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Our Vision – to Improve the Health & Wellbeing of our Communities

Item Number: 508

PRIMARY CARE CO-COMMISSIONING COMMITTEE MEETING Meeting Date: 27 February 2019 Report’s Sponsoring Governing Body Member: Dr Phil Garnett

Report Author: Sally Brown

1. Title of Paper Extended Access

2. Strategic Objectives supported by this paper: (check those which apply) ☒ To create a viable & sustainable organisation, whilst facilitating the development of a different,

more innovative culture

☒ To commission high quality services which will improve the health & wellbeing of the people in

Scarborough & Ryedale

☒ To build strong effective relationships with all stakeholders and deliver through effectively

engaging with our partners

☐ To support people within the local community by enabling a system of choice & integrated care

☒ To deliver against all national & local priorities incl QIPP and work within our financial resources

3. Executive Summary: NHS SRCCG commissioned two hubs for an 18 month pilot scheme to deliver the Extended Access services across practices and this commenced on 1 October 2018. Practices have worked collaboratively to ensure the additional hours on primary care appointments are offered each week on an evening ( in addition to the extended hours DES) and at weekends. There have been technical issues with TPP practices in setting up the Systmone GP hub which allows shared administration and remote booking. This is currently being tested and once rolled out will allow greater flexibility of access to appointments across all practices. A solution for EMIS integration is still being explored. The attached summary provides information on the additional appointments with a utilization rate of 89% Monthly contract management meetings continue and plans are in place to develop services further with options for a variety of clinics held.

4. Summary of any finance / resource implications: The contract value is as per the NHSE guidance and a value for money questionnaire from NHSE has been completed and returned. In the recently published Investment and Evolution documents reference is made to future funding plans for Extended Hours DES and Extended Access services Further work is required to understand the impact of the recent guidance on procurement and commissioning processes.

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Our Vision – to Improve the Health & Wellbeing of our Communities

For further information please contact: Name: Sally Brown Title: Associate Director of Primary Care ☎: 01723 343660

5. Any statutory / regulatory / legal / NHS Constitution implications:

NHS SRCCG has delegated responsibility for the commissioning of primary medical services and Extended Access services. 6. Equality Impact Assessment: This has been completed and is attached 7. Any related work with stakeholders or communications plan: The providers of the services will be conducting a patient satisfaction survey in the next 6 months which will help inform future service commissioning. 8. Recommendations / Action Required The PCCC is requested to

- note the summary report - Accept the Equality Impact assessment

9. Assurance The PCCC will receive updates on implementation plans and delivery against the key milestones.

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Equality Impact Assessment New Service

General Information Service Title: Extended access to primary care

Date of Analysis: 24/1/19

Completed by: (Name and Department)

Andrew Platt, Programme Management Officer, Scarborough & Ryedale CCG

Description of the service:

Extended access to primary care will provide patients 1½ hours additional appointments after 6.30pm each week day and an effective weekend service based on the local needs of the area. Practices will also effectively communicate these additional services to patients offering a choice of evening or weekend appointments on an equal footing to core hour’s appointments.

The following section outlines the service in detail:

Timing of appointments:

To provide weekday access to pre-bookable and same day appointments to general practice services in evenings (after 6:30pm) – to provide an additional 1.5 hours a day

To provide weekend access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs

To provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week

Capacity:

To provide a minimum additional 30 minutes consultation capacity per 1000 population, rising to an aspirational 45 minutes per 1000 population. For Scarborough and Ryedale this equates to an approximate total of 60 hours per week (based on 120,000 population) of additional appointments in 2018/19, rising to 90 hours, (based on the same 120,000). This would be pro rata for localities.

Measurement:

To ensure usage of a nationally commissioned new tool to be introduced during 2018/19 to automatically measure appointment activity by all participating practices, both in-hours and in extended hours. This will enable improvements in matching capacity to times of high demand.

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Advertising and ease of access:

To ensure services are advertised to patients, including notification on practice websites, notices in local urgent care services and publicity into the community, so that it is clear to patients how they can access these appointments and associated services;

To ensure ease of access for patients including all practice receptionists being able to direct patients to the service, and offer and book appointments to extended hours services on the same basis as appointments to non-extended hours services; patients should be offered a choice of evening or weekend appointments on an equal footing to core hours appointments.

Digital:

To promote use of digital approaches to support new models of care in general practice, for example online consultations

Inequalities:

To ensure issues of inequalities in patients’ experience of

accessing general practice are identified by local evidence

and actions to resolve are in place.

Effective access to wider whole system services

Effective connection to other system services enabling patients to receive the right care from the right professional, including access from and to other primary care and general practice services such as urgent care services

In addition to delivering these national requirements for extended

access, the CCG intends to utilise this extra capacity to target key

patient groups as part of its overall aim of reducing inequalities, the

avoidable use of emergency services and hospital admission by

some groups within our registered population, e.g. diabetes, obesity,

COPD, children with minor illness, people with long term conditions

and mental health issues.

How does the service reflect the organisation’s equality objectives?

Scarborough & Ryedale CCG Equality & Diversity Objectives: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership at all levels

The extended access services responds directly to the requirements

of objectives1 and 2 (highlighted above). By increasing the range of

opportunities for members of the public to see and/or consult a

healthcare professional the service improves and increases access

to services thereby helping to improve outcomes for all.

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Data What sources of

equality information

have you used to

inform your piece of

work?

(Please refer to the JSNAs and Population data, previous engagement findings, research, patient experience reports etc.)

The North Yorkshire County Council Strategic Needs Health Assessment 2019 – Scarborough and Ryedale CCG Profile Scarborough District Profile 2015 – North Yorkshire County Council

How has engagement

informed your

strategy?

An engagement plan, targeted principally at working age and younger

people was commissioned by the CCG in winter 2017 to help to refine a

service specification. This has been the approach taken by other CCGs

across the country, as has proved quite informative, particularly around the

days and hours of service, and of the mix of services that patients would

wish to access during these times.

Patients were asked to complete a survey, either online or on hard

copy. Via both means, there were 365 respondents. 97% of

respondents said that they would be willing to see a healthcare

professional outwith their own practice for one off or urgent care. 73%

of respondents said they would be willing to see a healthcare

professional outwith their own practice for ongoing care.

Patients were asked about the most convenient time of day and week

for extended access to Primary Care. 75% of respondents indicated

that between 6pm – 7pm was convenient, and 64% of respondents

indicated that between 7pm – 8pm was convenient. 75% of

respondents said that they would be willing to make an appointment at

any time on the weekend, and 6% of respondents said that they would

not want to access an appointment at the weekend.

56% of respondents said that they were willing to travel between 15-30

minutes for an appointment and 5% of respondents said they would

travel for an appointment regardless of time or distance. 61% of

respondents indicated car was their method of travel, with 33%

indicating walking.

94% of respondents said that they would be agreeable to their records

being shared with an extended access hub in order to facilitate their

effective treatment.

85% of respondents viewed initial telephone triage as an acceptable

route into the extended access service

Services that patients indicated they would like access at an extended access hub included: travel vaccinations, physiotherapy, health checks, pharmacy, podiatry, blood tests, wound dressings, ear syringing, mental health consultations, long term condition reviews and new patient health checks. Not all of the above are core primary care services, but could be considered for development by the provider of extended access.

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How has engagement

reached out to, and

captured the views of

people from

protected

characteristic

groups?

The North Yorkshire Joint Strategic Needs Assessment 2019 for Scarborough and Ryedale was used to help identify and document the health needs of the local population across the nine protected characteristics.

Age

There are a high proportion of older people in the region. In 2017, 24.2% of

the population was aged 65 and over (28,900), higher than the national

average 17.3%. Over 3,800 (3.2%) are 85 or over, which again, is higher

than the national average of 2.3%.

An elderly population will have a higher incidence of ill health, particularly

multiple chronic debilitating diseases resulting in a general lack of mobility.

Cognitive impairments will be higher increasing the likelihood of patients not

understanding or being aware of new services. Elderly people are also

statistically less likely to use information technology as a means to

communicate and/access services.

A substantial number of children grow up in relative poverty. In 2015 19.8%

of children aged 0-15 years were living in low income families. Deprivation

scores for the following practices are above the national average - Central,

Brook Square, Eastfield with Castle Health having the highest levels of

deprivation

The consequences of child poverty are poor physical and mental health

resulting in increased reliance on medical services.

Gender

The split of males and females in the region is almost 50-50. Due to problems of deprivation in the region, life expectancy for males at 78.4 years is below the national average and four years lower than females in the region. Although there is no data available in the JSNA report showing the health differences between males and females it could be inferred that male lifestyle habits are more likely to have a detrimental effect on their health than females in the region.

Race /

Nationality

97.7% of people in the area speak English. Polish is the next most common language at 0.7% followed by a wide range of other languages at 0.1% each.

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Disability

Many people have long standing health and disability problems in the

region. 23,500 people are living with long – term health and disability

problems. This represents 21.3% of the population which is significantly

higher than the national average of 17.6%.

In terms of disease prevalence the main conditions are hypertension

(16.9%), obesity (12.9%), depression (10.9%), and asthma (7.9%)

In accordance with the Equality Act 2010 you are disabled if you have a

physical or mental impairment that has a ‘substantial’ and ‘long-term’

negative effect on your ability to do normal daily activities. All of above

conditions are disabling to varying degrees.

For each of the above conditions the following practices have a higher than

national average prevalence:

Hypertension – Hunmanby, Hackness Road, Ayton & Snainton, Filey and

Eastfield

Obesity – Filey, Sherburn, Eastfield, Derwent, Hackness Road, Central,

Hunmanby, Brook Square, Castle

Depression – Eastfield, Central, Hackness Road, Castle

Asthma – Hunmanby, Eastfield, Ayton & Snainton, Sherburn, Central,

Ampleforth.

There is a high incidence of hearing impairment in the region with up to

25,000 suffering from some form of hearing loss. Hearing impairment affects

up to 2/3 of the elderly.

Sexual

Orientation

In relation to sexual orientation, local population data is not known with any certainty. In part, this is because until recently national and local surveys of the population and people using services did not ask about an individual’s sexual orientation. However, nationally, the Government estimates that 5% of the population are lesbian, gay or bisexual communities.

Gender

Reassignment

There are not any official statistics nationally or regionally regarding transgender populations, however, GIRES (Gender Identity Research and Education Society - www.gires.org.uk) estimated that, in 2007, the prevalence of people who had sought medical care for gender variance was 20 per 100,000, i.e. 10,000 people, of whom 6,000 had undergone transition. 80% were assigned as boys at birth (now trans women) and 20% as girls (now trans men). However, there is good reason, based on more recent data from the individual gender identity clinics, to anticipate that the gender balance may eventually become more equal.

Religion /

Belief

The predominant religion in the region is Christianity (67%) with ‘no religion’

being the second most popular group (24.4%). There are small numbers of

Muslims (0.5%), Buddhists (0.3%), Jews (0.1%), Sikhs (0.1%) and 0.4%

who fall into the ‘other’ category).

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Pregnancy and

Maternity

The latest statistics available show that there were 1,034 live births in the area and 6 still births

Marriage and

civil

partnership

Using 2011 Census data the following statistics are available for marital

status:

Married – 57,934 (49.7%)

Single – 32,980 (28.2%)

Divorced – 12,013 (10.3%)

Widow - 10,486 (9%)

Separated – 2,866 (2.5)

Same sex - 259 (0.2%)

This information is mainly from employee records

Research in recent years has revealed that single men are more likely to

neglect their health and have health problems than single women. It has not

been possible to obtain information on the numbers of single people by

gender and practice area.

Actions

Action Required Who by?

Age

The higher numbers of elderly residents will mean populations maybe much less mobile and less able to travel longer distances to see a health practitioner. This will need to be taken into account when providing extended access face to face services. Elderly people tend to rely more on traditional methods of communication such as face to face or telephone communication when consulting with or arranging to see a health practitioner. It is therefore important that these methods of communication are clearly advertised to the elderly as they are unlikely to participate in on-line booking or consultations in large numbers. Incidence of dementia and cognitive disorder is higher in the elderly and care must be taken to ensure communication of services to this group is targeted, clear and unambiguous. The high incidence of children living in poverty within the region is likely to mean higher numbers of parents needing to get their children to see a health care professional. Where practices have high numbers of socially deprived children, targeting of their parents with publicity of extended access services should be considered.

Practices

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Like the elderly, families living in poverty are less mobile and would therefore benefit from not having to travel too far for extended hour’s services.

Gender

When advertising extended access services it may be useful to consider targeting areas where men tend to congregate. For example public toilets have proved to be particularly effective in advertising health related services for men.

Practices

Race/Nationality

When communicating and providing extended access services, it would useful for those practices with higher numbers of Polish residents to have advertising literature written in Polish. Also Polish interpreters may need to be available for extended hour’s services. Although other nationalities are in a minority in the region, practices may also need literature translated into other languages dependent on the population mix.

Practices

Disability

A physical disability will often result in a lack of mobility. Practices therefore need to consider the following:

How and where extended services are advertised in order that they reach all groups. In addition to poster advertising on streets and in surgeries, other advertising such as local newspapers, local radio leaflet drops and one to one communications should be used.

Lack of mobility will limit the distances people can travel for face to face consultations with health professionals. This needs to be taken into account when located extended hours services

Elderly and more cognitively impaired people are unlikely to use on-line and telephone consultation services and alternatives need to be made available

See action also detailed in the ‘age’ section

Practices

Sexual orientation

There are no known negative impacts on this protected characteristic and therefore no actions required at this stage.

N/A

Gender reassignment

There are no know negative impacts on this protected characteristic and therefore no actions required at this stage.

N/A

Religion and belief

The statistics available show the majority of the local population are either Christian or non-religious. However this information is not representative of the population as whole as it has been sourced from working population data. There are no know negative impacts on this protected characteristic and therefore no actions required at this stage.

N/A

Pregnancy & Maternity

There are no know negative impacts on this protected characteristic and therefore no actions required at this stage.

N/A

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Sign-off All EIAs must be signed off by a member of SMT

I agree / disagree with this assessment / action plan

If disagree, state action/s required, reasons and details of who is to carry them out

with timescales:

Signed off by (Name/Job Title)

Signed:

Date:

Marriage and civil partnership

Given that single males are more likely to neglect their health, it may be worth practices targeting this group by advertising the extended service in areas where men gather and/or promoting the service face to face when seeing single male patients. See also the action detailed in the ‘gender’ section

Practices

Prepared by Martin Braidwood, Primary Care Business Manager, 18-02-19

SCARBOROUGH AND RYEDALE EXTENDED ACCESS UPDATE – FEBRUARY 2019

PERFORMANCE The data is provided in the format that is submitted to NHSE monthly on the SCDS pro-forma for GP Forward View return.

ALL

Day

Additional Capacity available

(mins) Appointments

available Appointments

booked % Utilised DNAs GP

appts

ANP or equivalent

appts PN

appts Pharmacist

appts HCA

appts

Monday 6170 457 336 73.5 15 59 49 229 0 120

Tuesday 6030 453 360 79.5 25 57 44 169 0 183

Wednesday 6420 434 375 86.4 15 169 62 67 0 136

Thursday 8430 571 467 81.8 32 152 83 186 0 150

Friday 7295 491 422 85.9 15 206 69 107 6 103

Saturday 23110 2959 2757 93.2 95 351 642 1458 0 508

Sunday 13205 845 675 79.9 55 305 135 170 0 235

Mon - Fri 34345 2406 1960 81.5 102 643 307 758 6 692

Sat - Sun 36315 3804 3432 90.2 150 656 777 1628 0 743

Weekly totals (Mon - Sun) 70660 6210 5392 86.8 252 1299 1084 2386 6 1435

From: To: 01/10/2018 03/02/2019

Overall utilisation of appointments has been consistently positive, and dialogue is ongoing weekly with practices to identify opportunities to maximise uptake. The providers are encouraged to be pro-active and make suggestions to the CCG on how the service can be improved / delivered to meet the needs of the different demographics of Scarborough and Ryedale, and the contract is flexible to enable that whilst still meeting the 7 core requirements.

Prepared by Martin Braidwood, Primary Care Business Manager, 18-02-19

CONTRACT MANAGEMENT The contracts are being performance managed via weekly calls between the Primary Care Business manager and the practice contract lead for each service, with weekly activity returns in the above format being submitted to the CCG. RYEDALE HUB The Ryedale hub has gone live as of 14/02/19 with TPP “Remote booking” through the GP Hub, which will allow the 3 practices within that hub to book into and see each other’s patients, which had not been the case up until now. Practices had previously been seeing their own patients, with a local arrangement via a TR process for seeing patients of the other practices in the hub. SCARBOROUGH HUB The Scarborough hub is in the advanced testing phase of TPP “Shared Admin” through the GP Hub, which has proven to be complex and time intensive due to issues such as issuing prescriptions, and ordering tests through the labs, as well as having to explore options within S1 that will ensure all data governance issues are compliant with requirements. The phased launch of “shared admin” across the Scarborough hub is anticipated by late February, with full roll out by mid-March. SYSTEM INTEGRATION The TPP/EMIS integration module (called SLIP) is anticipated to be available by early March, which will ensure a fully joined up Scarborough hub, in which there is one EMIS practice. NHS111 DIRECT BOOKING This is not currently available, and will need careful consideration before any implementation, given that EA is delivered across 8 sites in the Scarborough locality on an alternating rotational basis, which will require weekly updating of the NHS111 DOS.