© Nuffield Trust 22 June 2015

Prime Minister’s Challenge Fund

Local evaluation

Better access, better care better lives: Barking, Dagenham, Redbridge and Havering

Dr. Alisha Davies MSc PhD FFPH

Nuffield Trust

© Nuffield Trust

The team

Miranda Davies

Chris Sherlaw-Johnson

Sandeepa Arora Holly Holder

Helen Crump

BHR Team including

Rob Meaker

Sarah See

Colleen Atkinson

Mike Gill

Sandeep Sharma

Lizzie Hardy

Karen Stubbs

Simon Lam

Daniel Glasgow

and many more…

© Nuffield Trust

NHS England “Improving general

practice - A call to action”

August 2013

Prime Ministers Challenge

Fund

“to enable groups of practices

around the country to pilot new

ways of working that transform

patient access to services”

April 2014 £50m 20 pilots

Mar 2015 £100m 37 pilots

Background

http://www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/pm-ext-access/

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Barking & Dagenham and Havering and Redbridge:

Local context

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Barking & Dagenham and Havering and Redbridge

1. GP Hubs

• Out of hours GP service 7 day/wk

• GP-led triage service in A&E

• Practice-based telephone/skype consultation service.

Outcomes

• Improved patient access to primary care

• Improved patient experience with primary care

• Reduced A&E attendance

© Nuffield Trust

Patient

requires

urgent

advice

Calls

NHS 111

Attend

A&E

Attends OOH

GP

Attends walk-

in centre

Does

nothing

Offered

appointment

at GP Hub

Advice

only

Patient meets

eligibility criteria

GP Hubs: Access points

© Nuffield Trust

Barking & Dagenham and Havering and Redbridge

2. Health 1000

• Health and care hub for the management of those with complex care needs.

• Primary care led - pro-active planned care to support patients to manage

their conditions.

• Multi-disciplinary workforce (including social care, consultant specialists).

• Target of N=1000 patients with 5 or more LTCs.

Outcomes

• Improved patient and carer experience

• Reductions in admissions (ambulatory care sensitive conditions) and A&E

attendances.

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Evaluation questions: Mixed methods approach

• How has the availability of services changed? (Descript/Qual)

• Who is using the new services? And why? (Quant/Qual)

• What is the patient experience in the new service? (Qual)

• What is the experience and views of the staff delivering the new

service? (Qual)

• What is the impact of the new service on other primary and acute

care services? (Quant/Qual)

• What is the impact on health outcomes? (Quant/Qual))

• What is the impact on cost? (Quant)

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Measurable outcomes

Process measures

• Levels of activity

• Use of secondary services

Outcome measures

• Preventable admissions to hospital

• Event free survival

• Measures derived from local primary and community care data

• Costs

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Quantitative data

Data specification for Health 1000 and GP Hubs

• Ethnicity, Disability

Routine collected data

• A&E attendance (HES)

• GP Hub activity (ADASTRA, PELC)

• Primary care data

• Inpatient and Outpatient data (HES)

• Social care data

Additional data

• PROMS (Health 1000) (where possible)

Processed locally and

pseudonymised data

sent to Nuffield Trust

© Nuffield Trust

Quantitative methods

GP Hubs

• Descriptive analysis of patients attending the hubs

• Compared patient population to other urgent care settings

• Measuring impact on A&E attendance: Difference in Differences

• Comparison period Oct 2013-Aug2014 (pre-hub)

Dec 2014 onwards (hub)

• Comparator ratio of levels of activity at different time periods

• Non-hub opening hours

• During hub opening hours

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6 mths after opening 12-18 months after

opening

GP Hub Health 1000 GP Hub Health 1000

Interviews • Staff delivering the

service

• Staff NOT delivering

service

15

-

15

10

Interviews

Patients

30 12 30 12

Focus groups patient groups missing from the

interview sample, or to explore

specific issues in greater detail

(where possible)

patient groups missing from the

interview sample, or to explore

specific issues in greater detail

(where possible)

Staff survey

Qualitative methods

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Challenge:

Collating views of those who do not use the service

Importance of understanding why eligible/appropriate patients are not using the service.

Two key themes

• Those not aware of or not offered the new service

• Possibly run focus groups with target populations to gauge level of awareness in local population

• Offered but declined to attend/be referred

• GP Hubs – difficult as no method to collate reason for declined at point of referral.

• Health 1000 – beginning to collect reason for decline at consultation.

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Qualitative methods

Topic guides

• Derived from literature with focus on access and joined up/care continuity.

• Themes include experience of service, service outcomes, changes to the way care delivered.

Patient consent

• Consent to approach patients sought via receptionists/practice staff.

• Patients asked if agree to details being shared with the Nuffield Trust to contact them.

• Working for GP Hub evaluation (Health 1000 not started as yet).

© Nuffield Trust 30 June 2015 © Nuffield Trust

What has been implemented?

GP Hubs

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GP Hubs

Out of hours GP service 7 days a week

• Phase 1 Face to face consultations with a GP/nurse

• Phase 2 As above and to include telephone/skype consultation between GP and patient.

• 3 sites opened (2 in Sept 2014, 1 in Jan 2015)

Mon/Fri 6.30pm to 8pm

Sat/Sun 12pm to 6pm

• 2 secondary sites opened (March/April 2015)

• 4 appointments per hour per GP

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Findings

…watch this space

© Nuffield Trust 30 June 2015 © Nuffield Trust

Challenges and reflections in

the evaluation

GP Hubs

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It is more complex:

Service implementation is not in isolation

A&E data

at Trust

level not

site level

Some

settings not

in HES

(GP OOHs,

Walkin

centres)

© Nuffield Trust

It is more complex:

Service delivery changes

Weekday opening hours

Oct-14 Feb-15 May-15

Havering Hub 1

Hub 2

Redbridge Hub 1

Hub 2

B&D Hub 1

Saturday opening hours

Oct-14 Feb-15 May-15

Havering Hub 1

Hub 2

Redbridge Hub 1

Hub 2

B&D Hub 1

Sunday opening hours

Oct-14 Feb-15 May-15

Havering Hub 1

Hub 2

Redbridge Hub 1

Hub 2

B&D Hub 1

Mar-15Jan-15

Jan-15

Jan-15

Nov-14

Nov-14

Nov-14

Apr-15

Apr-15

Apr-15

Mar-15

Mar-15

Dec-14

Dec-14

Sep-14

Sep-14

Sep-14 Dec-14

6.30pm to 10pm

12 to 6 pm

12 to 8pm 9 to 5pm

12 to 5pm

12 to 6 pm

12 to 8pm 9am-1pm

12 to 5pm

© Nuffield Trust

Contextual factors

Patient choice

• Location of hubs

• Awareness of hubs – supply induced demand?

• Prior experience elsewhere

Interdependence with other services

• NHS 111

• GP – awareness of hub? offers an appointment at the Hub?

• Hospitals - decision to refer on, or not?

© Nuffield Trust

Patient

requires

urgent

advice

Calls

NHS 111

Attend

A&E

Attends OOH

GP

Attends walk-

in centre

Does

nothing

Offered

appointment

at GP Hub

Advice

only

Patient meets

eligibility criteria

Implementing a new service: Access routes change

© Nuffield Trust

Implementing a new service: Access routes change

Calls

NHS 111

Attends walk-

in centre

Patient meets

eligibility criteria

Patient

requires

urgent

advice

Referred to and attends GP Hub

Attend

A&E

Calls own

GP in pm

Referred onto another health care setting Advice and resolved

Benefit

in GP

access

not A&E

Self refer

Supply

induced

demand

© Nuffield Trust

Benefits not in A&E ?

With greater focus on improving primary care access – are the benefits now in primary care, rather than A&E?

With a focus on patterns of primary care activity, we need better understanding of primary care data.

Two challenges

• How to identify appointments?

Patient “incidents” not appointments, including patient letters, blood test

results etc.

• How to identify “time” of appointment?

© Nuffield Trust

Lessons - evaluators

Skills in all languages of the trade!

• Service providers, commissioners, evaluators, data analysts.

Communicate

• Be clear on needs and expectations.

• Be clear on who is the audience for the evaluation.

Supportive, but persevere

Flexible

• Awareness in reality best intentions change.

© Nuffield Trust 30 June 2015

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alisha.davies@nuffieldtrust.org.uk

@alishadavies1