Hampshire County Council

Health Overview and Scrutiny Committee Item 7

28 March 2006

Health Overview and Scrutiny Thematic Review Programme

Report of the Chief Executive

Contact: Martin Combs ex 7479

1. Summary and Purpose

1.1 The purpose of this report is to provide members with a progress update on the review programme agreed by the Committee in May 2005 for 2005/6.

1.2 The format and focus of each topic presented reflects the previously agreed criteria selected by members, namely:

· Capacity to influence and improve the service under consideration

· Timeliness and relevance to local health services

· Issues not under consideration elsewhere

· Issues not subject to other scrutiny or performance monitoring activities

2. The Thematic Reviews

2.1 Two thematic reviews have been undertaken:

· Review of Public Health & Wellbeing (attached at Appendix One)

· Review of Out-of-Hours Services (attached at Appendix Two)

2.2 The background, key issues and recommendations will be summarised in this report, but each review is appended in its own right for further information.

2.3 This report and supporting recommendations support the delivery of the annual work programme of the Health Overview and Scrutiny Committee for 2005/6, and Aim 5 (Improving Services) of the Corporate Strategy.

3. Review of Public Health & Wellbeing

3.1 Background to the Public Health & Wellbeing Review

3.1.1 The Review of Public Health and Wellbeing was presented in draft to the Committee 31 January 2006. The review was opportune in terms of the timing of the increasing focus of the Department of Health in community health, and the recent review of Public Health departments in Primary Care Trusts.

3.1.2 Public Health and Wellbeing is a wide agenda that requires partnership working and cuts across many departments. The Review plays a role in attempting to consolidate a view of initiatives being undertaken by local authority and health organisations against a set of Public Health and Wellbeing objectives.

3.2 Responses and updates to the Public Health & Wellbeing Review

3.2.1 The first draft of the Review of Public Health and Wellbeing was circulated with the intent that Districts, PCTs, LSP Chairs, and the Public Health Network could comment on it, or provide information if they felt that representation of work or initiatives should be more accurately reflected. As a result, Rushmoor Borough Council and Mid Hampshire PCT sent additional information, and the tables have been adjusted to reflect the new material.

3.2.2 The SHA, in addition, sent a draft Review of Delivering Choosing Health: making healthier choices easier in Hampshire and Isle of Wight, published by the SHA, December 2005. The review addresses nine National Service Framework targets and uses the self assessments of PCTs to record progress against the targets. While there is partial co-incidence of the targets, and objectives considered in this paper, The SHA Review does not, however, focus on the wider Public Health and wellbeing initiatives or objectives planned by the PCTs for their areas.

3.2.3 The original draft attracted two types of comments. A number of comments have expresses appreciation of the attempt to bring together Public Health and Wellbeing information from NHS and Local Authority sources. On the other hand some have expressed concern that the tables may not be underpinned with enough information to give a fair representation of the relative contributions of the different bodies to the objectives. This latter issue is acknowledged in the paper, and indeed some organisations sought to address the matter by providing that information.

3.3 Key issues in Public Health & Wellbeing

· This is a complex area of work that transcends professional, organisational and directorate boundaries. The initial baseline set by the Review now needs to be built on and consolidated to take this agenda forward.

· There is a considerable amount of activity supporting the delivery of the Public Health and Wellbeing agenda across the County Council, District Councils and the NHS.

· There are excellent examples of partnership working and the opportunity exists to identify good practice and share it widely.

· The consolidation work initiated by the Review of Public Health and Wellbeing be taken forward by an appropriate body such as the Public Health Network.

· As a preventative approach that often looks to future health benefits, Public Health funding can be threatened by competition for funding current day-to-day health and care service delivery, in a climate of financial pressure.

· The Public Health and Wellbeing agenda makes most effective and efficient use of resources when partners work co-operatively and play to their strengths, and cross-cutting work is facilitated.

3.3 Recommendations for Public Health & Wellbeing

It is recommended:

a) That this report be shared with the Adult Services Restructuring Board Working Group that is taking forward joint working with the Public Health Network. This will include:

· A more detailed mapping of public health plans and programmes across the county, including opportunities to share best practice and identify gaps in delivery.

· The development of LSPs and LAAs.

· Identification of the health improvements to be delivered by local people.

b) That lead officers from Adult Services and the Public Health Network will report back to the Committee on progress with this work on 28 November 2006 detailing the outcomes of the review.

c) That a small working group of members is convened to oversee the rollout of the Public Health and Wellbeing agenda, including representation from different parts of the county.

4. Review of Out-of-Hours Service Provision

4.1 Background to the Out-of-Hours Review

4.1.1 Out-of-Hours (OOH) services became of particular interest in 2004 following the introduction of the new GP contract and the transfer of responsibility of OOH services to PCTs. In July 2004 the Health Overview and Scrutiny Committee (HOSC) raised a number of questions with the Strategic Health Authority about OOH about the arrangements for these services.

4.1.2 Early discussions with the SHA about the review confirmed that, as part of a new series of short term programmes, the SHA intended to undertake an internal evaluation of these services. In light of this, it was agreed that further work by the HOSC would be deferred until the SHA had completed its work.

4.1.3 The SHA Review noted that, "currently there are five separate arrangements across Hampshire for the organisation and provision of out-of-hours services with variations in demand, handling of demand, standards and costs." The review identified strengths and weaknesses of the models, and provided comparisons with national benchmarks

4.1.4 The initial findings of the SHA Review Group appears to suggest a direction of travel for OOH services that would deliver a single telephone number call handling service. There would be one telephone number for people to get medical help or advice out-of-hours. The proposal is that the service is piloted one area and potentially phased into remaining areas over time into one coherent system for the county.

4.1.5 The Committee's commentary also considers the National Quality Requirements in the Delivery of Out-of-Hours Services, October 2004, which complement the original OOH Standards for Better Health, 2002

4.1 Key Issues in Out-of-Hours

· Ensuring that implementation and expansion of the OOH pilot into Hampshire is accompanied by robust and meaningful patient and public engagement

· That current relative stability in OOH service provision is not jeopardised by profound organisational changes in the NHS

· Ensuring conformance with National Quality Requirements and patient safety, whilst looking to achieve lower costs

4.2 Recommendations for Out-of-Hours

4.3.2 The SHA Review provides a useful summary of information about current performance of Out-of-Hours in Hampshire, and is helpful in identifying a way forward that will support the development of an integrated pan-Hampshire model for OOH services.

4.3.3 The Committee has previously acknowledged the complexity of OOH care and the additional challenges that national policy changes will pose for local service delivery. In taking this work forward it is recommended that the Committee continues to take an active interest in the development of OOH services. In the first instance it would be helpful to have a response to the queries raised in 7.8 of the attached report.

4.3.4 In addition the Committee will wish to have a response to the following:

· Feedback on performance against the National Quality Requirements and appropriate Quality Standards relating to:

o Response

o Timeliness

o Patient and Public Involvement

· Confirmation of the clinical evidence and needs assessment underpinning the proposals

· Feedback from current providers about the proposals (including the LMC)

· Confirmation of the way in which Section 11 engagement will be build in to the planning process

· Details of the impact on service delivery as a result of implementing the proposals

· An assessment of key risks and dependencies

· Confirmation of the governance arrangements that would underpin the implementation process, taking account of the reconfiguration proposals for SHAs, PCTs and Ambulance services, that are currently out to consultation.

4.3.5 The SHA leads be invited to the May meeting to advise members of their response to the issues raised and confirm the next steps in moving this process forward.

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

Appendix One

Hampshire Health Overview and Scrutiny Committee

Review of Public Health and Wellbeing in Hampshire

1. Introduction

1.1 Public Health and Wellbeing was identified as an area of interest for the Committee's Review Programme for 2005/6. Since then Government has given increasing attention to improving the health foundations for citizens of all ages by identifying that a preventative agenda is the way forward for Local Authorities and Health alike. This review attempts to bring together summary information from Local Authority and Health sources into one place to enable members to view at a glance initiatives being undertaken against a generally acknowledged set of objectives.

1.2 Of significance are the recent statements by the Secretary of State for Health which say that HOSCs are increasingly conducting reviews that recognise the role of local authorities in improving community wellbeing, instead of only focusing on the NHS. The Secretary of State also says that Scrutiny Committees are very active, not only looking at the planning and delivery of healthcare, but increasingly tackling the public health agenda and promoting what local councils can do to improve health

1.3 Since the Committee selected public health as a key topic for review there have been a number of national and local developments that have significantly raised the profile of this work and the way in which it can be most effectively delivered for local people. Key drivers of change have been:

1.3.1 Choosing Health, the Department of Health white paper on Public Health, 2004, with the following overarching priorities:

· Reducing the numbers of people who smoke

· Reducing obesity and improving diet and nutrition

· Increasing exercise

· Encouraging and supporting sensible drinking

· Improving sexual health

· Improving mental health

1.3.2 Health Improvement Foundations for LAAs (proposed by the SE Public Health Group, GOSE/DH), July 2005, adds the priorities:

· Health inequalities

· Older people

1.4 Hampshire County Council's published Local Public Service Agreement schedule supports the Public Health and Wellbeing agenda, where some targets have a direct bearing on objectives in this paper.

1.5 As a consequence the Committee has been able to work with those currently considering the way in which public health is planned and delivered across Hampshire. The emphasis of this initial report has therefore been on identifying activities already taking place across Hampshire, to inform the identification of any gaps and more importantly, highlight good practice.

1.6 This report therefore, represents one element of a number of work strands that are currently being progressed.

1.7 Particular thanks need to be expressed to Katie Crabbe and Mary Amos for their contribution to the findings that informed this report.

1.8 The report and recommendations provide members with an opportunity to inform and influence the planning and delivery of Public Health across Hampshire and therefore support Aim 5 (Improving Services) of the Corporate Strategy.

2. Public Health and Wellbeing Objectives: reported activity - updated

2.1 The first draft of the Review of Public Health and Wellbeing was circulated with the intent that Districts, PCTs, LSP Chairs, and the Public Health Network could comment on it, or provide information if they felt that representation of work or initiatives should be more accurately reflected. As a result, Rushmoor Borough Council and Mid Hampshire PCT sent additional information, and the tables have been adjusted to reflect the new material.

2.2 The SHA, in addition, sent a draft Review of Delivering Choosing Health: making healthier choices easier in Hampshire and Isle of Wight, published by the SHA, December 2005. The review addresses nine National Service Framework targets and uses the self assessments of PCTs to record progress against the targets. While there is partial co-incidence of the targets, and objectives considered in this paper, The SHA Review does not, however, focus on the wider Public Health and wellbeing initiatives or objectives planned by the PCTs for their areas.

2.3 The earlier draft produced by the Committee attracted two types of comments. Some comments have expressed appreciation of the attempt to bring together Public Health and Wellbeing information from NHS and Local Authority sources. On the other hand, some have expressed concern that the tables may not be underpinned with enough information to give a fair representation of the relative contributions of the different bodies to the objectives. This latter issue is acknowledged and has been addressed where organisations sought to assist by providing that information. The paper also acknowledges that in summarising, details get lost.

2.4 This is a complex area to analyse, reflecting the diverse nature of communities across Hampshire. As such, this is only a `snapshot' of information provided to us in October 2005. This work gives an impression of the range of work currently being taken forward by local Government and the NHS across Hampshire and hopes it may be seen as a whole system.

2.5 The following tables capture initiatives taken forward by Hampshire County Council, Hampshire District Councils and Primary Care Trusts (PCTs) against the national standards for Public Health/Well-being outcomes. Symbols are used to provide a quick indicator of work initiated or planned in different communities.

2.6 The additional information has been gratefully received, however caution should still be exercised since it is still probable that the tables may not include all activity, and some commitments to initiatives may have been frustrated due to lack of funding or critical staff shortages. Therefore the charts are primarily indicative of activity or achievement and not absolute guides.

2.7 The tables try to align council areas with PCT areas as far as possible. This is a first draft attempt to consolidate information about progress against the Public Health objectives. In subsequent reports it may be helpful to include, where possible, activity by voluntary sector partners.

2.8 What do the symbols represent? Given the foregoing comments, the responses have been analysed as follows:


Reported Initiatives
Significant variety of initiatives or investment in resource	_
Initiatives under way, commitment of resource	_
No reported initiatives or investment in resource	_

2.9 Please note: this report does not see its purpose as judgemental, but rather as an instrument, and in so far as it summarises activity and intent, broad brush. In particular we are very conscious that the difficulty in aligning county, district and health boundaries of influence (administrative responsibility) and activity, in turn this makes it difficult to consolidate information. The tables attempt to relate district with local health boundaries, whilst county activity is taken to be broadly true for all district and health areas. The current consultation `Commissioning a Patient-Led NHS' provides an opportunity to addresses some boundary anomalies between local government and the NHS

2.10 The report is organised to reflect the following health and well-being objectives:

1. Reducing the number of people who smoke

2. Drinking sensibly and harm reduction

3. Reducing Health inequalities

4. Tackling obesity

A. Healthy eating for Adults

B. Increasing physical activity for Adults

5. Helping Children and Young People to lead healthy lives

6. Mental health and well-being

7. Promoting healthy and active life amongst older people

8. Promoting health and well-being

9. Promoting health and well-being for LA staff `investing in the workforce'

2.11 The objectives include the `Health Improvement Foundations for LAAs' developed by the Government Office for the South East in conjunction with the Department of Health. They also capture the `overarching priorities' of the Government/Department of Health white paper, `Choosing Health: making healthy choices easier', 2004.


Objective 1: Reducing the number of people who smoke
County Council		District Council		PCT
Departments · PBRS	_	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Local Strategic Partnership organisations are committed to smoke-free workplaces by March 07 in line with current Government legislation. Some districts are committed to smoke-free council-owned & occupied premises by April 2006 e.g. Eastleigh.


Objective 2: Drinking sensibly and harm reduction
County Council		District Council		PCT
Departments · Trading Standards · Hampshire DAAT · PBRS	_ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Partnership working e.g. JIGSAW¹ in Havant with funding from Hampshire DAAT^2.


Objective 3: Reducing health inequalities
County Council		District Council		PCT
Departments · Environment	_	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· An emphasis on people's living conditions - a prime area for tackling, in part, the root of some health problems.

· Community strategies reflect the strategic priority to promote & support the well-being of local communities; this is achieved in partnership by addressing gaps in provision via health equity audits with PCTs.


Objective 4A: Tackling obesity - Healthy eating for adults
County Council		District Council		PCT
Departments · PBRS	_	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Joint or partnership initiatives may not have been identified


Objective 4B: Tackling obesity - Increasing physical activity for adults
County Council		District Council		PCT
Departments · R&H · Environment	_ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Some partnership working, e.g. Havant and East Hampshire PCT (SE Cluster), Eastleigh, Test Valley South & New Forest PCT ( SW Cluster).


Objective 5: Helping children and young people to lead healthy lives
County Council		District Council		PCT
Departments · Children's Services · R&H · PBRS · Environment	_ _ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

·Local government reports a range of activities and initiatives.

·Initiatives to support the delivery of sub-objective 5.7 (Supporting young people involved in substance misuse) need to be identified.


Objective 6: Mental health and well-being
County Council		District Council		PCT
Departments · R&H · Adult Services · Children's Services	_ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Partnership working e.g. JIGSAW¹ in Havant with funding from Hampshire DAAT^2.


Objective 7: Promoting healthy and active life amongst older people
County Council		District Council		PCT
Departments · Adult Services · Corporate Comms · R&H - Arts Service	_ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Eastleigh has an inter-agency older people strategy- `Live Long & Better'.


Objective 8: Promoting health and well-being
County Council		District Council		PCT
Departments · Chief Executive's · Adult Services · R&H · PBRS · Trading Standards · Environment · Health Scrutiny · Hampshire DAAT²	_ _ _ _ _ _ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· The Healthy Eastleigh Living Network , funded by the Big Lottery, brings together a variety of initiatives designed to improve the health & well being of people living & working in the Borough.

·The contribution of PCTs to delivery of this objective is not clear, and this needs to be addressed in subsequent work. Further work could be done with the following sub-objectives:


3. Promoting health and well-being Sub-objective
3.1	Promoting health and well-being	What staff have the specific remit for promoting health?
3.2	Improving fitness levels	What partnership initiatives such as `walking to health' are in place?
3.3	Health & Safety/Food safety and environmental health	What local initiatives are in place?
3.4	Working to improve the health service	What specific initiatives are in place across PCTs?


Objective 9: Promoting health and well-being for LA staff `investing in the workforce'
County Council		District Council		PCT
Departments · HR · R&H · Chief Executive's · Environment	_ _ _ _	Hart	_	Blackwater Valley & Hart	_
		Rushmoor	_		_
		Fareham	_	Fareham & Gosport	_
		Gosport	_		_
		Havant	_	East Hampshire	_
		East Hampshire (S)	_		_
		East Hampshire (N)	_	North Hampshire	_
		Basingstoke	_		_
		Winchester	_	Mid Hampshire	_
		Test Valley (N)	_		_
		Test Valley (S)	_	Eastleigh & Test Valley South	_
		Eastleigh	_		_
		New Forest	_	New Forest	_

Comment:

· Eastleigh Borough Council runs health screening, annual staff health events & supports national awareness days.

· Hampshire County Council is the winner in the Most Improved Employer Category in the Solent Area BBC Healthy Workplace Awards. It is also in the final three employers, nationally.

4. Summary and Key Issues

4.1 This paper sets out the first steps in identifying plans and programmes to improve the health of people living in Hampshire. It provides a baseline, albeit tentative, of progress reported against national objectives for Public Health. By drawing together work undertaken by local government and the NHS in Hampshire, a dialogue across different communities can be encouraged, raising the profile of public health and supporting any further action required.

4.2 The County Council, local NHS and District Councils have recently undertaken a programme of seminars to support the effective delivery of Commissioning a Patient-Led NHS. Part of this work includes consideration of the local arrangements that need to be in place to improve the health of the population of Hampshire.

4.3 This version of the paper is the final draft, however it is hoped that the work will be taken up and continued, possibly by the Public Health Network, who are in the best position to discover and consolidate Public Health and Wellbeing activity across Hampshire. As a living document, it will always be valuable for stakeholders to identify how the Review could be improved by better local information, and presentation. The potential to better identify partnership working and including the contribution of voluntary sector partners could add further to a more holistic perspective.

4.4 It is noticeable that in some reports provided by NHS organisations, lack of resource prevents progress on some issues. Given the breadth of the Public Health and Wellbeing agenda, resources will always face the challenge of finite resources, but resources will need to follow commitment to agreed objectives.

4.6 Further updates and amendments will then be driven through lead officers in local government and NHS organisations. A report back on progress will be presented to the Committee at the November meeting

5. Recommendations

It is therefore recommended:

a) That this report be shared with the Adult Services Restructuring Board Working Group that is taking forward joint working with the Public Health Network. This will include:

· A more detailed mapping of public health plans and programmes across the county, including opportunities to share best practice and identify gaps in delivery.

· The development of LSPs and LAAs.

· Identification of the health improvements to be delivered by local people.

b) That lead officers from Adult Services and the Public Health Network will report back to the Committee on progress with this work on 28 November 2006 detailing the outcomes of the review.

c) That a small working group of members is convened to oversee the rollout of the Public Health and Wellbeing agenda, including representation from different parts of the county.

Glossary

¹JIGSAW is a flexible working partnership of active players and supporters (including Havant BC and East Hampshire PCT) aiming to educate, inform and support young people around health-related issues, including: physical activity, healthy eating, sexual health, alcohol and substance awareness, stress, self-esteem and bullying, and smoking.

²Hampshire DAAT: the Hampshire Drug and Alcohol Action Team is a multi-agency partnership working to implement the National Drug Strategy; it includes a number of statutory and voluntary sector partners. Each year an Annual Plan is produced, which sets out the county drug policy and targets for the year.

Hampshire County Council departments

Acronym	Department
CX	Chief Executive's Department
HR	Human Resources
PBRS	Property, Business and Regulatory Services
R&H	Recreation and Heritage

Appendix Two

Hampshire Health Overview and Scrutiny Review of Out-of-Hours Services in Hampshire

1. Introduction

1.1 Out-of-Hours (OOH) services became of particular interest to the Committee in 2004 following the introduction of the new GP contract and the transfer of responsibility of OOH services to PCTs. In July 2004 the Health Overview and Scrutiny Committee (HOSC) raised a number of questions with the Strategic Health Authority (SHA) about the arrangements for these services. Since then there have been a number of changes in PCT configurations and in OOH arrangements. Therefore, in 2005 provision of OOH was identified as a topic for review by key stakeholders and agreed by the HOSC.

1.2 Early discussions with the SHA about the review confirmed that, as part of a new series of short term programmes, the SHA intended to undertake an internal evaluation of these services. In light of this, it was agreed that further work by the HOSC would be deferred until the SHA had completed its work. The SHA Review draft was completed at the end of January 2006, with reports going to the Chief Executive Community Meetings of 31 January, and 27 February. At the latter meeting agreement was sought from the Out of Hours Review Group to endorse a proposed way forward. This paper summarises and comments upon the SHA Review and way forward proposed.

1.3 The Committee's commentary also considers the National Quality Requirements in the Delivery of Out-of-Hours Services, October 2004, in the SHA Review, which complement the original OOH Standards for Better Health, 2002.

2. What does the `Out-of-Hours' service consist of?

2.1 Out of hours provision consists of a range of health support and treatment services that are, or should be, accessible to communities outside normal working hours, typically from 6:30pm until 8:00am Monday to Thursday, and from 6:30pm Friday until 8:00 Monday. While each service element may have its own particular function and role in out-of-hours provision, the service has to be available as a coherent whole that operates effectively, efficiently and safely.

2.2 The range of services provided out-of-hours includes:

NHS Direct

999 Ambulance

A&E

Walk-in Centres

Minor Injuries Units

Primary Care Centres

Pharmacies

GP out-of hours

Specialist teams/services

(24/7)

(ext hrs, eg. 8am - 10pm, 7days)

(retail hours and ext hrs rotas)

(weekday nights and weekends)

(eg. mental health service referrals for `on call' work)

2.3 Different services operate at different times, and some services will be more appropriate for a given situation than others.

2.4 The range of services needs to cover situations such as where a patient:

· Needs to be transported to a health facility for unscheduled or emergency treatment

· Needs an unscheduled visit from a health professional

· Needs unscheduled or emergency treatment (or medication) at a health location

· Needs advice about a medical condition or situation

· May simply need re-assurance or to wait until in-hours service is available

2.5 The Committee has previously commented on the benefits of a fully integrated model of OOH care to ensure the most effective and efficient use of resources to meet the needs of patients who find themselves requiring help before 8am and after 6:30pm weekdays and during weekends. It is also true that all of the out-of-hours services are also provided during normal hours and therefore complement normal unscheduled health provision.

3. National Quality Requirements: Out of Hours

3.1 The Department of Health published National Quality Requirements in the Delivery of Out-of-Hours Services in October 2004. The delivery of OOH services is expected to comply with these quality requirements, therefore any proposed model of delivery will need to be seen to address them. In addition they will also need to comply with the relevant Standards for Better Health (2002). In broad terms the Quality Standards tend to fall within four areas:

· Information and systems

· Patient experience

· Demand planning

· Performance

3.2 The relevant Standards for Better Health tend to focus more on issues to do with ensuring safety and reducing risk to patients, underpinned by effective governance mechanisms.

4. Terms of reference for the SHA Review Group

4.1 The SHA Review Group was charged with the following objectives, to:

1. Take stock of current arrangements

2. Identify opportunities to deal with present concerns and for improvement

3. Prepare a plan to revise and improve out-of-hours within available resources and to deliver savings of up to £5 million

4. Develop and agree a project plan to deliver the previous two objectives

5. Identify the impact of such proposals on the LDP 2006/7

6. Commend recommendations for agreement by the HIoW Chief Executive Community

4.2 The Group submitted recommendations to the Chief Executive Community Meeting at the end of January. The Group's financial model predicted that if all Hampshire were to participate there could be recurrent cost benefits. This would help to bring the cost of OOH services within the funding envelope available.

4.3 The financial model for the proposed new pan-Hampshire approach proposes to "move the current average costs per call from £50.59 to £39.15 (compares to a national median benchmark of £45.90) and current costs per head of population from £8.21 to £6.36 (compares with national median benchmark of £8.31). It is important to note that nationally OOH services have been set up in a similar way to HIOW health community. Therefore the proposed service and workforce model has an impact on overall benchmark costs without compromising on quality and patient safety. However, the Committee would want to be reassured that neither service quality, nor patient safety would be compromised as a result of moving below the national median.

4.4 On 27 February, the Hampshire Isle of Wight Chief Executives decided to endorse the proposal thus potentially phasing in a pan-Hampshire approach.

5. Current Hampshire Out of Hours

5.1 The SHA Review noted that, "currently there are five separate arrangements across Hampshire for the organisation and provision of out-of-hours services with variations in demand, handling of demand, standards and costs." The review identified strengths and weaknesses of the models, and provided comparisons with national benchmarks.

6. Learning from current out-of-hours models and experience

6.1 A SHA Out-of-Hours Review Event workshop was held November 2005, from which feedback was obtained. The SHA Review draws on feedback from this event, when stating, "Hampshire and Isle of Wight OOH leads considered and identified the strengths and challenges of current out-of-hours systems." "Observations" from the event are included within the SHA Review "in order to gain a more complete understanding of the current out-of-hours environment". Attendees at the event included some members of Patient and Public Involvement Forums

6.1.1 The OOH Workshop identified current strengths as:

o Complete clinical engagement

o Generally good patient satisfaction

o Achievement of Quality Standards

o Cost efficient

o Local services and local knowledge, supported by local staff

o Integrated with local services such as District Nursing

o Patients receive care by most appropriate health or care professional

o Service is fast and efficient and value for money

o A&E would be swamped without it

6.1.2 When considering the feedback from the workshop, and the findings of the Review, there are a number of questions that would merit further exploration. For example:

o If, cited as a `driver for change', "triage and prioritisation is not consistent" (p27), is it possible to demonstrate that current systems meet quality standards or deliver good patient satisfaction?

o If the models are `cost efficient' and offer fast services that are `efficient and value for money', then how can significant savings be taken out of the system(s) without adversely affecting them?

o Can the current services be considered "cost efficient" if at the same time "there is evidence of service duplication " ?

o Figures provided in the review indicate that efficiency and value for money is variable, for example there are significant differences in `cost per head of population' and in `cost per call' between the five models. `Cost per head of population' ranges from £6.26 in the East Hampshire cluster, to £12.91 on the Isle of Wight. Similarly the `cost per call' ranges from £31.08 in East Hampshire to £74.91 in the West Cluster. Can all these services therefore be equally "value for money"?

6.1.3 Given the different models, service configurations and costs it is difficult to determine if the generalisations made about services in `current strengths' in Hampshire are appropriate, or if different models have different benefits; just as they make direct comparisons between the models very difficult.

6.1.4 The variation in the skill mix of staff providing these services compounds this difficulty, and the Committee is therefore not clear that "patients receive care by most appropriate health or care professional". Indeed part of the search for better solutions, involves finding the skill mix that does deliver the Quality Standard which requires patients are "treated by the clinician best equipped to meet their needs...".

6.2 The OOH Workshop identified the current challenges as:

o Increasing activity

o Keeping costs in line with the increased activity

o Keeping GPs interested in working in the service

o Training and governance issues

o Integration with the local A&E provider(s)

o Some patients use the out-of-hours service as opposed to the in-hours service

o Activity is consistent throughout the year

o In localities where the services operate from multiple sites there are staffing difficulties

o Complex geographical area

o Business continuity in climate of potential change

6.2.1 `Increasing activity' refers to growth in demand for these services. However the National Quality Requirements explicitly task OOH providers with having to "demonstrate their ability to match" capacity with demand. It would therefore be helpful to have further information about the activity assumptions that underpin the findings of the SHA Review.

6.2.2 Evidence would also be useful to support the contention that some patients use out-of-hours rather than in-hours services. If this is the case, then the issue has to do with demand management. The Department of Health Commentary on the National Out-of-Hours Quality Requirements and their Performance Management, says that, "Demand is variable but there is much evidence to show that the changing pattern of demand for OOH services is broadly predictable." Elsewhere the Commentary states, "If there are permanent changes to patient flow, this should be recognised when funding urgent care services so that as far as possible, funding follows the patient."

6.2.3 Training, governance and staffing challenges are of particular concern for Standards for Better Health, where the focus is on ensuring patient safety. This includes appropriately trained staff who have undergone proper employment checks for all out-of-hours roles.

6.3 The OOH Workshop identified weaknesses in the current provision as:

o Evidence of service duplication

o Service providers across county tend to operate in relative isolation

o A clear process for pharmacy service provision is lacking throughout the county

o The arrangements for dental services are variable

o Receipt of patients calls by call handlers is not consistent through the health system

o Triage and prioritisation is not consistent which may result in equity issues;

o Separate systems in some localities

o Variation in the percentage of people who are seen at home/in primary care centres across the locality

o Variation in the percentage of people who are referred to A&E

6.3.1 Highlighted in `Weaknesses in current provision' are a number of performance issues. The National Quality Requirements include four criteria specifically tied to performance. These include, `initial telephone calls', `telephone assessment', `face-to-face clinical assessment' and `consultations'. The operational variations identified above suggests that there may be local variation in the performance of the different service models.

6.3.2 In addition the SHA Review identified a number of risks associated with retaining the current service structures, amongst which were:

o Continued lack of coherent services for the whole population of Hampshire and Isle of Wight

o Failure to address issues of `productive time' for clinical teams

o Retention of a model which does not meet demand in a timely way across the out-of-hours period

6.3.3 The proposed solution for the weaknesses identified in the current context of five different models across the county, and to mitigate the risks, is a pan-Hampshire and Isle of Wight out-of-hours service where access is stream-lined to a single call number and services such as home visits are provided by local GPs and specialist nurses. This will combine economies of scale with the benefits of local clinical knowledge of patients.

7. Recommendations to the Chief Executive Community

7.1 The initial findings of the SHA Review Group appears to suggest a direction of travel for OOH services that would deliver a single telephone number call handling service for people telephoning for medical help or advice out-of-hours. The service envisaged would:

· Take the call

· Prioritise the call

· Make an initial clinical assessment

· Take the appropriate decision to close the call or move it on.

(see Appendix for a diagrammatic representation of this service model)

7.2 Advantages of this approach would make it possible to:

· ensure that appropriate standards are met across all parts of Hampshire

· monitor performance of the service against national measures

· to learn on the basis of recorded information, then optimise model/practice for most appropriate patient care and cost effectiveness.

· achieve economies of scale

7.3 The coincidental development of the common health record, together with efficient call handling software, could support the initial clinical triage process with additional clinical and care information being available for more complex cases if patients are known to the system.

7.4 This Pan-Hampshire model would complement, at this point, the use of locality hubs that facilitate the coordination of multi-agency, multi-disciplinary community-based care for patients or clients with known complex needs. Locality hubs would co-ordinate and prioritise local resources for home visits by appropriate professionals and specialist services such as mental health practitioners.

7.5 Initially there would still be four models of OOH care in Hampshire, although all areas are signed up to the suggested `direction of travel' to one degree or another. The localities are identified as:

· Blackwater Valley and Hart and North Hampshire

· Mid and South West Hampshire (one of two national pilots for NHS Pathways decision support software for single access through Hampshire Ambulance)

· Portsmouth and South East Hampshire

· Isle of Wight

7.6 Next steps will be the development of an outline implementation plan to include setting up of an Implementation Group and subgroups by the end of May 2006, to progress the development of the pilot pan-Hampshire model. It is proposed that the membership of the Implementation Group include a PCT chief executive as Chair, a selection of PCT leads from Commissioning, OOH, Finance, Governance, Workforce Development and Integrated Service Improvement Programme (ISIP) and a Clinical lead.

7.7 Key tasks for the Implementation Group will include:

· Developing and agreeing the service specification that builds on the National operational and quality standards, plus local data and information about current and anticipated demand for out-of-hours services.

· Managing engagement with key stakeholders

· Managing procurement processes

· Managing a detailed, phased implementation plan with local health communities

· Agreeing the performance monitoring and management arrangements

· Setting up a clinical reference group to audit impact of changes to the way the service is provided on clinical and quality standards and outcomes for patients.

7.8 Whilst the principle of a pan-Hampshire out-of-hours model may promise operational benefits in terms of efficiency and economies of scale, the `phased' process will be complex, at least in the shorter term. The Committee will therefore be interested in contributing to this work and would highlight a number of initial questions for consideration by the Implementation Group:

· What might be the impact of giving notice to NHS Direct?

· What the evidence base is for, say, reducing the number of home visits, whilst maintaining or improving clinical care for patients?

· Where funding/investment is to come from for training and workforce development, eg. for emergency care practitioners?

· Whether projected workforce requirements are reasonable in terms of meeting demand or `discovering' the best skills mix?

· How the roll-out is to be monitored in terms of service delivery and efficiency if reliable reporting systems are not in place?

· How, if costs are reduced to below national benchmarks, service delivery is to be measured to ensure there is no reduction in the level or quality of service?

· When and how patients and the public are to be engaged in the planning, development, and feedback mechanisms for progressing OOH across Hampshire?

· What are the timescales and project management arrangements envisaged for this `short term' deliverable, given a number of identified `threats', `challenges' or `issues'?

· satisfy the National Quality Requirements with respect to its concerns with:

a) Information and systems?

b) Patient experience?

c) Demand planning?

d) Performance?

· Given the uncertainty associated with aspects of the pilot model (implied by the pilot status of the pan-Hampshire model), what are the best and worst case cost scenarios?

· In six months time there may be one or three PCTs in Hampshire, excluding unitary areas. How could this impact on the phasing in or evolution towards a pan-Hampshire OOH model?

· If it is possible for a pan-Hampshire model to achieve substantial cost savings on the basis of reduced duplication and more efficient use of resources, how sustainable is it to have three different models in Hampshire, particularly in view of PCT reorganisation?

· If a pan-Hampshire OOH model achieves financial goals and improvements in patient experience, how will the model for unscheduled care accommodate possible changing patterns of patient choice and demand for care that are caused (possibly) by (the success of) the model itself?

· How will the evolving model of OOH care be evaluated in terms of patient outcomes, safety, and impact on other parts of the system, as the balance of skills mix changes for different roles?

8. Next Steps in progressing Out-of-Hours in Hampshire

8.1 Whilst many questions may have been prompted by the SHA Review and the proposed way forward, it should be emphasised that despite the different models of service currently in operation in Hampshire, much success has been achieved since 2004 with relatively little turbulence. An example of this would be the change of providers in South West Hampshire which has significantly reduced the number of concerns raised with the Committee.

8.2 It should also be acknowledged that the journey towards the `strategic direction of travel' ie. achievement of a pan-Hampshire model, is closer to the starting point than the finishing line. The next stages will require the development of a comprehensive plan for engaging with key stakeholders. This will be critical at a time when the local NHS is likely to be experiencing significant reorganisation. Consultation is likely to follow and the Committee will wish to play a full part in this.

8.3 The SHA recognises that scope exists for improving consistency and achieving efficiencies, and will work closely with the Committee as the implementation programme is developed.

9. Recommendations

9.1 The SHA Review provides a useful summary of information about current performance of Out-of-Hours in Hampshire, and is helpful in identifying a way forward that will support the development of an integrated pan-Hampshire model for OOH services. The Committee has previously acknowledged the complexity of OOH care and the additional challenges that national policy changes will pose for local service delivery. In taking this work forward it is recommended that the Committee continues to take an active interest in the development of OOH services. In the first instance it would be helpful to have a response to the queries raised in 7.8 of this report.

9.2 In addition the Committee will wish to have a response to the following:

· Feedback on performance against the National Quality Requirements and appropriate Quality Standards relating to:

o Response

o Timeliness

o Patient and Public Involvement

· Confirmation of the clinical evidence and needs assessment underpinning the proposals

· Feedback from current providers about the proposals (including the LMC)

· Confirmation of the way in which Section 11 engagement will be build in to the planning process

· Details of the impact on service delivery as a result of implementing the proposals

· An assessment of key risks and dependencies

9.3 The SHA leads be invited to the May meeting to advise members of their response to the issues raised and confirm the next steps in moving this process forward.

Appendix