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

2. 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

3. 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 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.

4. 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 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.

5. 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 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.

6. 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

7. 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 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.

8. 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 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.

9. 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 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.

10. 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

11. 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 more telephone consultations from 111 GPs, and possibly more F2F consultations from local GPs
(via the extended 8-8 GP working (seven days/week)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. Questions Mention pressures on system; Current arrangements:
Out of hours services provided to Islington and Camden by Care UK (previously Harmoni); contract ends March 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.

20. 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

21. 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?