Objective: To evaluate the cost effectiveness to primary care trusts (PCT) in commissioning general practitioner (GP) referrals in-hours to emergency care practitioners (ECP).
Methods: A retrospective case note review for patients referred by GPs in-hours to ECP over a 4-month period to ascertain any added value over a GP visit.
Results: In a 4-month period 105 patients were referred. In most cases (90.5%) the ECP was utilised as a substitute for a GP rather than providing any additional skills. Defining an avoided attendance as the ECP undertaking an intervention outside a GP skill set this equated to a 9.5% avoided attendance rate compared with the ECP service standard rate of 60%. This has implications both in terms of financial benefit and ongoing ECP service sustainability.
Conclusions: There is little value in a PCT commissioning this service as they will pay twice and care must be taken in accepting new referral streams into existing services.
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Emergency care practitioners (ECP) are a developing role in the UK with no single model of practice nationally. Yorkshire Ambulance Service (YAS) operates an ECP service, including a scheme in the Sheffield area, which is ambulance service-based using single responder ECP in appropriate vehicles.
ECP are paramedics or nurses who have received additional training, at diploma or degree level, to allow them to function autonomously and manage patients with minor injuries or illnesses in their own home. Although there is still a lack of consistency nationally as to the exact skill set of these practitioners the YAS ECP have undergone 12-month training courses coordinated by local higher educational institutions and work to the competencies set out in the current Skills for Health competence and curriculum framework.1 ECP can autonomously assess a patient’s needs, perform simple wound interventions, undertake suturing and other wound closure techniques, dispense drugs using patient group directions and refer directly to multiple community and secondary care acute services.
In 2005 commissioners from the local primary care trust (PCT) asked the Sheffield ECP scheme to trial accepting referrals in-hours from general practitioners (GP) with the aim of reducing emergency department (ED) attendances and potentially admissions. The remit was to try to attend calls in which the GP would otherwise have arranged hospital attendance directly, or rung 999, as the clinical need for the patient was outside the normal GP skill set.
This short report summarises the evaluation of this pilot and tries to assess whether PCT should commission ECP to manage this type of referral.
A review was undertaken of referrals made by GPs, or their practice nurses, during normal working hours for primary care (08:00–18:30 hours) from a selected number of surgeries in the Sheffield area. Thirteen surgeries were initially selected based upon high hospital usage and willingness to engage in the project.
Referrals could be for any area within the ECP skill set but looked to focus on the elderly. A GP or practice nurse spoke to the ECP coordinating the service and requested ECP attendance. If the referral was accepted the referring clinician informed the patient, to ensure they were happy with this alternative.
For service evaluation, the patient care records were retrospectively reviewed by a GP (JG). The records were assessed to see if any skills had been used by the ECP that were outside the skill set of primary care; suturing would be an example. These reviews were then presented to representatives from the commissioners who cross-checked and agreed the conclusions reached.
A definition of attendance or admission avoidance was produced: if an ECP attended a call on behalf of a GP and used only skills that were within the primary care skill set it was assumed the patient destination would have been the same, consequently no attendance or admission had been avoided. It is accepted that this is a significant assumption; however, it serves as a useful definition for comparing referrals from different sources.
The pilot ran for 4 months (August 2005 to November 2005 inclusive) during which time 105 patients were seen based upon referrals from the 13 practices.
Of these 105 cases only 10 involved the ECP utilising skills specific to their role, and thus applying the above definition gives an avoided attendance rate of 9.5%. This compares to an avoided attendance rate of approximately 60% for the current standard workload of the YAS ECP service, which includes 999 calls, crew referrals and direct care-home referrals.
Review of the cases by the service commissioners agreed completely with the review carried out by the GP.
Based upon the scheme cost to commissioners and the total number of cases seen in the financial year, the cost per case for ECP response was approximately £130 at the time of the pilot. This compared with an estimated ambulance response cost of a minimum of £115 per call.2
If a case is dealt with by an ECP that would otherwise have been sent to the ED there is a saving based upon the ambulance and ED costs. There is also a potential admission tariff saving.3 Work from the School of Health and Related Research in Sheffield estimates overall cost saving to the healthcare community to be approximately £290 per case.4 If a case was referred by a GP to the ECP service and no ECP-specific intervention was undertaken then there was a double cost to the PCT; the cost of the GP (already paid for under the GP contract) and the additional cost of the ECP.
The pilot was targeted at high referring, but motivated, practices and regular contact was made by JG to promote the pathway and monitor use. Despite this the numbers of referrals were low, which may have influenced outcomes. This may have been due to GPs expecting that the patient outcome of most cases was unlikely to be significantly affected by ECP intervention. This could also be due to these practices proactively modifying their own referral rates as a result of it being highlighted that they had high unscheduled service usage.
When considering new referral streams for ECP services the effectiveness of the new referral pathway should be considered; first, whether the level of demand can be absorbed into the service as it currently stands, and second around the outcomes for this group of patients compared with the existing scheme outcomes, in particular attendance/admission avoidance rates. The PCT had been looking towards the pilot rolling out across all 97 Sheffield practices. Without expansion of the existing ECP service, the new pathway projected for all city practices would have taken up all of the in-hours (08:00–18:30 hours) ECP capacity with little overall health economy benefit.
The decision based upon the outcome of the pilot was not to continue the referral from in-hours GPs to ECP.
This work suggests that there is little value in a PCT commissioning this service as they will pay twice for each case. There may be merit in practice-based commissioning consortia looking at this if it is a cheaper, more productive option than GP visits; however, such a conclusion is outside the scope of this work.
Care must be taken in accepting new referral streams into existing services. When we do so, clear and measurable objectives and criteria must be formulated against which service outcomes and whether it meets the original aims can be judged.
Competing interests: None.
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