Review of Lothian Unscheduled Care Service

August 2014Patricia DawsonNHS LothianDraft Version 3

Table of Contents

1. Service Model: an Overview

2. Introduction

3. Why a review?

4. How the Review was undertaken

5. What LUCS Delivers 0 Core Activity 0

dditional Activity 0

6. National Benchmarking 1 Cost Comparisons 1

.2 Patient Experience 3

.3 Quality 4

7. Reviewing LUCS Activity 6ore Activity 6

Additional LUCS Activity 8 7.2.1 Untriaged Calls 8 7.2.2 A&E Referrals 8 7.2.3 Profession to Profession (P2P) Referrals 9 7.2.4 Self Referrals 0 7.2.5 Protected Learning Time (PLT) 2 7.2.6 Services for NHS Borders 3

8. GPand ENP Recruitment and Retention 4 8.1 Current Issues 4 8.2 alaried and ad hoc GPs 4

Sickness Absence 5 8.4 hift Patterns & Rota Managemen 6 8.5 What Doctors said about working in LUCS 8.6 mary Care Workforce Survey 7 8.7 ddressing the Issues 8 8.8 National GP Training 9 8.9 ddressing ENP Issues 9

9. Improving Safety & Effectiveness 0 9.1 linical Models Mid and East Lothian 0

9.1.1 linical Models t John’s, WIE and RIE Sites 31 9.2 OHs Services for Children and Young People 2 9.3 ome Visits 3 9.4 Right Patient, Right Place, Right Time 4 9.5 Efficient Use of Infrastructure 5 9.6 ublic Holidays 5 9.7 mprove Managerial and Administrative Mode 36 9.8 linical Leadership

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10. ntability and Governance

11. and Integrate

12. ext Steps

13. xecutive Summary 1

14. ppendices and References 42

Appendix 1: Terms of ReferenceAppendix 2: Improvement Plan Summary Document 43Appendix 3: LUCS Review 2010 Key Recommendations 53Appendix 4: LUCS Action Plan – April 2010 4Appendix 5: Summary of Actions 2014 Review 7References 3

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REVIEW OF LOTHIAN UNSCHEDULED CARE SERVICE

1. Service Model: An Overview

Background

The General Medical Services contract in 2004 permitted General Practioners to opt out of providing Primary Care services in the Out Of Hours period (OOH). The responsibilities for this care delivery transferred to Scottish NHS Boards and NHS24. NHS Lothian established the Lothian Unscheduled Care Service (LUCS) with a multidisciplinary and multi site care model

Current Core Functions

The role of LUCS is to provide OOHs urgent primary medical care services across Lothian from 6 pm to 8 am Monday to Thursday, from 6pm Friday to 8 am Monday (70% of the week) and on Public Holidays.All requests for health care from members of the public come to LUCS hub from NHS 24 following triage for doctor advice, home visit or to attend a Primary Care Emergency Centre(PCEC).Patients are transferred to LUCS from A and E departments and from LUCS to A and E departments under established protocols.People also attend the sites without triage or appointments to access health care and are referred to as walk ins. An agreed transfer of untriaged calls from NHS24 are also triaged by LUCS. LUCS additionally provides telephone advice to other health, social care and emergency services professionals called a Professional to Professional line (P2P). This includes a clinical service to the laboratory services to interpret and action abnormal results. More recently LUCS has absorbed the provision of medical care to a range of NHS Lothian in patients. It is also providing planned patient reviews requested by in hours GPs

Current Issues

The provision of Unscheduled care is a key priority for NHS Lothian .Concerns were expressed about the safety and sustainability of the service. The key issues were;

Safety of the current service and clinicalActivity changes and additional area of service de sNational and local recruitment and retention challenges especially sProfessional and leadership issues with Emergency Nurse PractionerSustainability of a 5 site delivery model.

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for GP

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4

Current Clinical Mode

Appointments, cars, visits, telephone advice and attendances are coordinated by the hub at WGH. GPs do all the doctor advice, triage, P2P, and home visits and have 3 appointment slots per hour at the sites. ENPs have 2 appointment slots per hour and see most patients including children. Each site also has driver and reception staff andthere are service supervisors and administration functions. WGH, St John’s and RIE are the busiest sites with broadly similar activity but have differing staffing and skill mix. idlothian Community Hospital and Roodlands have similar and rich staffing and skill mix but low levels of activity. vernight services are provided from midnight in 2 sites, RIE and St John

New Clinical and Service Mode

LUCS should refocus on the core business of providing PCOOHs services and be renamed as such.

There should be 2 clinical models reflecting activity and staffing needs:-WGH, St John’s and RIE should have GPs and ENPs, retain existing clinical roles , improve productivity and retaining existing opening hours with effective car and doctor dispatching and management. These should be the core sites for PCOOHs service delivery in the event of staffing shortages or other business continuit s sMCH and Roodlands should be GP delivered service with reduced opening hours and one car, driver and GP covering both East and Mid Lothian in the evenings with support from RIE as n d

People will continue to walk in to sites to access health care but actions should seek to move this to a managed demand.

Home visits are a key and core component of PC OOH s services delivered by GPs and this should continue until alternatives are demonstrated safe and effective and efficient.

Profession to Profession (P2P) advice calls are also core business but need to be better understood and managed.

Medical cover arrangements for patients in In Patient Continuing Care (IPPC), step down and delayed discharge beds in the OOH period could be core PCOOHs service delivery but only following a strategic service review. This must address issues of GP competency in caring for patients with intermediate care needs, clinical governance and

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patient safety, skill mix, continuity of care and decision making and care documentation.

An efficiently managed and delivered PCOOH service provides a key component of Lothian Unscheduled Care but it is not a Lothian Unscheduled Care Service unless it is designed and resourced to be so.

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2. Introduction

A review of LUCS was indentified as an action in the Lothian Unscheduled Care Plan 2012-2014 and as an action in the draft NHS Lothian Strategic Plan – Our Health, Our Care, Our Future 2014 2024(Ref 1)

The review was commissioned by David A. Small, Director, East Lothian Health and Social Care Partnership with agreement from the ExecutiveNurse, Medical and HR Directors. Patricia Dawson (previously Associate Nurse Director, Strategic Development) was asked to undertake the review. The terms of reference are attached at appendix 1.

The key purpose is to review the current service delivery model and bring forward an action plan to ensure LUCS is fit now and in the future; “with a pragmatic approach to current staffing constraints, productivity and efficiencies to ensure person centred, safe, effective care, delivery within financial limits.”

From the review there may be a second phase of potential redesign ambitions. These arise from opportunities from the current integration agendas, National Primary Care Out Of Hours care delivery, GP recruitment retention pressures, alignment of medical cover for continuing care, care homes and step down beds. It was further agreed that the 3 outputs from the review were:-

An internal LUCS Service Improvement Plan, AppendThe review of LUCS ReportA draft Project Plan aligned to the Strategic Planning Process.

All the above products to be presented to David A. Small by mid July 2014.

3. Why a Review?

This is the second service review in 4 years. The Better Acute Care in Lothian Group commissioned the Associate Director of Strategic Planning and Service Modernisation to undertake a review, completed

April 2010 and presented in December 2010 to the Unscheduled Care Board (Ref 2)The key aim was to “understand how LUCS contributed to unscheduled care delivery and identify opportunities to develop the role.” The key recommendation (Appendix 3) and the Action plan (Appendix 4) are provided for comparison.

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The current review is prefaced by different drivers:-

- a more mature service with a changing activity profile and increasing complexi

- an increase in the type of internal PC OOH care deexpected by NHS Lo

- changes in the perception of the service and the need to examine service and staffing models

- shortages of doctors and nurses necessitating closure of site(s) and modified service del

- implementation of National Quality Standards for PC OOH’s services (R

- A national integration agenda driving significant changes in health and social care service models, funding and governance arrangements.

4. How the Review was undertaken

An investigative approach was undertaken including:-- face to face interviews with over 70 staff from all LUCS staff

- meetings with senior managers, specialist staff in Finance, HR, Health Intelligence Unit, transport, clinical governanc c

- 2 professional advisers were co-opted:- Patricia McIntosh, Clinical Services Development Manager, East Lothian CHP, Dr. Nigel Williams, Associate Medical D

- meetings/phone interviews with Director of Public Health, HA&E Clinical Lead, and service Clinical Leads including Clinical Nurse Manager co-opted to LUCS

- telephone interviews with lead staff from NHS Ayrshire and Arran, Greater Glasgow and Clyde and Tayside PC OOH’s Serv c

- visits to each of the 5 OOH’s sites called Primary Care Emergency Centres (PCEC), hub at WGH and regularly to administration at Astley Ai s e ,

- attendance at 3/4 GP Practice representatives meetings in East Lothian, Midlothian and Edinburgh CHP’s (West was arranged but cancelled),

- partnership representative engaged,- attendance at CHP Clinical Director’s Meet

Semi structured interviews about what works, what can be improved and personal and professional observations were shared. Data and financial information was requested.I am very grateful for the honesty which everyone engaged in the process demonstrated. There were many strong views expressed and

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there was also a large degree of similarity in the issues which need addressed. The LUCS service Improvement Plan has captured most of this and translated it into actions that need to be progressed to improve how staff view their work in the service.

Broadly summarised the staff felt:-- isolated, distant from management and poorly communicated

t- not valued and not involved in decisions which affect them- Emergency Nurse Practi i s were particularly disillusioned with

unresolved HR and professional concerns;- upset by different pay mechanisms and single pay rise of over

15% for doctors(first rise in 10 years- increasingly concerned about safety and staffing l v ;- most really enjoyed their contact with the public and wanted to

do a good j- some receptionists and some drivers felt underut- many staff had good ideas or had thought through how things

could be better- many GPs’ expressed a lack of local ownership and continued to

be critical about the totality of the resource and role of NHS2 .- mainly positive views about local team working and professional

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5. What LUCS Delivers

5.1 Core Activity

LUCS provides out of hours primary care medical services across Lothian from 6pm until 8am Monday to Friday, from 6pm Friday to 8am Monday, 118 hours or week 70% of each week c Holidays and for 6 Protected Learning Time Sessions annually (12.00 to 18.00). All requests for healthcare from members of the public come to LUCS hub via NHS 24, who handle external calls and following triage pass those contacts assessed as requiring Doctor advice, home visit or to be seen at a Primary Care Emergency Centre (PCEC) to LUCS. LUCS hub located at WGH provides co-ordination across the 5 PCECs and up to ten home visiting cars. In addition to serving all Lothian residents, services are also provided out of hours to patients in West Linton, on behalf of NHS Borders.

The LUCS service is staffed by primary care practitioners comprising GPs, Emergency Nurse Practitioners and supported by a range of administrative staff, receptionists and drivers.

5.2 Additional Activity

In addition to this core activity CS takes untriaged calls from NHS 24 at peak times of each week. A number of other services include a professional to professional advice line (P2P) for other community health professionals and to NHS Lothian laboratories including pharmacists, SAS paramedics, and District Nurses. LUCS also provides out of hour’s medical cover to fifteen NHS continuing care and similar units across Lothian through provision of telephone advice and doctor visits when required via the professional advice line. It offers a planned review service to patients in the community at the request of primary care clinicians. The LUCS hub provides a call handling service for Edinburgh, East and Midlothian District Nursing evening and overnight service through a specific phone line available to existing District Nurse patients.

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6. NATIONAL BENCHMARKING

6.1 Cost Comparisons

The latest available published information relates to 2012/13 and it shows that LUCS had the lowest cost per head of population HOP)(see Table 1) in Scotland at £10.05 per registered patient. This is a 14.7% increase over the cost per head in 2005/6 which was £8.76. However it is actually a reduction in real terms when cost inflation is taken into account.

TABLE 1

(

OOH Cost per head of population board

Cost Totals 2011 -2012

2010 Population

2010/11 Cost £000s

Cost per HOP 2010/11

2011 Population

2011/12 Cost £000s

Cost per HOP 2011/12

2012/13 Contacts

2012/13 Cost

Cost per

£000s HOP 2012/13

NB1. Notice that Lothian have the lowest cost per head of population figure for two of the last three years, and are second lowest in the other year

NHS Ayrshire & Arran 366,860 4,498 £12.26 367,029 4,601 £12.54 367,174 4,752 £12.94

NHS Borders112,870 3,381 £29.95 113,559 3,068 £27.02 114,268 3,020 £26.43

NHS Dumfries & Galloway 148,190 3,298 £22.26 148,237 3,262 £22.00 148,295 3,165 £21.35

NHS Fife364,945 4,816 £13.20 366,954 4,652 £12.68 369,122 4,411 £11.95

NHS Forth Valley293,386 3,952 £13.47 295,193 3,795 £12.86 297,055 3,967 £13.36

NHS Grampian550,620 7,775 £14.12 556,085 7,619 £13.70 561,941 7,490 £13.33

NHS Greater Glasgow & Clyde 1,203,870 13,514 £11.23 1,206,846 12,935 £10.72 1,210,337 12,715 £10.51

NHS Highland310,830 9,852 £31.70 312,385 9,519 £30.47 314,067 9,553 £30.42

NHS Lanarkshire562,477 7,640 £13.58 564,039 7,396 £13.11 565,612 6,906 £12.21

NHS Lothian836,711 8,657 £10.35 846,104 9,262 £10.95 856,071 8,601 £10.05

NHS Orkney20,110 704 £34.98 20,250 1,791 £88.46 20,390 1,741 £85.40

NHS Shetland22,400 268 £11.96 22,516 409 £18.17 22,625 380 £16.77

NHS Tayside402,641 6,127 £15.22 405,500 5,965 £14.71 408,540 6,451 £15.79

NHS Western Isle26,190 962 £36.75 26,197 1,001 £38.23 26,196 1,151 £43.92

s

Totals 5,222,100 75,445

5,250,894

75,275

5,281,693

74,302

11

Another cost guide often used for benchmarking purposes is the cost per patient contact (see Table 2). For 2012/13 this was £67.92, which is the lowest cost for any board in Scotland using this measure and a reduction from £71.17 in 2010/11 or 4.8%. However these costs may have been impacted in 2013/14 when compared nationally given the NHS Lothian pay uplift of 15.2% for GP and ad hoc GP pay rates, the first pay uplift in 10 years.

TABLE 2: OOH Cost per contact per board

Cost Totals 2011 -2012

2010/11 Contacts

2010/11 Cost £000s

Cost per contact 2010/11

2011/12 Contacts

2011/12 Cost £000s

Cost per contact 2011/12

2012/13 Contacts

2012/13 Cost £000s

Cost per contact 2012/13

NHS Ayrshire & Arran 55,929 4,498 £80.43 55,555 4,601 £82.82 59,953 4,752 £79.26

NHS Borders

0 3,381 0 18,363 3,020

-

-

-

-

NHS Dumfries & Galloway 22,325 3,298 £147.74 22,040 3,262 £148.00 22,693 3,165 £139.49

NHS Fife 52,520 4,816 £91.70 55,262 4,652 £84.17 58,191 4,411 £75.80

NHS Forth Valley 46,243 3,952 £85.47 45,555 3,795 £83.31 42,056 3,967 £94.33

NHS Grampian 90,522 7,775 £85.89 86,290 7,619 £88.30 90,394 7,490 £82.86

NHS Greater Glasgow & Clyde 175,825 13,514 £76.86 179,124 12,935 £72.21 186,598 12,715 £68.14

NHS Highland 42,597 9,852 £231.29 41,780 9,519 £227.84 41,325 9,553 £231.16

NHS Lanarkshire 79,316 7,640 £96.32 81,741 7,396 £90.48 85,487 6,906 £80.78

NHS Lothian 121,645 8,657 £71.17 121,712 9,262 £76.09 126,632 8,601 £67.92

NHS Orkney 1,676 704 £419.77 1,530 1,791 £1,170.81 1,400 1,741 £1,243.72

NHS Shetland 0 268 0 1,488 380

-

-

-

-

NHS Tayside 0 6,127 0 83,853 6,451

-

-

-

-

NHS Western Isle 6,430 962 £149.68 0 1,001 0 1,151s

-

-

Totals 695,028 75,445

690,589

65,833

818,433

74,302

NB1. Where there is no contacts figure and thus no contact figure, this is because the board did not gather figures about the number of contacts

NB2. Notice that NHS Lothian have the lowest cost per contact figure for two of the last three years and are second lowest in the other year

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Cost Comparisons from 2010 Review (Ref 2) T

.

he above review reported some internal cost comparisons which complement the national data (Table 3). This data was used to offer a snapshot of unscheduled care services costs. From this the key cost to target would be to reduce the cost per home visit. The imminent roll out of a fleet management system aligned to “Sat Nav” technology could have efficiency effects on these costs. Redesigning the geographic coverage and deployment of cars, drivers and doctors may also help and is discussed later in the report

TABLE 3: Activity Cost

Original table info 2008/09 2012/13

LUCS cost per PCEC Contrac

£58 £43 t

LUCS cost per Home Visit £136 £147

LUCS cost per phone advice

£26 £28

RIE cost per A&E Attendance

£78 £78

SJH cost per A&E Attendance

£67 £62

WGH Minor Injuries cost per Attendance

£13 £11

S ource NHS Lothian Finance

6.2 Patient Experience

The National Health and Care Experience Survey 2013/14 (Ref 4)compares public views on Primary Care and OOHs care results with the previous survey in 2011/12. This shows overall patients are slightly less “positive” about their experiences and that positive ratings for access to GPs and GP care may have Scotland wide “root causes”.

Out of Hours care had similarly reported less positively than 2011/12 the overall rating reduced from 72% positive to 71% positive. The figures for NHS Lothian and each of the 4 CHPs are set out in Table 4.

Staff expressed a good deal of pride in the quality of service provided and the ability to focus on the individual patients.

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TABLE 4 ating overall care provided Out of Hours:- R

Positive Responses Difference From Difference 2011/12

From Scotland

NHS Lothian

73 -2 +2

East CHP 74 -1 +3

Midlothian 71 -5 0

Edinburgh 73 -2 +2

Wes 72 -3 +1 t

Note: the question includes aspects of care provided by NHS24, SAS, A&E with only 27% of those who

used an OOH’s accessing a PC OOH service

On this indicator, although limited specificity for PC OOH’s and LUCS, NHS Lothian is 2% above the Scottish average which is statistically significant.

6.3 Quality

Quality Indicators for Primary Care Out of Hours Services were published in March 2014 (Ref 3). There are 6 indicators of which only one is reported locally. All the others will require additional clinical time, to put in place manual audit systems. Some rely on the improvements to the functionality of ADASTRA (national OOH’s IT system) and most will be reported by an ISD “data mart”.The Indicators are:-

Response HS24, home visit, 1-2-4 hoAppropriateness of triage for home v inically

appropriate 1-2-4 hour visits.Effective information exchange.Implementing national clinical standards and guidel

tracer condiAntimicrobial prescribing (PRIMS + GP 10 data) x 4 groups

antimicrobPatient experi ent experience, positiv

outcome, number of complai

Given the recent pressures on the system much of the preparatory work needed is not as far advanced as the service would wish. However the actions suggested in the LUCS service Improvement

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Plan will help realise the clinical infrastructure needed for this small team to deliver these national standards.

Of the above the performance against 1, 2 and 4 hour home visits is reported by LUCS and Table 5 shows the performance between 2008/9 and 2013/14

Table 5

.

1 Hour Visits 2 Hour Visits 4 Hour Visits

% 1 hour %1 hour 15

mins

%2 hour %2 hour 15 % 4 hour

mins

90 96 94 96 97

86 92 88 92 97

Overall performance has been reasonably maintained with a fall of 4% on 1 and 2 visits achieved with >15 mins. Given increasing activity and complexity in care this may be acceptable

There is an active Quality Improvement Team which will lead the implementation and delivery of the national quality indicators. Critical incidents and complaints are already being reviewed and patient experience local survey tools are being tested.

Actions1. The clinical leadership capacity for doctors and nurses needs increased to support quality, clinical and staff governance in the PC OOH’s service2. A target of 90% achievement of % 1 hour and 2 hour should be set and priority given to reporting regularly on the appropriateness of home visit triage by NHS243. Performance against the National indictors should be reported to the Unscheduled Care Board;-

Interim report by Wint rFull report Spring/Summ r

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e 2014 e 2015

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7. Reviewing LUCS Activity

7.1 Core Activity

Tables 6 & 7 show changes and smoothing in activity over a 4 year period and the changes in the mix of that activity. Did not attend (DNA) rates are problematic in Primary Care and OutPatient settings. Although not shown the DNA rates for LUCS are very small: 343 in 2009/10 and 480 in 2013/14.

Table 6: Core Activity

Core LUCS Activity

2010/11 2010/11 2011/12 % Incr 2012/13 % Incr 2013/14 % Incr

Primary Care Emergency Centre visits

75,318 £ 753.18

75,798 1% 78,096 3% 69,845 (11%

)

Home Visits 20,034 £ 200.34

20,475 2% 21,569 5% 20,215 (6%)

Doctor Telephone Advice

26,293 £ 262.93

25,429 (3%) 26,967 6% 24,645 (9%)

Calls transferred for District Nurse Action

8,650 £ 86.50

10,249 18% 12,640 23% 13,058 3%

Total LUCS contacts

121,645 £ 1,216.45

121,702 0% 126,632 4% 114,705 (9%)

Total NHS 24 Lothian Calls

200,267 £ 2,002.67

203,313 2% 216,578 7% 207,209 (4%)

NHS 24 Nurse advice (includes A & E and SAS

69,972 £ 699.72

71,362 2% 77,306 8% 79,446 3%

)

Overall activity has changed ince 2010:-

- Total NHS Lothian calls has ↑ by 3- Total LUCS contacts has ↓ by 5 .- NHS24 has increased the number of calls from Lothian it

manages by 3%.- Overall most LUCS activity is down from 2012/13 but up o- Total LUCS activity in 2008/9 was 114,215 and in 2013/14 114,705.

s .5% .7%

verall

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Table 7: Core activity as a Percentage of calls

Core LUCS Activity 2009/10 % of Total Calls

2013/14 % of Total Calls

Primary Care Emergency Centre visits

82,807 39% 69,845 34%

Home Visits 20,739 10% 20,215 10% Doctor Telephone Advice 32,801 15% 24,645 12%

Total LUCS contacts 136,347 114,705

Calls transferred for District Nurse Action

8,899 4% 13,058 6%

NHS 24 Nurse advice (incl A&E, SAS outcomes)

67,688 31% 66,806 32%

Total Lothian Calls (NHS24 & LUCS)

215,055 100% 207,209 100%

Of these total the % mix (Table 7) shows- Attendance at a PCEC as a % of total calls has decreased from

- Home visits as a percentage of total calls has remained relatively t

- There has been a small percentage decrease in doctor advice calls as a percentage of the total calls.

- NHS24 completes the call percentage has increased from 31% to 32% meaning 68% of all NHS Lothian calls are currently dealt with by LUCS (Table 8 .

Table 8

39- 34%.

s able.

)

Outcome of NHS24 Calls not transferred to LUCS

2009/10 % of total Lothian Calls

2013/14 % of total Lothian Calls

NHS24 Nurse advice only 45,963 21% 47,371 23%

NHS24 outcome to A&E 10,597 5% 10,597 5%

NHS24 outcome to SAS 11,128 5% 8,838 4%

Tota 67,688l 31% 66,806 32%

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7.2 Reviewing Additional LUCS Activity

Table 9 sets out “service development activity which has evolved since LUCS started. For some this is seen as non core activity but that would certainly appear to be an outdated view. It does however paint an interesting snapshot of the way the service and mix of activity is changing. Each of these is reviewed in more detail

Table 9 Additional activity

”

.

Additional LUCS Activity 2009/10 2010/11 2011/12 2012/13 2013/14Untriaged Calls diverted from NHS24

28,590 22,840 20,329 19,070 15,598

Patients seen on referral from A&E (RIE & St John’s

4,172 5,677 4,683 4,062 3,284

Professional to Professional referrals

7,964 7,312 8,196 9,166 9,686

Planned Review Service 399 394 497 616 853 Self Referra 4048 4607 4592 3460l

7.2.1 Untriaged calls

Untriaged calls diverted from NHS24 shows a decrease of 45%. This trend is welcomed and given current pressures in all OOH’s services. There may however be perceived benefits to the service as these calls offer local control but have decreased as staffing problems increase.Action

4. The national group should review with NHS24 the volume of calls which need to be triaged locally and continue to reduce this activity flow, except during periods of peak activity.

7.2.2 A&E Referrals

Patients seen as referred from A&E at RIE or St. John’s has also decreased by 27%, 91% of these referrals are discharged home by LUCS (2013/14).Action

5. Protocols exist to manage this flow and it should be kept under review by the relevant Clinical Directors (A&E + LUCS)

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7.2.3 Profession to Profession (P2P) Referrals

This is a direct phone line to LUCS hub at WGH and on to Doctor advice. Its activity has grown by 5% in the last year and 32% from 2010/11. While classed as “additional” activity it is replicated in other OOH’s services and is clearly important to a range of health professionals. The percentage usage is set out in Table 10.

TABLE 10

%of total Change since

2010/11

Laboratorie 2492 25% Up 69%s

District Nurses 2057 21% Up 20%

Pharmacists 1922 19% Up 27%

2013/2014

SAS 913 9% Up 15%

The scale of the increase in laboratories phoning LUCS doctors with abnormal (mainly blood) results needs further investigation. Key to this would be:-

- assuring the right protocols for escalation are in place based on assessed significant patient safety in OO

- assuring systems maximise calls to in hours GPs;- assuring in hours GPs are requesting or identifying those blood

test results which they are particularly concerned and would wish to see escalated and actioned and that OOH’s are informed and clear about what action is expected.

These factors are important as GPs in OOH are frequently phoned with abnormal results to act on in the absence of other forms of detailed patient information.Consideration should also be given to look at models of laboratory nurses in other countries to see if there is a potential service development model.The following actions are recommended:-Actions

6. The Service Manager and Clinical Director in conjunction with the Laboratories should review all protocols for escalation to an OOH’s doctor and ensure these are for urgent patient safety concerns only. This should include clinical assessment at the lab before calls to LUCS.

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7. The Clinical Nurse Manager should with the CHP Chief Nurses, review the nature of calls made by District Nurses to OOH’s Doctors and act on the findings. It is likely that this growth is reflective of demographic changes, frailty and co-morbidities of elderly people.8. The calls from Pharmacists should also be reviewed and it is suggested a 2 week audit for all calls to P2P line would be sufficient to understand the call reason and disposition.9. The calls from SAS also need to be understood and consideration (based on the audit) given to see if this is a service chargeable to SAS.10. Protocols should be developed for planned service reviews as this is likely to be an area of increased activity.

7.2.4 Self Referrals

Self referrals are people who attend one of the PCEC sites without firstly calling NHS24. They are therefore not triaged or assessed for the urgency of their health care need. LUCS has protocols for deciding with walk-in patients or those who attend without an appointment how quickly they will be seen. Two types of appointment are offered –next available following assessment and by protocol where the wait may be up to 4 hours, and “early” where a speedier response is needed and a clinician may be asked to advise. Two other key categories of patients who self refer are people not registered with a GP and visitors to the area.

The reasons why people turn up at the PCEC sites is poorly understood from the patients perspective. There are also geographic variations with the highest number of walkins at W.G.H and Mid Lothian Community Hospital. trends in self referrals is set out in Tables 12a and 12b.

Table 11 Walk-in trends

A summary of the

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The number of walkin at each site overall have remained fairly static over the period with the exception of WGH which has peaks during August as a result of the Festival Centre. The number of walkins at the WGH are a lot higher than at the other sites which is may be as a result of the perceived ‘open door’ at the WGH as it is located beside the Minor Injuries Unit reception.However, the overall figures mask a trend in increasing number of walkins at the WGH on a Saturday & Sunday. A similar but a lot smaller trend is also seen at the MCH on a Saturday & Sunday. This Saturday& Sunday trend appears in 2014 after a drop in walkins during 2013 at MCH, while the MCHWeekday trend is in the opposite

TABLE 12a

21

The number of walkin at each site overall have remained fairly static over the period with the exception of WGH which has peaks during August as a result of the Festival Centre. The number of walkins at the WGH are a lot higher than at the other sites which is may be as a result of the perceived ‘open door’ at the WGH as it is located beside the Minor Injuries Unit reception.However, the overall figures mask a trend in increasing number of walkins at the WGH on a Saturday & Sunday. A similar but a lot smaller trend is also seen at the MCH on a Saturday & Sunday. This Saturday& Sunday trend appears in 2014 after a drop in walkins during 2013 at MCH, while the MCHWeekday trend is in the opposite

TABLE 12a

. .

TABLE 12b

There may be a historical legacy at WGH of having had an A&E, being able to do X-rays and co-location with Minor Injuries Unit. Conversely in Midlothian Community Hospital it may be there is a new public awareness of new services:- a type of minor injuries, minor illness

21

service, neither of which have been put in place by the CHP. Easy parking and location at MCH may also encourage opportunistic use. It may also be related to the relative deprivation of the local areas around each of these sites.For LUCS people who walk in directly pose a clinical risk (as they can sometimes be very ill) and a service risk as they may not appreciate being redirected or asked to wait. On a more positive note the overall number is reducing but trends of increasing activity at weekends are emerging.The potential move of PCEC from it’s current location in WGH may help manage an open door “perception” but it will need monitored and may need further protocols between MIU, ARU Ambulatory Care and PC out of hours.

Actions11. A public survey of those attending WGH and MCH should be undertaken in partnership with the CHP and Public Partnership Foras, to understand why people attend.12. LUCS should review the Policy and Procedure for self referrals written in 2010 and consider asking people to phone NHS24 instead of a “next available” appointment.13. The Communication Team should be involved in the findings of the public surveys and address “routing” issues which arise. They should consider making the “Right Care, Right Time, Right Place (2011)” leaflet more locally relevant, at the CHP level addressing and reinforcing the local access routes in Out of Hours Care Services.

7.2.5 Protected Learning Time (PLT)

Since LUCS has been providing in hours cover for PLT from 12.00 to 18.00 X 6 per year. Each CHP is cross charged 25% of the cost i.e. £12,200There are historic staffing levels and 4 sites open, charging is an equal percentage for each CHP with no relationship for activity to cost. There is no SLA in place.

Actions14. There should be a review of PLT activity to ensure cost effective service provision. Consideration should be given to reducing number of centres open and or staffing model related to West Lothian and rest of Lothian cover. 15. If staffing and cost pressures on LUCS continue then consideration must be given to handing this back to Practices or negotiate an alternative model.

22

7.2.6 Services for NHS Borders

LUCS has an informal agreement to cover the West Linton Practice in NHS Borders. A cross charge is in place with an uplift annually of 2.5%. The charge this year was £32,595.78. However on 2012/13 head of population costs of £10.05 this income should be higher.

Action16. An SLA should be put in place between NHS Lothian and NHS Borders, which agrees the costing model and uplift agreements for the PC OOH’s cover of West Linton Practice population

.

23

8. GP and ENP Recruitment and Retention

8.1 Current Issues

LUCS is experiencing significant difficulties in recruiting and retaining GP’s to fill its OOH’s shifts. No data for % of unfilled hours or retention figures were available. However, although there is no regular reporting of unfilled shifts the following data was made available for the review:-Unfilled shifts in 2014 (note hours and shifts vary considerably in length). Easter – 9.8%, summer 4.5% of which June 4%, July 6.7% and August 3.2%. LUCS is not alone and of the 3 other Boards contacted 2 are escalating concerns to executive level meetings. The pay uplift of 15.2% awarded in 2013 to GP’s in LUCS has had no discernable positive impact on recruitment and retention.It has however had an impact on other boards where anecdotally some doctors have moved to ad hoc shifts in NHS Lothian There is currently no formal reporting of unmet shifts, nor an agreed escalation process for managing the shortfall. The staffing pressures have meant centres have been closed to manage patient safetyRoodlands has closed twice due to staff shortages and MCH closed on Easter Sunday for the same reason. These pressures continue with regular threats to service delivery due to unfilled shifts. Although pressures are exceptionally problematic historically during summer school holidays, Easter, Christmas and 4 day Public Holidays, it is now becoming a year long problem. Some other Boards use locum doctors from agencies. NHS Lothian and some other larger boards do not.

8.2 Salaried and ad hoc GPs

NHS Lothian has a mix of salaried GP’s and ad hoc doctors. Ad hoc doctors are GP’s on a NHS Board list, mainly NHS Lothian, who are paid a fee for hours worked. They are not NHS Lothian employees and attract no leave entitlements. NHS Lanarkshire was audited by HMRC and changes to this arrangement are required to ensure legal payments of National Insurance and Income Tax. Based on the model developed and agreed in Partnership (with BMA in NHS Lanarkshire) NHS Lothian is moving to implement the required changes. This will mean within the next 3 months > 220 ad hoc doctors will be paid via NHS Lothian payroll with National Insurance and Income Tax being taken off at source.NHS Lothian has had variable mix of ad hoc to salaried GP’s in a range of 40% to 60%. The current level is around 50% of hours covered. Not all Boards have salaried GP’s and NHS Greater Glasgow and Clyde run the service predominantly on ad hoc GP’s

.

.

.

24

While it is attractive to suggest increasing the percentage of salaried GP’s as a solution to this, formalised contracts with shifts all within the OOH are largely unattractive. here is currently 240 ad hoc GP’s supplying 10.74 WTE and 58 salaried GP’s supplying 13.47 WTE. More salaried GPs have resulted in a reduction of the WTE contribution in recent years.

8.3 Sickness absence

Medical and nursing staff sickness is having a significant impact on rota management and attracting other doctors to cover shiftsIn 2013/14 the financial impacts were

- £96,000 Medical cover put in place to cover unfilled, paramedic and nursin

- £238,000 increase in salaried and ad hoc pay for medical c r- £43,000 medical cover for long term salaried GP si k- £99,000 medical cover for unfilled vacanc

TABLE 13 Sickness absence

T

.

g shifts.

ove c ness ies

Sickness Absence 2013/2014 By job –

No. over 4%

Doctors 2.38% 11

ENP’s 6.09% 9

Drivers 2.4% 8

Receptionists 4.47% 11

HUB 3.71% 2

Management 3.74% 3

District Nurse 4.99% 8s

The Table 13 represents the sickness absence by “job”. There are clearly actions needed to manage this especially in the nursing groups. Of the headcount of 269 – 52 nearly 20% of the staff have sickness higher than 4%. This must be addressed in the Service Improvement Plan.The doctor and dentist average sickness absence rate in NHS Lothian was 0.97% in-2013/14 and 2.38% in LUCS

Action17. The Service Improvement Plan includes actions to address sickness absence management.

.

25

8.4 Shift Patterns and Rota Management

Rotas are managed by an IT system called Rotamaster which is not used elsewhere in NHS Lothian but is used in the majority of OOHs nationally. The Service Improvement Plan makes recommendations for

W

a review of systems and process to be undertaken by the Staff Bank Manager to explore efficiencies. It is also likely NHS Lothian will implement a rota management system in the next 12-18 months and LUCS should be integrated to a pan Lothian system subject to the other systems interdependencies. eb enabled access, phone and text are all used in a targeted and generic way to try and fill shifts. Currently Rotamaster is an effective IT system.

Shifts are also managed by a range of consortia the largest of which is Midlothian. These are groups of GP’s who come together to commit to covering certain shifts. In Midlothian this is all the shifts at MCH and shifts are rarely handed back to LUCS to fill. In total there are 4 consortia filling shifts.Day shift lengths vary from around 4 hours to 10-12 hours per night. This flexibility is needed to meet peaks in activity and encourage doctors to work in the service.

8.5 hat doctors said about working in LUCS

- Focus on giving high quality person centre- Sites varied, different practices in some, very different workload

in some.- In general shifts much busier, patient needs more complex care.- For many GP s there is no financial incentive to pay more as tax

and pension negatively impacted as pay is inc- Doctors working as GP’s in the day job are working “flat o t”-

demands have increased markedly within the last 2-5 years.- Shift patterns, length and start times are good for some and

difficult for others.- Doctors recognise the different expertise of doctors good at

telephone tr xpert at manag- Doctors needing OOH’s exper- Doctors needing to recognise and develop the contribution

OOH practitioners make to their patient population care s- Productivity differences between Doctors an s

Team working and mix of clinical colleagues positive When asked how more doctors could be attracted to work in OOH’s services some of the themes which emerged were:-

There is a lack of local and community ownership – the co-ops worked for some and unclear if there was an appetite to go back

W

d care

reased u

iage or e ing risk ience.

need d ENP

.

26

.

There is a national shortage of GP’s at the route of the problemThe day job has changed so much more GP’s have no enthusiasm or energy to do more in OOH’s.The day job doesn’t finish until 18.00 or later.Attracting partners to GP Practices is also d ffFinding locums is very difficult and shifts are often covered internally in pr s

In seeking to find potential actions to address some of these issues a review of the national workforce data was undertaken to ascertain NHS Lothian position compared to other boards

8.6 Primary Care Workforce Survey, Sept 2013. (Ref5)

The summary key findings from the ISD publication (noting data may not be complete as 68% of Practices responded)

To the year ending 01/01/13- NHS Lothian had 271 GP’s contributing to - The percentage split between salaried and ad hoc was 60-40%.- NHS Lothian, Tayside and Dumfries and Galloway had only

between 10-20% of GPs in post contributing to OOH’s while Borders had the lowest at 10%. All other boards had higher % of GPs contri .

- Female doctors under 35 were the largest group (head count) contributing to OOH’s.

- GP’s aged under 35 input average 3.5 hours per week in Scotland, 2.5 hours in NHS Lothi

- Older male doctors (over 55 years) in Scotland contributed 19% of the total hours and 16.3% in NHS Loth

- Doctors aged between 35-54 contribute over 65% of the total hours, but the female contribution is highest between the ages of 35-44.

- 92% of GP retainers (often but not always female GP’s returning to work on a part-time basis after an extended period of leave) had a session commitment of 1-4 hours pe we

- NHS Lothian has 17.1% of GP’s in Practice (N=89) doing 1-4 sessions per week, n Scotland this is 13.

Summary

i icult.

actice

.

.

OOH’s.

buting

an.

ian.

r ek.

i 4%.

This is a complex picture with National and local dimensions. There are also a number of issues that may negatively impact the current arrangements:-

- re-negotiation of GP contract in Scotland.- shortages of GP’s and nursing vacancy rates.- implementing HMRC changes for ad hoc GP’s may

disenfranchise more GP’s from O .

OH’s

27

- threats of permanent closure of East or Midlothian sites will anger local GP’s and reduce their likelihood to contribute to OOH’s

r- different pay rates, terms and conditions for salaried GP’s across

Sc t .- perception of a fixed service model in NHS24 with a budget of

approximately £73m (2013/14) and a further £74m in Scotland GP OOH’s (2012/13); and questions of effectiv

- the continued access demands on in hours service and patient routing to other services e.g. LUCS, w n

In all the interviews and discussions there were very few positive concrete examples of how this picture could change for the better.

8.7 Addressing the Issues

The following are a range of potential actions which may help NHS Lothian address some of the issues it can control.Actions

18. Differentiate NHS Lothian:-develop attractive Terms and Conditions for salaried GPs.develop attractive training and education opportunitPackages for wider medical workforce to learn OOH’s care e.g. in paediatrics and mental healtOffer joint posts for individuals within specific career paths potentially in unscheduled care.Create training for GP’s and ENPs in telephone triage and doctor advicCreate links with medical schools for research opportunities and specialised module development e.g. risk taking in GP OOH’s care or an Academic Primary Care Consortia with a Research infrastructure.Improve the culture and perception of the service and increase the clinical management. Support the above by undertaking further fact finding with GPs in Lothian about what would attract them to contribute, however limitedly, to OOH r

19. TargetYounger female doctors and GP retainers who currently work under 4 sessions a week.GP ST3/registrars with attractive and individualised “fellowships” similar or aligned to A&E fellows.“Selling” the uniqueness/importance of the professional development opportunities GP OOH care o .Identify at GP ST3 stage those individuals who, with training, could offer sustainability to the ser

ca e.

o land

eness.

alk-i s.

ies.

h.

e calls.

s ca e

ffers

vice.

28

GP’s who have never worked in OOH and offer taster/ refresher sessions.Develop a targeted recruitment plan assisted by the Head of Recruitment NHS Lothi .

20. ConsideThese are some examples being considered under OOH’s core delivery to address potential problems with GP recruitment.

Using medical locums in a targete .Training ENPs or develop ANP role for home v iIntroducing stand-by shifts or on call for clinic l .Have doctors working from home with appropriate IT and telephone and privacy arrangements.Band 5 nurses to undertake diagnostic/arrange referrals and support doctor in peak tiCommunity paramedic role in home visi

8.8 National GP Training

GP ST1 and 3 do part of their training in LUCS. Not all services in Scotland provide this opportunity. Trainers need:-

Training to undertake thi r l .Extra time while on duty to access/advise/support/supervPaid an additional element.

Action 21. Currently LUCS GP’s provide this support on a good will basis with no additional funding or recognition. This needs rectified and should be addressed in two ways:-- By the development of Terms and Conditions for salaried GP’s- By the Executive Medical Director investigating if monies are

transferred to NHS Lothian for this post graduate national programme – and take appropriate action to fun

8.9 Addressing ENP Issues

The review found significant professional and contractual concerns in this staff group. They were critical with historic and current management and partnership actions in respect of a range of issues, most noticeably A f C banding. The outcome of the final review held in May /June 2014 is still not known (July 2014).Some expressed a strong belief that they were working as Advanced Nurse Practitioners’ and were upset that the service continued to undervalue their role.

an

r

d way is ts. a staff

mes. ts.

a) s o e b) ise. c)

.

d.

29

The appointment of a Clinical Nurse Manager who is also Lead for Advanced Nurse Practice and non medical prescribing is very welcome even for only 2 days per week. It is also clear that there were a range of professional issues which needed urgently addressed. It was also observed that especially at East and Mid Lothian sites there were anecdotal reports of high levels of patients for whom minor injuries were the presenting cause but that ADASTRA had no data code for these presentations. This adds to the need for clarity in the clinical model and the training and skills needed for the role.The Service Improvement Plan sets out a range of actions needed to address the following:-

Professional isol Need to underpin professional practice with clinical protocols, assessed clinical competencies, clinical supervision and effective Personal Developmen nAddress workforce issues e.g. succession planning, skill mix, and educational preparation stanAlign the nursing contribution to service needs and strengthen clinical leadership and manag m n

9. Improving Safety and Effectiveness

9.1 Clinical models Mid and East Lothian

Managing clinical risk is an important consideration of East and Midlothian sites as currently ENP’s can be left relatively isolated of medical or hospital cover. They are also geographically isolated. The staffing model on both sites is one doctor, driver, receptionist and 2 ENP’s

Actions22. The analysis of the activity at the Roodlands and MCH sites would suggest the following changes to the hours of service and clinical staffing

both Roodlands and MCH should close at 22.00 instead of 24.00 i.e. Monday to Friday opening from 18.00 to 22.00Both Roodlands and MCH should close at 22.00 on Saturday, Sunday and Public Holidays i.e. open from 08.00 to 22.00 hours.One car, driver and doctor should cover the 2 geographic areas with support from car based at RIE when necessary.Each base should have a receptionist and doctor as core

Consider substituting a band 5 registered nurse for the receptionist at each site to support, record, manage, assess patients prior to doctor consultation.

1. ation 2.

t Pla s 3.

dards 4.

e e t

.

;

hours.

staffing

30

9.1.1 CLINICAL MODELS - T JOHN , WGH AND RIE SITES

The activity levels (excluding visits) at the other 3 sites are significant and comparable. Based on 2013/14 data:-

St. John’s Mon-Fri – needs appointments for 3-

5 patients 18.00-24.00

Sat-Sun eeds appointments for 8 patients

10.00 to 24.00

S ’S

– n

WGH Mon-Fri – needs appointments for 4

patients 18.00 to 24.00

Sat-Sun – needs appointments for 8-10

patients 10.00 to 24.00

RIE Mon-Fri needs appointments for 4-5

patients 18.00 to 24.00

Sat-Sun – needs appointments for 8-10

patients 10.00 to 24.00

–

Actions23. The Clinical Director and Service Manager will review the staffing for the 3 sites based on 2013/14 activity analysis which shows only very small variation to previous years’ activity and is reasonably stable in days of week and weekend site attendance yet there are staffing differences.24. There should be an increase in the available appointments by health profession to 4 appointment slots for GP’s (an increase from 3) and 3 appointment slots for ENPs (an increase from 2)and consideration of trialling of appointments for doctor advice calls.25. ENPs should be concentrated at the above 3 sites and the CNM should review competencies, team working and potential skill mix.26. Consider introducing: on call or Saturday arrangements for peaks in activity and clinical advising Doctors based in their own home with supporting technology/telephone to provide triage/doctor advice supplementary provision.

Clinical Models - Summary

Two clinical models are emerging driven by safety and activity:-

odel 1

M East and Midlothian (Roodlands & MCH)

- GP delivered service (No ENPs) and recepti- One car and driver for geographic area in the ev n .e. East

and Mid Lothian Support from RIE car when n d- Opening hours reduced Mon-Fri 18.00 to 22.00/ Sat-Sun 08.00 to

22. .- Increased appointment numbers for Doctors from 3 to 4 p r- CHP’s to agree what if any Minor Injuries ser- Locally relevant public information re access to a range of OOH

r

onist. e ing i

ee ed

00 er hou vice.

ca e.

31

- Doctor advice calls distributed to the least busy base at the time, not necessarily the most geographically relev t

Model 2

an

RIE, ST Johns and WGH- Multidisciplinary teams wi NPs working to comp t c. Increased appointment numbers for Doctors as above ndENPs increase from 2 to 3 appointments per hou- Sites to be maintained if staffing shortages and escalation

procedure a e- Majority of cars dispatched from two of the 3 sites St Johns and

RIE as currently happens overnight after mi- Doctor advice calls distributed to the least busy base at the time,

not necessarily the most geographically relev t

9.2 OOHs Services for Children and Young People

There is a not unsurprising number of children attending an OOH’s site every month (LUCS very rarely provides a home visit). 22% of LUCS contacts are for children and young people from 0 – 14 years. NHS24 refers approximately 75% of all children to OOHs services for a face to face consultation.

Average numbers October 2013 May 2014 by site

th E e en y

a r

gr ed

dnight.

an

– MCH RGH RIE STJ WGH AVERAGE

Age 0-5 227 181 407 480 303 319

Age 5-15 92 72 159 195 104 124

A focus of the review was to ensure safety of patient care and that there was a supporting competency and training framework especially for children’s care. Based on the investigative findings where GPs and ENPs see children who are not triaged and have undifferentiated presentations and noting the difficulty in telephone triage of childrenand absence of robust clinical protocols it is recommended that the service:-

Actions27. Appoint a named Clinical Lead Professional Adviser(s) in the care of children and young people28. The Clinical Nurse Manager and Chief Nurse (East and Midlothian) provide evidence of ENP competency to the Executive Nurse Director of the current level of expertise and professional updates completed in the last 3 years to assure that competency in the care of sick children, especially those under 5 years

;

;

32

In the absence of this evidence, the Executive Nurse Director should decide if ENPs employed in NHS Lothian should see both/either triaged children, walk-ins or any child under 5

29. The service and the Clinical Lead Professional Adviser will agree within 3 months:

The minimum clinical competency framework for care of children for doctors and nurse;Updates and mandatory training requirements;Plans to shadow and participate in emergency care delivery at RHSC and St. John’s and potential reciprocal arrangements to OOH’sEnsure a plan is in place to align, share or develop relevant clinical protocols for use in acute/urgent and emergency children’s careBring forward plans to review the care of chi

It is also suggested that the Executive Medical Director and Clinical Director highlights the training opportunities which could be developed in LUCS i.e. current training programmes for doctors in child health and acute/illness care. There may also be a need to have a strategic review of all urgent care services for children and young people in Lothian to ensure they are aligned and integrated into the new RHSC service model.

9.3 Home Visits

A high number of the GP’s interviewed offered as a suggestion that the current national disposition of NHS24 calls to a 1-2-4 hour doctor visit was an area for improvement. Comments included:-

- Frequency of 1 hour visits as a disposition from NHS 24 not being sufficiently critical for a 1 hour v s

- Acknowledged difficulties in telephone triage of chi- Fixed time slots for hom re not given in the in hours per

for home visits;- Number of home visit dispositions i.e. 3 dispositions (1-2-4 hour

appointments- Number of home visits which are not “needed”.

While accepting that home visits were an important outcome suggestions included:-

- reducing to 2 visit protocols from 3 potentially -1, up to 2 hours and 2, within 4 hours;

- trialing a triaging of home visit calls by LUCS i.e. NHS24 disposition would be “the doctor will phone you to assess if you need a

.These would need discussed with other boards and nationally with NHS24.

;

;

; ldren.

i it; ldren; e visits a iod

);

visit”

33

NHS Lothian has good links with NHS24 and is well represented on the National OOH's Operation Group. Many of the issues highlighted in this review are not unique to NHS Lothian. It is very important that while acknowledging and empowering local solutions, NHS24 is flexible to test different models for service delivery. The national nature of the shortage of GP’s willing to work in OOH’s period’s means novel and previously tested solutions may need to be re tested.Action

30. he Clinical Director and the Executive Medical Director should meet similar NHS24 staff with a view to negotiating;reductions in untriaged calls passed to NHS Lothian (note reduction in income which would follow), trials of different disposition options as above, and a test of triaging locally for home visits

9.4 Right Patient, Right Place, Right Time

It is quite surprising that given the focus on appropriate attendance at A&E’s by the public that the PC OOH’s service is branded by Primary Care Emergency

T

Centre titles. This is not the case across Scotland. The public become further confused by calling NHS24 for an out of hours, (OOH), appointment supplied by Lothian Unscheduled Care Service(LUCS), to attend a hospital Out Patient Department(OPD) where a PCEC is located.NHS Lothian current patient information “Right Patient, Right Place, Right Time” is high level and is now needing updated to reflect the new NHS 24 111 number.The increase in Did Not Attends (DNA PCEC) see table 7 may be partly explained by the lack of a mechanism to cancel an appointment once made t is therefore recommended thatAction

31. Each CHP have a geographic and service specific information leaflet which is widely circulated.

It should encourage people to phone NHS24 to discourage walk-ins (especially in Midlothian and around WGH postcodes)It must also address the number of DNA’s and advise people of the number to phone to cancel an appointment. It could provide local communities with a range of OOH’s care and support contacts of which NHS24 is for urgent out of hour’s medical care when the GP is closedAdvice should also be given that this service is not for “second opinions” or patients whose key problem has been getting an appointment in hours with a GP Practice

. I

.

.

.

34

It should also direct patients to local minor injuries units ere this is agreed and it needs to somehow differentiate/direct people to minor illness, minor injury and minor aliment services.

32. Finally LUCS should be renamed, as it is not an unscheduled care service although it is an important part. It is Lothian PC OOH Service.

9.5 Efficient Use of infrastructure

LUCS has invested in fleet management (TOM TOM Sat Nav) ,“tough books” and call centre capability (call handlers /dispatchers) via a central hub at the WGH.

From information gathered, the following improvements should be considered in addition to those identified in the Improvement Plan:-Actions

33. Efficiency savings and productivity improvements targets should be set and monitored for effective car dispatching, linked to staff training, and led by the operations manager;34. Up to midnight cars cover NHS Lothian and are dispatched from all 5 sites, consideration should be given to reduce this to 2 ; West Lothian (only) and – RIE (rest of Lothian) with training and effectiveness in fleet management this model may be possible as standard and this is what currently happens overnight.35. Doctors should be encouraged to complete patient record in Tough Book while car is being driven;36. The Operations and Hub Managers should review activity, call numbers and number of dispatchers needed;37. A trial should be undertaken to test if a doctor advice calls can be routed to cars when not attending home visits with the appropriate recording and governance arrangements;38. A strategic review/ redesign of all NHS Lothian “hubs” e.g. transport hub, LUCS hub dispatchers call handlers, Emergency Bed Bureau should be undertaken to maximise efficiencies. This should include the use of the cars in the in hours period.

9.6 Public Holidays

There is no doubt that the position of having 4 day Public Holiday periods is extremely challenging for OOH’s services in Lothian. This Easter for example staff shortages necessitated the closure of MCH OOH’s site for Easter Sunday. NHS Tayside have an alternative model which could be considered.

– w

35

The following are suggested to try and reduce these pressures.Actions

39. The Director of HR should bring forward plans in partnership to realign public holidays to do away with 4 consecutive Public Holidays.40. Staff working in LUCS should have managed A/L allocations where A/L on PHs is permitted only if the service is covered.

9.7 Improving Managerial and Administrative Mode

The Service Improvement Plan has detailed actions to achieve improvements and these can be summarised as:-

- Immediately recruit to cover Service Manager role for 6 months, preferably with someone with clinical experi

- Immediately move administration/management offices to one of the 3 busiest clinic

- No further supervisory or managerial roles are required other than in clinical r

- Empower the site supervisors to lead and resolve site specific

- Service Manager and Operations Manager should review potential effic handling and car dispatching hub, utilising receptionists (especially at East and Midlothian) with routine administrative functions e.g. bag and equipment checks

9.8 Clinical leadership ee Action 1

There is a clear and real need to increase the clinical management and leadership capacity in the service as set out in the service improvement plan. The key aspects are- Increase Clinical Director to 1.0 WTE- Increase Associate Clinical Director from 12 hours to 1. 0 WTE contribution.- Negotiate the contribution of Advanced Nurse Practitioner, Lead for Hospital at Night to full time for 6 months rather than 2 days per week.- Refocus service and role of Quality Improvement Team to an emphasis on safe person centred effective care which is clinically audited and focus on delivery of National Standards see Action 3.- Organisational change will be needed for ENPs irrespective of outcome of banding review.A suggested new professional structure would be to have x 3 ,0.5 WTE team leads on each of the 3 large sites from the current x1.0 wte band 7. bove this a CNM needs to be replaced in the service, at least for the next year.

l

ence.

al sites.

oles.

issues.

iencies – the call

. -

- S

;

A

36

There is an urgent need to put in place a realistic clinician on call rota which is currently delivered mainly by the Clinical Director. It is suggested that there be 3 Associate CD s each with on call responsibilities, the CNM and 3 Team Leaders also participate creating the potential for 8 person on call rota.

10. Accountability and Governance

LUCS is currently a “hosted service” within East Lothian CHP. These arrangements have been in place for several years. NHS Lothian is reflecting on the future governance arrangements for a number of services including hosted services to align with the delegationframework relating to the integration of Health and Social Care.

In the immediate terms there is a need to strengthen the relationship between:-

-LUCS and the CHP- and its Board- and between LUCS and Primary Care Planning and Strategy development (Ref6)- and LUCS and the other CHP’s.

OOH’s care and National Strategies

The current governance arrangements are linear with no current reporting to other CHP’s. Suggested include.

41. Managed protocols should be developed and tested out on how LUCS communicate and report performance to all CHPs and scheduled services. This could help when LUCS needs to escalate concerns on a safe service provision.42. Current management arrangements for attendance at the LUCS SMT and the line management of the CD and service manager need reviewed43. The role of the Unscheduled Care Board in relation to performance reporting and strategic direction should be clarified

NHS Lothian Board have under the Scheme of Delegations, delegated the governance arrangements of LUCS to East Lothian CHP Board.Shadow Boards for the Health and Social Care Partnerships are in place and will need to understand their role in respect of hosted services.

It is expected that as the integration of health and social care progresses there is a desire to localise current pan Lothian services within the new Partnerships. Primary Care OOH’s care, single of point of contacts (SPOC’s) and greater roles for community hubs for

-

Actions

37

integrated service delivery e.g. in Mid and East Community Hospitals and at St. John’s and sites across Edinburgh City are all possible.

There also needs to be a more detailed review of the internal and external expectations of the future of Primary Care in hours and out of hours. There is a significant lack of content and consideration to the PC Healthcare needs of the people of Lothian in the OOH’s periodcurrently 70% of the week in current strategies (Ref 7).While this review makes some recommendations which may help in the short/medium term, it is sensible to consider whether even this is fit for the future.

The future of NHS24, Public expectations of direct access 7/24, walk-inspoly clinics, potential for longer opening hours in GP Practices despite current access and recruitment challenges, localised integrated shared public service provision will all necessitate more radical thinking

There is also a need for the new Partnerships to think about this and plan on how all services are provided in the day time, at the weekends to maximise patient flow through systems and maintain safe, high quality, seamless care.

11. Localise and Integrate

The last LUCS review in 2010 discussed various aspects of integration between and within services especially A&E and minor injuries. As LUCS has matured, protocols for routing patients between services have stabilised.

2013/14 Total activity 114,705 contacts of which 3284 were referred from A&E to LUCS (down 22% in a year) 91% thereafter discharged by LUCS2013/14 Total activity 114,705 of which approximately 10% was referred to A&E or emergency medics from LUCS approximately 85% thereafter discharged

There was little appetite expressed by those interviewed for any further service integration as each part of unscheduled care seeks to focus on its core business.The key area for NHS Lothian to address is the medical model which is needed now and in the future to care for patients in continuing care beds (IPCC), step down, care homes and NHS sites especially beds in the old RVH. There are also a number of care homes where no in hours cover through enhanced GP services and lead practices has been negotiated.

–

,

.

–

.

38

The addition of this cover provided by LUCS has been evolutionary with “assumptions” made that LUCS is (a) able to undertake this activity and (b) the right or only model. Other models exist but generally the OOH period remains problematic.Questions need answered as straightforwardly as - what medical model does NHS Lothian want for continuing care beds etc?

- will developing a Care Home Liaison Service cover OOH- other solutions includ se led integrated approach which

includes OOH's for frail elderly are po- Is the internal cross charging and income to LUCS for the current

service provision of home visits and P2P sufficient (11.6% of P2P activity is from NHS in patient c

The assumption that LUCS can continue to take on additional activity or service initiatives needs challenged. It must focus on providing a safe and efficient OOH’s service for urgent primary care needs.

Localise

’s? ing a nur

ssible?

are)?

The key criticism from the GP representatives was the lack of local ownership and GP engagement with LUCS. The National Integration Agenda developing Health & Social Care Partnerships does offer opportunities for moving to more localised options, more integrated within other community services.Midlothian GP’s demonstrated strength and a cohesive community focused ambition. Ambition to maximise the use of functionality of the new MCH was also evident. The Mid Lothian consortium supplying LUCS is also successful. There was also a concern expressed that the review would result in the closure of the service at Mid Lothian or East Lothian If either site were to close it is highly unlikely that those hours currently delivered or the workforce would continue to work in LUCS

Both CHPs and the new Partnerships may wish to consider testing ,given the integration agenda whether local GP’s may wish more local ownership of PC OOH’s care and may wish to consider:-

- strengthening the current consortium in Midlothian and assessing if GP’s would opt back in to OOH’s care delivery. Midlothicould be a “test bed” mo

maximising the overall use and GP use of MCH e.g.further integrating Mental Health, Palliative Care, Frail Elderly Care in sdeveloping a Single Point of Contact model for directing calls to alternative services in social and voluntary sectors,

- re-engaging with East Lothian GP’s who are particularly negative about historic relationship issues with LU

- East and Midlothian CHP’s need to confirm what, if any, minor injuries service they are, or wish to provide. (There is no provision

.

an del for –

OOH’

CS;

39

in the new East Lothian Community Hospital plans and Midlothian “have no funding” for Minor Injuries Ser .

- Strategic level planning in West and Edinburgh is ongoing to review potential integration and PC OOHs services should be part of that longer term planning.

12. Next Steps

The LUCS review is being monitored as part of the Strategic Planning Board and is one of three work streams being given additional project management supportThe following is a list of potential work streams, which could be considered as Phase 2 projects from the review:-Loca

- Organisational change and introductions of new clinical mod- Review all Prof to Prof calls to ascertain if all calls are necessary

and consider development of other models to m n - Implementing the national standards and an infrastructure of

patient safety underpinned by clinical audit and gove

Pan Lothian

- Redesign of LUCS hub, transport hub, DN call handling, taxi and fleet management, and dispatching, EBB, links to PTS SAS and development of local SPOC’s

- Project to consider different medical models and funding of care provision in hours and out of hours for patients in IPCC, step down beds, care homes, hospic s c

Nationa - National interface issues identified in the review should be addressed

ices)

.

l

el;

a age

rnance

;

e et .;

l

40

13. Executive Summary

The Review has suggested a number of actions to strengthen and focus on the delivery of Out Of Hours Primary Care.

Of particular importance are;

Improving the relationship with GPs, increasing the number who provide OOHs care,

Agreeing the 2 clinical models and escalation processes to maintain patient and staff safety, and provide clarity in the contribution of ENPs

To move the service forward as suggested by these recommendations it will be necessary to strengthen and realign both the serv clinical manag t

Influence the national agenda re interface improvements with NHS24 and GP n mb s

Agreeing the medical model, responsibilities and finances for in hours and out of hours Primary care for patients in NHS Lothian IPCC, step down, winter beds, hospital to home, delayed patients, patients in care homes and patients who choose to die at home

Deliver the LUCS Improvement plan, rename the service and work with public and partnership representatives to support Right Patient, Right Place, Right Ti .

Maximising the localisation of services aligned in the new integrated Health and Social care Partnersh s

ice and emen

u er

etc

me

ip

41

42

14. Appendices & References

Terms of Reference

Aims

Appendix 1

To ensure that LUCS is working in the most efficient and productive way to provide effective, holisitc patient care and an efficient, productive environment for staff. To ensure LUCS is fit for purpose now and in the future

Objectives

To provide a pragmatic review of the ways of working within each part of the service

Systems and pro sManag t

To identify any effencies to be gained to ensure best value for money whilst continuing to provide excellent, safe and effecive patient care.To identify optimum levels of staffing in each serve area in conjuction with current (and future expected activity figures: not undertaken)To facilitate team ethics and workingTo ensure out of hours national standards are met.To identify if any additional training/training budget is required.

Professional Advisers

Clinical cesse emen

.

Dr. Nigel Williams, Associate Medical Director, NHS LothianPatricia McIntosh, Clinical Services Development Manager, East Lothian CHPJane McNulty, Lead Advanced Practtioner

Service Lead

;

;

Sian Tucker, Clinical DirectorStart Date: April to Mid July 2014

Our Health, Our Care Our Future NHS Lothian action 5.1.24To review the operation and design of LUCS in the face of increasing numbers of patients with complex needs being seen in the OOH , the increase in direct access to OOHPC advice via the P2P telephone line and the additional demands OOH over and above the normal core work e.g. Public Health

Improvement Plan Summary Docu

Appendix 2ment - Final

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By

RequiremeWhen

nts

Evidence of Completion

Service management

Absence of service manager effectiveness of manage am ,performance monitoring and reportingaccoun y to CHP , need to address clinical models, service models, and current leadership and management issues

Interim replacement service manager needed, (consideration should be given to a clinically qualified manager given the need for robust and safe decision making), infrastructure of reporting perf mgt needs to reflect current service challenges. Member of CHP SMT should be a member of the LUCS SMT. A regular monitoring template of risks and challenges must be taken to the CHP Board

D SmalSMT

MID July 2014

Additional salary to cover absence

Service manager in place, accountability to CHP board demonstrated

, ment te

, tabilit

l

-

Management profile and communication with front line staff requires significant improvement, potential for new structure and team leads

This is a key action which will require support from other NHS Lothian corporate services and learning from communicating with remote teams and workers, there is currently huge disjoint and isolation of employees from the service and NHS Lothian and its values

D Small SMT, HR Development

Plan ready in 3 month

Likely in hous

Reaudit staff attitudes and complete plan

s

e

Management working hours not aligned to service delivery

Most mgt and admin staff should work no less than 30 % of week in OOH period. This may be by local agreement or by organisational change and based on peak activity norms

SMT SM Nov Potential for additional pay costs

Improved mgt identity with staf

f

43

Area for Improvement

Reason/Assessment of problem Actions needed By Whom

Resource By Evidence of

RequiremeW enh Completion

nts

Site supervisor role has considerable potential to deliver and resolve local problems and service efficiencies

Service manager to agree key short term site fix plan with each site supervisor and hub manager and support the delivery including any appropriate training, consider additional admin type functions for receptionists

SM Site supervisorJ M n

asap ni Fix plan per site completed

s o k

l

Clinical Director continuously on call and regularly undertaking service manager role, need to understand roles and responsibilitie

Enable differentiation of Clinical Director role and service manager role, bring forward sustainable plan for clinical on call which may include CHP clinical team

CD D Smal

By Sep

Clarity of rol

s

l t e

Absence of SOP s for contingencies and decision making for staff shortages, service capacity, closure of

srevie all business continuity plans and risk registe

Urgent action needed to formalise arrangements and SOPs for service delivery maintenance in the face of staff shortages and other scenarios. These must be agreed by CHP Board, aligned to business continuity plans and placed on the risk register

SM, CD D Small

asap ni SOP s agreed and in us

site( )

w r

l

e

Staff

Governance

Culture of staff and service isolation, not feeling valued or involved in decisions which affect them

Urgent and concerted action needed supported by HR and comms functions to re engage staff into local teams and service and within NHS Lothian, new management with clinical leadership inpu

Assoc Dir workforce development/SMT

asap nil Evidence of staff governance standard being me

t

t

Consistency needed in meeting mandatory training and PDP processes in all staff groups

Audit of current attainment of 100% compliance with PDP process to be undertaken and action plan to address

SM/SMT By Sep

ni All staff have annual PDP

t

l

Need to comply with annu iew mechanisms to assure competencies, for salaried GPs

GP Clinical leaders time insufficient to meet this requirement, additional Assoc CD time needed

CD /SMTDF

By Dec Will need costed

All GP must have an annual review meeting

al rev

44

Area for Improve Reason/Assessment of problem Actions needed

ment

By Whom

By When

Resource Requirements

Evidence of Completion

Drivers working infrequent and short shifts, and need for assessing standards, feedback and training

Transport manager and H and S assessor to audit current arrangements for driver assessments and agree potential for internal assessor. Transport manager to advise on maximising efficiencies from fleet management

Ian Sneddon H and SJ Mon

By Oc Clarity of processe

k

t nil s

Need to comply with HMRC requirements re payment via payroll for ad hoc GPs

Assoc Director HR pay has plan to implemen R KellySM in partneship

Within 3 month

?? All ad hoc GPs on payrol

t

r

l

Staff movement between sites for some groups of staff problematic due to contract specifying base site

All staff should be able to work at all sites subject to NHS Lothian policy exceptions and organisational change policy should be followed to make this a reality

SM J Gaskil

By Jan 2015

Flexible staff options

l

Need for consistency and adherence to NHS Lothian HR policies e.g. uniform and dress code , absence management, and managerial competency to undertake

Managers need to understand their role and enforce policies, training may be needed and processes for policy awareness and compliance needs improved, HR case management and follow through need improved

SM J Gaskill, SMT and all manager

ni Improved levels of compliance with policies, case work reductions

s

l

Absence of regular review locally for rates of pay for GPs in OOH services Potential negative variance of paid study leave for salaried GPs from norm

Assoc Director for Pay has been asked to develop T and C for salaried GPs in NHS Lothian

R Kelly in partneship

tbc ??? T and C s including study leave agreed and in place

s

r

Sustainability of on call arrangements and need to evaluate recent split between clinical and non clinical routes

Evaluation of new arrangement to inform overall on call provision of service and reduce need for duplication

SM /SMT asap ni Revised On Call system in place

l

45

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By Evidence of

RequiremeWhen Completion

nts

LUCS could be seen as running a staff bank outwith the NHS Lothian staff bank and there may be efficiencies to be had and standards need audited. Currently no use of Locum Agencies, Ad Hoc GPs will move on to payroll in near future

Staff bank manager to conduct an audit of LUCS processes and set out plan for any efficiencies or refined processes re shift fill, communication with staff, potential med locum use, IT and other systems e.g. call centreFunctionality, reports and staff recruitment processe

F Towe and SM

End Sep2014

tbc Audit completed with recommendations

s

t

Complexity of rota management, shift variations, unfilled shifts, use of rotamaster and potential for improved method

As above, potential for training As above

End Sept 2014

As above

s

Disillusioned ENP staff group, with ongoing and protracted banding issues, no skill mix, no effective annual competency review of practice, limited professional updates, no clinical supervision, limited succession planning , no local or national networks, isolated within NHS Lothian and diminished clinical and managerial leadership

Interim CNM support to start asap for 6 months to draw up a plan to address all these issues, especially reviewing competencies, potential new staffing models ,caring for children and pregnant ladies and act on the results of banding review. Dependent on the outcome a further review of clinical leadership function is needed, Delivering Better Person Centred care N and M leadership and management standards should be used alongside specialist competency frameworks , a JD that reflects modern professional practice , skill mix and service need is also needed and aspects of delivery of the plan may require organisational change

J Mc Nulty/ et all

Plan by end August, delivery over 6 month

Funding for education courses and assessment may be needed

Engaged team of professionals, with skill mix and underpinned by educational prep

s

46

Area for Improve Reason/Assessment of problem Actions needed

ment

By Whom

By When

Resource Requirements

Evidence of Completion

Absence of staff training and education budget, no coherent development plan for the service and its staf

A training needs assessment for the service is needed and aligned to the organisation opportunities and individual PDP

SM / SMT

March 2015

ed to inform budget BUT will cos

Staff are appropriately trained and developed to do the job and receive feedbac

f

s

Cost

t

k LUCS does not receive additional

finances for the pay uplift for GPs in the service who supervise the GP trainees

Exec Med director to advise on potential solution re NES or advise other internal income funding is available to cover the additional costs

DF and Finance ?? NES

Sept 2014

Potential income

Income secured

High numbers of staff who have concurrent employment and difficulties in monitoring to assure safety and legal duties

HR to work in partnership and with Service Manager to ensure NHS Lothian policies on this are consistently in place and followedthrough

J Gaskill SM, Partneship

Dec 2014

nil Effective monitoring processe

r

s

There are historic pro lems with most staff groups sickness especially nurses and doctors which needs addressed

The serv ce manager CNM and CD should be clear about their plan to address the issues within the application of NHS Lothian policies. Reporting should form part of a regular monitoring with agreed actions

SMT ongoing

nil Sickness absence reduced

b

i

LUCS operates a satellite recruitment process for salaried GPs and undertakes checks on the ad hoc GPs on the NHS Lothian or other Boards Lists to practice held by the Executive Medical Director, there are no locum agencies or recruitment packages in place other than direct contact and securing Registrars at completion of course

The Head of Recruitment should undertake a review of the current governance arrangements for these processes and work with the Clinical Director and service manager to develop a recruitment approach to maximise opportunities for shared post and learning within Lothian service to enhance the attractiveness of the experiences this service offers

Jenni Duncan

Dec 2014

Robust employment selection processes are in place to protect the publi

c

47

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By Evidence of

RequiremeWhen Completion

nts Facilities

and ITOffice accommodation at Astley Ainslie is poor and not aligned to any of the clinical site

To improve proximity of management to service, the admin and mgt function should move to a clinical site potentially as part of the current accommodation discussions at WGH

Site mgt WGH SMT PartneShip

Dec 2014

tion costs

Mgt collocated with a clinical servic

s

r

Reloca

e

Most sites have issues with IT and printers

E health to identify a lead contact for LUCS to work with site supervisors out of hours to resolve the issues

E health/ site supevisor

asap In house Clinicians have access to printers and effective IT systems

r

s

HIU have no access to Adastra for data analysis or linkages to other data sources

Adastra is a key info system for NHS Lothian and HIU can help harness data for management

SM and Bill Ramsay

asap License fe

Senior analyst has access to Adastra

e

St Johns OPD restricts LUCS staff access to rest areas, chairs etc and clinical supplies, reception and staff area are all in one room, other low level issues and car parking need resolved and signage needs improvedSites are not well linked into local site mgt groups in hours and variably for interdependencies and security etc in OOH

Site Supervisor and site manager St Johns to resolve as these issues have been ongoing and the clinical area is not fit for purposNew service manager to walk through the issues

SM Site suprvis

asap nil Issues resolved

e

e or

WGH accommodation is poor for purpose, colocated with MIU, confusing for the public and site planning is looking to move the servic

Ongoing discussions about moving LUCS are to be welcomed

CD SMT Ongoing

Relocation costs

More acceptable accommodaction

e

48

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By Evidence of

RequiremeWhen Completion

nts

RIE OPD 6 is in need of modernisation, distraction, children’s areas, large open plan desk area is untidy and not welcoming, also serves as a staff area, but well placed for links to A and E, signage from new bus stop needs improved

This needs fed into the site mgt at RIE and an audit of public acceptability of this area and local signage should also be reviewed as should provision for children

SM/ site MGER RIE

ongoing

vement costs

Refurbished area

Impro

Public are asked to call NHS 24 for an OOH appointment provided by LUCS, based at an OPD, but its called a Primary Care Emergency Centre

Confusing, why use the term Emergency? Consider renaming…

SMT Potentially signage

Improve public understanding

A number of investments with potential for efficienciesTom Tom and fleet mana emenAdastra and a range of audits and report

SMT needs a plan to achieve the potential efficiencies for more effective working practices and opportunity for clinical audit and effective practioner reviews

SMT / J Monk

By Sep

nil Maximise efficiencies and safety

; g t

s

t

QIT and Clinical governa

nce

Potential for safety improvements by standardising processesBag checkingPaper work in bags and at basCommunication booksEquipment checks a pairsPharmaceutical checks

Site supervisors can solve local issues once SMT have agreed the policy, Service manager needs to bring forward plans to resolve , bagsdo not need checked by clinical staff , but meds should and checking should not delay car being road ready. Problems with equipment infuriate clinicians

SM/ SMT/ and Site Supevisor

Asap by sep

nil Standardisation of key and routine process to improvesafety

e

nd re

r s

t

49

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By Evidence of

RequiremeWhen Completion

nts

Potential to use existing Lothian audit tool for patient experience indicators

PQI audit Patient Experience QualityIndicators for clinics and OPD should be used annually on each site and action plans for improvement developedReleasing Time to Care rog offers means to resolve

CNM and SMT

Ongoing

nil Evidence of audit and improvement plans

p

Considerable progress in recent years with QIT action plan and support from pan Lothian team

Maximise all staff involvement and concentrate on clinical audit and effectiveness type activities, and actions needed for training needs assessmen

QIT ongoing

nil Continued progress

t

Testing of local patient experience survey

This positive step needs finalised ,formalised with support from pan Lothian patient experience team and further developed as part of meeting national standards

QIT By Dec Small cos Local site specific patient experience

t

Review and internal audit of medical

and non medical prescribing will be more easily enabled when Adastra updatedPotential to improve awareness of and use of Datix incident and risk management system, complaints reviews and mechanisms to sharelearning

QIT should agree how audit under aken frequency reporting etc and gain acceptance of methods as p[art of a higher emphasis across the service on patient safety. The patient safety lead should be invited to consider actions that the QIT can take within the SPSP

QIT / PATIENT SAFETY LEAD

Clinicians have individual review of their professional practice to improve learning and patient safet

t

y

Challenges of managing skill mix , staff and patient safety while maintaining service delivery within staffing constraints

See main review reporPotential to reduce op ng hours of 2 siteIncrease opening hours of one site review minimum staffing and skill mix at East and MID initially, plan for skill mix variations and succession planning

SMT /CHP

By Dec tbc Improve staff and patient safety

t eni s

50

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

Resource By Evidence of

RequiremeWhen Completion

nts

Limited clinical protocol infrastructure to support standardised decision making

The LUCS intranet page should be heavily developed similar to the Hospital at Night page to provide a minimum set of clinical protocols for the servic

QIT ./ SMT

ongoing

Ma need extra suppor

Improve safety and standardisation

e

y

t

Challenge of delivery of new national standards , plan and leadership

QIT to lead the planning delivery and reporting ACD time needs increased to comply with standards, audit and medical staff governance

QIT/ SMT

ongoing

Additional med mgt costs

Level of clinical mgt increased

Patient groups identified by staff where improvements in clinical care could be madeChildren and y ung peoplePeople with mental health suesPregnant ladiePalliative care anagemen

TO BE COMPLETED see full reporGenerally improve alignment and cover arrangements in OOH period

SMT ET ALL

ongoing

n/a Improved alignment and cove

o is

s m t

t

r

Transport Hub

and dispatc

hers

Potential to integrate hub functions with EBB , Transport , taxi requests and maximise dispatcher functions in and OOH s

Opportunity for service redesign , potential at Partnership level and integrated service aligned to SPOC

Pan Lothian grp

March 2015

Potential savings

Redesign option

Decision re offering Taxis and Transport is outwith control of LUCS

Criteria must be agreed with NHS Lothian for offering taxis similar to those set out in getting help with transport costs for accessing all other health care

Nat OOH grp

Dec 2014

Potential savings

Potential to use fleet in hours Transport manager to review and advise IS JM Sept 2014

efficiency Issue considered

Not all cars are ready to go on the

road at start of shifAll cars must be ready to leave base at start of shif

JM asap productivitt

t y

51

52

Area for Improve

ment Reason/Assessment of problem Actions needed

By Whom

By When

Resource Requirements

Evidence of Completion

Some Drs wont input data into the tough book while the car is in motion reducing efficiency of home visit

Clinical Director to action advice to DRs and drivers

CD asap tivit

s

producy

Effectiveness of current OOH DN dispatching model and resource< collocation of senior DN in WGH and non use of pocket books in East and Mid Lothian

Chief Nurse East CHP to review current model of DN dispatching and to resolve issues of non use of pocket books in East and Mid

A Mc D Dec 2014

efficiency

Current app intment system 5 patients per hour for PCEC attendance

Opportunities to testNo appt system especially at East and MidIncrease productivity to 4 appts per hour for GPs and 3 per hour for ENPs

SMT Sept 2014

productivito

;

y

NHS24 untriaged call volumes have reduced by over 40% in 4 years

Given current service pressures negotiate further reductions of this number and maximise use of those GP s whose skill set is expert at telephone triage

Nat ooh NHS24

Dec 2014

Manage activit

y

- App n

LUCS REVIEW 2010 Key Recommendations - L TAIT

Recommendation 1Unscheduled care services should be planned and overseen in an integrated way, through the mechanism of the Unscheduled Care Board, and LUCS, along with the other Lothian services A&E departments. Minor Injuries Unit, GP in A&E – should report on performance and agree actions through that group. Metrics should include the performance of SAS and NHS24 for Lothian patients, and these key partners should be fully involved. Consistent mechanisms to review and feedback outcomes and share learning from these should be established.

Recommendation 2Consideration should be given to appointing a pathway manager for unscheduled care response across Lothian, with the responsibility to monitor performance and improve interfaces across the system, reporting to the Unscheduled Care Board

Recommendation 3The delivery of unscheduled care for walk-in patients should be streamed through a single front door reception point at RIE and St. John’s, prior to clinical triage, with further development of agreed protocols to direct patients to minor injuries, LUCS (GP in A&E in day time if available) as appropriate. Protocols should allow for the inevitable need to redirect occasional patients with ease should clinical examination require it

Recommendation 4The IT infrastructure to support unscheduled care across the system should be the focus of a development plan to systematically work towards enabling the sharing of information about patients and services to support clinical decision making. This should include driving forward the wider use of the Emergency Care Summary and e-anticipatory care plans and access to these for A&E, community pharmacy, community nursing as well as LUCS, and system interfaces to ensure feedback outcomes across the system.

Recommendation 5Community response services and LUCS should work more closely and opportunities to join up district nursing call handling in the short term, and services provided jointly with health and social care in the longer term should be progressed by CH(C)Ps. This should be integral to the single point of contact being developed with the aim of brining together information about an access to urgent health and care needs across Lothian.

Recommendation 6A systematic process for obtaining patient feedback on their experiences of LUCS services should be developed as part of the patient experience programme being introduced system wide

e dix 3

–

.

.

.

53

Appendix 4

LUCS Review Action Plan April 2010 – – Recommendation Lead UCS Collaboration As the primary care provider for 70% of each week, LUCS has a key role to play in planning, delivering and reviewing Lothian’s unscheduled care response. The service should be fully represented on, and participate in, the Unscheduled Care Board. There is potential to integrate the LUCS Board with the USC board, making this the forum for overall unscheduled care performance management

Chief Operating Officer, UHD/East Lothian CHP GM

Improved communication with NHS24 across the whole system, including processes for audit and feedback on specific cases to support systematic learning and thus improve triage and outcomes

LUCSClinical Director

Development of further protocols for pre-clinical streaming of self presenting patients from A&E at RIE and St. John’s to LUCS Primary Care Emergency Centres

LUCS CD/ A&E Clinical Leads

Scoping of impact of LUCS service on RHSC A&E attendances in early evening peak times to deal with acute illness more appropriate for primary care, to inform operating processes within new RHSC at Little France

LUCS CD/RHSCA&E Consultant

Examination of the potential to locate and integrate LUCS within the front door changes planned for RHSC and RIE A&E (alongside minor injuries) providing a single unscheduled care point of entry and streaming process for adults and children

RHSC Project Board/USC Board

Separation of Minor flows from A&E Department major flows, linked to single reception and streaming role above

USC Board

Identification of practice nurse type role, dealing with dressings, patient education etc. ithin front door range of services

USC Board – w

There are opportunities for greater joint working and flexibility between LUCS staff and those nurse practitioners working in the minor injuries service at WGH, and in the equivalent flows in RIE and St John’s

Service Manager, Medical Directorate, LUCS Lead Nurse

Review effectiveness of West Lothian mental health response supporting both LUCS and A&E during the out of hours periods

West Lothian Head of Health

E-Health Development of the NHS24 IT system to allow LUCS to give real time feedback to NHS24 on action underway and outcomes in relation to patients referred to LUCS

NHS24

54

Recommendation Lead Development of the Adastra system to improve the quality of clinical reports in terms of layout and content to practices; the potential to develop an electronic interface with the new PC practice systems will exist longer term

LUCS CD

Drive introduction of e-anticipatory care plans to improve the management of long term conditions without unnecessary recourse to hospital services

Primary Care Futures Group

Complete the rollout of ePalliative Care Summary across GP Practices in Lothian to ensure that LUCS has enough information on patients in palliative phase of illness to provide care in a consistent and compassionate manner. Extend this to pharmacists, district nurses and SAS to support the palliative care strategy

LEAD Cancer GP NHS Lothian

SAS Implement changed protocols to allow 999 cases triaged by Paramedics as non emergency to be routed to LUCS-aligned to greater use by SAS Paramedics of LUCS professional to professional line advice line.

LUCS CD/SASG

r

Greater use of see and treat by SAS paramedics to reduce the number of minor injuries presenting at A&E

USC Board/SAS

Widely to support better direct access by patients to pharmacy out of hours and divert patient from LUCS/A&E

USC BOARD/SAS

The anticipatory care plan, emergency care summary and e-palliative care should be widened to make available to Community Pharmacists to promote better medication management and compliance

Director ofE-health

The extended roles for community pharmacists which have been introduced require to be communicated as part of the social marketing campaign on unscheduled care routes

USC BoardDirector of Pharmacy

.

Injuries presenting at A&E Protocols to allow SAS to take minor injury cases to centre/north of city to WG MI Unit to reduce pressure on RIE A&E department

USC Board/LUCSCD/SAS

Implement a system to allow SAS to feedback to GPs information on patient contacts to allow persistent misusers of 999 calls to be identified – possibly using ADASTRA system

SAS

CH(C)Ps Review the operation of Local Enhance Service for Care Homes, to identify how system can be further improved to avoid unnecessary transfers and patient suffering

Care HomeReview Group

Greater integration of out of hours District Nursing Services with LUCS in East Lothian and Midlothian in particular, and further development of joint working with District Nurses in Edinburgh, including co-location if possible

CHP LeadNurses

55

56

Recommendation Lead The minor injury service already provided by LUCS at its PCEC bases in Midlothian and East Lothian should be thebasis for expansion of minor injury services in these localities if this is required; in hours services if required should be integrated

LothianUnscheduledCare Board

SPOC The LUCS hub provides call-handling and decision making infrastructure which should be build upon, along with the existing expertise of the Lothian Bed Bureau, to provide the single point of contact (SPOC to support effective patient flows)

Service Manager

.

, MedicalDirectorateLUCS, CD, Head of Health WL

,

PATIENT EXPERIENCE A systematic process for obtaining patient feedback for the service is required: Consider how this could be taken forward as part of the overall “better together” programme in Lothian

Director of NursingLUCS GM

PHARMACY Lothian wide out of hours community pharmacy cover arrangements should be standardised and communicated more

Director of Pharmacy

Appendix 5

Summary of Actions 2014 Review

Action No Action 1 The clinical leadership capacity for doctors and nurses needs

increased to support quality, clinical and staff governance in the PC OOH’s service

2 A target of 90% achievement of % 1 hour and 2 hour should be

set and priority given to reporting regularly on the appropriateness of home visit triage by NHS24

3 Performance against the National indictors should be reported

to the Unscheduled Care Board;-Interim report by WintFull report Spring/Summ

er 2014 er 2015

4 The national group should review with NHS24 the volume of calls which need to be triaged locally and continue to reduce this activity flow, except during periods of peak activity

5 Protocols exist to manage this flow and it should be kept under

review by the relevant Clinical Directors (A&E + LUCS)

6 The Service Manager and Clinical Director in conjunction with

the Laboratories should review all protocols for escalation to an OOH’s doctor and ensure these are for urgent patient safety concerns only. This should include clinical assessment at the lab before calls to LUCS

7 The Clinical Nurse Manager should with the CHP Chief Nurses,

review the nature of calls made by District Nurses to OOH’s Doctors and act on the findings. It is likely that this growth is reflective of demographic changes, frailty and co-morbidities of elderly people

8 The calls from Pharmacists should also be reviewed and it is

suggested a 2 week audit for all calls to P2P line would be sufficient to understand the call reason and disposition

9 The calls from SAS also need to be understood and

consideration (based on the audit) given to see if this is a service chargeable to SAS

10 Protocols should be developed for planned service reviews as

this is likely to be an area of increased activity

11 A public survey of those attending WGH and MCH should be

undertaken in partnership with the CHP and Public Partnership Foras, to understand why people attend

12 LUCS should review the Policy and Procedure for self referrals

written in 2010 and consider asking people to phone NHS24 instead of a “next available” appointment

57

13 The Communication Team should be involved in the findings of the public surveys and address “routing” issues which arise. They should consider making the “Right Care, Right Time, Right

Place (2011)” leaflet more locally relevant, at the CHP level addressing and reinforcing the local access routes in Out of Hours Care Services

14 There should be a review of PLT activity to ensure cost effective service provision. Consideration should be given to reducing number of centres open and or staffing model related to West Lothian and rest of Lothian cover

15 If staffing and cost pressures on LUCS continue then consideration must be given to handing this back to Practices or negotiate an alternative mode

l 16 An SLA should be put in place between NHS Lothian and NHS

Borders, which agrees the costing model and uplift agreements for the PC OOH’s cover of West Linton Practice population

17 The Service Improvement Plan includes actions to address

sickness absence management

18 Differentiate NHS Lothian:-

develop attractive Terms and Conditions for salaried GP’s.develop attractive training and education opportuni .Packages for wider medical workforce to learn OOH’s care e.g. in paediatrics and mental health.

ties

Offer joint posts for individuals within specific career paths potentially in unscheduled care.Create training for GP’s and ENP’s in telephone triage and doctor advicCreate links with medical schools for research opportunities and specialised module development e.g. risk taking in GP OOH’s care or an Academic Primary Care Consortia with a Research infrastruct re.Improve the culture and perception of the service and increase the clinical manage

Support the above by undertaking further fact finding with GPs in Lothian about what would attract them to contribute, however limitedly, to OOH’s care

e calls.

u

ment.

19 Target

Younger female doctors and GP retainers who currently work under 4 sessions a week.GP ST3/registrars with attractive and individualised “fellowships” similar or aligned to A&E fellows.“Selling” the uniqueness/importance of the professional development opportunities GP OOH care offers.Identify at GP ST3 stage those individuals who,

58

with training, could offer sustainability to the serGP’s who have never worked in OOH and offer taster/ refresher sessions.

Develop a targeted recruitment plan assisted by the Head of Recruitment NHS Lothian

20 Consider

These are some examples being considered under OOH’s core delivery to address potential problems with GP recruitment.

Using medical locums in a targeteTraining ENP’s or develop ANP role for homIntroducing stand-by shifts or on call for clinical

Have doctors working from home with appropriate IT and telephone and privacy arrangements.Band 5 nurses to undertake diagnostic/arrange referrals and support doctor in peak ti

Community paramedic role in home visits

d way. e visits.

staff.

mes.

21

and should be addressed in two ways:-- By the development of Terms and Conditions

s

programme – and take appropriate action to fund

Currently LUCS GP’s provide this support on a good will basis with no additional funding or recognition. This needs rectified

for salaried

GP By the Executive Medical Director investigating if monies

are transferred to NHS Lothian for this post graduate national

22

would suggand clinical staffing

22.00 hours.

Saturday, 08.00 to 22.00 hours.

when necessary.

core Consider substituting a band 5 registered nurse for the receptionist at each site to support, record, manage, assess, patients prior to doctor consultation

The analysis of the activity at the Roodlands and MCH sites est the following changes to the hours of service

; both Roodlands and MCH should close at 22.00 instead

of 24.00 i.e. Monday to Friday opening from 18.00 to

Both Roodlands and MCH should close at 22.00 on Sunday and Public Holidays i.e. open from

One car, driver and doctor should cover the 2

geographic areas with support from car based at RIE

Each base should have a receptionist and doctor as staffing

59

23

staffing for the 3 sites based on 2013/14 activity analy

attendance yet there are staffing differences

The Clinical Director and Service Manager will review the sis which

shows only very small variation to previous years’ activity and is reasonably stable in days of week and weekend site

24 There should be an increase in the available appointments by

health profession to 4 appointment slots for GP’s (an increase from 3) and 3 appointment slots for ENPs (an increase from 2)and consideration of trialling of appointments for doctor advice calls

25 ENPs should be concentrated at the above 3 sites and the

CNM should review competencies, team working and potential skill mix

26 Consider introducing: on call or Saturday arrangements for

peaks in activity and clinical advising Doctors based in their own home with supporting technology/telephone to provide triage/doctor advice supplementary provision

27 Appoint a named Clinical Lead Professional Adviser(s) in the

care of children and young people

28 The Clinical Nurse Manager and Chief Nurse (East and

Midlothian) provide evidence of ENP competency to the Executive Nurse Director of the current level of expertise and professional updates completed in the last 3 years to assure that competency in the care of sick children, especially those under 5 years. the absence of this evidence, the Executive Nurse Director should decide if ENP’s employed in NHS Lothian should see both/either triaged children, walk-ins or any child under 5

n

29 The service and the Clinical Lead Professional Adviser will agree within 3 months:

The minimum clinical competency framework for care of children for doctors and nurseUpdates and mandatory training requirements;Plans to shadow and participate in emergency care delivery at RHSC and St. John’s and potential reciprocal arrangements to OOH’sEnsure a plan is in place to align, share or develop relevant clinical protocols for use in acute/urgent and emergency children’s care;

Bring forward plans to review the care of children

;

;

30 The Clinical Director and the Executive Medical Director should meet similar NHS24 staff with a view to negotiating;reductions in untriaged calls passed to NHS Lothian (note reduction in income which would follow), trials of different disposition options as above, and a test of triaging locally for

60

home visits 31 Each CHP have a geographic and service specific information

leaflet which is widely circulated.It should encourage people to phone NHS24 to discourage walk-ins (especially in Midlothian and around WGH postcodes)It must also address the number of DNA’s and advise people of the number to phone to cancel an appointment. It could provide local communities with a range of OOH’s care and support contacts of which NHS24 is for urgent out of hour’s medical care when the GP is closed.Advice should also be given that this service is not for “second opinions” or patients whose key problem has been getting an appointment in hours with a GP PracticeIt should also direct patients to local minor injuries units – were this is agreed and it needs to somehow differentiate/direct people to minor illness, minor injury and minor aliment services

.

.

32 LUCS should be renamed, as it is not an unscheduled care

service although it is an important part. It is Lothian PC OOH Service

33 Efficiency savings and productivity improvements targets

should be set and monitored for effective car dispatching, linked to staff training, and led by the operations manager

34 Up to midnight cars cover NHS Lothian and are dispatched

from all 5 sites, consideration should be given to reduce this to 2 ; West Lothian (only) and – RIE (rest of Lothian) with training and effectiveness in fleet management this model may be possible as standard and this is what currently happens overnight

35 Doctors should be encouraged to complete patient record in

Tough Book while car is being driven

36 The Operations Manager should review activity, call numbers

and number of dispatchers needed

37 A trial should be undertaken to test if a doctor advice calls

can be routed to cars when not attending home visits

38 A strategic review/ redesign of all NHS Lothian “hubs” e.g.

traBed Bureau should be undertaken to maximise efficiencies. This should include the use of the cars in the in hours period

nsport hub, LUCS hub dispatchers call handlers, Emergency

39 The Director of HR should bring forward plans in partnership to

realign public holidays to do away with 4 consecutive Public Holidays

40 Staff working in LUCS should have managed A/L allocations

where A/L on PH’s is permitted if the service is covered

41 Managed protocols should be developed and tested out on

how LUCS communicate and report performance to all CHPs

61

and scheduled services. This could help when LUCS needs to escalate concerns on a safe service provision

42 Current management arrangements for attendance at the LUCS SMT and the line management of the CD and service manager need reviewed

43 The role of the Unscheduled Care Board in relation to

performance reporting and strategic direction should be clarified

62

63

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1) c Plan –

NHS Lothian Draft Strategi Our Health, Our Care, Our Future, 2014-2024 1b.NHS Lothian Unscheduled Care Action Plan 20L.U.C.S. Service Review L. Tait NHS Lothian 16.Quality Indicators for Primary Care Out of Hours Services NHS H.1.S March 2014.Health and Care Experience Survey 2013/2014. National NHS Lothian and CHP results. Scottish Government May 2014.Primary Care Workplace Surve vey of Scottish General Practices and GP Out of Hours Services ISD 24.NHS Lothian Strategic Plan – Developing Primary and Community Services Final Draft 19.03.13. Appendix 1 NHS Lothian Primary Care Strategy, Demand-Capacity-Access V.15 2014. Appendix 2 NHS Lothian Primary Care Premises Strategy V.

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5)

6) y 2013 – A sur

09.13 7)

9 2014.

- R

CN Competencies: Advanced Nurse Practitioners – RCN London

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Guidance on the Management and the use of Vehicles within NHS Lothian MaPQI Patient Experience Quality IndNursing and Midwifery Leadership and Management Standar sReleasing Time t rRight Care, Right Patient, Right Time 20

1) y 2012

2) icators. 3) d 4) o Ca e. 5) 11