Islington CCG NHS 111 & GP Out-of-Hours Samit Shah Clinical Lead, North Central London NHS 111

Introduction Focus: Procurement of a combined NHS 111/Out of Hours (OOH) service, with other North Central London CCGs, by April 2016 What we will cover: Context – our urgent care review Explain the clinical model for NHS 111 and out of hours services Plans for re-procurement of NHS 111 and GP out of hours services An update on the engagement we are undertaking Next steps

Local Context 2010: GP OOH delivered to C&I by Harmoni 2012, November: Care UK take over from Harmoni providing OOH Service 2013, April: LCW (not for profit) commence contract to provide 111 for C&I 2013, October: Primary Care Foundation review of Harmoni/Care UK Out of Hours Service. The review found the service was clinically safe and provided good care. 2014, March: Urgent Care Review Camden and Islington Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

Urgent Care Review: Community engagement Engagement August to November 2013 Through media and advertising; online survey; audit day; workshops with community groups People wanted: Smooth and efficient links between NHS111 and OOH A service that is easy to use and accessible Staff operating NHS 111 have the right knowledge and skills Easy referral into the necessary services Everyone in the community will find the service easy to use More local knowledge of NHS 111 and OOHs. Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

Urgent Care Review: Conclusions Requires High quality, safe care, 24/7, right care, right place, first time Easy to navigate and understand with equity of access A smooth patient pathway, with minimum number of organisations, repeated information gathering and handovers. Recommends Commission 111 across all of NCL Combined NHS 111, GP Out of Hours (OOH) service as a single whole system model (though not necessarily a single provider) Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

The 111 patient journey in London ANSWER APPROPRIATE CARE ASSESSMENT London directory of local skills and services (DoS) Contains information for a wide range of organisations in a locality, including opening hours, referral criteria, and real-time capacity 999 A&E UCC GP in hours OOH NHS Direct Midwife Mental Health crisis services Pharmacy Rapid response nursing Palliative care services, hospices ACCESS NHS Pathways Consistent assessment of clinical needs NHS 111 call advisers Locally commissioned call handling Integration with pan-London ‘Co-ordinate my Care’ (CMC) Register for end-of-life care GP GP

111, OOH and LAS data Nov 13-Dec14 Population of 218,000 (JSNA 2014) If every patient has four GP appointments per year, this amounts to approximately 880,000 appointments. Circa 25,000 calls to NHS 111: Circa 18,000 calls to GP out of hours services Circa 22,000 attendances at UCLH Emergency Department Circa 35,000 attendances at Whittington Emergency Department Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

Re-procurement features Procurement is legally required by NHS England, current contracts end March 2016 All the 5 NCL Boroughs, and across London re-procurement is being undertaken It requires community engagement, not consultation GP out of hours services providing telephone assessments, face to face visits, and home visits. Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

Re-procurement features re 111 It is a national requirement for all CCGs We aim that it will be across five boroughs, as now It will be an integrated service this does not necessarily mean a single provider for both services, partnership bids are encouraged NHS 111 is a nationally mandated model, but we will adapt as much as we can to fit local need. Primary Care Foundation review of Harmoni Out of Hours Service, Jul–Oct 2013 (considered by the Governing Body November 2013): Highlighted: additional step and potential delay where OOH service undertakes additional clinical assessment following that undertaken by NHS 111 – intended as an interim arrangement to provide assurance while NHS 111 introduced; the need for an over-arching clinical and operational governance process, bringing relevant providers together to support the urgent care system as a whole; that the requirement for an out of hours service to integrate with other unscheduled care services implied a lead provider taking responsibility for a range of urgent care services. Camden and Islington Urgent Care Review, Jul 2013 – Mar 2014 (considered by the Governing Body Jan 2014, May 2014 & Strategy and Finance Committee Apr 2014) Significant patient and public engagement: Widely advertised Listening and engagement through online survey and public events; Input on proposed model through engagement events and email survey; Key themes from engagement: Relationship – Regardless of the group, personal interaction was important.   Convenience – some felt convenient location was most important, while other felt getting an appointment at a convenient time was most important.   Simplicity – Most models were considered too complicated and attendees wanted a clear simple understanding of what constituted urgent care.  Knowledge – Clearer definition of urgent are, clearer understanding of the services available and where to go to be seen where considered of importance.  Equality – There were concerns about the equality of service being provided, particularly for those with long-term conditions, disabilities or non-native English speakers.

What’s possible? One governance structure Improved pathways for patients (avoiding patients repeating information) Prescriptions available far earlier when a person calls. Quicker access to specialist help for dental problems Clinicians “in the room” enabling 111 staff to pass calls directly to a GP Integrated IT: improving information flow and patient experience and safety Direct booking of “in hours” GP appointments

GP out of hours Regardless of the future provider, will continue to offer “traditional” service of telephone, face to face and home visits assessments. Islington CCG Board committed to ensuring high quality service Until now activity split 40%tel, 40% F2F, 20% Visits By 2016- more telephone consultations from 111 GPs, and possibly more F2F consultations from local GPs (via the extended 8-8 GP working (seven days/week)

Engagement undertaken Public engagement January to March Community meetings undertaken with a wide range of groups Survey Monkey questionnaire to all GP practice patient groups Focusing on - Clinical Model & Procurement Process

Engagement plan Islington Borough User Group (iBUG) – mental health service users Drayton Park Women’s Crisis House Age UK Body & Soul (HIV) Elfrida Society (Learning Disabilities) Young Carers Disability Action Islington Joint meeting with Camden; open meeting, 23 February, 5.30pm – 7.30pm, St. Pancras Hospital Last Years of Life Group/Voices for Change, Bingfield Medical Centre Last Years of Life Group, Islington Carers Hub North Locality Patient Forum, Resource Centre, 19 March, 2.00pm – 5.00pm Central Locality Patient Forum, Venue tbc, 26 March, 5.30pm – 8.30pm South Locality Patient Forum, St Luke’s Centre, 31 March, 5.30pm – 8.30pm Community Members / Independent Patient Group Survey Monkey questionnaire to GP practice patient groups HealthWatch All GP practices in pan-Islington forum

Emerging themes GP OOH Everyone wants a high quality service (Patients, CCG Board, GPs, patient community groups) Some people think this should be run and/or delivered by Local GPs Others have focused on the need for “high quality GPs”- who may or may not be local Service needs to be responsive to diverse language needs and vulnerable groups Service needs to minimise unnecessary referrals to A&E or 999

Emerging themes - PPG feedback Following on from the December 14 PPG in South Provided a set of FAQ for any patient Sent a survey to all Islington PPG groups Asked for the survey to go to all the practices “virtual patient groups” Asked all the CCG to undertake the same exercise

Emerging themes – re 111 Combining NHS111 and GP OOH is a good idea NHS111 and GPOOH needs to be able to make good links with the local health system NHS111 needs to be better at helping people with mental health needs Service needs to be more responsive to diverse language needs and patients with a disability Prescriptions, next day GP appointments, record sharing(with consent) – all well received. NHS 111 needs more marketing

Next steps This phase of the engagement finishes end of March Report on the outcome of the engagement Finalise on-going public involvement in the procurement process End March commence tendering process Finalise the service specification by the end of April ready for the second stage of the procurement New service starts 1 April 2016

Involvement in the procurement Are you are interested in becoming involved in the procurement process? If so, please give your name to: Lizzie Stimson estimson@nhs.net

Questions Mention pressures on system; Current arrangements: Out of hours services provided to Islington and Camden by Care UK (previously Harmoni); contract ends March 2015 - seeking to extend to March 2016 NHS 111 service provided to all of North Central London by LCW; contract ends March 2016 Requires GB to approve procurement in March.

Questions Have you used NHS 111 or GP OOH service in the last year? How would you rate your experience of NHS111 and OOH? When you call 111, how important would it be to you to be able to talk to the following healthcare professionals? GP Pharmacist Nurse Paramedic Dentist Mental health professional Is there anyone else you’d like to be able to talk to? Please specify

Questions Would you like the 111 or OOH service to be able to book an appointment at your GP practice the following day if it was thought necessary? We want our OOH GPs to have a good understanding of what local services are available in Islington when your GP is closed. How important is this issue to you? Is there anything else you would like us to consider?