Urgent Care Transformation in Richmond Background briefing paper 14 July 2016 Victoria Otley Groom – Director of Commissioning Attracta Asika – Head of Primary and Urgent Care Anca Costinas – Commissioning Manager (Urgent Care)

Programme Presenter Time Activity/Topic 14.00 – 14.10 Welcome and introductions Dr. Graham Lewis Objectives of the session 14.10 – 14.20 Objectives Victoria Otley - Groom 14.20 – 14.30 Defining urgent care 14.30 – 14.40 How does the current urgent care system work Anca Costinas 14.40 – 14.50 Why is change needed? Attracta Asika 14.50 – 15.00 What do our patients need? 15.00 – 15.15 What does a good service look like? (proposed approach for services) 15.15 – 15.25 What needs to change for patients in Richmond? 15.25 – 16.20 What options are in Richmond to get good quality patient centred care closer to home? Principles for change Evaluation criteria High level options All (in tables) 16.20 – 16.30 How do we work together? (communication, additional network members) 16.30 – 16.40 What is next? 16.40 - 16.50 Have we achieved our objectives? 16.50 – 17.00 End of session 2

Objectives of the day What do our patients need? What does a good service look like? Defining urgent care Why is change needed? How does the current urgent care system work? What needs to change? What options are in Richmond to get good quality patient centred care closer to home? What is next? Who is involved? How will we communicate with you? Have we achieved our objectives? 3

Defining Urgent and Emergency Care By definition*, Urgent and Emergency Care includes the following services : for people with non-life threatening short-term illnesses or health problems for which they need prompt and convenient treatment or advice. that are set up to provide safe and high quality management of urgent and emergency care needs of the population 24 hours a day, seven days a week for people who have pre-existing health problems which fluctuate or deteriorate. A small proportion of people suffer from serious illness or have a major injury which requires swift access to highly-skilled, specialist care to give them the best chance of survival and recovery. To meet these needs an improvement in information and advice and access to timely and appropriate urgent and emergency care, across the 24hour period within the Richmond, is required. *Urgent Care Review , January 2013 4

Motto of the day!!!! 5

Current services for Richmond patients 6

What is in the current urgent care health system for Richmond? Service provision (17 services) Where (Richmond and SWL) Level of influence A&E KHFT Medium/ Low WMUH Acute Assessment Unit Medium/Low Urgent Care Centre Paediatric Assessment Unit Low Walk In Centre TMH High Queen Mary`s Medium GP Core Hours Borough wide GP Out of Hours GP extended Hours Primary Care Hubs Minor Injuries Unit NHS 111 High/Medium London Ambulance Service Pharmacies (45) 7

National and local drivers Why is change needed? (1) National and local drivers 1950s for 2020s 8

r three gaps - to be met through the STP Why is change needed? (2) Sustainability for health services – (South West London STP) r three gaps - to be met through the STP Gap 1: Improving health and wellbeing Growing and ageing population, but also an unusually young population. Inequalities with pockets of deprivation that are linked to poorer health and wellbeing outcomes Prevention in early years could be improved (focus on childhood obesity) The number of people living with dementia is rising and embedding high quality dementia care into services is key. Developing cross partner prevention plans The development of this plan has been welcomed as an opportunity to improve collaboration between the NHS and local authorities. Gap 2. Improving care and quality Our care and quality base case demonstrates: We are failing to meet minimum standards for acute urgent and emergency care More could be done in the community to reduce the amount of care delivered in hospitals We can do more to improve the quality of general practice We are not consistently meeting the needs of people who have mental health needs or dementia Underlying factors Two main factors underpin these gaps in the quality of our services: The lack of an available workforce to provide safe, effective care in the existing configuration of services The provision of preventative and proactive care, including primary care and services supporting earlier discharge from hospital, is inadequate. Gap 3: Improving finance and efficiency The cost of delivering services is rising much faster than inflation due to rapidly increasing demand; this is creating a financial gap which will make current services unaffordable by 2020/21 if we do not make changes now. Our initial analysis suggested that if we do nothing, the financial gap in five years would be £900m. We believe that making changes to the way in which services are delivered can deliver changes that improve the quality of care as well as making services more cost-effective to the taxpayer. 9

Why is change needed? (3) Good patient flow National Agenda (Transforming Urgent and Emergency Care In England – August 2015) 6 key areas Good patient flow Governance and whole system partnership Commissioning Demand management Escalation plans Interdependencies 10

High level proposed model for Urgent Care services in Richmond 11

What needs to change? Duplication of resources and services creating confusion for patients and inefficiencies at a financial loss Residents have many ways of accessing care services but we haven`t seen a reduction in emergency hospital admissions (although Richmond is in a good place compared to other SWL CCGs for emergency admissions and attendances to A&E) There is not enough emphasis on proactive and preventative care Signposting can be a confusing and complex process and needs to be coordinated IT systems are not talking to each other at present Underutilisation of voluntary sector, community resources and pharmacies Lack of integration for NHS 111 with other services 12

Attendances for Richmond patients 13

Accident and Emergency (A&E) attendances Increase in Kingston Hospital A&E attendances by 3.3% (14/15 compared to 13/14) and an increase of 3.21% (15/16 compared to 14/15) Increase in West Middlesex A&E attendances by 1.4% (15/16 compared to 14/15) Increase in Other providers A&E attendances by 6.83% (15/16 compared to 14/15) The majority of minor and major A&E attendance happens between 8am and 6pm. Roughly equal attendance every day of the week, with elevation on Mondays. People who attend A&E the most are : children (0- 4), people aged over 75, people aged 35 – 40 due to trauma, alcohol etc. 14

Activity at WMUH UCC has increased by 8.34% (15/16 compared to 14/15) Attendances at the Urgent Care Centre (UCC) - West Middlesex University Hospital ( WMUH) and at the Walk In Centre (WIC) - Teddington Memorial Hospital (TMH) Activity at WMUH UCC has increased by 8.34% (15/16 compared to 14/15) Activity at TMH WIC has increased by 11.49% (15/16 compared to 14/15) The UCC at WMUH is open 24 hours a day for the whole year TMH WIC attendances are constrained to opening hours and peak at opening hours (8am). For the rest, attendances are fairly constant between about 10am and 8pm. The Walk-in Centre sees an increase in attendance at the weekend. 15

NHS 111(Kingston and Richmond calls) Number of calls has increased by 33.5% (Mar 16 compared to April 15) for both Richmond and Kingston 16

Out of Hours service Operated by East Berkshire Primary Care out of Hours services Activity hours are from 06.30 pm to 8.00 am weekdays and weekends (from 06.30 pm Fridays to 8.00 am following Monday) Increase in activity for March `16 total calls per month increased by 29.6% (compared to Feb 2016) increase of 37% of total PCC calls (compared to Feb 2016) 32% of calls – children (0-10) 17

Directed Enhanced Services (DES) A snapshot of indicative costs of 6 out of 17 services currently used in Richmond (based on the national tariff) A&E Cost may vary from £57 to £246 per attendance (minor/major A&E) UCC £57/per attendance WIC GP Core hours £27.2 per attendance/per year Extended hours £27.81 per attendance/per year Directed Enhanced Services (DES) £29.71 per attendance/per year *Analysis underway for the other services 7

Service provision in Richmond 19

Conclusions Increase of activity in all services Significant overlap between services available 24/7 in the community and urgent care services Increase in A&E attendances in spite of all the available services in the community Patients are confused about which service to access and when - this leads to inappropriate use of services Some services in the community (vol. sector and pharmacies etc.) are underutilised Current provision is not financially sustainable 20