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Urgent Care Programme Board meeting

Friday 25th July 2014 10am – 12noon

ER meeting room HUHFT

Item no. Subject Papers Lead Time

1. Introduction and Apologies

verbal MC 5

2. Minutes of the last meeting

Enc 1 MC 5

3. Winter planning for 2014/15 Feedback from NHSE events 17 and 24 June

Enc 2 FC/MC/HF

20

4. PARADOC – update, reflections and experiences following first 4 months

Enc 3 SC/NY 15

5. OOH • 6 months reflections • Service development plans • Strategic links

Enc 4 VH/JB 10

6. PUCC redesign – things to consider ahead of the September Workshop:

• Integrating HOPs and CHAPs • Triage and assessment • Workforce mix • Relationships • Quality

Verbal MS/MC 20

7. Non-clinical Navigators update Verbal JL/MC 5 8. A&E Performance

Enc 5 FC 10

9. Comms – Public health leaflet and Tollgate Enc 6 AL 10 10. Process for Duty Doc payments Verbal RO 5 11. OMU pathways launch at GP education session

19 September – for noting Verbal DW/HH

/MC 5

12. UC activity – for noting Enc 7 RO 5 13. AOB verbal All

Urgent Care Programme Board Meeting Friday 30th May 2014 @ 10am – 12:20pm

Meeting room, Emergency Department, Homerton Hospital Present at the meeting 1. May Cahill – Chair 2. Malcolm Alexander 3. Dorothy Briffa 4. Rebecca Clarkson 5. Frank Coathorpe 6. Heather Finlay 7. Anna Garner 8. Wayne Gillon – part meeting 9. Hannah Home 10. Jean Lyon 11. Mischa Mills 12. Rae Morrison 13. Jarlath O’Brien 14. Ryan Ocampo 15. Osian Powell – part meeting 16. Claire Power - Minutes 17. Emma Rowland 18. Ilona Sarulakis 19. Mark Scott 20. Natasha Wills 21. David Wilson

1. Introduction and apologies Introductions were made and apologies were received from Siobhan Bay, Paul Haigh, Victoria Holt and Nick Yard.

2. Actions from last meeting The group reviewed the minutes from the previous meeting. They were accepted as an accurate record of the meeting with the following amendments: HF apologies noted. CHAPs item on page four be amended to indicate that more children seen by PUCC GP relieves pressure and waiting times in A&E. ACTION:

• MS to update minutes & ensure corrected version are updated to the CCG website.

Chair: Dr Clare Highton Chief Officer: Paul Haigh

3. Activity/ Finance Data

AG presented the report. She asked that any further comments be sent to AG/MS/MC. A lengthy debate followed and the key points can be summarised as:

• CHUHSE and 111 disposition data demonstrates need to retain local OOH model when considering new 111 provider

• Need cautionary/caveats when comparing Trusts, e.g. Bart's and UCH major trauma

centres. Might be worth looking at more compatible Trusts e.g. Newham, Whipps Cross and Royal London.

• A group discussion was held regarding busiest periods of activity both in terms of

times of day and days of the week for A&E. It was noted that different predictive models had been trialled, however it has remained a challenge to get this right given the unpredictability of A&E activity. It was noted that LAS predict 2-3weeks ahead based on historical and recent data and other influences e.g. weather which tends to be accurate.

• Moderate to strong relationship between proximity to Homerton and A&E referral

rates.

• MA queried whether a delay in responding to C1/C2 LAS calls may create an increase in A2. NW advised that this is a possibility, but it is all written into their surge plan.

ACTIONS:

• AG to look at data to establish how many patients attending HUHFT A&E are City & Hackney residents & where other patients are coming from;

• AG to investigate whether CHAPs has made a difference to A&E attendances; • AG to remove Moorfields from the A&E comparison table; • AG to look at patient satisfaction levels with GP access per practice to see if there is

any correlation with A&E attendances; • AG to compare frequent attenders data with last year; • AG is trying to benchmark admission costs against the London average. • All to advise AG if there is any data that they would like added to the “still to do” list.

4. Current A&E performance FC presented the report. The Board congratulated HUHFT for their “outstanding” result in the recent CQC report. The Board discussed the report and made the following observations:


• A successful recruitment drive has been held for nursing staff. • There are still some challenges in recruiting PUCC specialists. • Attendances have not decreased in recent months, despite coming out of the winter

period, this has coincided with winter funding ceasing and has created added pressure on A&E. This trend is reflected across London.

• It was noted that there is a difference in reporting timeframes between DoH guidance and the agreements between CCG and Homerton - HUHFT report on a calendar month, as per their contract, whereas the DoH consider data up to 27 of the month and not beyond. It was the Board’s view that Homerton had achieved the target.

• A winter planning and review event will be held on 24 June 2014, organised by the Tripartite panel. Representatives from the Board were invited to attend.

ACTIONS:

• FC to send the invitation to the winter planning event; • RO/FC to discuss this event outside this meeting.

5. PARADOC

. NW presented the report. The following key messages were noted:

• This service started during the last week of March • Overall colleagues were pleased with the utilisation seen so far. • Most referrals are made by LAS crews. • Feedback is given to the crews on a daily basis. • A flyer will be produced in May to educate the crews further. • Both internal and external communications are updated weekly. • Referral criteria will be expanded and lower level control staff will be trained to take

calls. Paediatrics and mental health will be included as the service develops. • NW advised that the clinical governance included communications back to patients’

GPs and between referring providers. ACTIONS:

• NW to provide a quote for an Ipad with EMIS software. MS confirmed that the CCG are happy to fund this;

• NW to let MC know if there is any feedback regarding poor compliance from GPs when required to do follow-ups that PARADOC cannot do;

• Service specification agreed with the following amendment: “Inappropriately referred” to be removed and other form of wording to describe patients being better servied by an alternative treatment rather than an A&E visit..

• Board agreed to extend the pilot for 2 years.

6. RICs


JB presented the report and highlighted the following key points: • RICs has not been fully commissioned as yet. • The pathways have all been written but these need to be confirmed and will then be

distributed. • Priority on expanding the existing First Duty Response Team (FDRT) service. As

this is made up of physiotherapists, occupational therapists and nurses it is proving difficult to cover later hours.

• It is felt that the best option is to link with PARADOC and CHUHSE over the weekends.

• The project would incorporate a phased implantation.

7. Links to Integrated Care – Crisis Response Workshop MS briefed the board on a workshop designed at pulling together multi-disciplinary teams that look at how City and Hackney can respond in a system wide manner to crisis and urgent care. The group also discussed the City and Hackney Care plan which was a scheme designed for every patient over 75 to have an individual care plan that would be shared across different health provider with the patients GP responsible for keeping the plan up to date. The following points were noted in the discussion:

• The Board need to be mindful of safeguarding and ensure that appropriate training and support from managers will be needed.

• An Ipad with EMIS access will be necessary to ensure that emergency staff have

access to the most up to date records. Records to be available to A&E via Health Information Exchange (HIE).

• HF advised that consent is not a stable state and therefore this area of the care plan

may need some further thought. ACTION:

• JL to send MS the details of a tagging system recently seen with patients medical and contact details;

• HUHFT to consider whether NCNs have a role in identifying where patients have a care plan or when changes are made.

8. Frequent Attenders WG advised that he is hoping to present his work with regard to frequent attenders at the College of Emergency Medicine and have an article included in their journal. He will be


looking to improve communication with GPs and will also be liaising with LAS to try to reduce the number of frequent attenders.

9. Discharge JO’B advised that care planning and integration with community services will be the focus of this initiative. They hope to build on existing services. Discharge planning will need to start earlier in order to tie up all aspects. ACTIONS:

• JO’B to provide a further update at the next meeting; • MA to feedback to Healthwatch.

10. Step-up planning for winter months

RO thanked colleagues for supporting the return to NHSE. He proposed the setting up of a task & finish group to ensure that work on winter planning is started earlier this year and to give providers every opportunity to recruit clinical staff as soon as the funding is confirmed. Providers would need to consider how winter funding might be stretched over a longer period to consider the busy Easter period and the May bank holidays. Providers would also need to demonstrate how they could flex staff up and down during the periods that see variable activity. ACTIONS:

• Service leads to consider their workforce requirements in the Winter periods and work with RO and FC to prepare outline bids for consideration in September

11. Communications plan

MM is working on a comprehensive holistic communications plan. The priority for communications is de-commissioning of the Tollgate Health Centre. It is anticipated that there will be a minimal impact on Urgent Care as the centre has been reducing its activity in recent years and the drive will be for patients to register with their own GPs and access in-hours primary care. This will be monitored. Local services, partners, stakeholders and patients will be advised from end of June. ACTIONS:

• All to contact MM with any questions or suggestions; • A communication piece on NCNs should be considered, with the initial focus being

on HUHFT internal communication.

12. Voluntary Sector Urgent Care bids


Rebecca Clarkson from the HCVS presented a summary outlining a funding scheme initiated by the Cabinet Office for services that enhance existing provision with volunteers/third sector at their core. Her proposal was to enhance the work of the Frequent Attenders group to conduct outreach work to support better care and services out of hospital and in the community, thus reducing additional pressure in hospitals. The process set out that bids must be submitted by 13 June, for money to be approved by July 2014 and spent by March 2015. ACTIONS:

• MS/AG/ RC to discuss data regarding specific groups outside this meeting; • RC to send the bid to MS/MC/OP.

13. 111 and Out of Hours

RO summarised the report on 111 and out of hours, the following points were made: Across WELC the proposal is to extend the existing service to 31.03.2016. A WELC working group will be formed to look at how we can make 111 work for us in City and Hackney, whilst retaining the existing OOH model. HF, HH, MC and VH volunteered to be on the WELC working group. All recommendations in the briefing paper were approved. ACTION:

• RO to propose a framework for monitoring performance which will be discussed and approved by the UCPB.

• RO to draft a letter for Paul Haigh agreeing the recommendations in Jane Milligan’s paper on 111.

14. OMU Audit

ER advised that they did not feel that the pneumonia audit would be useful from an A&E perspective and that the sepsis audit also on-going is much more useful and should be a priority. It was agreed to postpone the pneumonia audit for now.

15. AOB N/a


1 Confidential – LAS NHS Trust Service provision summary

London Ambulance Service NHS Trust Service Provision Summary: Pilot Service title: ‘ParaDoc’ – City & Hackney. Pilot Project Extension 1st August 2014 – 31st March 2015. Pilot Service local lead: Nick Yard, Ambulance Operations Manager, City & Hackney Date: Mon 21st July 2014

Pilot Service description ‘ParaDoc’ – City & Hackney Service Model:

Pilot project: The service aims to provide a joint paramedic and GP clinical response addressing urgent primary care needs.

Known locally as ‘ParaDoc’ - this is a new and innovative pilot project based in the City & Hackney CCG locality. It comprises of a London Ambulance Service NHS Trust (LAS) paramedic working with a General Practitioner (GP) from the City and Hackney Urgent Healthcare Social Enterprise (CHUHSE), deployed in a response vehicle providing a responsive primary care led service to patients who have been referred by an LAS clinician, with the intention of reducing unnecessary conveyance to A&E via ambulance. This service is designed to respond to patients who access the emergency ambulance services via 999. LAS clinicians on scene or in our control room will refer patients, after appropriate triage, to the “ParaDoc” team to facilitate access to suitable local healthcare pathways. The aim of ParaDoc is:

To provide an integrated and multidisciplinary approach for patients who present with urgent primary healthcare needs rather than life threatening emergencies.

To improve patient experience by providing access to the right healthcare professional at the right time in the right setting.

To provide high quality, cost effective healthcare. Objectives – (City & Hackney CCG Urgent Care Programme) [Extract from NHS City & Hackney CCG PID] The objectives of service are to support the maintenance of the A&E four target, minimising inpatient lengths of stay and reducing median time to treatment. These objectives are met through the non-conveyance of patients to ED and initiation of treatment with follow up to avoid hospital admission. Scope [Extract from NHS City & Hackney CG PID] Ambulance clinicians on scene can refer patients that would benefit from urgent assessment and intervention by a GP, subject to clinical inclusion/exclusion criteria. Normally referrals from ambulance crews will be for patients in residential locations including care homes, nursing homes, hostels and hotels. Referrals from business/work place or other public places are generally not appropriate unless there is a suitable room available to assess the patient in dignity and privacy.


As and when required, it may be expected that as the nearest available resource, for the paramedic deployed to this service to respond to Emergency Ambulance Service Red 1 calls or in line with the response profile for the AMPDS Red 1 determinants. It is expected that in instances such as these, the Paramedic will take responsibility for the management of patients in cardiac arrest with the GP providing suitable clinical support if or where appropriate.

Service Specification

Patient Cohort: The service will provide a joint paramedic and GP urgent care response for adult patients with urgent care needs. The service will treat patients who are resident within the boundaries of the London Borough of Hackney and the City of London. Patients who will not be treated:

- Residential addresses outside City & Hackney CCG boundaries - Patients in public places and business/work place locations - Non-urgent or critical patients that do not need to be seen within an agreed

timeframe of 6-8 hours - The service will respond to urgent primary care cases rather than acutely ill

patients. Referral Mechanisms: - Via ambulance clinicians following an on scene assessment as described above - Via referrals from the LAS control room following an enhanced clinical telephone

triage - Via referrals from the LAS Control room for “Red 1” AMPDS calls –

predominantly cardiac arrests.

Key service outcomes: - An increase in the number of patients who can be appropriately treated at

home for an urgent primary care need - Reduction in the number of patients inappropriately conveyed by ambulance to

the ED - Improved communication and referral pathways between LAS and other urgent

care providers. Service provision: The service is managed and led by LAS with the GP services provided by CHUHSE, as defined by the City & Hackney CCG.

LAS provides each shift: Paramedic x1 FRU car fully equipped x 1 Consumables Communications (airwave radio/ mobile phone)

CHUHSE provides for each shift : General Practitioner x 1 GP OOH drug packs Additional OOH consumables packs Mobile technology comprising of laptops x 2 for the GP and Paramedic to access Adastra, EMIS web and for data collection. Digital recording for mobile phones Dispensing and prescribing.

Note: CHUHSE will be responsible for communicating the outcome of the


consultation/ attendance to the GP for whom the patient is registered (via ADASTRA). The outcome should be shared no later than 08:00 the next day. It is recognised that there may be instance where one party is not able to provide resources appropriate to the service due to unforeseen or unplanned circumstance, notice of such issues will be sent to the lead contacts concerned and the service will be stood down on an interim basis. Neither party will be held liable in these instances.

Service Location:

Based at City & Hackney Complex

The service operates from the LAS Homerton Ambulance Station, City & Hackney Complex using a LAS response vehicle. The service accepts referrals for patients within the City & Hackney CCG area only.

LAS contact and management

Local complex Ambulance Operations Manager

The service is managed locally by the Ambulance Operations Manager for City and Hackney with support from the following contacts: Director of Operations Asst Director of Operations for East Central Area Head of Contracts & Commissioning Control Services Medical Director IM&T Finance Governance LAS will hold a local service level agreement with CHUHSE that outlines the requirements for the provision of service including: service charge, staff specification (eg. General Practitioners); staff management and supervision; the provision of equipment and expectations on reporting. This arrangement with CHUHSE is managed on behalf of City & Hackney CCG by LAS. Governance Whilst both LAS and CHUHSE have their own separate and existing arrangements for governance, for the purposes of the service, the overall responsibility for governance rests with the LAS as the lead provider. However it is important that both LAS and CHUHSE have a collaborative approach to governance through information sharing, transparency and joint working. LAS and CHUHSE will meet on a monthly basis to review and discuss operational performance and governance. This meeting will include areas such as: review of operational and governance KPIs; feedback from CHUHSE on governance audit; review of any incidents or complaints and a case study presentation. A one day induction programme will be held for both CHUHSE GPs and LAS Paramedics deployed to the service. All staff will be invited to attend the monthly education evenings held by CHUHSE.

LAS responsibilities - The LAS will lead on incident and complaint investigations including Serious Incidents but will engage and share the outcomes of investigations with CHUHSE. The only exceptions, where CHUHSE would lead a complaint or incident investigation, are situations solely related to the clinical practice of the GP. The outcomes of these investigations will then be shared with the LAS. CHUHSE will retain the liability regarding the clinical practice and care given by the GPs. Liability for the actions of LAS staff and associated processes rests with the LAS.

- In all cases, primacy of care will be the responsibility of the GP. However, there may be some emergency situations where it may be more appropriate for the paramedic


to take the clinical lead, for example; the Paramedic has primacy of care for patients in cardiac arrest / peri-arrest.

- In circumstances where there may be a difference of clinical opinion, the paramedic will contact the LAS senior clinician on-call for advice.

- LAS Paramedics working on the service, should work within the JRCALC (2013) Clinical Practice Guidelines and LAS policies. Any treatment outside of these guidelines must be carried out by the service GP.

- Complaints or concerns raised by GPs concerning LAS Paramedics should be escalated via CHUHSE Operations Manager to the LAS Ambulance Operations Manager for City and Hackney. Incidents of a serious or urgent nature should be escalated to the on LAS pan-London Ambulance Operations Manager via EOC.

- LAS documentation will be audited as per the current Clinical Performance Indicators framework. Additional audits will be carried out to collate information for a monthly KPI report and ongoing review of the service. CHUHSE responsibilities - The Chief Medical Officer (CMO) of CHUHSE will provide leadership, management and supervision to ensure that all clinicians are sufficiently supported. Support will be provided for supervision, audit of the clinicians and review of how the service is developing. - CHUHSE will utilise systems of performance management, clinical audits, prescribing audits, incident-reporting systems and Serious Incident reviews based on best practice. - All clinicians will have regular appraisals and supervision opportunities provided by CHUHSE - Feedback from clinicians is encouraged by CHUHSE. All concerns will be collated and discussed at each CHUHSE planning/management meeting and monthly meeting with LAS. If urgent concerns arise the CMO will deal with these promptly. All concerns will need to be reviewed by the CMO (or representative) so that they can be appropriately categorised. - Complaints from patients and relatives will be collated and reviewed by CMO with direct feedback and discussion with the clinician involved. - Concerns raised by paramedics will be shared with the CMO via the Ambulance Operations Manager for City & Hackney, the CMO will review and discuss these with the clinician involved and feedback. - There will be a regular and systematic audit of the medical notes of all clinicians keeping in mind quality of medical records, appropriate assessments and appropriate decision making regarding risk, use of community services, contact with local GPs and on-scene treatment being given where necessary. - Serious Incidents will be reviewed and discussed by the whole clinical team in a structured way for learning and service improvement. CHUHSE will be responsible for checking that GPs working on the service are suitably experienced and qualified, have CRB clearance and an appropriate level of indemnity insurance cover.

Local commissioning lead

Mark Scott Programme Director Integrated Care and Urgent Care City and Hackney CCG

The service is commissioned by City & Hackney CCG, led by Urgent Care Board and chair (Dr May Cahill). City & Hackney CCG have identified a member of the public as a patient representative for the service.


Ryan Ocampo Programme Manager, Urgent Care City and Hackney CCG

Service hours & deployment

7 Days a week from midday to midnight (inclusive of rest breaks)

The service will accept referrals from midday; the last referral will be accepted at 23.00. The service will be covered until midnight and will remain available for Red 1 calls until midnight.

Service reporting and monitoring

Schedule 1 – Reporting to City & Hackney CCG Schedule 2- Internal LAS reporting

Schedule 1 – Reporting to City & Hackney CCG A monthly report including the following items to be provided to the CCG for all patient attendances where a patient has been referred to the service:

Referral Source

- Ambulance Clinician on scene

- Clinical Hub

- Red 1 Call

Referral accepted Y/N

Reason & outcome if referral declined

The intervention given to the patient

The follow-up arrangements/ outcome

See & advise (self care or sign post to own GP/ other services)

See & treat

See & treat and refer

See & treat & follow up +/- refer

See & convey to hospital

See & refer/convey to hospital speciality

See & refer/convey to A&E

Evidence of whether a hospital visit was avoided (A&E and admission)

Where patients are seen/ contacted on a follow-up visit by the service, the report should include:

The intervention given

The follow-up arrangements

The service should make a minimum of 8 attendances per 12 hour shift

A summary of the above information to be provided to the CCG on a monthly basis.

The summary should include the total number of attendances per month and

whether the attendance was for an initial referral or a follow-up visit. The report

should also provide details of any shifts not covered by LAS Paramedic or CHUSHSE

GP.

The service provision, activity and reporting will be reviewed at a monthly

performance and operations meeting held between LAS and City & Hackney CCG.

CHUHSE will be invited to attend these meetings to discuss relevant performance and

operational issues.


The service Paramedic will record data on a daily basis. The data should include CAD

number as a unique identifier for each episode but should not include patient

identifiable data including name or NHS number.

CHUHSE will provide appropriate information reports via the Adastra system, the

reports will include interventions, patient outcomes and follow up arrangements. LAS

will include this information in a monthly report, provided by 21st

of each month.

Schedule 2- Internal LAS reporting General Data

LAS CAD number

Date

Day of week

Time of referral

Age

Gender

Ethnicity

Job cycle time

On-scene time (duration in mins)

Is patient a C&H resident Y/N Referral Data

Total number of patients referred with break down by referral source i.e. crew referral or CHUB

Total number of accepted referrals with break down by referral source i.e. crew referral or CHUB

Reason for referral not accepted (capacity, out of area, age, outside of protocol, other (specified)) broken down by source of referral.

Original LAS MPDS Determinant

Reason for referral (working diagnosis) - ?pick list

Was the referral an alternative to A&E (yes/no)

Outcome Data

GP diagnosis (? Pick list)

Disposal (hear and advise/self care, see and treat + /- follow up visit/call, see and refer to other service/pathway (eg ACERS, FRDT, SS (+/- treatment), conveyed to hospital (referral to specialty or A&E)

Follow up visit (phone same day, phone next day, same day visit, next day visit, extended follow up)

Clinical summary of randomly selected patients (10% of accepted referrals)

Admission avoidance (Y/N)? Red 1 Calls

Number of Red 1 Calls

Red 1 Outcomes (beyond resuscitation, cardiac arrest with/without ROSC, not as given with/without ParaDoc intervention)

Resourcing

Number / percentage of GP shifts covered/ uncovered

Number / percentage of Paramedic shifts covered/uncovered Feedback

Number/ percentage of written feedbacks (all referrals)


Clinical Governance

Complaints

Incidents

SI

Audit of Doctor’s notes Public Patient Involvement

City & Hackney CCG have identified a member of the public as a patient representative for ParaDoc.

A patient satisfaction survey will be undertaken as part of the evaluation of the service

Service commencement

1st

August 2014 Note: This is an extension to the current pilot that commenced on 28th

March 2014. Initial period of funding for 3 months, with further funding agreed for July 2014. LAS has been asked to extend the pilot project from 1

st August 2014 – 31

st March

2015.

Service cost & payment terms

Annual Service: Annual total: £692,989

CHUHSE Element (GPs) £366,000

LAS Element £326,989 Service Cost 1

st August 2014 – 31

st March 2015 (8 months)

Pro rata total: £ 461,993

CHUHSE Element (GPs) £244,000

LAS Element £217,993 Payment terms: Purchase order applicable, monthly payment in advance.

Service notice period

Notice to terminate service Stand down of service

Notice to terminate service – a period of 2 calendar months. Stand down of service: It is recognised that there may be instances where one party is not able to provide resources appropriate to the service due to unforeseen or unplanned circumstance, notice of such issues will be sent to the lead contacts concerned and the service will be stood down on an interim basis. Neither party will be held liable in these instances. SERIOUS AND MAJOR INCIDENTS

1.1 The Civil Contingencies Act 2004 identifies that the Local Ambulance Service has the statutory responsibility for major incidents.

1.2 Therefore the LAS will declare a serious or major incident when necessary and has the responsibility to activate and coordinate the provision of clinical care at the incident scene, which may include the tasking of LAS resources or assets identified within this agreement.


In line with the above the LAS will provide leadership and management responsibility to all healthcare and NHS assets at the scene of a major incident. The LAS Ambulance Scene Commander supported by the LAS Medical Advisor will provide the necessary direction and support.

FORCE MAJEURE

1.3 No Party shall be entitled to bring a claim for a breach of obligations under the Agreement by the other Party or incur any liability to the other Party for any Loss or damages incurred by that party to the extent that a Force Majeure Event occurs and it is prevented from carrying out obligations by that event of force majeure.

1.4 In the occurrence of a Force Majeure Event, the Affected Party shall notify the other Party as soon as practicable. The notification shall include details of the Force Majeure Event, including evidence of its effect on the obligations of the Affected Party and any action proposed to mitigate its effect.

As soon as practicable, following such notification, the Parties shall consult with each other in good faith and use all reasonable endeavours to agree appropriate terms to mitigate the effects of the Force Majeure Event and facilitate the continued performance of the Agreement.

Internal authorisation / sign off

Finance: Operations: Clinical governance: Contracts & Commissioning:

Homerton University Hospital NHS Foundation Trust CHUHSE

Homerton Row London E9 6SR

In Hours:020 8211 7769

Out of Hours: 020 8510 5794

[email protected]

CHUHSE Briefing for City and Hackney Urgent Care Board

Friday 25th July 10am

1. CHUHSE Story so:

Having succeeded in the competitive tendering process in the Summer of 2013 and having got the final go ahead in the Autumn of 2013 CHUHSE went live on the December 2nd 2013. The CCG was given data about the number of calls received by our predecessor which meant that we were taken by surprise by the sheer volume of calls from day 2 onwards, despite there being no real advertising of CHUHSE’s existence in the local press other than the usual Christmas and New Year advice.

This presented us with significant challenges and meant that meeting the National Quality Requirements for telephoning 95% of patients back within one hour or within 20 minutes if deemed as Urgent by the Call Handlers was initially impossible.

We rapidly developed a system of providing Home Working experienced GPs using the Adastra IT system via a secure system and making voice recorded phone calls to patients. In addition we added more doctors to the rota at peak times and located doctors in the PUCC Treatment Room and in our Portacabin office for phone triage.

The adaptations made in order to meet demand safely would not have been possible without the cooperation of the Homerton Hospital and Winter Pressures funding from the CCG.

We are continuing to recruit new GPs to work for CHUHSE, both those working and/or trained locally (5 doctors in the past month all meet these criteria) and those from outside the area with appropriate experience. This is because we need to continue to replenish our pool of doctors: some have left the area, some are too exhausted to take on OOH work and one doctor was removed from the rota due to concerns about their practice.

mailto:[email protected]

The following demonstrates some of the key improvements

NQR9

June 2014

(Month 7) May 2014 (Month 6)

April 2014 (Month 5)

March 2014 (Month 4)

February 2014 (Month 3)

January 2014 (Month 2)

ILTCs 100% 100% 0% 43% 57% 0% Urgent 95.9% 90.5% 89% 89% 79% 79% Routine 96.6% 94% 92% 90.5% 81% 86%

NQR 12

PCC

June 2014 (Month 7)

May 2014 (Month 6)



Febuary 2014 (Month 3)


Urgent 100% 97% 93% 90% 94% 100% Routine 99.7% 99.5% 99% 100% 100% 99%

Home Visits

June 2014 (Month 7)

May 2014 (Month 6)



Febuary 2014 (Month 3)


Urgent 95.7% 91% 84% 100% 93% 96% Routine 95.2% 99% 97% 100% 99% 100% Staff were TUPE’d over from the previous provider and we employed some new staff as well. The staff are expected to take a greater responsibility e.g. leading shifts which was not required in their previous jobs and this has involved extensive training by our small management team, who have provided on call support to staff every hour that we have been live.

Under pressure from the local GP trainers we started to provide training for GP Registrars in May 2014 and have helped several local Registrars to complete their required sessions to qualify as GPs at the end of July. This has required recruiting appropriately qualified GP OOH Supervisors and developing a rota which matches supervisors to the appropriate Registrars. One young GP had 10 sessions outstanding which she has now completed in this period!

The governance of the organisation has continued to be developed including:

• Set up of CHUHSE Board and Committee meetings commenced. Board Meetings are set up bi-monthly and the first meeting is planned for the 24th September 9.30am-11.30am.

• Set up of CHUHSE bi-monthly Clinical Governance meeting is in progress to oversee all clinical governance e.g. procedures, policies, incidents, performance and audit.

Monthly clinical audits of GP records have been undertaken since January 2014, with 5-15% of each doctors’ records being reviewed anonymously using an IT tool, Clinical Guardian. All doctors have received feedback about their work.

• Set up of CHUHSE Financial Governance meetings e.g. Finance and performance committee, Audit Committee, Remuneration Committee.

• Staff structure is being reviewed in line with business requirements. • Staff Meetings

2. Plans for call handling in the autumn: 1st September 2014 transfer of call handling from Tower Hamlets to CHUHSE. Interim Project Manager employed to support the safe and efficient transfer of service. Interviews held on 10th July 2014 and successful candidate commenced week of 21st July 2014.

3. Overnight nursing This is a service to provide out of hours acute district nursing type care for adult patients between midnight and 8am. The intention is that by providing catheter care, emergency dressings and palliative care interventions such as setting up syringe drivers all through the night some admissions can be avoided. Service is commencing mid-August 2014. Interim CEO and Medical Director met with Head of Nursing, Homerton Hospital on the 8th July 2014 to discuss development of service. Initially a bank of Band 7 nurses will be used (e.g. current District Nurses, PUCC Nurses, Site Managers).

4. CHUHSE has provided input into the development of the One Hackney Vision from the outset and has prepared a new additional bid such that CHUHSE can deliver a part of the One Hackney vision through the Urgent Care Board. A first draft of a bid has been developed and submitted to the commissioners for feedback. The funding requested is to provide an overnight on call GP who can manage phone calls, allowing the night CHUHSE GP to remain in a patient’s home for longer if necessary, plus a night time care co-ordinator.

5. Other strategic issues.

Paradoc, the service whereby a GP and a Paramedic are called to the homes of patients who called LAS, but who might be able to safely stay at home with the appropriate input, went live in March 2013. Whilst this is a GP Federation provided service it would have been impossible without the CHUHSE infrastructure of rota management, GP payment systems, GP equipment provision and drug dispensing arrangements.

We look forward to working with the CCG and the GP Federation on further projects to improve primary care out of hours.

Front page

Hackney health services for parents with small children – find out where you can get fast local care for your child Having a sick child can be stressful. This guide helps you figure out how to get the right care for your child and where to go to get the best advice. You can also click here (dedicated kids page on CCG website) to get the most up to date information in your area Page 2-3

There’s often better options than A&E It can be difficult to know when to call an ambulance or go to the accident and emergency (A&E) department, but use the following as a guide.

Comment [M1]: Different content for printed and online versions

1

A&E is a service for emergencies- there are many other health professionals who can provide expert advice for most of the injuries and illnesses your child may face

Call an ambulance for your child if they:

-stop breathing -are unconscious or seem unaware of what's going on

-won’t wake up -have a fit for the first time, even if they seem to recover

-are struggling for breath (you may notice their skin being sucked in under the ribcage)

Take your child to A&E if they:

-have a fever and are persistently lethargic, despite taking paracetamol or ibuprofen

- have severe abdominal pain -have a cut that won't stop bleeding or is gaping open

-are having difficulty breathing (either breathing fast or panting, or they are very wheezy)

-have a leg or arm injury that means they can’t use the limb

-have swallowed a poison or tablets

During normal working hours Evenings/Weekends/Public Holidays

Child health clinics are held at 36 venues in the borough. Your local clinics are able to help if your child is experiencing problems with: - Feeding or breast feeding concerns or difficulties -Get your child immunised -Nappy Rash -Growth -Nutrition -Sleeping

http://www.homerton.nhs.uk/our-

services/childrens-services-in-the-community/

You can often get an appointment on the day at your GP surgery if you call as soon as they open (check times) and many surgeries have drop-in slots. Your GP can help your child more quickly and locally if your child is experiencing symptoms for: -Conjunctivitis -Constipation -Diarrhoea -Ear Ache -Eczema -Headache -High Temperature -Sore Throat -Stomach ache and vomiting

There are 49 pharmacies in Hackney, your local pharmacist can advise and help if your child is experiencing any of the following: -Chicken Pox (if your child is over 4 weeks old) -Common colds and coughs -Sore throat

NHS 111 is available 24 hours a day, seven days a week. It can provide medical advice and details of the best local service that can provide care. Telephone consultations and triage (an assessment of how urgent your medical problem is) are an important part of all out-of-hours care. This service was previously known as NHS Direct

Hackney’s out-of-hours GP service is provided by City & Hackney Urgent Healthcare Social Enterprise (CHUHSE). They can be contacted on 020 8185 0545

Whenever you visit a health service for your child, be sure to take their Red Book with you- this way the

professional will have the main record of your child's health and development

EMER

GEN

CIE

S

Comment [M2]: This content is lifted from NHS Choices http://www.nhs.uk/Conditions/pregnancy-and-baby/pages/accidents-what-to-do.aspx#close

Comment [M3]: The content on fever requires local clinical guidance

Comment [M4]: Does the Urgent Care Board have a view on community pharmacists advising on chicken pox?

2

http://www.homerton.nhs.uk/our-services/childrens-services-in-the-community/

http://www.homerton.nhs.uk/our-services/childrens-services-in-the-community/

http://www.nhs.uk/Conditions/pregnancy-and-baby/pages/accidents-what-to-do.aspx%23close



Pages 4-5

Centrespread map with A&E, children’s health centres, GP practices and pharmacies highlighted and listed.

3

Pages 6-7 List of Child surgeries and Immunisation clinics Clinic Child Health Clinics and your GP practice are usually closer to your home, waiting times are normally much longer in A&E, and you can find a child friendly environment at child health clinics within children's centres. You don’t need an appointment and will be seen by a qualified health visitor, who are registered nurses or midwives and are specialists in child health and development.

4

(back page)

Useful numbers CHUHSE 111 Late-night pharmacies A space to write in GP contact details A space to write in key medical details

Write your child’s name(s) and age (s) here: Allergies to medication Other allergies Medical conditions, if any

Write your child’s GP details here: Name Tel Email Address

Comment [M5]: Include 24 hour pharmacy on Old Brompton Rd? (Zafash)

6

Urgent Care Programme Board

Month 2 Finance and activity data for Urgent Care

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111 key headlines Activity • The number of calls to the ELC 111 service has continued to rise during May at a consistent rate to that reported during April (120% of commissioned call

volumes for the month). Taking into consideration achievement against the 15 financially linked KPIs this equates to a £6.7k cost pressure to the CCG for the month and £13k YTD.

• In total, 10,290 calls were received by the ELC service for the month, of which 64% were triaged. City and Hackney CCG accounted for 31% of total calls (it is important this includes an equal split of the out-of-area calls received by the service*).

Performance • The service achieved the 95% threshold for calls answered within 60 seconds (96.9%) and the call abandonment threshold (4.2%) in May. In month the

service also performed consistently against the London average for the number of clinical call backs achieved within ten minutes, achieving 69.5%, against a London average of circa 58% (fig 25.1, slide 25).

• Unfortunately, early indications suggest performance for June has not been as strong with 94.8% of calls being answered in 60 seconds and 5.4% of calls abandoned. Both measures therefore falling below the contractual requirements for the month. Where required weekly exception reports have been shared with NHSE and non-achievement for the month will be managed in accordance with the appropriate contract leavers and a proportional reduction of the 20% performance payment for the month for each KPI not achieved.

• The service has experienced 0 SIs (since launch). Six HCP feedback forms were however received in May, mainly relating to incorrect referral to OOH based on catchment area and / or GP opening times (e.g. patients referred to OOH services during the in-hours period). Action has since been taking by the Provider to prevent future occurrence. However, while this has not been raised as a consistent issue in ELC or in London, the appropriateness and timeliness of OOH referral will continue to be monitored to ensure clinical safety.

• Increased activity across April and May has also been seen in the ONEL 111 service. It has therefore been suggested that increased activity across both services may be a result of increased public awareness driven by the use of more pro-active advertising locally across Barts Health sites.

• * It is important to note the number of out-of-area calls received by the

service remains significant (57% of calls during May). As a result of this, it was agreed at the ELC 111 Contract and Performance meeting held in June that an audit to provide detail of the CCG source of all non-ELC calls will be completed over a defined period to gain a better understanding of the issue, including the impact of the City’s commuter population on this.

111 Fig 3.1 ELC NHS 111 Access April 2013 – May 2014

Fig 3.2 ELC NHS 111System Impact 999 Referral April 2013 – May 2014

Fig 3.3 ELC NHS 111System Impact A&E Referral April 2013 – May 2014

Key messages

• The number of calls transferred to 999 in May (fig 3.2) has also remained consistent with previous months (circa 10% referral). However, due to the sensitivities around this an audit is also due to be completed in July in collaboration with the LAS, to provide a greater insight of 999 generated calls, including the true local impact on the LAS as a result of the implementation of 111. The audit will also look at how many ELC 111 referrals to the LAS are re-triaged successfully i.e. not requiring an ambulance.

• While 999 referrals for the month have remained broadly steady, the number of calls referred to A&E has increased 0.8% in May compared to the previous month (fig 3.3) Conversely, the number of calls referred back into Primary and Community care has also increased by 1% in May.

UCB Considerations key areas for progression during July are as follows: • Ongoing contract management and clinical quality review in line with business as usual processes. The next quarterly CQRM, including OOH, LAS, NHSE Primary Care

and Patient Representation is due to be held on 31st July. Unregistered patients, frequent callers and an end to end call audit of 999 referral will form the main agenda items.

• Completion and early evaluation of the GP intervention pilot (being led by the London Learning Programme) running until 25th July. • Further investigation to be completed into the source and impact (activity cost, resource & clinical quality) of out-of-area calls on the ELC 111 service; • Completion of an audit of referrals to 999 to gain greater clarity of 999 activity driven by the ELC 111 service, as well as the appropriateness of referral, as per LAS

action plan; • Following the initial briefing paper presented to CCG Urgent Care Boards outlining the recommended next steps for the future of 111 locally, ongoing discussions are

to be had with all three ELC CCGs to scope the work and support that may be required to identify and secure the most optimal and robust service model for 2016/17. 3

London Ambulance Service

• When compared to April activity, in May there was an increase of 9,5777 calls to 999 pan London and a slight increase in LAS activity overall (fig 4.2). This however, only represents a small increase on 2013/14 levels, 198,417 in April and May 2014 compared to 195,473 in April and May 2013.

• The number of City and Hackney patients conveyed to A&E in May is also down on the previous month (April 2014) and for the same month (May 2014) last year, 3% and 6% respectively at 58.4% for the month. This is significantly lower than the Pan London average of 66.6% for the month.

• Overall, non-conveyance was also up 2% for the month and 5% compared to

the same month last year. This is likely to be a result of increased utilisation of ‘see, treat/refer, ‘hear and treat’ and DMP implemented by the LAS as they work to improve emergency performance.

• Poor performance against the Cat A8 target has continued into M2, with the LAS achieving 70% pan London and 73.8% for City and Hackney (68.8% Newham, 65.7% Waltham Forest and 74.1% Tower Hamlets). While poor performance is ongoing, patient safety and clinical risk continues to be monitored in response to increasing CCG concern. In May, 98.9% of Cat A calls were reached within 23 minutes. The longest waits continue to be monitored on an individual basis.

• As previously reported, poor performance continues to be attributed to: - A lack of resource caused by attrition in the paramedic workforce, inability to

recruit and reluctance to take up overtime in the remaining workforce - Slight activity growth. At the end of May 2013 activity in City and Hackney is

up 2.2% compared to May 2013 and up 2.3% pan London.

Fig 4.1 City and Hackney CCG Category A Incidents 2014/15 Key messages

UCB Considerations

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Fig 4.2 LAS Pan London Activity -Calls, Incidents & Responses 2014/15

1. Continue to support Brent CCG as lead commissioner and NHS England to challenge poor performance at LAS, maintain a safe service and implement the turn around action plan set out in next slide.

2. Monitor activity to determine if demand continues to increase beyond the 3.0% threshold for contractually funded activity growth. 4

Key messages • A&E activity at the Homerton is consistent with the current national

trend • The Urgent Care Programme Board is committed to delivering its

strategy to encourage patients to contact primary care in the first instance and not revert to A&E as a default.

• A number of these schemes have not yet mobilised or are in very early stages, however the board is confident that the strategy coupled with a good communications plan will see more activity diverted away from A&E

• Some of the outcomes the board has hoped to achieve are now being realised, the OOH activity for example has been increasing with very good early feedback from patients, users and stakeholders. The referral rates to A&E or LAS from the OOH service are below 3%

• The numbers shown in fig 33.1 for OOH activity are not correct as the provider had 2511 contacts in May not over 5000. An updated chart will be available at the next FPC

• The board will look at why there was a decrease in PUCC activity May as its been a strategy of the board to increase diversion rate to the PUCC. At the last analysis, PUCC activity was shown at 35% an increase from earlier on in the year of 33% so this month appears to be an outlier

• This month the board has been focusing on developing its plans for Winter resilience. The plan is to build on last year’s successful performance over Winter and introduce 1 or 2 innovations

City and Hackney Urgent Care Trend Analysis, April 2012 – May 2014

CCG Considerations • To note Urgent Care Board’s focus on delivering the strategy of

diverting activity away from A&E • Note the national trend experienced by most trust, as displayed in fig

33.2, whereby the traditional fall in A&E activity that follows winter has not occurred this year – the UC board is looking into that

• Support the Board’s Winter Resilience Plans

City and Hackney A&E Trend Analysis, April 2012 – May 2014

Urgent Care Programme Board – trend analysis 5

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Key messages

• This graph demonstrates that A&E activity for C&H is following the annual trends.

• There is however a slight growth in A&E activity overall and this follows a national trend

• This year is slightly different to previous years in that the traditional dip in activity seen after the winter period has not been sustained and has spiked quite rapidly in May.

• Nationally the focus is on integrating RTT, A&E activity and elective with a view to creating system resilience group to address performance across the whole acute pathway

• The City and Hackney Urgent Care Board is committed to delivering its strategy of seeing patients in primary care first.

Fig 6.1 City and Hackney A&E Attendance All Providers, April 2012 – May 2014

CCG Considerations

• Urgent Care Chair to meet with Clinical lead at Barts Health to give more detail on C&H strategy

• C&H UC strategy welcomed by London’s tripartite panel and was seen as an example of best practice

• UC Board to look at other high performing health economies to look at best practice and service development of the whole system

Urgent Care Programme Board – trend analysis 6

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