Urgent
Care in
General
Practice
Out of
Hours
Benchmark
Urgent
Care
Centres
Primary
Care in
A&E
Meeting the quality and productivity
challenge in out of hours care: what can we
learn from the out of hours benchmark?
Improving Patient Safety in Out of Hours Care
22nd June 2010
Rick Stern
Director, Primary Care Foundation,
NHS Alliance Lead for Urgent Care
rick.stern@primarycarefoundation.co.uk 07709 746771
© Primary Care Foundation
What I will cover
The current context – learning from recent reviews
The out of hours benchmark – what we can learn about
quality and productivity
How can this lead to improvements in patient care and
safety?
Shifting the focus: from organisational to individual
Improving the benchmark
Where are we heading … the future of OOH and 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
Jayne Hetherington
Eddie Jahn
Dr Darren Mansfield
Chief Executive
Barndoc Healthcare Ltd
General Manager
OWLS CIC Ltd
Managing Director
Harmoni
GP Clinical Lead in Urgent
Care
Chief Executive
NHS Bolton
Alison McWilliam
General Manager
Dr Ray Montague
Dr Russell Muirhead
Diane Ridgeway
Dr Bruce Websdale
Gilly Wilford
Medical Director
Nottingham Emergency Medical Services
Limited (NEMS CBS)
Brisdoc Healthcare Services
Chairman
Shropshire Doctors Cooperative Ltd
Chief Executive
East Lancashire Medical Services Ltd
Medical Director
Primecare
Director of Finance &
Contracts
Chief Executive
South East Health
Lesley McCourt
Nigel Wylie
Partnership of East London Co-operatives
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
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
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) Out-of-Hours Services: project to consider
and assess current arrangements
and still to report …
● Care Quality Commission (still ongoing) Enquiry into Take Care Now
© Primary Care Foundation
What can we learn from recent
reports on out of hours services?
Key areas in the Department’s Review
●
●
●
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
Actions following on from the Review:
 Reviewing the National Quality Requirements
 Developing a new national model contract for OOH services
 Stronger performance management (including use of English and
applying the performers list)
 Greater involvement of local GPs
But we now have a new government …
© 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
● 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 – to be
completed by end July 2010
● Fourth benchmark, again a full benchmark including patient
experience – to be completed October 2010.
© Primary Care Foundation
How does it work?
● Data extract – most from one information system but now
working with a number of others
● Web based questionnaire for commissioner
● Web based questionnaire for providers
● Validate data
● Produce reports
● Workshops
● Anonymity – about to change
● 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
The evidence suggests …
Out of hours services are improving
… despite what you might hear in the media
Most providers have made a rapid transition from
‘rota organising clubs’ into true healthcare
providers.
In doing so they have got much better at:
● Matching capacity to predictable demand, giving ample time for clinicians to
do their work well
● Meeting performance standards
● Introducing governance processes to ensure a consistent and safe response
to patients
● Engaging local clinicians in the service.
© Primary Care Foundation
A rapid response matters to
patients
● Patients value a responsive service and associate
this with good care. There is a wide difference
between wide the difference is between the
responsive and the comparatively slow.
© 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%
Seven years on, most providers are
still falling short on a key NQR
Many providers are falling short on the standard
for definitive clinical assessment of urgent cases
which we see as an important issue of patient
safety.
© Primary Care Foundation
We reported the percentage of urgent
cases that were assessed in 20 minutes…
100%
90%
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
70%
60%
Percentage of
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?
Coding needs to be improved …
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
What is quality in OOH?
Quality is likely to be a composite measure of a
number of these factors. Our conclusion is that
those that perform well on all these factors are far
from being the most expensive, but also that the
very cheap providers do not appear to have the
management headroom to perform consistently
enough to feature in this group.
© Primary Care Foundation
Using this measurement of productivity
to drive improvements in care
● An example: an out of hours provider who were part of earlier pilots
● Concerned that productivity was low
● Looked at productivity by each clinician – reported this back and
reviewed performance with clinical manager
● Also looked at other factors. Identified some doctors regularly late
for sessions and others not picking up calls when no visits at centre.
● Results included:
● Productivity more than doubled
● Clinicians happier that workload was more evenly spread
● ‘by making clinicians more productive - supporting them as
necessary, sorting out the problems that they face and addressing
one or two poor performers – it has improved care for patients
because clinicians can focus on the job that they are there to do’
● Learned that variations in performance tend to be less about
external factors (e.g. geography, demography) and more about how
staff are supported and managed.
© Primary Care Foundation
Improving Patient Safety - responding
to low level of urgent cases on receipt
● Concern about benchmark results led to a rigorous base line audit of
calls taken and priority given.
● Call handlers clear about life threatening calls & A&E referrals
● Other specific areas identified that could be addressed by training designed to develop each call handler’s confidence and knowledge
● Results included:
● post training audit showed that % of urgent calls has increased and
is moving towards the national average
● more importantly, has shown to be appropriate to each presenting
case as evidenced by the end priority given by the consulting
clinician
● Supported and reassured call handlers - benefitted from extra
training and comparing how they work with others
● Better identification of urgent needs improved patient safety
© Primary Care Foundation
From variation across organisations
to variation between clinicians
● There is substantial variation within a typical service
between individual clinicians. The response will often be
shaped more by who deals with the case rather than the
details of the case itself.
● Developing a consistent, safe and appropriate response
does not just involve looking at the outliers, but involves
consistent feedback to individuals comparing them with
their peers so that they can identify specific things that they
might do differently for the benefit of patients and the
service.
© Primary Care Foundation
Future Changes …
For services
● All services need to ensure that they are using the results work out
how to improve local care – it is about using national comparisons
to drive local improvements
● Recent reviews have highlighted the importance of good
recruitment, induction, training and continuing support of staff.
● Some services need to make sure that they are responding to calls
more rapidly than is currently the case
For the OOH Benchmark
● The benchmark will extend to cover all these areas
● Making the benchmark more open and transparent will ensure that
it is more useful to services as a tool for driving improvements
● Creating a new governance group as well as a user group
© Primary Care Foundation
Key Issues for the future
● Patient Safety
● A new initiative for rapidly sharing learning?
● tighter rules or a cultural shift?
● Focus on learning and improvement
● responding to benchmarking and other comparisons across and within
organisations
● Better internal scrutiny – good governance and independent NEDs
● Greater openness and transparency
● Working as part of an integrated system
● Networks and accountability
● Three Digit Number
● Clarity for the public and patients about using urgent care services
● Commissioning for quality
● Commissioning pathways
● identifying the cost of quality in urgent care services
© Primary Care Foundation
Discussion
& Questions
And for more information, visit our website at:
www.primarycarefoundation.co.uk
Or contact me:
Rick Stern
07709 746771
rick.stern@primarycarefoundation.co.uk
© Primary Care Foundation