Argyll and Bute CHP

OUTCOME OF THE SHORT LISTING OF THE SERVICE OPTIONS

24 / 7 REVIEW OF GP OUT OF HOURS AND GP HOSPITAL SERVICES

Version 5 02/05/12 1 Contents Page No.

Summary of short listed options 3

1 Introduction 5

2 Methodology 5

3 Steps to filling in the Matrix 6

4 Short Listing Workshop 19/04/12 6

5 Option Long List and Existing Service Feedback and Comments 7

6 Option Short Listing Outcome 7-9

7 Next Steps 10

9 Appendices

• Appendix 1 Table Option Assessment Matrix

• Appendix 2 Table Voting on the Options to include in the short list of options Cowal 24 / 7 Review Group Short Listing Options Workshop 19/04/12

• Appendix 3 Table Characteristics of Options

• Appendix 4 - Workshop Attendees and Submissions Received

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Option Description Table Summary of Short Listed Options

1 Community Health Partnership (CHP) employed Doctors based in Cowal Community Hospital (CCH) provide the following in the Hospital; Casualty, cover for patients (in patients) Out of Hours ie after 6pm and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from the Hospital .

The 3 GP practices based in Dunoon cover inpatients during the day Mon-Fri 8am to 6pm.

3 Centre Options Centre 3 Options Rural GPs provide Out of Hours services in rural Cowal.

A contract with NHS Greater Glasgow &Clyde (NHS GG&C) provides a service to Lochgoilhead from the Vale of Leven Hospital ( VoL).

2 CHP employed Doctors based in CCH provide the following in the Hospital; Casualty, in patients during Out of Hours including weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CCH

GPs contracted to cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal - Tighnabruaich, Strachur and extend the coverage to Ardentinny (currently covered by CCH OOH)

Contract with NHS Greater Glasgow &Clyde providing OOH service to Lochgoilhead from the Vale of Leven Hospital

4 CHP employed Doctors based in CCH provide the following in the Hospital; Casualty, inpatients during Out of Hours and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CCH.

The 3 GP practices based in Dunoon cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal, Tighnabruaich, Strachur and Lochgoilhead 6 CHP employed Doctors based in CCH provide the following in the Hospital; Casualty, in

2 Centre Options Centre 2 Options patients during Out of Hours including weekends/bank holidays. They provide the Out of Hours service for the whole of Cowal. Enhanced nurse or paramedic practitioner to provide initial response

Contract with GPs to provide inpatient hospital service Monday to Friday 8am – 6pm.

In rural Cowal Saturday & bank holiday ‘drop in’ out of hours GP surgery in one of Strachur/Tighnabruaich/Lochgoilhead 7 CHP employed Doctors to provide hospital inpatient and casualty service

GP practices form consortium to provide GP Out of Hours service via a contract for the whole of Cowal 8 CHP employ Doctors to provide hospital inpatient (out of hours, weekends & bank holidays) and casualty service

GP practices form consortium to provide hospital inpatient service Mon-Fri 8am to 6pm

GP practices form consortium to provide GP out of hours service via a contract for the whole of Cowal

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Option Description Table Summary of Short Listed Options Option Centre 11 1 1 CHP employed Medical Staff based in Cowal Community Hospital cover the Casualty, Inpatient and Out of Hours service for the whole of Cowal from the hospital

4 1 Introduction

The 24/7 Review Group met and assessed the long list of 17 options to reduce them to a short list. This shortlist will be put through an options appraisal process to decide which option is best.

The short listing of options was done by assessing the option against: • Project objectives • Key features expected from the new model • Service principles • Project boundaries or parameters • Feedback received from the public events, staff and stakeholders.

It is a “reality check”, assessing which options are viable and should be put through a formal appraisal process. The characteristics of the 17 “Long Listed” options are detailed in Appendix 3. The full description of the long list of options can be found at http://www.nhshighland.scot.nhs.uk/CHP/ArgyllandBute/PPF/Pages/CowalGPS ervices.aspx

However, an option does not have to be assessed as viable using simply this process as there are other considerations to take into account including: • The existing service model to be considered and also used as a benchmark- Option 1 is always included • Objective evidence that comes from formally appraising a model favoured by some stakeholders to ensure transparency, fairness and inclusion

This initial assessment, feedback and consideration process will also clarify and develop further the short listed options. This is through working up the detail of each option, or by highlighting issues that require consideration.

2 Methodology

The methodology used is a “matrix”, a clear way of comparing how each option rates against the project objectives, boundaries and key features.

The matrix • is colour coded • rates how each option would perform in practice against the project objectives, boundaries and key features • is a first step in assessing the viability of the options • is subjective – those rating options have to make judgements about the performance of each option

The rating takes account of the following: • Service description and operating profile of each option • Feedback and comments received from the public, users, stakeholders and staff • Information which has been presented to the Project Group regarding the current service and how it is provided re types and number of staff and shift patterns • The activity and demand profile of the service i.e. the Cowal Community Hospital and Out of Hours Service Activity Profile as well as other information • Benchmarking information on other service models

5 • The comments log informing the development of the options

Some of the above is factual information and considered to be objective, some are opinions based on experience and is considered to be subjective.

Appendix 1 details the matrix used as part of the process. The following rating using colour coding was used. • The rating least likely, occasionally, etc , which is felt to be the most accurate for the service objective, boundary or key feature is chosen • The colour that indicates that rating is then used to insert into the matrix, e.g. least likely is red and red is inserted into the matrix.

Matrix Key Least Likely Occasionally Likely Most of time All the time

3 Steps to Filling in the Matrix

Cowal 24 / 7 Project Group members were asked at the Project Group meeting 29 th March 2012 to do some “homework” as an individual or as a group (a group is recorded as such) as follows : • The matrix template should be filled in with the individuals or groups assessment of the options • Once the rating and colour coding of all the options has been completed, a judgement is made on which options individuals or groups feel should be short listed or not • This is recorded by indicating Yes or No in the final row of the matrix • The results of this assessment to be brought to the project short listing workshop (19 th April 2012)

4 Short Listing Options Workshop 19/04/12

At the short listing meeting on the 19 th April the project group collated and examined the results of their “homework” recording their choice of options to include. They were then put into three categories: a) consensus agreement to include b) consensus agreement to exclude c) consensus that there is uncertainty to include / exclude

The results of this stage of the assessment are detailed in Appendix 2. They are summarised in preference ranking order below.

6 Table short listing ranking Agreement to No of votes for Rank of include in short Option each option options listing

1 Existing service Agreed by all to automatically short list these selected 1 options 4 11 2 2 9 3 8 8 4

3 7 5 Uncertain whether 7 to include or 6 6 exclude these 6 5 7 options so further 9 discussion 5 8 needed 11 4 9 13 4 10 15 4 11

12 3 12 Agreed by all to exclude these 5 2 13 options 14 1 14 10 0 15 16 0 16 17 0 17

5 Option Long List and existing service feedback and comments

As part of the Review programme, a number of information events for local communities and NHS staff were held providing the opportunity to look at the long list of options. People were asked to make comments, decide which options would best meet their needs and ask questions.

Local communities were also encouraged to share their experience of using the current Out of Hours Service and medical cover in Cowal Community Hospital. The ‘Your Stories’ feedback form was used to capture these stories and the Voxcer, a computer video recorder.

The full report detailing this feedback is appended as a separate document ‘Cowal 24 / 7 Review Community and Staff Feedback on the Long List of Options & “Your Stories”’

The workshop group considered these comments and feedback on the existing service and option preferences made by the public.

7 A number of specific points were noted by the members as important consideration in the finalisation selection process: • Options 1, 4 and 3 were the most popular selections from submissions. • Tighnabruaich residents submitted the most responses • Importance of having a doctor in the hospital and a doctor covering the out of hours work rural and urban • Concern over travel time and response not only from Dunoon but also if the doctor is on a call in Tighnabruaich and has to get to Lochgoilhead or vice versa • Concern over the emergency response (999), the role of Scottish Ambulance service, doctors and how a first responder scheme could support this • Doctors making better use of surgery premises to see patients out of hours in their community • Difficulties in access pharmacy drugs out of hours • Preference for a local service based in community • Response times – especially if the doctor is required in two places at the same time and a call occurs at the same time • Acknowledgement that the service is costly and some 1 centre options offered better value for money • NHS 24 experience was generally good • Patients choice in using their own transport to take patients to Primary Care Emergency Centres at Vale of Leven or Dunoon or Strachur. Concerns the level of transport available in rural areas to take patients into and back from PCEC when required

6 Option Short Listing Outcome

After reviewing this feedback, the project group members at the workshop undertook some focused group work to refine the option shortlist.

The following additional points were noted as important to inform the short listing and further option development.

• There was a very significant resource underutilisation in the existing rural out of hours service – i.e. the level of activity was so low it clearly did not offer best value or effective use of resources in GP time or cost. • The option to include an enhanced nurse practitioner or paramedic practitioner resource within some of the other options would provide a more responsive service. • Options which had only 1 doctor covering the hospital and out of hours were deemed of a higher risk if the doctor left the hospital unattended beyond the current catchment boundary of 30 minutes • GP home visit response was not for an emergency situation, 999 calls for an ambulance should always be made. • Greater information and improved communication with the public on arrangements and response of the service should be made. • Options utilising improved transport, better triage of calls and use of telemedicine technology as demonstrated in NHS Grampian could reduce home visits numbers in Cowal. • Maintaining patient choice to travel to PCEC if they wished. • Reflection that 1 doctor on during the day covering casualty and the ward activity may not be enough. • Clarification and quantification of out of hours workload for palliative care

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This work resulted in the following changes to the option short list

Table Final Shortlist

1, 2, 4, 6, 7, 8, 11 Agreed Options to short list

3, 5, 9, 10, 12, 13, 14, 15, 16, 17 Agreed Options to exclude

Rational for exclusion and inclusion on the short list is as follows:

Options included in the Short List

All the options included meet the majority of service objectives.

• Option 1 is the existing service and automatically included as a benchmark • Option 2 is similar to 1 but extends rural OOHs cover to include Ardentinny which is currently covered by Cowal Community Hospital • Option 4 is similar to 1 although it may be doctor heavy for the service activity, through tendering and contract processes it could offer better value for money. • Option 6 provides additional day time medical input during the working week and could incorporate local GPs in the service. It simplifies arrangements for out of hours a single service. It offers an additional “routine” out of hour’s surgery in the rural catchment area which could reduce OOH calls. It is enhanced by including a nurse or paramedic practitioner as a first response. • Option 7 streamlines the medical workforce by providing separate out of hours and hospital services. The out of hours service covering the whole of Cowal hence “supply” more accurately matching “demand” • Option 8 is similar to option 4 but allows anew consortium of GP practices to provide inpatient care rather than the existing contracted ones. Again this may be a doctor heavy option. • Option 11 simplifies and streamlines medical staffing arrangements as all staff is employed by the CHP. This offers opportunities to change the day time workload through greater integration with the hospital multidisciplinary team. This could add value and be a more responsive day time service to patients.

Options Excluded from the Short List

• Option 3 was assessed as being similar to option 7 without the advantages. It was considered overstaffed. The publics wish for an OOHs service based in the rural parts of Cowal is captured in options 1, 2 & 4. • Option 9 did not meet enough service objectives. Also the feedback received identified that merger of some of its elements into option 6 (the paramedic/nurse practitioner response would be better • Option 13 as per option 9 hence its exclusion • Option 15 feedback from GP practices in the town and rural GPs reflected that they would not tender for the whole service • Options 5, 10, 12, 14 16, 17 did not meet a variety of the objectives identified notably quality of care, efficient use of resources, response to rural needs and ability to attract and retain staff,.

9 7 Next Steps

This report will be presented for consideration at the Cowal 24 / 7 Project Group meeting on the 26 th April 2012. This meeting will agree and approve the options to be short listed for formal appraisal.

If approved the short listed options will then require to be clarified and further developed to ensure they are understandable to the public. This is in response to public feedback regarding difficulties in understanding the 17 option paper. It is proposed that this work be undertaken by an editing sub group with final sign off by the co-chairs no later then Wednesday 9 th May .

The short listed options will then be taken out for a further period of public, staff and stakeholder consultation to canvass their views and opinions on the short listed options. This will inform the appraisal process.

10 Appendix 1 – Table Cowal 24 / 7 Option Long List Assessment Matrix EXAMPLE 3 Centre 2 Centre Options Options Cowal 24/7 Option Long List Assessment 1 2 3 4 5 6 7 8 Comparing Options to Objectives, Boundaries & Key Features Continuity of Care- Primary Care to Hospital to Community Quality of care – Inpatient, Out of Hours, Casualty

Safety of Service - clinical

Sustainability of Service

Number of Drs on duty to cover casualty & inpatient day time and Casualty, Inpatient and GP Out of Hours in Cowal • Day time 4 3+ 1 2 1 2 1 2 • Out of hours 3-2 3 3 2 2 (peak) 2 (peak) 2 2 1 W.E. 1 W.E. Surgery Surgery Cope with future service demand.

Flexibility to cope with peaks and troughs in demand

Respond to Rurality as per standard -1, 2 & 4 hour

As far as possible/practical ensure accessibility for patients to the accepted performance standards To provide ‘fit for purpose’ services for use by staff – training, skills, accommodation, transport, working together in a co-ordinated way To attract and retain high quality staff

Demonstrates efficient and cost effective use of resources, maximising capability and capacity

SHORT LIST OPTION- YES (Y) OR NO (N)

Key Least Likely Occasionally Likely Most of time All the time Peak - Refers to 6pm-11pm week days & 8am- 11pm weekends and bank holidays

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1 Centre Options Cowal 24/7 Option Long 9 10 11 12 13 14 15 16 17 List Assessment Comparing Options to Objectives, Boundaries & Key Features Continuity of Care- Primary Care to Hospital to Community Quality of care – Inpatient, Out of Hours, Casualty Safety of Service - clinical

Sustainability of Service

Number of Drs on duty to cover casualty & inpatient day time and Casualty, Inpatient and GP Out of Hours in Cowal • 2 2 1 2 2 0 GP 2 3 Day time 2 (peak) 2 (peak) 2 2 (peak) 2 & SAS 2 & SAS consortium 2 (peak) 2 • Out of hours & Nurse & SAS Response Response organise & Nurse (peak) Response Response Response Cope with future service demand. Flexibility to cope with peaks and troughs in demand

Respond to Rurality as per standard -1, 2 & 4 hour As far as possible/practical ensure accessibility for patients to the accepted performance standards To provide ‘fit for purpose’ services for use by staff – training, skills, accommodation, transport, working together in a co- ordinated way To attract and retain high quality staff Demonstrates efficient and cost effective use of resources, maximising capability and capacity

SHORT LIST OPTION- YES (Y) OR NO (N) Key Least Likely Occasionally Likely Most of time All the time

12 Appendix 2

Table Voting on the Options to include in the short list of options Cowal 24 / 7 Review Group Short Listing Options Workshop 19/04/12

Clinicans Public Representatives Management Head of Comm Kate nurses. Mhari Evelyn Planning Casualty Heather Hyde Stephen Brian Kate/Sheil Mowatt Tom Law Denis ContractinClinical John Nurses Grier Peter McLachlaa g & Services Pearce/To n Perfroman Campbellwn Gps Rural Gps Manager Casualty & practice ce Option SalariedYes Drs Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Total re e tr n e C i n tio p o 1 s 3 2 1 1 1 1 1 1 1 19 1 Cente i s n tio p O tre n e C 2 3 1 1 ? 1 1 17 1 1

4 1111 1?11 111 111

5 1 ? 1 2

6 1 1 1 ? 1 1 5

7 1 1 1 1 1 ?6 1

8 1 1 1 1 1 1 18 ? 1

9 1 1 ? 1 ? 15 1

Cent Optons n tio p O e tr n e C 1 10 0

11 1 1 1 ? ?4 1

12 1 1 ? 1 3

13 1 1 1 1 ? 4

14 ? 1 1

15 1 1 1 ? ? 14 16 ?? 13 0 17 0 total 3 5 6 5 3 9 4 5 5 0 5 3 3 7 6 Appendix 3 CCCHARACTERISTICS OF OPOPTIONTIONTIONSSSS

OOH Operational Bases PCEC 1 Centre based in Cowal OOH Out of Hours (General Medical Services) Community Hospital PCEC Primary Care Emergency Centre. PCEC 2 Centre based in Strachur, NP Nurse Practitioner Tighnabruaich or Lochgoilhead CCH Cowal Community Hospital PCEC 3 Centre based in Vale of Leven Hospital CHP Community Health Partnership (Argyll and Bute) VoL Vale of Leven Hospital NHSGG&C Greater Glasgow & Clyde Health Board PP Paramedic Practitioner

NUMBER OF CENTRES INVOLVED KEY PROFESSIONALS INVOLVED IN THE WHO IS INVOLVED IN DELIVERING 24/7 COVER AND DELIVERY OF THE SERVICE HOW THEY ARE EMPLOYED 1 CENTRE 2 CENTRE 3 CENTRE DOCTORS NURSE CONSULTANT PARAMEDIC GP S- EITHER RURAL CHP VOL PRIVATE (D UNOON ) (D UNOON , (D UNOON , (GP S OR CHP PRACTITIONERS PRACTITIONERS EXISTING TOWN GP S –EITHER EMPLOYED L’ GOILHD CONSORTIUM RURAL PRIMARY RURAL PRIMARY EMPLOYED ) (ENPS) GP S OR EXISTING GP S DOCTORS PATIENTS CARE CENTRE ) CARE CENTRE & CONTRACTED OR VALE OF LEVEN GP S) CONTRACTED HOSPITAL ) GP S OOH

CLUSTER ONE - BASED ON THREE CENTRES

1 • • TOWN RURAL • • 2 • • CONTRACTED RURAL • •

CLUSTER TWO - BASED ON TWO CENTRES

3 • • CONTRACTED • O • • TOWN RURAL • P 4 5 • • SAT . GP • T SURGERY

I 6 • • CONTRACTED SAT . GP • O SURGERY N 7 • or • • • •

S 8 • or • • CONTRACTED CONTRACTED •

CLUSTER THREE - BASED ON ONE CENTRE

9 • • • CONTRACTED • 10 • • • • 11 • • • 12 • • • •

13 • • • CONTRACTED • 14 • • • • GP OOH SERVICE ONLY 15 • • 16 • • • •

17 • • • CONTRACTED

For Further Information Regarding Options Please Refer To Options Paper Or 14 Appendix 4

Short Listing Workshop 19 th April 2012 - Cowal 24 / 7 Project Group Members Attendance

Co-Chair Dr Brian McLachlan Senior Charge Nurse / Wards Kathy Graham Team Lead Community Sheila Mckechnie & Katie Stewart Head of Planning, Contracting & Performance Stephen Whiston Cowal Locality Public Partnership Forum (CLPPF) Evelyn Hide Community Council Representatives / Public Kate Stephens, Tom Law, Denis Bolt Liz Higgins Acting Clinical Services Manager Local GP-Dunoon Dr Peter Campbell Local GP-Rural Dr Jurgen Tittmar

In attendance not voting Communications Officer David Ritchie Planning & Public Involvement Manager Caroline Champion Scottish Health Council Alison McCrossan Cowal Community Care Forum (CCCF) Development Officer / CLPPF Coordinator Lorna Ahlquist

Submissions received and considered at the workshop:

Co-Chair Heather Grier Casualty Department Salaried staff Casualty Department nursing staff Community Council Representatives / Public Mhairi Mowat Town GPs (Church & Bank Street Practice)

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