Urgent
Care in
General
Practice
Out of
Hours
Benchmark
Urgent
Care
Centres
Primary
Care in
A&E
Out of Hours Services in the Spotlight:
what can we learn from recent reviews?
The Integrated Care Journey, 19th May 2010,
Adastra National Conference 2010
Rick Stern
David Carson
Director, Primary Care Foundation,
NHS Alliance Lead for Urgent Care
Director, Primary Care Foundation,
[email protected] 07703 025775
[email protected] 07709 746771
© Primary Care Foundation
New Leadership Group
for Urgent Primary Care
Dr Albert Benjamin
Anita Dixon
Clinical Director
Waldoc CBS (Waldoc Ltd)
Chief Executive
Central Nottinghamshire Clinical Services
Alan Franey
Jayne Hetherington
Eddie Jahn
Dr Darren Mansfield
Chief Executive
Barndoc Healthcare Ltd
General Manager
OWLS CIC Ltd
Managing Director
Harmoni
GP Clinical Lead in Urgent
Care
Chief Executive
NHS Bolton
Alison McWilliam
General Manager
Dr Ray Montague
Dr Russell Muirhead
Diane Ridgeway
Dr Bruce Websdale
Gilly Wilford
Medical Director
Nottingham Emergency Medical Services
Limited (NEMS CBS)
Brisdoc Healthcare Services
Chairman
Shropshire Doctors Cooperative Ltd
Chief Executive
East Lancashire Medical Services Ltd
Medical Director
Primecare
Director of Finance &
Contracts
Chief Executive
South East Health
Lesley McCourt
Nigel Wylie
Partnership of East London Co-operatives
Urgent Care 24
© Primary Care Foundation
Emerging Priorities
1. Patient Safety
2. Integrated Urgent Care
3. Demonstrating quality
4. ‘Rebranding’ Out of hours
© Primary Care Foundation
What we will cover
Summarise and reflect on the key points from two reports
on out of hours services:
1.
General Practice Out-of-Hours Services: project to consider and assess
current arrangements (February 2010) David Colin-Thomé, Department of
Health & Steve Field, Royal College of General Practitioners
2.
Improving out of hours care: what lessons can be learned from a
national benchmark of services? Reflections and recommendations for
commissioners and providers of out of hours services in England based
on the first two rounds of the benchmark in 2009 (January 2010).
Henry Clay, Primary Care Foundation.
© Primary Care Foundation
A long history of reports and
reviews …
● Department of Health (Carson Review, 2000) Raising Standards for
patients: new partnerships in Out-of-Hours care
● National Audit Office (May 2006) The Provision of Out-of-Hours care in
England
● Four inner London PCTs (May 2007) Report into the death of Penny
Campbell
● Health Care Commission (September 2008) Not just a matter of time: A
review of urgent and emergency care services in England
and still to report …
● Care Quality Commission (still ongoing) Enquiry into Take Care Now
© Primary Care Foundation
Key areas in the Department’s Review
General Practice Out-of-Hours Services: project to consider and assess
current arrangements (February 2010) David Colin-Thomé, DH & Steve
Field, RCGP
● Commissioning and performance management, including
tackling inappropriate variation
● Selection, Induction, Training and use of out-of-hours
clinicians (including the use of locums)
● Management and operation of Medical Performers Lists
© Primary Care Foundation
Key areas in the Department’s Review:
1. Commissioning & performance management
● Surprised by lack of compliance with NQRs 5 years on
● PCT Boards need better scrutiny and oversight of OOH
services
● Limited involvement of PBC
● The level of variation between organisations and between
individual clinicians cannot be justified
● Now an active performance management issue in NHS
© Primary Care Foundation
Key areas in the Department’s Review:
2. Selection, Induction, Training & use of staff
● Found most providers do not make assessment of clinical
skills or competence of clinical staff – rely on Performers
List
● Importance of language test
● Range of skill mix – must be to ensure that patients are
seen by most appropriate clinician for condition, not just
to reduce use of GPs
● Use of locum agencies – 6 providers using 15 agencies
● Ensuring staff are not tired or working double shifts?
© Primary Care Foundation
Key areas in the Department’s Review:
3. Medical Performers List
● Protect patients from unsuitable or inefficient
practitioners – but confusion
● Implement DH review 2009 ‘Tackling Concerns Locally’
● As a minimum, doctors should be able to:
●
●
●
●
Converse with patients or their helpers
Able to read and understand the BNF
Talk to pharmacists & other healthcare professionals
Able to arrange admissions to hospitals
● Better sharing of information across PCTs nationally
© Primary Care Foundation
Actions following on from the Review
● Reviewing the National Quality Requirements
● Developing a new national model contract for OOH
services
● Stronger performance management (including use of
English and applying the performers list)
● Greater involvement of local GPs
© Primary Care Foundation
Key Issues for the future
● Patient Safety
● A new initiative for rapidly sharing learning?
● tighter rules or a cultural shift?
● Focus on learning and improvement
● responding to benchmarking and other comparisons across and within
organisations
● Better internal scrutiny – good governance and independent NEDs
● Greater openness and transparency
● Working as part of an integrated system
● Networks and accountability
● Three Digit Number
● Clarity for the public and patients about using urgent care services
● Commissioning for quality
● Commissioning pathways
● identifying the cost of quality in urgent care services
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
Improving out of hours care: what lessons can be learned from a
national benchmark of services? January 2010, PCF
1. Out of hours services are improving. Most
providers have made a rapid transition from ‘rota
organising clubs’ into true healthcare providers.
In doing so they have got much better at:
● Matching capacity to predictable demand, giving ample time for clinicians to
do their work well
● Meeting performance standards
● Introducing governance processes to ensure a consistent and safe response
to patients
● Engaging local clinicians in the service.
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
2. Patients value a responsive service and associate
this with good care. There is a wide difference
between wide the difference is between the
responsive and the comparatively slow.
© 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
85%
Rating of care received either good or very good
80%
75%
70%
65%
60%
55%
50%
45%
40%
40%
45%
50%
55%
60%
65%
70%
How quickly care was received % About right
Each dot is one PCT
© Primary Care Foundation
75%
80%
85%
Learning from the first two rounds
of the benchmark
3. There are a number of different models for out of
hours provider services. Split services and double
assessments seem to perform less well than
currently reported.
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
4. Many providers are falling short on the standard
for definitive clinical assessment of urgent cases
which we see as an important issue of patient
safety.
© Primary Care Foundation
We reported the percentage of urgent
cases that were assessed in 20 minutes…
100%
90%
Many of these providers
had too many cases
with double assessment
80%
70%
60%
50%
40%
30%
Increasingly falling below standard
20%
10%
0%
Each bar is one service – a provider/PCT
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
5. There is an enormous range across different
services in the proportion of cases that are
identified as urgent and particular attention
should be paid to those that are well below the
norm.
© Primary Care Foundation
There is a very striking variation between
services in the proportion of cases
identified as urgent on receipt
70%
60%
Percentage of
cases identified as
urgent by non
clinical callhandlers
50%
40%
30%
20%
How safe?
10%
0%
Each bar is one service – a provider/PCT
© Primary Care Foundation
How safe?
Learning from the first two rounds
of the benchmark
6. There is striking variation in cost, even amongst
providers serving communities with similar
population density.
© Primary Care Foundation
In general it costs more to service a rural
PCT than an urban one – but there are
wide variations within any band
●Rural
●Mixed
City/Urban
£18.00
£16.00
£14.00
Cost per head
£12.00
£10.00
£8.00
£6.00
£4.00
£2.00
£0.00
0.00
20.00
Each dot is one service
40.00
60.00
Population density
© Primary Care Foundation
80.00
100.00
120.00
Learning from the first two rounds
of the benchmark
7. Coding needs to be improved in some key areas.
© Primary Care Foundation
In far too many services it is impossible to
be sure how many patients make their
way towards hospital
25%
20%
We know that many services,
particularly to the left, are undercounting patients going towards
hospital
15%
Normal band?
10%
5%
not credible?
suspect
0%
Each bar is one service
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
7. We have suggested three criteria to arrive at a
small number of 'good all-rounders'. Our
conclusion is that those that perform well on all
these factors are far from being the most
expensive, but also that the very cheap providers
do not appear to have the management
headroom to perform consistently enough to
feature in this group.
© Primary Care Foundation
From variation across organisations
to variation between clinicians
● There is substantial variation within a typical service
between individual clinicians. The response will often be
shaped more by who deals with the case rather than the
details of the case itself.
● Developing a consistent, safe and appropriate response
does not just involve looking at the outliers, but involves
consistent feedback to individuals comparing them with
their peers so that they can identify specific things that they
might do differently for the benefit of patients and the
service.
© Primary Care Foundation
Final reflections: future changes
For services
● All services need to ensure that they are using the results work out
how to improve local care – it is about using national comparisons
to drive local improvements
● Recent reviews have highlighted the importance of good
recruitment, induction, training and continuing support of staff.
● Some services need to make sure that they are responding to calls
more rapidly than is currently the case
For the OOH Benchmark
● The benchmark will extend to cover all these areas
● Making the benchmark more open and transparent will ensure that
it is more useful to services as a tool for driving improvements
● Creating a new governance group as well as a user group?
© Primary Care Foundation
Discussion
& Questions
And for more information, visit our website at:
www.primarycarefoundation.co.uk
Or contact us:
Rick Stern
07709 746771
[email protected]
David Carson
07703 025775
[email protected]
© Primary Care Foundation