Older patients seeing same GP each time "key to reducing hospital admissions"

Seeing the same GP each time they visit the doctor can reduce avoidable hospital admissions among older patients, a study published in the British Medical Journal has found.

But the government’s focus on increasing access to GPs, such as through longer hours, may have unintentionally affected the continuity of care patients experience, the authors warn.

The study, by researchers at the Health Foundation charity, found that older patients who saw the same GP most of the time were admitted to hospital 12% less for conditions that could be treated in doctors’ surgeries than those who had a lower continuity of care.

The researchers looked at ambulatory care sensitive conditions: these include long-term conditions such as asthma, where flare-ups can be reduced by high-quality GP care, acute conditions such as gangrene that can be prevented by timely treatment, and illnesses such as flu and pneumonia that can be prevented through vaccination.

Admissions for these types of illness are expensive for the NHS: hospital admissions for conditions that could be treated at doctors’ surgeries cost £1.42bn in 2009-10, or more than £170,000 for each GPs’ practice.

Under changes to the GPs’ contract introduced in 2014, all patients in England must have a named GP who is accountable for their treatment. But researchers at the University of Bristol warned in response to the BMJ study’s findings: “There is evidence that continuity of primary care is actually declining in the UK.”

In an editorial for the BMJ, they called for policies to help ensure greater continuity of care.

Seeing the same doctor more of the time could reduce hospital admissions because it “builds trust and a sense of mutual responsibility between patients and GPs”. Older patients were particularly likely to appreciate seeing the same GP, although they were less likely to receive it, the researchers said.

The editorial added: “A primary care system that is increasingly fragmented, in which neither patients nor doctors feel strongly connected to their local general practice, provides the setting for patients to choose to attend an emergency department.”

Difficulty in getting appointments at GP surgeries, “which are at least as overwhelmed as emergency departments”, compound the problem.

Improving the proportion of the time that patients saw the same GPs would improve doctors’ job satisfaction, and was “very likely” to reduce pressure on hospitals, they added.

The Health Foundation researchers analysed patient-level data for more than 230,000 people in England aged between 62 and 82, focusing on older patients because they make up a high proportion of GP appointments and avoidable hospital admissions.

Patients who experienced a medium level of continuity of care had almost 9% fewer avoidable admissions, while those who saw the same GP a high proportion of the time saw just over 12% fewer avoidable hospital admissions in comparison with patients who had a low continuity.

The researchers found a particularly pronounced association between continuity of primary care and reduced hospital admissions among patients who were frequent users of primary care, which they defined as more than 18 visits over the two-year period covered by the data.

The study was observational, and did not prove cause and effect, the researchers emphasised. But improving the continuity of care could reduce hospital costs, especially for the heaviest users of the system, they added.

A spokeswoman for the Department of Health said: “This government is committed to making sure patients can get the right care at the right time from well-resourced GPs and, from April 2015, all patients have had the right to continuity of care through a named GP, as part of the GP contract.

“This remains a key part of our plan to reduce pressure on hospitals, and is in no way diminished by extending access.”

Older patients seeing same GP each time "key to reducing hospital admissions"

How real-time data is reducing A&E waiting times

In many trusts, the only way to find out something like how long people are waiting in accident and emergency is to phone the department and ask. “There are not many people at any one time who know what’s going on,” says Marc Farr, director of information at East Kent hospitals university NHS foundation trust. “A hospital has lots of people phoning people all day for information,” he says.

The trust has ended the need for such phone calls. It displays live average emergency waiting times, as well as the number of people waiting, at each of its four hospitals, on its website. As well as informing the public, the business intelligence system helps the trust know when to redirect emergency patients to manage demand.

Farr tells of one situation where they arranged for ambulances to be diverted from one hospital. For six hours, some ambulances that would normally have used Margate’s Queen Mother hospital went to Kent and Canterbury hospital. “You need that type of data and those types of predictions to make those kinds of decisions,” he says.

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Chris Dodgson, head of information for the Royal Bournemouth and Christchurch hospitals NHS foundation trust, says that real-time information also helps meet the target for 95% of patients to be seen by emergency departments within four hours. This is often affected by other wards being full, preventing patients being moved on from an emergency bed. “You want to know roughly where your blockages are, and this is where real-time information really helps to unpick those questions.”

East Kent shares data with external organisations, including a nursing agency which it pays to support those leaving hospital to return home. “Having a data flow between us prompts us to discharge patients more quickly …”, Farr says. “Having a mobile, real-time view of how many patients they can take at any one time is really helpful.”

East Kent sells the information-sharing systems it has developed through Beautiful Information, a company jointly owned by the trust, Farr – its founder – and other individuals. Its customers in the NHS and private healthcare sectors access up-to-date data on areas such as bed usage, finance and the workforce through online systems including a smartphone app.

Providing data through smartphones means managers can react quickly, but small screens require clear and simple presentation. The information dashboards use the common traffic light code, with green indicating few problems, amber some and red a serious situation.

However, it also offers black for the worst cases and blue for measures that continually meet targets, meaning “you don’t need to keep checking up on these people,” according to Farr. Users of the system can set their own thresholds for each colour code, which he says is important in getting them to trust its warnings.

Royal Bournemouth and Christchurch, which is working on developing its own data visualisations, uses business intelligence to monitor its progress on treating strokes. The Royal College of Physicians works out a grade for hospitals based on more than 50 clinical measures every four months. The trust puts the same data into the same formula to calculate the grade as often as clinicians want to check it, allowing them to redesign the service and see improvements far faster. “The impact of that over the last few months is that if you plot our scores we’ve gone from being at the lower end up to the very top end,” says Dodgson.

The trust has just installed a Microsoft SQL 2016 data warehouse to improve its work in this area. In his previous job at Salisbury NHS foundation trust, Dodgson established a business intelligence system that greatly speeded flows of information. Demand on beds varied significantly throughout the year, so Dodgson and colleagues used three years of data to predict availability for each week. As a result, more staff were placed on-call for the weekend after New Year’s Eve: “It was a really busy weekend,” he says, adding that by publishing what actually happened as well as predictions, staff gained confidence in the accuracy of the forecasts.

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Dodgson says business intelligence can be hit by poor-quality information if staff do not have the time to collect it. This can be tackled by using data that is already being gathered for other purposes, such as patient observations.

He has also occasionally met opposition, including a consultant who didn’t like the idea that decreasing lengths of stay could lead to bed closures. He says it is vital to take all views into account: “The numbers say one thing, operationally it says something different. Where do we meet in the middle? Business intelligence from my point of view is about the beginning of a conversation, it’s not about cast-iron certainties, especially when you’re talking about service transformation and change.”

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How real-time data is reducing A&E waiting times

How GPs in London are reducing hospital referrals

Charlotte Levitt, a GP based in south London, faced a dilemma. One of her patients was taking a drug that had just come onto the market and his kidney function had started deteriorating. Should she refer the patient to a consultant, or take him off the drug?

Whereas many GPs might automatically make a referral, Levitt, referral management lead at Wandsworth clinical commissioning group (CCG), was able to resolve the question quickly. She logged on to Kinesis, web-based software from Cloud21 that enables GPs to confer with local hospital consultants. In this case, the consultant advised further blood tests: if they were abnormal, the patient should be referred. If not, the drug was likely to be the problem.

Last year, there were 13.6m GP referrals in England, a 5% rise on the previous year, representing an increasing cost burden on CCGs. A 2009 report from the NHS Institute for Innovation and Improvement found that up to 65% of patients referred to outpatient specialty clinics were discharged with “no significant pathology detected”, meaning many were unnecessary.

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Four years ago, Wandsworth CCG implemented Kinesis across its 43 GP practices as part of a wider plan to manage referrals more effectively. If a GP isn’t sure whether to refer a patient, or simply wants to ask a consultant for advice, they log on to the Kinesis website and choose the consultant or specialism they are interested in. The GP submits their question, attaching any relevant documents, ECGs, photographs or videos, which the consultant receives via the NHS’s secure N3 network (though the software can also run on Microsoft’s Azure cloud platform).

The first local hospital to come on board was St George’s, but since then Chelsea and Westminster, Guy’s and St Thomas’s and Kingston have also joined. Consultants are not obliged to take part, but at St George’s, most specialties are represented on the system. As part of hospitals’ agreement with the CCG, the consultant is required to reply within 24 hours. If a consultant is off sick or on holiday, it won’t be possible to message them.

In 2015/16, Wandsworth GPs sent 3,993 requests via Kinesis. Of those, 48% did not lead to a referral, saving the CCG £276,730, if we assume that without the ability to confer with the consultant, the GP would have referred the patient.

So what are the advantages for consultants? Simon Hudson, founder director of Cloud21, says the most immediate benefit is that, because routine cases can now be dealt with over Kinesis, they have “slightly more interesting and more complex patients turning up at outpatient appointments”. Longer term, he says, the hospitals save money and see patients more quickly.

Some consultants worry that they will be overwhelmed with requests, but Sarah Thurlbeck, a paediatric consultant at St George’s and an early adopter of Kinesis, says she receives, on average, one request a day and it takes about 10 minutes to respond. “It’s usually borderline cases,” she says. “If the child has something obviously wrong, they’re going to be sent up, but if it’s just some niggling thing, I might advise the child is watched, or I might advise some simple tests.”

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Thurlbeck, who does some GP teaching, has also found that it gives her a sense of what local GPs are concerned about and where they would like more training. She also likes the fact that Kinesis keeps an audit trail of questions and answers. “What you see is what was said. When you have a telephone conversation, what you say and what is heard may be two different things.”

Levitt agrees that Kinesis has been good for building relationships between hospital consultants and GPs, as well as for improving her own practice. “I might ask a weird and wonderful question,” she says. “It’s amazing how often you see that again in the future, and I don’t ask the question again because I now know the answer.”

Two years ago, Sutton CCG in south-west London implemented Kinesis, enabling GPs to confer with consultants at St Helier hospital and St George’s. Dino Pardhanani, clinical lead for Sutton CCG, uses Kinesis about twice a week and says that GPs are also using it to request MRI and CT scans from radiologists, who can authorise the request without the patient having to see a consultant. The ability to receive a quick response to a query benefits the patients too, he says. “You can reassure the patient that they’re getting input from an expert, but it’s much more streamlined.”

Hudson believes that as Kinesis is more widely adopted, its potential will grow. It could be extended to allow access to international experts, for example, while the stored anonymised conversations could be analysed to identify trends such as an emerging epidemic. Already, he says, Wandsworth CCG has noted a surprisingly high incidence of gout being discussed on Kinesis, resulting in the introduction of a dedicated gout pathway. “That’s had a direct patient impact because they get access to the care they want more rapidly,” he says.

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How GPs in London are reducing hospital referrals