Joined up urgent care provision February 2011 Henry Clay:

© Primary Care Foundation The Primary Care Foundation has looked urgent care from a number of angles Reports for Department of Health ●Primary Care in A&E ●Urgent Care in general practice ●Benchmark of out of hours services ●Urgent care centres (report with DH) Various projects for: ●Hospital Trusts ●PCTs ●PBC Groups ●Commercial and mutual provider organisations

© Primary Care Foundation Topics that I aim to cover... ●Why it matters…. ●How to commission for safety and consistency – measures and what you should expect of the provider ●How to link services – and how not to! ●How to develop your provider over time ●Looking at Primary Care too….

© Primary Care Foundation

The CQC investigation highlighted shortcomings in commissioning ●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. ●Staff did not fully understand the national quality requirements or TCN’s reports on activity and performance ●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.

© Primary Care Foundation The Health secretary believes that GP Commissioners will fix it!

© Primary Care Foundation Key message – you get what you insist on Alternatively, you get what you deserve ●You need a wide range of measures – and making comparison is vital ●Services have to manage clinicians if they are to perform effectively and consistently ●Each part must work well if you are to have a hope of joining different parts – and a similar wide range of measures is needed ●You will need to look at how practices deliver their share of care ●Look to establish contracts for longer and to drive improvements over a period

© Primary Care Foundation What qualities should data about a clinical service exhibit? ●Competently collected and collated ●Correct ●Clear, well presented information ●Consistent – to allow comparison within the data set and over time ●Complete – it should provide a full picture of all aspects ●Compare and contrast outcomes – so we can understand the cause of differences and which innovations work ●Collaborative - to secure the information and to engage stakeholders ●Communicate – so that users can understand what it means ●Convincing – if users are to change what they do based on the evidence ●Challenge or corroborate assumptions about clinical practice and outcomes ●Costed – because of the requirement for efficiency we need this too

© Primary Care Foundation A wide range of measures to give a rounded picture is needed if perverse incentives are to be avoided A&E departments ●Ambulatory care ●Unplanned re-attendance ●Total time spent ●% leaving before being seen ●Patient experience ●Time to initial assessment ●Time to treatment ●% with consultant sign-off Out of Hours benchmark ●% definitively assessed in 20 and 60 minutes ●% answered in 60 seconds ●% with face to face consultation in 1, 2 and 6 hours ●% of urgent cases ●Patient experience ●% of patients going to 999/hospital ●Cost per case, cost per head ●Productivity

© Primary Care Foundation There are big differences between services (four London A&E departments looking at % discharged by 10 minute slots) 22.7% admitted 13.9% admitted 28.5% admitted 18.3% admitted

© Primary Care Foundation There are big differences between services delivering out of hours care (this looks at QR9 for urgent cases in 20 minutes….)

© Primary Care Foundation..and there are big differences in what they identify as urgent Those with higher levels of urgent on receipt find it difficult to better 90% definitively assessed in 20 minutes These have low %urgent on receipt but have a low percentage of urgent cases assessed in 20 minutes

© Primary Care Foundation In general it costs more to provide OOH cover in a rural PCT than an urban one (but there are wide variations within any band)

© 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

© Primary Care Foundation The majority of services give telephone advice in 40 to 50% of cases and offer home visits to 10 to 17%. % Advice % Home visits

But whatever the variation between services the variation between individuals will be greater This looks in greater detail within a service to demonstrate this variation

© 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%

© 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

© Primary Care Foundation For one provider showing percentage urgent and less urgent by call handlers (over 50 cases)

© Primary Care Foundation Same service, same call-handlers but showing the proportion that had priority changed by clinicians Less urgent on receipt changed to emergency or urgent is at the bottom

© Primary Care Foundation Integrating services – some guidelines for designing the process ●Describe the process – in sufficient detail to engage clinical staff ●Identify the underlying principles and objectives around the patient pathway. Avoid hand-offs and batching ●Count the cases – How many, by hour of day are we talking about? ●Recognise the cost and resource implications of dividing the cake ●Use the information to prove, refine and redesign the process

© Primary Care Foundation A model format A service delivery model for urgent care centres – commissioning advice for PCTs centre-guidelinesFINAL.pdf

© Primary Care Foundation ● Why not expect ED to communicate episode too? ● Who is in charge if resource needs to be redeployed? ● How do you ensure governance processes look at the whole patient pathway? ● Is it at the front or alongside? ● Who does this?

© Primary Care Foundation Do you really need UCC and ED alongside each other for less than 5 cases an hour? How can we make this work – streaming is to take place before diagnosis How will we define clinical assessment?

© Primary Care Foundation Counting the cases – demand is predictable, in this example by age bands….

© Primary Care Foundation …average demand by hour of day is also entirely predictable

© Primary Care Foundation …and the random variation within an hour is exactly what would be expected

© Primary Care Foundation Staffing to provide a 15 minute initial consultation (within 15 minutes in 80% of cases) totals 92 hours in the week Five to six staff Two staff

© Primary Care Foundation Splitting it into two by separating children under 16 increases the staffing to 119 hours in the week (+30%) Six to eight staff Three staff

© Primary Care Foundation When integrating services, commissioning new services or reviewing existing services ●Check that each separate service is operating properly and use the same measures across services (but recognise the reasons for variation) ●Beware of establishing urgent care services that actually meet primary care needs (but recognise that all urgent care services have to provide some follow-up care) ●Be very careful of making sure that savings are real ●Too often the tariff is compared with only part of the direct cost ●Look at the saving to tax-payer – if the justification is reducing cost of A&E tariff then there not only has to be a reduction in the numbers attending, but A&E also have to employ less people

© Primary Care Foundation You should look carefully at the length of the contract…. Short contract ●We can change the specification if it is wrong ●We can change provider if they are no good ●We may be paying over the odds ●We need the lever of competition Long contract ●The provider can invest in ●Equipment and IT ●Facilities ●Developing the team ●Training

© Primary Care Foundation Care will not be as good and costs will be higher if the contract is short Short contract ●We can change the specification if it is wrong ●We can change provider if they are no good ●We may be paying over the odds ●We need the lever of competition Long contract ●The provider can invest in ●Equipment and IT ●Facilities ●Developing the team ●Training ●We can work with the provider to develop the service ●We can change the provider if they are no good ●We can demand an action plan if the cost is greater than a level related to comparators ●You have the lever of competition

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

© 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

© Primary Care Foundation Acute Admission Timeline ● 8.30 ● ● ● ● 3 Hours ● 2 Hours ● 2 (often 4) Hours ● 8.30 ● 8.45 ● ● ● 15 Minutes ● 1 Hour Just as hospital staff go home! In time to set up alternative to hospital Early enough to avoid risk of deterioration

© Primary Care Foundation A new approach ●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

© Primary Care Foundation What do we look at? ●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

© 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 ●Once these issues are addressed, there are a range of options – the practice will need to identify what works for them

© Primary Care Foundation Commissioning Urgent Care Key points to remember … ●GP commissioners are well placed to use their clinical knowledge to drive improvements ●Define what you want and use good comparative information to drive improvements in care ●Tackle unacceptable variation - both between and within services ●Design individual services and the flow between services with a good understanding of process and volumes ●Don’t forget the role of general practice ●Long term contracts will allow you to shape long-term improvement in care

Henry Clay