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Dewar Group:

Bench Testing and Risk Management of Remote Practice Models:

Background Paper, Spreadsheet and Mind Map.

Introduction and background

Proposals to change existing models of service delivery for Remote Primary Care are known to cause considerable concern in remote communities and professionals delivering existing models of care.

It is evident from public discussions that there is a limited understanding of the breadth and depth of the modern GP role in healthcare, with a focus on ambulance emergencies.

In order to facilitate professional and public discussion there is a need to ‘bench test’ and ‘stress test’ proposed models for remote medical primary care with current practitioners and community groups to gauge the consensus on risk management. ‘Stress testing’ could include variables such as weather, wider team response compromised or practice team compromised.

Risk management requires an understanding of likelihood and consequence of clinical events with particular reference to a ‘delayed response’.

Accurate prevalence data is available from group practices. The Practice Team Information scheme run by Information Services Division can supply reliable prevalence data for bench testing.

The accompanying ‘Mind Map’ sets out the issue of rural fragility and the influences on the provision of remote medical practice.

Types of GP Care

The overriding principle of modern NHS GP care is ‘caring with science’ from ‘cradle to grave’ with particular attention to holism for individuals and a fixed list system of patient registration for care provision.

There is clearly much blurring of categories but broadly primary medical care splits into the following:

Episodic Medical Care:

  1. Diagnosis and treatment requested by patient, for example:
  2. Back pain
  3. Exacerbation of asthma
  4. Mental health problems
  5. Alcohol and drug problems
  6. Palliative care
  1. New symptoms such as:
  2. Abdominal pain
  3. Chest pain
  4. Skin rash

Long term condition management:

  1. Call and recall for patient groups with known long term conditions

such as:

  1. Asthma
  2. Diabetes
  3. Epilepsy
  4. Mental Health problems etc
  1. Repeat prescribing and monitoring of disease treatments

Emergency care in hours and out of hours:

  1. Triage response by Scottish Ambulance Service or GP,

Category 1:

  1. Chest pain
  2. Stroke
  3. Collapse
  4. Trauma

Category 2:

  1. Child with fever
  2. Adult with abdominal pain
  3. Frail elderly
  4. Changing condition
  5. Mental health crisis

Category 3:

  1. Patient view of emergency but suitable for routine care

Anticipated workload in Remote Practice:

The prevalence from a group practice population can be made to estimate likelihood of health problems in small populations by reducing data from bigger practices to smaller populations.

However, somebody with a rare condition may move to an Island or somebody with moderately common conditions such as insulin dependant diabetes might happen to live on an Island despite the prevalence data suggesting this is unlikely.

The prevalence of care episodes and requirements to respond could be categorised into:

Daily

Weekly

Monthly

Annually

Every 5 years

Every 10 years

Risk Management:

The consequences of a ‘delayed response’ for care, assessment or treatment can be categorised as follows in bench stress testing:

Outcome 1 – Minimal serious impact on the patient or their illness

Outcome 2 – Permanent disability/reduced outcome/longer term more expenses to NHS

Outcome 3 – Death, litigation, complaint, adverse publicity.

Bench Testing Spreadsheet:

1st Column ‘Scenario’Describes the scenario

2nd Column‘Category 1,2 or 3’Triage response category which would be allocated byScottish Ambulance Service or GP Triage

3rd Column‘Likely prevalence..’ The estimated likely prevalence for the location is given toyou

Your Planned Normal Response:

4th Column‘Provider Response’In the ‘provider response’ we need a short summary of your response

The next set of columns, under the yellow banner, requires yes or no answers as to whether you would use the following to deal with the patient from the list:

Boat

SAS 1st Responder

SAS Paramedic

SAS Helicopter

Community Nurse Same Day

Community Nurse within 48hrs

Pharmacy

Patient to attend within 48hrs

Use of Network Vision Record

Use of Video Conferencing

Use of Team Telephone Conferencing

Use of Skype or Similar to Patient

Use of a Telecare Home Monitor

Belford Admission

Community Care/Social Work Response within 24hrs, Community Care/Social Work Response within 7 days

GP Home Visit same day

GP Home Visit within 48hrs

Patient to attend the Practice that day

The Patient Outcome with your normal response, in other words ‘the problem is sorted and a plan is in place’.

Then you choose one of three likely outcomes for each case for your model response.

Assuming everything works to plan will it be?:

on 90% of occasions,

less than 50% of occasions or will it be

less than 10% of occasions?.

The Prevalence of care episodes and requirements to respond can be categorised into:

Daily

Weekly

Monthly

Annually

every 5 years

every 10 years

This column asks you to estimate the case prevalence from your own experience. You can add any comments in the next column.

Stress Testing – Bad Weather:

The next set of columns asks you to consider adverse weather and the ferries being off for 3 days or roads blocked. How would you change your provider response and what is your estimate of achieving ‘problem sorted and a plan’ based on the previous choice of:

90% of occasions

less than 50% of occasions or an

less than 10% of occasions.

Give your estimated annual prevalence of such bad weather.

Stress Testing – Another Service Can’t Help:

In the next stress testing response assume that your key co-responder is unable to help.How you would change your response? Despite the other service not helping on this occasion, could you manage to get the problem sorted and a plan in place?

Again, would this be on 90% of occasions, less than 50% of occasions or on less than 10% of occasions?

Estimate how often you anticipate you could be ‘let down’ because of circumstance (e.g. ambulances out of area).

Stress Testing – You Don’t Have Enough Staff:

In the third stress testing scenario you have not enough GPs to provide your usual response due to sickness or recruitment. Again, work through the change in your response and estimate how close you could get to ‘problem sorted and a plan’ on 90% of occasions, less than 50% of occasions or on less than 10% of occasions.

Again estimate how often in a year you might be compromised by lack of available staff.

Potential Impact of Any Adverse Outcome:

Please allocate an adverse outcome score for the case scenario and location.

Outcome 1:Minimal serious impact on the patient or their illness

Outcome 2:Permanent disability/reduced illness outcome/longer term more expense to NHS

Outcome 3:Death/litigation/complaint/adverse publicity.

Usage and Development of this Bench Testing Model:

This paper and spreadsheet was developed by:

Dr James Douglas

Tweeddale Medical Practice

FortWilliam

PH33 7AQ

The accompanying ‘Mind Map’ on rural fragility was developed by:

Dr Miles Mack

Dingwall Health Centre

Dingwall

They have been part of a historical collaboration which has researched and celebrated the ‘Dewar Report’ if 1912.

Both are copyright/intellectual property of Dr Douglas and Dr Mack as part of the Dewar Group. However, both welcome wider dissemination of the concepts with acknowledgement as a means to support and develop remote practice in Scotland ‘in the spirit of Dewar’.

Both welcome suggestions and feedback for further development of the ‘mind map’ and ‘bench testing’ of service provision.

Dr James DouglasDr Miles Mack

On behalf of the Dewar Group

14.01.13

JDMD/HC/08.01.12

Updated 14.01.13