Measurement of Quality Outcomes Making Sure Your Urgent Care Delivers April 2011 David Carson

© Primary Care Foundation The Primary Care Foundation has looked urgent care from a number of angles Reports for Department of Health ●Primary Care in A&E ●Urgent Care in general practice ●Benchmark of out of hours services ●Urgent care centres (report with DH) Various projects for: ●Hospital Trusts ●PCTs ●PBC Groups ●Commercial and mutual provider organisations

© Primary Care Foundation A whole system perspective: urgent & emergency care components Patient ● General Practice ● Out of Hours ● Community Services ● UCCS and WICs ● Ambulance service ● A & E ● NHS Direct Surgery Ortho Obs & Gyn Self care Episode complete Acute medicine From any of the above Each component must work well - separately and as part of the whole Hospital From clinicians

© Primary Care Foundation Topics that I aim to cover... ●General Practice In and Out of Hours ●A&E ●Acute Services

© Primary Care Foundation Reviewing Urgent Care in General Practice Will they get through? Will they be spotted? Will they be seen rapidly?

© Primary Care Foundation Some of our key findings ● Speed of initial response – or ensuring patients can get through - matters ● Review and understand your number of appointments and the proportion that can be booked same day ● Managing peaks in demand - such as Monday mornings – is important ● Practice staff need to recognise what is potentially urgent and agree how to respond ● Rapid clinical assessment is important – especially of requests for home visits ● Telephone consultation can play a useful role

© Primary Care Foundation Acute Admission Timeline Hours2 Hours 2 (often 4) Hours Minutes1 Hour Just as hospital staff go home! In time to set up alternative to hospital Early enough to avoid risk of deterioration

© Primary Care Foundation ● Currently developing a web based planning and monitoring tool. Focuses on: ● Telephony – checking the capability to answer the phone promptly ● Capacity in terms of appointments to meet the demand from patients ● Recognition of potentially urgent cases ● Response to urgent cases ● Brings together practice data and patient experience to give a strong evidence base for making changes ● Practices are able to benchmark their own system and process against other local practices and across England A new approach

© Primary Care Foundation Better evidence supporting change ● Range of indicators provide a rounded picture of what is happening in the practice, including : ● staffing by hour answering phones compared to what is needed for an effective response (Erlang Formula) ● consultation rate, weighted for age, compared to national average ● Detailed report builds on how the practice understands its processes with analysis of data and options for change ● Tweaking process will not work if people can’t get through on the phones or there are too few appointments ● Once these issues are addressed, there are a range of options – the practice will need to identify what works for them

© Primary Care Foundation

Outcome of intervention ●Cons rate of 10 last July ●Could not get through on phone ●Difficult to see doctor of choice ●January ●Cons rate 6 ●Less pressure ●Continuity improved ●Quality improved

GP Out of Hours

© Primary Care Foundation

The CQC investigation highlighted shortcomings in commissioning ●Out-of-hours services were low priority at the time and the PCTs had limited understanding of these services. ●There was a lack of leadership in commissioning and monitoring services as part of an integrated urgent care service. ●There was a lack of experience in the PCTs in contracting with a commercial organisation. ●Staff did not fully understand the national quality requirements or TCN’s reports on activity and performance ●The PCTs did not have a high standard of commissioning or contract monitoring in out-of-hours - these contracts should have been monitored more thoroughly. ●Not highlighted in national targets and finances – so not seen as a priority for SHAs or PCTs.

© Primary Care Foundation The Health secretary believes that GP Commissioners will fix it!

© Primary Care Foundation Key message – you get what you insist on Alternatively, you get what you deserve ●You need a wide range of measures – and making comparison is vital ●Services have to manage clinicians if they are to perform effectively and consistently ●Each part must work well if you are to have a hope of joining different parts – and a similar wide range of measures is needed ●You will need to look at how practices deliver their share of care ●Look to establish contracts for longer and to drive improvements over a period

© Primary Care Foundation What qualities should data about a clinical service exhibit? ●Competently collected and collated ●Correct ●Clear, well presented information ●Consistent – to allow comparison within the data set and over time ●Complete – it should provide a full picture of all aspects ●Compare and contrast outcomes – so we can understand the cause of differences and which innovations work ●Collaborative - to secure the information and to engage stakeholders ●Communicate – so that users can understand what it means ●Convincing – if users are to change what they do based on the evidence ●Challenge or corroborate assumptions about clinical practice and outcomes ●Costed – because of the requirement for efficiency we need this too

© Primary Care Foundation A wide range of measures to give a rounded picture is needed if perverse incentives are to be avoided Out of Hours benchmark ●% definitively assessed in 20 and 60 minutes ●% answered in 60 seconds ●% with face to face consultation in 1, 2 and 6 hours ●% of urgent cases ●Patient experience ●% of patients going to 999/hospital ●Cost per case, cost per head ●Productivity

© Primary Care Foundation There are big differences between services delivering out of hours care (this looks at QR9 for urgent cases in 20 minutes….)

© Primary Care Foundation..and there are big differences in what they identify as urgent Those with higher levels of urgent on receipt find it difficult to better 90% definitively assessed in 20 minutes These have low %urgent on receipt but have a low percentage of urgent cases assessed in 20 minutes

© Primary Care Foundation In general it costs more to provide OOH cover in a rural PCT than an urban one (but there are wide variations within any band)

© Primary Care Foundation There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received

© Primary Care Foundation The majority of services give telephone advice in 40 to 50% of cases and offer home visits to 10 to 17%. % Advice % Home visits

A&E

© Primary Care Foundation A&E Proposed Measures ●Ambulatory care ●Unplanned re-attendance ●Total time spent ●% leaving before being seen ●Patient experience ●Time to initial assessment ●Time to treatment ●% with consultant sign-off

© Primary Care Foundation There are big differences between services (four A&E departments looking at % discharged by 10 minute slots) 22.7% admitted 13.9% admitted 28.5% admitted 18.3% admitted 19.6% admitted 30.7% admitted

© Primary Care Foundation What do people often focus on? ●Numbers of attendances ●Admission avoidance ●Quality = Volumes (or lack of them) ●What about people who need hospital

© Primary Care Foundation Process integrated and not competative GPs are part of the process – Not in front of it

© Primary Care Foundation Acute care ●Ambulatory sensitive conditions – Outcomes ●Percentage discharged same day ●Process and timely care – Rapid Care is often good care ●Readmission rates ●Time to theatre for # NOF ●Stroke – compliance with pathway ●Etc etc

© Primary Care Foundation So what have we been missing? ●Professionals and organisations have been competing ●GPs - we manage risk better than A&E ●A&E - We deliver detailed and proper assessment ●Etc etc ●Each group has specific and valuable expertise ●Build a system in which the expertise is complementary and cooperative and not competitive ●I have never ever met a clinician who was admitting a patient because the trust would get a tariff payment!