A fictitious 82-year-old who likes a drink has helped a PCT to rethink how it delivers out of hours care. Daloni Carlisle explains

Making up fictitious patients is not something primary care trusts normally do. But in the case of Bedfordshire PCT, the invention of "Ethel" was above board and done in the name of workforce planning.

Assistant director for strategy Diane Meddick explains how this 82-year-old, with a penchant for bingo and a glass or two of wine more than might be strictly good for her health, came about.

It was all to do with a piece of work commissioned by NHS East of England on workforce modelling, she explains. A consultancy called Organisation Development Services was invited to visit PCTs and work through its population-centric model.

Healthcare scenarios

"It's a six-stage model that takes you through a process, from looking at the contextual framework of the environment in which you work, to looking at the demography and environment, and then scoping out how it plays into scenarios," she says.

Or, put more simply: "It helps you to look at what you would change in an ideal world."

For the Bedfordshire PCT team, this was the out of hours service - or rather how out of hours was separated from the rest of the service in what must seem to patients an entirely artificial way.

Elderly patients

In particular, they were interested in how elderly people, and particularly those who have falls, access the service. Hence Ethel, elderly and living alone in sheltered accommodation.

In the scenario played out for the exercise, Ethel has a sherry too many, stumbles out of bed and falls.

"Currently, nine times out of 10, that would mean a 999 call to an ambulance and into hospital," says Ms Meddick. "That's because most sheltered accommodation wardens are not equipped to take responsibility for anything else."

The other factor limiting Ethel's access to urgent care other than in accident and emergency was the number of different possible contact points to community health services - the team identified 66.

Ideal care

In the ideal world dreamed up by Ms Meddick and her team, the warden would call an expert on a single access number to make an initial telephone assessment. This would trigger a blue light to hospital if necessary but a range of other options if not, including a face-to-face assessment.

Ms Meddick explains the options. "Ethel would then have a care package put in place. If she only needed sitting back in bed and the carpet tacked down, it would be dealt with. But if she needed a community bed where she could have her medication reviewed, that could be arranged too."

The next step looked at whether this model was both desirable and achievable within existing capacity.

Making changes

"We took the model to stakeholders," says Ms Meddick. "We said this is what we have developed behind closed doors, but we are not clinicians and we are not Ethel. What do you think? They said it was spot-on and what they had been saying for 10 years."

With strategic health authority sponsorship and chief executive buy-in, this time it could be made real.

It took the team just five weeks to map out existing capacity and competency. The local ambulance trust was able to adapt its call-handling system and provide a single access number. The community hospital had capacity to provide intermediate care for people like Ethel. The PCT could draw up admission criteria.

Massive savings

"We developed access criteria: a senior assessment process will lead to intermediate care or a community bed," explains Ms Meddick. "We had the skills and competencies to develop this new model and used Skills for Health job competencies to map it."

Ms Meddick even got an Agenda for Change banding for a (then fictional) senior clinician to do the assessments. It came out at band 8a.

The next step was to take the system live. At first, the ambulance call centre simply diverted 999 calls using the admission criteria. Next, the PCT introduced a new 0845 number and started to feed that out to potential service users - social services and nursing homes, for example.

Integrated care

Today, the service has a name: 1call. It is integrated into in-hours and out of hours care, providing a 24/7 service. It did not require any new staff and has been developed entirely out of existing resources.

Clinicians say it avoids unnecessary hospital admission in over half the average 20 referrals a week - saving more than£1.4m in avoidable hospital admissions since it started in October 2007.

Ms Meddick says: "We have seen massive savings, although we are trying to validate the figures. We know from practitioners that 38 per cent of the clients using 1call stay at home and only 23.4 per cent are admitted to hospital."

Flagship achievement

Bedfordshire PCT is so pleased with the population-centric model that, along with its local authority, it is now applying it to children's services.

Donna Bradshaw is co-founder of the consultancy and developed the model. "The public sector tends to replace its workforce, not to remodel," she says. "We help people to think about how the population is changing and how needs and demands are changing, then to identify government policy and finally to look at how to reshape services and map out the competencies you need."

It is what Ms Bradshaw calls a "structured approach to common sense".

Population-centric has been used extensively across NHS North West, Yorkshire and Humber, Leeds and Cumbria and the East of England, but rarely with quite such tangible benefits as in Bedfordshire PCT.

"We were absolutely delighted with how well the team at Bedfordshire PCT were able to use it," says Ms Bradshaw. "It is one of our flagships."

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