Change of pace

Published: 24/07/2003, Volume II3, No. 5865 Page 28 29

By improved assessment of emergency calls, a GP practice has managed to take some of the weight off emergency services and make considerable savings.

Paul Everden and colleagues explain

Unintentional barriers in primary care restrict access for patients - and it may be the most ill or socially disadvantaged patient who is least able to negotiate them. Receptionists are usually the people who manage the seeking of medical help, based on their control over appointments. Doctors, meanwhile, try to use time efficiently by multitasking - booking full surgeries and being on call for emergencies.

Something ‘has to give’ - usually immediate need, which is transferred to the emergency services.

Once transferred, the patient will often travel down an inappropriate care pathway.

Birchwood Medical Practice, in the market town of North Walsham in Norfolk, has six partners serving a list of about 10,500. It is 20 miles from the nearest hospital with an accident and emergency department. The appropriate care at point of need (ACAPON) system was launched in April 2002 and is based on a multidisciplinary team: a GP, a practice nurse, a new healthcare assistant and a community paramedic ‘on loan’ from East Anglian Ambulance Service trust. This last and vital addition was part of a wider programme by the ambulance trust to bring down response times by locating paramedics in GP practices.

ACAPON has been developed to address a range of problems in pre-hospital, primary and secondary care. Government initiatives to provide routine patient appointments within 24 or 48 hours have increased pressure on primary care. Patient demand is not necessarily based on clinical need and nonurgent problems may compete with the urgent, reducing access to urgent care with a potential knock-on of more calls being referred to emergency services and to A&E departments.

Patients and relatives may also use ambulance services inappropriately. ‘Good’ care is measured primarily by response times, with a target of 75 per cent of category A calls attended within eight minutes.Ambulance crews are at risk of responding to many ‘red calls’ that do not require such urgency but still result in taking patients to hospital A&E.

Furthermore, GP-assessed admissions will be delayed by emergency 999 calls - many of which may be inappropriate. Finally, there is evidence that assessment in secondary care is more likely to lead to admission and that once admitted to hospital it is much harder to get patients back home.

The ACAPON team provides more appropriate immediate and emergency care within the community through improved assessment.Once the receptionist has taken the message from a patient with perceived immediate need, it is sent directly via intranet messaging to the ACAPON lead, a GP in the practice on rotation. The patient is transferred for immediate assessment by a member of the ACAPON team or given an appointment relevant to urgency.

The assessment may take place at the surgery or elsewhere as appropriate, thereby easing access for the patient.All patients are discussed with the relevant members of the team - no-one works in isolation. If a patient requires more advanced assessment or treatment, a specific referral is made to admit. The team aims to give earlier delivery of care in the most appropriate environment by the most appropriately qualified clinician or carer, thus reducing repeated assessments.

A key aspect of ACAPON is the development of the role of the primary care paramedic. The paramedic’s traditional expertise has been developed to include more routine assessment and care of patients who come through the primary care route. The paramedic is able to carry out examinations appropriate to patients’ needs and provide relevant information to the clinician who has responsibility for decisions about care. The paramedic has been trained to provide treatments, help with clinics, make home visits and liaise with the doctors once the patient has been assessed. The paramedic teaches resuscitation skills to the team and continues to respond to emergency calls allocated from control through ACAPON. This pathway process is based on GP triage and works in various ways:

A patient calls the surgery for urgent home visit and the GP assesses the urgency. This may lead to a number of options, including dispatch of the paramedic to assess the patient, who then contacts the GP to discuss the next step. This may result in immediate referral to hospital, or the patient may be requested to attend the surgery or a routine GP visit may be arranged.

A patient consults the doctor via a routine surgery visit and the GP asks ACAPON to carry out any necessary tests, investigations and treatments.

A patient attends surgery as a medical emergency or walk-in injury. ACAPON provides immediate treatment - the GP oversees the process and decides on management plans.

In the first 33 weeks of the programme, 125 category A calls from ambulance control or via the practice have been dealt with by the ACAPON system. Previously all would have been transferred to A&E by emergency ambulance. Two-thirds of these calls were medical, a quarter were trauma and 8 per cent were others, such as overdose. Of the calls processed by the ACAPON team, just under half remained appropriately within the community and the rest were admitted by the most appropriate pathway. This resulted in an appropriate admission pathway for three-quarters of calls.

Of 63 back-up ambulances sent to medical calls by ambulance control, just over half were stood down from ‘red’; about a third being stood down completely and a quarter being stood down from ‘red’ to urgent. The percentage of category A calls responded to within target time has increased from 55 per cent to 85 per cent. Out of the 305 patients seen by the paramedic as part of the ACAPON team and perceived by the patient as immediate need, only 11 needed hospital admission and five were transferred to A&E for minor injury assessment due to lack of diagnostics.

Looking at the cost impact of the inappropriate transfers to hospital, based on units of medical time and A&E consultation:

Without ACAPON, 82 patients would have been transferred direct to A&E, 40 of whom were treated in the community.

The average cost of paramedic unit journey is£263 and the cost per A&E attendance is£75.

A further 14 patients using the same paramedic would not have been transferred to A&E if ACAPON had been available in their practice, saving£4,732.

Total savings =£18,232 (£28,729 per annum).

ACAPON should be piloted more widely. It should also be trialled for out-of-hours as well as in-hours care. An ACAPON team could provide immediate care to a group of practices - this would greatly increase during out-of-hours, but the same principles would apply.Rotational working could take place in the ACAPON unit.

Out of hours, a lead GP could work closely with both ambulance control and NHS Direct, assisting with first contact and placing patients into more appropriate pathways from the outset, preventing ‘medicalisation’ and pre-destined outcomes of management.

An extensive research and evaluation programme should be put in place to confirm that the pilot results of this study can be applied to other sites.

Attention should also be paid to how electronic patient records can improve the communication interface between healthcare providers.

Mark Eardley

I was one of about 35 paramedics assigned to the community to help improve category A response, but I do not know of anyone who is working in the way I am. It didn’t require any particular training although my experience was probably wider than the average paramedic.Working with the rest of the team has given me greater diagnostic skills.Without that primary care knowledge in assessing, they would see me as the Achilles heel.

Dr Paul Everden

We thought the commitment to making immediate assessments would mean we would be snowed under with more work.But we have found that making the process more efficient has freed up time.

Putting clinical input at the front end meant many patient problems could be ‘demedicalised’.And being the duty doctor is no longer unpopular because you are not left with a big backlog.

Also we believe we are operating to a higher standard because we have freed up time.We had a three-year-old come in with tonsillitis and because we had the time to pause and do more tests we referred them to hospital with diabetes.

Some GPs would be wary of something which appears to give them more work.But we think there are great overall benefits.We have had interest from practices in other primary care trusts and the Department of Health has sent a delegation down to see what we do.We estimate that if ACAPON was implemented across East Anglia it could save up to£10m a year.

Dr Paul Everden is a GP and lead partner, Birchwood Medical Practice and Mark Eardley is a community paramedic, East Anglian Ambulance Service trust. Dr Paula Lorgelly is lecturer in health economics and Professor Amanda Howe is professor of primary care, University of East Anglia.

Key points

A GP practice set up a new system of assessing patients, with an emphasis on appropriate immediate need.The aim is to speed up treatment and reduce inappropriate accident and emergency admissions.

A new role of community paramedic on loan from the ambulance trust was a vital part of the team.

The first eight months dramatically cut accident and emergency admissions and sped up category A response times.