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Ray, Doesn't matter. They'll change it again in a few months!!! Simon -----Original Message----- From: Ray [mailto:[log in to unmask]] Sent: 07 March 2006 10:24 To: [log in to unmask] Subject: Re: Primary care front door "the tariff comes in only three bands, which following their initial publication were almost immediately withdrawn and replaced by something lower." Does anyone know what the new tariffs will be? In terms of financial planning this situation is nothing short of ludicrous! Ray ----- Original Message ----- From: Jonathan Benger <mailto:[log in to unmask]> To: [log in to unmask] Sent: Monday, March 06, 2006 11:10 PM Subject: Re: Primary care front door Dear Colleagues, My grateful thanks to everybody who has responded to my original posting. As Rowley says, this is one of the great strengths of a list like this. It is interesting to see how many people are facing the same issues, and encouraging that a primary care "front door" is not really taking over: indeed it would appear that this has already been tried in various forms, largely without success. However there may still be interesting times ahead, particularly with the new element of payment by results (which should, of course, be called payment by activity, because results have nothing to do with it). As Rowley points out the tariff comes in only three bands, which following their initial publication were almost immediately withdrawn and replaced by something lower. In some respects this could still benefit us, because if our activity continues to climb so will our income: this is exactly what the PCTs are afraid of, and is also the reason why the tariff has been reduced. On the other hand, £50 for a quick minor is attractive, whilst £100 for the most complex medical or trauma sickie is grossly inadequate. This means that in order to pay for the high end work you need to turn over a lot of low end stuff. Meanwhile, the PCTs are looking at the low end stuff and thinking that every one which can be diverted to primary care, without booking into the ED, is £50 saved. The view of my local PCT is that £50 pays for 2 nurses for 2 hours and they see it as a money-making option: presumably "independent" (private) healthcare providers could take the same line. Like Steve Crane we are being asked to integrate with our local Walk-in Centre and GP out of hours service, on a six month trial basis, with the express intention of channelling our minor end work through primary care, thereby reducing our income and saving the PCT money. Indeed, the whole point of our proposed "primary care front door" is that it will be paid for entirely from the current ED revenue, and also save the PCT large sums of cash. However, this is the pessimistic view. I am encouraged to learn that most patients in the ED aren't suitable for primary care, and that a primary care front door is likely to be ineffective and prohibitively expensive, particularly if it is staffed by GPs who are, in any case, highly unlikely to be interested in providing a 24/7 service in their local urban ED. These will be useful messages on which to build our case. Thanks again, Jonathan. [log in to unmask] PS: I too was surprised by the number of admitted patients who called their GP in hours, or GP out of hours, or NHS Direct or went to a Walk-in Centre first. However anecdotally a lot of our patients would arrive saying that they'd called their GP and been told to dial 999, whilst the PCT assured us that this hardly ever happened. To settle the dispute I did the research, and showed that actually only 25% of admitted patients came to us directly. The PCT accepts that this suggests an additional primary care filter is unlikely to reduce admissions, but tell me that they feel compelled to try their new scheme anyway(!) -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]]On Behalf Of Rowley Cottingham Sent: 06 March 2006 09:56 To: [log in to unmask] Subject: Re: Primary care front door Funnily enough, Jonathan, we have just been 'offered' a very similar system. This is the enormous value of lists such as this. See my comments. My response is quite long, but please read on - this could change emergency care as we know it. Best wishes Rowley. -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Jonathan Benger Sent: 04 March 2006 12:18 To: [log in to unmask] Subject: Primary care front door Dear Colleagues, I would value your assistance with an issue that has arisen locally, but which may have implications across the UK. In common with everywhere else, our local health community is under substantial financial pressure, and this will only worsen with the additional savings and imperative to achieve financial balance that are being imposed during 06/07. In an effort to reduce costs, our local PCTs have decided that patients are increasingly bypassing primary care and attending the ED because this is an easy option. From the ED they are being unnecessarily admitted to hospital because this is also an easy option, and makes more money for the acute trust under the payment by results system. I am informed that 50% of the patients in my emergency department could be dealt with in primary care (does anybody have any evidence to support this?). As you will know, Ed Glucksmann and Jeremy Dale looked at this at Kings and found 38% could be seen by a GP. I repeated their paper in Eastbourne a year or so later, and in winter I too found 38% rising to 44% in summer could be seen by a GP. So from that point of view they are correct; however, GPs are very expensive resources, and have leaped with alacrity from OOH work so the proposals will almost certainly use ENPs, ECPs, or other non-doctor health care providers (NDHCPs) instead. However, we already have that addressed in our department with ENPs performing a meet'n'treat service where possible, but it remains true that OOH work is still done by junior doctors as the nurses prepared to work then are more difficult to find. The question is now whether patients are being unnecessarily admitted. This of course, is an entirely different population, and our figures show that a substantial number of people are being admitted unncessarily. However, when you analyse the reasond for excess admissions, it is very rare for it to be as the result of an unsupported SHO admitting for the sake of safety. No, we admit because community and social services are not available or cannot be mobilised in time. Patterns of discharge always show a marked decrease on Saturday and Sunday - because they need a home assessment, a Zimmer Frame, moving from a rest home to a nursing home or similar. These are community failures of provision, and hospital beds are essentially used as a safe haven until they are provided, the home manager is back from holiday or any one of a dozen excuses. Of coursem in this time the poor patient becomes confused, develops a UTI, falls and breaks a hip etc, and the discharge is still further prolonged. In response, the four PCTs in our region have decided that they will institute a "primary care front door" to all local emergency departments. Nobody will be allowed to attend an ED unless they have first been seen and "triaged" by a primary care practitioner. I have pointed out the costs, problems and potentially negative publicity that may result from this, and have even undertaken research to show that only 25% of acutely ill patients admitted to hospital come to the ED directly, with the vast majority contacting primary care first, from where they are often directed to the ED (some of you have kindly helped me with this, and I will be presenting the results at the BAEM conference later this month). Nevertheless, the PCT tell me that this revolutionary idea is currently sweeping the country and is being successfully instituted all over the place. I fail to see how it can make a difference without the above issues being addressed. I fail to see the point of these navigators as I do not understand what they can do we are not already doing. "You should go and see your GP with this!". And we don't say that? However, I do see substantial risks, and there are a few plants moving into conjunction. The first planet is Payment by Results. This has come in a year earlier than I for one expected, and the tariff is much lower than expected; £53 for a straightforward patient, £75 for a more complex one and £99 for a very complex one. A quick calculation shows that this cuts our department's income substantially. Add in a planet of a non-ED employee, this navigator, turning up to 40% away, and our department's financial viability is called into question. I can't believe we are alone. Furthermore, the plan is clearly to embed GPs in A&E as the thinking is, "A GP is perfectly capable of deciding in the community who goes to hospital - let's just move the GP into the ED and why do we need these expensive Consultants, SpRs, Staff Grades and SHOS? Although a moment's reflection will give you many reasons why this reduction of an ED to a signposting facility is unacceptable, it has one great benefit - it is cheap. So I view these developments with considerable suspicion and not a little alarm. It might be paranoid, but is there a concerted effort to downgrade facilities to a Spanish style polyclinic, with someone calling down the cardiologists to a chest pain, orthopods to a Colles' and so on? Is the GP in the department a Trojan Horse? Is the primary care navigator first out of the hatch? Will we be eclipsed? My main question is, does anybody have a primary care front door to their ED? If so, does it work? Has it been suggested and dropped: if so, why? I recall corresponding with Ruth on this subject a few months ago, and thought the whole thing had been laid to rest, but round here it just refuses to lie down. As usual, please feel free to contact me off list: [log in to unmask] Best regards, Jonathan. PS: It will come as no surprise to many that the PCT's thinking around this issue is very woolly: Obviously the cost of placing a GP in the ED 24/7 is phenomenal, and when I pointed this out it was suggested that perhaps a nurse could do it with GP back-up, or maybe a GP could spend a few hours in the ED during weekday afternoons. Interestingly, the PCT actually paid to put a GP in our ED about four years ago to screen and reduce acute medical admissions (the GAMA project: GPs avoiding medical admissions). This showed that GPs had a marginal effect (<5% reduction) at best, and really only worked well when they encountered their own patients in the ED. Sadly, the local PCTs have a very short memory, and are desperate for some sort of "magic bullet" that will save immense amounts of cash in a very short space of time.