Severn Urgent and Emergency Care Network
Workstream 1 – Integrated Clinical Hub
Project Initiation Document
1
Project aim
To develop and support the implementation of a model of care for an Integrated Clinical
Hub (across 111/ambulance service /Out of Hours provider s across the Severn Urgent
and Emergency Care Network area) which will facilitate patients being sent to the right
service first time.
2
Project Objectives
2.1
To minimise the number of ‘hand-offs’ between different people and different
organisations to avoid unnecessary re-triage or re-work.
2.2
To ensure patients are advised to use the most appropriate care setting in a timely
manner first time
2.3
To reduce the number of Green ambulance referrals from NHS 111 where clinically
appropriate
2.4
To reduce the number 1 and 2 hour dispositions from NHS 111 to OOH where
clinically appropriate
2.5
To reduce the number of A&E referrals from NHS 111 where clinically appropriate
2.6
To increase the number of self-care referrals from NHS 111 where clinically
appropriate
3
Project stages
Stage 1 – Diagnostic and mapping

To understand the current flow from NHS111 to other services and map current
referral process

To understand number of unnecessary ‘hand-offs’ and ‘re-triage

To map desired state, including Integrated Clinical Hub
Stage 2 - Development of options

To define the potential options available to manage or refer patients to the most
appropriate service first time.
o
Options for short term – winter 15/16
o
Options for medium term – 1-3 years
Stage 3 - Model development

Using the available data, quantitative and qualitative (including costs), develop a new
model of care
Stage 4 - Testing
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To test new model of care over a defined time period with an agreed methodology
(PDSA) and agreed measures of success
Stage 5 - Evaluation

To evaluate the new model to determine effect on the system and provide a list of
recommendations
Stage 6 - Commission based on evidence

To support any required changes to commissioned services

To review/amend and develop existing and new Key Performance Indicators(KPIs)
4
Approach
Stage 1 – Diagnostic and mapping
Task - To understand the current flow from NHS111 to other services and map
current referral process (Note: as of Oct 15, many actions now complete)
Approach:
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Define all NHS 111 facing service providers across Severn UECN
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Determine what information is available on;
o Out of hours providers
o 111 providers
o Ambulance providers

Determine the flow to and from NHS111, GPOOHs, Ambulance and ED
services.
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Request relevant analytical support
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Request and collect desired information
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Collate and analyse data
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Determine likely benefits required/expected.
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Produce analytical report
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Collect available process diagrams from relevant sources
o Providers
o Commissioners
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Organise a stakeholder event bringing together relevant parties.
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Use mapping techniques to define the current pathway

Test with wider stakeholder group for accuracy

Make any suggested changes

Determine whether a further stakeholder event required to define desired
future state

Define required aspects of a defined system
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Map out a desired pathway and share with relevant group

Conduct paper testing exercise looking for clinical and cost effectiveness.

Share final desired state as work stream aspiration.
Stage 2 - Development of options (two phased approach)
Task - To define the potential options available to manage or refer patients to the
most appropriate setting.

Options for short term – winter 15/16 – Phase 1

Options for medium term – 1-3 years – Phase 2
Options for short term – winter 15/16 – Phase 1
Following holding an Integrated Urgent Care Workshop in August 2015,
Clinical Hub/Demand Management Project Board has been formed. This
group has determined, from available data and engaging with relevant
stakeholders, the initial areas for focus and developed the followings as the
short term options and priorities:
1
To reduce the number of Green ambulance referrals from NHS 111 where
clinically appropriate
o As ICT teams in respective organisations (SWAST and Care UK) had
stated they would not be able to support any IT driven changes (i.e. to
virtual models) in this financial year.
 In order to achieve the action on green ambulance we need to
identify mechanism(s) to achieve this;
 Explore co-location opportunities
 Explore floorwalkers including reviewing governance
arrangements
 Explore call streaming opportunities into SWAST
o SWASFT and Care UK to work with each other to understand how
familiarisation courses operate in the SWASFT hubs and how they
demonstrate compliance with NHS Pathways licence/national NHS111
specification.
o SWASFT to consider how organisational governance for their staff
working in a Care UK hub could be achieved, including capability to
use required clinical systems.
o Consideration to be given to the management of red calls (although
there is an acknowledgement of Urgent Care Standards which state
there should be no delay in the transfer of red calls from 111 to 999 for
retriage).
o Care UK to explore options to maintain or increase level of Navigator
roles including potential options.
o To understand the referrals to ED and understand whether clinical
intervention would improve the flow to ED.
2
To reduce the number 1 and 2 hour dispositions from NHS 111 to OOH where
clinically appropriate
o Identify options for use for use of OOH resource to support system
o GPOOH providers to share learning and evaluation from Queue
Management and Call Streaming, further options to be determined.
o To review the Pharmacy Repeat Medications LES to demonstrate its
impact in order that CCG’s not currently commissioning this service
could consider whether they wanted to adopt it for this winter.
o To review and understand different approaches to appointment
booking. To agree on an approach which moves demand away from
OOH into In- Hours services.
3
Mental Health(MH)
o The existing MH working group would work with 2Gether Trust and
Avon and Wiltshire Partnership (AWP) to determine if there are any
actions that could be taken to enhance MH support to Care UK, either
through joint working, directly or access to services through the DOS.
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Directory of Services
o Note- there is a separate DoS PID.
o DOS team to continue the work regarding postcode mapping.
o Increasing the transparency of the DOS/MiDOS utilisation and put
forward a proposal for performance reporting.
Stage 2 - Development of options (two phased approach)
Task - To define the potential options available to manage or refer patients to the
most appropriate setting.

Options for short term – winter 15/16 – Phase 1

Options for medium term – 1-3 years – Phase 2
Options for medium term – 1-3 years – Phase 2

To appraise options that will be fully in line with national guidance and
recommendations.

To incorporate any identified learning from Phase 1

Option appraisal would need to be developed (IT to be included)

To consider how GP OOH input can be maintained in terms of Integrated
urgent care

To understand what other services (such as 999, community services etc) can
access any Integrated Urgent Care solution.

Work with wider stakeholders to identify how other professionals (such as
GPs, nurses, , mental health professionals, dental professionals, children’s
nurses, midwives, social care etc) can be available to offer telephone advice
and support to patients contacting NHS 111 or 999, and to other healthcare
professionals seeking specific expertise
Stage 3 - Model development
Task – Using the evidence of best practice, available data, quantitative and qualitative,
develop a new model of care.
Approach:
Short term:
To agree a model of service based on the priorities mentioned in stage 4.
Long term:

Bring together desired pathway

Research current best practice thinking to inform model development.
o Research of local or national practice
o Guidance, government or other sources

Bring in research data to ensure local experience is a factor in model
development

Describe suggest model in relevant format

Share with stakeholders

Share/Present with wider interested groups (CCGs etc)

Agree model with relevant organisations
Stage 4 – Testing
Task - To test new model of care over a defined time period with an agreed
methodology (e.g. PDSA)
Approach:

Take model and develop test regime

Consider using defined methodologies such as Plan, Do, Study, Act (PSDA)
or Test and Learn.

Agree with relevant stakeholders which methodology to use, agree time.

Begin testing using agree methodology

Record results and report back

Adjust and repeat as necessary
Stage 5 – Evaluation
Task - To evaluate the new model to determine effect on the system and provide a list
of recommendations
Approach:

Take test results and compare against expected outcomes.

Discuss at relevant forums

Determine if tests are as expected, define any adjustments.

Make recommendations
Stage 6 - Commission based on evidence
Task - To support any required changes to commissioned services
Approach:tbc
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Take evidence of results and determine next steps.
5
Products / deliverables
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6
Project Plan
Schedule of meetings
Risk and issue log
Highlight reports
Stakeholder map
Analysis of current activity
Equality Impact Assessment
Options appraisal
Current state pathway
Future state pathway
Model of care
Test plan
Evaluation
Project closure report
Scope and exclusions
6.1
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In Scope
Referrals from 111 to 999, to include;
o Green 2 referrals made from 111 to 999 dispatch.
Referrals from 111 to ED
Referrals from 111 to GPOOHs
Clinical Commissioning Group area coverage
1. Bath and North East Somerset
2. Bristol
3. Gloucestershire
4. North Somerset
5. Somerset
6. South Gloucestershire
7. Swindon
8. Wiltshire
Project management to agreed time, cost and quality
Any event/meeting co-ordination, planning, support and write up.
To project manage the development of a model of care to support an Integrated
Clinical Hub (across 111/ambulance service provider/s/Out of Hours across the
Severn Urgent and Emergency Care Network area) which will facilitate the
management of patients to a community setting or a patients home where
appropriate.
The development and content of an equality impact assessment
Over 18 patients
6.2
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Outside Scope
Referrals from 111 to 999, to excluding;
o Any red or emergency transfer
Any area outside of those describing in scope
The development of a bespoke DoS database using the NHS Pathways system
The content of the NHS Pathways service profile template
Any development or inclusion of data on the DoS system
Children and young people up to the age of 18.
Development of the MiDoS system
Assumptions
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The use of NHS Pathways system to record the DoS

The use of the Bristol, North Somerset and South Gloucestershire (BNSSG) DoS
Team to make any changes
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The use of MiDoS as a ‘front end’ to the system to allow searches and access to
relevant service data.
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That the DoS will be used by the clinicians
Dependencies
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The development of the DoS to support the Integrated Clinical Hub
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The use of NHS Pathways to inform non-clinical decision making.
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The regional DoS Team to develop and maintain system
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The NHS Pathways system to hold the NS DoS
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The defined community pathways have the capacity to manage additional activity
Strategic drivers
NHS England has requested that Urgent and Emergency Care Networks (UECNs) be
created across the country. The Severn UECN has defined an Integrated Clinical Hub as
a key priority along with the production of an enhanced Directory of Services.
Policy drivers are as follow:

NHS England 5 year forward view

Urgent and Emergency Care Review

Transforming Urgent and Emergency Care, Safer, faster, better: good practice in
delivering urgent and emergency care

Urgent care commissioning standards
10
Benefits
The outcomes would include;
11

Improved patient experience by reducing the number of ‘hand-offs’

Reduced number of Green Ambulance 111 referrals to SWAST- Target to be based
on contract KPI’s

Reduced number of 111 referrals to ED Target to be based on contract KPI’s

Increased number of patients referred to MIUs, WICs – tbc and agreed

Increased number of patients treated in a community or home setting – tbc and
agreed
Risks
Potential risks
 That action cannot be taken prior to winter 15/16 leading to overloading of
downstream providers, increased costs and reduced patient outcomes
 That actions to change current model are taken prior to understanding what the
problem is leading to reduced patient outcomes
 That a model cannot be uniformly developed across the Severn Network due to
the number of providers and complexity involved.
 Somerset not included in Severn UECN model which may lead to reduced
patient outcomes.
 Providers cannot comply with the priorities in the required timeline.
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Reporting
This work stream will report to the Severn Urgent and Emergency Care Network.
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Stakeholder list
Stakeholder name
Commissioners
Patrick Mulcahy
Catherine Philips
Organisation
Maria Metherell
Felicity Taylor Drew
Lucy Parson
Jill Sheperd
Ruth Gazzane
Jacqui Chidgey-Clark
GCCG
GCCG
BCCG
BCCG
NSCCG
Thomas Kearny
Peter Crouch
SCCG
SCCG
WCCG
BANESCCG
NSCCG
Pat Nagle
Dave Jarrett
Liam Williams
Roshan Robati
Rich Crocker
Sue Firks
Ross Hamilton
Providers
David Sheasby
Sue Brooks
James Head
Neil LeChevalier
Adian South
Caroline Brown
Paul Birkett-Wendes
Gill White
Liz Rugg
SGCCG
SGCCG
SCWCSU
SCWCSU
SCWCSU
SCWCSU
SCWCSU
Care UK
Care UK
Care UK
SWAST
SWAST
SWAST
SWAST
Brisdoc
Medvivo