Leading change

Advanced Nurse Practitioners (ANP) at the Primary Integrated Community Services (PICS) in Nottinghamshire have led the development and introduction of a new Acute Home Visiting Service to ensure timely assessment and support for vulnerable patients. The service is preventing hospital admissions, improving patient experience and has led to better use of resources.

Where to look

Housebound patients (in residential care or their own homes) are at higher risk of deteriorating health and hospital admissions. The importance of early triage of requests for a GP home visit to enable prioritisation was highlighted in the NHS England Patient Safety Alert (2016).

However, home visits take time and GPs have to fit them around other clinical commitments. This has meant that patients unable to attend their surgery could experience a delayed holistic assessment of their needs. The ANPs recognised that this can lead to inequalities and unwarranted variation in the delivery of timely care.

What to change

PICS is a GP-owned NHS provider of community services. In Nottinghamshire, GP shortages have led to challenging workloads. Home visits were often carried out in the middle or after surgery, reducing the potential to mobilise community services to support safe case management. Smaller practices in particular struggled with on-the-day peaks in demand for home visits.

The NHS England ‘Addressing Ambulance Handover Delays’ letter asks that earlier GP visits are not all left until after morning surgery, to reduce the resulting surge in ambulance conveyances.

The solution in the Newark area has been to commission an Acute Home Visiting Service (AHVS), developed and led by Advanced Nurse Practitioners (ANPs).

How to change

With input from an ANP and local GPs, Newark and Sherwood Clinical Commissioning Group (CCG) provided a brief specification of the service required – a same-day response for seven practices in and around Newark for a comprehensive, holistic assessment of patients’ acute needs.

ANPs then produced a more detailed service description with a comprehensive evaluation mechanism as part of this. They worked closely with administration and IT colleagues to develop a system for managing referrals through a call centre, devising a template to document consultations and extract evaluation data. The team attended GP practice meetings and produced marketing materials to promote the new service.

The AHVS clinical team consists of ANPs and an Emergency Care Practitioner. The clinicians have advanced skills in clinical assessment and the ANPs are prescribers. Between them they have experience across A&E, Out of Hours, the ambulance service, community nursing and specialist respiratory nursing.

They are supported by administrators and a management team which includes GPs, a Nurse Operations Manager and Business Managers. There is also clinical supervision from a GP and strategic direction from the CCG and Newark GP Federation.

The new service encourages GPs to triage patients as early in the day as possible, enabling an AHVS visit based on the clinical need. ‘Urgent’ patients are seen within two hours and all patients receive a same-day visit.

Adding value

The ANPs produce a monthly report detailing service progress and activity data for the CCG and GP Federation.

Better outcomes

• The service averted 66 admissions in August 2017. CCG figures show a significant reduction in admissions in the area this service is provided, compared to localities without it.
• Patient reviews are timelier, there is quicker access to acute medication and earlier referrals to community services for support at home.

Better experience

• A survey demonstrated high patient satisfaction: “The Nurse was very patient with me because I cannot hear well. She took her time to find out what was wrong with me and arranged carers to come and assess me further. Her level of care was excellent”.
• GP feedback about the service has been very positive: “This is the best development that primary care has seen for years”.

Better use of resources

• The service is supporting the prevention agenda and giving GPs more time to focus on visits involving complex or end-of-life care.
• Previously, when a patient was classed as urgent and the GP was in clinic, an ambulance may have been called – leading to a potentially unnecessary hospital admission. The new service has reduced that risk.
• Prompt AHVS visits reduce the number of patients arriving at hospital at the end of the working day.

As well as closely monitoring activity data, the service is also undertaking audits of documentation, prescribing practice and a survey of care home managers.

Challenges and lessons learnt for implementation

• Experience has been invaluable. The broad range of skills available including service development, management and experience in commissioning enabled the team to lead the development of the service as well as deliver it. One of the AHVS ANPs has worked in similar services elsewhere, which was a great help in setting up the Newark service.
• One of the biggest challenges has been working with the CCG to agree realistic targets about the number of visits that can be undertaken per day, given the geographical distribution of Newark practices and the need to provide high quality, holistic clinical care.

Find out more

For more information contact:

• Hazel Firmin, Advanced Nurse Practitioner, h.firmin@nhs.net