out of hours services in the spotlight: what can we learn from recent reviews?

© Primary Care Foundation

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 [email protected] 07709 746771

The Integrated Care Journey, 19th May 2010, Adastra National Conference 2010

David CarsonDirector, Primary Care Foundation, [email protected] 07703 025775


New Leadership Group for Urgent Primary Care

Dr Albert Benjamin

Clinical Director Waldoc CBS (Waldoc Ltd)

Anita Dixon Chief Executive Central Nottinghamshire Clinical Services

Alan Franey Chief Executive Barndoc Healthcare Ltd

Jayne Hetherington

General Manager OWLS CIC Ltd

Eddie Jahn Managing Director Harmoni

Dr Darren Mansfield

GP Clinical Lead in Urgent Care

NHS Bolton

Lesley McCourt Chief Executive Partnership of East London Co-operatives

Alison McWilliam

General Manager Nottingham Emergency Medical Services Limited (NEMS CBS)

Dr Ray Montague

Medical Director Brisdoc Healthcare Services

Dr Russell Muirhead

Chairman Shropshire Doctors Cooperative Ltd

Diane Ridgeway

Chief Executive East Lancashire Medical Services Ltd

Dr Bruce Websdale

Medical Director Primecare

Gilly Wilford Director of Finance & Contracts

South East Health

Nigel Wylie Chief Executive Urgent Care 24


Emerging Priorities

1. Patient Safety

2. Integrated Urgent Care

3. Demonstrating quality

4. ‘Rebranding’ Out of hours


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.


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


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


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


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?


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


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


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


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

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.


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.


There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received

40%

45%

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55%

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85%

40% 45% 50% 55% 60% 65% 70% 75% 80% 85%

How quickly care was received % About right

Rat

ing

of

care

rec

eive

d e

ith

er g

oo

d o

r ve

ry g

oo

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Each dot is one PCT



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.



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.


We reported the percentage of urgent cases that were assessed in 20 minutes…

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10%

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100%

Increasingly falling below standard

Many of these providers had too many cases

with double assessment

Each bar is one service – a provider/PCT



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.


0%

10%

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40%

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70%

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

Each bar is one service – a provider/PCT

How safe?

How safe?



6. There is striking variation in cost, even amongst providers serving communities with similar population density.


In general it costs more to service a rural PCT than an urban one – but there are wide variations within any band

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£2.00

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£18.00

0.00 20.00 40.00 60.00 80.00 100.00 120.00

Population density

Co

st p

er h

ead

●Rural City/Urban

●Mixed

Each dot is one service



7. Coding needs to be improved in some key areas.


0%

5%

10%

15%

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25%

Normal band?

suspectnot credible?

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



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.


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.


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?


Discussion & Questions

And for more information, visit our website at:www.primarycarefoundation.co.uk

Or contact us:

Rick Stern 07709 [email protected]

David Carson 07703 [email protected]

out of hours services in the spotlight: what can we learn from recent reviews?

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