Contact us Request demo
Link to Home

View navigation


Frimley ICS project sees GPs reach out in real-time to patients in A&E who don’t need to be there

23 February 2023

A pilot project at Frimley Integrated Care System, which helps GPs identify and reach out in real-time to patients who are attending A&E inappropriately, is helping alleviate pressures and providing better continuity of care for individuals.

Patients have responded positively, welcoming direct contact and advice from their GP as they wait. 16% have been redirected and seen in other care settings.

For many years, initiatives to reduce the burden on A&E services have been designed and led by secondary care. A GP in Slough, Dr Bharan Kumar, wanted to try a different approach and the availability of real-time shared care data in Connected Care, powered by Graphnet, got him thinking.

Dr Kumar commented: “Data and technology have given primary care greater awareness and insights into our patients’ journeys and needs as they navigate the wider health and care system. Using these tools, as a GP, I want to take the lead on my patients’ care beyond the surgery, where possible, ensuring they are accessing the right care, at the right time, in the right place.

He started to use a real-time dashboard in Connected Care showing which of his patients are currently in A&E and why. Viewed in the context of the wider Shared Care Record, he could identify individuals who might benefit from being seen elsewhere. The next step was to make direct contact with patients as they waited, assess their need and direct them to other care settings, if appropriate.

The results from the pilot period revealed that more than a quarter of patients were in A&E inappropriately and 50% of those patients who could be redirected were seen back in their GP practice.

Dr Kumar continued: “This initiative is not about stopping people going to A&E when they need to, but it is about educating people and promoting the different services available and, importantly, how and when to access them. It is also contributing to the vital rapport needed between a patient and their GP.”

The initiative has been expanded over the past 6 months. 13 practices, across 4 PCNS within Frimley ICS are now using a Standard Operating Model developed from lessons learned by Dr Kumar during the pilot.

Dashboard views have been enhanced following feedback from other GPs now participating. This includes the addition of a Red Amber Green (RAG) status, with green being a patient who is generally well, to red, someone, for example, with complex needs / multiple long-term conditions for easier triaging. 

This relatively simple solution and intervention is not only alleviating pressure on A&E departments but means better continuity of care for patients. They all responded positively, re-assured to be contacted by their GP and keen to understand what other, more appropriate, services could be used and when.

Dr Tariq Darr, GP, got involved when the project expanded. He said: “It has been fascinating to see which of my patients are attending A&E and be able to contact them whilst they wait. They are surprised to hear from me, but very impressed that I can do this. Feedback has been very positive so far.

One patient was fairly new to the country and presented to A&E with a lump on her neck, assuming this was the best place to go. After careful assessment talking to her and looking at her records, I felt it was clinically safe for her to see me back in the surgery. It was the right decision, and she was very grateful for that.”

Read Frimley's case study