Out of hours contact can prevent unnecessary admissions

Patients with long term conditions or complex medical needs tend to be heavy users of out of hours services and may end up being admitted to hospital inappropriately. A scheme in Derbyshire aims to share information between health organisations to ensure patients receive appropriate care and unnecessary admissions are avoided.

This kind of scheme is run for a minimal cost and saves everyone time. It stops people going into hospital unnecessarily

The RightCare scheme ensures registered patients have direct access to a clinician through calling a dedicated phone number. The call is swiftly transferred to a clinician who can access clinical information and a care plan for that patient: a copy is also kept at the patient’s home.

Care plan discussion

Patients can be referred to the scheme by community and primary healthcare professionals. Many have terminal illnesses and may need palliative care, but others have long term conditions such as chronic obstructive pulmonary disease or heart failure, have complex medical needs, are known to be repeat accident and emergency attenders or 999 callers, or have mental health or learning disabilities.

The patient is visited at home and a care plan is drawn up and discussed with them. The patient has to agree that the information about their condition can be shared with the agencies involved in the scheme, including the ambulance service, NHS Direct and the A&E department at Chesterfield Royal Hospital, as well as the out of hours provider which runs RightCare.

The details of the care plan are then sent to the out of hours provider, where they are reviewed by a RightCare nurse, and input into the computer system; the referrer is notified.

The copy of the plan kept at the patient’s home also has a traffic light system to help the patient and carers decide what to do - green means the patient is stable and needs to take no action, amber means symptom changes should prompt self-treatment, and red means they need to contact their GP in normal hours or RightCare out of hours.

Surgeries have aligned with the RightCare scheme so patients will receive the same response of quick access to a clinician whether they call in or out of hours.

Plans are usually valid for six months and the referrer is contacted at the end of this to see if the patient needs to be removed, the plan amended or if they should continue as they are.

Plans are available to staff on the 11 Derbyshire Health United response vehicles as well as at 15 primary care centres. If a patient does need to go to hospital, staff there can access the care plan and information about them as well. The hospital clinician can, of course, override the care plan.

Practical challenges

The major challenges in setting up the scheme have been practical, says Derbyshire Health United operations manager Pauline Hand, and concern access to the NHS network in GP practices and staff being unfamiliar with entering information in an electronic format. But Derbyshire Health United has worked with practices and done roadshows around the county to boost awareness. It also has an electronic newsletter to keep users informed.

“Everyone says it’s a really good scheme,” says Ms Hand. “Some patients with complex medical conditions can be admitted simply because it is not realised that the symptoms they have are normal for them. This scheme can save emergency admissions.”

The RightCare system has been running across Derby City and Derbyshire County primary care trusts for the past year, after smaller pilots. Around 600 patients are on the scheme, although many more could be accommodated. Patients tend to move off the scheme fairly frequently, as there are a lot of palliative care patients, so several times that number have been through the scheme.

Two administrators and a part time nurse run the scheme at a cost of £66,000, but the savings for the local NHS have been substantial. Derbyshire County PCT estimates the savings in the first six months were over £250,000 through likely reductions in admissions and A&E visits. In the pilots, the costs of managing some patients with patterns of repeat admissions were cut by tens of thousands of pounds a year.

Derbyshire Health United chief executive William Jones says: “This kind of scheme is run for a minimal cost and saves everyone time. It stops people going into hospital unnecessarily and gives patients a seamless crossover to out of hours care.”

Patients seem to be reassured by the uniform response the scheme offers. It has helped Chesterfield patient Derek Ashmore, 60, cope with his angina without going to A&E.

“Since I’ve been on RightCare I’ve been able to get the ambulance out to check my readings and I’ve stayed at home instead of going into hospital,” he says. “It’s more comfortable, with less messing about and fewer needles being stuck into you.”