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Basingstoke and North Hampshire Doctors On Call (HANTSDOC)The development of a new emergency health delivery service in Southern England. |
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The hog (or wild boar) is a traditional Hampshire symbol. They still populate the New Forest, the ancient royal hunting ground, usually without stethoscope and doctor's bag. |
In 1995, the UK Government was under pressure to address the increasing workload
of the country's General Practitioners (GPs) who provide primary medical
care to UK citizens. Previous actions, such as the introduction of the Patients'
Charter, had raised patient expectations, and these were further exacerbated
by a changing social environment, such as the move to a 24 hour society.
GPs are self employed and are contractually bound to provide 24 hour cover,
365 days a year. Whilst many GPs worked in partnerships (typically with about
5 other GPs), where they could share duties in the evenings or weekends,
many still worked alone. These GPs could only resort to using a commercial
deputising service, although they were still legally responsible to
their patients.
| The Government solution was to provide an additional
allowance so that all GPs could sub-contract out-of-hours calls to 3rd parties
or set up their own scheme. The form of these schemes was not prescriptive
and they varied in their legal and organisational structures, and in the
services provided. See box.
At the same time the Government changed some of the legal requirements of the NHS 1947 Act. Patients could no longer demand a home visit and doctors could delegate to qualified deputising doctors would become legally responsible for their own actions. Health Authorities acted as the Government's agent and were required to vet proposals to ensure value for money, suitability and viability of any proposals. |
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| Some were run as true co-operatives, with all their
allowances entered into the common pool and with duty rotas equally shared.
At the other end of the spectrum, were those established as commercial
operations, where GPs could freely purchase individual sessions and equally
freely choose which sessions to work, indeed whether to work any sessions
at all. In this scenario, session fees and wages vary according to supply
and demand.
Out-of-Hours schemes also vary in their service provisions. These include the hours covered, from evenings, nights, and weekends; the medical coverage, from telephone advise, home visits or the provision of a central walk-in clinic complete with pharmacy. Naturally, the infrastructure also varied, from a doctor at the end of a telephone line, to fully staffed call centres with high levels of IT and sophisticated call handling switches. Transport varied from the doctors own cars through to pool cars with trained drivers, equipped with emergency equipment, drugs, green flashing lights and sirens, and PCs and wireless telecommunications systems. |
| In December 1995 a group of 6 GPs in the Basingstoke area of
North Hampshire established a small committee to define the requirements,
benefits and feasibility of an out of hours (OOH) scheme for the area. The
6 GPs had identified about 80 GPs in 23 medical practices in the area who
might be willing to participate.
Owing to the short time limits set by the Government there was an urgent need to respond. On the other hand it was important to have a well constructed proposal that would meet the diverse requirement of the GPs, would prove to be viable, and would be ratified by the local Health Authority (HA). All GPs value their independence and are usually wary of the competencies of other unknown GPs. Further many of the GPs in the larger medical practices already have some form of out-of-hours scheme. |
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Map of England & Wales showing Hampshire and the HANTSDOC area based on Basingstoke. |
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| The committee retained Managing Change to first undertake a feasibility study and to help make the initial proposals to the HA. This was later followed by assistance with the detailed proposals and then with business design and an assessment of an out-sourcing service supplier. Each phase lasted approximately 1 month. | |
Managing Change conducted interviews with representatives of the 23 medical practices to identify their needs, expectations and concerns. Existing national pilot schemes were reviewed and 5 strategic options identified. These ranged from pure co-operative through to commercial like services expanding to an ever wider geographical coverage. Managing Change prepared an outline proposal including various scenarios of costs and expected charges to GPs. With assistance from Managing Change (including all the OHP overheads) the proposals were presented to the all GPs and to the Health Commission, and unanimous approval obtained to proceed to next phase.
6 teams of GPs were established to define requirements for various aspects including legal, finance, clinical, premises, transport, and information technology. Managing Change provided overall project management. With the IT team, Managing Change defined IT requirements and then assessed systems and technology products in the market place should the co-operative undertake the whole operation by itself. Technologies included call handling and dispatch systems, including telephony switches, mobile data and voice systems, and administrative systems for roster scheduling and logging, financial systems for general accounting, doctor and employee payments, invoicing, management reporting.
Business simulation models helped the committee to predict likely costs,
income, resource capacity, and that key performance targets could be met.
Both in-house and out-sourcing options were assessed.
Managing Change then produced a comprehensive Detailed Proposal and a second presentation to all the GPs. The report was entered into the joint Glaxo/Welcome, BMA competition alongside 70 other entries. It gained a Highly Commended award.
Following approval to implement, Managing Change introduced the teams to business and process modelling techniques and then worked with the teams to help them defined the processes in detail. Using the detailed process models, Managing Change then liaised with a number of potential out-sourcing suppliers. Berkshire Ambulance Trust (BAT) was selected as a preferred supplier, subject to contract. Managing Change then worked closely with BAT to define clear responsibilities, interfaces and performance requirements. Various aspects of the supplier's service were then verified. Finally, Managing Change drew up an initial contract based on the CCTA model contract.
Click to view the Business and Support Process Models
The chosen design was for BAT to provide call handing and dispatch, cars and drivers and IT links to the central base and to the cars. The Management Committee formed a company limited by guarantee, and this was to directly provide the central premises for walk-in patients, receptionists, financial accounting, and the day-to-day management. Regular meetings with BAT would monitor performance standards and co-ordinate any future operational changes. The aim was for automated, integrated and seamless processes that provided a high quality efficient service at an affordable price.
Over 70 GPs initially joined the scheme and a further 10, including some from outside the initial operating area, joined the scheme after another 6 months.
| During a 6 week hectic period BAT obtained and fitted the cars and recruited
and trained the call handlers and drivers. Driver's training included first
aid and good driving practice. It also made major upgrades to its telephone
switch, installed terminals in the central premises, and adapted its call
handling and dispatch system. The Management Committee acquired, adapted
and decorated its premises and recruited and trained the receptionists. It
also implemented the necessary administrative processes, defined codes of
practice, the co-operatives rules, and also its legal charter. The first
rota was established and doctors, receptionists and drivers trained in the
various procedures and use of the equipment.
Last but not least, publicity ensured patients and medical centres were reassured about the new service and appraised of any process changes. |
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One of the HantsDOC cars fitted with green flashing lights and emblazened
with the HantsDOC logo of the |
On 1st June 1996 HANTSDOC went live. The co-operative provides cover for 155,000 patients from 7 p.m. to 8 a.m. Mondays to Fridays, and all hours at the weekend. Patients needing advice make a local telephone call to BAT, or in some instances are directly transferred when they call their usual medical centre. Call handlers note the details and using a strict protocol determine the priority of the situation. Calls then enter a priority queue and a duty doctor in the central premises can review each case and determine whether a house call is needed, or they can call the patient to discuss the situation, and perhaps arrange a visit to the centre. Where a house call is required, then the request enters a second priority queue and is dispatched by a call handler to an appropriate vehicle. Depending on the time of day or night, there are either one or two cars available, each complete with doctor and medical equipment.
Prior to each month participating doctors select a minimum number of sessions with session fees varying according to how unsociable are the hours for that session. If there are unfilled sessions, then the rota manager can mandate doctors filled a session. At the end of the month, each medical centre receives an invoice in respect of their patients who have been treated by HANTSDOC. Charges vary according to time of day or night and the type of service provided (telephone consultation, patient seen at the central premises or house visit).
For the Medical Director's assessment of Managing Change's performance, click on the link.
HANTSDOC membership has increased to 82 doctors and a number of other out of hours schemes have approached HANTSDOC to explore possible provision of services. The General Manager produces a wide range of call and financial statistics showing a rolling comparison with the previous 12 month period. This analysis is performed on raw data downloaded from the RBAT mainframe system. Forward planning included cash flow and profitability forecasts. Service times are well within the GMC guidelines and patient surveys are recording a very high level of satisfaction.
Technology improvements have included use of call line identification to capture caller's telephone numbers and address. This then drives digital mapping system to display the house location on a map. The mobile short message system with priority transmission is being tested and this will open the way for the in-car printing of calls.
HANTSDOC now have their own web site.
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