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Out of Hours Care: Empowerment at a Local Level
Rick Stern Director, Primary Care Foundation, NHS Alliance Lead for Urgent [email protected] 07709 746771
Primary Care Live 2010 25th November 2010 Manchester Central
© Primary Care Foundation
The Primary Care Foundation developing best practice in primary and urgent care
A resource for commissioners of urgent care
© Primary Care Foundation
New Leadership Group for Urgent Primary Care
Dr Albert Benjamin
Clinical Director Waldoc CBS (Waldoc Ltd)
Anita Dixon Chief Executive Central Nottinghamshire Clinical Services
Alan Franey Chief Executive Barndoc Healthcare Ltd
Eddie Jahn Managing Director Harmoni
Dr Darren Mansfield
GP Clinical Lead in Urgent Care
NHS Bolton
Lesley McCourt Chief Executive Partnership of East London Co-operatives
Alison McWilliam General Manager Nottingham Emergency Medical Services Limited (NEMS CBS)
Dr Ray Montague Medical Director Brisdoc Healthcare Services
Dr Russell Muirhead
Chairman Shropshire Doctors Cooperative Ltd
Diane Ridgeway Chief Executive East Lancashire Medical Services Ltd
Gilly Wilford Director of Finance & Contracts
South East Health
Nigel Wylie Chief Executive Urgent Care 24
© Primary Care Foundation
Emerging Priorities
1. Patient Safety
2. Integrated Urgent Care
3. Demonstrating quality
4. ‘Rebranding’ Out of hours
© Primary Care Foundation
What I will cover
1. What can we learn from recent reviews?2. What is the emerging national agenda
for urgent care3. What can we learn from the national
benchmark and how has it driven local improvements?
4. Changing the culture of out of hours services – a new initiative
5. The future for out of hours services and opportunities for local empowerment
© 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
● Primary Care Foundation (January 2010) Improving out of hours care: what lessons can be learned from a national benchmark of services?
● Department of Health (February 2010) General Practice Out-of-Hours Services: project to consider and assess current arrangements
● Care Quality Commission (July 2010) Investigation into the out of hours services provided by Take Care Now
© Primary Care Foundation
Key areas in the Department’s ReviewGeneral Practice Out-of-Hours Services: project to consider and assess current arrangements (February 2010) David Colin-Thomé, DH & Steve Field, RCGP● Commissioning and performance management,
including tackling inappropriate variation ● Selection, Induction, Training and use of out-of-
hours clinicians (including the use of locums)● Management and operation of Medical
Performers Lists
© Primary Care Foundation
Key issues raised by the CQC’s Review Investigation into the out of hours services provided by Take Care Now (July 2010)For Providers● TCN failed to recognise the importance of learning lessons, failing to act on two
similar previous incidents involving overdoses of diamorphine● TCN struggled to recruit local GPs and relied heavily on doctors flying in from
Europe to work weekends● TCN tolerated staffing levels that were potentially unsafe, with pressure on
other staff (e.g. one nurse covering alone at night)● TCN’s systems for medicines management were inadequate leading to
controlled drugs being stored and administered inappropriately● The performance reported to PCTs on NQRs did not accurately reflect their
actual performance● TCN grew too rapidly and the focus on expansion and business priorities was at
the expense of governance and clinical services
© Primary Care Foundation
Key issues raised by the CQC’s Review Investigation into the out of hours services provided by Take Care Now (July 2010)For Commissioners● 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.● 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.
● The PCTs had all recently tightened their procedures in respect of their performers lists, although there were still different levels of scrutiny.
© Primary Care Foundation
●Integrated 24/7 care is about greater coherence
●Patients will be free to choose how and when to access care - meeting needs not re-educating
●Simpler routes into the system – 999, 111 & web based self assessment
●Consistency in clinical assessment – not redirecting
National Agenda for Urgent Care: developing integrated 24/7 urgent care
© Primary Care Foundation
●New metrics for urgent care – quality indicators and standards – starting with A&E, but across pathway
●New role for GP commissioners
●Crucial role of general practice as the main provider
●Developing a single point of access - 111
●Clarity about the separate parts of the system – should ‘do what it says on the tin’
●Realigning incentives
●New technologies – especially telecare
●Role of QIPP in prioritising urgent care
Key initiatives: developing integrated 24/7 urgent care
© 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
© 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 September 2010
●Fourth benchmark, again a full benchmark including patient experience with complete overhaul of questions to ensure full compliance with CQC report
© 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
© Primary Care Foundation
12 headline indicators
Cost1. Cost per head2. Cost per case
Productivity3. Number cases per clinician per hour
Outcomes4. Referrals to hospital (if possible,
sub-divided between referrals to A&E and referral to a hospital bed)
5. Overall breakdown of dispositions (advice/PC Centre/home visit)
6. % Calls classified Urgent on receipt
Process7. The quality of clinical governance systems
and processes
Performance8. Time to clinical assessment for all calls as a
%age 9. Time to face to face consultations for urgent
calls (including % urgent after assessment)
Patient Experience10.Patient experience of receiving telephone
advice11.Patient experience of treatment at a centre12.Patient experience of home visits
© Primary Care Foundation
Learning from the first two rounds of the benchmarkImproving out of hours care: what lessons can be learned from a national benchmark of services? January 2010, PCF1. Out of hours services are improving 2. Patients value a responsive service3. Split services and double assessments seem to
perform less well4. Many providers are falling short on the standard for
definitive clinical assessment of urgent cases5. 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
© 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
40%
45%
50%
55%
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65%
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85%
40% 45% 50% 55% 60% 65% 70% 75% 80% 85%
How quickly care was received % About right
Rat
ing
of
care
rec
eive
d e
ith
er g
oo
d o
r ve
ry g
oo
d
Each dot is one PCT
© Primary Care Foundation
We reported the percentage of urgent cases that were assessed in 20 minutes…
0%
10%
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30%
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60%
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80%
90%
100%
Increasingly falling below standard
Many of these providers had too many cases
with double assessment
Each bar is one service – a provider/PCT
© Primary Care Foundation
0%
10%
20%
30%
40%
50%
60%
70%
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?
How safe?
© 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
£0.00
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0.00 20.00 40.00 60.00 80.00 100.00 120.00
Population density
Co
st p
er h
ead
●Rural City/Urban
●Mixed
Each dot is one service
© Primary Care Foundation
0%
5%
10%
15%
20%
25%
Normal band?
suspectnot credible?
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
© 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?
© 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
© Primary Care Foundation
Example provider
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Phone Walk
Average demand by day is predictableTotal of all services
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Phone Walk
© Primary Care Foundation
Services fall short of the quality requirements Definitive assessment of urgent cases in 20 minutes …
Services ranked by % of urgent cases started definitive assessment in 20 minutes:Average across all services is ranked 41 out of 98
Red shows % where definitive assessment starts in 20 minutes. Green shows the figure where a first attempt to assess was begun in 20 minutes. Average across all services is at 79.6% (definitive) plus 8.3% (to first attempt)
ALL 7
9.6%
0%
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© Primary Care Foundation
0
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A: less than 20 mins B: 20 to 40 mins C: 40 to 60 mins D: 1 to 2 hrs E: 2 to 4 hrs F: Over 4 hrs
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
A: less than 20 mins B: 20 to 40 mins C: 40 to 60 mins D: 1 to 2 hrs E: 2 to 4 hrs F: Over 4 hrs
Reason number 1 – Not enough people on the busy days to keep up with demand
At weekends and bank holidays significant numbers of cases are above the green and are taking more than an hour to definitive assessment
This is the picture by hour for the weekends – the service gets behind in the busy morning period and takes a long time to catch up
© Primary Care Foundation
Reason number 2 – unmanaged variability between individuals
Advice Advice Advice Advice Advice Advice Advice Advice Advice Advice Base Base Base Base Base Base Base Base Base Base Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9 10 11 12 13 14 15 16 17 Average 9 10 11 12 13 14 15 16 17 Average 9 10 11 12 13 14 15 16 17 Average03236bf5-45d0-43fa-99a3-d3046a61587b 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 4.0 0 0 0 0 0 0 0 0 00d74c10a-ef6d-4e77-b563-5134e2feda2a 0 0 0 3 0 0 0 0 0 3.0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 1 0 1 1.51849ef44-8b17-403a-9a43-42536f23f51a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 1 2 1.518b8e095-b3db-4bb8-adbd-c2b2d21eae22 4 0 0 1 0 0 0 0 0 2.5 1 4 4 4 0 0 0 0 0 3.3 0 0 0 0 0 0 0 0 01a9fd568-9663-4ad0-83f3-3bf946820c56 0 0 0 0 3 9 5 0 1 4.5 0 0 0 0 0 0 0 0 5 5.0 0 0 0 0 0 0 0 0 0244e88e6-bf0d-4566-a1d7-c989a55ac03f 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1.0 0 0 0 0 0 0 0 0 000fae413-c635-4429-b535-1461d2735afa 0 0 0 0 0 6 1 2 1 2.5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 004359181-3438-485f-9677-1d4823523a55 0 1 2 0 0 0 0 0 1 1.3 2 1 0 3 2 3 4 3 3 2.6 0 0 0 0 0 0 0 0 0076ebd21-813d-4c59-959a-3f2f0d0bc7e4 0 0 0 0 0 0 0 0 0 0 0 0 0 4 4 4 6 3 4.2 0 0 0 0 0 0 0 0 0088f53e7-5bfb-44e2-9b46-b089ba720a5c 3 0 0 1 1 0 0 0 0 1.7 1 4 3 1 0 0 0 0 0 2.3 0 0 0 0 0 0 0 0 00d8234b0-a4c0-4f3f-85d0-76eb599165a3 0 0 0 0 0 0 0 0 0 0 1 0 2 0 0 0 0 0 1.5 0 0 0 0 0 0 0 0 00dc7cac4-99d6-4d17-bb94-9ec98bcd723f 0 0 0 0 0 0 0 0 0 1 5 1 4 3 2 0 0 0 2.7 0 0 0 0 0 0 0 0 0125105b1-8f26-11d9-85d1-0002b35d7fe5 0 0 0 1 0 0 0 0 0 1.0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1.012510602-8f26-11d9-85d1-0002b35d7fe5 8 6 2 0 0 0 0 0 0 5.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 012510611-8f26-11d9-85d1-0002b35d7fe5 0 0 0 0 0 0 0 0 0 0 3 3 3 3 0 0 0 0 3.0 0 0 0 0 0 0 0 0 012510623-8f26-11d9-85d1-0002b35d7fe5 0 0 0 0 0 1 0 0 0 1.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1.012510628-8f26-11d9-85d1-0002b35d7fe5 3 3 3 5 0 0 0 3 1 3.0 0 0 0 0 0 0 0 1 2 1.5 0 0 0 0 0 0 0 0 0125106ab-8f26-11d9-85d1-0002b35d7fe5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 6 2 3.5 0 0 0 0 0 0 0 0 04e3c24ba-1308-4dba-a851-2ea37eadd5a5 15 17 11 11 13 0 0 0 0 13.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 014faae0a-c609-4a09-bc94-9a469096f2ad 1 1 2 5 3 2 3 4 2 2.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Standard values for comparison
Phone advice 6 minutes
Base F2F 12 minutes
Home visit 30 minutes
All All All All All All All All All All Weight Weight Weight Weight Weight Weight Weight Weight Weight28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9 10 11 12 13 14 15 16 17 Average 9 10 11 12 13 14 15 16 17 3503236bf5-45d0-43fa-99a3-d3046a61587b 4 4.0 48.0 4.0 480d74c10a-ef6d-4e77-b563-5134e2feda2a 3 2 2 1 1 1.8 18.0 60.0 60.0 30.0 30.0 1.8 401849ef44-8b17-403a-9a43-42536f23f51a 1 2 1 2 1.5 30.0 60.0 30.0 60.0 1.5 4518b8e095-b3db-4bb8-adbd-c2b2d21eae22 5 4 4 5 4.5 36.0 48.0 48.0 54.0 4.5 471a9fd568-9663-4ad0-83f3-3bf946820c56 3 9 5 6 5.8 18.0 54.0 30.0 66.0 5.8 42244e88e6-bf0d-4566-a1d7-c989a55ac03f 1 1.0 12.0 1.0 1200fae413-c635-4429-b535-1461d2735afa 6 1 2 1 2.5 36.0 6.0 12.0 6.0 2.5 1504359181-3438-485f-9677-1d4823523a55 2 2 2 3 2 3 4 3 4 2.8 24.0 18.0 12.0 36.0 24.0 36.0 48.0 36.0 42.0 2.8 31076ebd21-813d-4c59-959a-3f2f0d0bc7e4 4 4 4 6 3 4.2 48.0 48.0 48.0 72.0 36.0 4.2 50088f53e7-5bfb-44e2-9b46-b089ba720a5c 4 4 3 2 1 2.8 30.0 48.0 36.0 18.0 6.0 2.8 280d8234b0-a4c0-4f3f-85d0-76eb599165a3 1 2 1.5 12.0 24.0 1.5 180dc7cac4-99d6-4d17-bb94-9ec98bcd723f 1 5 1 4 3 2 2.7 12.0 60.0 12.0 48.0 36.0 24.0 2.7 32125105b1-8f26-11d9-85d1-0002b35d7fe5 1 1 1 1 1.0 30.0 30.0 30.0 6.0 1.0 2412510602-8f26-11d9-85d1-0002b35d7fe5 8 6 2 5.3 48.0 36.0 12.0 5.3 3212510611-8f26-11d9-85d1-0002b35d7fe5 3 3 3 3 3.0 36.0 36.0 36.0 36.0 3.0 3612510623-8f26-11d9-85d1-0002b35d7fe5 2 1 1 1 1.3 36.0 30.0 30.0 30.0 1.3 3212510628-8f26-11d9-85d1-0002b35d7fe5 3 3 3 5 4 3 3.5 18.0 18.0 18.0 30.0 30.0 30.0 3.5 24125106ab-8f26-11d9-85d1-0002b35d7fe5 3 3 6 2 3.5 36.0 36.0 72.0 24.0 3.5 424e3c24ba-1308-4dba-a851-2ea37eadd5a5 15 17 11 11 13 13.4 90.0 102.0 66.0 66.0 78.0 13.4 8014faae0a-c609-4a09-bc94-9a469096f2ad 1 1 2 5 3 2 3 4 2 2.6 6.0 6.0 12.0 30.0 18.0 12.0 18.0 24.0 12.0 2.6 15
Average contacts per hour
Weighted standard minutes per hour
Average weighted standard minutes
Clinician identifier Number of phone consultations by hour for each clinician
Number of base consultations by hour
Number of home visits by hour
Number of contacts by hour
Weighted SMV ‘earned’ per hour
This is illustrative data
© Primary Care Foundation
Final reflections on the benchmark: future changes
For services● All services need to ensure that they are using the results: it is
about using national comparisons to drive local improvements● Some services need to make sure that they are responding to calls
more rapidly than is currently the case● The big difference between providers is how they support their
staff ensuring good governance and reducing unnecessary clinical variation
For the OOH Benchmark● The benchmark has now been extended 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● Created a new national steering group as well as a user group● Future in the new world?
© Primary Care Foundation
Key Issues for local empowerment● Patient Safety is always the top priority
● A new initiative for rapidly sharing learning? ● tighter rules or a cultural shift?
● There is now better performance date – use it!● responding to benchmarking● Better internal scrutiny – good governance and independent NEDs● Greater openness and transparency
● Work as part of a 24/7 integrated urgent care system● Networks and accountability● Three Digit Number● Clarity for the public and patients about using urgent care services
● Commissioning for quality – new leaders in the system
● Now driven by GP commissioning groups● Commissioning pathways● identifying the cost of quality in urgent care services
© Primary Care Foundation
The future for commissioning out of hours services GP Newspaper 18th November 2010● GP commissioners are well placed to use their
clinical knowledge to drive improvements.● It will be important to work closely with other
services to commission at the right level.● There is now good benchmark information to help
identify areas for improvement.● Time and attention is needed. Unless GP consortia
give out-of-hours care the priority it deserves, it may come back to haunt them.
● A shift in culture to supporting clinicians who report problems is as important as meeting standards..
