1. Integrated Urgent Care / 111 5 th January 2017 Dr May Cahill

2. Integrated urgent care (IUC) – what and why?
UEC review and FYF view
Delivery requires closer integration of urgent care services
Integrated urgent care – the offer to the public
Single entry point (111)
Organisational collaboration - fully integrated services
High quality assessment, advice and treatment
Shared standards and processes
Clear leadership and accountability
The Clinical Advice Service (CAS) (aka ‘Clinical Hub’)
Central to the vision
Access to a wide range of clinicians (specialist and generalist)
Available for patients who need it
Also available to health care professionals (HCPs)

3. IUC – The vision
Access, Assessment, Advice, Treatment
The vision:
If I have an urgent need, I can phone a single number (111) and they will, if necessary, arrange for me to see or speak to a GP, or other appropriate clinician / healthcare professional – any hour of the day and any day of the week.

4. The 8 Key Elements of IUC NHSE specification
A single call to get an appointment Out of Hours
Data can be sent between providers
The capacity for NHS111 and OOHs is jointly planned
The Summary Care Record (SCR) is available in the hub and elsewhere
Care plans and patient notes are shared
Appointments can be made to in-hours GPs
There is Joint governance across urgent and Emergency Care providers
There is a Clinical Hub containing GPs and other health care professional

5. IUC from the patient’s perspective
A single number – NHS 111 – for all your urgent health needs
Be able to speak to a clinician if needed
Your health records available to clinicians treating you wherever you are (111, 999, community, hospital)
To be booked into the right service for you, when convenient to you
A clinically appropriate response to 999 which may be: treatment advice by phone, in person by ambulance staff, or taken to hospital
Care close to home (or at home) unless you need a specialist service
Access to specialist care services (e.g. major trauma/stroke) through a network that includes specialist hospitals in your wider area

6. Current 111 arrangements Limitations of current 111 service
Restricted to use of CDSS /pathways algorithm
Risk averse
Over referral to other services
Small % of closed calls / self care
Restricted range of clinicians available
Little direct booking
Patients do not follow advice
Poor patient experience

7. Clinical Advisory Service (CAS)7
Proposed IUC model
Clinical Advisory Service (CAS)
All calls routed through 111 – no direct access to CHUHSE
Introduction of clinical advice service (CAS)
Access to patient notes and care plans
Capability to directly book into other urgent care services
Collaboration with 7 NEL CCGs

8. Aims of the new model To better manage the growing demand by:
Closing more calls within the service (increased advice and self care)
Ensuring that those who need a face to face appointment get the most appropriate service
(closest to home)
Simplified access
All calls through 111, no direct access to GPOOH
Enhanced clinical assessment
Early transfer to CAS for priority groups
Further assessment for interim dispositions
Availability of clinical notes
More treatment within 111
Wide range of clinicians for advice/telephone consultations
Increase number of closed calls
Integration with the rest of the system
Transfer of information
Direct booking

9. Clinical advice service (CAS)
Functions
Clinical assessment
Enhanced clinical assessment for complex patients
Advise, signpost and treat
Patients and HCPs
Outcomes
Definitive assessment – making the best decisions with access to patient notes
Selective onward referral for those who need F2F*
Reduced transfers / handoffs
Increased self care advice
Skill set
Paramedics
Pharmacists
Nurses
ANPs
GPs
*recent testing of this in the Lincoln Clinical Hub showed up to 80% of green ambulance and A&E dispositions can be sent to the Clinical Hub, resulting in up to 70% having an A&E disposition cancelled.

10. Clinical advice service: who is transferred?
Safe/early exit for priority groups
? Pre-existing Care plan
Patients > 75 years
Patients < 5 years
?Streaming of mental health, pharmacy, and dental calls
Interim dispositions
Transferred to a Clinical Advisor in NHS111 (Current)
Speak to GP dispositions
? Urgent contact GP
Green ambulance assessment
A&E referral assessment
Complex cases, multiple symptoms
Refused disposition
Repeat callers
HCPs

11. Current patient model / activity
Own GP/ duty doc
Current patient model / activity
16,662
22,746
999
CHUHSE call handler
A&E (ED and PUCC)
25,407
CHUHSE GP telephone
111
Closed
Self care, etc
35%
55%
15%
Base
CHUHSE GP F2F
Home
999 / ED
Other F2F urgent 7%
999 / ED
Significant percentage of 111 calls are referred to GPOOH
Those referrals are re-triaged by GPOOH (duplication)
and 62% referred as F2F are closed with telephone call
Recorded outcome might not be true end outcome 11 11

12. Comparison of outcomes from CHUHSE and 111
CHUHSE outcomes (May 2015 – March 2016)
111 outcomes (FOT 2016/17)
111 referred 4 times more patients to 999 than CHUHSE
111 referred 1.4 times more patients to A&E than CHUHSE
89% of GPOOH patients needed no further urgent care input

13. Proposed model activity for 2021/22:
Including demographic uplift and re-routing GPOOH
111 is the smart call to make
Own GP/ duty doc
Call 111 before going to A&E
999
43,980
A&E (ED and PUCC)
111
(CDSS)
40%
Exit with original disposition
Early / safe
exit
60%
CAS
Forecast outcomes from CAS not yet received
Evidence suggests downgrade of significant proportion
CHUHSE currently close 62% ‘contact GP’ with telephone consultation – CAS likely to achieve similar
999
A&E
GP / urgent primary care
Pharmacy
Other

14. Impact on the system: concerns
Increased demand on A&E and 999 and over referral to F2F
111 refers more patients to 999 and A&E than CHUHSE
CHUHSE currently closes 62% ‘contact GP’ referrals from 111 with telephone advice
Mitigation: These dispositions will be transferred to CAS for further assessment – but will it produce the same outcomes?
Cost of new IUC will be more than current 111 funding
CAS will manage ‘speak to GP’ dispositions previously managed by CHUHSE therefore a proportion of the budget could be transferred to meet this cost
Savings across the system from reduced duplication and more appropriate onward referral
CHUHSE will not be viable as standalone OOH F2F service
Loss of a high quality, valued service
Reconfiguration of existing services will be required to provide 24/7 F2F response

15. Impact on the system: benefits
Network level CAS maximises efficient use of scarce workforce
GPs advice available 24/7
Wider range of clinicians
Wider range of dispositions can benefit from further clinical assessment / treatment (not just those currently referred to GPOOH)
Achievement of KPIs and standards
(in essence the network CAS aims to act in a similar way to CHUHSE re-triage but will use a wider range of clinicians and pool resources)
All calls through 111 so that all simple calls can managed by CDSS – protecting clinical capacity for those that need it
Aligns with NHSE agenda and will benefit from national branding

16. Current services – providing 24/7 F2F without CHUHSE
Open hours
Workforce
Current actvity
Funding
PUCC
(every day)
NPs x (3 shifts)
GPs x 2 on M, Th, F M: , Th: , Fr: ,
GPx1 on Tu, We, Sa, Su T, Sa,Su:
F2F appts at HUH
22,394
£1,073,000.00
HOPS
1 GP
Specific activity not recorded
£176,000.00
CHAPS
(M-F) (w/end)
Specific activity not measured
£182,400.00
Duty Doctor
(M-F)
43 GPs Phone + F2F
Telephone & F2F in practice and home
£1,500,000.00
GPOOH
(M-F) (W/end & B/H)
2x GP x GP on standby 1x driver 1x call handler
Telephone F2F at HUH and home visits
25,407 telephone 10,337 base 1118 home visit
£2,162,263.26
Paradoc
1x GP 1x Parmedic
F2F Home visit
data from leah
£600,000
Likely that 45-58% of CHUHSE funding will be transferred to IUC ( approx. £1M remaining)
Although telephone activity will be transferred – it is likely that there will be a continued requirement for 2 GPs and 1 driver in OOH period
Current core PUCC budget is approx. £1M – additional £1M from CHUHSE could be sufficient to fund additional GP capacity in OOH period
Consideration to service offered to City patients
Detailed planning requires predicted IUC output (awaited)

17. Do we have any choice?
All calls to be routed through 111 – no direct calls to GPOOH
IUC must include a clinical advice service
performance and interoperability requirements make local provision unfeasible
Transfer of ‘speak to GP’ activity makes CHUHSE funding the logical source for CAS despite the fact that it will destabilise it.

18. Questions ? Do you see any other potential concerns or benefits?
Can you suggest any amendments to the proposed IUC model to minimise concerns?
Do you have any alternative proposals?
different model?
different funding? Could some funding be released from Duty Doctor as 111 will take calls in hours from Patients and HCPs?
What is your opinion on reconfiguration of existing services

19. Appendices

20. 20

21. NHSE Quarterly return: Delivery of the 8 key elements
2121
NHSE Quarterly return: Delivery of the 8 key elements
For calls to 111 made in the out of hours period, where the disposition agreed with the caller corresponded to “Contact Primary Care Service”, and which resulted in a face-to-face appointment with a clinician: Did more than 70% of these calls have the appointment booked before the call ended?
For calls to 111, where the disposition agreed with the caller corresponded to “Contact Primary Care Service”, and which resulted in an in-hours face-to-face appointment with a clinician: Did more than 5% of these calls have the appointment booked before the call ended?
For calls to 111 where the patient needed further contact (either face-to-face or on the telephone): Did more than 50% have the information captured during the first call available to the next person to make contact? If the next person was in a different organisation, information must have been shared point-to-point, or via the Interoperability Toolkit.
For calls to 111 or 999 that were transferred to a clinician: Did more than 50% have the Summary Care Record available to that clinician?
Does the organisation that receives Care Plans and Special Patient Notes share them with the Ambulance Service and all organisations providing the IUC service?
Within the clinical hub, 24 hours a day, seven days a week, was there at least one GP working?
Of calls answered, did more than 30% result in a patient speaking to a clinician?
Were capacity plans made jointly by the providers of NHS 111 and Out of hours care, and approved by commissioners?
Did a multi-disciplinary team carry out End to End reviews, and share consequent actions with the UECN, via the IUC clinical lead? Reviews must include calls to 111, to 999, and face-to-face Out of hours consultations.
Was more than 50% of the CCG population covered by either a single IUC contract, or an overarching agreement linking the contracts for NHS 111 and Out of hours services?
Did the Urgent and Emergency Care Network (UECN) discuss and give feedback on the plans for IUC procurement?
Was there a lead CCG arrangement in place for the NHS 111 / IUC contract, with just one CCG negotiating with the provider? And if there was still a separate OOH contract, did that have a similar lead CCG arrangement?
Did the UECN discuss and give feedback on plans for workforce retention and development in IUC?
Was the Directory of Services (DoS) set up to provide accurate, real-time information to searches by NHS Pathways, Integrated Urgent Care services and mobile applications?
Did more than 50% of green ambulance dispositions (via 999 or 111) receive clinical assessment, in addition to the AMPDS / NHS Pathways Health Advisor assessment?