Urgent care - How to commission urgent care

Neil Durham reports on essential tips for commissioners contained in guidance from the RCGP.

Dr Agnelo Fernandes: 'We now have an opportunity to be proactive and provide a truly integrated health and social care response for patients' (Photograph: Wilde Fry)
Dr Agnelo Fernandes: 'We now have an opportunity to be proactive and provide a truly integrated health and social care response for patients' (Photograph: Wilde Fry)

Commissioning provides an 'ideal opportunity' to look differently at urgent care provision, according to the RCGP.

Dr James Kingsland, England's national clinical commissioning network lead at the DoH, says many GP commissioners have been 'shocked' to discover the high level of NHS spending on urgent care. 'There is a sense that urgent care is broken and something needs to be done to fix it,' he explains.

Clinical commissioning groups
The RCGP urges clinical commissioning groups (CCGs) to aim to create a coherent 24-hour, seven-day service, with improved quality and safety, and better value for the taxpayer.

It says CCGs must move away from 'silo' thinking about urgent and emergency care services, towards a more integrated model.

The 86-page Guidance for Commissioning Integrated Urgent and Emergency Care - A 'whole system' approach says: 'It is essential that primary care is strengthened with redirected resources as well as new ways of working, for example more widespread use of telemedicine and telecare to free up capacity in the current system.'

Dr Agnelo Fernandes, report author and RCGP Centre for Commissioning clinical commissioning champion, says CCGs should move away from the 'disjointed and reactive' approach to urgent care.

'We now have an opportunity to take a fresh look at this whole pathway, to be genuinely proactive and provide a truly integrated health and social care response for patients,' he says.

The document gives examples of practical measures that could be taken to help deliver efficiency savings as well as improve urgent and emergency care. Here are 16 of them:

1. End of life

Reduce hospital admissions at the end of life. Use of end-of-life care co-ordinator.

2. Developing integrated discharge service at acute trust

Create integrated discharge posts, director and manager jointly with local authority. Referral to community pharmacy for new medicines review or follow-up post discharge.

3. Care homes

Recruit pharmacists and GPs for routine clinical and medication reviews of patients in nursing homes, to identify and address risks in order to avoid hospital admission.

4. Primary care

Develop community-based multidisciplinary 'hot clinic' for COPD patients, case management to cut hospital attendance and emergency admission.

5. Telehealth

Use of telehealth for patients with COPD/heart failure to improve control of symptoms and reduce use of emergency care services.

6. Alcohol deflection initiatives

Night triage to differentiate between 'intoxicated and in need of secondary care' and 'intoxicated'. Latter provided with secure setting to sober up.

7. Mental health

Proactive discharge planning to prevent readmission. Innovative approaches such as 'buddying' could be scoped.

8. Target specific groups

Engage and inform those whose first language is not English about local urgent care services, out-of-hours and reducing the inappropriate use of 999.

9. Reablement funding

Develop current reablement capacity in councils, community health services and the independent and voluntary sectors, according to local needs.

10. QOF

There are three QOF incentives for practices to take steps to avoid and reduce emergency hospital admissions.

CCGs can support and peer review the performance of all of their practices.

11. Urgent care local enhanced service

Some PCTs use local enhanced services to support the development of a high-quality urgent care offering in general practice.

Good urgent care
  • No confusion of what to do, who to call or where to go
  • A joined-up and co-ordinated system
  • Safe, responsive and a high-quality service
  • Self-care, prevention, anticipatory care and patient empowerment
  • Patient and public involvement
  • Monitoring of urgent and emergency care services
  • Knowledge to influence the spend on services
  • Integrated mental and physical healthcare for all
Source: RCGP

 

12. Funds for training clinical commissioning groups

There will be a sum of £2 per registered patient available in 2011/12. Pathfinders/CCGs have been innovative in using this to develop practices to deliver better outcomes.

Establishing clinical, managerial and patient champions to support practice team engagement.

13. Residual practice-based commissioning funding

Freed-up funding from previous groups has been used by CCGs to top up development funds for training, CPD and achievement of local priorities.

14. Commissioning for Quality and Innovation (CQUIN) payment

The CQUIN payment enables commissioners to reward excellence by linking a proportion of providers' income to the achievement of local quality improvement goals.

15. Provider contracts, service quality reviews and service level agreements

Working with other CCGs to contract with larger providers creates opportunities for service quality and contract performance reviews.

16. Integrated care organisations

Hospitals, local councils, community and social care organisations join up to plan each patient's care based on their individual needs.

Pilot schemes are under way to manage long-term conditions within the community and to prevent unnecessary admissions to hospitals and nursing homes.

GPs work more closely with consultants and social care teams to develop innovative ways of caring for patients, giving them faster access to the right kind of treatment, in the right place, at the right time, with a stronger focus on their long-term needs.

Neil Durham

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