Feasability study for the provision of cross border out of hours GP services
Item Type Study
Authors Moore, Adrian;Co-operation and Working Together (CAWT)
Publisher Impact Publishers
Download date 30/09/2021 23:42:05
Link to Item http://hdl.handle.net/10147/244585
Find this and similar works at - http://www.lenus.ie/hse ,
-.j.'i~ 'Inn>l"'lq "" V""'no l..lltUfl .( ...~ '_>.<;,--[Jo .i)fU>.'!"!\ 1"""11:<
\}". ,-~;, " ';~""~':~_,, __"': .~ ...-:;._ .. :,,;-, :::,;" ,;, ;.;;.;c;",;",,:,,:, :;,;)~.,,~}J"i
:l "x'::-f
;:.~.:. :t ':~: ~ , .'--::.- :~%::~~
:';:,::;: ';~i
x: :O;,;:@::';~~: .:-., :t ; :::~~:::: ,r.;~"" -:~.: .?: "",' .. '-~
:'om'.: ,",' .',
, :}:: ;:% '. -', ~ :S :",:' ;,;W'=- m q ::;;:: •
./w -.',' . ~::~::;4.. : .
::w:;::;_, _,w.
::3t<. '---'.~
,
::%
:;:;:;~: Feasibility Study for the provision of Cross Border Out of Hours GP Services
Authors: Adrian Moore, Carol McQuillan, Stephen McAlister, Joanna Freeman, Andrew W Mu rphy, Catherine Loughrey, Scott Brown © CAWT ISBN 0 948154 01 2
Printed & Published by Impact Publishers Co leraine & Ba llycastle Feasibility Study for th e provision of Cross Border Out of Hours GP Services
CONTENTS
page
Foreword 3 Acknowledgements 4 Executive Summary 5
1. Introduction 7 1. 1 Background 7 1.2 A Socio-Economic Profile of the Irish Cross-border Region 11
2. Methodology 15 2.1 Terms of Reference 15 2.2 Geographical Issues 16 2.3 Tech nical Issues 16 2.4 Professional and Business Issues 16 2.5 Methodologies Employed 17
3. Geographical Issues 19 3.1 Objectives 19 3.2 Methods 19 3.3 Data 20 3.4 Current 'within jurisdiction' primary care centre catchment a rea~ 21 3.5 Cross border 'irrespective of jurisdiction' primary care centre catchment areas 23 3.6 Areas which would be suitable for cross border out of hours arrangements 24 3.7 Popul ations and estimated number of people residing in areas that are closer to a primary care centre outside their residential jurisdiction 25 3.8 Gains, loses and net differences in catchment populations for each primary ca re ce ntre 26 3. 9 Con clusion 26
4. Technical Issues 28 4.1 Objectives 28 4.2 Methods 28 4.3 Technical eva lu ation of current call handling system and procedures employed by co-ops 29 4.4 Proposed Solution - Model for Cross Border Out of Hours Calls 33 4.4.1 Technical Architecture 33 4.4.2 Integrating GIS output into the ADASTRA system 34 4.5 Overview of Recommended Cross Border Ca ll Handling Procedures 35
5. Professional and Business Issues 39 5.1 General Professional and Business Issues 39 5.2 Objectives 39
1 5.3 Methodology 39 5.4 Medical Registration 40 5.5 Nursing Registration 41 5.6 Medical Indemnity 41 5.7 Procedures for dealing with cross border complaints 43 5.8 Attitudes of the Medical and Nursing Unions 44 5. 9 Premises Insurance 45 5.10 Hospital and Crown Indemnity 45 5.11 Ambulance Services 46 5.12 Patient Advocate Groups 47
6. Pharmacy Issues 48 6.1 Objectives 48 6.2 Methods 48 6.3 Current provision of Out of Hours ph armacy services 48 6.4 Evaluation of Options for Cross Border Co-a ps 49 6.5 Operational Issues 51
7 Additional Workload and Demand Issues 53 7.1 Objectives 53 7.2 Data Collection 53 7.3 Methodology 54 7.4 Estimating the number of people from NI who would be offered the choice of attending a RaI out of hours ce ntre in a one year period 55 7.5 Estimating the number of people from the ReI who wou ld be offered the option of attending a NI out of hours centre 57 7.6 Workload estimates for a one year period 60
8 Financial I ssues 62 8.1 Objectives 62 8.2 The current structure and fi nancing of co-ops in the study area 62 8.3 Comparison of financial systems 63 8.4 Important issues for a cross border service 64 8.5 A financial model for cross border transactions 66
9 Conclusion 68 9.1 Summary of Geographical Research 68 9.2 Summary of Technical Research 69 9.3 Summary of Professional/Business Issues 69 9.4 Overall Recommendation 69 9.5 Recommendations for a Pilot Scheme 69
10 Operational Plan for Pilot Scheme 72
Appendices 75 Appendix I - Profile of Research Team Members Appendix II - Attendees of Introductory Feasibility Study Workshop Appendix III - Recommended Pi lot Area Maps
2 Feasibility Study for the provision of Cross Border Out of Hours GP Services
FOREWORD However, on the basis of the research and various analyses, the In June 2001 CAWT conclusion is that the introduction commissioned a of a cross border G.P. out-of-hours study to be carried service is indeed feasible. Based on out by the University the r eport's recommendations, of Ulster, the National CAWT is now in a position to develop University of Ireland, a pilot scheme, which will be Ga lway and implemented for a trial period. Causeway Data Communications Ltd., to examine CAWT beJieves that such a service the issues necessary for has tremendous potential to improve consideration before cross border access to health care for inhabitants out-oF-hours arrangements could of the border region. One of its take pl ace. The results of this study many strengths lies in the fact that are now complete and are contained it adopts a locality-based approach in this report. to needs assessment and service delivery and indeed might be seen The research reveals that of the one as a first stage in the wider m illion inhabitants in the CAWT development of improving regional region approximately 65,000, across access to services, regardless of the length of the border, are closer jurisdiction. to G.P. out-of-hours services in the opposite jurisdiction. The report also I would like to congratulate all those highlights that over 70% of this who have contributed to this population live in areas that can be excellent study. CAWT will maintain classed as socially deprived. If a its support for this and for other patient were free to travel across the innovative developments in border to see a GP out-of-hours, the healthcare provision, as we continue travel distance, depending on to work for the benefit of our location, would be considerably resident populatians. reduced. Mr. Paul Robinson A number of detailed legislative, Director General of CAWT financial and practical issues have been raised in the feasibility study. It IS also c lear that the implementation af a cross-border service would require considerable organisation and preparation.
3 ACKNOWLEDGEMENTS
The authors would like t o acknowledge the assistance of all of those who contributed to this project. In particular, we would like to thank Fra nces McReynolds, Judith Doherty and the staff at the CAWT Resource Un it, The CAWT Secretariat and members of the CAWT Out of Hours Sub- Group, namely Tadhg O'Brien, Eugene Gallagher, Noel Scott, Eddie Ritson and Dr. Robert Thompson.
We are also indebted to all of those who participated in the va rious workshops throughout the duration of t he project (named in the Appendices), and especially to Dr. Brian Sweeney, Eug ene Dunn, Sharen Fu lton, Mark Armstrong, Joy Synnott, Ka te Mu lvenna and Martina Ralph for t heir valuable assist ance and advice.
We were amazed at the level of enthusiasm, support and encouragem ent we received f rom the vari o us health service professionals on both sides of t he border, with whom it has been a pleasure to work.
4 Feasibility Study for the provision of Cross Border Out of Hours GP Services
EXECUTIVE SUMMARY and operational issues and a number of basic principles as guidelines, a A multi-disciplinary team of project management plan and academics, medica l professionals methodology was formulated, which and techn ical experts from the divided the key research tasks into University of Ulster, the National three d isti nct sections, University of Ireland, Galway, and Geographical, Professional and Causeway Data Communications Business, and Te chnical. Ltd., Colera in e, was commissioned by CAWT to undertake a feasibil ity A Geog raphic Information Systems study into the provision of cross approach was adopted to identify border out of hours primary care and quantify the areas and services in the Irish border region. populations in the border areas who The project, initiated through the could potentially benefit from the Primary Ca re sUb -group's Primary availability of a cross border out of Care Project 'Developing Primary hours service. It was shown that Care across Borders and circa. 65,000 people would be Boundaries', began in May 2001 and eligible for the service on the basis was completed in May 2002. This of living closer to an out of hours report presents the findings and centre on the other si de of the recommendations from the study. border. Further analysis revea led that the majority of those eligible The basic t erms of reference for the reside in areas t hat are deSignated study were 'to research jOint working as being materially deprived. and co -operation between professionals on a cross-border GP From the technical perspective, an ou t-of-hours arrangement and analysis of the current protocols, produce an operationa l plan processes, software and network addressing the organisational and solutions used by the various co management issues, which need to operatives in th e region was be considered before cross-border undertaken. It was fortunate that all co-operation can take place'. The of the co-operatives use the same study focused only on patients ADASTRA software as this faCi litated travelling across the border to seek the development of an inter care in primary care centres. The connected cross-border software option of GPs crOSSing the border to solution. provide home visits was not considered. A range of professional and bUSiness issues was investigated including Using an agreed set of core strategiC matters of professional registration,
5 indemnity insurance, prescribing and dispensing . It was concluded that most issues could be readily addressed with the exception of the dual registration issue, which should be resolved between representatives of the Boards, co-ops, GPs and the registration bodies.
A retrospective study of demand for co-op services over a one-year period was used to identify the potential increases and decreases in demand for consultations at primary ca re centres that operate on a cross border basis. In general, it was predicted that the co-aps in the North would experience a net gain in su rgery visits whist those in the South would experience a net loss. In addition, the current structures, funding and charging arrangements in each of the co-ops were examined and a proposal for the costing and administration of financia l transactions in a cross-border arrangement was put forward.
The resea rch team has recommended the implementation of a pilot study to test the system in practice before attempting a roll-out across the whole cross-border area. It is recommended that the service should be piloted in two areas, one where patients from NI travel to the RoI and the other where patients from the RcI travel to NI for care. An operational p lan for implementation has been devised. -
6 ~aSibility Study for the provision of Cross Border Out of Hours GP Services
1. Introduction
Improv ing the health and social The basic t erms of reference for the wellbeing of the population, study were 'to research joint working including access to primary health and co-operat ion between care, is a centra l component of professiona ls on a cross-border GP national, regional and focal health out-of-hours arrangement and strategies in both the Republic of produ ce an operationa l plan Ireland and Northern Ireland. In addressing the organisational and 1992 health boards on both sides of management issues, which need to the Irish border entered an be considered before cross-border arrangement (known as the co -operation can take place'. The Ba llyconnell Agreement) to co work began in May 2001 and was operate in identifying and addressing completed in May 2002. This report specific health and social needs in presents the find i ngs and the border region. Since then, the recom mendations from the study. formal entity created from the agreement, CAWT (the acronym for U Background 'Co-operating and Working Together'), has undertaken a series It is widely recognised that, relative of broad-ra nging projects and to national standards, border areas initiatives, organised through tend to suffer from high levels of various sub-group specialities. Th is material and social deprivation. The study was initiated through the reasons for this are many and varied Primary Care sub-group's Primary bu t tend to focus around general Care Project 'Developing Primary problems of rurality, peripherality Care across Borders and and low levels of economic activity, Boundaries '. which are compounded by the i nhibitive nature of political/ A multi - d isciplinary team ( See administrative borders. The Irish Appendix 1) of academics, medical cross-border region is a typical professionals and technical experts example, where these classic from the University of Ulster, the problems have been exacerbated by National University of Ireland, the consequences of 30 years of Galway, and Ca useway Data politically motivated conflict and Communications Ltd ., Co leraine, violence (Cook et al. 2000., Bond et was commissioned to undertake a aI., 2001, Moore et aI., 2001). feasibi lity study of the provision of out of hours primary care services It is also well recognised that the in the Irish cross-border region. more deprived populations tend to suffer from poorer levels of health and therefore tend to have greater
7 leve ls of need for health care pressures of service provisio n have services. I n addition, the more resulted in increased stress and deprived populations (even in urban reduced morale within the medical areas) also tend to have poorer profession (Hallam, 1994).
levels of access to health care • services. This is known as the Such co-operatives provide urgent 'Inverse Care Law' (Hart, 1972). primary care services for patients Poor access to health care can lead who require advice from their GP to low levels of utilisation, which can after their surgery has closed . The ultimat ely lea d to poorer health advice offered by the co-operatives outcome. Co nsequently, from a triage GP or nurse is provided either health care provider perspective, the via a telephone co nversation or a residents of deprived areas, consultation at an out of hours especially deprived rural areas, primary care centre. A much smaller which have poor access to services proportion of pa tients receive home may experience 'unmet hea lth ca re visits. needs'. I mproving access to health ca r e services is ther efore an A key feature of the new co impo rta n t issue for health operatives is that they operate from authorities in both the UK and the a limited number of centralised Republic of I reland. I mproving rural primary care centre (PCC) locations. access to health care is a particularly This has co nsiderable be nefits in importa nt goa l for loca l hea lt h terms of ra tionalising costs and authorities in the Irish border reg ion. significantly reducing the after hours commit ments of participating GPs Out of Hours Primary Care and/or: locums. An u nfortunate Services consequence of this arrangement, One of the most significant however, is that many patients who developments in the provision of requi re a pri ma ry care centre primary health care services in both consultation must travel a distance the United Kin gdom and the Rep ublic that may be in excess of 30 or 40 of Ireland in the 1990s has been the miles (O'Reil ly, 2001). Primary care m ove towards establishing co centres tend to be strategically ope ratives for the management and located in towns or near centres of delivery of out of hours services. The population in order to provide the mai n impetus behind th is best access for the greatest nu mber development has been the relentless of patients. The corollary of this is increase in demand for out of hours that popu lation s experie nc ing care. This ever-in creasing demand g enera l prob lems of access to for services and the associated primary care services during normal
8 Feasibility Study for the provision of Cross Border Out of Hou rs GP Services
surgery hours have even greater provision of services, which will problems with access to out of hours improve the health, and social well primary care centres. In the context being of their resident populations'. of the Irish Border region t he Investigating the opportunity for consequences are considerable, providing a cross-border out of hours given that there are few large service is therefore a logical step in centres of population along the pursuing that o bjective. A recent border corridor. study co mmissioned by the Centre for Cross-Border Studies (2001) It is recognised that many people entitled 'Cross-Border Co -operation Jiving in the border region actually i n Hea lth Servi ces in Ireland' live closer to an out of hours primary highlighted both the enthusiasm for care centre on the other side of the and potential benefits of providing border. To date, the number of cross-border out of hours services. people residing in such areas ha s not The report also suggested that the been quantified. Following on from implementation of such a scheme the general problems of availability could improve cross-border relations of and access to health care services at the primary care level and open in rural border areas, it is logical to the way for further co-operation. question whether it is possible to provide out of hours services on a Out of Hours Co- operatives in cross-border basis. The benefits Northern Ireland and the would appea r to be clear. If currently Republic of Ireland available out of hours services on In Northern Ireland, up until the both sides of the border were made early 1990s out of hours provision attainable on a cross-border basis, was provided by General then there would be a potential Practitioners working as part of an opportunity to improve access for on-call rota within their practices. In many people. 1995, the General Medica l Services CounCil (GM SC) negotiated a new Cu rrently, the political border deal for the provision of Out of Hours functions as a d iscrete entity Care with the Department of Health providing a finite demarcation and Socia l Security (DHSS). This had betwee n the two health ca r e three main areas of change. systems. A key objective of the 1. Developm ent fu nd money Boards and Trusts in the border area, became available for the set out in the Ballyconnell provision of Out of Hours Agreement (revised in 1998) is 'to services. exploit opportunities for co 2. It gave GPs the option of operation in the planning a nd transferring t heir out of hours
9 responsibility to another hours co·operative model arose from principal. increasing reliance on commercial 3. It established the right of a GP deputising services in urban areas to decide whether the patient where there were concerns about needed an out of hours the supply of suitably qualified locum consultation and, if they did, doctors. There were also concerns where this consultation should that these commercial ventures take place . were not widely available in rural areas. In 1997 and 1998 These cha nges provided the basis agreements were reached between for the formal establishment of the the Department of Health and out of hours co·operative system Children and the Irish Medical that exists t oday. Although the first Organisation which a llowed GP co-operatives within the NHS significant adj ustments i n the were established as early as 1970, provision of scheduled General the major change in out of hours Practitioner Services which were services in NI came after the 1995 directly relevant to the out of hours deal. In 1990 there were only six context. co-operatives nationwide. By 1999, 80% of GPs were working within a The first GP co - operative to be co-op system. In Northern Ireland, established in the Republi c of Irelan d the border area is currently covered was CAREDOC in 1999. CAREDOC by three co ·operatives (FOYLEDOC, initially covered services within MOURNEDOC and ASADOC) . Carlow and its surrounding areas. The FOYLEDOC operates out of two North Eastern Health Board Area premises. Services are provided at piloted· its co -op in September 2000 eithe r centre on an alternate and was the first regional co monthly basis. MOURNEDOC operative in the country. NEDOC now provides services from a single covers the eastern border area with primary care centre, whilst ASADOC the exception of the Cooley Peninsula, services a re provided from six Dundalk and Monaghan town. I n different primary care centres. 2001, the North Western Health Board established an out of hours co In the Rep ublic of Ireland in 1997, operative (NOWDOC), which provides 51 % of all GPs were sing le-handed urgent out of hours care to the boards and only 8% of GPs work practices resident population initially in the of three or more partners. Until very north Donegal area. The majority of recently, a large number of GPs were the areas along both sides of the working over 100 hours a week on border are therefore served by out call. Consideration of the out of of hours co -operative schemes.
10 Feasibility Study for the provision of Cross Border Out of Hours GP Services
1.2 A Socio-Economic Profile of the The region thus defined consists of Irish Cross-border Region the following: the counties of Donegal, Leitrim, Cava n, Monaghan The geographica l area covered by and Louth; and the DCAs of Derry, CAWT encompasses four health Straba ne, Omagh, Fermanagh, boards, the North Eastern Health Dungannon, Armagh and Newry & Board and the North Western Health Mourne. This produces two sub Board in t he Republic of Ireland and regions that are similar in terms of the West e rn Health and Social population size; the total population Services Boa rd and Southern Health of the five Republic of Ire land a n d Socia l Se rvices Board in counties is in the region of 350,000, Northern I r e land. The area while t he Northern Ireland DCAs comprises approximately 1 million contain a population a little over people, representing about 21 % of 410,000 (Table 1). the tot al island population and 25% of its land area (CAWT, 2002). NI Border RI Border Total population 4 11,705 348,231 The focus of this stud y is upon the % of population of Ireland 8.1 6.8 areas closest to the actual border % of land area of Ireland 7.7 12.5 itself. Defining what actually number of census units 1154 428 . . . constitutes the border area and its Table 1.. Population and census umts m population is real ly a matter of the border region (Cook et al., 2000) choice and d ep,ends upon the context in which it being discussed. There is therefore no clear, definitive Tab le 2 presents demographic data, or universally accepted definition of split into six cat egories t o a ll ow what constitutes the I ri sh cross compa rison betwee n severa l border region. For t he purposes of different geographic bases. For providing a general socio-economic example, comparisons can be made profile of the region, the definition between the border region and all adopted (and analysis) by Cook et ofIreland, between Northern Ireland al (2000) is used here. and the Republic, and between each country and its own border region. In very general terms, the Irish border region can be defined as the The border region conta ins seven District Council Areas (DCAs) approx imately 15% of Ireland's in Northern Ireland, which share a population, with a marginally higher land border with the Republic of proportion of the population in the Ireland, and the five counties in the economically inactive age groups, Republic, which adjoin the border. and a co nsiderably lower percentage
11 Ire/and N. Ire/and R. /re/and Border NI Border I RI Sorde population 5,103,409 1,577,690 3,525,719 759,936 411,705 348,231 households 1,545,085 525,362 1,019,723 221,098 121,543 99,555 mean h'hold size 3.30 3.00 3.46 3.44 3.39 3.50 % in towns> 500 68.2 73.2 66.0 50.9 56.9 43.8 % in towns> 5,000 55.2 61.0 52.6 32.7 41.5 22.2 % in towns> 10,000 48.6 55.3 45.6 27.0 36.7 15.6 % males 49.4 48.7 49.7 50.1 49.7 50 .6 % females 50.6 51.3 50.3 49.9 50.3 49.4 % S 15 years 27.8 26.0 28.6 29.7 29.5 30 .1
% ~ 65 years 11.8 12.6 11.4 12.0 11.0 13.3 . . • Table 2: DemographIc characteristIcs• of the border regIon ( Cook et a/./ 2000) of the urban population (defined as to the border experiences a higher those living in settlements of over level of several forms of deprivation 500 people). The level of namely, higher unemploy ment urbanisation is particularly low on levels, a more dependent age the southern side of the border. On ly structure, and a greater proportion one settlement in the border region of housing with poor amenities. In has a population greater than deprivation terms, the significance 50,000 and the majority of towns of urbanisation (the level of wh ich are below 20,000. Although two of is far lower in the border region) is the three largest towns in the reg ion open to question. On the one hand are in the Republic of Ireland, all but it could be argued that those who one of the remaining towns with a live in more rural areas are less likely popu lation over 10,000 are on the to be exposed to particu larly urban northern side of the border. The forms of deprivation, relat ed to majority of the population of t he aspects of the physica l and social border reg ion lives either in rura l environment. Such forms of areas or in relatively small towns; deprivation include overcrowding less than 30% of people live in towns and high population denSity, nOise, of 10,000 or above, compared to poll ution, crime and so on, which nearly 50% throughout Ireland, tend to impinge more on the wh ile the figure for the five border economica lly d isadvant aged counties of the Republic of Ireland sections of the population of a large is just over 15%. urban centre. On the other hand, while residence in rural areas or The regiona l level data presented in small towns may mean the Table 3 (overleaf) suggests that avoidance of some of the worst overall, the population living close aspects of the urban social and
12 Feasibility Study for the provision of Cross Border Out of Hours GP Services
physical environment, it can itself be References associated with a form of deprivation which is based on poor access to a Bond, D. et al (2001) 'Cross Border wide range of services. This type of Development in Northern Ireland: A deprivation would include poor Focus for the Future' in Cooperation, access to services provided in the Environment and Sustainability in retail, education and health-care Border Regions, edited by Ganster, sectors, and to the employment P. San Diego University Press and opportunities offered by larger the Institute for Reg ional Studies of towns. Such access deprivation the Californias, California. poses particular problems for the economically disadvantaged residing CAWT (2002) Annual report 2001 for in r emote rura l areas, who a re health gain and social well being in unable to afford private transport, border areas, CAWT, Derry. and reside in areas where public transport is infrequent and or Centre for Cross Border Studies relatively expensive. (2001) Cross-border Co-operation in Health Services in Ireland, March 200L
Cook,S. et at (2000) Comparative Spatial Deprivation in I reland: A
Ireland N. Ireland R. Ireland Border NI Border RI Border
male unempl (age 16-64) 19.0 19.3 18.9 24.2 25.0 22 .7 male unempl (age 16-24) 26.5 24.2 27.6 29.9 29.2 30.8 female unempl (age 16-64) 13.0 10.9 14.3 14.5 13.2 16.3 female unempl (age 16-24) 21.2 17.0 23.1 21.3 19.4 23.8 age dependency 39.6 38.6 40.1 41.8 40.5 43.4 Economic dependency 66.2 63.6 67.4 69.2 68.4 70.1 % with no car 34.6 35.5 34.1 33.7 33.2 34.4 % <:: 75 yrs living alone 4.8 5.8 4.2 5.1 5.0 5.4 % lone parents 3.5 4.6 2.9 3.3 4.2 2.2 Persons per room 0.60 0.53 0.64 0.62 0.59 0.67 % public housing 16.5 29.4 9.8 20.1 30.7 7.2 % without bath or shower 4.5 1.7 5.9 5.4 2.5 9.0 % without central heating 32.7 17.2 40.7 31.2 19.2 45.8 . . . . Table 3.• Unemployment levels and selected deprIVation characteristics of the border region
13 Cross-Border An alysis. Oak Tree Press, Dublin, 205 pp.
Hart,J.T. ( 1971) The Inverse Care Law. The Lancet, 405-412
Hallam, L. (1994) Primary medical care outside normal working hours: review of published work, BMJ, 308: 249-253
Moore, A.J . et al ( 2000) 'Project BORDER- Business opportunities for Reg ional Development a nd Economic Regeneration: A Case Study in Developing an Irish Cross Border Te lematic Inf ormation Serv ice' In Cooperatio n, Environment and Sust ainability in Border Regions, edited by Ganster, P. Sa n Diego University Press and t he Institut e for Regional Studies of the Ca lifornias, California.
O'Rei ll y,D. (2001) General Practice OOH service variations in use and equality in access to a doct or. British Journal of General Practice : 51 ;625- 9
14 FeaSibility Study for the provIsion of Cross Border Out of Hours GP Services
2. Methodology
II Terms of reference for the project:
The basic terms of reference for this • There would be no change to study were: existing co-operatives unless by 'To research joint working and co agreement operation between proressionals on • Patients would have the right to a cross-border GP out-or-hours choose which Co-op centre they arrangement and produce an attend operational plan addressing the • In the short term, there would organisational and management be no cross-border home visits issues, which need to be considered by GPs berore cross-border co-operation • In emergencies, patients should can take place: be admitted to the most appropriate hospital, closest to A steering committee made up of the OOH primary care centre members of t he CAWT Primary Care (subject to patient choice) sub-group and an advisory group • Ambulances should be with representation from the four dispatched across the border (if boards, GPs and the ,co -operatives necessary ) o n t h e basis of in the CAWT area -was established shortest distance travelled to assist and monitor the • There must be agreement on development of the project on a payments and inter-board regular basis. transactions, arranged to fund t he service The steering committee provided an illustrative set of core operational It was accepted that from a purely and strategic issues (including joint practical and logistical perspective, reg istration, professional indemnity the implementation of the fu ll ra nge and public liability, funding charges of out of hours services on a cross and bi lling arrangements, border basis in a single phase was prescribing and dispensing of drugs, unrealistic. It was also accepted that patient choice and access t o the whole process of introducing out secondary ca re services) to be of hours services on a cross-border addressed in the study. basis should be managed in a logical and phased manner. It wa s therefore In ad dition, the research team and agreed that the feasibil ity study CAWT identified and established a would be conducted on the basis number of basic working principles that, in the first instance , the service
15 would be restricted to patients only estimate number of people travelling across the border to residing in areas that are closer consult at cross border primary care to a primary care centre outside centres. their residential jurisdiction • To estimate the gains, losses and Using the set of core strategic and net differences in catchment operational issues and basic populationsofeach primary care principles as a guideline, a project centre management plan was drawn up dividing the key tasks into t hree U Technical Issues distinct sections, Geographical, Technical and Professional and The main aim of this section was to Business. These three distinct areas identify software solutions to the were used as a basic structure for technical and telecommunication conducting the research and for challenges that emerge from the presenting the findings in this report. proposed cross border out of hours Each key area had its own specific arrangements. To this end, a set of objectives and tasks. These number of key objectives were are outli ned below. identified: • To undertake a techn ical Geographical Issues evaluation of current ADASTRA system employed by co -ops The main aim of this section was to • To undertake a technical identify the border areas and evaluation of the mechanisms for quantify the population residing in intersystem networking and these areas that could benefit (in connectivity on a cross border terms of improved access) from the basis provision of a cross-border out of • To identify a mechanism that hours service. The specific objectives facilitates the integration of the were: inventory of eligible populations • To identify current 'within (GIS output) into the ADASTRA jurisd iction' primary care centre system catchment areas • To identify 'irrespective of 2.4 Professional and Business jurisdiction' primary care centre Issues catchment areas • To identify areas which would be The main aim of this section was to suitable for cross border out of identify any possible professional or hours arrangements economic barriers to the successful • To identify the populations and implementation of cross border out
16 Feasibility Study for the provision of Cross Border Out of Hours GP Services
of hours GP services and to of this study, the key issues that determine whether and how such would be i nvestigated and the professional and economic obstacles proposed methodology that would could be overcome to facilitate the be used. establishment of collaborative out of-hours service. The fo llow ing Attend ee s were offered the objectives were therefore set: opportunity to contribute their • To identify potential professional thoughts and ideas on both the key and business barrier s ( e.g. issues ra ised and the proposed med ical r egistrat io n, methodology. The stakeholders profess ional ind em nity, were also provided with details of compla ints procedu res and the feasi bi lity study's websit e p remises insurance) t o the address, which was used throughout successful implementation of the study to provide stakeholders cross border out of hours GP with up to date details of the study's services and to make progress. A discussion board was recommendations as to how also posted on the website to allow these barriers may be overcome stakeholders to voice their opinions • To determine the feasibility of on relevant issues. providing licensed medicines, prescribed by out of hours GPs Given the discrete nat ure of the to cross-border patients three key areas, three different • To estimate changes in demand methodologica l approaches were for centre consultations, that employed to achieve the overall aims would occur at each out of hours and obj ectives. The geographical centre if a cross border provision issues were investigated through the was established use of a Geographical Information • To identify suitable financial System (GIS) approach. Primary arrangements for the payment and secondary data sources were of cross-border centre utilised and interrogated within the consultations GIS to accomplish the geographical aims and objectives . .2....5 Methodologies Employed The t echnical expert s employed After the initial research period, an desktop research techniques, which introductory workshop, held in Ju ly included an examination of the 2001, was used to inform the ADASTRA systems technica l reports, attending key st akehoJders (from to gain an in-depth understanding the co - ops, boards a nd loca l of the systems architecture, practices) of the terms of reference functionality and capabilities. Visits
17 were made to primary care centres representatives f rom t he m a in and ca ll management centres on professional bodies, ambulance and both sides of the border to view the acute service providers. Th is final system in operation. Key technical workshop was used to inform the personnel at these sites were also attendees of the study's ma in consulted with regard to the current findings and recommendations and softwa r e so lution and thei r also to provide the key stakeholders perception of software requirements with a final opportunity to express for the proposed service. In-depth any outstanding concerns/ issues interviews w ith the software that required further investigation. developers and providers were also co nducted. The focus of these interviews was upon the development of a cross border telecommunication system.
A number of key business a nd professional issues were identified. These included general professional issues ( including indemnity and registration), pharmacy issues and financial issues. A multidisciplinary team of academics, medics a nd health care profess ionals, investigated these issues. Verbal communication fol lowed up by wri tten correspondence was used to investigate the general professional issues. A series of meetings and interviews was held to address the key pharmacy issues. A on e-day workshop, attended by key co-op and health board pe rsonnel was devoted to the financial issues ra ised by the proposed service.
A final workshop was held in April 2002. Again, the key stakeholders from the local co-ops and health boards were invited, along w ith
18 Feasibility Study for the provision of Cross Border Out of Hours GP Services
~ Geographical Issues
One of the fundamental data their residential jurisdiction requirements for the successful • To estimate the gains, losses and implementation of the cross border net differences in catchment out of hours arrangements, is an populations of each primary care inventory of the populations that centre qualify to avail of cross border services. Such an inventory would Methods include details of all populations residing in areas that are closer to a A Geographic Information Systems primary care centre located across (GIS) approach was employed to the border. An important component perform the necessary spatial of the project remit was therefore analyses for this section. A GIS is a to conduct a geographical analysis computer-based system that of out of hours provision within the faci litates the creation, storage, CAWT region. The overall aim of the manipulation, query, analysis and analysis was to identify areas and display of geographically referenced their population s on either side of data. Data can be geographically the border that could benefit (in referenced either explicitly, via an X terms of improved access) from and Y co-ordinate system such as cross border out of hours service the Irish Grid or Latitude/ Longitude, provision. Five key objectives were o r implicitly v ia an address or identified and are set out below. postcode and a related georeferencing software package. Objectives The benefit of GIS over standard database and statistical software is • To identify current 'within that it provides the capability of jurisdiction' primary care centre performing complex spatial catchment areas analytical queries and analysis such • To identify 'irrespective of as 'where are the areas that have jurisdiction' primary care centre very high mortality rates and very catchment areas poor access to health care services?'. • To identify areas which would be suitable for cross border out of Some of the basic key fu nctionality hours arrangements within GIS and employed in this • To identify the popuJations and study include: esti mate number of peop le • Buffer Analysis: selectin g an residing in areas that are close r area around a feature and to a primary ca re ce ntre outside identifying and querying information within that area;
19 • Overlay Analysis: integra ting California. The catchment analysis attribute information from a in the study was produced using the number of disparate datasets Network Ana lyst extension for that are referenced to the sa me ArcView. geographical base e.g. integrating mortality data with Data census data and health care facility locations; Data identifying the location of out of hours primary care cent res were • Network Analysis: obtained from each co-op in the identification of best route, study area. 22 sites providing out nearest facility or finding a of hours cover to the population service/catchment area (some proposed and some fully operational) were included in the Given the fact that so much of the study ( see Table 3.1 ) . The site routine data co llected and held by locations in the NWHB area were health authorities is or can be provided before the NOWDOC Co geographically referenced, it is not op service was established. As such, surprising that GIS has been used they represented all proposed out widely in this sector for research and of hou rs primary care centre plann in g purposes. Examples locations in the North Western include epidemiologica l analysis, Health Board Area. At the time of patient distribution, accessibility undertaking this study, it was not analysis, needs assessment and site possible to determine at which location analysis. Today GIS is one NWHB locations primary care of the fastest growing technologies centres would be established, so all in the health arena, helping hea lth locations were included in the care professiona ls and managers ana lysis. make better informed decisions by making ful l use of ava il ab le The locations of the NI primary care information. For more information centres were assigned geocodes on GIS, refer to DeMers (2000) or (grid references) from the Post Gatret! and Loytonen (1998). Office's Central Postcode Directory (CPD). RoI primary care centre Software: All of the spatial dat a addresses do not have postcodes. analyses were conducted using These locations were manually ArcView 3.2, a vector-based GIS geocoded from paper maps. The software product from locations were then mapped within Environmental Systems Research the GIS using the assigned Institute Ine (ESRI), Redlands, geocodes.
20 FeaSibility Study for the provision of Cross Border Out of Hours GP Services
; Carndonagh Cavan Downpatrick Enniskillen Carrick on Shannon Drogheda Moy Limavady Donegal Navan Newry Omagh Du ngloe Strabane Ki llybegs Letterkenny Sligo
Table 3.1: Pdmary Care Centre locations provided by the Four CAWT Health Boards
Two digital road network datasets, were provided at the small area level one representing al l roa d s i n in tabular format. Northern Ireland, the other representing roads in all the Republic .lA Current 'within jurisdiction' of Ireland's border counties were primary care centre catchment areas used in the study. Both data sets included details of all motorways, A, ArcView's Network Analyst extension Band C (minor) class roads. product was used to simulate patient journeys from thei r place of Popu lation data for the two residence to the nearest out of hours jurisdictions was acquired from the centres. Rather than measuring NI Statistics and Research Agency euclidean distance (as the crow (NISRA) and the Central Statistics flies), the simulated patie nt journeys Office, Dublin (CSO). The most up were routed accord i ng to the to-date population data available for underlying road network. the analysis were collected via the 1991 and 1996 population censuses NI road centrelines were used to in NI and the Ro I respectively. simulate NI patient journeys and RoI Census derived population data are road vector data were used to collect ed and disseminated at a simulate RoI patient journeys. The small area level. These small areas patient journey simulations were are known as enumeration districts determined by i mpedance (EDs) in Northern Ireland, and as calculations. Impedance is defined district electoral divisions (DEDs ) in as the ' cost' assOC iated with the Republic of Ireland. There are t raversing each road segment or 1464 EDs and 601 DEDs in the study junction. For this study, the cost of area (i.e. the CAWT area) . The traversing each road segment was NISRA and CSO population data determined by the road segment
21 Map 3.1: Nf Digital Road Network Map 3.2: Rof Digital Road Network length. The two road network patient journeys within the RoI to datasets are displayed in Map 3.1 RoI primary care centres. Both and Map 3.2. simulations were run according to the shortest distance to each Two different si mulations were run. primary care centre. These The first Simulation modelled patient simu lations were then used to journeys within NI to NI primary care identify 'within jurisd iction' primary centres and the second modelled care centre catchment areas. These
• • •
•
30 o 30
Map 3.3: Within jurisdiction primary care centre catchment areas
22 Feasibility Study for the provision of Cross Border Out of Hours GP Services
,
• . . '"' .. : . A Map 3.4: Combined digital road -- - networks Map 3.5: Distribution or ED and DED Population centroids 'within jurisdiction' catchment areas are illustrated in Map 3.3. The road network database used to conduct the cross border patient .3.....S. Cross Border 'irrespective of journey simulations was prepared jyrisdiction' primary care centre from the NI road centrelines catchment areas (provided by Ordnance Survey Northern Ireland ) and the RaI road
• •
• •
N •
Map 3. 6: Primary care centre catchment areas (Irrespective ofjurisdiction)
23 vector data (provided by Ordnance from the Simulations and are Survey I reland). GIS data presented in Map 3.6. conversion tools were used to merge these two disparate datasets into a M Areas that would be suitable co ntinuous topologically linked road for cr oss border out of hours network. This exercise was crucial, arrangements given the need for the road network to contain interconnected NI and RoI Overlay analysis tools were used on roa ds to facilitate cross border the two catchment area maps (Maps journey simulations. Map 3.4 3.3 and 3.6) to identify the areas displays the digital road network that are closer to a cross border out data used in the analysis. of hours centre (i.e. a centre located outSide the home jurisdiction) than Cross border patient journeys were to a centre located in their home simulated to measure the distance jurisdiction. These areas, which to the nearest centre, regardless of could benefit from cross border jurisdiction. 'Irrespective of service arrangements are illustra t ed jurisdiction' primary care centre in Map 3.7. catchment areas were identified
, A.
care arrangements
24 Feasibility Study for the provision of Cross Border Out of Hours GP Services
PopulatjQos and estimated for the study area (Map 3.5). number of people residing in areas that are closer to a An overlay analysis was conducted primary care centre outside on the mapped population data (Map
their reSidential •jurisd iction 3.5) and the map of areas closer to a primary care centre outSide the The results of the overlay analysis home jurisdiction (M ap 3.7). ThiS were used to identify the populations analysis was used to identify the that would benefit from a cross populations residing closer to cross border out of hours arrangement. border out of hours centres. Map Population data, derived from the 3.8 displays results of the analysis. smallest census divisions avail able ( EDs and DEDs i n NI and RaI The map displays the current 'within respectively) were used in the j urisdiction' catchment area analyses. The population centroid boundaries of the out of hours datasets were merged, using GIS primary care ce ntres (black lines), data conversion tools to create a along with cross border service areas single population distribution map (i.e. co loured areas) eligible for cross
• ""0
Map 3,8: Popu/ations and Estimated number ofpeople residing in areas that are closer to a primary care centre outside their home jurisdiction
25 border care. These cross border populations and the size of the service areas are shaded according proposed cross border catchment to the nearest out of hours centre. areas are also included in Table 3.2. The size of the populations residing in each area is also indicated. For il Conclusion example, of the patients currently served by the Carndonagh primary GIS was used to monitor access to care centre, 8459 are actually closer out of hours care in the CAWT area to the primary care centre in Derry. and to evaluate the possibility of developing cross border arrangements. Th is study has II Gains. losses and net modelled patient journeys and differences in catchment populations identified the areas that would for each primarv care centre benefit from improved access to out of hours primary care consultations, Details of the eligible populations through cross border co-operation. illustrated in Map 3.8 are also This benefit is however, based upon presented in tabular format in Tab le the assumption that a cross border 3.2 Table 3.2 shows the original consultation is available at the time catchment population (based on a call is received. shortest journey) and the number who would qualify for a cross border The results of this analysis support consultation (again, based on the idea that a significant proportion shortest journey). The net of the rural border populations would difference in service area benefit from cross border out of
Table 3.2: Cross border Catchment Population
26 Feasibility Study for the provision of Cross Border Out of Hours GP Services
hours services. More consultations References could be made more accessible. This is significant, especially given the DeMers, M.N. ( 2000) Fundamentals poor access experienced by rural of Geographic Information Systems. populations in the border reg ion, Chichester : J. Wi ley which is often compounded by high levels of area deprivation. Gatrell, A .C. and Loytonen, M. (1998) GIS and Health. London: The resu lts of this research also Tayl or & Francis potentially provides part of a technical solution, which could be used by tria ge GPs!nurses to determine which out of hours centre would be most convenient for a patient to attend.
This study has proved the value of GIS in the health service planning field. The analysis has illustrated the important role of GIS in highlighting current spatial constraints on service delivery, by identifying areas that are poorly served under existing arrangements. A clear picture of such constraints is essential to aid more informed decision-making in health care planning and evaluation. It is therefore for this reason that GIS technology will continue to play a role in improving the quality of hea lth care provision.
27 4 . Technical Issues
The out of hours co-op services on • To undertake a technica l both sides of the borde r are evaluation of the mechanisms for managed using call management intersystem networking and protocols, which are facilitated connectivity on a cross border through the use of sophisticated call basis management software . The • To identify a mechanism that technical solutions in the various co facilitates the integration of the ops, provide advanced facilities for inventory of eligible populations the communication of patient details (GIS output) into the ca l l between Call Management Centres management systems and Out of Hours Primary Care Centres. Cross border 1.2 Methods communication (between ca ll management centres and primary Visits were made to the ASADOC co care centres) is one of the key op's ca ll management centre in technical requirements of a cross Craigavon and to the NEDOC co-op's border out of hours service. The call management centre in Ardee. development of a technica l solution Key technical pe rsonnel working in is imperative to the successful each cal l centre provided an implementation of cross border out overview of the ca ll processing of hours services and is therefore mechanisms (discussed below). Out the focus of this section of the of hours primary care centres in each report. Through examining current jurisdiction were also visited. During IT and technical issues, the overa ll these · visits the researchers aim of this section is to identify observed the ca ll process ing solutions to the technica l challenges mecha nisms in operation. t hat emerge from the proposed cross bor der out of hours The call management software arrangements. Three key employed by each co-operative was objectives were identified and are identified. Staff at the ca ll set out below. management centres and primary care centres provided an overview 4.1 Objectives of the basic functionality of the software. Important information • To und ertake a technical was also gathered from the software evaluation of current ca l l providers. The software developers management systems employed were also consulted. They provided by co-ops imperative technical information.
28 Feasibility Study for the provision of Cross Border Out of Hours GP Services
Access was a lso gained to the DOS based environment provides software user's documentation and the system wit h an 'old-style' menu web based support services. driven user interface. ADASTRA is currently developing a windows Technical evaluation of interface system, which is due for current caU management release in 2003. When ava ilable, co system and procedures operatives will be entitled to upgrade employed by CO-aDS from t he DOS to the Windows interfaced system. System details T he current ca l l management Procedure details process is facilitated by commercial Ca ll han dling procedures in both the software. All co-operatives operating RoI and NI are very simil ar. The within the CAWT region use the general procedures utilised in both ADASTRA call management system. jurisd ictions are discussed below and Th is system is developed a nd illustrated in Figure 4. 1. There are supplied by ADASTRA Softwa re a number of m ino r d ifferences Ltd.(Kent). between t he various co-ops. These are discussed at the end of this The ADASTRA system provides section. capabilities for hand ling a wide variety of operational aspect s Upon answering eac h ca ll th e relatin g to out-of-hou rs service operator asks the ca ller for his/her provision. The functionality includes phone number. The phone number faci lities for a nsweri ng cal ls, is entered into the system. A system automatica ll y transferring patient search is then performed. This detail s to GPs a nd transmitting search identifies whether a call has patient detail s between ca lf centres previously been received from a and out of hours ce ntres. The patient using the same phone software also provides facili ties for number. If details of a previous call notifying surgeries of out of hours from the current number are found, contacts made by their patients. In the operator asks t he caller to addit ion, it provides functions for confirm the patient's personal details generating sum mary statistics and a nd to describe t he patient's ca lculating charges and payments symptoms. If the ca ll is being made due to GPs. by/ or on behalf of a first time patient, the operator asks for the The system runs on a Microsoft patient's pe rsonal detail s (induding Windows NT4 platform usin g a 32- name, address and GP) and for BIT DOS based environment. The symptom details. These details are
29 then input into the system. The nurse provides the advice and enters operator then informs the caller that details of the same on the system's the details are being forwarded to patient record. The GP or triage the doctor or triage nurse on call and nurse may alternatively decide that that the doctor or triage nurse will the patient requires a face-ta-face return the phone call as soon as consultation . If such a patient is fit possible. to travel to a primary care centre, he/she is invited to attend the co The call record is passed to the GP op's nearest ce ntre for a or triage nurse via an assessment consultation. The GP or triage nurse pool where the GP or triage nurse determines the nearest centre. If the receives details on his/her VDU (via patient is not fit to travel, a pop-up message), which informs arrangements will be made for the him/her of the awaiting patient's patient to receive a home visit. If it details. If the patient is the only is decided that the patient requires ca ll er awaiting a reply, the GP or emergency care, the emergency triage nurse assesses the case and services are notified. returns the ca ll. If there are numerous callers awaiting a reply If the patient has agreed to attend concurrently, the patient's details are an out of hours centre, the GP or added to a list of waiting calls on triage nurse will then forward a copy the pop-up list. Calls are not of the patient's details to the returned on a first-in first-out basis. relevant out of hours primary care Instead, each individual call is centre (i.e. the one the patient has assessed by the GP or triage nurse agreed to attend). These details are and ranked in order of urgency. The forwarded either via phone, fax or most urgent call is returned first. by dial-up connection. Dial-up Patients are therefore triaged connection transmits a call from a according to the perceived urgency computer terminal in the call centre of the call. to a terminal in the out-of-hours centre. Once the patient has When the most urgent ca ll has been received a consultation, the GP id entified and returned, the GP or enters details of the course of the triage nurse d iscusses the action onto the patient's file. symptoms with the patient/caller and then decides upon a course of If a patient receives a home visit, action. The GP or triage nurse may the GP located at the patient's loca l decide that the patient can be given out of hours centre will conduct the adequate advice over the telephone. home visit. Once consulted, the GP In such instances, the GP or triage enters details of the consultation and
30 Feasibility Study for the provision of Cross Border Out of Hou rs GP Services the course of the action taken, onto a higher percentage of patients the patient's fil e. triaged by nurses sought further medical advice (50% as opposed Once the completed consultation to 29% when GPs triaged). details are entered onto the system, the patient's record is flagged as • The process of central triaging 'complete'. Periodica ll y the central is carried out in both RoI co-ops hub, located in the call management (i.e. NE DDC and NOWDOC). In centre, requests t he return of all NI , central triaging is only used completed tall details from the in co-operatives where there is remot e servers at the out-of-hours only one out of hours base Le. cent res. The details of all calls FOYLEDOC and MOURN EDOC. flagged at the out-of-hours centre ASADOC does not offer as 'complete' are updated at the hub centralised triage. Ca lls are t erminal in the original call centre passed on to the local out of and t he original ca ll record is closed. hours ce ntres before bei ng At the end of each out of hours t riaged. Therefore no clinical period, details of all ca ll s received assessment of t he call is made are summarised, both by GP and by until the ca ll handler transmits practice. Each practice with a the call record to the out of hours patient who has used t he service is centre to which the patient's GP faxed details of t heir patient's out is attached . of hours consultations on a daily basis. • In t he RoI, any patient invited for a face to face consultation is Differences in co- op call direct ed to the out of hours management procedures centre nea rest to that patient's home. However, in NI , the • Although the majority of co-ops decision of which centre a patient employ GPs to triage incoming is invited to attend depends on ca lls, some co -ops prefer to use the location of the surgery at nurse triage. The proportion of which the patient is registered. face to face consultations varies NI patients are therefore not depending upon whether nurse necessarily invited to the out of or GP triage is used. A previous hours centre nearest to t heir comparative st udy of nurse and homes. GP triage in NDADOC (North Down and Ards Doctors on Ca ll) • The method employed to found that nurse advisors triaged communicate patient detail s fewer ca ll s per session and that both within t he call centres and
31 between call centres and primary information to the t riage care centres varies amongst the personnel. In addition, the different co-ops. In all co-ops, electronic transferral of patient patient details are passed from details between call centres and the operator to the triage GP or primary care centres is, in some nurse electronically: however, co -ops, backed up by either a some co -ops also choose to telephone ca ll or by fax. forward a hard copy of this
Caller makes a call to too Call Centre (H Lb)
Operator asks for patient" phone number
Does pacenrs phone number exist on a recocd on ~ dalat p se 1
< ~, <' "'
Are the pot>etl!'s name and address de:ails Patient's ....me. adCIrass.and pnooe nurroe< held In me svs".m correcI ? de!ails ara erl!
COrrecI da1aIIs ira8I.terfl'd Operator a.1Is for aod inpuli <;SetailS oItrle InlO the svstem patient's symptoms -'- Operator ;,!o ""'" -, r """""'"'0._ E...... o:: V ,- y~ ...... Conwltaion - -. Patien1 tlas face 10 !ace consultation n.. eours. of set"" recomme OOed by t!le GP or tria!:je rll,lr$e is I!len entered on 10 the computer system Figure 4.1: General Current Call management Process 32 Feasibility Study for the provision of Cross Border Out of Hours GP Services After identifying the call Options for transfemng cross border • management procedures currently patient details employed by the co-ops, a number If the patient decides t o attend a of strateg ic cross-border issues cross border centre, t he triage requiring further consideration were personnel at the home call centre identified: sends the patient's details to the • How wou ld cross border patients receivi ng cross border primary care be managed? centre. The patient's details held at • How would triage personnel the original cal l ce nt re could be decide which centre is the transmitted either directly to the patient's nearest out of hours cross border primary ca re centre, or centre? indirectly via a cross border ca ll • Would the caller be offered any management centre. The key information on waiting times to sta kehold ers were consulted and the assist h im/her in decid ing general consensus favoured the whether to avail of a cross border second option- that is ca ll details consultation? being sent firstly to the cross border • How would loca l out of hours call centre, and from there onto the centres be informed of a cross cross border primary care centre border patient's impending visit? where the patient would consult. • How would co-ops record cross border consultations? It was ag reed that ca ll details would be transmitted indirectly from the 4.4 Proposed Model for Cross ca ll centre to the cross border call Border Out of Hours Calls centre and then on to the cross border out of hours centre. So for 4.4,1 Technical Architecture example, the syst em would be set The compati bility of the call up so that a ca ll originally made to management systems used by all the A5ADOC ca ll centre (Craigavon) CAWT region co-ops, to manage out by a patient residing in Crossmaglen, of hours ca lls is assured, as all the would be redirected t o the NEDOC co -ops employ the ADA5TRA call call centre (Ardee) and then on to management software solution. A the nearest primary care centre cross border system could be (Castleb laney). configured in the same manner as the present systems . Therefore, A variety of methods were identified g iven the architecture of the for the indirect transmission of ca lls. currently used software, cross Ca ll transmitt ance options included border communication is technically telephone, fax and dial - up possible, connection. 33 The systems at both the hub and should undergo an initial trial remote site would both req uire before being used to facilitate reconfiguration to facilitate the cross border servicing transmission and management of • Call centres and primary care ca lls which result in cross border centres should have access on ly consu ltations. The hubs at the ca ll to detaifs of patients who will centres would be reset to enable cross the border to consult communication with cross border hubs. Cross border hubs would be 4.4.2 fnteqcating GlS ou(putinto the privileged to access details of cross AOASTRA svstem border patients only. The cross At present, when a patient is advised border hub would then redirect to consult a GP at an out of hours details of all consulted patients back centre, (s)he is given directions to across the border to the original ca ll the appropriate primary care centre centre. Reports and charges would nearest to the patient's home. A be compiled and distributed to the look-up facility is used to determine relevant surgeries. The co-operating the "most appropriateN primary ca re cross border call centres could also centre. In NI, the allocated primary run charge reports for cr oss care centre depends solely on the referencing purposes. location of the practice to which the patient belongs. In the RoI the Recommendations decision of which centre to attend is based solely on distance. Here the • Appropriate ca ll management GP or nurse triage confers with the software should be developed. patient to decide upon the most The design of such software convenient centre avail able. should include new functionality that can be used to identify A mechanism for infor ming triage patients who have travelled personnel of a patient's eligibility to across the border for a avail of a cross border consultation con sult ation. is required. If the patient lives closer • Responsibility for following the to an out of hours centre located ca ll t h rough to completio n , within his/ her own jurisdiction, the issuing the surgery report and patient is not eligible and therefore implementing cha rges should does not qualify for the option of a rest with the call centre t hat cross border consultation. In such received the initial call circumstances, the GP or triage • A dial up connection should be nurse advises the patient to attend employed for ca ll transmission the ou t of hours centre within their • The new reconfigured syst em reSidential jurisdiction. If, however, 34 Feasibility Study for the provision of Cross Border Out of Hours GP Services the patient lives closer to a cross Recommendatjons border out of hours centre, he/ she is eligible and should be informed • Patient eligibility and choice of his/ her choice to avail of a cross should be built into the system border consultation. through the development of a look-up facility which identifies The required mechanism would rely the patient's nearest out of hours upon a patient's residential address, centre. w hich could be attributed with • Triage per sonnel shou ld be closest prima ry ca r e centre informed of a patient's eligibility i nformation. This ad ditiona l and subseq uent available choice, information would be stored in a v ia a seamless support tool separate dat abase and accessed provided within the software through a look-up t a b le. It is system recommended that the key link field • Postcodes should be used as the would contain a geographic code/ geographic identifier for patients identifier, such as a postcode (for NI calling from NI addresses ) or a DED code (for RoI • DED codes should be used as the addresses). geographic identifier for patients calling from RoI The ability to add an additional attribute to the database is beyond the current functionality of the i.:..S. Overview of Recommended software. This facility would have Cross Border Call Handl i ng to be developed in conjunction with Procedures software developers. Potentia l developers have been contacted Where a patient requires a face-to regard ing this matter. face GP consultation and is also fit t o travel, he/she is invited to attend 1 Market Crossmaglen BT35 9JJ Centre Pl ace Consultation BTXX XXX not eligible Figure 4.1: Patient Look-up Process 35 an out of hours primary care centre to utilise the cross border service, for a consu ltation. he/she will then travel across the border to the nearest out of hours If the nearest out of hours centre is centre to consu lt with a cross border located outside the patient's GP. The cross border GP consults residential jurisdiction then under with the patient and enters the the proposed service, the patient will advice given onto the patient's have two options. The first option record. The patient's record is then is to travel across the border to this flagged as complete and is nearest out of hours centre. The transferred back to the original call second option is to stay within the centre via the cross border call residential jurisd iction and consult centre. Cross border out of hours a GP at the local primary care centre. calls can be summarised by GP and If the patient chooses the second by practice. The patient's option (L e. to stay within their home consu ltation details are jurisdiction), then the call is communicated to their home co-op processed using the procedures that on a regular basis. In tum, the home are a lready in place. These co-op can communicate this procedures are detailed in section information to the patient's GP. As 4.3. illustrated later, this procedure will be essential for billing purposes. Additional procedures have been proposed to handle call details of patients who choose to avail of cross border consultations. These additional procedures have been developed in consultation with local service planners and build upon the current call-handling model. This process is illustrated in figure 4.2. Wh en a patient decides to travel across the border for a consultation, his/her call details are communicated to the relevant cross border call management centre. This ca ll centre contacts the nearest primary care centre to check availability and appointment times. This information is then relayed back to the patient. If the patient decides 36 Feasibility Study for the provision of Cross Border Out of Hours GP Services Primary Care Centre Consultaion Does patient live closer to a cross border primary care centre? ? Ye, < No Patient has choice of consulting in home Pati ent has no choice - must consult within jurisdiction or across the border home jurisdiction t Availability and appointment times are checked Procedures currently in place at cross border call centre are loliowed Patient will attend cross border Patient will attend co-op primary care centre in home jurisdiction J.. Patient details are forwarded to cross border out of hours centre Patient consults GP j GP enters patient details onto system lile .J.. Patient file is flagged as closed and returned (across the border) to Original call management centre A'gure 4,2: Proposed Cross Border Call management Process 37 Recommendatioos aforementioned technical aims and objectives, a number of other key • The cross border call technical recommendations were management process should be identified whilst investigating the built upon the cu rrent! existing Professional and Business Issues. processes Since these recommendations are of • The process used to a technica l nature, they have been accommodate patients who included in this technical section. decide to avail of a cross border consultation shou ld be as similar • The system should provide a as possible to the process used facility to inform triage personnel to accommodate patients who of any patient known to be visit an out of hours centre within mentally or terminally ill since, their home jurisd iction as recommended in section 5.12, • Cross border patient details these individuals should be should be forwarded to the cross excl uded from the study border p rimary care centre (Professional Issue). Indirectly via the cross border • The ca ll management system's call management centre outcome sheet s hou ld be modified to include details of A number of key system medications administered to requirements have been identified c ross border patient s. This in this study of cross border service information will inform practice techn ical issues. These staff and make the patients own requirements will have to be met GP aware of the drugs prescribed through co llaboration with a chosen (Pharmacy Issue). software provid er/developer. It is • The system shou ld also include therefore recommended that, prior a facility to identify/ differentiate to rolling out this service, a bUSiness GMS and fee-paying patients. case should be formulated and This amendment is necessary, presented to software developers g i ve~ the payme nt systems who will be responsible for t he discu ssed later in the Busi ness design, mod ification and Issues section. development of the required service • Faci lities should also be set up interface. to ease proced ures relating to the charg ing and paym ent of Other Technical Recommendations cross border services (see Business Issues). In addition to the recommendations that result from addressing the - 38 Fea sibility Study for the provision of Cross Border Out of Hours GP Services s.... Professional and Business Issues A range of concerns identified fo r 4. Examine procedures for dealing consideration w ere cl assed as with cross border complaints professional and business issues. 5. Exa mine the attitudes of These issues were further organisations/unions whose subdivided into general professional members will work on a cross and business, pharmacy, workload border arlQngement (such as the and financial. This section of the British Med ica l Association, The r epo r t d iscusses the genera l Irish Medical Organisation, The profess ional and business issues. Irish Co llege of Gen era l The investigations into the other Practitioners, The I rish Nursing three issues (i. e. pharmacy, Association and The Ro y a l workload and financia l) are College of Nursing) presented in later sections. 6. Examine issues of premises insurance 5..:..1 Gener al profess iona l and 7. Examine issues of hospital and Business Issues crown indemnity for doctors treating cross border in-patien ts The overall aim of this section of the in the secondary health care study was to identify any general setting professional and business barriers to 8. Examine issues for the border the successful implementation of ambulance services cross border out of h ou r s GP 9. Exa mine attitudes of patient serVices, and to make advocate groups recommendations as to how these barriers may be overcome. 5.3 Methodology 5..,2 Objectives Numerous stakeholding orga nisations were identified and included in this 1. Ex am ine issues of medica l study. Contact was made with a registration in Northern I reland named official from each relevant and the Republic of Ireland organisation via an initial telephone 2. Ex a mine issues of nursing conversation . A letter followed registration in Northern Irela nd within twenty-four hours, requesting and the Republic of I reland the organisations opinions on the 3. EXamine issues around indemnity proposed cross border service and for Northern Ireland and Republic any perceived ba rri ers to its of Ireland GPs and nurses who successful implementation. consult cross border patients 39 All contacts were informed that the GPs cross the border to consult . feasibility study wa s considering 2. GPs providing services to cross patients only travelling across the border patients should have a border and that all eligible patients contract and a compla ints would be offered the choice of where procedure in place prior to the to consult. It was also affirmed that, commencement of the scheme. at this stage of the project, GPs and 3. If at any t ime in the future the nurses would only practice in the scheme were roll ed out to allow jurisdiction in which they are GPs to cross the Irish border, registered. then each NI GP would have to be fully registered with the I rish SA Medical Reg istration Medical Council. The Irish Medical Counci l in the The Gen eral Medical Council (GMC) Republic of Ireland and the General expr essed two main areas of Medica l Council i n the Un ited concern: Kingdom are the statutory medica l 1. Under Sect ion 47 of the Medical bodies responsible for the annual Act, a ll doctors holding an reg istration of all medical doctors appo intment in any p ub li c practising wit hin their respective establishment in the UK must be jurisdictions. The councils a r e registered with the GMC. The responsible fo r the protection, GMC expressed concern over the promotion and ma intenance of the lega lity of t he proposed health and safety of t hei r arrangement. Thei r m ain communities. If necessary they may concern was that doctors from also instigate d isci p lina ry the ·Ro I wo rking under a formal proceedings. arrangement to see NI NH S patients could be perceived to be The I rish Medica l Council was holding an appointment in the supportive of the proposed service NHS. All doctors in the NHS must and made three ma in points: be regist ered w:th the GMC 1. Current Irish legislation does not 2. Under the Medical Act, doct ors facifitate the practice of doctors cannot prescribe unless they are crossing European Union borders regist ered. A doctor from to practise in a noth e r Northern Ireland is ab le to jurisdiction. However, there are prescri be t o a patient from the no perceived difficult ies wit h Republic who consults the GP in current legislatio n, given the NI. However, any RoI pa tient proposed service outline, requiring medication prescribed whereby patients rather t han by the NI GP out of hours would 40 Feasibility Study for the provision of Cross Border Out of Hours GP Services have to have their prescription dispensed in the NI. This may The UKCC had no add itional be inconvenient for patients. requirements for those nurses registered in Northern Ireland who The General Medical Council has consult patients from the Rol. Bard stated that in its opinion the most Altranais stated that a nurse appropriate solution would be to registered with them and practising ensure that all the doctors in any in the Republic can care for patients cross-border scheme are registered withi n a health ca re facility in both the Republic and the UK. The regardless of their address. GMC advised that CAWT should seek independent legal advice if they did Recommendation not intend to dual register RoI GPs who provide a cross border service. • Both nursing registration bodies shou ld be informed in writing of Recommendation the start date of any proposed service. • Taking due consideration of the correspondence from the Medical Indemnity General and Irish Medical Councils, CAWT should examine Th e Medical Defence Organisations the issue of dual registration for provide indemnity for individual Republic of Ireland doctors who practitioners. Insurance is essential will consult with patients from for each doctor. Such organisations Northern I reland . We provide GPs with advice and legal recommend that CAWT seek support, as well as financial ind ependent legal advice settlements, when necessary. RoI regarding the issues of dual GP subscriptions are higher than NI registration. The implications of GP subscriptions due to the higher dual registration on future re level of litigation in the Rol. Unlike accreditation should also be hospital doctors, who are covered considered. by ' block cover' i ndemnity arrangements provided by the 5..:...5. Nursing Registration employing hospital, GPs in both jurisdictions purchase their own The statutory bodies for nursing indemnity cover. regulation are the United Kingdom Central Council of Nursing, Midwifery The Medical Defence Union (London and Health Visitors (UKCC) i n and Dublin) and The Medical Northern Ireland and Bord Altranais Protection Society already provide in the Republic of Ireland. 41 Name of Indemnity in Indemn ity in Response t o the study Organi sation t he Republic Northern Of I reland Ireland Medica l Defence Union Ye, Ye, Will provide Indemnity to GPs from both jurisdictions who partake rn the scheme at no extra cost. Medica l Protection Ye, Ye, Will provide indemnity to GPs from Society both jurisdictions who partake in the scheme at no extra cost. Medisec Ye, No Will provide indemnity to GPs from the Republic of Ireland who partake in the scheme at no extra cost. Medical and Dental No Ye, MODUS have no plans to extend Defence Union of indemnity to those Northern Ireland Scotland GPs who intend to consult patients crossing the border from the republic of Ireland . . Table 5.1: Summary table of Medlca/ Indemmty Orgamsattons• • contacted and replies received indemnity for GPs practising in both Recommendations jurisdictions. Neither organisation wa s aware of any medica- lega l • GPs and nurses working within impediment that wou ld prevent GPs out of hours primary care centres on e ither side of the bo r der should seek their own indemnity consulting pa tients who have cover, stipu lating thei r crossed the border to see them. involvement in this scheme. • CAWT should consider options The Medical and Dental Defence for reimbursing any differences Union of Scotland does not provide in subsc ription charges that any cover for GPs practising in the might arise if a GP ha s to change Republic of I reland and has no plans indemnity organisations in order to extend medical indemnity t o cover to provide cross border care. GPs practising in Northern I reland • Hospita ls shoul d check that their who wish to treat patients from the existing indemnity arrangements Republic. Medisec in Dublin will only cover their medical and nursing provide medical indemnity to GPs staff who consult cross border from the Republic. The St. Pau l pa tients referred through a cross International Insurance Company is border out of hours service. w it hdraw in g from al l med ica l indemnity work from October 2002. 42 Feasibility Study for the provision of Cross Border Out of Hours GP Services Organisation Rate per annum (£ sterllng,May 2002) Medical Defence Union 3275 Medical Protection Sodety 2980 Medical and Defence Union of Scotland 2479 Table 5.2: Annual Subscription rates for full-time Northem Ireland GPs 5.7 Procedures for deali ng with review of the complai nt. The cross border complaint s i ndependent review involves a formal meeting, run by a convenor An accessible, efficient and f air and an independent panel in which complaints procedure shou ld be t he doctor and t he patient are available to all patients who use the usually expected to attend, not proposed service . Ideally the necessarily at the same time. The procedures in place in each of the Western and So uthern Health and participating co-ops should be as Socia l Services Boards in Northern similar as possible. Ireland have these procedures in place. In Northern Ireland co-ops, the complaints procedure has t wo The GMC stated that patients from stages. The first is local resolution, the Republic who consult a GP who which involves the service provider practises in Northern I reland would attempting to resolve a complaint have to u se NHS co mpla ints as q uick ly and as d i rectly as procedures and ultimately complain possible. If a complaint cannot be to the GMC if something went wrong. resolved locally, the complainant may take t he complaint to t he In the Republic of I reland, NEDOC second stage and apply for an has developed a complaints independent review. In 1996, the procedure to handle any complaints NHS Executive in NI directed each ariSing from the uptake of out of practice to appoint a complaints hours services. The health board officer and develo p a complaints that supports the co-op deals with protoco l . This enabled many co mplaints made by GMS patients, complaints from patients to be whilst the Irish Medical Council deals resolved 'in-house'. If the complaint directly with co mplaints made by could not be resolved to t h e private patients. satisfaction of all concerned in this manner the health board would Recommendations beco me more actively involved, culminating in an i ndependent • The four border health boards 43 shou ld develop i n - house Medical Organisation welcomed the co mpla i nts procedures to spirit of the proposal and requested specifica l ly cover problems to be kept informed of all contracts arising from consulting a cross and any difficult issues. border GP. These should have an agreed protocol across a ll The Royal Co l lege of General health boards. Practitioners (Northern Ireland) was supportive of the proposal. The Irish • Complaints should be handled by College of Ge neral Practitioners the jurisdiction in which the noted the proposal and, although not consulting GP is registered to specifying any particular needs, practise. Therefore a ll were keen that GP needs would be co mplaints from RoI patients identified . who attended NI primary care centres should be dealt with The Roya l Co llege of Nursing (UK) using the NH S complaints was supportive of the proposed procedure, and all complaints service. The RC N stated that nurses from Northern Ireland patients working in the scheme should have who attended RoI primary ca re good systems of cross border centres should be m anaged communication to ensure seamless using the GMS compla ints pathways of clinical care. As regards procedures . indemnity for RCN members, the RCN stated that it would have to ~ Attitudes of the Medical and further investigate genera l Nursing Un ions legislative issues regarding the legal provision of health care on either In Northern Ireland the main GP side of the border. The Irish Nursing un ion is the British Med ical Organisation has neither responded Association and the main nursing to two letters nor any of the union is the Royal College of Nursing. telephone contacts made. Their equivalents in the Republi c of Ireland a r e the Irish Medical Recommendation Organisation and the Irish Nursing Association . These four unions, • All organisations that have been a long w ith the two Co ll eges of contacted should be informed in General Practitioners, were writing of the starting date of the contacted. proposed scheme. The British Medica l Association (Northern Ireland) and the Irish 44 Feasibility Study for the provision of Cross Border Out of Hours GP Services 5.....2 Premises Insurance 5.10 Hospital and Crown Indemnity The British Medical Association The initial t elephone response from Insurance Services fou nd that the Altnagelvin Hospital was that proposal presented some difficulty although the likely numbers of with the underwriters they patients admitted would be small, approached. Cover given to a the hospital would expect to have a commercial insurance policy applies contract with the NWHB that would to territories forming part of the cover indemnity. Th e hospital United Kingdom. This cover would required a clearer idea of t he exclude premises whose users hold anticipated number of RoI patients a contract to consult Re public of req ui ring in-patient admission each Ireland patients. Ne gotiations are week. An estimat e of 1-2 inpatient ongoing to secure an underwriter, admissions per week (derived from The cost of the additional policy will the study into demand for cross be related to the number of Republic border services ( section 7)) was of Ireland residents expected to visit provided. the premises in any month. Hospitals in the border counties are Irish Pu b!i c Bodies Mutual Insurance used t o receiving cross border is the current insurer of the NEDOe patients, In the summer months, and will also be the insu rer of for example, up to 25% of inpatients NOW DOe from September 2002. in Letterkenny hospital are from The Irish Publi c Bodies Mutua l Northern Ireland. Under current EU Insurance stated that any premises, arrangements, all Northern Ireland owned and operated by the board patients in need of urgent ca re and to provide services to patients, also admitted to Letterkenny/Monaghan/ oper ated to cater for patients Cavan General Hospita l, receive the travelling from Northern Ireland. necessary treatment. Recommendations Recommendations • The insurance of out of hours • Hospitals should check that their premises, treating patients from existing indemnity arrangements a nother j urisdiction s hou ld would extend to cov er the remain the responsibility of the treatment of cross border owners, Owners of premises patients admitted through cross should inform their underwriters border out of hours that they are contracted to arrangements. consult cross border patients. • CAWT should monito r the 45 changes in activity that might 1. Where clinically appropriate, occur in hospita ls that are patients should be encouraged affected by the provision of cross to travel to hospital in the mode border services. of transport used to reach the • Some in -patients will require primary ca re centre. follow-u p as ou tpatients. It is 2. For those patients who either recommended that in such arrive at the centre in urgent Circumstances, the patients GP need of hospital attention or shou ld organise ap propriate whose condition deteriorates follow-up within the patient's whi lst at the centre, an own jurisdiction. emergency ambulance will be required to transfer the patient 5.11 Ambulance Services to the nearest app ropriate accident and emergency centre. The NI Ambulance Service Trust 3. There will be a group of patients provides services throughout NI. f or whom there is no easy The Trust's Southern and Western solution, fo r example, a patient divisions, which cover the NI border with atypica l ca rdiac chest pa in area s, and the Ambulance Se rvice in whom a myoca rdial infarction providers of the North East ern and needs to be excluded in an North Western Health Boards were accident and emergency centre. contacted. The consens us amongst In this case, the clinical condition the service providers was that there of the patient does not warrant is good cross-border co -operation an emerge ncy vehicle but between the services for emergency because of the risk of a cardiac cover. The ambu lance service arrest (associated with an acute providers felt that they did not have myocard ia l infarction), the the additional resou rces required to patient shou ld not be allowed to facilitate additional cross-border out drive or be driven in a private of hours transfers. It was however car. made clear that in the majority of cases patients will be travell ing to Recommendations secondary care using the private mode of transport used to reach the • CAWT should negotiate primary ca re ce ntre. arrangements for cross border se r v ice provisio n with the Three different scenar ios for t he re levant ambulance providers transport of out of hou rs patients • Each clin ica l presentation should from a primary ca re centre to a be assessed on individual merit. hospital, were envisaged: • Co -operatives should develop 46 feasibility Study for the provision of Cross Border Out of Hours GP Services local protacols to manage certain be used to exclude such patients situations, e.g. cardiac-type from the scheme. chest pain. 5.12 patient Advocate Groups The So uthern Health and Socia l Services Council (SHSSC) and the Western Health and Social Services Council (WHSSC) were supportive of the proposed service. The WHSSC stated that its support was ' .. .cond itional on continuing peace and the absence of a terrorist campaign in those border localities.' No equivalent patient advocate groups exist in the Rol. No RoI organisations able to comment on the patient's perspective were identified. Other Genera l recommendations • A named individual orgroup with agreed and explicit responsibi lity fo r suspending the scheme, for w hatever reason, should be identified • Two groups of patient s- those who are receiving either terminal or mental healthcare- may not benefit from this project and they should be excluded from the service. We recommend that GP practices provide the OOH co ops with a continually updated list of those patients who are mentally or terminally ill. The telephone triage systems should 47 6. Pharmacy Issues I mportant pharmacy issues arise each of the four CAWT Hea lt h from t he question of providing cross Boards. The working g r o up's border primary ca re services. These m e mbers were consulte d issues have been investigated and i ndividua l ly and col lective ly are reported here. One of t he key throughout the research. Local GP principles behind the pharmacy p rescribing advisors and unit stud y is t hat any medication pharmacists were also consulted. prescribed to a patient m ust be These i ndivid ua ls provided l icensed i n the dispens ing inva luab le inf ormation and jurisd ict ion. Emergency or starter clarification of key cross bo rder medication licensed only in the RaI pharmacy issues. must only be dispensed in that j urisdiction. The same applies to .6.J. Current provision of out of medication licensed in NI. The hours pharmacy services overall aim of this section is to determine the feasibility of providing Pharmacists do not presently licensed medicines, prescribed by provide dispensing services at out out of hours GPs, to cross-border of hours centres in either NI or the patient s. Rol. Cu rrently, there are three different methods employed to Objectives, d ispense licensed med icines prescribed out of hours. • To inv estig ate the cu rrent provision of out of hours L Ad hoc out of hours dispensing pha rmacy services services are provided by some • To evaluate the dispensing pharmacies in both jurisdictions. options available to cross-border To date the provision of ad hoc co-ops out of hours pharmacy services • To identify and conside r key has not been monitored . operational issues (including the Pharmacists a re not supply, labelling and financing of remunerated for this service. drug packs) 2. Pharmacies in NI also operate a rota system to provide out of hl Methods hours services. As with the ad hoc service provision, there are The CAWT pharmacy working group no records of how many pat ients i ncludes sen ior pharmacy are dispensed drugs through the management representatives from provision of such services: 48 ______-""e:='=';=';"lit,,'-=5::t,,'d,,'-=for the provision of Cross Border Out of Hours GP Services however ph armacists are In terms of pati ent care and remunerated for this service. convenience, the CAWT Pharmacy There is no rota system in the Sub Group considered this option to RoI, although pharmacists do be the most desirable. The provision open on the basis of'good faith', of such a service would have 3. Out of hours GPs in both NI and important financial and human the RaI co-a ps dispense starter resou rce implications. Demand for drug packs. These drug packs such a service is likely to be limited : contain the medicines that are consequently, in terms of resources, prescribed most often during t his option was viewed as the least out-oF-hours. efficient. M Ev aluation of Options for The 'on call' pharmacist scheme in Cross-border Co-aDs the Northern Healt h and Social Services Board area was piloted over The three different methods a one year period. The pharmacists' discussed above were identified and call-out rate was extremely low and, considered as being potentia l as a consequence of the limited options for providing pharmacy demand, the se rvice was withdrawn. services dispensing on a cross Without a significant increase in border out of hours basis. These demand for out of hours services, it options are described and evaluated is envisaged that the provision of in below. house pharmacy services would be economically inefficient. Even if Pharmacist dispensing demand increased to a sufficient medicines in -situ in Co- op level, this model would be difficult setting to implement due to the current The first option is for co -operatives shortage of pharmacists. to employ pharmacists on an 'out of hours, on - call' basis. Th is would Pharmacies opening on a ' rota' all ow pharmacists to be in situ in out basis of hours centres as and w he n At present, pharmacies in NI and the required. Under this model, cross RoI open ou tside normal working border patients who are prescribed hours. In the RoI, these pharmacies medicines by a GP would have their open on an ad hoc basis, providing medicines d ispensed by a services as and when required. In pharmacist working within the out NI , as well as ad hoc provision, a of hours centre. A similar model has number of pharmacies operate rota previo u sly been piloted in the systems, providing services at Northern Health and Social Services scheduled times. It was proposed Board area in Northern Ireland. t hat a pharmacy rota system could 49 - - be put into operation. T he rota Patients receiving a starter pack are would be determined by t he co informed that the administered operatives. A co-ordinated and dosage is an incomplete course of mirrored rota system on both sides the required medication and that of the border would be necessary, they should contact their own GP in order (i) to enable health boards du ring normal surgery hours to to reim burse their respective complete the script. Following this, pharmacists and (ii) to a llow the patient is responsible f or medicines to be dispensed in the contacting his or her own GP, who licensed j urisd iction. The overall then p rescribes the remaining consensus was that although it course of medication. In the would be helpful to de velop a majority of cases, the patient then pharmacy rota system, this would presents the final prescription to the probably not be viable. pharmacist who dispenses the remaining drugs. In a minority of ThiS second proposed model would cases, where the GP can dispense, require se rvice duplication on both the patient can actually receive the sides of the border. In light of the remaining medication from their own current pressures on pharmacy GP. provision, it is anticipa ted that such a mirrored system would not be Recommendations viable. This would be due to the extra demands that would be placed • The provision of starter drug on pharmacy services and the packs was considered to be the current shortage of pha rmacists. most viable option. This was because it offers both Provision of Starter Drug Packs convenience for the patient and and Emergency Drugs to Co-ops is thought to be more cost The medications provided in starter effective than the other two drug packs are mainly oral models. medications used for the initial treatment of patients. These starter • Any medication given to patients dru g pack s provide sufficient must be licensed i n that medication for up to 48-72 hours. juri sdiction. Hence cross border Co -operatives also hold a stock of patients can be provided with emergency drugs. These starter or emergency drug packs emergency drugs are sometimes licensed in the GP's jurisdiction. re'quired for the immediate Any modification to be made to treatm e nt of patients in an the medication will be dealt wi th emergency/acute situation. through fo llow-up contact with the patient's own GP. 50 Feasibility Study for the provision of Cross Border Out of Hours GP Services • The out of hours GP wou ld In NI drug starter packs are supplied complete an electronic outcome and packaged by manufacturing sheet detailing prognosis and units to pharmacies . The drugs administered. The ca ll pharmacies then supply the starter management system should packs and emergency medicines to prompt the co -ops GP to detail local out of hours co-operatives. So the drugs administ ered. This for example, the WESTDOC co-op outcome sheet would then be in the WHSS B area receives starter sent electr onica ll y to the packs and emergency drugs from patient's GP. This system is no m i nated pharmacies i n the already in operation in the NEHB. WH SSB area. We recommend that all patients who receive medication, should In the RoI, pharmacies make up be advised to contact their own starter drug packs which are GP when the surgery reopens in supplied directly to the out-of-hours order to receive fol low- up centres. For exa mple, each month medication or a co nsultation. four nominated pharmacies su pply each of the four out of hours centres • The patient's GP is li able for any in the NEHB. medication (s)he prescribes as follow-up medication. Therefore, I n the event that the drugs needed on receiving the information on by the patient are not contained medication provided on t he within the drugs pack or emergency electronic outcome sheet, the medicine supplies, RcI patients are patient's GP s houl d decide usua lly considered as European whether a consultation is visitors and on production of ID, necessary before the patient is receive a script. A list of pharmacists given a follow-up script. willing to open in these infrequent situations is held by the co-op's GPs. Operational issues Alternatively, on occaSion, where the necessary drugs are not held in the Supply of starter packs out of hours cent re, patients are In bo th NI and the RoI, drug referred to seconda ry care settings. compani es leave random supplies of sample sta r ter packs with Labelling Starter Packs pharmacies. However these are not Each starter pack of medicine IS solely relied upon as they do not packaged and labelled by the always reflect optimum prescribing supplier. The labels include details choice. Starter drug packs are of each medication's dosage an d th erefore sourced f rom batch number. The label also manufacturing units. includes a space where the GP can 51 fill in the patient's name and GMS (Payments) Board for payment. address, as well as the date and co op of issue. Recommendations In NEDOC the medication labels • CAWT s hould also consider applied by the pharmacies advise on making alternative the agreed dosage and batch arrangements for dispensing number. The labelling also detail s drugs that are not held in the the name and address of the primary care ce ntre. pharmacy supplying the drugs. • Cross border dispensing Financing Starter Packs arrangements should be In Northern Ireland, a nominal sum negotiated locally amongst co is top-sliced from the GP prescribing operatives and loca l health budget. For example in WESTDOC boards. money has been top-sliced from GPs' prescribing budgets an d held • The provision of a cross border at Board level. The Co-op manager out of hours service will increase orders st ock from agreed demand for dispensed medicines pharmacies and submits delivery in certain areas. It is therefore notes and orders to the Board on a recommended that the uptake of monthly basis. These are cross starter drugs and emergency checked and payments are made. medicines should be formally GPs are not responsible for covering monitored. Th is information the cost of starter packs. could then be used to determine whether demand for out of hours NEDOC have been allocated a grant dispensing is high enough to from the GMS (Payments) Board to justify the provision of on call cover pharmaceutical costs of the pharmacy services. out of hours services. In the North Ea stern Health Board the drugs are ordered on weekly basis by the Unit pharmacist on receipt of stock counts submitted by the Cl inical Nurse Managers of the out of hours centres. They are delivered by the nominated pharmacy of that month and at the end of the month, the pharmacist receives formal stock order forms to be submitted to the 52 Feasibility Study for the proviSion of Cross Border Out of Hours G? Services 1.,. Additional Workload and Demand Issues Changes in provision will have consulting at a NI out of hours important implications for future centre demand for out of hours care. 3. To est imate changes in demand Changes in demand will have knock for centre consultations in CAWT on implications for resources. An area co - ops over a one year accurate prediction offuture demand period was therefore required to assess the potential financial implications of the 7.2 Data Collection proposed service. Utilisation data can be used to predict demand for The data required for the study are services. As already noted in section routinely collected by each out of four (technical issues), out of hours hours co -op. Details of all calls util isation data are routinely received by co-ops are logged onto collected by ea ch of the out of hours t he co-ops central ca ll management co-operatives in the CAWT area. database. The call details presented Utilisation data for the one year in Table 7.1 were requested for each period prior to commencement of patient who contacted the service this feasibility study were requested during the one year stud"y period and received from the out of hours (from-1 st August 2000- to 3p! July co-ops in the study area. Geo 2001). statistical analyses of the NI and RoI utilisation data were carried out in The datasets received from each co order to produce an estimate of the op are summarised in Tab le 7.2. All changes in demand for centre data were fully anonymised to consultations that would occur at protect the identity of the patients. each out of hours centre if cross Both ASADOC and FOYLEDOC border provision was put in place. provided data for t he time period requested. In total t here were 1.1 Objectives 47,519 and 38,287 records in the ASADOC and FOYLEDOC data sets 1. To estimate the number of respectively. The call records people from NI who would be received from ASADOC were a 50% offered the chOice of consulting representative sample of all calls at a RoI out of hours centre in a received over the study period. Calls one year period made to MOURNEDOC after 2. To estimate the number of midnight, between 1st August 2000 people from the RoI who wou ld and 31St Ju ly 2001 were included in be offered the option of t he FOYLEDOC dataset. All calls 53 • Ag e • Sex • Triage method • Date ca ll was received • Fu ll postal address • Postcode in NI/ DED code of ROI Table 7.1: Call details requested kom each co-op received by MOU RNED OC before procedure as detail ed ea rlier in August 2001 were paper based, but section 3.3. The ca ll s received by NI cal ls received from 1"t August 2001 out of hours centres were mapped onwar ds were stored in d igital and overlaid with the cross border format . MOURNEDOC co-op wa s service areas identified earlier in the only able t o provide approximately geographical section of this report two mont hs of cal l data (2,792 (Map 3.7). records). The RoI ca ll records received from At the time of collecting the data, NEDOC also included patient address out of hours patient co ntacts in the information. However, the data North West Healt h Boa rd were not provided did not include the DED available in digital format. A t ot al of code as had been requested. 54,289 records were received from Without this spatial id entifier it was NEDOC. These records covered all not possible to map the calls made ca lls received betwee n 18th wit hin the Rol. As a result, an September 2000 and 31St Aug ust alternative methodological approach 2001. w as devi sed to esti mate t he additional workload that would resu lt U Methodology from RoI patients consulting at NI primary care centres. The age-sex The call records received from the utilisation rates in t he NEHB were NI co-ops included details of the applied t o the populations residing patients' residential postcodes. The in the areas of the RoI closer to NI patient postcodes were assigned a centres. geocode through linkage with the Central postcode directory (CPD), a product produced and maintained by the Post Office, using the same 1 year 1/8/00·31/7/01 1/8/01-3/10/01 Table 7.2: Data received for workload study 54 ______-'F-'e,,",,;"'b;""lity Study fo r the provision of Cross Border Out of Ho urs GP SefVices Estimatina the number of In total, 25 % of all Northern I reland people from NI who would be co·op records ( 0= 21,862) did not o ffered the choice of have postcodes. attending a RaI out of hours centre in a ODe year period Quick Address System (QAS ), a commercial sof twa r e package The postcodes held in the Northern e mployed to clean UK address Ireland co-op records were used to data bases, was used t o clean the map the origin of all out of hours addresses held in the NI co-op calls m ade to NI co-aps . T he patient database. This processing proportion of postcoded records in amended and corrected records that each in dividual co-op dataset varied had incorrect postcode details. After greatly. T he datasets from processing the database using QAS, MOURN EDOC and FOYLEDOC were 95% of all records held full postcode well postcoded, with over 92% of details. Five percent (n= 4147) records in each dataset containing were left without postcodes due to postcodes. The 50% sample dataset insufficient address information . received from ASADOC was poorly These records were excluded from postcoded with over 50% (0= the study, 19,197) of records not postcoded. •• • • • ..· " ...... • \ , • • • • '.~ • • • • • • t •• •• .'O • • • , • • , , • · . ." .-\• ...... "'# • • .. • • • • • \ • . ..". • • • • .' • • ... • • • • ,• ~ • • • • • , • · J.. ..• . • •• • • • • " • • • .' • • • • • • • • • " • • • , • • • • • • • • • • • • , • • '. •• • • • • • '. • • • • • • • • • • • • .' • • • • • • • . • • • • • • • • • • • • • .' • • • • • • • '. • .• • • .-- p, • 'Q'OQbordeI'tlNicl __ Map 7.1: Sample of base visits made by South Fermanagh residents who would quality for a crossborder conSUltation 55 The postcoded patient records held care centre in NI. 270 patients lived in the processed database were then closer to the proposed out of hours assigned geocodes/map references, centre in Ba llyshannon, 228 closer obtained from the CPD. Once to Cavan, and a further 984 closer geocoded, the origin of each ca ll was to Castleblaney. then plotted within the GIS. Spatial analysis tools were employed to overlay call origins with cross border service areas. Once overlaid, it was po ssible t o identify all ca ll s received from patients who reside closer to a RoI than to a NI primary care cent re. As an illustrative Table 7. 3: Base consultations example, Map 7.1 reveals the origin made in Northern Ireland by of a sample of South Fermanagh patients who reside closer to a ca lls, which resu lted in a base Rol out of hours centre consultation. Here, NI patients who reside closer to the Cavan out of The query facilities in the GIS were hours centre in the RoJ are depicted also used to identify the NI out of by a red dot. All other pa tients (i.e. hours centre that these 1518 those made by patients who resid e patients actually attended. Tab le 7.4 closer to a NI centre) are depicted reveals that of the 36 patients who by a blue dot. were closer to Donegal, 16 actually attended the Strabane centre and a Th is overlay technique enabled the further 20 attended the Enn iskillen identification of all NI pa tients who centre. All of the 270 ind ividuals attended a NI primary ca re centre who reside closer to Ba ll yshannon during the study period, and who attended the Enniskillen centre. actually resided closer to an existing Enniskillen co-op GPs also co nsulted or proposed RoI primary care centre. a further 228 patients who reside These visits have been summarised closer to Cavan. Therefore, over the according to the RoI centre to which study period, Enn iskillen GPs patients lived nearest (Table 7.3). consulted 518 patients who resided From Tab le 7.3, it is evident that 36 close r to a cross border out of hours patients who received an out of centre than to the En niskillen centre. hours consultation at a NI centre GPs at May and Newry consu lted 496 during the study period resided and 488 patients who lived closer closer to the proposed out of hours to the Castlebla ney out of hours centre in Donegal than t o a primary centre. 56 Feasibility Study for the provision of Cross Border Out of Hours GP Services To tal 1518 Table 7.4: Estimated number of NI patients who would consul at a RoI Primary Care Ce ntre in a one year period * It should be noted that, due to the consultations in the NWHB area lack orcomputer based records held (now covered by NOWDOC) for the by MOURNEDOC, an alternative study period were not accessible methodology was devised to since t hese were held on paper estimate the number or NI patients rather than on the required digital who would be ofre red the option to form at. NEDOC supplied the consult at Donegal instead of requested data in digital format. The Strabane. The alternative NEDOC dataset contained 54,289 methodology is the same as the one patient ca ll records. Each record used to estimate the number orRoI conta ined detail s of the patient's patients who would attend a NI postal address. However, this primary care centre over a one year address information did not include period. This alternative the spatial id entifier (DED) required methodology was based on the age to undertake the same type of sex utilisation rates observed in the spat ial analysis applied to the NI NI population during the previous data. year. An alternative methodology was Estimating the number of t herefore devised to estimate the people from the RoI who number of RoI patients who, in a would be offered the option one-year period, would be offered of attending a NI out of hours the choice of consult ing at either a centre NI or a RoI centr e . Age/sex ut ilisation rates within the NEHB Utilisation data were requested from area were ca lculated. The the RoI co-ops to estimate the population residing in t he Dundalk number of people from the RoI who area was excluded from the would be offered a consultation at a calc ulations s ince Dundalk's primary care centre in Northern population is not serviced by Ireland. Records of out of hours NEDOC. 57 Males ~14 Females ~14 5689 34756 164 Males 15-24 1488 2_ 61 15-24 225/ 21 958 103 Males 25-44 2328 38602 ro Females 25-44 3442 37676 91 Males 45-64 1362 20021 49 Females 45-64 1541 26284 !Il Males 65+ 745 14169 53 Females 65+ 1105 17758 62 200393 .. Table 7.5: Age/ Sex Base Consultation Rate (per 1000 a/the population) To ca lculate the centre utilisation females aged 25-44 in the NEDOC rates for each of the age/ sex cohorts population. These utilisation rates in the NEHB area, the number of were appli ed t o the populations base visits made by each age/ sex residing in cross border services cohort to a NEDOC primary ca re areas to approximate the number of centre during the study period RoI patients who wou ld be offered a (Column A- Table 7.5) was divided consultation at a Northern I reland by the number of NEHB residents in primary care centre each yea r. each age/sex coh ort (Col umn B). This result was then multiplied by Table 7.6 provides a summary of the one thousand to revea l the base visit predicted number of patients from ra te per on e thousand of the the RoI who would be given the population (i.e. the utilisation rate choice of availing of a cross border Column C). consultation over a one year period. 1185 Ra! patients would be eligible As is evident from t he utilisation to consult at the Derry out of hours rates revealed in Table 7.5, 176 centre, 979 at Strabane, 240 at primary care centre consultations En niskillen, 414 at May and 1252 at were made per one t housand males Newry. aged 14 and under in the population during the study period. Similarly, Further analysis reveals the age/sex 91 primary care centre consultations breakdown of these patients as well were mad e per one thou sand as their loca l RoI co-ops (Table 7.7). 58 ___ _ -',,,'::",,'b"""'''ty"-.:S'''tudy for the provision of Cross Border Out of Ho urs GP Services It should be noted that there is potential for overestimation in this prediction of additional workload expected for NI primary care centres. This is because the age/ sex based utilisation rates that have or been used have not accounted for base visits made by RoJ patients to urban~rural variations in utilisation. out of hours centres in Northern Rurality and more specifically Ireland in a one year period distance fro m services, is known to So for example, it is predicted that have a detrimental effect on of all males aged 0- 14 currently utilisation rates. Those residing in served by the Carndonagh primary rural areas with poor access to GP care centre, 219 would be given the services are less likely to make use option of travelling to Derry (their of services compa red to their urban nearest out of hours centre). The counterparts who are more likely to final column in Table 7.7 reveals the avail of services. total number of people who would have the option of availing of a cross It should also be noted that an border consultation. It is predicted un known proportion of service that, each year, a total of 855 utilisation in NI is a lready patients who are currently residing attributable to RoI residents who use in the Carndonagh catchment, would NI addresses to avail of health care be offered a consultation at the which is free at the point of delivery. Derry primary care centre (which is If formal arrangements for the closer to the patient's place of provision of cross border health care residence). are put in place, this will have an effect on the recording of cross Table 7. 7: Breakdown oT patients by current and cross border primary care centre) who would be offered the choice oT a cross border consultation (based on the above estimates). S9 border service uptake. It is however In Donegal would be minima l impossible to quantify the effect of (currently predicted to be formalising cross border out of hours approximately 18 patients per year). arrangements on NI cross border However, the predicted workload workload. increase in Deny is more Significant, with an additional 1185 patients U Workload estimates for one expected per annum. The Newry year period primary care centre is predicted to receive even more patients from the Finally, by com piling the information RoI (1 252) per year than the Derry presented in the previous two primary ca re. However as noted sections, it is possible to predict the above, the reader should bear in workload changes that would be mind that the workload gains experienced at each out of hours predicted for NI co-ops are likely to centre. The predicted changes are be overestimated since, due to data presented in Table 7.8. limitations, it was not possible to control for the effects of distance and Two co-ops, Derry and the proposed rurality on utilisation. centre in Donegal, would not lose any of their service populations. Other centres will experience no Both would however experience additional workload (Letterkenny, increases in their service areas and Carndonagh and the proposed therefore increases i n their centre in Carrick on Shannon). workloads. The increase in workload These co-ops will however lose Strabane 979 16 963 EnniskiJl en 240 518 -278 Moy 414 496 -82 Newry 1252 4BB 764 cavan 22B 84 144 9B4 1666 -682 0 1309 -1309 0 B55 -855 Ba li yshannon 270 78 192 Donegal 36 0 36 Cam ck-o n -Shan non 0 7B -78 Table 7. 8: Predicted Base Visits in One Year 60 Feasibility Study for the provision of Cross Border Out of Hours GP Services approximately 394, 1309, 855, and 78 centre consultations respectively to NI co-ops. The net difference in out of hours work load is a lso displayed in Table 7.8. Letterkenny is li kely to experience the greatest decrease in workload, whilst Derry will ex pe r ie nce t he great est increase. 61 8. Financial Issues This section examines the complex .8..2 The current structure and issues of funding and charging financing of CO-aDS in the study area arrangements in co-aps a nd identifies the mechanisms required Northern Ireland to faCilitate charging and payment I n Northern I reland, co-ops are transactions in a cross-border independent non-profit organisations context. The resea rch team was owned and run by groups of General given the general brief of Practitioners to provide quality out determining the financia l of-hours primary care services to arrangements for the payment of their patients. Co -op funding falls cross-border centre consultations. into two general categories: ( i) from discussions at the first infrastructural funding and (H) introductory workshop held in Ju ly service funding. Infrastructural 2001 in En niskillen, it was clear that funding covers the costs of facilities, the financing and costing of a cross such as electricity, heat and border out of hours service could be transport, while service funding is problematical. The lack of any simple used to pay for the items of service so lution was due to sign ifica nt and provided (i.e. telephone advice, complex differences in both the primary care centre consultations • structuring and financing of t he and home consultations). While the various co-aps in the study area basic co-op model is the same across (between and within jurisdictions). the province, there is considerable It was ag reed that these matters fle xibil ity in the system. There are would be investigated further and therefore many differences in the discussed via a dedicated one-day ways individual co-ops decide to run financial workshop (held in Omagh their financial affairs. in November 2001), involving representatives from the Boards, co Infrastructure funding is partly ops and GPs. financed by the DHSSPS Out of Hours Development Fu nd, partly U Objectives funded by the local health board and partly funded by the co-op • To examine the current structure members. Infrastructure funding and financing of co -ops in the from members is capitation based. study area Capitation fees are paid by GPs for • To identify the main differences each patient covered by the out of in financial systems hours service and are therefore • To develop a financial model for dependent upon practice list size. cross border transactions 62 _ ____----' Feasibility Study for the provision of Cross Border Out of Hours GP Services The basic fee pa id per patient varies Republic of Ireland both between and within co-aps. The system in the RaI is less complex. The NEDOC and NOWDOC Northern Ireland co-ops also receive Co-aps are funded and supported by service fu nding which covers the their local Health Board. The health costs of service provision. Service boards cover all infrastructure and funding is derived from the Central services funding. GPs are not Services Agency (CSA) for services required to contribute to co-op provided after lOpm a nd at funding. Participating NOWDQC weekends. In addition, most co-aps GPs receive Specia l Type also receive (top-up) service funding Consultation (STC) fees for out of from co-op members to cover other hours consultations. However, service costs, such as services NEDOC GPs waive their rights to provided before lOpm. The amount cfaim the src fees for out of hours secured from members varies from services. Instead, NEDOC GPs are co - op to co-op as it rel ates to paid by the employing co -op for different consultation levels and hours worked. There are two levels types of se rvice provided, such as of payment, tria ging and specialist cars and drivers for home consultation. Fees paid by private services. Most co-ops pay a fee for patients are accrued and distributed GPs working out of hours shifts, t he amongst the GPs proportionate to costs of which are covered by the hours worked at the end of the CSAjmember contribution. Others financial year. The amount charged prefer to operate a simple rota for primary care centre or home system whereby GPs do not receive consultation varies within co-ops and payment from the co- op but do IS determined by the GPs receive the CSA payment for each themselves. patient seen. Co - ops the ref ore operating under this scheme do not U Comparison of financial require service funding from t heir systems members. The consequence of these variations in modes of service The ba sic differences, which stem provision means that there is no from the different structural models standard fee for items of se rvice. adopted in NI and the RoI are Within Northern Ireland, there is a illustrated in Table 8.1. In the ROI, mave to have a regional solution co- ops are sup ported and where fund i ng is standardised maintained by t he health boards throughout. However, this is not with GPs receiving a salary for hours likely to happen in the near future. worked and an additional payment from consulting private patients. I n 63 • RoI NI funding 100% from Health Board Partially funded by DoH Partially funded by GP members Service payments Partially pa id by DoH (GMS) Pa rtially paid by CSA Partially paid by Private Patients Partially paid by GP members GP Income Profit shared amongst GPs Cost n eutral~ no profit . . Table 8.1. Fundamental cross border differences In• co-ops financia. l systems NI co-ops are owned and maintained provided between 6pm and lOpm. by the member GPs, and receive variable infrastructural and service M Important issues for a cross contributions from the hea lth border service departments. These co-ops are run on a cost neutral basis. There are a number of key issues pertinent to the development of a In Northern Ireland, all patients financial model for a cross-border receive health care free at the point OOH service. of delivery through the NHS system. I n the Republic of Ireland GMS From the workload study it is patients receive free care whilst non apparent that in any North/ South GMS patients pay a fee per service out of hours arrangement there wi ll provided at point of delivery. Co-ops not be parity in terms of cross border in the RoI have facifities to accept patient flows. Some areas will have financial transactions for the net gains in primary care centre payment of service, including cash visits, while others will have net payments. Th is facility is not losses simply as a consequence of available in NI. current population distribution and service provision. This will have The actual t ime of consultation in knock-on effects in terms of co-op Northern Ireland has significant income. For example in NI, increases financial implications for both GPs or decreases in consultation rates and co-ops. If a GP in Northern will affect the service income I rela nd consults a patient after component for co-a ps. Similarly, in lOpm, the Central Services Agency the ROI, increases or decreases in (CSA) will currently contribute consultation rates will affect the £23.50 towards the cost of providing income of GPs through gains/losses that consult ation. There is no such of non-GMS patient fees. contribution for consultations 64 Feasibility Study for the provISion of Cross Border Out of Hours GP Services In ROI non-GMS patients pay for European Union Regulations services at point of delivery. NI co European Union regulations were ops do not have this facility. In a studied to ascertain whether any situation whe re ROI non-GMS forma l arrangements already in patient s seek care in the NI, a place at the European level could payment system would have to be assist or be used in determining a introduced. suitable financial model fo r a cross border OOH service. While all Internal charges for items of service European citizens are free to t ravel vary widely, both between and and seek medical care in other EU within each jurisdictions. It is countries, there are a lim ited accepted that cross-border services number of ways of having the costs must be pa id for. The dilemma is covered. whether to apply a standard charge which m ight be accepted by a ll Form Ell! does not cover participating co - ops or to allow individua ls for free or reduced-cost corresponding co-ops on either side treatment who travel to another EEA of the border to negotiate their own country specifically for medical care. rates. It is only va lid when a person becomes ill whilst abroad, not when While the numbers of patients a patient travels for the purpose of expected to use the cross-border seeking medica l help. service may be r elatively small compared to overall usage in the Form E112 covers individuals who region, from a financial perspective, travel specifically for medical ca re. the t iming and geograph ical The scheme is on ly available where distribution of these consultations a clear need for on-going treatment could be important. At present, is establ ished and accepted by the many co-ops operate close to their health authority. Form E112 is not staffing threshold levels at peak time issued automatically but requires periods ( e.g. weekends). Any authorisation f rom t he Health Significant increase in workload from Department within t he patient's cross-border consu ltations may have jurisdiction. The scheme is not considerable staffing and therefore available on an ad hoc emergency financial implications. This issue consultation basis and would would need to be considered on an therefore be inappropriate in the individual co -op/PCC basis. context of a regular cross-border out of hours service. 65 .B..:..S. A financial model for cross • This fee should be reviewed border transactions periodically t o consider the impact of any currency This is a complex issue for wh ich fluctuations between the EURO there is no easy or straightforward and sterling. solution. The numerous imponderable factors and 'what if... ?' • Fees for consultations provided scenarios make it impossible to to NHS (NI) patients in the south devise a comprehensive si ngle should be pa id for by the solution satisfactory to all parties patient's co-op to the RoI involved. This point was recognised provider. Normal internal and accepted at both the financial arrangements for charging GPs/ and fin a l workshops. However, practices and claiming from CSA progress was made in that a number should still apply. of basic working principles were agreed upon with respect to • Fees for consultations provided achieving an acceptable working in NI to GMS (RoI) patients financial model. should be pa id for by the respective board to the providing Recommendations co-op. • There should be a single • All transactions should be standard fee for surgery recorded, and bi lling consult ations on either side of administered through the the border. standard software procedures currently in place. • On comparison of the charging mechanisms within the various • Non-GMS patients receiving a co-ops, it was noted that at the consultation in NI should pay the time of the study, a base standard fee to the co-op at the consultation cost around £25 point of service delivery. This (sterling) existed. As a simple would mean that NI co-ops solution, it is therefore would have to accept financial recommended that the receiving transactions in sterling or EURO. co-op should accrue a £25 (or EURO equivalent) payment for • In NI, there should be no change each centre consu ltation to the income currently received provided to a cross border from the Out of Hours patient. Development Fund. 66 Feasibility Study for the provision of Cross Border Out of HOurs GP Services • The development of a financial model should be negotiated with loca l co-op m embers. The financial model developed should (i) depend upon workload trade offs and CH) consider both the structure and funding of the local co-ops. There is no guarantee that the scheme will be cost neutral for all parties when rolled out. It Is our overall recommendation that a pilot scheme should be undertaken to test how these financial arrangements would work in practice. The pilot scheme would require two test sites, one where RoI patients travel to an NI primary care centre and the other where NI patients travel to an RoI primary care centre. The principles outlined above would form the basis of a financial model, which could be tested and refined prior to any roll-out across the whole border region. The pilot scheme should be used to monitor and negotiate the impact of cross border patients being admitted to hospital on an emergency basis from an out of hours primary care centre. 67 - 9. Conclusion ThiS feasibility study was 9.1 Summary of Geographical commissioned and carried out with Research a view to facilitating the development of cross border co A Geographic Information Systems operation in primary care service approach was adopted to ident ify provision. The primary purpose of and quantify the areas and developing a cro ss border out of populations in the border areas who hours service is to improve access could potentially benefit from the to care in border areas. avai la bility of a cross border out of hours service. It was shown that The ba sic terms of reference for the circa. 65,000 people would be study were 'to research joint working eligible for the service on the basis and co-operation between of living closer to an out of hours professionals on a cross-border GP centre on the other side of the out-ot- hours arrangement and border. Further analysis revealed produce an operational plan that the majority of those eligible addressing the organisational and reside in areas that are designated management issues which need to as being materially deprived. be considered before cross-border co-operation can take place', The A retrospective study of demand for study focused on patients travelling co-op services over a one-year across the border to seek care in period was used to identify the primary care centres: the option of potential increases and decreases in GPs crossing the border to provide demand for consultations at DOH home visits was not considered. centres that may operate on a cross border basis. In general, it was Using an agreed set of core strategic predicted that the co-ops in the and operational issues and a number North would experience a net gain of basic principles as guidelines, a in surgery visits whist those in the project management plan and South would experience a net loss . methodology was formulated. This In addition, the current structures, divided the key research tasks into funding and charging arrangements three distinct sections, in each of the co-ops were examined Geographical, Professional and and a proposal for the costing and BUSiness, and Technical. admin istration of financial transactions in a cross-border arrangement was proposed. 68 Feasibility Study for the provision of Cross Border Out of Hours GP Services ~ Summary of Technica l The need for a complaints procedure Research that is accessible, efficient and fair was recognised, as was the From the technical perspective, an importance of giving patients the analysis of the current protocols, choice of where they consult and an processes, software and network assurance that there were no plans so lut ions used by the various co+ to limit the existing out of hours operatives in the region was arrangements. undertaken. It is fortunate that all of the co+operatives use the same The General Medical Council (UK) software so lution to manage out of continues to recommend dual hours ca lls as this facilitates the r egistration for a ll doctors development of an inter-connected participating in this scheme. The cross-border software solution. A Medical Council of Ireland does not software and network solution has consider dua l reg istration necessary, been proposed to accommodate for so long as there are no plans for necessary linkage of cross-border doctors to cross the border in a OOH centres, interface professional capacity. The issue of modifications, integ ration of dual registration of RoI GPs requires address-based 'nearest OOH centre' further clarification. data bases and additions to the electronic record sheet. Overall Recommendation 2....1 Summary of professional! This project aimed to determine the Business Research feasibility of implementing a cross border out of hours primary care A range of professional and business service in the Irish border region . It issues was investigated including wa s also intended to deliver a model matters of professional registration, that would not only provide greater indemnity insurance, prescribing patient access in the region but one and dispensing. It was concluded that would also be acceptable to that most issues could be readily those who use and provide the addressed. The majority of service. On the basis of our research stakeholder organisations contacted and various analyses it is our belief was very supportive of the proposed that the introduction of such a scheme. The general opinion was service is indeed feasible. It has that the proposal was potentially a been our experience in both significant step forward in improving correspondence and workshops with access to out of hours primary care. key stakeholders that there is No organisations were opposed to considerable support and the scheme. encouragement for the initiative to 69 proceed to the next stage. In this arrangements can be eva luated reg ard, we recommend that before • Infrastructure and t echnica l attempting to roll out the service systems can be tested and across the whole region, a pilot refined scheme be implemented for a trial • Pub lic opinion can be measured period. and used as a basis for awa reness and promotiona l 2....5. Recommendation for a Pilot activities required for the roll out Scheme • Starter drug packs and fo llow up prescribing can be monitored It has been apparent f rom • Impact o n hospital and conducting the feas ibility study that ambu lance service can be a myriad of issues from geographica l evaluated and technical to professional and financial needs to be addressed in The research team recognises these order to facilitate the establishment advantages and is strongly of the of a cr oss border o ut of hou rs opinion that the best way forward is servi ce . It is c lear that t he to undertake a pilot scheme whereby implementation of the ' live' system a ll the basic infrastructure, will take considerable organisation procedures and protocols are put in and preparation. The processes place in a limited number of areas involved will not be simple, nor will and then monitored and eva lu ated it be straightforward. It shou ld be overa trial period of 1- 2 yea rs . Our apparent that some issues ar e recommendation is fo r two areas to considerably more important than be select ed , one where patients in others. Each issue needs to be Northern Ireland will have access to addressed if t he proposal is to an OOH ce ntre in the Rep ublic of become operational. Ireland and one where patients in the Republ ic of I reland will have The i mplementation of a pilot access to an OOH centre in Northern scheme has many advantages: Ireland. On the basis of the workload • The various procedures and ana lysis (see section 7 L we infrastructur e can be recommend the following two areas: continuously monitored at a loca l 1. NI bor der area: population level residing i n the area which • Actual workload impact can be stretches from north of Keady to quantif ied a nd poss ib le Crossma 9 I en/ Si Iverbrid ge problems/barriers to uptake of should be given the opportunity the service can be identified to consult at the NEDOC OOH • Financia l costs and centre in Castleblaney 70 Feasibility Study for the provision of Cross Border Out of Hours GP Services 2. RaJ border area: population resid i ng i n the area which stretches from south of Buncrana to Newton Cunningham should be given t he opportunity to consult at the FOYLEDOC OO H centre in the city of Derry Both areas are il lustrated I n Appendix 3. These areas have been se lected for recommendation si mply on the basis of attempting to achieve comparability in the number of cross border consultations. However, the final decision will rest with CAWT, and will depend upon their negotiations with local co-ops, GPs and other relevant bodies. , 71 10. Operational Plan for Pilot Scheme To assist CAWT in the development should identify and agree upon of a pi lot se rvice, we have devised two out of hours primary care an operational plan. This plan details centres, one on each side of the the next steps that shou ld be taken border, to be included in the pil ot to facilitate the development of cross study. CAWT should then engage border out of hours services. in local negot:ations with the relevant co-aps, secondary care 1. A steering committee should be and ambula nce serv ice formed of relevant personnel providers, with the ultimate aim from each of the healt h boards, of signing these bodies up t o the co -aps and other organisations scheme. The boards and involved in the study_ T he participating co-ops shou ld steering committee should agree upon the costing consider the cost implications of mechanisms to be employed. t he pilot service and secure funding for the same. The 4. A cross-border software solution steering group should then should be develo ped. The est ablish a project team to system interface should be include a project manager and developed to anow access to look an external monitoring team. up tables that will be used to The project team should meet up inform t riage personnel of a on a monthly or quarterly basis patient's eligibility. System to review progress. modifications should also be made to allow for the recording 2. Tak ing due consideration of our of any medications prescribed co rrespondence with the General and for the id entification of those Med ica l Council and The Medical who are to be excluded from the Council of Ireland, CAWT should pilot (L e. termina lly and mentally examine and resolve the issue ill). Geocoded databases should of dual registration for Republic be used to create look-up tables of Ireland GPs who will consult of NI and RoI addresses to be with patients from Northern included in the pilot. Ireland. The implications of dua l r eg istration on fu ture re 5. The four CAWT health boards accreditation shou ld also be and the out of hours co- ops considered. should modify existing in-house compla ints procedures to 3. The fou r CAWT hea lth boards speci fica lly cover problems 72 Feasibility Study for the provision of Cross Border Out of Hours GP Services arising from the provision of management of patient s who cross border out o f hours avail of cross border services services. These should have an should be developed. These agreed protocol across all health protocols should be as similar as boards. possible to those used to manage patients who consult at 6. GPs and nurses working within a primary care centre within their the Out of Hours centres in this home jurisdiction pilot study will need appropriate indemnity arrangements which 10. A monitoring strategy should be take into account their developed . An independent involvement in cross border monitoring team should be put service provision. Appropriate in place to monitor the pilot indemnity cover should be service. The monitoring process established and, where a GP or shou ld commence prior to the nurse has to change indemnity operationalisa tion of the cross organisations i n order to border service. participate in this study, CAWT should consider the issue of l1.AJI organisations and reimbursing the difference in the professional bodies (e.g. nursing subscription rates of the two unions), whose members will be agencies. participating in the pilot scheme should be informed in writing of 7. Primary care centres will have to the start date of the proposed be insured for providing care to pi lot. cross border patients. Premises underwriters will have to be 12. Taking on board the informed and premises cover will recommendations presented in have to be amended. section 8.5 the boards and co ops shou ld n eg otiate both 8. The Boards should monitor the service charges and charging change in activity that might mechanisms locally. Protocols occur in hospitals. This might for processing GMS and NHS be particularly applicable in the patient payments and handling Altnagelvin Area Hospita l to cash payments shou ld be cover any RoI patient admitted developed. to the same under this pilot scheme. 13. Mechanisms for the supply and dispensing of drugs should also 9. Administrative protocols for the be negotiated locally between 73 co -ops and boards. CAIIVr should also consider ma king alternative arrangements for dispensing drugs that are not held in the primary care centre. 14. Networks professionals shou ld be con tract ed to connect hubs and terminals at each of the call centres and primary care centres involved in the pilot service. 15. CAWT should embark upon a publicity campaign targeted at those who are eligible to use t he cross border service. The result of the geog raphical ana lysis could be used to identify the addresses which should receive information about the pilot service . 5 ignage, including information leaflets, should provide details of the service available and advise patient s that they should continue to contact the out of hours service within their home jurisdiction. 74 ______c..: Feasibility Study for the provision of Cross Border Out of Hours GP Services Appendix One: Profile of Research Team Members Or Adrian Moore BSc, MSc, DPhil, accessibility of prima r y a nd has over ten years experience in t he secondary health ca re services in design and management of GIS Northern Ireland in relation to (i) projects ranging from project need for services and (H) hea lth care specific desktop solutions to larg e provision policies. She has recently sca le mult imedia distributed spatial completed a series of projects information systems. He is a Senior including location / al location Lecturer in Geographic Information modelling for hea lth service Systems and Head of the Spatial provision. Analysis and Information Technologies Research Group at the Mr Stephen McAlister BSc (Hons), University of Ulster. He has bee n MSc, CertFCP, MCP, is t he Networks project leade r or consultant on over & Distributed Systems Manager for thirty GIS research and consultancy CDC. He has had 9 years experience proj ects costing over £2 million. He in the field of Computer Science - specialises in GIS based health and where he has spent time as a Data health care applications. He has Management Analyst, recently completed a number of GeoTelematics Researcher a nd la rge national and Europea n Networks Developer. He has recently distributed spatial information completed the successful networking system projects (IRDSS, CATCH and of new prem ises for CDC a nd BORDER). In addition he has been maintains server ba nks in two working on a number of locally based locations for file storage, internet con sulta ncy projects for loca l applications and web hosting. He is government agenci es and also involved in the development of authorities, Health Boards and Trusts Web-based GIS. Previou sly he has in Northern Ireland and the Republic. worked on severa l successfu l European Telematics projects as a Or Carol McQuillan BSc ( Hons), researcher and software developer. PhD, is currently employed by CDC as a GIS Consultant where she is Dr. loann a Fr eeman MBBS primarily responsible for projects DRCOG MRCGP has worked in both relating to Health and Healthcare. the UK and the RoJ as a Genera l Dr McQuiHan has previously worked Practitioner and was instrumental in as a Resea rch Officer and latterly a developing clinica l protocols for an Lecturer in Human Geography at out of hours co-operative in London. UUC. Her PhD employed a GIS As a c linica l tut or in National approach to investigate the University of Ireland, Galway she 75 teaches clinical and communication researching health issues for skills to undergraduate medica l voluntary and statutory agencies. students and she also works as a Recent work has included Primary GP in Tuam, Co. Ga lway. Health Care research for CAWT into the perceptions of social and health Prof. Andrew W Murphy I S care professionals of health needs currently the Foundation Professor in the Blacklion and Be lcoo region of General Practice at the National (March 2001), Illicit Drug Use in the University of Ireland, Gal way and a Omagh District (October 2001) and General Practitioner in a rura l Cross-border Peer Research into practice in Turloughmore, County I lHcit Drug Use (forthcoming, June Ga lway. This post is supported by 2002). She is curr ently the North Western and Western commissioned to conduct a range of Health Boa rds. He was previously research an d evaluation projects Senior Lecturer in the Department relating to social and health issues. of Ge neral Practice at the Med ica l Schoo l of the Royal College of Prof. Scott Brown is an NHS Surgeons in I reland. As Foundation Principa l in General Practice, based Professor, he has been responsible in the on ly RCGP Research Practice for developing under and post in Ireland ( Coleraine). He is a graduate general practice/ primary former Vice Chariman of the RCGP care education in the University. His Council, London and a member of postgraduate ed ucation has centred the co lleges international and on primary healthcare systems and financial committees. He currently teams and cardiac and trauma holds the chair in General Practice emergency care. He has published St udies at the Institut e of nationally and internationa lly on Postgraduate Resea rch in Medicine research interests of the and Health. management of cardiovascula r disease in the community, the delivery of hea lthcare in rural areas and the genera! practice/Accident & Emergency interface. Or. Catherine Loughrey BSc (Hons), PhD ., was employed by the University of Ulster to research the pharmacy issues within this study. She has 9 years research experience of which five have concentrated on 76 Feasibility Study for the provision of Cro ss Border Out of Hours GP Services Appendix Two Attendees of Introductory Feasibility Study Workshop, th Klllyhevlln Hotel, Enniskillenl 6 July 2001 Dr. Morris Brown Dr. Ca rol McQui llan Western Health and So University of Ulster ci al Se rvices Board Ms. Fra ncis McReynolds Ms. Oonagh Carson CAWT Western Health and So cial Services Board Dr. Adrian Moore University of Ulster Mr. Eugene Dunn Foy le GP Eme rgency Mrs. Kate Mu lvenna Service North Eastern Health Board Ms. Sharon Fulton Asadoc Mrs. Hayley Neely University of Ulster Dr. Pat Harrold Blacklion Health Ce ntre Dr. Theo Nugent Errigal Med ica l Centre Mrs. Margaret Headon Primary Care Develop Dr. Brendan O/Hare ment Board Castlederg Clinic Dr. Catherine Loughrey Ms. Martina Ra lph University of Ulster North Eastern Health Board Dr. Norbert Lynch Lisnaskea Hea lth Centre Mr. M.Redmond No rth Eastern Health Dr. John Madden Board North Wes tern Health Board Mr. Edd ie Ritson Southern Hea lth and Dr. loe McEvoy Social Services Boa rd Foyle GP Emergency Service 77 Mr. Paul Rob inson North Ea stern Health Board Mr. Noel Scott Primary Care Develop ment Board Ms. Joy Sinnett North Western Health Board Mrs. Linda Stewart Western Health and So cial Services Board Dr. Brian Sweeney Fintona Med ical Centre Mr. Mark Timoney Southern Hea lth and Social Services Boa rd Dr. Lorraine Wasson University of Ulster 78 Feasibility Study for the provision of Cross Border Out of Hours GP Services Attendees of the Financial Workshop, Postgraduate Medical Centre, Omagh, 30 t h November 2001 Mr Mark Armstrong Asadoe Mrs Judith Doherty C4WT Mr Eugene Dunn Foyledoe Dr. Joanna Freeman National University of lrelan~ Galway Ms. Sharon Fulton Asadoe Ms Ge ra!dine Kane North Eastern Health Board Ms Do lores McCormick Southern health and Social Services Board Dr. Carol McQuillan Causeway Data Communications (CDC) Dr. Adrian Moore University of Ulster Mr Tadhg O'Brien North Eastern Health Board Mr Noel Scott North Western Health Board Or Brian Sweeney Asadoc Ms Joy Synnott Nowdoc 79 Attendees of the Final Feasibilit y Study Workshop, Carrickdale hotel, Dundalk, 19th April 2 002 Mr. Harold Andrews Western Health & Social Services CounCIl Dr. Lee Casey Fay/eDoe Ms. Moira Oavren UKCC/RCN Mrs. Ju dith Doherty CAWT Mr. Eugene Dunn Fay/eDoe Ms. Lesley Edgar Southern Health and Social Services Board Dr. Jo Freeman National UniversIty ofIreland Mr. Eugene Gallagher Western Health and Social Services Board Mr. Jahann Hoey NO/th Eastern Health Board Dr. Catherine Loughry UniversIty of Ulster Mr. Stephen McAlister CDC Ms. Karen McCoy Southern Health & Social Services Council Ms. Frances McLaughHn CAWT Mr. Kenny McMahon NI Ambulance Service/Southern Division Dr. Carol McQuillan CDC Dr. Adrian Moore University of Ulster Mrs. Kate Mulvena North Eastern Health Board Mr. Sammy Nicholl NI Ambulance Service, Western Division Dr. Theo Nugent Asadoc Mr. Tadgh O'6rien North Eastern Health Board Mrs. Charmaine O'Donnell Western Health and Social Services Board Mrs. Martina Ralph NEdoc Mr. Eddie Ritson Southern Health and Social Services Board Mr. Noel Scott North Western Health Board Dr. John Sheeran NOWdoc Dr. Brian Sweeney Asadoc Dr. Robert Thompson Southern Health and Social Services Board Mr. Joe Travers Sperrin Lakeland Trust Dr. Peter Wahlrab NEdoc 80 To Carndonagh Three Tree"" (467) -- ~ n IQ o c u 3 ,. ~ Fahan 3"1:1 d' I (1209) I (963) m "1:1 , ~ ~ ID ~ , Island (644) Q.::s ro :l.c._. ~ ,,>< ~ •o 0-1 o ~J Q. Burt "-'=m (943) ~ID •• ~ g' "- / \ l '\ ,• ' ~wtown o CUnning ham \Caslleforward c ~ (710)1 (825) \ Q. I o l c To Letlerkenny ----_ j /)- Killea Cl Carndonagh Catchment , (1049) o Letterkenny Catchment I OEOs & EO. Kilomelers NB ··DED Pop ul ations In brackets.... - ~~~L-__b ===~ To Moy , J'\ Keady (2402) Derrynoose (1626) (2031 ) Carrigatuke (329) ~ c > 3'C 3'C Newtown m 11> il. ::I hamllton m Co (1552) a. _. z >< M-j ,,:::r :: ~ ~ 11> rc:;;iie bl.ne~ ~ .. ~ Creggan w (2474) • Crossmagle Moy Catchment Area N (2425) Newry Catchment Area DEDs & EDs o NI Ward Boundaries A Kilomelers NB'" Ward Populations in brackets~~ ._ .. ...... • [IIj ••"j? • :I ,."