Joan Mercer
Senior Nurse,
Bassetlaw PCT
Tel: 01777 274520
Email: joan.mercer@bassetlaw-pct.nhs.uk
Summary:
To provide an Out of Hours unscheduled and palliative care service for patients in their own home. Prior to the service being established, it was delivered by an external organisation. Patient’s frequently waited several hours for a GP visit or had to travel over 50 miles to access a GP. The night nursing team and their senior nurse, employed by the PCT had recognised the need to improve services to housebound patients during the out of hours period. Feedback from Health and Social Care professionals, patients and carers has been extremely positive
Abstract:
Since the publication of the Out-of-Hours Review (the Carson Report) November 2000, PCTs have been required to develop better-integrated emergency care networks. There were two main principles of the review; primary care out-of-hours services to be modernised to ensure that all patients have access to the high quality services, no matter where they live or the GP practice with which they are registered; and the new services to bring together a variety of different health professionals working in different parts of the NHS, enabling patients to access the service and the health professional best equipped to meet their urgent needs.
The new GP contract enabled GPs to opt out of providing patient care during the out-of-hours period. Bassetlaw GPs took this opportunity and the responsibility to provide a service passed to the PCT, who became responsible for; ensuring 24-hour care is available to all patients; ensuring that care is delivered to specific quality standards; developing integrated emergency care services; and integrating services with other parts of the network.
These policies were complemented by the DoH and RCN joint publication ‘Dispelling the Myths 2003’, which highlighted the benefits of nurses extending their roles to provide more effective and efficient care to patients, and the DoH ‘Patient Led NHS’ and ‘End of Life’ initiatives.
The aim of the service change was to establish a safe and effective service, which took account of the national drivers for change, while taking the opportunity to locally design patient focussed care.
The Senior Nurse responsible for establishing the night nursing service had a specific interest in palliative care and unscheduled care. The nursing team had identified and expressed areas of advanced practice, which would improve patient care. The Professional Executive Committee and the Board both deemed this piece of work timely and appropriate particularly with the governments’ modernisation agenda
Prior to the service change, numerous concerns had been expressed to the PCT, local MPs and the local media regarding the current service.
A public consultation was carried out, which involved presentations to local patient groups, meetings with other stakeholders, such as the acute trust, local ambulance service, local health and social care professionals and voluntary agencies and extensive publicity about the service change, including posters, leaflets, suggestion boxes and interviews with local media.
The Out of Hours Steering Group considered the views expressed and adopted where appropriate, for example, it was agreed that patients would be given full courses of medication rather than starter packs, and emphasis was placed on the practitioners working with local care homes to avoid unnecessary admissions to hospital
The team, including nurses and paramedics were trained to practitioner level. The senior nurse worked closely with local universities to under-write a specific course for the practitioners, enabling them to gain the skills and knowledge required. The paramedics also undertook in-house training at the local hospice, enabling them to undertake palliative/terminal care visits. The nurses undertook a non-medical prescribing course. All practitioners undertook therapeutic training.
The role of the Healthcare Support Worker was also developed to provide skilled nursing care, previously undertaken by Registered Nurses, for example, changing blocked catheters of patients and undertaking support visits for palliative care patients.Regular meetings are held between A&E, Wards and Senior Nurse to review direct patient admissions. Local GP practices also provide feedback.
Trent Strategic Health Authority has undertaken two peer reviews of Out of Hours arrangements across their area. On both occasions, we were commended by the Strategic Health Authority and other local organisations, for the robust and innovative service we have established.
Performance is also measured against the Health Care Standards and the national Quality Requirements for Out of Hours Services.
Each patient seen by the Out of Hours service is given a free-post feedback form to return to the PCT. These are collated and comments received are fed back to the practitioner team and the Out of Hours Steering Group. Feedback to date has been extremely positive showing that patients recognise and appreciate the service change and the improvements this has delivered.
Also the national patient survey showed an increase in patient satisfaction with the Out of Hours Service following the service change.
Bassetlaw has a registered population of 110,000 covering a large geographical area, including two towns, semi-rural and rural areas. Previously, this has caused difficulties for patients accessing medical services during the out-of-hours period. The governments’ modernisation agenda and legislative changes have enabled nurses to work in new and advanced ways. Bassetlaw PCT has utilised this to develop a local service, meeting the needs of patients.
The Senior Nurse, Interagency and Heads of Department meetings receive regular updates about the service, ensuring community services are integrated at practice level, enabling professionals to work across service boundaries.
The service is also closely linked through the Single Point of Access service. A palliative care handover form is used to inform and update all community staff about patients requiring palliative/terminal care.
The establishment of the practitioner team is imaginative and innovative for a number of reasons. The practitioners lead an effective home visiting service, instead of the traditional GP model. The practitioners have direct referral rights to the wards at the local hospital, thanks to successful negotiations with the local consultants. The practitioners dispense full courses of medication instead of the traditional starter packs, including working to Patient Group Directives for palliative care drugs. A locally agreed pathway is in place for patients requiring end of life care, which encourages local GPs to pre-emptively prescribe controlled drugs. A locally agreed verification of death policy is in place, which was agreed with the coroner.
I believe that the team were energised to become innovative because they recognised the need to improve practice. They were encouraged and enabled by the Senior Nurse to develop the skills they required to work in advanced ways.
