1. Benchmark for out of hours How to make sure that the benchmark figures align with yours…. Henry Clay 07775 696360 henry.clay@primarycarefoundation.co.uk

2. © Primary Care Foundation Agenda – and thank you!  Some very detailed and specific points  …and perhaps a more general discussion about how we try to ensure comparability  Time to definitive assessment  Coding  Inconsistent use of the system

3. © Primary Care Foundation I know that there are difficulties…  Wide range of staff, some working irregularly  By definition staff work awkward hours so may be seen infrequently  Difficult to get staff together for training  Not everyone reads the messages or notes issued  Many Adastra systems have legacy coding structures from when the system was less capable than now  There is often little headroom in the contract price to allow these things to be fixed..but the aim is to highlight some of the issues and point you towards solutions

4. Time to definitive assessment Some specific points

5. © Primary Care Foundation Time to definitive clinical assessment – the standard Definitive clinical assessment is an assessment carried out by an appropriately trained and experienced clinician (not a call-handler) on the telephone or face-to-face. The adjective ‘definitive’ has its normal English usage, i.e. ‘having the function of finally deciding or settling; decisive, determinative or conclusive, final’. In practice, it is the assessment which will result either in reassurance and advice, or in a face-to-face consultation (either in a centre or in the patient’s own home).

6. © Primary Care Foundation This slide shows the differences in measuring time to definitive assessment Standard process for a base visit Walk in patient or Call streaming to a base visit – clinical assessment is part of face to face consultation Standard process for a base visit with two assessments (say by a nurse then a doctor) Standard process for a home visit with one assessment but a call by doctor on the way or locked case Key Initial call or contactTelephone assessmentFace to face consultation Green is the time to definitive assessment by the standard, red as measured by most services. Yellow shows the time to face to face consultation. Green is the time to clinical assessment, but the standard does not recognise call streaming. Because of the possible long wait before the patient talks with a clinician it is vital that processes for making and reviewing call-handler decisions are robust. In our analysis these cases are excluded from the main measure of time to assessment Green is the correct way to calculate time to definitive assessment if there are two assessments. Red is as measured by most providers

7. © Primary Care Foundation How to set up to report in line with the standard (1) Set these to Y

8. © Primary Care Foundation How to set up to report in line with the standard (2) Set these to Y

9. © Primary Care Foundation Locking telephone advice calls This puts them back in the advice queue – so they still count as awaiting assessment Lock cases if the assessment is not complete or you are checking something – for example ●The mobile phone signal dropped and you haven’t immediately re- connected ●You need to check if there is a bed available ●You need to check with the poisons specialists ●You need to check with the district nurse before ringing again Do NOT lock the cases if you spot two or three duplicate cases for the same patient Do NOT lock the case if you have finished the assessment, even if ●You plan to ring again later (comfort call) ●You are interrupted and know that you have yet to complete the notes

10. © Primary Care Foundation Suggested solutions… Speak to the Adastra consulting team but look at…  A standard process for dealing with multiple cases to look through them, close all except the earliest without entering any consultation details and record the phone assessment on the first case  Setting up a separate case type and queue for comfort calls  Looking at other case flow methods with your Adastra consulting team such as…..  Using delayed messaging capability as a reminder about a comfort call that is needed  Adopting a standard practice of completing notes promptly in every case (but when this is impossible, closing the case and completing the notes using by editing them)

11. Coding The sorts of problems we see…

12. © Primary Care Foundation Coding Coding – typical issues  Codes where completion is not mandatory so obvious gaps in the record  Drop-down lists with ●insufficient options to cover all possibilities ●so many that users have difficulty  Codes that are confusing and interpreted inconsistently by users  Fields that are used for more than one thing, making use and analysis problematic

13. © Primary Care Foundation Informational outcomes – 106 of them…and they mix condition and outcome Condition Outcome

14. © Primary Care Foundation Informational outcomes – some shorter lists Admission or referral? Different to A&E? By service or GP? What does this tell us? Condition Outcome Difference?

15. © Primary Care Foundation A suggested approach for coding informational outcomes  Completion of the code is made mandatory  Use field for one thing only - to report next contact with NHS  Staff trained to respond consistently  List is comprehensive (to cover each situation) but..  …short enough to be easy to choose  Structured in a logical order Example:  Ambulance/999  GP follow-up recommended  Hospital - A&E  Hospital - for admission  Hospital – for assessment  Hospital – patient choice  No further contact expected  Primary Care – see own GP  Primary Care – WIC/MIU  Primary Care – Other service

16. © Primary Care Foundation Coding – further examples where services confuse themselves (and me!) Call origin  A&E referral  Ambulance call Case type  A&E referral  Ambulance call Case type  Admitted to hospital  999 Ambulance  Asylum seeker Agreed: These were referred FROM A&E and Ambulance service Confused: Were they from or to A&E and Ambulance service? But were these cases assessed by phone or seen face to face?

17. Mis-use of the system …often with the best of intentions!

18. © Primary Care Foundation Clinicians phone a patient when sent a home visit Reasons for the phone call  To confirm likely arrival time, check priority, reassure  Because the doctor thinks that the case can be closed as phone advice  Because the organisation has built it in as part of the process  Appears to be more prevalent where two services are involved or nurses send cases to home visits But it means that you report incorrectly on QR9 and12… …and you say you will visit a patient but then don’t.

19. © Primary Care Foundation Here is an extreme example – this is a random selection of case type home visit but 7/10 have two home visits recorded on the system Advice finishes at 14.24 First ‘home visit’ at 14.38 Second home visit at 16.36 Adastra reports measure QR12 from the end of the advice call to the start of the first hoe visit – which is right…...but only if it was a home visit!

20. © Primary Care Foundation Suggested solution….  Ban doctors from re-assessing cases once a decision has been made for a home visit  Focus your attention on making sure that the right decision is made first time  Enter details of any extra phone call not as if they were the home visit consultation, but as case notes HOW?  And, for the rare occasions where a home visit has to be changed to an advice call, speak to the Adastra consulting team about setting up an informational outcome as ‘given advice – no visit needed’ and set this up to change the case type

21. © Primary Care Foundation Converting a planned base visit to advice when closing a DNA Reason for doing this  Good safety precaution that a clinician should check the case if the patient does not attend – may or may not phone the patient Problems  Clinician goes into case and makes a note – but the system records it as a base visit  Case is changed to advice – but it looks as if it is a second advice call – so time to definitive assessment is wrong Solution  Speak to the Adastra consulting team about setting up an informational outcome as ‘DNA - given advice’ and set this up to change the case type

22. © Primary Care Foundation Failure to count all the cases you have dealt with…  Call-handlers who refer a patient without capturing any details – ‘we don’t have X-ray so you would need to go to A&E’  Solution – training!  Providers who filter all their reports by doctors operating group (say) forgetting that there are some cases where this field is not completed  Solution – check your filters carefully and make sure that you populate the field correctly  Providers where the mapping of practices to PCTs does not reflect the CfH list  Solution – check mapping periodically against latest versions

23. Discussion and questions….

24. © Primary Care Foundation This slide shows the differences in measuring time to definitive assessment Green arrow is time to definitive assessment, yellow to fact to face consultation Standard process for a base visit Walk in patient – clinical assessment is part of face to face consultation Standard process for a base visit with two assessments (say by a nurse then a doctor) Key Initial call or contactTelephone assessmentFailed contactFace to face Failed contact – usually excluded as patient attributable delay Walk in patient – triaged before full face to face consultation F to F Triage Very few services distinguish triage from any other face to face consultation

25. © Primary Care Foundation This slide shows how we handle cases where there is streaming or non-clinical decision-making (provided the process is robust) Streamed direct to a face to face – not included in measure of time to definitive assessment Streamed to telephone assessment followed by face to face consultation Key Initial call including streaming or non- clinical assessment Telephone assessmentFace to face consultation Using NHS Pathways to complete the episode – not included in measure to definitive assessment or to face to face consultation