Innovative out-of-hours schemes
March 2003
The following innovative out-of-hours schemes have been identified by NHS Confederation members and considered during the new GMS contract negotiations.
Exemplar 1
- Large co-op (500 GPs) incorporating visiting service, five primary care centres
- Integration between NHS Direct and co-op. All A&E calls intercepted and routed as appropriate
- In A&E department nurses triage patients in waiting area where there are also phone boxes for patients to speak to NHS Direct.
- Aim is to provide patients with the same experience whether accessing emergency care in person or by telephone
- Partnership between co-op, NHS Direct, primary care trust (PCT), accident and emergency (A&E), acute trust, out-of-hours co-op, community pharmacists, mental health and social services
- A&E streamline patients into minor illness, minor injury and majors
- Minor injury seen by Senior House Officers
- Minor illness seen by nurse practitioners or GPs
- Skill mix being implemented (injury/illness)
- GPs contracted so their indemnity remains with medical defence organisations (MDOs)
- Running since April 2002, and currently under evaluation.
Model tested with a number of GPs – largely supportive but questions raised in relation to terminal care and out-of-hours cover for community hospitals.
Level 1
- Home visits by GPs would cease between 7pm and 8am
- An experienced doctor would be present in two centres within the PCT area
- These doctors would have admission rights to the hospitals, on-call diagnostic imaging and emergency pathology facilities
- These doctors would assume responsibility for the inpatients of the hospital
Three paramedics in three ambulance vehicles on the road in radio contact with medical centres and ambulance control for:
- urgent home assessments
- transportation to medical centres if necessary
- initiation of front line treatment eg pain control, catheterisation etc.
Nursing and social care staff (numbers required are not yet clear) on the road in radio contact with medical centre, paramedical service and ambulance control for:
- palliative care
- general nursing interventions to sustain people at home
- social care interventions to sustain people at home
- to remain if required in people's homes throughout the night for crisis management.
Exemplar 4
- Integration of local co-operative and the nurse-led walk-in centre onto one site by April 2003
- Service development consistent with the Carson vision, phased implementation due to some current issues connecting to NHS Direct
- Will provide base for evening and night community nursing and paramedic support team
- In the interim GPs are being resourced to cover the 'red eye' shift – there are proposals for nurses working initially in parallel with the out-of-hours doctors to determine if a nurse-led service is viable
- Additional nursing required has been identified in the Access & Capacity return.
- Trust provides call answering & referral, organisation of GP out-of-hours bases and provision of vehicles, drivers and communications to local co-ops
- A variety of commercial deputising, self-funding and 'paying' GP co-operatives currently exist in the area
- All are under pressure with fewer GPs willing to participate in out-of-hours work
- In 2000, a community paramedic was based in a GP surgery in a very rural area – resulting in improved ambulance response times. GPs have integrated the paramedic into their work
- The paramedic now does emergency house calls, takes bloods and performs ECGs, assists practice nurses and responds to 999 calls
- In 2001, 29 additional paramedics were based in GP practices in community roles. They refer suitable 999 cases back to practice team, resulting in increased ambulance performance. They are being used to ease some aspects of GP and primary care workload
- The Trust is working with the Workforce Confederation to extend higher education programmes for paramedics to develop primary care emergency practitioners and thus be able to undertake more of the role of the out-of-hours GP.
The emerging vision is to develop a high quality, integrated, multi-agency, multidisciplinary, urgent out-of-hours service with single call access. Key features of this service are perceived to be:
- An integrated urgent care service operating from a single set of premises, incorporating out-of-hours nursing services, GP out-of-hours services and accident and emergency care
- A multidisciplinary approach to triage, assessment and treatment which is nurse-led, with streaming to appropriate health and social care professionals
- Joint development of the role of nurse practitioners across A&E and primary care
- A satellite nurse-led out-of-hours service, with appropriate links to the core out-of-hours centre in terms of transport and back-up from medical staff
- Strong links with intermediate care services and social care services, and the ability to access these as and when required
- Primary care practitioners to have access to investigations out of hours
- Integrated information systems to facilitate communication and transfer of data between agencies
- A seamless care pathway for people accessing services
- Single telephone access to out-of-hours health and social care services.