Out of Hours Care:
Empowerment at a Local Level
Primary Care Live 2010
25th November 2010 Manchester Central
Rick Stern
Director, Primary Care Foundation,
NHS Alliance Lead for Urgent Care
rick.stern@primarycarefoundation.co.uk 07709 746771
The Primary Care Foundation
developing best practice in primary and urgent care
Urgent
Care in
General
Practice
Out of
Hours
Benchmark
Urgent
Care
Centres
Primary
Care in A&E
A resource for commissioners of urgent care
© Primary Care Foundation
New Leadership Group
for Urgent Primary Care
Dr Albert Benjamin
Anita Dixon
Clinical Director
Waldoc CBS (Waldoc Ltd)
Chief Executive
Central Nottinghamshire Clinical Services
Alan Franey
Eddie Jahn
Dr Darren Mansfield
Chief Executive
Barndoc Healthcare Ltd
Managing Director
Harmoni
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
Dr Russell Muirhead
Diane Ridgeway
Gilly Wilford
Medical Director
Brisdoc Healthcare Services
Chairman
Shropshire Doctors Cooperative Ltd
Chief Executive
East Lancashire Medical Services Ltd
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. What can we learn from recent reviews?
2. What is the emerging national agenda for urgent
care
3. What can we learn from the national benchmark
and how has it driven local improvements?
4. Changing the culture of out of hours services – a
new initiative
5. The future for out of hours services and
opportunities for local empowerment
© Primary Care Foundation
A long history of reports and
reviews …
● Department of Health (Carson Review, 2000) Raising Standards for
patients: new partnerships in Out-of-Hours care
● National Audit Office (May 2006) The Provision of Out-of-Hours care in
England
● Four inner London PCTs (May 2007) Report into the death of Penny
Campbell
● Health Care Commission (September 2008) Not just a matter of time: A
review of urgent and emergency care services in England
● Primary Care Foundation (January 2010) Improving out of hours care:
what lessons can be learned from a national benchmark of services?
● Department of Health (February 2010) General Practice Out-of-Hours
Services: project to consider and assess current arrangements
● Care Quality Commission (July 2010) Investigation into the out of hours
services provided by Take Care Now
© Primary Care Foundation
Key areas in the Department’s Review
General Practice Out-of-Hours Services: project to consider and assess
current arrangements (February 2010) David Colin-Thomé, DH & Steve
Field, RCGP
● Commissioning and performance management, including
tackling inappropriate variation
● Selection, Induction, Training and use of out-of-hours
clinicians (including the use of locums)
● Management and operation of Medical Performers Lists
© Primary Care Foundation
Key issues raised by the CQC’s Review
Investigation into the out of hours services provided by Take Care Now
(July 2010)
For Providers
●
●
●
●
●
●
TCN failed to recognise the importance of learning lessons, failing to act
on two similar previous incidents involving overdoses of diamorphine
TCN struggled to recruit local GPs and relied heavily on doctors flying in
from Europe to work weekends
TCN tolerated staffing levels that were potentially unsafe, with pressure
on other staff (e.g. one nurse covering alone at night)
TCN’s systems for medicines management were inadequate leading to
controlled drugs being stored and administered inappropriately
The performance reported to PCTs on NQRs did not accurately reflect
their actual performance
TCN grew too rapidly and the focus on expansion and business
priorities was at the expense of governance and clinical services
© Primary Care Foundation
Key issues raised by the CQC’s Review
Investigation into the out of hours services provided by Take Care Now
(July 2010)
For Commissioners
●
●
●
●
●
●
Out-of-hours services were low priority at the time and the PCTs had
limited understanding of these services.
There was a lack of leadership in commissioning and monitoring
services as part of an integrated urgent care service.
there was a lack of experience in the PCTs in contracting with a
commercial organisation.
The PCTs did not have a high standard of commissioning or contract
monitoring in out-of-hours - these contracts should have been
monitored more thoroughly.
Not highlighted in national targets and finances – so not seen as a
priority for SHAs or PCTs.
The PCTs had all recently tightened their procedures in respect of their
performers lists, although there were still different levels of scrutiny.
© Primary Care Foundation
National Agenda for Urgent Care:
developing integrated 24/7 urgent care
● Integrated 24/7 care is about greater coherence
● Patients will be free to choose how and when to
access care - meeting needs not re-educating
● Simpler routes into the system – 999, 111 & web
based self assessment
● Consistency in clinical assessment – not redirecting
© Primary Care Foundation
Key initiatives:
developing integrated 24/7 urgent care
● New metrics for urgent care – quality indicators and standards
– starting with A&E, but across pathway
● New role for GP commissioners
● Crucial role of general practice as the main provider
● Developing a single point of access - 111
● Clarity about the separate parts of the system – should ‘do
what it says on the tin’
● Realigning incentives
● New technologies – especially telecare
● Role of QIPP in prioritising urgent care
© 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
September 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
12 headline indicators
Cost
1. Cost per head
2. Cost per case
Productivity
3. Number cases per clinician per hour
Outcomes
4. Referrals to hospital (if possible, subdivided between referrals to A&E and
referral to a hospital bed)
5. Overall breakdown of dispositions
(advice/PC Centre/home visit)
6. % Calls classified Urgent on receipt
Process
7. The quality of clinical governance systems and
processes
Performance
8. Time to clinical assessment for all calls as a %age
9. Time to face to face consultations for urgent calls
(including % urgent after assessment)
Patient Experience
10. Patient experience of receiving telephone advice
11. Patient experience of treatment at a centre
12. Patient experience of home visits
© Primary Care Foundation
Learning from the first two rounds
of the benchmark
Improving out of hours care: what lessons can be learned from a
national benchmark of services? January 2010, PCF
1. Out of hours services are improving
2. Patients value a responsive service
3. Split services and double assessments seem to perform
less well
4. Many providers are falling short on the standard for
definitive clinical assessment of urgent cases
5. 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
There is a clear relationship between IPSOS
Mori respondent’s view of speed of response
and the rating for the care received
85%
Rating of care received either good or very good
80%
75%
70%
65%
60%
55%
50%
45%
40%
40%
45%
50%
55%
60%
65%
70%
How quickly care was received % About right
Each dot is one PCT
© Primary Care Foundation
75%
80%
85%
We reported the percentage of urgent cases that
were assessed in 20 minutes…
100%
90%
Many of these providers
had too many cases
with double assessment
80%
70%
60%
50%
40%
30%
Increasingly falling below standard
20%
10%
0%
Each bar is one service – a provider/PCT
© Primary Care Foundation
There is a very striking variation between services in
the proportion of cases identified as urgent on
receipt
Percentage of
70%
60%
cases identified as
urgent by non
clinical callhandlers
50%
40%
30%
20%
How safe?
10%
0%
Each bar is one service – a provider/PCT
© Primary Care Foundation
How safe?
In general it costs more to service a rural PCT than an
urban one – but there are wide variations within any band
●Rural
●Mixed
City/Urban
£18.00
£16.00
£14.00
Cost per head
£12.00
£10.00
£8.00
£6.00
£4.00
£2.00
£0.00
0.00
20.00
Each dot is one service
40.00
60.00
Population density
© Primary Care Foundation
80.00
100.00
120.00
In far too many services it is impossible to be sure
how many patients make their way towards hospital
25%
20%
We know that many services,
particularly to the left, are undercounting patients going towards
hospital
15%
Normal band?
10%
5%
not credible?
suspect
0%
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
© Primary Care Foundation
Phone
Walk
10/01/2010
09/01/2010
08/01/2010
07/01/2010
06/01/2010
05/01/2010
04/01/2010
03/01/2010
02/01/2010
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31/12/2009
30/12/2009
29/12/2009
28/12/2009
27/12/2009
26/12/2009
25/12/2009
24/12/2009
23/12/2009
22/12/2009
10/01/2010
5000
21/12/2009
20/12/2009
19/12/2009
18/12/2009
17/12/2009
500
16/12/2009
600
09/01/2010
08/01/2010
07/01/2010
06/01/2010
05/01/2010
04/01/2010
03/01/2010
02/01/2010
01/01/2010
31/12/2009
30/12/2009
29/12/2009
28/12/2009
0
15/12/2009
Walk
14/12/2009
Phone
27/12/2009
26/12/2009
25/12/2009
24/12/2009
23/12/2009
22/12/2009
21/12/2009
20/12/2009
19/12/2009
18/12/2009
17/12/2009
16/12/2009
15/12/2009
14/12/2009
Average demand by day is predictable
Total of all services
50000
45000
40000
35000
30000
25000
20000
15000
10000
Example provider
400
300
200
100
0
Services fall short of the quality
requirements
Definitive assessment of urgent cases in 20 minutes …
Services ranked by % of urgent cases started definitive assessment in 20 minutes:
Average across all services is ranked 41 out of 98
100%
90%
80%
70%
50%
40%
30%
ALL 79.6%
60%
20%
10%
0%
Red shows % where definitive assessment starts in 20 minutes. Green shows the figure where a first attempt to assess
was begun in 20 minutes. Average across all services is at 79.6% (definitive) plus 8.3% (to first attempt)
© Primary Care Foundation
Reason number 1 – Not enough people on the
busy days to keep up with demand
800
700
At weekends and bank holidays
significant numbers of cases are
above the green and are taking more
than an hour to definitive assessment
600
500
400
300
200
700
100
600
0
500
A: less than 20 mins
B: 20 to 40 mins
C: 40 to 60 mins
D: 1 to 2 hrs
E: 2 to 4 hrs
F: Over 4 hrs
400
This is the picture by hour for the
weekends – the service gets behind
in the busy morning period and takes
a long time to catch up
300
200
100
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
© Primary Care Foundation
A: less than 20 mins
B: 20 to 40 mins
C: 40 to 60 mins
D: 1 to 2 hrs
E: 2 to 4 hrs
F: Over 4 hrs
20
21
22
23
Reason number 2 – unmanaged
variability between individuals
Advice
Advice
Advice
Advice
Advice
Advice
Advice
Advice
Advice
Advice
Base
28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9
10
11
12
13
14
15
16
17
Average
03236bf5-45d0-43fa-99a3-d3046a61587b
0
0
0
0
0
0
0
0
0
0d74c10a-ef6d-4e77-b563-5134e2feda2a
0
0
0
3
0
0
0
0
0
3.0
1849ef44-8b17-403a-9a43-42536f23f51a
0
0
0
0
0
0
0
0
0
18b8e095-b3db-4bb8-adbd-c2b2d21eae22
4
0
0
1
0
0
0
0
0
2.5
1a9fd568-9663-4ad0-83f3-3bf946820c56
0
0
0
0
3
9
5
0
1
4.5
244e88e6-bf0d-4566-a1d7-c989a55ac03f
0
0
0
0
0
0
0
0
0
00fae413-c635-4429-b535-1461d2735afa
0
0
0
0
0
6
1
2
1
2.5
04359181-3438-485f-9677-1d4823523a55
0
1
2
0
0
0
0
0
1
1.3
076ebd21-813d-4c59-959a-3f2f0d0bc7e4
0
0
0
0
0
0
0
0
0
088f53e7-5bfb-44e2-9b46-b089ba720a5c
3
0
0
1
1
0
0
0
0
1.7
0d8234b0-a4c0-4f3f-85d0-76eb599165a3
0
0
0
0
0
0
0
0
0
0dc7cac4-99d6-4d17-bb94-9ec98bcd723f
0
0
0
0
0
0
0
0
0
125105b1-8f26-11d9-85d1-0002b35d7fe5
0
0
0
1
0
0
0
0
0
1.0
12510602-8f26-11d9-85d1-0002b35d7fe5
8
6
2
0
0
0
0
0
0
5.3
12510611-8f26-11d9-85d1-0002b35d7fe5
0
0
0
0
0
0
0
0
0
12510623-8f26-11d9-85d1-0002b35d7fe5
0
0
0
0
0
1
0
0
0
1.0
12510628-8f26-11d9-85d1-0002b35d7fe5
3
3
3
5
0
0
0
3
1
3.0
125106ab-8f26-11d9-85d1-0002b35d7fe5
0
0
0
0
0
0
0
0
0
4e3c24ba-1308-4dba-a851-2ea37eadd5a5
15
17
11
11
13
0
0
0
0
13.4
14faae0a-c609-4a09-bc94-9a469096f2ad
1
1
2
5
3
2
3
4
2
2.6
Base
Base
All
All
All
All
All
All
All
Base
Base
Base
Base
Base
Base
Base
28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9
10
11
12
13
14
15
16
17
Average
0
0
0
0
0
0
0
0
4
4.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
4
4
4
0
0
0
0
0
3.3
0
0
0
0
0
0
0
0
5
5.0
0
0
0
0
0
0
0
0
1
1.0
0
0
0
0
0
0
0
0
0
2
1
0
3
2
3
4
3
3
2.6
0
0
0
0
4
4
4
6
3
4.2
1
4
3
1
0
0
0
0
0
2.3
0
1
0
2
0
0
0
0
0
1.5
1
5
1
4
3
2
0
0
0
2.7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
3
3
3
0
0
0
0
3.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
2
1.5
0
0
0
0
0
3
3
6
2
3.5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Number of
contacts by hour
03236bf5-45d0-43fa-99a3-d3046a61587b
0d74c10a-ef6d-4e77-b563-5134e2feda2a
1849ef44-8b17-403a-9a43-42536f23f51a
18b8e095-b3db-4bb8-adbd-c2b2d21eae22
1a9fd568-9663-4ad0-83f3-3bf946820c56
244e88e6-bf0d-4566-a1d7-c989a55ac03f
00fae413-c635-4429-b535-1461d2735afa
04359181-3438-485f-9677-1d4823523a55
076ebd21-813d-4c59-959a-3f2f0d0bc7e4
088f53e7-5bfb-44e2-9b46-b089ba720a5c
0d8234b0-a4c0-4f3f-85d0-76eb599165a3
0dc7cac4-99d6-4d17-bb94-9ec98bcd723f
125105b1-8f26-11d9-85d1-0002b35d7fe5
12510602-8f26-11d9-85d1-0002b35d7fe5
12510611-8f26-11d9-85d1-0002b35d7fe5
12510623-8f26-11d9-85d1-0002b35d7fe5
12510628-8f26-11d9-85d1-0002b35d7fe5
125106ab-8f26-11d9-85d1-0002b35d7fe5
4e3c24ba-1308-4dba-a851-2ea37eadd5a5
14faae0a-c609-4a09-bc94-9a469096f2ad
Number of base
consultations by
hour
Number of phone
consultations by hour
for each clinician
Clinician identifier
All
Number of home
visits by hour
Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit Home Visit
28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9
10
11
12
13
14
15
16
17
Average
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2
1
0
1
1.5
0
0
0
0
0
1
2
1
2
1.5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
0
0
0
0
0
0
1.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Weighted SMV
‘earned’ per hour
All
All
28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9
10
11
12
13
14
15
16
17
Average
4
4.0
3
2
2
1
1
1.8
1
2
1
2
1.5
5
4
4
5
4.5
3
9
5
6
5.8
1
1.0
6
1
2
1
2.5
2
2
2
3
2
3
4
3
4
2.8
4
4
4
6
3
4.2
4
4
3
2
1
2.8
1
2
1.5
1
5
1
4
3
2
2.7
1
1
1
1
1.0
8
6
2
5.3
3
3
3
3
3.0
2
1
1
1
1.3
3
3
3
5
4
3
3.5
3
3
6
2
3.5
15
17
11
11
13
13.4
1
1
2
5
3
2
3
4
2
2.6
This is illustrative data
Weight
Weight
Weight
Weight
Weight
Weight
Weight
Standard values for comparison
Phone advice
Base F2F
Home visit
Weight
Weight
28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009 28/12/2009
9
10
11
12
13
14
15
16
17
48.0
18.0
60.0
60.0
30.0
30.0
30.0
60.0
30.0
60.0
36.0
48.0
48.0
54.0
18.0
54.0
30.0
66.0
12.0
36.0
6.0
12.0
6.0
24.0
18.0
12.0
36.0
24.0
36.0
48.0
36.0
42.0
48.0
48.0
48.0
72.0
36.0
30.0
48.0
36.0
18.0
6.0
12.0
24.0
12.0
60.0
12.0
48.0
36.0
24.0
30.0
30.0
30.0
6.0
48.0
36.0
12.0
36.0
36.0
36.0
36.0
36.0
30.0
30.0
30.0
18.0
18.0
18.0
30.0
30.0
30.0
36.0
36.0
72.0
24.0
90.0
102.0
66.0
66.0
78.0
6.0
6.0
12.0
30.0
18.0
12.0
18.0
24.0
12.0
© Primary Care Foundation
6 minutes
12 minutes
30 minutes
Average contacts
per hour
Weighted standard
minutes per hour
4.0
1.8
1.5
4.5
5.8
1.0
2.5
2.8
4.2
2.8
1.5
2.7
1.0
5.3
3.0
1.3
3.5
3.5
13.4
2.6
48
40
45
47
42
12
15
31
50
28
18
32
24
32
36
32
24
42
80
15
Average weighted
standard minutes
35
Final reflections on the benchmark:
future changes
For services
● All services need to ensure that they are using the results: it is about
using national comparisons to drive local improvements
● Some services need to make sure that they are responding to calls
more rapidly than is currently the case
● The big difference between providers is how they support their staff
ensuring good governance and reducing unnecessary clinical variation
For the OOH Benchmark
● The benchmark has now been extended to cover all these areas
● Making the benchmark more open and transparent will ensure that it
is more useful to services as a tool for driving improvements
● Created a new national steering group as well as a user group
● Future in the new world?
© Primary Care Foundation
Key Issues for local empowerment
● Patient Safety is always the top priority
● A new initiative for rapidly sharing learning?
● tighter rules or a cultural shift?
● There is now better performance date – use it!
● responding to benchmarking
● Better internal scrutiny – good governance and independent NEDs
● Greater openness and transparency
● Work as part of a 24/7 integrated urgent care system
● Networks and accountability
● Three Digit Number
● Clarity for the public and patients about using urgent care services
● Commissioning for quality – new leaders in the system
● Now driven by GP commissioning groups
● Commissioning pathways
● identifying the cost of quality in urgent care services
© Primary Care Foundation
The future for commissioning out
of hours services GP Newspaper 18 November 2010
th
● GP commissioners are well placed to use their clinical
knowledge to drive improvements.
● It will be important to work closely with other services to
commission at the right level.
● There is now good benchmark information to help identify
areas for improvement.
● Time and attention is needed. Unless GP consortia give outof-hours care the priority it deserves, it may come back to
haunt them.
● A shift in culture to supporting clinicians who report
problems is as important as meeting standards..
© Primary Care Foundation