Out of Hours Services in the Spotlight: what can we learn from recent reviews?

1. Out of Hours Services in the Spotlight: what can we learn from recent reviews? Rick Stern Director, Primary Care Foundation, NHS Alliance Lead for Urgent Care rick.stern@primarycarefoundation.co.uk 07709 746771 The Integrated Care Journey, 19th May 2010, Adastra National Conference 2010 David Carson Director, Primary Care Foundation, David.carson@primarycarefoundation.co.uk 07703 025775

2. New Leadership Group for Urgent Primary Care

3. Emerging Priorities • Patient Safety • Integrated Urgent Care • Demonstrating quality • ‘Rebranding’ Out of hours

4. What we will cover Summarise and reflect on the key points from two reports on out of hours services: • 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 • 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.

5. 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

6. Key areas in the Department’s ReviewGeneral 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

7. 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

8. 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?

9. 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

10. 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

11. 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

12. Learning from the first two rounds of the benchmarkImproving out of hours care: what lessons can be learned from a national benchmark of services? January 2010, PCF • 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.

13. Learning from the first two rounds of the benchmark • 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.

14. There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received Each dot is one PCT

15. Learning from the first two rounds of the benchmark • 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.

16. Learning from the first two rounds of the benchmark • 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.

17. We reported the percentage of urgent cases that were assessed in 20 minutes… Many of these providers had too many cases with double assessment Each bar is one service – a provider/PCT

18. Learning from the first two rounds of the benchmark • 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.

19. There is a very striking variation between services in the proportion of cases identified as urgent on receipt Percentage of cases identified as urgent by non clinical call-handlers How safe? How safe? Each bar is one service – a provider/PCT

20. Learning from the first two rounds of the benchmark • There is striking variation in cost, even amongst providers serving communities with similar population density.

21. 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 Each dot is one service

22. Learning from the first two rounds of the benchmark • Coding needs to be improved in some key areas.

23. In far too many services it is impossible to be sure how many patients make their way towards hospital We know that many services, particularly to the left, are under-counting patients going towards hospital Each bar is one service

24. Learning from the first two rounds of the benchmark • 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.

25. 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.

26. 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?

27. Discussion & Questions And for more information, visit our website at: www.primarycarefoundation.co.uk Or contact us: Rick Stern 07709 746771 rick.stern@primarycarefoundation.co.uk David Carson 07703 025775 david.carson@primarycarefoundation.co.uk