Hampshire County Council Annexe E

Health Review Committee: 27 July 2004

Out of Hours Briefing

From: Carole Le-Marechal, Policy and Performance Manager (Primary Care Lead), Hampshire & Isle of Wight Strategic Health Authority. Presented to SHA Board 13^th April 2004

1. Background

1.1 In March 2000, the Department of Health commissioned an independent review of GP out-of-hours (OOH) services. The report of the Review "Raising standards for patients, New partnerships in Out-of-Hours Care" was published in October 2002 and, in accepting all of its twenty two recommendations, the government endorsed its view that a new, integrated out-of-hours service could be in place by 2004. This new model will ensure that, for the first time, the same high quality out-of-hours service will be available to all NHS patients in England, regardless of where they live, or the GP practice with which they are registered.

1.2 The Review identified a number of ways in which this consistency would be secured, of which two of the most important were:

· The quality of the out-of-hours service was explicitly defined in a number of Quality Standards, and all those who deliver these services will report quarterly to their PCT on their delivery of those standards.

· All organised providers of out-of-hours services will be accredited. Accreditation will ensure that all organised providers meet a common set of minimum standards but it will also establish a structure in each local health community that will ensure that all providers continue to develop and improve their services after their initial accreditation has been secured. All organised providers of out-of-hours services will be accredited by 31st March 2004 and thereafter they will be subject to re-accreditation once every three years, unless there are grounds to initiate an earlier re-accreditation.

1.3 The following sets out the national timetable:

2. Hampshire and Isle of Wight Current Position

2.1 The current position is set out in Annex A.

3. Delivery of Services Across HIOW April 2004 - December 2004

3.1 Across HIOW there are currently several different schemes under development for the future provision of out-of-hours services across the patch. The nGMS contract has been the driver for change and PCTs have actively engaged with each other, and other stakeholders, to develop the most appropriate models of care for their populations.

3.2 As a result of this joined up approach, the configuration for the provision of the service is shown below:

Isle of Wight Isle of Wight PCT

West Cluster: Mid Hampshire PCT

Eastleigh and Test Valley South PCT

New Forest PCT

Southampton City PCT

East Cluster Portsmouth City PCT

Fareham and Gosport PCT

East Hampshire PCT

North Hampshire North Hampshire PCT

North East Hampshire Blackwater Valley and Hart PCT

3.3 In order to deliver this new agenda, PCTs have established OoH project boards (linked to nGMS steering boards) and a limited number of personnel have been appointed to project manage implementation. PCTs have however, struggled to find the appropriate manpower and resource to enable completion of fully worked up plans for delivery to be available any earlier than those submitted to the SHA in February.

3.4 A Pan-Hampshire Collaborative group has also been established to share good practice and develop strategic direction. Membership includes all PCTs, Hampshire Ambulance Service, NHS Direct, OoH Providers, Social Services, LMC, DoH and SHA.

3.5 Isle of Wight - From April 2004, the IOW PCT will become the providing organisation for Out of Hours services on the Island. This builds on the existing structure and working arrangements in such a way as to retain GP ownership and continuity of the Co-operative principles. The PCT and their partners are working hard to ensure a safe and sustainable service will be available to their population. The next eighteen months to two years will be focussing on implementing the IOW vision of a single system of integrated emergency care for the Island.

3.6 West Hampshire Cluster - This group of PCTs will continue to procure provision of Out of Hours services from Primecare, a commercial provider, until approximately June 2005. Negotiation on the model of service required from Primecare is ongoing.

From April 04 the PCTs will be actively working up the necessary arrangements for bringing on stream local Primary Care Centres (7 planned) across the cluster and addressing the training and education needs of staff required for the provision of services in the longer term e.g.; nurse practitioners and paramedics. The PCT will also take over the responsibility for Home visits in the medium to long term.

3.7 East Hampshire Cluster - Due to the closure of the Portsmouth branch of Primecare, and the resulting changes locally, the PCT will become the provider of Out of Hours services for a substantial number of their practices from April 2004. The PCT have been assuming the HavantDocs (HDOC) responsibilities since January, including the staff management and operational duties. The PCT and HDOC staff have aimed at securing a sustainable, safe service to be provided from April onwards and have plans in place to consolidate and modernise the service in line with their original ambition of an October start date.

3.8 North Hampshire - The PCT have worked on a steady transition into the new arrangements and are looking to secure the current provision of service from both providers in the short term, whilst developing services to become fully integrated in the medium to long term. Agreement has already been reached with Hantsdoc (current provider) and the A&E department of North Hampshire Hospitals, to commence a project to develop and plan an integrated Out of Hours Service. This service would be skill-mixed, using senior nurses and "See and Treat" Emergency practitioners (STEP), and would see GPs supporting the A&E department through triaging and streaming of "primary care" / "minor" cases. The aim is to start this service in May 2005.

3.9 North East Hampshire - The Blackwater Valley and Hart PCT have been working closely with the local GP Co-Operative (GP Call) for the past year to develop a team of GPs and Nurse Practitioners to meet the OoH health needs of the PCT population. A description of the service has been drawn up which details shift patterns, skill mix, financial flows, clinical and corporate governance, managerial arrangements, clinical competencies, processes and procedures. Additional nurses are currently being recruited and training courses procured.

The PCT has been piloting the use of Nurse Practitioners working within OoH services over the last few months and plans are in place to integrate twilight and night nursing nursing services.

Current arrangements will continue until October 2004 when the full integration of services is scheduled to begin.

4. Accreditation

4.1 Currently all non NHS organisations providing Out of Hours care in HIOW have met the national accreditation standards. The exception to this is Southampton Primecare who are accredited until July 2004. The SHA are working with the West Hampshire Cluster, Primecare and the Department of Health regional co-ordinator to secure full accreditation from July onwards.

4.2 Below are the dates HIOW PCTs have agreed, with their GP colleagues, to take responsibility for the provision of Out of Hours services. Also listed are the agreed providing organisations.

5. IT - Clinical Integration

5.1 All PCTs, other than IOW who are already compliant with NHS Direct connection, are registered with the national Technical Links programme and are scheduled to be connected in line with their opt out dates. Agreement is still to be reached with NHS Direct on the priority of capacity allocation to the remaining PCTs but it is unlikely NHSD will be able to meet demand until 2005/06. The SHA have agreed to co- ordinate this process.

6. Transitional Arrangements

6.1 Each PCT in HIOW have agreed that the priority in the transitional period is to deliver a comprehensive and safe service. The Local Medical Committee have been very supportive in the development process and continue to assist PCTs in moving the provision of OoH services forward.

6.2 Further work to develop plans in more detail are needed and organisations are actively engaging with stakeholders and partner organisations on how to implement the required changes. All organisations are focussing their efforts in maintaining a robust, "safe" service, whilst planning change on an incremental basis. It is intended this approach will:

· Reduce Clinical "risk" in the system

· Ensure continuity of service

· Manage financial risk in the system

· Ensure new "skilled" workforce is available (See table below)

· Enable appropriate Management Capacity

7. Workforce Development and Education

7.1 Nationally, PCTs are encouraged to modernise the way emergency services are provided to their populations as a priority. Locally the current service is no longer sustainable or affordable given the introduction of the nGMS contract and therefore new models of delivery need to be considered.

7.2 The increasing use of nurses and "See and Treat" Paramedics in proposed new models must be supported by the procurement of appropriate training and education programmes. Workforce plans for these roles have not been finalised, and the demand for staff in these new roles is not known. However, the Workforce Development Confederation proceeded at risk in 2003-04 to increase the supply of certain post-registration programmes that will prepare nurses for primary care roles in OoH services. In particular, investment in programmes that develop autonomous practice (63 trainees) and increase the number of supplementary prescribers (43 trainees). The table below shows the number of nurses, by PCT, who started these programmes in 2003-04. The total number of registered nurses and midwives in each PCT is also shown, together with training take-up rates expressed as the number of trainees per 100 nurses. Some PCTs have low take-up rates, this year and will be given priority in next years's intake (2004/05).

8. Finance

8.1 All PCTs have identified financial gaps in the funding available to support the implementation of this initiative. The late allocation of nGMS funding has contributed to the difficulties in planning new models of care with only assumed funding. The anticipated levels of funding associated with practice Global sum allocations are lower than expected and have further contributed to a funding shortfall.

8.2 All PCTs are reviewing costs and alternative funding/ models of care and details are to be included in revised plans to be submitted to the SHA by 30^th April 2004.

9. SHA Role

9.1 The SHA have a role to performance manage and co-ordinate the implementation of this national agenda.

Performance Management - The SHA is fully engaged as members of

· Pan Hampshire OoH Steering Group

· Constituent OoH Steering Boards (open Invitation)

· Regular Meetings with DoH regional co-ordinator

· National nGMS Leads (monthly)

· HIOW nGMS Leads (monthly)

· Establishment of SHA OoH executive steering group.

9.2 During early February 2004, all PCTs submitted and presented their OoH plans to the SHA for assessment. A panel from the SHA included:

· Chief Executive

· Medical Director

· Modernisation Lead

· Public and Patient Involvement Lead

· OoH Lead

· Finance

· DoH Regional Co-Ordinator

· Workforce Development Chief Executive/ SHA HR Lead

9.3 A thorough assessment of OoH plans was undertaken and areas of concern identified as needing further development were communicated to PCTs for inclusion in revised plans to be submitted to the SHA by 30^th April 2004. These plans will be further assessed to satisfy the SHA that all elements of service provision meet national standards.

9.4 During March the DoH announced and additional £30m OoH incentive scheme. This scheme has been developed to enable each PCT to access an additional £100k each, payable in two tranches of £50k against set criteria. In the absence of further DoH Guidance, it is proposed the first payment is made once revised PCT OoH plans have been received (30^th April 04) and signed off as demonstrating state of readiness by the SHA. All plans to be finalised and signed off by the end of May 2004.

9.5 It is proposed the second payment is made after two quarterly reviews once the service has gone live. This may be sooner for those going live in October but will be reviewed on receipt of further guidance from the DoH. The attached timetable sets out the key milestones and performance management arrangements until April 2005.

10. Next Steps

10.1 As a result of the assessments highlighted above, it was agreed the SHA would co- ordinate some workstreams Hampshire wide. PCTs were keen for the SHA to co- ordinate the communications approach across the patch in line with national guidance. It was also agreed the SHA would co-ordinate the commissioning of access to NHS Direct capacity.

10.2 Workforce training and education was another area the SHA Workforce Development Confederation (WDC) agreed to lead on behalf of the health community. The WDC are keen to work with PCTs to develop a HIOW model that could be procured across the patch offering better value for money. To date, few requests for specifically tailored alternative training and education have been identified.

10.3 During May, revised plans will be subject to a similar assessment process to that undertaken in February as set out in Annex 2.

11. Conclusion

11.1 The will exists across Hampshire & the Isle of Wight to design and develop new ways of working, however there are very real challenges associated with the development and implementation of the OoH service, not least resources and the need to develop the necessary expertise within PCTs.

11.2 The whole health community recognises the critical need to ensure a "safe" service is maintained during the transition period (i.e. 1 April onwards) and this has and continues to be the priority for PCTs and the SHA. However, there is also ongoing work to develop and deliver effective and, significantly, financially sustainable longer term solutions that meet OoH service requirements.

11.3 The arrangements for OoH in Hampshire and the isle of Wight represent a pragmatic response to a challenging timetable which ensures a seamless transition to the new arrangements. The PCTs with SHA support are committed to implementing new ways of working on an incremental basis in the coming years.

Hampshire and Isle of Wight Position Annex 1

Current Responsibilities

Listed below are the current arrangements as contracted by GPs. These have been listed in the agreed new PCT Configurations for future provision.

Isle of Wight

OoH services on the Island are currently provided by the Island Doctors (IDOC), which is a limited company, run as a co-operative. All of the 80 GPs on the island are members of the co-operative and 75 actually work shifts. Access to the IDOC service is via NHS direct who provide a triage service, passing on calls suitable for IDOC to respond to. IDOC is an exemplar site and has national funding to improve the premises used within the Acute Hospital site and to improve IT communications systems.

West Hampshire Cluster

The majority of GPs in the West Hampshire cluster currently delegate some/all of their OoH responsibilities to Primecare who are a commercial organisation providing cover across approximately one third of the country. Some GPs provide an extended GP rota to cover their responsibilities e.g. Andover, and a very small number provide their own cover.

In recent months there have been issues around the quality of service provided by Primecare. The issues were non clinical and were in the main, associated with the call handling service which moved to Birmingham in July 2003. Primecare and the PCTs have addressed the issues and the service is now delivering and acceptable service and appropriate care to the population.

The majority of this population will be supported by the current providers during the transitional phase.

East Hampshire Cluster

Provision of service across the three PCTS is by both a Commercial Provider and GP Co-Operatives. When the decision was reached in January 2004 to procure provision of OoH services from Havant Doc from October 2004, Primecare Portsmouth gave three months notice to GPs, as per their contractual agreement, of withdrawal of service from 8^th April 2004. The impact of this decision meant the PCT would become responsible for the provision of OoH services six months earlier than planned.

Given there were real concerns that the current service would collapse before 8 April 2004, the three PCTs in Portsmouth & SE Hampshire worked with HavantDoc to establish an OoH service covering the vast majority of the population from mid-January 2004 (i.e. the population previously serviced by Primecare and HavantDoc).

After much anxiety by the practices affected by the withdrawal of Primecare, and consultation across the rest of the patch, the PCT agreed to take over responsibility from Hdoc for the operation and business by 1^st April 2004. Fareham and Gosport GPs who were previously contracted with Primecare Portsmouth, will now receive support from the Primecare Southampton branch during the transitional period until October 2004.

North Hampshire

The HantsDoc GP Co-Operative and commercial organisation ThamesDoc, are the two organisations currently providing OoH cover to the North Hampshire PCT. North Hampshire have good working relationships with all stakeholders and are actively engaged with Blackwater Valley and Hart PCT around cross border provision by HantsDoc.

North East Hampshire

Both of the current GP Co-Operatives will continue to provide services until April 2005. Patients within the PCT should see no difference in service as nurse triage and Saturday morning surgeries are currently provided as part of the OoH service.

Accreditation Annex 2

Currently all non NHS organisations providing Out of Hours care in HIOW have met the national accreditation standards. The exception to this is Southampton Primecare who are accredited until July 2004. The SHA are working with the West Hampshire Cluster, Primecare and the Department of Health regional co-ordinator to secure full accreditation from July onwards.

Below are the dates HIOW PCTs have agreed, with their GP colleagues, to take responsibility for the provision of Out of Hours services. Also listed are the agreed providing organisations.

Throughout Hampshire and the Isle of Wight, PCTs have, and continue to develop, plans for the delivery of new models of Out of Hours services. In the longer term, these models will be more integrated incorporating other professionals such as community nursing teams, paramedics, senior nursing staff, see and treat practitioners etc, in addition to GPs. Whilst recognising the key role of GPs, future models of care are not expected to be predominantly GP led.

All PCTs are planning to provide Primary Care Centres (PCCs) where patients will be seen. The two Walk in Centres in Southampton already operate an Out of Hours service to the population and this has proved very successful. Plans are also being developed with social care providers to ensure the vulnerable members of our population are not disadvantaged and have equal access to services e.g.: transport, social support etc.

Thorough monitoring and performance management arrangements are also being developed in line with the Carson standards.