A&E GP streaming provider urges caution over rapid national roll-out

Commissioners of new A&E GP streaming systems could risk patient safety if they impose excessive pressure to redirect patients to cheaper services, a leading urgent care provider has warned.

Dr Sally Johnson: medical director at Greenbrook Healthcare
Dr Sally Johnson: medical director at Greenbrook Healthcare

Dr Sally Johnson, medical director of London provider Greenbrook Healthcare, said there was a ‘potential risk’ in redirection which commissioners of new services needed to properly understand.

The warning comes after a coroner last month called for a review of front-door streaming services following the death of a man in Bristol from a pulmonary embolism two days after being diverted from A&E through a streaming service.

NHS England has instructed every A&E in England to set up a streaming system in time for the winter to help relieve pressure on emergency departments. The government has allocated £100m capital funding to help trusts meet infrastructure requirements for the new systems.

GP A&E service

Dr Johnson, whose private provider company runs seven A&E front-door urgent care centres (UCCs) across London as well as a number of GP practices and walk-in centres, told GPonline that an ‘unintentional consequence’ of the new requirements on trusts and commissioners to get the new systems in place ‘may be that if there is too much pressure to redirect patients away, the wrong decision might be made’.

‘It's important commissioners work with providers to make sure they have a safe system,’ she said. ‘Commissioners need to understand there is a potential risk in redirection and be careful with the guidance they give their providers.’

Dr Johnson said her UCCs only redirect away from the hospital front door ‘patients who are clearly extremely safe - very, very minor cases’.

‘We do think there is a big potential for risk, if you are going to turn a patient away from the front door you need to know they are absolutely safe to turn away. And the public needs that assurance to know that is being done,’ said Dr Johnson. ‘Every provider needs to be absolutely sure if they are going to redirect, they have trained their staff and have a clear policy to only redirect the very minor things.’

Greenbrook’s services use specially trained band seven emergency nurse practitioners to assess whether patients need A&E treatment, should be see in the co-located UCC, or in very minor cases redirected. Around 80%-85% of walk-in patients are managed by the GP-led UCC, around 50%-55% of total attendances.

NHS cost savings

Patients treated by the service cost around half what it would cost to treat them in A&E, creating significant savings for commissioners. The Greenbrook service is required to meet all the same targets and safety standards - such as the four-hour waiting time and triage targets - as the emergency departments.

The UCCs are tendered by CCGs and funded either through a block contract or a tariff.

NHS England’s decision to require streaming systems at all A&Es has been criticised by doctors’ leaders. The GPC has said the additional government funding for the scheme would be better spent in general practice, and warned the new system could attract more patients to hospitals. The RCGP has said GPs should be in their communities.

Dr Johnson said there was a cohort of patients who wanted to go to A&E, often out of hours, but who should not be seen by emergency doctors. ‘They want to go when it suits their work life,' she said.

‘Nobody wants to erode traditional general practice,' Dr Johnson added. ‘There is a massive need for that, for chronic disease management, continuity of care, frail elderly.’ But she said there was also a need for ‘newer ways’ to provide acute urgent care that need not be done in practices and may be more effectively done in UCCs.

Patient demand

‘Practices can't meet the on-the-day demand,’ said Dr Johnson. ‘So maybe we need to rethink the whole system, so on-the-day stuff goes to treatment centres or UCCs, but see your GP for chronic disease management, ongoing problems.’

While Greenbrook’s model - which it has been fine tuning for five years - worked in urban areas, Dr Johnson said it may not be right everywhere. While the intention of NHS England’s plan was good, the GP said, ‘it shouldn't be a one-size-fits-all model’.

‘We think commissioners and providers need to be given some principles but be allowed flexibility to interpret that for what is best for their population.'

While NHS England and NHS Improvement did consult Greenbrook on the plan to roll out A&E screening services nationally - after it was announced - Dr Johnson said commissioners needed to work out how many different primary care services they need. ‘We do have some concerns now with the growth of GP hubs as well, and GP out-of-hours still happening, and UCCs.’

An investigation by GPonline in June found that providers could require more than 200 extra GPs to staff new and expanded front door streaming services over the next year.

NHS Providers - which represents trusts - has warned the plans need more funding from commissioners and could be undermined by GP shortages.

Dr Johnson said Greenbrook did not have problems recruiting GPs. ‘We can recruit because doctors enjoy working with us,' she said. GP at Greenbrook’s UCCs usually work sessionally as part of a portfolio career. They are often younger GPs who do not want to join a partnership, or older GPs who are ‘disillusioned’ with regular general practice.

GPs are trained by Greenbrook in urgent care medicine and then work in teams of up to five GPs and five nurse practitioners.

‘It also suits people who want flexible working,' said Dr Johnson, ‘because they're open 24/7, you can just do evening shifts, some just do overnights. You can pick the hours you want to suit your life. It is certainly easier to recruit to urgent care than it is to GP practices.’

‘We have developed a niche area for GPs that are a bit tired of general practice, so they are able to use a blend of primary care skills with some additional emergency medicine skills, which they really enjoy,' said Dr Johnson. 

‘You don’t have any of the paperwork or bureaucracy of normal general practice. You come in, you see patients. It's good old fashioned medicine.’

Despite some primary care services paying GPs ‘way above the market rate’, Dr Johnson said Greenbrook has not been forced to. Greenbrook has also recently signed up to a new indemnity provider deal which allows its GPs to obtain significantly cheaper insurance.

Greenbrook’s centres are also beginning to employ ‘patient champions’ whose role includes providing education to patients on how to use the health service and where they should go to be seen appropriately in future. Patients are also offered support to book GP appointments, register with a practice or given referrals to community health services.

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