal with genuine emergencies more quickly. Since the service started, two out of the three triage nurses at the front door have been redeployed to work alongside the emergency team.

Why did we do this?

Haverstock Healthcare came into being in 2008 when 26 local practices federated to bid to run a local GP-led ‘Darzi’ walk-in centre. When we lost out to a private company, we decided to build resilience for future bids by concentrating on work that played to our strengths and detailed knowledge of the local patient population.

We noted that the Royal Free’s A&E, designed to cope with up to 40,000 patients a year, was dealing with double that number. But hospital admissions were not rising at anything like the same rate. It was clear that huge numbers of patients who did not need emergency care were being seen by hard-pressed A&E staff and then sent home.

We asked the trust if a local GP could sit in A&E and assess walk-in patients. We quickly realised that not only did most of them not need to be there, but they also did not need to see a doctor. We felt there was an excellent opportunity to use our clinical and risk management skills as GPs to quickly sort out the genuine emergencies, galvanise the local community to self-care, and relieve the pressure on A&E.

How we did it

Haverstock Healthcare negotiated a block contract with the trust to staff a two-GP surgery in A&E from 10am-10pm 7 days a week. We pay competitively, offering shifts on the BMA-approved day- time locum rate to every practice in the federation, all of whom have signed up for it.

GPs can buy and sell shifts within Camden, depending on workload, but generally the same GP covers a regular shift each week.

Besides the income, what’s in it for practices? There is a fair amount of job satisfaction. GPs appreciate the opportunity to spend a whole shift in face-to-face clinical care without the reams of paperwork that normally go with it. They also get the opportunity to work and network with their local colleagues, and spend time with their GP trainees.

We mostly offer reassurance about self-limiting conditions, and send patients home with information leaflets or to the chemist.  It is also a good opportunity to give alcohol, smoking, STD and other health promotion advice. In one 24-hour HIV awareness event in the urgent care centre (UCC) for example, we picked up two undiagnosed HIV cases.

Our UCC is deliberately designed to look like a GP practice. We dress like GPs (no scrubs), carry a doctor’s bag, talk like GPs, prescribe as GPs, and have an average practice’s facilities for tests etc. It has a powerful psychological effect. Once seen by us, patients have the knowledge not to use A&E casually again. We call it ‘positive redirection’.

The next step for us is to enable EMIS Web to send an e-discharge letter to patients’ own GPs, giving them timely and accurate information about their patient’s visit to A&E. We are also developing an alert system to let GPs know when a patient is visiting A&E so that they can look at how to reduce the likelihood of this in future.

Since setting up the service, we have had visits from more than 50 organisations in other parts of the country, many of whom are now running a similar service.  We delighted to see other federations fully using their GP skills in this way. The benefits for the NHS are crystal clear.

  • Dr Mike Smith is a GP and chief executive of Haverstock Healthcare, and governing body member of National Association of Provider Organisations (a branch of the NAPC set up to help federations within primary care)

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