Archived decisions

Contact: Martin Combs 01962 847479 [email protected]

1 Introduction

1.1 In January 2006 the Hampshire and Isle of Wight Strategic Health Authority (SHA) published its draft review of Primary Medical Out-of-hours services, for which it had lead planning responsibility. Subsequently the Hampshire Health Overview and Scrutiny Committee (HOSC) undertook its own review, using the SHA's work as the main basis for comment. The HOSC provided its report at its meeting in March 2006.

1.2 Later, in May 2006, the SHA responded to the HOSC's recommendations, but with the impending organisational upheavals in the NHS, coupled with their need to address serious financial challenges, work on developing out-of-hours services slowed considerably.

1.3 This update refers in the main to out-o-hours access to primary medical services.

2 Key Issues identified to Hampshire Strategic Health Authority by the Committee, March 2006

2.1 The main concerns identified by the Committee can be found in the HOSC report (/decisions/decisions-docs/060328-hovasc-R0331091640 ); the SHA subsequently responded to all recommendations. The key issues in the Committee's work included:

· Financial: in a climate of financial pressures, concerns existed about a) whether sufficient funding would be available to invest, for example in training/workforce development, and b) whether it would be possible to reduce the cost of services (below national benchmarks) without damaging them, for example by reducing visits made to patients in the community.

· Monitoring: concern existed about how developments in out-of-hours service delivery would be monitored, given the acknowledgement of reporting weaknesses. This was considered important, given changing approaches to delivery and coordination of services.

· Workforce development: concern existed about the capacity of the preferred model of development to `learn' with respect to projected estimates of `best' skills mix, and therefore be adjustable with respect to locality staffing needs.

· Stakeholder / public engagement: the Committee wanted to know how stakeholders, including the public, would be engaged at the planning stages and in feeding back experience of service delivery and its coordination.

· National Quality Requirements (NQRs): the Committee wanted to be sure that proposed developments in out-of-hours care would achieve improved performance against the NQRs.

· Needs assessment and demand: the Committee wanted to be sure that planning for out-of-hours services was based on robust data regarding needs assessment and knowledge of demand, however Members was also aware that changes in services and approaches might also result in changing patterns of demand.

· Management / timeframes: Members were concerned to know what timescales and management arrangements were going to be put into place, given the number of identified changes, challenges and issues to be addressed.

3 Summary of National Context 2006 - 2007

3.1 In the approximately two years since the Committee's review of out-of-hours services, a number of documents have been produced by national bodies that have now become part of the backdrop against which current services and planning are developed. The original concerns and thinking of the Committee are echoed in papers and discussion documents summarised below. In general, focus has sharpened, and few would question that providers and commissioners must make integration of out-of-hours services work for the benefit of patients.

The Provision of Out-of-Hours Care in England, National Audit Office, May 2006

3.2 In 2000, an independent review of GP out-of-hours services was published called `Raising Standards for Patients: new partnerships in out-of-hours care'. The review, commonly referred to as the Carson Review, proposed a model of integrated out-of-hours care provision. This review is considered by the National Audit Office (NAO) report to have "set the foundations for current out of hours services", however it should be noted that this predated the introduction of the new GMS contract for General Practitioners which gave PCTs the responsibility for commissioning out of hours GP services.

3.3 The 2006 NAO report observed that many providers and commissioners indicated an ongoing confusion about whether `out-of-hours' was supposed to be an urgent or an unscheduled care service. The report goes on to say, "A truly urgent primary care service would likely treat patients classified as `emergency' or `urgent' and all others would be asked to make an appointment...". An unscheduled service, by contrast, "...would be more responsive to patients and would not seek to restrict access...". A focus on `urgent' out-of-hours services could be less costly, but an unrestricted service could offer "more flexibility" and "...could interact better with existing daytime primary care services".

3.4 Performance of PCTs against National Quality Requirements provided in the report, however, present a picture in which only a small proportion of PCTs performed adequately against requirements for patients to be clinically assessed or to receive consultations (for urgent and non-urgent purposes) within required time limits. From this time the focus of national reports tends to be more on `urgent', and less on `unscheduled' out-of-hours services.

Report on responses to Direction of Travel for Urgent Care: a discussion document, Department of Health, March 2007

3.5 The discussion document itself was published in October 2006. It recognised the Audit Commission report and acknowledged that National Standards for out-of-hours services were not being universally met. In addition the discussion document noted that the standards that apply to out-of-hours services for urgent care, do not apply to in-hours urgent care and that "...people may receive different pathways of care within different timescales depending on when and where they access urgent care...".

3.6 The paper proposed a "conceptual model of effective urgent care" that excludes specific detail, but includes most or all types of service provider that would need to be part of an integrated seamless service for patients.

3.7 Respondents did not question the overall direction of travel put forward in the discussion document, that is to say, there is no question that `urgent' out-of-hours services require collaboration and co-ordination between all services that provide `urgent' out-of-hours care and support to patients or service users. Most of the concerns expressed by respondents were around implementation, not the intention of the paper.

Urgent Care: A position statement from the Royal College of General Practitioners, March 2007

3.8 In this paper, the expressions `out-of-hours' (OOH) and `urgent' care are used, with out-of-hours being more frequently, though not always, interchangeably with `urgent' care. The position statement identifies the following key issues:

· "There is public confusion about what to do and which service to access out-of-hours"

· "It would be sensible to learn from past (urgent) care successes of the GP co-operative movement"

· "A collaborative approach is essential, as is the need to keep OOH care high on the agenda"

· "Provision of care in rural locations poses particular challenges"

· "Although standards exist for monitoring OOH services, these are inconsistently applied..."

· "There is wide variation in quality of services"

· "GP specialty training registrars must continue to receive adequate, high quality training in urgent care backed up by robust monitoring and assessment measures"

· "...There is a need for better patient education and the promotion of self-help policies"

3.9 The Royal College emphasises the following themes should be addressed when generating solutions:

· "...organisation of urgent care services needs to improve. Fragmentation of care must be dealt with..."

· "...Focus on quality and safety of clinical care...training of health care professionals to national quality standards"

· "...Empower patients by providing information to make access and navigation easier"

3.10 The paper specifically notes the importance of continuity of care for the "terminally ill, older frail patients with multiple and complex medical conditions, and those with mental illness". It also notes the "high volume of paediatric urgent care contacts" and the important role that social services have to play in urgent care. Understandably, the paper strongly emphasises the experience of GPs as the de facto experts in urgent care, and urges PCTs to engage with them, recognising "...their pivotal role in leadership, planning and support of OOH services; they should incentivise GP practice involvement in urgent care..."

3.11 Much of the content of the paper links well with the `direction of travel' promoted by the Department of Health, even if the emphases differ slightly in some respects. For example, they note, "The traditional approach to urgent care provision has been from the service providers' perspective. This must change to that of the patient...", thereby taking quite a strong line that will in turn benefit the system, "Successful, effective delivery of urgent care depends upon patient empowerment...". Whilst the tone of the paper tends to be clinically biased, the general approach is totally consistent with that of recent national documents.

4 Hampshire Primary Care Trust

4.1 Responsibility for the planning of out-of-hours services for Hampshire passed from Hampshire Strategic Health Authority (SHA) to the Primary Care Trust (PCT) in the latter part of 2006 following the creation of Hampshire PCT on 1st October. In February 2007 the PCT produced a briefing paper to inform the management team of the issues and strategic direction of out-of-hours, Unscheduled Care - Out of Hours Primary Care Services. In the same month it also produced, Unscheduled Care: Hampshire PCT, A Clinical Strategy (a draft for discussion). More recently, in December 2007, the PCT provided a status report for internal management purposes.

5 Summary

5.1 This short update paper on out-of-hours care shows how Hampshire and Isle of Wight SHA had taken forward their planning for these services prior to the restructuring of NHS organisations in 2006. In these circumstances work on taking forward out-of-hours services "lost momentum" as it was picked up again by Hampshire PCT in a changed context. The PCT then took the opportunity to take stock of the position. Four options were proposed, of which the preferred choice was option `3':

"...Undertake short Hampshire focussed review of current setting across 2007/08, followed by consultation with health and social partners. This in the context and setting of the developing unscheduled care strategy and the PBC agenda, core task to agree a re-design and savings plan to:

· promote the links with local health care systems

· maximise the strengths of existing local differences

· building in improved quality, equity and performance..."

5.2 This option was "...considered to be the most likely to succeed in both short and medium term, will use clinical evidence and best practice to support the case for change with greater engagement and support...".

5.3 Today, a year on from the adoption of option `3' by the PCT, it is unclear how far the PCT has progressed this. The PCT reported that whilst there had been success in some areas in terms of achieving savings in out-of-hours services against the Financial Recovery Plans, in other areas the savings had either not been achieved, or it was difficult to know whether they had or not. It is also the case that the path chosen by the PCT still maintains three models of out of hours services across Hampshire.

6 Health Overview and Scrutiny Committee: Further recommendations May 2008

6.1 It is further recommended that Hampshire PCT provides the Committee with confirmation of:

· the current governance arrangements that underpin the delivery of out-of-hours care in Hampshire.

· the clinical evidence and needs assessment that underpins the development of out-of-hours care in Hampshire.

· an assessment of the key risks and dependencies associated with the different models of out-of-hours care, and of having three/four existing operating models as opposed to a single pan-Hampshire approach.

6.2 It is also further recommended that Hampshire PCT provides the following information:

· how a strategy for the development of out-of-hours over the next three/five years will be developed taking account of:

o health needs and equality impact assessments

o access issues, including rural and urban considerations such as travel times and transport

o links between out of hours services and other interdependent service providers

· anticipated patient pathways and access points

· performance of out of hours providers in Hampshire against the key quality standards criteria over the last year

Appendix One: HOSC Recommendations from March 2006

HOSC Recommendations from March 2006

It is recommended that the PCT (as lead NHS organisation) demonstrates:

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

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

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

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

· How the evolving model(s) of out-of-hours care is to 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.

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

· When and how the public and other stakeholders are to be engaged in the planning, development, and feedback mechanisms for progressing out-of-hours across Hampshire.

· The way in which Section 11 engagement will be built into the planning process.

· How it intends to satisfy the National Quality Requirements with respect to:

o Information and systems

o Patient experience

o Patient and public involvement

o Demand planning

o Performance

o Response

o Timeliness

· If a pan-Hampshire out-of-hours model achieves financial goals and improvements in patient experience, how the model for unscheduled care would accommodate possible changing patterns of patient choice and demand for care that might be caused (possibly) by (the success of) the model itself. [note: that a `pan-Hampshire' model has probably now been discounted]

· If, as was anticipated by the previous HIOW Strategic Health Authority, 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 it is to have three different core models of out-of-hours care in Hampshire.

· That there has been an assessment of the key risks and dependencies associated with the different models of out-of-hours care, and of having three/four existing operating models rather than adopting a single pan-Hampshire approach.