1. Establishing a GP in A/E Service Dr Laura Ryan Unscheduled Care Clinical Lead (Primary Care) Dr Sheena MacDonald Associate Medical Director Primary Care NHS Borders

2. Outline  Introduction  Background  Milestones  Challenges  Things to think about/planning

3. Introduction  Other existing models-one size doesn’t fit all  Generic lessons can be learned  National Drivers eg T10  ‘blurring of lines between secondary and primary care’

4. Background  NHS Borders 113,000 population  Semi rural and rural with remote areas  Cross Border coverage  DGH approx 300 beds  Community Hospitals 135 beds

5. Background  OOH GP service Borders Emergency Care Service (BECS)  11.55 wte GP  Salaried Service (77% as of 8/2010)  One GP overnight with two OOH Nurses  PCEC daily in three Community Hospitals with MIU  GPs provide medical cover in MIU

6. Milestone 1 – New GMS 2004  Referral pathways from A/E to BECS .e.g. Gynaecology patients  Nurse Triage – When BECS doctor on duty  A woman presenting with a gynaecological condition should be referred to the BECS doctor.  Exception:  Any woman presenting with a gynaecological condition that is likely to require in-patient care or resuscitation should be referred directly to the SHO on-call for Gynaecology.

7. Milestone 2 - Unscheduled Care Collaborative  Local PDSA to look at Flow 1  50 % breaches in Flow 1 group  Orthopaedic junior/GP/Associate Specialist Orthopaedics /ENP  GP most effective at reducing waiting times

8. Milestone 3- First GP A/E Feb 2007  13.00 – 21.00  Subsequent capacity analysis  Shift better moved to 10.00 – 18.00  Flow 1 100% compliant within months

9. Milestone 4 - Clarity regarding patient groups  RCGP Curriculum Competencies  Placed in Triage  Consultant appointment November 2008

10. Results 7 days a week 10.00 – 18.00 Total attendances at times when GP available Percentage seen by GPs (ED or BECS) Percentage seen in ED by GP Percentage seen by OOH service 95918.39 %13.89 %4.50%

11. Three Saturdays in May between 10-18.00 Total attendanc es at times when GP available % seen by GP (ED or BECS) % seen in ED by GP % seen by OOH service 11225% %24.10 %1%

12. Three Saturdays in May from 18.00 – 08.00 Total attendances at times when GP available Percentage seen by GP (ED or BECS) Percentage seen in ED by GP Percentage seen by OOH service 10419.23%1.92%17.30%

13. Challenges  Accountability/professional management  Personality and change management  Training and development  Appraisal Revalidation-for those GPs who work only in this role

14. What sort of Doctor?  Dedicated pool of ‘speciality doctors’ or  Interaction with OOH GP service or  Ad hoc sessional doctors

15. Reflections for the future  Planning event  Stakeholders  Managers  Funding  Appraisal  Potential workload implications for OOH services