2 Manage calls by telephone advice with referral to local services wherever possible

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1 Ambulance, NHS 111 and out of hours performance Briefing paper, December 2013 Helen Medlock, Associate Partner KMCS 1 Emergency ambulance service 1.1 Contract background: SECAmb provides the emergency and urgent ambulance service across Kent, Surrey and Sussex. The overall commissioning strategy for emergency ambulance services was put in place 6 years ago, but the principles remain valid: 1 Ensure response time performance is delivered 2 Manage calls by telephone advice with referral to local services wherever possible 3 Minimise unnecessary conveyance to A&E 4 Ensure the clinical skills and clinical outcomes are continuously improved 5 Ensure the service operates efficiently Each CCG has a local activity plan based on the previous year s PCT activity and increased by 4.4% for 2013/14 to take into account the continued upward trend in calls to 999. This trend has averaged 5% per year for many years and so far, commissioners have not been able to affect the call volume reaching SECAmb. The contract is funded on a cost per case basis, with a 2.5% tolerance above and below the overall plan, within which there is no charge, and then a marginal rate of 65% for activity outside the tolerance. The national currencies are used for hear and treat, see and treat and see and convey for 999 or healthcare professional calls. The national standard for response times are applied for the contract as a whole (and this is the figure used for performance monitoring and for CCG quality premium). Local response times are reported and CCG profiles are now being developed to enable a quality view on response times for all patients rather than simply a target for 75%.

2 1.2 Current performance Response time performance is above the 75% standard for Red 1 calls (the most life threatening) year to date to January 14 for SECAmb as a whole, but below for both CCG s. Also, both CCGs fall below the standard for Red 2 calls, and for SECAmb as a whole. Red 2 performance has been below standard since last December. Actual activity to Jan 14 Ashford C&C K&M SECAmb H&T S&T S&C - HCP S&C Total Overall Non-Conveyance 37% 39% 40% 42% Managed Conveyance (exc HCP) 58% 56% 54% 52% Total over activity 10.8% 3.7% 7.0% 3.9% R1 YTD % in 8 min R2 YTD % in 8 min Overall activity is well above plan by 10.8% in Ashford and 3.7% in Canterbury and Coastal, and 3.9% across SECAmb as a whole. Much of this activity has been managed by Hear and Treat, which is now 12.3% double the national average (and with a re-contact rate of 10.5%, two points above the national average of 8.6%). The activity increase seems at least in part to be related to the numbers of calls passed from NHS 111 for ambulance dispatch, and the requirements of the NHS 111 specification is for these to trigger dispatch automatically without re-triage. The hourly profile of calls has changed and this has caused particular pressure on performance as the capacity and demand has had to be reassessed and staffing rota s changed. Handover at hospital has significantly improved in some areas but remains a clinical risk, and resource pressure in a number of hospitals in other parts of Kent and in Sussex. It is not a major concern in East Kent SECAmb Performance Update Page 1 of 11

3 The numbers of patients being maintained at home and not conveyed has been increasing, and the conveyance rate decreasing, although there has been little change in this financial year and the rate has increased in Canterbury and Coastal in November. The benchmark national data shows SECAmb is in the upper quartile for non-conveyance (note the calculations are different to those reported locally). The SECAmb re-contact rate for non-conveyance is 4.3%, below the national average of 5.5%. Benchmark non conveyance rate (December 13 data only) SECAmb England (inc convetance to non A&E sites, % of calls receiving ambulance response) 43.7% 36.7% Benchmark Hear & Treat 12.3% 6.5% Non conveyance, all calls 50.7% 43.0% The clinical indicators are published nationally, and SECAmb continue to show good performance on most indicators. Details are available at: Service developments The key areas for SECAmb to develop in this year and where beneficial, into next year, are: GP in Emergency Operations Centre funded through CQUIN, and expanded through the North Kent A&E funding, this scheme to provide experienced GPs within the control centre is considered beneficial to enable the increased Hear and Treat rate and support safe nonconveyance. Hard evidence is however proving difficult and the lead GP Tony Jones, with Debbie Stock COO for Swale CCG are working on demonstrating the benefits. IBIS the web based system for enabling ambulance crews to see specific instructions for individual high risk patients is demonstrating a reduced admission rate for those patients, especially where it has been embraced by Sussex CCGs. KCHT are working on inputting data for specific patients (as part of their CQUIN), but more emphasis needed locally. The system does not interact with the summary care record or share my care which has limited the uptake in Kent but it has a very specific purpose and is able to link directly into the ambulance dispatch system SECAmb Performance Update Page 2 of 11

4 Supported conveyance pilots in West Sussex and Brighton are looking at changing the default for ambulance crews to not convey (except for specific types of call). This is requiring a significant change in procedures and culture to manage the potential clinical risk, and is being monitored by the local CCGs, before being reported back to all areas for potential roll out. Increasing use of alternative services local work between SECAmb and the East Kent Federation urgent care lead is continuing to emphasise the potential for crews to contact the patient s own GP, or IC24 for advice. NHS number this is still proving difficult for SECAmb as the call handling and dispatch system is location focussed. Until the electronic patient record is in place this will continue to be undertaken through manual processes. It continues to be a high priority for commissioners. Speed of urgent GP admission responses historically a lower priority than a 999 call, this has been identified as an area for improvement to reduce the risk of hospitalisation through late arrival. This is being followed up through the contract for 2014/15 Clinical skill mix Kent has had a lower proportion of paramedic staff compared to other parts of SECAmb and the workforce plan to address this has been implemented with a significant number of new paramedics recruited into Kent. However, the increased activity has meant that SECAmb have had to continue to utilise the private and voluntary sector resources that they had planned to reduce their reliance on following the recruitment process. More detailed monitoring of this resource will be a requirement going forward contract The increase in call volume this year has triggered a joint capacity review with an external provider Lightfoot solutions. This will help to objectively assess SECAmb s potential to manage more efficiently and look at the implications of performance and conveyance rates at county and CCG level. It will inform the contract negotiations for 2014/15 which is expected to ensure a much more locally focussed set of performance standards. The final report is now available to commissioners and highlights are being presented to the Integrated Urgent Care Board. The draft commissioning intentions have been shared with urgent care leads reflecting the strategic direction and developments described above. These have been collated and inform the negotiation strategy. The contract will be much more locally focussed, and must reflect individual CCG/urgent care area requirements. With 22 CCGs served by the same provider, and very specific requirements as an emergency service, some co-ordination will be required but there is a strong view that whilst one contract will continue, there will be three schedules (Kent and Medway, Surrey and Sussex) to help ensure more local focus SECAmb Performance Update Page 3 of 11

5 2 NHS Contract background: The NHS 111 contract is also with SECAmb, in partnership with Harmoni (now Care UK) and is also across Kent, Medway, Surrey and Sussex. The service follows the national specification but also includes a Speak to GP component and also an element of professional support mirroring previous arrangements in parts of Sussex. The contract is a block, with a marginal rate if call volume is more than 10% over plan. There is no reduction for underperformance. The KPIs are the national standards with the critical ones being for call answering (95% in 60s, and abandonment rate below 5%), and for the clinical response (calls should be warm transferred or called back within 10 minutes). 2.2 Current performance After a poor start, performance for call answering is now routinely achieving the standards although there are sometimes problems on a busy weekend. Christmas has also proved very difficult on some days. The clinical standards have proved more difficult (and are not routinely met in many other providers). They are now improving with some of the January data showing over 60% of calls requiring a clinician being transferred immediately, and for those needing a call back, half receive it within 10 minutes [January average monthly figure] SECAmb Performance Update Page 4 of 11

6 The proportion of ambulance dispatch [10.4%] remains slightly above the national average of 9.5%, but SECAmb are slightly below the national average for referral to A&E which is around 6% Around 50% of calls in the out of hour s period are referred on to the out of hour s providers % of calls are being referred into the 111 internal speak to GP disposition, but recent information has shown that of those, some 60% are needing to be seen by a GP and so gone on to the out of hours providers. This has led to a review of the protocols for speak to GP to identify those problems which should go directly to the OOH service without delay SECAmb Performance Update Page 5 of 11

7 The dispositions are being reported for each CCG, the following summarises the key areas: 1 Oct - 31 Dec 2013 Ashford Cases % ambulance dispatch % No further action 408 7% Clinical home management 277 5% Test results 20 0% Medication enquiry 35 1% Repeat prescription 160 3% GP (non urgent, inc 24 hours) 488 8% GP (inc OOH) % Speak to GP % ED 369 6% Dental 125 2% Community 86 1% Other 268 4% Total % 1 Oct - 31 Dec 2013 C4 CCG Cases % ambulance dispatch % No further action 510 6% Clinical home management 377 4% Test results 24 0% Medication enquiry 53 1% Repeat prescription 247 3% GP (non urgent, inc 24 hours) 733 9% GP (inc OOH) % Speak to GP % ED 455 5% Dental 240 3% Community 201 2% Other 151 2% Total % 2.3 Service developments The main areas for development have been reviewed and prioritised by the programme board: Professional Support including Review of GP speak to service Clinical Call backs and warm transfers Professional Support line Health Care Professional/clinician advice lines Repeat prescribing SECAmb Performance Update Page 6 of 11

8 Utilising existing procedures with community pharmacists instead of OOH services for repeat prescriptions Mental Health Implementation of the Mental Health action plan Interoperability Direct appointment booking review ITK messaging to GPs simplified Post Event Messages Interoperability with Community Services There was also further work considered regarding special patient notes, including links with IBIS and end of life registers. In view of the emphasis on the enhanced summary care record and the need to ensure the systems are fully integrated, the programme board agreed to review this further. The further development of information and reporting, and benefits realisation also continues to be a priority. 2.4 Contract review SECAmb have asked to review the contract price in view of the very different call profile and staffing requirements. This is being taken forward by the lead commissioner in conjunction with the associates. At a national level, there is a review of the specification underway, and it is likely to include requirements for GPs in the service as well as direct booking of appointments. This is unlikely to be finalised until well into next year. Commissioners are keen to ensure the interaction between the 111 and 999 service is managed differently to reduce the calls going to 999, and to review some of the clinical pathways to improve the dispositions to alternative services. The local GP commissioner leads involved in the national clinical governance process are trying to exert some influence. 3 Out of Hours services 3.1 Contract background The out of hour s service is provided by IC24 (previously known as SE Health Ltd). The contract covers the old Eastern and Coastal Kent PCT and is a block contract. With the introduction of NHS 111 the contract had to change as call handling was transferred to NHS 111. As the IC24 model included almost all calls being triaged by a GP, and a large proportion SECAmb Performance Update Page 7 of 11

9 being closed with advice from the GP at that stage, the change to 111 was a very significant service change with unknown risks. It was expected that the contacts would all be face to face, and that there would be a greater proportion of urgent contacts required. A calculation of the predicted face to face contacts was made (36% of all NHS 111 calls) and the contract renegotiated to take that into account. A marginal rate outside the revised block was agreed, and where advice calls were made, it was agreed these would be counted notionally as a half a face to face contact. It was agreed that the clinical capacity in IC 24 would remain as removing GP telephone advice did not allow for fewer clinicians, unless some bases were closed. This was to be reviewed in year, once the implications were understood. IC24 have now been asked to provide the information about activity at each base. The KPIs have also had to be revised as those related to call handling (most of the national quality requirements) were no longer applicable to the OOH provider. 3.2 Current performance The current activity is within the tolerance for the revised contract, although as expected it is considerably lower than the previous year s activity. The proportion of calls managed by advice (37%) is much higher than initial expected with NHS 111 (almost none were expected). This is because IC24 have put in place a means of calling patients to discuss whether a visit or base attendance is required, and at that point a number of calls are resolved as definitive clinical advice. This advice figure also includes calls from health professionals on scene. The calls recorded as DN message are where IC24 act as an answering service for district nurses. It has recently been confirmed that these are not included within the contract activity. Ashford CCG SECAmb Performance Update Page 8 of 11

10 Monthly activity % change between the same months in 2012/13 and 2013/14 Ashford CCG April May June July Aug Sep Oct Nov Dec Jan Advice -50% -37% -48% -42% -42% -50% -47% -41% -45% -44% Base -28% -19% -44% -31% -19% -4% -10% 1% -28% -15% Visit -30% -17% -47% -54% -5% -28% -37% -21% -20% -2% Canterbury and Coastal CCG Monthly activity % change between the same months in 2012/13 and 2013/14 C4G CCG April May June July Aug Sep Oct Nov Dec Jan Advice -55% -35% -50% -52% -28% -32% -48% -35% -32% -28% Base -34% -28% -39% -31% -14% -7% -7% 3% -4% -6% Visit -49% -22% -47% -39% -19% -15% -24% -16% -14% -7% The reduction in home visits had not been predicted, but maybe related to the increased number of 999 dispatches. The KPIs for the service have been updated and are being met. A new service has been added to the IC24 contract, to formalise the provision of a line for professionals on scene with a patient to be able to access rapid GP advice. This was introduced after it became clear that NHS 111 was not aimed at such situations and yet there was no other means of accessing GP advice. Paramedics, community nurses and nursing homes are the main users. Reporting is still being developed so that commissioners can assess the impact. 3.3 Service developments SECAmb Performance Update Page 9 of 11

11 The main emphasis with the out of hours service is to review the required capacity and demand to inform the future service model for the re-provision as part of the integrated urgent care system by April Local developments with GPs in A&E are also being put in place as a separate arrangement. 3.4 Contract review IC24 are to provide the activity at each base which will enable commissioners to take a view as to whether any further changes are required prior to the tendering process for April An audit to establish any potential for profit share under the current contract is being planned by the Ashford and Canterbury and Coastal CCGs SECAmb Performance Update Page 10 of 11