Reducing short stay hospital admissions

There was a desire by GP commissioners in Stockport (Stockport Managed Care) to provide more care and treatment in the community for groups of patients who would traditionally result in frequent short stay hospital admissions. Analysis of Ambulatory Care Sensitive (ACS) conditions, as defined by the NHS Institute for Innovation and Improvement, showed Stockport expenditure on 4,200 short stay admissions from a group of 19 ACS conditions to be approximately £6 million in 2007-2008. Particular groups of patients, as highlighted by the Royal College of Physicians in the Report of the Acute Medicine Taskforce (October 2007), could have received care and treatment in the community had it not been for a lack of immediate diagnostics and senior clinical support. A model was devised for an enhanced form of primary care where GPs could refer patients from a defined list of ACS conditions (Table 1), for anything from a clinical discussion or diagnostic/opinion, to more intensive day care investigation and treatment. Development of the Early Intervention Service (EIS) concept has proven challenging for the local health care community in both logistical and financial terms, causing the scheme to undergo much scrutiny. Patient groups have, however, praised this new model of care and its aims, namely to provide rapid treatment for certain conditions in the early stages of deterioration and to avoid not only admission, but also declining morbidity and ultimately mortality. After approval of the business case, a purpose-built conversion of a building in the centre of the town was undertaken. This included an on-site digital plain radiology and point of care laboratory diagnostic equipment (Roche Diagnostics) utilising the latest technology to allow previous “hospital-laboratory based” tests to be undertaken in the community without the need for on-site pathology technicians.

Specialist community-based care

The EIS will be available initially from 9 am to 11 pm, Monday to Friday (with expected expansion to seven days a week in the future). Staff will consist of full time GPs (specialist practitioners in ambulatory care), senior advanced nurse practitioners (ANPs), nurse assessors, healthcare assistants and administrative support. They will work as a team, taking referrals from GPs, active case managers, district nurses and intermediate care. The GPs will be offered a two-year post with an academic attachment leading to a Diploma in Ambulatory Care, which is currently being developed to facilitate the EIS. The EIS team will be supported by daily attendance of an emergency care consultant from Stockport NHS Foundation Trust to undertake clinical case reviews, as well as to provide clinical support and governance advice. Radiology support is to be provided through on-site radiographers from the Trust and consultant reporting for clinical governance. Diagnostic support will also be provided by the Trust’s pathology department, with input from the point of care testing (POCT) coordinator based at the Trust who will oversee and monitor the use of the POCT equipment to ensure that appropriate diagnostic standards are met and maintained. Care pathways have been jointly developed with a strong ethos of empowering GPs to undertake diagnostics and act earlier in a patients’ illness. The new service has been commissioned by Stockport Managed Care (practice based commissioning vehicle at NHS Stockport) and will be provided by Stockport PCT’s provider services with a service level agreement with Stockport NHS Foundation Trust for some parts of the service, including consultant, pathology and radiology support.