A Staffordshire GP explains why Clinical Hubs are vital to the future of primary and urgent care:
Urgent care is the term usually given to work that takes place in emergency departments (EDs), Out of Hours (OOH), minor injury units (MUI) and walk in centres (WIC).
Much urgent care occurs within in-hours primary care. Pressure caused by urgent care demands within in-hours primary care causes pressures within the whole urgent care system.
Rather than simply being a one sided effect there is an equilibrium. When the urgent care system is under pressure then primary care feels this.
A packed ED department leads to earlier discharges from the acute trusts. Increasingly sick and unstable patients are discharged into the community which results in more pressure on general practice to keep these patients safe and in their homes.
At the time of writing this blog GPs will soon be balloted on strike action, recruitment is extremely difficult and many GPs are retiring, leaving or emigrating. We need to reduce the pressure on primary care and the urgent care system.
The GP Five Year Forward View suggests ways to transform primary care into a more sustainable and attractive field. The move toward more integrated urgent care, enabled by the proposed clinical hub, will reduce demand within the urgent care system.
The clinical hub aims to provide timely, specialist advice to both patients and clinicians via a single point of access (111), 24 hours a day, 7 days a week. It will reduce the need for clinicians to make complex decisions in isolation and reduce inappropriate dispositions from 111 to primary care or the ED. The hub will offer advice from GPs, pharmacists, dental and mental health nurses and specialists. The clinical hub will be staffed centrally, virtually or a combination of both. It will be based in 999,111 or OOH centres.
How is this any different to the 111 service people currently have access to? In March 2016, there were 1.5million calls to 111, a third more than in March 2015, with just under one million callers being given advice to attend primary care. My question is this, if the clinical hubs were active, how many of these dispositions could have been avoided with clinical advice with or without a prescription sent electronically to a pharmacy?
For example, a patient with a history of migraines contacts 111 at 10pm with a classical exacerbation with no red flags. Over the counter analgesics are not helping. Prior to the clinical hub the disposition would either be to attend their own practice when they next open; attend an OOH centre or attend the ED. When the clinical hub is created then the 111 call handler could transfer the caller to a nurse practitioner, GP or another specialist who could take a brief history and provide advice and/or a prescription for the patient to collect from a designated pharmacy. The caller will have a more responsive patient journey and the practice wouldn’t need to see the patient.
Another example involves people who are vulnerable due to frailty and/or long term conditions. These people often have multiple contacts with primary care and other providers during an acute illness or exacerbation of their long term condition. They are often much more likely to be admitted. In more mature clinical hubs, practices will have the opportunity to share care plans with the hub operators. This would mean that vulnerable patients would be able to call 111 at the start of an acute illness or exacerbation, be transferred to the clinical hub and talk to a clinician who will already have their wishes documented and their individual urgent care plan.
To be successful, the clinical hub will need to be supported in both principle and practice by primary care and by GPs in particular. They will need to use the hub in order for it to fully develop to support primary care. They will need to promote the hub to patients and share care plans with their patients consent. GPs will need to either work physically within or virtually in these hubs.
Those already working in OOH centres will already be comfortable with providing telephone advice and treatment. For others this may require a further training.
For all GPs, the hub may provoke a cultural transformation where primary care is an integrated part of the urgent care system and not just the end point for patients leaving the system.
I am certain that clinical hubs are a vital tool to reduce pressure and release capacity within primary care. It is up to us, as GPs and other clinicians, to grasp this opportunity to transform primary care that is presented by the clinical hubs.
Dr Mark Williams is a GP in rural Staffordshire, a New Models of Care Clinical Associate and a Clinical Director for a mental health trust.
He grew up in Staffordshire, studied in Manchester and returned to Staffordshire to complete his studies and training.
Mark, who is married with two children, previously worked for the two Northern Staffordshire CCGs before leaving and then becoming a co-founder of a GP federation of 87 practices serving almost 500,000 patients.
He is driven by a desire to promote patient centred, clinician led and relationship based health care that benefits communities.