Contact: Martin Combs ext. 7479 e.mail [email protected]

1. Summary and Purpose

1.1. The attached report from NHS Hampshire contributes to the Committee's continuing interest in out-of-hours and unscheduled care in the county.

1.2. Members will be pleased that it will be possible to follow development and improvement by the four provider organisations relevant to Hampshire through the benchmarking programme undertaken by the Primary Care Foundation progresses

1.3. Importantly, the benchmarking exercise will also be taking into account patient experience of the services.

1.4. Although in its early stages the benchmarking programme is having the positive effect of identifying areas where greater understanding is required and improvement potential is indicated.

BENCHMARKING OF OUT OF HOURS PRIMARY CARE SERVICES.

NHS Hampshire participated in the benchmarking programme undertaken by the Primary Care Foundation for subscribing Primary Care Trusts in conjunction with its four providers of out of hour's services. This exercise is due to run every 6 months for a further 2 ½ years. Data comes from questionnaires completed by PCTs and providers and from a data extract for 4 sample weeks spread through the previous six month period. Individual reports have now been received for each provider for the baseline exercise and we hope that at the next stage the Primary Care foundation will be able to provide a Hampshire comparison report. In the meantime we have undertaken some comparative analysis of the reports for some of the indicators used in the exercise - 61 providers and their commissioning PCTs participated in this first baseline analysis.

Out of hours providers

NHS Hampshire commissions primary care services out of hours from 4 providers:

· Thamesdoc provide services to the majority of East Hampshire District council area with a primary care centre (PCC) at Bordon.

· North Hampshire Urgent Care (NHUC) provides services to Basingstoke and Deane, Hart and Rushmoor with centres at Basingstoke and Frimley Hospitals.

· Portsmouth City teaching PCT (PCPCT) provide services to part of East Hants, Havant, Fareham and Gosport with centres at Drayton and Gosport.

· Southampton City PCT (SCPCT) provides the West Hampshire out of hour's service with centres at Lymington, Fordingbridge, Totton, Andover and Winchester.

Summary benchmark of NHS Hampshire service providers (selected indicators only)

Cases per 1000 registered population

Benchmark Range: 70 -210

National analysis shows there is no simple relationship between demand and geography though holiday areas tend to have a higher demand per head and towns & cities, (where there are a number of alternative healthcare services) have lower demand. High cases per head could indicate either high levels of confidence in the service and low use of alternatives like A and E, or could indicate lower thresholds for contact versus advice. The two lowest in our benchmark both provide services to significantly rural populations.

Cost per Head of registered population

Benchmark Range: £3.30 - 12.80

Cost per Case

Benchmark Range c£30 - £120

Although the volume of cases is an obvious cost driver, the geography of the area and the breadth of the service specification may also drive cost higher. For instance, keeping centres open at less busy times will impact both cost and productivity, but may be required under the service specification. The cost of clinicians is typically over 60% of the entire cost of the service. Locally the service in west Hampshire provided by Southampton City PCT operates from 5 primary care centres compared to two for Portsmouth City and operates 7 visiting cars compared to 2 in North Hampshire..

Cases per clinician hour

Benchmark Range 0.95 - 4.5

The productivity of the service will be affected by such factors as case mix, availability of alternative services, the skills mix employed, proportion of home visits, geographical area, the number of PCCs open and many other factors. It is also noted that a rapid consultation is not necessarily a through one. The Benchmark observed that those services which manage and measure how clinicians spend their time and what decisions they make avoid being among the least productive group, and ensure a consistent response to patient demands.

Outcomes

First figure is %, (bracketed figure is position in Benchmark 1-61)

Whilst the cost of servicing home visits is high, and the cost of a simple advice call is low it is not safe to assume that an increase in the percentage of calls receiving advice will support a reduction in cost. NHS Hampshire are wary of setting absolute Performance Indicators for OOH services as geography and demography and PCC opening times also influence the call's outcome. SCPCT were the highest benchmarked provider of Home Visits, and they have subsequently taken remedial actions addressing this, showing the value of this comparative information to drive change, which we hope will be evidenced in the next benchmark report.

% Referred or self-referred to Hospital

Benchmark Range 1% - 18%

The Benchmark notes this is an important measure for PCTs to compare, however the consistency with which `informational outcomes' are completed in records by clinicians varies. The report proposes that providers need to look at a simple but comprehensive list of outcomes and make completion of this field mandatory so that future outcome reports are reliable, data quality could therefore be a factor in the results reported for this measure. Ease of access and proximity to hospital services may also be factor in influencing the choice people make of urgent care service. NHS South Central has undertaken social marketing research to explore the reasons for this choice further.

Time to Definitive Assessment

The Benchmark found that these standards were difficult to measure performance against, as providers reported inclusions and exclusions in the data set, (for instance - patient's phones being engaged), start times and the number of calls classified as Urgent in a number of ways. Detailed review of the data quality for Hampshire providers will be undertaken in conjunction with a future benchmark data collection.

*Thamesdoc was not benchmarked against these targets as they were changing IT systems and comparability with other providers was not possible

Time to Definitive Assessment - Urgent

% of definitive assessment of urgent cases in 20minutes (range 28-96%) AND % of calls classified as urgent upon receipt (range 2% - 60%).

Time to Definitive Assessment - All

% of all cases regardless of priority assessed in 20 and 60 minutes.

Services with adequate staff and who ensure clinicians keep pace with work typically assess 60% of cases in 20 minutes and 95% in 60 minutes. All three providers benchmarked performed well against the 20 minute benchmark but PCPCT fell behind on the 60 minute performance.

% of Urgent cases seen within 2hrs of end of definitive assessment call

(Benchmark range 55%-100%)

Patients needing to be seen with a categorisation of `urgent' following triage should be seen within 2 hours (national quality standard) This measure shows both the outcome of triage, where SCPCT have a high proportion classified as urgent, and the proportion seen within 2 hours, which will be influenced by patient choice if a PCC appointment is required and geography for home visits. A higher number of cases classified as urgent may indicate a higher threshold and undoubtedly has some impact on the operational efficiency of the service.

Patient Experience

As part of the next benchmark, patients' view of their experience of out of hour's services will be measured through annual surveys with the initial survey setting a baseline. In addition the quarterly GP patient survey will ask simple questions about access to out of hour's services and this analysis will be available at practice and out of hour's provider level.

Conclusion

The baseline benchmarking has identified clearly a number of areas where individual providers can focus to improve their performance. Discussions about how this improvement can be realised are an integral part of our contract monitoring with them and we encourage the practice based commissioning localities to engage with us to ensure that improvements contribute to the overall management of urgent care within local health systems.