Out of Hours Services in the Spotlight: what

Out of Hours Services in the Spotlight: what can we learn from recent The Integrated Care Journey, 19 reviews? May 2010, Adastra National th Conference 2010 Rick Stern David Carson Director, Primary Care Foundation, NHS Alliance Lead for Urgent Care Director, Primary Care Foundation, [email protected] 07709

746771 [email protected] 07703 025775 Primary Care Foundation New Leadership Group for Urgent Primary Care Clinical Director Dr Albert Benjamin Anita Dixon Chief Executive Waldoc CBS (Waldoc Ltd) Alan Franey

Jayne Hetherington Eddie Jahn Dr Darren Mansfield Lesley McCourt Chief Executive Central Nottinghamshire Clinical Services Barndoc Healthcare Ltd General Manager OWLS CIC Ltd Managing Director Harmoni

GP Clinical Lead in Urgent Care NHS Bolton Chief Executive Alison McWilliam Dr Ray Montague Dr Russell Muirhead General Manager Partnership of East London Cooperatives Nottingham Emergency Medical Services Limited (NEMS CBS) Medical Director

Brisdoc Healthcare Services Chairman Shropshire Doctors Cooperative Ltd Primary Care Foundation Emerging Priorities 1. Patient Safety 2. Integrated Urgent Care 3. Demonstrating quality 4. Rebranding Out of hours Primary Care Foundation What we will cover Summarise and reflect on the key points from two reports on out of hours services: 1.General Practice Out-of-Hours Services: project to

consider and assess current arrangements (February 2010) David Colin-Thom, Department of Health & Steve Field, Royal College of General Practitioners 2.Improving out of hours care: what lessons can be learned from a national benchmark of services? Reflections and recommendations for commissioners and providers of out of hours services in England based on the first two rounds of the benchmark in 2009 (January 2010). Henry Clay, Primary Care Foundation. Primary Care Foundation A long history of reports and reviews Department of Health (Carson Review, 2000) Raising Standards for patients: new partnerships in Out-of-Hours care National Audit Office (May 2006) The Provision of Out-of-Hours care in England Four inner London PCTs (May 2007) Report into the death of Penny Campbell

Health Care Commission (September 2008) Not just a matter of time: A review of urgent and emergency care services in England and still to report Care Quality Commission (still ongoing) Enquiry into Take Care Now Primary Care Foundation Key areas in the Departments Review General Practice Out-of-Hours Services: project to consider and assess current arrangements (February 2010) David Colin-Thom, DH & Steve Field, RCGP Commissioning and performance management, including tackling inappropriate variation Selection, Induction, Training and use of out-ofhours clinicians (including the use of locums) Management and operation of Medical Performers Lists

Primary Care Foundation Key areas in the Departments Review: 1. Commissioning & performance management Surprised by lack of compliance with NQRs 5 years on PCT Boards need better scrutiny and oversight of OOH services Limited involvement of PBC The level of variation between organisations and between individual clinicians cannot be justified Now an active performance management issue in NHS Primary Care Foundation Key areas in the Departments Review: 2. Selection, Induction, Training & use of

staff Found most providers do not make assessment of clinical skills or competence of clinical staff rely on Performers List Importance of language test Range of skill mix must be to ensure that patients are seen by most appropriate clinician for condition, not just to reduce use of GPs Use of locum agencies 6 providers using 15 agencies Ensuring staff are not tired or working double shifts? Primary Care Foundation Key areas in the Departments Review: 3. Medical Performers List Protect patients from unsuitable or inefficient practitioners but confusion Implement DH review 2009 Tackling Concerns Locally

As a minimum, doctors should be able to: Converse with patients or their helpers Able to read and understand the BNF Talk to pharmacists & other healthcare professionals Able to arrange admissions to hospitals Better sharing of information across PCTs nationally Primary Care Foundation Actions following on from the Review Reviewing the National Quality Requirements Developing a new national model contract for OOH services Stronger performance management (including

use of English and applying the performers list) Greater involvement of local GPs Primary Care Foundation Key Issues for the future Patient Safety A new initiative for rapidly sharing learning? tighter rules or a cultural shift? Focus on learning and improvement responding to benchmarking and other comparisons across and within organisations Better internal scrutiny good governance and independent NEDs Greater openness and transparency Working as part of an integrated system Networks and accountability Three Digit Number Clarity for the public and patients about using urgent care services

Commissioning for quality Commissioning pathways identifying the cost of quality in urgent care services 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. Most providers have made a rapid transition from rota organising clubs into true healthcare providers. In doing so they have got much better at: Matching capacity to predictable demand, giving ample time for clinicians to do their work well Meeting performance standards Introducing governance processes to ensure a consistent and safe

response to patients Engaging local clinicians in the service. Primary Care Foundation Learning from the first two rounds of the benchmark 2. Patients value a responsive service and associate this with good care. There is a wide difference between wide the difference is between the responsive and the comparatively slow. Primary Care Foundation There is a clear relationship between IPSOS Mori respondents view of speed of response and the rating for the care received 85%

Rating of care received either good or very good 80% 75% 70% 65% 60% 55% 50% 45% 40% 40%

45% 50% 55% 60% 65% 70% How quickly care was received % About right Each dot is one PCT Primary Care Foundation 75% 80%

85% Learning from the first two rounds of the benchmark 3. There are a number of different models for out of hours provider services. Split services and double assessments seem to perform less well than currently reported. Primary Care Foundation Learning from the first two rounds of the benchmark 4. Many providers are falling short on the standard for definitive clinical assessment of urgent cases which we see as an important issue of patient safety. Primary Care Foundation

We reported the percentage of urgent cases that were assessed in 20 minutes 100% 90% Many of these providers had too many cases with double assessment 80% 70% 60% 50% 40% 30% Increasingly falling below standard 20% 10%

0% Each bar is one service a provider/PCT Primary Care Foundation Learning from the first two rounds of the benchmark 5. There is an enormous range across different services in the proportion of cases that are identified as urgent and particular attention should be paid to those that are well below the norm. Primary Care Foundation There is a very striking variation between services in the proportion of cases identified as urgent on receipt Percentage of 70% 60%

cases identified as urgent by non clinical call-handlers 50% 40% 30% 20% How safe? 10% 0% Each bar is one service a provider/PCT Primary Care Foundation How safe?

Learning from the first two rounds of the benchmark 6. There is striking variation in cost, even amongst providers serving communities with similar population density. 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 City/ Rural Mixed Urban 18.00 16.00 14.00 Cost per head

12.00 10.00 8.00 6.00 4.00 2.00 0.00 0.00 20.00 40.00 Each dot is one service 60.00 Population density Primary Care Foundation 80.00

100.00 120.00 Learning from the first two rounds of the benchmark 7. Coding needs to be improved in some key areas. Primary Care Foundation In far too many services it is impossible to be sure how many patients make their way towards hospital 25% 20% We know that many services,

particularly to the left, are under-counting patients going towards hospital 15% Normal band? 10% 5% not credible? suspect 0% Each bar is one service Primary Care Foundation

Learning from the first two rounds of the benchmark 7. We have suggested three criteria to arrive at a small number of 'good all-rounders'. Our conclusion is that those that perform well on all these factors are far from being the most expensive, but also that the very cheap providers do not appear to have the management headroom to perform consistently enough to feature in this group. Primary Care Foundation From variation across organisations to variation between clinicians There is substantial variation within a typical service between individual clinicians. The response will often be shaped more by who deals with the case rather than the details of the case itself.

Developing a consistent, safe and appropriate response does not just involve looking at the outliers, but involves consistent feedback to individuals comparing them with their peers so that they can identify specific things that they might do differently for the benefit of patients and the service. Primary Care Foundation Final reflections: future changes For services All services need to ensure that they are using the results work out how to improve local care it is about using national comparisons to drive local improvements Recent reviews have highlighted the importance of good recruitment, induction, training and continuing support of staff. Some services need to make sure that they are responding to calls more rapidly than is currently the case

For the OOH Benchmark The benchmark will extend to cover all these areas Making the benchmark more open and transparent will ensure that it is more useful to services as a tool for driving improvements Creating a new governance group as well as a user group? Primary Care Foundation Discussion & Questions And for more information, visit our website at: www.primarycarefoundation.co.uk Or contact us: Rick Stern 07709 746771 [email protected] David Carson 07703 025775 [email protected]

Primary Care Foundation

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