Primary Care Out of Hours Service Review. Workshop Report

Transcription

1 Primary Care Out of Hours Service Review Option Appraisal Short-listing 27 th June 2014 Workshop Report (FINAL VERSION ) 1 P a g e

2 Contents Page 1. Introduction 3 2. Current Service Background 8 3. Option Appraisal Options Development Benefits Criteria Ranking and Weighting the Criteria Summary of the Final Ranking and Weighting Option Appraisal (Assessing the Long List) Scoring the Long List of Options Groupwork Scoring Process Results Overall Results The Status Quo and Do minimum Option Score Breakdown for All Groups Sensitivity Testing Evaluation 20 Appendix 1 Participants Briefing Paper for Option Appraisal 23 Appendix 2 Event Programme 26 Appendix 3 Participants Scoring Sheet 27 Appendix 4 - List of Participants 28 2 P a g e

3 1. Introduction 1.1 Scottish Government s Vision for Health The Scottish Government published their 2020 Vision in September This set out the actions required to achieve sustainable quality in Scotland s Healthcare system. This strategic narrative, which was set out by the Cabinet Secretary for Health, Wellbeing and Cities, provided the context for taking forward the implementation of the Scottish Government s Healthcare Quality Strategy (2010) and the actions required to improve efficiency and achieve financial sustainability. 1.2 NHS Lanarkshire s Strategic Health Planning Framework NHS Lanarkshire developed the framework A Healthier Future published in 2012 to support future strategic health planning and to gain a shared understanding of the actions required to achieve the Scottish Government s 2020 Vision. We have identified strategic aims to achieve this vision, which are set in the context of delivering a healthier future for all from cradle to grave. Transforming Patient Safety and Quality of Care in NHS Lanarkshire, Healthcare Quality Assurance and Improvement Strategy supports the on-going implementation of A Healthier Future with its four strategic aims: 1 To reduce health inequalities and improve health and healthy life expectancy 2 To support people to live independently at home through integrated health and social care working 3 For hospital day case treatment to be the norm, avoiding admissions where possible 4 To improve palliative care and supported end of life services NHS Lanarkshire s quality vision is to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. We are committed to transforming the quality of health care in Lanarkshire to be the safest health and care system in Scotland. 1 Strategy June-2014-Board.pdf 3 P a g e

4 We will accomplish our quality vision by: setting and delivering ambitious quality goals to support the provision of high quality services to the people we serve engaging staff, patients and the public to improve our quality of care ensuring that everyone in the organisation understands their accountability for quality and are clear about the standards expected of them, embedding our organisational values of Fairness, Respect, Working Together and Quality gaining insight and assurance on the quality of our care managing risk to quality 1.3 Primary Care Out of Hours in Lanarkshire The General Medical Services (GMS) contract came into force in April It gave General Practitioners (GPs) the opportunity to opt out of providing out-of-hours care for their patients. The GMS contract means that NHS Lanarkshire is responsible for ensuring all patients can get out-of-hours care. Each NHS Board in Scotland has developed a service for the people living in their area. This means there is no consistent model or standardised practice for the provision of GP Out-of-Hours Services in Scotland creating a market place that results in competing demands for the available staff and thus each NHS Board area might have a slightly different model of service. NHS Lanarkshire commissioned a comprehensive review of Primary Care Out-of-Hours Services (PC OOHs) in September A structured programme management and robust service change process to support informed decision making has been objectively facilitated by the Change & Innovation function of NHS Lanarkshire. The process has closely followed the guidance and policy set out below: NHS Boards have a statutory duty2 to involve patients and the public in the planning and development of health services, and in decisions which will significantly affect the operation of those services. Scottish Government s Guidance3 sets out how NHS Boards should inform, engage with, and consult their local communities. Involving Patients, Carers and the Public in Option Appraisal for Major Health Service Changes, 4 Scottish Health Council (March 2010) 2 National Health Service Reform (Scotland) Act 2004, section 7, 3 Informing, Engaging and Consulting People in Developing Health and Community Care Services CEL 4 (2010), Scottish Government 4 P a g e

5 All new policies, programmes and projects, whether revenue, capital or regulatory, should be subject to comprehensive but proportionate assessment, wherever it is practicable, so as best to promote the public interest. Core guidance is contained in The Green Book5. The Scottish Health Council is a member of the Review Board and has been in attendance to observe and advise on the process and to conduct an independent evaluation. Phase 1 carried out a significant review of the current service including all demand, activity and workforce capacity as well as the current clinical model. Throughout this time extensive communication and engagement was carried out through a variety of communication mechanisms to capture the views of staff, service users and the public. Phase 1 concluded in April 2014 with a review of all information and data gathered. Analysis of all available information reinforced the need to explore options for change and associated improvement. 1.4 What is Emergency and Urgent Care There is often confusion about the terminology referred to by service users and providers of urgent and emergency care. Terms such as unscheduled care, unplanned care, emergency care and urgent care are often used interchangeably Unscheduled care is defined as:...care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is out with the core working period of NHS Scotland. It follows that such demand can occur at any time and that service to meet this demand must be available 24 hours a day. 6 Urgent care is the response before the next in hours or routine (primary care) service is available. The work of the Primary Care Out-of-Hours Review (PC OOHs) review should also been seen in context of allowing the patient to be seen by the right professional in the right place, at the right time. 4 Involving Patients, Carers and the Public in Option Appraisal for Major Health Service Changes The Green Book - Appraisal and Evaluation in Central Government, HM Treasury available at 6 Building a Health Service Fit for the Future Scottish Government P a g e

6 Continuous review and recently published documents 7 8 which contain quality statements and indicators have contributed to our thinking and planning for future provision of PC OOHs across NHS Lanarkshire. To enable service improvements to go forward agreement must be reached on the best clinical model and service configuration of PC OOHs to ensure the service is above all clinically safe, delivers the most appropriate treatments and interventions, and that support and services will be provided at the right time and in the right place by the right person. The reasons and rationale for the review and the case for change and improvement are set out below. 1.5 Case for Change The current service is under consistent pressure due to the lack of availability of GP s willing to participate in the PC OOHs service. This is exacerbated at holiday periods including summer and during winter with high levels of demand particularly in the busiest centres and at the busiest times. The service has approximately 1,000 slots per week across Lanarkshire; however the availability of staff to cover in the areas of highest demand is low and on many occasions can go below core staffing levels. The service demand can go up or down in any given week or month. Frequently the staff availability is extremely unpredictable, therefore the planning can be very reactive with changes to service delivery locations and staff are asked to relocate at short notice which can result in centres being closed to deliver a safe service. The constant unpredictability has an impact on the morale of staff working in the service and creates a constant fragility within the planning of service provision. A recent example (May, 2014) highlighted this fragility as a significant issue and one that impacts on key performance areas such as Out-of-Hours centre appointments breaching the triage time allocated of 1 or 2 hours. In this example people required to be directed to go to an already busy Emergency Department and the 4 hour home visits were under constant assessment resulting in some appointments being allocated 12 hours in advance. The overall activity for this period was comparable to that of previous years however the delays were as a result of the shortfall in staffing being insufficient to meet patient demand. This level of demand with limited resources (GP availability) resulted in Business Continuity Plan (BCP) 9 arrangements being put in place to ensure the service could be delivered. 7 The Healthcare Quality Strategy for NHS Scotland, Scottish Government May Quality Indicators for Primary Care Out of Hours Services. Healthcare Improvement Scotland A business continuity plan is a plan to continue operations if adverse conditions occur, The plan includes moving operations, (recovering operations) to another location if a high risk to normal operations exists. 6 P a g e

7 1.6 NHS Lanarkshire challenges Significant difficulties in maintaining the current service model for the provision of Primary Care Out-Of-Hours services due to the availability of clinicians to cover all shifts in all centres. Covering the Out-Of-Hours service across five centres creates inefficiencies GPs and support staff report a degree of isolation from colleagues at times Activity levels in each centre have differing levels of demand varying from very high to low demand across the OOH spectrum. A reduction in the pool of GP s prepared to work on weekends and public holidays. Changes in GP working practices make it increasingly difficult to recruit GPs to work in the OOH period. A high number of people appear to be using the PC OOH Service as their means of choice to access health care. Current service configuration requires consideration as accommodation is problematic with insufficient space and equipment stored at Law House which is not accessible at weekends. The management team based in Law House work predominately in hours and the HUB where the calls are received operates out-of-hours and is based at Hairmyres. This makes communication and coordination challenging. The service has 6 vehicles stored at different locations making cover for breakdown difficult. 1.7 National issues There is a growing concern nationally around the sustainability of PC OOH services in their current form with a number of Boards experiencing problems filling rotas. The lack of a consistent workforce model or pay arrangements for the group of sessional GPs who make up approx 90% of the NHS Lanarkshire OOH workforce. There is no consistent contracted status nationally for sessional GPs, leaving the market open and vulnerable to GP availability to cover the appointment slots. This makes the current arrangements unsustainable and open to further destabilisation without review and redesign. The current HUB accommodation is subject to operational demands requiring relocation and disruption on Public Holidays when GPs are not working and the rest of the NHS is working a normal day. This is also less than ideal when patients are redirected to the temporary centres resulting in the potential for confusion for the public. 7 P a g e

8 2 Current Service Background Primary Care Out-of-hours services in Lanarkshire currently include the following: NHS 24 as the national 24-hour phone service on the new number 111, provide a first line assessment, health information and nurse advice through telephone consultations and triage (assessment of how urgent the medical problem is) as an important part of all out-ofhours care. Where necessary, NHS 24 assessment refers onto a local Primary Care OOHs HUB where a home visit, doctor s advice call or an appointment is allocated at one of the current 5 centres either at a core hospital based OOHs centre or within a health centre located in the outlying areas in the community. General Practioners within the Out of Hours Service provide an advice service. Face to face consultation by appointment at one of the current 5 centres. Provision of a professional to professional consultation by telephone. A domiciliary service where doctors carry out home visits to people who are too unwell or incapacitated to attend an out of hours centre. Day-to-day management of the service is provided from the base at Law House. The HUB (control centre) is based at Hairmyres Hospital 2.1 Summary of Review timeline The review was commissioned in September 2013 and has completed the following work. Setting up the Review Board structure and membership - set up phase (October 2013) Strategic Analysis and Diagnostic phase (Nov 2013 April 2014) to assess and review: o All aspects of the current service provision o Undertake face-to-face and on-line Communication and Engagement with staff and service users o The current clinical and workforce model Undertake an Options Development process from scratch to create a Long List of Options (May 2014) Carry out an Options Appraisal of Long List to inform short-listing options (June, 2014) The Review Board will meet 20 th August 2014 to agree the short list and set out the plans and workstreams for the next phase of work. The output from the first option appraisal short-listing process will be taken to a further 8 P a g e

9 Option Appraisal event in October/November 2014 to consider preferred options and explore future service configuration. 3 Option Appraisal 3.1 Options Development In May, 2014 an Options Development event attended by a wide range of stakeholders created a Long List of Options. At the evening workshop a group of approx 30 people representing the Review Board and other interested stakeholders heard a presentation on the case for change, communication and engagement updates and the findings of the review so far which includes full detailed analysis of potential attendance trends. It was agreed at this event that a given 10 across all of the proposed options would be that the workforce model ensured the right levels of staff were available to provide a safe service; future locations will provide fit for purpose accommodation 11 and consideration and research will go into planning the necessary skill mix to enable new ways of working. This is to ensure NHS Lanarkshire can provide the right service, in the right place, at the right time to the growing and shifting population of Lanarkshire. The ten proposed options below were presented to the Programme Board meeting on 29 th May, The Long List of proposals is as follows: Table1. Long List of Options 1. Status Quo/Do Minimum The current service would remain the same, working across the five centres. 2. One Out-of-Hours Centre for Lanarkshire One GP Out of Hours Centre consolidating all aspects of the service within one reachable location for the Lanarkshire population. 3. GP Co-operative model NHS Lanarkshire would develop a tender for urgent out-of-hours service provision and offer to local GP co-operatives for provision of the service across NHS Lanarkshire. 4. Primary Care Out-of-Hours Centres within the (Acute Hospitals/Emergency Departments Three Hospital based out-of-hours centres sites working on the current co-location model. 5. Two Centres: One in North and One in South Lanarkshire Two Out of Hours Primary Care Centres one North one South 10 Specified and fixed elements 11 the product should quality assured and be suitable for the intended purpose 9 P a g e

10 Lanarkshire based within a Health Centre environment. 6. Two PC OOHs centres with nurse led satellites This is Option 5 plus (Two Out of Hours Primary Care Centres one North one South Lanarkshire based within a Health Centre environment) supported at peak times with peripheral clinics. 7. Two PC OOHs centres North and South plus GP Co-Op (Service to operate out of two Health Centres North and South Lanarkshire) with a GP Cooperative working in the Rural area. 8. Outsource the Primary Care Out-of-Hours Service to another NHS Board area Transfer all operational responsibility to another Health Board 9. Three Primary Care Out-of-Hours Centres based in Community Health Centres Three Primary Care Out of Hours centres in community based facilities in locations across Lanarkshire to meet population demand. 10. Transfer service and staff to Emergency Department NHS Lanarkshire Acute Division Emergency Departments to join with and operate urgent out of hours service. The current step in the comprehensive review has been to carry out an appraisal of all proposed options utilising the benefits criteria below. The stakeholder engagement event to explore the long list was held on the 27 th June, 2014 (the subject of this report). 3.2 Benefits Criteria: The benefits criteria adopted are the six quality dimensions set out below, recognised as key indicators of what quality means in the delivery of services to patients in healthcare settings. These have been utilised by NHS Lanarkshire for many years in service improvement processes. They are adopted from the dimensions of quality established by the Institute of Medicine (2001)12 and include the Quality ambitions as set out in the Scottish Government s Healthcare Quality Strategy, 2010 and reflected in NHS Lanarkshire s planning framework. Although pre-chosen, the criteria were reviewed (with opportunity for correction or adjustment), discussed and agreed by the Review Board as relevant and sufficiently rigorous to support the right outcome for future provision of PC OOHs service. 12 IOM Crossing the Quality Chasm: A New Health System for the 21st Century, (2001) 10 P a g e

11 Table 2 - Benefits Criteria Quality Attributes Key Features Reduced Clinical Risk and avoiding harm to patients from care that is intended to help them. A safe Primary Care Out of Hours service would therefore ensure: The environment is safe for the patients/staff Staff are appropriately trained to deal with presenting conditions or refer on seamlessly Access to specialist advice is available if required Appropriate facilities are available to meet the urgent care needs of the patient in the out of hours period Evidenced based clinical and quality standards are in place to avoid/prevent significant events Increased patient safety is achieved due to team based working Higher number of staff working together in the same place brings improved compliance with governance, greater opportunity for peer support and increased accountability Safe storage, monitoring and supply of medication Service is delivered and monitored against National Clinical Quality Standards for OOH Services. Providing services based on scientific knowledge and best clinical standards and improved quality of Care and outcomes An effective Primary Care Out of Hours service would therefore provide: Sufficient staff working together in teams to ensure a responsive and flexible service The range of staff with the right skills available to meet all expected urgent clinical conditions A fit for purpose clinical environment to deliver evidence-based care Training opportunities for the multi-skilled workforce Access to assessment/medication/emergency treatment (where indicated) Structures and mechanisms to utilise and deploy staff and resources effectively. Improved linkage with integrated health and social care teams. Greater opportunities for peer support within the workplace Care is responsive and appropriate to patients needs and the patient is included in clinical decisions. A patient-centred Primary Care Out-of- Hours service would therefore provide: Improved access to urgent primary care services Support through availability of transport where clinical need is established Care delivered within the timeframe triaged by NHS 24 Improved experience of patients and service users Patients seen by the right person in the right place within the right timeframe Patients not rushed through consultation and value is placed on the patients views 11 P a g e

12 EQUITABLE TIMELY Patients are listened to and treated with respect and dignity Avoidance of waste including energy, supplies, equipment, resources including staff and ensuring a seamless journey through services An efficient Primary Care Out of Hours service would therefore provide: A service configured to meet evidence-based demand Better utilisation of mobile units. (home visiting) An available workforce which has a range of knowledge and skills responsive to the urgent care needs of all patient groups Efficient deployment of skills and knowledge Informed deployment of the workforce and resources to allow faster access to assessment, care and treatment. A well resourced, financially viable and deliverable service Providing care that does not vary in quality because of geography, location or socio-economic status. All patients have access to a range of service provision An equitable Primary Care Out of Hours service would therefore provide: Access to urgent Primary Care services Access to a workforce who are suitably trained to meet the needs of urgent care, reduce any risk of harm and manage the care and treatment effectively Access to interpretation services Equitable application of clinical criteria to access transport to support attendance to a Primary Care Centre in out-of- hours period. Reduction of harmful delays for those who give and receive care A timely Primary Care Out of Hours service would therefore ensure: Patients are assessed and treated within the timeframe triaged by NHS 24 i.e. 1hr, 2hr, 4hr Patients are seen at the appointment time given. Sufficient workforce available at peak times. 3.3 Ranking and Weighting the Criteria The Review Board confirmed the list of benefit attributes and agreed to delegate the ranking and weighting to a sub-group of the Board (29th May 2014). To establish and assess the relative importance of the benefits criteria a group of subject matter experts (OOHs service staff) and lay group members (Patient Partnership Forum) from the Review Board met on the 10 th June, 2014 to agree the ranking and weighting of the benefits criteria. Those present went through a rigorous and robust process of exploring the case for change, the rationale behind each criterion as it applied to the OOH service change and the aims of the Option Appraisal process. The meeting was chaired by an objective service change facilitator (Kate Bell). 12 P a g e

13 3.4 Summary of the Final Ranking and Weighting The option appraisal methodology, in this instance a 'weighting and scoring method, is a form of multi-attribute or multi-criterion analysis. This involved identification of all the non-monetary factors (or "attributes") that are relevant to the service improvement programme; the ranking and allocation of weights to each of them to reflect their relative importance; and the allocation of scores to each option to reflect how it performs in relation to each of the benefit criterion as it relates to the Out of Hours service change. This process was split into two stages: The sub-group of the Programme Board ranked the benefits criterion in order of importance which was shared with the participants at the event. The sub-group gave a weighting to each of the benefit attributes in line with the ranking. Table 3 Ranking and Weighting Benefits Criteria Final Ranking Final Weighting Attributes Person-Centred 3 16 Effective 2 20 Safe 1 40 Efficient 4 14 Equitable 5 5 Timely Options Appraisal (Assessing the Long List) The aim of the event was to measure all ten proposals (Long List) against the benefits criteria and scoring process to reach a short-list of viable, feasible and deliverable options. An option appraisal pack, circulated seven days in advance of the event for pre-reading included background information, notification of the programme, an explanation of the option appraisal methodology, the vision, constraints and limitations, and the information on each of the proposed options developed at the Options Development workshop held 8 th May covering the Benefits, Risk and Opportunities for Improvement. The stakeholder engagement event set out to: 13 P a g e

14 Assess the potential benefits of different options against the information presented. Assess options objectively using agreed benefits criteria and scoring methodology. To ensure all attendees were informed of the background and detail of the options an information and briefing session was held on Friday 20 th June for Public Partnership and Carers representatives. On the day of the event a number of key presentations were delivered to cover: The Case for Change by Craig Cunningham, Interim Head of South Lanarkshire Community Health Partnership (CHP) and NHS Lanarkshire Executive Sponsor for the Review A description of the current service delivery and challenges was delivered by Lorraine Smith, Out-of-Hours Service Manager An explanation of the decision-making methodology and scoring process was covered by Kate Bell, Senior Manager, Change & Innovation Each proposed Option was described in detail covering the Benefits, Risks and Opportunities for Improvement by Dr Chris Mackintosh, Associate Medical Director for South CHP and GP in East Kilbride. 3.6 Scoring the Long List of Options All stakeholders were identified through the Programme Board and invited to the event with no less than 6 weeks notice. The event was attended by 59 people with a total of 48 people eligible to score. The non-scorers included the 5 facilitators, the event receptionist and communications manager, a non-executive board member, a representative of Health Scotland and a Scottish Health Council member. Two attendees failed to hand in a score sheet making 12 non scorers. This resulted in 47 completed score sheets. All attendees were allocated to one of five groups pre-event to ensure equal representation. The groups were facilitated by experienced facilitators not involved in the delivery of the Out-of-Hours service. In setting out the options, Dr Mackintosh highlighted five main areas. 14 P a g e

15 a) By having sufficient critical mass of patients, it supported optimum team working between GPs and nursing staff such that each complimented the other and maximised the care available to patients. b) A service which required GPs to be predominantly working alone for the majority of the time would not be attractive to recruiting more GPs/retaining current GPs to the service. c) Having accommodation which was fit for purpose was preferable to both patients and staff. d) The recent analysis of activity demonstrated that approximately 25% of all appointments were for under-5 year olds, and a further 25 % for children aged between 5 and 18. Accordingly, significant scope existed for utilising nurses with specific skills in managing childhood illness. e) The recent analysis of activity also identified that the vast majority of home visits were for people aged >65 and who might have difficulty accessing public transport and/or have mobility difficulties. 3.7 Groupwork Scoring Process All invited attendees were allocated to a group pre-event to ensure a mixed representation of expertise and knowledge across all groups. As described in the briefing paper distributed in advance of the event and presented on the day of the event the facilitated groupwork process enabled each proposed option to be discussed in turn by the five mixed stakeholder groups with opportunity for further interrogation of the Benefits, Risks and Opportunities for Improvement before individual scores were applied to represent the value of each of the benefits criterion as it applied to the options and to the PC OOHs service. (See Appendix 3 Participants Score Card) 15 P a g e

16 4 Overall Results Table 4 All Options, all Groups - Ranking and Scoring All groups ranking Option 5 - Two Primary Care Out-Of-Hours centres 1 Option 2 - One Primary Care Out-Of-Hours Centre 2 Option 9 - Three primary Care Out-Of-Hours Centres based in community health centres 3 Option 4 - Primary Care Out-Of-Hours Centres co-located with Emergency Departments 4 Option 10 - Combined Out-Of-Hours and Emergency Departments services with one clinical and managerial setting 5 Option 6 - Two health centres with nurse led satellites 6 Option 7 - Two Primary Care Out-Of-Hours Centres North and South plus GP Co-operative 7 Option 1 - Status quo, do minimum 8 Option 3 - General Practitioners Co-op model 9 Option 8 - Outsource the Primary Care Out-Of-Hours service 10 Please note: The options above will be subject to further engagement and consultation before a preferred option is recommended. 4.1 The Status Quo and do minimum option The next meeting of the Review Board in August, 2014 will consider the details within this report to validate the options for short-listing. A clear rationale will be written up to explain the reasons for excluding any options. The options selected for in-depth appraisal must include a baseline or benchmark option. This is the "status quo" option which will be short-listed and appraised even although it is not considered to be a realistic option. The function is to provide a benchmark so that the value of the alternative 'do something' options may be judged by reference to current service provision. 16 P a g e

17 4.2 Score for All groups - Table 5 Option 1 - Status quo, do minimum Total Weighting Weighted total 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 1 = 9818 Option 2 - One Primary Care Out-Of-Hours Centre 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 2 = Option 3 - General Practitioners Co-op model 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 3 = 7970 Option 4 - Primary Care Out-Of-Hours Centres colocated with Emergency Departments Total Weighting 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 4 = Weighted total Option 5 - Two Primary Care Out-Of-Hours Centres 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 5 = P a g e

18 Option 6 - Two Health Centres with nurse-led satellites 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 6 = Option 7 - Two Primary Care Out-Of-Hours Centres North and South plus GP Co-op Weighting 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 7 = Weighted total Option 8 - Outsource the Primary Care Out-Of-Hours service Weighting 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 8 = Weighted total 7404 Option 9 - Three Primary Care Out-Of-Hours Centres based in Community Health Centres Weighting 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 9 = Weighted total Option 10 - Combined Out-Of-Hours and Emergency Departments with one clinical and managerial setting Weighting 1 Safe Effective Patient-centred Efficient Equitable Timely Total for option 10= Weighted total P a g e

19 4.3 Sensitivity Testing In order to test the robustness of the results of the option appraisal an assessment of the sensitivity of the ranking of the scores to key variables and assumptions was carried out. The table below shows the outcomes of the scoring exercise for each individual group (by group), by combination and what the outcome/ranking would have been. Table 6 Overall scores and rankings per group Sensitivity Option Option Option Option Option Option Option Option Option Option Test Overall Scores and Ranking Rank Baseline Scores Weighted Scores Rank NHS Lanarkshire Staff NHS Managers Rank Scores NHS Lanarkshire Clinicians Rank Scores Scottish Ambulance Service Rank Scores Public Partnership/Voluntary Sector Representatives Rank Scores Table 7 - Scores Make up of Scorers Number of NHS Lanarkshire clinicians 9 Number of NHS Lanarkshire management/staff 16 Number of Patient Partnership Representatives 9 Number of Voluntary Sector 6 Number of Public participants 1 Number of Scottish Ambulance Service staff 6 Total P a g e

20 5 Evaluation The Review process has been set out with a structured and disciplined approach to ensure we capture and collect high quality information on the current service context, demand activity, workforce information and the findings of the communications and engagement process to date. Analyses of the data and information have enabled the Review Board to set out the challenges/expose issues or opportunities; and present informed options to stakeholders involved in supporting the service improvement process. This will ensure NHS Lanarkshire is well placed to respond to the immediate, emergent and future challenges within the Primary Care Out-of-Hours Service. The stakeholder event was attended by a total of 59 stakeholders including clinicians and managers from the Out-of-Hours Service, other relevant managers and clinicians, strategic, and community council/public and patient representatives from the North and South Lanarkshire. A representative of the Scottish Health Council attended the event to observe the process. 36 (75% of total attendees) evaluation forms were returned. Of the 36 returns 20 (56%) from NHS staff including the Scottish Ambulance Service and 16 (44%) were from PPF/Carers representatives. 5.1 Replies from the Public and Patient representatives groups 15 (94%) of the 16 replies stated they had received easy to understand and all relevant information in advance of the workshop to prepare or make enquiries. 15 (94%) of the 16 replies noted that they had received an invitation to a pre-briefing meeting on the 20 th June, The table below relates to perceived influence. Table 9 Agreeing the long list of options Considering the benefits criteria Developing the short list of options A strong Influence Some Influence No Influence Unsure/blank 7 (44%) 4 (25%) 1 (6%) 4(25%) P a g e

21 All 16 (100%) of the lay representatives evaluation forms highlighted they were given opportunities to ask questions, they could raise any issues/concerns and felt listened to with one participant feeling their questions were not answered. Comments from Public, Carers and Patient representatives I came from Kilsyth and the options offered do not suit our area Good management of sessions Thought the groups had a good mix of expertise and constructive conversations Well Done Process was informative, well presented and organised, intentional and purposeful, all discussions well facilitated Part of the Review Board and felt included in the process Involved in the Review Board, not scared to speak out Overall Influence comments recorded by 15 (94%) of Public Partnership participants said they were able to have a strong or some influence on decisions by participating in the event with the same number registering an interest to remain involved through the Review Board or through the future consultation process. 5.2 Replies from NHS Staff All staff felt they had either a strong or some influence on agreeing the long list of options, considering the benefits criteria and developing the short list of options. 19 of the 20 staff in attendance felt they had sufficient, understandable information in advance of the event. All staff felt they got the opportunity to ask questions, raise any concerns and felt listened to. Comments Lots of pre-reading and involvement in groups, good chance to get additional information The groups were well mixed and all had the ability to contribute which they exercised! Very balanced Opportunity to offer Scottish Ambulance Service (SAS) perspective and opinion A good group discussion where all parties were involved in participation As a service provider and user I feel this will help make the service stronger for the future 21 P a g e

22 Only came in at short-listing stage but felt I could engage and have equal input to the short-listing All relevant information provided, good engagement, good exercise and well run project Time limited but good facilitated discussion All staff registered an interest in remaining involved with the review programme. One form had a blank second page P a g e

23 Appendix 1 Participants Briefing Paper for Option Appraisal (Short-listing) OPTION APPRAISAL PROCESS A. Purpose of this briefing This briefing sets out information on the process for Option Appraisal of the Primary Care Out-of-Hours service (PC OOHs) across NHS Lanarkshire. B. How are we planning to do this? The Scottish Government sets out very clearly the process for Informing, Engaging and Consulting People in Developing Health and Community Care Services 13, which Health Boards must follow. The Project Board confirmed the list of benefit attributes (29 th May 2014). A sub-group of the Review Board have ranked the attributes in order of importance which will be shared with the participants at the event. (10 June 2014) The same sub-group of the Review Board have given a weighting to each benefit attributes in line with the ranking. (10 June 2014) We have: 1. Agreed the key features according to the OOHs service attached to each of the benefit attributes to be used as a guide for participants to score each option accordingly 2. Ranked the criteria in order of importance (subject matter experts with lay input) 3. Weighted the criteria (subject matter experts with lay input) 3.1 The benefit attributes are based on the six dimensions of healthcare quality and include key features relevant to the delivery of Out Of Hours services attached to each. A paper giving more detail can be found in the information pack. The group of key informants have discussed the ranking and weighting of the attributes or what is most important to this service change prior to the event. 13 Informing, Engaging and Consulting People in Developing Health and Community Care Services CEL P a g e

24 C. Weighted Scoring Method explained The weighted scoring method is a form of multi-criterion analysis. It involves identification of all the non-monetary factors (or "attributes") that are relevant to the service change project; the allocation of weights to each of them to reflect their relative importance; and the allocation of scores to each option to reflect how it performs in relation to each attribute. The result is a single weighted score for each option, which may be used to indicate and compare the overall performance of the options in non-monetary terms. This process necessarily assigns numeric values to judgements. These judgements should not be arbitrary or subjective, but should reflect expert and service user/lay representatives views, and should be supported by objective information. To achieve meaningful results which decision-makers (NHS Lanarkshire and key partners) can rely on, it is important that all stakeholders are represented and that: 1. the exercise is not left to the 'experts', but is undertaken by a group of people who represent all of the interested parties, including, for example, those who are directly affected by the project, and those who are responsible for its delivery; 2. the group possesses the relevant knowledge and expertise required to make credible measurements and judgments of how the options will impact upon the attributes; 3. the group is led by an objective person to steer the process, probe opinions, promote consensus and avoid prejudice; and 4. the justification for the group's chosen weights and scores is fully explained D. Benefit Attributes The criteria ranking is in order of their importance (1 6) where 1 is the most important, 2 is a little less important and so forth until all 6 are ranked. The weightings are applied across the ranking to reach a total of 100. Attributes Ranking Weighting Person Centred 3 Effective 2 Safe 1 Efficient 4 Equitable 5 Timely 6 The event will: 24 P a g e The agreed weightings will be applied to support a rigorous reporting and analysis of scores

25 Assess the potential benefits of different options against the information presented Assess options as objectively using agreed benefits criteria The outcome of this exercise utilising individual participant scores will be used at the stakeholder event to score the improvement options against the above ranked/weighted attributes. This exercise will determine the short list of options to proceed to the Options Appraisal event in Autumn E. What am I expected to do at the Option Appraisal Meeting? Note - This exercise will be led by NHS Lanarkshire facilitators who will support and guide the group through every step of the process. You are required to do the following: On the 27 th June you will hear a presentation giving background information relating to the Primary Care Out-of-Hours services and the options for improvement developed by a group of key informants. You will as a group then consider the six benefit criteria headings and the key features of each. There will then be group discussion of the options where additional information and detail can be further discussed using experience and knowledge from the key informants present. There may be one or more groups involved in discussion. You will then fill in a score sheet for each option. These sheets will be added together after the event to produce the decisions of the group. You will be invited to complete an evaluation form on the day and a report capturing the outcome of the day will be sent to you after the event. Outputs from the short-listing workshop will be reported to NHS Lanarkshire Board. 25 P a g e

26 Short-listing event Programme Appendix am Registration & Tea/Coffee 10.00am Welcome Kate Bell, Senior Manager, Change & Innovation 10.05am Introduction and Background Craig Cunningham, Head of South CHP (Interim) 10.10am Current Service Lorraine Smith, Out of Hours Service Manager 10.20am Review Process- Kate Bell, Senior Manager, Change & Innovation Decision Making methods Description of groupwork 10.40am Options for Consideration Dr Chris Mackintosh, Associate Medical Director 11.00am Refreshments 11.20am Groupwork discussion Kate Bell, Senior Manager, Change & Innovation am Facilitated Groupwork session ALL/Facilitators Each group will discuss each of the options and score individually against each of the criterion 1.00 pm Lunch 1.45pm Options for Consideration Dr Chris Mackintosh, Associate Medical Director 2.00pm Facilitated Groupwork session - Each group will discuss the remainder of the options and score individually against each of the criterion ALL/Facilitators 3.00pm Refreshments 3.15pm Feedback and Plenary Kate Bell 3.45pm What Happens Next /Close Craig Cunningham 26 P a g e

27 Short-listing Workshop 27 th June 2014 Appendix 3 Scoring Key Score Evaluation 5 Excellent Fits all attributes perfectly 4 Very Good Fits attributes very well 3 Good Fits some attributes well 2 Unsatisfactory Meets few attributes 1 Poor Only one attribute met. 0 Offers no benefit No attributes met at all 1. Which one of the following groups do you represent today (please tick one) 1 NHS Lanarkshire Clinician 2 NHS Lanarkshire management/staff 3 Service Users 4 Patient Partnership representatives 5 Voluntary Sector 6 Public Participant 2. You will be asked to score the options. Please use the scoring key above to indicate your scores by placing the number 0-5 in the boxes below. Attributes Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 Option 9 Option 10 Safe Effective Person Centred Efficient Equitable Timely TOTALS 27 P a g e

28 List of Participants Appendix 4 NHS Lanarkshire (19) 1 Sandra Smith (Non Non Executive Director (Non Kirklands Board HQ Scorer) scorer) 2 Dr Andrew Palombo Clinical Lead for Emergency Hairmyres Hospital Medicine 3 Carolann O Donnell Charge Nurse Emergency Monklands Hospital Department 4 Margaret Johnston Team Leader for the Integrated Wishaw General Hospital Community Children s Nursing Team 5 Mary Neilson Charge Midwife Triage/ Union Wishaw General Hospital Steward 6 Janie Thomson Head and Professional Lead for the Hairmyres Hospital NHS Lanarkshire Physiotherapy Service 7 George Lindsay Chief Pharmacist, Primary Care Kirklands Board HQ 8 Joyce Higgins Chief Pharmacy Technician Monklands Hospital 9 Jacqueline Kelland Medicines Management Monklands Hospital Pharmacist 10 Jean Donaldson Senior Nurse, South West Unit Red Deer Day Centre 11 Craig Cunningham Head of South Lanarkshire CHP Kirklands Board HQ (Interim) 12 Graham Johnston Head of Management Services Kirklands Board HQ 13 Richard Burgon Unit Manager, North East Unit Wishaw General Hospital 14 Tom Bryce General Manager South West Unit 15 Paul McDaid Service Manager South West Unit 16 Liz Swan Service Manager East Kilbride Locality 17 Hina Sheikh Equality & Diversity Manager Law House 18 Hazel Towers Senior Information Analyst Kirklands Board HQ 19 Jacqui Cringles Senior Management Accountant Kirklands Board HQ 28 P a g e

29 General Practitioners (3) 20 Dr Chris MacKintosh Associate Medical Director Kirklands Board HQ 21 Dr Keith McIntyre General Medical Practitioner Lanarkshire GP Subcommittee /LMC Alan Moffett General Practitioner East Kilbride Out of Hours Staff (6) 23 Gavin MacLeod General Practitioner Out of Hours Service 24 Lorraine Smith Out of Hours Manager Law House 25 Edena Donald Operational Service Manager Law House 26 Alistair Griffiths Driver, Receptionist/Union Law House Representative 27 Owen Walpole National Management Trainee Law House 28 Linda Duncan Out of Hours Practitioner Lanarkshire Scottish Ambulance Service (5) 29 Mairead Johnston Area Service Manager Lanarkshire 30 Daniel Rankin General Manager Lanarkshire 31 Andrew Graham Head of Service Lanarkshire 32 Carol-Ann Jamieson Head of Service Lanarkshire 33 Sam Paul Team Leader Lanarkshire Service Users, Carers and Public Representatives (16) 34 Richard Carlson PPF 15 Representative Coatbridge Community Forum 35 Helen Reston PPF Representative Coatbridge Community Forum 36 Carol Carter (Non scorer) PPF Representative Community Forum, North Lanarkshire 37 Donald Masterton Public Partnership North Lanarkshire Forum 38 Ann Muir Public Partnership North Lanarkshire Forum 39 Carol Robb PPF Representative North Lanarkshire 40 Bill Angus PPF Representative South Lanarkshire 41 Fiona Boyle PPF Representative South Lanarkshire 42 David Downie PPF Representative South Lanarkshire 43 Liz Forbes PPF Representative South Lanarkshire 44 Colin Angus PPF Representative South Lanarkshire 45 Sean Harkin Representative North Lanarkshire Carers Together 45 Margaret Moncrieff Director South Lanarkshire Carers Network 47 Brenda Vincent Service Manager Equals Advocacy Partnership 48 Susanne Hamilton Representative North Lanarkshire Voluntary Sector 14 Lanarkshire Medical Committee 15 Public Partnership Forum 29 P a g e

30 49 Kay Thomson Locality Development Officer Voluntary Action South Lanarkshire 50 Brian Duffy Representative Voluntary Action South Lanarkshire Other - Non Scorers (2) 51 Louise Wheeler Service Change Advisor Scottish Health Council 52 Arma Sayed Equality Officer NHS Health Scotland Event Management and Facilitation non scorers (7) 53 Kate Bell Senior Manager, Change & Innovation Kirklands Board HQ 54 Susan Dunne Deputy Director, Organisational Kirklands Board HQ Development 55 Marjorie McGinty Programme Manager Kirklands Board HQ Reshaping Care for Older People & Long Term Conditions 56 Trudi Marshall Nurse Consultant, Older People Kirklands Board HQ 57 Pam Milliken Head of Clinical Governance & Risk Kirklands Board HQ Management 58 Calvin Brown Communications Manager Kirklands Board HQ 59 Lorraine Forrest Projects Officer, Change and Innovation Kirklands Board HQ The methodology and event management for the stakeholder engagement event was designed by NHS Lanarkshire Change and Innovation to ensure a transparent, rigorous and auditable decision-making process. The approach was approved by the Primary Care Out- Of-Hours Review Board. For further information on this report contact: Kate Bell, NHS Lanarkshire Kate.bell@lanarkshire.scot.nhs.uk Senior Manager, Change & Innovation Tel: P a g e