How can providers shape and inform the intentions of new GP Commissioners?

1. How can providers shape and inform the intentions of new GP Commissioners? Rick Stern NHS Alliance Lead for Urgent Care Director, Primary Care Foundation, rick.stern@primarycarefoundation.co.uk 07709 746771 Advanced Health & Care National Conference 24th May, 2011, Cotswold Water Park Hotel

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

3. Leadership Group for Urgent Primary Care

4. Purpose of this presentation • Open up a wider debate about 24/7 urgent care & start a process for informing urgent care commissioning in the new world of GP consortia • NHS Alliance Leadership Group meeting with Department of Health in July • Lead to a publication in the autumn

5. What I will cover • Background – what we know so far • Principles • Myths • Key Messages • Potential measures for outcome based urgent care specification

6. Sourcesall available from the PCF website at: http://www.primarycarefoundation.co.uk/downloads/reports-and-articles.html • ‘Review of Urgent Care Centres’, PCF, yet to be published • 
‘Commissioning out-of-hours care’, Rick Stern, Pulse, 16 February 2011 • ‘Improving out-of-hours care’, Rick Stern, GP Newspaper, 19 November 2010 • ‘Primary Care and Emergency Departments’, PCF, March 2010 • 
‘Improving out of hours care – what lessons can be learned from a national benchmark of services?’, PCF, January 2010 • ‘Urgent Care - a practical guide to transforming same-day care in general practice’, PCF, May 2009

7. A whole system perspective:urgent & emergency care components Patient • NHS Direct • General Practice • Out of Hours • Ambulance service • UCCS & WICs • Community Services • A & E From any of the above From clinicians Self care Episode complete Hospital Obs & Gyn Ortho Surgery Acute medicine Each component must work well - separately and as part of the whole

8. What we know: principles established in previous PCF urgent care research & reviews • Prompt care is good care – and it is cost-effective. • Patient satisfaction and speed of response are linked. • Most service users are accessing care in the right place. • Demand is pretty predictable. • Matching supply to demand works. • Queues are usually caused by management and governance decisions. • There are risks of regular preliminary assessment or ‘triage’ • Measuring individual clinical productivity drives improvement. • Urgent care is about the whole system - A&E does not offer a ‘quick fix’. • There are benefits in integrating primary care skills into a multi-disciplinary team – but primary care is not a ‘magic bullet’. • We need good measures of each part of the system, and the whole.

9. Principles • patient safety always comes first • capacity should be closely matched to real demand • clear objectives should be set for all component services being commissioned • clinical and operational governance must apply consistently to all patients and pathways • changes to services should be evidence-based where possible • commissioning must be led by clinicians from the key component services of urgent care • quality must be measured and proven, not asserted – quality should be measured both within and across component services • activity and outcome data should be produced in as close to real time as possible

10. Myths • There is always too much demand for service to cope with • Patients misuse urgent care services (or the myth of ‘inappropriate attenders’) • It is important for commissioners to educate the public about services • It is safer for patients and better for services, to assess and triage everyone • Much of the care being delivered in A&E is primary care • There is a direct link between A&E attendance and hospital admissions • Commissioners are required to tender out of hours services

11. 1-5 key messages for commissioning urgent care • Patients will make their own judgement about what they think is urgent. • Recent policy has increased patient choice but led to more confusion. All commissioners should take a fresh look at their urgent care strategy taking a hard look at the range of disparate services commissioned over the last 10 years. • We need to make it easier for everyone to understand how to access urgent care. • 111 will make it easier for patients, but only if it sits above an effective, integrated system. It is not an end in itself. • General Practice is the bedrock of any urgent healthcare system.

12. 5-10 key messages for commissioning urgent care • We need to look at consistency nationally in how we refer to services, with a clear list of minimum services and standards so that patients would know what to expect. • We need to develop system wide metrics but also ensure that we understand the performance of each part of the system. It’s not one or the other but both. • We have found a strong link between how quickly patients are seen and what they think of the quality of the service. • There should be a greater emphasis on commissioning for quality, including making clear the ‘quality cost’. • There remains a heavy reliance on triage or assessment when it would be much more effective if the service was designed to see and treat patients straight away.

13. 11-15 key messages for commissioning urgent care • Urgent care services, like all health services, have variable demand, but demand is predictably unpredictable. • We have found repeatedly that services that support clinicians to work well together in an integrated team provided a better quality of care. • Urgent & Emergency Care Networks have an important role to play in leading local health care systems – but they need real executive authority and budgets. • Fragmented services, with different organisations working alongside each other without any clear agreement about governance put both staff and patients at risk. • Think about the culture of the service as well as outcomes e.g. do they learn from others about when things go wrong?

14. 16-19 key messages for commissioning urgent care • Any new currency in the NHS such as developing shared tariffs to incentivise new ways of working, require a high level of co-operation at all levels. • We need to align the financial incentives and ensure that commissioners stop paying more than once for the same service provided at different points in the system. • The tendering process is costly and should not be seen as the default position for commissioners in urgent care. • Commissioners need to take an active role in the urgent healthcare system.

15. Developing an outcome based specification for 24/7 urgent care – potential measures the metrics for successful 24/7 urgent care in your community might include: • Time from arrival to treatment (not triage assessment) median – but look at % in 30 minutes – and to look if all acute/pain in this time • Median time from arrival to completion • % of patients that re-attend the service within seven days for the same or a related condition where this was not planned • % of cases where the patient left without being seen • % of cases where full information (history, examination, results, diagnosis, treatment, follow-up action) is made available to the GP before the start of the next working day • Some specific measures associated with sentinel conditions (time to pain relief, follow-up after falls etc.) • Use consistent nationally validated measure of patient experience across services

16. How to add your ideas … If you have any ideas or suggestions for How providers can shape and inform the intentions of new GP Commissioners? Please get in touch: Call Rick Stern on 07709 746771 Email: rick.stern@primarycarefoundation.co.uk For more information on PCF go to: www.primarycarefoundation.co.uk For more information on the NHS Alliance go to: http://www.nhsalliance.org/