OOHCare

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OOHCare

• MAPPING CASEMIX AND PLANNING SKILLMIX
• Dr Jeremy Lade

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REDDOCReading Doctors On Call

• An ISO 9001-2000
• Company

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REDDOC The ISO LOGO awarded by Systeme General
Surveillance of Switzerland Management Quality
Standards and Protocols approved every 6 months
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REDDOC

• REDDOC Ltd
• A private company, non profit-making.
• Employs 50 staff
• Office staff
• Operators
• Nurses
• Drivers
• Turnover 750,000 pa
• Mainly financed by the GPs themselves and not by
  the NHS.
• ISO 9001 2000 certificate awarded in 2001

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REDDOC

• REDDOC opened in April 1996
• 120 GP Members
• 225,000 patients covered each night
• Reading and Wokingham PCTs
• 40,000 calls per year.

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Berkshire OOH Providers 2003
BEDROCK
NEWDOC
REDDOC
SEBDOC
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The Present Situation

• The PCTs now have the opportunity to set up and
  provide a fully integrated system for providing
  OOH and unscheduled care across their areas.
• What should they be doing or have done by now??

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PCT preparation tasks

• 1 ASSESS THE DEMAND
• Look at call volumes and casemix of
• OOH services.
• Community Nursing IH and OOH
• Ambulance Trusts
• AE and Minor Injuries
• Palliative Care
• Social Services/Homecare
• Major Incident Planning

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PCT preparation tasks

• 2 PLAN
• The types of service and resources available to
  meet the demand
• ie Premises, Transport, Organisational and
  Technical Networks for
• Primary Care Centres
• Walk in centres
• AE
• Minor Injuries Units
• Ambulance/PTS
• District Nurses, Social Services, Homecare
  Services.

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PCT preparation tasks

• 3 ESTIMATE COSTS
• Bearing in mind that
• Many funding streams in Emergency Care will
  overlap.
• Redesign of OOH services will need setup funding
  initially that should not be borne by existing
  providers.

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West Berkshire

• 251 GPs
• OOH care provided by five Co-operatives Majority
  of 178 with REDDOC and NEWDOCS
• Future Provider pattern not yet decided by PCTs
  who are waiting until January 2004

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REDDOC/NEWDOCS Berkshire OOH provision proposal
East Berkshire Provider Bedrock 415000 patients
West Berkshire Provider REDDOC/NEWDOCS
465000 patients
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REDDOC/NEWDOC planning across NHS departments
includes

• Accurate workforce/skillmix design.
• AE and CDU sessions for OOH doctors
• Integrating with District Nursing OOH
• Integrating with Social Services OOH
• Working with Palliative Care OOH
• Working with Mental Health Services
• Working with Hospital Outpatient Services
• Working with PCTs to provide Central Operations
  Role In and Out Of Hours
• Major Incident Planning and Co-ordination

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Planning Casemix and Skillmix

• It has been said that after April 2004 OOH
  Doctors will be few and expensive and much of
  their current OOH work can perhaps be done by
  First Contact Clinicians (Nurse or Paramedic)
• Question What is the current OOH Workload?
• Question How much of it can be done by FCCs and
  where are they to be found?

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Present REDDOC Nursing Staff

• 12 nurses
• None yet trained as FCC
• None do Redeye shifts
• All wish to continue routine work at PCC
• ALL wish to train for Triage
• 4 wish to train for FCC
• All have family and work commitments
• Conclusion There are very few (if any) FCC
  nurses available in West Berkshire at present.

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Demography of Reading/Wokingham

• Reading
• Urban, mixed leafy affluent suburbs, inner city
  and deprived areas.
• Centre for teenage drinking. Gun crime common.
• Wokingham
• More rural, villages, happiest place in
  England in 2002. Second healthiest in 2003.
• High 3 car per family area.
• Patients know their rights, highest OOH demand
  per patient in UK.

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TRIAGE CALLS TO REDDOC Number 15,100 per
annum 40 of calls
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The commonest advice call typesare spread across
all age groups

• Advice about prescriptions
  1164
• Intestinal problems, gastroenteritis
  1166
• URTIs
  803
• Symptoms, signs, ill defined conditions
  1308
• Injuries, burns, poisoning, allergies
  1237
• TOTAL
  6960
• 
  (46)

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Nurse Triage

• Should they use a CAS system? It may slow call
  handling down.
• Problem areas
• Age 0-2 may be difficult.
• Multiple pathology.
• Multiple or complicated prescriptions.
• Mental Health problems.
• However
• Self-assessment suggests 50-90 could be managed,
  ie 8,000 plus now and 16,000 plus per annum in
  the future.
• This will be a major contribution to OOH

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Visits by REDDOC Number 8095 per annum 21 of
calls
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Most Frequent reasons for visiting (not in order)

• Heart Failure
• Circulatory system
• Strokes and TIAs
• Chest Infections
• Pyrexia/UTIs in elderly
• Abdominal pain (all ages)
• Ill defined problems in elderly
• Injuries in elderly
• Gastroenteritis (all ages)

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Visiting older patients
Visits in 75 and over 2731 Visits
in 65-75 997 Visiting 65
and over 3728 46 of annual calls These are
clinically the most challenging calls and will
need GP assessment
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Problems with Visiting the Elderly Diagnosis
often uncertain until patient is seen - Who to
send? Elderly have multiple pathology and
polypharmacy. There are often Social Services and
home care problems. Consultation time available
is usually short. Experience, confidence and the
authority to make rapid and effective management
decisions including hospital admission are
essential. OOH services can only afford a single
consultation, double visits are not efficient.

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First Contact Clinicians and Home
Visiting Elderly visits needing GP assessment
46 The other 54 more likely to need GP
assessment (perhaps 50) ie up to 70. Hence
FCCs attending all visits would need to request
70 doctor follow up call rate. This would be
expensive and inefficient This problem is avoided
by sending GPs in the first place (However
District Nurses do have a very important role in
managing chronic conditions at home and should
become part of the OOH team if hours on call can
be extended as they are already out on
duty).
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Problems with bringing patients into PCC/hospital
for assessment in West Berkshire

• Shortage of ambulance facilities
• Co-op transport not safe
• PCC not equipped, staffed or large enough
• Acute Trust already stacking patients at home
• Elderly patients tend to be admitted
• Confusion in elderly
• AE 4 hour target figures
• Process delays run over into morning
• Hospital bed occupancy around 98

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OOH Attendance at the REDDOC PCC Number 14259
per annum 38 of calls
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PRIMARY CARE CENTRE PATIENTS MOST SUITABLE FOR
MANAGEMENT BY FIRST CONTACT CLINICIANS
Disorder Number Ages Gastroent
eritis 519 0-2, 2-10, 10-35 Viral
rash 154 0-2, 2-10 Other viral 662 0-2,
2-10 Conjunctivitis 371 0-2, 2-10 Otitis
media 1012 0-2, 2-10 Tonsillitis 752
0-2, up to 50 URTIs
1314 0-10, up to 50 LRTIs 540 Any Asthma
533 Any UTIs 726
2-10, 20-50 Injuries/burns
710 Any Total 6654 47 of 14061
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FCCs working in the Primary Care Centre

• Majority of work involves children
• Doctor back up always available
• This work is ideal for FCCs who could probably
  deal with 75 of the workload (depending upon day
  of week and time)
• This work is clinically interesting and
  fulfilling for FCCs

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Mental Health Statistics
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FCCs working in West Berkshire in the
future FCCs could manage 60 of the workload of
80,000 calls per year
Triage 25,000 patients PCC
21,000 patients BUT Visits would be only
approx 1,000 (less than 2 per week night).
Conclusion For West Berkshire it will more
efficient to employ FCCs on Triage and PCC shifts
BUT District Nurses already on shift may be very
helpful when integrated into the system. Their
job specification may have to be altered to allow
for long shifts.
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CONCLUSIONS 1 First Contact Clinicians (Nurses
or Paramedics) should be employed for Triage and
Primary Care centre work with doctor back up 2
Training of FCC nurses is a priority.( If they
start with Triage they will be able to work
sooner) 3 Home visits are often clinically
challenging but essential given the current NHS
organisation and low bed capacity. 4
Experienced GPs are the most effective clinicians
to carry out Home Visits at present
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Doctors working OOH
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Making OOH work attractive for GPs

• Full time OOH GP
• Practice contract GP
• Weekend sessions GP
• AE and CDU Hospital GP shifts
• Include
• On going Training, Team working, Appraisal,
  Re-validation, Clinical Governance.

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West Berkshire OOH SkillmixShort Term provision

• Triage GPs and FCCs
• PCC GPs and FCCs
• Mobile GPs
• AE and CDU GPs
• Mobile DNs
• Social Services and CPNs when required
• Palliative care when required

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West Berkshire OOH Future development to improve
cross-service integration

• New building next to Hospital to include
• Walk-in centre
• Minor Injuries Unit/XR
• PCC and GP technical links
• 24 hr Pharmacy
• 24 hr Dental Services
• Hospital patient management systems and services
  to include SS, DN, Transport, Mental Health
• In and OOH Operations Room, PCT services, single
  point of access for community services

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