Temporary Residents Service

Dr Eilir Hughes, Dwyfor Cluster, Dwyfor

The problem:

As a popular holiday destination, the Dwyfor area attracts thousands of holiday-makers every year. The population more than doubles during peak holiday periods, creating an increased workload demand on local healthcare services. Dwyfor contains five GP surgeries with long-standing issues with recruitment and retention due to their rurality and increased workload challenges in addition to a significant national shortage of GPs.

GPs face significant time pressures due to having to undertake lengthy home visits, significant commuting requirements, providing support to the Community Hospital, in addition to their increasingly complex practice responsibilities. This demand is inflated further during holiday periods due to the increasing number of Temporary Residents (TRs) that stay in the area. Many stay for extended periods as they make the most of their second home ownership.

Prior to this innovation, TRs had to identify a GP surgery within the area, navigate a telephone system designed for the permanent resident, and secure an appointment with the receptionist. The booking system for all five surgeries varied, and it was suspected that TRs were biased towards choosing specific practices due to a perception that they were easier to access.

TRs posed their own unique challenges to clinicians. The patient's background medical notes were not available. Past medical history and current prescribed medications had to be obtained during the consultation. In addition, it could be difficult to triage TRs and allocate an appointment within a timescale appropriate to their clinical need given that their full history was not to hand. Understandably in such circumstances, practices took a cautious approach, often offering a same-day appointment to the majority of TRs when they phoned for an appointment with a GP.

The Bright Idea:

The Dwyfor cluster decided to run a single, standalone service for all TRs staying within the cluster over the Easter, Whitsun and Summer school holidays. This would standardise the service offered to all TRs, offering better access whilst ensuring that permanent residents continued to enjoy access to their primary care service without being affected by the high volume of visitors during holiday periods.The TR service required collaboration and team-working across all of the five practices so that a single, overarching service was in place for the whole cluster TR population. This required a single-point of access to the service. This challenge was initially met through working with the Health Board’s Out of Hours service (OOH) to provide 'in-hours' telephone call handling, and booking of appointments.

This then led to recruiting OOH GPs to work during in-hours, and the OOH service's medical centre and its IT systems being used. Commissioning the OOH to provide a 'complete package' meant that a lot of the necessary resources and roles were ready to go, and the service could commence with minimal delay. The recruitment of OOH doctors was relatively easy since the financial incentives were favourable. Indemnity cover was provided by the Welsh Risk Pool, and telephone handlers were familiar with the role of supporting the GP in the OOH centre and were able to assist with reception and administrative tasks during the TR service.

A dedicated appointment line, with its own unique telephone number was set up. TR patients were signposted to the service's phone number if they contacted one of the five cluster practices. The cluster support team went out into the community to raise awareness of this new dedicated service, and notified large holiday complexes, caravan and camping sites, as well as the area's pharmacies and minor injury units.

This initial partnership with the OOH was successful in proving the concept. Providing a dedicated service for TRs from a single location delivered what the cluster had hoped for. However, it was expensive and soon enough the OOH were unable to secure telephone handling and reception cover for the service. This jeopardised the service's future. The cluster had to re-group, and quickly re-think how the service could be safely delivered.

Doing the service in-house was the only viable solution, and Nefyn Surgery volunteered to be the host practice. A second dedicated telephone line for the TR service was secured to the practice, and the practice's own receptionists booked and managed the administrative tasks of the clinic. The OOH GP was given a consulting room in order to conduct the clinic. Concerted efforts were made in trying to install the OOH IT system which is a BCUHB hosted programme onto a 'Primary Care Wales' hosted hardware, but unfortunately it was not possible to overcome this particular IT incompatibility issue. We took the pragmatic decision of using Nefyn's own clinical IT system for documentation and recording purposes.

The TR service was saved, and ran successfully throughout 2018 from Nefyn. However, there was one oversight made when we decided to use Nefyn's IT stem. The antibiotics prescribed by the TR service were recorded as those issued by the practice and thus grossly inflated the practice's overall antibiotic prescribing rates. For the 2019 service, the cluster support team have managed to rectify this problem so that the TR service now has its own prescribing number.

We were very conscious that the cost of using an OOH GP was high. Following evaluation of the cases seen by the service in 2018, it was decided by the cluster that the majority of the work could be handled by an experienced ANP. The financial benefits of providing an ANP-led service is obvious, and for the Summer of 2019 an ANP has been recruited and will see TRs at Nefyn, whilst being supervised by a GP from within the cluster.

The impact:

  • Patients: The TRs found the service easy to navigate, and did not mind having to travel a bit further because they were being seen quickly and promptly by the service. The cluster is taking a proactive action to safeguard local populations access to GP services
  • Staff: No longer did the GPs face a grossly inflated appointment list
  • Practice: More TRs being seen by allied services within the cluster, such as the minor injury units and the common ailments and emergency medication supply services provided at Pharmacies. Surgeries during holiday periods were now manageable

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