Evaluation of winter pressures on general practice in Manchester: a cross-sectional analysis of nine GP practices.

BACKGROUND: The Nuffield Trust's report on NHS winter pressures highlights a lack of data for primary care, with a consequential focus on secondary care. An increase in data is required on the scale of the winter demand on primary care, so the need for investment in this area can be clearly seen. AIM: To quantify seasonal variation in workload in primary and secondary care. DESIGN & SETTING: Analysis of data for nine GP practices in Greater Manchester with a patient population of 75 421. METHOD: Descriptive and comparative analyses were performed for winter and summer periods in 2018-2019. Data were obtained from the North of England Clinical Support Unit (NECSU) via the Rapid Actionable Insight Driving Reform (RAIDR) toolkit, and EMIS Enterprise clinical audit tools. RESULTS: Accident and emergency (A&E) attendances increased by 4% (P = 0.035) during winter with no difference in the number of hospital admissions (P = 0.668). The number of problems (defined as separate diagnoses or causes for a GP consultation, for example, chest infection or medication request) seen in general practice increased by 61% (P<0.001) in winter compared to summer, as did the number of GP consultations, which was also 61% (P<0.001). Respiratory diagnoses saw the greatest seasonal variation accounting for 10% in winter compared with 4% in summer (P<0.001). Self-referral accounted for 66% of all A&E attendance and increased by 16% in winter. GP referral accounted for 7% in winter and 6% in summer (P = 0.002). CONCLUSION: General practice observed a greater seasonal increase in presenting patients compared with secondary care. Any winter pressures strategy should target both respiratory illness and patients who self-refer to A&E. Transferring 50% of self-referrals in Manchester to GP appointments would achieve a £2.3 million cost saving. Increasing provision in primary care requires funding and increased appointments, but more importantly improved patient opportunities to easily access timely advice and assistance.

Improving access to clinical guidance: redevelopment of a junior doctor intranet page.

Junior doctors frequently rely on electronic access to clinical guidelines to inform assessment and management, particularly whilst on-call and occasionally during emergencies. Difficulties in locating and accessing up to date guidance from different hospital intranet sites can lead to delays or errors in patient management. We used a focus group and email feedback to redesign an intranet site for junior doctors which logically organised the documents which doctors said they needed access to in one readily accessible location. A quality improvement project was carried out over six months, testing two iterations of the new junior doctors' intranet site before a third version was launched and evaluated. Their performance was measured by the number of mouse clicks and the time required for doctors to find a representative subset of five guidelines, and revisions were made at each cycle based on feedback from doctors and stakeholders. Cumulatively, we demonstrated a decrease in the total number of clicks required to access the sample of guidelines from 18 to 12 clicks, a corresponding decrease in the time required to access the sample of guidelines from 130 seconds to 22 seconds, and an increase in user satisfaction. We maintained one-click access to emergency guidance. In conclusion, we have developed and implemented an electronic resource for junior doctors which provides more immediate access to both emergency and non-emergency clinical guidance. To ensure the resource remains up to date, it will be maintained by Foundation Programme representatives at our hospital on a rolling basis.

Improving the quality of weekend handover at Yeovil District Hospital.

"Handover of care is one of the most perilous procedures in medicine" (British Medical Association, Safe Handover, Safe Patients). The system in place for weekend handover at YDH was deemed disorganised, unstructured and frequently missing key pieces of information, leaving the on-call Foundation Year 1 (FY1) doctor with only vague jobs and management plans. Baseline surveys demonstrated that junior doctors felt the system was inadequate, potentially compromised patient safety and increased their stress levels. In order to improve this problem a structured weekend handover proforma was created, comparable with the "Out of hours handover record keeping standards: template" from the Royal College of Physicians. This was made readily accessible on the local intranet. Education sessions were organised for the FY1 and FY2 doctors. The impact of the newly introduced proforma was measured using feedback surveys each week from the FY1 on ward cover for six months. A further change implemented was the introduction of a Friday Ward Round proforma. The aim was to reduce the time required to review notes by the on-call doctor, to minimise avoidable weekend jobs and to improve compliance with the management plans. The results demonstrated 100% compliance with the new proformas. There were notable improvements in the presence of a plan (37.5% to 91.7%, max. 100%), a minimum of two patient identifiers (68.8% to 100%) and relevant background information (62.5% to 100%). Qualitative data showed a much higher level of satisfaction with the new system. Future plans include rolling out electronic handover to improve problems such as illegible handwriting and missing data (enable 'compulsory' fields), and also for this system to be implemented Trust-wide.

Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors.

Junior doctors commonly make mistakes which may compromise patient safety. Despite the recent push by the NHS to encourage a "no blame" culture, mistakes are still viewed as shameful, embarrassing and demoralising events. The current model for learning from mistakes means that junior doctors only learn from their own errors. A survey was designed by the author for all the Foundation Year 1 doctors (FY1s) at Yeovil District Hospital to understand better the culture surrounding mistakes, and the types of mistakes that were being made. Using the results of the survey and the support of senior staff, a "Near misses" session has been introduced for FY1s once a month at which mistakes that have been made are discussed, with a consultant present to facilitate the proceedings. The aims of these sessions are to promote a culture of no blame, feedback information to clinical governance, and share learning experiences. 100% of the FY1s had made a mistake that could compromise patient safety. 63% discussed their mistakes with colleagues, 44% with seniors, and only 13% with their educational supervisor. Barriers to discussing mistakes included shame, embarrassment, fear of judgement, and unapproachable seniors. 94% thought a "Near misses" session would be useful. After the third session 100% of the FY1s agreed that the sessions were useful; 53% had changed their practice as a result of something they learned at the sessions. After discussing errors as a group we have worked with the clinical governance department, enacting strategies to avoid repetition of mistakes. Feedback from the junior doctors has been overwhelmingly positive and we have found these sessions to be a simple, inexpensive, and popular solution to cultural change in our organisation.