Urgent and Emergency Care Delivery Plan - Medicas Health · Urgent and Emergency Care (UEC) is one...

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DRAFT FOR DISCUSSION – NOT FOR ONWARD CIRCULATION

Urgent and Emergency Care Delivery Plan

April 2017

Contents

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1. Introduction

2. Summary of UEC workstreams

3. Summary of UEC regional funding by STP

4. Appendix: detailed delivery plan

Purpose of this document

• The “Next Steps on the NHS Five Year Forward View (5YFV)” was published on 31 March 2017. This plan explains how the 5YFV’s goals will be implemented over the next two years. Urgent and Emergency Care (UEC) is one of the NHS’ main national service improvement priorities.

• This document accompanies the “Next Steps on the NHS Five Year Forward View (5YFV)” publication, articulating in more detail the offer, specification, delivery plan, expected costs and benefits of seven UEC priorities, which will deliver transformation of Urgent & Emergency Care.

• In addition to these seven priorities, transforming urgent and emergency mental health care services is key to improving A&E performance. For more information, please see the Mental Health Delivery Plan.

• The document is aimed at NHS England regions and STPs, providing them with the supporting information they require to write detailed delivery plans for 2017/18 that align with these priorities and workstream activities. These plans must be secured during Q1 2017/18.

• Regions will work with STPs to develop plans which evidence delivery of the specifications of the seven priorities. Whilst the outcomes and standards have been centrally set, it will be for regions to determine if the specification will be met by proposed plans.

• Regions and STPs should determine which of the priorities they will focus on, based on local needs, however it is crucial that plans deliver the requirements of the appropriate priorities based on scaling up standardised initiatives, and not implementing multiple different forms of the same intervention.

• UEC Networks will also play an important role in determining priorities. Whilst some planning will be made at individual organisation level there is a clear expectation that STPs should coordinate activity (in conjunction with regional PMOs).

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https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

Context of the UEC 5YFV Delivery Plan We are fully committed to the four hour target, but;

• Patients have a lifestyle view of what is urgent rather than a clinical view and services need to reflect this

• Too many people are going to A&E rather than more appropriate alternatives and therefore we are not using our expert resources to deal with our sickest patients

• Capacity is stretched and we need to ensure that patient flow is optimised

• The system is too complicated and fragmented leading to patients not getting the best care and large variations in performance across the country

We need to change this so that:

• The system is intuitive and helps people make the right decision;

• There are alternatives offered to A&E that provide timely clinical access for urgent close to people’s homes

• We focus our skilled resources in hospitals on the sickest patients and those with serious or life-threatening needs

• We reduce the pressure on our hard-working staff enabling them to provide higher quality care

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Summary of the seven priorities to deliver transformation

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• Throughout 2017 we will be testing innovative new models of service that enable patients to enter their symptoms online and receive advice online or a call back.

• We will continue to develop the response patients receive when they call 111. By the end of 2017/18 the percentage of calls receiving clinical advice will exceed 50%.

• By March 2019 patients and the public will have access to evening and weekend appointments with general practice.

• Standardise access to ‘Urgent Treatment Centres’ through booked appointments via NHS 111. These facilities will have an increasingly standardised offer - open 12 hours a day and staffed by clinicians, with access to simple diagnostics.

• The ambulance service will offer a more equitable and clinically focused response that meets patient needs in an appropriate time frame with the fastest response for the sickest patients.

• In Emergency Departments we will develop new approaches prioritising the needs of the sickest patients. Our frail and elderly patients will get specialist assessments at the start of their care and those patients who could be better treated elsewhere, will be streamed away from Emergency Departments.

• We will speed up the assessment process and ensure that patients are sent home as soon as possible and if home is not the best place for their immediate care, they will be transferred promptly to the most appropriate care setting for their needs.

Contents

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1. Introduction




Text

Getting Urgent and Emergency Care Back on Track (1)

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The offer • Online triage services that enable patients to enter their symptoms and receive tailored advice or a call back from a healthcare professional

• Services closely connected to NHS 111 calls (and other services including Primary Care over time)

• Offer an increasingly personalised experience to patients

The plan • Pilot the service in 4 areas from February 2017 onwards

• Complete evaluation by July 2017

• Roll out to 5 or 6 111 areas per month by December 2017

• Introduction of intelligent personalised triage by March 2019

NHS 111 Online

The offer • Increase the percentage of calls transferred to a clinician when a patient calls the NHS111 service

• The service will better support the number of patients who can be dealt with as ‘self-care’

• Where applicable patients will be referred on to an appropriate point of care

• NHS 111 Care Home Line will enable dedicated access for healthcare professionals (starting with care home staff) to get urgent advice from a GP out of hours

The plan • 30% of 111 calls transferred to a clinician by March 2017, rising to 50+% by March 2018

• Operational readiness for Care home Line by March 2017 with roll out from April 2017

Text

The offer • Continued provision of

urgent care services by general practice

• Additionally by March 2019 the public will have access to pre-bookable evening & weekend appointments with general practice

• Delivering this aims to secure: Transformation in general

practice Step change in use of

digital technologies The foundations for a

model of more integrated services

The plan • Coverage of enhanced

access will reach: 50% of England by March

2018 100% of England by

March 2019 • Invest at least £138m in

2017/18 and at least £258m in 2018/19

• Allocate at least £6 per head of population to all CCGs recurrently from 2019/20 for ongoing service provision

Text GP Access

The offer • Urgent Treatment Centres across the country will be: Open at least 12 hours

a day Staffed by doctors and

nurses Will do blood tests, and

most will have x-ray facilities

Patients will be able to book an appointment via NHS 111, their own GP, or walk in

Able to give a prescription, when needed

The plan • These services will be in

place as follows: c.150 facilities by

March 2018 Plan for remainder by

March 2018 All Urgent Treatment

Centres in place by Dec 2019

Text Urgent Treatment Centres

NHS 111 Calls

Getting Urgent and Emergency Care Back on Track (2)

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The offer • More clinically focused response for patients

• Quicker recognition of life threatening conditions

• Telephone advice, treatment on scene or conveyance to hospital

• End to long waits for an ambulance and handover delays at hospitals

The plan • Subject to SofS approval • Rollout of the Ambulance

Response Programme complete by Autumn 2017

• Implement enhanced Hear & Treat and See and Treat by March 2018

• STPs offer integrated model of urgent care, with clear referral pathways offering alternatives to conveyance to A&E by March 2018

• Development of ambulance workforce, to December 2018

The offer • Highly skilled emergency department workforce to deliver life-saving care for our most sick patients

• Variation between hospitals will be reduced

• Patients streamed by a highly trained clinician to the most appropriate service

• Rapid, intensive support to those patients at highest risk of admission

• Use of a wide range of ambulatory care services.

• Effective metrics used in oversight of hospitals

The plan • Comprehensive front-door clinical streaming models in all UEC systems by September 2017

• Establish Frailty Assessment processes and Frailty Units

• 7-day ambulatory care • Implementation of core best practice on medical wards to facilitate discharge

Text

The offer • Patients only stay in hospital for as long as they need to be

• Earlier planning of discharge and further joint working across different sectors

• With liaison across sectors, coordinated and timely transfer of care from hospital to the most appropriate setting

• Provide patients with comprehensive packages of health and social care

The plan • Support local areas to implement the 8 High Impact Changes for discharge and Quick Guides

• To incentivise local areas to work together through the 2017/19 Proactive and Safe Discharge CQUIN

• Introduction of CCG Quality Premium for 2017-19 to reduce Continuing Healthcare (CHC) full assessments occurring within acute settings to <15% (dependency on out of hospital capacity )

Text Ambulances Hospitals Hospital to Home

NHS 111 Online: Summary

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How will it be delivered? • We will work with CCGs to develop partnerships

with Industry/NHS Digital/AHSNs and providers to identify the best products for online triage.

• Cycles of testing and evaluation with local services will inform success criteria & standards (patient experience, safety, interop and service demand).

• We expect to define a series of services that work. • A national team will support local deployment.

What is the offer to the public? Throughout 2017 we will be working to design online triage services that enable patients to enter their symptoms and receive tailored advice or a call back from a healthcare professional, according to their needs. As an evidence based organisation our decisions will be based on robustly testing and evaluating a range of innovative digital solutions that balance effectiveness, safety and patient experience. To do this we have established a series of partnerships with local commissioners and providers. We will be testing apps, web tools and interactive avatars, in house NHS developed clinical triage algorithms alongside those developed by industry and used in other parts of the world. The online triage services need to be closely connected to NHS services, initially we are focused on the links to NHS 111 services, in time this could potentially extend to other settings including primary care. Patients have already highlighted an online service must allow information they have entered online to be made immediately available to the health professional who will call them back. Moving into 2018/19 we want to explore how we can increase the personalisation that online systems can offer. The opportunity for patients to enter specific conditions or link to care plans will be an important next stage development.

Where will it be delivered?

• Live testing will initially be in 3 areas London, W. Mids and W. Yorks. A range of products will be tested in these areas.

• Fast follower sites of Suffolk, Cambridge and Peterborough and South Central, Nottingham have come forward

• Wider roll out plans will be developed in April 2017 • Initial testing for GP connections will be established in

early 2017

• London are evaluating an app based approach in partnership with Babylon; West Midlands have adopted the Sens.ly avatar linked to TAS Odessey and in West Yorkshire as part of the WYAZ we are focused on testing the in house web app developed in partnership NHS Digital

• The core focus for these and all tests will cover; 1) Clinical safety and governance; 2) Patient experience 3) Comparisons with telephone triage and impact on clinical call backs from NHS 111 ; 4) The types of symptoms patients use an online service for 5) the burden of operational change 6) shifting demand v stimulating demand 7) technical issues (including interoperability)

• The impact of the online service still needs to be tested and evaluated. At present there are concerns about the potential for it to increase demand and pressure on services

• Determining which components of a digital 111 service (e.g. front end, triage, service search, referral) should be operated nationally vs locally will be complex and will require trade-offs.

• At scale we will need to consider the business continuity aspects across and between NHS 111 providers

Examples Outstanding Issues

NHS 111 Calls: Summary How will it be delivered? What is the offer to the public?

• By March 2017 we will be offering clinical advice to 30% of all callers to 111. By March 2018 this will increase to half of all callers to 111.

• We will continue to develop the response patients receive when they call 111.

• We are piloting new approaches at 12 sites across the country, testing the ‘consult and complete’ model to establish whether new care pathways can provide a viable alternative to A&E attendances.

• We will be considering how to increase the number of directly booked primary care appointments in 2017/18, as we expand evening and weekend access.

• By March 2019 it will be possible to book all patients who call NHS 111 out of hours directly into further appointments, if required, with 30% of patients able to book appointments in hours. It will also be possible for more people to be offered a prescription by the NHS 111 service.

The IUC Offer 2017 to 2019

Examples

Outstanding Issues • Review, evaluate and agree best provider for clinical triage model • New contract specification to be issued • Workforce - Training / Career progression

• Guidance will be developed by April 2017 to support NHS 111 services to move from “assess and refer” to “Consult and Complete”, followed by a revised service specification to inform future 111 contracts by autumn 2017.

• An enhanced performance management and assurance framework, covering capacity and demand modelling will be introduced to ensure progress is made

• Re-procurement of telephony contract and review of business continuity processes by March 2017 to ensure a robust platform for NHS 111 services

• In 2017 NHS England and HEE will deliver a blueprint for a sustainable NHS 111 workforce, including a competency and career framework and resources to support staff wellbeing and resilience.

Information indicates that a call dealt with by a clinician will result in a different disposition to the one reached if the call was dealt with by a Health Advisor: • In the North West there was an 82.2% reduction of A&E and

ambulance dispositions following further clinical review. 12 IUC pilots will establish: • The system impact of transferring a greater number of NHS

111 calls for clinical advice; and • The service structure (staff types) that allow a ‘consult and

completed’ episode which minimises use of other NHS services taking account of patient outcomes and the net financial impact.

There will be four sources of evidence: • Analysis of NHS111 and ED data using the RAIDR tool; • Learning from the Phase 1 and 2 NHS111 Learning and

Development pilots; • Case Study information from early implementers, and; • Analysis using the financial toolkit on an England-wide basis

Offer Area 16/17 17/18 18/19 Notes

Level of Clinical Input

30% 51%+ 51%+ The majority (i.e. >50%)of symptomatic callers will have their call reviewed by a clinician. The optimum level of clinical input will be directed centrally based upon evidence derived through pilots and other data sources, but implemented locally.

Level of Booked Appointments In Hours

5% 10% 30% Callers will be able to have an appointment booked with their GP practice or other GP/primary care service.

Level of Booked Appointments Out of Hours

70% 90% 95% Callers will be able to have an appointment booked in a primary care service.

RAIDR rollout RAIDR to be rolled out across the country by April 2017

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Fully integrated 24/7 urgent care services, combining NHS111 and GP out-of-hours services, will cover the whole population by March 2019 with 60% coverage achieved by March 2018.

• Provision of urgent appointments with general practice in hours (8am-6.30pm). This is available now. Provision of urgent services by general practice outside of core hours (6.30 pm – 8am weekdays, and weekends). This might include attending an out of hours centre or a home visit. This is available now.

• Expansion of capacity and services to offer pre bookable and same day appointments to general practice services during the evening and at weekends. Coverage will reach 50% of England by March 2018 & 100% by March 2019

GP Access: Summary

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How will it be delivered? What is the offer to the public?

Where will it be delivered? • It is most likely to be delivered by existing general

practices, working at scale across groups of practices, and often using central hubs to create appointments.

• It may include some independent providers, potentially offering additional support through phone consultations and app access (we are testing this in London with the Digital First programme).

Context • We have set out the aspiration for general practice in the General Practice Forward View,

published in April 2016, which commits to an extra £2.4 billion a year to support general practice services by 2020/21. As part of this additional funding, there is a non-recurrent five year £500 million sustainability and transformation package to support GP practices. This is partly comprised additional funds from local clinical commissioning groups (CCGs).

• GPFV includes help for struggling practices, plans to reduce workload, expansion of a wider workforce, investment in technology and estates and a national development programme to speed up transformation of services. We are committing to an increase in investment to support general practice over the next five years.

• Public satisfaction with general practice remains high, but increasingly, we are seeing patients reporting more difficulty in accessing services. We know that many practices report that they would like to offer better access, but that they are experiencing increasing pressure and are having difficulties in offering their patients timely appointments. This is frustrating for practice staff, and for patients alike.

• NHS England is providing additional funding, on top of current primary medical care allocations – over £500 million by 2020/21 - to enable CCGs to commission and fund extra capacity across England to ensure that everyone has access to GP services, including sufficient appointments at evenings and weekends to meet locally determined demand, alongside effective access to out of hours and urgent care services.

Outstanding Issues

• We will need to ensure systems are supported to enable best quality and value from effective connections across the UEC system

• Using technology to connect practices and support at scale working and the wider UEC system

• Through implementation of many of the measures in the GPFV to build up today’s general practice services, and improve in-hours access

• Through plans developed and implemented by CCGs to deliver the specification for extended access as set out in the Planning Guidance. This is supported by additional funding of at least £138m in 2017/18 and at least £258m in 2018/19.

• CCGs will be required to secure services following appropriate procurement processes

• CCGs will be required to deliver from when they receive improving access funding, going live from 17/18 or 18/19 in accordance with Planning Guidance roll out.

Examples The GP Access Fund was launched to test new ways of working in general practice and to improve access for patients. The wave one evaluation identified a 14% reduction in minor A&E attendances for patients who were offered extended access services as part of the GPAF programme. Schemes have developed multiple ways of improving access that impact on wider system including introduction of a pharmacy first scheme in Devon, and Torbay involving 134 pharmacies made 8,000 consultations saving nearly 3,000 GP appointments, nearly 2,000 GP OOH appointments and 200 A&E appointments in first five months of operation. In Erewash in 9 month pilot shows ANP care home work stream resulted in avoidance of 417 unplanned admissions

Urgent Treatment Centres: Summary How will it be delivered?

• Completed: assessment of current services against proposed key standards

• April 2017 – Publish updated standards for urgent treatment services

• Through 2017/18 – STPs to complete gap analysis against standards, supported by regional PMOs and NHS Digital, Including staffing and capital requirements. Proposed solution for every site to be identified.

• Through 2017/18 – direct booking from NHS 111 to be prioritised

• Through 2017/18 – designation of ~150 services (based on regional returns)

• By December 2019 - All services designated as UTC will meet guidelines

What is the offer to the public? By December 2019 patients and the public will:

• Be able to access Urgent Treatment Centres that will be open at least 12 hours a day and staffed by nurses and doctors, with access to simple diagnostics.

• have a consistent route to access urgent appointments offered within 4hrs and booked through NHS 111 and GPs, with walk-in access also retained.

• Increasingly be able to access extended hours and out of hours general practice, for both urgent and routine appointments, at the same facility, where geographically appropriate.

We expect reduced attendance at A&E as a result of this standardisation, as well as an improved patient experience. The key components to be considered to deliver this include:

• Staffing – GP led, multidisciplinary teams (which may include nurse practitioners, mental health practitioners, paramedics, pharmacists etc.) in line with locally identified need

• Opening hours – minimum 12hrs, to be agreed in line with locally identified need

• Direct booking from NHS 111 and other services, with access to DoS • Access to basic diagnostics and access to x-ray facilities (with clear access

protocols if not available on site) • Interoperability of clinical systems to enable clinicians to review patients’ care

records, with goal of read/write access. Timely communication of outcomes back to own GP

• Implementation of new Emergency Care Data Set (ECDS) to ensure all activity is captured accurately.

Not all existing services described as MIU or WiC will meet UTC criteria, however local commissioners will want to align provision of other facilities such as GP Access Hubs – i.e. change of usage, not necessarily closure of services.

Where will it be delivered? Community and primary care facilities – some co-located with A&E, others in community. STPs will be responsible for ensuring equitable access across their geography in accordance with local need.

Examples

• East Riding of Yorkshire have set out local plans for six MIU following consultation – expansion of three MIU into ‘UCC’ (16hrs), direct booking for minor injuries at two 12hr primary care services plus one other 8-8 service primary and community service..

Outstanding Issues

• Stocktake of services indicates many existing primary and community urgent care services are far from new guidelines

• Digital capability stocktake to be undertaken – aligned to ECDS review

• Alignment to primary care access hubs – work underway with primary care team

• Workforce – unknown requirement (gap analysis required at local level) 12

Ambulances: Summary Subject to SofS approval of ARP recommendations

How will it be delivered?

• Recommendations from ARP – April 2017. • Implementation of ARP - Sept 2017 • NHS England will support ambulance services

to close a greater proportion of calls without conveyance to hospital – 2017-19

• Ambulance Clinical Assessment services will be supported by NHS England to introduce and support the technical , clinical and workforce enablers to introduce and consolidate Hear and Treat and See and Treat services (2017-19)

• Preceptorship model for new Band 6 JD – 2017-19

What is the offer to the public? Patients with life-threatening conditions, such as cardiac arrest where the heartbeat and breathing stop, will receive the fastest response. Overall offer: • A more equitable and clinically focussed response from the ambulance service, that

meets patient needs in an appropriate time frame • Faster recognition of life threatening conditions, with the best response for each patient • This will include telephone advice, treatment on scene or conveyance to hospital or

alternatives. • Better allocation and distribution of resources in the face of rising demand, and an end to

very long waits for an ambulance and handover delays at hospitals • Response standards that encourage the best possible patient outcomes • An improved experience for all patients To deliver this: • Alternative referral pathways, and supporting community-based services will be in place

to ensure that ambulance services have a safe and viable alternative to taking patients to A&E (such as Urgent Treatment Centres).

• Adoption of ARP Dispatch on Disposition (available in all ambulance services in pilot format), Nature of Call (in development across all ambulance services) and a new Clinical Code Set (currently being trialled in 3 services).

• Key standards – new measures to be recommended; Hear and Treat; See and Treat.

Where will it be delivered?

10 ambulance trusts (100% coverage), working with IUC, and other community and acute providers. Commissioners working with current IUC providers and Ambulance services should utilise existing community services via the Ambulance Service CAS and, where required, establish alternative referral pathways to ensure ambulance services have alternative options to conveyance to A&E.

Examples

Ambulance Response Programme (evaluation due end March) Dispatch on Disposition, giving call handlers more time to assess a 999 call except when an emergency dispatch is needed has been piloted in every ambulance trust. Three ambulance trusts have been trialling a new way of coding calls, with the intent of improving outcomes for patients in terms of safety, care and experience (SWAST, WMAS, YAS). Alternative pathways and ways of working West Midlands Mental Health Street triage (police, mental health nurse and paramedic), reducing attendance at A&E and unnecessary detentions, providing the most appropriate care to vulnerable patients. East Midlands Crisis Response Falls Team, supporting patients after a fall and reducing conveyance to hospital. South West: Right Care, Right Place, Right Time – paramedics trained in advanced clinical decision-making skills, GPs have joined 999 clinical hubs – resulting in reduced conveyance to A&E.

• Implementation plan for delivering modelled savings to be agreed, supported by ambulance transformation programme.

• ALBs will work with ambulance services to implement the new band 6 paramedic job description in a way that will drive increased skills in the workforce.

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Outstanding Issues

Hospitals: Summary

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We know the four hour standard, while being an important indicator of how ED’s are performing, needs to be developed to take account of the changing needs of patients and how patients access UEC services. To respond to these changes for 2017, we will develop new approaches, prioritising the needs of the sickest of patients. Our frail and elderly patients will get specialist assessments at the start of their care and those patients who could be better treated elsewhere will be streamed away from Emergency Departments. We will also include within the four hour standard other UEC settings of care so that wherever you access care you will receive a response in four hours. In addition, we will provide a more holistic view of performance in Emergency Departments based not only on time waited but quality of care, patient and staff experience. This will mean that nationally hospitals deliver 90% performance by September with the majority delivering 95% in March 2018.

Where will it be delivered? • In hospitals with Type 1 Emergency Departments, through A&E Delivery Boards

supported by NHSE and NHSI regions. • In partnership with Royal College of Emergency Medicine, Society of Acute

Medicine and clinicians in the system.

Examples

• Certain Trusts have maintained performance whilst all others have struggled. These include Luton and Dunstable, Harrogate, South Warwickshire, Chelsea and Westminster.

• Luton and Dunstable have a particularly strong front-door clinical streaming approach.

• South Warwickshire have developed a range of innovative discharge models. • Royal Berkshire have developed a good frailty service. • Derby have an excellent ambulatory care service.

• There needs to be renewed focus on delivery of the A&E plan measures around patient flow in hospitals and discharge.

• We need to understand the delivery and support mechanism to drive sustainable change.

Through the implementation of best practice models of care supported by a regional and national programme that: • Provides practical support for systems; • Aligns the national framework around delivery. The focus of the workstream is (a) the implementation of best practice on patient flow locally; (b) supporting this implementation regionally and nationally; and (c) supporting the workforce. Key milestones By end Q1 2017/18 Publication of core expectations of all hospitals based building on existing A&E Improvement Plan supported by a patient flow dashboard.. By end Q2 2017/18 Hospitals to have implemented core best practice on streaming, ambulatory care, frailty pathways, internal flow and discharge. Winter plans to be agreed with all system partners August 2017 New Emergency Care Data Set (ECDS) to start implementation from August 2017

Outstanding Issues

We know that too many patients admitted to hospital are kept in hospital for many days after they no longer require acute care . This is a concern to both patients and families and can also cause delays for sicker patients who are waiting to be admitted to hospital beds. We will ensure that patients are sent home as soon as possible and if home is not the best place for their immediate care, they will be transferred promptly to the most appropriate care setting for their needs. We will also develop with patients and their families longer term plans such as home adaptions or nursing/residential care if necessary, making more facilities available out of hospital for this purpose.

Hospital to Home: Summary

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Examples of good practice Discharge • Sutton Homes of Care Vanguard has introduced the Hospital Transfer Pathway

(HTP) red bag initiative, which involves care home staff packing a dedicated red bag upon hospital admission that includes the resident’s standardised paperwork as well as their medication. Early evaluation suggest that residents’ length of stay in hospital has been reduced by 4 days.

• A daily health and social care MDT reviews all discharged patients in York, identifies patients who may need additional health or social care assistance, and follows up with a phone call and refers on if required. For those patients, hospital attendances have decreased and length of stay has decreased by approximately 25%.

Discharge to Assess (D2A) • Sheffield’s D2A model has seen a 37% increase in patients who can be

discharged on their day of admission or the following day. Housing • Staffordshire Housing Group and their partners provide those with complex health

needs support with health, housing, financial, social and navigation services shortly after discharge from hospital. The project, funded by Stoke-on-Trent CCG, ensured that 92% of service users were not readmitted to hospital from July-December 2014.

Community • Leicester has reduced DToC rates by 46.3% in a 12 month period through

proactive identification and case management which was supported by a Clinical Response Service, with links back to community and primary care.

• D2A is seen by most systems as the solution that will have the most impact, though NAO work suggests implementation varies substantially across England

• Hospital at Home schemes are at an embryonic phase and therefore we will pilot and evaluate models for providing these types of services

• Regional teams to support implementation of discharge to Assess by September 2017, incentivised through the new national discharge CQUIN 2017/18-2018/19

• Introduction of CCG Quality Premium for 2017-19 to reduce Continuing Healthcare (CHC) full assessments occurring in acute settings to <15% (dependency on out of hospital capacity)

• To review local commissioning for health and social care • Support the increase in out of hospital capacity required with a

piece of strategic work with the community services • Enhanced Health in Care Homes roll-out in each STP footprint • By April 2017, the new NHS Urgent Medicines Supply Advance

Service should be available across the country. This is estimated to free up 200,000 GP out-of-hours appointments a year.

• Pilot work is in progress with a view to increase the number of NHS111 calls referred to community pharmacy, beyond the current 1% of calls.

• The NHS England central team will provide a national lead, ensuring implementation is aligned with the suite of Quick Guides related to the Eight High Impact Change Areas listed in the BCF Framework in addition to developing new projects

• Regional support, local system management and delivery through STPs and A+E Delivery Boards

• Ongoing support to challenged health systems through central executive teams and via Independent Care Sector leads to support regional implementation

Outstanding Issues

Contents

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1. Introduction




Contents

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Summary of UEC regional funding by STP

Allocations for the South to be confirmed.

Contents

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1. Introduction




Contents

Delivery Plan - NHS 111 Online

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NHS 111 Online: Offer

The NHS 111 online service will provide: • Online triage services that enable patients to enter their symptoms and receive tailored

advice or a call back from a healthcare professional, according to their needs.

• Members of the public will be able to make use of these new services in the pilot areas from February 2017 onwards, providing with them with a new digital access into the urgent care system.

• NHS 111 online will direct patients to the same standard of accuracy when compared to the initial call handling element of the NHS 111 voice service.

• Patients will be connected seamlessly to services they need to without having to repeat their assessment

• Information that patients enter online will be made immediately available to the health professional who will call them back.

• From 2018/19 there will be increasing personalisation offered with the opportunity for patients to enter specific conditions or link to care plans will be an important next stage development.

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NHS 111 Online: Specification – Core Requirements

• Clinically safe and direct patients to appropriate services: The underpinning clinical algorithms used in online services deployed for self service use by the general public must be clinically safe, with proven and tested medical reliability/ accuracy with appropriate clinical governance arrangements to manage potential risk. The initial standard will focus on demonstrating the digital channel can direct patients to the same standard of accuracy when compared to the initial call handling element of the NHS 111 voice service.

• Enable connection to NHS 111 and other services: Intensive user research has shown that patients want to be connected seamlessly to services they need to without having to repeat their assessment. Being connected seamlessly to the right clinical service to resolve the issue (consult and complete) is deemed to be a clear requirement for this initiative to be valued and used by patients. Initially we are focused on the links to NHS 111 services, in time this could potentially extend to other settings including primary care.

• Robust testing: As an evidence based organisation our decisions will be based on robustly testing and evaluating a range of innovative digital solutions that balance effectiveness, safety and patient experience. All NHS 111 regional clinical leads are being engaged in the process of testing and reviewing the range of triage products.

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NHS 111 Online: Specification – Core Requirements

• The delivery approach will build from the live pilots are in operation in all 4 regions with pilots in London and West Midlands, Cambridge and Peterborough, West Yorkshire and Suffolk these will cover approximately 10% of CGGs. An independent evaluation of the live pilots is being undertaken by London and Yorkshire AHSNs and will report at the end of March. We will work with the remaining NHS 111 areas once the detailed evaluation report has provided clarity around the definitive digital solutions that will be taken forward.

• Understand and monitor the impact on wider UEC system: The service needs to able to monitor and understand public usage, the impact on demand across the UEC and wider NHS system and therefore measure benefits.

• Understand the effectiveness of different communication approaches to prompt patients to use a digital service: A range of media will be tested 1) GP OOH answerphones, 2) Recorded messages on the NHS 111 telephone service 3) marketing in GP practices 4) NHS.uk and 5) Standard planned media campaigns.

• Enable and support local areas to deploy appropriate tested digital solutions supported by national specifications and standards. This approach will be informed in more detail by the evidence gained from the pilot studies.

A) National service based on NHS Pathways; with local referrals via secure messaging

A national service, which sits somewhere on NHS.UK website; it is driven by the NHS Pathways clinical content algorithms which currently support many 111 calls around the country; This builds on the prototype built by NHS Digital and being tested in Leeds. Patients would be referred to local services (e.g. IUC CAS) via Directory of Service lookup and ITK messaging.

B) National service based on other triage algorithms; with local referrals via secure messaging

Same as scenario A i.e. still a website maintained by NHS Digital and integrated with NHS.UK, but using a different suite of clinical content for triage, for instance by being brought in via an API. This would be an adaptation of the prototype built by NHS Digital being tested in Leeds. Patients would be referred to local services (e.g. IUC CAS) via secure messaging.

C) Locally varied web based triage

In this scenario, local CCGs or consortia of CCGs would be able to commission whatever triage software they preferred from a list of accredited suppliers. A national website would determine a user’s location and direct them to correct local service/website. Standards, platforms and guidance would be supported by a central team.

D) Ecosystem of apps with urgent care connectivity

CCGs are able to select accredited apps in their area to connect to urgent care services. For instance like the Babylon and Sensely trials in London and the West Midlands. A central team would provide guidance and standards.

E) Hybrid It would be possible to combine, for instance, B and D to ensure CCGs have local flexibility but economies of scale were realised.

There are a number of ways the 111 online service can be architected as a digital service. A number of possible models are set out below. Their advantages and disadvantages from an economic, social, technical, political perspective will need to be considered as part of the business case process; in collaboration with local STP leads and commissioners.

23

NHS 111 Online: Specification – Deployment options

24

NHS 111 Online: Key deliverable milestones

2016/17 2017/18 2018/19 2019/20

Q1-Q3: Development

NHS Pathways online / market

intelligence

Q4: Live Testing across 10%

CCGs including industry systems

Q4: Simulation Testing clinical

and user : industry products

Q1: Evaluation / inclusion in NHS 111 Specification

Q1 : Decision to procure / develop

/ partner

Q2-3: Roll out with NHS 111

service 5/6 111 areas per month

Introduction of intelligent

personalised triage

Channel shift from telephone to

digital access to NHS 111 30%

25

NHS 111 Online: Delivery Chain

The NHS 111 online workstream will be delivered at three levels across the NHS.

NHSE Regions

STPs

National team

• Strategic coordination of NHS 111 online workstream • Work with partners and stakeholders to agree implementation approach • Carry out national level procurement (where required) • Engage with regional leads on roll out plans and pilots • Ensure appropriate connections with the wider UEC programme

• Support identification of pilot sites, wave 2 sites and implementation prioritisation

• Deliver support as requested / required to STPs • Support testing at regional level • Engage with STPs on progress, risks and issues

• Foster a series of partnerships with local commissioners and providers. • Support for pilot work and subsequent evaluation • Plan and carry out delivery based on specification and policy • Support testing at local level

26

NHS 111 Online: Delivery Plan

Scenario Mar 17 - May 17 Jun 17 - Jul 17 Aug 17 - Sep 17 Oct 17 - Nov 17 Dec 17 - Jan 18 A/B • Pilots underway

in London, Midlands, Yorkshire, Suffolk

• Commissioning strategy determined.

• Continued redesign of pathways (OR start discovery on new triage content)

• Pilots now running in Suffolk, SCAS & Cambridge and further fast follower CCGs

• Re-architecture for national roll out and clear technical debt

• (Start procurement of new triage content.)

• Continue to onboard CCGs

• Publish toolkit for local implementation managers

• Develop logic to enable local configuration of suitable DOS results

• Continued onboarding of CCGs

• Further product development (informed by data and research)

• Product available in all CCG by end of December 2017

C/D • Pilots underway in London, Midlands, Yorkshire, Suffolk

• Commissioning strategy determined.

• Define clinical and interoperability standards

• Define new clinical risk and governance model

• Develop national landing page

• Publish toolkit for local implementation managers

• Develop logic to enable local configuration of suitable DOS results

• Support commissioning activity in CCGs to bring services online

• Product(s) available in all CCG by end of December 2017

Broad timeline and deliverables for next 18 months - two potential timelines dependant on deployment options

The associated costs are given in the following table. The only committed funding is for this financial year. Future funds are indicative numbers and not allocations. They will be revised after the pilots as a programme business case is drafted, so will form part of a wider NIB funding prioritisation process for next year and beyond.

27

NHS 111 Online: Cost to deliver

Financial assumptions The NHS 111 Online project is commissioned from NHS Digital as part of NIB. The current funding approach is built on an assumption of a single national service developed in house by NHS Digital The preferred option will be identified through the evaluation of pilot phase and business case analysis the defined solution will need to be delivered with the allocated funding envelope The local deployment costs for the NHS 111 online solution are expected to be included in the development costs for the NHS 111 IUC CAS as identified in the NHS 111 commissioning standards 2016

2016/17 2017/18 2018/19 2019/20 2020/21

NHS Digital staffing 1.6 TBC TBC TBC TBC Hosting and infrastructure costs 0.2 TBC TBC TBC TBC

Legal and professional services costs

0.4 TBC TBC TBC TBC

Total (£m) 2.2 2.8 3.1 4.1 7.1

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NHS 111 Online: Benefits

• The core benefits of this development is to deflect demand from NHS 111 services and to enable patients to access the right services to meet their needs.

• Intensive user research in this areas has highlighted that patients will most likely use an online service for lower acuity symptoms, therefore it is anticipated it has the potential to divert more people to self-care, and other non-urgent services.

• The purpose of this initiative is to find the most efficient and accuracy system of triage available. This includes the introduction of intelligent triage informed by outcome data, evidence and personal patient information.

Delivery Plan - NHS 111 Calls

30

NHS 111 Calls: Offer (1) 1. Delivering ‘Consult and Complete’ • The Urgent and Emergency Care Review provided evidence that patients would benefit from

greater access to clinicians.

• Therefore by March 2017 we will be offering clinical advice to 30% of all callers to 111.

• By March 2018 this will increase to half of all callers to 111.

• Patients will be dealt with more effectively and receive a better experience by being routed directly to a clinician.

• This will support an increasing the number of patients who can be dealt with as ‘self-care’ and ensuring if they need to be referred on that it is to the most appropriate point of care.

• The transfer rate to a clinician for patients calling NHS111 will increase from the current 22% and early modelling indicates that up to 78% of calls could be passed to a clinician.

31

NHS 111 Calls: Offer (2) 2. NHS 111 Care Home Line to be introduced as a further measure to alleviate pressure

on A&E and 999 services and accelerate the implementation of IUC • From April 2017 NHS 111 will provide dedicated access codes for care home staff to enable

them to get urgent advice from a GP in the out of hours period.

• The codes will allow them to bypass 111 call handlers to speak directly to a GP or get a call back.

• The NHS 111 line will be made available for all healthcare professionals in the future and will be rolled out in a phased approach, starting with Care Homes and will only operate in the out of hours period.

3. Direct booking into appointments out of hours • By March 2019 it will be possible to book all patients who call NHS 111 out of hours directly

into further appointments, if required, with 30% of patients able to book appointments in hours.

• It will also be possible for more people to be offered a prescription by the NHS 111 service.

32

NHS 111 Calls: Specification (1)

1. Delivering ‘Consult and Complete’

• Work within the IUC team has determined it could be possible to increase % transferred to clinician up to c78%

• The diagram shows the IUC Call Flow indicating exit points to Clinical Assessment Service to increase transfer percentage to clinicians:

33


1. Delivering ‘Consult and Complete’ (cont)

• Increasing the boundary of what now counts as transferred for clinical advice for the MDS will immediately increase the percentage.

• However, this must be more than a statistical redefinition – we need to ensure more patients speak to a clinician than under the current system with a resultant change in dispositions to downstream services

• Therefore the expected change to this standard will be as a result of:

1. Addition of a new definition in the MDS

2. Further assessment by a clinician of calls previously assessed only by a health advisor.

These two changes will mean an increase to the current level calls assessed by a clinician

• In addition The Directory of Services (DoS) is a mechanism whereby we can direct an increased percentage of cases to the CAS. This is done by re-profiling services so that they appear as option for a greater range of dispositions.

• The Clinical Assessment Service (CAS) will appear on the DOS as a referral point (and can be profiled to appear for various dispositions (bearing in mind it is likely to contain a variety of clinical skills e.g.: GP, Dental, mental health etc.)

• This process is currently locally determined but we will give national direction: e.g. request that commissioners configure their DoS so that all ED dispositions are directed to the CAS

34


1. Delivering ‘Consult and Complete’ (cont) • The transfer to clinician target is designed to measure the amount of calls where a patient is

transferred to a clinician. This includes clinicians working in other organisations (i.e. a virtual Clinical Assessment Service).

• Commissioners should coordinate the collection of data where more than one organisation is involved

• The New Minimum Data Set field (5.22, see slide below) describes in detail the parameters around recording this statistic. However, for the March 30% target we want to recognise only cases where there has been a change in patient experience, so cases which qualify as the result of statistical re-definition will not be included (see slide above) for March.

• In order to achieve this target there are two types of change required:

1. Operational change: Providers need to ensure that their operation processes allow for more cases being transferred to clinicians than previously (e.g. Green 4 and ED dispositions). They should ensure they have sufficient clinical staff in place.

2. Reporting change: Providers must ensure that they report accurately against the MDS definition (5.22), that they capture data from all places (which meet the 5.22 definition) where clinical assessment is taking place and that this data is collated and recorded in the Unify 2 system which feeds the MDS. Commissioners should ensure that all organisations involved cooperate to provide data.

35


2. NHS 111 Care Home Line Hours of Operation (Phase 1) • Initially the service will operate in the out of hours period, i.e.: • Monday to Friday 18:30 to 08:00 • Saturday/Sunday 24 hours Coverage • The service will be routed through national NHS111 telephony to all organisations contracted to receive

NHS111 calls. These organisations will either provide the clinical expertise required from within their own organisation (if contracted to provide an IUC CAS), or transfer the call to the appropriate out-of-hours provider for the patient.

Services which have already implemented Clinical Assessment Service (CAS) • If the NHS111 provider already has a CAS operating within the out of hour’s period the fast-track calls

should be transferred/queued by the fast track booking agent to the CAS in order for them to speak to the HCP. No assessment of the patient will be undertaken by the booking agent.

• Organisations will ensure there are sufficient clinical staff to deal with these calls. In many cases this will not be additional activity as these calls may have previously been routed through NHS111 and received an NHS Pathways assessment or have arisen from a 999 call which would have been referred back to NHS111 or the out-of-hours primary care provider, however, in some cases this will be additional workload.

Services which have not implemented a Clinical Assessment Service • If the NHS111 service does not operate or have links to a CAS they will transfer the fast-track call to the

appropriate out -of-hours primary care provider. This process is similar to that used for calls which have gone through the NHS Pathways assessment process and have resulted in a GP ‘Speak to’ disposition.

36

Area 2016/17 2017/18 2018/19 1. Delivering ‘Consult and Complete’

• Update to Minimum Data Set

• Re-procurement of telephony contract and review of business continuity processes

• IUC Evaluation Pilots complete • Trajectories, delivery plans and

implementation for the future 50%+ target for clinical input

• Refreshed IUC guidance • Detailed IUC service specification • Operating model for monitoring

progress • NHS Social Marketing Campaign

• Trajectories and delivery plans for future target for clinical input

2. NHS 111 Care Home Line

• Technical infrastructure in place

• User acceptance testing • Phase 1 Service Commencement

– 44% coverage • Phase 2 Service Commencement

- 79% coverage • Phase 3 Service Commencement

– 92%

• Phase 4 Service Commencement - 100% coverage in place

3. Direct booking into appointments

• Establish interoperability requirements

• Technical infrastructure in place • Stakeholder engagement • Sharing of good practice

• Stakeholder engagement

NHS 111 Calls: Key deliverable milestones

37

NHS 111 Calls: Delivery Chain

The NHS 111 Calls workstream will be delivered at four levels across the NHS.

NHSE Regions

STPs

National team

• Manage national level contracts (i.e. Vodafone) • Provision of common service specification and guidance • Oversee workforce strategy development • Work with partners and stakeholders to agree implementation approach • Development of the minimum data set (MDS) and collaborative work with

providers for accurate capture of clinical input

• Assure development of delivery plans at STP level • Regular dialogue and challenge of providers and commissioners via the

Provider and Commissioner Networks • Deliver support as requested / required to STPs • Engage with STPs on progress, risks and issues

• Plan and carry out delivery based on specification and policy • Foster partnerships between local commissioners and providers • Provide reporting information to monitor delivery progress • Escalate issues and risks to the region

National governance

• National overview of progress with targeted support when required • Performance management through regular performance calls with regional

leads

38

NHS 111 Calls: Activities and responsibilities 1. Delivering ‘Consult and Complete

Milestone(s) Implementation activities Responsibility Timeframe

Update to Minimum Data Set

• Development of the minimum data set definitional changes • National team June 2017

• Communicate changes to regions, providers and STPs • National team June 2017

• Collate additional data as part of business as usual reporting • STPs Ongoing

• Quality assurance review of MDS data submissions • National team / regions

October 2017 onwards

Re-procurement of telephony contract and review of business continuity processes

• Extension of current NHS111 telephony contract • National team December 2017

• Ensure robust business continuity policy and process for NHS111 and IUC services • National team June 2017

• Ensure interoperability of data/information between component IUC providers • National team June 2017

IUC Evaluation Pilots complete

• Evaluation work at 12 sites, supported by regions • National team / regions

June 2017

• Establish learning from IUC evaluation pilots

• Publish evaluation pilot site Phase 2 Report • National team December 2017

• Feed evaluation learnings into IUC guidance and national specification • National team December 2017

Refreshed IUC guidance

• Produce clinical input and clinical assessment service guidance • National team June 2017

• Develop Business Intelligence strategy • National team June 2017

• Production of upgraded clinical governance guidance • National team June 2017

• DN [do we expect the regions and STPs to do anything?] • Implementation and adherence to clinical governance guidance

• STPs Ongoing

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NHS 111 Calls: Activities and responsibilities 1. Delivering ‘Consult and Complete (cont)


Detailed IUC service specification

• Carry out site visits • National team / Regions

April 2017 – September 2017

• Clinical peer review and support visits to each site • Regions Ongoing

• Deliver Pathways-light • National team April 2017 – September 2017

• Publish new IUC Service Specification • National team December 2017

Trajectories, delivery plans and implementation for the future 50%+ target for clinical input

• Carry out baseline assessment of known contract positions of CCGs, including: Census against IUC 8 key elements NHS 111 Providers performance against NHS 111 calls transferred to clinical

adviser

• Regions / STPs

June 2017

• Commissioners configure their DoS so that all ED dispositions are directed to the CAS

• STPs Aligned to CAS rollout

• Develop plans so provider operational processes allow for more cases being transferred to clinicians than previously, ensuring sufficient clinical staff in place.

• STPs June 2017

• Review and provide feedback on plans • National team / Regions July 2017

• Implementation of plans, overseen by regions • Regions / STPs June onwards

• Providers report against the new MDS definition with commissioners ensuring that all organisations involved cooperate to provide data

• STPs MDS 5.22 currently being reported

• Regional assurance of STP delivery of national IUC commissioned model. • Regions Ongoing

40

NHS 111 Calls: Activities and responsibilities 1. Delivering ‘Consult and Complete (cont)


Operating model for monitoring progress

• Review of national information requirements • National team June 2017

• Agreement of operational model • National team June 2017

• National rollout of RAIDR data linkage approach • National team June 2017

• Produce new IUC information strategy

• National team September 2017

Development of new KPI dashboard • National team

October 2017 to March 2018

Publication of the new KPI performance data • National team

/ Regions

October 2017 to March 2018

NHS Social Marketing Campaign

A pilot campaign in North East and West Yorkshire. The priority segments identified for this pilot are: • Parents with young children; and • C2DE Socio demographic groups.

• National team June 2017

The evaluation of the campaign in the pilot areas will ensure that all aspects of the campaign are thoroughly tested. Evidence from this pilot will inform potential national campaign approach for 2017/18. The national campaign will be rolled out in a ‘phased’ way across the regions and timing will depend on how quickly BP/cabinet office approvals process is navigated (estimated at 3 months duration).

• National team July 2017 to December 2017

41

NHS 111 Calls: Activities and responsibilities 2. NHS 111 Care Home Line


Technical infrastructure in place

• Technical solution sign off • National team 03/03/2017

• Finalise Vodafone change control • National team 06/03/2017

• Instruct commissioners & issue specification • National team 13/03/2017

• Negotiate with providers (NHS111 / IUC CAS & OOH) • Issue instructions regarding delivery numbers and local configuration

• Regions / STPs 10/03/2017

• Local configuration complete • National team 24/03/2017

• Funding and contractual issues resolved • Regions / STPs 24/03/2017

• Vodafone build complete • National team 31/03/2017

• Operational procedures developed and signed off • Regions / STPs 31/03/2017

• Operational readiness (technical and operational) • National team 31/03/2017

User Acceptance Testing

• Issue user guides • National team

03/04/2017

• Publicity • National team

03/04/2017

• User Acceptance Testing • National team

04/04/2017

• Defect management complete • National team

07/04/2017

• Service commencement • National team

10/04/2017

42

NHS 111 Calls: Activities and responsibilities 2. NHS 111 Care Home Line


Phase 1 Service Commencement

• Identify and confirm sites for roll out • Regions April 2017

• Develop implementation and roll out plan, factoring in readiness of Clinical Assessment Service and workforce requirements

• STPs April 2017

• Assure plan and finalise • Regions April 2017

• Implementation, including communications and training • Regions / STPs

April 2017

• Learn lessons from roll out and factor into the next phase • National team April 2017


• Identify and confirm sites for roll out • Regions June to December 2017


• STPs June to December 2017

• Assure plan and finalise • Regions June to December 2017


June to December 2017

• Learn lessons from roll out and factor into the next phase • National team June to December 2017


• Identify and confirm sites for roll out • Regions January to March 2018


• STPs January to March 2018

• Assure plan and finalise • Regions January to March 2018


January to March 2018

• Learn lessons from roll out and factor into the next phase • National team January to March 2018

43

NHS 111 Calls: Activities and responsibilities 3. Direct booking into appointments


Technical infrastructure • Ensure interoperability of data/information between component IUC providers • National team September 2017

• Subject matter expertise support • National Team Ongoing

Stakeholder Engagement

• Co-create engagement plan with UHUK to start the dialogue with Out of Hours providers

• National Team May 2017

• Launch engagement plan through the national clinical leads conference • National Team June 2017

• Engagement workshops • National Team • Regions

September 2017

Sharing of good practice

• Shared learning outputs from IUC Evaluation Pilots • National Team September 2017

• Shared learning through clinical leads network • National Team • Regions

Ongoing

• Development of case studies (clinical leads to contribute) • National Team • Regions

Ongoing

44

NHS 111 Calls: Cost to deliver

Potential Costs to achieve March 2017 – 30% of contacts made by a clinician • Many providers have already made good progress towards target achievement, this has been

achieved largely within the existing cost base. There is an expectation that most providers will be able to achieve the March target without additional funding.

• A key support which has enabled this is the GP winter indemnity scheme, due to finish March 31st (to extend to end of Apr = circa 6/700k). Where additional clinicians are required this should be limited. Furthermore, other initiatives (e.g. NHS111 Care Home Line, IUC pilots) will provide sufficient additional clinical staff to also meet the transfer target in the first instance (details of these costs are available elsewhere)

• There will be non-cash and cash releasing benefits to the local health care economy

• Financial Modelling information on the implementation of the IUC model (of which this target is a part) is available and is in the process of being refreshed by the NHSE Finance team.

45

NHS 111 Calls: Benefits

Benefit Identified Business Change Benefit Measures

Quantitative Target

Qualitative Target

Improvement in patient and staff experience of urgent and emergency care services Opportunity to reduce high acuity referrals; improving system impact - Reduction in minor attendances at A&E

Standardised service offer and access to UTC via booked appointments NHS 111

Data collection

Patient and staff experience

Opportunity for co-location of services – UTC, Clinical Assessment Services, GP OOH, GP access hubs offers patient convenience and professional variety

Standardised service offer and access Data collection

Patient safety outcomes

Offers alternative to conveyance to ED for ambulance services

Commissioners implement alternative referral pathways

Data collection


Enhanced clinical quality

Electronic access to patient records, diagnostic information and prescribing Standardised digital support package Data

collection

Patient safety & experience; staff experience

Access to specialised advice through a) clinical assessment service and b) networked approach to UEC

Introduction of CAS; co-location where appropriate

Data collection


Increase in patient safety and satisfaction Successful implementation of proposed changes

Data collection

Patient safety & experience

Improvement in the way people access urgent and emergency care Clear access route – directly booked appointments through NHS 111, general practice, ambulance services and walk-in

Standardised access to UTC via booked appointments NHS 111

Data collection

Patient experience

Care delivered in a more convenient setting / closer to home Standardised service offer and access Data

collection Patient experience

Delivery Plan - GP Access

47

GP Access: Offer

• Continued provision of urgent care services by general practice

• Additionally, by March 2019 the public will have access to pre-bookable and same day, evening & weekend appointments with general practice

• Coverage will reach:

50% of England by March 2018 100% of England by March 2019

• In delivering this we will want to secure: Transformation in general practice, including a step change in our use of

digital technologies Support for urgent care with more integrated service delivery Changes in general practice services that lay the foundations for general

practice providers to move to a model of more integrated services such as MCPs or PACs

GP Access: Specification (1) In enabling CCGs to commission and fund extra capacity across England to ensure that everyone has access to GP services, including sufficient appointments at evenings and weekends to meet locally determined demand, alongside effective access to out of hours and urgent care services, the are 7 core requirements that CCGs will need to meet:

Timing of appointments

Capacity

Measurement

48

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

• Commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs.

• Provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week.

• Appointments can be provided on a hub basis with practices working at scale.

• Commission a minimum additional 30 minutes consultation capacity per 1,000 population, rising to 45 minutes per 1,000 population.

• Ensure usage of a nationally commissioned new tool to be introduced during 2017/18 to automatically measure appointment activity by all participating practices, both in-hours and in extended hours.

• This will enable improvements in matching capacity to times of high demand.

GP Access: Specification (2) There are 7 core requirements that CCGs will need to meet in commissioning improved access.

Advertising and ease of

access

Digital • Use of digital approaches to support new models of care in general practice.

Inequalities • Issues of inequalities in patients’ experience of accessing general practice identified by local evidence and actions to resolve in place.

Effective access to

wider whole system

services

49

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

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

• Ensure ease of access for patients including: all practice receptionists able to direct patients to the service and offer

appointments to extended hours service on the same basis as appointments to non-extended hours services;

patients should be offered a choice of evening or weekend appointments on an equal footing to core hours appointments.

2016/17 By March 2017/18

By March 2018/19 2019/20

50

GP Access: Key deliverable milestones

Deliver improved access to

populations covered by

GPAF schemes -17 million

people

Deliver enhanced access to 50% of

the population

Advertising & ease Advertising in place &

practices offering evening and weekend appointments

Digital Digital approaches to

support general practice in use

Deliver enhanced access to 100% of

the population

Measurement GP workload tool

(available from 17/18) in use

Effective access to wider system Access from & to other

NHS services

Inequalities Issues identified and actions to resolve in

place

Maintain enhanced access

to 100% of the population

Timing of appointments

Evenings and weekend in place

Capacity 30 mins additional

appointments per 1k patients in place rising to 45 mins

On commencement of enhanced access service evidence of

51

GP Access: Delivery Chain

The GP Access workstream will be delivered at four levels across the NHS.

NHSE Regions

CCGs & STPs

National team

National governance

• Provision of service specification, policy and guidance, sharing best practice and learning

• Lead development of national level products Ensure connection between UEC and Primary Care programmes

• Work with partners and stakeholders to agree implementation approach including communications

• Assure development of delivery plans • Regular dialogue and challenge of providers and commissioners • Deliver support as requested / required to CCGs & STPs • Engage with CCGs & STPs on progress, risks and issues

• Plan and carry out delivery based on specification and policy • Ensure effective connection across system services, including effective alignment

and integration of general practice urgent care services with wider urgent and emergency care

• Foster partnerships between local commissioners and providers • Provide reporting information to monitor delivery progress • Escalate issues and risks to the region

• National overview of progress with targeted support when required • Performance management and assurance through regular formal and informal

dialogue with regional leads

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GP Access: Activities and responsibilities 1. Delivering 2017/18 (1)


Deliver improved access to 50% of England (by March 2018)

• Assure implementation plans for delivery: - For CCGs that will be delivering improved access in 2017/18 - For CCGs planning for extended access delivery in 2018/19 and follow up areas of risk

Regions From April 2017

• Transfer funding to CCGs delivering in 2017/18 and confirm CCGs in receipt of access funding will deliver to 2017/18 timescales.

National team/ Regions June 2017

• Reconcile implementation plans with UNIFY trajectories, identify and resolve any discrepancies

STPs/ CCGs Regions March – April 2017

• Review implementation progress, against plans including meeting seven national core requirements

National team/ Regions

Quarterly deep dives to March 2018

• Improved access services ,which meet core requirements as set out in the Planning Guidance, fully operational in CCGs delivering in 2017/18 (those covering GP Access Fund (GPAF) scheme areas , other geographies outlined in the planning guidance and London)

STPs / CCGs

By Sept 2017 for GPAF and other geographies

By March 2018 for London

• Confirm procurement route and timeline for securing integrated extended access service, where not already commissioned STPs/CCGs October 2017

Delivering the seven national core requirements as set out in NHS Planning Guidance (1)

• Timing of appointments – evenings and weekend in place fully operational in CCGs delivering in 2017/18 STPs/CCGs September 2017

• Capacity - 30 mins additional appointments per 1k patients rising to 45 mins in place in CCGs delivering in 2017/18 outside London and in London in accordance with London core requirement

STPs/CCGs September 2017

• Measurement – new GP workload tool in use in CCGs delivering in 17/18 STPs/CCGs September 2017

• Advertising & ease - advertising in place & practices offering evening and weekend appointments in CCGs delivering in 2017/18

• CCGs delivering improved access in 2017/18 provide evidence they are using

the nationally produced Communications and Engagement Resource

STPs/CCGs

September 2017

In place in 50% of live services by July 2017 and 100% by October 2017

53




• Digital – digital approaches to support general practice in use to understand utilisation and demand CCGs delivering in 2017/18 STPs/CCGs September 2017

• Inequalities – issues identified and actions to resolve in place in CCGs delivering in 2017/18

• Report on how CCGs are addressing inequalities in access

STPs/ CCGs Regions

September 2017

September 2017 and March 2018

• Effective access to wider system – access from & to other NHS services in CCGs delivering in 2017/18 STPs/CCGs September 2017

• For CCGs not commencing improving access in 2017/18 plan for delivery in 2018/19 that meets core requirements STPs/CCGs To March 2018

Metrics • Use the national General Practice bi-annual extended access survey, Unify

and regional assessment mechanisms to monitor progress against implementation plans

Regions To March 2018

Other nationally coordinated support activity

• Develop ‘Tops Tips’ for general practice providers National team May 2017

• Deliver inequalities resource for commissioners and providers National team April 2017

• Deliver learning material and share best practice to help commissioners and providers deliver extended access as part of wider transformational change in general practice.

National team December 2017

• Suport NHS Digital interoperability solutions including delivery of second phase of GP workload tool ensuring other systems are interoperable (eg Adastra) National Team March 2018

• Develop supporting resources on “procurement rules” and (Procurement Best Practice” National Team From July 2017

• Develop ongoing support materials for federations on market development and at scale working National Team From July 2017

• Commission the development of regional and STP slide packs presenting GPPS data un and publish bi-annual extended access survey National team From June 2017

54



Deliver improved access to 100% of England (by March 2019)

• Assure implementation plans for delivery: - CCGs planning for extended access delivery in 2018/19 and follow up areas of risk

Regions From April 2017 and ongoing

• Transfer funding to CCGs delivering in 2018/19 and confirm CCGs in receipt of access funding will deliver.

National team/ Regions June 2018

• Review implementation progress, against plans including meeting seven national core requirements

National team/ Regions

Quarterly deep dives to March 2019, with checkpoint for 18/19 delivery Sept 18

• Improved access services ,which meet core requirements as set out in the Planning Guidance, maintained in CCGs who delivered in 2018/19

STPs / CCGs Ongoing

• Improved access services ,which meet core requirements as set out in the Planning Guidance, fully operational in all CCGs STPs / CCGs By March 2019

• Confirm procurement route and timeline for securing integrated extended access service STPs/CCGs April 2018


• Timing of appointments – evenings and weekend in place fully operational in CCGs STPs/CCGs

Maintained for CCGs who implemented in 2017/18

By March 2019 for all other CCGs

• Capacity - 30 mins additional appointments per 1k patients rising to 45 mins in place in CCGs and in London in accordance with London core requirement STPs/CCGs



• Measurement – new GP workload tool in use in CCGs STPs/CCGs



55




• Measurement – new GP workload tool in use in CCGs STPs/CCGs



• Advertising & ease - advertising in place & practices offering evening and weekend appointments in CCGs STPs/CCGs



• Digital – digital approaches to support general practice in use to understand utilisation and demand CCGs STPs/CCGs



• Inequalities – issues identified and actions to resolve in place in CCGs

STPs/ CCGs



• Effective access to wider system – access from & to other NHS services in CCGs STPs/CCGs



Metrics • Use the national General Practice bi-annual extended access survey, Unify and

regional assessment mechanisms to monitor progress against implementation plans

Regions To March 2019

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GP Access: Cost to Deliver and Benefits

Cost to deliver • To support CCGs to commission and fund extra capacity across England to

ensure that everyone has access to GP services, including sufficient appointments at evenings and weekends to meet locally determined demand, alongside effective access to out of hours and urgent care services we will invest: at least £138m in 2017/18 at least £258m in 2018/19

• From 2019/20 all CCGs will receive at least £6 per head of population on a recurrent

basis to commission and fund improved access. Benefits • To make it easier for people to obtain the right care from the right person at the right

time in the right setting. General Practice is very often the most appropriate place for patients to be seen and cared for.

• To ensure people don’t experience delays in obtaining a diagnosis and treatment. Improving access is inseparable from our commitment to providing safe, effective and appropriate care for patients and maximising the value of NHS services for taxpayers.

• To make access to general practice more convenient for people and reduce inequalities.

Delivery Plan - Urgent Treatment Centres

58

Urgent Treatment Centres: Specification Increasingly over the next two years, a minimum service offer will be available anywhere in the country at an Urgent Treatment Centre. A detailed specification is available; key factors are considered below: 1. The key components of an urgent treatment centre include:

a. GP led service with other multidisciplinary clinical workforce as locally determined (including prescribing ability)

b. Opening hours - for at least 12 hours a day seven days a week 365 days a year c. Direct booking from NHS 111 and other services, with access to DoS d. Will have access to simple diagnostics such as swabs, pregnancy tests, urine dipstick

and culture, near patient blood testing and electrocardiograms (ECG). e. Access to x-ray facilities, with clear access protocols if not available on site

2. Urgent treatment centres will deliver a clearer service offer for patients, with a key aspect being the

offer of directly booked appointments via NHS 111, general practice and ambulance services, in addition to a walk-in offer.

3. This provides an opportunity for commissioning a genuine integrated urgent care service, aligning NHS 111, out of hours and GP access with face to face urgent care. Commissioners must align thinking with core requirements for extended access, as well as opportunities for the clinical assessment service.

4. The urgent treatment centre offer will result in decreased attendance at A&E, or, in co-located

services, the opportunity for streaming at the front door. All UTC services will be considered Type 3 / 4 A&E and will contribute to 95% target locally.

59

Urgent Treatment Centres: Specification 5. Urgent treatment centres will operate as part of a networked model of care, with referral pathways

into emergency departments and specialist services as required.

6. Focus for 2017/18 will be on prioritising direct booking through NHS 111 in facilities that already meet key criteria. NHS Digital will be required to undertake a gap analysis, aligned with their assessment of investment required to implement ECDS

7. Commissioners, supported by NHS England regions, will review current provision against guidelines and make a plan for each facility, subject to local consultation. Likely range of outcome of review:

i. Facility will meet guidelines with limited change required / already meet requirements ii. Facility will require some upgrade to meet guidelines, or local requirements will justify

alternative provision iii. Facility will become alternative community service, such as a GP access hub iv. Facility may close.

8. Trajectory of achievement:

i. c.150 services will meet new standards by March 2018 (based on regional returns – current estimate is that 102 will meet criteria; 52 likely upgrade)

ii. Remaining services will have plan by March 2018 to achieve guidelines or defined alternative service

iii. December 2019 - All services designated as UTC will meet guidelines (trajectory to be agreed in line with STP plans)

9. Whilst there will be no formal piloting stage, learning from wave one will inform future roll out and implementation support.

60

Area 2016/17 2017/18 2018/19 1. Regional assessment

2. Policy decision

3. Standards and specification

6. Roll out

Complete regional

assessment

Gap analysis against

specification

Wave 1: roll out

(including digital)

Policy decision and

announcement

Urgent Treatment Centres: Key deliverable milestones

UTC specification

finalised

STP designation of services and

implementation planning

STP roll out

complete

61

1. Regional Assessment


Complete Regional Assessment

• Regional assessment of primary and community urgent facilities and likely future arrangements - to support UTC policy development.

NHS England regions 17 March 2017

• Regional assessment of additional capital and revenue requirements (limited information available)

NHS England regions 17 March 2017

• Compile aggregated analysis based on returns received UEC Programme

22 March 2017

Urgent Treatment Centres: Delivery Plan

2. Standards and specification (1)


UTC specification finalised

• Further iteration of standards for urgent treatment centres, reflecting need to commission integrated urgent care (e.g. 111, OoH, GP Access)

NHS England UEC Programme 31 March 2017

• Digital specification to be developed for UTC requirements including: Direct booking from NHS 111, ambulance services and both from and into

general practice; Access to diagnostic information (e.g. radiography and lab results); Access to Enhanced Summary Care Record or local equivalent; Prescribing functionality ECDS

NHS England / NHS Digital

30 April 2017

• Publication or socialisation of revised UTC standards with STPs, ALBs and other partners (subject to agreement)

NHS England UEC policy

April 2017

Digital baseline • Plan with NHS Digital to undertake baseline assessment of digital capability of all

facilities currently identified as meeting core specification NHS England / NHS Digital

April 2017

• Baseline assessment across facilities, aligned to assessment of ECDS readiness NHS Digital [DN: TBC]

Note: indicative plan subject to outcome of review of regional returns

62

Urgent Treatment Centres: Delivery Plan 2. Standards and specification (2)


Gap analysis against specification

• STPs to complete gap analysis against standards, supported by regional PMOs including:

opportunities for co-location of services (e.g. GP Access Hubs, OOH services, Clinical Assessment Service)

opportunities to repurpose facilities as e.g. GP Access Hub where full UTC not locally feasible

Capital requirements Revenue requirements Workforce

STPs / Regions June 2017

Note: indicative plan subject to outcome of review of regional returns

3. Roll out and designation of services


Roll out of standards

• First wave identified from regional assessment (i.e. services in position to meet standards) NHSE/NHSI April 2017

• Local implementation plans developed in line with full gap analysis STP / local footprints July 2017

Digital roll out

• First wave cohort for ‘digital roll out’ to be identified following baseline assessment NHSE/NHSI [DN: TBC]

• Schedule implementation programme NHSE/NHSI [DN: TBC]

• Deliver across cohort NHS Digital [DN: TBC]

• Evaluation of digital implementation NHSE/NHSI [DN: TBC]

• Identify and plan implementation of second wave NHSE/NHSI [DN: TBC]

STP implementation planning

• STPs to make, and where necessary consult on, local decisions on how to offer standardised access to services, and to agree local plan for roll out of direct booking into UTC services from NHS 111, ambulance services and general practice.

• Subsequent designation of services as UTC / other facilities

STPs / NHS England regional PMOs

October 2017 onwards

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Urgent Treatment Centres: Cost to deliver

• There is insufficient assurance at this time of the likely capital and revenue implications.

• Using approximate costs drawn from indicative capital bids, we can assume an average cost of £320K to upgrade existing facilities (range of £820K to £50K).

• New urgent care facilities may be in the region of £1.8m (range of £2.5m – £1m).

• Assuming a range of 123 - 226 facilities need upgrading / developing to meet required standards, capital requirement would be in the region of £55m-£88m.

• No assessment has been made of additional staffing and revenue requirements.

• A comprehensive analysis of requirements would need to be drawn once STP gap analysis undertaken; these figures are indicative only.

• Baseline assessment of digital readiness will be required as part of planning process.

64

Urgent Treatment Centres: Benefits Benefit Identified Business Change

Benefit Measures Quantitative

Target Qualitative

Target

Improvement in patient and staff experience of urgent and emergency care services

Reduction in minor attendances at A&E Standardised access to UTC via booked appointments NHS 111 Data collection Patient

experience

Reduction in long waits for treatment (improved performance against 95% target) Standardised service offer and access Data collection


Opportunity for co-location of services – UTC, Clinical Assessment Services, GP OOH, GP access hubs offers patient convenience and professional variety

Standardised service offer and access Data collection Patient safety outcomes

Offers alternative to conveyance to ED for ambulance services

Commissioners implement alternative referral pathways Data collection


Enhanced clinical quality Access on site or via explicit referral pathways to diagnostics including x-ray

Standardised service offer including diagnostics and x-ray Data collection

Electronic access to patient records, diagnostic information and prescribing Standardised digital support package Data collection


Access to specialised advice through a) clinical assessment service and b) networked approach to UEC Introduction of CAS; co-location where appropriate Data collection

Increase in patient safety and satisfaction Successful implementation of proposed changes Data collection Patient safety & experience

Improvement in the way people access urgent and emergency care

Clear access route – directly booked appointments through NHS 111, general practice, ambulance services and walk-in

Standardised access to UTC via booked appointments NHS 111 Data collection Patient

experience

Care delivered in a more convenient setting / closer to home Standardised service offer and access Data collection Patient experience

Financial Savings Contributor to SR modelled savings as part of networked model of care (cost-incurring in isolation) Successful implementation of proposed changes Data collection

Delivery Plan - Ambulances

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Ambulances: Offer

Patients with life-threatening conditions, such as cardiac arrest where the heartbeat and breathing stop, will receive the fastest response. • A more equitable and clinically focussed response from the ambulance service, that

meets patient needs in an appropriate timeframe. • Faster recognition of life threatening conditions, with the best response for each

patient.

• This will include telephone advice, treatment on scene or conveyance to hospital or alternatives.

• Better allocation and distribution of resources in the face of rising demand, and an end to very long waits for an ambulance and handover delays at hospitals.

• Response standards that encourage the best possible patient outcomes.

• An improved experience for all patients.

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Ambulances: Specification • Adoption of the three elements of the Ambulance Response Programme (ARP):

• Nature of Call – a pre-triage set of questions to identify those patients in need of the fastest response (in development across all ambulance services);

• Dispatch on Disposition – dispatch of the most clinically appropriate vehicle to each patient within a timeframe that meets their clinical need (available in all ambulance services in pilot format); and

• a new Clinical Code Set that better describes the patient’s presenting condition and response / resource requirement (trialled in 3 services).

• These measures will collectively act as an enabler for ambulance services to change their operational model through greater efficiency.

• The detailed specification for these three areas will be finalised following receipt of the ARP evaluation, and recommendations will be made to SoS for roll out based on this.

• NHS England will work with providers and commissioners to support a safe reduction in conveyance to A&E – referred to as the Ambulance Integration Programme. This will be supported by commissioner (CCG IAF) and provider incentives (CQUIN) – detail in the delivery plan slides. Further detail of this phase of the programme will be developed in response to recommendations within the ambulance non-conveyance report.

• Implementation of a new band 6 job description for paramedics that will ensure enhanced skills for paramedics as standard is critical; this work is led by NHS Improvement.

• Alternative referral pathways, and supporting community-based services, will be in place to ensure that ambulance services have a safe and viable alternative to taking patients to A&E (such as Urgent Treatment Centres). STPs and commissioners must plan for an integrated urgent care offer to deliver this, including a comprehensive clinical assessment service – aligned to NHS 111, GP access and urgent treatment centres.

• Key measures - rates of Hear and Treat and See and Treat will be tracked (i.e. safe reduction in conveyance to A&E); new performance measures to be recommended following receipt of evaluation in March 2017.

Note: a detailed specification is subject to evaluation of the ARP

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Area 2016/17 2017/18

Ambulance Integration Programme

Ambulances: Key deliverable milestones

ARP enabler implementation

Implementation of ARP at STP

level

Complete ARP pilots and trials

ARP Evaluation Report

Ambulance workforce

development

Enable enhanced H&T

and S&T

Publication of non-conveyance

CQUIN

Update to CCG Improvement

and Assurance Framework

Operational Readiness

Assessments

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Ambulances: Delivery Chain

The Ambulances workstream will be delivered at three levels across the NHS.

NHSE Regions

STPs (CCGs)

National team

National governance

• Collaborative approach between NHS England, Sheffield School of Health & Related Research (ScHARR), the 10 ambulance services, DH, NHS Improvement and National Ambulance Commissioners Network.

• Provision of service specification, policy and guidance • Lead the ARP evaluation work • Collaborative work with ScHARR and key stakeholders to ensure mutual

understanding of the programme deliverables • Collaboration with DH and NHSI to achieve consensus

• Work with STPs and commissioners to ensure that ambulance services, and safely reducing conveyance, forms an integral part of STP planning

• Assure development of delivery plans at STP level • Regular dialogue and challenge of providers and commissioners • Deliver support as requested / required to STPs • Engage with STPs on progress, risks and issues

• Plan and carry out delivery based on specification and policy • Foster partnerships between local commissioners and providers • Provide reporting information to monitor delivery progress • Escalate issues and risks to the region

70

Ambulances: Delivery Plan (1) – all timelines subject to evaluation and approval of ARP recommendations Ambulance Integration Programme


Complete ARP pilots and trials

• 999 call handlers given additional time (DoD) to collect the information they need from a caller to make sure the most appropriate clinical response for that patient can be sent (except for Red 1 calls).

NHS England, Ambulance Services (AS)

Completed in pilot form

• Trial of a new clinically led and evidence-based 999 call coding system to better reflect new models of care in 3 services

NHS England and 3 AS Completed

ARP Evaluation Report

• ARP Report to include i) evaluation of interventions and ii) revised set of measures which better reflect needs of patients and use of new models of care.

ScHARR, NHS England central team, DH

Submitted by end March 2017

Operational Readiness Assessments

• Readiness assessments in place to support remaining ambulance services to undertake the required control room and operational changes

NHS England central teams, AS, NHS I

Ready by end March 2017


• Issue readiness checklists and monitor preparedness NHS England central team April - July 2017

• Develop guidance for standardised pre-triage sieve NHS England central team, AACE, AS

April 2017

• Rewrite Ambulance Quality Indicators

NHS England central team, AACE and NACN

May 2017

• Publication of baseline evidence to support implementation NHS England central team May/June 2017

• Support national implementation of clinical code set in remaining 7 trusts and adoption of revised metrics

NHS England central team By October 2017

• Investigation of technical solutions to support use of interventions to divert from ED NHS England central teams & NHS Digital

End March 2017

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Ambulances: Delivery Plan (2) - all timelines subject to evaluation and approval of ARP recommendations Ambulance Integration Programme


STPs to ensure safe reduction of conveyance to ED forms part of local delivery plans

• STP and local footprint plans must include action to safely reduce conveyance to A&E STPs April 2017

• STPs and local footprint plans must offer integrated model of urgent care, with clear referral pathways that offer alternatives to conveyance to A&E STPs March 2018

• Regions to gain assurance that local footprints are establishing alternative referral pathways in collaboration with ambulance services, and that ambulance services form an integral part of STP plans

NHS England regional teams Ongoing

• NHS England to provide support to, and assurance of, STP planning and delivery NHS England regional / central team

Ongoing

Ambulance workforce development

• Establishment of B6 implementation Board NHS Improvement April 2017

• Review of paramedic job description to ensure enhanced clinical autonomy

NHS Improvement B6 Implementation Board

September 2017

• Undertake gap analysis of paramedic B5 to B6 skills, knowledge and competencies AS and HEE and commissioners

March 2018

• Develop appropriate training and clinical supervision opportunities, including effective performance management regime

AS, HEE, NHS England, NHSI & commissioners

September 2018

• Set out monitoring guidance to ensure benefits realisation

NHSE / NHSI central teams (monitoring at regional level) , STPs and commissioners

December 2018

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Publication of non-conveyance CQUIN

• Publication of Ambulance non-conveyance CQUIN NHS England Completed

• Support and track implementation of CQUIN measures NHS England regional teams

Update to CCG Improvement and Assurance Framework

• Inclusion of Ambulance non-conveyance indicator in CCG Improvement and Assurance Framework

NHS England central team

Submitted January 2017

Enable enhanced H&T and S&T

• Ambulance non-conveyance report delivered to include: Analysis of recording and reporting of H&T, and S&T rates Recommendations on future recording and recording of H&T, and S&T rates Identification and recommendation of future opportunity to use interventions to

divert from ED

NHS England central team AS

May 2017 December 2017

• Ambulance services to put enablers detailed within CQUIN in place: Establish the technical ability to PDS match patients at point of emergency call Develop and agree DoS minimum data set for AS Establish access method for the DoS Support AS access to NHS No & SCR

NHSE, NHSD, Provider, NACN NHS Digital AS

March 2018

• EOC and road crew skills analysis AS, STPs March 2018

• Develop and agree workforce support programme AS, STPs and commissioners March 2018

• Tracking of benefits NHS England regional teams March 2019

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• Support readiness workshops Regions / commissioners

April - July 2017

• Monitor and assure preparedness Regions / commissioners

April - July 2017

• Support implementation of clinical code set in local trusts and adoption of revised metrics

Regions / commissioners

May - September 2017

• Agree go-live plans

NHS England central, regional teams and commissioners

By October 2017

Contractual arrangements

• Contract variations to be agreed according to national revised standards • Contract variations to be set according to locally agreed standards • Assessment of potential ARP efficiencies and reinvestment opportunities

• Work with local STPs to develop offer of alternatives to ED conveyance, particularly

H&T and S&T

Commissioners Commissioners Commissioners and AS Commissioners and STPs

Summer 2017 Summer 2017 Summer 2017 Summer 2017

Commissioning of Ambulance Services

• Develop national commissioning ambulance framework and recommend next steps to NHSE.

NHSI April 2018

• Develop commissioning model for ACO and devolution pilot and recommend next steps to NHSE.

NHSI April 2018

74

Ambulances: Cost to deliver (1) • The ARP is at worst cost neutral, and we anticipate efficiencies to be identified following further

modelling. Any cash released as a result of efficiencies would be expected to support increasing Hear and Treat / See and Treat.

• Modelling undertaken for the Spending Review indicated the potential for £302m savings annually from implementation of new models within the ambulance service and related reduction in conveyance.

Summary – ambition by 2020/21 • The Ambulance Response Programme (ARP) will enable a clinically appropriate shift in call

categorisation and response times. We anticipate that this will deliver improved outcomes and operational efficiency; trialling remains in progress.

• The ambulance workstream (including paramedic at home) will allow for more patients to be appropriately dealt with at home or at scene. This will be achieved through the use of enhanced clinical models to support an increase in the proportion of calls to 999 dealt with via ‘see and treat’ and ‘hear and treat’ and an increased use of referral pathways set between paramedics and other providers.

• A shift in the conveyance of patients to alternative provision other than A&E Type 1/2 and non-conveyance with referral to primary care/community support is also anticipated

• Table (left) indicates current modelling for anticipated activity split in 20/21. This remains under review and will be refreshed to reflect evidence as developed in the Ambulance Improvement Programme.

Activity Latest modelling position for 2020/21

Hear & Treat 11%

See & Treat 40%

See & Convey to Type 1/2 ED 43%

See & Convey to other than Type 1/2 ED 6%

Dependencies • These figures are dependent upon the full implementation of the UEC review, the workforce

enhancements predicted by the adoption of PEEP, the availability of primary care/community provision to allow for reduced conveyance and the outcomes of the ARP. The ambulance conveyance CQUIN 2017-19 and proposed commissioner CCG IAF will support delivery of the ambition.

Risks/ Issues • The Spending Review modelling of the impact of ambulance interventions was the most

optimistic scenario we modelled and showed savings by 2020/21 of £438m. Trusts are now more pessimistic about their ability to achieve this case-mix. Despite this decrease in the savings forecast we are more optimistic about a positive impact in terms of reduced admissions as result of non-conveyance.

• Trusts were optimistic about further improvement in case mix beyond 2021 as the benefits of PEEP are felt more widely.

• Affordability to the Trusts and CCGs of PEEP implementation is a risk; College of Paramedics have questioned the PEEP cost savings.

Progress to date • The paramedic banding issue has been resolved with an implementation board in place. • The ARP evaluation is in first draft which allows us to investigate the efficiencies to be

achieved through the implementation of the programme’s interventions.

75

Ambulances: Cost to deliver (2)

76

Ambulances: Benefits Benefit Identified Business Change

Benefit Measures Quantitative

Target Qualitative

Target

Improvement in patient and staff experience of urgent and emergency care services

Early identification of the most life threatening incidents. Standardise and roll out Nature of Call Data collection Clinical consensus

Patients needs met in a clinically appropriate timeframe by the most appropriate clinician for their presenting condition. System reform through implementation of ARP interventions Data collection Patient safety

outcomes

Shorter waits for lower acuity calls System reform through implementation of ARP interventions Data collection

Reduction in overall 'tail' of waits, putting an end to long waits for calls which were hidden by the old time standards, even in the most time critical categories

Revised set of AQIs to make all category call cycles visible Data collection Patient safety outcomes

Decreased attendance (and admissions) at A&E Control room behavioural change and enhanced clinical decision making on scene Data collection

More efficient use of resources; decrease in multiple dispatches and stand downs resulting in less driving hours and overall efficiency improvements Roll out of Dispatch on Disposition Data collection

Improved staff morale due to greater resource availability Successful implementation of proposed changes Staff survey Staff experience

Decrease in staff attrition in both control room and on the road Successful implementation of proposed changes Workforce information Staff experience

Enhanced clinical quality

Sickest patients receive the fastest response System reform through implementation of ARP interventions Data collection

Reduction in clinical risk Successful implementation of proposed changes Patient safety & experience

Response standards that encourage the best possible patient outcomes Revised set of AQIs to make all category of call cycles Data collection

New clinical quality indicators to measure benefits to the sickest groups of patients Revised set of AQIs to make all category of call cycles Data collection Patient safety &

experience

Increase in patient safety and satisfaction Successful implementation of proposed changes Data collection Patient safety & experience

Improvement in the way people access urgent and emergency care

Patients receive highly responsive care in the most appropriate setting Development of new models of care Data collection Patient experience

Increase in hear and treat rates Facilitate control room behavioural changes Data collection

Increase in see and treat rates Empower clinical decision making on scene Data collection

Financial Savings

Modelled savings of £302m annually by 2020/21 Successful implementation of proposed changes Data collection

Delivery Plan - Hospitals

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Hospitals: Offer

• Our hospitals will be supported to focus their highly skilled emergency department workforce to deliver life-saving care for our sickest patients. Variation between hospitals will be reduced and best practice shared and implemented more widely.

• Upon entering Emergency Departments patients will be streamed by a highly trained clinician to the most appropriate service to meet their needs in a timely way – whether that is through the Emergency Department itself, specialist frailty care, to GPs or a range of other services.

• Hospitals will provide rapid, intensive support to those patients that have some risk of admission to try to avoid this where possible, ensuring that patients can be treated in the most suitable location for their needs, which can often be at home, through comprehensive ambulatory care services.

• In Emergency Departments the focus will be on high quality, rapid treatment for our sickest patients applying expert resource to deal with the most urgent emergency cases.

• Throughout the process delays will be minimised and long waits avoided ensuring that patients flow through the system to deliver the best care for their needs.

• Our oversight of hospitals will reflect the full range of experience of patients and staff from the quality of their care, to timeliness, experience and outcomes.

79

Hospitals: Specification By end Q2 2017/18, all hospitals are expected to have in place core best practice to deliver patient flow. These are: • Ambulance/Hospital interface – clear escalation processes to address ambulance handover delays over

30 minutes based on ECIP guidance; • Comprehensive front-door clinical streaming – a comprehensive front-door clinical streaming offer

tailored to local case-mix; • Ambulatory Emergency Care – 7-day a week ambulatory emergency care tailored to local case-mix; • Frailty Pathway – a clear frailty pathway starting with a multi-disciplinary assessment that agrees an

expected date of discharge; • Ward rounds – Consistent implementation of the SAFER bundle on all assessment and medical wards.

S – Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions.

A – All patients will have an Expected Discharge Date and Clinical Criteria for Discharge. This is set assuming ideal recovery and assuming no unnecessary waiting.

F – Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10am.

E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R – Review. A systematic MDT review of patients with extended lengths of stay ( > 7 days – ‘stranded

patients’) with a clear ‘home first’ mind set. • Discharge

Trusted Assessment process in place agreed with local partners Discharge to Assess service in place Seven-day discharge capabilities in place

• By end Q4 2017/18, 25% of trusts are expected to have psychiatric liaison services in place.

• This should be supported by an electronic patient tracking and bed management system to understand

patient flows and blockages in the system.

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Hospitals: Specification (2) This focus on patient flow needs to be supported by processes and systems that support frontline staff and builds resilience into the system. This includes: • An understanding of case-mix and patient flows into hospital that allow resources to be matched

to activities appropriately, e.g. matching ED workforce to arrivals by time of day. • An electronic patient tracking and bed management system that identifies blockages in the

pathway;

• Modelling of the appropriate bed base and workforce mix to facilitate patient flow, including the use of non-bedded ambulatory care and alternative treatment areas outside of hospital – e.g. step-down beds, where possible;

• Hospitals to begin planning for winter with system partners in Q1 2017/18. This should include:

• planning for a significant reduction in occupancy pre-Christmas including the impact on elective care;

• developing clear escalation protocols should occupancy move above 92%; and • planning for a perfect-week or alternative focused ‘breaking the cycle’ event for December 2017

and/or January 2018.

81

Hospitals: Key deliverable milestones

Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18

Publication of core clinical operating requirements for

all hospitals

Publication of patient flow dashboard

Getting it Right First Time

Programme for ED begins

Winter plans to be finalised

Implementation of the Emergency Care Dataset

Implementation of core patient flow

best practice in all hospitals

Winter planning to begin

Specialist liaison psychiatry

services in place in more than a

quarter of acute hospitals

82

Hospitals: Delivery Plan (1) 1. Hospitals – Implementing Patient Flow best practice locally

Work areas Key milestones Responsibility Timeframe

Implementing best practice in individual hospitals

• Expectations set of local systems for delivery NHSI Central April

• Development of plans for implementation including gap analysis STPs April and May

• Implementation of best practice STPs By end Q2

• Monitoring and iteration of plans STPs Q3 and Q4

Planning for winter

• Discussions start on cross-system winter plans STPs April

• Winter plans agreed with funding in place STPs By end Q1

• Assurance of winter plans Regional teams July and August

• Final sign-off of Winter plans STPs and regional teams End August

Bed capacity audit

• Development of national bed modelling tool NHSE and NHSI Central Completed

• Assessment of local capacity to deliver required occupancy to meet standard STPs and regions April and May

• Decision on results of audit and potential need for additional capacity NHSE and NHSI Central June

2. Hospitals – Supporting implementation of Patient Flow (1)


Implementation support - Best practice - Nurse-led discharge

• Collaborative launched to develop criteria based nurse-led discharge for selected pathways NHSI central April

• Development of pathways and sign-off NHSI central May

• Dissemination of pathways and follow-up with selected trusts to support implementation NHSI regions and STPs June

Implementation support - Best practice – Getting It Right First Time (GIRFT)

• Appointment of GIRFT leads for A&E (to also include ambulatory care) NHSI central Completed

• Visits to systems start GIRFT leads April

• Data contract to produce detailed provider packs let GIRFT PMO April

• Data packs completed GIRFT PMO July

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Hospitals: Delivery Plan (2) 2. Hospitals – Supporting implementation of Patient Flow (2)


Implementation support - Broader Improvement Offer

• Regional development and implementation of improvement offers NHSE and NHSI regions Ongoing

• Agreement of operating model for ECIP in 2017/18 NHSI central April

• Development of wider improvement offer based on feedback from regions and providers, e.g. tactical COO training NHSI central April - June

• Rollout of broader national improvement offer NHSI central June

Implementation support- Emergency Care Dataset

• Agreement of metrics and completion of development work for Emergency Care Dataset (ECDS) ECDS Programme Completed

• Development of implementation programme including support for ECDS ECDS Programme and NHSI Ongoing

• Implementation of ECDS Local systems October

Implementation support - Broader Improvement Offer

• Regional development and implementation of improvement offers NHSE and NHSI regions Ongoing

• Agreement of operating model for ECIP in 2017/18 NHSI central April

• Development of wider improvement offer based on feedback from regions and providers, e.g. tactical COO training NHSI central April - June

• Rollout of broader national improvement offer NHSI central June

Implementation support- Emergency Care Dataset

• Agreement of metrics and completion of development work for Emergency Care Dataset (ECDS) ECDS Programme Completed

• Development of implementation programme including support for ECDS ECDS Programme and NHSI Ongoing

Aligning national framework - Development of Core Clinical Operating Model for Hospitals

• Conceptual agreement from Colleges (RCEM, SAM, RCP) on Core Clinical Operating Model (CCOM) NHSI central Completed

• Development of first draft of CCOM NHSI central Completed

• Iteration and testing of CCOM with Royal Colleges, CQC, regional colleagues and clinical leads NHSI central April

• Testing of the CCOM with the sector NHSI central May

• Publication of the CCOM NHSI central June

• ECIP support for implementation of CCOM ECIP June

84

Hospitals: Delivery Plan (3) 2. Hospitals – Supporting implementation of Patient Flow (3)


Aligning national framework -Patient flow dashboard

• Agreement of metrics for Patient Flow Dashboard NHSI central By end March

• Agreement of presentation format and publication approach of dashboard NHSI central By end March

• Wider testing of dashboard with Royal Colleges, CQC, regional colleagues and others. NHSI central April

• Agreement of technical support to develop dashboard NHSI central April

• Building of the dashboard NHSI central May

• Publication of the Patient Flow Dashboard NHSI central June

Aligning national framework - Aligning NHSI and CQC focus on patient flow

• In principle agreement between CQC and NHSI to align focus on patient flow through improvement and regulation activities NHSI central Completed

• Development of approach focusing on data and Key Lines of Enquiry NHSI central and CQC April

• Testing of approach CQC tbc

• Rollout of new inspection approach as part of wave 2 of acute hospital inspection CQC tbc

Aligning national framework -RCEM and NHSI workforce programme

• Agreement of shared workforce baseline across NHSI, HEE, RCEM and other national partners

NHSI central with HEE and RCEM April

• Costing of options to improve recruitment and retention and reduce attrition. Development of options around training increases.

NHSI central with HEE and RCEM April and May

• Agreement of workforce programme across NHSI, HEE, RCEM and other national partners

NHSI central with HEE and RCEM May

• Publication of workforce programme NHSI central with HEE and RCEM June

Aligning national framework – financial incentives

• Develop STP incentives that give greater weight to improving performance through driving patient flow NHSE and NHSI Completed

• Develop CQUIN payments to incentivise better patient flow NHSE and NHSI Completed

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Hospitals: Delivery Plan (4) 3. Hospitals – Workforce


Implementation support - ACPs

• Agreement of funding for 200 additional ACPs focused on Emergency Care NHSI central Completed

• Agreement of (20) systems to target ACP support and development of offer NHSI regions and central April

• Rollout of ACP training programme to targeted systems NHSI regions and STPs June

Implementation support- tactical support to reduce attrition

• Development of best practice guidance on workforce recruitment and retention NHSI central with RCEM April

• Development of support offer for specific trusts to help implement best practice NHSI regions and central April

• Publication of best practice guidance and dissemination to Trusts NHSI central May

• Begin work with small number of trusts to support implementation of best practice NHSI regions and STPs June

Aligning national framework -RCEM and NHSI workforce programme

• Agreement of shared workforce baseline across NHSI, HEE, RCEM and other national partners

NHSI central with HEE and RCEM

April

• Costing of options to improve recruitment and retention and reduce attrition. Development of options around training increases.

NHSI central with HEE and RCEM April and May

• Agreement of workforce programme across NHSI, HEE, RCEM and other national partners

NHSI central with HEE and RCEM May

• Publication of workforce programme NHSI central with HEE and RCEM

June

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Hospitals: Cost to Deliver and Benefits

Cost to deliver • Implementing the majority of patient flow measures is expected to be delivered within

current resources. Good patient flow is correlated to having a more efficient and productive system – e.g. reducing waste in the system – which should be cost reducing

• £100m capital funding has been provided to support comprehensive front-door

clinical streaming in those organisations where it is not currently in place. Streaming will have workforce costs but these will need to be met from within current systems.

Benefits • We know that higher mortality is associated with crowded ED departments and high bed

occupancy, reducing crowding and occupancy through focusing on patient flow will help address this

• Patients will benefit from not facing avoidable delays in flowing through the system

– e.g. in being admitted from Emergency Departments to hospital wards or in being discharged from hospital when medically fit – as they decondition significantly when spending time in hospital beds

• Emergency Departments should be less crowded with patients facing fewer delays inside Departments and being streamed to more appropriate areas for treatment. This will reduce pressure on staff and improve patient and staff experience.

Emergency Care Data Set (ECDS): Offer

87

• The Emergency Care Data Set (ECDS) is a new national data set for urgent and emergency care. This new dataset will be implemented in all type 1 and type 2 Accident and Emergency Departments in England and types 3 and 4 as defined by the NHS Data Dictionary.

• The ECDS will replace the current Accident & Emergency Commissioning Data Set (CDS type 010) with a

data set that be compared and aggregated to provide an accurate picture of the complexity and acuity of all emergency attendances.

• The data set brings together many disparate local initiatives and practices from across the UK and is informed by collaboration with national and international emergency care colleagues.

• The scope of the project includes providing support and guidance to emergency department information systems (EDIS) suppliers to ensure systems are updated to facilitate the collection of data via the ECDS and also includes working with providers to support the implementation and operationalisation of the data set following the issue of a formal Information Standard.

• The ECDS is currently under review. Full approval is expected in March 2017, with ISN publication planned for April 2017. The anticipated date for implementation in type 1 and type 2 A&E Departments is from August 2017, with full implementation in all Type 1 and Type 2 A&E Departments in England by October 2017. Types 3 and 4 will follow in a further phase of implementation to be completed by October 2018.

• The benefits to be enabled by the ECDS by 2021/2022 are anticipated to amount to £28 million. The bulk of the benefits are likely to be realised by local commissioners. Other benefits include: a better understanding of the value added by the introduction of new models of care ensuring patients

receive care in the most appropriate setting support for future healthcare policy and strategy to ensure an improved quality of patient care improved data access, research and audit in emergency healthcare to support service improvement

initiatives.

http://www.datadictionary.nhs.uk/data_dictionary/messages/cds_v6-2/data_sets/cds_v6-2_type_010_-_accident_and_emergency_cds.asp?shownav=1

Emergency Care Data Set (ECDS): Delivery Plan

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Implementation activities Responsibility Timeframe

• Implementation of ECDS component of national CQUIN 8a (Proactive and safe discharge) Gulnaz Akhtar and national CQUIN team 2017-19

• Creation and publication of guidance to support CQUIN implementation Peter Sherratt and ECDS team April 2017

• Re-constitute ECDS Implementation Board Jonathan Benger and Aaron Haile May 2017

• Agree sponsor and SRO Simon Weldon, Iain Wallen and Tim Donohoe May 2017

• Establish delivery model through regional PMOs Lis Nixon and Raghuv Bhasin April 2017

• Agree implementation measures ECDS Implementation Board May 2017

• Agree early adopter incentivisation scheme Keith McNeil and Will Smart April 2017

• Implement early adopter incentivisation scheme Lis Nixon and Raghuv Bhasin May 2017

• Complete ISN approvals process and publish Information Standards Notice Jonathan Benger and Aaron Haile April 2017

• Undertake gap analysis of digital maturity in type 3 and type 4 A&E Departments, in preparation for ECDS implementation by October 2018

Keith McNeil, Will Smart and NHS Digital

October 2017

• Engage providers, suppliers and other stakeholders through publicity, website, webinars, etc.

Aaron Haile, Peter Sherratt and ECDS team Ongoing

Delivery Plan – Hospital to Home

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Hospital to Home: Offer

We will ensure that health and care services work more effectively together across acute and community services so that:

• Planning of discharge is commenced with relatives and/or carers and other sectors are involved in

decision making and planning at an earlier stage

• Patients only stay in hospital for as long as they need to be by developing local integrated systems between health and social care to allow a prompt discharge and handover of care into the community

• We create liaison across sectors, patients experience a coordinated, multi-disciplinary and timely transfer of care from hospital to the most appropriate community setting for the patients individual needs

• We provide patients with comprehensive packages of health and social care to enable optimal health and wellbeing to reduce the risk of readmission or an avoidable emergency admission in the future.

Through the Better Care Fund (BCF), Health and Well Being Boards will deliver change using

the High Impact Change Model included within the Better Care Fund (BCF) Framework

Hospital to Home: Specification

• Fewer bottle-necks in hospital, community and social services working as a more flexible system and reduce National DToC rates by working with health, social care, independent care sector, housing and the third sector.

• Able to match demands with capacity with a more flexible and integrated service • Develop intelligent metrics which measure flow, quality, patient care and minimise duplication

• A “Home First” approach when discharging patients from hospital and utilising Discharge to Assess principles to facilitate discharge for more complex patients

• Strengthened joint commissioning arrangements with CCGs and local authorities to facilitate more flexible health and social care packages to allow step down from acute settings

• CCGs will be eligible for part of a Quality Premium if they achieve: • Less than 15% of NHS CHC full assessments undertaken in an acute hospital environment

• For NHS CHC assessments in an acute location, there should be no delays in discharge. CCGs should be ensuring that, where NHS CHC Assessments are happening in the acute setting:

There is daily liaison with acute hospitals of individuals being assessed for NHS CHC There is adequate capacity/capability in the workforce to undertake a full NHS CHC assessment Verification of a recommendation for NHS CHC is done same day/as close to the recommendation as

possible. • Monitoring and data collection (for location of NHS CHC assessment) will be embedded into regional assurance

processes as ‘business as usual’ from April 2017 and developed onwards as set out above.

2) Monitoring Patient Flow

3) Multi-disciplinary

teams

4) Home first/discharge

to assess

1) Early Hospital Discharge Planning

• Early engagement of patients with relatives and/or carers in hospital for discharge decisions and planning • Early planning in the community in preparation of a hospital discharge • Involving and referring to community pharmacists to highlight vulnerable patients being discharged to prevent

readmission due to medication

• Further integrated discharge teams across sectors – including community, independent, voluntary and housing sectors to support coordinated discharges back home or into the community

• More centres and models of care in the community providing access to a mixture of health and social care professionals working together

• To strengthen relationships between NHS providers and commissioners and their local social care providers and commissioners, including the improvement of CCGs’ capability to work with councils to commission care.

The High Impact Change Model contains 8 high impact changes which have been agreed by NHS England, NHS Improvement, DH, LGA and ADASS

High Impact Change Service Specification

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Hospital to Home: Specification

92

• To consistently engage with patients, family and carers at an earlier stage about future care • Integrating the voluntary care sector as part of the health and social care team both in the trust and the

community to support people from hospital to home • Promoting choice and self-care for patients with the increasing use of assisted technology (in GP and MCPs)

7) Focus on choice

8) Enhancing health in care

homes

6) Trusted assessors

• Use of Trusted Assessor models to ensure one person/team to perform health and social care assessments on behalf of multiple teams to reduce waiting for assessments and duplication in the system

• Supporting and retaining staff in the community by providing guidance to upskill staff and provide innovative services with technology solutions

• More streamline access to a clinician via NHS 111 for Care Homes to provide more support out of hours • High quality care – in Care Homes by community health and social care teams working proactively • More pharmacists in Care Homes to support with complex patients and polypharmacy

The High Impact Change Model contains 8 high impact changes which have been agreed by NHS England, NHS Improvement, DH, LGA and ADASS

High Impact Change Service Specification

5) Work towards a 7-Day Service

• Have further alternative options available in the community for patients to present to for minor ailments, support for self care therefore reducing presentation and pressure in the acute setting

• Utilising further and promoting services which have extended hours and access to clinicians/health care professionals i.e. community pharmacies, urgent care, NHS 111 to reduce avoidable A&E presentation and pressure

Enablers

• Community Services National Strategy (including workforce considerations) • Suite of Quick Guides published • Regional leads and corresponding support teams • Hospital to Home - Communications Strategy

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Hospital to Home: Deliverables with key milestones

ENABLERS

Utilising resources in

primary care to support acute

pressures

PMO and governance

Regional Lead and support posts for local

delivery

Delivery support, events, bulletins,

case studies

Behavioural market research results on

discharge

Homelessness project developed to enhance

discharge

Themes Work Stream Key deliverables/outputs

Housing – discharge support

and admission prevention

Financial incentives CQUINs – D2A

Analytics/metrics for discharge and

community services

Mechanisms to encouraging good

practice and shared learning

Quick Guides and download rates

Masterclasses / Workshops /

Thematic research

Accessing urgent care for care homes

guide

Analytical data on discharge and community services

Developments in communication and information across

sectors

Central executive

deep dives

D2A and Trusted Assessor

workshops

National Strategy developed for

community services

DH Policy review of NHS CHC and acute setting

Support for mental health inpatients and

discharge

Providing support to

upskill staff in the community –

Pharmacists, Nursing homes

Ensuring assessments are appropriate and

add value

Enabling integration and

building networks

Support work with NHS 111 and NHS

digital

Hospital Discharge

Engaging CCGs and Councils for commissioning

Improving discharge

information for patients and

across sectors

Pilot work with community pharmacists and discharge referrals

Discharge Pilot with voluntary

sector

Strengthening relationships and joint initiatives in health and social

care

NHS email addresses for care homes and

domiciliary care

Better Commissioning

BUCH (Care Homes)

Pharmacy in the Community

BUCAH (Care at Home)

Communications strategy

Community Services

Voluntary Care

NHS CHC Assessments

Learning labs – Nursing Homes and

Multispecialty community provider

Additional analytical support for evaluation and data refinement

High Impact Change 2016/17 2017/18 2018/19 1. Early hospital discharge planning

• Red bag implementation toolkit

• ‘Red bag’ rolled out regionally • Behavioural market research results on

discharge • Updated standard NHS contract • Further pharmacy pilots on referral to

community pharmacy for complex patients

• Homelessness project to reduce readmissions and DTOCs

• Evaluate results from behavioural market research and make/implement recommendations

2. Monitoring patient flow

• Development of new discharge dashboard

• Implement further analytical data on discharge and community services

• Develop national metrics for community and intermediate care

• Improved measurement of delays through refinement of data reporting

3. Multi-disciplinary teams

• CCG Engagement Programme: Health and Housing rolled out.

• Relationship development between CCGs, local authorities and adult social care commissioners

• Publication of Integrated Discharge Teams Quick Guide

• Future CSU engagement project

• Continuation of New Care Model Learning Laboratories

4. Home first/discharge to assess

• Publication of Discharge to Assess (D2A) Quick Guide

• Increase implementation of D2A

• Increase implementation of Discharge to Assess (D2A)

• 2017/18 CQUIN on proactive and safe discharge

• Discharge pilot with voluntary sector • Central Exec Improvement Team deep

dives For NHS CHC: Implement regional assurance processes • Monitoring and data collection to support

assurance • Capability development for regions

• Evaluate progress and make recommendations

• Implement transfer using hospital messaging to GP systems

• Future STP work on housing and homelessness: roll out

• Revise DH National Framework

Hospital to Home: Deliverables with key milestones (1)

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95

High Impact Change 2016/17 2017/18 2018/19 5. Work towards a 7-Day Service

• National Strategy development for community services

6. Trusted assessors • Support ECIP publication of Trusted Assessor guidance through dissemination and working group input

• D2A and Trusted Assessor workshops

7. Focus on choice • Implement policy on supporting patients’ choices to avoid long hospital stays

8. Enhancing health in care homes

• Development and management of Care Home Vanguard Learning Labs.

• ‘Red bag’ toolkit published for local usage • Care Home guidance on managing

avoidable prescribing, reducing ambulance conveyances and hospital admissions

• Supporting national spread of the Enhanced Health in Care Homes Framework

• NHS mail in Care Homes phase 1 rollout • Deploy 200 pharmacy professionals into

care homes • Falls prevention guidance and programme of

support (North region led)

• Additional deployment of pharmacy professionals over following 3 years to 2020/21

• NHS mail in domiciliary care phase 2 rollout

• Work with medical/nursing directorates on self-activation and technological solutions within GP (links with MCPs)

Hospital to Home: Deliverables with key milestones (2)

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Hospital to Home: Delivery Chain

NHSE Regions

STPs

National team

National governance

The delivery of the Hospital to Home workstream will be delivered at four main different levels of the delivery chain across the NHS in England.

• Two national steering groups (Independent Care Sector; Community Services & Hospital Discharge) within the UEC governance structures providing multi-agency oversight, including NHS and social care commissioner and provider representatives, housing and VCSE sector.

• Co-ordinate strategic and operational improvement focus on community health services, working across multiple NHS England national directorates and national bodies

• Shift focus from developing tools and guidance (e.g. through the Quick Guide series), to implementation support and evaluation

• Engage with regional leads

• Implementation support delivered by working through ICS and Community Service Regional Leads

• Engage with STPs on progress, risks and issues • Deliver support as requested / required to STPs

• Lead local system delivery, involving local governance as required, including A&E delivery boards

• Plan and carry out delivery based on specification and policy • Escalate risks and issues and put in request for support

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Hospital to Home: Activities and responsibilities (1) 1. Early hospital discharge planning


Roll out red bag initiative

• Implementation toolkit available to include: a step by step process of ‘How to implement the pathway’; detailed case study from Sutton CCG EHCH vanguard; interactive materials; costing resources; procurement approaches; ‘how to’ templates; evaluation materials; and further support links.

NHSE national team March 2017

• Regions develop roll out plans based on the implementation toolkit • Confirm regional roll out plans via regional PMOs Regions / STPs March 2017

• Additional workshops and webex events, from April 2017 (aligned with national spread programme) to support organisations to implement

NHSE national team / Regions April – July 2017

• Implementation takes place at local level; progress risks and issues are reported NHSE national team / Regions

April 2017 – Sept 2017

• Engage with regions on communications strategies to raise awareness Regions April 2017 – Sept 2017

• Seek agreement with CQC that they will regulate care homes on Hospital Transfer Pathways NHSE/I & CQC September 2017

Behavioural market research results on discharge

• Behavioural market research to gather data and investigate cultural factors around staff and engagement of patients with regards to hospital discharge and possible delays

NHSE national team September 2017

• Engage with regions on communications strategies to raise awareness and to support implementation of recommendations from the research Regions / STPs Sept 2017 –

Sept 2018

Hospital Pharmacy teams identifying high risk patients prior to discharge

• Pharmacy pilots to be undertaken 2017/18 to further evaluate benefits and refine referral criteria for complex patients discharged from hospital to their community pharmacy for follow-up with a view to scale up initiative during 2018/19. Need to scope technological options available to facilitate communication for referrals/changes to medication to GPs and Community Pharmacists

NHSE/Pharmacy Integration Fund /NHS Digital

August 2017 – April 2019

• Regional and STP teams to engage with pharmacy teams to support implementation of initiatives for referral and transfer of care between providers Regions / STPs October 2017 –

April 2019

Hospital to Home: Activities and responsibilities (2) 2. Monitoring patient flow


Development of further analytical data on discharge and community services

• Working in more depth with further analysis performed on factors that affect acute care pressures i.e. readmissions, unavoidable admissions and community services

NHSE central teams


• Monitor the coordination of community services data projects occurring at a national level to ensure joined up working.

NHSE central teams

April 2017 - July 2018

• Investigate reason codes to more accurately determine key factors for DToC and add to existing data dashboards

NHSE central teams

April 2017 – July 2017

• Create and analyse national metrics for services in the community, intermediate care and ICS i.e. new minimum dataset to be agreed together with CQC NHSE central team April 2017 -

September 2017

• Feedback from regions to verify data refinement/findings to further develop discharge data dashboards Regions / STPs April 2017 –

September 2018

• Provide national support/steer for implementation, ongoing monitoring, analytics and evaluation of interventions to inform further guidance/policy work and implementation

NHSE central teams


• Regions to directly support uptake of data collection at sites and reinforce the importance of reporting Regions / STPs April 2017 – July

2018

Increasing Capacity

• Increasing community capacity is essential – development of the National Strategy (including consideration of workforce – early stages)

NHSE central teams June 2017

3. Multi-disciplinary teams


Relationship development between CCGs, local authorities and adult social care commissioners

• National and local programme of work to improve knowledge, skills and confidence of CCGs, LA, Adult social care services, independent sector and voluntary services

NHSE central teams


• Implementation of the Quick Guide: Integrated Discharge Teams and Acute Provider Engagement Programme: Health and Housing projects to develop relationships between health and the Independent Care Sector.

NHSE central teams


• Following the Quick Guide implementation strategy guide engage in activities to support best practice initiatives with workshops, presentations, webinars, social media and also virtual clinics to facilitate trouble shooting and sharing of learning.

Regions / STPs April 2017 – September 2018

• Care Sector Forum – evaluation and learning from 2016/17 contract . Procurement of further local area support

NHSE central teams/ Regions

April 2017 – September 2017 98

99

Hospital to Home: Activities and responsibilities (3) 4. Home first/discharge to assess


Increase implementation of Discharge to Assess (D2A)

• Publication of discharge to assess guidance for local health and care systems NHSE central teams/ECIP September 2016

• Pilot a variety of hospital to home schemes to determine the best quality and most effective schemes for patients

NHSE central teams / regions November 2017

• Discharge to assess open days at exemplar sites to encourage spread of best practice - tailored to issues identified through trend monitoring

NHSE central teams / regions September 2017

• Embed ‘home first: discharge to assess’ ways of working: assessment and implementation STPs April 2017 –

September 2017

2017/18 CQUIN on proactive and safe discharge

• Develop the CQUIN and launch to the system NHSE central team April 2017

• Plan for and implement CQUIN at local level STPs May 2017 – June 2017

• Assure implementation and assess impact Regions May 2017 – March 2018

Upon discharge, referral to Community Pharmacy followed up of high risk patients

• Learn lessons from the work in East Lancashire “Refer to Pharmacy” scheme and Newcastle referral scheme

NHSE Digital/ Pharmacy Reference Group/NHSE

April 2017

• NHS Mail in place in all community pharmacies NHSE Digital June 2017

• With support from the Pharmacy Integration Fund ,further pilots/evaluation collected for reduction on readmission and determination of vulnerable patient referral criteria

Pharmacy Reference Group/NHSE teams September 2017

• Using the standard implementation approach develop implementation plans for local roll out, consideration of involvement of HEE for further development of this workforce

Regions / STPs October 2017

• Implement the roll out in a staged phase and oversee Regions / STPs October 2017 – March 2018

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Hospital to Home: Activities and responsibilities (4) 4. Home first/discharge to assess


Discharge Pilot with voluntary sector

• Currently in early stages – require this to be scoped out and identify organisations and services

NHSE central teams


• Implement discharge pilot, measure the impact and evaluate results to determine effectiveness and scope for scaling up

NHSE central team

August 2017 – December 2017

Central Executive Improvement Teams (CCGs, Trust and ADASS) deep dives

• Agree target systems for deep dive visits NHSE central teams

November 2016 / April 2017

• Carry out visits for each system, which involve ‘peer to peer’ discussion and analysis of the issues that are contributing to poor flow and delayed discharges across the systems

NHSE central team / Regions

November 2016 / April 2017

• Develop reports and improvement plans and communicate to systems NHSE central team / Regions

April 2017 – March 2018

• Plan for and implement identified improvements; report on progress, risks and issues STPs April 2017 – March 2018

• Assure implementation of recommendations Regions April 2017 – March 2018

Collaborative commissioning and supporting CCGs with Local Authorities to commission Adult social care providers

• Produce commissioning guidance to CCGs about contracting and payment processes that follow what processes that local authorities have to support reablement and rehabilitation in the community

• Facilitating discussions with CCGs and promoting collaborative working

NHSE central teams NHSE central team / Regions

July 2017 July 2017

• Implementation of guidance and support locally to facilitate implementation Regions / STPs August 2017

101

Hospital to Home: Activities and responsibilities (5) 5. Work towards a 7-Day Service


Enhancing support and resilience in community services

• Via workstreams working across several sectors – comprising of independent care, third sector, social care, housing and pharmacy to increase utilisation, collaboration, resources, services and support in the community

NHSE central team


• Development of a National Community services strategy. NHSE central team


6. Trusted assessors


D2A and Trusted Assessor workshops

• Alongside ECIP, lead roll out and implementation of the trusted assessor initiative alongside the Quick Guides

NHSE central team/ECIP

April 2017-July 2018

• Local support to drive uptake and ongoing review of progress with services Regions / STPs April 2017 – July 2018

7. Focus on choice


Supporting patients’ choices to avoid long hospital stays

• Develop rehabilitation, recovery and reablement quick guide NHSE central teams

November 2017 – June 2018

• Rehabilitation, recovery and reablement pilots; learn lessons and refine approach NHSE central teams / regions

November 2017 – June 2018

• Implementation of rehabilitation, recovery and reablement STPs June 2018 onwards

• Commission sufficient capacity within services to support demand STPs November 2017 onwards

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Hospital to Home: Activities and responsibilities (6) 8. Enhancing health in care homes


Roll out red bag initiative • Refer to 1. Early hospital discharge planning for details NHSE national

team March 2017

EHCH guidance and ‘How To’ guides

• Best practice operating models, templates, contracts and tools developed and made available

NHSE national team End June 2017

• Ensure take-up and implementation of vanguard best practice NHSE regions Ongoing

Supporting national spread of the Enhanced Health in Care Homes Framework

• Support STP and CCG plan development and self-assessment • Co-ordinate national and regional support offer across NHSE and social care • Baseline data, reporting and evaluation guidance and tools (e.g. Ready Reckoner,

reporting template) • Work on policy development and barriers (e.g. contracting and commissioning, CQC

regulation) • Develop and deliver effective mechanisms for support to STPs and CCGs, working

with NHSE Regions and partners

NHSE national team

April / Oct 2017 Ongoing

• Help identify support each STP and CCG requires to develop plans • Co-ordinate and broker support for each STP to deliver the EHCH care element,

including work on UEC, PHIF, Redbag, NHS 111 and secure email. • Provide implementation support delivered by working through ICS regional leads • Engage with STPs on progress, risks and issues • Deliver ad-hoc support as requested / required to STPs and CCGs

NHSE regions

April / Oct 2017 Ongoing

• Plan and carry out delivery based on EHCH framework, How to guides and other national policy

• Co-ordinate local system delivery of EHCH care model, involving PMO or governance if required/desired

• Escalate risks and issues and put in requests for support

STPs April / Oct 2017 Ongoing

NHS mail in care homes

• With NHS Digital and the NCM team, support roll-out of NHS mail access for all care homes (residential and nursing) and domiciliary care providers in England NHS Digital March 2018

• Supporting local implementation and uptake to achieve a greater traction in providers using NHS mail accounts Regions / STPs April 2017 –

March 2018

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Hospital to Home: Activities and responsibilities (7) 8. Enhancing health in care homes


Reduce Data Duplication in Care Homes

• Through the Care Homes Data project reduce the duplication in data requests from CQC and commissioners

NHSE national team End July 2017

Deploy additional pharmacy professionals in Care Homes working with the Care home Vanguard Programme

• Develop the criteria / operating model for deployed pharmacy professionals NHSE central teams August 2017

• Develop process and template materials for the recruitment process NHSE central teams August 2017

• Develop workforce requirements, model and costing HEE September 2017

• Run the recruitment process at local level and deploy 200 pharmacists across the country Regions By March 2018

• Learn lessons from the first wave of deployment and refine approach NHSE central teams March 2018

• Plan and start delivering wave 2 deployment Regions By March 2019

Improved End of Life Care in Care Homes

• To work with expert colleagues to facilitate a project to support improvement in end of life care for people in care homes and receiving care at home – in early stages currently

NHSE central teams

August 2017

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Hospital to Home: Activities and responsibilities (8) 9. NHS continuing healthcare


Regional assurance

• Develop co-design plan for strengthened regional assurance NHSE central team/NHSE Regional team

July 2017

• Implement co-design to strengthen regional assurance NHSE central team/NHSE Regional team

March 2018

Monitoring and data collection

• Develop CHC quality premium / CCG IAF indicator for 2017-19

NHSE central teams

September 2016 – January 2017

• Implement NHS CHC quality premium/CCG IAF indicator for 2017-19

NHSE central team

April 2017 onwards

Capability development for regions

• Engage with regions on the requirements for enhancing capability and capacity NHSE central team/NHSE Regional team

June 2017 onwards

• Develop and implement capability and capability offer NHSE central team/NHSE Regional team

March 2018

DH National framework Review

• 12 week public consultation starts DH 5th July 2017 – September 2017

• Publication of new National Framework and associated tools and documents DH January 2018

• Implementation of new framework -Go live Operationally (Secondary changes made)

NHS England Central Team/NHSE Regional team

April 2018

105

Hospital to Home: Activities and responsibilities

• Using pilots to produce initial data and evidence to inform impact before launching on a larger scale • Further investigation of the factors around certain data i.e. DToC which will develop the discharge dashboard • Through the Care Homes Data Project reduce duplication in data required from CQC and commissioners

• By using workstreams that involve and deliver across several sectors – comprising of independent care, third sector, social care, housing and pharmacy to increase utilisation, collaboration, resources, services and support in the community

• Positive uptake of Integrated Discharge Team (IDT) and Improving Hospital Discharge information Quick Guide • With support from the Pharmacy Integration Fund – Improve the support community pharmacy can deliver to

local UEC systems, including input to care homes, medicine reviews, and urgent repeat prescription services with pilot schemes to minimise admissions and readmissions due to polypharmacy

• In partnership with NHS Digital and the New Care models teams, support roll out of NHS mail access for all care homes (residential and nursing) and domiciliary care providers in England by March 2018 to improve communication

• Roll-out and utilisation of NHS mail in the community as a platform to enable collaborative working across sectors, sharing of information, referring complex polypharmacy patients to providers in the community i.e. community pharmacy and care homes. Community pharmacies to have in place by June 2017.

• Using social media, online platforms sign-posting for patients and professionals to Quick Guides • Through an assisted technology roll-out programme raise awareness and use of this in health and social care • Pilots with better systems for referring to community pharmacists via NHS 111 for minor aliments

• To scope out relevant support work with a number of STP areas about health and housing and to develop better partnerships with the Independent care sector (care homes, homecare and housing).

• To work with expert colleagues to facilitate a project to support improvement in end of life care for people in care homes and receiving care at home.

• To reduce falls rates by developing a falls prevention guide using learning from the North Region’s programme that can support care home, homecare and housing care and support services to prevent falls.

• Deployment and programme costs commissioned by HEE working with the enhancing health in care homes vanguard programme, deploying up to 200 pharmacy professionals 2017/18, with additional deployment by 2020/21

• Using expert facilitation from a central executive group (Trusts, CCGs and ADASS) for challenged areas • Implementation of care home educator models through transformation funding • Vanguard – using learning labs to improve sharing of learning, collaboration and standardisation

Cross Sector relationships

Data and metrics

Bespoke National Support

Integrated working

Technology

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Hospital to Home: Benefits

• The number of people being discharged to interim care and then to their normal place of residence will increase moving to a non acute environment will reduce the likelihood of deterioration within an acute setting inappropriate for their needs

• Support mandate commitment of reducing the national Delayed Transfer of Care (DToC) rates to 3.5%

• Reduced delays in transfer will allow for increased bed capacity to support the U&EC pathway to flex in response to surges in activity

• Further data/evidence to support what factors might be affecting patient flow, therefore discharge and A+E

pressures. This will feedback into our workstreams and drive implementation of the most effective and evidence based interventions/models

• More transparency from services, driving up quality standards, method to recognise struggling centres early,

use to inform areas for positive change

• Greater adoption and uptake at a local level of evidence based care and system models such as D2A, Trusted assessor and the ‘red bag’ initiative which have a record of improved efficiency, patient outcomes and length of stay (LoS)

• Increased partnership working and collaborative learning across sectors lead to higher quality patient care

and improved patient outcomes • Locally ensuring integration of care, social and commissioning systems as well as patient pathways is able

to be implemented by reducing care interface barriers for change .

Urgent and Emergency Care Delivery Plan - Medicas Health · Urgent and Emergency Care (UEC) is one...

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