Partha Kar

Acute trusts should take over out-of-hours care

It’s late Friday evening, the 87-year-old frail lady, living alone at home, finds herself on the floor. Not sure what happened, she is frightened and her relatives are away for Easter too. Thankfully she has had all the relevant numbers stuck on her fridge door. Her own GP number stands out; lovely young lady but no, she isn’t there at that hour. She used to have the number of NHS Direct on her fridge, but that’s now changed. Drat. What about 999 – but she doesn’t want to make a fuss. Should it be 111? Oh dear.

So how about the lovely consultant who knows her so well? Nope, he’s not available at this time, bless him, he does work hard.

I suspect you are starting to get the picture. And then one way or the other, to complete the story, she gets to hospital. Discharged a few days later, she is seen by community nurses, is given a falls clinic appointment and the saga goes on. They’re all different providers, fractured, fragmented, with different IT systems and different referral forms. And what will competition bring? More providers, phone numbers, IT systems, etc.

A few days back, I tweeted an idea that out-of-hours (OOH) services should be run by the local acute trust? Could it work? One provider running emergency, or unscheduled care, in and out-of-hours. It could result in over investigation by those ‘clever specialists’, but then the trust could employ or contract GPs to deliver some of the service.

Why have another provider run it with little or no links or access to specialist clinics when needed? In 2004, primary care renegotiated their contracts to ensure their high workload during the day was adequately recognised. Nothing wrong with that except that it blew a hole in OOH care. I don’t care about who shows me what statistics, my personal experience with OOH when my little one was unwell was appalling – there was far better care in my local hospital.

So why not run OOH via acute trusts? One provider, minimal fragmentation and if one gets to the world of finances, revenue for trusts to help them keep existing services rather than losing money to yet another provider.

Locally, a new provider won our OOH. Within seven days of them winning the new contract, as the local clinical director of diabetes, I emailed them offering support for any patients with diabetes who may need support OOH; I was eager to explore options, see what we could do to avoid admissions. After an initial “Oh yes, that would be fabulous”, I heard no more. I see plenty of admissions which I know could have prevented by offering next day slots or through education or advice.

If the local acute trust ran this service, I know for a fact they would have access to my clinic slots or a chance to speak to someone as to whether the admission could be provided. Does every patient with a hypo or blood sugar more than 20 need to be admitted? No they don’t.

Now wouldn’t it be nice for that elderly lady to have one point of contact, one phone number stuck to her fridge, that  she could just call when she was frightened; one person who could reassure her, visit her and organise a specialist or GP review if needed.

If we are moving to a culture whereby chronic disease, quite rightly, is going to be managed more in a primary care setting, then by the same token acute care should be held primarily by the local acute trusts? Once we get past the problems, then a generous amount of innovative commissioning, a dollop of will to “make it happen” with a generous sprinkling of mutual trust between primary and specialist care and, you know what, you may just have a gourmet dish.

It’s worth a try.

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6 Responses to “Acute trusts should take over out-of-hours care”

  1. Anon says:

    I am a hospital consultant. Other services are expanding except for Endocrinology and Diabetes. 2 is enough for a catchment of 450,000. They keep on saying that they need more but when we were told by the managers that one of my ‘diabetes consultants’ had arranged 7 follow-ups appointments on a patient that ‘DNAed’; we realised 2 was more than enough. In fact, we don’t really need anymore diabetologist in the hospital. We can make them run the OOH. Most are already diverting their interest away from their specialty once they get appointed.

  2. Partha says:

    I agree- and you opinion is perhaps formed by your local experience? To a catchment area of approx 700,000, we have 3.6 WTE Consultant- which is more than enough- and that’s inclusive of general medicine work and endocrinology.
    If anything, if there is to be an “expansion” then it needs to be within community providers, not acute trusts. Its a debate whether that “expansion” should involve side ways move to the community- as we have done

  3. Partha says:

    To Anon, this is the second blog where your comments haven’t been about the blog but about diabetologists. Happy to engage in a debate about their role but difficult to do so with “Anon”- perhaps a case where the GMC guidance as regards anonymity on social media is relevant?

    Either way, always happy to discuss further- do bear in mind that all diabetologists are not the same or work to the same ethos.

    Regards

  4. Anon says:

    Oh dear using GMC guidance to silent a whistleblower. Is it a surprise why we have the mid- staffordshires debacle? Everytime a fact is made, you have clinical leads, clinical directors and medical directors wanting to silent them. I was offered a clinical director post but kindly declined as I don’t think I can keep silent about these sort of things.

  5. Partha says:

    Not sure how having an opinion about a diabetes specialist is “whistleblowing”. Anyhow, view respectfully disagreed with. Happy to have a debate about blog topic (or even role of diabetologist) as and when.

    As regards “fact”, yours is one based on local knowledge- which I also agree with- is not correct. All I am saying is that the NHS is a vast organisation, 1 hospital cannot be representative of the whole diabetes community. And yes, diabetologists do not do themselves favour sometimes…which is what we are trying to change, hopefully, locally.

  6. Tom Hyde says:

    Our Acute Trust has taken over community services and this seems a logical way to join up services especially as details are available on PAS will look into this thanks Partha

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