joined up urgent care provision february 2011 henry clay: 07775 696360...
TRANSCRIPT
© Primary Care Foundation
The Primary Care Foundation has looked urgent care from a number of angles
Reports for Department of Health
● Primary Care in A&E
● Urgent Care in general practice
● Benchmark of out of hours services
● Urgent care centres (report with DH)
Various projects for:
● Hospital Trusts
● PCTs
● PBC Groups
● Commercial and mutual provider organisations
URGENT CARE
a practical guide to transforming same-day care in general practice
Supported by the Department of Health
lth
© Primary Care Foundation
Topics that I aim to cover...
● Why it matters….
● How to commission for safety and consistency –
measures and what you should expect of the provider
● How to link services – and how not to!
● How to develop your provider over time
● Looking at Primary Care too….
© Primary Care Foundation
© Primary Care Foundation
The CQC investigation highlighted shortcomings in commissioning
● Out-of-hours services were low priority at the time and the PCTs had limited understanding of these services.
● There was a lack of leadership in commissioning and monitoring services as part of an integrated urgent care service.
● There was a lack of experience in the PCTs in contracting with a commercial organisation.
● Staff did not fully understand the national quality requirements or TCN’s reports on activity and performance
● The PCTs did not have a high standard of commissioning or contract monitoring in out-of-hours - these contracts should have been monitored more thoroughly.
● Not highlighted in national targets and finances – so not seen as a priority for SHAs or PCTs.
© Primary Care Foundation
The Health secretary believes that GP Commissioners will fix it!
© Primary Care Foundation
Key message – you get what you insist onAlternatively, you get what you deserve
● You need a wide range of measures – and making comparison is vital
● Services have to manage clinicians if they are to perform effectively and consistently
● Each part must work well if you are to have a hope of joining different parts – and a similar wide range of measures is needed
● You will need to look at how practices deliver their share of care
● Look to establish contracts for longer and to drive improvements over a period
© Primary Care Foundation
What qualities should data about a clinical service exhibit?
● Competently collected and collated● Correct● Clear, well presented information● Consistent – to allow comparison within the data set and over time
● Complete – it should provide a full picture of all aspects● Compare and contrast outcomes – so we can understand the cause
of differences and which innovations work● Collaborative - to secure the information and to engage stakeholders● Communicate – so that users can understand what it means● Convincing – if users are to change what they do based on the
evidence● Challenge or corroborate assumptions about clinical practice and
outcomes● Costed – because of the requirement for efficiency we need this too
© Primary Care Foundation
A wide range of measures to give a rounded picture is needed if perverse incentives are to be avoided
A&E departments
● Ambulatory care
● Unplanned re-attendance
● Total time spent
● % leaving before being seen
● Patient experience
● Time to initial assessment
● Time to treatment
● % with consultant sign-off
Out of Hours benchmark
● % definitively assessed in 20 and 60 minutes
● % answered in 60 seconds
● % with face to face consultation in 1, 2 and 6 hours
● % of urgent cases
● Patient experience
● % of patients going to 999/hospital
● Cost per case, cost per head
● Productivity
© Primary Care Foundation
There are big differences between services (four London A&E departments looking at % discharged by 10 minute slots)
22.7% admitted
13.9% admitted
28.5% admitted
18.3% admitted
© Primary Care Foundation
There are big differences between services delivering out of hours care (this looks at QR9 for urgent cases in 20 minutes….)
Services ranked by % of urgent cases started definitive assessment in 20 minutes:Average across all services is ranked 41 out of 98
Red shows % where definitive assessment starts in 20 minutes. Green shows the figure where a first attempt to assess was begun in 20 minutes. Average across all services is at 79.6% (definitive) plus 8.3% (to first attempt)
ALL 7
9.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
© Primary Care Foundation
Showing the % of urgent cases started definitive assessment in 20 minutes against the % of urgent cases on receipt for different services
Those answering the calls for Average across all services identify 22% of cases as urgent on receipt and 79.6% of urgent cases are definitively assessed in 20 minutes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0% 10% 20% 30% 40% 50% 60% 70%
Perc
enta
ge o
f urg
ent c
ases
defi
nitiv
ely
asse
ssed
in 2
0 m
ins
Percentage urgent on receipt
..and there are big differences in what they identify as urgent
Those with higher levels of urgent on receipt find it difficult to better 90% definitively assessed in 20 minutesThese have low %urgent on receipt
but have a low percentage of urgent cases assessed in 20 minutes
© Primary Care Foundation
In general it costs more to provide OOH cover in a rural PCT than an urban one (but there are wide variations within any band)
£2.00
£4.00
£6.00
£8.00
£10.00
£12.00
£14.00
£16.00
£18.00
0.00 20.00 40.00 60.00 80.00 100.00 120.00Population density
Co
st p
er h
ead
Rural City/UrbanMixed
© Primary Care Foundation
There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
40% 45% 50% 55% 60% 65% 70% 75% 80% 85%
How quickly care was received % About right
Rat
ing
of
care
rec
eive
d e
ith
er g
oo
d o
r ve
ry g
oo
d
© Primary Care Foundation
The majority of services give telephone advice in 40 to 50% of cases and offer home visits to 10 to 17%.
% Advice
% Home visits
0%
10%
20%
30%
40%
50%
60%
70%
80%
0%
5%
10%
15%
20%
25%
30%
But whatever the variation between services the variation between individuals will be greater
This looks in greater detail within a service to demonstrate this variation
© Primary Care Foundation
Percentage of advice calls converted to advice - only including those that handled more then 25 advice calls
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
134 1
35
72
61
181
29 31
46
74
34
130 46
09
31
16 48
133
154
161 2
1 71
26 89
53
98
120
132 5
95
14
29
5 61
131
58 87
144
121 4
04
79
91
03 58
100 9
71
011
60 16
94
43
92
33
109
114 6
54
93
01
10 18
17
55
85
145 5
21
56 84
105 7
93
52
31
06
61
27 88
165 6
4 31
551
471
15 90
69
91
12
73
19
75 1
150
140 4
41
641
62 28
76
29 8
Advice other
This looks at the percentage of calls given telephone advice for one service Doctor only, six months data, at least 25 consultations
Dr 147 gives phone advice to
over 60%
Dr 116 gives phone advice to just less
than 30%
●Each bar is one doctor
Dr 7 gives phone advice to just over
30%
© Primary Care Foundation
Advice calls which ended in PCC Surgery sorted by percentage of calls completed in under 4 minutes
Graph only includes those who handled more than 25 advice calls (but not all of these to PCC)
0%
20%
40%
60%
80%
100%
29 42 85 105 3 40 34 47 87 150 44 65 69 95 94 147
145 33 13 90 162 21 66 155 12 160 75 91 101 7 4
164 64 6
133
158
126
110
134 52 115 35 19 127 31 1 49 43 58 100 26 99 121 23 55 60 132
129 46 17 130
103 16 144 30 76 97 113
156
161
120
118 28 88 89 57 84 93 48 18 53 109 10 92 8 74 114 79 51 73 165 98 116 59 140
154
under 4 mins more than 4 less than 6 mins more than 6 mins
This looks at the length of the advice calls that ended with a PCC visit – doctors are ranked on the % completed in 4 minutes
Dr 147 completes around 18% in four
minutes
Dr 116 completes over 90% in four
minutes
●Each bar is one doctor
Dr 7 completes around 35% in four
minutes
© Primary Care Foundation
For one provider showing percentage urgent and less urgent by call handlers (over 50 cases)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Urgent
Less Urgent
© Primary Care Foundation
Same service, same call-handlers but showing the proportion that had priority changed by clinicians
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Urgent - 3
Urgent - 2
Urgent - 1
Less Urgent - 3
Less Urgent - 2
Less Urgent - 1Less urgent on receipt changed to emergency or urgent is at the bottom
© Primary Care Foundation
Integrating services – some guidelines for designing the process
● Describe the process – in sufficient detail to engage clinical staff
● Identify the underlying principles and objectives around the patient pathway. Avoid hand-offs and batching
● Count the cases – How many, by hour of day are we talking about?
● Recognise the cost and resource implications of dividing the cake
● Use the information to prove, refine and redesign the process
© Primary Care Foundation
A model formatA service delivery model for urgent care centres – commissioning advice for PCTs http://www.healthcareforlondon.nhs.uk/assets/Urgent-care-centre-guidelinesFINAL.pdf
© Primary Care Foundation
●Why not expect ED to communicate episode too?
●Who is in charge if resource needs to be redeployed?
●How do you ensure governance processes look at the whole patient pathway?
●Is it at the front or alongside?
●Who does this?
© Primary Care Foundation
Do you really need UCC and ED alongside each other for less than 5 cases an hour?
How can we make this work – streaming is to take place before diagnosis
How will we define clinical assessment?
© Primary Care Foundation
Counting the cases – demand is predictable, in this example by age bands….
All England
Population by age for City and Hackney Teaching PCT
20% 15% 10% 5% 0% 5% 10% 15% 20%
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70+
Males
Females
All England
Population by age for All England
20% 15% 10% 5% 0% 5% 10% 15% 20%
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70+
Males
Females
© Primary Care Foundation
…average demand by hour of day is also entirely predictable
© Primary Care Foundation
…and the random variation within an hour is exactly what would be expected
Poisson curve compared with the actual spread of demand over the 28 days looking at one hour (20.00) for Homerton
0
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0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Poisson curve for an average demand of 19.04 showing the cumulative chance of demand in any particular hour equalling the value shown at the bottom
0
0.1
0.2
0.3
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0.8
0.9
1
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
© Primary Care Foundation
Staffing to provide a 15 minute initial consultation (within 15 minutes in 80% of cases) totals 92 hours in the week
0
5
10
15
20
25
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
No Yes
Five to six staff
Two staff
© Primary Care Foundation
Splitting it into two by separating children under 16 increases the staffing to 119 hours in the week (+30%)
0
5
10
15
20
25
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
No Yes
Six to eight staff
Three staff
© Primary Care Foundation
When integrating services, commissioning new services or reviewing existing services
● Check that each separate service is operating properly and use the same measures across services (but recognise the reasons for variation)
● Beware of establishing urgent care services that actually meet primary care needs (but recognise that all urgent care services have to provide some follow-up care)
● Be very careful of making sure that savings are real● Too often the tariff is compared with only part of the direct cost● Look at the saving to tax-payer – if the justification is reducing
cost of A&E tariff then there not only has to be a reduction in the numbers attending, but A&E also have to employ less people
© Primary Care Foundation
You should look carefully at the length of the contract….
Short contract● We can change the
specification if it is wrong● We can change provider if they
are no good● We may be paying over the
odds● We need the lever of
competition
Long contract● The provider can invest in
● Equipment and IT
● Facilities
● Developing the team
● Training
© Primary Care Foundation
Care will not be as good and costs will be higher if the contract is short
Short contract● We can change the
specification if it is wrong● We can change provider if they
are no good● We may be paying over the
odds● We need the lever of
competition
Long contract● The provider can invest in
● Equipment and IT● Facilities● Developing the team● Training
● We can work with the provider to develop the service
● We can change the provider if they are no good
● We can demand an action plan if the cost is greater than a level related to comparators
● You have the lever of competition
© Primary Care Foundation
ReviewingUrgent Care inGeneral Practice
URGENT CARE
a practical guide to transforming same-day care in general practice
Supported by the Department of Health
lth
© Primary Care Foundation
Some of our key findings
● Speed of initial response – or ensuring patients can get through - matters
● Review and understand your number of appointments and the proportion that can be booked same day
● Managing peaks in demand - such as Monday mornings – is important
● Practice staff need to recognise what is potentially urgent and agree how to respond
● Rapid clinical assessment is important – especially of requests for home visits
● Telephone consultation can play a useful role
© Primary Care Foundation
Acute Admission Timeline
●8.30 ●11.30 ●13.30 ●17.30●3 Hours ●2 Hours ●2 (often 4) Hours
●8.30 ●8.45 ●09.45 ●10.45●15 Minutes ●1 Hour ●1 Hour
Just as hospital staff go home!
In time to set up alternative to hospital
Early enough to avoid risk of deterioration
© Primary Care Foundation
A new approach
● Currently developing a web based planning and monitoring tool. Focuses on:
● Telephony – checking the capability to answer the phone promptly● Capacity in terms of appointments to meet the demand from
patients● Recognition of potentially urgent cases● Response to urgent cases
● Brings together practice data and patient experience to give a strong evidence base for making changes
● Practices are able to benchmark their own system and process against other local practices and across England
© Primary Care Foundation
What do we look at?
● Number of lines and number staff answering calls● Length of average call● When do you run out of appointments on the day● Appointments - face to face, by phone, home visits &
extras; split by same day and book ahead● Completion rate of phone consultations, by practitioner● Additional information, including staffing and age profile
of the practice population● Results from the General Practice Patient Survey
© Primary Care Foundation
Better evidence supporting change
● Range of indicators provide a rounded picture of what is happening in the practice, including:
● staffing by hour answering phones compared to what is needed for an effective response (Erlang Formula)
● consultation rate, weighted for age, compared to national average
● Detailed report builds on how the practice understands its processes with analysis of data and options for change
● Once these issues are addressed, there are a range of options – the practice will need to identify what works for them
© Primary Care Foundation
Commissioning Urgent Care Key points to remember …
● GP commissioners are well placed to use their clinical knowledge to drive improvements
● Define what you want and use good comparative information to drive improvements in care
● Tackle unacceptable variation - both between and within services
● Design individual services and the flow between services with a good understanding of process and volumes
● Don’t forget the role of general practice● Long term contracts will allow you to shape long-term
improvement in care
