rick stern nhs alliance lead for urgent care director, primary care foundation ,
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Commissioning Urgent Care: what do we know now and what does this mean for the new pathfinder consortia?. Rick Stern NHS Alliance Lead for Urgent Care Director, Primary Care Foundation , [email protected] 07709 746771. - PowerPoint PPT PresentationTRANSCRIPT
Commissioning Urgent Care:what do we know now and what does this mean for the new pathfinder consortia?
Rick Stern NHS Alliance Lead for Urgent CareDirector, Primary Care Foundation, [email protected] 07709 746771
NHS Direct & NHS Alliance workshop 22nd February, 2011 Central London
© Primary Care Foundation
The Primary Care Foundation developing best practice in primary and urgent care
A resource for commissioners of urgent care
© Primary Care Foundation
New Leadership Group for Urgent Primary Care
Dr Albert Benjamin
Clinical Director Waldoc CBS (Waldoc Ltd)
Anita Dixon Chief Executive Central Nottinghamshire Clinical Services
Alan Franey Chief Executive Barndoc Healthcare Ltd
Eddie Jahn Managing Director Harmoni
Dr Darren Mansfield
GP Clinical Lead in Urgent Care
NHS Bolton
Lesley McCourt Chief Executive Partnership of East London Co-operatives
Alison McWilliam General Manager Nottingham Emergency Medical Services Limited (NEMS CBS)
Dr Ray Montague Medical Director Brisdoc Healthcare Services
Dr Russell Muirhead
Chairman Shropshire Doctors Cooperative Ltd
Diane Ridgeway Chief Executive East Lancashire Medical Services Ltd
Gilly Wilford Director of Finance & Contracts
South East Health
Nigel Wylie Chief Executive Urgent Care 24
© Primary Care Foundation
Emerging Priorities
1. Patient Safety
2. Integrated Urgent Care
3. Demonstrating quality
4. ‘Rebranding’ Out of hours
© Primary Care Foundation
What I will cover
1. The breadth of urgent care2. Urgent Care in general practice3. What can we learn from the national
OOH benchmark and how has it driven improvements?
4. Primary care in Emergency Departments5. Changing the culture of out of hours
services – a new initiative6. Key issues for commissioning urgent
care
© Primary Care Foundation
A whole system perspective:urgent & emergency care components Patient
Self careEpisode complete
From any of the above
Each component must work well - separately and as part of the
whole
Hospital
From clinicians
© Primary Care Foundation
Why focus on General Practice?● Its where most people access care and get
treated:300m consultations a year; about 100m same day.
● Until recently, not properly acknowledged as part of urgent care pathway
● Individual decisions in general practice shape the NHS as a whole – good management of urgent care starts here
● Supports idea that all partners in the health community are working together
© Primary Care Foundation
ReviewingUrgent Care inGeneral Practice
URGENT CARE
a practical guide to transforming same-day care in general practice
Supported by the Department of Health
lth
© Primary Care Foundation
Some of our key findings
● Speed of initial response – or ensuring patients can get through - matters
● Review and understand your number of appointments and the proportion that can be booked same day
● Managing peaks in demand - such as Monday mornings – is important
● Practice staff need to recognise what is potentially urgent and agree how to respond
● Rapid clinical assessment is important – especially of requests for home visits
● Telephone consultation can play a useful role
© Primary Care Foundation
Acute Admission Timeline
8.30 11.30 13.30 17.30
3 Hours 2 Hours 2 (often 4) Hours
8.30 8.45 09.45 10.45
15 Minutes 1 Hour 1 Hour
Just as hospital staff go home!
In time to set up alternative to hospital
Early enough to avoid risk of deterioration
© Primary Care Foundation
●Currently developing a web based planning and monitoring tool. Focuses on:●Telephony – checking the capability to answer the
phone promptly
●Capacity in terms of appointments to meet the demand from patients
●Recognition of potentially urgent cases
●Response to urgent cases
●Brings together practice data and patient experience to give a strong evidence base for making changes
●Practices are able to benchmark their own system and process against other local practices and across England
A new approach
© Primary Care Foundation
●Number of lines and number staff answering calls
●Length of average call
●When do you run out of appointments on the day
●Appointments - face to face, by phone, home visits & extras; split by same day and book ahead
●Completion rate of phone consultations, by practitioner
●Additional information, including staffing and age profile of the practice population
●Results from the General Practice Patient Survey
What do we look at?
© Primary Care Foundation
Better evidence supporting change●Range of indicators provide a rounded picture of
what is happening in the practice, including:
● staffing by hour answering phones compared to what is needed for an effective response (Erlang Formula)
●consultation rate, weighted for age, compared to national average
●Detailed report builds on how the practice understands its processes with analysis of data and options for change
●Tweaking process will not work if people can’t get through on the phones or there are too few appointments
●Once these issues are addressed, there are a range of options – the practice will need to identify what works for them
© Primary Care Foundation
Developing the benchmark
●Awarded tender by DH in November 2007
●Numerous pilots including across all of North East
●National advisory group to steer progress and set price
●Established three years support, with benchmark every six months and patient experience survey once a year
●Reduced rates & local review workshops if all PCTs in SHA area
●Currently over 100 out of 152 PCTs in England are members
© Primary Care Foundation
Developing the benchmark:rounds 1, 2, 3, & 4●First benchmark completed March 2009 with reports on 63 services and half-day workshops for commissioners & providers
●Second benchmark, with reports on over 90 services, completed November 2009,with first patient experience survey managed by our partners, CFEP UK Surveys
●Third benchmark reviewing performance at period of peak demand at Christmas 2009 and New Year 2010 –completed November 2010
●Fourth benchmark, again a full benchmark including patient experience with complete overhaul of questions to ensure full compliance with CQC report
© Primary Care Foundation
How does it work?
●Data extract – from a number of different information systems
●Web based questionnaire for commissioner
●Web based questionnaire for providers
●Validate data – consistent but personalised
●Produce reports
●Workshops
●Anonymity – about to change
●National Steering group and User Group
© Primary Care Foundation
The benchmark of out of hours services is comprehensive and provides considerable detail● Performance against all of the national quality
requirements● Clinical governance processes● Comparing advice, visits at a centre & visits at home● Urgent on receipt● Productivity● Additional measures of patients going towards hospital● Patient perceptions of your service● Case volume per 1,000 patients● Cost per case and cost per head
© Primary Care Foundation
Learning from the first two rounds of the benchmarkImproving out of hours care: what lessons can be learned from a national benchmark of services? January 2010, PCF1. Out of hours services are improving 2. Patients value a responsive service3. Split services and double assessments seem to
perform less well4. Many providers are falling short on the standard for
definitive clinical assessment of urgent cases5. There is an enormous range across different
services in the proportion of cases that are identified as urgent
6. There is striking variation in cost, even amongst providers serving communities with similar population density
7. Coding needs to be improved in some key areas
© Primary Care Foundation
In general it costs more to service a rural PCT than an urban one – but there are wide variations within any band
£0.00
£2.00
£4.00
£6.00
£8.00
£10.00
£12.00
£14.00
£16.00
£18.00
0.00 20.00 40.00 60.00 80.00 100.00 120.00
Population density
Co
st p
er h
ead
●Rural City/Urban
●Mixed
Each dot is one service
© Primary Care Foundation
Red and Blue service are very different – red has very high advice and low home visits, blue has low advice and just above average home visits….% Advice
% Home visits
0%
10%
20%
30%
40%
50%
60%
70%
80%
0%
5%
10%
15%
20%
25%
30%
© Primary Care Foundation
…despite their differences they are both rated highly for the quality of care by patients – the common factor is their speed of response
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
40% 45% 50% 55% 60% 65% 70% 75% 80% 85%
How quickly care was received % About right
Rat
ing
of
care
rec
eive
d e
ith
er g
oo
d o
r ve
ry g
oo
d
© Primary Care Foundation
0%
10%
20%
30%
40%
50%
60%
70%
There is a very striking variation between services in the proportion of cases identified as urgent on receipt
Percentage of cases identified
as urgent by non clinical
call-handlers
Each bar is one service – a provider/PCT
How safe?
How safe?
© Primary Care Foundation
We reported the percentage of urgent cases that were assessed in 20 minutes…
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Increasingly falling below standard
Many of these providers had too many cases
with double assessment
Each bar is one service – a provider/PCT
© Primary Care Foundation
0%
5%
10%
15%
20%
25%
Normal band?
suspectnot credible?
In far too many services it is impossible to be sure how many patients make their way towards hospital
We know that many services, particularly to the left, are
under-counting patients going towards hospital
Each bar is one service
© Primary Care Foundation
A new focus in the third benchmark: performance at times of peak demand
What can we learn from looking at performance and variation at Christmas 2009 and New Year 2010 when services face their highest levels of demand across 100 services in England?
© Primary Care Foundation
Key Learning from the 3rd Round of the Benchmark
● Demand is predictable
● Although performance is improving it falls short of the quality requirements
● There are two reasons● Not enough people on the busy days● Not addressing the variation between
individuals
● Services can do something about both
© Primary Care Foundation
Whatever the variation between services the variation between individuals will be greater
© Primary Care Foundation
Percentage of advice calls converted to advice - only including those that handled more then 25 advice calls
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
134 1
35
72
61
181
29 31
46
74
34
130 46
09
31
16 48
133
154
161 2
1 71
26 89
53
98
120
132 5
95
14
29
5 61
131
58 87
144
121 4
04
79
91
03 58
100 9
71
011
60 16
94
43
92
33
109
114 6
54
93
01
10 18
17
55
85
145 5
21
56 84
105 7
93
52
31
06
61
27 88
165 6
4 31
551
471
15 90
69
91
12
73
19
75 1
150
140 4
41
641
62 28
76
29 8
Advice other
This looks at the percentage of calls given telephone advice for one service Doctor only, six months data, at least 25 consultations
Dr 147 gives phone advice to over 60%
Dr 116 gives phone advice
to just less than 30%
Each bar is one doctor
Dr 7 gives phone advice to just over
30%
© Primary Care Foundation
Advice calls which ended in PCC Surgery sorted by percentage of calls completed in under 4 minutes
Graph only includes those who handled more than 25 advice calls (but not all of these to PCC)
0%
20%
40%
60%
80%
100%
29 42 85 105 3 40 34 47 87 150 44 65 69 95 94 147
145 33 13 90 162 21 66 155 12 160 75 91 101 7 4
164 64 6
133
158
126
110
134 52 115 35 19 127 31 1 49 43 58 100 26 99 121 23 55 60 132
129 46 17 130
103 16 144 30 76 97 113
156
161
120
118 28 88 89 57 84 93 48 18 53 109 10 92 8 74 114 79 51 73 165 98 116 59 140
154
under 4 mins more than 4 less than 6 mins more than 6 mins
This looks at the length of the advice calls that ended with a PCC visit – doctors are ranked on the % completed in 4 minutesDr 147
completes around 18%
in four minutes
Dr 116 completes
over 90% in four minutes
Each bar is one doctor
Dr 7 completes
around 35% in four
minutes
© Primary Care Foundation
How does the benchmark improve care for patients? Three case studies …
1. Using the measurement of productivity to drive improvements in care – Urgent Care 24
2. Improving Patient Safety in response to comparative low level of urgent cases on receipt – Chorley Medics Ltd
3. Using the benchmark to drive improvements in commissioning out of hours care - NHS Bedfordshire
© Primary Care Foundation
Primary Care & Emergency Departments
© Primary Care Foundation
Three models for offering primary care within or alongside A&E
1. Situated alongside the Emergency department running separate reception and operational processes
2. Situated alongside the Emergency department and running common reception and separate operational processes
3. Fully integrated with common reception and operational processes
© Primary Care Foundation
Key Issues – reflections 1 “if everyone is involved it becomes seen as a joint baby, not a primary care service in their midst”
● Primary care practitioners and their complimentary skills offer an important way of improving services within A&E … but it is only one way, of many, for improving urgent care for patients.
● Good governance – or the way clinicians and organisations integrate care – is vital. The best services, have good systems for ensuring that consultants, GPs and nurses all work together.
● Best of both primary care and emergency medicine or clash of cultures? (varying approaches to training, managing risk, governance systems, language and their experience of different case mixes)
● Patients want to make choices about how and where to access health care, based on their own needs as well as their understanding of how easy it is to access the particular range of services in their area.
© Primary Care Foundation
Key Issues – reflections 2
● Although primary care can potentially reduce pressure on Emergency Departments and improve patient care there is little evidence that it reduces Emergency Admissions or reduces overall costs to the NHS.
● There is also no evidence that public information campaigns – telling people not to go to A&E unless it is an emergency – change the way patients behave. What does make a difference is when patients consistently receive a rapid and effective service.
● Effective urgent healthcare systems have also begun to look at how financial and organisational incentives are aligned to promote the best possible care for patients (role of Urgent & Emergency Care Networks?)
● Important to remember other approaches for improving access to urgent care, especially improving the management of same day urgent care in the 8,200 practices across England.
© Primary Care Foundation
A process for rapid learning
© Primary Care Foundation
●Out of hours services have been under heavy scrutiny
●Review of TCN highlighted organisation slow to learn from mistakes
●Conference in April on Patient Safety highlighted even slower to learn across organisations
●Reviews focus on commissioning and ‘rules’
●Say less about prevailing culture where few errors are reported
A Process for rapid learningsharing experience when things go wrong in out of hours services
© Primary Care Foundation
●Learning from others – experience of aviation & maritime sectors
●Initial discussions and trial within the Leadership Group for urgent primary care
●Meeting of national stakeholders including DH, RCGP, CQC, QIPP, NPSA and MPS
Testing out this approach
© Primary Care Foundation
●Developing an extended pilot with 12 OOH providers
●Simple format – ‘What Happened’, ‘What did you do to address it?’, and ‘What did you learn?’
●Access a secure website to submit and review reports
●No individuals or organisations are identified
●Commitment to share reports and support learning
●Review at end of pilot (April 2011)
●Seek to change culture within and across organisations, improving patient safety
What does it look like?
© Primary Care Foundation
●Finding solutions to practical issues e.g.●Exploring the detailed process for receiving & circulating
information
●How do individuals and organisations use this information?
●Is this an effective process for developing learning organisations in out of hours?
●focus on out of hours providers, but a view to shaping 24/7 urgent care
●Seeking funding
Next Steps
© Primary Care Foundation
Commissioning Urgent Care Key points to remember …1. GP commissioners are well placed to use their
clinical knowledge to drive improvements2. Look at in-hours general practice as the key to unlocking
improved performance3. Understand where there is good information and use it to drive
improvements in care4. Tackle unacceptable variation both between and within services5. Design individual services and the flow between services with a
good understanding of process and volumes6. A shift in culture to supporting clinicians who report problems is
as important as meeting standards7. develop a compelling local vision for 24/7 urgent care, with 111
as a lever for integrating care8. There is a cost to tendering – long term contracts may offer more
value
For more information please go to our new and improved website at www.primarycarefoundation.co.uk
Rick Stern07709 [email protected]