Patient and Public Involvement Consultation Event Report

To review a proposal for a Primary Care Intervention around Multidisciplinary Teams and their role in reducing unscheduled episodes of care

Henry Smithson, Brigitte Colwell and

Joanne Thompson

August 2013

ISBN 978-0-9571207-2-3

Published by the Academic Unit of Primary Medical Care (AUPMC), University of Sheffield

Principal Investigator

Dr Henry Smithson, Deputy Head of Department, Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU

Patient and Public Involvement Team

Brigitte Colwell, Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU

Joanne Thompson, Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU

Other members of the Team Trial team

Dr Judith Cohen, Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA

Professor Richard Baker, OBE Department of Health Sciences, University of Leicester 22-28 Princess Road West, Leicester LE1 6TP

Professor Stuart Parker, Institute for Aging and Health, University of Newcastle, Newcastle upon

Tyne

Professor Michael Campbell, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA

Professor Nigel Mathers, Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU Dr

Nicholas Latimer, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA

Dr Lorna Warren, University of Sheffield, Department of Sociological Studies, Elmfield, Northumberland Road
Sheffield S10 2TU

Mrs Alison Kirk, Holme and Bubwith Medical Group, Highfield RdBubwith, Selby YO8 6LY

Ms Rosalind Eve, Age UK Sheffield, 44 Castle Square, Sheffield

Ms Jo Cooke, CLAHRC SY, Sheffield Teaching Hospitals, 11 Broomfield Road, Sheffield S10 2SE

Introduction

Increasing numbers of elderly patients with multi-morbidity are being admitted to hospital as emergencies [1,2], with the rate of hospital admissions for high-risk older patients up to 20 times greater than the general population[3]. A number of NHS initiatives have been introduced to address the problem of rising rates of episodes of unscheduled care (EUC) and emergency admissions, including regular incentivised multi-disciplinary team (MDT) meetings within general practices. NHS Sheffield has been working on the risk stratification of older people initially focusing on developing risk registers for use in practices,[4] which form the basis for the identification of ‘high risk’ patients. These patients can then be discussed at the MDT meetings. A recent evaluation of a single practice MDT, representing primary, secondary & social care, identified and case managed ‘high risk’ patients in the community, showed a slowing in the increase of elderly emergency admissions.[5]

This study will examine the effectiveness of components of practice MDTs on reducing EUC for targeted vulnerable elderly in general practice. Despite a lack of evidence, the NHS is incentivising practices to hold MDT but with no standard format or composition. Recent reviews suggest that targeting community interventions in this way may result in fewer EUC, and that continuity of care by the GP appears to be associated with a low risk of admission. Integration of health & social care and primary and secondary care is encouraged (NHSE & HWB) but not universal. By using the incentivised MDT as a starting point and adding social care and/or secondary care components to teams, the study will answer the question

‘Does the inclusion of a social worker and or geriatrician as members of a regular proactive practice based MDT reduce episodes of unscheduled care (EUC)?’ Unnecessary admission of older people puts patients at risk of confusion, infections and loss of independence, is expensive for the NHS but is still the intervention of ‘last resort’ due to lack of plans of care and timely services close to home.

Unscheduled admissions are under increasing scrutiny, and many of these admissions could be avoided by better primary care.[6] This crisis management is of no benefit to the patient or carers. A proactive approach to developing active plans through multidisciplinary assessment could result in less social disruption, fewer unnecessary investigations and fewer episodes of unscheduled care including emergency admissions.

However, the team believed it was essential to elicit the views and opinions from both representatives of the patient population who may be the recipients of this type of intervention in the future, and staff from general practice who may be responsible for administering and delivering the intervention. In order to do this, we held a PPI event on a Thursday afternoon, where we discussed the bid in detail and held two focus groups to elicit the participants’ views and opinions.

Method

Patients were identified as potential participants in the PPI event by two Sheffield GPs (Drs Henry Smithson and Alastair Bradley) and two practice managers, using the following criteria.

· 65 years of age or over

· Suffering from a long term condition or

· Caring for someone with a long term condition

Patients who fitted the criteria were provided with information about the event, particularly the purpose of the event and the role of various participants.

Members of the public who work in practices as receptionists, managers or nurses were recruited from urban and rural practices across Yorkshire.

Patient Group

The patient group consisted of three married couples, six participants in total. They were all aged 65 years of over, and at least one of each couple had one or more long term condition.

Practice group

The practice group consisted of five participants; one GP, two practice managers, one assistant practice manager and one practice nurse.

The PPI event was held during the afternoon of Thursday 29 August 2013, at the Academic Unit of Primary Medical Care (AUPMC), Samuel Fox House, NGH, Sheffield. Henry Smithson gave a short presentation about the research bid before breaking off into two focus groups. Joanne Thompson facilitated the patient group, and Brigitte Colwell facilitated the practice group.

The facilitators, Joanne Thompson and Brigitte Colwell, together with Henry Smithson, developed a question framework specific to each of the two groups. (See Appendices 1 and 2)

Contributions made by the Patient and Practice Groups

Patient Group

The key themes emerging from this group were:

· Prevention/avoiding admission to hospital

· Services/support to enable people to stay at home

Prevention/avoiding admission to hospital

Support was seen as an important factor around preventing or avoiding admission to hospital, particularly from family members, with a recognition that living alone, makes an individual more vulnerable to admission because of their home circumstances.

“I had a very bad fall, and I fractured me shoulder, and it were extremely painful, and they didn't keep me in coz there nothing they could do, they couldn't pin a plate in it or anything and the pain I went through for a week, I couldn't lie down, it were horrendous. Well nobody came to see me, it were all done on the phone weren't it….(P1[husband]) And this is the point I'm making, if I wasn't there, if [husband] lived solely on his own, what would the recommendation have been then?....(P2[wife]) Well I would've had to go into hospital wouldn't I. (P1[husband])” (P1 &P2)

The group also talked about the importance of managing their own care, with help from their GP or other health care professionals. One participant spoke of his experience of being called in for, what he describes as an ‘MOT’, from his GP.

“My own doctor has an excellent way, I've got to the age of 65, which wasn't yesterday and he said er, I think it's time we considered you for an MOT. He went through everything that he could go through and found that I'd got an eneurysm, it wasn't ready for surgery for then but within a matter of a month, or two or three months, it was but they found what was happening and I'm told, told, that normally you don't find out about them til it's too late, you've got seconds before they get you sorted so you can still survive.” (P3)

Another participant suggested that more could be done to help patients understand symptoms and what they could mean to help avoid admission to hospital.

“…one of the things that er, I think about is the matter of er, pain, a person having pain. Now what do we do, does the partner phone and think it's to go straight into hospital, or is there is some way that your partner can sort of, er I'm going to say this, er help you and calm you down, and what is the way that they could stop somebody from having pain? It doesn't always mean a heart attack, does it? It can be, er, and suddenly they're all rushed off into hospital and I think understanding pain, er, we should know more about it, er, what we should do.” (P5)

The participants agreed that previous experiences of care were an important factor when considering their views around admission to hospital, and their preference to receiving care at home.

The majority of the participants agreed that their experience of hospital care has been good.

“Well I've had 8 operations this year and I've got nothing but praise for them all,” (P3)

However, participants felt that the changes in nursing, the set-up of a ward and particularly about the workload can impact on care.

“I found that when I spent some time in hospital, this hospital in fact, when I say some time, about six months, um I noticed that the sisters desk, is no longer a sisters desk, it was a staff nurse, and most of them, most of the time, it was occupied by nurses, sitting there filling in reams and reams and reams of paper…they weren't nursing, they were er... Carrying out an academic exercise” (P3)

“The other thing that gives me a little bit of concern about, if you do go in hospital, is, when I was younger, when we were all younger, and you go in hospital and there was a sisters desk on the ward and she could see every bed, and if you were poorly, she'd be on, or the nurse would be on it like that, but now, you're in little bits where there's four people and they can't see you so unless you ring your bell, and if you ring your bell and they're too busy, they're short staffed now obviously, and if they're too busy, which is not really their fault, they don't get to you” (P4)

The participants felt that it was safer to receive their care at home, but again, felt this was dependent on the support received at home.

“But it's like this lady said, it's if you're on your own. I mean I feel safe enough because I've got my husband and he probably feels the same coz he's got me, and like this lady and her husband, but it's if you're on your own, like my mother was and she's totally blind, and I couldn't be there 24/7 er, and she had no help at all, she never got one social worker or anybody from the practice.” (P4)

Services/Support to enable patients to stay at home

The participants agreed that support from their GP surgery is necessary for patients to enable them to receive care at home rather than admission to hospital.

“But you're talking about, we're talking about putting support workers from your, from your doctors surgery to come and do that…you could have a support person coming, and I think everybody would rather be at home and have a support person come from your surgery to say are you alright, and just do a bit here and there.” (P4)

They also talked about the necessity for having some sort of plan in place to ensure that the right level of care is delivered.

“You can have a full care plan, and you can have it identified that you need this, you need this that…” (P2)

When talking about support, there was agreement amongst the participants that there would be some benefit to having a point of contact, perhaps in their GP practice or placed within the community, who they could speak to about any health concerns they might have, who could then advise them about who best to contact.

“If you felt that you could pick up a telephone to your surgery and say I'm feeling a little bit iffy here, you know, and if somebody could just come and talk to ya, and you could get this out and say well, I'm frightened it's this or, and they can give you support and say well, if you do so and so, and contact so and so…”(P4)

Practice group

The key themes emerging from this group were:

· Collaboration and integration

· Feasibility

· Triggers for emergency admission

Collaboration and integration