Lesley Hill On primary care

Published: 05/08/2004, Volume II4, No. 5917 Page 21

When is an acute admission not an acute admission? When it is just an acute assessment. This happens with nearly half of the acute admissions at our local hospital.

Forty-eight per cent of reported acute admissions last year had a length of stay of zero - admitted and discharged on the same day, or with an overnight. For gynaecology this figure is 85 per cent, in general medicine 56 per cent and in paediatrics 55 per cent. Even in geriatrics the number is 20 per cent.

Like many primary care trusts, North Bradford has been struggling with why so many patients are admitted acutely and have such a short length of stay, which patients these are and what is wrong with them.

Only a few patients were creating most of the acute admissions.

Most of these have complex chronic disease.We have identified those high users of healthcare. These patients will have a practice-based case manager. The manager will be the patient's key worker, similar to the role in the care plan approach used in mental health. They will coordinate about 50 practice patients' care.

Next, we will have one point-of-contact telephone number for targeted patients to use to contact the case manager, with back-up services if they need to be seen acutely. The same telephone number will also be used by other clinicians and social care to contact case managers and also be put through to other PCT-wide acute services.

These include GP out-of-hours services, the community nursing intervention team, a bed bureau and our local crisis resolution team for mental health patients (as these patients are already case managed).

This number will also be used by West Yorkshire Metropolitan Ambulance Service trust for transferring patients who need clinical input but do not need blue lighting and to redirect some NHS Direct callers. NHS Direct can reduce the number of patients they advise to go to accident and emergency from 9 per cent to 3 per cent if there are other services available.

We are also developing one, or maybe two, urgent care centres. These will house the telephone service and also the GP out-of-hours service, the crisis resolution team, the community nursing intervention team, diagnostic x-ray services and a laboratory for basic clinical chemistry and haematology.We should be able to have a co-ordinated response to acute healthcare provided in a local facility with easy access.

We also need to think about how we manage acute assessment and diagnosis. Currently patients with these conditions are dealt with as acute inpatient admission in the local NHS hospital. This is both costly and probably unnecessary for many patients.With payment by results we could do this differently and save the cost of an acute admission.

However, we will probably need to do this outside the local hospital because with current payment by results rules there is no incentive to change practice.An acute admission is always going to get paid at a higher rate than an acute outpatient diagnosis and assessment.

We need to manage acute care in a much more focused way. The solution to this does not lie in simply agreeing new contracts, rather whole new pathways of care which avoid and prevent the need to access secondary care.

Lesley Hill is deputy chief executive of North Bradford PCT, winner of the prime minister's special category at last year's HSJ Awards.