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Item 4.4 PRINCIPLES for DELIVERING out of HOURS UNSCHEDULED CARE

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Item 4.4 PRINCIPLES for DELIVERING out of HOURS UNSCHEDULED CARE Highland NHS Board 3 February 2015 Item 4.4 PRINCIPLES FOR DELIVERING OUT OF HOURS UNSCHEDULED CARE Report by Gill McVicar, Director of Operations, Tracy Ligema, Area Manager, West and Evan Beswick, Project Manager on behalf of Deborah Jones, Chief Operating Officer The Board is asked to: • Note the outputs of the Steering Group workshops • Discuss and agree the key principles for a new model of care • Consider having a Non Executive Director on the Steering Group • Endorse the plan for the next steps including opportunistic changes based on the key principles 1 BACKGROUND AND SUMMARY 1.1 Introduction The Out of Hours service in NHS Highland is a patchwork of local arrangements that have been successful in providing cover in this period but which are increasingly difficult to sustain due to staffing models, lack of GPs working in the system, high use of Locums and the current level of spend which is not affordable. The cost means that other important and urgent developments are not able to be progressed, thus creating an opportunity cost as well as an overspend. With the changing demographics and the need for more community based care, this is no longer acceptable. At present, there is limited cooperation across boundaries which can lead to one area being extremely busy and staff stretched whilst another has very low activity. There are also different pay rates across area boundaries which can lead to quieter areas being more attractive to the workforce than those parts where activity and need is greater. This paper will outline the current service, highlight the need for change, provide information on activity and performance and propose key principles to be used to redesign the service to make it more sustainable and affordable whilst also ensuring that it is safe, integrated to in- hours services and the Local Unscheduled Care Programme and with key Partners, in particular, Scottish Ambulance Service. 1.2 Background The current Out of Hours [henceforth OOH] service has been in place since 2004. It was put in place very quickly to allow the opt out of GPs as agreed through the General Medical Services contract of that year. Of necessity, it was piecemeal, due to the fact that there were only two existing OOH cooperatives in Inverness and East Ross and most Practices had continued to provide out of hours services in the traditional way. Attempts to change since then have also been opportunistic, and in many cases, resisted, although some significant improvements have been made, especially in the larger centres such as Inverness, East and Mid Ross, Caithness and Fort William, where it has been possible to be better integrated with A&E departments, be more multi disciplinary, and cover larger areas. In 2008, the responsibility for out of hours was devolved to localities to allow very local agreements to be put in place and this has been successful to some degree especially in maintaining service, but has led to a fragmented approach, lack of ability to cross cover and it is extremely expensive. In addition, it has been increasingly difficult to attract Doctors into the service and last minute arrangements are significantly more expensive. The different pay 1 rates also makes it inequitable. This is a national problem (see §3.4.3 Media Coverage), made particularly acute in Highland by the difficulty of attracting GPs to the more remote parts of the region. Argyll and Bute CHP is involved in discussions and has intimated the need for change there as well. However, there are more business to business contracts in place and it will take some time to move to a new model, but the key principles will also apply there. A limited home visiting policy already applies in Argyll and Bute. It is important to note that the OOH Primary Care service must be differentiated to an emergency care service of the likes provided by the Scottish Ambulance Service or by hospital-based Emergency (A&E) Departments. OOH in Primary Care is concerned with delivering urgent care of the sort that you would make an appointment to see your GP about as opposed to dire emergency care which should be through the ambulance service. The minimum NHS 24 disposition time of 1 hour in primary care (compared to an 8 minute ambulance response time for the most serious emergencies) is reflective of this. In rural areas, however, due to the distance that ambulances require to cover, communities still rely on having a doctor or nurse close at hand and this is not going to be possible or desirable in all communities in the future. There is a memorandum of understanding (Appendix 2) in place with SAS who accept the responsibility for emergency care and who have been working to develop more resilient models, working with communities on initiatives such as public access defibrillators, First and Emergency Responders. NHS Highland has been working closely with SAS on this. Primary care is only one of a number of OOH care providers, including: NHS 24; Accident and Emergency Departments; Minor Injuries Units; Pharmacies, Emergency Ambulance Service; Emergency Dental Services; Social Work emergency services; Home care; Community Nursing; Mental Health services. 1.3 Work so far Two very successful and well attended workshops have been held with clinicians and managers, where the current service was discussed and analysed and a potential future model described. There was unanimous agreement that a Highland wide networked approach is necessary to build sustainability for the future at a more affordable cost. In reality, Highland comprises a city, several large towns, small towns and villages, and very rural communities. In the past, models have attempted to meet local demands more than local need and there now needs to be a more robust plan that reflects actual activity and recognises that with improved technology and travel times, a more networked approach is possible and that changes will be required to ensure that the available resource is better utilised both in and out of hours Those attending the workshops have agreed to form the Steering Group and a smaller Taskforce has been established to develop the detail and to formulate the action plan for consideration. 2 CURRENT SERVICE The Highland Hub provides a local call handling and support service for the system linking with NHS 24 and the local responders. The typical patient pathway begins with a patient calling NHS24 (‘111’). This call will be triaged and completed through the provision of advice for self care, or passed to the emergency services or the Highland Hub. At the Highland Hub, the call becomes the responsibility of NHS Highland. The Hub dispatch the call locally as appropriate. A flow diagram for this pathway is provided in Appendix 1. In Highland, there are four main models for local processing of OOH calls: 2 a. Highland Hub triage to PCECs b. Highland Hub triage to GP areas (especially in remote and rural locations) c. Patient walks in to PCEC (may either be seen, or directed to a phone to call NHS24) d. GP areas provide initial call triage (Nairn, North-West Sutherland) This variation is largely due to the arrangements in place since the 2004 GPs contract when practices (not individual GPs) were able to opt out of providing OOH care. The majority of practices did opt out, with responsibility for OOH provision allocated to the health board. Some practices remain opted in, retaining responsibility for ensuring OOH provision in their practice area (the board cannot mandate a practice to opt in or opt out). A number of these practices chose not to use the NHS24 triage, opting instead to give a phone number to their patients. It will be noted below that this causes problems for data collection. Where practices do not use NHS24 triage, activity data may be collected. This may, however, lack the detail provided by NHS24 (see §4.2.1 Data caveats). Where GPs are opted in, they have responsibility for their own practice area (unless by agreement with neighbouring practice areas. A Primary Care Emergency Centre (PCEC) covers a number of practice areas. In Highland these are frequently co-located with an Emergency Department (A&E), or a Minor Injuries Unit. The locations of OOH Practices and PCECs are provided in Map 1. Map 2 shows the drive times for many of these locations. Map 3 illustrates the population densities across NHS Highland. Map 4 shows the locations of Scottish Ambulance Service vehicles and first responders. 3 Map 1: PCEC and GP Area locations 4 Map 2: Drive time extents from a number of OOH locations 5 Map 3: NHS Highland Population Distribution (as at 2008) 6 Map 4: Scottish Ambulance Service vehicle and First Responder locations 7 These maps illustrate the following: i. That, in most instances, PCECs are concentrated around the areas of high population ii. That a number of areas of lower populations are well-served by PCECs (e.g. Skye, Alness/Golspie, some parts of Argyll &Bute) iii. That a number of PCECs are within an hour’s drive of each other (1 hour being the minimum NHS24 disposition at present) iv. That PCECs and GP locations are frequently positioned in line with drive times, rather than the shorter distances that could be accomplished using sea and air transport. This should be built into further modelling of transport times. v. That, even before changes in the service, populated areas of Highland are outwith areas that can be reached within a 1 hour primary care response time. This paper does not propose to distribute Primary Care OOH by travel times. Rather, what the present picture demonstrates is that the unique remoteness and rurality of Highland means there is a pressing need to respond differently using non-traditional methods – for instance drawing upon first responders, duty paramedics, BASICs responders or developing skills and assets within communities.
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