Out of Hours

1
Out of Hours Urgent Care Developments update
in England 7th September 2006Dunkeld, Scotland

• Dr. Agnelo Fernandes MBE MRCGP
• www.urgenthealthcaresolutions.com

2
Developments down south

• New GP contract changes Jan 2005
• NAO Report May 2006
• Review of OOHs Quality Requirements July 2006
• Which? Report July 2006
• NHS Direct
• Practice Based Commissioning / PBR April 2005
• White Paper Our Health Our Care Our say Jan
  2006
• National Urgent Care Strategy development 2006
• Choice
• NHS Pathways / CMS

3
1. nGMS OOHs Opt-Out

• New GP contract OOHs changes by 1st Jan 2005
• GP Opt-out Rural gt Urban
• Responsibility for OOHs with PCT where GP
  Opt-out
• Positive Effects
• GP Work Life balance
• Individual / Practice Responsibility
• Negative Effects
• Financial
• GP Workforce de-skilling???
• GP Involvement / Influence
• GP Registrar Training in Urgent Care ( cf PCT
  funds)
• Value for Money / Performance monitoring

4
2. National Audit Office Report

• The Provision of Out of Hours Care in England
  May 2006
• Review of new arrangements where PCTs now
  responsible
• Key Findings
• Commissioning issues due to PCT inexperience
• delayed contracts / data availability
• 39 of PCTs had a competitive tendering process
  not cheaper / better
• Satisfactory standard but not meeting all QRs
• E.g. speed of response demand peaks Sat
  mornings
• Confusion over compliance of QRs
• High satisfaction but 20 not Patient
  Experience captured?
• Limited progress with integrated NHS urgent
  care services
• Costs 392 million (322 million allocated by DH)
• 22 more from average 9,500 to 13,000 per WTE
  GP some PCT confusion
• Contracts - multiple providers Market
  maturing
• Skill mix developing ? Cost effective
• Providers Co-ops, NHSD, Private, PCTs

5
2. National Audit Office Report

• The Provision of Out of Hours Care in England
  May 2006
• Recommendations for DH to address
• Confusion about the meaning of full compliance
  with QR target of 100 achievement
• Lack of clarity around the meaning of the phrase
  definitive clinical assessment
• Need to focus further on quality and the
  character of the patient experience
• Many providers struggling to comply with some QRs
  
• A prompt response to the initial telephone call
  and subsequent access to clinical assessment on
  the telephone
• RCGP concerns about the quality of OOH services
• QRs not adequately monitored or enforced
• ensuring patients had access to a GP where
  clinically appropriate (Quality Requirement 11)

6
2. National Audit Office Report

• The Provision of Out of Hours Care in England
  May 2006
• Recommendations for PCTs to address
• Benchmarks costs to comparable PCTs
• To identify areas for improvement
• Improve commissioning capacity
• Service specifications market management
• Local unscheduled care patient flows analysis
• For more appropriate patient access to services
• Improve quality of patient questionnaires
• More realistic patient feedback
• Use contractual Performance levers fully
• Achieve access requirements within QRs

7
2. National Audit Office Report

• The Provision of Out of Hours Care in England
  May 2006
• In response to NAO report DH has worked with RCGP
• Address misunderstanding or misinterpretation of
  QRs
• Some QRs remain challenging
• particularly at periods of peak demand
• Discussions with providers or commissioners
  suggest
• QRs were neither inappropriate or nor
  unachievable.
• DH therefore NOT made any changes to the QRs
  (October 2004)
• Remains Contractual obligation for all providers
  of OOH services to comply fully with all the QRs
• Commissioners to achieve compliance with QRs, and
  report regularly and accurately regards
  compliance.
• DH therefore re-issued the QRs with a new
  introduction

8
Quality Requirements - 2004

• One Reporting to PCT
• Two Report OOH consultations to patients own GP
  practice by 0800 next working day
• Three Regular exchange of up-to-date information
  about patients with predefined needs e.g.
  Palliative care
• Four Clinical audit of all who provide clinical
  service
• Five Regular audit of patients experience of
  the service
• Six Complaints procedure
• Seven Capacity and contingency planning

9
Quality Requirements - 2004

• Eight Telephone answering requirements
• Nine Telephone Clinical Assessment
• Ten Face-to-face Clinical Assessment
• Eleven Patients must be treated by clinician
  best equipped to meet their particular needs
• Twelve Face-to-face consultations
• (Emer 1hr / Urgent 2hrs / Routine 6hrs)
• Thirteen Providing services for people with
  language difficulties, impaired hearing or
  impaired sight

10
3. Review of OOHs Quality Requirements July
2006

• DEFINING COMPLIANCE
• Full Compliance
• Requirement with average performance within 5 of
  the target. Thus,
• where the target is 100 average performance of
  95 and above
• Partial compliance
• average performance was between 5 and 10 of the
  Requirement
• commissioner explore the situation with the
  provider and identify ways of improving
  performance.
• Where the target is 100, average performance of
  between 90 and 94.9 would be deemed to be
  partially compliant.
• Non-compliance
• average performance was more than 10 short of
  the target
• the commissioner would specify the timescale
  within which the provider would be required to
  achieve compliance.
• Where the target is 100, average performance of
  89.9 and below would be deemed to be
  non-compliant

11
3. Review of OOHs Quality Requirements July
2006

• Current measures ONLY record average performance
• This can conceal wide variations
• in practice from day to day, and
• at different times within the day.
• Where further analysis reveals an inability to
  put in place sufficient resources on
• a particular day or
• a particular time of the week or both
• the provider could be deemed to be partially or
  non-compliant.

12
3. Review of OOHs Quality Requirements July
2006

• Definitive Clinical Assessment
• Confusion about what this means
• This term is used in Quality Requirements 9 and
  10
• Definitive clinical assessment
• is an assessment carried out by a clinician (not
  a call-handler) on the telephone or face-to-face.
  
• The adjective definitive has its normal English
  usage, i.e. having the function of finally
  deciding or settling decisive, determinative or
  conclusive, final.1
• In practice, it is the assessment which will
  result either in reassurance and advice, or in a
  face-to-face consultation (either in a centre or
  in the patients own home 1 Oxford English
  Dictionary, Second Edition Oxford, 1989.

13
3. Review of OOHs Quality Requirements July
2006

• Focus on Quality
• QR 4 requires providers regularly to audit the
  clinical quality of the service
• Audit work of every individual working within the
  organisation who contributes to clinical care.
• Difficulties in delivering effective clinical
  audit
• RCGP commissioned to develop a new toolkit
• Toolkit will be published in the autumn of 2006

14
Quality Systems In Out Of Hours

• Monthly AUDIT Good Practice PERFORMANCE
  Criteria
• Assesses the need for emergency intervention
• Identifies clearly main presenting problem
• Records past medical history
• Records medication/allergies
• Records a diagnosis
• Practice shows evidence of effective
  decision-making
• based on clinical knowledge and critical
  appraisal of information
• Consultation displays empowering behaviour
• Reaches a safe and appropriate outcome based on a
  full assessment
• Records worsening instructions
• Referral to appropriate specialty
• Documentation meets organisational, professional
  and legal requirements

15
3. Review of OOHs Quality Requirements July
2006

• Focus on patient experience
• QR 5 requires providers to audit patients
  experience of the service
• Commentary published alongside the QRs made clear
  
• Different from traditional tools for measuring
  patient satisfaction.
• Need for questionnaire to explore the patient
  experience
• More than satisfaction,
• looking at patients access to the service
  (including timeliness )
• character and quality of their telephone
  encounters
• character and quality of any face-to-face
  consultation
• environment within which face-to-face
  consultations take place
• An example of a questionnaire developed by
  Client-Focused Evaluation Programmes
  (http//www.cfep.co.uk/products.html).

16
3. Review of OOHs Quality Requirements July
2006

• Matching capacity to demand
• Striking aspects of the NAO data
• Overwhelming majority of PCTs reported very high
  levels of compliance with QR 7 (the obligation to
  plan capacity to meet predictable fluctuations in
  demand),
• While at the same time reporting very low levels
  of compliance with those QRs that are designed to
  measure the match between capacity and demand (QR
  8, 9, 10, 11 and 12)
• Raises questions about the accuracy of data??
• Evidence at periods of peak demands
• Providers struggle to achieve compliance with the
  access QRs
• QR 7 - plan effectively to meet peaks in demand.

17
4. Which? Report July 2006

• In the last year, around 14.5 millions adults in
  England sought medical treatment outside of
  normal GP surgery hours.
• Patients confused about what services available
  and how to access them.
• Some face long delays and significant
  difficulties in getting appropriate care out of
  hours, result in overburdened Accident and
  Emergency (AEs)
• Almost a third of people (32 per cent) who
  needed out of hours care in the last year went to
  AE, even though they might well have received
  care better suited to their needs elsewhere
• Awareness of services that can ease the burden
  on AE is low. Only 39 per cent of consumers know
  about NHS Walk-in Centres and only 21 per cent
  know that about Minor Injury Units. And these
  services are not available in all areas.
• NHS Direct, the telephone helpline for
  consumers, was also found wanting.
  Inconsistencies in the quality of service,
  response times and advice, and consumer confusion
  over its purpose risk NHS Direct being seen as an
  obstacle on the path to care.

18
5. NHS Direct

• Re-Organisation Re-structuring
• Call centres staff profile rationalisation
• Final decisions October 2006
• Effects of Contestability
• Less than anticipated OOHs market share
• Exploring new models with partners
• Front ending OOHs service with LIVE call transfer
  (both voice data) to a GP (at co-op) for all
  Urgent calls ( the current 20min category in QRs)
  Kingston Croydon PCTs. AE only after GP
  assessment. Limited nurse assessment

19
Patient calls single local phone number (or
transfer from GP practice OOH)
Kingston Health On Call 0845 601 0909
Phase 1
NHSD Health Advisor call taking, prioritisation
streaming
NHSD deals with simple, single issues
Urgent Clinical Calls transferred Live to GP
Croydoc Streams dispatches to Local services
Life threatening Calls to 999
Dispatch to local agencies- Mental Health,
District Nurse etc
Refer on as needed
GP telephone assessment for all other clinical
calls
Home Care advice
PCC
Home Visit
Other Service
AE only after GP Assessment
20
6. Practice Based Commissioning

• Commissioning a Patient Led NHS
• Indicative Budgets for GP practices
• Individual, cluster or consortium commissioning
• But no management allowance (cf GP Fundholding)
• Practices incentivised to participate (DES
  95p/patient)
• Service re-design Healthcare outside hospitals
• Tariff for hospital attendance AE, OPD, IP
• PBR payment by results
• Re-designed care pathways
• reducing hospital contact will result in savings
• Savings can be utilised by GP practices for other
  service improvements
• PBC Collaborative will eventually involve all
  PCTs
• Urgent Care Re-design including OOHs a workstream

21
7. White PaperOur Health, Our Care, Our Say

• Our health our care our say said
• During 2006 we will develop an urgent care
  strategy for the NHS, providing a framework
  within which PCTs and local authorities can work.
  This will take full account of the implications
  for other providers including social care and
  ambulance services.

22
8. Urgent Care Strategy

• This means
• A description of the whole system strategic
  direction
• Saying what DH will do nationally to enable
  delivery
• Saying what should be done locally
• Understanding how to measure delivery
• It will not
• Tell local communities what services they need
• Decide on the configuration of local services

23
8. Urgent Care Strategy

• Two stage approach
• September/October 2006
• publication of Direction of Travel document for
  Urgent Care after some internal and external
  engagement
• Consultation with wider group of stakeholders
  to road test vision, principles and actions
• Stakeholder events
• December 2006 publication of strategy and
  implementation

24
8. Urgent Care Strategy

• Whats the problem?
• Service user frustrations (Your health, your
  care, your say)
• delays and duplication
• multiple handovers
• Repetition of details in a disjointed journey to
  definitive care
• Value For Money and appropriate care not
  optimised need to provide same or better
  services through optimal use of resources e.g.
• AE/Ambulance redesign
• Urgent Care Centres
• joined up health and social care
• care closer to / in home
• more self care,
• support for independence and well-being
• and public health
• Inequalities in access (?mental health/hard to
  reach)

25
8. Urgent Care Strategy

• DEFINITION OF URGENT CARE
• Urgent care is the range of responses that
  health and care services provide to people who
  require or who perceive the need for urgent
  advice, care, treatment or diagnosis. People
  using services and carers should expect 24/7
  initial assessment of their needs and an
  appropriate response to that need.
• user defined system responsive
• e.g. Urgent Care Centres front end to AE
• Health and Social Care
• in and out of hours consistent assessment /
  prioritisation
• Not 24/7 care but link this message to issues of
  convenient access (GP hours)

26
8. Urgent Care Strategy

• KEY PRINCIPLES
• My voice as a service user or carer is clearly
  heard and acted on.
• I know how to access services if I have an urgent
  need
• If I have an urgent need I can access care
  quickly and simply
• My safety is paramount to everyone who cares for
  me
• I can rely on getting the right care (including
  support to self care) whenever I need it and
  wherever and whoever I am.
• The care I receive is appropriate and represents
  good value for money

27
8. Urgent Care Strategy

• ACTIONS REQUIRED
• Principle 1. My voice as a service user or carer
  is clearly heard and acted on.
• Where are we now user/carer voice increasingly
  heard more emphasis needed on user experience
  across episodes of care and using information to
  inform change.
• Where should we be all providers regularly
  assess user experience and share with
  commissioners findings and actions made public.
• National actions good practice examples
• Local actions regular audit of user experience
  and action taken in response.

28
8. Urgent Care Strategy

• Principle 2. I know how to access services if I
  have an urgent need
• Where are we now public and staff unsure lots
  of different terms used eg WiCs, MIUs
  frustrating and disjointed. Self care support
  less evident to all
• Where we should be information available
  personalised care plans available and people know
  what to do if things change
• National actions media templates for local
  comms shared info on services (Nhs.uk/NHS
  Direct) Expert patient programmes policies eg
  LTCs, End of Life care
• Local actions PCTs provide up-to-date service
  info commissioners identify referral
  systems/patient pathways joint and PbC
  personalised care plans workforce development
  co-location of facilities

29
8. Urgent Care Strategy

• Principle 3. If I have an urgent care need I can
  access care quickly and simply.
• Where are we now ease of access variable
  locally. Multiple hand-offs. Changes in provision
  in development e.g. diagnostic capacity, care
  closer to home
• Where should we be commissioners understand
  local demand patterns and develop services for
  quick and easy access telephone and face-to-face
  access routes understood more community/home
  based care available and provided by flexible
  multi-skilled workforce 24/7 access to
  consistent assessment of need reduced hand-offs.
  
• National actions define urgent care good
  practice examples development of single 3 digit
  number and/or patching of voice and data between
  services guidance on workforce development
• Local actions demand analysis to inform joint
  commissioning and re-engineering implementation
  of single number and/or voice and data patching
  adoption of consistent 24/7 assessment systems
  for telephone and face-to-face needs in and out
  of hours

30
8. Urgent Care Strategy

• Principle 4. My safety is paramount to everyone
  who cares for me.
• Where are we now variety of standards and
  quality requirements in and out of hours and
  across health and social care multiple
  hand-offs limited access to records access to
  medicines an issue
• Where should we be consistent whole system
  standards audit and action on patient
  experience performance management care
  histories available consistent assessment of
  urgent care need governance strong medication
  available
• National actions standards reviewed consistent
  performance framework good practice on clinical
  and corporate governance good practice on
  quality audits good practice on performance
  management integrated IT solutions.
• Local actions commissioning includes
  requirements to report and deliver on standards
  compliance providers publish their quality
  compliance effective performance management
  care pathways limit hand-offs records shared
  access to medicines addressed

31
8. Urgent Care Strategy

• Principle 5. I can rely on getting the right
  care (including support to self care) whenever I
  need it and wherever and whoever I am.
• Where are we now growing emphasis on self care,
  public health, independence and well-being
  improving urgent care e.g. NAO report on
  out-of-hours inconsistent standards in and out
  of hours some less well served e.g. mental
  health and hard to reach
• Where should we be 24/7 consistent initial
  assessment of need more fully engaged public
  services meet needs of vulnerable groups
• National actions good practice examples
  identified local communication campaigns
  facilitated standards set
• Local actions service reconfiguration target
  vulnerable groups

32
8. Urgent Care Strategy

• Principle 6. The care I receive is appropriate
  and represents good Value For Money
• Where are we now equitable access to care not
  based on consistent initial assessment of need
  (in and out of hours) health and social care
  integration relatively weak scope to realign
  services not yet realised.
• Where should we be commissioners understand
  demand and re-engineer service provision
  accordingly joint and PbC regular benchmarking
  costs and quality consistent initial assessment
  leads to appropriate response needs met first
  time and close to home, avoiding unnecessary
  admissions through AE
• National actions good practice examples of
  re-engineering benchmarking tool support for
  demand and capacity management guidance on
  urgent care networks commissioning guidance and
  PbR to facilitate care in appropriate local
  settings
• Local actions PCTs develop demand analysis
  commissioners re-engineer services urgent care
  networks in place, consistent assessment in
  place benchmarking undertaken joint and PbC

33
8. Urgent Care Strategy

• What levers will make the strategy work in
  practice?
• Key levers likely to be a combination of
• Voice
• Local tariff unbundling
• Joint / Practice Based commissioning
• Whole system standards (monitored)
• Patient safety/governance

34
8. Urgent Care Strategy

• Cross Cutting Issues
• May include
• Attitudes to risk (as described in Independence
  Wellbeing and Choice)
• Wider integration eg housing
• Rural/urban issues eg transport

35
9. CHOICE

• Key Principles
• Everyone is entitled to express a choice about
  their healthcare and services.
• Choices offered should reflect the individuals
  beliefs, values and preferences as well as
  clinical need.
• Choice should be about type of treatment as much
  as about the place of care.
• Choices should be offered at decision points
  along the patients care pathway where this
  improves the patients experience and is
  clinically safe.
• The choices offered should be clinically
  appropriate and in accordance with professional
  guidelines and meet NHS core standards.
• Appropriate information and advice should be
  available to empower people to make informed
  choices.
• Patients exercising informed choices should also
  take some responsibility for their choices.
• The choices offered should be affordable within
  the NHS budget.The choices an individual makes
  should not prejudice the treatment they receive.

36
10. NHS Pathways

• What is NHS Pathways?
• DH project
• Wholly NHS-owned product
• A team of developers (doctors, nurses and
  information experts) with national and
  international experience of CDSS design and use
• Widely experienced in primary care and in setting
  up and working in urgent care delivery

37
How NHS Pathways could help
999
Appropriate 999 care
NHS PATHWAYS CDSS
Caller
AE

• Appropriate attendance
• Treat

See PCP
Appropriate PCP face-to-face consultation
(person, place, time)
Appropriate PCP telephone consultation in real
time or as advised
Speak to PCP
Other Services
e.g Police, Social services
38
Pilots of NHS Pathways

• First pilot of NHS Pathways
• Live in West Hampshire OOH Service (WHOOHS)
• since 27 September 2005 A new system of urgent
  care delivery in West Hampshire a testing
  environment!
• New call handlers and nurses
• New OOH service
• PCTs with no previous OOH experience
• Brand new clinical system
• Second pilot of NHS Pathways
• North East Ambulance Service
• 1st Oct 2006 to 31st March 2007
• clinical assessment, call prioritisation,
  redirection to appropriate services and
  associated on-line clinical advice for 999 calls.
  NHS Pathways embedded into CAD Cleric
• CMS Capacity Management System Live directory
  of services

39
NHS Pathwayssupporting Consistency in
Assessment A common front end tool for urgent
care?NB Not available yet !-pilots evaluation
40
Capacity Management Services (CMS)

• A live time directory of all available
  services specific to
• patients clinical need via Pathway disposition
• patients location
• patients GP
• time of day
• clinical skill set of referrer
• capacity of receiving unit or team
• A tool to highlight gaps in service delivery due
  to
• lack of capacity
• over provision of services
• insufficient or inappropriate geographical
  coverage
• insufficient or inappropriate hours of
  availability

41
Capacity Management Services (CMS)

• Available in modular form to meet specific
  health social care economy requirements
• Currently operational in varying stages of
  implementation in
• Surrey, Berkshire, Buckinghamshire, Oxfordshire,
  Warwickshire, Herefordshire, Worcestershire,
  Norfolk, Suffolk, Cambridgeshire, Lincolnshire,
  Sussex, Durham.
• Entirely owned and designed by NHS
• Developed and managed by a Consortium
• Established since 1997 with a proven track
  record of equalising emergency pressures
• Works equally well in urban and rural settings
  to postcode sensitivity

42
Developments down southSummary

• New GP contract changes Jan 2005
• NAO Report May 2006
• Review of OOHs Quality Requirements July 2006
• Which? Report July 2006
• NHS Direct
• Practice Based Commissioning / PBR April 2005
• White Paper Our Health Our Care Our say Jan
  2006
• National Urgent Care Strategy development 2006
• Choice
• NHS Pathways / CMS

43
PATIENT EMPOWERMENT with 24hr INFORMATION A
Range of NHS SERVICES What is an Emergency ?
Health Promotion ILLNESS PREVENTION STRATEGIES
URGENT HEALTHCARE
Treated Or ADMITTED to HOSPITAL
PATIENTS At Home
Pharmacists
INTERMEDIATE CARE
GPs
PERCEIVED NEED For URGENT / EMERGENCY HEALTHCARE
NHS DIRECT 08454647
NHS DIRECT ONLINE www
ACCESS CHOICE
999 Ambulance
AE
DIGITAL TV
URGENT ASSESSMENT Outside Hospital
Walk-In Centres M I Us, Minor Illness Clinics,
ECPs
A.Fernandes June 2000 updated 2005
44
Out of Hours Urgent Care Developments update
in England 7th September 2006Dunkeld, Scotland

• Dr. Agnelo Fernandes MBE MRCGP
• agnelo.fernandes_at_blueyonder.co.uk
• www.urgenthealthcaresolutions.com