As semi-rural Lincolnshire GPs whose nearest A&E department is eight miles away, dealing with minor injuries has always been part of our routine work.
The extra time taken by our nurses and the GPs to assess and manage lacerations, head injuries, dislocations and so on is something our patients expect and, overall, it has been balanced by the extra funding generated by the practice’s dispensing income.
The 2004 GMS contract has, however, allowed us to be partially reimbursed for some of this extra work - just as well, as the dispensing income we had available to cover this service had begun to fall.
Why we got funding
Our PCT decided to negotiate funding a minor injury local enhanced service (LES), concentrating on practices who wanted to supply the service.
The PCT negotiated with practices sited five to 10 miles from any A&E department - ours is the Deeping Practice in the small town of Market Deeping - as it wanted to try to reimburse practices for the extra effort involved in managing patients after accidents.
Making a case for funding
To make the case for funding we needed to do some data collection to demonstrate the level of service already provided. This was done by using a ‘local code’ on our practice IT system. The code was separate from Read coding and an entry was made for any patient attending within 48 hours of an injury.
The PCT asked for data collection over three months. We felt some disquiet over this as the three month period was in the autumn, one of the quieter quarters for accidents, compared to winter, when there falls on ice, and the summer when children on school holiday have more accidents.
National guidance (dating back to 2004) sets out on the range of injuries to be included. In my practice’s case this meant mainly minor head injuries, sprains, burns and minor lacerations.
Accept fee level or upset patients
The data collection results were discussed with the PCT, which found it difficult to believe how much work we do. However neighbouring practices produced proportionately similar figures that supported our data.
The PCT had budgeted for approximately a third of the sum that practices could claim if payments were paid as per the national enhanced service (NES) specification, so it put together a LES with payments per case of two-thirds less.
My practice was over a barrel: either we accept the lower fee, or created ill feeling by stopping a service we had provided for years. In any case, as we run some open surgeries this would not really be practical as once the injured patient was seen, we would still have to undertake some initial assessment and care. So we accepted the lower fee.
Accreditation and monitoring
Since this was in effect a continuation of a service we were already providing and most of the GPs had some A&E experience, there were no issues with accreditation.
Ongoing monitoring is maintained with data collection using the afore-mentioned IT system local code. Our PCT asks us to re-supply information on the numbers of patients seen on an occasional basis and these records facilitate this. We are also asked to supply audit data on the numbers we refer on to secondary care, both to A&E and outpatients.
Staffing the service
Implicit in the initial consultation document was that we would provide the service throughout the 8am to 6.30pm time period. This entails having qualified nurses available at the practice for all this time who can triage all cases and, if needed, call an on-call doctor quickly.
We were already doing this before the LES was commissioned so this did not cause a problem. While a nurse and an on-call doctor are not always available at our branch surgery, the PCT was happy that patients could easily access the comprehensive service at our main site.
Since starting the LES several years ago, the service has seen little development. We received pay rises in the early years but none recently and I am not aware of any GP practices being commissioned to provide a minor injury LES in recent years.
This may all change as A&E attendances are studied in greater detail as part of the new quality assessment. Clinical commissioning groups (CCGS) in England may well see the financial and patient convenience benefits of encouraging and paying for practices to provide local care.
For us there is a degree of frustration that the payments we receive bear little resemblance to the money saved from preventing secondary care attendances. But as we were already providing the service for no reimbursement, it was always clear we had little room to manoeuvre. At least we are being partially financed for a costly service.
- Dr Phipps is a GP in Market Deeping, Lincolnshire
|The Deeping Practice's minor injury service|