Rick Stern Director, Primary Care Foundation , NHS Alliance Lead for Urgent Care

© Primary Care Foundation

Meeting the quality and productivity challenge in out of hours care: what can we learn from the out of hours benchmark?

Rick Stern Director, Primary Care Foundation, NHS Alliance Lead for Urgent [email protected] 07709 746771

Improving Patient Safety in Out of Hours Care 22nd June 2010


What I will cover

The current context – learning from recent reviews

The out of hours benchmark – what we can learn about quality and productivity

How can this lead to improvements in patient care and safety?

Shifting the focus: from organisational to individual

Improving the benchmarkWhere are we heading … the future of OOH

and urgent care


New Leadership Group for Urgent Primary Care

Dr Albert Benjamin

Clinical Director Waldoc CBS (Waldoc Ltd)

Anita Dixon Chief Executive Central Nottinghamshire Clinical Services

Alan Franey Chief Executive Barndoc Healthcare Ltd

Jayne Hetherington

General Manager OWLS CIC Ltd

Eddie Jahn Managing Director Harmoni

Dr Darren Mansfield

GP Clinical Lead in Urgent Care

NHS Bolton

Lesley McCourt Chief Executive Partnership of East London Co-operatives

Alison McWilliam

General Manager Nottingham Emergency Medical Services Limited (NEMS CBS)

Dr Ray Montague

Medical Director Brisdoc Healthcare Services

Dr Russell Muirhead

Chairman Shropshire Doctors Cooperative Ltd

Diane Ridgeway

Chief Executive East Lancashire Medical Services Ltd

Dr Bruce Websdale

Medical Director Primecare

Gilly Wilford Director of Finance & Contracts

South East Health

Nigel Wylie Chief Executive Urgent Care 24


Emerging Priorities

1. Patient Safety

2. Integrated Urgent Care

3. Demonstrating quality

4. ‘Rebranding’ Out of hours


The Primary Care Foundation developing best practice in primary and urgent care

A resource for commissioners of urgent care


A long history of reports and reviews …

● Department of Health (Carson Review, 2000) Raising Standards for patients: new partnerships in Out-of-Hours care

● National Audit Office (May 2006) The Provision of Out-of-Hours care in England

● Four inner London PCTs (May 2007) Report into the death of Penny Campbell

● Health Care Commission (September 2008) Not just a matter of time: A review of urgent and emergency care services in England

● Primary Care Foundation (January 2010) Improving out of hours care: what lessons can be learned from a national benchmark of services?

● Department of Health (February 2010) Out-of-Hours Services: project to consider and assess current arrangements

and still to report …● Care Quality Commission (still ongoing) Enquiry into Take Care Now


What can we learn from recent reports on out of hours services? Key areas in the Department’s Review● Commissioning and performance management, including

tackling inappropriate variation ● Selection, Induction, Training and use of out-of-hours

clinicians (including the use of locums)● Management and operation of Medical Performers Lists

Actions following on from the Review: Reviewing the National Quality Requirements Developing a new national model contract for OOH

services Stronger performance management (including use of

English and applying the performers list) Greater involvement of local GPsBut we now have a new government …


Developing the benchmark

●Awarded tender by DH in November 2007

●Numerous pilots including across all of North East

●National advisory group to steer progress and set price

●Established three years support, with benchmark every six months and patient experience survey once a year

●Currently over 100 out of 152 PCTs in England are members


Developing the benchmark:rounds 1, 2, 3, & 4●First benchmark completed March 2009 with reports on 63 services and half-day workshops for commissioners & providers

●Second benchmark, with reports on over 90 services, completed November 2009,with first patient experience survey managed by our partners, CFEP UK Surveys

●Third benchmark reviewing performance at period of peak demand at Christmas 2009 and New Year 2010 – to be completed by end July 2010

●Fourth benchmark, again a full benchmark including patient experience – to be completed October 2010.


How does it work?

●Data extract – most from one information system but now working with a number of others

●Web based questionnaire for commissioner

●Web based questionnaire for providers

●Validate data

●Produce reports

●Workshops

●Anonymity – about to change

●Steering group and user group


12 headline indicators

Cost1. Cost per head2. Cost per case

Productivity3. Number cases per clinician per hour

Outcomes4. Referrals to hospital (if possible,

sub-divided between referrals to A&E and referral to a hospital bed)

5. Overall breakdown of dispositions (advice/PC Centre/home visit)

6. % Calls classified Urgent on receipt

Process7. The quality of clinical governance systems

and processes

Performance8. Time to clinical assessment for all calls as

a %age 9. Time to face to face consultations for

urgent calls (including % urgent after assessment)

Patient Experience10.Patient experience of receiving telephone

advice11.Patient experience of treatment at a

centre12.Patient experience of home visits


The evidence suggests …Out of hours services are improving … despite what you might hear in the mediaMost providers have made a rapid

transition from ‘rota organising clubs’ into true healthcare providers. In doing so they have got much better at:● Matching capacity to predictable demand, giving ample time

for clinicians to do their work well● Meeting performance standards● Introducing governance processes to ensure a consistent and

safe response to patients● Engaging local clinicians in the service.


A rapid response matters to patients

● Patients value a responsive service and associate this with good care. There is a wide difference between wide the difference is between the responsive and the comparatively slow.


There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

40% 45% 50% 55% 60% 65% 70% 75% 80% 85%

How quickly care was received % About right

Rat

ing

of

care

rec

eive

d e

ith

er g

oo

d o

r ve

ry g

oo

d

Each dot is one PCT


Seven years on, most providers are still falling short on a key NQR

Many providers are falling short on the standard for definitive clinical assessment of urgent cases which we see as an important issue of patient safety.


We reported the percentage of urgent cases that were assessed in 20 minutes…

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Increasingly falling below standard

Each bar is one service – a provider/PCT


0%

10%

20%

30%

40%

50%

60%

70%

There is a very striking variation between services in the proportion of cases identified as urgent on receipt

Percentage of cases identified

as urgent by non clinical

call-handlers

Each bar is one service – a provider/PCT

How safe?

How safe?


0%

5%

10%

15%

20%

25%

Normal band?

suspectnot credible?

Coding needs to be improved …In far too many services it is impossible to be sure how many patients make their way towards hospital

We know that many services, particularly to the left, are

under-counting patients going towards hospital

Each bar is one service


What is quality in OOH?

Quality is likely to be a composite measure of a number of these factors. Our conclusion is that those that perform well on all these factors are far from being the most expensive, but also that the very cheap providers do not appear to have the management headroom to perform consistently enough to feature in this group.


●An example: an out of hours provider who were part of earlier pilots

●Concerned that productivity was low

●Looked at productivity by each clinician – reported this back and reviewed performance with clinical manager

●Also looked at other factors. Identified some doctors regularly late for sessions and others not picking up calls when no visits at centre.

●Results included: ● Productivity more than doubled

● Clinicians happier that workload was more evenly spread

● ‘by making clinicians more productive - supporting them as necessary, sorting out the problems that they face and addressing one or two poor performers – it has improved care for patients because clinicians can focus on the job that they are there to do’

●Learned that variations in performance tend to be less about external factors (e.g. geography, demography) and more about how staff are supported and managed.

Using this measurement of productivity to drive improvements in care


●Concern about benchmark results led to a rigorous base line audit of calls taken and priority given.

●Call handlers clear about life threatening calls & A&E referrals

●Other specific areas identified that could be addressed by training - designed to develop each call handler’s confidence and knowledge

●Results included:● post training audit showed that % of urgent calls has

increased and is moving towards the national average

● more importantly, has shown to be appropriate to each presenting case as evidenced by the end priority given by the consulting clinician

● Supported and reassured call handlers - benefitted from extra training and comparing how they work with others

●Better identification of urgent needs improved patient safety

Improving Patient Safety - responding to low level of urgent cases on receipt


From variation across organisations to variation between clinicians● There is substantial variation within a typical service

between individual clinicians. The response will often be shaped more by who deals with the case rather than the details of the case itself.

● Developing a consistent, safe and appropriate response does not just involve looking at the outliers, but involves consistent feedback to individuals comparing them with their peers so that they can identify specific things that they might do differently for the benefit of patients and the service.


Future Changes …

For services● All services need to ensure that they are using the results work

out how to improve local care – it is about using national comparisons to drive local improvements

● Recent reviews have highlighted the importance of good recruitment, induction, training and continuing support of staff.

● Some services need to make sure that they are responding to calls more rapidly than is currently the case

For the OOH Benchmark● The benchmark will extend to cover all these areas● Making the benchmark more open and transparent will ensure

that it is more useful to services as a tool for driving improvements

● Creating a new governance group as well as a user group


Key Issues for the future

● Patient Safety● A new initiative for rapidly sharing learning? ● tighter rules or a cultural shift?

● Focus on learning and improvement● responding to benchmarking and other comparisons across and

within organisations● Better internal scrutiny – good governance and independent NEDs● Greater openness and transparency

● Working as part of an integrated system● Networks and accountability● Three Digit Number● Clarity for the public and patients about using urgent care services

● Commissioning for quality● Commissioning pathways● identifying the cost of quality in urgent care services


Discussion & Questions

And for more information, visit our website at:www.primarycarefoundation.co.uk

Or contact me:

Rick Stern 07709 [email protected]

Rick Stern Director, Primary Care Foundation , NHS Alliance Lead for Urgent Care

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Transcript of Rick Stern Director, Primary Care Foundation , NHS Alliance Lead for Urgent Care