1. Commissioning Urgent Care: what do we know now and what does this mean for the new pathfinder consortia? Rick Stern NHS Alliance Lead for Urgent Care Director, Primary Care Foundation, rick.stern@primarycarefoundation.co.ukrick.stern@primarycarefoundation.co.uk 07709 746771 NHS Direct & NHS Alliance workshop 22 nd February, 2011 Central London

2. © Primary Care Foundation The Primary Care Foundation developing best practice in primary and urgent care Urgent Care in General Practice Out of Hours Benchmark Urgent Care Centres Primary Care in A&E A resource for commissioners of urgent care

3. © Primary Care Foundation New Leadership Group for Urgent Primary Care Dr Albert Benjamin Clinical DirectorWaldoc CBS (Waldoc Ltd) Anita Dixon Chief ExecutiveCentral Nottinghamshire Clinical Services Alan Franey Chief ExecutiveBarndoc Healthcare Ltd Eddie Jahn Managing DirectorHarmoni Dr Darren Mansfield GP Clinical Lead in Urgent CareNHS Bolton Lesley McCourt Chief ExecutivePartnership of East London Co-operatives Alison McWilliam General ManagerNottingham Emergency Medical Services Limited (NEMS CBS) Dr Ray Montague Medical DirectorBrisdoc Healthcare Services Dr Russell Muirhead ChairmanShropshire Doctors Cooperative Ltd Diane Ridgeway Chief ExecutiveEast Lancashire Medical Services Ltd Gilly Wilford Director of Finance & ContractsSouth East Health Nigel Wylie Chief ExecutiveUrgent Care 24

4. © Primary Care Foundation Emerging Priorities 1.Patient Safety 2.Integrated Urgent Care 3.Demonstrating quality 4.‘Rebranding’ Out of hours

5. © Primary Care Foundation What I will cover 1.The breadth of urgent care 2.Urgent Care in general practice 3.What can we learn from the national OOH benchmark and how has it driven improvements? 4.Primary care in Emergency Departments 5.Changing the culture of out of hours services – a new initiative 6.Key issues for commissioning urgent care

6. © 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

7. © Primary Care Foundation Why focus on General Practice? ● Its where most people access care and get treated: 300m consultations a year; about 100m same day. ● Until recently, not properly acknowledged as part of urgent care pathway ● Individual decisions in general practice shape the NHS as a whole – good management of urgent care starts here ● Supports idea that all partners in the health community are working together

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

9. © 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

10. © Primary Care Foundation Acute Admission Timeline 8.3011.30 13.30 17.30 3 Hours2 Hours 2 (often 4) Hours 8.308.45 09.45 10.45 15 Minutes1 Hour Just as hospital staff go home! In time to set up alternative to hospital Early enough to avoid risk of deterioration

11. © 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

12. © Primary Care Foundation ● Number of lines and number staff answering calls ● Length of average call ● When do you run out of appointments on the day ● Appointments - face to face, by phone, home visits & extras; split by same day and book ahead ● Completion rate of phone consultations, by practitioner ● Additional information, including staffing and age profile of the practice population ● Results from the General Practice Patient Survey What do we look at?

13. © 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

14. © Primary Care Foundation Developing the benchmark ● Awarded tender by DH in November 2007 ● Numerous pilots including across all of North East ● National advisory group to steer progress and set price ● Established three years support, with benchmark every six months and patient experience survey once a year ● Reduced rates & local review workshops if all PCTs in SHA area ● Currently over 100 out of 152 PCTs in England are members

15. © Primary Care Foundation Developing the benchmark: rounds 1, 2, 3, & 4 ● First benchmark completed March 2009 with reports on 63 services and half-day workshops for commissioners & providers ● Second benchmark, with reports on over 90 services, completed November 2009,with first patient experience survey managed by our partners, CFEP UK Surveys ● Third benchmark reviewing performance at period of peak demand at Christmas 2009 and New Year 2010 –completed November 2010 ● Fourth benchmark, again a full benchmark including patient experience with complete overhaul of questions to ensure full compliance with CQC report

16. © Primary Care Foundation How does it work? ● Data extract – from a number of different information systems ● Web based questionnaire for commissioner ● Web based questionnaire for providers ● Validate data – consistent but personalised ● Produce reports ● Workshops ● Anonymity – about to change ● National Steering group and User Group

17. © Primary Care Foundation The benchmark of out of hours services is comprehensive and provides considerable detail ● Performance against all of the national quality requirements ● Clinical governance processes ● Comparing advice, visits at a centre & visits at home ● Urgent on receipt ● Productivity ● Additional measures of patients going towards hospital ● Patient perceptions of your service ● Case volume per 1,000 patients ● Cost per case and cost per head

18. © Primary Care Foundation Learning from the first two rounds of the benchmark Improving out of hours care: what lessons can be learned from a national benchmark of services? January 2010, PCF 1.Out of hours services are improving 2.Patients value a responsive service 3.Split services and double assessments seem to perform less well 4.Many providers are falling short on the standard for definitive clinical assessment of urgent cases 5.There is an enormous range across different services in the proportion of cases that are identified as urgent 6.There is striking variation in cost, even amongst providers serving communities with similar population density 7.Coding needs to be improved in some key areas

19. © Primary Care Foundation In general it costs more to service a rural PCT than an urban one – but there are wide variations within any band ● Rural City/Urban ● Mixed Each dot is one service

20. © Primary Care Foundation Red and Blue service are very different – red has very high advice and low home visits, blue has low advice and just above average home visits…. % Advice % Home visits

21. © Primary Care Foundation …despite their differences they are both rated highly for the quality of care by patients – the common factor is their speed of response

22. © Primary Care Foundation There is a very striking variation between services in the proportion of cases identified as urgent on receipt Percentage of cases identified as urgent by non clinical call- handlers Each bar is one service – a provider/PCT How safe?

23. © Primary Care Foundation We reported the percentage of urgent cases that were assessed in 20 minutes… Many of these providers had too many cases with double assessment Each bar is one service – a provider/PCT

24. © Primary Care Foundation In far too many services it is impossible to be sure how many patients make their way towards hospital We know that many services, particularly to the left, are under- counting patients going towards hospital Each bar is one service

25. © Primary Care Foundation A new focus in the third benchmark: performance at times of peak demand What can we learn from looking at performance and variation at Christmas 2009 and New Year 2010 when services face their highest levels of demand across 100 services in England?

26. © Primary Care Foundation Key Learning from the 3rd Round of the Benchmark ● Demand is predictable ● Although performance is improving it falls short of the quality requirements ● There are two reasons ● Not enough people on the busy days ● Not addressing the variation between individuals ● Services can do something about both

27. © Primary Care Foundation Whatever the variation between services the variation between individuals will be greater

28. © Primary Care Foundation This looks at the percentage of calls given telephone advice for one service Doctor only, six months data, at least 25 consultations Dr 147 gives phone advice to over 60% Dr 116 gives phone advice to just less than 30% Each bar is one doctor Dr 7 gives phone advice to just over 30%

29. © Primary Care Foundation This looks at the length of the advice calls that ended with a PCC visit – doctors are ranked on the % completed in 4 minutes Dr 147 completes around 18% in four minutes Dr 116 completes over 90% in four minutes Each bar is one doctor Dr 7 completes around 35% in four minutes

30. © Primary Care Foundation How does the benchmark improve care for patients? Three case studies … 1.Using the measurement of productivity to drive improvements in care – Urgent Care 24 2.Improving Patient Safety in response to comparative low level of urgent cases on receipt – Chorley Medics Ltd 3.Using the benchmark to drive improvements in commissioning out of hours care - NHS Bedfordshire

31. © Primary Care Foundation Primary Care & Emergency Departments

32. © Primary Care Foundation Three models for offering primary care within or alongside A&E 1.Situated alongside the Emergency department running separate reception and operational processes 2.Situated alongside the Emergency department and running common reception and separate operational processes 3.Fully integrated with common reception and operational processes

33. © Primary Care Foundation Key Issues – reflections 1 “if everyone is involved it becomes seen as a joint baby, not a primary care service in their midst” ● Primary care practitioners and their complimentary skills offer an important way of improving services within A&E … but it is only one way, of many, for improving urgent care for patients. ● Good governance – or the way clinicians and organisations integrate care – is vital. The best services, have good systems for ensuring that consultants, GPs and nurses all work together. ● Best of both primary care and emergency medicine or clash of cultures? (varying approaches to training, managing risk, governance systems, language and their experience of different case mixes) ● Patients want to make choices about how and where to access health care, based on their own needs as well as their understanding of how easy it is to access the particular range of services in their area.

34. © Primary Care Foundation Key Issues – reflections 2 ● Although primary care can potentially reduce pressure on Emergency Departments and improve patient care there is little evidence that it reduces Emergency Admissions or reduces overall costs to the NHS. ● There is also no evidence that public information campaigns – telling people not to go to A&E unless it is an emergency – change the way patients behave. What does make a difference is when patients consistently receive a rapid and effective service. ● Effective urgent healthcare systems have also begun to look at how financial and organisational incentives are aligned to promote the best possible care for patients (role of Urgent & Emergency Care Networks?) ● Important to remember other approaches for improving access to urgent care, especially improving the management of same day urgent care in the 8,200 practices across England.

35. © Primary Care Foundation A process for rapid learning

36. © Primary Care Foundation ● Out of hours services have been under heavy scrutiny ● Review of TCN highlighted organisation slow to learn from mistakes ● Conference in April on Patient Safety highlighted even slower to learn across organisations ● Reviews focus on commissioning and ‘rules’ ● Say less about prevailing culture where few errors are reported A Process for rapid learning sharing experience when things go wrong in out of hours services

37. © Primary Care Foundation ● Learning from others – experience of aviation & maritime sectors ● Initial discussions and trial within the Leadership Group for urgent primary care ● Meeting of national stakeholders including DH, RCGP, CQC, QIPP, NPSA and MPS Testing out this approach

38. © Primary Care Foundation ● Developing an extended pilot with 12 OOH providers ● Simple format – ‘What Happened’, ‘What did you do to address it?’, and ‘What did you learn?’ ● Access a secure website to submit and review reports ● No individuals or organisations are identified ● Commitment to share reports and support learning ● Review at end of pilot (April 2011) ● Seek to change culture within and across organisations, improving patient safety What does it look like?

39. © Primary Care Foundation ● Finding solutions to practical issues e.g. ● Exploring the detailed process for receiving & circulating information ● How do individuals and organisations use this information? ● Is this an effective process for developing learning organisations in out of hours? ● focus on out of hours providers, but a view to shaping 24/7 urgent care ● Seeking funding Next Steps

40. © Primary Care Foundation Commissioning Urgent Care Key points to remember … 1.GP commissioners are well placed to use their clinical knowledge to drive improvements 2.Look at in-hours general practice as the key to unlocking improved performance 3.Understand where there is good information and use it to drive improvements in care 4.Tackle unacceptable variation both between and within services 5.Design individual services and the flow between services with a good understanding of process and volumes 6.A shift in culture to supporting clinicians who report problems is as important as meeting standards 7.develop a compelling local vision for 24/7 urgent care, with 111 as a lever for integrating care 8.There is a cost to tendering – long term contracts may offer more value

41. For more information please go to our new and improved website at www.primarycarefoundation.co.uk Rick Stern 07709 746771 rick.stern@primarycarefoundation.co.uk