A high number of patients with ambulatory care conditions were continuing to place pressure on Primary and secondary care in the Hyde area.
Early treatment for UTIs and persistent chest infections could avoid presentation at hospital settings. Urgent action and treatment can avoid the need for secondary care. Whilst Hyde did not have any specific targets to reduce the number of secondary care admissions they understood the role primary care can play in doing so.
Paramedics in Hyde recognised that there was a need to enhance the patient experience by treating more people, more quickly and locally, whilst protecting continuity of care.
The aim of Healthy Hyde’s Paramedic Appointment Hub was to free up time and capacity in General Practice for GP’s, to manage more complex patients who really benefit from continuity of care and to relieve the impact of unnecessary visits to A&E.
They also identified a wider opportunity that a reduction in admissions would present, knock-on paperwork, subsequently presented to the Practice team, post-treatment, for processing.
Realistic about their own operational challenges there was no additional capacity within the existing operational model.
Hyde facts
- Healthy life expectancy is below the national average by 5.3 years for men & 6.1 years for women
- 0.99% of the PCN population has dementia
- 21% of patients smoke
- 3.9% COPD rate – England 1.9%
- 48.3% of Hyde’s population live in the 20% most deprived LSOAs
Healthy Hyde Primary Care Network in Greater Manchester cares for 72,000 patients via eight Practices across Tameside
Strategy
Using an online patient platform solution to coordinate patient communication and pre-existing ARRS funding to employ the people needed. Hyde employed a further 4 paramedics and created a paramedic appointment management hub. The service brought together Practices from across the PCN to deal with healthcare needs that, if not dealt with locally, may otherwise have presented at emergency care.
Working in a contact-led environment, paramedics aimed to deal with as many enquiries over the ‘phone as possible, only ‘bringing-in’ those patients who they felt needed to see someone. The scheme began by making just five face-to-face appointments available per paramedic to the service each day, gradually increasing this to 18 as their confidence grew. There are now plans in place to increase the number of appointments further soon.
The team established a rota of eight paramedics, rotating between the hub, home visiting service and practices, they rotate into the hub service every two weeks. This gives practices certainty and allows the paramedics to increase their skill set, develop confidence of working in General Practice whilst ensuring each employee had variation in their role.
Understanding the data produced each day is an important part of the continuous improvement process for Hyde. Telephony data tells the team where the highest patient demand is and whether or not repeat call attempts (false demand – i.e., the same person trying to get in touch multiple times) are reducing. In turn, resources are being aligned to optimise the daily response.
In the first three months, the Hub handled over 1,000 calls. Capturing the reason for each call is also allowing the PCN to understand themes in their local healthcare setting, the aspiration being to proactively target future responses.
Leadership
The project was led by Hyde’s PCN Manager, a full-time dedicated role that the team see as critical to future success across their patch. Free from the pressures and allegiances of local Practice, the role acts in the interest of everyone across the PCN – as the team at Hyde put it, “with the headspace to act in everyone’s interest”.
The challenges
In the early days of the initiative, the paramedics were being held back by their ability to administer prescriptions, having to rely on GPs and other clinicians to write these.
It was agreed that two paramedics should be put forward to do the prescribing to allow the team to provide a full service and ensure as little work as possible is passed back to the GP, decreasing the time it takes for patients to receive their prescriptions.
The supplier of the online consultation platform was on board from the start of the project, with relationships and supplier collaboration being seen as an important part of the project’s success.
There was also a need for EMIS write-back, minimising the amount of effort required to update and maintain patient records by the hub, but also to create clear audit trails of patient care. However, this could not be achieved within the timescales of the project and so a workaround was required in the first instance, whereby paramedics had access to everyone’s EMIS system. This issue was soon overcome and with the use of the online system and the PCN having its own EMIS instance auditable patient access was achieved.
The lack of a PCN estates strategy also impacted the deployment of the project, meaning that finding a suitable space to house the centralised team was a challenge as well as enough clinical space to host the new appointments on offer. Hyde sighted this as being an ongoing issue for them, with the constant demands placed on facilities bringing the need for a resolution into sharp focus. Working with the local Police team, Hyde converted an under-used interview room into a new clinical space. Whilst this has helped, the team recognise they are still being held back by space availability as well as IT limitations, which mean that expansion investment is about more
What made it a success?
Hyde recognises that it wasn’t always easy to get everybody on board with the idea of a centralised service. A key part of the project was to make sure that people were engaged and clearly understood the benefits of the changes that were being proposed. This meant deploying at a sensible pace, learning, sharing and evolving, so that everyone began to trust and see the benefits of the changes as they happened.
Key success factors include:
Can-do attitude
Agile application
Shared vision
Alignment to a single goal
Paramedics were involved in every step of the design, build and tweak process
Outcomes
Shared learning and cross-working. Being in the same room as other healthcare professionals and PCN staff meant that the wider team could share ideas and help each other – something which Hyde feels has had a positive impact on patient outcomes.
The programme has itself created both physical and clinical capacity, which translated into an average of 800 more patient appointments per month in an environment where the value of the total healthcare team is recognised.
The prevention of A&E footfall was one of the primary goals of the service and the team have dealt with over 1000 patients since the inception, most of whom have been cared for remotely. The knock-on impact of this on patient paperwork and coding is an additional benefit too.
The most obvious and rewarding outcomes of the paramedic hub has been the rise in patient praise, recognising that they’ve received timely care, if not necessarily recognising that they have avoided going to emergency care for support.
Feedback
Feedback shows that patients are benefiting from the changes and that the value of alternative care pathways can’t be underestimated in addressing the sense of helplessness that was created by turning away patients when the system was at capacity.
In the context of post-pandemic service challenges, there was a real need for Hyde to “get on and do this” and so it is with a real sense of pride that the team are able to report positive patient and staff feedback. This includes praise for faster response and care resolution times from patients and recognition from staff of the increased
What next?
Continuing to grow the number of appointments available, targeting 20 per day in the near future.
To expand the model into new areas including pharmacy services, making use of ARRS funding to create an efficient and centralised offer to patients reducing pressure on both primary and secondary care.
The Duty GP will bring an additional layer of supervision to the team, help to build confidence, make clinical decisions as necessary and coach the team in-situ.
Add-in plans for the community matron and six complex case nurses to be working with the 600 care home patients and housebound patients and you have a proactive care team that has the potential to make a significant difference to healthcare in the local community.
