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

1. Meeting the quality and productivity challenge in out of hours care: what can we learn from the out of hours benchmark? Rick Stern Director, Primary Care Foundation, NHS Alliance Lead for Urgent Care rick.stern@primarycarefoundation.co.uk 07709 746771 Improving Patient Safety in Out of Hours Care 22nd June 2010

2. What I will cover • The current context – learning from recent reviews • The out of hours benchmark – what we can learn about quality and productivity • How can this lead to improvements in patient care and safety? • Shifting the focus: from organisational to individual • Improving the benchmark • Where are we heading … the future of OOH and urgent care

3. New Leadership Group for Urgent Primary Care

4. Emerging Priorities • Patient Safety • Integrated Urgent Care • Demonstrating quality • ‘Rebranding’ Out of hours

5. The Primary Care Foundation developingbest practice in primary and urgent care A resource for commissioners of urgent care

6. A long history of reports and reviews … • Department of Health (Carson Review, 2000) Raising Standards for patients: new partnerships in Out-of-Hours care • National Audit Office (May 2006) The Provision of Out-of-Hours care in England • Four inner London PCTs (May 2007) Report into the death of Penny Campbell • Health Care Commission (September 2008) Not just a matter of time: A review of urgent and emergency care services in England • Primary Care Foundation (January 2010) Improving out of hours care: what lessons can be learned from a national benchmark of services? • Department of Health (February 2010) Out-of-Hours Services: project to consider and assess current arrangements and still to report … • Care Quality Commission (still ongoing) Enquiry into Take Care Now

7. What can we learn from recent reports on out of hours services? Key areas in the Department’s Review • Commissioning and performance management, including tackling inappropriate variation • Selection, Induction, Training and use of out-of-hours clinicians (including the use of locums) • Management and operation of Medical Performers Lists Actions following on from the Review: • Reviewing the National Quality Requirements • Developing a new national model contract for OOH services • Stronger performance management (including use of English and applying the performers list) • Greater involvement of local GPs But we now have a new government …

8. Developing the benchmark • Awarded tender by DH in November 2007 • Numerous pilots including across all of North East • National advisory group to steer progress and set price • Established three years support, with benchmark every six months and patient experience survey once a year • Currently over 100 out of 152 PCTs in England are members

9. Developing the benchmark:rounds 1, 2, 3, & 4 • First benchmark completed March 2009 with reports on 63 services and half-day workshops for commissioners & providers • Second benchmark, with reports on over 90 services, completed November 2009,with first patient experience survey managed by our partners, CFEP UK Surveys • Third benchmark reviewing performance at period of peak demand at Christmas 2009 and New Year 2010 – to be completed by end July 2010 • Fourth benchmark, again a full benchmark including patient experience – to be completed October 2010.

10. How does it work? • Data extract – most from one information system but now working with a number of others • Web based questionnaire for commissioner • Web based questionnaire for providers • Validate data • Produce reports • Workshops • Anonymity – about to change • Steering group and user group

11. 12 headline indicators Cost Cost per head Cost per case Productivity Number cases per clinician per hour Outcomes Referrals to hospital (if possible, sub-divided between referrals to A&E and referral to a hospital bed) Overall breakdown of dispositions (advice/PC Centre/home visit) % Calls classified Urgent on receipt Process The quality of clinical governance systems and processes Performance Time to clinical assessment for all calls as a %age Time to face to face consultations for urgent calls (including % urgent after assessment) Patient Experience Patient experience of receiving telephone advice Patient experience of treatment at a centre Patient experience of home visits

12. The evidence suggests …Out of hours services are improving … despite what you might hear in the media Most providers have made a rapid transition from ‘rota organising clubs’ into true healthcare providers. In doing so they have got much better at: • Matching capacity to predictable demand, giving ample time for clinicians to do their work well • Meeting performance standards • Introducing governance processes to ensure a consistent and safe response to patients • Engaging local clinicians in the service.

13. A rapid response matters to patients • Patients value a responsive service and associate this with good care. There is a wide difference between wide the difference is between the responsive and the comparatively slow.

14. There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received Each dot is one PCT

15. Seven years on, most providers are still falling short on a key NQR Many providers are falling short on the standard for definitive clinical assessment of urgent cases which we see as an important issue of patient safety.

16. We reported the percentage of urgent cases that were assessed in 20 minutes… Each bar is one service – a provider/PCT

17. There is a very striking variation between services in the proportion of cases identified as urgent on receipt Percentage of cases identified as urgent by non clinical call-handlers How safe? How safe? Each bar is one service – a provider/PCT

18. Coding needs to be improved …In far too many services it is impossible to be sure how many patients make their way towards hospital We know that many services, particularly to the left, are under-counting patients going towards hospital Each bar is one service

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

20. Using this measurement of productivity to drive improvements in care • An example: an out of hours provider who were part of earlier pilots • Concerned that productivity was low • Looked at productivity by each clinician – reported this back and reviewed performance with clinical manager • Also looked at other factors. Identified some doctors regularly late for sessions and others not picking up calls when no visits at centre. • Results included: • Productivity more than doubled • Clinicians happier that workload was more evenly spread • ‘by making clinicians more productive - supporting them as necessary, sorting out the problems that they face and addressing one or two poor performers – it has improved care for patients because clinicians can focus on the job that they are there to do’ • Learned that variations in performance tend to be less about external factors (e.g. geography, demography) and more about how staff are supported and managed.

21. Improving Patient Safety - responding to low level of urgent cases on receipt • Concern about benchmark results led to a rigorous base line audit of calls taken and priority given. • Call handlers clear about life threatening calls & A&E referrals • Other specific areas identified that could be addressed by training - designed to develop each call handler’s confidence and knowledge • Results included: • post training audit showed that % of urgent calls has increased and is moving towards the national average • more importantly, has shown to be appropriate to each presenting case as evidenced by the end priority given by the consulting clinician • Supported and reassured call handlers - benefitted from extra training and comparing how they work with others • Better identification of urgent needs improved patient safety

22. From variation across organisations to variation between clinicians • There is substantial variation within a typical service between individual clinicians. The response will often be shaped more by who deals with the case rather than the details of the case itself. • Developing a consistent, safe and appropriate response does not just involve looking at the outliers, but involves consistent feedback to individuals comparing them with their peers so that they can identify specific things that they might do differently for the benefit of patients and the service.

23. Future Changes … For services • All services need to ensure that they are using the results work out how to improve local care – it is about using national comparisons to drive local improvements • Recent reviews have highlighted the importance of good recruitment, induction, training and continuing support of staff. • Some services need to make sure that they are responding to calls more rapidly than is currently the case For the OOH Benchmark • The benchmark will extend to cover all these areas •  Making the benchmark more open and transparent will ensure that it is more useful to services as a tool for driving improvements • Creating a new governance group as well as a user group

24. Key Issues for the future • Patient Safety • A new initiative for rapidly sharing learning? • tighter rules or a cultural shift? • Focus on learning and improvement • responding to benchmarking and other comparisons across and within organisations • Better internal scrutiny – good governance and independent NEDs • Greater openness and transparency • Working as part of an integrated system • Networks and accountability • Three Digit Number • Clarity for the public and patients about using urgent care services • Commissioning for quality • Commissioning pathways • identifying the cost of quality in urgent care services

25. Discussion & Questions And for more information, visit our website at: www.primarycarefoundation.co.uk Or contact me: Rick Stern 07709 746771 rick.stern@primarycarefoundation.co.uk