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How our in-hours acute visiting scheme cut emergency admissions

Dr Shikha Pitalia describes how a PBC scheme dramatically reduced emergency admissions.

Dr Pitalia: scheme has been well-received by patients and carers
Dr Pitalia: scheme has been well-received by patients and carers

Our Acute Visiting Scheme (AVS) is an in-hours, rapid access home visiting scheme, seeing patients within 30-60 minutes of a request and giving consultations of 20 minutes on average.

We set up our practice-based commissioning (PBC) consortium, United League Commissioning, in St Helens, Merseyside, in 2006 with 30 doctors in 13 practices, from single-handed to group practices.

Live in eight weeks
With the principles of the AVS(R) agreed, we were fortunate to have support for a pilot from directors at our PCT, NHS Halton and St Helens. It took less than eight weeks - from initial discussions to implementation - to go live.

I felt it was crucial to get the AVS(R) in place for the 2006/7 winter pressures. Our PCT had one of the highest admission rates in the SHA. Local service utilisation reviews indicated that more than 40 per cent of patients occupying hospital beds would not have needed admission if appropriate community services were available.

Having consulted patients, GPs and the PCT on the scheme's design, we kept the referral process simple, commissioned the existing out-of-hours provider to handle calls and recruited experienced doctors with local knowledge.

We reassured the practices that doing immediate telephone consultations to assess the urgency of all home visit requests was worthwhile.

We kept the patient and public involvement forum and the PCT informed of progress.

Once launched, I personally reminded the practices daily to use the scheme. It took only days for GPs to start appreciating its benefits such as easier workload planning and more surgery appointments. On average, each practice now offers three additional appointments per session - effectively a whole time-equivalent GP for the consortium at no additional cost.

The PBC management allowance funded the pilot and, recognising its success, the PCT then agreed long-term funding.

Some commentators initially thought the AVS(R) was a maverick idea, duplicating resources from core GMS to PBC, so it was essential to demonstrate a return on investment.

The NHS Institute for Innovation and Improvement gave us exceptional support in retrospectively analysing the data to understand the impact more fully. We received the NHS Institute's support having won its NHS Live Award at the 2009 Health and Social Care Awards.

With an average cost of only £6 per patient and a population of 54,500, avoiding just two complex elderly admissions a week makes the AVS(R) self-funding.

The key aim to reduce non-elective admissions has been achieved beyond all expectations for specific patient groups.

Falls in admissions
Figures show we have reduced our emergency admissions, zero-length stays and stays of less than 48 hours at the local acute trust. The scheme's most frequently seen conditions include chest and abdominal pain, for which the risk of admission is high. Its admission rates for chest pain are 14 per cent below the PCT average and for abdominal pain, 15 per cent below.

I stress that these figures are based on total admissions for 24 hours over seven days, including children, but the AVS(R) is only operational Monday to Friday 9am to 6.30pm, so 40 per cent of the week, and predominantly sees adults (average age 77).

We are working on a detailed comparison for solely in-hours admissions for adults, which will inform further development. Subjective analysis suggests our admissions for this period and group are 30 per cent lower than if AVS(R) was not operational.

Patients and carers report high satisfaction levels. Patients are seen quickly, so anxiety about their illness is reduced. They are assessed thoroughly; and they have the genuine choice of staying at home.

The lessons learned are many. The foremost is persistence if you have confidence in a scheme. Our PCT trusted our assertions, which helped us develop the robust relationships essential to successful innovation and to provide a strong foundation for subsequent work.

  • St Helens GP Dr Shikha Pitalia is chair of PBC consortium United League Commissioning. AVS(R) is a registered trademark
What they say

'My chest flared up and I didn't feel right at all. I thought I'd end up in hospital, but the doctor was there before I knew it. He arranged for a prescription to be delivered and for the nurse to check on me later.'

'I had a good chat with the doctor and said "Is there any way I could be looked after at home?" He gave me a really thorough check-up and sorted out my nebuliser and tablets. He said I could call him out again if I was worried. I feel so much happier.'

'I was wondering whether my father needed to go into hospital, but he was seen so quickly and I didn't need to panic. I was very impressed with the level of care the doctor gave.'

'I used to feel guilty for calling my mum's GP out and once I just called an ambulance instead. It's much better now.'


Fast facts
  • United League Commissioning's patient population is about 54,500.
  • Member practices total 13.
  • Location is St Helens, Merseyside.
  • The acute visiting scheme started in 2006/7 and won the NHS Institute for Innovation and Improvement's NHS Live Award in 2009.
  • It operates Monday to Friday, 9am to 6.30pm.
  • The average cost is only £6 per patient. Avoiding two complex elderly admissions a week makes it self-funding.
  • Most frequent conditions include chest and abdominal pain. Chest pain admissions are 14 per cent below the PCT average and 15 per cent below for abdominal pain.

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