Out of hours primary care and 111

1. Out of hours primary care and 111 Henry Clay henry.clay@primarycarefoundation.co.uk 07775 696360

2. Agenda – I have included more detail in the slides but intend to focus on a few areas • Primary Care Foundation • What do we know? • Patients with an urgent need expect a prompt response • The traditional OOH model is expensive compared with in-hours GP practices • Out of hours operated with a wide range of dispositions • There is considerable scope for variation in the NHS 111 model • Discussion • Lessons from Penny Campbell and David Gray cases • Some thoughts on commissioning

3. The Primary Care Foundation The Primary Care Foundation seeks to support the development of best practice in primary and urgent care.  • We use information to create understanding that drives improvements in care • Seek to reduce unnecessary variation across organisations and between individual clinicians • Develop practical tools that can be widely applied across the urgent care system and • Apply our understanding of national policy in urgent care to support local changes

4. We have looked urgent care from a number of angles Reports for Department of Health and others • Primary Care in A&E • Urgent Care in general practice • Benchmark of out of hours services • Urgent care centres • Commissioning guide (with NHS Alliance) Recent projects • 700+ practices looking at access and urgent cases • Review of A&E and urgent care centres • Service model design (and spec) for community hospitals

5. There is a strong relationship between patients views of how quickly they are seen and their rating of care

6. Cost per case averages around £60 – about twice that for GP primary care

7. With the traditional out of hours model there was a wide variation in the disposition to advice, home visit and base attendance And the variation within a service was even greater…..

8. Two different services… Service 1 • Over 75% advice • 22% base • Less than 3% home Service 2 • 52% advice • 35% base • 13% home …which would patients prefer?

9. NHS 111 offers considerable freedom of operating model…..

10. …and in most cases involves two contracts “We highlight particularly the consequences in some PCTs where the service is split between two providers, where the service is integrated with other types of service and where double assessment or misallocation of case type takes place.”

11. In particular, be very careful about how you utilise the leeway for ‘definitive clinical management’ Traditional out of hours model (case priority urgent then emergency) 20 60 NHS 111 model 2 with warm transfer to nurse 60 NHS 111 model 1 with warm transfer to nurse and call back from doctor 60 60 NHS 111 model 1 with call back from both nurse and doctor 10 60 60 Initial assessment by call-handler Key: Assessment by nurse using NHS pathways Assessment by doctor Face to face consultation

12. Discussion - your models for OOH

13. What lessons from the Penny Campbell and David Gray cases?

14. Lessons from the suggested reading… • Penny Campbell case:- Clinical notes of any consultation to be recorded and available to other health professionals that may see the patient later • David Gray case:- 17 recommendations: • Systematic investigation of serious incidents with strong processes to control drugs • Proper staffing levels supported by robust recruitment processes • Strong management processes using data to audit and feedback information to clinical staff • Common to both • Need for commissioners to recognise the importance of OOH and to scrutinise the arrangements more closely

15. The Health secretary believes that GP Commissioners will fix it! I am not as sanguine as Andrew Lansley….

16. Keeping an eye - weekly report (with a brief written summary highlighting any issues and planned changes) • Performance against key NQRs say (detail to be agreed): • Time to end of definitive clinical assessment (to start is meaningless with 111) • Answered in 60 seconds • Time to face to face, Urgent and Emergency cases • Time to treatment from arrival/appointment • Staff shortfall v planned rota and time any centre shut • A brief set of bullet points summarising: • Any performance worries • Any trends or concerns • Any changes made or planned

17. Keeping an eye – monthly review plan over the year – based on planned meetings (with possible variation) but, say: • Twice a year. Review of NQRs (reported each month). Below par performance to include action plan and projection for improved performance • Twice a year. at their audits of Individual performance - clinical and call-handler, Referrals (including to A&E/999), One other topic to be agreed • Twice a year. Patient perceptions (GPPS and own findings) - Trends, links with performance, actions taken and planned • Twice a year. Look at outcomes/dispositions, numbers referred, trends • Once a year. Staff effectiveness – to consider productivity, rota adequacy, training, recruitment process • Once a year. Working with others: opportunities for integration and improved care – Hospitals, community services, GP practices (also winter/Christmas planning) • Once a year. Analysis of comparative performance from benchmark • Once a year. Future direction (and formal review/feed-back) – commissioner to lead If more than one provider then lead provider to ensure that they work as one and this covers the entire process

18. Keeping an eye – unannounced visits Clinical and non-clinical team to look at: • Staffing levels • Assessment of cleanliness, tidiness, waiting times • Observation/listening to some consultations (with permission) • Quality of notes/records communication to others • Discussion with staff about: • Issues they face • Quality of care – how might it be better? • Training and confidence in role • Processes for feedback and audit • Clear understanding of ‘what to do if’ • Discussion with patients (topic guide, participation in phone survey)

19. Henry Clay07775 696360 henry.clay@primarycarefoundation.co.uk