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OOHCare

OOHCare. MAPPING CASEMIX AND PLANNING SKILLMIX Dr Jeremy Lade. RED DOC Reading Doctors On Call. An ISO 9001-2000 Company. RED DOC The ISO LOGO awarded by Systeme General Surveillance of Switzerland Management Quality Standards and Protocols approved every 6 months. RED DOC. REDDOC Ltd

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OOHCare

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  1. OOHCare MAPPING CASEMIX AND PLANNING SKILLMIX Dr Jeremy Lade

  2. REDDOCReading Doctors On Call An ISO 9001-2000 Company

  3. REDDOC The ISO LOGO awarded by Systeme General Surveillance of Switzerland Management Quality Standards and Protocols approved every 6 months

  4. REDDOC REDDOC Ltd • A private company, non profit-making. • Employs 50 staff: • Office staff • Operators • Nurses • Drivers • Turnover £750,000 pa • Mainly financed by the GPs themselves and not by the NHS. • ISO 9001 2000 certificate awarded in 2001

  5. REDDOC • REDDOC opened in April 1996 • 120 GP Members • 225,000 patients covered each night • Reading and Wokingham PCTs • 40,000 calls per year.

  6. Berkshire OOH Providers 2003 BEDROCK NEWDOC REDDOC SEBDOC

  7. The Present Situation • The PCTs now have the opportunity to set up and provide a fully integrated system for providing OOH and unscheduled care across their areas. • What should they be doing or have done by now??

  8. PCT preparation tasks • 1 ASSESS THE DEMAND: • Look at call volumes and casemix of: • OOH services. • Community Nursing IH and OOH • Ambulance Trusts • A&E and Minor Injuries • Palliative Care • Social Services/Homecare • Major Incident Planning

  9. PCT preparation tasks • 2 PLAN: • The types of service and resources available to meet the demand : • iePremises, Transport, Organisational and Technical Networks for: • Primary Care Centres • Walk in centres • A&E • Minor Injuries Units • Ambulance/PTS • District Nurses, Social Services, Homecare Services.

  10. PCT preparation tasks • 3 ESTIMATE COSTS • Bearing in mind that: • Many funding streams in Emergency Care will overlap. • Redesign of OOH services will need setup funding initially that should not be borne by existing providers.

  11. West Berkshire • 251 GPs • OOH care provided by five Co-operatives Majority of 178 with REDDOC and NEWDOCS • Future Provider pattern not yet decided by PCTs who are waiting until January 2004

  12. REDDOC/NEWDOCS Berkshire OOH provision proposal East Berkshire Provider Bedrock 415000 patients West Berkshire Provider REDDOC/NEWDOCS 465000 patients

  13. REDDOC/NEWDOC planning across NHS departments includes: • Accurate workforce/skillmix design. • A&E and CDU sessions for OOH doctors • Integrating with District Nursing OOH • Integrating with Social Services OOH • Working with Palliative Care OOH • Working with Mental Health Services • Working with Hospital Outpatient Services • Working with PCTs to provide Central Operations Role In and Out Of Hours • Major Incident Planning and Co-ordination

  14. Planning Casemix and Skillmix • It has been said that after April 2004 OOH Doctors will be few and expensive and much of their current OOH work can perhaps be done by First Contact Clinicians (Nurse or Paramedic) • Question: What is the current OOH Workload? • Question: How much of it can be done by FCCs and where are they to be found?

  15. Present REDDOC Nursing Staff • 12 nurses • None yet trained as FCC • None do Redeye shifts • All wish to continue routine work at PCC • ALL wish to train for Triage • 4 wish to train for FCC • All have family and work commitments • Conclusion: There are very few (if any) FCC nurses available in West Berkshire at present.

  16. Demography of Reading/Wokingham • Reading: • Urban, mixed leafy affluent suburbs, inner city and deprived areas. • Centre for teenage drinking. Gun crime common. • Wokingham: • More rural, villages, “happiest” place in England in 2002. Second healthiest in 2003. • High 3 car per family area. • Patients know their rights, highest OOH demand per patient in UK.

  17. TRIAGE CALLS TO REDDOC Number: 15,100 per annum 40% of calls

  18. The commonest advice call typesare spread across all age groups • Advice about prescriptions: 1164 • Intestinal problems, gastroenteritis: 1166 • URTIs: 803 • Symptoms, signs, ill defined conditions 1308 • Injuries, burns, poisoning, allergies: 1237 • TOTAL 6960 • (46%)

  19. Nurse Triage • Should they use a CAS system? It may slow call handling down. • Problem areas: • Age 0-2 may be difficult. • Multiple pathology. • Multiple or complicated prescriptions. • Mental Health problems. • However • Self-assessment suggests 50-90% could be managed, ie 8,000 plus now and 16,000plus per annum in the future. • This will be a major contribution to OOH

  20. Visits by REDDOC Number: 8095 per annum 21% of calls

  21. Most Frequent reasons for visiting (not in order) • Heart Failure • Circulatory system • Strokes and TIAs • Chest Infections • Pyrexia/UTIs in elderly • Abdominal pain (all ages) • Ill defined problems in elderly • Injuries in elderly • Gastroenteritis (all ages)

  22. Visiting older patients Visits in 75 and over : 2731 Visits in 65-75: 997 Visiting 65 and over: 3728 = 46% of annual calls These are clinically the most challenging calls and will need GP assessment

  23. Problems with Visiting the Elderly Diagnosis often uncertain until patient is seen - Who to send? Elderly have multiple pathology and polypharmacy. There are often Social Services and home care problems. Consultation time available is usually short. Experience, confidence and the authority to make rapid and effective management decisions including hospital admission are essential. OOH services can only afford a single consultation, double visits are not efficient.

  24. First Contact Clinicians and Home Visiting Elderly visits needing GP assessment 46% The other 54% more likely to need GP assessment (perhaps 50%) ie up to 70%. Hence FCCs attending all visits would need to request 70% doctor follow up call rate. This would be expensive and inefficient This problem is avoided by sending GPs in the first place (However District Nurses do have a very important role in managing chronic conditions at home and should become part of the OOH team if hours on call can be extended as they are already out on duty).

  25. Problems with bringing patients into PCC/hospital for assessment in West Berkshire • Shortage of ambulance facilities • Co-op transport not safe • PCC not equipped, staffed or large enough • Acute Trust already stacking patients at home • Elderly patients tend to be admitted • Confusion in elderly • A&E 4 hour target figures • Process delays run over into morning • Hospital bed occupancy around 98%

  26. OOH Attendance at the REDDOCPCC Number: 14259 per annum 38% of calls

  27. PRIMARY CARE CENTRE PATIENTS MOST SUITABLE FOR MANAGEMENT BY FIRST CONTACT CLINICIANS Disorder Number Ages Gastroenteritis 519 0-2, 2-10, 10-35 Viral + rash 154 0-2, 2-10 Other viral 662 0-2, 2-10 Conjunctivitis 371 0-2, 2-10 Otitis media 1012 0-2, 2-10 Tonsillitis 752 0-2, up to 50 URTIs 1314 0-10, up to 50 LRTIs 540 Any Asthma 533 Any UTIs 726 2-10, 20-50 Injuries/burns 710 Any Total 6654 = 47% of 14061

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