Diverting children from unnecessary hospital attendances in York

Key benefits and outcomes

• Reduction in unnecessary attendances to hospital for families with under-fives.
• 98 per cent of patients were able to be monitored on site and go home, without needing to go to A&E.  
• Creative use of trainee students and retired GPs to see the delivery of almost half a million vaccinations, enabling GPs and nurses to remain focused on providing frontline services from their clinics.
• Close working between primary care, the local authority and voluntary sector has brought together a health village that is part of the community, supports the local economy and is investing in the health and wellbeing of its population for the future.

What the organisation faced

In August 2020, six months into the pandemic, Nimbuscare, an at-scale provider of primary care, began to look at possible sites for the administration of health services on behalf of the population of York. The immediate push was for the delivery of a mass flu vaccination clinic for the city’s residents, with a view to giving COVID-19 vaccinations once they had been approved. The challenge was finding a site that was accessible, available and safe to use and mobilising a workforce to help support the running of the health hub.

What the organisation did

Nimbuscare’s ethos is to work collaboratively across the York area, and it wanted to deliver the service as a city partnership to improve the health and wellbeing of its local population.

Nimbuscare approached the local council and emergency resilience forum and secured a disused park and ride car park on the edge of the city. The site began the administration of vaccinations in October 2020 and a year later has delivered almost half a million vaccinations (COVID-19, flu and booster) at the site, underpinned by a workforce of 400 volunteers, retired GPs and trainees.

However, it was realised early on that it could be used for much more than just delivering vaccinations. In August 2021, GPs were seeing a large spike in A&E attendances (80 a day) for children under two with respiratory syncytial virus (RSV). Many of these children required a period of observation but did not necessarily need to go to A&E or stay on a ward.

Nimbuscare worked with GP practices and the chief paediatric nurse from York and Scarborough Teaching Hospitals NHS FT to look at what they could do differently.  Nimbuscare offered up space in the health village to establish a paediatric treatment hub, where GPs can refer children with respiratory problems. The service started on 1 October 2021, and children are seen by a paediatric nurse and doctor and monitored, rather than having to go to A&E. 

Results and benefits

• Reducing demand on A&E: The service started on 1 October 2021 and is currently being evaluated. It has been well used each day with children who would have potentially ended up in A&E. Out of the first 50 patients evaluated, 49 (98 per cent) were able to go home without a trip to hospital.
• Improving patient experience and education: Families are providing very positive feedback. The service is also using the opportunity to provide education and signposting to the parents, which helps manage anxiety and will hopefully help to prevent readmissions.
• Saving time and appointments for GPs: GPs no longer need to see the patients and can quickly refer into the service through the shared booking leger.
• Protecting clinician frontline time: By using trainee students (dentists and nurses) and retired GPs for the vaccination service, GPs and nurses can remain focused on providing frontline services from their clinics.
• Investing in future workforce: Nimbuscare has been developing a pathway for trainees, and during the pandemic it hosted dentistry students who were unable to get placements in practices due to COVID-19 restrictions.
• Community mobilisation: The use of the site has been collaborative from the outset, not just from the involvement of the council, but also the commitment of local businesses who have provided everything from the marquee and fencing round the site, to food and drink from the local supermarkets and cafes. It’s been a real community effort. There has also been significant voluntary support with 400 volunteers helping to assist people attending the site.

Overcoming obstacles

• Funding: In a cash-strapped system there was no funding for the service, so Nimbuscare committed to funding an eight-week pilot (investing in the building, equipment and GP staff) and the acute trust provided the specialist paediatric nurse resource. This meant that the service could be codesigned, clinically led and set up quickly to respond to demand.
• Getting the message out to GPs and referrers: As with any new pathway it can take time for people to hear about it. Electronic communications and word of mouth worked best.
• Formal commissioning: This has now happened and there is an APMS contract in place, which allows contracts with organisations other than general practitioners/partnerships of GPs to provide primary care services, with NHS funding now moving forward.
• Appropriate patients: During the initial few weeks the paediatric hub was set up for children under two with RSV symptoms. It was open 4pm to 10pm, and the child had to be referred in after seeing a GP. However, by the time the service opened the RSV surge had diminished, and they were getting fewer than ten cases a day. As the service was clinician led, they were quickly able to adapt the model and increase the range of conditions accepted. They moved the opening times to 2.30pm to 8.30pm, changed the referral criteria to under-fives who were experiencing respiratory problems, and accepted calls from 111 and GPs without the patient needing to be seen in the first instance.

Takeaway tips

• Build relationships between organisations, think beyond health boundaries and work towards shared objectives so you can provide at scale.
• Listen to clinicians and provider services, as they have the ability to think how services can be delivered innovatively.
• Develop a GP provider vehicle with enough scale to collaborate horizontally. It will also generate revenue streams and surplus that can be invested in innovative services without bureaucratic processes.
• The beauty of collaborative, integrated working means that providers can turn the quality improvement wheel quickly and broaden the scope to meet the need. 
• Sometimes it needs a leap of faith. This pilot allowed GPs to use GP money to reduce activity in the hospital, at a time when general practice was on its knees. As it evolved, the GPs didn’t need to see the patients and could just refer them in, so it took demand off both ends of the spectrum. This was the system helping the system.

Further information

For more nformation on the work in this case study, pleasecontact Professor Mike Holmes, chair of Nimbuscare, York and GP partner at Haxby Group: michael.holmes@nhs.net

Integration and Innovation in Action

This case study forms part of our Integration in Action series, a collection of publications, podcasts and webinars which explores how effective partnership working is helping to address the biggest challenges facing health and care.