Changes in the ways that care is delivered are increasing the expectations on community doctors and shifting more recovery and rehabilitation away from hospitals. Acute care can now be effectively delivered outside of an acute setting and technological changes such as point-of-care testing allow for more care closer to home.
Values of general practice can be lost
While GPs provide compassionate and skilled care for weeks, months and years before an individual needs hospital assessment, and accept on-going responsibility when people leave hospital, the knowledge and values from this relationship can be lost when care moves into a hospital setting.
The Acute GP Service was launched in Plymouth more than 10 years ago to manage this interface between hospital and home:
- We have a clinical conversation with referring doctors at the point of need for acute medical assessment, and capture and record this information.
- We have the capacity to offer an assessment by a GP with access to the resources of the hospital.
- We liaise directly with our acute medical colleagues and negotiate the development of specialty pathways to meet patient needs.
- We provide timely updates to community colleagues on discharge and use a GP clinical system to facilitate record sharing.
- We are able to review and audit our advice and interventions.
The service is hosted by Livewell Southwest, a community interest company that provides a range of community services, and we are part of their urgent care offering to provide alternatives to hospital admission.
Consistent rise in referral activity
Like the whole urgent care system, we have seen a consistent rise in activity. Our busiest service day was on 9 January 2017, with 59 telephone referrals for acute medical assessment. We were able to provide alternatives to admission for 29 people.
This is consistent with our overall service experience, with 46% of referrals avoiding admission. We achieve this through close collaboration with community services, with a focus on frailty, acute care at home and community crisis response. We also have a responsive and flexible approach to accessing secondary care resources such as specialist opinion and investigations.
Our presence in the hospital gives us a unique perspective. There are tensions within secondary care and challenges around the commissioning of services in the patient’s best interest. There are also complications in the ways our GP systems interact with hospital processes. But we have built good relationships with our secondary care colleagues and work alongside them in the ambulatory care unit.
Primary care under pressure
Primary care is under incredible pressure. Service design is important and individual interactions are critical. We provide support to community colleagues facing clinical and management dilemmas and we advocate for patients, which can involve a degree of friendly challenge at the point of referral.
We are confident in the quality of referrals that we accept, and we absorb and refute the assumptions and grumbles of hospital teams under stress. We can legitimately share risk with GPs through individual accountability, consistent record keeping and robust governance processes.
There is increasing interest in a proactive approach to managing the interface between hospital and home but who should lead this - the hospital or the community? How do we ensure that there is a collaborative approach to avoid magnifying pressures around preservation of services in the face of financial challenge?
The Sustainability and Transformation Plans aim to work across health and social care to build efficiencies and improve care delivery. Key to this will be integration and it is essential that the contribution of primary care is recognised and respected.
- Dr Jameson is clinical director of the Acute GP Service, Livewell Southwest, Plymouth. Follow him on Twitter @AcuteGP