Governing Body meeting agenda and papers

Transcription

Retention of Records: This agenda will be confidentially destroyed 2 years after the date of the
meeting, in line with CCG policy and guidance from the Department of Health.
Agenda
Meeting: Southampton City Clinical Commissioning Group Board – PART 1
Date: 27th January 2016
Time: 14:00 – 16:00
Location: Conference Room, Oakley Road, Southampton, SO16 4GX
Time
14:00
14:15
Item
no
Subject
Lead
Purpose
1.
Welcome and Apologies
2.
Questions from the public
3.
Declaration of Interest
Dr Sue
Robinson
Receive and
Consider
4.
Minutes of the Previous Meeting and
Matters Arising
Dr Sue
Robinson
Receive and
Approve
ASSURANCE
14:20
5.
Assurance Framework 2015/16
Dr Sue
Robinson
Approve
14:35
6.
Update on Bitterne Walk in Service
Peter Horne
Receive and
Approve
John Richards
Receive and
Approve
Kay Rothwell
Receive
FORWARD LOOK
14:45
15:00
7.
Chief Executive Officer Report
BREAK
FINANCE AND PERFORMANCE
15:10
8.
Finance and Performance Report
GOVERNANCE
15:25
9.
Information Governance Framework
Dr Mark
Kelsey
Ratify
10.
Quality Exception Report
Stephanie
Ramsey
Receive
QUALITY
15:30
FOR INFORMATION
15:40
11.
Urgent and Emergency Care Update
Peter Horne
Receive and
Agree
15:55
12.
Sub Committee Minutes
Dr Sue
Robinson
Information
16:00
13.
Date of Next Meeting: 23rd March 2016, 14:00 – 17:00, Conference Room,
Oakley Road, SO16 4GX
Please send apologies to: Emily Chapman, Business Support Manager, Tel: 02380 296075,
Email: emily.chapman@southamptoncityccg.nhs.uk
Southampton City CCG Board Register of Interests
Name
Dr Sue Robinson
Chair
Southampton City CCG
Relevant and Material Interests
•
•
•
Shareholder in Circle Health Ltd (Reg Company
No. 05042771) - 300 shares
CCG GP lead for the Better Care Fund
Locum GP
Dr Mark Kelsey
Deputy Chair, GP Board Member
•
Dr Chris James
GP Board Member
•
•
GP Partner - University Health Service
Practice is a shareholder of Southampton
Primary Care Limited, also known as the GP
Federation
Dr Tony Kelpie
GP Board Member
•
•
GP Partner – Cheviot Road Surgery
Director of Southern Alliance Healthcare (SAH
have ceased trading and in the process of
closing)
Shareholder in Circle Health Ltd (Reg Company
No. 05042771) - 300 shares.
Medicines Management GP Task Group Chair
Federation
•
•
•
•
Ex-officio member of Southampton Voluntary
Services Executive Committee
Locum GP at various practices
Dr Richard McDermott
GP Board Member
•
•
•
GP Partner - Bitterne Park Surgery
Shareholder of Solent Medical Services
Federation
Dr Chris Budge
GP Board Member
•
•
GP at Bath Lodge Surgery
Federation
Shareholder Solent Medical Services SMS
•
Dr Richard Day
Secondary Care Doctor
Updated January 2016
•
•
Part time Consultant Physician (Geriatrics) Poole
Hospital NHSFT
Medical Director of Care South, Charity
•
John Richards
Chief Executive
1014679, a charity providing residential and
domiciliary care across southern England
(unremunerated)
On the NICE Acute Medical Emergencies
Guideline Development Group, representing
commissioners
Nil
•
James Rimmer
Chief Financial Officer
•
•
•
•
Foundation Trust (FT) member in personal
capacity for; Solent NHS Trust, Southern NHS
FT, University Hospital Southampton FT & South
Central Ambulance Foundation Trust. These
roles hold no power within the respective
organisation and only involvement is through
receiving regular members newsletter (which are
publicly available)
Vice Chair of NHS Commissioning Assembly
Finance Working Group – an informal group
made up of a cross section of CFOs of CCGs,
and members of the NHS England Finance
Senior Team. Co-Chaired with CFO of NHS
England.
Executive Branch Committee Member South
Central HFMA (Healthcare and Financial
Management Association)
Trustee of HFMA (Healthcare and Financial
Management Association) 3 year term from
December 2015.
Partner is an employee of NHS Portsmouth CCG
•
Is jointly appointed with Southampton City
Council
Margaret Wheatcroft
Lay Member – Patient and Public
Involvement
•
Foundation Trust (FT) member for University
Hospital Southampton (UHS)
Dr Andrew Mortimore
Director of Public Health
Southampton City Council
•
Employee of Southampton City Council and
jointly appointed with Public Health England
Foundation Trust (FT) member for Southern
Health and UHS.
Stephanie Ramsey
Director of Quality and Integration
SCCCG / SCC
Chief Nurse
June Bridle
Lay Member - Governance
Nil
•
Non-voting members
Peter Horne
Director of System Delivery
•
•
Wife is: a lay member for SE Hants CCG and
Board member for NHS Clinical Commissioners
Trustee of Valley Leisure limited. The charity
operates leisure facilities in Test Valley. They do
not have any business interests with the CCG.
Lesley Gilder
Healthwatch
Councillor Dave Shields
Councillor
•
Director of Solent Credit Union
•
On the Council of Governors for Solent NHS
Trust
Foundation Trust member for Southern Health,
University Hospital Southampton (UHS) and
South Central Ambulance Service (SCAS)
•
These meeting minutes may become available to the public under the Freedom of Information Act 2000.
Retention of Records: These minutes will be confidentially destroyed 2 years after the date of the
Meeting Minutes
Southampton City CCG Board – Part 1
th
The meeting was held on Wednesday 25 November 2015, 14:00 – 17:00
Conference Room, Oakley Road, Ground Floor, Southampton, SO16 4GX
Present:
NAME
Dr Sue Robinson
Dr Richard
McDermott
Dr Tony Kelpie
Dr Chris James
Dr Mark Kelsey
John Richards
James Rimmer
June Bridle
Margaret Wheatcroft
Andrew Mortimore
Stephanie Ramsey
INITIAL
TITLE
SRobinson Chair
RM
GP Board Member
ORG
SCCCG
SCCCG
TK
CJ
MK
JRichards
JRimmer
JB
MW
AM
SRamsey
SCCCG
SCCCG
SCCCG
SCCCG
SCCCG
SCCCG
SCCCG
SCC
SCCCG
Peter Horne
Cllr Dave Shields
Lesley Gilder
PH
DS
LG
GP Board Member
GP Board Member
GP Board Member
Chief Executive Officer
Chief Finance Officer
Lay Member, Governance
Lay Member, PPI
Chief Nurse / Director of Quality
and Integration
Councillor
Member
Apologies:
Dr Richard Day
RD
SCCCG
In
Attendance:
Emily Penfold
EP
SCCCG
Rebecca Willis
Dawn Buck
RW
DB
Kayleigh Moore
KM
Business Support Manager
(minutes)
Head of Business
Head of Stakeholder Relations and
Engagement
Communications Officer
2015-86
SCCCG
SCC
Healthwatch
SCCCG
SCCCG
SCCCG
Welcomes and apologies
All members were welcomed to the meeting and apologies were noted and
accepted.
2015-87
Questions from the public
The following questions were received from the public:
Question from Southampton Keep Our NHS Public Group - At the SCCCG
meeting in public on 30th September, where the Board announced its decision
to close the Bitterne Walk in Service, the CCG promised to review the
workings of the proposed alternatives to BWIS in 6 months’ time, i.e. late
March 2016. Could you tell us how it is proposed to carry out this review and
publicise its conclusions?
It was agreed that this would be discussed and dealt with under the Bitterne
Walk in Service Update.
2015-88
Declarations of Interest
No declarations of interest were made in relation to the agenda.
2015-89
Minutes of the Previous Meeting and Matters Arising
The minutes of the meeting that took place on the 30th September 2015 were
reviewed and the following amendments were made:
-
-
-
-
EP
The meeting took place at Central Hall
Under questions from the public expand the answer regarding mortality
rates
CEO report – add 2 actions, regarding the decision to submit the
primary care co-commissioning application and the ratification of
financial assessment
CEO report – add risks raised by JRimmer on the primary care cocommissioning application specifically around uncertainties on financial
resource
Bitterne Walk In Service – add names against the actions
Bitterne Walk In Service - PH to send minor amendments particularly
around the concern on the health centre being closed
Bitterne Walk In Service – need to amend RMc comments on
community nursing support. It needs to state that reducing the
community nurse support to practices would have an impact on
workload and impact on providing urgent access for patients who
needed it
EPRR – needs to state that mutual aid has a specific meaning for
category 1 responders (PH to provide wording)
With the stated amendments the Board agreed the minutes as a true, accurate
record of the meeting.
Matters arising
There were no matters arising.
2015-90
Assurance Framework 2015/16
Page 2 of 7
The Board received the Assurance Framework (BAF).
There were no new risks added on the Assurance Framework.
It was highlighted that the risk score for SC001, SC002, SC013, SC014 and
SC015 had reduced.
The Board discussed risk SC004 in relation to the ED A&E four hour standard.
It was queried what the CCG want University Hospital Southampton
Foundation Trust (UHSFT) to put in place to achieve the standard. The CCG
need to ensure the actions in place, remain in place and are continually
worked on to allow the performance to improve. It was highlighted that in
System Chiefs it was noted that front line staff are to have regular contact with
the leaders in the organisation to support them in delivering the target.
Each lead director talked through the highlights of their risks.
AM queried if the issue around safe staffing was related to operational issues
or if the demand has grown. If the demand has grown, is there a
commissioning responsibility to work with Solent NHS Trust? SRamsey
responded that work has taken place with Solent around refocusing resources
to support community nursing. The work on rehab and reablement will also
increase community support.
SRamsey provided the rationale for the risk score being at a 16 for SC011 and
SC012. For Southern Health Foundation Trust and Solent NHS Trust there are
significant concerns across the organisations and it would be inappropriate to
reduce the risk score when these concerns are known. For UHSFT there has
been assurance provided with actions in place and these are regularly
reviewed at the Clinical Quality Review Meeting (CQRM), therefore this risk
score has reduced.
JB raised the Junior Doctor strike and what impact this will have e.g. if elective
surgery is delayed. PH provided assurance that the management of the strike
was being handled by the Operational Resilience Group (ORG) which is a
multi-agency group. A weekly teleconference is in place and there is a link with
communications colleagues to ensure the messages out to the public are
handled appropriately. The strike may need to be included onto the CCG risk
register, this will be discussed.
ACTION: Directors to consider the risks for 2016/17
2015-91
Directors
/ RW
Chief Executive Officer Report
The Board received the Chief Executive Officer (CEO) report.
The Board were asked to:
-
To discuss the SCC budget consultation
To note and endorse the approach to the forthcoming
planning round
It was agreed that JRichards/JRimmer would draft a response to the SCC
budget and this would be circulated for Board members to comment. The
Board expressed they wished to express their disappointment on the named 3
priorities in the city, particularly on the loss of focus on vulnerable adults.
Page 3 of 7
SRamsey highlighted that there is work taking place regarding vulnerable
people which ensures basic needs are covered. The CCG also needs to use
integrated commissioning to achieve the most for its population whilst
recognising the financial challenges.
The Board also endorsed the approach for the forthcoming planning round.
2015-92
TARGET 2016/17
The Board received the TARGET 2016/17 papers for discussion and decision.
It was agreed that this item did not provide a conflict of interest for the GP
Board Members as there was no direct pecuniary interest for them.
SRobinson talked through the highlights of the report.
RMc suggested that there is another option of increasing the number of events
particularly in-house events as they are invaluable to GP practices.
It was suggested that it would be useful to see more solid outcome measures,
such as the education received to feature in Personal Development Plans and
appraisals.
The Board also discussed using TARGET to get greater impact for the
population of Southampton. TARGET can be used for service development or
redesign workshops.
It was agreed that TARGET was a positive event that provides education for
GPs, Nurses and HCAs within the city and also provides a valuable networking
experience.
The Board discussed the option of sponsorship for the events (to cover the
venue costs). Some members raised concern on the use of sponsorship.
The Board voted on the options as follows:
-
Option 1 (change nothing) – 7 votes
-
Option 3 (sponsorship) – 7 votes
-
Options 2 and 4 (to continue with TARGET less frequently / no longer
continue with TARGET) – received 0 votes
It was agreed that TARGET will continue in its current format, however the use
of sponsorship would be explored.
ACTION: A short policy on the use of sponsorship to be developed and
brought back to a future Board meeting.
2015-93
SRob
Bitterne Walk in Service Update
The Board received the Bitterne Walk in Service (BWIS) update for discussion.
PH talked through the highlights of the report.
This paper focuses on the decommissioning of the service, increasing
awareness of urgent and emergency services and monitoring of impact.
Page 4 of 7
The Board were asked to comment on monitoring and if they thought the
proposals were appropriate.
JB queried how proactive the CCG are in engaging with providers. PH
responded that the Primary Care Development team have visited all
pharmacies in the East to ensure they are aware of the closure and to talk
through alternative services and this will also happen in central and west. The
majority of pharmacists in the city are signed up to the Pharmacy First
Scheme. In terms of GP practices, visits have taken place and all surgeries are
advertising alternative services to patients. It is also a regular item on the
Practice Managers Forum.
The Board discussed communication to the public and the harder to reach
communities/groups. It was noted that there has been extensive awareness
raising activity in the community and engagement work has taken place with
those groups.
It was suggested it would be useful to see the percentages of NHS 111 calls
that are attributed to each locality.
The Board thanked PH and team for the thorough suite of reports.
The Board noted the progress on the decommissioning of the service and that
it has been safely and thoroughly decommissioned.
The Board also endorsed the communications plan for urgent and emergency
care services.
2015-94
PH
Finance and Performance Report
The Board received the Finance and Performance Report.
JRimmer highlighted that the Comprehensive Spending Review had been
released and the NHS received £3.8b additional funding. It was also
announced, that by 2020 GP services will be accessible on evening and
weekends and there will be 7 day coverage in all hospitals. By 2021 cancer
diagnostics will increase.
JRimmer talked through the highlights of the report.
The Board noted that the System Delivery Team is reviewing the SCAS
performance.
JB raised concern on the performance on the Out of Hours service. It was
agreed that a briefing note on this would be provided at the next meeting.
PH highlighted that work is taking place with SCAS to ensure 999 responses
are not being conveyed inappropriately and part of this relates to the use of
Out of Hours.
2015-95
The Board received the Quality Report for discussion / information.
SRamsey talked through the highlights of the report.
Page 5 of 7
ACTION: Board briefing to be organised on Transforming Care.
2015-96
SRam /
EP
EPRR Assurance 2015/16
The Board received the EPRR Assurance 2015/16 papers for information,
noting progress and the associated action plan.
The Board thanked Rebecca Willis, Head of Business for the work that had
been undertaken.
2015-97
Integrated Care Update
The Board received the integrated care update for information.
SRamsey talked through highlights of the report.
It was noted that a stock take is currently in progress on the work undertaken
on Better Care and a stakeholder event has also been organised for the 3rd
December 2015.
The Board discussed the proposals regarding Rehab and Reablement. It was SRob/
agreed that the clinical colleagues would provide a statement of support on the Clinical
proposals as they are crucial to the Better Care work.
Board
Members
The Board discussed the involvement of primary care. It was noted that this is
being looked into whilst developing the Primary Care Strategy.
2015-98
Information Governance Report
The Board received the Information Governance report for information.
The Board passed on their thanks to Rebecca Willis, Head of Business for
undertaking the IG work and the report.
The Board were assured that all staff undertaken annual IG training and IG is
also on the staff induction.
2015-99
Freedom of Information Report
The Board received the Freedom of Information report for information.
2015-100
Sub committee minutes
The Board received the following sub committee minutes for information:
•
•
•
•
Finance and Audit Committee – 29th July 2015
Clinical Executive Committee –16th September 2015
Clinical Governance Committee – 1st July 2015, 5th August 2015 and
2nd September 2015
Commissioning Partnership Board – 19th August 2015 and 23rd
Page 6 of 7
•
•
2015-101
September 2015
Summary of SMT and Business Team – September and October 2015
Primary Medical Care Joint Commissioning Committee – 17th June
2015
Date and venue of next meeting
27th January 2016, 14:00 – 17:00, Conference Room, Oakley Road
Signed as a true record
Signed: …………………………………………………….
Print Name: ………………………………………………..
Designation: ……………………………………………….
Date: ……………………………………………………….
Page 7 of 7
Change from initial risk
to
current residual risk
Impact
Likelihood
RAG Status
Solent NHS Trust have raised concerns that safe levels of staffing may be untenable
due to significant demand growth in a number of service areas which include
community nursing, CAMHS, specialist service support, Walk in Services, COAST
and Paediatric Medical Services
UHS FT have 19 compliance issues from CQC inspection which grades the
13 organisations as 'Requires improvement'. Ongoing issues with flow impacting on ED
and Delayed Transfers of Care
The Out of Hours contract with PHL is to be run 100% by PHL from May 2015 rather
than some elements sub contracted by PHL to Care UK. PHL have now taken back
14
full responsibility for delivery of all of this service, clearly as this service transitions
back there is a service failure risk.
12
RAG Status
Southern Health action plan being implemented following CQC assessment
'Requires Improvement'. Southern Health, in addition has a Quality Improvement
11 Plan in place for Southampton, including reduction needed in community team
caseloads and increased resources to acute mental health team
Likelihood
There is a risk the CCG fails to achieve its current planned surplus of £2.431m
(0.80%).
The risk of non delivery of the CCGs 2015/16 QIPP challenge of £14.150m (4.7% of
2 our allocation). Should the QIPP savings not be delivered the CCGs surplus and
financial sustainability would be at risk
There is a risk the CCG fails to achieve the 4 hour A&E performance standard as laid
4
out in the NHS Constitution
The CCG will be taking the lead for commissioning placements for many vulnerable
clients from a range of providers. Failure of a provider to meet key standards
requires speedy intervention to keep clients safe and avoid safeguarding
7
issues/CQC involvement/closure. There is an additional risk that reviews may be
delayed if effective co-ordination is not achieved with Social Services undertaking
joint assessments
Failure to achieve effective strategic approach to quality improvements across the
8
Health & Social Care System
Insufficient focus on top priorities for achieving system change across all
9 organisations at pace; particularly in relation to the new models of integration being
implemented under Better Care during 15/16
Engagement of members and localities may not be sufficiently robust to enable the
10 CCG to achieve its objectives and carry out its functions and responsibilities
1
Impact
High-level potential risks are unlikely to be fully resolved and require on-going control
RAG Status
Potential Risk Description
Impact
Risk
Ref
Likelihood
Southampton City CCG Board Assurance Framework Summary- January 2016
4
4
R
4
3
A
4
2
A
4
4
R
4
3
A
4
2
A
5
4
R
5
4
R
4
2
A
4
3
A
4
3
A
2
3
A
4
3
A
4
3
A
5
2
A
4
4
R
4
3
A
3
2
A
4
3
A
4
3
A
2
3
A
4
4
R
5
4
R
4
3
A
4
4
R
4
4
R
4
2
A
5
5
R
4
3
A
4
2
A
5
4
R
5
4
R
4
2
A
Initial Risk
Score
Current Residual
Risk Score
Anticipated
Risk Score
Following
Mitigration
Southampton City CCG Board Assurance Framework: January 2016
Risk Ref Obj No
SC001
Obj 1
Objective
Date Raised Description of the Risk and Impact
Improve the
01/04/2015
quality and safety
of commissioned
services
Original
Risk
Score
(IxL)
There is a risk the CCG fails to
achieve its current planned surplus of
£2.431m (0.80%).
16
(4x4)
SC002
SC004
Obj 1
Obj 1
Improve the
01/04/2015
quality and safety
of commissioned
services
Improve the
01/04/2015
quality and safety
of commissioned
services
The risk of non delivery of the CCGs
2015/16 QIPP challenge of £14.150m
(4.7% of our allocation). Should the
QIPP savings not be delivered the
CCGs surplus and financial
sustainability would be at risk.
16
(4x4)
Obj 1
Improve the
01/04/2015
quality and safety
of commissioned
services
12
(4x3)
12
(4x3)
There is a risk the CCG fails to achieve
the 4 hour A&E performance standard
as laid out in the NHS Constitution
20
(5x4)
SC007
Current
Risk
Score
(I x L)
The CCG will be taking the lead for
commissioning placements for many
vulnerable clients from a range of
providers. Failure of a provider to
meet key standards requires speedy
intervention to keep clients safe and
avoid safeguarding issues/CQC
involvement/closure. There is an
additional risk that reviews may be
delayed if effective co-ordination is not
achieved with Social Services
undertaking joint assessments
12
(4x3)
20
(5x4)
12
(4x3)
Key Controls in Place what is in place to control the
risk
Key assurances in place How do we know the controls are
working
Gaps in
Control/Assurances
Actions required
All budgets clearly delegated to
directors and authorisation limits
of all staff reviewed. Monthly
financial reporting and
forecasting is used to forecast
risk areas. The forecasts are
reviewed at a number of places
including Day 8. Monthly directors
Financial Control Meeting and
Business Management Team to
focus upon QIPP delivery. The
CCG undertook the required self
assessment around the financial
controls environment which was
approved by the Board, in most
cases giving a high level of
assurance.
Bi monthly Board Finance and
Performance report + CFO internal
monthly review of year end forecasts
Business SMT receive reports on
financial forecasts and Directors
have convened a Financial Control
Group to focus on the current
financial pressure areas and QIPP
non delivery areas.
None at present, budget
managers have been
reminded via the CEO
about their responsibilities
to operate within their
budgets.
Monthly Senior Management
Team Business Meeting
(reporting to Clinical Executive
Group ) in place to monitor QIPP
delivery and milestones. PMO
working with managers to
monitoring PIDs for all schemes.
All QIPP schemes are formally
delegated to a lead Director.
Bi monthly Board Finance and
Performance report , Clinical
Executive Group (CEG) and Monthly
Business SMT QIPP report along
with monthly reports to NHS
England. Directors have convened a
Financial Control Group to focus on
the current financial pressure areas
and QIPP non delivery areas.
None at present, budget
managers have been
reminded via the CEO
about their responsibilities
to operate within their
budgets and deliver QIPP.
The CCG has made significant
investment into capacity and
capability of community based
services to support citizens and
to prevent unnecessary
attendances or admissions to
UHS. CCG QIPP plans seek to
reduce further the level of
attendances at ED and NEL
admissions. System Delivery
QIPP projects to focus on clinical
improvements to service at the
ED front door and CDU;
Integrated Care QIPP projects to
focus on Ambulatory Care
Sensitive conditions, Complex
Discharge, Rehabilitation and
reablement. In addition, the
Whole System Action Plan
(WSAP) is being refreshed to
focus efforts onto seven day
clinical standards and operational
resilience.
Daily reporting of performance.
Nil
Weekly scrutiny of system patient
flow. Monthly oversight from the
contract performance panel. CCG
scrutiny of actions and plans at CEG
and monthly business meeting. The
refreshed Whole System Action Plan
will be taken to Boards of NHS
partners (Southampton City CCG;
Solent; Southern; University Hospital
Southampton (UHS); West
Hampshire CCG) and Senior
Management Teams of Local
Authorities (Hampshire County
Council and Southampton City
Council) to ensure accountability at
all levels. Following escalation, the
draft ED RAP was agreed in
September 2015.
Nil
*Programme of placement
reviews with target of 90%
achievement
* User/carer/advocate
involvement in reviews
* Working with local authority
safeguarding and CQC
* Supervision/oversight by
Designated Nurse
* NHS contract with key quality
standards in place for all
providers
* Improve range of providers and
quality and marker
Monitoring of review achievement via
Senior Management Team and
Clinical Governance.
Quality reviews in place and joint
working with CQC developing to
ensure sharing of intelligence about
providers.
Ongoing Leadership programme for
NHS registered managers.
Peer support network in place for
NHS registered managers.
Education programme (VIP scheme)
in place for care homes and
domiciliary care providers.
Ensure any vacancies in
team filled speedily to
maintain required
programme of reviews.
Further increase working
with SCC teams to
complete joint reviews.
Refresh processes for
monitoring of placements
for children/young people
and those with mental
health issues.
Target
Risk
Score
(I x L)
The CCG is clear about
the financial challenges it
faces through the staff
news letter and staff
briefings.
Deadline
for Action
Responsible
Individual
Delegated
Action Owner
(for listed action)
* Pressures on team to
complete all reviews
* Standards of current
market variable
* Need to increase quality
of reviews in light of
Winterbourne and Francis
report
* Additional capacity
needed
* Monitoring of children
and young people
placements / service
providers
Date of Last
Review
Comments
Link to
evidence
On-going
CFO
CFO
Month 7 reporting continues to show significant 8.12.15
pressures in CHC and prescribing with acute
demand also over performing, performance
over the winter period needs to be carefully
monitored. The Board have approved the CCGs
financial recovery plan which is required to
show how the CCG will return to a 1% surplus
over the next 3 years. This will be closely
monitored by NHS England. At the CCGs
October Board Briefing a discussion was had
around the 2016/17 financial challenge and
actions required.
Finance report
On-going
CFO
CFO
Month 6 reporting shows QIPP on target which 8.12.15
is pleasing with few schemes back-ended,
however winter demand pressures can have an
impact upon this. An update has been taken to
Clinical Executive Group.
Finance report
N/A
Director of
System
Delivery
Director of
System Delivery
ED RAP being progressed. One of two
milestones missed for September 2015 have
now been concluded after CEO escalation
meeting. In addition, work is in place to better
understand the potential impact on UHS of
pressures in other areas
7.1.16
Finance and
performance
report
On-going
Chief Nurse
Deputy Chief
Nurse
Programme of reviews continues. Making
significant progress with QIPP.
05.01.2016
Reported to
Clinical
Governance
Committee
8
(4x2)
PMO team are working
with lead managers to
review milestone plans
and Directors have
requested their teams
identify new schemes or
how they can accelerate
new schemes.
Progress
8
(4x2)
8
(4x2)
6
(2x3)
Risks remain around Mental Health placements
as increase in referrals for CHC / Section 117
funding noted. Action plan being implemented
between CHC team and Mental Health
Commissioners. Proposals made to
Southampton City Council to improve speed of
reviews where Social Worker input is required
including Trusted Assessor development.
05.01.2016 - good progress continues with
QIPP.
Work ongoing with SCC to improve speed of
reviews. Proposal in development to integrate
LD teams between SCC and CCG
Risk Ref Obj No
SC008
Obj 1
Objective
Improve the
01/04/2015
quality and safety
of commissioned
services
Original
Risk
Score
(IxL)
Current
Risk
Score
(I x L)
Failure to achieve effective strategic
approach to quality improvements
across the Health & Social Care
System
12
(4x3)
12
(4x3)
risk
working
* Clinical Quality Review
Meetings (CQRM) in place with
providers
* Quality contracts
* Effective quality reports
including triangulation of
evidence
* Focus on Healthcare Acquired
Infections (HCAI)
* Assurance visits undertaken
Report to Clinical Governance and
Commissioning Partnership Board Quality report and CQRM outcomes.
CQRM and quality contract meeting
in place with providers across Health
and Social Care.
Assurance visits and discussions
with provider by quality team and
Board to Board visits to review
assurance processes - undertaken
with UHS, Solent, Southern and
Southampton Treatment Centre.
Integrated Commissioning Unit has
combined Council and CCG team
quality teams.
Monitoring of CQC action plan via
CQRM's as appropriate
Gaps in
Control/Assurances
* Quality reporting to
ensure triangulation and
monitoring of trends
across the system
* Comprehensive Quality
reporting of social care
providers (NH, RH and
Domiciliary Care)
Actions required
Target
Risk
Score
(I x L)
Quality reporting across
whole system (health and
social care)
Contracts for NH sector to
be aligned with NHS
standard contract
Deadline
for Action
On-going
Responsible
Individual
Chief Nurse
Delegated
Action Owner
(for listed action)
Deputy Chief
Nurse
Progress
Date of Last
Review
System wide Pressure Ulcer Strategy is now
05.01.2016
being implemented. Work on standard NHS
contract for nursing homes progressing well.
Health Care Aquired Infections reduction plan
continues to be implemented. C.difficile rate is
improving. Ongoing work on mixed sex
accommodation at UHS.
Comments
Link to
evidence
Reported to
Clinical
Governance
Committee
Board visit programme to providers in place.
Mental Health commissioners working with
Southern Health FT on Quality Improvement
Programme.
10
(5x2)
Single Sex Accommodation remains an area of
focus with UHS particularly AMU and other
admission areas.
05.01.2015 Mazars report into Southern Health
being presented to CGC on 06.01.2016 which
will include agreement of CCG action plan.
Process of monitoring to be agreed but likely to
be via CQRM and CGC
SC009
Obj 2
Deliver service
01/04/2015
and system
change in line
with the Five year
Plan and national
priorities
Insufficient focus on top priorities for
achieving system change across all
organisations at pace; particularly in
relation to the new models of
integration being implemented under
Better Care during 15/16:
- integrated rehab and reablement
service - to be in place September
2015
- integrated working at cluster team
level
- IT systems and infrastructure to
enable data sharing
16
(4x4)
12
(4x3)
* Programme boards are in
Performance dashboard
Maintaining shared
place and meet monthly
Oversight from Health and Wellbeing ownership of key priorities
* Clear commissioning
Board
intentions are in place
Integrated Commissioning to
support co-ordinated
commissioning with City Council.
* Joint system chiefs
commitment to top priorities
* Health & Wellbeing Board
strategic oversight of Better Care
Fund Implementation
Shared performance
metrics that are monitored
regularly and remedial
actions
On-going
Chair
Chief Nurse
Review of system resilience processes to focus 05.01.16
on top priorities undertaken.
Reported to
SMT and CEG
System Chiefs identified cross system priorities
for sustainability programme.
Regular reporting on Better Care outcomes to
Health & Wellbeing Board and nationally.
Health and Wellbeing Board review
commenced and new strategy in development.
Joint session between CCG Governing Body
and Cabinet to develop vision
6
(3x2)
Better Care Stakeholder event held in
December to review progress and to establish
future priorities.
Consultation on Phase 1 Integrated Rehab and
Reablement completed and implementation
commenced, Phase 2 going to SCC Cabinet in
February
SC010
Obj 2
Deliver service
01/04/2015
and system
change in line
with the Five year
Plan and national
priorities
Engagement of members and
localities may not be sufficiently robust
to enable the CCG to achieve its
objectives and carry out its functions
and responsibilities
12
(4x3)
12
(4x3)
* TARGET in place
Feedback at General Assembly
* Action Learning sets in place
Number of clinicians involved in
* Local improvement scheme in commissioning
place
* CCG is an active member of
Health &Wellbeing Board
* Clinical leads are in place
* Soft intelligence is sought at
every locality meeting
Action plan from 360 stakeholder
feedback
* Portal
Variable level of
engagement
Primary Care strategy
development and
implementation of Joint
Commissioning
On-going
Chair
Chief Nurse
Local Improvement Scheme 2015-16 aligns
closely with BCF cluster development and care
planning.
Use of GP Portal to share and gain GP insight.
Active leadership from clinical leads and
Governing Body members on key priorities and
implementation of CCG 5 year strategy.
Federation of practices implementing PMCF
pilot.
6
(2x3)
Primary Medical Care Joint Commissioning
Committee in place and bid for delegated
commissioning supported.
Active engagement with Primary Care and
stakeholders on Primary Care Strategy
development. The first of the refreshed GP
Forum's in October also focussed on Primary
Care Strategy.
05.01.16
Board agenda
and papers
Risk Ref Obj No
SC011
Obj 1
Objective
Improve the
01/04/2015
quality and safety
of commissioned
services
Original
Risk
Score
(IxL)
Current
Risk
Score
(I x L)
Southern Health action plan being
implemented following CQC
assessment 'Requires Improvement'.
Southern Health, in addition has a
Quality Improvement Plan in place for
Southampton, including reduction
needed in community team caseloads
and increased resources to acute
mental health team
risk
Regular CQRM and Contract
review meetings in place with
SHFT.
Southampton contract in place
Mental Health review to inform
future commissioning
working
Gaps in
Control/Assurances
Performance report via contract and Trust needs to show
CQRM meetings
sustained improvement in
outcomes including
staffing levels
Actions required
Target
Risk
Score
(I x L)
CCG assurance visit plan
including unannounced
visits
Deadline
for Action
Mar-16
Responsible
Individual
Chief Nurse
Delegated
Action Owner
(for listed action)
Deputy Chief
Nurse
Progress
Southern Health consulting on developments
with stakeholders on changes needed in
response to quality challenges. Commenced
implementation of Quality Improvement Plan to
be monitored by CQRM and contracting
meetings.
Date of Last
Review
05.01.2016
Comments
Risk score has
increased
Link to
evidence
Reported to
Clinical
Governance
Committee
Strategic Oversight Group for Southern Health
Foundation Trust (SHFT) to increase frequency
due to ongoing concerns in relation to
governance, serious incident management and
to ensure effective implementation of CQC
action plan.
16
(4x4)
20
(5x4)
12
(4x3)
Southern Health visit to Antelope House has
seen positive improvements and concerns are
being followed up.
Publication of Mazars report into unexpected
deaths in December 2015 has resulted in CCG
action plan to manage recommendations. Being
presented to Clinical Governance Committee on
06.01.2016 to agree and set in place monitoring
system. Analysis of Southampton aspects of
report underway and for discussion / action
planning at Jan Local CQRM with SHFT. Visit
plan to provider to be enhanced.
SC012
Obj 1
Improve the
01/07/2015
quality and safety
of commissioned
services
Solent NHS Trust have raised
concerns that safe levels of staffing
may be untenable due to significant
demand growth in a number of service
areas which include community
nursing, CAMHS, specialist service
support, Walk in Services, COAST and
Paediatric Medical Services
*CQRM and contract query
*Commissioning reviews of
specific areas such as mental
health services, Walk in Services
and specialist nursing
16
(4x4)
*Clinical Governance Committee
Performance reporting
* Clinical Quality Review Meetings
(CQRM) in place with providers
* triangulation of evidence
* Assurance visits undertaken
The Trust needs to provide
further assurance that
patient safety is being
maintained and also that
contractual commitments
are being delivered
a) The CCG is seeking
evidence for the claimed
demand growth through a
joint project aimed at
reconfiguring the contract
b) a contract query has
been issued
16
(4x4)
Mar-16
Chief Nurse
Deputy Chief
Nurse
8
(4x2)
Safe staffing levels continue to be monitored
monthly via CQRM. Areas of concerns are
nursing staffing levels on Snowdon and
monitoring of community staffing levels. Work
is underway to develop a community nursing
dependency and acuity tool for use across
Solent. Major staffing problems remain in the
complaints team however recruitment is
underway.
05.01.2016
Reported to
Clinical
Governance
Committee
Reported to
Clinical
Governance
Committee
Ongoing work across South West System with
West Hampshire CCG colleagues on child
related services.
05.01.2016 - no new concerns highlighed.
Monthly reporting to CQRM in place
SC013
SC014
Obj 1
Obj 2
Improve the
05/05/2015
quality and safety
of commissioned
services
UHS FT have 19 compliance issues
from CQC inspection which grades the
organisations as 'Requires
improvement'. Ongoing issues with
flow impacting on ED and Delayed
Transfers of Care
Improve the
08/04/2015
quality and safety
of commissioned
services
The Out of Hours contract with PHL is
to be run 100% by PHL from May 2015
rather than some elements sub
contracted by PHL to Care UK. PHL
have now taken back full responsibility
for delivery of all of this service, clearly
as this service transitions back there is
a service failure risk.
20
(5x5)
20
(5x4)
New Risk
Updates
12
(4x3)
20
(5x4)
* CQRM performance meetings
* ED RAP
* Assurance visits
*DTOC action plan
Monthly CQRM and performance
report
1. As part of transition to PHL
running the service, assurances
were sought on PHL's ability to
provide the service including
financial sustainability and the
ability to quickly deliver improved
performance.
2. Currently, there are Remedial
Action Plans (RAP) in place to
cover issues that relate to
performance and quality
respectively. The focus for the
quality RAP is mainly around
incident reporting and
management. In addition, the
provider is required to provide
daily updates on staffing and rota
fill rates.
3. NHS England are seeking
legal advice on the legal status of
the contracts with PHL folowing
the disolution of the PCTs to
clarify the contract owner.
4. Pan -CCG project group in
place which meets weekly to
manage the situation.
1. Monthly contractual meetings,
NIL
with supporting evidence and data.
2. There are a series of
unannounced visits by CCG staff
during January 2016 to gain greater
understanding of way in which PHL
plan and then manage their
operation.
3. CCGs are working more closely
and in concert to ensure consistency
of approach with the provider. In
addition, SC CCG have agreed to
chair the contract performance
meetings for the foreseeable future
to maintain consistency of approach.
Monitoring of
implementation of action
plan via CQRM
Nov-15
Chief Nurse
Deputy Chief
Nurse
AD System
Redesign
CQC/ Monitor follow on summit completed, still 05.01.2016
waiting minutes from this event. Action plan has
been reviewed at CQRM and is progressing.
8/02/116
Director of
System
Delivery
AD System
Delivery
Following the detrition in in performance
15.1.16
highlighted in the December contract meeting
across all local CCGs the current risk score has
been reviewed and additional controls and
actions have been put in place.
8
(4x2)
Following assurance and
assessment work in
January, CCG to assess
quality and safety of
service delivery and
recommended further
actions.
8
(4x2)
Risk score has
increased
Reported to
CEG
Southampton City Clinical
Commissioning Group Board
Date of meeting
27 January 2016
Agenda Item
6
Update on the Bitterne Walk in Service
Topic Area
Getting the Balance Right in Community Based Health Services
Proposal
To update the Governing Body on the actions that were agreed at
Governing Body and HOSP following the decommissioning of the
Bitterne Walk-in Service (BWIS)
Background information
The CCG decommissioned the Walk-in service at Bitterne Health
Centre on 31st October 2015.
As part of the decision making, the following actions were
identified by the Governing Body:
•
Develop a clear plan with the GP federation and other primary
care providers to improve GP access. This will also inform the
Primary Care Strategy
•
Increase public awareness on urgent and emergency care
•
Develop and implement a detailed communication plan
•
Provide a detailed report reviewing both quantitative and
qualitative impact of closing the service
Key issues to be considered •
The actions around communications and engagement are
now part of routine CCG work as is the monitoring of impact
•
A communications plan to improve access to primary care is
in place and will complement the broader strategic plan for
primary care which is part of Better Care Southampton.
Please indicate which
None
meetings this document has
already been to, plus
outcomes
1
Principal risk(s) relating to
this paper
•
SC004: Delivery of ED performance
•
SC009: Implementation of the Better Care Southampton plan
(Assurance
Framework/Strategic Risk
Register reference if
appropriate)
HR Implications (if any)
Nil
Financial Implications (if
any)
Nil
Public involvement –
activity taken or planned
Nil
Equality Impact
Assessment required /
undertaken
N/A
Report Author
Peter Horne, Director of System Delivery
Contact details
Board Sponsor
Peter Horne, Director of System Delivery
Date of paper
21st January 2016
Actions requested
/Recommendation
The Governing Body is requested to:
•
Note the progress on the actions that were directed as part of
the decommissioning of the BWIS.
•
Note that subsequent actions are now part of the routine work
within the CCG.
•
Agree that further progress can be incorporated into routine
reporting mechanisms.
2
Getting the Balance Right in Community Based Health Services
Introduction
1.
Following a public consultation in the summer 2015, the CCG decommissioned the Walk-in
service at Bitterne Health Centre (BWIS), provided by Solent NHS Trust, on 31st October
2015. Funding for the service has remained with Solent and transferred to the community
nursing service line, as set out in the case for change.
2.
As part of the decision making of the Governing Body, the following actions were identified:
3.
•
Develop a clear plan with the GP federation and other primary care providers to
improve GP access. This will also inform the Primary Care Strategy.
•
Increase public awareness on urgent and emergency care services as a priority
•
Develop and implement a detailed communication plan
•
Develop and implement reporting mechanisms to review both quantitative and
qualitative impacts of closing the service
Subsequent to the decision by the Governing Body, Southampton City Health Overview
and Scrutiny Panel (HOSP) accepted the decision and made the following monitoring
recommendations:
•
Circulate the draft Urgent and Emergency Communication Plan to the Panel for
comment. This action is complete.
•
Circulate response times and key performance information relating to the NHS 111 and
GP Out of Hours services to the Panel. This action is complete.
•
Consider the proposal for a community hub on the east side of Southampton at a future
meeting of the Panel, if the scheme progresses. The Governing Body should note that
this action lies with Southampton City Council.
•
Provide data reports for the Panel to scrutinise the impact and implementation of the
closure of the BWIS at each HOSP meeting until the Panel informs the CCG that the
information is no longer required. This action is in progress.
Aim
4.
The aim of this paper is to report on the progress of the actions taken following the
decommissioning of the BWIS and the early indications on any impact of the closure on
urgent care services and East locality residents.
Scope
5.
The paper will cover the following:
•
Update on the communications and engagement plan, including increasing public
awareness on urgent and emergency care
•
Impact monitoring.
•
Summary and recommendations
3
Communications and engagement plan.
6.
Communications and engagement has continued apace over the last two months with
particular emphasis on supporting local people to manage common winter conditions such
as coughs and colds. Messaging included top tips to treat symptoms along with the
promotion of the relevant services. Information was disseminated via:
•
social media, being shared by a number of our partners and reaching around 70,000
people
•
press releases, articles regarding pharmacies and online access to GP practices
including repeat prescription ordering were covered by the Daily Echo
•
ongoing radio advertising aimed at 15-40 year olds
•
Solent NHS Trust and Southern Health NHS Foundation Trust who have provided all
their front line staff with a supply of NHS 111 wallet cards to hand out during patient
consultations
•
posters advertising NHS 111, pharmacies and online services were distributed to
practices throughout the city
•
BBC Radio Solent’s Big Cuppa event at the Guildhall to reduce isolation
•
public engagement events at community centres, children’s centres and Sikh and Hindu
temples
•
community groups such as Black Heritage and Priory Road Luncheon Club
The urgent and emergency communications plan now forms part of the CCG’s business as
usual.
7.
8.
A separate communications plan has been developed to improve access to GPs. This is
intended to provide a firm platform for the delivery of the overarching strategy for primary
care which is part of Better Care Southampton plan. The communications plan will be
supported by both the CCG and NHS England and will involve practices advertising the
service on their websites, in their newsletters, via social media and on a face to face basis.
In conjunction with this the CCG has committed to:
•
providing practices with a comprehensive communications and marketing pack.
•
disseminating messages throughout our wide ranging network of schools, nurseries,
major employers, community and voluntary groups via a variety of channels.
•
working with local media to promote the benefits of online access.
•
attending local community events to encourage people to register.
Baseline data has been recorded on a per practice basis and we will measure ongoing
progress.
Impact monitoring
9.
Quantitative Impact. The BWIS closure impact monitoring data pack for January (based
mainly on M8 data) can be found at annex A. For this first month post BWIS closure there
have not been any substantial activity changes, in particular relating to East locality
patients, which are unexpected or raise significant concern.
4
10.
The data for the community nursing service is also monitored monthly. The profile of alert
status for the community nurses is shown below. This reporting will be incorporated into
the data pack at Annex A from February 2016 onwards.
DATE
JUN
JUL
AUG
SEP
OCT
NOV
Black
15%
70%
63%
70%
68%
20%
Red
34%
6.3%
23%
2%
9%
14%
Amber
26%
2%
2%
2%
4%
8%
Green
9%
0%
0%
1%
3%
5%
Data not available
5%
19%
11%
23%
15%
22%
11.
These metrics will continue to be reviewed monthly for at least 6 months in order to ensure
that trends can be identified. It is proposed that the metrics will be included in the CCG
performance reporting packs as part of normal monitoring.
12.
Qualitative impact. The qualitative impact is monitored through the CCGs normal
monitoring mechanism. The main activities related to this have been: gathering feedback
from service users; a stall in Bitterne market and a survey that is being run at present.
There are no issues to report.
Summary
13.
Good progress has been made on all actions that the Governing Body and the HOSP
directed the CCG to complete as part of the decommissioning of the BWIS
14.
The communications and engagement work has been embedded into routine reporting
within the CCG.
15.
Impact monitoring will also be embedded into the routine reporting of the CCG.
Recommendations
16.
•
Note the progress on the actions that were directed as part of the decommissioning of
the BWIS.
•
Note that subsequent actions are now part of the routine work within the CCG.
•
Agree that further progress can be incorporated into routine reporting mechanisms.
5
BWIS closure impact monitoring – data at January 2016 (mainly M8)
Contents
January update report for monitoring of SCCCG and East GP registered patients’ activity within
the urgent care system
•
Slide 2 - reporting time line
•
Slide 3 - utilisation of Pharmacy First minor ailments scheme
•
Slide 4 - GP patient access and experience
•
Slide 5 - referrals to PCMF hubs (Southampton Primary Care Ltd, SPCL)
•
Slide 6 - calls to 111 (SCAS)
•
Slide 7 - 111 patient experience
•
Slide 8 - calls to GP Out of Hours (OOH, PHL)
•
Slide 9 - OOH patient experience
•
Slide 10 - utilisation of COAST (Solent)
•
Slide 11 & 12 - attendances to Minor Injuries Unit (MIU, Care UK)
•
Slide 13- MIU patient experience
•
Slide 14 - attendances to Emergency Department (ED UHS)
Impact monitoring and reporting timeline
Month
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Report
Baseline
1
2
3
4
5
6
7
8
9
10
11
12
CPT
28th
11th
2nd
6th
3rd
9th
SMT
29th
12th
3rd
7th
4th
10th
CEG
18th
9th
13th
10th
16th
GB
(*public)
25th *
27th *
24th
23rd *
HOSP
26th
28th
24th
1st
impact
review
Add
dates for
16/14
Confirm
reports
will
continue
into
16/17
Check
points
Baseline
Notes
All
baseline
data to
be
received
by 30/10
First
reports
received
and
reporting
format
approved
Reports
timely
and
working
Follow up
GP
survey
NB:
Data will
be mainly
M5 (Aug)
Data will
be mainly
M6 (Sept)
Data will
be mainly
M7 (Oct)
Data will
be mainly
M8 (Nov)
Data will
be mainly
M9 (Dec)
Data will
be mainly
10 (Jan)
2nd
impact
review
3rd
impact
review
Final
impact
review
Follow up
GP
survey
Data will
be mainly
M11
(Feb)
Data will
be mainly
M12
(Mar)
Follow up
GP
survey
Data will
be mainly
M1 (Apr)
Data will
be mainly
M2 (May)
Data will
be mainly
M3
(June)
Data will
be mainly
M4 (July)
Data will
be mainly
M5 (Aug)
BWIS closure impact monitoring – data at January 2016 (M9)
Pharmacy First minor ailments scheme utilisation
GP registered
pratice
Baseline
Nov-15
Dec-15
Pharmacy accessed
Baseline
Nov-15
Dec-15
Average weekly activity
West
Central
East
4
4
7
3
2
12
7
3
7
% of total utilisation
West
Central
28%
24%
48%
15%
14%
71%
45%
15%
40%
Average weekly activity
East
West
Central
East
3
3
9
2
2
12
7
2
8
% of total utilisation
West
Central
22%
17%
61%
12%
14%
74%
42%
12%
46%
East
Would otherwise
have attended
GP
Baseline
Nov-15
Dec-15
Weekly feedback
WIC
ED
Other
85%
4%
0%
11%
91%
3%
0%
6%
89%
6%
0%
5%
•
Increase in activity from patients registered with an East practice GP
•
Increase in activity at accredited pharmacies in the East locality
o
•
including a 100hr pharmacy and 2 in close proximity to Bitterne Health Centre
Small increase in patients who say they would otherwise have gone to the BWIS
BWIS closure impact monitoring – data at January 2016
GP access and patient experience
Question
Overall, how would you describe your experience of your GP surgery?
SCCCG
84% good
National
85% good
East locality practice notes
6/10 practices at or above national average
Generally, how easy is it to get through to someone at your GP surgery on the phone?
68% easy
71% easy
How helpful do you find the receptionist at your surgery?
87% helpful
87% helpful
The last time you wanted to see or speak to a GP or nurse, were you able to get an
appointment to see or speak to someone?
How convenient was the appointment you were able to get?
84% yes
85% yes
90%
convenient
72% good
92%
convenient
73% good
58% don’t
wait too long
92% yes
Did you have confidence and trust in the GP you saw or spoke to?
51% don’t
wait too long
91% yes
Did you have confidence and trust in the nurse you saw or spoke to?
84% yes
85% yes
How satisfied are you with the hours that your GP surgery is open?
76% satisfied
75% satisfied
Overall, how would you describe your experience of making an appointment?
How do you feel about how long you normally have to wait to be seen?
Baseline data: GP patient survey – NHS SCCCG published July 2015 (Data July – September 2014 and January – March 2015)
•
Patient complaints, issues and feedback will be collated on a monthly basis and form part of the qualitative reporting
•
Next surveys due in January and July 2016
Note GP feedback and experience will be reported in the qualitative impact monitoring
BWIS closure impact monitoring – data at January 2016 (to w/c 7/12/15)
Referrals to SPCL hub
•
3 hubs in city (1 in each locality, East went live first)
•
East locality practices averaging 28% of all hub activity since BWIS closure
•
Expecting to see activity increase further when hubs on 111 DoS
BWIS closure impact monitoring – data at January 2016 (to M8)
Calls to 111
111 calls
Total calls answered
Calls answered within 60 seconds (≥95%)
Calls abandoned before answered (<5%)
Southampton patient call volume
Southampton as % of all
East
West
Central
Jun-15
37945
98%
0.2%
5582
15%
2193
1707
1682
Jul-15
38115
96%
0.4%
5480
14%
2117
1782
1581
Aug-15
40722
97%
0.7%
5687
14%
2221
1727
1739
Sep-15
38611
95%
0.5%
5753
15%
2167
1840
1746
Oct-15
Nov-15
43024
46610
93%
92%
0.8%
0.9%
6539
6981
15%
15%
2121
2737
2379
2145
2039
2099
Southampton 111 calls by East practice
Bath Lodge (registered population 12351)
Bath Lodge as % of East calls
Bitterne Park (registered population 8979)
Bitterne Park as % of East calls
Chessel (registered population 12758)
Chessel as % of East calls
Ladies Walk (registered population 8223)
Ladies Walk as % of East calls
Old Fire Station (registered population 8605)
Old Fire Station as % of East calls
St Peter's (registered population 5223)
St Peter's as % of East calls
Townhill (regisistered population 5465)
Townhill as % of East calls
West End Road (registered population 11627)
West End Road as % of East calls
Weston Lane (registered population 9369)
Weston Lane as % of East calls
Woolston Lodge (registered population 13749)
Woolston Lodge as % of East calls
SO18/19 no GP recorded
SO18/19 no GP recorded as % of East calls
Jun-15
208
9%
185
8%
331
15%
133
6%
157
7%
103
5%
109
5%
244
11%
193
9%
229
10%
301
14%
Oct-15
Nov-15
Aug-15
Sep-15
Jul-15
230
280
259
238
231
11%
10%
11%
12%
11%
157
176
148
139
166
7%
6%
8%
7%
6%
280
343
320
373
342
12%
13%
15%
15%
18%
136
150
165
154
138
7%
6%
6%
7%
6%
138
112
127
150
204
7%
5%
6%
7%
7%
98
135
98
75
82
5%
3%
4%
5%
5%
127
98
108
90
94
5%
5%
5%
4%
4%
231
213
234
287
206
10%
10%
10%
11%
10%
213
244
249
210
211
12%
9%
10%
10%
10%
248
271
260
270
317
12%
12%
12%
13%
12%
306
334
322
379
455
17%
14%
15%
15%
18%
•
Calls from Southampton GP registered patients represent ~15% of all calls to the local 111 service
•
Across the city, East locality patients are the highest user of the service (averaging 39% of Southampton calls at baseline)
•
Although numbers have increased (seasonal trend) the proportion of East patients remains consistent in the first month post BWIS closure
111 patient experience
111 patient expereince (SHIP)
Complaints
Compliments
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15
3
4
6
3
1
4
3
2
5
8
17
4
13
3
5
2
Patient satisfaction survery 6 monthly (SHIP - contract level)
Respondants who said they would use the service again
Respondants who said they would be extremely unlikley to use the service again
Respondants who would recommend the service to friends and family
Respondants who said they followed some or all of the advice given by 111
Respondants who felt the advice they were given was right for them
•
next patient satisfaction survey results expected next month
•
Feb 15 patient satisfaction shows almost 90% of respondents would recommend the service and use it again, with the
majority feeling the advice given was both appropriate and applied
•
the service generally receives more compliments from patients than complaints
Feb-15
89%
4.6%
88%
96%
90%
Calls to GP OOH
OOH calls
Total patient call volume (SHIP)
Southampton patient call volume
Southampton as % of all
East
West
Central
Jul-15
13329
2237
17%
909
706
622
Aug-15
15351
2485
16%
1005
781
699
Sep-15
12812
2150
17%
804
692
654
Oct-15
14654
2427
17%
893
782
752
Nov-15
15760
2729
17%
1077
814
838
Southampton OOH calls by East practice
Bath Lodge (registered population 12351)
Bath Lodge as % of East calls
Bitterne Park (registered population 8979)
Bitterne Park as % of East calls
Chessel (registered population 12758)
Chessel as % of East calls
Ladies Walk (registered population 8223)
Ladies Walk as % of East calls
Old Fire Station (registered population 8605)
Old Fire Station as % of East calls
St Peter's (registered population 5223)
St Peter's as % of East calls
Townhill (regisistered population 5465)
Townhill as % of East calls
West End Road (registered population 11627)
West End Road as % of East calls
Weston Lane (registered population 9369)
Weston Lane as % of East calls
Woolston Lodge (registered population 13749)
Woolston Lodge as % of East calls
Jul-15
112
12%
55
6%
151
17%
81
9%
66
7%
54
6%
32
4%
112
12%
109
12%
137
15%
Aug-15
140
14%
80
8%
188
19%
81
8%
58
6%
41
4%
56
6%
100
10%
118
12%
143
14%
Sep-15
126
16%
72
9%
124
15%
63
8%
50
6%
30
4%
48
6%
89
11%
85
11%
117
15%
Oct-15
98
11%
65
7%
179
20%
69
8%
65
7%
46
5%
44
5%
93
10%
108
12%
126
14%
•
Calls from Southampton GP registered patients represent ~17% of all calls to the local OOH service
•
Across the city, East locality patients are the highest user of the service (averaging 39% of Southampton calls at baseline)
•
Although numbers have increased (seasonal trend) the proportion of East patients remains consistent in the first month post BWIS closure
Nov-15
143
13%
93
9%
164
15%
77
7%
91
8%
59
5%
60
6%
126
12%
123
11%
141
13%
OOH patient experience
Patient satisfaction with OOH (SHIP)
Total patient call volume
% respondents who say they would recommend the service
Complaints
Compliments
Apr-15
16791
98%
6
1
May-15
17960
98%
6
2
Jun-15
13078
99%
3
0
Jul-15
13329
98%
6
N/A
Aug-15
15351
96%
6
N/A
Sep-15
12812
96%
3
1
Oct-15
14654
96%
6
N/A
Nov-15
15760
84%
4
N/A
•
% of respondents saying they would recommend the service to family and friends dipped in November, this will be monitored
•
complaints exceed compliments, but in relation to the total call volume, complaint rate averages at 0.03%
Utilisation of COAST
Referrals to COAST
East
West
Central
•
•
1415
monthly
average
9
6
8
Oct-15
7
9
9
Nov-15
18
9
14
Dec-15
11
8
3
East practice referrals to COAST have increased post BWIS closure, with activity mostly from one practice in
November (West End Road referred 11) and one practice in December (Bath Lodge referred 6)
Compared to the same time period last year, East practice non-elective short stay admissions have increased by 8%
(+6) but note this is significantly lower than West practices (increased by 48% (+29)), while central practices are the
same as previous year
MIU attendances
East locality activity M5 to M8
Sum of Activity
Row Labels
J82040 - West End Road Surgery
J82076 - Woolston Lodge Surgery
J82101 - Chessel Practice
J82128 - Old Fire Station Surgery
J82141 - Bath Lodge Practice
J82171 - Bitterne Park Surgery
J82180 - Townhill Surgery
J82187 - Weston Lane Surgery
J82208 - St.Peters Surgery
J82622 - Ladies Walk Practice
Grand Total
Column Labe
2014/2015
2015/2016
266
346
460
510
387
535
260
312
362
419
312
367
171
187
293
349
172
213
259
339
2942
3577
KEY:
Activity is higher than last year, but less than 10%
Activity is more than 10% higher than last year
•
MIU attendances increased in general in November, compared to previous months and same period last year
•
Proportion of East locality patient attendance increased slightly post BWIS closure – expected and will monitor
•
Activity for all bar one East practice has increased by over 10% compared to same time period last year (trend mirrored by most Southampton practices)
•
East locality patient attendance activity across the day follows the same pattern to rest of the city
MIU attendances
Minor illness presentations
Southampton attendances
% Southampton attendances with minor illness
East locality patients
East as % of Southampton
Jul-15
2483
28%
865
35%
Aug-15
2417
30%
847
35%
Sep-15
2426
28%
863
36%
Oct-15
2659
33%
855
32%
Nov-15
2708
40%
1060
39%
Wound dressings
Southampton attendances for wound dressings
East locality patients
West & central
% East locality patients for wound dressings
Jul-15
39
5
34
13%
Aug-15
90
20
70
22%
Sep-15
51
11
40
22%
Oct-15
30
6
24
20%
Nov-15
26
17
9
65%
•
Proportion of East locality patient attendance increased slightly in the first month post BWIS closure – expected and will monitor
•
Minor illness presentations have increased in the first month post BWIS closure – seasonal trend, expected and will monitor (93% of
minor illness patients received ‘choose well advice’ in November and MIU are promoting Pharmacy First)
•
Proportion of East locality patient attendance for wound dressings has increased in the first month post BWIS closure, although numbers
are smaller – will monitor and target practices as required. SPCL hubs can offer this service out of hours
MIU patient experience
Patient experinece
Complaints
Compliments
Jul-15
1
4
Aug-15
2
3
Sep-15
2
2
Oct-15
1
2
Nov-15
2
3
•
Friends and family test at November 2015 shows 98% of patients would be extremely/very likely to recommend service
•
Generally the service is receiving more compliments than complaints
ED attendances
ED attendances East locality M1 to M8
Sum of Activity
Column Labels
Row Labels
J82040 - West End Road Surgery
J82076 - Woolston Lodge Surgery
J82101 - Chessel Practice
J82128 - Old Fire Station Surgery
J82141 - Bath Lodge Practice
J82171 - Bitterne Park Surgery
J82180 - Townhill Surgery
J82187 - Weston Lane Surgery
J82208 - St.Peters Surgery
J82622 - Ladies Walk Practice
Grand Total
2014/2015
1491
1651
1683
887
1520
999
583
1356
591
1049
11810
2015/2016
1489
1534
1537
904
1404
1121
566
1228
581
906
11270
KEY:
Activity has decreased by 10% or higher than last year
Activity has decreased from last year, but less than 10%
Activity is equal to last year
Activity is higher than last year, but less than 10%
Activity is more than 10% higher than last year
•
East practice ED attendances in November are have increased slightly compared to previous months and same time period last year – in
line with the rest of the city
•
Year to date, activity for all bar two East practices has decreased compared to same time period last year
•
Attendances by time of day for East locality patients mirrors that of the rest of the city
Date of meeting
27 January 2016
Agenda Item (number)
7
Chief Executive Officer’s Report
Topic Area
Summary of paper and key
information
General update on the development work of the CCG, key
national developments and working with the wider health and
social care system since the previous meeting of the Board.
1.
Delivering the Forward View: NHS Planning guidance
2016/17 – 2020/21. The new planning guidance was
published on 22 December 2015 and may be found at
www.england.nhs.uk. It is authored by the six national NHS
bodies and sets out a list of national priorities for 2016/17
together with longer term challenges for local systems,
together with financial assumptions and business rules. The
Government’s Mandate to NHS England is not solely for
commissioners but the NHS as a whole. The NHS is
required to produce two separate but connected plans:
•
•
A local health and care system ‘Sustainability and
Transformation Plan’ (STP), place based and driving
delivery of the Five Year Forward View, covering the
period October 2016 to March 2021; and
A plan by organisation for 2016/17., organisationbased but consistent with the emerging STP
A brief summary is attached at Annex A. An early decision
is required to agree a proposed ‘footprint’ for the STP by
29 January. NHS England have organised an event for
Trust and CCG leaders on 20 January at which it is
intended to discuss this issue. It is likely to be proposed
that the local footprint for the STP should cover Hampshire
and the Isle of Wight to align with devolution proposals. It
is recommended that this idea should be supported by the
CCG with the proviso that this forms the ‘umbrella’ plan
with a set of ‘sub’ plans included within it including a plan
for the City of Southampton, adhering to the principle of
subsidiarity and ensuring that work at the wider Hampshire
level is focussed on adding value. This matter can be
discussed more fully at the Board meeting.
2. Financial Allocations. The CCG received details of its
three year 2016/17-2018/19 running costs and programme
allocations for current CCG commissioning responsibilities,
1/4
including for the first time an allocation for commissioning of
GP services in the City which we will take responsibility for
from April 2016. Indicative allocations were also provided for
2019/20-2020/21. The documentation also included details
of the CCG’s ‘notional’ allocation for specialised
commissioning which is undertaken by NHS England, to give
an overall ‘place based’ allocation. The CCG is working
through the detail of these allocations and more detail will be
provided in the 2016/17 opening budget paper which will be
presented to the board at the end of March 2016. Further
detail across a longer period will be included in the STP.
3. Delegated Primary Care Commissioning. On 17
December 2015, the CCG received approval from NHS
England for delegated arrangements for commissioning GP
services from April 2016. The letter is attached at Annex B.
4. Southampton City Council Budget. .Following discussion
at the November Board meeting, the CCG’s formal response
to the Council’s budget consultation was submitted on 24
December 2015. In summary, the CCG:
• welcomes the opportunity to comment on the budget
proposals so far
• is concerned to see that the Council should express its
clear commitment to prioritising social care needs
• acknowledges that the proposals currently fall short of
what will be required and expects to be closely
consulted on further proposals as they emerge
• acknowledges that, whilst the CSR contains some
recognition of the pressures facing social care, this still
falls some distance short of a sustainable settlement
• firmly commits to closer alignment of the planning and
funding of health and care between the Council and
CCG in order to mitigate the threats to the continued
provision of services vital to those in greatest need in
our City and to enable the delivery of a sustainable
and transformed health and care sector that we can be
proud of.
5. Developing Our Partnership for Wellbeing in
Southampton. On 17 December, the CCG Board held a
joint seminar with the Council’s Cabinet to:
• Develop a shared understanding between leaders on
what the significant health, care and wider well-being
challenges and opportunities are for people who live in
Southampton City.
• Build shared understanding and insights t what the
implications of these challenges and opportunities are,
in terms of integration of both commissioning and
provision and to identify any barriers to making positive
progress.
• Develop a shared ambition about how these
challenges can be met, building on the good
foundations already in place, and agree a broad way
forward together.
• A small working group has been set up to develop
proposals which will be discussed further during march
and presented to the Board and Cabinet for approval.
2/4
6. CCG Assurance. A report has been received from NHS
England summarising the outcome of the review of the
second quarter, 2015/16. It is attached at Annex C for
information.
7. 2016/17 Financial Plan. Despite the better than expected
allocations, it remains clear that a substantial savings
programme will be required.in 2016/17. The financial plan
will be set out in the opening budget paper (March 2016) and
as a key part of the 2016/17 Operating Plan. Following the
stocktake last October, the CCG management team have
been developing the approach to delivering savings as a key
component of the overall financial plan. It was agreed that
the position would be reviewed at the end of January 2016 to
consider options for enhancing delivery. The CCG’s
programme for 2016/17 will build upon the successful
delivery of QIPP in 2015/16 by the CCG. A number of critical
steps have been taken to accelerate the work-up of 16/17
savings plans:
•
•
•
•
•
•
Early November workshops were held with Directors and
the programme team (PMO) to identify and prioritise
schemes for 16/17;
Also in early November, weekly governance meetings
were set up (and are ongoing) with Directors and PMO,
providing a weekly drumbeat and check-in of progress;
Late December, Commissioning Managers - with support
from Finance and PMO - completed the work-up of 16/17
scheme proposals, which include detailed finance and
delivery plans;
Early January, the 16/17 schemes were presented at the
senior management team by the accountable Associate
Directors and their confidence levels of scheme delivery
were discussed and agreed.
The 2016/17 draft savings programme is the outcome of
the above steps taken to work-up schemes and we are
confident that these numbers are robust, following our
thorough focus over the last 3 months.
Further schemes will be required prior to finalisation of the
Plan:
o a ‘pipeline’ list of ideas also exists which has
potential to be worked-up in-year and may help to
mitigate any slippage that may arise.
o work is commencing on RightCare may also help
us to identify additional opportunities by tackling
unwarranted variation and a workshop will be run
at CEG on 16th March to review clinical pathways
8. Mental Health Matters. Following the successful period of
engagement to identify priorities for improving mental health
in the City, a formal consultation will be launched shortly.
The Commissioning Partnership Board will agree the final
documentation and process to support this when it meets on
22 January. Intention is to commence a 12 week
consultation from the 1st February 2016 and the final
decision to be made at a future Board Meeting.
9. Contracts Awarded. None in this period.
3/4
Key/Contentious issues to
be considered and any
principal risk(s) relating to
this paper
N/A
(Assurance
appropriate)
N/A
outcomes
N/A
any)
N/A
N/A
Equality Impact
undertaken
Not required for this report.
Report Author
(name and job title)
John Richards, Chief Executive Officer
Board Sponsor
(GP Board member or
Executive Director)
John Richards, Chief Executive Officer
Date of paper
12 January 2016
Actions requested
/ Recommendations
The Board is invited to receive the report and:
•
•
•
4/4
Agree the proposal (at para 1) to develop, subject to the
agreement of partners, an STP based on a Hampshire
and the Isle of Wight footprint, maintaining a clear principle
of subsidiarity with a comprehensive ‘sub’ plan for
Southampton City and ensuring that the elements of the
wider Hampshire plan clearly add value to this.
Confirm the approach to delivering the CCG’s savings
programme (outlined at para 7)
Endorse the approach to proceed to consultation on
mental health (para8).
Operational Plan: The nine ‘must-dos’ we need to address
Southampton City
Clinical Commissioning Group
1. Develop a high quality and agreed STP, and subsequently achieve what you determine are your most locally critical milestones for
accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View
2. Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively
engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates
set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through
implementing the RightCare programme in every locality.
3. Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues
4. Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four
hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making
progress in implementing the urgent and emergency care review and associated ambulance standard pilots.
5. Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency
pathways wait no more than 18 weeks from referral to treatment, including offering patient choice.
6. Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the
constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year
improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following
an emergency admission.
7. Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of
psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common
mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of
referral, with 95 percent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number
of people with dementia.
8. Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community
provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy.
9. Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition,
providers are required to participate in the annual publication of avoidable mortality rates by individual trusts
Clare Young - PMO
1
ANNEX B
NHS England
Quarry House
Leeds
LS2 7UE
CONFIDENTAL
John Richards
Accountable Officer
By Email
Email: england.co-commissioning@nhs.net
john.richards@southamptoncityccg.nhs.uk
17 December 2015
Dear John
Primary Care Co-commissioning: Approval for Delegated Arrangements
Further to your recent submission to take forward delegated co-commissioning
arrangements, I am delighted to inform you that NHS Southampton City CCG has
been approved to take on delegated responsibility for NHS England specified
general medical care commissioning functions from 1 April 2016, as per the
functions set out in the forthcoming delegation agreement.
Delegated commissioning gives CCGs an opportunity to develop a more holistic
and integrated approach to improving healthcare for local populations. It gives
CCGs an opportunity to further improve out-of-hospital services provision and
deliver the new models of care set out in the NHS Five Year Forward View. By
aligning primary and secondary care commissioning, it also offers the opportunity
to develop more affordable services through efficiencies gained.
Delegated commissioning is a step on the journey towards a more place based
approach to commissioning and the primary care team in the local office of the
South Region are committed to supporting you in your new arrangements. In
addition, the joint CCG and NHS England primary care co-commissioning
programme oversight group, co-chaired by Ian Dodge (National Director:
Commissioning Strategy, NHS England) and Dr Amanda Doyle (Chief Clinical
Officer, NHS Blackpool CCG and Co-chair, NHS Clinical Commissioners), will
continue to provide national support and advice to assist the delivery of cocommissioning arrangements.
High quality care for all, now and for future generations
A. Delegation Agreement
A copy of the Delegation Agreement will be sent to you in January 2016. Last
year, we agreed with CCGs and NHS Clinical Commissioners a standardised set
of primary medical functions for delegated arrangements, as set out in the
delegation agreement. The same primary medical services functions will be
delegated to CCGs in 2016/17 as 2015/16. To keep the process as simple and
easy as possible, and avoid unnecessary legal fees, CCGs applying for
delegation for 2016/17 should not seek local variations.
B. National webinars
A suite of documents are available on NHS England’s website to support CCGs
to establish delegated arrangements, including draft terms of reference for
primary care commissioning committees. In addition, there will be a number of
national webinars to answer any queries you may have about delegated
arrangements.
The webinar series will begin with two webinars on the Delegation Agreement,
which will be supported by the NHS England co-commissioning policy and legal
teams. These webinars will be held on:


Tuesday 19 January 2016 11am to 12noon
Thursday 4 February 2016 2pm to 3pm
For joining details, please email england.co-commissioning@nhs.net
In addition, further webinars will be held between February and March on a range
of topics, including governance arrangements and workforce models. The exact
dates will be communicated via the CCG bulletin in early January.
C. Lay member training
NHS England is providing a further training programme for CCG lay members, to
support them in their new roles in chairing primary care commissioning
committees. The training programme will have a specific focus on conflicts of
interest management and include practical exercises and advice on applying the
conflicts of interest safeguards. The training days will be held at the following
locations:





Tuesday 9 February – Sheffield
Tuesday 23 February – London
Tuesday 8 March – Leeds
Tuesday 22 March – Reading
All events will be held at a central location, with easy reach of train and motorway
links. CCG lay members can register here
[https://www.surveymonkey.com/r/MV8R6DG]
Places will be offered on a first come, first serve basis and are only open to CCG
lay members in light of their increased responsibilities in primary care
commissioning. We strongly recommend that CCG lay members attend one of
the training events.
NHS England will formally announce the list of CCGs that have been approved to
proceed to delegated primary care commissioning in the next few days and in the
meantime, the NHS England Region South will be in touch shortly to finalise the
arrangements for implementation of the delegation arrangement.
We look forward to working with you.
Yours sincerely,
Andrew Ridley
Regional Director South
NHS England
C.c.
June Bridle
Margaret Wheatcroft
Dominic Hardy
ANNEX C
Southampton CCG – Assurance ratings as at 25/11/2015
Component
Categorisation
Rationale
Well led
Good
OD Plan in place, with feedback from staff & board members.
Succession Plan in place for Board members, Execs and Clinical Leads
Patient & Public responses to 360 shows improvement in positive responses since 13/14
Constitution reviewed twice yearly
All policies and TORs reviewed regularly & robust governance arrangements in place
CCG plays a robust role in HWB, good relationship with Council & Providers
CCG maintains a robust risk management framework and BAF/risk register reviewed regularly
Patient & Public engagement well embedded. CCG uses a range of public engagement techniques to
understand & build relationships with local communities
Delegated
functions
Good
CCG is performing to contract management responsibilities for OOH, to include identifying key health
needs & service improvements. Joint commissioning COIs appropriately recognised and managed.
Following concerns with OOHs provider delivery contract management has been strengthened and CCG
working collectively with other commissioning CCGs to improve performance and quality of services.
Finance
Limited Assurance
CCG is delivering against Plan in year
Financial recovery plan submitted to NHSE to achieve 1% surplus
Performance
Limited Assurance
A&E target not delivered in Q1 & Q2 of 2015/16; Remedial Action Plan signed off at the September UHS
Performance Board with agreed actions, milestones and penalties
C Difficile – 3 cases against a threshold of 3 for September 2015, 27 cases against a threshold of 23
year to date.
Two Week Wait for Breast Symptoms (where cancer was not initially suspected) – not achieved in Q2
Planning
Good
Comprehensive operating plan produced in consultation with neighbouring commissioners and
addresses local priorities as well as all national planning (including 5YFV) requirements
Robust BCF plans in place with appropriate governance arrangements
SRG plans agreed and aligned
Plans aligned with HWB partners
Overall
rating/rationale
n/a
Summary of key
discussion
points
Winter preparedness and robust system resilience arrangements.
1
Southampton City CCG – Remedial action being taken
What is the failing leading to a ‘limited assurance’ or not assured rating
The CCG has a limited assurance rating for finance due to non-compliance with 1% surplus business rules. The CCG also has a limited
assurance rating for performance, largely owing to UHSFT A&E.
Time period over which the CCG has been failing
The non-compliance with 1% surplus business rules started at plan.
The A&E performance of its main acute provider UHSFT has continuously failed to meet and sustain the 95% standard in 2015/16.
Remediation taken so far
The CCG has worked closely with partner organisations to develop a system-wide resilience plan and it is clear that good progress has
been made since the system summit on 12 June 2015.
A whole systems plan is now in place, with clear executive leads accountable for delivery of the plan across both provider and
commissioners.
Next steps
The system faces significant challenges and it should continue developing its approach to whole-system demand and capacity modelling
with Deloitte as part of wider system work.
Once the system resilience work programme is finalised, the system should consider the implementation of an accountability framework.
The CCG will continue to strengthen its relationship with University Hospital Southampton NHS FT, particularly with continuing board to
board discussions. During the meeting, the CCG outlined the intention for the next discussion to focus on managing elective capacity in
relation to non-elective capacity.
NHS England Wessex team and the CCG will schedule a discussion on the reablement consultation that was discussed during the
meeting.
2
Date of meeting
27 January 2016
8
Finance and Performance Report – Month 9
Topic Area
Finance and Performance Update
information
Finance and performance update as at December (month 9):
this paper
The month 9 finance and performance report is attached. The
CCG is continuing to forecast an on-plan position for year-end.
That is an in-year deficit of £1,317k and a cumulative position of
£2,431k surplus.
(Assurance
appropriate)
Cost pressure areas continue to be acute activity; continuing
healthcare; and prescribing. Forecasts continue to be relatively
stable, with some increase in acute activity this month. Directors
and commissioning teams continue to monitor positions closely
and take mitigating action as necessary to ensure the CCG meets
its targets and delivers the plan for this year.
N/A
outcomes
None
any)
See report
N/A
Equality Impact
undertaken
N/A
1/2
Report Author
Kay Rothwell
Deputy Chief Financial Officer
Board Sponsor
(GP Board member or
Executive Director)
James Rimmer
Date of paper
January 2016
Actions requested
/ Recommendations
The Governing Body is asked to note this report.
2/2
Finance & Performance
Report
Month 9 2015/16
Financial Performance
At the end of December the CCG is reporting achievement of its financial plan of £1,317k in-year deficit, with a cumulative position of
£2,431k surplus, after taking into account the brought forward surplus from previous years. Acute activity has seen an increase in the
forecast activity this month and pressures continue to be faced within Continuing Healthcare and Prescribing. QIPP performance remains on
track, however pressures are being felt in other budget areas that require action to manage to plan. Mitigating actions are being discussed
and taken by directors and the position will be monitored very closely. For more detail see pages 6 to 12.
Key Performance Issues
Cancer
4 cancer waiting time standards were not achieved at CCG level in November 2015:
• First definitive treatment within one month of a cancer diagnosis – 95.37% vs 96% standard. 5 out of 108 patients breached. All UHS
patients; all due to capacity.
• 31 Day Subsequent Treatment (Surgery) – 92.31% vs 94% standard. 3 out of 39 patients breached. All UHS; 2 due to capacity and 1 due
to complexity.
• All Cancer 62 Day Urgent Referral to Treatment – 82.69% vs 85% standard. 9 out of 52 patients breached. All UHS; 5 due to diagnostic
delays, 2 due to complex pathways, 1 patient choice and 1 unknown.
• 62-Day Wait for First Treatment For Cancer Following a Consultants Decision to Upgrade The Patient Priority – 83.33% vs 86%
standard. 2 out of 12 patients breached. Both UHS; both patient choice.
Activity
Activity performance for the period to November 2015 overall is showing that demand is being managed within planned levels. Referrals
have reduced marginally from previous month, as have outpatient appointments; elective activity is reporting on Plan and is an
expected increase from previous month, reflective of continued reduction in waiting list. Both Non elective and A&E activity
have increased slightly from previous month.
2
Commentary on NHS Constitution Performance
Accident and Emergency
• CCG’s performance for October 2015 was 92.50% against the 95% standard a worsening in performance from only just missing the
standard at 94.95% in September 2015.
• UHS’s performance declined to 88.48% for October 2015, having achieved 92.65% in September 2015. Weekly figures supplied by the
Trust show weekly performance between 80.85% and 93.45% through November with provisional performance of 83.90% for the first
week of December. Actions to improve UHS Performance include:
• Remedial Action Plan signed off at the September UHS Performance Board with agreed actions, milestones and penalties.
November milestone signed off by Commissioners on 15th December 2015. Recent actions include:
• The Trust launched their electronic bed management system giving staff earlier sight of bed availability
• Increased clinician hours and provision of additional senior decision making support for ED by providing ED consultant
cover during evenings and weekends
• Pit stop bay opened on the 4th December 2015
• Ward G7 now operating as a transition ward to assist flow through the hospital
• Focus continues on the Home before lunch Programme
• Delayed Transfers of Care are included in the Whole System Action Plan in relation to improving and speeding up complex
discharge arrangements.
• In 2015/16, Type 1 A&E attendances at CCG level and UHS trust wide are down approximately 4% on 2014/15 year to date following a
similar trend to last year.
• Breaches however are also significantly down year on year, approximately 13-15%, this is a noteworthy improvement from last year
which saw breaches approximately 41% higher at year end compared to the previous year at both CCG and UHS trust wide.
• At England Total Type 1 A&E Attendances are down 1% compared to the same period last year, breaches however are 16.4% higher
this year to date, completely different to the local trend.
Year on Year Analysis (M7)
SC CCG A&E Attendances
Type 1 2014/15 to M7
Type 1 2015/16 to M7
Year on Year Change
Attendances
34925
33489
-1436
-4.11%
Breaches
4432
3823
-609
-13.74%
England Total A&E Attendances
Type 1 2014/15 to M7
Type 1 2015/16 to M7
Year on Year Change
UHS A&E Attendances Trust Wide
Type 1 2014/15 to M7
Type 1 2015/16 to M7
Year on Year Change
Attendances
8848574
8752591
-95983
-1.08%
Breaches
686761
799361
112600
16.40%
Attendances
57773
55194
-2579
-4.46%
Breaches
7555
6380
-1175
-15.55%
3
Accident & Emergency Key Indicators
Notes:
A&E Reporting is no longer Nationally required on a weekly basis and is now monthly.
4
Commentary on NHS Constitution Performance
Healthcare Associated Infections
• No cases of MRSA were reported for November 2015, 3 cases year to date against a threshold of 0.
• 2 cases of C.difficile against a threshold of 3 for November 2015, 32 cases against a threshold of 29 year to date, 3 over.
Referral to Treatment
• In November 2015, the CCG achieved the incomplete standard; 95.05% against the 92% standard.
• Total CCG waiting list has decreased from 9,452 (October) to 9,264 (November), a decrease of 188.
• Total CCG backlog has increased from 410 (October) to 444 (November), an increase of 34.
Diagnostics
• November 2015 CCG performance is 0.76% against the 1% standard, a worsening position from October (0.26%) but still within
the standard – 23 patients were waiting over 6 weeks for a diagnostic test; 10 at UHS (9 MRI and 1 Peripheral Neurophys), 9
Southampton NHS Treatment Centre (4 Gastroscopy, 4 Flexi Sigmoidoscopy and 1 Colonoscopy), 1 HHFT (Echocardiography), 1
RBCH (Gastroscopy), 1 University Hospitals of Leicester (Colonoscopy) and 1 InHealth (Dexa Scan).
Mixed Sex Accommodation
• There were no breaches in November 2015 or year to date.
Cancelled Operations
• At University Hospital Southampton there were 5 patients in December whose procedure were cancelled and were not readmitted within 28 days: 2 Surgery, 2 Orthopaedics and 1 Child Health.
5
CCG Finance Report
NHS Southampton City CCG Finance Report Month 9 2015/16
Annual
M9 YTD
Actual (Under) / Over Spend
£'000
£'000
%
120,524
1,416
1%
1,855
135
8%
919
(48)
(5%)
4,092
88
2%
3,376
(171)
(5%)
8,364
(12)
(0%)
14,107
(187)
(1%)
1,797
125
7%
6,768
1,063
19%
25,339
0
0%
3,366
0
0%
4,109
(40)
(1%)
27,123
0
0%
2,323
(62)
(3%)
21,106
603
3%
2,037
(3)
(0%)
8,108
114
1%
3,056
(146)
(5%)
35,770
612
2%
1,785
(23)
(1%)
2,694
37
1%
1,316
(172)
(12%)
410
(1,533)
(79%)
4,370
(1,795)
(29%)
University Hospitals Southampton FT
Acute
Commissioning Portsmouth Hospitals NHS Trust
Hampshire Hospitals FT
Other NHS Acute
Non-Contracted Activity (NCA)
Ambulance Services
Treatment Centre
Minor Injuries Unit
Other Independent Sector
Mental Health Southern Health FT
Commissioning Solent NHS Trust (CAMHS)
Other Mental Health Contracts (inc NCAs)
Solent NHS Trust
Community
Other Community Contracts
Services
Continuing Healthcare and Special Placements
Non-NHS
Commissioning Funded Nursing Care
Other Non-NHS
Clinical Corporate Costs
Prescribing
Primary Care
Commissioning Local Enhanced Services
Out of Hours (inc 111)
Other Primary Care
Managed Programmes
Running Costs Running Costs
Plan
£'000
119,109
1,720
967
4,005
3,547
8,376
14,294
1,672
5,705
25,339
3,366
4,149
27,123
2,385
20,503
2,040
7,994
3,202
35,158
1,809
2,657
1,488
1,942
6,165
Total Expenditure
304,715
304,715
In Year Resource Allocation
303,398
303,398
In Year Surplus / (Deficit)
(1,317)
(1,317)
Surplus brought forward
3,748
3,748
Total Surplus / (Deficit)
2,431
2,431
(0)
0%
Last Month FOT
(Under) / Over
Spend
£'000
830
86
(48)
4
(332)
(294)
(361)
93
739
0
0
(32)
0
(43)
259
(15)
(26)
(116)
524
(21)
11
(179)
(10)
(1,069)
%
0.9%
6.7%
(6.6%)
0.1%
(7.1%)
(4.7%)
(3.4%)
7.5%
17.2%
0.0%
0.0%
(3.1%)
0.0%
(10.1%)
1.7%
(1.0%)
(0.4%)
(4.9%)
2.0%
(1.6%)
0.5%
(16.0%)
5.9%
(25.3%)
(Under) /
Over
£'000
1,080
141
(36)
55
(208)
(43)
(187)
104
884
0
0
(63)
0
(14)
591
17
21
(127)
612
(23)
73
(71)
(1,477)
(1,329)
0
0.0%
(0)
Change
A / (F)
£'000
335
(6)
(12)
32
37
31
(0)
21
180
0
0
23
0
(48)
12
(20)
92
(20)
0
0
(36)
(101)
(56)
(466)
0
6
CCG Finance Report
Statement of Financial Position as at Month 9
Property Plant and Equipment
Total Non-Current Assets
Cash and Cash Equivalents
Inventories
Current Trade and Other Receivables
Total Current Assets
Opening
Balance
£'000
0
0
474
0
4,512
4,986
Year to
Mvmt
Date
Balance
YTD
£'000
£'000
0
0
0
0
(120)
0
(1,105)
(1,225)
354
0
3,407
3,761
Current Trade and Other Payables
Current Borrowings
Current Provisions for Liabilities and Charges
Total Current Liabilities
(17,563)
0
0
(17,563)
1,641 (15,922)
0
0
0
0
1,641 (15,922)
Total Current Assets / (Liabilities)
(12,577)
416 (12,161)
Non Current Liabilities
Total Net Assets
0
(12,577)
0
0
416 (12,161)
I&E Reserve - General Fund
Revaluation Reserve
Reserves
Statement of Comprehensive Net Expenditure
Total Taxpayers Equity
12,577 (227,120) (214,543)
0
0
0
12,577 (227,120) (214,543)
0
226,704
226,704
12,577
(416)
12,161
7
CCG Finance Report – Month 9 2015/16
•
At the end of December the forecast position is achievement of our financial plans to deliver an in-year
deficit of £1,317k, with a cumulative year end position of £2,431k surplus (0.8%), after taking into account
the brought forward surplus from last year.
•
This position is based on 8 months' acute activity data; up to date continuing healthcare data and 7
months' prescribing data.
•
After remaining stable for several months the forecast spend on our main acute provider, University
Hospitals Southampton NHS FT (UHS), has increased this month to £1,416k over plan (1%). This follows a
particularly busy November, which is explained further below. A detailed breakdown of activity can be
seen on the following slide.
•
Scheduled Care, Unscheduled Care and Maternity activity continue to be under plan year to date, however
in the first two of these areas increased activity in November has meant the % under has decreased this
month. This has fed through into the increased forecast year end position.
•
Unscheduled Care activity was higher that our estimates in November. A particular increase was seen in
Paediatric Medical admissions as a result of Bronchiolitis. A similar increase was seen last year, so this is
likely to be the beginning of the seasonal trend for these types of condition. Overall unscheduled care
remains very marginally under plan in activity terms. The next few months activity will be key as pressures
build over the winter period. This will be monitored closely to inform our forecast and mitigating actions
will be considered and taken as necessary.
•
Scheduled Care activity is very close to plan at the end of November and activity levels were only
marginally higher than expected. Waiting list levels have, however increased marginally (47 patients),
indicating that the backlog of patients that has built up over the last couple of months still exists. As in
previous months an element of increased activity has been factored into the forecast position to reflect
this. The estimated casemix of this activity has been reduced this month as the waiting list for Trauma and
Orthopeadic patients has come down.
8
NHS Southampton City CCG Activity at University Hospitals Southampton NHS FT
April to November 2015
Activity
Plan
Annual
Service Area
Scheduled Care
Point of Delivery
Inpatients
Outpatients
Scheduled Care Total
Unscheduled Care
Inpatients
A&E
Unscheduled Care Total
Maternity
Pathway episodes
Inpatients - births
Maternity Total
Critical Care
Direct Access
Excl Drugs & Devices
Critical Care
Direct Access
Exclusions
Other
Other 1
Financial Adjustment
Grand Total to M8
1
2
Activity Activity
Plan YTD Actual
YTD
22,049
14,699
14,682
167,303 111,535 111,495
189,352 126,234 126,177
44,430
29,620
28,132
61,451
40,967
41,816
105,881
70,587
69,948
7,282
4,855
4,619
4,240
2,827
2,873
11,522
7,682
7,492
3,214
2,143
2,121
1,767,726 1,178,484 1,163,089
79,421
52,947
77,472
Activity
Variance
YTD
Activity
Variance
YTD %
Last
Month
Activity
Var % 3
(0.27%)
(0.09%)
(0.11%)
(5.66%)
1.42%
(1.55%)
(4.78%)
2.67%
(2.04%)
0.69%
(1.37%)
53.29%
(17)
(40)
(57)
(1,488)
849
(639)
(236)
46
(190)
(22)
(15,395)
24,525
(0.12%)
(0.04%)
(0.05%)
(5.02%)
2.07%
(0.91%)
(4.86%)
1.63%
(2.47%)
(1.03%)
(1.31%)
46.32%
29,818
2,250
8.16%
7.60%
0
0
0
2,198,468 1,465,645 1,476,117
0
10,472
0.00%
0.71%
0.00%
0.87%
41,352
27,568
Finance
Variance
YTD
£'000
Finance
Variance
YTD
%
749
150
900
239
117
356
(505)
(58)
(564)
(106)
(72)
(14)
5.67%
1.32%
3.65%
0.90%
2.36%
1.13%
(9.33%)
(1.38%)
(5.83%)
(4.21%)
(3.33%)
(0.25%)
160
8.22%
(224) (14.30%)
436
0.55%
This includes Specialist Palliative Care services; Burseldon House; Paediatric Diabetic Medicine and AMD.
2
The Financial Adjustment line includes 30 day re-admissions credit; best practice credits; block services; a small amount of QIPP that
has not been allocated to a service line and CQUIN.
9
•
The next couple of months' activity will be key to seeing how the balance of activity between scheduled
and unscheduled plays out and once December activity is available this can be reflected in the forecast
position.
•
A significant increase was seen in November in the spend on Excluded Drugs at UHS. The majority of this
relates to Cytokine Modulators - Anti TNF, where the spend in November was £510k, £188k (61%) higher
than the average per month from April to October. No such swings were seen in 2014/15, when the
average monthly spend was £331k. The increase was seen across commissioners at UHS and has been
queried with the Trust.
•
Activity at our other acute NHS providers has remained relatively flat this month, with only a small
increase in the forecast spend of £52k, the majority being in non-contracted activity.
•
Activity at other independent sector providers was higher in November and the forecast position has
deteriorated by £180k to £1,063k over plan (19%). The main providers within this position are: Spire £504
over (53%); Nuffield £250 over (42%) and BMI £65 over (19%). The majority of this activity is Trauma and
Orthopaedic, with some Ophthalmology at Spire. The position will be monitored very closely. Although
activity at Spire seems to have levelled off, both Nuffield and BMI saw significant increases in forecast this
month, as activity has been increasing steadily month on month. Waiting lists are also taken into account
when calculating the forecast, although as these are relatively small numbers they can be volatile.
•
Outside of Acute activity our other two key risk areas of Continuing Healthcare and Prescribing have
remained relatively stable this month. The continuing healthcare position is £603k over plan (3%). The
team continue to work hard to review placements and achieve the best quality, most appropriate
packages of care for clients. Demand from new clients and increasing complexity is outstripping the £1.2m
QIPP savings that have been achieved, resulting in the overspending position.
10
•
The Prescribing forecast has held stable and includes an estimate of savings on Cat M drugs in the last
quarter of the year. Local estimates are that this saving will not be as high as has been suggested
nationally, due to the local pattern of drugs prescribed. The latest data available for October did see an
increase in prescribing expenditure, but it is anticipated that this will be offset by the Cat M savings and
the forecast position continues to be £612k over plan (2%).
•
Forecast positions on OOH and NHS 111 have improved marginally this month. For OOH this relates to an
increase in penalties anticipated, due to performance issues. The decrease in NHS 111 relates to lower
activity estimates and sanctions applied.
•
Other primary care is forecast to underspend by £172k (12%). The movement this month relates to revised
estimates on over 75 nurses and the minor ailments service following a review of estimated costs and
activity.
•
Over spendings are being offset by under spends within clinical corporate, running costs and managed
programmes.
•
Below are the key risks and mitigations over and above the forecast position reported here:
Risks
Acute activity
Continuing Care
QIPP under delivery
Prescribing
NHS Property Services
Mitigations
Contingency held
Non-recurrent measures
Investment slippage
£'000
Probability
3,000
65%
1,200
50%
1,000
50%
800
75%
1,500
50%
1,520
2,500
3,250
100%
51%
49%
Potential
Risk
£'000
1,950
600
500
600
750
4,400
1,520
1,280
1,600
4,400
11
Summary of QIPP Performance
Acute Services
Mental Health Services
Community Health Services
Continuing Care Services
Primary Care Services
Other Programme Services
Running Costs
Total
2015/16 Annual QIPP Savings
YTD QIPP Savings
Plan Forecast
% of
Var
Plan
Actual
Var
£'000
£'000
£'000
Plan
£'000
£'000
£'000 % of Plan
3,826
4,260
434
111%
2,875
3,116
241
108%
909
910
1
100%
675
680
5
101%
1,476
1,480
4
100%
929
930
1
100%
3,296
2,850
(446)
86%
2,484
2,170
(314)
87%
2,402
2,400
(2)
100%
1,800
1,810
10
101%
1,251
1,260
9
101%
945
950
5
101%
990
990
0
100%
747
740
(7)
99%
14,150 14,150
0
100% 10,455 10,396
(59)
99%
12
CCG Performance Against NHS England Assurance Framework
for CCGs: NHS Constitution
Reporting
Level
Target
RTT:% of admitted patients who waited 18 weeks or less
CCG
RTT:% of non-admitted patients who waited 18 weeks or less
CCG
RTT:% of incomplete patients waiting 18 weeks or less
Q1
Q2
Q3 (QTD)
YTD
2015/16
90.81%
94.49%
94.34%
92.36%
93.88%
95.05%
97.90%
97.29%
95.94%
97.17%
95.68%
95.21%
96.74%
96.28%
95.21%
95.21%
0
1
4
0
1
5
6
0
0
0
0
0
0
0
0
0
0
6
0
0
6
6
99.54%
99.49%
99.66%
99.74%
99.24%
99.63%
99.66%
99.24%
99.24%
96.34%
95.11%
91.03%
94.95%
92.50%
94.26%
93.71%
92.50%
93.78%
97.26%
96.31%
97.09%
95.81%
95.65%
95.70%
96.26%
96.80%
96.18%
95.98%
96.35%
91.25%
92.86%
94.59%
92.59%
88.16%
92.00%
93.67%
93.28%
92.58%
92.86%
92.60%
97.53%
96.26%
98.10%
95.92%
97.09%
96.00%
95.37%
97.64%
97.42%
95.67%
96.73%
97.05% 100.00% 100.00% 90.00% 100.00% 92.31%
96.00%
80.00%
92.31%
96.20%
96.25%
87.50%
93.64%
2014-15 Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
90%
93.18%
94.46%
94.74%
94.28%
95.33%
94.29%
93.35%
93.94%
97.21%
97.34%
98.04%
98.23%
97.43%
97.61%
96.87%
96.80%
CCG
95%
92%
96.74%
96.75%
96.70%
96.74%
96.71%
96.73%
96.28%
RTT: Number of admitted patients who waited >52 Weeks
CCG
0
14
0
0
0
0
1
RTT: Number of non-admitted patients who waited >52 Weeks
CCG
0
1
0
0
0
0
0
RTT: Number of incomplete patients waiting >52 Weeks
CCG
0
0
0
0
0
1
% Patients waiting <6 weeks for a diagnostic test
A&E waits
CCG
99%
99.83%
99.72%
99.62%
99.63%
A&E <=4hrs
Cancer waits – 2 week wait
CCG
95%
91.99%
91.94%
94.91%
Cancer patients seen <14 days after urgent GP referral
CCG
93%
95.42%
96.68%
Breast Cancer Referrals Seen <2 weeks
Cancer waits – 31 days
CCG
93%
95.18%
95.00%
Cancer diagnosis to treatment <31 days
CCG
96%
97.02%
97.85%
Cancer Patients receiving subsequent surgery <31 days
CCG
94%
Cancer Patients receiving subsequent Chemo/Drug <31 days
CCG
98%
99.25% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00%
Cancer Patients receiving subsequent radiotherapy <31 days
Cancer waits – 62 days
CCG
94%
97.67% 100.00% 96.67% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
98.99% 100.00% 100.00% 99.62%
Cancer urgent referral to treatment <62 days
CCG
85%
78.95%
80.95%
87.50%
Cancer Patients treated after screening referral <62 days
CCG
90%
85.71%
93.75%
75.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Cancer Patients treated after consultant upgrade <62 days (local threshold)
Category A ambulance calls (SCAS)
CCG
86%
91.51% 100.00% 100.00% 92.31% 100.00% 100.00% 100.00% 100.00% 83.33%
Cat A calls within 8 minutes - Red 1
Trust
75%
75.04%
76.67%
75.59%
72.70%
67.75%
71.22%
68.74%
70.70%
71.78%
Cat A calls within 8 minutes - Red 2
Trust
75%
74.49%
76.54%
76.14%
74.54%
70.87%
71.64%
70.89%
72.94%
76.16%
Cat A calls within 19 minutes
Mixed Sex Accommodation Breaches
Trust
95%
95.49%
95.66%
95.22%
94.43%
93.65%
93.87%
93.67%
94.52%
95.27%
Mixed Sex Accommodation Breaches
CCG
0
2
0
0
0
0
0
0
0
0
CCG
95%
95.8%
Indicator
Dec-15
Referral To Treatment waiting times for non-urgent consultant-led treatment
Diagnostic test waiting times
86.44%
85.51%
92.06%
87.10%
90.57%
82.69%
86.34%
87.63%
86.67%
86.83%
90.91% 100.00% 100.00% 95.56%
96.88% 100.00% 90.00%
95.71%
74.32%
75.13%
69.19%
72.34%
72.46%
75.06%
75.73%
71.14%
74.74%
74.00%
95.57%
95.10%
93.73%
95.13%
94.74%
0
0
0
0
95.35%
97.58%
Mental health
Care Programme Approach (CPA): The proportion of people under adult mental
illness specialties on CPA who were followed up within 7 days of discharge from
psychiatric in-patient care during the period.
95.35%
97.58%
Notes:
• Referral to Treatment admitted and non admitted standards abolished June 2015.
• SCAS ambulance April to October, Q1 and Q2 data is from Unify. November, December, Q3 and YTD data is from SCAS report as at w/e 03/01/16.
96.44%
13
UHS – Delayed Transfers of Care Key Indicators – October 2015
14
CCG – Activity Report – 2014/15 v 2015/16 as at November 2015
FY Plan
YTD Plan
YTD Actual
YTD %
YTD Variance Variance
against Plan
YTD Variance
against Plan
after adj%
Previous
Month
Variance
against Plan
%
Movement
%
GP Referrals
42,189
28,252
25,317
-2,935
-10.4%
-3.3%
-2.8%
-0.5%
Other Referrals
22,221
14,797
14,801
4
0.0%
0.0%
-0.2%
0.2%
Non Elective FFCEs
32,112
21,298
20,933
-365
-1.7%
-0.5%
-1.0%
0.5%
Total elective
28,688
19,148
19,139
-9
0.0%
0.0%
-0.1%
0.1%
All 1st outpatients
55,016
36,343
34,885
-1,458
-4.0%
-4.0%
-3.3%
-0.7%
GP Seen
35,380
23,422
21,948
-1,474
-6.3%
-6.3%
-5.9%
-0.4%
A&E
113,786
74,761
72,648
-2,113
-2.8%
-2.8%
-3.0%
0.2%
Notes:
GP Referrals
Non Electives
Solent reduced against Plan as now excluding T&O from 1.4.15 - reduced figure to -3.3%. GPs referring directly more to
GPSI, for diagnostics & community based tier 2 services. CCG visits to GP surgeries to refresh them of community
pathways, tier 2 services, MoM,Choice. Growth of 1% included
SCCG Plan adjusted following NHSE adjustment to buy 1.2% additional activity. Adjusted to -0.5%
Total Electives
On plan, slight increase since previous month
All 1st Outpatients Continued reduction
1st Outpatients
attendances
following GP
referral
A&E
UHS decreased in October -8% (159) against Plan
Overall reduction in Non NHS Providers -10% (767) - increased access to A&G; better community MSK&Pain Service;
expanded GPSI opthamology service;
BWIC now not reporting any activity against a pre set Plan. Fewer people attending A& E - better use of 111/ alternatives;
CCG communication plan ongoing
15
CCG – Quarterly Activity Return
General Notes
Q2
NHS Southampton CCG
There is the same number of working day s in Q4 2014 compared to Q4 2013.
Quarterly Activity Reporting Dashboard
YTD there are 2 less working days compared to 2013/14.
Please review the QAR Issue log for data quality issues raised with the Trusts.
0.00 >5%
25.00 between 2% and 5%
50.00 <2%
Performance Improving
Performance Staying about the same
Performance Declining
2015/16 Actual
GP Written Referrals
Year on Year Comparison
Q2
YTD
10894
20759
2015/16 Actual
2014/15 Actual
10889
21820
2014/15 Actual
Year on Year variance
5
-1061
2015/16 Actual
Patients Admitted
Q2
YTD
5620
11313
2015/16 Actual
2014/15 Actual
5917
11606
2014/15 Actual
-297
-293
2015/16 Actual
All 1st Outpatients Seen
Q2
YTD
15442
30525
2015/16 Actual
2014/15 Actual
13612
28073
2014/15 Actual
1345
2858
1830
2452
92
-77
-4.9%
-2.5%
8.7%
Other Referrals
Q2
YTD
6599
13136
6749
13698
-150
-562
291
-46
-36
2015/16 Actual
2014/15 Actual
-4.1%
Patients Failed to Attend
Q2
YTD
125
255
171
Number of Decisions to Admit
Q2
YTD
6922
14131
-12.4%
-2.7%
15492
-765
-1361
2015/16 Actual
851
1619
-130
-136
-8.4%
Subsequent Attendances DNA
Q2
YTD
3001
6033
2015/16 Actual
2014/15 Actual
2322
4815
679
1218
All Subsequent Outpatient Attendances
-8.8%
Removals Other Than Admissions
Q2
YTD
721
1483
2014/15 Actual
All 1st Outpatients DNA
Q2
YTD
1437
2781
7687
25.3%
GP Referrals Made All Specialties (MAR)
2015/16 Actual
Q2
33385
YTD
66651
2015/16 Actual
Q2
10178
YTD
20480
2014/15 Actual
26677
52622
2014/15 Actual
10729
21439
6708
14029
-551
-959
26.7%
-4.5%
QAR Headlines Q2
Notable variances include those patients failing to attend for admission has reduced year on year by 12.4%; DNAs remain stable with a small
reduction of 2.7% on the previous year, whilst there were still 2780 appointments missed, which is 9% of those outpatients seen. There were
6027 follow ups that did not attend, a 25% increase year on year.
16
CCG Performance – Waiting List (All Incomplete Pathways)
Incompletes by Provider
Total CCG waiting list has decreased from 9,452 (October) to 9,261 (November) . Breakdown of key providers:
BMI - SARUM ROAD HOSPITAL
HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST
INHEALTH GROUP LIMITED
NUFFIELD HEALTH, WESSEX HOSPITAL
OTHER
PORTSMOUTH HOSPITALS NHS TRUST
SALISBURY NHS FOUNDATION TRUST
SOLENT NHS TRUST
SOUTHAMPTON NHS TREATMENT CENTRE
SOUTHERN HEALTH NHS FOUNDATION TRUST
SPIRE SOUTHAMPTON HOSPITAL
UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST
Total
Dec
25
127
619
76
170
76
51
855
1,735
34
68
5,367
9,203
2014 / 15
Jan
Feb
29
24
160
157
568
626
67
68
158
166
69
76
48
54
856
926
1,542 1,394
27
31
87
97
5,309 5,377
8,920 8,996
Mar
22
146
619
82
163
65
62
1,026
2,032
28
116
5,445
9,806
April
39
127
645
82
166
68
59
775
1,981
32
121
5,437
9,532
May
32
133
691
84
172
73
66
750
1,858
30
98
5,568
9,555
June
36
126
624
87
178
71
61
630
1,946
16
89
5,530
9,394
2015/16
July
Aug
35
44
130
126
501
600
87
75
182
191
86
93
56
54
630
673
2,009 2,053
41
42
81
112
5,780 6,087
9,618 10,150
Sep
37
129
470
67
196
78
42
592
2,071
34
109
5,748
9,573
Oct
34
126
411
70
191
92
50
507
1,878
39
195
5,859
9,452
Nov
31
132
538
82
169
74
43
582
1,480
42
182
5,906
9,261
Backlog (Patients waiting >18 weeks)
Total CCG backlog has increased from 410 (October) to 444 (November). Analysis of key providers below:
INHEALTH GROUP LIMITED
SOLENT NHS TRUST
Dec
0
14
2014/15
Jan
Feb
0
0
3
1
Mar
1
6
April
2
3
May
0
0
June
2
2
2015/16
July
Aug
0
2
4
2
Sep
1
0
Oct
1
5
Nov
1
4
SOUTHAMPTON NHS TREATMENT CENTRE
UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST
Total - All Providers
0
263
325
4
301
355
0
260
320
0
253
310
0
260
315
0
249
306
0
269
316
0
306
356
0
343
410
47
326
444
0
287
327
0
273
332
17
CCG Performance: Referral to Treatment Times – Incomplete
Pathways – November 2015
96.49%
98.72%
97.61%
91.96%
97.90%
0.00%
95.35%
97.53%
96.82%
UNIVERSITY HOSPITAL
SOUTHAMPTON NHS FOUNDATION
TRUST
SPIRE SOUTHAMPTON HOSPITAL
SOUTHERN HEALTH NHS
FOUNDATION TRUST
100.00% 100.00% 95.17%
83.33%
90.81%
16.67% 98.54% 85.26%
66.67%
92.61%
100.00% 100.00% 96.57%
100.00%
97.58%
100.00%
97.19%
0.00%
96.00%
86.84%
100.00%
98.00%
100.00%
100.00%
100.00%
100.00%
96.62%
100.00%
98.97%
80.95% 98.90% 94.48%
Total Provider
100.00% 85.71% 100.00%
100.00% 100.00% 100.00% 100.00%
100.00% 88.89% 66.67% 100.00%
60.00% 100.00% 100.00%
100.00% 92.31% 100.00% 100.00%
0.00%
50.00% 100.00% 86.21%
83.33%
81.82% 100.00%
80.00%
97.65%
83.33% 78.57%
100.00% 100.00%
94.12%
100.00% 100.00%
100.00%
87.50% 85.71% 100.00%
80.00% 100.00% 100.00% 100.00%
96.34% 85.80% 94.59% 90.70% 99.31%
SOUTHAMPTON NHS TREATMENT
CENTRE
SOLENT NHS TRUST
SALISBURY NHS FOUNDATION
TRUST
PORTSMOUTH HOSPITALS NHS
TRUST
OTHERS
80.00%
100.00%
84.85%
70.00%
100.00%
85.00%
100.00%
81.82%
66.67%
100.00%
100.00%
75.00%
100.00%
86.36%
NUFFIELD HEALTH, WESSEX
HOSPITAL
100.00%
91.67%
100.00%
100.00%
50.00%
100.00%
90.32%
INHEALTH LIMITED
General Surgery
Urology
Trauma & Orthopaedics
ENT
Ophthalmology
Oral Surgery
Neurosurgery
Plastic Surgery
Cardiothoracic Surgery
General Medicine
Gastroenterology
Cardiology
Dermatology
Thoracic Medicine
Neurology
Rheumatology
Geriatric Medicine
Gynaecology
Other
Total
HAMPSHIRE HOSPITALS NHS
FOUNDATION TRUST
Specialty
BMI - SARUM ROAD HOSPITAL
Incomplete pathways are those patients who are still on the waiting list and is a snapshot at the end of the month. Includes
patients whose clock is ‘paused’.
99.81%
99.81%
95.52%
92.32%
91.22%
95.26%
96.80%
0.00%
0.00%
86.11%
96.95%
96.11%
96.58%
85.05%
97.18%
95.45%
100.00%
100.00%
96.13%
98.90%
95.21%
18
South Central Ambulance Service / 111 / Out of Hours
Performance
Monthly Reporting
Provider
SCAS
111
15/16
Area
Metric
Red 1
YTD
14/15
Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15
YTD
15/16
% of Red 1 Incidents within 8 minute target
Trus t
75%
74.76% 76.67% 75.59% 72.70% 67.75% 71.22% 68.74% 70.70% 71.78% 74.32% 72.46%
Trus t
75%
74.46% 76.54% 76.14% 74.54% 70.87% 71.64% 70.89% 72.94% 76.16% 75.06% 74.00%
Callers booked into GP Out of Hours s ervice as a percentage of
total
Total number of ans wered calls within 60 s econds as a % of total
Trus t
95%
95.47% 95.66% 95.22% 94.43% 93.65% 93.87% 93.67% 94.52% 95.27% 95.57% 94.74%
Abandoned Calls
Abandoned calls as a % of total
Trus t
Warm trans ferred
% of calls warm trans ferred
Trus t
Outcome calls as a percentage of total
Trus t
Ambulance dis patch as a % of total (nat. av. 10% of calls triaged)
Total no. of non-conveyed 999 dis patches
Calls Overview
Outcome calls
Dis patch
Non Converyance
OOH
Reporting
Target
Level
Referral to A&E Hos pital Total number of referrals to A&E as a percentage of total
Call to final dis pos ition Start DCA for urgent calls within 15 mins of the call being
ans
Startwered
DCA for non urgent calls within 1 hr of the cas e being
(DX Code SLA)
received
Start DCA for non urgent calls within 2 hrs of the cas e being
NQR12
Trus t
51.33% 52.17% 51.74% 46.77% 46.58% 50.36% 44.78% 45.85%
48.32%
Trus t
>=95% 92.86% 96.71% 97.21% 98.18% 96.34% 96.54% 95.22% 93.24%
96.21%
<5%
1.43%
0.40%
0.32%
0.19%
0.39%
0.65%
0.52%
0.84%
0.47%
2.77%
5.13%
5.23%
6.08%
5.63%
5.04%
6.45%
5.98%
5.65%
Trus t
6.61%
8.91%
8.62%
9.60% 10.49% 10.16% 10.16% 10.41%
9.76%
Trus t
1440
25%
Trus t
CCG
95%
95.12% 96.45% 95.86% 95.24% 94.38% 99.43% 94.70%
96.01%
CCG
95%
87.60% 90.67% 88.75% 87.77% 88.65% 90.38% 85.47%
88.62%
CCG
95%
87.58% 92.19% 88.93% 87.50% 85.69% 88.70% 80.33%
87.22%
CCG
95%
91.33% 91.46% 89.66% 87.64% 84.59% 86.43% 83.39%
87.20%
CCG
95%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
Primary Care Centre (Urgent) - SLA < 120 minutes
CCG
95%
92.78% 100.0% 100.0% 95.00% 100.0% 100.0% 94.74%
98.3%
Primary Care Centre (Routine) - SLA <360 minutes
CCG
95%
97.40% 94.24% 91.66% 98.26% 98.88% 100.0% 95.99%
96.51%
Home Vis it (Emergency) - SLA < 60 minutes
CCG
95%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
Home Vis it (Urgent) - SLA < 120 minutes
CCG
95%
94.96% 96.61% 95.35% 95.56% 89.83% 96.08% 94.44%
94.65%
Homes Vis it (Routine) - SLA < 360 minutes
CCG
95%
92.30% 96.42% 94.43% 94.95% 87.64% 90.23% 91.12%
92.47%
received
Start DCA for non urgent calls within 3 hrs of the cas e being
received
Primary Care Centre (Emergency) - SLA < 60 minutes
Notes :
Warm trans ferred - the difference between the calls being completed and the Clinician contacting the patients is les s than 15 s econds
Outcome calls - calls pres ented to a clinical advis or following an initial as s es s ment within Pathways
DCA - Dual crewed ambulance
1. SCAS ambulance April to October data is from Unify. November, December and YTD data is from SCAS report as at w/e 03/01/16.
19
Commentary on South Central Ambulance Service / 111 / Out
of Hours Performance
SCAS
• Overall position is slightly improving although it is recognised that a difficult October resulted in a poorer than usual performance
even at CCG level. Contractually a RAP is now in place to address performance however this has only commenced recently so it is
difficult to assess outcomes at this stage. SCAS will be embarking on a dispatch on disposition pilot which will improve Red 1
performance. A recognised side effect of this initiative at a national level is a slight reduction in Red 2 performance. However,
locally the impact of all performance initiatives is yet to be measured.
111
• 111 performances has started to deteriorate with respect to call answering, warm transfers and dispositions to ED and 999. This
is currently being addressed through the contractual route. An action plan is in place for warm transfers although this has not yet
been successful in improving performance for this. It should be noted that SCAS have suggested that whilst they underperform
against the local KPI, the actual performance is in line with the national average. The other areas of concern are not under formal
remediation at this stage as route causes are being identified. It is however, expected that SCAS work to improve these.
OOH
• OOH performance remains of significant concern. DCA performance continues to be the subject of a RAP and this process is
managed contractually. Other areas of concern that have been raised by the provider are being addressed by the CCG with
partner organisations where necessary. Staffing is of significant concern and it is recognised that competing issues of increased
indemnity payments and other local demands on GP time can make securing GP hours challenging. The service continues to be
expected to deliver against these standards in a safe and effective manner. A joint commissioning/quality approach is being used
to ensure that patients receive safe care and to flag potential issues at the earliest opportunity.
20
South Central Ambulance Service Performance – CCG Level
SHIP and MK
Category RED 8 Incidents
Month to Date:October 2015
Number of
Number of
% of RED 1
RED 2 % of RED 2
RED 1
Incidents
Incidents
Incidents
Number of within 8
Incidents
within 8
within 8
Number of RED
RED 2
within 8
Minute
Minute
Minute
1 Incidents
Minute Target Target (75%) Incidents
Target Target (75%)
Southampton City
South Cluster
Number of
RED19
Incidents
(conveyin
g vehicle
response
s)
Total
Number of
RED 19 % of RED 19
Incidents
Incidents
within 19
within 19
Minute Minute Target
(95%)
Target
2
3
4
5
6
7
11
12
13
80
59
73.8%
1253
998
79.6%
1333
1307
98.1%
505
372
73.7%
7598
5582
73.5%
8099
7746
95.6%
SCAS overall Response
70.7%
72.2%
94.5%
Ambulance Response Times
• At Trust level all 3 Ambulance Response Time standards were not achieved in October 2015: Red 1 within 8 minutes 70.7% vs 75% standard, Red 2 within
8 minutes 72.2% vs 75% standard and Red 19 within 19 minutes 94.5% vs 95% standard. All have seen an improvement in performance from September
2015.
• At CCG level 2 of the 3 Ambulance Response Time standards were achieved in October 2015:, Red 2 79.6% vs 75% standard and Red 19 98.1% vs 95%
standard. Red 1 was not achieved with 73.8% vs 75% standard.
Activity
Calls
% of Incidents: incl HCP
See,
Hear & See & Treat
Subtotal
HCP's
Treat Treat
incidents
and
Convey
% of
calls that
become
incidents
Hear &
Treat
See &
Treat
See,
Treat
and
Convey
HCP's
Nonconveyance conveyance
excl urgent rate (1 - non
(H&T+S&T)/( coveyance
rate)
HT+ST+STC
)
SCAS - October 2015
30,130
2,565
7,800
11,085
1,541
22,991
76.31%
11.16%
33.93%
48.22%
6.70%
48.32%
51.68%
Southampton City
5,129
558
1,115
1,816
256
3,744
73.01%
14.90%
29.77%
48.49%
6.84%
47.94%
52.06%
• Non-conveyance at CCG level remains high at 47.94% for Month 7 2015/16 but lower than the SCAS trust wide non-conveyance (48.32%). Both Trust wide
and CCG level non-conveyance have worsened since month 6.
21
Date of meeting
27 January 2016
9
Topic Area
Information Governance
information
The IG Framework has been reviewed in line with its refresh date
(annually). The Framework has been received and reviewed by
the Data Custodians and Senior Management Team. The review
concluded that no changes need to be made to the current
document.
this paper
N/A
(Assurance
appropriate)
Data Custodian Meeting
meetings this document has Senior Management Team
outcomes
N/A
any)
N/A
N/A
Equality Impact
undertaken
N/A
1/2
Report Author
Rebecca Willis, Head of Business
Board Sponsor
(GP Board member or
Executive Director)
Dr Mark Kelsey, Caldicott Guardian
Date of paper
January 2016
Actions requested
/ Recommendations
The Board are asked to receive and ratify the Information
Governance Framework.
2/2
Southampton City Clinical Commissioning Group
December 2015
1. Introduction
This Information Governance Framework document aims to capture the Southampton City
Clinical Commissioning Groups (CCG) approach to Information Governance (IG).
Robust Information Governance (IG) requires clear and effective management and
accountability structures, governance processes, documented policies and procedures,
trained staff and adequate resources. The way that an organisation chooses to deliver
against these requirements is referred to within the Information Governance Toolkit. This
Framework will be approved by the Governing Body and reviewed annually.
This Information Governance Framework must be read in conjunction with the CCGs
Information Governance Handbook and associated documents / policies.
There are many different standards and legislation that apply to information governance and
information handling, including:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Data Protection Act 1998
Access to Health Records Act 1990
Freedom of Information Act 2000
Caldicott Guidance
Public Records Act 1958
Records Management NHS Code of Practice
Mental Capacity Act 2005
Common Law Duty of Confidentiality
Confidentiality NHS Code of Practice
International information security standard: ISO/IEC 27002: 2005
Information Security NHS Code of Practice
Current performance standards (NHS Information Governance Toolkit)
Computer Misuse Act 1990
Copyright, Designs and Patents Act 1988
Subject Access Requests
The Department of Health has developed standards of information governance requirements
and compliance is measured by the Information Governance Toolkit (IGT). The CCG will
complete this annual self-assessment tool in March including an interim submission in
October. The requirements of the IGT cover all aspects of information governance including:
•
•
Information Governance Management
Confidentiality and Data Protection Assurance
Southampton City CCG Information Governance Framework
•
•
Information Security Assurance
Clinical Information Assurance
2. Strategic Aims
The aim of this Framework is to set out how the CCG will effectively manage Information
Governance. The organisation will achieve compliance by:
•
•
•
•
•
•
Establishing robust information governance processes that conform to Department of
Health standards and comply with relevant legislation.
Establishing, implementing and maintaining policies for the effective management of
information.
Ensuring that clear information is provided for service users, families and carers
about how their personal information is recorded, handled, stored and shared.
Providing clear advice and guidance to staff to ensure that they understand and
apply the principles of information governance to their working practice.
Sustaining an Information Governance culture through increasing awareness and
promoting Information Governance, thus minimising the risk of breaches of personal
data.
Assessing CCG performance using the Information Governance Toolkit and Internal
Audits and developing and implementing action plans to ensure continued
improvement.
3. Roles and Responsibilities
CCG Chief Executive Officer
The CCG Chief Executive Officer (CEO) has overall responsibility for Information
Governance within the organisation. As CEO, they are responsible for the management of
the organisation and for ensuring appropriate mechanisms are in place to support service
delivery and continuity. Information Governance provides a framework to ensure information
is used appropriately and is held securely. The management of information risk and
information governance practice is now required within the Statement of Internal Control
which the CEO is required to sign annually.
Senior Information Risk Owner (SIRO)
The Senior Information Risk Owner for the CCG is senior member of staff with the allocated
lead responsibility for the organisation’s information risks and provides the focus for
management of information risk at Board level. The SIRO must provide the CEO with
assurance that information risks are being managed appropriately and effectively across the
organisation and for any services contracted by the organisation.
Caldicott Guardian
The Caldicott Guardian is a senior person responsible for protecting the confidentiality of
patient and service-user information and enabling appropriate information sharing. For the
CCG, this will be a Clinical Board Member.
Acting as the 'conscience' of an organisation, the Caldicott Guardian will actively support
work to enable information sharing where it is appropriate to share, and will advise on
options for lawful and ethical processing of information. The Caldicott Guardian will also
have a strategic role which involves representing and championing Information Governance
requirements and issues at executive team level and where appropriate, at a range of levels
within the organisation's overall governance framework.
Information Governance Lead
The Information Governance lead will be responsible for ensuring all tasks meet the required
standards in line with any formal undertaking between the parties.
Key tasks will include:•
•
•
•
•
•
•
•
•
•
Developing and maintaining the currency of comprehensive and appropriate
documentation that demonstrates commitment to and ownership of IG
responsibilities, e.g. the production of an overarching high level Framework
document supported by relevant policies and procedures.
Ensuring that there is top level awareness and support for IG resourcing and
implementation of improvements within the CCG clinical executive.
Establishing working groups, if necessary, to co-ordinate the activities of staff given
IG responsibilities and progress initiatives;
Ensuring annual assessments and audits of IG and other related policies are carried
out, documented and reported;
Ensuring that the annual assessment and improvement plans are prepared for
approval by the Chief Executive Officer and relevant meeting in a timely manner.
Ensuring that the approach to information handling is communicated to all staff and
made available to the public;
Ensuring that appropriate training is made available to staff and completed as
necessary to support their duties. Liaising with other committees, working groups and
programme boards in order to promote and integrate Information Governance
standards;
Monitoring information handling activities to ensure compliance with law and
guidance;
Providing a focal point for the resolution and/or discussion of Information Governance
issues.
Provision of the Registration Authority business process.
Data Custodians
Data Custodians are required to support the CCG SIRO and will work with staff to ensure
they apply the Data Protection Act and Caldicott Principles within working practices.
All Staff
All staff, whether permanent, temporary, volunteers, contracted or contractors are
responsible for ensuring that they are aware of their responsibilities in respect of Information
Governance.
Review October 2016
Date of meeting
27 January 2016
10
Topic Area
Quality
information
The Quality Exception Report outlines potential quality concerns
in commissioned services that have been reviewed by the Clinical
Governance Committee.
The Board has ultimate responsibility and accountability for the
quality of commissioned services and this exception report
highlights the key issues for review, detailing the extent of the
issue and actions being taken by the provider, the CCG or both
organisations to achieve positive outcomes for patients.
this paper
(Assurance
appropriate)
N/A
This report aims to identify potential quality concerns in
commissioned services and to provide assurance to the Board
that actions are in place and effective monitoring processes in
place.
Clinical Governance Committee
outcomes
N/A
any)
N/A
N/A
Equality Impact
undertaken
N/A
Report Author
Carol Alstrom, Associate Director of Quality / Deputy Chief Nurse
Board Sponsor
(GP Board member or
Executive Director)
Stephanie Ramsey, Director of Quality and Integration / Chief
Nurse
Date of paper
January 2015
Actions requested
/ Recommendations
The Board are asked to receive the Quality Exception Report
Report for the Board
Quality Exception Report – January 2016
This Quality Report highlights, by exception, to Southampton City Clinical Commissioning
Group (SCCCG) the key quality successes and challenges.
1. Safety
1.1
Infection prevention and control
Overall the CCG position for the CCG at the end of December 2015 remains at three MRSA
bacteraemia cases reported.. The number of Clostridium difficile cases is 3 cases over the
maximum number for the year to date at the end of December with 32 cases identified
against a maximum of 29. The numbers of new cases for November was one case below the
expected level. If this trend continues the position could still improve to allow the number at
year end to be at or within the trajectory maximum. No links have been established between
cases, GP practices are working with Infection Prevention and Control and the Medicines
Management Team to review cases to ensure any themes or trends are identified.
1.2
Safer Staffing
All providers continue to be monitored via Clinical Quality Review Meetings to ensure safer
staffing practices are being achieved. Main areas of concern continue to relate to the ability
to recruit staff with specialist qualifications e.g. midwives and mental health nurses, and all
providers are reviewing skill mix based on patient dependency and acuity to inform safe
staffing. Monitoring of the agency cap continues and providers in Southampton are not
reporting any specific concerns at this time.
2. . Outcomes
2.1
CQC compliance
The current picture of CQC compliance with the essential standards to the end of March
2015 was mixed across the city. The full database of CQC compliance is presented to each
Clinical Governance Committee and a summary of compliance across the city is outlined in
the table on page 2 of the report
South Central Ambulance Service NHS Foundation Trust has recently undergone
and inspection, the results are not yet available. Following the publication of the
Mazar’s report into unexpected deaths in Southern Health NHS Foundation Trust the
CQC have indicated the organisation will be subject to further inspections during
2016.
Not yet
inspected
0
8
7
0
1
1
Care Homes with nursing
0
3
4
0
0
0
Care Homes with nursing used
outside of the City
0
2
1
0
1
1
Domiciliary care providers
0
1
3
0
0
7
General Practices
0
7
0
0
3
23
Health Providers (Overall ratings
only)
0
1
4
0
4
TBC*
Requires
Improveme
Inadequate
Care Homes
Good
No rating as
pilot site
Based on 5 Questions – overall
rating
Outstanding
New style inspections
* TBC = relates to health providers we are currently confirming whether or not they are
required to have CQC registration (small specialist providers)
Previous style inspections
Fully
Compliant
Non
Compliances
Enforcement
action taken
Based on 16 areas of compliance – overall
rating
Care Homes
32
1
0
Care Homes with nursing
1
1
0
Care Homes with nursing used outside of the
City
1
0
0
Domiciliary care providers
20
1
0
General Practices
5
0
0
Health Providers (Overall ratings only)
8
1
0
2.2
Quality Assurance and Safeguarding in Nursing and Residential Homes and
Domiciliary Care Agencies
At the 18th January 2016
•
No Nursing Homes in Southampton are formally suspended from placements or have
a caution in place.
•
No Residential Homes within Southampton City are suspended from placements or
have a caution in place. This is a significant achievement as this is the first time this
has happened since the ICU was established.
•
2.3
Two domiciliary care providers are currently suspended from accepting new clients,
work is ongoing with these providers to resolve the concerns identified.
Continuing Healthcare (CHC)
Overall good progress continues to be made to ensure all CHC clients are reviewed in line
with national requirements and the CCG remains on target to ensure at least 95% clients
have had a review by 31st March 2016. Personal Health Budgets continue to be offered to
clients and these are put in place either via a direct payment or notional budget as
requested. Progress with completion of retrospective reviews continues in line with NHS
England requirements to complete by August 2016 and it is anticipated this will be achieved,
currently the team are slightly ahead of the required trajectory.
3. Experience
3.1
Complaints and PALS
During July, August and September the CCG received 5 formal complaints in total (October
3, November 5) 2 of these relate to continuing healthcare and the others a range of issues
including NHS 111, wheelchair services and attitude of provider staff.
The number of PALS type enquiries fell in November with a total of 4 calls received. The
calls related to delays in being offered appointments (GP), general query re NHS 111,
detailed query re Care UK and general query re NHS v Private healthcare
4. Provider Update
4.1 Southern Health NHS Foundation Trust
Following the publication of the Mazars report into unexpected deaths at SHFT
commissioners have been working with NHS England to develop an action plan in response
to the commissioner recommendations. The report was presented to the Clinical
Governance Committee in January for consideration and it was recommended that SCCCG
work with other commissioners via the Strategic Oversight Group to ensure consistency in
approach. All other providers have been asked to consider the implications of this report. At
the local CQRM with Southampton based SHFT managers consideration will be given to any
specific actions arising for Southampton.
4.2 University Hospital Southampton NHS Foundation Trust (UHSFT)
UHSFT is implementing a Home for Lunch project focusing on ensuring patients who are
due for discharge are discharged before lunchtime, with their medication and their hospital
discharge summary completed. Early indications suggest the project is having an impact. An
updated will be provided to the CCG Clinical Governance Committee in March 2016 by Gail
Byrne Director of Nursing at UHSFT
4.3 Solent NHS Trust
Two clinical visits have been undertaken and good practice was noted in the Sexual Health
Service and the Safeguarding Service. The Safeguarding Service has recently been
reconfigured to provide a comprehensive service to both children and adults and this was
observed in action.
4.5 Care UK – Minor Injuries Unit and Southampton NHS Treatment Centre
Care UK presented to the CCG Clinical Governance Committee in January 2016 highlighting
a range of good clinical practice ongoing in the service. They highlighted the new staggered
admissions process which has been well received by patients, the wait time on the day of
surgery before the operation for each patient has been reduced significantly by bring people
in at staggered times. Additionally the changing case mix at the treatment centre was
discussed with more complex cases now being treated here.
4.6 Out of Hours GP services
There are some current quality concerns with this provider which are under review by the
Quality Team and Commissioning Managers.
5.
Conclusion
This report provides an overview of the current quality assurance work underway within the
Integrated Commissioning Unit Quality Team. Any feedback on this report would be very
welcome to enhance it for Governing Body Members
Report compiled by
Carol Alstrom, Associate Director of Quality
18th January 2016
Date of meeting
27 January 2016
Agenda Item
11
Transforming urgent and emergency care services in
England
Topic Area
Urgent and Emergency Care
Proposal
To outline the national direction of travel for urgent and
emergency care and highlight the implications for the CCG
Background information
•
Growth in demand and changing patterns of disease is set
to continue as people live longer with increasingly
complex, and often multiple, long-term conditions.
•
The current model of urgent and emergency care is
regarded by many as unsustainable and there is need to
redesign and tailor services to meet current and future
needs. National recognition of these issues has resulted in
a comprehensive review being carried out.
•
The Urgent and Emergency Care Review (UECR) led by
Sir Bruce Keogh and Professor Keith Willett was
established in 2013 to investigate how to make urgent
care safe, sustainable and accessible in all areas of the
country.
•
The review concluded in August 2015 with the publication
of ‘Transforming urgent and emergency care services in
England.’ The document is a synthesis of good practice
for local health and care communities to draw upon in
order to improve urgent and emergency services.
•
NHS England Planning Guidance requires future plans to
explain how the CCG will deliver transformation in urgent
and emergency care. the work outlined in this paper will
be used to inform this aspect of the CCG’s plan.
1
Key issues to be
considered
The proposed five priority areas for future strategic focus in urgent
care are:
•
Ensuring that capacity and demand are correctly balanced
now and in the future.
Delivery of parity of esteem across urgent care services.
The role of primary care for Southampton City.
The delivery of seven day clinical standards for urgent
care at UHS.
The development of NHS 111 into a service that provides
an integrated gateway to health and care in the city.
•
•
•
•
meetings this document
has already been to, plus
outcomes
None
Principal risk(s) relating
to this paper
SC004: Delivery of 4 hour ED standard
SC013: UHS CQC rating of ‘requires improvement’
SC014: Delivery of OOH performance
(Assurance
appropriate)
None
any)
None
Ongoing communication and engagement
Equality Impact
undertaken
None required
Report Author
Robert Hansford
Contact details
Board Sponsor
Peter Horne
Date of paper
January 2016
Actions requested
/Recommendation
•
•
Note the national good practice in urgent care
Agree the five proposed priority areas highlighted in the
summary.
2
Introduction
1. This paper outlines the national direction of travel for urgent and emergency care and
highlights the implications for the CCG.
2. The paper will cover the following:
•
Background.
•
Summary of the Urgent and Emergency Care Review
•
Analysis of ‘Transforming urgent and emergency care services in England’.
•
Management of delivery.
•
Summary.
•
Recommendations.
Background
3. The landscape of urgent and emergency care has changed over the past decade, with many
variations on services being made available in addition to the traditional family GP and
Emergency Department (ED). The increased range of services and nomenclature has made it
confusing for patients to get the right care, in the right place first time. In parallel, the demand
on these services has grown significantly.
4. Growth in demand and changing patterns of disease is set to continue as people live longer
with increasingly complex, and often multiple, long-term conditions. The current model of
urgent and emergency care is regarded by many as unsustainable and there is a need to
redesign and tailor services to meet current and future needs. National recognition of these
issues has resulted in a comprehensive review being carried out.
5. The Urgent and Emergency Care Review (UECR) led by Sir Bruce Keogh and Professor Keith
Willett was established in 2013 to investigate how to make urgent care safe, sustainable and
accessible in all areas of the country.
6. The review concluded in August 2015 with the publication of ‘Transforming urgent and
emergency care services in England.’ The document is a synthesis of good practice for local
health and care communities to draw upon in order to improve urgent and emergency services.
A copy is at Annex A.
Summary of the Urgent and Emergency Care Review
7. The vision of the review is that for those people with urgent but non-life threatening needs there
will be responsive, effective and personalised services outside of hospital, delivering care in or
as close to people’s homes as possible. For those with more serious or life threatening
emergency needs, treatment will be available in centres with the very best expertise and
facilities in order to reduce risk and maximise chances of survival and a good recovery.
8. The key principles behind this are to streamline services (see diagram 1) and deliver five key
elements of change:
•
provide better support for people to self-care through services such as NHS 111,
pharmacies
3
•
help people with urgent care needs to get the right advice in the right place, first time
through NHS 111
•
provide highly responsive urgent care services outside of hospital, other than ED, such
as same day access to GPs, NHS 111, pharmacies
•
ensure that those with more serious or life threatening emergency needs receive
treatment in centres with the right facilities and expertise in order to maximise chances
of survival and a good recovery. I.e. ED, major trauma centres
•
connect urgent and emergency care services so the overall system becomes more than
just the sum of its parts – urgent care networks incorporating all urgent care services in
primary care, community care and secondary care
Diagram 1: proposed new streamlined system (Keogh/Willett report)
9. The CCG’s approach to urgent and emergency care is a key strand to the organisations clinical
strategy that was published in 2015. As an organisation we undertook to streamline urgent
care; this was not only to improve patient experience and to ensure the right level of capacity in
acute care settings but also to provide a firm platform for the Better Care Southampton plan. A
copy of the strategy is at Annex B.
Assessment of ‘Transforming urgent and emergency care services in England’
10. The CCG has conducted a desktop review of the current system and plans that are in place
against the guidance in ‘Transforming urgent and emergency care services in England’ to
benchmark plans. A summary is at Annex C.
11. The review revealed most areas of good practice are either in place or being progressed within
the local system. In addition, the review highlighted a few areas which require more attention.
The main areas were:
4
•
Reducing variation when managing patient flow.
•
OOH Primary care and NHS 111.
•
Systems and processes for acute medical assessment and surgery.
12. Where appropriate, these areas will be highlighted to the SRG for inclusion in the existing work
programme.
13. From a CCG perspective, it is proposed that the main strategic areas for future development
are:
•
Ensuring that capacity and demand are correctly balanced now and in the future.
•
•
The role for primary care for Southampton City.
•
The delivery of seven day clinical standards for urgent care at UHS.
•
The development of NHS 111 into a service that provides an integrated gateway to
health and care in the city.
Future developments.
14. To support the overarching good practice guidance, NHS England have recently also published
a document that outlines a common set of standards for commissioners to use when
commissioning future integrated urgent care access, treatment and clinical advice services.
15. The document is at Annex D and the outline model for an integrated gateway to care services
is in diagram 2 below:
5
16. The model has two key components:
•
Call taking and clinical assessment by senior practitioners to be based in a single
location 1. The centre will provide a location for urgent response services to be
physically based.
•
The services within urgent care system will be reflected in the Directory of Services and
will be connected to the centre where required.
17. The infrastructure of the centre will build on the architecture of the current services. In
particular the use of NHS Pathways will provide clinically assured assessment. The Directory
of Services will be comprehensive and proactively managed to ensure that all services and
providers are listed. As the service will be more than a call centre many services that do not
currently sit well within the NHS 111 structure can be developed into the model (Rapid
response, mental health services and primary care are key examples).
18. It is envisaged that the model above will allow patients to access advice on self-care or book
into the most appropriate service. Ideally these will all be booked via 111 creating a single
point of access. Over time all urgent care services will become linked to the centre. This will
either be through physical colocation or through virtual team working where care is delivered
from a different location (e.g. ED). It is important to note that this model does not necessarily
mean that a single organisation need provide all the services. The key to success is the
connectivity of services to the single point of advice and access.
1
Practitioners may also be able to support the centre through remote access
6
19. As a CCG, we should also consider how the relevant services that are part of Better Care
Southampton plan are connected to this model as there are likely to be benefits of a true single
point of access, advice and triage for our population.
Management of delivery
20. The Southampton City and South-West Hants System Resilience Group (SRG) oversees the
development and delivery of improvements in the local urgent and emergency care system. It
also considers elective care and cancer care. The group comprises partners from across the
health and care system in the local area.
21. The work of the SRG is defined in a Whole System Action Plan (WSAP) which is monitored
monthly. The WSAP currently has five workstreams which are as follows:
•
The development of a system wide capacity planning tool. This work is due to conclude
in January 2016 with the delivery of a capacity planning tool.
•
Building and sustaining operational resilience. This area focusses on the operational
planning for known periods of pressure through the year. It has a standing working
group comprising all partners which focusses on timely planning and subsequent
management and escalation.
•
Transforming urgent and emergency care services. This work focusses on the
streamlining of services to avoid unnecessary admission to acute hospitals.
•
Transforming In-Hospital care. This work has two elements: first, there is the UHS ED
Remedial Action Plan; secondly, there is the work that UHS are doing to achieve the 7
day clinical standards in urgent care.
•
Delayed Transfers of Care. This work links to the Better Care Southampton work.
Summary
22. This paper has provided an overview of the national direction for urgent care services. It has
confirmed that the CCG strategy for urgent care is congruent with the national direction of
travel and highlighted the proposed key strategic areas for focus for the future as:
•
Ensuring that capacity and demand are correctly balanced now and in the future.
•
•
The role of for primary care for Southampton City.
•
The delivery of seven day clinical standards for urgent care at UHS.
•
The development of NHS 111 into a service that provides an integrated gateway to
health and care in the city.
23. The paper has also provided an overview of the system oversight of delivery within the SW
SRG.
7
Recommendations
24. It is recommended that the Governing Body:
•
Note the national good practice in urgent care
•
Agree the five priority areas highlighted in the summary.
Annexes:
Annex Description
A
Document
Transforming urgent and emergency care services
in England
Annex A Transforming urgent a
B
CCG Five Year Clinical Strategy
a-healthy-southampt
on-for-all---section-1-
C
D
CCG review of existing plans against ‘Transforming
urgent and emergency care services in England’
Annex C Assessment of Transf
Commissioning Standards – Integrated Urgent care
Annex D Commissioning Standa
E
Annex E - Whole
System Action Plan.do
8
ANNEX A
Transforming urgent and emergency
care services in England
Safer, faster, better: good practice in delivering urgent and
emergency care
A guide for local health and social care communities
NHS England INFORMATION READER BOX
Directorate
Medical
Nursing
Finance
Commissioning Operations
Trans. & Corp. Ops.
Publications Gateway Reference:
Patients and Information
Commissioning Strategy
03926
Document Purpose
Guidance
Document Name
Safer, Faster, Better: good practice in delivering urgent and emergency
care. A Guide for local health and social care communities.
Author
UEC Review Team and ECIST
Publication Date
August 2015.
Target Audience
CCG Clinical Leaders, CCG Accountable Officers, Care Trust CEs,
Foundation Trust CEs , NHS England Regional Directors, NHS England
Directors of Commissioning Operations, Emergency Care Leads,
Directors of Children's Services, NHS Trust CEs, System Resilience
Groups; Urgent and Emergency Care Networks
Additional Circulation
List
CSU Managing Directors, Medical Directors, Directors of Nursing,
Local Authority CEs, Directors of Adult SSs, NHS Trust Board Chairs,
Allied Health Professionals, GPs, Special HA CEs
Description
This document is designed to help frontline providers and
commissioners deliver safer, faster and better urgent and emergency
care to patients of all ages, collaborating in Urgent and Emergency
Care Networks to deliver best practice.
Cross Reference
Superseded Docs
(if applicable)
Action Required
Timing / Deadlines
(if applicable)
Contact Details for
further information
Revised planning guidance for 2015/16; Five Year Forward View
N/A
Best practice
N/A
england.urgentcarereview@nhs.net
0
0
0
0
0
0
Document Status
This is a controlled document. Whilst this document may be printed, the electronic version posted on
the intranet is the controlled copy. Any printed copies of this document are not controlled. As a
controlled document, this document should not be saved onto local or network drives but should
always be accessed from the intranet.
2
Transforming urgent and emergency care services in England
Safer, faster, better: good practice in delivering urgent and
emergency care
A guide for local health and social care communities
Version number: 27 FINAL
First published: FINAL
Updated: (only if this is applicable)
Prepared by: UEC Review Team and ECIST
The National Health Service Commissioning Board was established on 1 October
2012 as an executive non-departmental public body. Since 1 April 2013, the National
Health Service Commissioning Board has used the name NHS England for
operational purposes.
Promoting equality and addressing health inequalities are at the heart of NHS
England’s values. Throughout the development of the policies and processes cited in
this document, we have:


Given due regard to the need to eliminate discrimination, harassment and
victimisation, to advance equality of opportunity, and to foster good relations
between people who share a relevant protected characteristic (as cited under
the Equality Act 2010) and those who do not share it; and
Given regard to the need to reduce inequalities between patients in access to,
and outcomes from healthcare services and to ensure services are provided in
an integrated way where this might reduce health inequalities.
3
This report has been endorsed by the following partners:
4
Contents
Contents ..................................................................................................................... 5
1
Document summary ............................................................................................ 7
1.1
1.2
1.3
1.4
1.5
Transforming urgent and emergency care services in England ..................... 7
Purpose ......................................................................................................... 8
Audience ....................................................................................................... 8
Structure ........................................................................................................ 8
How it will be used ......................................................................................... 9
2
Introduction.......................................................................................................... 9
3
The evidence base ............................................................................................ 10
4
General principles of good patient flow ............................................................. 11
4.1
4.2
4.3
4.4
Balance capacity and demand .................................................................... 11
Keep flow going ........................................................................................... 12
Reduce variation.......................................................................................... 13
Manage interfaces and handovers .............................................................. 14
5
Governance and whole system partnership ...................................................... 15
6
Commissioning .................................................................................................. 17
7
Demand management ....................................................................................... 18
7.1
7.2
7.3
7.4
Reducing acute hospital admissions ........................................................... 18
Supporting people to manage long-term conditions .................................... 19
Managing seasonal pressures ..................................................................... 20
Balancing elective and emergency care ...................................................... 21
8
Escalation plans ................................................................................................ 21
9
Primary care ...................................................................................................... 23
9.1
9.2
9.3
9.4
10
General practice .......................................................................................... 23
Out of hours primary care ............................................................................ 24
Residential care homes ............................................................................... 25
Community pharmacy.................................................................................. 26
Community Services ....................................................................................... 27
10.1
10.2
Community nursing, rapid response, early supported discharge .............. 27
Community hospitals ................................................................................ 29
11
Urgent care centres (Walk-In & Minor Injuries Units) ...................................... 30
12
NHS 111 ......................................................................................................... 31
13
Emergency ambulance services ..................................................................... 32
14
Emergency departments ................................................................................. 35
5
15
Ambulatory emergency care (AEC) ................................................................ 37
16
Mental health .................................................................................................. 38
16.1
16.2
16.3
The Mental Health Crisis Care Concordat ................................................ 38
Accessing care ......................................................................................... 38
Liaison mental health services ................................................................. 39
17
Paediatrics ...................................................................................................... 40
18
Acute medical assessment ............................................................................. 41
18.1
18.2
18.3
18.4
Streaming of patients referred to medical specialties ............................... 41
Advice ...................................................................................................... 41
Appointment in out-patient clinic .............................................................. 42
Acute medicine unit (AMU)....................................................................... 42
19
Short stay medical units .................................................................................. 43
20
Planning transfers of care from hospital to community ................................... 43
21
Bed management ........................................................................................... 45
22
Pathways for frail and vulnerable people ........................................................ 46
23
General acute wards and specialty teams ...................................................... 48
24
Surgery ........................................................................................................... 48
24.1
24.2
Hospital care ............................................................................................ 48
Surgical networks ..................................................................................... 50
25
Care management and the role of social care ................................................ 50
26
Managing information ..................................................................................... 51
26.1
Principles of information flow in urgent care ............................................. 51
26.1.1
Enablers ............................................................................................ 51
26.1.2
Access to data ................................................................................... 51
26.1.3
Efficient transfer of information .......................................................... 52
6
1 Document summary
1.1 Transforming urgent and emergency care services in England
The NHS Five Year Forward View (5YFV) explains the need to redesign urgent and
emergency care services in England for people of all ages with physical and mental
health problems, and sets out the new models of care needed to do so. The urgent
and emergency care review (the review) details how these models of care can be
achieved through a fundamental shift in the way urgent and emergency care services
are provided to all ages, improving out-of-hospital services so that we deliver more
care closer to home and reduce hospital attendances and admissions. We need a
system that is safe, sustainable and that provides high quality care consistently. The
vision of the review is simple:

For adults and children with urgent care needs, we should provide a highly
responsive service that delivers care as close to home as possible, minimising
disruption and inconvenience for patients, carers and families.

For those people with more serious or life-threatening emergency care needs, we
should ensure they are treated in centres with the right expertise, processes and
facilities to maximise the prospects of survival and a good recovery.
As part of the review, a number of products are being developed to help create the
conditions for new ways of working to take root and when combined, deliver an
improved system of urgent and emergency services. The review proposes that five
key changes need to take place in order for this to be achieved. These are:

Providing better support for people and their families to self-care or care for their
dependants.

Helping people who need urgent care to get the right advice in the right place, first
time.

Providing responsive, urgent physical and mental health services outside of
hospital every day of the week, so people no longer choose to queue in hospital
emergency departments.

Ensuring that adults and children with more serious or life threatening emergency
needs receive treatment in centres with the right facilities, processes and
expertise in order to maximise their chances of survival and a good recovery.

Connecting all urgent and emergency care services together so the overall
physical and mental health and social care system becomes more than just the
sum of its parts.
NHS England is collaborating with patients and partners from across the system to
develop a suite of guidance documents and tools to promote best practice and
support commissioners and providers in achieving a fundamental shift towards new
ways of working and models of care. These guidance documents are being
7
developed as a suite entitled ‘Transforming Urgent and Emergency Care Services in
England’ and are designed to be read together. The suite comprises the following
components:

Role and establishment of urgent and emergency care networks (UECNs),
published June 2015.

Clinical models for ambulance services.

Improving referral pathways between urgent and emergency services in England.

‘Safer, faster better: good practice in delivering urgent and emergency care’,
published July 2015. This good practice guide focuses on the safe and effective
care of people with urgent and emergency health problems who may seek or
need specialist hospital based services.

Urgent and emergency care: financial modelling methodology.
1.2 Purpose
This document is designed to help frontline providers and commissioners deliver
safer, faster and better urgent and emergency care to patients of all ages,
collaborating in UECNs to deliver best practice.
It sets out design principles drawn from good practice, which have been tried, tested
and delivered successfully by the NHS in local areas across England. However, the
guide should not be taken as a list of instructions or new mandatory requirements.
Implementation should be prioritised taking into account financial implications and
local context.
This document has been prepared by NHS England in conjunction with the
Emergency Care Intensive Support Team (ECIST). Contributions have been sought
from the review’s delivery group (comprising a wide range of experts in urgent and
emergency care services, as well as patient representatives).
1.3 Audience
The primary audiences for this document are providers and commissioners of urgent
and emergency health and social care services to all patient groups, including
children and people with urgent mental health needs.
The secondary audience for this document is the wider membership of UECNs.
Suggested membership for these Networks is outlined in the role and establishment
of urgent and emergency care networks, which forms part of the suite ‘Transforming
urgent and emergency care services in England’.
1.4 Structure
The document begins with an introduction arguing the need for collaboration and
consistency in the delivery of best practice in urgent and emergency care. It refers to
8
the evidence base that underpins the review and goes on to set out design principles
for a number of key service areas.
1.5 How it will be used
The revised planning guidance for 2015/16 required UECNs to start establishing
themselves across England from April 2015, acknowledging that they already exist in
some parts of the country. Commissioners and providers should utilise the principles
outlined in this document, tailoring them to meet local need as identified by the
UECNs across England. The recently published Five Year Forward View (see:
http://tinyurl.com/nhs5yearforwardview) emphasises the importance of this and how
we will increasingly need to manage health care systems through networks of care,
not just by, or through, individual organisations.
The planning guidance 2015/16 further outlines that commissioners should take into
account their duties as defined by the Equality Act 2010 and, with regard to reducing
health inequalities, the Health and the Social Care Act 2012. Service design and
communications should be appropriate and accessible to meet the needs of diverse
communities and address health inequalities (see: Guidance for NHS Commissioners
on Equality and Health Inequalities Legal Duties http://tinyurl.com/pvj2onl).
Safer, Faster, Better will be updated regularly to reflect emerging practice and the
developing evidence base.
2 Introduction
This guide has been written for providers and commissioners of urgent and
emergency care in England. Our aim is to create a practical summary of the design
principles that local health and social care communities need to adopt to deliver
safer, faster and better urgent and emergency care for people in all age groups with
physical or mental health problems. For ease of reference, we have divided the guide
into sections covering major topics. However, delivering safe and effective urgent
and emergency care cannot be done from within organisational or commissioning
silos. It requires cooperation between and within numerous organisations and
services, and collaboration between clinicians and supporting staff who place patient
care at the centre of all they do.
Everything we discuss has been turned into reality somewhere in the country. All the
building blocks are available and have been tested by clinicians and managers and
shown to work. However, we know from experience that piecemeal implementation of
great care in isolated parts of the pathway only creates disjointed ‘islands of
improvement’. Critical mass is only developed when good practice is implemented
systematically, without unwarranted variation, along the entire pathway.
The challenge is considerable. A social movement, committed to ensuring that urgent
and emergency care in England is truly world-class, is needed. This guide is a
contribution to making that happen.
9
3 The evidence base
There is a considerable evidence and experience base for ‘what works well’ in urgent
and emergency care systems, and the damage caused by poor patient flow1. A
summary was published by the Review in 2013 and is available at:
http://tinyurl.com/UECRph1EvBase.
It is important that clinical and managerial leaders across local health communities
are aware of the evidence so they can create a compelling narrative of good practice
to inspire safer, faster, better care.
Below are some top, evidence-based principles that everyone should know:

Preventing crowding in emergency departments improves patient outcomes and
experience and reduces inpatient length of stay (see:
http://tinyurl.com/edcrowding).

Getting patients into the right ward first time reduces mortality, harm and length of
stay (see: http://tinyurl.com/patientboarding).

Patients on the urgent and emergency care pathway should be seen by a senior
clinical decision maker2 as soon as possible, whether this is in the setting of
primary or secondary care. This improves outcomes and reduces length of stay,
hospitalisation rates and cost (see: http://tinyurl.com/benefitsofcdc ).

Daily senior review of every patient, in every bed, every day, reduces length of
stay and costs of care (see: http://tinyurl.com/bmjopen).

Frail and vulnerable patients, including those with disabilities and mental health
problems of all ages, should be managed assertively but holistically (to cover
medical, psychological, social and functional domains) and their care transferred
back into the community as soon as they are medically fit, to avoid them losing
their ability to self-care (see http://tinyurl.com/acutecaretoolkit3). Ambulatory
emergency care is clinically safe, reduces unnecessary overnight hospital stays
and hospital inpatient bed days (see: http://tinyurl.com/acutecaretoolkit10 ).

Acute assessment units enhance patient safety, improve outcomes and reduce
length of stay (see: http://tinyurl.com/amureview ).
1
The term ‘flow’ describes the progressive movement of people, equipment and information through a
sequence of processes. In healthcare, the term denotes the flow of patients between staff,
departments and organisations along a pathway of care (see: http://tinyurl.com/patientflow p7-12).
2
The term, ‘senior clinical decision maker’, is used throughout this document and should be taken to
mean a clinician with the skills and competencies to assess, determine a treatment plan and safely
discharge patients under their care. Consultants and general practitioners typically fall within this
definition. Doctors in their third year of specialist training (ST3) or above; experienced non-training
grade doctors; and nurses, therapists and other clinicians with recognised advanced skills and training
may also be considered to be ‘senior clinical decision makers’ within their spheres of competence.
10

Mental health problems account for around five per cent of A&E attendances,
25% of primary care attendances, 30% of acute inpatient bed occupancy and
30% of acute readmissions. Mortality and morbidity ratios amongst people with
mental illness are much higher than amongst the general population (see:
http://tinyurl.com/ncnkbar ). Well-resourced liaison mental health services
provided seven days a week and 24-hour a day are cost effective and an
essential part of any urgent and emergency care system (see:
http://tinyurl.com/p4lwkox).

Continuity of care is a fundamental principle of safe and effective practice within,
and between, all settings (see: http://tinyurl.com/mjjz97g and
http://tinyurl.com/qcuerdk). The sharing of and access to key patient information is
essential to this.

Getting patients to definitive, specialist hospital care can be more important to
outcomes than getting them to the nearest hospital for certain conditions, such as
stroke, major trauma and STEMI (for examples, see: http://tinyurl.com/q82nk5q;
http://tinyurl.com/klybmcn; http://tinyurl.com/m93duu3).

Properly resourced intermediate care, linked to general practice and hospital
consultants, can prevent admissions, reduce length of stay and enable home
based care and assessment, including supporting ‘discharge to assess’ models
(see: http://tinyurl.com/llgak9d and http://tinyurl.com/k9zjl6h ).
4 General principles of good patient flow
4.1 Balance capacity and demand

The first essential in maintaining good patient flow is to ensure that there is
enough capacity along all parts of the pathway to manage demand.

Demand should be taken to mean all referrals or presentations to a service, not
just its historical activity. Measuring activity can often underestimate demand, as
it may exclude referrals or presentations that have been deflected (for example,
by refusals to accept a referral due to ‘no capacity’; patients leaving without
treatment due to long waits; abandoned calls because no one was available to
answer the phone, etc.).

Patterns of urgent and emergency referrals and presentations, while not random,
will always exhibit variation hour by hour and day by day (this is ‘normal
variation’). When calculating demand, it is therefore essential to take into account
normal variation and not to plan around averages. Ignoring variation and planning
to meet average demand will inevitably mean the service is under regular stress
and queues will develop that may be difficult and expensive to manage.

Variation in demand for a service can be best illustrated using statistical process
control (SPC) run charts. The upper control limits on an SPC chart represent the
11
level of demand that, if planned for, will enable to service consistently to manage
demand, except in unusual circumstances.

Capacity relates to a service’s ability to treat referrals or presentations to it. In
health care, capacity will mean clinicians, support staff, diagnostics, procedures
etc. While beds are often referred to as ‘capacity’, this is really a misnomer. Beds
are places where patients wait to be treated. They are not the treatment itself and
therefore are not capacity.

Imbalances between demand and capacity will create bottlenecks and delays
along the pathway. These imbalances can be caused by temporary or long-term
under-resourcing of services along the pathway or, paradoxically, by overresourcing (for example where a new surgical service floods diagnostic imaging
or intensive care due to poor planning). Smooth flow requires all parts of the
pathway to be resourced to meet demand (including normal variation), but not
over resourced.
4.2 Keep flow going

Maintaining patient flow through hospitals relies on a dynamic equilibrium
between admissions and discharges. In broad terms, the daily number of
discharges will equal the daily number of patients a system has capacity to
manage, divided by length of stay.

For example, if a system has capacity (hospital staff/procedures/intermediate tier
support etc.) to manage around 250 acute inpatients each day and hospital
average length of stay is five days, we will expect around 50 discharges a day
(note there will be some variation in numbers treated and discharged).

If admissions increase by 10%, it will be necessary to discharge an extra 10% a
day to keep the system in balance. This can be achieved either by increasing
capacity (doctors/nurses/tests) so that more patients can be treated each day, or
by increasing efficiency. In the short term, this can be done by everyone working
harder and in the longer term through better processes. If neither capacity nor
processes are changed, there is a likelihood that a hospital or service will rapidly
reach a tipping point and fill up with patients waiting for capacity to become
available to treat them. The ever growing number of patients typically leads
managers and staff to see the problem as mainly one of lack of beds, rather than
lack of capacity or a need to improve processes.

Beds are important only insofar as they are places where patients are monitored
receive nursing care and spend time recovering. If the number of beds is
insufficient, treatment capacity cannot be brought to bear to treat all the patients
who could be treated. Queues therefore develop (e.g. trolley waits in A&E) and
resources are wasted (e.g. operations not carried out due to lack of beds).
Closing beds without either increasing capacity or efficiency is generally a recipe
for an overcrowded hospital. However, increasing beds above the number
needed to match available treatment capacity is inefficient and will have no
beneficial impact on discharge or treatment rates.
12

Having a greater number of patients in beds than capacity to treat them stretches
staff, reduces efficiency, creates harm and halts flow. The result is increasing
length of stay and a sicker patient population.
4.3 Reduce variation
Unwarranted variation is a major obstacle to achieving safe, cost effective patient
care and flow. Research has shown there is huge variation in clinical practice
between hospitals; between hospital departments; between community teams; and
between individual clinicians, even where statistically the patients and facilities are
identical. The variation is so large, that it is impossible to say that all patients could
be receiving good care.
To reduce variation, it is essential to apply simple rules that set boundaries within
which health professionals and managers work. The following, good practice
principles, should be considered to improve safety, patient flow and help reduce
variation. These principles are outlined more fully in the sections that follow.

Urgent or emergency care patients in any setting should receive the earliest
possible review by a senior clinical decision maker.

All emergency hospital admissions should be seen and have a thorough clinical
assessment by a competent consultant as soon as possible but at the latest
within 14 hours of arrival at hospital.

All adult patients3 should have a National Early Warning Score (NEWS)
established at the time of admission.

Consultant involvement for patients considered ‘high risk’ (defined as where the
risk of in-hospital mortality is greater than 10%, or where a patient is unstable and
not responding to treatment as expected) should be within one hour.

There should be a senior review of the care plan and its delivery, for every
patient, in every bed, seven days a week.

Consider all potential acute admissions for ambulatory emergency care unless
their care needs can only be met by an inpatient hospital stay.

People in mental health crisis presenting at emergency departments should have
their mental as well as any physical health needs assessed as rapidly as possible
by a liaison mental health service.

All potential admissions to acute mental health inpatient services should be
assessed for intensive home treatment by crisis resolution home treatment teams
3
NEWS is not appropriate for people under 16 or pregnant women (see: http://tinyurl.com/nn7oa7x
page xiii).
13
unless there are significant immediate issues of risk, safety and complexity that
warrant assessment under the Mental Health Act.

Hospitals and local health and social care communities should prioritise activities
aimed to achieve the earliest possible discharge of patients. A realistic expected
date of discharge, with associated physiological and functional criteria for
discharge, should be established as a goal for professionals and patients to work
towards.

Best practice is to establish a time, as well as a date, of discharge. This focusses
clinical teams and increases the proportion of morning discharges, which are
essential to avoid hospitals and emergency departments becoming overcrowded
in the middle of the day.

Assertively manage frail older people, and younger people with specific
vulnerabilities, such as learning disability or those with long term conditions,
ensuring they have their needs comprehensively assessed on arrival and are
discharged immediately they are clinically ready for transfer home or to on-going
care facilities.

Promptly assess and place patients into the most appropriate care stream to meet
their needs.

All hospitals should promote ‘internal professional standards’ (IPS) that have
been agreed by clinical teams as the basis for response times and relationships
between departments (for the theory underpinning IPS, see:
http://tinyurl.com/p35uqmv)

All health services should actively seek to provide continuity of patient care.

Design the capacity of health services to manage variation in demand, not just
average demand.
4.4 Manage interfaces and handovers
Effective handover of patients between organisations and clinical teams is absolutely
essential to patient safety and maintaining flow. It is good practice for all services
regularly to review how effectively patients are handed over both internally and
externally, and work collaboratively to improve processes along the whole pathway.
The following principles should be considered:

Hospitals and ambulance services must agree handover processes that ensure
patients wait safely for assessment and ambulances are released promptly.

All registered health and social care professionals, following telephone
consultation or clinical review of a patient, should be empowered, based on their
own assessment, to make direct referrals for patients to mental health crisis
services and community mental health teams.
14

All teams receiving emergency patients must be informed of the patient’s arrival.
Best practice is to include an agreed, formal communication method such as
situation background assessment recommendation (SBAR) (see:
http://tinyurl.com/2arr26m).

Good practice is for all patients being referred for admission or assessment to be
discussed with the receiving clinical team.

All patients being admitted from emergency departments should be discussed
with the receiving team to agree an appropriate plan of care.

All patients with additional care complexity should be flagged and have additional
needs discussed with receiving teams (e.g. patients with learning disability
needing reasonable adjustments to standard care processes).

All patients leaving hospital must have a completed e-discharge letter for
themselves and their general practitioner and relevant associated professionals,
including health visitors, school nurses etc. Where discharges are complex, best
practice would include a telephone discussion with the GP.
The following sections cover good practice principles that can be applied to the main
components that make up local urgent and emergency care systems in England. The
sections build on each other and should not be read in isolation. Exemplary practice
in one component will not produce good performance in a system. The system is
organic, relying on all its parts working together to produce results.
5 Governance and whole system partnership
NHS England’s guidance document, the ‘Role and establishment of urgent and
emergency care networks’, advises that the planning and delivery of urgent and
emergency care improvements is divided between system resilience groups (SRGs)
and UECNs, with networks focussed on programmes that cannot easily be delivered
at a more local level by SRGs or clinical commissioning groups (CCGs).
To successfully deliver operational scrutiny and oversee strategic developments
across the complex, multi-agency emergency care pathway, the following good
practice principles should be applied:

SRGs must have senior level participation and commitment, including chief
officers and executive directors. A local lead officer or chief executive should chair
the group. Regular participation from senior clinical staff for all age groups,
including secondary care consultants and GP clinical leads is necessary. Senior
attendance from mental health providers, adult and children’s social care,
ambulance services and NHS 111 is essential.

The SRG should ‘get things done’ through clearly defined works streams and
specialist groups that are formally accountable to it. These need to involve a wide
group of senior clinical staff from across the system, with clear reporting lines to
the SRG.
15

Where there are overlapping work programmes (such as those focused on
integrating care or managing chronic disease), relationships need to be clear,
transparent and formalised to avoid confusion. Shared information about the
remit, membership and content of work programmes is important.

An important role of UECNs is to maintain an oversight of the whole pathway,
especially at the interface between organisations. One way of achieving this is to
agree standards at key points along the emergency pathway, including response
time standards. These should be monitored (ideally using live information
‘dashboards’) and reviewed to identify pathway bottlenecks that need whole
system attention.

Strong links must be established and clearly articulated between SRGs, UECNs
and local Mental Health Crisis Care Concordat steering groups (see:
http://tinyurl.com/lbcnaq3).

UECNs and SRGs need to have an agreed strategic vision of what 'good'
services and pathways look like for all patient groups, which is meaningful to
stakeholders across the system. The vision should be developed with effective
patient, carer and public input, as well as that of health and social care
professionals and managers. The 2014/15 resilience guidance contains a
schematic example (see p23-24 http://tinyurl.com/oa7ks5x), while some local
systems use a set of patient centred principles. The vision needs to be used by
members of the UECN/SRG to engage clinicians to develop improvement
objectives and milestones, especially at the interface between organisations.

It is important that UECNs and SRGs develop clear quality and performance
frameworks to enable them to hold their systems to account. Well-designed
whole system performance dashboards, that include outcome measures and
patient and carer experience data, are useful in highlighting system bottlenecks
and priority themes for action.

Local systems should take responsibility for assessing demand and capacity at
key points in the pathway for all patient groups. It is important to avoid scaling
capacity to meet average demand - it should be designed to manage demand
variation of up to two standard deviations from the mean4.

Demand and capacity planning should take into account demand pressure-points,
such as those around bank holidays, school holiday weeks, festivals and as a
consequence of temperature extremes (for references on weather effects on
health, see: http://tinyurl.com/Weather-effects)
The UECN should create an expectation that prediction and prevention are as
important as escalating to meet demand surges.

4
Planning capacity to meet average demand will mean that on 50% of occasions, capacity will be
inadequate and queues will form. Fluctuations in demand must therefore be taken into account. Best
practice is to use statistical process control (SPC) run charts to plot demand over time and variation.
As a rule of thumb, capacity and processes should be planned to manage between 85% and 95% of
normal variation in demand at an appropriate level of granularity (e.g. hourly or daily).
16

UECNs and SRGs have an important role in establishing effective partnerships
between the health, social, voluntary and community care sectors. The growth in
demand for non-elective care and the sizeable funding challenges for local
authorities and health services creates scope for conflict and tensions. Collective
action and risk sharing are essential if these challenges are to be met without
damaging patient care.
6 Commissioning

A commissioning strategy for urgent and emergency care should be developed
using a collaborative approach with health and social care partners across the
whole system. Involvement from the voluntary and community sector, patients
and carers is important.

The strategy needs clearly to define, ‘what good looks like’, be evidence based,
have clear outcome measures and map demand and the capacity needed to
manage it.

SRGs, working in partnership with CCGs, should be responsible for the strategy
development process so that the strategy and commissioning intentions are
understood by all partners.

A plan is needed within the strategy to develop extended, seven-day access to
all relevant services in the local health and social care system, and take into
account the ten clinical standards for seven day services (see:
http://tinyurl.com/ngt79hp).

Clear plans are required for how the population with frailty, or additional needs
due to disabilities, will be managed in all settings, with the aim of enabling people
to remain in their own homes as long as possible and ensuring that admissions to
hospital are appropriate and as short as possible.

The rate and trend in potentially preventable admissions of patients with
ambulatory care sensitive conditions (ACSC) is an important part of the strategic
analysis (see: http://tinyurl.com/mjwz7mc). A higher than expected rate should
trigger a review of the whole system approach to the management of the specific
patient groups and conditions that are outliers. These often include frail older
people (with urinary tract infections) and people with learning disabilities (with
epilepsy, see: http://tinyurl.com/m5syabd). It is important that every ACSC
admission is alerted to the patient’s GP, as such admissions are in principle
preventable with good quality primary care.

The strategy should operationalise the principle of ‘parity of esteem’, incorporating
the requirements of the Mental Health Crisis Care Concordat to ensure that
services for people experiencing mental health crisis are at all times as
accessible, responsive and high quality as other urgent and emergency services
(see section 16).
17

Commissioning levers can be used to promote collaboration and mutual support
between providers. The benefits of continuity of provision and care should be
considered before formal procurement exercises are contemplated.

A strategy is necessary to maximise support for self-management so that carers,
individuals and their families feel better able to manage their physical and mental
health (or that of those they care for) and can avoid unplanned admissions. This
can be achieved through personalised care and support planning for people with
long-term conditions and identifying a range of support services to help people
build their knowledge, skills and confidence (e.g. through structured education
programmes, information resources, peer support, use of technology and
connecting people to their local community).
7 Demand management
7.1 Reducing acute hospital admissions

The urgent and emergency care review evidence base suggests that schemes
designed to reduce hospital admissions or readmissions need to be carefully
selected, properly designed and rigorously evaluated.

Commissioners and providers need first to focus on the relatively small number of
interventions that are well-evidenced to be effective in reducing admissions
before investing in less well-proven schemes.

Where the evidence base is limited or absent, rigorous evaluation needs to be
built into demand management schemes. Implementation should be programme
managed using effective improvement tools (such as plan, do study, act (PDSA)
cycles) and appropriate research methodologies. The project should clearly state
what the aim is (e.g. ‘the aim is to reduce admissions from primary care by 3%
within 6 months'). The project should be evaluated against this aim. Due to the
risk of optimism bias, any evaluation needs to be independent of staff and
organisations that may have a stake in the ‘success’ of a project (a guide to
evaluation is at: http://tinyurl.com/n9b76jj).

Purdy et al (2012: http://tinyurl.com/p7qgskk) carried out a comprehensive
systematic literature review to identify interventions that are effective in reducing
unplanned hospital admissions. She found good evidence relating to a relatively
small number of interventions:
o Education with self-management reduces unplanned admissions in adults
with asthma and in chronic obstructive pulmonary disease (COPD)
patients.
o Pulmonary rehabilitation is a highly effective intervention in patients who
have recently suffered an exacerbation of COPD.
o Exercise-based cardiac rehabilitation for coronary heart disease is
effective. Specialist clinics, with ongoing follow-up for heart failure patients,
reduce unplanned admissions (but not in asthma patients or older people).
o Visiting acutely at-risk populations in the community may result in less
unplanned admissions. The current programme of individual care planning
for the most frail older people, which was implemented after Purdy’s study,
18
has had promising results reported in some areas. There is a strong case
to commission randomised control trials to strengthen the evaluation of this
and similar programmes.

It should be borne in mind that while the evidence base suggests that only a small
number of the interventions studied reduce unplanned admissions, there have
been few studies of the combined effect of multiple linked projects run
collaboratively across a locality. Improvement science suggests that improving
and smoothing the whole pathway is much more effective than optimising parts of
it. This should be considered when evaluating the evidence base and planning
future interventions.

Many studies have shown that up to a quarter of admissions of frail older people
could be avoided if there is an early review by a suitably qualified clinical decision
maker supported by responsive intermediate care services (see:
http://tinyurl.com/k9zjl6h). Early expert intervention with multiagency support to
manage older people may be more promising than other interventions that have
been attempted (see: http://tinyurl.com/nhdcgys).
7.2 Supporting people to manage long-term conditions

Proactively managing long-term conditions should involve creating programmes
to help people develop the knowledge, skills and confidence to manage their
physical and mental health, access the support they need, make any necessary
changes and be better prepared for any deterioration or crisis.

People who are more ‘active’ in relation to their physical and mental health – who
understand their role in the care process and have the knowledge, skills and
confidence to take on that role – are more likely to choose preventative and
healthy behaviours and have better outcomes and lower costs (for a discussion,
see http://tinyurl.com/q63eufg).

People with long-term conditions or additional vulnerabilities (such as learning
disability) who present acutely may often be doing so as a result of inadequate
planning and support (including self-management) in the community or lack of
confidence in or access to effective services near to home (see Healthcare for All
2008).

Health and social care professionals need to work collaboratively with individuals
and their carers on personalised care and support planning that identifies the
outcomes that are important to the individual, what support is needed to achieve
these and the actions they can take themselves to self-manage (for more
information see: http://tinyurl.com/nadg8kc).

There are a range of different interventions, programmes and networks that can
help individuals to better manage their health and well-being including peer
support, structured education programmes, tailored and accessible information
19
resources, health coaching, behavioural change programmes, and linking people
to voluntary and community resources.


Children, young people and their families should have the opportunity to become
‘expert patients’ with access to services that help them to develop the selfconfidence and self-management skills needed to deal with the impact of their
condition.
Integrated, multi-agency approaches to the management of long term conditions
should be focused around the needs of children, young people, and their families,
to enable a coordinated package of care, including a quality assessment, and
access to a key worker approach.
7.3 Managing seasonal pressures

Typically, around 50% of adult emergency admissions to acute hospitals have
lengths of stay of two days or less, and 80% stay less than seven days. The
admission rate of the <7day cohort has no obvious seasonal variation, and
therefore does not directly contribute to ‘seasonal pressures’. However, the
number of these shorter admissions varies randomly by around 25%, which can
trigger in-day bed pressures.

Around 15% of adult emergency admissions remain in hospital for between seven
and twenty-one days and utilise more than 40% of bed days. This cohort is
distinctive in displaying a drop in bed occupancy just before Christmas followed
by a considerable increase after Christmas. Easter can display a similar pattern.

Trusts need to have sufficient capacity to manage the random variation inherent
in the number of shorter stay admissions. Above average admission numbers
require increased efficiency and effort (for example, more frequent board rounds5,
more early morning discharges). Of equal importance is the need to ensure that
length of stay does not creep up when, due to normal variation, admission
numbers fall and pressure on beds is reduced. To achieve this it is essential that
activities associated with expediting straightforward discharges continue to be
prioritised.

Managing the longer stay cohort, many of whom will have complex discharge
needs, needs considerable focus from clinical teams and multiagency
collaboration. The post-Christmas rise in length of stay is not generally due to
admissions being ‘sicker’. It is due to a relative fall in whole system discharge
capacity over the holiday period, leading to hospitals becoming crowded.
Regaining equilibrium can take much longer than expected because processes
have been destabilised. This means that even when the discharge capacity
returns to normal, it may not be able to cope with the increased demand for
discharge services. There will therefore be a period before the system restabilises.
5
The terms ‘ward round’ and ‘board round’ are used throughout this guide. A board round is a rapid,
‘desk top’ review of the progress of each patient on a ward that does not generally involve seeing
patients in person. A ward round involves a clinical team meeting their patients face to face, and
typically is a longer and more detailed process than a board round.
20

Loss of discharge capacity can rapidly destabilise a hospital and create a
downward spiral from which it is difficult to recover. This typically happens after
Christmas and Easter, although funding issues may chronically reduce discharge
capacity and with it a hospital’s resilience.

It is essential that the need to maintain a relentless focus on straightforward as
well as complex discharges, and to maintain whole system discharge capacity, is
seen as a priority.
7.4 Balancing elective and emergency care

Best practice is to segregate elective surgery from emergency care entirely
through the use of dedicated beds, theatres and staff. This greatly reduces
cancellations and improves outcomes and flow.

It is essential to avoid both surgical and medical outliers due to the associated
risks, poor outcomes and increased length of stay.

Surgeon of the day (or of many days) models, with a surgical team entirely
dedicated to managing emergency admissions, is essential (see section 24).

Day surgery and ambulatory emergency (surgical) care should be maximised to
reduce pressure on beds.

Surgical admissions should be carefully planned based on expected length of
stay of individual cases. This is best done centrally through a bed bureau and not
left to the discretion of individual surgeons.

Surgical staffing and theatre capacity should be planned to meet variation in
seasonal demand. This is important to manage all cases within the national 18
weeks standard.

Any backlog of patients who have breached 18 weeks needs to be addressed
before the winter, as accelerating elective surgery at a time of high winter demand
may be impractical.
8 Escalation plans
Year round capacity planning and escalation plans are essential for all health care
organisations. The following guidance should be considered in order to achieve this:

Local integrated health and social care escalation plans need to clearly define
trigger levels for escalation across all organisations.

Linkages between the escalation plans of partners across the local health
community are important, so that mutual support is achieved at times of stress.
21

The practical and concrete actions that will be taken by individual organisations in
the event of escalation being triggered should be clearly described. This must go
beyond a communications cascade.

As most escalations are due to high hospital occupancy levels, escalation plans
need to focus on processes to review and rapidly discharge patients who are
medically fit but held up in hospital. This should involve the whole local health
community working collaboratively, not just acute hospitals.

Opening additional beds at short notice is a high risk tactic that may worsen,
rather than alleviate, pressures by straining staffing resources, increasing length
of stay and providing sub-optimal care. Before opening beds at short notice, a
trust’s executive team should satisfy itself that:
o Every patient, in every bed, has been reviewed by his/her consultant that
day.
o There has been a rapid review of every patient who has been assessed to
no longer require acute inpatient care by a team of clinicians and
practitioners from the hospital, general practice, community health and
social care services, the voluntary sector and commissioners. The aim
must be to discharge safely as many patients as possible.
o There is a clear de-escalation plan to close the beds as soon as possible.
o Escalation wards will have dedicated consultant, nursing and therapy
staffing, with twice daily consultant ward rounds. The nurse in charge
should be senior, experienced and seconded to the ward until it is closed.
o Escalation wards will not be used to accommodate frail older people
moved from other wards to become ‘outliers’.
o The hospital’s ‘full capacity protocol’6 has been invoked.

Timely de-escalation protocols are important.

There should be sufficient clinical leadership and involvement from primary and
secondary care to resolve local issues in relation to escalation.

It is important systematically to review the effectiveness of system and
organisational policies following periods of escalation. The information from this
review should be used to inform capacity and demand planning.

An assessment of how escalation processes are operating should be a standing
item on the agenda of both the system resilience group and urgent and
emergency care network.

Any decision to reduce or close a service (including residential and nursing home
beds) should be discussed with the executive leads of all areas and organisations
that will be affected, and a plan should be made to support the impact of
additional activity on other services.
6
A ‘full capacity protocol’ enables patients to be ‘boarded’ on inpatient wards before a bed has
formally been vacated. See: http://tinyurl.com/qbmdd27.
22

If a system is very frequently in a state of heightened escalation, it is likely that it
is in fact operating within normal process variation. Using extraordinary tactics to
manage normal variation is inappropriate. A fundamental review of demand and
capacity combined with systematic process changes will be necessary.
9 Primary care
9.1 General practice
Urgent care in general practice matters. Primary care clinicians have many more
interactions with patients than any other part of the NHS. Early diagnosis and
treatment in primary care reduces harm and distress for patients. Effective and timely
responses can avoid unwell adults and children being driven to use emergency
departments. Achieving this is difficult, even in practices that are performing well,
due to rising demand and skill shortages. Nevertheless, many practices are
managing to deliver high quality urgent care by adopting a small number of goodpractice principles:

Focus particularly on responding to the small number of requests for an urgent
home visit. Typically this involves a rapid assessment by a clinician, usually by
phone so that, if needed, the home visit can be prioritised. This early response
provides greater opportunity to plan an alternative to a hospital admission whilst
other community services are able to respond and, if admission is needed, avoids
delay with the associated risk of deterioration.

Define a practice standard for the time from first call/contact to initial assessment,
and from first call/contact to clinical intervention or referral for any cases identified
as urgent – then audit and monitor performance against this standard.

Offer a range of options for patients to access same-day care. These may include
telephone consultations, e-consultations and walk-in clinics, as well as face-toface appointments. Channelling patients into a single, rigid process inevitably
disadvantages some, can lead to ‘gaming’ of the system and may lead to
inappropriate use of emergency departments. The overall aim should be that no
patient should have to attend A&E as a walk-in because they have been unable to
get an urgent appointment with a GP.

Provide early morning appointments for children who have deteriorated during the
night to avoid parents attending A&E because of anxieties and doubt that they will
get an appointment.

Look at the practice’s operational model to ensure that continuity of care,
particularly for the elderly and those with long term conditions or additional
vulnerabilities, is provided so far as is practical and that the processes (for
example of using the duty doctor to assess and see those looking for an urgent
appointment) don’t make this more difficult.

Establish mechanisms to ensure that the practice takes part in the discharge
planning of frail and vulnerable patients. The discharge of clinically vulnerable
patients should be reframed as the transfer of care to the general practice-led
23
community health and social care team so that this team can become more active
in the reception and re-settlement of their patients back in the community.

Practices can play an important role in supporting patients with long-term physical
and mental health conditions with personalised care and support planning. They
can also help patients to self-manage their condition(s) to reduce the risk of
crises.

Ensure that the practice team has the right skills and competencies in place to
deal with paediatrics and develop a training plan in conjunction with local
specialist paediatric services where there are skills gaps.
SRGs and CCGs should coordinate local health and social care services to support
general practices in the management of patients with urgent care needs:

GPs and adult and paediatric on-take consultants should consider dedicated
telephone numbers to enable rapid discussions to ensure patients enter
appropriate clinical pathways.

Intermediate and social care services should support general practice to manage
patients without defaulting to acute hospital admission.

Ambulance services should have immediate telephone access to general practice
to enable discussion of appropriate patient dispositions.

Practices should use agreed protocols with ambulance services for requesting
ambulance transport, which include expected timeframes for responses. This can
help optimise the use of ambulance resources.
These types of changes in the environment within which general practice works can
be transformative – but practices need to work with others to shape the support that
they need.
9.2 Out-of-hours primary care

Primary care out-of-hours (OOH) services need to have arrangements in place
with NHS 111 to enable call-handlers to directly book appointments where
appropriate.

Commissioners and providers should minimise the number of ‘hand-offs’ between
different people to avoid unnecessary re-work. Where possible, warm transfers
should take place between staff within the integrated NHS 111 service, with early
identification of the best person to meet the patient’s needs (e.g. dental nurse,
pharmacist, senior clinician).

Processes need to be in place to minimise delays between NHS 111 receiving a
call and a patient being assessed over the telephone by an out of hour’s
clinician. It is good practice for commissioners and providers to investigate cases
that took longer than an agreed period, from the start of the initial call to the end
24
of the final call, that results either in reassurance and advice, or in a face-to-face
consultation. The aim of the investigation should be to improve processes.

Providers and commissioners should monitor the percentage of patients referred
(or self-referred after an initial call to the service) to hospital, A&E and the
ambulance service. This should be measured across both NHS 111 and the
primary care out of hours service and be part of an SRG’s standard data
dashboard.

Primary care out-of-hours services, NHS 111 and commissioners need to agree
how best to implement primary care dispositions indicated by clinical assessment
systems (such as NHS Pathways). Such agreements should always put the best
interests of patients first, which may require a degree of pragmatism.

The co-location of primary care out of hours services with emergency
departments provides opportunities for collaboration, routine two-way transfer of
appropriate patients and can help decongest emergency departments (see:
http://tinyurl.com/og9qv7t for further guidance on primary care supporting
emergency departments).

Co-located services should actively encourage transferred patients to use the
service best suited to meet their needs rather than defaulting to attend emergency
departments.
9.3 Residential care homes
The needs of care home residents require co-ordinated input from generalists and
specialists of multiple disciplines in partnership with social care professionals and
care home staff. This can reduce unnecessary admissions that are often linked to
prolonged hospital stays. Partnerships are essential, built on shared goals, reliable
communication and trust. Partners should agree to share joint responsibility for
resident’s outcomes. The following guidance should be considered for local
implementation:

It is important that patients being considered for admission from care homes are
discussed with a senior clinical decision maker in the hospital and with the
patient’s GP, so that an optimal plan for the individual patient is agreed and
understood, taking into account the wishes of the patient and their family.

Residents should receive comprehensive, multiagency assessment on admission
and should agree, with appropriate involvement of relatives/carers, a personcentred care plan that is reviewed at least once every six months.

The majority of residents of care homes are older people with dementia (although
some will be younger with learning disabilities). Acute mental health assessment
should be considered where mental and/or physical health problems are
expressed with challenging behaviours. Assessments should be multi-disciplinary.
Particular care should be taken if antipsychotics are prescribed to people with
dementia (see: http://tinyurl.com/nf9fbxl).
25

Care needs to be planned to include regular medicines reviews and falls risk
assessments. A ceiling of care should be established with respect to future health
crises and added to the care plan.

Advance care planning for end of life care should be offered to all residents. This
should be based on established good practice, such as the gold standards
framework (see: http://tinyurl.com/qhvdbjp), and be accompanied by education
and training for staff and access to specialist palliative care when required.

‘Do not attempt active resuscitation’ orders (DNAR) are clinical decisions that
should be based on a patient’s clinical condition and likelihood to benefit.
However, a DNAR decision must not be taken to mean that other treatments and
interventions should be withheld (see: http://tinyurl.com/lk5tozp).

Where safe and efficient to do so, it is good practice to bring care to the resident
in the care home, including GP and specialist reviews and clinical interventions
(e.g. intravenous antibiotics and subcutaneous fluids).

Care home staff at all hours must be aware of each resident’s advance care plan
and the agreed response to unexpected events.

All care homes need a falls strategy to avoid inappropriate referrals to the
ambulance service and hospital. Staff training to assess risk and manage
residents who have fallen is important. They should be supported by community
health services, local pharmacies and ambulance professionals trained to
manage fallers without defaulting to conveyance to hospital.

Care home staff should be supported by NHS and social care professionals
through training and education, 24/7 access to advice, rapid response teams and
encouragement to use clinical tools, protocols and service improvements.

All local health communities need up to date strategies and commissioned
services for the care and management of people in care homes that is based on
good practice guidance, such as that from the British Geriatrics Society (see:
http://tinyurl.com/njtwllt).
9.4 Community pharmacy
Community pharmacies can make valuable contributions to local health communities’
urgent care programmes. They can enhance patient safety and reduce pressure on
other parts of the local health community, particularly general practice, thus creating
headroom for the management of patients with more serious problems. NHS England
has published a toolkit to support this (see http://tinyurl.com/o4mpq5k ).

Community pharmacies can reduce pressure on general practice and enhance
patient safety where they are proactively involved in:
o medicines reviews
o repeat prescription management
o supporting hospital discharge (see: http://tinyurl.com/leb5vws)
26
o medicines reviews of patients in care homes
o multi-disciplinary community health service reviews of patient with long
term conditions
o supporting patients to optimise medicines use
o supporting self-care for minor ailments and long term conditions
o providing urgent access to medicines
o providing flu vaccination to at risk groups

NHS 111, general practice receptions and urgent care centres should have
protocols to direct patients to community pharmacies where these can
appropriately respond to a patient’s care needs, including to services locally
commissioned from pharmacy by NHS England, CCGs and Local Authorities.

The local Directory of Services should reflect services available from community
pharmacy and pharmacy opening hours. NHS England has published, ‘Urgent
Repeat Medication Requests Guide for NHS 111 Services: how to refer directly to
pharmacy and optimise use of GP out of hours services’. (see
http://tinyurl.com/px7wps9 ).

When providing clinical services, such as minor ailments services and provision of
urgent repeat medication, it is helpful if community pharmacies have access to
patient care information. The Health and Social Care Information Centre (HSCIC)
has been commissioned to support all community pharmacies in England to
implement access to the Summary Care Record (see http://tinyurl.com/pt9m75t ).
Community pharmacy has an important role in promoting health and wellbeing and
prevention of disease (e.g. flu vaccination to over 18s in at-risk groups has been
commissioned nationally. See
http://tinyurl.com/pyg9s96).
10 Community services
10.1 Community nursing, rapid response, early supported discharge
It is good practice for commissioners and providers of community health services to
work together to turn what is currently urgent care into planned care by developing:

Support for self-management, including helping to build peer networks and
disease or disability support groups.

Facilitated connection to voluntary support for mental, physical and personal
needs and to address social isolation.

Support for individual carers before they get to crisis point.

More timely diagnosis of dementia and debilitating impacts of ageing.

Prevention of falls and other mobility deteriorations.
27

Personalised care and support planning, including advance care planning for end
of life that can be done by older people themselves or with help from friends and
family, advocates, spiritual leaders, solicitors or health and social care
professionals. This needs to go beyond the highest risk people who are typically
picked up using risk stratification tools. Schemes aimed at earlier intervention to
prevent health crises in people lower down the risk stratification pyramid are
particularly important.

Support for nursing and residential homes to prevent admission.

Education and support to children, young people and their families in community
settings to create a ‘virtual ward in the community’ (for example, in injury
management or illness prevention and management).

Support to key professionals such as health visitors and school nurses in
preventing admissions and responding rapidly to the needs of children and young
people.

Crisis care planning to enable direct access to specialist hospital wards for people
with specific conditions and symptoms.
To achieve these objectives, it is necessary to:

Build community capacity to ensure a timely response. Teams need to be able to
respond rapidly, seven days a week and into the late evenings, and engage wider
personalised community support. Access to equipment and short term care
packages is essential.

Develop person-centred, rather than task-based, care delivery.

Promote collaboration and integration between nurses in general practice,
community based services and voluntary support.

Develop metrics that measure outcomes as well as activity and processes.

Simplify processes so that hospitals, general practice, ambulance services and
social care can make referrals with a single phone call.
Best practice is for community services to be organised to support ‘discharge to
assess’:

Wherever possible, frail older people should be transferred from hospital back to
their normal place of residence as soon as the treatment of their acute problem is
complete.

Multidisciplinary functional assessments generally should be carried out in a
patient’s normal place of residence, rather than in a hospital, before decisions are
made about higher levels of care (e.g. transfer to a nursing or residential home).
28

Integrated health and social care teams should respond rapidly, so that
assessment and basic care can be put in place within two hours of a person
arriving home.
10.2 Community hospitals
Where commissioned, good practice is for community hospitals to provide:

Step-up care: to prevent inappropriate admission to acute care by taking referrals
from the community or care home settings.

Step-down care: to facilitate a stepped pathway out of hospital by taking
referrals from acute hospitals and to facilitate the return of patients to their normal
place of residence (‘home’).
Investment in community hospitals should not be at the expense of domiciliary
community health and social care services, which should be the preferred pattern of
service provision. An appropriate balance should be struck, with beds being provided
for the minority of cases that cannot be reabled in their normal place of residence.
Community hospital beds should be managed in accordance with the good practice
principles that apply to acute hospitals:

All patients need an expected date of discharge (EDD), which should be set by a
senior clinician, within 14 hours of admission to a ward. Functional and
physiological criteria for discharge should also be established so treatment goals
are clear. The EDD should be tailored to the patient’s condition and treatment
goals and not based on an arbitrary length of stay.

It is good practice for every day to start with a multidisciplinary board round.
Those present need to include a senior clinician (which can be a GP, a senior
nurse practitioner or a senior therapist), the nurse in charge, and other
representatives from the allied healthcare professional team. This meeting should
be short and focussed on checking each patient’s progress against their goals,
removing any barriers to discharge and managing internal waits.

As the vast majority of community hospital patients will be frail older people, it is
essential that the team understand, apply and deliver comprehensive geriatric
assessment.

Daily senior review, by a competent clinician who may be a doctor, senior
therapist, advanced nurse practitioner or consultant, should be normal practice 7
days a week.

At least one ward round a week should normally include a hospital consultant with
expertise in managing frail older people.

Patients should be accepted for admission based on their ability to benefit from
the care provided. There should not be arbitrary exclusion criteria.
29

Discharges by midday should be the norm to allow new patients to be admitted
early enough in the day for safer and more effective care.

Care providers, including relatives, must be involved in and made aware of
discharge plans. Any required ambulance transport should be confirmed as soon
as the timing for discharge is known.

Processes should be in place to ensure discharges can happen at the weekend if
patients have achieved their treatment goals. Ensuring that treatment goal
criteria are documented in a way accessible to nursing and therapy teams will
support this.
11 Urgent care centres (Walk-In & Minor Injuries Units)

Urgent care centres (UCC) that are co-located with emergency departments
provide an opportunity to stream patients with less serious illnesses and injuries
to a service that is resourced to meet their needs, while reducing crowding in
emergency departments. To preserve flow, UCC staff and cubicles must
wherever possible be entirely separated from the majors/admission stream.

UCCs must aim to manage most of their patients within two hours of presentation.
Triage is generally inappropriate in UCCs – best practice is to use a ‘see and
treat’ approach, with protocols to ensure that those waiting for treatment are fast
tracked where necessary.

Adults and children should generally be assessed and treated at the first point of
NHS contact capable of meeting their immediate needs. Redirection may lead to
assessments being duplicated, patients inconvenienced and necessary care
delayed.

Where UCCs are co-located with emergency departments, it is essential that
there is appropriate integration, with shared governance arrangements and
clearly defined protocols for the two-way transfer of patients. Commissioners
must ensure that this requirement is embedded in contracts and effectively
delivered where separate providers deliver care within an emergency centre.

UCCs that are remote from emergency departments should be part of wider
clinical network, with clear transfer arrangements and shared clinical governance.

Procedures must be in place to ensure safeguarding of children and adults occurs
to guard against the possibility of repeated presentations with injury.

Commissioners need to ensure that the aim of UCCs is clear to avoid costly
service duplication. Co-located UCCs may have a useful role in managing people
with minor illnesses to avoid emergency department crowding. However, it may
be more appropriate for other UCCs to focus on treating less serious injuries that
would otherwise gravitate to an emergency department, rather than on illnesses
that are best managed by in and out-of-hours general practice and community
pharmacies.
30

Recent good practice guidance on primary care in emergency departments has
been produced by ECIST, the Primary Care Foundation and the Royal College of
Emergency Medicine (see: http://tinyurl.com/mbgauyk ).
12 NHS 111

Commissioners should refer to the NHS 111 Commissioning Standards document
for a detailed description of the NHS 111 integrated service (a revised version is
due to be issued September 2015).

Commissioners, SRGs and UECNs should develop a functionally integrated
service, incorporating NHS 111 and primary care out-of-hours services, and
collaboration with ambulance services. There need to be close links with in-hours
primary care and other health and social care partners. The aim is to provide
patients with an enhanced urgent care treatment and advice service with a single
point of access for all health and social care urgent calls.

It is important that the local directory of services (DOS) is complete, accurate and
continuously updated so that a wide range of agreed dispositions can be made
following initial assessment. The DOS must include information regarding
services available to support individuals at high risk of, or experiencing, mental
health crisis.

It is essential that a stable and properly resourced and skilled team is in place to
ensure that the DOS is maintained and developed.

NHS 111 must use an evidence based clinical assessment tool to help determine
the clinical priority of callers. It must be connected to the DOS to define the
service that best meets their needs.

Call centres should have on-site clinical support so that call handlers have
immediate access to professional advice (see also section 9.2, out-of-hours
primary care).

Call handlers require training to meet the needs of those with sensory
impairments and disabilities (e.g. deafness, dementia, learning disability).

Systems should be in place to enable the direct booking of appointments and the
electronic sharing of patient information between service providers.

Calls categorised as ‘green calls’ to the 999 ambulance service and NHS 111
should, where appropriate, undergo further telephone clinical assessment before
an ambulance disposition is made.

A common clinical advice hub across NHS 111, ambulance services and out-ofhours GPs should be considered to support clinical review and help patients with
self-care advice to avoid onward referral.
31

NHS 111 should have the ability to auto-dispatch ambulances where a 999
response is required.

The integrated NHS 111 service should have access to all special patient notes
(SPNs) and advanced care plans (ACPs). It is important that these influence how
relevant calls are dealt with. Details of the plans should be shared appropriately
with receiving organisations in the patient’s best interests. SPNs should be
regularly updated by the responsible general practitioner.

The staffing capacity and capability of NHS 111 services must take into account
variation in call volumes by hour of day and day of week so that calls can be
responded to in a timely manner without queues developing. This applies to callhanders, supervisors and clinicians. It is also important to ensure that all patient
problems can be effectively addressed, including mental health, dental and
medication needs.

If queues of calls form, the NHS 111 service must take appropriate steps to
minimise the risk to patients through messaging and clinical oversight of the
nature of the caller’s condition, escalating calls for immediate intervention where
necessary.

Processes should be established to ensure that the integrated NHS 111 service
contributes to the co-ordination of the care of frail and vulnerable patients,
developing links with social care and voluntary agencies to support ongoing care.

Services should provide detailed management information and intelligence to
local health systems regarding the demand for and use of emergency and nonemergency healthcare services to enable evidence based planning.

Continuous improvement needs to be at the heart of integrated NHS 111
services, with providers working in partnership with commissioners and clinical
leads to review calls, investigate incidents and look for opportunities to make the
services better for patients.
13 Emergency ambulance services
Ambulance services play a central role in the provision of urgent and emergency
care. Ambulance services and their commissioners should work together to develop
a mobile urgent treatment service capable of dealing with more people at scene and
avoiding unnecessary journeys to hospital. The following, good practice principles,
should be used to inform service development plans:

Ambulance services should consider maintaining ‘clinical hubs’ in their control
rooms to ensure the appropriateness and timeliness of responses provided to
patients. Hubs should be staffed by a range of clinicians, which may include
pharmacists, midwives, palliative care nurses and specialist or advanced trained
paramedics and offer ‘hear & treat’ care to patients, as well as clinical support to
paramedics on scene.
32

As in other health contexts, care delivered by senior clinical decision makers
(such as specialist or advanced paramedics / nurses) produces better clinical
outcomes and can reduce demand for an emergency ambulance transport for
non-critical 999 calls through ‘see & treat’, referral to community services or other
pathways.

SRGs should ensure that paramedics have routine access to community health
and social care services to enable them safely to manage more patients at scene,
either treating and discharging or referring onward to other appropriate services.

Local health communities, through their SRGs and wider networks, should work
collaboratively with ambulance services to develop and evaluate alternatives to
conveyance to hospital, including:
o Pathways to take patients directly to urgent care and walk-in centres in
accordance with agreed and clearly documented standardised clinical
criteria.
o Referral direct from competent ambulance professionals to hospital
specialties, including direct conveyance to assessment and ambulatory
emergency care units, and out-patient appointments (same or next day).
o Working with community mental health teams to provide triage and/or crisis
care at home or in the community, and when necessary, conveyance to a
designated health or community-based place of safety rather than to an
emergency department or police station.
o Falls partnership vehicles with advanced, multidisciplinary practitioners, or
direct access to falls services.
o The use of ambulances in alcohol ‘hot spots’ to provide a field vehicle to
treat minor injuries at the scene or care for intoxicated people until they
can safely make their own way home.
o Increasing the scope of practice for more paramedics to provide ‘see and
treat’ and ‘hear and treat’ care.
o Paramedic practitioners undertaking acute home visits on behalf of GPs to
avoid unnecessary admission and admission surges.
o ‘Call back’ schemes for ambulance crews both in-hours and out-of-hours to
GPs.
o Joint planning with GPs and acute trusts for the management of highvolume service users/frequent callers.
o Direct referral to intermediate care/community rapid response nursing
services and direct conveyance to hospices.

For patients who do need to be taken to hospital, ambulance services can help
minimise handover delays by:
o Reviewing patients’ conditions and needs en-route and sending details
ahead to the receiving emergency department in the case of any special
requirements/circumstances.
o Avoiding the use of ambulance trolleys for patients who are able to walk
into the department.
o Using alternative vehicles to convey patients to the emergency department
(e.g. patient transport service vehicles to transport patients, thus keeping
paramedic staffed ambulances available.
33
o Implementing electronic patient handovers.
o Sharing predicted activity levels with acute trusts on an hourly and daily
basis to trigger effective escalation when demand rises.

The local healthcare system should work with ambulance services to enable them
to have access in real time to patient care plans to develop a whole systems’
approach to patient management and flow.

Handover delays should be systematically and jointly reviewed by ambulance
operations managers, hospital managers and clinicians. Shared actions can then
be developed and agreed to maximise local availability of ambulances to respond
to emergency calls.

Local health communities must actively cooperate to ensure that ambulance
queuing and handover delays are minimised. Where patients experience long
waits, their national early warning score (NEWS or, for children, an agreed
paediatric equivalent) should be recorded, pain assessed and managed and
essential care given. Written guidelines must be agreed between the ambulance
service and receiving hospital clarifying specific responsibilities for the care of
waiting patients.
34
14 Emergency departments
The following principles of good practice should be considered to improve safety and
flow, and to help reduce unwarranted variation and manage demand:

Emergency departments (EDs) should be resourced to practice an advanced
model of care where the focus is on safe and effective assessment, treatment and
onward care. While it is essential to manage demand on EDs, this should not
detract from building capacity to deal with the demand faced, rather than the
demand that is hoped-for.

ED crowding adversely affects every measure of quality and safety for patients of
all ages, and for staff, and creates a ‘negative spiral of inefficiency’. The main
causes of ED crowding include surges in demand and lack of access to beds in
the hospital system due to poor patient flow and high hospital occupancy rates.
These can result in the physical and functional capacity of the ED (especially
staffing and numbers of cubicles) and internal processes and responsiveness of
other services being exceeded. Performance against the 4-hour standard is a
useful proxy measure of crowding.

The staffing of emergency departments should be planned so that capacity meets
variation in demand, rather than average demand, and the variation in demand
patterns between different patient groups including children, frail older people and
people with mental health problems.

The majority of emergency departments have 24/7 liaison mental health services
to ensure that people of all ages presenting with acute mental health needs
receive timely assessment by a skilled mental health professional. All ED staff
should receive specific training in working with people with mental health needs.

Effective clinical staffing models, based on different professional groups, led by
senior emergency physicians, are required. If GP referrals are routed via ED,
there should be the appropriate workforce to receive the demand. Such staffing
models should aim to deliver a capable, sustainable and resilient workforce. The
ED nursing and ancillary workforce should be configured to deliver care, and
maximise efficiency, using currently accepted best practice.

The ED shop floor should be well-led with real time ‘command and control’
achieved through a senior medical, nursing, and administrative team. A good
leadership model involves regular board rounds, walk-throughs and active
progress chasing.

There should be a joint plan with the ambulance service to manage ambulance
handover safely, with dedicated ED staff to take ambulance handovers and care
for waiting patients. Suitable chairs should be available so that where
appropriate, patients are not obliged to wait on ambulance trolleys.

Triage, where used, should be a brief and value adding process aiming to
prioritise care, provide first aid and analgesia, and initiate key investigations and
35
treatments. However, triage may act as a bottleneck at times of high arrival rates
and there should be triggers to manage this problem, which may require a senior
overview of all patients waiting.

Co-located urgent/primary care models should be considered. Where there is a
co-located urgent care model there should be shared governance and a single
‘front door’ (see section11and http://tinyurl.com/lqcstpv)

The co-location of GP out-of-hours services with emergency departments
provides opportunities for collaboration and the two-way transfer of appropriate
patients.

‘See and treat’ for ‘minors’ is an alternative to processes involving triage. It can
free up nurses, thereby increasing the number of staff treating patients and
reducing queues. Departments using see and treat take steps to fast track
patients with red flag conditions and often use a ‘navigator’ role to supervise
waiting patients.

Rapid assessment systems can improve safety and efficiency for certain patient
groups and reduce length of stay in the ED. They do not significantly improve
crowding that is caused by exit block. Rapid assessment systems generally
require dedicated space, equipment and staff and wherever possible should be
consultant led.

Separating patients into streams (e.g. ‘majors’, ‘minors’, ‘resuscitation’, children’s
‘majors’ and ‘minors’) based around similar processes promotes higher quality
care and is beneficial. Streams and workforce should be configured, where
possible, to work independently so that demand in one area does not impact upon
function in another.

Secure, audio-visually separate facilities and care should be provided for children
in accordance with the recommendations of Royal College of Paediatrics and
Child Health (see: http://tinyurl.com/kr4kmju).

Emergency medicine doctors should focus on those patients who require
resuscitation, have undifferentiated conditions and musculoskeletal injuries. There
should be clear clinical pathways for the prompt transfer of care from ED to inpatient specialist teams, especially for high volume pathways including acute
(internal) medicine, frailty and paediatrics.

Fast-track processes to bypass the main emergency department patient streams
are important for some patient sub-groups with clearly differentiated conditions,
such as hip fracture, bleeding in early pregnancy, stroke and STEMI.

Close attention to reducing waste within the ED can improve effectiveness.
Standardising clinical processes and pathways can improve overall quality.

Using internal professional standards to agree expectations of and between the
emergency department and supporting services can greatly improve cooperation
between departments and overall effectiveness.
36
o ED standards should include all the A&E national care quality indicators,
not just the 4-hour standard.
o Response standards should be agreed with inpatient teams and wards,
radiology, and pathology, and should be monitored. Examples include time
from referral to being seen, time from decision to admit to reaching the
destination ward and time from request to report/result.
o Within this framework, escalation procedures should be established with
clear triggers and meaningful actions, to deal with both surges in demand
and crowding.

Clinical Decision Units are highly effective environments supporting the delivery of
modern emergency care. Together with ambulatory care, frailty units, other short
stay units (such as paediatric assessment units), and early access to appropriate
outpatient clinics, they help reduce overnight admissions and maximise shorter
episodes of care. Where there is a CDU, standards for clinical review should be
agreed. These units should not be used for time-standard breach avoidance or for
patients waiting for a decision to admit.
15 Ambulatory emergency care (AEC)

Each acute site should consider establishing an AEC facility that is resourced to
offer emergency care to patients in a non-bedded setting. Models may vary
between hospitals, including emergency department (ED) based models and
physician-led models outside of the ED.

The aim of AEC is to manage as many patients as possible who, in the absence
of an ambulatory care facility, would need to admitted to an inpatient ward.
Hospitals introducing AEC for the first time should expert to convert 25% of their
adult acute medical admissions to ambulatory care episodes.

The aim should be to consider all patients for AEC management as a first line
unless they are clinically unstable. Patients should be streamed to AEC based on
fulfilling four simple rules:
o The patient is sufficiently clinically stable to be managed in AEC.
o The patient’s privacy and dignity will be maintained in the AEC facility.
o The patient’s clinical needs can be met in the AEC facility.
o The patient requires emergency intervention.

The AEC facility should have immediate access to a senior doctor who is
responsible for agreeing the case management plan for each patient.

The time frames for initial assessment and medical review in the AEC facility
should be similar to those in the main emergency department.

Patients in the AEC facility should have access to diagnostics within the same
timeframe as all other emergency patients.

The percentage of patients who are transferred from the AEC facility to inpatient
wards should be monitored. A low rate may suggest risk aversion, while a high
37
rate may indicate problems with patient selection (around 90% of referrals should
be managed without admission to an inpatient ward).

While this care process is called ‘ambulatory’ care, it is important not to exclude
non-ambulant, frail, older people who might benefit, simply because they are
unable to walk.
16 Mental health
16.1 The Mental Health Crisis Care Concordat

Services for people with urgent or emergency mental health needs should be
commissioned and delivered in line with the principles of the Mental Health Crisis
Care Concordat (see: http://tinyurl.com/pbea9ub).

An effective local crisis care pathway should be developed, with the following key
components:
1. Good governance, through setting measurable standards of care and
outcomes (for example, see: http://tinyurl.com/od97awv).
2. Empowerment of people and their families, through the provision of accessible
information (for example, see: http://tinyurl.com/nl8e9g3).
3. Prevention, through identifying and addressing the causes of crisis in local
joint strategic needs assessments (for example, see:
http://tinyurl.com/pke76ca).
4. Improved and timely access to the right care through effective out-of-hospital
care (for examples, see: http://tinyurl.com/o7bvw2j and
http://tinyurl.com/oc2qkkm and http://tinyurl.com/ocfq5ue).
5. Seven day a week, 24-hour liaison mental health services in acute hospital
settings (for example, see: http://tinyurl.com/q5uq2v6).
16.2 Accessing care

Commissioners, working with mental health providers, should ensure that care
pathways are clearly defined in their directory of services for use by NHS 111,
GPs, the ambulance service, police and social services to avoid the inappropriate
conveyance to emergency departments of adults, children and young people.

Mental health providers should work in multidisciplinary teams with GPs to riskstratify patients and identify frequent attenders. These patients can then be casemanaged proactively, with support to carers, and offered personalised care
planning and support for self-management to help identify how to avoid the need
for crisis care.

Adequate local places of safety should be commissioned so that people of all
ages detailed under S136 of the Mental Health Act can be assessed and cared
for in an appropriate environment.
38

Community mental health services should work collaboratively with police and
ambulance services, particularly exploring multidisciplinary street triage models,
to provide a joint response that reduces conveyance and admission rates and
avoids emergency departments being the default entry point into the system.
16.3 Liaison mental health services

24/7 liaison mental health services for people of all ages should be commissioned
in line with recognised quality standards (see: http://tinyurl.com/nffha77) and be
available at all times within one hour of referral by an emergency department to
navigate patients swiftly to appropriate physical or mental health services. Liaison
mental health services providing senior decision makers at the front of the
pathway can reduce repeat attendances, reduce admissions and inpatient length
of stay and ensure that the patients get the right National Institute for Health and
Care Excellence (NICE)-approved treatment (e.g. for self-harm). Response
standards should also be agreed for liaison mental health service assessments
on the wards.

Alcohol intoxication should not automatically be used as an exclusion criterion to
delay initial assessment by either ED staff or mental health teams (while noting
that any assessment under the Mental Health Act of an intoxicated person has
the risk of leading to poorly informed decisions and legal challenge and so must
be carefully considered) .

Where a patient is at high risk and needs to be assessed under the Mental Health
Act but does not have an immediate physical health need requiring physical
health treatment or admission, a standard for that assessment should be set by
commissioners for a response within the 4 hour A&E standard.

The Mental Health Act requires patients to be assessed by an approved mental
health professional (AMHP) and by two S12 assessing medical practitioners, one
of whom has previous knowledge of the patient, usually the patient’s GP. It is
important that the pool of S12 responders is large enough to ensure timely
assessment under the Mental Health Act. Local Authorities also need to ensure
that they commission sufficient AMHPs to meet local demand.

Children and young people with mental health needs are especially vulnerable.
Commissioners should ensure that emergency department and paediatric
emergency department staff have rapid access to paediatric mental health liaison
via both telephone consultation and an on-site response from a dedicated pool of
children and adult mental health (CAMH) professionals, 24-hours a day, seven
days a week.

In their work to integrate mental health in the local UEC pathway, SRGs should
ensure that:
o Senior responsible officers from the whole of the health and social care
economy lead the process of improvement, keeping the person at the centre
of the service.
o An all-ages approach is taken.
39
o Training in mental health awareness, brief interventions and signposting
becomes a mandatory part of the training of all UEC professionals.
o Mental health NICE guidelines and quality standards are adhered to – e.g.
self-harm (see: http://tinyurl.com/pbpsbs6).
17 Paediatrics
Much of the good practice highlighted in this paper for adult services is relevant for
paediatric care. However, paediatric standards are generally more demanding as
paediatrics is a very short stay specialty service and is increasingly provided on a
network basis (see: http://tinyurl.com/o8nuj7f). The following good practice principles
should be considered by commissioners and providers of children’s health services:

Children and their parents/carers need to be confident that the minimum national
standards have been built into agreed care pathways. These are summarised in
the Intercollegiate Emergency Care Standards (see: http://tinyurl.com/kr4kmju).

All staff should follow the recommendations outlined within the guidance
document, Safeguarding Children and Young People: roles and competences for
health care staff (see: http://tinyurl.com/kcorx6l).

There should be a focus on ensuring that effective primary and community
services can be accessed. GP paediatric access must be good, particularly after
school hours and into the evening.

There should be a commissioned, 24-hour children’s place of safety service away
from the emergency department (ED).

In hospitals, there should be either a separate paediatric ED or a separate
children’s stream that includes a specific reception and waiting area, assessment
and treatment area and clinical decision unit that meets national standards.

Dedicated paediatric staffing is important, including paediatric nurses 24/7, a subspeciality qualified ED consultant or a lead consultant, ENPs or paediatric
practitioners. There should also be staff rotations between paediatric and adult
EDs and inpatient units.

Short stay paediatric assessment units should be considered to provide an
alternative to both the ED and to admission (see: http://tinyurl.com/npfgte4).

Triage systems should be paediatric specific and operated by practitioners with
training in paediatrics. This will allow streaming of children and young people to
be seen by the most appropriate health care professional (e.g. GP, paediatric
emergency nurse practitioner, ED clinician).

EDs need 24/7 access to paediatric mental health liaison (PMHL) through
telephone consultation and an on-site response from a dedicated pool of CAMH
professionals skilled in dealing with psychiatric emergencies and managing the
risk of young people who self-harm or attempted suicide.
40

A separate primary care stream should be developed if there are substantial
numbers of attendances that might appropriately be managed by primary care
clinicians.

Initial assessments should incorporate appropriate treatments such as
antipyretics and pain relief.

Provision should be made for high volume surges to reduce the risk of children
waiting more than 15 minutes for assessment. This should include a senior
decision maker undertaking rapid overviews of any children waiting.
A dedicated consultant or middle grade should be present throughout the opening
hours of the paediatric service.


Commissioners should develop, agree and monitor response standards with all
relevant providers, to ensure timely access to appropriate community paediatric
services.
18 Acute medical assessment
The following good practice principles should be considered to improve safety and
patient flow:
18.1 Streaming of patients referred to medical specialties

All patients referred for emergency assessment should be discussed with a senior
clinician who is immediately available to receive the call.

The senior clinician receiving the call should be able to offer a minimum of four
options to the referring clinician:
o Advice.
o An appointment in an out-patient clinic.
o Assessment in an ambulatory emergency care facility.
o Admission to an acute assessment unit (and access to an acute frailty
service where appropriate) or directly to a specialty service.

The most appropriate options should be determined locally, and should aim to
maximise the non-admitted options.
18.2 Advice

Typically a senior clinician, with good local knowledge of available services, can
handle 10-15% of GP referrals over the phone without the need for the patient to
attend hospital.

This senior clinician should be able to refer to rapid response, hospital at home
and intermediate care services to be able to offer the best options to the referring
clinician to allow patients to be appropriately managed without attendance at the
hospital.
41

The clinical conversation with the referrer from primary care can be used to preplan the patient’s care and manage their expectations. This may include informing
the patient that their care will be in an outpatient setting; requesting investigations
before arrival; or planning their transfer back to primary care.
18.3 Appointment in out-patient clinic

All high volume medical specialties (including paediatrics) should ensure that outpatient capacity is available for patients referred in as emergencies. This should
include patients with long term conditions who are experiencing an exacerbation
or complication related to treatment. This is especially relevant for patients
already attending the service.

Specialist nurse services are an important option in the patient streaming
process, and provide patients with access to expertise in managing exacerbations
of their illness.
18.4 Acute Medicine Unit (AMU)

Best practice is to plan the physical and functional capacity of AMUs to meet
variations in the number of admissions of at least two standard deviations from
the mean. The number of beds / trolleys should be based on turning them over up
to twice during each 24-hour period. Inadequate staffing or physical capacity can
lead to increased outliers, poor outcomes and prolonged length of stay. It is
important to note that patients requiring side rooms on the AMU often wait longer
for another side room to become available on an appropriate ward. This should
be taken into account when planning physical capacity.

Patients on the AMU should have face-to-face contact with a senior clinician at
least twice daily. The process of providing ward rounds should meet the
standards of the RCP/RCN ward round document (see: http://tinyurl.com/qcj4zhu)

Senior clinical review on the AMU, usually by a consultant, should commence as
early as possible and normally within one hour for sick patients and three hours
for all others. AMUs should consider designing rapid assessment models that
systematise early senior review.

Where this standard cannot immediately be met 24/7, workforce plans need to be
developed to meet it and as an absolute minimum, first consultant review of
clinically stable patients should be commenced within 14 hours.

Board rounds should be used to co-ordinate a multi-disciplinary approach to
patient care, and to maintain the tempo of care.

The AMU should have pharmacy support to ensure the immediate availability of
medications for discharge and medicines reconciliation for patients with
polypharmacy.

An expected date of discharge should be established as part of the care plan and
linked to functional and physiological criteria for discharge.
42

Specialty in-reach into an AMU should follow an agreed process, which can be
based on attendance at board rounds or on request by senior decision makers.
The transfer of patient care from the AMU to specialty teams should follow good
handover guidance (e.g. using SBAR). Once a patient has been accepted as
requiring inpatient specialty care, the patient should be reviewed daily by the
specialty, even if remaining on the AMU or transferred to another ward.

Senior therapy support to the AMU to facilitate the early assessment of patient
mobility and functional capacity is important. Ready access to equipment such as
walking aids and commodes is required, so that patients assessed as needing
these aides will not be delayed unnecessarily.

Discharge planning should begin on the AMU and include:
 Anticipated discharge needs.
 Place of discharge.
 Discharge date and time.
 Follow-up arrangements.
 Frail older people should be managed by clinicians competent to deliver
comprehensive geriatric assessment. This is best delivered in a discrete area,
either on the AMU or in a dedicated facility. Evidence suggests liaison services
are neither effective nor cost-effective.
19 Short stay medical units

It is good practice for acute hospitals to provide short stay medical units for
patients with an anticipated length of stay of up to 72 hours. These are best colocated with assessment units as part of the AMU.

Consultants should provide ward cover in blocks of more than one day to provide
continuity of care and be present seven days a week and into the late evenings.
This will reduce delays and improve outcomes.

Twice daily, seven day a week face-to-face consultant review is an important
feature of a really effective short stay service.
20 Planning transfers of care from hospital to community
The following good practice principles should be considered when designing
processes for the safe and effective transfer of care of patients from hospital to
community settings:

From the time of admission, all patients (and their carers) need to know four
things:
o What is going to happen to me today?
o What is going to happen to me tomorrow?
o How well do I need to be before I can go home?
o When can I expect to go home?
43

To answer these questions, every patient must have a medical care plan that
contains:
o Clinical criteria for discharge (functional and physiological),
o linked with a patient specific expected date of discharge (EDD) and
o a differential diagnosis.

EDDs should be set by a consultant. They should represent a reasonable
judgement of when a patient will achieve their treatment goals (clinical criteria for
discharge) and can leave hospital to recover and rehabilitate in a non-acute
setting (usually in their normal place of residence).

EDDs should be set no longer than 14 hours after admission.

The progress of every patient towards their EDD should be assessed every day at
a board or ward round led by a senior clinical decision maker, who should
normally be a consultant. EDDs should only be changed with the agreement of
the consultant.

It is important that patients are actively engaged in the discharge process as this
promotes realistic expectations and can improve outcomes, self-care ability and
patient experience.

It is essential that a hospital’s discharge profile mirrors its decision-to-admit profile
so that beds are available as admission decisions are made. In many cases,
changing the discharge profile, so that all patients leave two or three hours earlier
each day, will be sufficient. This can be achieved by ensuring that take-out drugs,
discharge letters, transport, essential equipment and carers are all prepared. Of
equal importance is a ‘can-do’ attitude amongst clinical staff, who should prioritise
activities necessary to achieve prompt discharges.

Maintaining a steady flow of transfers out of hospital over weekends and bank
holidays is essential to avoid very high occupancy levels at the beginning of the
week. Routine consultant weekend presence is necessary, supported by
diagnostics, a multidisciplinary team and community health and social care
services. Priorities should include seeing all potential discharges and patients with
a NEWS score of >3.

Patients should be transferred out of acute hospitals as soon as they cease to
benefit from acute care (i.e. have achieved their clinical criteria for discharge). At
every board and ward round, the following questions should be considered:
o If the patient was being seen for the first time as an outpatient or in A&E,
would admission to hospital be the only alternative to meet their needs?
o Considering the balance of risks, would the patient be better off in an acute
hospital or in an alternate setting?
o Is the patient’s clinical progress as expected?
o What needs to be done to help the patient recover as quickly as possible?
o What are the patient’s views on their care and progress?
44

Providers should systematically maintain a list of patients who are no longer
benefitting from being in an acute hospital. This list may include patients who are
officially reported as having a delayed transfer of care (DTOC), but should not be
limited to them. The term ‘medically fit for discharge’ should be avoided, as it is
too vague to be helpful.

Run charts (using statistical process control) of officially reported delayed
transfers of care should be maintained to identify trends. Collaborative action by
health and social care should be triggered where the number of DTOCs exceeds
an agreed threshold (for example a statistically relevant trend above 3.5% of the
permanently established bed base).

Progress-chasing meetings should take place daily to review all patients who are
no longer benefitting from acute inpatient care. Attendees should include NHS
community services and social services staff. Attendees must be briefed on
relevant patients and able to sign off actions on behalf of their organisations.

Support services in the hospital, primary and community care setting must be
available seven days a week and into the late evenings to ensure that the next
steps in the patient’s care pathway, as determined by the daily consultant-led
review, can be taken.

Primary and community care services should have access to appropriate senior
clinical expertise (e.g. by phone), and where available an integrated care record,
to mitigate the risk of emergency readmission.

Responsive transport services must be available seven days a week.

In addition to the above, all prolonged hospital stays above a locally defined level
(e.g. 10 days) should be reviewed at least twice weekly. During such reviews,
three key questions should be asked:
o Has the patient ceased to benefit from acute hospital care?
o What needs to be done now to expedite a safe discharge?
o What could or should have been done earlier in the patient’s stay to
prevent or mitigate a long length of stay?

‘Discharge to assess’ is the concept of planning post-acute care in the
community, as soon as the acute episode is complete, rather than in hospital
before discharge. This should be the default pathway, with non-acute bedded
alternatives for the very few patients who cannot manage this. Many health
communities have committed as a whole system to develop comprehensive
pathways based on this principle.
21 Bed management
The following, good practice principles, should be considered to improve bed
management:
45

All acute and community hospitals and acute mental health inpatient wards need
to maintain a real-time bed state that is widely and easily available to all staff.
Predictive information (taking into account rolling averages and variation) on
admissions and discharges throughout the day is needed to inform decision
making.

A dedicated named lead should be assigned for patient flow 24/7. This individual
should be responsible for managing a clearly defined escalation process where
demand for beds is predicted to exceed capacity.

Acute hospitals should have agreed ‘full capacity protocols’ that are triggered
when emergency departments (EDs) reach predefined occupancy levels. The
protocol may include processes to transfer appropriate patients to inpatient wards
to wait for beds to become free; to mobilise additional staff to move patients who
have been assigned beds on wards out of the ED; and to trigger additional
discharge board rounds.

Following assessment, patients on acute medical units who require longer stay
specialist management should be handed over to specialty teams, which should
be responsible for managing them throughout their episode in hospital.

Best practice is for adult patients with an expected length of stay of less than two
midnights to be managed in a short stay unit (ideally co-located with the acute
medical unit) and not transferred to a specialty bed unless clinically indicated.

Handovers between consultants for non-clinical reasons and transferring patients
to non-home wards as outliers are associated with poor clinical outcomes and
should be avoided. Frail older people should never be transferred to inappropriate
wards as outliers due to the high risk of decompensation, harm and extended
length of stay.

Frail older people should be managed assertively with the shortest possible
length of stay in a specialist short stay unit for older people or, where a longer
length of stay is justified, a ward specialising in acute medicine for older people.
Such patients should not be transferred more than once following assessment on
an acute medical unit.

Acute hospitals should ensure that there are enough staff and beds on the AMU
for the next 4-hours work (e.g. if the admission rate is between two and four
patients an hour during daytime, then 16 beds and enough staff need to become
available during that period to ensure adequate flow and timely assessments).
22 Pathways for frail and vulnerable people
The following, good practice principles, should be considered to help improve the
safety and effectiveness of pathways for frail and vulnerable people.

It is essential that frail older people (including those with dementia) receive care
by a team of professionals competent to assess and manage their individual
46
needs. Early diagnosis and treatment will minimise time in an acute hospital while
maintaining functional status or giving the best chance of restoration of function
(see: http://tinyurl.com/cebaqz3)

Best practice is to identify patients with frailty syndromes in the community and
provide appropriate support (see: http://tinyurl.com/msc9ctu).

Comprehensive geriatric assessment is the cornerstone of care. Teams may
provide this from a ward base (including acute frailty units) or as a mobile team.
Early identification of patients with frailty syndromes at the time of proposed
admission is essential so that assessment is not delayed. Best practice is to
deploy consultant led acute frailty teams at the front of the hospital pathway to
identify patients with frailty. Where this is not possible, a suitable assessment tool
may be used to identify patients with frailty (for example, see:
http://tinyurl.com/nkazj22)

Usual functioning should be recorded on admission and used to inform clinical
criteria for discharge. There should be goal setting by the multidisciplinary team
aiming to attain sufficient functional status to allow the patient to return to their
normal place of residence.

It is essential for teams to ensure there is no further deterioration in physical and
mental function while a patient is in hospital.

There should be an agreed complex discharge planning process with shared
responsibility for success between the acute trust, community and social care.

Restorative care and parallel social care assessment should continue in a place
of safe care (ideally the patient’s usual place of residence) other than an acute
hospital (the ‘discharge to assess’ model). If there is a wait for community
capacity to become available, active re-enablement should start in the acute
hospital as soon as the patient has met his/her clinical criteria for discharge. This
should include helping patients to dress in their own clothes, to walk and exercise
and to avoid unnecessary time in bed.

Transfer to ongoing re-enablement services should be seamless, with a clear
process to ensure that therapeutic goals are clearly communicated.

Assessment of a patient’s suitability for transfer to a community hospital can be
done by any competent health care professional based on a patient’s ability to
benefit from a longer period of inpatient rehabilitation. It is vital for flow that
patients waiting in acute hospitals for rehabilitation beds are pulled into them at
the earliest opportunity.

Other patient groups with vulnerabilities require additional considerations, input
and adjustments to standardised care in order that their needs are fully
recognised and met. These groups may include people with acquired brain injury
and people with physical and learning disabilities. Trusts should develop
vulnerable patient group pathways and processes (e.g. most trusts employ
47
learning disability liaison nurses to support development of pathways and train
and assist staff around the specific issues that might arise or need addressing).
23 General acute wards and specialty teams

There should be simple rules in place to standardise ward processes and
minimise variation between individual clinicians and between clinical teams.
Implementation of the SAFER bundle should be considered (see:
http://tinyurl.com/ngz67l3).

Ward round check lists should be used routinely (see: http://tinyurl.com/pgrtzbw).

Ward rounds should always include an appropriately senior nurse and other
members of the multidisciplinary team (for best practice guidance on ward
rounds, see: http://tinyurl.com/nat2d7a).

Wherever possible, specialty consultants should work in teams, with at least one
member of the team ward-based and responsible for inpatients as ‘consultant of
many days’, while the remainder focus on other activities. Separating emergency
from elective care enhances continuity and avoids conflicting responsibilities.

Daily senior medical review (by a person able to make management and
discharge decisions) must be normal practice seven days a week. Daily, early
morning board rounds enable teams rapidly to assess the progress of every
patient in every bed and address any delays and obstacles to treatment or
discharge. A second, afternoon board round is best practice. Patients whose
condition warrants face to face review should be identified by the nursing team
and highlighted on the board round.

All patients should have a consultant approved care plan containing an expected
date of discharge and clinical criteria for discharge, set within 14 hours of
admission.

Morning discharges should be the norm, to reduce emergency department
crowding, to allow new patients to be admitted early enough to be properly
assessed and for their treatment plan to be established and commenced. The aim
should be for 35% of the day’s discharges to have left their wards by midday. This
requires teams to prioritise activities associated with discharge.
24 Surgery
The following good practice principles should be considered when planning and
delivering processes aimed to improve the safety and flow of patients requiring
surgical assessment or intervention:
24.1 Hospital care

Surgical resources should be planned to meet the daily demand for elective and
emergency admissions. This can vary considerably by day of the week and time
48
of the day. Best practice is to model bed numbers on not less than two standard
deviations from the mean demand, not on averages.

Surgical treatment of acutely ill patients must take priority over planned, elective
surgery when necessary. Adequate provision for urgent access to operating
theatre time must be available such that it does not impact on elective operating
for the efficient management of both patient pathways.

Emergency centres should consider dedicated surgical assessment units. These
may be nurse led, supported by consultant led surgical teams. There should be
care pathways for common conditions such as abdominal pain and abscesses.

A hospital offering emergency surgery should have a consultant of the day/many
days model, where the surgical team has 24/7 access to dedicated and staffed
emergency theatres and is free from all other commitments.

A surgeon (at ST3 grade or above or a Trust Doctor with MRCS and ATLS)
should be available to see and treat acutely unwell ED referrals at all times within
30 minutes and all routine referrals within 60 minutes. Resident doctors should be
supported by consultants who are immediately available by phone and who can
attend to provide senior support within 30 minutes of request (see Royal College
of Surgeons standards at: http://tinyurl.com/qdsd5oh). Surgery on high risk
patients must be carried out by a consultant surgeon supported by a consultant
anaesthetist.

All trusts managing patients requiring emergency laparotomy should consider
implementing the Emergency Laparotomy Pathway Quality Improvement Care
Bundle (see: http://tinyurl.com/oulb8bl )

All patients considered to be at high risk (>10% mortality) must be reviewed by a
consultant in less than four hours (ideally within 60 minutes) if their management
plan is undefined and they are not responding to treatment as expected.

All patients should be reviewed by a consultant within 14 hours of admission and
then twice daily while on the surgical assessment unit (SAU) and at least daily on
inpatient wards until discharged.

All patients should be set a consultant approved expected date of discharge as
part of the care plan. This should be linked with clinical criteria for discharge.

Many low risk surgical conditions can be managed through ambulatory
emergency care units. These include uncomplicated head injuries, abscesses,
kidney stones, urinary retention and early pregnancy bleeding. It is important that
bed days are not used where ambulatory care is a viable option.

Orthopaedic services should be supported by ortho-geriatricians. Hospitals should
provide surgical units with proactive ‘in-reach’ from physicians and geriatricians.
This can reduce length of stay significantly.
49

Hospitals providing emergency care to children must have comprehensive
paediatric facilities, 24/7 paediatric cover and paediatric nursing and anaesthetic
support. They must also ensure that on-call surgeons have the training and
competency to manage the emergency surgical care of children and young
people (for a full discussion of surgical standards for children, see:
http://tinyurl.com/o3rsc4s and the draft consultation document
http://tinyurl.com/q3ksntt).
24.2 Surgical networks

Hospital surgical services should be part of wider operational networks with an
identified network lead. This particularly applies to emergency general surgery
(see: http://tinyurl.com/qgndpsb).

Adult and paediatric emergency surgical services delivered within a network must
have arrangements in place for image transfer, telemedicine and agreed
protocols for bypass/transfer.

Agreed guidelines and protocols for the transfer of critically ill patients must be in
place, and regularly audited, to ensure patient safety.
25 Care management and the role of social care

There should be a local agreement between health and social care services that
packages of care can be restarted, without an automatic need for reassessment,
where a patient’s care needs remain largely unchanged. This can be facilitated by
implementing a trusted assessor model.

For the majority of patients, definitive assessment of social care needs should
occur outside of hospital (see section 10).

The multidisciplinary team should have same-day access to social care advice,
ideally at the morning board round, or by phone.

There should be a local agreement between health and adult social care to ‘fund
without prejudice’ while responsibility for funding a patient’s care is being
established. This will allow assessment to take place outside hospital, ideally at
home with support.

Health and social care communities should work together to reach local
agreement that all referral processes are as simple as possible (i.e. simple, short
electronic documentation that is quickly and easily completed).

Trusts in particular should ensure that the legal requirement of
Assessment/Discharge Notices from acute trusts to social services - to share
patient information (and the required response standards) - are understood and
initiated by ward staff (see: http://tinyurl.com/qz7csc7). They should seek
feedback from social care that notifications are appropriate to avoid wasting social
50
workers’ time. Embedding care managers, for the most complex patients, within
wards encourages a proactive and co-operative approach.
26 Managing Information
Safe and efficient patient care requires effective, timely and appropriate transfer of
key information that follows the patient through the healthcare system. This is
particularly important in the urgent and emergency care system where, by definition,
the patient is accessing care from outside of their routine care providers.
This section should be read in conjunction with the National Informatics Board
strategy: Using Data and Technology to Transform Outcomes for Patients and
Citizens, A framework for Action (2014) (http://tinyurl.com/p2tetmd).
26.1 Principles of information flow in urgent care
26.1.1 Enablers

The NHS Number must be used as the primary identifier along the patient
pathway. All activity within an organisation must be able to be identified using it. It
is mandatory to include the NHS number in all clinical correspondence.

Systems should implement the GS1 standard for unique identification of patients
using technology to support identification as patients move around the system. It
is essential that access to patient information is auditable.

Improved information flows and access to systems should be used as an
opportunity to improve collaborative working. For example, shared information
can allow clinicians in community pharmacies to support NHS 111.

Ambulance services should develop plans to get access to the NHS Number,
through solutions such as Spine mini-services or directly. This is a key building
block in enabling information captured by ambulance services to be shared. This
will also form the basis for use of electronic messaging of information between
ambulance services and other parts of the urgent and emergency care system.
26.1.2 Access to data

While access to patient information should be governed by appropriate
information governance controls, this must be balanced against the need to share
information to enable integrated and effective care that is in best interests of
patients of all ages, as highlighted by the Caldicott 2 principles.

Patient consent for sharing information must be sought wherever possible, unless
it is an emergency or otherwise in the patient’s best interests.

Access to core general practice information should be made available to all
services in urgent and emergency care. This should include special patient notes
(including any red flags), medicines and contra-indications, and allergies. In the
51
absence of (or alongside) a local integrated digital patient care record (such as
the Hampshire health record), the national summary care record (SCR) should be
used, as it offers a low cost, high value solution to summary patient record access
(see http://tinyurl.com/opatmmq). The SCR is available to all clinicians across the
NHS in England either through the web based application or suitably enabled
clinical applications. The SCR should be used by community pharmacies as it
becomes available from autumn 2015.

As of June 2015, 96% of the English population have an SCR containing key
details of their medication history and any known allergies and adverse reactions
sourced from their GP record. With patient consent, further additional information
can be added to the SCR by their GP practice such as significant past medical
history and procedures, anticipatory care information, patient preferences and
other relevant information often included in special patient notes. Inclusion of this
additional information is encouraged to benefit patients in urgent and emergency
care pathways. For more information, visit: http://tinyurl.com/khg3868

Patient held information is valuable in empowering choice and increasing patient
safety. Simple tools such as ‘This Is Me’ (from the Alzheimer’s society:
http://tinyurl.com/p9wf5vp) should be widely adopted across local health and
social care communities.

Carers are vital to a sustainable health care service and they should also have
access to shared digital tools and information (such as access to the NHS
Choices website) to support those they look after.
26.1.3 Efficient transfer of information

The first point of contact must be able to capture enough detail to enable
appropriate advice and onward referral.

Current guidance to NHS 111 is that a ‘warm transfer’ (i.e. with the call
transferred to a person, rather than being added to a queue) must be used
wherever possible. The SCR can support this by providing key information to
clinical advisors.

Electronic handover of care using standardised datasets is a key priority. The
Academy of Medical Royal College’s publication, “Standards for the clinical
structure and content of patient records” should be followed to ensure that this is
achieved safely.

Electronic discharge summaries must be used to aid safe and effective transfers
of care. The Academy of Medical Royal College’s agreed headings should be
used to provide consistency in the way that information is displayed.

The NHS directory of services should be developed as a key source of
information on local services and used strategically to support navigation and
referral of patients to appropriate settings.
52

Wherever possible, systems should be designed so that relevant information
arrives at a service ahead of the patient (e.g. ambulance services sharing
information electronically prior to their arrival at ED; urgent repeat prescriptions
being filled before a patient arrives at a community pharmacy).

At the end of the episode of care, appropriate transfer of care documents should
be relayed to the patient’s GP and other relevant services, such as community
pharmacy, to ensure continuity of care. The patient should also receive a copy.

Data should be used to support the demand management of urgent and
emergency care services. For example, repeat users of services can be identified
and followed-up to address their specific care needs.
Reading List
References to the following supporting information are included in this document:
The NHS Five Year Forward View (http://tinyurl.com/nhs5yearforwardview).
Improving Patient Flow (http://tinyurl.com/patientflow).
UECR Phase 1 Report Evidence Base (http://tinyurl.com/UECRph1EvBase).
Crowding and Exit Block in Emergency Departments (http://tinyurl.com/edcrowding).
Boarding – impact on patients, hospitals and healthcare systems
(http://tinyurl.com/patientboarding).
The benefits of consultant delivered care (http://tinyurl.com/benefitsofcdc).
A cost-benefit analysis of twice-daily consultant ward rounds and clinical input on
investigation and pharmacy costs in a major teaching hospital in the UK
(http://tinyurl.com/bmjopen).
Acute care toolkit 3 – acute medical care for frail, older people
(http://tinyurl.com/acutecaretoolkit3).
Acute care toolkit 10 – Ambulatory emergency care
(http://tinyurl.com/acutecaretoolkit10 ).
Oxford Journal - effectiveness of AMU’s in hospitals: a systematic review
(http://tinyurl.com/amureview).
Physical morbidity and mortality in people with mental illness
(http://tinyurl.com/ncnkbar).
Guidance for commissioners liaison mental health services to acute hospitals
(http://tinyurl.com/p4lwkox).
53
Continuity of care for older hospital patients (http://tinyurl.com/mjjz97g).
BMJ Open – Which features of primary care affect unscheduled secondary care use
– a systematic review (http://tinyurl.com/qcuerdk).
BMJ Research – Impact of centralising acute stroke services in English metropolitan
areas on mortality and length of hospital stay (http://tinyurl.com/q82nk5q).
British Journal of Surgery – Effect of regional trauma centralization on volume, injury
severity and outcomes of injured patients admitted to trauma centres
(http://tinyurl.com/klybmcn).
RCP Journal – The impact of consultant delivered multidisciplinary inpatient medical
care on patient outcomes (http://tinyurl.com/m93duu3).
National audit of intermediate care summary report 2014(http://tinyurl.com/llgak9d).
RCP National Early Warning Score (NEWS) – standardising the assessment of
acute-illness severity in the NHS (http://tinyurl.com/nn7oa7x).
Harvard Business Review – Promise based management: The essence of execution
(http://tinyurl.com/p35uqmv).
NHS Quality and Service Improvement Tools - SBAR (http://tinyurl.com/2arr26m).
Crisis Care Concordat – Mental Health (http://tinyurl.com/lbcnaq3).
Operational resilience and capacity planning for 2014/2015
(http://tinyurl.com/oa7ks5x).
Weather effects on health (http://tinyurl.com/Weather-effects).
NHS Services seven days a week forum clinical standards
(http://tinyurl.com/ngt79hp).
Quality Watch – focus on preventable admissions (http://tinyurl.com/mjwz7mc).
Improving Health and Lives: Learning Disabilities Observatory – Hospital admissions
that should not happen (http://tinyurl.com/m5syabd).
The Health Foundation – Evaluation: What to consider (http://tinyurl.com/n9b76jj).
Interventions to reduce unplanned hospital admissions: a series of systematic
reviews (Final Report) - (http://tinyurl.com/n9b76jj).
NCBI - Effect of telehealth on quality of life and psychological outcomes over 12
months (http://tinyurl.com/o5tralq).
BMJ - Effectiveness of paramedic practitioners in attending 999
calls from elderly people in the community (http://tinyurl.com/opyog4w).
British Journal of Healthcare Management – avoidable acute hospital admissions in
older people (http://tinyurl.com/k9zjl6h).
54
International Journal of integrated care – reducing hospital bed use by frail older
people: results from a systematic review of the literature (http://tinyurl.com/nhdcgys).
Researchgate article – What the evidence shows about patient activation
(http://tinyurl.com/q63eufg).
NHS outcomes framework – personalised care for long term conditions
(http://tinyurl.com/nadg8kc).
Primary Care Foundation – urgent care in general practice
(http://tinyurl.com/og9qv7t).
Alzheimers.org.uk factsheet: Changes in behaviour (http://tinyurl.com/nf9fbxl).
Gold Standards Framework in end of life care (http://tinyurl.com/qhvdbjp).
MPS – Dilemma: DNR orders (http://tinyurl.com/lk5tozp).
BGS Commissioning Guidance – high quality healthcare for older care home
residents (http://tinyurl.com/njtwllt).
NHS England: Community Pharmacy – helping provide better quality and resilient
urgent care (http://tinyurl.com/o4mpq5k).
RPS – Hospital referral to community pharmacy: an innovators’ toolkit to support the
NHS in England (http://tinyurl.com/leb5vws).
Urgent Repeat Medication Requests Guide for NHS 111 Services: how to refer
directly to pharmacy and optimise use of GP out of hours services (see
http://tinyurl.com/px7wps9).
HSCIC – summary care record rolled out to community pharmacists
(http://tinyurl.com/pt9m75t).
NHS Interim Management and support – Primary Care in Emergency Departments: a
guide to good practice (http://tinyurl.com/mbgauyk).
Primary Care and Emergency Departments – Report from the Primary Care
Foundation March 2010 (http://tinyurl.com/lqcstpv).
Standards for children and young people in emergency care settings
(http://tinyurl.com/kr4kmju).
Mental Health Crisis Care Concordat: Improving outcomes for people experiencing
mental health crisis (http://tinyurl.com/pbea9ub).
London mental health crisis commissioning standards and recommendations
(http://tinyurl.com/od97awv).
55
NHS Choices: a guide to mental health services in England
(http://tinyurl.com/nl8e9g3).
Annual Public Health Report 2014: Mental health and wellbeing in Kingston
(http://tinyurl.com/pke76ca).
Bradford District Care Trust: Our acute care services (http://tinyurl.com/pke76ca).
Oldham mental health phone triage/raid pilot project evaluation report
(http://tinyurl.com/oc2qkkm).
Hertfordshire Partnership University NHS Foundation Trust: Easier access, better
care – single point of access success (http://tinyurl.com/ocfq5ue).
Mental Health Network NHS Confederation: Briefing Issue 228 November 2011- The
benefits of Liaison Psychiatry (http://tinyurl.com/q5uq2v6).
Mental Health Partnerships: Developing models for liaison psychiatry services Guidance (http://tinyurl.com/nffha7).
NICE Self Harm: The short term physical and psychological management and
secondary prevention of self-harm in primary and secondary care
(http://tinyurl.com/pbpsbs6).
Facing the Future: Standards for acute paediatric services
(http://tinyurl.com/o8nuj7f).
Safeguarding children and young people: roles and competencies for health care
staff (http://tinyurl.com/kcorx6l).
Short Stay Paediatric Assessment Units: Advice for Commissioners and Providers –
January 2009 (http://tinyurl.com/npfgte4).
RCP/RCN Ward rounds in medicine: principles for best practice
(http://tinyurl.com/qcj4zhu).
Quality care for older people with urgent and emergency care needs
(http://tinyurl.com/cebaqz3).
Toolkit for General Practice in supporting older people with frailty and achieving the
requirements of the unplanned admissions enhanced service
(http://tinyurl.com/msc9ctu).
Dalhousie University Clinical Frailty Scale (http://tinyurl.com/nkazj22).
Safer patient flow bundle (http://tinyurl.com/ngz67l3).
Quality and safety at the point of care: how long should a ward round take?
(http://tinyurl.com/pgrtzbw).
56
Emergency Surgery – Standards for unscheduled surgical care: Guidance for
providers, commissioners and service planners (http://tinyurl.com/qdsd5oh).
The Health Foundation Shine 2012 final report: improving outcomes from emergency
laparotomy (http://tinyurl.com/oulb8bl).
Children’s Surgical Forum – Standards for Children’s Surgery
(http://tinyurl.com/o3rsc4s).
Standards for non-specialist emergency surgical care of children
(http://tinyurl.com/q3ksntt).
RCS England – Emergency General Surgery (http://tinyurl.com/qgndpsb).
Care and support statutory guidance: Annex G the process for managing transfers of
care from hospital (http://tinyurl.com/qz7csc7).
National Informatics Board strategy: Using Data and Technology to Transform
Outcomes for Patients and Citizens, A framework for Action (2014)
(http://tinyurl.com/p2tetmd).
HSCIC – Clinical use of the summary care record (http://tinyurl.com/opatmmq).
HSCIC - Summary Care Records (http://tinyurl.com/khg3868).
Alzheimers.org.uk factsheet: This is me (http://tinyurl.com/p9wf5vp).
57
ANNEX B
Action Plans – Goal C. Improve Productivity
C: Improve Productivity (achieving more with less, more effectively)
We will bring control to the acute healthcare system. This means:
• Providing swift access to the right care when people become unwell
• Providing effective alternatives to hospital admission
• Ensuring people receive the most effective and efficient care when they need treatment in hospital
• Supporting people to get the onward care they need as soon as they are ready to move on from hospital
Our guiding principles/core standards for improving productivity:
1. Uphold the NHS Constitution by ensuring that patients receive treatment within the requirements of the NHS constitution by commissioning
capacity that is available and accessible to all.
2. Care is high quality and in particular that patients experience is good, with the best possible clinical outcomes.
3. The delivery of care is designed around the needs of the patient, not organisations.
Improve Productivity – interventions:
C1.Streamline Urgent Care
C2. Efficient & Reliable Planned Care
C3. Prevention, Earlier Detection and Diagnosis
C1. Streamline Urgent Care
What we plan to do by March 2019 (our aims)
What we will achieve by 2017 (our expected progress)
•
−
The NHS England review will take place in 2014/15 – will create a
full action plan in response to the recommendations and begin
implementation.
An agreed joint urgent and emergency
care vision in line with national strategy
across all localities
−
We will develop our Urgent and Emergency Care system in light
of:
o The learning that the system has done during the delivery of
the Emergency Care Intensive Support Team (ECIST)
Whole System Action Plan since it began in 2012/13.;
Effective joint working and collaboration
with key local CCGs, members, providers
and stakeholders
A clearly defined Urgent and Emergency Care System
that aligns with the national requirements to be detailed in
NHS England Review of Urgent and Emergency Care
How we will track our progress
An urgent and emergency care system
Page | 50
o
The progress of our Better Care Southampton programme
and its impact on the Urgent and Emergency care work
o
The needs of Specialist Commissioning working through the
Strategic Clinical Networks (especially Major Trauma) to
ensure local services are safe and sustainable
Patients will be choosing services appropriate to their urgent
care needs:
−
The NHS 111 Directory of Services will be developed to show the
map of Urgent and Emergency Care, to aid decision making.
•
−
The early findings from the initial implementation of the Better
Care Southampton will be being considered for inclusion in the
NHS 111 Directory of Services.
•
•
•
map that shows:
·
patient flows
·
number and location of emergency
and urgent care facilities
·
services provided
·
the pressing needs and future needs
for our population
Increased use of 111
Increased use of the Minor Injuries Unit
People are well informed about the services that are
available and are able to choose well
NHS 111 is being used as the gateway into an Urgent and
Emergency Care system that is easy to navigate.
There will be demonstrable improvements in clinical
decision making
New approaches to dealing with Serious or Life
Threatening Emergency Care needs will see:
Consistent levels of senior clinical staffing.
Senior clinical decision making seven days a week in
accordance with demand profiles.
Consistent access to rapid diagnostics seven days a
−
We will have a single set of call taking software being used in 999
and NHS 111 services to eliminate waste and confusion.
−
Shared decision-making techniques will be being tested in Urgent
and Emergency Care
−
Where clinically appropriate, NHS 111 will be able to book
patients into the right place
−
Ambulance services will be supporting the delivery of urgent and
emergency care across the system with a focus on the needs
within a non-acute environment
−
Ability to ‘treat’ over the phone will be enhanced
−
NHS 111 will have piloted access to clinical opinion based on the
well-developed concepts for elective clinical decision making
(Map of Medicine and Advice and Guidance)
−
The right level of Emergency Care capacity will be in place at our
main acute service provider (University Hospital Southampton
(UHS)) to cater for current and future needs
−
Core requirements of a Major Emergency Centre have been fully
implemented at UHS.
Reduced conveyances to hospital
Increased levels of self-management by
patients and carers
Reduction in frequent ‘callers and
attendees’
Improved management of patients at risk
of falling
Reduced length of stay for those patients
requiring admission
Fewer patients spending time in a Clinical
Decision Unit and being discharged
having not had a procedure
Page | 51
week.
•
Where patients are admitted, they can expect the
following to be in place:
Daily consultant led ward rounds
Early and frequent review.
No delays: patients move through the care pathway
with no differences in discharge flow rates because
of the day of week.
−
Clinical decision support tools are being tested in 50% of
specialties
Reduced emergency re-admissions within
30 days of discharge from hospital
−
Full provision of support services in place: on site critical care,
acute medicine, acute surgery, Trauma &Orthopaedics, Major
Trauma.
Improved pathway and patient experience
for patients attending hospital with chest
pain
−
Real time capacity management in support areas.
Reduced number of Ambulatory Care
Sensitive admissions
−
Management of patient flow across providers and by providers
against a set of jointly commissioned flow metrics
−
•
There will be improved levels of efficiency and resilience
of the Urgent and Emergency care System
Ambulatory Emergency Care is being used as much as possible
to support the wider system capability and response.
−
Improved system capacity through more joined up planning and
management:
o Predictive and resilient planning and management by
providers across pre hospital, hospital and community
services
−
Plans for effective management of surges in demand will be
developed and implemented
Reduced number of Delayed Transfer of
Care
Ambulatory Emergency Care provision
and performance will be benchmarked
against national comparators
Sustained achievement of performance
standards across all urgent and
emergency care providers
What will change as a result of our plans:
Patients receive treatment within the requirements of the NHS constitution by commissioning sufficient capacity
Care is of a high quality and in particular the patients experience is good, with the best possible clinical outcomes
Delivery of care is designed around the needs of the patient
15% reduction in emergency activity
Delivery of Better Care Southampton Outcomes
Value for money is delivered
Page | 52
Annex C - Assessment of Transforming Urgent and Emergency Care Service in England for the Southampton System
Ser
(a)
1.
Theme
(b)
General principles
of good patient flow
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Governance and
whole system
partnership
Commissioning
Item
(c)
CCG assessment
(d)
Point of Delivery
(e)
Balance capacity and
demand
Keep flow going
Reduce variation
In progress
WSAP, ED RAP
In progress
In progress
Manage interfaces and
handovers
In progress
In place
WSAP, ED RAP
WSAP, ED RAP, UHS Implementing 7 Day
Clinical Standards for
urgent care
ED RAP, UHS Implementing 7 Day
Clinical Standards for
urgent care
SRG
In place
CCG Strategy
In place
In place
UHS - Implementing 7
Day Clinical Standards
for urgent care
BCF
In place
BCF and WSAP
In place
In place
CCG Strategy
CCG Strategy
Strategy developed
with partners
Develop extended
seven day access to
relevant services
Clear plans for
population with frailty,
additional needs due
to disability and to
remain independent
Focus on preventable
admissions
Parity of esteem
Focus on selfmanagement
Comments
(f)
Area for focus
Ser
(a)
12.
Theme
(b)
Demand
management
13.
14.
15.
Item
(c)
Reducing acute
hospital admissions
Supporting people to
manage long-term
conditions
Managing seasonal
pressures
Balancing elective and
emergency care
CCG assessment
(d)
Point of Delivery
(e)
In place
BCF
In place
BCF
In place
ORG
In progress
WSAP, UHS ED RAP
Comments
(f)
•
•
16.
Escalation plans
17.
Primary Care
18.
19.
20.
21.
Community services
22.
23.
Urgent Care Centre
In place
ORG
General practice
In progress
Out-of-hours primary
care
Residential care
homes
Community pharmacy
Community nursing,
rapid response, early
supported discharge
Community hospitals
Area for focus
CCG Primary Care
Strategy and BCF
WSAP
In place
BCF
In progress
In place
WSAP
BCF
In place
BCF
In place
WSAP
Elective capacity
commissioned from
multiple providers.
For UHS, balancing
elective and emergency
care relies on robust
internal capacity
planning and
management.
Step up/down beds are
provided by Solent at RSH
• The services described
Ser
(a)
Theme
(b)
Item
(c)
CCG assessment
(d)
Point of Delivery
(e)
Comments
(f)
in the document are
already available at the
RSH.
• Future work is around
refining the way in which
partners coordinate
Future integrated service
will be defined prior to recommissioning in 2018.
24.
NHS 111
In place
WSAP
25.
Emergency
ambulance services
Emergency
departments
Ambulatory
emergency care
(AEC)
Mental Health
In place
WSAP, BCF
In progress
ED RAP
In place
Via AMU in UHS
In place
Mental Health Review
In place
In place
Southern Health
WSAP, ED RAP
Improvements to these
requirements are being
considered under the review
of mental health services.
In place
In place
UHS
UHS
Needs review
In place
In place
UHS
UHS
Needs review
Needs review
In place
UHS
Needs review
In place
CDU at UHS
26.
27.
28.
29.
30.
31.
32.
Paediatrics
Acute medical
assessment
33.
34.
35.
36.
Short stay medical
The Mental Health
Crisis Care Concordat
Accessing care
Liaison mental health
services
Streaming of patients
referred to medical
specialties
Advice
Appointment in outpatient clinic
Acute Medicine Unit
(AMU)
Ser
(a)
37.
38.
39.
40.
41.
42.
43.
44.
Key:
SRG ORG WSAP BCF ED RAP
AMU -
Theme
(b)
Item
(c)
units
Planning transfers
of care from hospital
to community
Bed management
Pathways for frail
and vulnerable
people
General acute
wards and specialty
teams
Surgery
Care management
and the role of
social care
Managing
Information
CCG assessment
(d)
Point of Delivery
(e)
In place
WSAP, UHS ED RAP
In place
UHS ED RAP
In place
BCF
In progress
UHS - Implementing 7
Day Clinical Standards
for urgent care
UHS
UHS
BCF
Hospital care
Surgical networks
In place
In place
In place
Principles of
information flow in
urgent care
In place
System Resilience Group
Operational Resilience Group
Better Care Fund
Emergency Department Remedial Action Plan
Acute Medical Unit
Comments
(f)
UHS have implemented an
electronic bed management
system in Dec 15.
Needs review
Needs review
HHR, SCR, e-discharge, All providers have access to
Provider information
the HHR and SCR. Where
systems
required internal systems
deliver other actions e.g.
warm transfers.
ANNEX D
1.1.1
Commissioning Standards
Integrated Urgent Care
September 2015
OFFICIAL
NHS England INFORMATION READER BOX
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Nursing
Finance
Commissioning Operations
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Publications Gateway Reference:
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Commissioning Strategy
04020
Document Purpose
Guidance
Document Name
Integrated Urgent Care Commissioning Standards
Author
NHS England, NHS 111 with CCGs
Publication Date
30 September 2015
Target Audience
CCG Clinical Leaders, CCG Accountable Officers
Additional Circulation
List
#VALUE!
Description
This document outlines the standards which commissioners should
adhere to in order to commission a functionally integrated 24/7 urgent
care access, treatment and clinical advice service (incorporating NHS
111 and Out-of-Hours (OOH) services). Aiming to bring urgent care
access, treatment and clinical advice into much closer alignment through
a consistent and integrated NHS 111 service model.
Cross Reference
Superseded Docs
(if applicable)
Action Required
Timing / Deadlines
(if applicable)
Contact Details for
further information
NHS 111 Commissioning Standards
n/a
n/a
n/a
NHS 111 National Programme Team
NHS England
Skipton House
80 London Road
SE1 6LH
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Document Status
This is a controlled document. Whilst this document may be printed, the electronic version posted on
the intranet is the controlled copy. Any printed copies of this document are not controlled. As a
controlled document, this document should not be saved onto local or network drives but should
always be accessed from the intranet
2
OFFICIAL
Commissioning Standards
Integrated Urgent Care
Version number: 1.0
First published: September 2015
Classification: OFFICIAL
The National Health Service Commissioning Board was established on 1 October 2012 as an
executive non-departmental public body. Since 1 April 2013, the National Health Service
Commissioning Board has used the name NHS England for operational purposes.
3
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Foreword
NHS 111 is already a vital service in helping all people with urgent care needs get
the right advice in the right place, first time. Many patients requiring urgent healthcare
access this through their GP practice and we expect that this will remain the first
point of contact for the majority of patients in the future. However, for those patients
who are unable to access their own GP – because the practice is closed or they are
away from home for example, NHS 111 will be the primary route to urgent care
services. This free to use number is available across England, 24 hours a day, 365
days a year with call volumes now exceeding 1 million per month.
These standards build on the success of NHS 111 and will help to deliver the
benefits for all patients set out in the Urgent and Emergency Care review led by Sir
Bruce Keogh. The intent is to enable commissioners to deliver a functionally
integrated 24/7 urgent care service that is the ‘front door’ of the NHS and which
provides the public with access to both treatment and clinical advice. This will include
NHS 111 providers and GP Out-of-hours services, community services, ambulance
services, emergency departments and social care.
Some parts of the NHS are already a long way towards functional urgent care
integration, but elsewhere there remain areas that have entirely separate working
arrangements between NHS 111, Out-of-hours and other urgent care services. This
makes accessing urgent advice and treatment very confusing for a large number of
patients.
These new Commissioning Standards have been developed in widespread
consultation with commissioners and providers, and have taken into account the
public feedback received during the earlier stages of the Urgent and Emergency
Care Review. They are intended to support commissioners in delivering this
fundamental redesign of the NHS urgent care ‘front door’. The standards are built on
evidence and what is known to be best practice; however, it is envisaged that as
Integrated Urgent Care services evolve and become more established then these
standards will be further enhanced and revised on an annual basis.
NHS England will continue to work with Commissioners in supporting them with the
implementation of the Urgent and Emergency Care Review, within which Integrated
Urgent Care will be essential.
4
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Dr Amanda Doyle
Professor Keith Willett
Chief Clinical Officer,
NHS Blackpool CCG
National Director for Acute Episodes
Care, NHS England
5
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1
1.1
1.2
1.3
1.4
2
Introduction ....................................................................................................... 8
Current arrangements ................................................................................... 8
Integrated Urgent Care .................................................................................. 9
Vision........................................................................................................... 10
Benefits ....................................................................................................... 12
Commissioning Standards ............................................................................. 14
2.1
2.2
2.3
2.4
2.5
Purpose ....................................................................................................... 14
Audience ..................................................................................................... 15
Roles and responsibilities ............................................................................ 15
Local commissioning specifications ............................................................. 15
Joint working arrangements ........................................................................ 17
2.5.1 Lead Commissioner Arrangement ........................................................ 17
2.6
Collaborative Provider Management ........................................................... 17
2.7
Payment approach for Integrated Urgent Care ............................................ 17
3
Standards of Delivery...................................................................................... 19
3.1
3.2
3.3
3.4
3.5
3.6
Access ......................................................................................................... 19
Assessment ................................................................................................. 19
Treatment & Clinical Advice ........................................................................ 20
Advice and Referral ..................................................................................... 21
Integrated Care Advice Service (or ‘Clinical Hub’) ....................................... 22
Improving Referral Pathways ...................................................................... 23
3.6.1 Referral Rights ...................................................................................... 23
3.6.2 Referral Mechanism .............................................................................. 24
3.6.3 Post Event Messaging .......................................................................... 24
4
Supporting Standards ..................................................................................... 25
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Access to Records....................................................................................... 25
Business Continuity ..................................................................................... 26
Clinical Decision Support System ................................................................ 27
The Directory of Services (DoS) .................................................................. 27
Clinical Governance .................................................................................... 29
Future Workforce ......................................................................................... 30
Staff working in Integrated Urgent Care ...................................................... 32
4.7.1 Health Advisers (Call Handlers) ............................................................ 32
4.7.2 Clinical staffing model ........................................................................... 33
4.7.3 Training of clinical staff ......................................................................... 34
4.7.4 Medicines and Poisons training ............................................................ 34
4.7.5 Staff continuous audit and improvement ............................................... 35
4.8
Repeat caller service ................................................................................... 35
4.9
Interoperability ............................................................................................. 36
4.10
Online Platform ............................................................................................ 37
4.11
KPIs & Metrics ............................................................................................. 38
4.12
Telephony.................................................................................................... 39
4.13
Patient experience ....................................................................................... 41
4.14
Procurement ................................................................................................ 41
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ANNEX A ................................................................................................................. 43
Integrated Care Advice Service roles: ...................................................................... 43
Dental ................................................................................................................ 43
Mental Health .................................................................................................... 45
Pharmacy .......................................................................................................... 46
ANNEX B ................................................................................................................. 51
Roles and Responsibilities........................................................................................ 51
ANNEX C ................................................................................................................. 55
Clinical Model: Self-Assessment Tool ...................................................................... 55
7
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1 Introduction
1.1 Current arrangements
NHS 111 is now available across the whole of England, making it easier for the
public to access urgent healthcare services when they need medical help fast.
It is free to use and directs all people to the right local service first time, or gives
health advice that is best able to meet their needs. NHS 111 has been critical to
improving the delivery of urgent and emergency care services, ensuring that all
patients receive convenient care and close to home.
Out-of-hours GP services give patients treatment and advice for medical
problems that are not life-threatening, but where the patient cannot wait to
attend their own GP practice.
The current Out-of-hours period is:
 the period beginning at 6.30pm on any day from Monday to Thursday and
ending at 8am on the following day.
 the period between 6.30pm on Friday and 8am on the following Monday.
 Good Friday, Christmas Day and bank holidays.
Out-of-hours does not include any period where for example a GP practice
closes during contracted hours. Should a GP practice close during contracted
hours, it is the practice’s responsibility (including financial responsibility) to
ensure appropriate cover is provided at such times.
Since February 2014, the commonest route for people to access Out-of-hours
GP services is to call NHS 111. However, amongst the public, knowledge about
the availability of GP Out-of-hours services is poor:
“The most recent GP patient survey found that over 40 per cent of respondents
did not know how to contact an Out-of-hours GP service. The survey found that
around a quarter of people had not heard of Out-of-hours GP services.
Awareness among certain groups, including younger people and black and
minority ethnic citizens, was lower than among others.”1
In some areas of England, people can also still call a designated Out-of-hours
GP telephone line.
The way Out-of-hours GP services are provided varies across the country.
Services differ in the number of GPs employed, the use of call takers, the
number of cars available for home visits, and the use of other clinical staff to
support GPs.
1
th
National Audit Office – Out-of-Hours GP Services in England HC439 9 September 2014
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On 1st April 2013, CCGs became responsible – by virtue of directions given by
NHS England – for commissioning Out-of-hours primary medical care services.
The only exception to this is for the small number of practices that have
retained contractual responsibility for providing Out-of-hours primary medical
care services (i.e. those that remain ‘opted in’ and who continue to contract or
provide the service themselves). Although NHS England has responsibility for
managing contracts with these practices, CCGs have responsibility for carrying
out some functions on its behalf, for example to support the monitoring of
quality for Out-of-hours Services.
1.2 Integrated Urgent Care
Around the country, commissioners have adopted a range of models for the
provision of NHS 111, Out-of-hours and urgent care services in the community.
In some areas a more comprehensive model of integration has been
implemented. Some parts of the NHS are already a long way towards urgent
care integration, but elsewhere there remain areas that have entirely separate
working arrangements between NHS 111, Out-of-hours and other urgent care
services. This position is entirely understandable given the way that primary
care, Out-of-hours and NHS 111 services have evolved; but it no longer fully
meets the needs of patients or health professionals.
The need to redesign urgent and emergency care services in England and the
new models of care which propose to do this are set out in the Five Year
Forward View (5YFV). The Urgent and Emergency Care Review proposes a
fundamental shift in the way urgent and emergency care services are provided,
improving out of hospital services so that we deliver more care closer to home
and reducing hospital attendances and admissions. We need a system which is
safe, sustainable and that provides consistently high quality. The vision of the
Review is simple:
 For those people with urgent care needs we should provide a highly
responsive service that delivers care as close to home as possible,
minimising disruption and inconvenience for patients and their families.
 For those people with more serious or life threatening emergency care
needs, we should ensure they are treated in centres with the very best
expertise and facilities in order to maximise the chances of survival and a
good recovery.
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1.3 Vision
The core vision for a more closely Integrated Urgent Care service builds upon
the success of NHS 111 in simplifying access for patients and increasing the
confidence that they, local commissioners and the public have in their services.
The offer for the public will be a single entry point - NHS 111 - to fully
integrated urgent care services in which organisations collaborate to deliver
high quality, clinical assessment, advice and treatment and to shared standards
and processes and with clear accountability and leadership.
Central to this will be the development of a ‘Clinical Hub’ offering patients who
require it access to a wide range of clinicians, both experienced generalists and
specialists. It will also offer advice to health professionals in the community,
such as paramedics and emergency technicians, so that no decision needs to
be taken in isolation. The clinicians in the hub will be supported by the
availability of clinical records such as ‘Special Notes’, Summary Care Record
(SCR) as well as locally available systems. In time, increasing IT system
interoperability will support cross-referral and the direct booking of
appointments into other services.
A plan for online provision in the future will make it easier for the public to
access urgent health advice and care. This will increasingly be in a way that
offers a personalised and convenient service that is responsive to people’s
health care needs when:
 They need medical help fast, but it is not a 999 emergency.
 They do not know whom to contact for medical help.
 They think they need to go to A&E or another NHS urgent care service.
 They need to make an appointment with an urgent care service.
 They require health information or reassurance about how to care for
themselves or what to do next.
Put simply:
“If I have an urgent need, I can phone a single number (111) and they will, if
necessary, arrange for me to see or speak to a GP or other appropriate health
professional – any hour of the day and any day of the week”
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Shown diagrammatically, a functionally integrated urgent care service:
An Integrated Urgent Care service, supported by an Integrated Clinical Advice
Service (Clinical Hub) will assess the needs of people and advise on or access
the most appropriate course of action, including:
 Where clinically appropriate, people who can care for themselves will be
provided with information, advice and reassurance to enable self-care.
 Where possible people will have their problem dealt with over the phone by
a suitably qualified clinician.
 People requiring further care or advice will be referred to a service that has
the appropriate skills and resources to meet their needs.
 People facing an emergency will have an ambulance dispatched without
delay.
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 999 will continue to provide an emergency service whilst 111 will take all
calls requiring urgent but not emergency care.
1.4 Benefits
Commissioners are responsible for the measurement and delivery of the
intended benefits for an Integrated Urgent Care service. The list below
describes the anticipated benefits to patients, commissioners and providers as
identified in the Urgent and Emergency Care Review:
For Patients:
 Increases the patient’s and/or their family/carer’s awareness of the service
and publicise the benefits of ‘phoning NHS 111’ as a smart call to make.
 Improves public access to urgent healthcare services 24/7.
 Makes it clear how all patients or their family/carer can access and navigate
the urgent and emergency care system quickly, when needed.
 Provides all patients and/or their family/carer with information and options
for self-care, and support them to manage an acute or long-term physical or
mental condition.
 Improves all patients’ care, experience and outcome by ensuring the early
input of a senior clinician in the urgent and emergency care pathway.
 When required, makes the onward referral increasingly seamless e.g.
through direct booking of appointments at a wider range of urgent care
services.
 Increases public satisfaction and confidence in the NHS.
 Measures the quality and experience of patient care and act upon these
assessments to ensure continuing service improvement.
For Health Professionals:
 Provides consistently high quality and safe care.
 Is simple and guides good, informed choices by patients, their carers and
clinicians.
 Provides access to the right care in the right place, by those with the right
skills, the first time.
 Promotes the appropriate and effective sharing of relevant patient
information across and between services.
 Improves decision making through access to records.
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OFFICIAL
For Commissioners:
 Is efficient and effective in the delivery of care and services for patients.
 Increases the efficiency and productivity of the urgent care system,
eradicating overlap and duplication in service provision and clinical time.
 Drives the improvement of urgent and emergency care services.
 Creates an opportunity to reduce high acuity referrals; improving system
impact.
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2 Commissioning Standards
2.1 Purpose
This document sets out the Commissioning Standards for a functionally
Integrated Urgent Care service in England which will provide the public with
24/7 access to urgent clinical assessment, advice and treatment. The standards
detailed throughout this document have been jointly developed between CCGs,
providers, NHS England and a wide range of stakeholders and take account of
public feedback received during the Urgent and Emergency Care Review.
The standards describe the core requirements and quality metrics for an
Integrated Urgent Care service.
However, all Out-of-hours providers, including those GP practices that retained
responsibility for Out-of-hours services under the GP contract (i.e. did not opt
out of responsibility for Out-of-hours services under the 2004 contract) are
currently required to meet the quality requirements set out in ‘National Quality
Requirements in Out-of-hours Services’ published on 20 July 2006. These
requirements are currently described in legislation (SI 2015 no196 section 8)
and NHS England will work with the Department of Health to consider whether,
and how, amending them. In the meantime, a companion publication describing
a proposed suite of new metrics and key performance indicators (KPIs) for the
functionally integrated service will be published alongside these Commissioning
Standards. In time, these new metrics and KPIs will be incorporated into further
iterations of this document.
The intent is to describe best practice in supporting commissioners and
providers to deliver these standards and ensure that all patients can depend
upon receiving the same high quality service wherever they live or access
urgent health care in England.
The standards have been informed by:
 The Five Year Forward View.
 The Urgent and Emergency Care Review.
 Learning and Development Phase 1 Pilots.
 Commissioners.
 Patient and the Public insights.
Crucially, in its 2014 report on: “The performance, oversight and assurance
arrangements, and integration of Out-of-hours GP services”, the National Audit
Office recommended that:
14
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“In taking forward its vision for urgent and emergency care, NHS England
should support and incentivise clinical commissioning groups and other bodies
to integrate. If the vision is to be realised consistently and cost-effectively, the
NHS will need guidance and sometimes central direction. Specifically, NHS
England will need to: understand how patients flow through the system;
identify and disseminate good practice; support clinical commissioning groups,
possibly financially, to align existing urgent care contracts; and address
perverse incentives in national payment and performance management
frameworks.”
The intent is to describe achievable best practice in supporting commissioners
and providers to deliver these standards and ensure that all patients can
depend upon receiving the same high quality service wherever they live or
access urgent health care in England.
2.2 Audience
The primary audience for this document is clinical commissioning groups and
providers of NHS 111 and Out-of-hours services as the responsible
organisations in the performance of local urgent care systems. Clinical
commissioning groups should be aware that it will be of considerable
importance to work with local providers, and should ensure that they are
involved in the development of local delivery plans.
2.3 Roles and responsibilities
The full roles and responsibilities are outlined within Annex A.
Commissioners are responsible for the procurement of an Integrated Urgent
Care service in line with the service standards described throughout this
document.
Annex B provides a useful self- assessment tool for commissioners to use as a
guide to the level of integration towards new clinical standards for an integrated
24/7 urgent care and clinical advice service. It can be used at Clinical
Commissioning Group, System Resilience Group or Urgent & Emergency Care
Network levels.
2.4 Local commissioning specifications
This document constitutes the national standards to deliver a 24/7 urgent
clinical assessment, advice and treatment service (Integrated Urgent Care).
Commissioners may wish to enhance these in delivering their local
15
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specifications and to ensure that they are comprehensive and appropriate in
meeting the needs of their local population.
It also gives commissioners and providers an outline of current developments
and further improvements to the service offering that are highlighted as
explanatory notes within the document.
Commissioners should take account of these standards and separate
supporting procurement guidance when commissioning ‘Functionally Integrated
Urgent Care’ services.
Commissioners must have robust plans to ensure that the newly commissioned
functionally integrated urgent care services fully realise the available financial
savings at the local healthcare economy level and that these savings are
realised at the same time as any new costs are brought on stream. When
evaluating these potential savings commissioners should include all costs and
savings across the whole healthcare economy that are borne by CCGs, NHS
England, or any other organisation with delegated authority to commission
healthcare locally.
Commissioners should assure themselves that any savings realised from the
newly commissioned services are not offset through commissioning of
unnecessarily duplicated services elsewhere in the urgent and emergency care
system (for example through ambulance services, urgent care centres or locally
commissioned general practice enhanced services).
Additionally, when commissioning new services commissioners should ensure
that there is sufficient flexibility built into the new contracts that the risk of future
duplication of commissioned services is mitigated. In particular, contracts
should allow for the possibility of longer in-hours general practice provision
consistent with the development of seven day services, and the possibility of a
future shift between telephony and digital access to 111 services.
NHS England is seeking to publish a financial modelling tool to support
commissioners in understanding the whole system potential cost and to
circulate a summary at CCG level comparing the costs prior to September 2015
of 111 and GP Out of Hours services.
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2.5 Joint working arrangements
2.5.1 Lead Commissioner Arrangement
As identified in the Urgent and Emergency Care Review it is critical that NHS
111 services are considered as part of the Urgent and Emergency Care
Network 2 . As such the Network would be the most appropriate level for
agreeing how a service such as an integrated service should be commissioned.
The lead or co-ordinating commissioner arrangement should be considered, in
which commissioners serving a wider area are brought together to commission
an integrated service. This has been shown in a number of areas to be an
effective model for engaging with providers (particularly those that deliver
services over an area covering a number of CCGs) and to effect strategic
change.
2.6 Collaborative Provider Management
Commissioners should continue to promote a healthy and diverse provider
market. It is envisaged that both large and small providers will have an
important part to play in delivering a successful and Integrated Urgent Care
service. Providers will need to collaborate to deliver the new investment
required in technology and clinical skills, and to ensure that services are
aligned. It is for this reason that commissioners should consider using the
procurement process to encourage current NHS 111 and Out-of-hours
organisations to collaborate or work within a lead provider arrangement, to
deliver the standards for an Integrated Urgent Care service.
In doing so, commissioners will need to ensure that the current provider market
continues to be developed and is not destabilised in any way. There should be
many opportunities for any qualified provider to meet these new service
standards in collaboration with other providers. To be clear, NHS England
has no expectation that any organisations should merge.
2.7 Payment approach for Integrated Urgent Care
NHS England and Monitor recognise that current forms of payment for urgent
and emergency care (UEC) services may create a barrier to coordination and
collaboration and that a new approach to payment may play a valuable role in
enabling a networked model of care.
2
http://www.nhs.uk/NHSEngland/keogh-review/Documents/Role-Networks-advice-RDs%201.1FV.pdf
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The document: Urgent and emergency care: a potential new payment model
outlines potential payment options and provides guidance on how to approach
developing and implementing one possible new payment approach locally to
support UEC service reform. In addition, it recognises the need to allow local
areas the freedom to develop alternative approaches should they better fit their
local needs.
We have now drafted a document which builds on this guidance, looking
specifically at NHS urgent and emergency care telephony assessment and
advice. We have outlined one suggested payment approach that is consistent
across providers and encourages coordination in providing behaviour to provide
the best patient care.
Local areas can use this document as a basis for planning. The options
described are at a development stage, and will be further developed and tested
with a small number of local areas during 2015/16. Updated versions of this
document will be published as we learn from this work and how it informs
refinement of the payment design, including how the proposed payment
approach will work alongside other payment models.
This document can be found at: https://www.england.nhs.uk/ourwork/pe/nhs111/resources.
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3 Standards of Delivery
3.1 Access
 Central to Integrated Urgent Care will be a 24/7 free to call number (111)
that gives patients and the public easy and swift access to urgent care.
 Patients and the public should be enabled to access Integrated Urgent Care
via alternative routes to the telephone; i.e. digital online platforms.
 Warm transfer of patients should be facilitated between organisations with
the avoidance of re-triage whenever possible and appropriate.
 Commissioners should ensure access to a range of multidisciplinary clinical
expertise and services in addition to nurses and paramedics. We expect
that the clinical hub (physical or virtual) will be the source of this expertise.
 Whilst it is not recommended, it is acknowledged that alternative routes of
telephone access to the urgent care system may be in place to reflect
current local arrangements, e.g. provision of extended access primary care
services. Commissioners should ensure that these are both absolutely
necessary and within the scope of Integrated Urgent Care governance
arrangements and that adequate signposting and transfer occurs if a patient
calls 111.
3.2 Assessment
 Patients calling 111 will speak first to a health adviser who will use an
accredited clinical assessment tool to assess and triage symptoms.
 Where local alternative routes of access are available (i.e. direct access via
local Out-of-hours telephone numbers) commissioners should assure
themselves that initial call handling and assessment also occurs using a
locally agreed clinical governance process.
 Patients with complex problems needing to speak to a clinician will be
identified quickly and transferred to speak to the appropriate clinician. It is
advised that commissioners work together with providers and clinical
governance leads to identify and utilise safe and effective process for this
purpose.
 Safeguarding alerts, Special Patient Notes, including End-of-Life Care
Plans and recent contact history, will be available at the point of access to
ensure appropriate assessment of need. In addition, as a minimum the
Summary Care Record will be available to all clinicians, with a commitment
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to widen access to other relevant patient records (e.g.) – virtually or in a
face to face setting.
 Integrated Urgent Care will have the capability to make an electronic
referral to the service that can best deal with a patient’s needs as close to
the patient’s location as possible.
 Integrated Urgent Care should aim to book face to face or telephone
consultation appointment times directly with the relevant urgent or
emergency service whenever this is supported by local agreement.
As networks and federations of GP practices develop, patients may be
offered an alternative practice-based appointment within their GP network
3.3 Treatment & Clinical Advice
 Red ambulance or equivalent dispositions are to be dispatched without retriage. This is not intended to prevent health advisers in NHS 111 seeking
clinical advice during a call, nor to prevent enhanced clinical assessment by
the 999 service which does not delay dispatch.
 Green ambulance dispositions may be subject to enhanced clinical
assessment within Integrated Urgent Care before an automated referral is
sent to the local ambulance service. This process must be agreed by
commissioners, clinical leads and providers as safe and robust, with
appropriate governance/escalation in place, and the impact on local
performance and incidents must be regularly reviewed.
Evidence: There have been 32,000 fewer green ambulance referrals from
London 111 since the start of enhanced clinical assessment of Green
ambulance dispositions in November 2014 – approximately 800 per week.
 Commissioners should assess the potential benefits and consider if
Emergency Department (ED) dispositions should be subject to early clinical
assessment within Integrated Urgent Care. Referral of patients from
Integrated Urgent Care to the ED should include the use of electronic
messaging and opportunities to book patients directly into the ED should be
explored.
 Ambulance services should have the facility to electronically transfer patient
details to Integrated Urgent Care for early clinical assessment if the call is
assessed as a green disposition rather than being required to deal with the
call themselves.
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 Self-care should always be considered as an option when treating and
offering advice to those contacting the service. In addition to this there may
be the option of tertiary sector involvement and in time the possibility of
linkage with social care systems that would support an individual in their
own home.
3.4 Advice and Referral
 The Directory of Service (DoS) will hold accurate information across all
commissioned acute, primary care and community services and be
expanded to include social care. The advantages of being able to contact
social care support through the 111 telephone number offer significant
benefits - specifically in relation to home support / carers etc. (Further detail
of the DoS is included in 4.4).
 The Directory of Services should reflect locally commissioned schemes and
services, especially those intended to utilise independent contractors such
as community pharmacists as appropriate alternatives for minor ailments
and urgent repeat medication. Commissioners must assure themselves that
arrangements are in place to ensure that entries are accurate and up to
date. Health advisers need to be confident in referring or signposting callers
to these services, where available.
Evidence: A Pharmacy Urgent Repeat Medication scheme was
commissioned for winter 2014/15, resulting in 1,084 fees claimed by
community pharmacists as at the end of May. This represents one third of
urgent repeat prescription activity; although it reduced pressure on GP Out-ofhours providers and EDs, the rate of referral to community pharmacists is
being increased through better processes and improved health adviser
confidence. In a survey of 469 patients using the scheme, in answer to the
question ‘Where would you have gone if this service was not available?’




41%
39%
19%
7%
would have gone to A&E or urgent care centre
would have gone to GP Out-of-hours
would have gone without their medicines
would have gone on to contact own GP
 An accredited search tool should be available to allow clinicians across all
Integrated Urgent Care settings to search the DoS [Access to Service
Information] direct. For appropriate staff, this should be permitted outside
the approved clinical algorithm software, where considered safe and
appropriate.
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Evidence: A Directory of Services search tool is being deployed across a
range of urgent care settings to provide access to GP bypass numbers and
locally commissioned services, especially those designed to support care in
the community (e.g. falls teams).
 To ensure adherence to these national standards, all providers, or
combinations of providers, must commit to adherence to the service
specification and contractual framework on patient disposition options and
shared clinical advice, recognising that the initial part of the assessment
accessed via 111 is a national service.
 There should be clear governance in place, informed by audit of service
selection, to ensure regular review of services returned from the Directory of
Service [Access to Service Information] and their relative priority especially
across borders with neighbouring CCGs.
3.5 Integrated Care Advice Service (or ‘Clinical Hub’)
To support effective Integrated Urgent Care it is recommended that
commissioners include an “urgent care clinical advice hub” in specifications. To
improve working relationships, dialogue, and feedback, some of the clinicians
that make up this hub should be physically co-located. For clinical specialisms
and care expertise which is consulted less frequently it may be more
appropriate to make arrangements to contact an individual who is off site
through the creation of a “virtual urgent care clinical hub”.
Commissioners will want to consider maximising the utility of the ‘clinical hub’
e.g. The Clinical Hub should serve two purposes: to provide clinical advice to
patients contacting the 111 or 999 services, as well as providing clinical support
to clinicians (particularly ambulance staff such as paramedics and emergency
technicians) to ensure that no decision is made in isolation. It could also
support the wider Urgent Care Network (for example nursing and residential
homes and other emergency services such as the police, for use in street
triage). We would encourage the joint commissioning and establishment of
hubs and at an appropriate scale – avoiding overlap and duplication. Over time
additional methods of communication and support (for example videoconsultation) should be explored to further increase the effectiveness of the
clinical hub.
The exact mix of clinicians and other urgent care staff in the integrated urgent
care clinical hub, and their seniority, should be specified in contracts/service
arrangements and dictated by a careful assessment of local needs and the
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UEC network design. Usually they will include one or more of each of the
following professionals:
 Specialist or advanced paramedics with primary care and telephone triage
competences.
 Nurses with primary, community, paediatric and/or urgent care experience.
 Mental health professionals.
 Prescribing pharmacists.
 Dental professionals.
 Senior doctor with appropriate primary care competences.
Additional competency areas that may require provision include: midwifery,
paediatrics, hospital specialists, occupational therapy, third sector
organisations, alcohol and drug services, palliative care nurses, social care,
housing and others depending on local need. Wherever possible individuals
working in the clinical hub should be based in that community, and be familiar
with local services and practice.
3.6 Improving Referral Pathways
3.6.1 Referral Rights
In addition, and in order to help facilitate an improved flow of patients and
information within the UEC system, all registered health and social care
professionals within physical and mental health (referred to in this document
using the general term “clinicians”), following telephone consultation or clinical
review of a patient, should be empowered, based on their own assessment, to
make direct referrals and/or appointments for patients with:
 The patient’s registered general practice or corresponding Out-of-hours
service.
 Urgent Care Centres.
 Emergency Departments in Emergency Centres and in Emergency Centres
with Specialist Services.
 Mental health crisis services and community mental health teams.
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 Specialist clinicians, if the patient is under the active care of that specialist
service for the condition which has led to them accessing the urgent and
emergency care system.
Urgent & Emergency Care Networks may wish to define the exact referral
pathways available to each professional working within their network. Further
guidance is available in the document: Improving Referral Pathways between
Urgent and Emergency Services in England - Advice for Urgent Care Networks.
3.6.2 Referral Mechanism
Referral of patients between urgent care services is best facilitated by transfer
of electronic messages. Detailed guidance is available in the Inter-operability
Standards
3.6.3 Post Event Messaging
Commissioners must ensure that a post event message (PEM) is sent to the
registered GP in-line with previous guidance from GP Out-of-hours national
quality requirements and NHS 111 inter-operability standards. Commissioners
should note that there are considerable opportunities to streamline the format
and content of the PEM using the receiving GP system and by working with
local
NHS
111
providers.
The
community
website
https://posteventmessaginginfo.readthedocs.org provides some useful guidance
on these matters.
Although considerable work has already been undertaken to improve the PEM
and to reduce the number of duplicate PEMs sent we continue to work with the
clinical decision support system (CDSS) supplier to improve this further.
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4 Supporting Standards
4.1 Access to Records
 Clinicians within the Integrated Urgent Care service must have access to
relevant aspects of patients’ medical and care information, where the
patient has consented to this being available.
 This must include knowledge about patients’ contact history and medical
problems; so that the service can help patients make the best decisions.
Patients with special notes or a specific care plan must be treated according
to that plan and, where patients have specific needs they must be
transferred to the appropriate professional or specialist service.
 Access to important patient information through the existing Summary Care
Record (SCR) service, and from other local systems that may be in place,
must be available to all clinicians working in the Integrated Urgent Care
system along with the necessary training to use it appropriately.
Commissioners should ensure that Integrated Urgent Care service
providers remain engaged to develop wider sharing of records across the
health care system, including the enrichment of SCRs with additional
information by GP practices for appropriate patient groups.
Explanatory Note: SCRs with additional information will include reason for
medication, significant medical history and procedures, patient preferences
(e.g. communication and end of life) and immunisations.
 Commissioners need to ensure that providers adhere to the Data Protection
Act in relation to access to records. It may be beneficial that the ‘Permission
to View’ (PTV) question for clinical records is asked by the call handler
during the initial stage of the patient’s encounter with the Integrated Urgent
Care service. The response to this question should be captured and stored
in the system, and passed through technical interfaces onto any further
system and/or organisation that will be responsible for direct patient care
during the episode.
Explanatory Note: Call handlers are not expected to view the SCR only to
capture the patient’s consent at the beginning of the call. This removes the
need for clinical staff having to ask the question whilst attempting to treat
the patient.
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 The SCR will be developed to allow the creation of ‘flags’ which will signal
the presence of key information held within the enhanced SCR or on other,
locally determined, systems. It is intended that these flags will be presented
at a point in the call flow that will allow for appropriate action e.g. routing
directly to a clinician, without the requirement for a full triage by the health
advisor.
 In time, we expect that the SCR will be developed as a strategic
solution to ensure that the presence of care plans and special notes
can be identified and accessed.
 We recognise the need to work with providers, commissioners and
system suppliers to create additional interoperability standards and
develop an interoperability roadmap by March 2016 to support more
advanced models of integration and access to records.
4.2 Business Continuity
 All Integrated Urgent Care commissioners should require through the NHS
standard contract that providers have arrangements in place so that in the
event of fluctuations in demand, technical failure or staff shortages they can
invoke contingency and continue to provide an acceptable level of service
to the population. It is vital that the service remains safe for patients at all
times.
 It is suggested that a collaborative provider-to-provider relationship, where
possible geographically separated, would be a pragmatic approach to this.
If providers are looking at implementing this approach then this should be
undertaken in conjunction with NHS England and the commissioner, so if
required any changes that may be required to telephone call routing can be
delivered. Any arrangement of this sort must have clear agreement
regarding how much activity could be potentially transferred to the support
provider.
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 Commissioners and providers should be aware of their responsibilities to
support disaster recovery in the event that another service provider is
unable to take calls due to some catastrophic event. In these
circumstances, the NHS 111 National Contingency would be invoked and
all commissioners and providers would be expected to accept an
appropriate proportion of calls in order to maintain national patient safety.
The proportion of calls will be determined by the amount of activity each
provider routinely experiences. Neither funding nor performances penalties
should be applied to the receiving call handling service in this situation. The
commissioner should seek to establish retrospectively whether the
catastrophic event was within the failing parties control and constituted a
breach, or whether it should be classed as “force majeure”.
 The National Contingency policy is detailed in a separate document
(https://www.england.nhs.uk/ourwork/pe/nhs-111/resources/). The capacity
of Integrated Urgent Care services should be sufficient to meet call volume
and fluctuations in demand, in line with the National Quality Requirements.
Providers must ensure they plan their resources in relation to historical
demand and ensure that any current trends in demand are also taken into
account. Integrated Urgent Care providers must ensure that their capacity
planning is conducted in liaison with other healthcare providers who may be
affected by their outputs (e.g. out of hour’s providers, ambulance services,
ED departments).
4.3 Clinical Decision Support System
Integrated Urgent Care service providers must ensure that health advisers and
non-registered clinicians use accredited clinical assessment tools/clinical
content to assess the needs of callers; this is a mandatory requirement. For
registered clinicians local commissioners will need to determine the use of any
CDSS based on the scope of practice, competences and educational level of
clinicians concerned. In addition, the provider of the service must ensure that
they adhere to any licensing conditions that apply to using their system of
choice. This must include the ability to link with the wider urgent and emergency
care system. Commissioners should also ensure that providers deploy any
relevant CDSS upgrade/version, associated business changes, training and
appropriate profiling changes to enable Access to Service Information (DoS)
within any specified deployment windows for the chosen system(s).
4.4 The Directory of Services (DoS)
The Directory of Services (DoS) provides access to service information, which
is a critical element of NHS 111 service provision. As patients should be able to
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access a wide range of services via NHS 111, access to service information
may be provided from the DoS and additional sources. Commissioners must
ensure that resource and infrastructure is in place to provide accurate and
relevant access to service information to Integrated Urgent Care providers.
Commissioners therefore:
 Need to enable the addition of services from social care, mental health and
third-sector services to improve accessibility for patients to these services.
 Should ensure that expert resources are available to engage with all
services in order to effectively maintain and update systems providing
access to service information. This involves regular, routine updating of
services for accuracy, profiling, ranking and the addition of new services
where appropriate. These activities must be undertaken in line with the
Clinical Decision Support System (CDSS) licence requirements, and
commissioners should work with their providers to plan and agree the timing
of CDSS version upgrades and consequent changes to service profiling.
 Should ensure that resources employed to maintain service information are
at an equivalent grade to other areas, are sufficiently senior and are
supported by a local governance model with clear reporting structures from
the local level through to national reporting and oversight.
 Must ensure that adequate resource is allocated to testing of service
information returns to the NHS 111 service following profiling changes
and/or CDSS upgrades. This testing should include clinical sign off against
defined scenarios and must respond to service improvements identified
during live operations or as a result of improvement initiatives, such as
context sensitive ranking of results.
 Should ensure that service information collected from social care, mental
health and the third sector is assured as being consistent with the data
collected from NHS services and therefore maintains clinical safety for
patients being signposted to those services. The access to service
information for services within and outside the NHS should be completed
without duplicating data across directories where possible.
 Should work with services and the Integrated Urgent Care provider to
ensure that "follow up" information is available to the person calling the
Integrated Urgent Care service by (for example) text message or e-mail
confirmation of details of the service that the patient has agreed to attend.
 Must engage with annual data quality audits to ensure that service
information is maintained to an agreed quality standard.
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 Should ensure that regularly updated Standard Operating Procedures are in
place for managing the day-to-day access to service information, business
continuity in the event that service information cannot be accessed, and
approaches to handling calls where access to service information does not
correctly link to the CDSS. Where national initiatives provide solutions to
continuity of access to service information, commissioners must work with
their providers to support these initiatives. Operating procedures should
also enable the capture of feedback from Integrated Urgent Care Service
staff relating to improvement of access to service information.
4.5 Clinical Governance
Each Integrated Urgent Care service must ensure that clinical governance
arrangements are in place to assure the clinical safety of the whole patient
pathway, not just the initial call handling service phase of ‘Integrated Urgent
Care’. These arrangements are underpinned by strong relationships and
partnership working between all providers involved in the patient pathway so
that issues can be identified and service improvements made. They are based
on an open, transparent and multi-agency approach to clinical governance.
The following is suggested good practice for Integrated Urgent Care clinical
governance;
1. The appointment of a local Integrated Urgent Care clinical governance
lead (CGL). This lead should be appropriately skilled and suitably
experienced for the role.

The CGL role involves the development of relationships across the
whole urgent and emergency care network, and the individual should
be clinically credible in order to work effectively in this complex
environment.

The CGL will be responsible for holding the provider to account for
clinical standards.

The CGL must have clearly defined links to the regional and national
NHS clinical governance structures, particularly the local system
resilience groups and urgent and emergency care network.

A minimum expectation is for the lead to have at least two days a
week to dedicate to this role. Where the geography, service
utilisation and complexity of service are greater, more capacity may
be required.
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2. A local clinical governance group, under strong clinical leadership and
with clear lines of accountability to the commissioners of the integrated
urgent care service, working alongside and closely with the contracting
team. The local governance group should bring together the Integrated
Urgent Care Service providers with all the NHS and social care providers
to whom patients may be referred, enabling all to develop a real sense of
ownership of their local service.
More detailed guidance on the role of local clinical governance groups,
including model terms of reference and membership is available in the
companion document ‘Integrated Urgent Care Clinical Governance
available at https://www.england.nhs.uk/ourwork/pe/nhs-111/resources
NB. Clinical Governance advice and a revised toolkit to encompass the
new Integrated Urgent Care service, based on the old NHS 111 CG
model, will be available ASAP.
3. Clarity about lines of accountability within the Integrated Urgent Care
service.
4. A policy setting out the way in which adverse and serious incidents will
be identified and managed, ensuring that the clinical leadership of the
Integrated Urgent Care service plays an appropriate role in
understanding, managing and learning from these events.
5. Clear and well publicised routes for both patients and health
professionals to feedback their experience of the service, ensuring
prompt and appropriate response to that feedback with shared learning
between organisations.
6. Regular surveys of patient and staff experience (using both qualitative
and quantitative methods) to provide additional insight into the quality of
the service.
7. Regular review of the ‘end-to-end’ patient journey, with the involvement
of other partner organisations, especially where outcomes have proved
problematic.
8. Provision of accurate, appropriate, clinically relevant and timely data
about the integrated urgent care service to ensure that it is meeting these
Commissioning Standards.
4.6 Future Workforce
As part of the wider Urgent and Emergency Care Programme, NHS England,
Health Education England and key stakeholders are presently working together
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on a number of key areas, these include:.
 Integrated Urgent Care health advisers and the integrated urgent care callcentre based ‘tele’ workforce.
 GP fellows in emergency and urgent care.
 Advanced practitioners from nursing, paramedics, pharmacy, podiatry and
physiotherapy.
 Emergency Medicine fellows.
 Physician Associates.
 Non-medical prescribers.
 Independent prescriber pharmacists.
 Paramedics.
The national NHS 111 (Integrated Urgent Care) Workforce Development
Programme has been setup to identify the urgent care workforce requirements
for the future; to define the optimal composition, scope of practice,
competences and associated development needs. The Programme will deliver
outcomes up until 2017/18, however in the interim commissioners and providers
must be clearly sighted on quality, composition and competence of the existing
workforce.
The clinical workforce will be comprised of generalist clinicians (paramedics,
nurses and GPs) who have specialised skills and competences in remote and
telephone assessment and management, supported by specialised clinicians
from a range of professions cover specific clinical areas, including mental
health, dental health and paediatrics.
Commissioners must ensure that services are commissioned for quality and
must ensure that there is a clear understanding of the continuous quality
systems (including appraisal and feedback) for staff to compliment robust and
high quality personal development at recruitment and this must not be limited to
solely audit systems, such as used with the CDSS systems.
The workforce will require support from commissioners and Local Education
and Training Boards to innovate and develop practice, particularly around the
introduction of specialist and advanced level practice clinicians and the Health
Advisors. Focus on the development of 'tele' competencies, including an
understanding of the CDSS systems and ensuring that they safely manage
patients in the telephone environment is required for ALL groups of staff, from
GPs to paramedics and nurses and strategies must be in place to ensure that
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all staff who practice have the correct competencies and are supported in
developing these.
The wellbeing, mental health and future careers of the Integrated Urgent Care
workforce are very important; commissioners and providers must ensure that
there are mechanisms in place to have a clear understanding of these issues
and systems and processes in place to manage them - including exit interview
data, an understanding of the rates of attrition for each group and a clear
process to ensure value is added from collecting this data.
Prior to these outcomes being available, the workforce should meet the
following, minimum requirements, adapted from the NHS 111 Commissioning
Standards 2014.
Providers and commissioners should always ensure that they undertake
employment checks in accordance with the guidance set out by the NHS
Employers, which includes relevant criminal records checks. Examples can be
found at: http://www.nhsemployers.org/case-studies-andresources/2014/07/eligibility-for-dbs-checks-scenarios
4.7 Staff working in Integrated Urgent Care
4.7.1 Health Advisers (Call Handlers)
Workforce training and development must be led by trainers with experience of
working within the NHS 111 and/or other telephone triage areas and training
and supervision must be provided by a multi-professional workforce, comprising
senior health adviser call handlers and clinicians (nurses or paramedics).
Newly trained staff must not deliver training and development when a new
service is ‘stood up’ without support from more experienced trainers. The focus
must be on quality that translates into positive patient experience, and
enhanced patient safety.
All staff involved in handling calls in Integrated Urgent Care must undertake
training that covers the following areas:
 Compliance with the licence requirements of the relevant Clinical Decision
Support Software (CDSS).
 How to interact with urgent care services.
 The use of Directory of Services.
 NHS values and behaviours.
 Delivering excellent, compassionate, customer-focused service.
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 Level 2 Safeguarding.
The above should only serve as an indicator and commissioners may wish to
specify minimum educational standards and competences over and above
these minimum standards. Supernumerary supervisory and clinical staff must
be available at all times to support and supervise health advisers. The
procedures for seeking clinical advice and the handover protocols from a call
handler to a clinician must be simple and clear with voice recording of all
interactions.
4.7.2 Clinical staffing model
The basic principles applying to non-clinical staff should be applied to the
clinical staffing model.
Commissioners should consider how increased or faster access to clinical
advice should be secured for their population. This should be in line with any
recommendations from their clinical quality group and include how clinicians
access patient records and how they ensure safe timely handover of patient
care.
Patient safety must be assured at all times, and clinicians must have the
necessary competence, knowledge and skills to operate in roles within the
system, including a core level of knowledge of the CDSS systems with which
they interface.
Within the Integrated Urgent Care contact environment, clinicians will perform a
dual function, providing both direct patient contact, and also clinical supervision
and support of the non-registered staff working within the environment – the
commissioning arrangements must facilitate this and recognise that clinicians
employed within this function will not always be providing direct patient contact.
There is also an opportunity to consider the rotation of staff through providers in
urgent care to increase skills, whilst, of course, acknowledging the very specific
skills required to give tele-advice.
Explanatory Note: Pilots and evaluations of different clinical models are on
going and will inform future standards. Initial pilots are focused on access to
GPs, but future pilots will include a full range of clinical professions including
nursing, pharmacy and mental health. Formal assessments of different models
will use operational research techniques in order to establish what is most cost
effective.
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4.7.3 Training of clinical staff
All clinical staff must be trained in line with the Clinical Decision Support System
used in the operational service; however their practice must not be restricted to
solely operating within the scope of the CDSS, instead their practice must
include the necessary specialist competences and capability to work safely and
effectively within the urgent and emergency care environment.
Explanatory Note: Currently it is acknowledged that there may be the need to
develop specific educational modules for clinical staff to undertake that will
increase their knowledge and improve patient outcomes. NHS England in
partnership with stakeholders is undertaking a piece of work to evaluate this
and any recommendations will appear in later versions of the commissioning
standards.
4.7.4 Medicines and Poisons training
NHS 111 is now the primary user of the National Poisons Information Service
(NPIS) to support the handling of accidental poisoning and overdose calls in
urgent care. Toxbase is the recognised web based resource to support
clinicians handling toxic ingestion calls and supporting decisions about selfcare.
Feedback from NPIS and the Toxbase service indicates that training of
clinicians working in urgent care contact centres is essential to support safe
decision making and managing patients who can be advised to stay at home or
need to attend Emergency Departments for clinical assessment.
The eToxbase learning module should be a minimum requirement training for
all clinicians supported by additional medicines and eBNF training in the context
of therapeutic overdose.
Further Information can be found at https://www.toxbase.org/.
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4.7.5 Staff continuous audit and improvement
Health advisers and clinicians (including GPs) must undergo a continuous
process of audit in line with the requirements of any clinical decision support
system (CDSS) licence and as specified in this document. This must be a
process that not only identifies where specific staff have gaps in skills and
knowledge but also must allow for continuous improvement of all staff. The
audit process should identify key areas where either additional training,
modifications to existing training or feedback to software providers are
needed.
The audit process itself should be quality assured; as a minimum there
should be both internal and external review of auditors.
The audit and development process outlined for health advisers above
should be adapted to meet the needs of clinicians and applied in an equally
rigorous and systematic way.
Audit by clinicians is preferable to reflect the wider assessment role provided
by these individuals, and should reflect the competences within the RCGP
Out-of-hours audit toolkit.¹
Continuous improvement must not be restricted to CDSS audit, but as
described earlier, be around appraisal, feedback, mentoring and
development – the focus should be on supported, self and system directed
learning and improvement to enhance quality, experience and safety.
4.8 Repeat caller service
As a result of the tragic death of Penny Campbell in 2005, the Department of
Health issued Directions requiring all GP Out-of-Hours services to ensure
that any health professional assessing a patient’s needs in the Out-of-hours
period would have access to the clinical records of any earlier contact that
patient (or their carer) may have recently made with the service.
Thus, where a patient (or their carer) calls the Integrated Urgent Care service
3 times in 4 days, the 3rd call should only be assessed by the health adviser
to determine whether or not an ambulance is required. If the outcome is not
to send an ambulance, then the call must result in a “Speak to GP within 1
hour‟ disposition and the GP must be alerted to the fact that this is the 3rd
time in 4 days that the caller has made contact with the Integrated Urgent
Care Service, and they should therefore complete a thorough re-assessment
of the patient’s needs. The GP should be sent details of all 3 calls.
The host software system will have to be able to identify where a caller has
called twice before within 4 days, so that it can then flag this third call in such
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a way that when it is answered by the call adviser, the outcome described
above is achieved.
None of this should apply to that small minority of people who regularly make
repeated calls to the same service, where the service will have made
separate arrangements to respond appropriately to those calls, nor should it
apply where there is an agreed care plan for the particular patient (e.g.
palliative care, long term conditions etc.). The host software system will
therefore also need to be able to identify these callers so that the Integrated
Urgent Care Service can respond appropriately to their needs.
Providers should monitor compliance with the above requirement and report
on any exceptions in a way that can be audited.
4.9 Interoperability
Interoperability within the Integrated Urgent Care environment is detailed in the
Interoperability Standards https://www.networks.nhs.uk/ The standards define
the technical standards that must be used for the transfer of data where
applicable, to and from NHS 111 application systems and the applications that
integrate with NHS 111 service providers.
The following outcomes are required for all services:
 All Integrated Urgent Care applications must connect directly with the
SPINE and have followed the Common Assurance Process with the ability
to perform an advanced trace to obtain patients NHS Numbers.
 All applications must connect with the Summary Care Record to ensure
access to patient records is achieved as a minimum.
 Integrated Urgent Care services must submit and retrieve data from the
National Repeat Caller Service.
 Services must be capable of receiving inbound messaging that can be
directed to the variety of clinical skill sets to support the online platform and
also offer potential integration with 999 should that be a local requirement.

Integrated Urgent Care services must follow the IM& T assurance
toolkit https://www.networks.nhs.uk/
 Commissioners must ensure that providers use approved software systems.
The following outcomes have flexibility in the approaches to how they are
commissioned from a technical perspective:
 All Integrated Urgent Care services must be able to book in either an
integrated manner, or using Interoperability Standards.
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 All services must be able to dispatch ambulances in either an integrated
manner locally, or using Interoperability Standards when dispatching to a
separate application or Out of Area 999 service.
 Integrated Urgent Care services must be able to determine where patients
are being referred or transferred to and transmit the data for all services and
all 999 services.
 It is recommended that there should be a technical requirement to provide a
text or email to patients to confirm direct bookings/appointments across the
UEC system.
 NHS England will be working with commissioners, providers and system
suppliers to develop interoperability standards and an interoperability
roadmap by March 2016.
4.10 Online Platform
An online channel for Integrated Urgent Care is currently being developed. If
rolled out nationally it is envisaged that it will provide a standardised mobile and
online platform that local urgent care (NHS 111) services can use to enable a
digital access channel for their populations.
It will be underpinned by accredited clinical decision support but redesigned for
online access directly by the patient. There will be key points in the online
process where patients are directed to a telephone interface with local services
or in time web/video chat as these are become available. The platform has
been designed specifically so that the questions the patient has already
answered are made available directly to the health adviser or clinician within the
urgent care service.
There remain detailed implementation and change management implications. It
is critical the platform is clinically safe, operationally efficient and simple to use.
NHS England will be working with industry experts and Integrated Urgent Care
services in London and across the West Midlands to refine and test the service.
It is expected that this stage of development will conclude during 2016.It is
possible that the platform will be available for use in 2017.
Commissioners should include the development and use of the online platforms
as a vital part of their agreements with service providers. It is acknowledged
that at this time with a developing service this cannot be definitely specified.
Therefore regular updates on progress will be provided on this development to
keep commissioners as informed as possible.
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4.11 KPIs & Metrics
Commissioners should ensure the data required to populate the Integrated
Urgent Care Minimum Data Set (MDS) is collected. This data should comply
with current metrics in line with the MDS Provider Specification.
The current data collection is derived from the existing Out-of-hours National
Quality Requirements (NQRs) and the NHS 111 Minimum Data Set (MDS),
however NHS England is working in close collaboration with providers and
commissioners to establish a new suite of metrics for Integrated Urgent Care
that will replace the NQRs and NHS 111 MDS.
The result will be the creation of a revised set of data items for the proposed
Integrated Urgent Care model aligned to the quality framework categories of
efficiency, safety and patient experience. Within this framework, the new MDS
will be grouped under the integrated delivery elements of access, assessment,
advice and treatment.
The intention will be to establish a data capture that facilitates three levels of
functionality:
1.
2.
3.
Appropriate for commissioners to answer any data query they may
have.
Appropriate for monthly submission to NHS England for publishing.
Appropriate for summary dashboard.
The finalised data collection will be taken through the Standardisation
Committee for Care Information (SCCI) and Burden Advice and Assessment
Service (BAAS) run by the Health and Social Care Information Centre and will
be subsequently mandated. This document remains in development –
Https://www.england.nhs.uk/ourwork/pe/nhs-111/resources/.
Longer term development work will continue through the Urgent and
Emergency Care Review to set system wide metrics responsible for tracking
patient outcomes as well as service performance. Commissioners should
ensure that Integrated Urgent Care providers comply with these metrics once
agreed.
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4.12 Telephony
Commissioners must ensure the following:
 Calls to the NHS 111 number must be received on specific direct dial in
(DDI) numbers that are devoted to 111, enabling the calls directly to
Integrated Urgent Care to be counted. It is no longer regarded as
appropriate to forward calls to 111 from GP practices or legacy Out-of-hours
numbers. A better approach is to play an announcement asking callers to
hang up and redial 111. There are normally 3DDI numbers (primary,
secondary and tertiary). The DDI numbers cannot be “non-geographic”
numbers, such as 0300; they must be a landline number.
 Integrated Urgent Care services must have reliable telephony provision that
allows calls to be networked across all the call centres directly receiving 111
calls in their contracted area. In the event of the loss of call answering at
any one location, calls can then be sent to other centres.
 Integrated Urgent Care services must have telephony systems that provide
management information as defined in the Integrated Urgent Care Minimum
Data Set.
 Groups (specifically users of BSL who are using the 111 BSL translation
service) it will be necessary to warm transfer a caller to the Integrated
Urgent Care service, as they cannot be called back.
 Recorded announcements must be compliant with the Integrated Urgent
Care Brand Guidelines.5
 All inbound and outbound calls to Integrated Urgent Care must be recorded.
Calls from adults must be retained for 8 years and calls from or about
children must be retained until their 26th birthday. (This requirement is
currently under review and the retention time is likely to be substantially
reduced but no decision has yet been made).
 Integrated Urgent Care providers are required to ensure that systems are in
place to comply with regulation concerning child protection and vulnerable
adults.
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 In order to cope with the very high level of demand that occurs on some
days there must be at least three times the number of lines available
compared to the maximum number of advisers. In addition there must be
sufficient “IVR ports” so that calls will go “off hook” (answer acknowledged)
within 5 seconds of a call being presented. This is normally done by
playing a message (see above). Calls that do not go off hook rapidly are
played a message asking the caller to try again. The playing of this
message is recorded nationally.
 If there is a call to 999 which is not of an emergency nature then the name
and number can be sent electronically to the appropriate Integrated Urgent
Care centre who will call them back. It is not currently legal to forward a
999 call from an ambulance service to another organisation which is not an
ambulance service.
 Calls to Integrated Urgent Care that need an emergency response are sent
to the ambulance service electronically. The ambulance service should
then treat them as if they had dialled 999.
 111 providers can if they wish use a local facility to spilt off dental,
pharmaceutical, repeat callers, health care professionals and other groups.
This should be done on the telephony platform of the provider.
 Integrated Urgent Care providers should have local contingency plans in
place for partial or full failure of their service. This could be forwarding of
their calls to another provider. Often such arrangements are reciprocal.
 As a last resort, NHS England can invoke national contingency. Calls are
then forwarded to all other providers. All providers are required to accept
national contingency calls in the event of it being invoked.
 Different organisations who are working collectively within the Integrated
Urgent Care system may wish to operate on a single telephony platform to
make it easier to manage voice communications between different
organisations, and to provide comprehensive telephony reports.
 Further requirements and information about Integrated Urgent Care
telephony can be found in the “NHS 111 Telephony Guide” which is
updated on a regular basis. This can be found at:
https://www.england.nhs.uk/ourwork/pe/nhs-111/resources
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4.13 Patient experience
Commissioners should ensure NHS 111 providers have a systematic process in
place to regularly seek out, listen to and act on patient feedback on their
experience of using the service, ensuring that they deliver a patient centred
service. This must include:
 Clear and well-publicised routes for both patients and health professionals
to feedback their experience of the service.
 Provide prompt and appropriate responses to that feedback.
 Regular surveys of patient and staff experience (using both qualitative and
quantitative methods) to provide additional insight into the quality of the
NHS 111 service.
 Systems in place to collate, aggregate and triangulate feedback from a
range of sources such as complaints, surveys, social media and online
resources including NHS Choices; www.nhs.uk or patientopinion.org.uk.
 The whole patient feedback process needs to be fully transparent whilst
recognising confidentiality. It is important that commissioners adopt an
approach that allows users to see the diverse views and experiences of
other patients and service users and the responses made by the service.
4.14 Procurement
It is for commissioners to decide what services to procure and how best to do
this within the framework of the regulations. This includes deciding whether
services could be improved by providing them in a more integrated way, by
giving patients a choice of provider to go to, and/or by enabling providers to
compete to provide services.
It is clear that both larger and smaller providers will have an important part to
play in delivering a successful and fully integrated service. To achieve this
integration and delivery of the revised commissioning standards, providers will
need to collaborate to deliver the new investment required in technology and
clinical skills, and to ensure that services are aligned. It is for this reason that
commissioners should consider using the procurement process to encourage
NHS 111 and Out-of-hours organisations to collaborate or work within a lead
provider arrangement, to deliver the specification for the Integrated Urgent Care
service.
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Further guidance to support the procurement of Integrated Urgent Care has
been developed and is available via the following:
https://www.england.nhs.uk/ourwork/pe/nhs-111/resources
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ANNEX A
Integrated Care Advice Service roles:
Dental
Dental pain without injury remains one of the highest reasons for calling NHS 111.
NHS England is responsible for commissioning all NHS dental services and CCGs
will need to work with NHS England Area Teams to ensure that dental services are
commissioned in local areas.
The dental case mix needs to be managed by suitably trained dental professionals,
which may include dental nurses trained in triage. This will usually be once anything
requiring urgent ED attendance has been ruled out by a clinical algorithm – see next
section. Ideally there would be the capability to book treatment slots direct with dental
treatment providers. To maximise efficiencies, this clinical group would need to be
able to refer cases to/receive cases from pharmacists and Independent Prescribers
within the Multidisciplinary Assessment Service. In addition, the use of Interactive
Voice Response (IVR) should be considered where it could be used to improve the
patient experience.
Management and Referral of callers with dental symptoms:
 The provider will need to manage callers with dental symptoms to NHS 111
using a clinical decision support system in use for the overall service.
 During normal working days (excluding public holidays), these callers will be
referred to services returning from the DoS between the hours of 0800 and
1800.
 Between the night time hours of 1800 in the evening until 0800 the following
morning, calls will be handled by NHS 111 and directed through the DoS
and sent to the Dental Assessment Service via ITK including an encounter
report.
 Callers who are not physically within their home area boroughs at the time
of their call will be managed through the CDSS and the DoS at all times.
 The provider must ensure that clinical staff receives suitable training on the
management of callers with dental symptoms in order to appropriately refer
or manage cases that cannot be referred to another service.
 The provider will be expected to provider a call log extract in relation to
dental cases.
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 Where a caller with dental symptoms is identified as a frequent caller the
provider will need to have processes in place to identify these cases and
manage them outside of the CDSS through a clinical advisor.
 The provider should ensure that all clinical staff working in the service have
received training on Toxbase or its equivalent to ensure that analgesia
overdose can be identified and managed amongst these callers.
 The provider shall ensure that all staff are trained in dental trauma
identification and management.
 The provider shall make contact with the Dental Assessment Service via a
telephone by-pass number where indicated.
 The provider shall co-operate with NHS England, commissioners and
providers with the end to end review of dental cases.
 The provider will need to communicate with NHS England, commissioners
and providers in order to manage any incidents, serious incidents and
complaints; this includes liaising with other dental providers.
Evidence:
In London, approximately 1750 callers per week with urgent dental problems are
being routed away from 111, and potentially ED and UCCs, to the Dental Hub (winter
resilience Dental Nurse Triage service) via IVR. Patient feedback for the Hub is
generally positive, especially for the overnight service. There have been instances of
patients who have gone to ED with an urgent dental problem, seen the posters to call
111 and had a positive outcome via the IVR. Patients appreciate being able to
access expert advice overnight.
Patient Experience Feedback:
Experiences are positive overall, callers would use the service again and satisfaction
was high, although service seemed variable in terms of call handler helpfulness and
outcome. The service helped callers gain an awareness of services in local area,
especially useful for a caller who had just moved to the area. Improved outcomes –
evidence that callers would have accessed A&E, minor injuries clinics or walk-in
centres if had not been able to use the service. One caller had recently come out of
rehab and may have relapsed without 111. Other callers said they would have just
put up with the pain.
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Mental Health
 In order to drive further improvements across the wider health economy,
Commissioners need to ensure that mental health services have the same
strategic focus as cancer and diabetes. (Five Year Forward View; Mental
Health Access and Waiting Time Standards, Urgent and Emergency Care
Review, Parity of Esteem Programme).
 Engagement with users and people with lived experience has highlighted
that there is more to do to deliver parity of esteem for mental health callers
in NHS 111. Urgent Care commissioners need to work jointly with Mental
Health commissioners to design the most appropriate range of services to
be connected with Integrated Urgent Care, this should be considered
across all areas of mental health but in particular the responses to crisis.
Ultimately, Integrated Urgent Care services should be adhering to the
Mental Health Crisis Concordat principles.
 Commissioners should seek to establish that the Integrated Urgent Care
service is staffed by competent call handlers who are appropriately trained
in mental health care, and who are supervised and supported by qualified
clinicians. Service user feedback should be obtained to ensure that patient
experience in this area is improving.
 Clinicians within the Integrated Urgent Care service must have access to
relevant aspects of patients’ mental health crisis record in line with the
section on access to record detailed in section 4.1 below.
 Networks of support and service user defined recovery outcomes should be
included, be reviewed regularly and kept up to date, particularly following
any crisis presentation, admission or significant change in an individual’s
circumstances. They should also identify factors which could potentially
precipitate a crisis and what steps can be taken to reduce the likelihood of a
crisis in such circumstances.
 Commissioners will want to ensure that the Directory of Services hold’s
accurate information across all acute, primary care and community services
and is expanded to include health based places of safety, NHS
commissioned services, (third sector / independent) social care and
services for homeless people. (Mental Health Access and Waiting Time
Standards, Urgent and Emergency Care Review).
 All commissioned services should be profiled with regards to their capacity
status to enable faster access to services, reduce the risk of suicide /
adverse events, as well as to maximise productivity of all agencies dealing
with mental health crisis. (National Suicide Prevention Strategy).
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Commissioners should ensure that their Integrated Urgent Care provider has chosen
clinical decision support system is capable of safely aiding the assessment of callers
in need of mental health care and / or advice in line with CQC safety standards.
Pharmacy
Pharmacists in the clinical hub:
Experience has shown that where pharmacists have been working in NHS 111
contact centres they can make a significant contribution to the efficiency and quality
of care handling a specific case mix of calls including:
 Medicines enquiries.
 Health information enquiries.
 Requests for urgent repeat medication.
 Medicines advice for minor illness.
 Poisons and accidental overdoses.
 Contraception advice.
Pharmacists have been working in the Yorkshire Ambulance Service (YAS) NHS 111
service since 2013 focusing on support at weekends and surge times. A recent
review of their activity has shown:
 Call centre pharmacists add value with shorter call lengths for medication
calls and are able to provide more specialist advice to patients than general
trained nurses and paramedics.
 Pharmacists are able to work as part of a multi-disciplinary team to advise
NHS 111 staff and 999 clinical teams.
 Clinical Pharmacists can be trained to multi-task in various roles e.g. Floor
Walking, working from a queue of calls, advising on repeat medication
needs and managing risk.
 Because of utilising the skills and knowledge of pharmacists, there are
fewer onward referrals.
The YAS pharmacy team is set to build on the experience and develop a more
integrated approach using the pharmacists to work throughout the week in the
evenings and weekends.
As part of the Winter Resilience plans for 2014/15, a Pan London Pharmacy Hub was
established in one of the NHS 111 provider contact centres at London Central and
West (LCW) Unscheduled Care Collaborative. The Pharmacists worked Saturdays
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and Sundays 9am to midnight taking medication calls that came directly via locally
arranged interactive voice recognition (IVR) for London. The calls were initially
answered by a call handler who screened out any acute symptomatic patients and
then the callers were advised a pharmacist would call them back within 2 hours.
Invariably the pharmacist called back within 1 hour with the hub handling an average
of about 100 calls each day staffed by one pharmacist available at any one time and
two at peak times. The pharmacists were able to close 95% of all the calls
themselves and any referrals were most often to contact GP Out-of-hours to request
a prescription.
Plans are underway to develop the pan London pharmacy hub as part of an
integrated clinical advice team that can support a wider range of calls that come via
the usual NHS 111 route and via the IVR at peak times. Supporting call handlers to
manage the repeat prescription requests will be an important part of the activity so
that patients can be referred on to community pharmacy or GP Out-of-hours services
where appropriate.
Referral to community pharmacy and Urgent Repeat Medication:
Guidance is available for NHS 111 and GP Out-of-hours providers to support the
referral of patients to community pharmacy to access urgent repeat medication
supplies.
http://www.england.nhs.uk/wp-content/uploads/2015/03/rept-medictn-guidnhs111.pdf
Local commissioning arrangements may enable referral to Pharmacy Urgent Repeat
Medication (PURM) services. Examples of local schemes include:
Pan London
Nearly 500 pharmacies registered to take referrals from NHS 111 since December
2014 with over 170 pharmacies actively supplying medicines. Referral process to
pharmacies via NHS Mail ensures pharmacies receive call details and SLA has been
in place for pharmacists to call patient within 30mins of referral. NHS 111 providers
have used a call from 111 to warn pharmacies an email has been sent.
An average 35% referral rate from NHS 111 with 28% going through to complete a
supply has been achieved. On Saturdays referral rate reaches 50% but midweek
drops down to 20%.
7% of all referrals resulted in no medication supply due to:
 controlled drugs being requested- referred back in to GP Out-of-hours
directly.
 pharmacist assessed patient and agreed supply not required and referred
back to in-hours GP for routine appointment.
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 patient did not come to collect medicines.
In London an exit survey of patients (489 responses) showed:
41% would have gone to A&E if 111 had not sent them to pharmacy
39% would have tried to contact GP Out-of-hours direct
19% would have gone without their medicines
North East of England
In November 2014 NHS England Cumbria, Northumberland and Tyne and Wear and
Durham, Darlington and Tees Area Teams, which are now combined as part of NHS
England North, working across Cumbria and the North East, commissioned the pilot
of an NHS Community Pharmacy Emergency Repeat Medication Supply Service.
http://medicines.necsu.nhs.uk/pharmacy-emergency-repeat-medication-supplyservice-permss/
The pilot was supported across 14 CCGs and has shown a 35% referral rate
compared to GP Out-of-hours. They referred call data directly to pharmacy via the
Pharmaoutcomes pharmacy IT system. Health advisors entered the call data directly
in to the Pharmaoutcomes web based system to be viewed by the receiving
pharmacy.
An evaluation of the service by Durham University has shown patients reported that
the service was easy to access; they were clear on the pharmacies to which they
were directed and what to take with them. The majority were referred to pharmacies
within 10 minutes travelling time, and most patients would keep a better check on
their medication supplies to prevent a reoccurrence in the future. The general high
satisfaction with the service was reflected in the high reported acceptability of the
patients towards accessing community pharmacy in the future for medication related
issues and minor ailments.
West Yorkshire
West Yorkshire has a commissioned PURM scheme that uses NHS Mail to refer from
NHS 111 to local pharmacies. An evaluation of the 2014/15 service has shown to be
very effective at reducing demand on other parts of the urgent care system.
http://www.cpwy.org/pharmacy-contracts-services/researchevaluation/evaluations.shtml
The NHS 111 provider YAS achieves a higher referral rate from NHS 111 primarily
as this service has been in place for longer and they have pharmacists in the contact
centre streaming the calls at weekends directly to community pharmacies taking out
the calls where controlled drugs are required.
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Key learning:

Call handlers/health advisor trusting the process and accepting disposition –
education programme required to encourage referral.

Move to a model where the patient is advised to call the pharmacy direct once
the email has been sent instead of the 111 provider calling the pharmacy to
encourage patient to attend pharmacy and reduce call-handling time for 111
providers.

Use of locums at weekends by pharmacies – particularly extended opening
pharmacies – need to ensure all pharmacy staff briefed about process and
ready to accept referral.

DoS entries optimised for opening times and all SG/SD codes for repeat
medication - urgent and routine to ensure capture weekend and bank
holidays.

Stakeholder engagement with local pharmacy groups and CCG medicines
management leads to embed and support on going service.
Minor illness/injury:
Work is underway to develop a minor illness/injury DoS template that can be used to
map community pharmacy services to primary care assessment end points. This will
support the signposting of patients to alternative services that can be delivered
locally. Community pharmacists are well placed to assess patients for minor
conditions and in some areas local commissioners have commissioned the provision
of “over the counter medication” on the NHS to support self-care. Referral to
community pharmacy from NHS 111 using NHS Mail has been used in West
Yorkshire to encourage patients to access community pharmacies as an alternative
to GP Out-of-hours and in hours GP services.
http://www.cpwy.org/pharmacy-contracts-services/researchevaluation/evaluations.shtml
Electronic messaging to community pharmacy:
Best practice for referring a patient to community pharmacy is to use ITK messaging.
A pharmacy specific message needs to be identified for urgent care referrals but in
the meantime it is technically possible to use the GP out of hours message to send a
case to community pharmacy if appropriate interoperability has been achieved. NHS
Mail is currently being used successfully to message pharmacies directly using the
DoS to support identification of the pharmacy NHS Mail address.
Prescribing:
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Commissioners will need to decide where they wish prescribing to be undertaken as
part of any urgent service. This will require allocation of appropriate prescribing
budget and designation of prescribing codes for the service.
GPs and non-medical prescribers can work together to support best practice
particularly for the prescribing of antibiotics, pain relief and palliative care medicines.
Access to the patient’s medication record held in the Summary Care Record (SCR)
or GP care record is essential to support safe prescribing.
Integrated Urgent Care should be working towards incorporating the use of the
electronic prescription service (EPS) and access to the EPS Tracker to support ongoing patient care.
Further information about EPS can be found at http://systems.hscic.gov.uk/eps
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ANNEX B
Roles and Responsibilities
Clinical Commissioning Groups (CCGs) are responsible for:
 Commissioning Integrated Urgent Care as an integral part of the urgent
care system according to national requirements and standards.
 Providing NHS England with evidence that they have undertaken a robust
procurement with an appropriate assurance process.
 Assuring NHS England that they have a contingency strategy in place
should the chosen provider fail to deliver the Integrated Urgent Care service
as contracted.
 Monitoring the impact of Integrated Urgent Care on local services so that
over/under utilised services are identified and improvements to the urgent
care system are made.
 Ensuring the effective mobilisation and operational delivery of an Integrated
Urgent Care service that serves the CCG population, either directly or via
joint commissioning arrangements.
 Performance managing the contract against agreed metrics and KPIs.
 Reporting on the quality, benefits and performance of Integrated Urgent
Care services.
 Ensuring that Access to Service Information (formerly DoS) is fully up to
date with the availability of local services and the agreed referral protocols
with service providers.
 Ensuring that the summary care record, special patient notes and end of life
care records are up to date and available to Integrated Urgent Care
services.
 Ensuring clinical governance of Integrated Urgent Care as an integral part
of the urgent care system. This will ensure the quality, safety and
effectiveness of the service, leading to people experiencing continuity of
service.
 Publicising Integrated Urgent Care locally.
 Local stakeholder communications and media handling.
 Ensuring that business continuity and disaster recovery procedures are in
place in the event of disruptions to the provision of the Integrated Urgent
Care service locally.
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 Meeting the public sector Equality Duty
Networks are responsible for:
 Creating and agreeing an overarching, medium to long term plan to deliver
Integrated Urgent Care aligned to the objectives of the Urgent and
Emergency Care Review.
 Designating urgent care facilities within the network, setting and monitoring
standards, and defining consistent pathways of care and equitable access
to diagnostics and services for both physical and mental health.
 Making arrangements to ensure effective patient flow through the whole
urgent care system (including access to specialist facilities and repatriation
to local hospitals).
 Maintaining oversight and enabling benchmarking of outcomes across the
whole urgent care system, including primary, community, social, mental
health and hospital services, the interfaces between these services and at
network boundaries.
 Achieving resilience and efficiency in the urgent care system through
coordination, consistency and economies of scale (e.g. agreeing common
pathways and services across SRG boundaries).
 Coordinating workforce and training needs: establishing adequate
workforce provision and sharing of resources across the network.
 Ensuring the building of trust and collaboration throughout the
network’spreading good and best practice and demonstrating positive
impact and value, with a focus on relationships rather than structures.
SRGs are responsible for:
 Developing a plan to deliver Integrated Urgent Care to support the 'high
impact interventions' as agreed by the national tripartite.
 The translation and delivery of network service designations and standards
to match the local provision of services. This will usually be achieved
through the development of written plans and protocols for patient care,
agreed with all 3 stakeholders, and adapted from national templates. High
priority plans will relate to high-volume and undifferentiated conditions,
where there are strong precedents for ambulatory and community-based
patient management.
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 Ensuring a high level of clinical assessment for the patient, in or close to
their home, and ready access to diagnostics where required. This will be
particularly important in more remote and rural communities, in which the
role of smaller hospitals will be developed and strengthened.
 The development and utilisation of “clinical decision-support hubs” to
support the timely and effective delivery of community-based care.
 Establishing effective communication, information technology and data
sharing systems, including real-time access to an electronic patient record
containing information relevant to the patient’s urgent care needs.
 The delivery of local mental health crisis care action plans to ensure early
and effective intervention to prevent crisis and support people who
experience mental health crisis.
 Ensuring the effective development and configuration of primary and
community care to underpin the provision of urgent care outside hospital
settings 24/7.
 Achieving accurate data capture and performance monitoring.
NHS England is responsible for:
 Monitoring the performance of Integrated Urgent Care and compliance with
national requirements, quality and performance standards.
 Monitoring the impact of Integrated Urgent Care with the urgent care
system.
 Assuring that CCGs are managing their responsibility for quality and safety.
 Commissioning and management of Integrated Urgent Care national
telephony infrastructure and IT systems including repeat caller service, NHS
Pathways and Access to Service Information (formerly DoS).
 Liaison with Ofcom over the use of the 111 number.
 Accreditation of Integrated Urgent Care Clinical Decision Support System(s)
 National communications and media handling.
 Ownership of and development of the Integrated Urgent Care (111) brand,
core values and guidelines for usage.
 Ownership of the Integrated Urgent Care Commissioning Standards and
governance of any changes.
 Identifying and sharing lessons learned and good practice across local
areas.
53
OFFICIAL
 Meeting its legal duties on equality and on health inequalities
 Assuring national business continuity and CCG’s contingency
arrangements for managing unforeseen surges in demand.
 Approving key decisions, plans, deliverables and any changes to the
Integrated Urgent Care service design.
 Overseeing interdependencies with related initiatives and programmes
outside the scope of Integrated Urgent Care.
 Assuring that the interests of key stakeholder groups are represented.
 Providing a formal escalation point for the NHS and other stakeholders for
issues and concerns relating to Integrated Urgent Care.
 Periodically providing assurance to the NHS England Board.
 Supporting CCGs’ re-procurements of Integrated Urgent Care contracts and
the transition of services from their current state to any new provider.
54
OFFICIAL
ANNEX C
Clinical Model: Self-Assessment Tool
This self- assessment tool can be used as a guide to level of integration
towards new clinical standards for an integrated 24/7 urgent care and clinical
advice service. It can be used at CCG, SRG or U&EC Network levels.
Clinical Standard
At the heart of the Integrated Urgent Care (IUC)
system will be a 24/7 NHS 111 access line working
together with 'all hours' GP services.
Additional clinical expertise available in IUC call
centre, via IVR or via warm transfer (e.g. Pharmacy,
dental, MH and GPs).
Enhanced Clinical assessment of green ambulance
dispositions
Direct booking from Integrated Urgent Care into
Emergency Department
Direct booking from IUC into GP and GP Out-ofhours
Direct booking from IUC to Community services &
'fast response' multi-professional community teams
Special Patient Notes (SPNs), End-of-life care plans
& crisis plans to be available at the point in the
patient pathway which ensures appropriate care
Integration via joint management of patient pathways
& capacity by NHS 111 and GP Out-of-hours
DoS to hold accurate information across all acute,
primary care & community services, and to be
expanded to include social care
All providers working with IUC demonstrate
integration by joint working to manage UEC patient
pathways & capacity
Enhance patient experience by early identification of
call that would benefit access of clinical adviser not
pathways
Ambulance services pass green disposition back to
the appropriate Clinician/Clinical Hub within IUC
Key

±

Clear and fully aligned
vision for integration
Partial alignment to
national vision
Ambition is not currently
consistent with national
ambition.
55
ANNEX E
Work Stream 1: Whole System Activity and Capacity Plan
Lead Director: Peter Horne Southampton City CCG
This Work Stream incorporates:
•
•
Delivery of a Whole System Activity and Capacity Plan for Winter 2015-16 and beyond, building on existing plans and complementing other projects
Development of a baseline tool for modelling alternative scenarios, assumptions and solutions to feed into the more detailed Whole System Vensim Model
Ref
Objective / Action
1.1
Produce and sign off a project initiation
document that sets out the purpose, scope,
objectives, outputs and risks of producing a
SW System Activity and Capacity Plan.
Expected impact
Agreement from all stakeholders
to share data, provide input and
commit to using the outputs to
help support system and
organisational decision-making.
Project
Lead
Lead Org
Delivery
Date
Progress this month
Delivery
against plan
th
PID signed off at SRG on 6 August with
minor amendments. Final Version 2.0
embedded.
Lisa
Sheron
SC CCG
End
August
G
150731 FINAL SRG
Capacity Plan PID v2.
1.2
1.3
1.4
1.5
Establish a Task and Finish Group to review
data requirements and methodologies to
start building the data set.
Agreed methodology and
dataset for an initial whole
system view.
Completed activity model showing activity
trends and trajectories across key metrics;
completed capacity model showing existing
capacity (including lack of capacity, e.g.
delays and waits).
Agreed baseline plan showing
current activity and capacity,
including capacity constraints/
unmet demand. Sign off the “do
nothing” model.
Identify existing planning assumptions that
will impact on activity flows and capacity
requirements, including a model for
optimistic and pessimistic delivery, e.g. BCF
impact.
Agreed plan describing
expected, potential and worst
case scenarios for managing
system activity flows
Lisa
Sheron
SC CCG
Strategic review of priorities and plans to
accelerate the impact of system changes to
target areas of greatest need/ impact.
Agreed system-wide plans and
priorities to focus on specific
change programmes.
Peter
Horne
SC CCG
Lisa
Sheron
SC CCG
End Sept
SC CCG
End
October
Task and Finish Group established with
weekly one hour teleconferences to
review progress. Draft data set circulated
and prototype spreadsheet produced.
On track
Data collection started
Lisa
Sheron
1
End
On track
Collation of planning assumptions started
On track
November
Q4
Not due
Version as at 30th September 2015
ANNEX E
Work stream 2: building and sustaining operational resilience
This Work stream incorporates:
Ref
Operational daily system resilience: escalation, alerts, daily dashboards, communications and predictive working
Operational resilience planning: system-wide seasonal plans, incorporating provider plans and contingencies and lessons learned, system-wide activity and capacity planning
Objective / Action
Expected impact
Project
Lead
Lead Org
(support
org)
2.1
Improve communication and predictive
capacity:
Implement the first stage of SHREWD to
strengthen predictive working, facilitate
management of system pressures and
support the sharing of system resilience
alerts/information across all organisations
on a daily basis . Ascertain how SHREWD
can be developed to incorporate the 8 High
Impact interventions.
Proactive system response
leading to a reduction in black
alerts
James
Lawrence
Parr
Rob
Chambers
2.2
2.3
Review escalation framework; Ensure that
the triggers and escalations are fit for
purpose
Seasonal Planning for 2015/16: Review
seasonal plan, implement 14/15 learning
Expected
delivery
date
All partners being clear about
triggers and expectations of
organisations
Updated seasonal plan and
processes accessible to system
James
Lawrence
Parr
Rob
Chambers
James
Lawrence
2
CCGs
July 2015
(providers)
CCGs
(providers)
CCGs
October
Progress this month
In month
progress
•
•
The first stage of SHREWD is
operational. Not all providers are
currently submitting daily updates:
UHS – All on track. Supplying daily
updates
HHFT – Have not yet supplied BRAG
ratings or daily updates. Will do so in
the future
Solent – All on track. Will be supplying
daily updates
Southern Health – Will be supplying
data on Lymington site. Data for other
sites has been queried with them
SCAS – Will be supplying data updates
OOH – Need to supply BRAG ratings
and daily updates
Coporma – All on track. Supplying
daily updates
HCC and SCC – Not yet supplying
updates but will be
Escalation Framework is in the process
of being updated, also awaiting further
guidance from NHS England.
2015
Submitted
on time at
Providers have been supplied with last
year’s submission and have been
Delivery
against plan
(as at July))
G
G
G
Ref
Objective / Action
Expected impact
Project
Lead
Lead Org
(support
org)
into practice and produce a revised plan for
15/16
Parr
Rob
Chambers
Cascade to all relevant organisations
2.4
Winter 2015 review for 2015/16 planning:
Post winter review, including review of
escalation and communication processes,
predictors identified and lessons learned for
next winter
(providers)
Further improve processes for
proactive management of
system pressures to prepare for
winter 2015
James
Lawrence
Parr
Expected
delivery
date
Progress this month
end of July
as part of
ORCP
submission
asked to update them. Awaiting further
from NHS England on requirements
and timescales.
In month
progress
ANNEX E
Learning shared with Operational
Resilience Group.
CCGs
May 2015
G
(providers)
Rob
Chambers
3
Delivery
against plan
(as at July))
ANNEX E
Work stream 3: Transforming Urgent & Emergency Care Services
BK-1
BK-2
Better support for people to self-care (information and self-treatment options), and comprehensive and standardised care planning
Enhanced NHS 111 – knowledge about people’s medical problems and allow them to speak directly to a nurse, doctor or other HCP if appropriate. Directly book call
back from, or an appointment with, a GP or at whichever urgent or emergency care facility can best deal with the problem
BK-3
Responsive and accessible urgent care services outside of hospital so people no longer choose to queue in A&E – faster same-day, every-day access to general
practitioners, primary care and community services (inc mental health teams and community nurses). Harnessing skills, experience and accessibility of community pharmacists and
ambulance paramedics. Extending paramedic training and skills, and supporting them with GPs and paramedics to develop 999 ambulances into mobile urgent treatment centres
BK-5
Connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts - develop emergency care networks to
dissolve traditional boundaries between hospital and community based services and support free flow of information and specialist expertise.
HIA-1
HIA-2
Robust in hours GP services and comprehensive out of hours services (links with BK-3)
Green calls to ambulance 999 service and NHS 111 should have the opportunity to undergo clinical triage before an ambulance or A&E disposition is made. A common
clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be considered
Directory of Skills and Services (DoSS) supporting NHS111 and ambulance services should be complete, accurate and continuously updated so that the wider range of
agreed dispositions can be made
HIA-3
HIA-4
HIA-5
Ref
SRGs should ensure the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support and responsive
community services
20-30% of ambulance calls are due to falls in elderly, many of which occur in care homes. Each care home should have arrangements with primary care, pharmacy and falls service for
prevention and response training, to support management of falls without conveyance to hospital where appropriate
Objective
Self Care and Public Communication
Primary Care Access- Pharmacists
3.1
•
Promote minor ailments
services
•
Review Community
provision to support
urgent and emergency
Work
stream
link
Expected impact
Milestones
Metrics
Project
Lead
BK-1
HIA1
Better support for people to
self-care - Information and selftreatment options
Responsive and accessible
urgent care services outside of
hospital so people no longer
choose to queue in A&E Harnessing skills, experience
•
•
LL
•
Development of
communications plan
promoting minor ailment
services
Implementation of
communications plan
4
•
Reduced number of
attendances to ED and
MIU coded as requiring no
treatment
Increased activity in
pharmacies
Delivery
date
Priority
(h,m,l)
ANNEX E
Ref
Objective
Work
stream
link
care services
Milestones
Review the capability of
community services to support
the provision of urgent eye
care
•
Call Handling and Clinical Triage – NHS 111 and 999, in hospital clinical triage and assessment
999 and Ambulance Response
•
Delivery of Quality and
•
Promote Hear/See and Treat
3.2
Support the ambulance service
to achieve all targets through
contract monitoring
•
•
•
SRGs to ensure the use of see
and treat local ambulance
services is maximised
improving access to clinical
decision support and
responsive community support
Preventing avoidable admissions by
a Consultant Physician telephone
access 12 hours per day, 7/7 days
per week – offering advice and
guidance, rapid same day
diagnostics and assessment and
urgent outpatient appointments.
•
3.3
•
•
•
Performance KPIs
Best use of available
workforce
Reduced conveyance to ED
Strengthened clinical
network
Improved clinical
outcomes
Best use of all capacity
Reduced ED attendances
and admissions
together with access to HCP
advice for paramedics/crews
Enhanced NHS 111 -
BK-2
•
Increase in numbers of
hear and treat, see and
treat
Reduction in conveyance
to ED
Achievement of
Performance KPIs
Achievement of Quality
KPIs
RH / SO
TBC
Increased assessments via
Forest Assessment Unit
Reduced acute ED
attendances
LR
April-15
•
•
3.4
LL
•
•
•
Best use of all
commissioned services
•
Full implementation of 7 day
working at LNFH with
consultant physician access 12
hours per day from April-15
Implementation of
Communication plan to raise
awareness
Monthly monitoring in place
•
Review of national guidance
(on publication) regarding
Attendances at ED, MIU, Eye
ED
5
Delivery
date
Number of appropriate
attendances to Eye ED
•
•
Project
Lead
•
Reduced activity at Eye
Casualty
Reduced activity at Main
ED
Appropriate attendance at
MIU
•
•
•
Metrics
and accessibility of community
pharmacists and ambulance
paramedics
Opticians
•
Expected impact
•
Monthly
RH / SO
TBC
Priority
(h,m,l)
H
ANNEX E
Ref
Objective
Work
stream
link
Expected impact
•
Fast access to the right
service first time
•
Reduced attendances
Reduced short stay
admissions for patients
with low risk chest pain
•
3.5
Green calls to have the
opportunity to undergo
clinical triage before an
ambulance or A&E
disposition is made
• Feasibility of common
clinical advice hub
between NHS 111,
ambulance services and
out of hours GPs to be
assessed
• Enhanced NHS 111 Directly book call back
from, or an appointment
with, a GP or at whichever
urgent or emergency care
facility can best deal with
the problem
Urgent Assessment, Diagnosis and
Treatment
ED
•
•
•
Review ED attendances
and develop further plans
to avoid unnecessary
attendances
Support acute provision
Continue to develop the
low risk chest pain
pathway at UHS ED
Milestones
Metrics
Project
Lead
Delivery
date
LP / RH
Mar 16
Priority
(h,m,l)
future integration of 111/OOHs
services including
commissioning of direct
booking services
HIA-2
BK-2
•
•
•
Review short stay pathways at
UHS
Continue to develop and
implement low risk chest pain
pathway at UHS
•
Reduction in chest pain
admissions, readmissions
Urgent Response Out of Hospital – better access to appropriate services and skills, all on the DoS (including 24/7 GPs in and out of hours, paramedics, pharmacists, mental health,
community nurses, MIU, care homes and Falls response).
6
ANNEX E
Ref
Objective
3.6
Primary Care Access; GP In-hours
•
•
Support the development of 7
day 12 hour opening of primary
care services
Work
stream
link
BK-3
HIA-1
Expected impact
•
Review and revise specification
of other services to support
and re-enforce new patterns of
patient care
•
•
•
Responsive and accessible
urgent care services outside
of hospital so people no
longer choose to queue in
A&E - Faster same-day,
every-day access to general
practitioners, primary care
and community services
(inc mental health teams
and community nurses) – in
hours and out of hours
Reduced attendance at ED,
MIU and Eye ED
Reduced call to SCAS 999
and NHS 111
Reduced call to Out of
Hours
Milestones
Metrics
Vanguard/New Models of Care
•
•
•
3.7
Primary Care Access
•
•
GP Out of Hours
•
•
•
•
Support development of an
ongoing work programme to
deliver timely and responsive
care to patients no matter the
time or day that they access
the service
Explore options to integrate
and join up out of hours and in
hour primary care
Review the skill base/staff mix
Reduced attendance at ED
Appropriate attendance at
Eye Casualty and MIU
Delivery of Quality and
Performance KPIs
•
•
•
West Hampshire:
Implementation of Primary
Care Access Centre at LNFH to
operate 8am to 8pm, 7 days a
week for routine and urgent
care. Co-location with MIU.
Pilot to enable evaluation of
new ways of working including
use of pharmacists and
physiotherapists and webGP to
facilitate self-help and more
flexible access to primary care
advice and guidance. Service to
commence Sept-15
Southampton City: To be
defined
Delivery of OOHs performance
RAP actions
services
Explore options for integration
within the local system
7
•
•
•
•
GP appointments
(numbers offered, booked,
attended)
A&E minor injuries – no.
that could have been seen
by GP (in hours & OoHs) in
a different setting
Patient satisfactions
surveys
attendances to MIU
calls made to SCAS 999
and 111
Project
Lead
Delivery
date
Priority
(h,m,l)
RK
Sept-15
H
LS
•
Achievement of service
performance KPIs
LP/RH
Nov 15
ANNEX E
Ref
3.8
3.9
Objective
DoS
Work
stream
link
Expected impact
•
Develop and promote the use
of MiDOS / mobile DoS to
ensure crews on scene have
access to the full range of
options for treatment
• Continue to the review DoS
endpoints to maximise the use
of non-ED facilities
Enhanced NHS 111 111 and the DoS
•
•
•
BK-2
•
•
•
Metrics
Project
Lead
Delivery
date
Reduced conveyance to ED
Strengthened clinical
network
Improved clinical
outcomes
Best use of all capacity
•
SCAS to identify approach to
mobile DoS access
•
RH / SO
TBC
Best use of all
commissioned services
Fast access to the right
service first time
•
services
Review progress of Health
Information Service
Explore opportunities for
expansion of Information
Service
Review and update DoS
RH / SO
TBC
across OoH provision to
support the monitoring and
potentially discharge of
patients into other services
•
•
Milestones
Review the progress of the
Health Information service
Explore further opportunities
to expand how the Health
Information service operates
• Review and update the
DoS to ensure that
dispositions are
signposted to the most
appropriate service
• Directory of Skills and
Services (DoSS) supporting
NHS111 and ambulance
services should be
complete, accurate and
continuously updated so
that the wider range of
HIA-2
•
•
•
8
Increase in numbers of
hear and treat, see and
treat
• Reduction in conveyance
to ED
• Achievement of
Performance KPIs
• Achievement of Quality
KPIs
Attendances at ED, MIU, Eye
ED
Priority
(h,m,l)
ANNEX E
Ref
3.10
Objective
Work
stream
link
agreed dispositions can be
made
Urgent Assessment, Diagnosis and
Treatment
Expected impact
•
•
MIU
Develop the MIU (Andover for
West Hampshire and RSH for
Southampton City) service and
models of treatment
•
Monitor attendance rates and
develop actions to
improve/maintain these
Falls prevention
•
3.11
•
•
20-30% of ambulance calls are due
to falls in elderly, many of which
occur in care homes. Each care
home should have arrangements
with primary care, pharmacy and
falls service for prevention and
response training, to support
management of falls without
conveyance to hospital where
appropriate
Milestones
Optimum utilisation of the
MIU
Reduced attendances at
ED
Reduced minor illness
activity at MIU (Andover)
Evaluation of MIU services and
baseline information across West
Hampshire to inform future
commissioned model. Completion
of review by Dec-15
Reduced ED attendances
and admissions
•
•
•
Full implementation of 7 day
working at LNFH with
consultant physician access 12
hours per day from April-15
Implementation of
Communication plan to raise
awareness
Monthly monitoring in place
Metrics
Project
Lead
Delivery
date
Priority
(h,m,l)
RK
(Andov
er)
RH
(RSH)
Dec 15
M
Increased assessments via
Forest Assessment Unit
Reduced acute ED
attendances
LR
April-15
H
To be defined
HH
(SRG
Chair)
Optimum utilisation of the
MIU
• Reduced attendances at ED
• Reduced minor illness
activity at MIU (Andover)
•
•
•
Monthly
Creating an Urgent Care Network - (IT links, training/ skills, HHR etc.) – processes and systems to underpin 2 and 3 above
3.12
Connecting urgent and emergency
care services
Connect all urgent and emergency
care services together so the
overall system becomes more than
just the sum of its parts:
• develop emergency care
BK-5
•
•
Improved access to urgent
and emergency care
services for patients
Reduction of reattendances
•
•
•
Define objectives
Define metrics
Implementation of objectives
9
•
TBC
ANNEX E
Ref
3.13
Objective
networks to dissolve
traditional boundaries
between hospital and
community based services and
support free flow of
information and specialist
expertise
Better support for people to selfcare - Comprehensive and
standardised care planning
Care plans and pre-hospital
working
Review the work of the prehospital group
•
Promote and manage the use
of care plan and special patient
notes to avoid admissions and
support continuity of care for
patients
Responsive and accessible urgent
care services outside of hospital so
people no longer choose to queue
in A&E :
•
Extending paramedic training
and skills, and supporting them
with GPs and paramedics to
develop 999 ambulances into
mobile urgent treatment
centres
•
Work
stream
link
Expected impact
Milestones
Metrics
Project
Lead
Delivery
date
BK-1
•
Tranche 1: Completion of the
current manual upload of AACPs
onto HHR – target date September
2015
100% upload AACPs onto HHR
PC
Sept-15
Reduced ED attendances,
admissions and
readmissions
Tranche 2: End of Life Care
Planning.
A. Replacement of the Adastra
EPACS functionality on a likefor-like basis with the HHR end
of life (EOL) care module
B. Automation of the creation of
EOL care plans on HHR
Tranche 3: Automatic creation of a
care plan on HHR.
Oct-15
A. The scope of this care plan
consists of data covering the
minimum data set (MDS) for
use by both the current widelyused paper AACP approved and
circulated by the Wessex local
medical committee in 2013
AND the emergency care plan
circulated by South Central
Ambulance Service (SCAS).
10
Priority
(h,m,l)
ANNEX E
Ref
Objective
Work
stream
link
Expected impact
Milestones
Metrics
Project
Lead
Delivery
date
B. Provision of this care plan in
Graphnet version 3 format,
including on iPAD/iPhone.
C. Additional care plans not yet
identified by users.
11
Priority
(h,m,l)
ANNEX E
Work Stream 4: In-Hospital Care
Lead Director: Jane Hayward University Hospitals Southampton NHS FT
This Work Stream is to coordinate in-hospital actions on behalf of the SRG to secure delivery of the ED, Elective Care and Cancer Standards at main NHS Acute Trusts within the South West System
(UHSFT and LNFH, plus other elective hospital providers).
This workstream incorporates:
•
•
•
The UHSFT ED Remedial Action Plan which includes internal capacity planning to manage elective, non-elective and cancer demand, and implementation of seven day service standards..
The LNFH hospital plans to manage elective and non-elective demand, and implementation of seven day service standards.
Mutually beneficial models of delivery to support flexible acute capacity across the system for extra resilience; hospital plans for outsourcing elective activity.
Part 1: ED Remedial action plan (with supporting documentary evidence removed)
Section
Actions in ED
Actions in ED
Ref
A1
A2
Action
Impact
KPIs/Measures,
where relevant
Sustain and improve the 'pit
stop' model of triage
(ECIST letter - points 1, 6)
Reduce waits for
diagnostics in
ED
Save approx 810 breaches per
month (+0.1%
performance)
Set of KPIs in place
and monitored,
including time to
bloods, time to triage
and time to radiology
Review/change/increase
clinicians hours (ECIST
letter - point 2)
Agree additional senior
decision making support for
ED.
Fit Dr timetable
more closely to
demand
month (+0.1%
performance)
GP model Save approx 3540 breaches per
month (+0.4%
performance)
Review of all doctors
job plans to more
closely match footfall
stage 1 e.g. 7am
shift start times in
place from May 15.
Stage 2, changes to
be agreed
Additional Information
Pit stop team funded in
15/16 budget setting.
Service Improver funded
until July 15. Monitoring
in place. Current action reviewing time for
bloods
Review ongoing funding
of CDU doctor for
weekend. Ongoing
recruitment of overseas
middle grades (one in
post to date).
12
Lead
Planned
Start Date
Proposed Completion
Date
Progress/Current Status
Financial
Sanction
for
Breach of
Action
Jun 15
AA
CM
April 2015
(continuing
from
2014/15)
April 2015
(continuing
from
2014/15)
Stage 1 - 7am starts
implemented by 31st
May
Stage 2 (original) evening and weekends
by July 15
Stage 2 (revised) evening and weekends
by 30th November.
Complete new shift
pattern by 30 November
- show evidence in
updated rotas.
COMPLETED: KPIs and
regular reporting in place and
monitored. Signed-off.
Updated metrics for
September to be added.
£8,000
GP Model in ED reviewed by
CCGs/UHS and not pursued;
focus is on improvements out of
hospital in primary care in and
out of hours, plus direction to
appropriate alternatives. This
strategy has successfully
reduced demand at Main ED.
Stage 1 delivered 7am starts in
May.
Stage 2 evening and weekend
working discussions underway
with clinicians via Caroline
Marshall and Ian Bailey under
£8,000
ANNEX E
Year 1 plan and
trajectory by June 2015.
Full 3-5 year plan by
31st October (revised
date agreed September
Performance Board).
Actions in ED
Actions in ED
A3
A4
Create workforce plan for
nursing staff and AHPs
(ECIST letter - point 3)
Create new handover and
reflective thinking
Enabling
initiative
KPIs will be
developed as part of
the plan; workforce
trajectory for year
one by end June
2015
Create a new 1 yr, 3 yr
and 5 yr nursing and
AHP workforce
development plan to
increase the skills and
capabilities of the
workforce and explore
an alternate workforce
(e.g. Paramedics). Any
investments would be
subject to an agreed
business case.
FH
Apr-15
Save approx 4-5
breaches per
month (+0.05%
performance)
Measure and
evidence impact to
establish whether 45 breaches per
month have been
saved by this action.
New daily clinical
handover meetings in
place. New monitoring
in place to support.
JH
Apr-15
13
3-5 year final document
submitted to UHS DMT
- to be reviewed and
ratified - updated
document will be
provided to
Commissioners by end
October. Exec
Summary is embedded
as interim.
June 15
7-day service standards.
August and September
progress: increased night cover
from November for as many
nights as possible to cover 8
hours instead of 6 hour shift.
- Slipped from June to
September; strategy not yet
fully defined, so business case
and year-one trajectory not yet
complete; also awaiting updated
safe staffing levels guidance.
Plan will not be implemented
until 16/17 as anticipated.
- Exec Summary for CCGs
received and attached; noted
additional staff recruited in
2014-15 and continued
investement into 15-16 for
paramedics and ENPs; quicker/
short term solutions being
actively explored such as
shared rotas across
organisations and better use of
porters and admin.
- Workforce is flagged as a risk
to the whole system, as all
organisations are competing for
the same skill set and staffgrades. This was discusssed at
August SRG; ongoing
discussion welcomed with
system partners.
Final
plan anticipated by the end of
October. RAG rating moved
from Red to Amber at
September meeting.
COMPLETED: handover
evidence in place by 30th June.
£8,000
£8,000
ANNEX E
Actions in ED
Actions in ED
Actions in ED
Actions in ED
A5
A6
Improve Psychiatric Liaison
support (ECIST letter point 9)
month (+0.1%
performance)
Improve patient experience
in ED and use patient
feedback for change
Improved staff
engagement
and patient
experience, to
support
delivery of the
ED standard
A7
ED Service Improvement
Support (ECIST letter point 6)
A8
Implement real-time tool for
performance management
and crowding in the ED on
Symphony (ECIST letter points 7, 10)
Earlier
awareness and
interventions of
impending
capacity issues.
Save approx 4-5
breaches per
month (+0.05%
performance)
Enabling
initiative
24 hour on site
service (revised
21.09.15 to 9am to
Midnight 7 days on
site, with improved
access to crisis
team overnight).
Measure and
evidence impact to
month have been
Show evidence of
patient engagement,
review of patient
feedback and
subsequent actions
taken and how this
has helped deliver
the ED standard
Daily operational
dashboard review
Measure and
evidence impact to
month have been
April 2015
(continuing
from
2014/15)
Revised deadlines:
30 Sept: Confirmation
from UHS and SHFT
that the delivery model
agreed with
Commissioners shall be
implemented, including
details of hours of
coverage and location.
31 Oct: Evidence that
the model agreed has
been implemented.
CM
Apr-15
October 2015
(Revised post-Sept
Performance Board )
Ongoing improvement in
escalation standards in
line with best practice,
including clarity of key
leadership roles;
NIC/COD. Operational
and performance
information dashboards
have been and continue
to be developed with
staged implementation
still ongoing. Front door
service redesign support
(see action A1)
TC
Apr-15
Ensures the right
information on overall
ED status is available to
the consultant of the day
and nurse in charge.
AA/TC
Apr-15
UHS has received
additional commissioner
funding to deliver this.
DS/JG
Consider best tools and
implementation strategy
14
July 15
May 15
AA has met with Southern
Health and FD has written to
SCC re role of the AMP standing agenda item at ED
Board. Contract funding has
been agreed.
June review reported this has
slipped to September; August
review reported increase to
11pm from September; now
needs to increase to midnight.
Discussions continuing between
UHS and Southern Health, with
commissioners. RAG rating
moved from Red to Amber
folllowing September meeting.
Sign off at November
meeting. UHS to clarify how
the Trust has used patient
feedback about waiting times
and breaches of the ED
standard to change working
practice and/or support other
aspects of the ED RAP, e.g.
the Workforce Plan,
diagnostic capacity.
COMPLETED but reviewing
ongoing use: Escalation
review underway. Operational
dashboard deployed. Escalation
dashboard developed.
Example of ED flow metrics
received and attached. UHS to
confirm how this is being
used operationally to forecast
capacity constraints and
initiate escalation.
COMPLETED: New tool in
place on klikview
£8,000
£8,000
£8,000
£8,000
ANNEX E
Actions in ED
Through the Hospital
A9
B1
B2
ED Performance Board to
be established (ECIST
letter - point 8)
Home for lunch programme'
- increasing pre 12 noon
discharges (ECIST letter points 4, 11) linked to the
Ward Round Project and 7
day service standards
Programme to improve
hospital discharge process
(ECIST letter - points 4, 11)
for both "simple" and
"complex" patients
Enabling
initiative
Improved flow
and release of
additional
capacity by
discharging
earlier in the day
month (+0.25%
performance)
Impact from
reduced bedrelated delays
Record of actions
agreed and
implemented.
Meeting to be
established to review all
available data, feedback
to ED team and gain
learning from ongoing
performance issues
Target of increasing
from 16.8% Trustwide, with 0.5%
improvement each
month to March 16;
detailed weekly
information
circulated and
reviewed
Separate action plan in
place
Evidence of
consistent processes
for discharge across
all wards, including
adherence to agreed
complex discharge
policies and
implementation of
the IDB leaders
recommended
actions
Supporting above for
discharge appointments
and discharge planning,
separate action plan in
place. Linked to the
delivery of the above
and the 7 day service
standard for transfer out
of hospital. IDB leaders
action plan to be agreed
by IDB leaders. Whole
system action plan in
place. Linked to the
system chiefs
agreement on IDB
15
COMPLETED and updated
action notes attached.
AA/CS
CM/JG
JH/JG/CM
01-Apr-15
April 2015
(continuing
from
2014/15)
April 2015
(continuing
from
2014/15)
May 15
March 2016
Discussed at
September meeting with
Commissioners; penalty
relates to delivery of the
final target of 19.3% by
31st March.
Demonstration of
monthly improvements
through each month to
March 2016- show
position for each month
against target as follows
but noting the
September start point is
worse than the April
position (i.e. the start
point should have been
19.3% not 16.3%)
30 Sept: 16.3%
31 Oct: 16.8%
30 Nov: 17.3%
31 Dec: 17.8%
31 Jan: 18.3%
29 Feb: 18.8%
31 Mar: 19.3%
Discharge Officers to be
in post by end October.
UHS to add their actions
into this RAP with
monthly deadlines but
final deadline will reflect
the agreed whole
system action plan
(March 2016 to be
confirmed).
Supporting evidence to
be provided with
backing data.
£8,000
Home for lunch baseline being
reset, national target is 35%.
Full update at September
meeting with metrics; overall
improvement with some wards
at 35%. See discharge by
midday charts in Action E5.
£8,000
New vision and plan in place,
being discussed at ICBs in June
15. Home for lunch programme
in place. IDB manager post out
to advert for interview 22nd
September. August update:
UHS need LA's to agree that
Band 5 Discharge Officers have
Trusted Assessor status - for
agreement at Integrated Care
Boards. September update:
Now agreed. UHS actions to be
clarified with timescales.
£8,000
ANNEX E
leadership
B3
Full implementation of bed
management system
Save approx 5
breaches per
month (+0.05%
performance)
Bed Management
fully deployed and in
daily use in adult bed
holding areas
CM
16
April 2015
(continuing
from
2014/15)
Software update
expected in November UHS to confirm exact
date. Expectation that
update will improve links
with other Trust
systems.
Full implementation to
be achieved by end
December 2015
Implementation will be
monitored through a
regular report that
shows utilisation of the
new system for the
Trust by specialty and
division.
System ready for
implementation in June. July
review could not confirm if fully
implemented across the whole
Trust; double-running at
present; expected benefits
unclear. August review: update
report will be circulated;
implemented on all wards but
culture-change is taking time to
embed with nurses; the new
Acuity system goes live in
October which will support full
use of the bed management
system as the two are interdependent. September meeting
confirmed new deadline is 31st
December for full
implementation and utilisation;
RAG rating changed from Red
to Amber.
£8,000
ANNEX E
Developing Seven Day
Services
B4
B5
C1
Outflow from ED to wards
Through the Hospital diagnostic capacity.
Implement the Trust wide
seven day services plan
Reduced
breaches
Outflow from ED to
Wards with a focus
on AMU (activity and
waits for downstream
flow)
This links to the 7 day
service standards for
first consultant review,
MDT Review, shift
handovers, intervention/
key services, mental
health and ongoing
review.
Reduced
breaches
Diagnostic
turnaround times for
urgent and
emergency demand;
admissions for
diagnostic test alone
Commissioner request
for unblocking delays in
diagnostics programme to increase
diagnostic capacity,
linked to Cancer and
RTT.
Enabling
initiative
Quarterly review
against the seven
day services
standards.
Discharges at the
weekends and
varaition in HSMR in
the weekday and
weekend.
Trust wide seven day
services audit
completed and action
plan in place. In 15/16
departmental level,
supported by Jules
Kause.
17
CM
April 2015
(continuing
from
2014/15)
31st October
Awaiting updates to
show improvements and
hourly inflow and
outflow from ED and/or
through AMU to wards
to show improvements.
ED outflow review data
received in July.
30 Sept 2015
CM
JK/DS/JH
Apr-15
Apr-15
Include in the wider
capacity planning
exercise.
Align with action D2
Completed by March
16, various dates for
different projects being
delivered through the
year.
Changes in work practices in
AMU e.g. Doctors assistant
roles to support the production
of electronic discharge
summary. New GP AMU/AMA
set up. New AMU ward rounds
at the weekend. New elderly
care ward rounds occuring
every day. Ongoing work to
clarify if AMU beds help flow
and overall length of stay, or
not; direct discharges from AMU
generally have shorter stays
than if transferred to a ward.
September agreed length of
stay data by destination might
evidence improvements in ED
and AMU flow.
Trust-wide Radiology covered
by capacity planning
discussions with MM; CS will
identify radiology capacity and
issues specific to ED e.g. CT
scans out of hours are all
transferred from the system to
UHS; not clear that plans
account for this. CS confirmed
that patients would not be
admitted before their scans had
confirmed the need for
admission, i.e. no one is
admitted just for a scan and
then discharged home. LS
queried this, e.g. short stay
admissions for headaches. No
updated data for September
meeting.
7 day action plan in place. This
is included in Workstream 4 of
the new SRG WSAP
£8,000
£8,000
£8,000
ANNEX E
Services
Services
Capacity Planning
C2
C3
D1
Implement new IT system
to support out of hours and
handovers in the Hospital
Improve weekend
discharges with 7 day
supporting services
Maintain Current bed stock
Enabling
initiative
N/A
IT investments agreed
for enhancements to
Dr's Worklist (complete),
acuity system, and the
EDMS - business cases
approved.
Enabling
initiative
New national metric,
80% of emergency
discharges during
the week.
Delivery of the projects
above plus new 7 days
services system wide
plan in development
Maintain current
number of beds,
subject to planned
Summer closures
and reopening for
Winter 15/16. All
maintenance is
carried out over the
Summer period to
ensure beds are
available for Winter.
The Trust plans to
maintain the 38
additional beds opened
in 14/15 and will include
an element of winter
UHS funding for the
overnight use of part of
the day of surgery unit
for winter 15/16 Staffing
is the major risk. The
bed numbers and
occupancy will be
monitored and flexed
accordingly linked to
Trust and system
pressures and essential
capital works below
CM
Planning team complete
this as part of the
operational plan.
Seasonal plan linked to
demand and capacity
flows to support delivery
of ED, RTT and Cancer
performance standards.
Mmu/CM
month (+0.2%
performance)
Monthly monitoring
of capacity and
occupancy against
plan and reporting of
variance
Capacity Planning
D2
Develop a Trust wide
capacity plan (ECIST letter
- point 11)
Production of
Forward Activity plan
reflecting 14/15
activity including
DTOCs at 60 and
plans for offsite
working
18
JG/DW/AB
CM
Apr-15
Apr-15
Apr-15
Jun-15
Phase 1 Completed by
May 15
Phase 2 complete by
March 16
Completion date March
2016 to align with C1
and C2.
From April 15 and
monthly throughout the
year.
30th September Summary paper to be
received by
Commissioners ahead
of any further discussion
and sign off. To be
completed by 30th
September including
diagnostic capacity
plans under B5.
Drs worklist is complete
Acuity system to be
implemented in October
EDMS product chosen and roll
out has commenced
7 day action plan in place. This
is included in Workstream 4 of
the new SRG WSAP
Current number of beds,
monitored at the weekly
capacity planning meetings.
September update: UHS
agreed to circulate the winter
bed plan and the full-year
month by month bed plan and
availability by Division to
demonstrate the KPIs. This
links with the Whole System
Capacity Plan.
Meetings with Mike Murphy
23td June and 29th July; further
meeting 1st September. Work in
progress to confirm activity
assumptions and queries;
written report requested in order
to sign off the original queries
which were reiterated in writing.
£8,000
£8,000
£8,000
£8,000
ANNEX E
Capacity Planning
Service Improvement
Capacity and Demand
D3
E1
E2
Create new out of Hospital
bed and virtual capacity
Breaking the Cycle
Ste of key metrics to be
published. Ten minute call
by exception.
month (+0.2%
performance)
New ideas to be
generated; Save
approx 25
breaches per
month from July
15 (+0.25%
performance)
Better
understanding of
the drivers of
poor
performance
Assist in
assurances
provided by
CCGs to NHS
England
Up to 25 beds
targeted as part of
the capacity plan
KPIs to be
developed as part of
the programme;
confirm which KPIs
have been
developed
Lessons learned
report, sustainability
and repeating of
actions taken.
Detailed flow metrics
previously agreed,
routinely available for
weekly review.
Working with local care
providers to increase
nursing home capacity
up to 20 beds. Working
with community partners
to explore bed options.
Creating 20 beds
through the use of
UHS@home or other
dom care providers and
more virtual pathways
ECIST supported week
planned for June 15,
planning session during
April 15
UHS and
Commissioners can
better establish where
key blockages are and
agree urgent mitigating
actions.
19
MMu/JH
JH
Apr-15
Jun-15
Jun-15
30th September Provision of detail
through Capacity report
- to be provided at end
Sept
Jun 15
From Jun-15 up to Mar16
Monthly reports
received for June and
weekly ED narrative for
September and
continuing - to continue
to receive weekly and/or
monthly as agreed - to
be signed off end Sept
once weekly ED inflow
and ouflow reports
received (as per A7).
Weekly Performance
Report embedded for
completeness.
Use of alternatives agreed to
support ward refurbishment;
slow take-up so far with 1
patient through BUPA and 5
through Hertford Homes.
£8,000
Update this RAP based on
actions undertaken. September
update: RAP to be updated with
any new actions and KPIs
resulting from the Breaking the
Cycle event, or confirmation
that there are no new actions to
add. RAG rating slipped from
Green to Amber until confirmed.
£8,000
Key metrics to be agreed based
on Peter Horne's original
document. July review agreed
total dataset not required but
BH will send a set of key weekly
metrics. Agreed that operational
resilience group would flag
known community events that
impact on ED (e.g. New Forest
Show) to provide narrative for
busy weekends. Monthly
metrics received for June.
August agreed: weekly ED
outflow reports will be sent by
CS; GC will do weekly narrative
of issues over the previous
week creating ED challenges;
board reports and monthly
reports to be routinely circulated
by BH. September agreed:
Further work to review and
confirm that weekly metrics
satisfy the agreed KPIs to show
hourly arrivals and discharges
by source and destination
through ED, CDU and AMU.
£8,000
ANNEX E
Part 2: Lymington New Forest Hospital Plans
Part 3: Oversight of Acute Hospital Activity and Capacity Plans
(These will feed into the high level whole system activity and capacity plan)
20
ANNEX E
Workstream 5: 2015/16 SW Hampshire Delayed Transfers of Care Action Plan – revised
Version: 18th September 2015
Nº
1
Priority
Managing Patient and Family Choice to reduce discharge delays
Action
Lead
Timescale
To reduce family choice delays by:
UHS supported by CCGs/LAs
By Aug 15
1.1 Implementation of a clear policy with clear information for
patients at the point of admission which enforces discharge as
soon as the patient is discharge ready and a safe and appropriate
destination for discharge has been identified.
Named lead = C.Handley
1.2 Delivery of Choice policy training for all staff members
(including those of external agencies) who are involved in the
discharge process
UHS/SCC/HCC/Solent/Southern/
CCGs
By
October
2015
1.3 Audit implementation of policy
UHS/CCGs
By Mar 16
1.4 Review and develop support mechanisms to support families
in making choice in a timely manner, e.g. partnership
arrangements with the third sector to support choice, including
for Hampshire embedding role of Care Navigators within IDB to
support discharge of self funders
CCGs/HCC/SCC/UHS
Named lead So’ton = Jamie
Schofield
Named lead Hampshire = Matt
Hutchinson
By Aug 15
Trusted Assessment – to reduce delays
in discharge processes
To review and build on the implementation of trusted assessors
in 2014/15 by:2.1 Extending the function to set up of new simple
packages in line with proposed new discharge process
21
RAG
Amber
TARGET – Reduce the monthly average number of SitRep days due to Family Choice below the 2014/15 baseline
average per month by April 2016. Hants Baseline Monthly Average 14/15 = 184 days Southampton Baseline
Monthly Average 14/15 = 345 days (Average number of patients causing delays due to family Choice 14/15:Hants 7.6 patients a month Southampto 12.4 patients a month)
2
This month's position
Policy to be signed off by
system chiefs.
SCC/ HCC/ UHS/Solent/
SouthernNamed Lead So’ton =
Sharon Stewart/Clare
HandleyNamed lead Hampshire =
Vicky Jessop
Roll out
from Sept
2015
Awaiting sign off of policy
primarily by Hants providers
Green
Green
Hampshire: Care Navigators
employed via Citizens Advice
Bureau and actively supporting
self-funders to select home of
choice
Evaluation report to be
produced by SHFT by end of
September
3 Month rolling average (May July 2015) Hants: 311 days
Soton: 330
(3 month Rolling average
patients: Hants 11.6 patients
Southampton 12.6 patients)
Positive meeting in August that
agreed the principles of
Trusted Assessment for both
social services and CHC.
Commitment from Social
services partners to commence
the first wave of trusted
assessor training week
commencing 28th September
2015, and from CHC teams to
commence during October
Amber
Amber
ANNEX E
when the new CHC team are in
place. Draft SOP circulated for
comment and further
development. To date, no
further update received from
Social Services.
TARGET – Number of trusted assessments carried out each month (target to be agreed)
3
Discharge to assess – to enable patients
who no longer need to be in hospital
but still require assessment to be
discharged.
3.1 To review the utilisation of Discharge to Assess in 2014/15
and agree the model moving forward in support of proposed
new discharge process
Named Lead So’ton = Mike Cooke/
Jamie Schofield/ Sharon Stewart
Agree
model by
end Jul
2015
Affordability will be a key
consideration and will require
whole system investment.
Meeting set up to begin
financial modelling.
By Oct
2015
Programme Board in place to
implement model. Service
specification agreed.
Consultations underway:- 2 x
45 day staff consultations and
1 x 90 day public consultation
(in parallel) re/co-location and
90 day staff consultation for
changes to roles/ management
structure. Implementation will
be phased with model fully in
place by Mar 16.
Amber
3.2 For WHCCG please refer to action 4.3
4
Implementation of new models of care
– to enable more timely discharge
Southampton City:
4.1 Implement integrated rehab and reablement service in
Southampton to support more proactive discharge.
Key Points:
• Two Phases - develop integrated team and bed based
supportive provision.
• Integrated processes and Management Structure.
• Phase 1 Implementation Sept 2015
• Phase 2 Implementation Jan 2016.
Solent/ SCC/UHS
West Hampshire:
4.2 Implementation of the Core Bed Offer model in West
Hampshire to improve flow into community beds by having
universal admission criteria (including D2A) in place whether care
is provided in a community hospital or nursing home. Alignment
of beds to demographic need
WHCCG/HCC/SHFT/UHS
22
Named lead So’ton = Jamie
Schofield
Lead: Rachael King / Catherine
Bowell
By Mar 16
Model developed and core
principles agreed by key
stakeholders. Service
specification developed and
agreed by Clinical Cabinet.
Business model finalised and
to be presented to Corporate
Governance Committee Aug15.
Model approved by HASC in
Sept-15. Phased
Amber
Amber
ANNEX E
implementation from Oct-15
West Hampshire:
4.3 Development and implementation of a strengthened
integrated discharge model in West Hampshire ('Push, Pull
Model')
5
Domiciliary (Personal) Care Provision –
to enable timely discharge
WHCCG/HCC/SHFT/UHS
By Mar 16
Lead: Rachael King (WHCCG);
Clare Handley (UHS); Ian Cross
(HCC), Karen Cubbon (SHFT)
Southampton City: 5.1 Implementation and monitoring of new
domiciliary care framework in Southampton
SCCNamed Lead So’ton = M.
Waters/Moraig Forrest-Charde
Apr-15
West Hampshire:
5.2 Implementation of Care at Home Framework by Hampshire
County Council
Named Lead HCC = Ian Cross /
Matt Hutchinson
Apr-15
23
Workshop held June-15
involving key stakeholders to
map current processes,
identify gaps and agree
strengthened integrated
push/pull model. Model
developed - presentation to
Integrated Commissioning
Board Aug-15. Sub-group
established to oversee
delivery. Phased
implementation from Sept-15.
SOP to be developed by
subgroup by October 2016
New framework in place.
Being mobilised. Activation of
Lot 5 (reablement dom care) to
be planned for late 2015
New framework in place from
April-15. Issues with
mobilisation being addressed;
significant issues experienced
in sourcing care packages
(particularly in West New
Forest) resulting in increased
delays
Agreement to commission
TQ&Home (SHFT) to provide
care packages to facilitate
discharge from Lymington New
Forest Hospital
Phase 2 of carers change lives
recruitment campaign
delivered in partnership with
Care at Home providers - 2
week media focus Jul-15 to
attract people into care market
Amber
Green
Red
ANNEX E
5.3 Development of domiciliary care workforce as part of Better
Care plans to better support people in their own homes
Named Lead Soton: Moraig
Forrest-Charde
Named Lead West Hampshire:
Nick Fripp
By
October
15
TARGET – Reduce the monthly average number of SitRep days due to Care Packages below 2014/15 baseline
average by April 2016:- Hants Baseline Monthly Average 14/15 = 55 days Southampton Baseline Monthly
Average 14/15 = 124 days (Average number of patients causing delays due to care packages 14/15:- Hants 1.8
patients a month Southampton 4.1 patients a month)
6
Nursing Homes – to build capacity to
meet key gaps and enable timely
discharge
Southampton City: 6.1 ICU quality team to continue to work
intensively with nursing and care homes to maintain quality and
capacity
SCC/ SCCCGNamed Lead Soton =
L.Rugman
Ongoing
Southampton City:
6.2 To improve 7 day access (including medical cover) by working
with targeted nursing homes – to improve Friday and W/E
discharge rates
SCC/ICU/UHS
Named Lead Soton = L.Rugman/
M.Cooke/ A.Penfold
by Oct
2015
Southampton City:
6.3 To negotiate access to bariatric and non-weight bearing bed
(following review of need) through working with targeted
providers, including exploring opportunities with Housing, e.g.
Weston Court
West Hampshire: See 4.2
SCC/ICU
Named Lead Soton = F.Islam/
S.Hards
By Oct
2015
Southampton City:
6.4 To negotiate improved access for patients with challenging
behaviour, working with targeted providers
SCC/ICU
Named Lead Soton = F.Islam
By Oct
2015
TARGET – Reduce the monthly average number of SitRep days due to Nursing homes below the 2014/15 baseline
average by April 2016:- Hants Baseline Monthly Average 14/15 = 60 Southampton Baseline Monthly Average
14/15 = 13 (Average number of patients causing delays due to nursing homes 14/15:- Hants 2.5 patients a month
Southampton 0.1 patients a month)
24
Part of SW Hampshire Health
Education Wessex funded
project - project manager in
place. Phase 1 15/16 will
involve SCC, Solent and
Southern staff. Phase 2 16/17
will focus on dom care and
voluntary sector providers
3 Month rolling average (May July 2015) Hants: 113.6 days
Soton:
102.6 days (3 month Rolling
average patients: Hants 6
patients Southampton 4.3
patients)
There has been sustained
improvement over the last
year in relation to maintaining
quality. 1 home is currently
under suspension.
This needs further work.
Nursing Home leads to discuss
possible ideas.
A review has been undertaken
the recommendations of which
need to be considered and
progressed further. Meeting
arranged with Nursing Home
leads to discuss possible ideas.
This work needs to be
progressed. Nursing Home
leads to discuss possible ideas.
Green
Amber
Amber
Amber
Amber
Soton: 57
days (3 month Rolling average
Southampton 1.6 patients)
ANNEX E
7
8
Continuing Healthcare Assessment
IDB Systems and processes
7.1 Review CHC processes and reduce the proportion of patients
who check list in for CHC who are not eligible for CHC funding as
part of proposals for overall discharge process
8.1 Employ manager to oversee Integrated Discharge Bureau
8.2 To embed new simplified discharge process (Simple and
complex as opposed to Sections 2 and 5), with discharge
planning commencing on admission with clarity of roles and
processes, taking action to ensure all staff fully understand the
process and comply with correct interpretation of notification
and denotification.
Named Leads = Mike Cooke/
C.Handley/Michelle Ennis
UHS/CCGs/LAs/ Solent/Southern
UHS/SCC/HCC/Solent/Southern/
CCGs
Named Lead = Clare Handley/IDB
Manager/IDB leads
By Aug 15
Aug/Sept
2015
By Oct
2015
West Hampshire: Streamlined
assessment processes piloted
in HHFT - to be implemented
at UHS; planned joint
procurement of care home
placements with HCC; work
underway to embed CHC
process into Integrated Care
Teams
Interviews occurring on 22nd
September with multi agency
panel. Four candidates being
interviewed. Expected to make
an appointment
Proposed new discharge
process under discussion. To
be signed off at Integrated
Care Boards in July and then
presented to System
Chiefs/SRG
Apex under development with
target finish date 5th October.
First and second test versions
have been reviewed and
deemed to have much more
user friendly and easier
functionality. Next step is to
get reviews from medical staff,
nursing, therapies and social
services staff to test out their
individual interfaces.
8.3 To fully implement the recommendations relating to
environment from the Review of the IDB System Lead (Mandy
Eltherington report May 2015)
25
UHS/SCC/HCC
Manager/Meriel Chamberlain
By 30th
July 2015
Comms strategy underway on
the new assessment and
discharge notifications – drop
in sessions, staff news, email,
individual ward meetings,
posters etc etc.
Interim options for additional
space being considered for the
newly increased size of the
UHS team.
Amber
Amber
Amber
Amber
ANNEX E
8.4 to fully implement the recommendations relating to IT access
from the review
UHS/SCC/HCC
Manager/Meriel Chamberlain
Named lead = Clare
Handley/IDB Manager/IDB leads
By 30th
July 2015
Social services now have
access to APEX
Mar-16
On Target for target date
8.6 Implement integrated ward link as outlined in new proposed
discharge process (see also 4.3 for West Hampshire)
Named Lead = IDB Manager/Clare
Handley/Meriel Chamberlain
By Sept
2015
On target for october
8.7 Review 7 day working across the system to increase
discharges at weekends and bank holidays, e.g. 7 day ward
round, diagnostics, pharmacy; community assessment available 7
days, dom care & care home providers available to accept
patients over 7 days (review baseline and set target and make
recommendations to ICB and SRG)
Named leads = IDB Manager/
J.Schofield/E.Mateus/C.Handley
Aug-15
A programme of change is
underway which includes
improved IT to support 7 day
working, “Home for Lunch”
initiative, Ward Round Project,
greater focus on bed
management schemes.
8.5 To audit discharge process to ensure properly embedded
throughout the pathway and in all parts of the hospital, including
correct interpretation of notification and denotification
Amber
Amber
TARGET – Reduce the monthly average number of SitRep days due to assessments below the 2014/15 baseline
average by April 2016:- Hants Baseline Monthly Average 14/15 = 94, Southampton Baseline Monthly Average
14/15 = 284 (Average number of patients causing delays due to assessments 14/15:- Hants 2.5 patients a month
Southampton 0.1 patients a month)
Amber
Amber
Soton:
251 (3 month Rolling average
Southampton 6 patients)
TARGET – to reduce % CHC checklist clients who are not eligible for CHC funding from (baseline and target to be
agreed)
TARGET – weekend discharges to be at 80% of weekday rate (target to be agreed)
TARGET – 35% discharges by midday (target to be agreed)
9
Further Intelligence gathering - to
improve understanding and target
action
9.1 Undertake review of a sample of NEL XBDs to determine
causes, extent to which XBDs relate to DTOC and test
assumptions
Overarching Key Performance Indicators
UHS/SCCCGNamed lead Soton =
J.SchofieldNamed lead Hants = E.
Mateus
Target
26
By end
Aug 15
This month’s position
Southampton:- Audit has taken
place and date put aside for
analysis.CSU, on behalf of
WHCCG, working with UHS to
identify correlation between
NEL XBDs and DToC
Last month’s
position
Green
Commentary
ANNEX E
Daily average S5 discharges
26 a day:
• 13 Southampton
• 13 Hampshire
• 6.23 Southampton
• 5.65 Hampshire
• 7.5 Southampton
• 6 Hampshire
• Southampton 862
days
• Hampshire 1243 days
60%
• 42% Southampton
• 28% Hampshire
• 2.53% Southampton
• 3.14% Hampshire
(Q1 15-16)
• Southampton 945
days
• Hampshire 1110
days
• 38% Southampton
• 35% Hampshire
• 2.96%
Southampton
• 2.24% Hampshire
(Q4 14-15)
Total number of SitRep Days this Month
Complex discharges discharged within 3 days
3.50%
% DTOC as a percentage of total bed days
West Hampshire Better Care Fund Accountability Agreement:
Target: Reduction in number of bed days lost due to delayed transfers of care by Mar-16 to April-14 levels
27
These meeting minutes may become available to the public under the Freedom of Information
Act 2000.
Retention of Records: These minutes will be confidentially destroyed 2 years after the date of
the meeting, in line with CCG policy and guidance from the Department of Health.
Meeting Minutes
General Assembly
The meeting was held on 8th September 2015, 1:30pm – 3:00pm, Conference
Room, Oakley Road
Present: see appendix A
Action:
1.
SRobinson welcomed all members to the meeting
All apologies were noted and accepted.
2.
The minutes of the meeting that took place on 9th June 2015 were agreed
as a true, accurate record of the meeting.
Matters arising
UHS ED performance – the performance improved into June and July.
August performance has deteriorated with high levels of breaches,
although attendances to ED have declined year on year. Work is ongoing
on the ED performance and the ED Remedial Action Plan (RAP) has still
not yet been agreed.
Bitterne Walk in Service Consultation – the Consultation has now
ended and the feedback is currently being collated. The Board will be
taking a decision on the closure at the Board at the end of September.
3.
Application for delegated co-commissioning 2016/17
The Assembly were informed that the CCG will be applying for delegated
primary care co-commissioning in 2016/17, as agreed at a previous
General Assembly.
The application deadline is the 6th November 2015 and the CCG will know
the outcome by the end of December.
There have been 2 meetings of the joint committee so far, and 3 more
scheduled throughout the year. There is work to be done on the
relationship between the CCG and NHS England.
The Assembly agreed to stand by the decision made in December 2014 to
apply for delegated co-commissioning in 2016/17.
Board vacancy update
4.
The Board vacancy has been advertised via the Local Medical Committee
(LMC). There has been one applicant for the vacancy. An election will not
be held, however they appointment will need to be ratified and they will be
meeting with the CCG Chair and CEO to discuss the role.
5.
Constitution Changes
The General Assembly received the Constitution changes which consisted
of the following:
Primary Care Delegated Commissioning :
- New model Terms of Reference to be attached to Constitution (as
set out by NHS England)
- Further strengthen Conflicts of Interest wording (as set out by NHS
England)
Change of Practice Numbers
- Merger of St Mary’s and Bargate contracts taking the CCG to 31
Practices as of 14 September 2015
It was agreed that the revised wording on the conflicts of interest could be
circulated if necessary.
The General Assembly approved the Constitution changes.
6.
Primary Care Strategy
Dr Steve Townsend (ST) presented an update on the development of the
Primary Care Strategy to the General Assembly.
A group has been set up to discuss the Strategy and ST ran through the
principles of the Strategy which included:
-
Responsive primary care services that meets the need of the
population
Equitable, patient centred primary care (including integrated and
urgent care)
Collaborative health and social care
Primary care system based on quality and reducing health
inequalities
-
A model that is attractive to professionals
The Assembly were informed that a GP forum will be convened in early
October to discuss the Strategy. The date will be circulated as soon as
available.
The Assembly discussed the following: the attraction of becoming a GP to
new GPs, the retention of current GPs and also why people would choose
to become a locum over a partner. Dr Amrik Benning (AB) raised that
whilst looking at the Prime Ministers Challenge Fund it has highlighted
duplication of services across the system and this needs to be worked on.
JRichards encouraged the Assembly to invite people, either through social
or professional relationships, to help develop this Strategy.
Any
suggestions are to be emailed to ST.
7.
Prime Ministers Challenge Fund (PMCF)
AB provided an update on the PMCF as follows:
-
Computerisation and telephone systems are in the place
In the next two weeks the call centre hub will be operating
Next two hubs are due to open (Grove Medical Practice and St
Marys Surgery) next Monday
Management infrastructure is now in place
AB encourage practices to provide feedback on services needed /
required
It was queried if the referrals will go from surgery referrals to patient direct
access. AB responded that in the future it may be a possibility that patients
can directly access the service, which is not currently possible due to it
being in a pilot phase.
8.
Date of Next meeting
The next meeting will take place on 8th December 2015, 13:30 – 15:00,
Conference Room, Oakley Road.
APPENDIX A
Present (from Southampton City CCG): Dr Sue Robinson (Chair), John Richards
(CEO), Alison Howett (Head of Primary Care)
Name
Job Title
Surgery
Conflicts of
Interest e.g. SMS,
Solent etc.
Dr Jo Curtis
GP
Adelaide GP Surgery
Solent employee
Dr Ildar Abdoulline
GP
Aldermoor Surgery
Nil
Dr Gail Ord-Hume
GP
Alma Medical Centre
Nil
Dr C.Law
GP
Atherley House Surgery
Nil
Dr Bruce Houghton
GP
Bargate Medical Centre
Nil
Dr Chris Budge
GP
Bath Lodge Practice
SMS Shareholder
GP
Bitterne Park Surgery
Dr Tony Kelpie
GP
Brook House Surgery
Dr Bhasker Dave
GP
Burgess Road Surgery
CCG GP Board
Member
CCG GP Board
Member
Nil
Chessel Practice
Dr Tony Kelpie
GP
Cheviot Road Surgery
CCG GP Board
Member
Dr Angus Ferguson
GP
Grove Medical Practice
Board member –
Solent Primary
Care Ltd
Highfield Health
Hill Lane Surgery
Dr Jo Curtis
GP
Homeless Healthcare
Team
Solent employee
Dr Samantha Davies
GP
Ladies Walk Practice
Dr Faycal Elhani
GP
Lordshill Health Centre
Solent Employee
SMS Shareholder
Nil
Dr M Amarapala
GP
Mulberry House Surgery
Nil
Dr Jo Curtis
GP
Nichols Town Surgery
Solent Employee
Dr Fiona Baber
GP
Old Fire Station Surgery
SMS
Dr Jo Curtis
GP
Portswood Solent
Surgery
Solent Employee
Dr Bram Ganesan
GP
Raymond Road Surgery
Nil
Dr Sue Robinson
GP
Regents Park Surgery
CCG Clinical Chair
Dr Bruce Hoghton
GP
St Mary’s Surgery
None
Dr H Boddington
Debbie Hill
St Peters Surgery
Nil
Nil
Dr Marc Thomas
GP
Practice
Manager
GP
Dr Camilla Evans
GP
Stoneham Lane Surgery
Nil
Dr Melissa Judd
GP
Townhill Surgery
Nil
GP
University Health Service
Dr T Jewson
GP
Victor Street Surgery
Nil
Dr Peter Goodall
GP
Walnut Tree Surgery
Board member –
Solent Primary
Care Ltd
Dr A S Benning
GP
West End Road Surgery
Director of City
Federation
Dr M Hughes
GP
Weston Lane Surgery
Nil
Dr Nigel Jones
GP
Woolston Lodge Surgery
SMS Ltd chairman
Nil
Meeting Minutes
Primary Medical Care Joint Commissioning Committee – Part 1
th
The meeting was held on Wednesday 19 August 2015, 14:00 – 15:00
Conference Room, Oakley Road, Ground Floor, Southampton, SO16 4GX
Present:
Apologies:
In
Attendance:
1.
NAME
Margaret Wheatcroft
(Chair)
June Bridle
James Rimmer
Stephanie Ramsey
INITIAL
MW
TITLE
Lay Member – PPI
ORG
SC CCG
JBridle
JRimmer
SR
SC CCG
SC CCG
SC CCG
Alison Howett
AH
Dr Steve Townsend
Mike Windibank
Lesley Gilder
Andrew Mortimore
Julia Bagshaw
Councillor Dave
Shields
John Richards
Nikki Osborne
ST
MW
LG
AM
JBagshaw
DS
Lay Member – Governance
and Chief Nurse
Head of Primary Care
Development
Clinical Lead for Primary Care
Practice Manager
Patient Representative
Interim Director of Commissioning
Councillor
JRichards
NO
Head of Public Health
SC CCG
NHS E
Dr Liz Mearns
LM
Medical Director
NHS E
Emily Penfold
(minutes)
Georgina
Cunningham
EP
SC CCG
GC
Commissioning Manager
SC CCG
SC CCG
SC CCG
SC CCG
Healthwatch
SCC
NHS E
SCC
All members were welcome to the meeting.
Apologies were noted and accepted.
2.
MW declared that she was registered with one of the practices that would be
discussed under item 5 on boundary charges.
3.
The minutes of the meeting that took place on the 17th June 2015 were agreed
Matters arising
28 practices out of 33 have signed up for the Local Improvement Scheme (LIS);
the 5 not signed up are in the East locality.
The submission date for delegated primary care co-commissioning has been put
back to the 6th November.
4.
Direct Enhanced Services (DES) sign up 15/16
The Committee received the DES sign up for 15/16 for information.
The Learning Disabilities (LD) service was discussed. There are 105 LD patients
related to the surgeries who haven’t signed up for the LD DES, with a majority of
the patients being at Burgess Road Surgery.
ACTION: SR to liaise with the commissioning team to look at the LD
patients in those surgeries
NO circulated the update on Public Health DESs to the Committee. NO
highlighted that the HPV catch up service has less sign up than the other
services.
5.
Boundary Changes
The Committee received the boundary changes papers for a decision.
The Committee supported the joint proposals to reduce their practice
boundaries.
JBagshaw left the meeting.
6.
GP Survey Outcomes – July 2015
The Committee received the GP survey outcomes (July 2015).
AH will take the results to the Practice Managers Forum in September and will
use the practice level comparator slides to stimulate discussion.
AH will also be undertaking deep dives on several areas and will work with
surgeries to produce an action plan. The Committee discussed that there needs
to be improvement against ourselves.
SR raised this could also be looked at via the Clinical Governance Committee.
ACTION: GP Survey outcomes to be added to the Clinical Governance
MW/SR
Committee work programme
Page 2 of 3
7.
Diabetes Accreditation Scheme
Georgina Cunningham, Commissioning
Commissioning Unit, attended the meeting.
Manager
from
the
Integrated
The Committee received the Diabetes Accreditation Scheme (DAS) papers for
discussion and decision.
GC talked the Committee through the papers.
AM raised that it would be helpful to see outcomes by practice so work can be
done to improve those areas.
The Committee supported the extension of the DAS up until 31st March 2016.
8.
21st October 2015, 13:00 – 15:00, CCG Conference Room, Oakley Road,
Southampton, SO16 4GX
Signed: …………………………………………………….
Print Name: ………………………………………………..
Designation: ……………………………………………….
Date: ……………………………………………………….
Page 3 of 3
Meeting Minutes
Primary Medical Care Joint Commissioning Committee – Part 1
st
The meeting was held on Wednesday 21 October 2015, 14:15 – 15:00
Meeting Room 2, Oakley Road, Ground Floor, Southampton, SO16 4GX
Present:
Apologies:
In
Attendance:
1.
NAME
Margaret Wheatcroft
(Chair)
June Bridle
James Rimmer
Alison Howett
INITIAL
MW
TITLE
Lay Member – PPI
ORG
SC CCG
JBridle
JRimmer
AH
SC CCG
SC CCG
SC CCG
Dr Steve Townsend
Len Bates
ST
LB
Lay Member – Governance
Head of Primary Care
Development
Clinical Lead for Primary Care
Practice Manager
Lesley Gilder
Andrew Mortimore
Julia Bagshaw
Councillor Dave
Shields
John Richards
Nikki Osborne
Dr Liz Mearns
John Duffy
LG
AM
JBagshaw
DS
Interim Director of Commissioning
Councillor
JRichards
NO
LM
JD
Head of Public Health
Medical Director
Associate Director of
Transformation and Outcomes
SC CCG
NHS E
NHS E
NHS E
Stephanie Ramsey
SR
and Chief Nurse
SC CCG
Emily Penfold
(minutes)
EP
SC CCG
All members were welcome to the meeting.
2.
SC CCG
St Mary’s
Surgery
Healthwatch
SCC
NHS E
SCC
3.
The minutes of the meeting that took place on the 19th August 2015 were
reviewed agreed the following amendments:
-
Add in the detailed information on Boundary Changes
With the stated amendments, the Committee agreed that the minutes were a
true, accurate record of the meeting.
Matters arising
LD DES – communication has taken place but there is not yet a way forward.
The LD Commissioning is working on this, an update is to be provided at a
future meeting.
ACTION: Update on LD to be provided at the January 2016 meeting
GP survey outcomes – the survey outcomes are, and will continue to be,
reviewed at the CCG Clinical Governance Committee. An update will be
reported back.
ACTION: Update on GP Survey to be at the March Committee meeting
Diabetes – the primary care team are reviewing the outcomes. The update on
this will be brought back to a committee in early 2016.
Action: Update to be provided at a future meeting on diabetes
4.
Primary Care Development Strategy – briefing
The Committee received the Primary Care Development Strategy Briefing for
information.
A telephone survey took place with practice managers and a series of questions
were asked. There were 3 incomplete replies and one survey has yet to be
undertaken. ST talked through some of the highlights of the survey.
A primary care strategy workshop has also been set up to discuss the
development of the strategy.
It was noted that a draft will be ready by early 2016.
ACTION: Primary Care Strategy to be an item on the January 2016
Committee meeting
5.
Application for delegated co-commissioning 2016/17
The Committee received the papers on the application for delegated cocommissioning 2016/17.
It was noted that the CCG are currently awaiting HR guidance from NHS
England, there is no expectation at this stage for resource transfer.
MW raised concern around the uncertainty and lack of guidance regarding coPage 2 of 3
commissioning. However the Committee reviewed the benefits of delegated cocommissioning and that this is the preferred option.
The decision was also discussed at the Southampton City CCG Board meeting
in September 2015, where members agreed all recommendations.
JB will sign off the application as the chair of the CCG Finance & Audit
Committee.
6.
14 January 2016
Signed: …………………………………………………….
Print Name: ………………………………………………..
Designation: ……………………………………………….
Date: ……………………………………………………….
Page 3 of 3
Act 2000.
Meeting Minutes
Clinical Executive Group
The meeting was held on Wednesday 14th October 2015, 14:00 – 17:00, CCG
Conference Room, Oakley Road, Ground Floor, SO16 4GX.
Present:
NAME
Dr Mark Kelsey
Dr Sue Robinson
Dr Tony Kelpie
Dr Chris James
Dr Richard
McDermott
John Richards
James Rimmer
Peter Horne
Stephanie Ramsey
INITIAL
MK
SRob
TK
CJ
RMc
TITLE
GP Board Member (Chair)
CCG Chair
GP Board Member
GP Board Member
GP Board Member
ORG
SC CCG
SC CCG
SC CCG
SC CCG
SC CCG
JRic
JRim
PHorne
SRam
SC CCG
SC CCG
SC CCG
SC CCG
Julia Bowey
Bob Coates
Beccy Willis
Dawn Buck
JB
BC
BW
DB
Director of Quality and
Integration
Head of Meds Management
Public Health Consultant
Head of Business
Head of Stakeholder
Engagement
Apologies:
Andrew Mortimore
AM
SCC
In
attendance:
Emily Penfold
(minutes)
Donna Chapman
Georgina
Cunningham
EP
SC CCG
DC
GC
Associate Director
Commissioning Manager
SC CCG
SC CCG
SC CCG
SC CCG
SC CCG
SC CCG
Action:
1.
Welcomes and Apologies
MK welcomed all members to the meeting.
All apologies were noted and accepted
2.
Declarations of interest
No declarations of interest were raised in relation to the agenda.
RMc raised that in the subcommittee minutes there is a reference to
community dermatology which has links to SMS. It was highlighted that
there was no decision made and did not provide a conflict.
3.
Minutes of Previous Meeting and Matters Arising
The minutes of the meeting that took place on the 16th September 2015
were reviewed and the following amendments were agreed:
-
BWIS briefing – wording to be changed to “JG and DB provided a
verbal update on the Bitterne Walk in Service focusing on the
process of the consultation”
-
EPRR assurance – add an action for the executive team to consider
if the clarity on roles should be included on the CCG risk register
-
Priorities Committee recommendations - remove the sentence
regarding Map of Medicine
-
IG Action plan - Update the cloud storage to reflect about breaching
the Data Protection Act
-
TARGET – add an action regarding service development workshops
being explored
With the stated amendments the minutes were agreed as a true, accurate
record of the meeting.
Matters arising
Action tracker
The action tracker was reviewed and updated.
ACTION: Primary Care Strategy timeline to be circulated to the Group
4.
PS Vision Screening
DC Joined the meeting to present the PS Vision Screening papers.
The group discussed the tariff for vision screening. There would be a local
tariff with UHS which needs to be determined.
DC raised that further work is taking place on PS vision screening regarding
referral criteria.
5.
Paediatric Clinical Pathways
The group received the Paediatric Clinical Pathways for approval.
The pathways have received consultation from a range of areas and have
also been reviewed at the Clinical Governance Committee.
It was highlighted that the pathways have been circulated by the LMC.
The group discussed temperature thresholds on the fever pathway.
It was suggested that the pathways should be localised e.g. including the
EP
COAST service.
The Group approved the Paediatric Clinical Pathways as they are based on
NICE guidelines. CJ will also include an update in FYIF and ask for
comments. The pathways will be reviewed in 6 months.
ACTION: GP leads to provide feedback on the pathways to CJ
6.
All
Diabetic Footcare
GC attended the meeting to present the diabetic foot care papers for
decision.
The group discussed the low risk patients and the procedures such as toe
nail cutting, particularly for non-diabetic patients.
JRichards raised that Solent NHS Trust will need to ensure they are not
accepting referrals for low risk patients.
The group discussed next steps. An informal discussion will be held with
HOSP and then a meeting with Solent NHS Trust. Stakeholder engagement
will also take place with UHS and Solent.
There will be a pro-active communications statement to support this change.
It was highlighted that the services are not being stopped but there will be a
tighter referral criteria.
CEG agreed the following:
•
•
•
Agreed to implement the whole of the foot care pathway and support
of the changes required for those at low, medium and high and
active foot disease
Agreed for the investment in 2015/16 and in 2016/17 for the
implementation of combined foot care clinics.
Agreed to continue to work with NHS Solent to implement the
introduction of a DFPT within the current contractual arrangements
The group agreed the recommendations should be implemented as quickly
as possible.
GC/DC left the meeting.
7.
Policy Recommendation’s
The Group received the following Priorities Committee recommendations:
-
Policy recommendation 005: Functional Electrical Stimulation in the
Management of drop foot of central neurological origin (specifically
post stroke and multiple sclerosis
ACTION: JB to ensure it is on Map of Medicine.
The Group approved the policy recommendation 005.
JB
JB left the meeting.
8.
CCG IM&T Development Group Terms of Reference
The group received and ratified the CCG IM&T Development Group Terms
of Reference.
The group discussed that the IM&T group is in place to ensure there is no
duplication throughout the CCG and also a central place to discuss internal
ICT.
9.
QIPP update
CY and PH attended the meeting to present the QIPP papers to the Group
for information.
ACTION: EP to add Professor Matthew Crips to the November CEG
agenda
EP
ACTION: all to attend GB seminar with suggestions of services that
could be de-commissioned
ALL
CY/PH left the meeting.
10.
Interoperability and Digital Road Maps
MK provided a verbal update on Interoperability and Digital Road Maps.
ACTION: Interoperability to be an agenda item on November CEG
Portsmouth and South East Hampshire CCG have set up a programme to
look at transforming systems to allow them to interoperate. A set of
requirements have been produced that are needed to procure and this has
been taken to System Chiefs to get buy in from CCGs locally. This has been
deliberated so it doesn’t duplicate the work that has been undertaken on
HHR.
The Group were also informed that the National Information Board has
published 8 work streams with the aim of getting the NHS paperless by
2018. As part of those work streams, CCGs are required to create a local
road map to go paperless. The patch covered will be the same as the
current HHR.
There is discussion of setting up a programme board which all CCGs and
providers would be a part of that to develop interoperability.
A CCG IT Strategy has been in development but has been paused due to
the roadmaps needing to be developed.
11.
BWIS Update
PH provided an update on the closure of the Bitterne Walk in Service
(BWIS).
•
Solent update
o Exit progressing against plan, no concerns
EP/MK
111 cards to service today, posters and written info for
patients in production, will be available shortly
o Referring providers written to, removed from 111 Directory of
Services (DoS) 8th Oct
Providers and referral sources written to 12/10/15 (111, 999, ED,
MIU, OOH, WHCCG & F&GCCG) with deadlines for
acknowledgment and confirming actions
Written communication to GPs and pharmacies
Visits to East pharmacies being booked November Board report to
Governing Body and HSOP
Communications and engagement Project plan drafted. Some
additional milestones about regular meetings (ie pensioners forum)
to be added for 2016.
Lessons identified/learned to be shared with execs for organisational
learning – report to go to SMT and CEG
Board report as requested by GB and HOSP for 25th and 26th Nov
HOSP actions to be placed on SMT action tracker
Response to HOSP actions – confirm with HOSP that community
hub action is for council to report on
o
•
•
•
•
•
•
•
•
12.
The group received the following sub-committee minutes for information:
•
•
•
13.
CCG IT Development Group – 15th July 2015 and 19th August 2015
Senior Management Team – 30th July 2015, 13th August 2015, 20th
August 2015 and 17th September 2015
Business Team Meetings – 3rd September 2015
Any Other Business
None raised.
14.
Date of next meeting
The next meeting will take place on 18th November 2015,14:00 – 17:00,
Conference Room, NHS Southampton HQ, Oakley Road, SO16 4GX
Act 2000.
Meeting Minutes
Clinical Executive Group
The meeting was held on Wednesday 18th November 2015, 14:00 – 17:00, CCG
Conference Room, Oakley Road, Ground Floor, SO16 4GX.
Present:
Apologies:
NAME
Dr Mark Kelsey
Dr Sue Robinson
Dr Tony Kelpie
Dr Chris James
Dr Richard
McDermott
John Richards
James Rimmer
Peter Horne
Stephanie Ramsey
INITIAL
MK
SRob
TK
CJ
RMc
TITLE
GP Board Member (Chair)
CCG Chair
GP Board Member
GP Board Member
GP Board Member
ORG
SC CCG
SC CCG
SC CCG
SC CCG
SC CCG
JRic
JRim
PHorne
SRam
SC CCG
SC CCG
SC CCG
SC CCG
Bob Coates
Beccy Willis
Dawn Buck
BC
BW
DB
Dr Richard Day
RD
Integration
Head of Business
Head of Stakeholder
Engagement
Andrew Mortimore
Julia Bowey
Dr Chris Budge
AM
JB
CB
Head of Meds Management
GP Board Member
SCC
SC CCG
SC CCG
SC CCG
SC CCG
SC CCG
Action:
1.
Welcomes and Apologies
MK welcomed all members to the meeting.
All apologies were noted and accepted
2.
No declarations of interest were raised in relation to the agenda.
3.
Professor Matthew Cripps – National Director from the Right Care
Programme
Professor Matthew Cripps, the National Director from the Right Care
Programme attended the meeting and gave an oversight on the Right Care
Programme.
4.
Minutes of Previous Meeting and Matters Arising
The minutes of the meeting that took place on the 14th October 2015 were
agreed as a true, accurate record of the meeting.
Matters arising
Pre School Vision Screening - BC advised that an FOI had been received
on pre-school vision screening. A paper will come back to a future meeting.
Diabetic Footcare – Information on alternative routes for nail cutting to go on
Map of Medicine (MoM) as part of the decommissioning process. DB
Communications will share all sign posting information with practices
EP
Interoperability – To go on December CEG agenda
PH
PH to make amendments to BWIS section on the minutes
BW
Action tracker to be updated
5.
Practice Visits Update
Rob Chambers attended CEG to provide an update on practice visits that
had been undertaken in the last 12 months.
The purpose of the visits was to:
•
•
•
•
•
Make GP’s aware of Clinical Variations - referral patterns and
relative referral rates
Make GPs aware of the community services available and seek
feedback on these services
Remind GPs of the Procedures of Limited Clinical Value and their
practices uses of these
Remind GPs of the system enablers available and seek feedback on
these
Make GPs aware of the cost of procedures and separately their Ereferrals rate for 2014/15.
So far 12 visits have taken place – This is meant to be part of a rolling
programme of visits across all practices, with an initial focus on those
surgeries who have the highest number of referrals.
Key themes emerging from the visits
•
•
•
•
During the visits, there have been a number of issues which have
been common across a number of practices:
Dissatisfaction with the quality of the diagnostic reports from
Inhealth. This has been formally raised with Inhealth.
Map of Medicine was found to be a useful tool. However, it would be
a lot easier for GPs if a single sign-on was possible. This is due to
be included in the latest release from Map of Medicine along with
automatic installation of side bar.
There was generally positive feedback on the GPSIs in place.
The way forward for reducing clinical variation
There will always be some variation in healthcare due to the complexity of
variables that produce it (for example, characteristics of the individual
patients, complexity of disease or unpredictability of symptoms). Such
variation is expected. However, the unwarranted variation in healthcare and
referral rates is the area for concern.
There are already a number of tools in place to reduce clinical variation:
•
•
•
Map of Medicine – which outlines the clinical pathways. Agreement
has been reached to extend this contract for a further year until
March 2017.
GP tutorials
GP Locum Pack available – so locums and new doctors are aware of
pathways and community services.
Going forward, with Co-Commissioning there is an opportunity to make the
practice visits more structured for 2016/17. This is currently being explored
and views are sought on this. In order to gain momentum on this, the
System Delivery Team are currently reviewing the best way to produce
monthly referral information for Primary Care.
The GP board members were asked if they had any feedback from their
practice visits and it was agreed that it was seen as a useful, positive piece
of work, however it would be useful to involve more individuals across the
practice and ensure that any feedback is acted upon (you said, we did).
It was suggested that data for each practice gets presented to their
colleagues at locality level or cluster hub for a discussion and potential
behaviour change.
PH highlighted that this work leads to a future work stream about reducing
variation and some thought needs to go into how best to engage with the
clusters. SRob also suggested that it needed to tie in with Primary Care
strategy group and Primary Care incentives and behaviours around
dashboard/performance/outcomes etc.
ACTION: identify active clinical lead support for the practice visit work
6.
Bitterne Walk in Service Update
PH confirmed that the Bitterne Walk in Service closed on 31 October 2015.
There has been a huge amount of publicity in terms of posters, emails,
texts, websites checked, cards handed out and media coverage
PH also wrote to system partners who may refer to BWIS to ask them to
confirm to PH what they were doing to ensure they are no longer referring to
BWIS. He also wrote to every GP practice and pharmacy with the primary
care development team following up all 17 pharmacies to talk through what
we would like them to do next, linked in with minor ailments and pharmacy
first scheme.
There has also been careful monitoring of any impact of the closure by
looking at performance and activity figures for ED, minor ailments, PC hubs,
111, OOH, Coast and practices.
Patient experience is also being monitored along with another market stall in
Bitterne in December to gather any feedback.
DB highlighted that there has been no complaint or concern received t
through the patient experience service.
7.
The group received the following sub-committee minutes for information:
•
•
•
CCG IT Development Group – 16th September 2015
Senior Management Team – 1st October 2015 and 8th October 2015
Business Team Meetings –24th September 2015
TK highlighted that at SMT on 30 July 2015 a discussion had been had
about not providing vasectomy service in the future. PH advised that this
was still be looked at and a decision was yet to be made and would be
brought to CEG in future for a discussion.
8.
Any Other Business
TK asked what communications will go to practices regarding CCG
finances? JRim to send out via FYI Friday.
9.
Date of next meeting
The next meeting will take place on 9th December 2015,14:00 – 17:00,
Conference Room, NHS Southampton HQ, Oakley Road, SO16 4GX
JRim
Meeting Minutes
th
The meeting was held on Wednesday 7 October 2015, 14:00 – 17:00
Conference Room, NHS Southampton HQ, Oakley Road, Southampton, SO16 4GX
Present
Apologies
In attendance
1.
NAME
Margaret Wheatcroft
(Chair)
Stephanie Ramsey
INITIALS
MW
JOB TITLE
Lay Member – PPI
ORG
SCCCG
SR
SCCCG/SCC
Dawn Buck
RM
DB
Bob Coates
Lesley Gilder
Antony Shannon
BC
LG
AS
Katherine Elsmore
Joan Wilson
Liz Bere
KE
JW
LB
Integration / Chief Nurse
GP Board Member
Head of Stakeholder
Engagement
Lead Infection, Prevention
and Control, Nurse
Specialist
Head of Safeguarding
Quality Manager
Senior Locality Pharmacist
Carol Alstrom
CA
SCCCG/SCC
Andrew Mortimore
Dr Richard Day
AM
RD
Quality
Emily Penfold
EP
SCCCG
Michael Cooke
Donna Chapman
MC
DC
(minutes)
CHC Lead
Associate Director
All members were welcomed to the meeting.
2.
There were no declarations of interest made in relation to the agenda.
SCCCG
SCCCG
SCC
Healthwatch
SC CCG
SC CCG
SCCCG
SC CCG
SCC
SCCCG
SCCCG
SCCCG
ACTIONS
3.
Minutes of the previous meeting and matters arising
The minutes of the meeting that took place on 2nd September 2015 were
reviewed by the Committee and the following amendments were agreed:
•
•
•
•
•
C.difficile to have a capital C
Page 3, second paragraph – change the word “skill swap” to “skill
rotation”
Page 3, paragraph 4 - remove the action re TIA and stroke
Page 4, 3rd paragraph - the Committee discussed the discharge
summaries. The last sentence should read “it was a requirement of the
previous CQUIN”.
Southern Health – add Foundation Trust at the end.
With the stated amendments the Committee agreed the minutes as a true,
accurate record of the meeting.
It was agreed, going forward, the draft Committee minutes will be circulated for
comment.
Matters arising
The no delays project is now called transformation.
The Committee passed on their thanks to GS for providing definitions on the
SIRI graphs within the quality report.
Action tracker
MC joined the meeting.
4.
Paediatric Clinical Pathways
DC joined the meeting.
The Committee received the Paediatric Clinical Pathways for approval to be
uploaded onto Map of Medicine.
The maps have been developed with extensive consultation from stakeholders.
EP/DC
ACTION: CEG to receive the paediatric clinical pathways
RMc raised the fever pathway in children under 3 months that it is not a clear
threshold for children under 3 months with a fever. DC will flag this.
The Committee discussed MIU and other urgent care settings having access to
Map of Medicine (MoM) It was also raised that some sessional GPs do not have
access to Map of Medicine.
DC
ACTION: DC to raise the issue of thresholds on the fever pathway.
SR/DC
ACTION: SR/DC to follow up on the urgent care access to MoM
Page 2 of 7
The following maps were approved:
•
•
•
•
•
•
Acute abdomen pain management primary / community care
Acute asthma wheeze (non-bronchiolitis)
Bronchiolitis – children younger than 1 year old
Diarrhoea and vomiting in children under 5 years
Fever in infants and children under 5 in primary care
Head injury primary care community settings
DC left the meeting.
5.
Quality Report
The Committee received the Quality Report for discussion and also the following
CQRM minutes were appended:
•
•
•
•
•
•
•
•
UHS CQRM – 21st August 2015
Solent CQRM – 13th August 2015
SHFT OPMH – 20th July 2015
SHFT AMH – 17th August 2015
SHFT MH/LD – 15th July 2015
SCAS 111 CQRM – 15th July 2015
STC CQRM – 19th August 2015
PHL OOH CQRM – 15th July 2015
The quality team talked through the highlights of the report.
SR raised it would be helpful to include the actions into the quality report so it
demonstrates what work is taking place, it also will provide assurance to the
Committee and the Board.
Quality
Team
ACTION: Actions to be included to the quality report to provide assurance
Solent NHS Trust
• The Committee discussed the issue regarding Solent NHS Trust and the
spend on wound dressings.
LB/RMc
ACTION: LB/RMc to liaise on wound dressings outside of the meeting
• The Committee discussed Solent NHS Trust and the concerns around the
complaints team not having permanent members of staff. Work is taking
place to recruit staff and an update is being taken to the October CQRM.
There have been a few issues that have affected the complaints service
which are being worked on with actions in place. The Committee raised
concern that the complaints service is a key function for the organisation.
ACTION: Update on complaints staffing issue to be taken to the October
CQRM
Southern Health
• LB raised that the medicines management team are looking at the antipsychotic drugs in LD in relation to Southern Health.
SCAS
• The Committee discussed SCAS and safeguarding and queried if
Page 3 of 7
ambulance staff would receive safeguarding alerts when being called
out.
KE
ACTION: KE to look at child protection information sharing
Infection control
• There has been several cases of C.difficile in the community. 2 cases
have been attributed to the CCG because they appear to be registered
to SCCCG GPs. This issue has been highlighted to PHE.
• AS also raised issues with receiving GP information regarding C.difficile
cases.
LB / RMc
ACTION: LB/RMc/AS to liaise to progress the issue of getting GP / AS
information in relation to C.difficile cases
• The Committee discussed the issues around the BCG vaccination and the
national issues.
BC/AS
ACTION: BC/AS to keep the Committee updated as appropriate
JW left the meeting.
Safeguarding
CA/KE
• The key themes around safeguarding adults relate to Mental Health and
also primary care.
ACTION: CA/KE to liaise with the relevant people to look at tackling the
themes in relation to safeguarding
ACTION: Measures to be put in place to assure the CCG regarding Adult
Mental Health and primary care safeguarding, included into the Primary
Care Strategy
ACTION: Safeguarding in Primary Care to be discussed at the next Primary
Care Medical Joint Committee
KE
MW/EP
Continuing Health Care
• CHC are meeting all targets for their reviews. It was also noted that the
CCG are on trajectory to complete all retrospective reviews by August
2016.
Complaints
• The CCG were invited to the Houses of Parliament to discuss the
feedback on the complaints service and how difficult it was to navigate
the complaints system.
• The Committee were asked to send any comments on the CQRM minutes
to the quality team.
MC left the meeting.
6.
Looked After Children update
The Committee received an update on Looked After Children (LAC).
Page 4 of 7
KE highlighted that Solent NHS Trust have a joint action plan iwith Southampton
City Council (SCC) which is very comprehensive.
The joint admin role between Solent and SCC has improved the notifications.
However there have been issues again this month. KE wants to work with SCC
to look at their responsibility of the health of children.
BC queried at what stage of a child’s life is the coding applied? KE responded it
is when the child is first seen.
KE will also be meeting with Portsmouth to discuss their role for LAC. An annual
survey is conducted in Portsmouth and KE wants to discuss this with corporate
parenting if it is something Southampton can do.
It was clarified that the performance data relates to all children who have had
their reviews completed. KE receives exception reporting from Solent NHS Trust
about children who haven’t had the reviews and what action has been taken.
KE
ACTION: KE to bring update report to the Committee in February 2016
The Committee agreed that the proposals outlined by KE will provide greater
assurance.
7.
Infection Prevention and Control (IPC) access to patient information
The Committee discussed the IPC access to patient information. The issue is
that it can take up to a month to receive Patient Identifiable Data (PID) and
gaining access.
Infection Prevention Nurses are a unique group who used to always be based in
a hospital or community setting and have now started to move into CCGs.
ACTION: Privacy Impact Assessment (PIA) to be completed for the access AS/ BW
to information
The Committee agreed that AS could have access to HHR/SCR.
8.
NHS England Quality Assurance
NHS England has produced a set of principles to monitor the Committee and
gain quality assurance as follows:
1. Gaining assurance that quality issues are considered and addressed
appropriately within the CCG
2. Gaining assurance that quality is embedded within the CCG’s day to day
business and planning processes
3. Gaining assurance that the CCG Governing Body can be confident that
they receive appropriate quality information in order to inform their
decisions
4. Gaining assurance that the CCG is viewing quality on a system wide
basis as well as internally
It was also highlighted that NHS England may shadow a couple of the
Committee meetings.
Page 5 of 7
LG raised it may be an opportunity to look at the way the meeting is conducted
and itemised or possible themed. This would need to be explored.
The quality report has improved and contains more information, however
sometimes there needs to be more information regarding providers having
actions plans, such as, actions being taken, who is responsible, and time for
completion / and or update.
It was suggested there is an overall document that contains the list of actions
plans in place to provide more precise detail.
The Committee discussed the dialogue between the Board and the Committee
itself.
The Committee agreed to come up with specific actions related to the principles.
It was suggested to do a summary on quality and how this is shared. It was also
raised to look at updates on patient experience and also challenging the
Integration Board.
Comments / suggestions are to be sent to EP.
LG/CA/SR
ACTION: LG/CA/SR to meet to look at the paperwork further
9.
10.
Any Other Business
•
SR raised that data was released in recent days regarding deprivation
which is negative for the city.
•
AS has submitted a bid for some additional funding regarding latent TB
infection testing based at 4 GP practices. The CCG awaits the outcome.
•
The decision to close the Bitterne Walk in Service was made at the
September Board which came with recommendations. It was agreed that
the Committee should monitor the effects of this action via patient
experience / feedback. Other recommendations included: 111 servicesmaking sure the population understand what 111 is and sending the
message that locally we have a good service. Also a commitment to
report back to HOSP on a regular basis on the effect of the closure of
the service.
•
It was suggested that a session on workforce is to be considered or a
briefing to the Board
`
Date and time of next meeting
The next Clinical Governance Committee is due to take place on 4th November
2015, 2 – 5pm, CCG Conference Room, Oakley Road, Ground Floor, SO16
4GX.
Signed: …………………………………………………….
Print Name: ………………………………………………..
Designation: ……………………………………………….
Page 6 of 7
Date: ……………………………………………………….
CQRM
UHSFT
SHFT
SCAS
SCC
STC
NHSE
AMH
OPMH
LD
MH
SCR
PES
FFT
ICU
IG
RCA
IPC
CHC
LSCB
LSAB
PALS
SIRI
MASH
CHC
IPC
Abbreviations
Clinical Quality Review Meeting
University Hospital Southampton Foundation Trust
Southern Health Foundation Trust
South Central Ambulance Service
Southampton Treatment Centre
NHS England
Adult Mental Health
Older Persons Mental Health
Learning Disabilities
Mental Health
Serious Case Review
Patient Experience Service
Friends and Family Test
Integrated Commissioning Unit
Root Cause Analysis
Infection Prevention and Control
Local Safeguarding Children’s Board
Local Safeguarding Adults Board
Patient and Liaison Service
Serious Incident Requiring Investigation
Multi Agency Safeguarding Hub
Page 7 of 7
Meeting Minutes
th
The meeting was held on Wednesday 4 November 2015, 14:00 – 17:00
Present
NAME
Margaret Wheatcroft
(Chair)
Stephanie Ramsey
INITIALS
MW
JOB TITLE
Lay Member – PPI
ORG
SCCCG
SR
SCCCG/SCC
Carol Alstrom
RM
CA
Bob Coates
Lesley Gilder
Antony Shannon
BC
LG
AS
Katherine Elsmore
Joan Wilson
Liz Bere
Dr Richard Day
KE
JW
LB
RD
GP Board Member
Quality
and Control, Nurse
Specialist
Quality Manager
Apologies
Andrew Mortimore
Dawn Buck
AM
DB
Head of Stakeholder
Engagement
SCC
SCCCG
In attendance
Emily Penfold
EP
SCCCG
Pam Sorensen
PS
(minutes)
Interim Complaints
Manager
1.
2.
SCCCG
SCCCG/SCC
SCC
Healthwatch
SC CCG
SC CCG
SCCCG
SC CCG
SCCCG
SCCCG
ACTIONS
3.
The minutes of the meeting that took place on 4th October 2015 were reviewed
by the Committee and the following amendments were agreed:
•
•
•
Under the quality report – amend the sentence to say “the quality team
went through the quality report
AS to provide amendments to the Infection Control update
Page 5 – the word “place” to read “plan” and in add in the word
“regarding” to ensure the sentence makes sense.
With the stated amendments the Committee agreed the minutes as a true,
accurate record of the meeting.
Matters arising
BCG vaccinations – resource has been sought and the backlog of vaccinations
has almost been cleared.
Paediatric Map of Medicines pathways – there were further discussion on the
fever pathway and the mistake that was highlighted will be corrected when the 6
month review takes place. The pathways were also discussed and approved at
the Clinical Executive Group (CEG).
Action tracker
4.
Quality Report
•
•
•
•
•
•
•
•
UHS CQRM – 18th September 2015
Solent CQRM – 10th September 2015
SHFT AMH – 21st September 2015
SHFT LD – 17th August 2015
SHFT MH/LD – 15th September 2015
SCAS 111 CQRM – 16th September 2015
STC CQRM – 16th September 2015
PHL OOH CQRM – 16th September 2015
CA went through the highlights of the report.
The Committee discussed the MRSA cases, there have been several cases
attributed to the renal service. It was agreed the Committee would ensure they
continue to discuss this issue and ensure the Committee are kept up to date.
ACTION: CA/AS to raise the issue on MRSA cases with the lead
CA/AS
commissioner. An update will be brought back to the next Committee.
UHS
• The Committee discussed the safe surgery action plan. This continues to
be an area that is monitored via the UHS CQRM. MW raised that there
have been issues around maternity theatres.
Page 2 of 6
• ACTION: Update on maternity theatre to be brought back to the JW
Committee
Southern Health
• ACTION: CA to query if there are any criminal charges being raised CA
in relation to the death of Connor Sparrowhawk
Care UK
• The Committee discussed the previous issues of being able to obtain
blood quickly when needed. Assurance was provided that this issue had
now been resolved.
• It was highlighted that there has been work undertaken on Information
Governance incident reporting and processes.
• The Committee discussed the CQC rating received by Care UK.
ACTION: CA to liaise with Communications on how to distribute the
message that this is the standard of rating that the CCG want to CA
commission
SCAS
• RD noted that South East Coast Ambulance had misreported its 111
response times, and asked if the CCG are assured that the SCAS 111
response rates are better than they have been reported nationally. It was
highlighted it is on the agenda for the next SCAS CQRM so the
assurance will be contained in the minutes.
PHL Out of Hours
• The Committee discussed the safeguarding policies in PHL. KE has
received the policies and there is a lack of details on adult safeguarding.
Infection control
• The Committee discussed the issue of care home staff receiving flu
vaccinations. The home who experienced issues last year have not
agreed to fund their staff to receive vaccinations, the CCG have
expressed their disappointment in this decision. AS has liaised with 3
other care homes and they have agreed to fund vaccination for their
staff.
• RMc queried if there was an outbreak of respiratory illness within a care
home setting, if primary care would be informed. AS responded that all
care homes have been provided with information packs on what to do
when there is a respiratory infection outbreak. If one nursing home has
an outbreak then all GPs will be automatically be informed.
Safeguarding
• The Committee discussed safeguarding training it was agreed that
training for sessional practice nurses would be discussed outside of the
meeting.
CHC
• The Committee were assured that the retrospective reviews number will
increase and this will be demonstrated in the October figures.
Friends and Family test
• Information on the friends and family test were circulated to the
Page 3 of 6
Committee. The graphs contained information on SHFT, UHS and
Solent. The Committee expressed their concern on the results for each
provider. The areas of concern will be picked up via the appropriate CA
CQRMs.
• ACTION: Committee to undertake a deep dive on the survey results
and possibly invite providers.
Any other queries on the quality report were to be picked up with quality team.
PS left the meeting.
5.
GP Survey Results
The Committee received the GP survey results for information. CA went through
the highlights of the report.
GP practices have been asked to review any actions they need to undertake in
relation to the results.
Updates on the actions that primary care will be undertaking will be included in
the next primary care update.
The Committee agreed that this is an area that needs focus as in many areas
the CCG have come out as average or below average.
6.
Revalidation for nurses
The Committee received the papers on revalidation for nurses for information.
This paper will also be received by the Board.
7.
Update on CQC status of providers across the City
The Committee received the update on CQC status of providers across the city
for information.
SR suggested that this should be used as assurance on monitoring quality
processes to HOSP and the Health and Wellbeing Board.
8.
NHS England Quality Assurance
The Committee discussed NHS England quality assurance.
The paper attached outlined some of the areas which contribute towards quality
assurance. It was also agreed this would be useful to share this information with
HOSP.
RD raised the importance of ensure there is an action or consequence of our
concerns.
The Committee discussed the Board visits to providers. It was suggested that
there are specific topics are discussed at those visits to gain assurance as
Board to Board.
LG suggested using case studies at the Committee and using the learning for
discussion.
Page 4 of 6
SR suggested that members may wish to attend a CQRM to see the challenge
and business that is transacted at those meetings.
JW raised that the Committee need to consider the contract outcomes and how
this is discussed.
9.
Any Other Business
• SR raised that Julia Bowey’s role will be changing and LB has taken the
lead as the Head of Medicines Management.
• RD raised that Junior Doctors are taking a vote on the proposed contract
change which may affect clinical services locally. ACTION: JW to
ensure this is included in CQRM agendas
10.
`
JW
The next Clinical Governance Committee is due to take place on 2nd December
4GX.
Signed: …………………………………………………….
Print Name: ………………………………………………..
Designation: ……………………………………………….
Date: ……………………………………………………….
CQRM
UHSFT
SHFT
SCAS
SCC
STC
NHSE
AMH
OPMH
LD
MH
SCR
PES
FFT
ICU
IG
RCA
IPC
CHC
LSCB
LSAB
Abbreviations
NHS England
Adult Mental Health
Mental Health
Serious Case Review
Root Cause Analysis
Page 5 of 6
PALS
SIRI
MASH
CHC
IPC
Page 6 of 6
Meeting Minutes
nd
The meeting was held on Wednesday 2 December 2015, 14:00 – 17:00
Present
Apologies
In attendance
1.
NAME
Margaret Wheatcroft
(Chair)
Carol Alstrom
INITIALS
MW
JOB TITLE
Lay Member – PPI
ORG
SCCCG
RM
CA
SCCCG
SCCCG/SCC
Bob Coates
Lesley Gilder
Theresa Gallard
Antony Shannon
BC
LG
TG
AS
Katherine Elsmore
Liz Bere
Dr Richard Day
Dawn Buck
KE
LB
RD
DB
GP Board Member
Quality
Quality Manager
and Control, Nurse
Specialist
Head of Stakeholder
Engagement
Andrew Mortimore
Stephanie Ramsey
AM
SR
SCC
SCCCG/SCC
Joan Wilson
JW
Quality Manager
Emily Penfold
EP
SCCCG
Jane Davies
Gemma Seymour
JD
GS
(minutes)
Patient Safety Manager
Clinical Quality Assurance
SCC
Healthwatch
SCCCG/SCC
SCCCG/SCC
SCCCG/SCC
SCCCG
SCCCG
SCCCG
SCCCG/SCC
NHS England
SCCCG/SCC
Jane Davies, Patient Safety Manager, NHS England attended the meeting to
gain assurance the CCGs quality process. A letter detailing the findings will be
sent to the CCG after the meeting.
ACTIONS
2.
3.
The minutes of the meeting that took place on 4th November 2015 were
reviewed by the Committee and with some minor typo amendments the minutes
Matters arising
Action tracker
4.
Quality Report
•
•
•
•
•
•
•
UHS CQRM – 16th October 2015
Solent CQRM – 8th October 2015
SHFT OPMH CQRM – 21st September 2015
SHFT AMH CQRM – 26th October 2015
SHFT MH/LD CQRM – 15th October 2015
STC CQRM 21st October 2015
PHL OOH CQRM – 21st October 2015
CA talked through the highlights of the report.
University Health Southampton Foundation Trust
• It was highlighted that the cancer breaches (for 31 and 62 day targets)
related to system / process issues.
• The Committee discussed the car park developments at UHS, MW
queried if the access will be improved for mums and babies, this will be
raised with UHS.
• It was highlighted that a SI relating to colorectal services, two specific
cases were being reviewed in more detail.
• ACTION: Update to be provided on the colorectal SIRIs at a future
Committee
Solent NHS Trust
• Resources are now in place for the complaints team
• ACTION: Request for a detailed plan on IT systems to be made at the
next CQRM
CA
CA
GS joined the meeting.
• The Committee discussed the changes to the structure that have taken
place locally. An update on progress will be received in January 2016.
No concerns have been identified locally.
Page 2 of 5
• The Committee discussed staff survey responses and this will be
discussed with SHFT
• An update was provided on Absent without Leave (AWOL) cases,
assurance has been provided, however it will continue to be included in
reporting.
Infection Control
• The Committee discussed MRSA. It was highlighted that Southampton
are not an outlier nationally in terms of MRSA cases.
• ACTION: Report of MRSA work linked to renal cases to be brought
back to the February 2016
AS
Patient Experience Feedback from Providers
• Work is taking place through the contracting process next year to ensure
more detailed information is being received by commissioners. This will
provide assurance on learning from patient experience.
• LG suggested a reporting system that reflects learning and actions with
progress.
Safeguarding
• KE is following up work with NHS 111/Out of Hours regarding information
on level of risks / flagging systems.
Medicines Management
• The Committee discussed general practice generated NRLS reports and
the confidentiality of them. Assurance was provided that learning from
the reports will be produced and shared.
5.
Serious incidents (SI)
The Committee received the Serious Incident Report for Quarters 3 and 4 2014/15 and Quarters 1 and 2 - 2015/16 for information.
GS talked through the highlights of the report.
Assurance was provided that learning from SI’s in UHS is shared widely in the
organisation.
6.
Latent TB Infection Testing (LTBI)
The Committee received the LTBI papers for discussion and to consider
supporting the initiative detailed in the papers.
Following lengthy discussion the committee supported the initiative.AS will
provide a progress report of the pilot in Southampton at its April meeting 2016
GS left the meeting.
7.
Patient insight report
The Committee received the patient insight report for April 2015 – November
2015.
DB talked through the highlights of the report.
Page 3 of 5
The committee expressed concerns that many members of the public remain
unaware of how NHS 111 operates. DB provided assurance that there is a
communications plan in place to raise awareness of NHS 111.
8.
Equality and Diversity (E&D) update
DB provided a verbal update on equality and diversity.
There is a Equality and Diversity Reference Group in place which meets
quarterly, the membership consists of people who all have 1 of the 9 protected
characteristics.
A workshop took place on E&D, the feedback was then discussed at the
reference group and actions have been developed which will be embedded in
the E&D Strategy.
Training is being developed for staff on Collecting ED data in order to improve
the volume of data collected and gain better information.
A Fairness Commission has been in existence in Southampton for 18 months,
the report is now out and available on their website which contains
recommendations. The CCG have signed up to each pledge that is included in
the report.
9.
Patient stories
The Committee received the plan for patient stories at Board.
The committee suggested that it may not always be appropriate for the patient
to present their story personally but background of the issue together with
actions and learning outcomes will be required for Board members or others in
order to assess the efficacy of the process and their own learning from the
experience. Patient stories should be positive as well as negative experiences.
The Committee discussed if it was a range of people who needed to hear the
stories and not just the Governing Body.
ACTION: email to be sent round to Board Members to determine the
purpose of patient stories. A proposal on format for patient stories to be
prepared and presented to January 2016 Governing Body
10.
DB
Any Other Business
The Committee were reminded if they want to attend the “Big Cuppa” event at
the Guildhall on 9th December they were more than welcome.
11.
The next Clinical Governance Committee is due to take place on 6th January
4GX.
Signed: …………………………………………………….
Page 4 of 5
Print Name: ………………………………………………..
Designation: ……………………………………………….
Date: ……………………………………………………….
CQRM
UHSFT
SHFT
SCAS
SCC
STC
NHSE
AMH
OPMH
LD
MH
SCR
PES
FFT
ICU
IG
RCA
IPC
CHC
LSCB
LSAB
PALS
SIRI
MASH
CHC
IPC
Abbreviations
NHS England
Adult Mental Health
Mental Health
Serious Case Review
Root Cause Analysis
Page 5 of 5
Act 2000.
Meeting Minutes
Commissioning Partnership Board
The meeting was held on 22nd October 2015, 15:00 – 17:00, Conference Room,
Oakley Road
Present:
NAME
John Richards
(Chair)
James Rimmer
Stephanie Ramsey
INITIAL
JRichards
TITLE
ORG
SC CCG
JRimmer
SR
SCCCG
SCCCG/SCC
Cllr Dave Shields
DS
Andrew Mortimore
Dr Sue Robinson
Andy Lowe
June Bridle
AM
SRob
AL
JB
Director of Quality &
Integration
Councillor, Cabinet
member
Chair
Lay Member
(governance)
Business Support
Manager (minutes)
Associate Director
SCCCG
In
attendance: Emily Penfold
Apologies:
EP
Donna Chapman
Matthew Waters
Chris Pelletier
Jeanette Clarke
DC
MW
CP
JC
Dawn Baxendale
DB
SCC
SCC
SCCCG
SCC
SCCCG
Associate Director
Care Placement Service
SCCCG
SCC
SCCCG
SCC
Chief Executive
SCC
Action:
1.
Members were welcomed to the meeting.
2.
No declarations were made in relation to the agenda.
3.
Meetings from the previous meeting and matters arising
The minutes of the meeting that took place on the 23rd September were
1
agreed as a true, accurate record of the meeting with the following:
-
Amendments to typos
Matters arising
Market Position Statement (MPS) – Provider relationships team have
been having discussions on linking the MPS with the housing strategy.
Domiciliary Care – discussions are taking place with SCC finance.
Rehabilitation and Reablement – there will be an item on Rehab and
Reablement at the November meeting detailed discussion and decision. SR/EP
Original costings are being reviewed to update savings and investment as
part of this.
The work programme for Rehab and Reablement is moving forward but
there has been some slippage, especially in relation to consultation
timescales. Considering options for additional project management support
for Adult social care to maintain momentum.
The Board discussed having more focussed discussion on items and
ensuring a longer time period for discussion. It was also suggested that the
frequency of the meetings is increased.
Action tracker
4.
Joint Equipment Store (JES) update
DC joined the meeting to present the Joint Equipment Store (JES) papers.
The paper presents the latest position since the discussion at the June
Commissioning Partnership Board.
There has been a significant reduction in overspend from over 30% to an
approximate 9.5% overspend currently. There has been a significant
increase in recycling of equipment.
The Board noted the progress already made in reducing expenditure at the
JES.
The Board also considered the options for introducing different control
measures. After considering the impact that it may have on patient safety
and agreed that a threshold should not be applied.
The Board passed on their thanks for a thorough and detailed paper.
DC left the meeting.
2
5.
Telecare
The Board received the Telecare papers which included the diagnostics
report. SRamsey talked through the highlights of the report.
The diagnostics work was undertaken by PA Consulting. SRamsey ran
through the phases that would take place if the work were to be
progressed. Further discussions are needed to consider investment
required, who will be the lead organisation and governance. The Board
supported the concept of a more comprehensive pilot to inform future
procurement decisions.
Action: SR, JR and AL to agree next steps for implementation after
further discussions at meeting planned for 3/11/15 if potential
savings are identified.
6.
Contract negotiation plan
MW/CP attended the meeting to present the Contract Negotiation Plan
paper which sets out a programme of negotiations with providers whose
contracts are due to expire prior to 31st July 2016. The negotiations will
enable the ICU to bring together current end dates for services to uniform
dates in line with commissioning intentions (and prior to formal
procurements), and to use this as an opportunity to review current costs
for services.
MW talked through the highlights of the report.
AL queried who is the lead commissioner for each contract and if the
organisations are getting value for money on each contract. CP responded
that the Commissioning Partnership Board is the commissioner for these
contracts. There are lead commissioners assigned to each contract. The
lead commissioners are responsible for monitoring the contracts and
regular reviews take place. The relevant individuals are involved
depending on what contract is being monitored.
The Board supported the strategic approach to negotiations.
Actions: It was agreed that changes to contracts would be discussed
in Cabinet Member Briefing (CMB) so the relevant Councillors are
aware.
Equality Impact Assessments will be provided for each service and
groups of services following the outcomes of the negotiations.
3
7.
Care placement service – 6 month review
Jeanette Clarke attended the meeting.
JC presented the Care Placement Service, 6 month review papers to the
Board and talked through the highlights.
The Board passed on their thanks for a well written paper which outlines
positive progress.
The Board noted the papers for information.
CP/JC left the meeting.
8.
Next steps for Integration
This item was deferred.
It was agreed an extra-ordinary meeting would be scheduled.
9.
DB/JR
Performance Report
The Board received and reviewed the performance report for information.
10.
Sub Committee Minutes
The Board received the following sub-committee minutes for information:
•
11.
Integrated Care Board – 19th August 2015
Any Other Business
None raised.
It was agreed that SRamsey would discuss police investment with
SR
AL/DB outside of the meeting. It would also be discussed at the
Health and Wellbeing Board.
12.
SRamsey raised there is an opportunity to apply for £50k through the
SR
Better Care local integration support fund which is being progressed.
Date of next meeting:
The next meeting is scheduled to take place on 19th November, 2015,
15:00 – 17:00, Conference Room, Oakley Road
4
Summary of Senior Management Team Meetings (SMT) and Business Team Meeting
November / December 2015 - Senior Management Team
-
Discussed the 2016/17 planning and contracting
Received an update on Information Governance
Reviewed and approved the Green Travel Plan
Reviewed and discussed the Communications Strategy
Received an update on the Organisational Development action plan
Discussed and supported Latent TB Infection Testing
Discussed and agreed the Mental Health Matters consultation
Received and approved the Information Governance Framework
Received and approved the updated Subject Access Request paperwork
Discussed co-ordinated approach to practice visits
Discussed CQUINs for 2016/17
Received and approved the CCGs Records Management Policy
November / December 2015 - Business Team Meeting
-
Reviewed and discussed month 7 performance
Reviewed and discussed month 6 activity performance
Reviewed and discussed month 6 and 7 QIPP 2015/16 performance
Discussed QIPP for 2016/17 (November and December)
Received a verbal update on NHS Right Care

Governing Body meeting agenda and papers

Transcription

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