Organisation redesigns service to manage increased pressure on GPs by offering digital assistance and professional expertise, reducing workload and improving staff wellbeing

Synopsis

What is it?

A responsive and effective home visiting service for patients that prevents them attending A&E and relieves GP workload.

Who is involved?

Any housebound or care home patient requiring an acute same day visit from a GP was seen by a highly skilled and experienced Advanced Nurse Practitioner, with non-medical prescribing skills, highly experienced in Primary Care with good skills and competencies in urgent conditions, including acute respiratory and cardiac conditions.

Who we serve?

Acute Home Visiting Service was piloted Newark in 2017, providing support to 7 general practices in the locality serving 76,000 patients.

Ambition

Context

This is an organisational, operational and medical initiative, to utilise the skills of highly trained Advanced Nurse Practitioners to help reduce workload on GPs and reduce unnecessary hospital admissions.

Ambition

GPs are under huge pressures with increasing patient demands, including urgent home visit requests at a time when GP recruitment and retention is challenging, and local pressures on CCGs and NHS finances under scrutiny. The initiative was proposed by local Newark GPs, supported by the CCG and PICS, a trusted local provider of community services. Targets were agreed in terms of achievable visits per day (7 per clinician) and an aspiration to reduce GP workload and admissions.

Targets and Planning

As this was a new initiative to reduce workload, it was a pilot to test what the art of the possible was. As a result KPIs were identified to measure what was achievable.

The pilot required careful selection of appropriately trained and experienced staff with the confidence of GPs to support workload. In setting out the service specification it was agreed that the field based staff were equipped with encrypted laptops with clinical systems access enabling assessment and feedback on visits and actions resulting.

Newark has higher than national average deprivation, percentage elderly, and numbers of patients in care homes. These demographics add more pressures to delivering Primary care for GPs.

Agreed criteria for referral were established between commissioners, GPs and ANPs. Agreed daily target of visits (7 per clinician), key performance indicators established:

• Visits per month
• Estimated Hospital admissions avoided
• Inappropriate referrals

Planning with stakeholders, colleagues partners and patients

Monthly performance was measured and reported to commissioners, Practices and PICS, highlighting issues and case studies of note. The CCG set an ROI of 1 to 1.3 but achieved 1 to 1.5.

Staff experience was measured, it was clear that improvement in patient care was evident, shown by positive patient, and GP feedback. Urgent cases were seen more quickly and significant numbers of patients avoided hospital admission, 21 % in first 4 months. Prompt patient attention gave reassurance and comfort to acutely ill patients.

GPs reported the service had a major impact on surgery pressures and staff wellbeing, GPs reported the service was invaluable.

Commissioners saw reductions in A&E attendances (66) compared to other localities in the area without the service.

Outcome

Results of redesign

This was a new service and improvement of productivity was seen in practices by visits numbers that GPs did not make, resulting in reduced workload improved and wellbeing for GPs. 803 visits were made in first 4 months. The avoided admissions estimated 168 of 803 visits. CCG analysis shows a reduction in A&E for Mid Nottinghamshire of non-elective admissions (from falls, chest infections, UTI’s) of 7.2%, equating to£229K savings in 4 months. GPs reported the value of the service.

Effectiveness of collaboration:

Unwarranted variation was delivered across the practices with a unified approach for dealing with acute home visit requests and consistency to patient care, record keeping, improving quality of reporting and shared learning opportunity discussions.

Collaboration

The locality held review meetings with Practice GPs, Managers, CCG representatives and PICS. Service reports were reviewed regularly, feedback on practice referral patterns, and patterns of inappropriate referrals. This helped to promote better, closer collaborative working, formative in developing PCNs.

Staff worked with local GPs on case reviews and conducted peer reviews to improve clinical care, quality and identify training needs. Staff reported high levels of motivation and satisfaction in newly developed roles, no staff turnover, low sickness absence.

“I love my job” (DB, ANP).

Patient surveys were conducted using family friends and Practice surveys conducted with excellent results.”Best thing that happened for Primary care locally in years Dr B, Lombard Street Surgery”

Financial Impact

The Service created 240 pa days clinical capacity in Newark, (over 1,600 visits), plus reduced travel time and stress for GPs not having to conduct as many home visits. ANPs updated patient records in real time clinical systems, could send messages, tasks and reminders to clinicians via systems for follow ups, removing paper work and potential risk of communication breakdowns. ANPs had rapid access to GPs for patients if required. Patients had quicker response to urgent need.

Qualitative and Quantitative Benefits

GPs felt able to concentrate on practice priorities and complex patients without the stress of urgent visit requests. ANPs felt empowered to care for patients autonomously, and patients/ carers appreciated a responsive service.

The CCG review showed an impressive return on investment and CCG reviews resulted in expansion of service.

GP surveys concluded the service was invaluable.

Patients valued the service redesign

Spread

Embed and Spread

The service has regular reviews with the CCG on progress. The results of the reviews have been shared with all of the member practices, to compliment the on-going feedback at monthly locality meetings. At the end of 2017 it was agreed to extend the service pilot to include Sherwood locality, before a tender process commenced at the end of 2018 for the whole of Mid Notts.

Regular reports on activity are provided to practices with their referral rates.

During 2019, the service extended to cover 40 practices, registered population of 330,000. The Clinical team has expanded to 12.6 WTE and the administration team increased to 2.6 WTE. The Service continues to grow, recruitment has been challenging, but the capacity for visits now exceeds of 1,600 per month and continuing to grow.

Sharing Success with the wider NHS System

The team have created poster presentations on the local success at an NHS England sponsored shared learning event, Leading Change Adding Value in Leicester 2018. This resulted in an article being published on the Atlas of Shared Learning on the NHS England web site.

From this shared learning page we have had over 10 enquiries from GPs, Federations and CCGs in many NHS organisations in England.

As a result numerous enquiries about the service, its specification, outcomes, costs and benefits have been shared with:

• GP Federation South Tyneside GP federation (December 2019)
• NHS Leeds CCG (Nov 2019)
• Sutton GP Federation (Nov 2019)
• NHS Brighton 8c Hove Federation (Sept 2019)
• East Riding Care Home Frailty Team (August 2019)
• Royal College of Nursing (August 2019)
• Leeds Community Healthcare team Can 2019)
• West Lincolnshire GP Federation (June 2019)
• The Wirral CCG, Croydon CCG, Leeds CCG (May 2019)
• Nottingham City CCG (NCGPA May 2019)
• Nottingham West CCG (PCN April 2019)
• Nottingham North and East CCG (Feb 2019 Hucknall)

The team had an enquiry from Channel 4 Production Company about a documentary around the service design and benefits in October 2019.

PICS follow up with all of the interest expressed in the service, with service specification, CCG reviews, and survey results, to ensure that they have sufficient understanding of the service to enable local business cases to be developed.

Results of the service have been communicated to the Nottinghamshire Integrated Care System for larger scale implementation. This service has proven to be easily replicable.

Value

Impact of redesign

The service pilot exceeded expectations in terms of the numbers of avoided admissions.

The unexpected benefit to the system has been the degree of satisfaction and feedback from General Practices about the service, and the impact it has had on practices particularly at times when pressures exist on staffing (Reference 13, 14). The Service lead attends the local Primary Care Network meetings and regular positive feedback is given about the service. This has enhanced the reputation of PICS and helped to enable future local primary care network developments to be undertaken.

Positive Staff and Patient experience

Surveys of patient’s shows 100% satisfaction as do regular surveys with the participating practices

The announcement of a tender bid for the Mid Nottinghamshire Service, has resulted in the need to recruit more ANPs into the service. Local practices report problems with recruiting skilled ANPs and issues with retention. In 2019 PICS has recruited an additional 8 staff to deliver the service and have had no staff leave since the inception of the original pilot. Staff have been attracted to the service from organisations across Primary Care, Emergency Services and Secondary Care. Staff satisfaction is measured by PICS staff surveys, regular 121 meetings and team meetings.

Effects on efficiency and wider system and organisation benefits.

The service has allowed general practices to focus more on the complex needs of patients presenting in Primary Care. The shared knowledge from the growing AHVS team has enabled peer reviews to help develop staff member’s knowledge, and professional competencies. Peer reviews and periodic audits ensure the clinical team are constantly reviewing their own practice and performance. The service has provided opportunities for Student nurses to experience community

aspects of primary care and associated allied health professionals to understand community services and provide support networks for the clinical teams in Nottinghamshire (e.g. Clinical Pharmacists, Social Prescribers). This aids future recruitment into PICS and Primary Care locally.

The use of live updates on clinical systems is providing opportunities for other health professionals working in the community to understand the benefits on real time record access and updates for the benefit of patient care. This reduces paperwork, provides audit trail of work and decisions and promotes quicker communications with GPs about the care of their patients.

Involvement

Team Engagement

The project team consults the key stakeholders on a regular basis as a critical part of on-going quality improvement and achieving value for money:

• Daily with GPs and practice staff on issues relating to patient care and visits
• Monthly reviews with clinical team, peer reviews and shared learning
• Bi monthly with Acute home visiting service team, including clinicians, administration, and PICS managers to review progress
• Annually with staff through personal development plans and appraisal.
• Annual PICS Staff surveys
• Regular GP (annual) practice surveys about the service

Continued consultation takes place with the direct stakeholders as well as the wider system:

• Regularly with CCG contracting teams with annual contract reviews
• Monthly with GP practices at locality meetings (now through Primary Care Networks) with summaries of visit performance and referral patterns
• Monthly with CCG colleagues reporting key performance indicators
• Periodically with the wider system when interest is shown in the service
• Weekly updates through PICS management team.
• Bi monthly with PICS board to review service performance.
• Monthly through attendance at the ICS Primary Care Workforce delivery group.
• Atlas of Shared Learning on the NHS England web site

Evidence of Partnerships

There are many items of evidence regarding the service in the attached appendices:

• Monthly Key performance indicator reports to CCGs
• Bi monthly acute home visiting team meetings
• Annual CCG reviews
• GP Practice surveys
• Patient surveys
• Monthly Primary Care Network meeting feedback, PICS attend 6 PCN meetings throughout Mid Notts providing an excellent forum for updates and feedback
• Regular feedback (anecdotal) from practices as it arises (e.g. Nov 2019):

Subject: AVS

Good Morning Ali, I would like to pass on my praise to your staff that cover our practice under the acute home visiting service, I have had glowing reports regarding the service itself and I myself have had brilliant service from Sophie who has handled my calls over the last few weeks. Many Thanks

• Use of allocations of visits based registered populations to provide equity of access, as agreed at PCN meetings
• Trial of e-referral system as agreed at PCN meetings
• Review of inappropriate referrals at PCN meetings

Patient Involvement

The local PPG groups were regularly consulted about redesign and results of the initiative.