Review of Lothian Unscheduled Care Service

Transcription

1 Review of Lothian Unscheduled Care Service August 2014 Patricia Dawson NHS Lothian Draft Version 3

2 Table of Contents 1. Service Model: an Overview 2. Introduction 3. Why a review? 4. How the Review was undertaken 5. What LUCS Delivers Core Activity A dditional Activity National Benchmarking Cost Comparisons Patient Experience Quality Reviewing LUCS Activity C ore Activity Additional LUCS Activity Untriaged Calls A&E Referrals Profession to Profession (P2P) Referrals Self Referrals Protected Learning Time (PLT) Services for NHS Borders GPand ENP Recruitment and Retention Current Issues S alaried and ad hoc GPs Sickness Absence Shift Patterns & Rota Management What Doctors said about working in LUCS Pri mary Care Workforce Survey A ddressing the Issues National GP Training A ddressing ENP Issues Improving Safety & Effectiveness C linical Models Mid and East Lothian C linical Models S t John s, WIE and RIE Sites O OHs Services for Children and Young People H ome Visits Right Patient, Right Place, Right Time Efficient Use of Infrastructure P ublic Holidays Improve Managerial and Administrative Model C linical Leadership 36 2

3 10. Accou ntability and Governance Localise and Integrate N ext Steps E xecutive Summary A ppendices and References 42 Appendix 1: Terms of Reference Appendix 2: Improvement Plan Summary Document Appendix 3: LUCS Review 2010 Key Recommendations 53 Appendix 4: LUCS Action Plan April Appendix 5: Summary of Actions 2014 Review 57 References 63 3

4 1. Service Model: An Overview Background REVIEW OF LOTHIAN UNSCHEDULED CARE SERVICE The General Medical Services contract in 2004 permitted General Practioners to opt out of providing Primary Care services in the Out Of Hours period (OOH). The responsibilities for this care delivery transferred to Scottish NHS Boards and NHS24. NHS Lothian established the Lothian Unscheduled Care Service (LUCS) with a multidisciplinary and multi site care model. Current Core Functions The role of LUCS is to provide OOHs urgent primary medical care services across Lothian from 6 pm to 8 am Monday to Thursday, from 6pm Friday to 8 am Monday (70% of the week) and on Public Holidays. All requests for health care from members of the public come to LUCS hub from NHS 24 following triage for doctor advice, home visit or to attend a Primary Care Emergency Centre(PCEC).Patients are transferred to LUCS from A and E departments and from LUCS to A and E departments under established protocols. People also attend the sites without triage or appointments to access health care and are referred to as walk ins. An agreed transfer of untriaged calls from NHS24 are also triaged by LUCS. LUCS additionally provides telephone advice to other health, social care and emergency services professionals called a Professional to Professional line (P2P). This includes a clinical service to the laboratory services to interpret and action abnormal results. More recently LUCS has absorbed the provision of medical care to a range of NHS Lothian in patients. It is also providing planned patient reviews requested by in hours GPs. Current Issues The provision of Unscheduled care is a key priority for NHS Lothian.Concerns were expressed about the safety and sustainability of the service. The key issues were; Safety of the current service and clinical model Activity changes and additional area of service demand s National and local recruitment and retention challenges especially for GP s Professional and leadership issues with Emergency Nurse Practioners(ENP) Sustainability of a 5 site delivery model. 4

5 Current Clinical Model Appointments, cars, visits, telephone advice and attendances are coordinated by the hub at WGH. GPs do all the doctor advice, triage, P2P, and home visits and have 3 appointment slots per hour at the sites. ENPs have 2 appointment slots per hour and see most patients including children. Each site also has driver and reception staff and there are service supervisors and administration functions. WGH, St John s and RIE are the busiest sites with broadly similar activity but have differing staffing and skill mix. Midlothian Community Hospital and Roodlands have similar and rich staffing and skill mix but low levels of activity. Overnight services are provided from midnight in 2 sites, RIE and St John s. New Clinical and Service Model LUCS should refocus on the core business of providing PCOOHs services and be renamed as such. There should be 2 clinical models reflecting activity and staffing needs:- 1. WGH, St John s and RIE should have GPs and ENPs, retain existing clinical roles, improve productivity and retaining existing opening hours with effective car and doctor dispatching and management. These should be the core sites for PCOOHs service delivery in the event of staffing shortages or other business continuit y issue s 2. MCH and Roodlands should be GP delivered service with reduced opening hours and one car, driver and GP covering both East and Mid Lothian in the evenings with support from RIE as needed People will continue to walk in to sites to access health care but actions should seek to move this to a managed demand. Home visits are a key and core component of PC OOH s services delivered by GPs and this should continue until alternatives are demonstrated safe and effective and efficient. Profession to Profession (P2P) advice calls are also core business but need to be better understood and managed. Medical cover arrangements for patients in In Patient Continuing Care (IPPC), step down and delayed discharge beds in the OOH period could be core PCOOHs service delivery but only following a strategic service review. This must address issues of GP competency in caring for patients with intermediate care needs, clinical governance and 5

6 patient safety, skill mix, continuity of care and decision making and care documentation. An efficiently managed and delivered PCOOH service provides a key component of Lothian Unscheduled Care but it is not a Lothian Unscheduled Care Service unless it is designed and resourced to be so. 6

7 2. Introduction A review of LUCS was indentified as an action in the Lothian Unscheduled Care Plan and as an action in the draft NHS Lothian Strategic Plan Our Health, Our Care, Our Future (Ref 1). The review was commissioned by David A. Small, Director, East Lothian Health and Social Care Partnership with agreement from the Executive Nurse, Medical and HR Directors. Patricia Dawson (previously Associate Nurse Director, Strategic Development) was asked to undertake the review. The terms of reference are attached at appendix 1. The key purpose is to review the current service delivery model and bring forward an action plan to ensure LUCS is fit now and in the future; with a pragmatic approach to current staffing constraints, productivity and efficiencies to ensure person centred, safe, effective care, delivery within financial limits. From the review there may be a second phase of potential redesign ambitions. These arise from opportunities from the current integration agendas, National Primary Care Out Of Hours care delivery, GP recruitment retention pressures, alignment of medical cover for continuing care, care homes and step down beds. It was further agreed that the 3 outputs from the review were:- 1) An internal LUCS Service Improvement Plan, Appendix 2 ; 2) The review of LUCS Report. 3) A draft Project Plan aligned to the Strategic Planning Process. All the above products to be presented to David A. Small by mid July Why a Review? This is the second service review in 4 years. The Better Acute Care in Lothian Group commissioned the Associate Director of Strategic Planning and Service Modernisation to undertake a review, completed April 2010 and presented in December 2010 to the Unscheduled Care Board (Ref 2). The key aim was to understand how LUCS contributed to unscheduled care delivery and identify opportunities to develop the role. The key recommendation (Appendix 3) and the Action plan (Appendix 4) are provided for comparison. 7

8 The current review is prefaced by different drivers:- - a more mature service with a changing activity profile and increasing complexity; - an increase in the type of internal PC OOH care demands expected by NHS Lothian; - changes in the perception of the service and the need to examine service and staffing models; - shortages of doctors and nurses necessitating closure of site(s) and modified service delivery; - implementation of National Quality Standards for PC OOH s services (Ref 3 ); - A national integration agenda driving significant changes in health and social care service models, funding and governance arrangements. 4. How the Review was undertaken An investigative approach was undertaken including:- - face to face interviews with over 70 staff from all LUCS staff groups, - meetings with senior managers, specialist staff in Finance, HR, Health Intelligence Unit, transport, clinical governance et c., - 2 professional advisers were co-opted:- Patricia McIntosh, Clinical Services Development Manager, East Lothian CHP, Dr. Nigel Williams, Associate Medical Director, - meetings/phone interviews with Director of Public Health, RHSC A&E Clinical Lead, and service Clinical Leads including Clinical Nurse Manager co-opted to LUCS, - telephone interviews with lead staff from NHS Ayrshire and Arran, Greater Glasgow and Clyde and Tayside PC OOH s Services, - visits to each of the 5 OOH s sites called Primary Care Emergency Centres (PCEC), hub at WGH and regularly to administration at Astley Ainsli e, - attendance at 3/4 GP Practice representatives meetings in East Lothian, Midlothian and Edinburgh CHP s (West was arranged but cancelled), - partnership representative engaged, - attendance at CHP Clinical Director s Meeting. Semi structured interviews about what works, what can be improved and personal and professional observations were shared. Data and financial information was requested. I am very grateful for the honesty which everyone engaged in the process demonstrated. There were many strong views expressed and 8

9 there was also a large degree of similarity in the issues which need addressed. The LUCS service Improvement Plan has captured most of this and translated it into actions that need to be progressed to improve how staff view their work in the service. Broadly summarised the staff felt:- - isolated, distant from management and poorly communicated with; - not valued and not involved in decisions which affect them; - Emergency Nurse Practitioners were particularly disillusioned with unresolved HR and professional concerns; - upset by different pay mechanisms and single pay rise of over 15% for doctors(first rise in 10 years); - increasingly concerned about safety and staffing lev els ; - most really enjoyed their contact with the public and wanted to do a good job; - some receptionists and some drivers felt underutilised; - many staff had good ideas or had thought through how things could be better; - many GPs expressed a lack of local ownership and continued to be critical about the totality of the resource and role of NHS mainly positive views about local team working and professional high quality service 9

10 5. What LUCS Delivers 5.1 Core Activity LUCS provides out of hours primary care medical services across Lothian from 6pm until 8am Monday to Friday, from 6pm Friday to 8am Monday, 118 hours or week 70% of each week and on Public Holidays and for 6 Protected Learning Time Sessions annually (12.00 to 18.00). All requests for healthcare from members of the public come to LUCS hub via NHS 24, who handle external calls and following triage pass those contacts assessed as requiring Doctor advice, home visit or to be seen at a Primary Care Emergency Centre (PCEC) to LUCS. LUCS hub located at WGH provides co-ordination across the 5 PCECs and up to ten home visiting cars. In addition to serving all Lothian residents, services are also provided out of hours to patients in West Linton, on behalf of NHS Borders. The LUCS service is staffed by primary care practitioners comprising GPs, Emergency Nurse Practitioners and supported by a range of administrative staff, receptionists and drivers. 5.2 Additional Activity In addition to this core activity LUCS takes untriaged calls from NHS 24 at peak times of each week. A number of other services include a professional to professional advice line (P2P) for other community health professionals and to NHS Lothian laboratories including pharmacists, SAS paramedics, and District Nurses. LUCS also provides out of hour s medical cover to fifteen NHS continuing care and similar units across Lothian through provision of telephone advice and doctor visits when required via the professional advice line. It offers a planned review service to patients in the community at the request of primary care clinicians. The LUCS hub provides a call handling service for Edinburgh, East and Midlothian District Nursing evening and overnight service through a specific phone line available to existing District Nurse patients. 10

11 6. NATIONAL BENCHMARKING 6.1 Cost Comparisons The latest available published information relates to 2012/13 and it shows that LUCS had the lowest cost per head of population ( HOP)(see Table 1) in Scotland at per registered patient. This is a 14.7% increase over the cost per head in 2005/6 which was However it is actually a reduction in real terms when cost inflation is taken into account. TABLE 1 OOH Cost per head of population board NB1. Notice that Lothian have the lowest cost per head of population figure for two of the last three years, and are second lowest in the other year Cost Totals Population 2010/11 Cost 000s Cost per HOP 2010/ Population 2011/12 Cost 000s Cost per HOP 2011/ /13 Contacts 2012/13 Cost 000s Cost per HOP 2012/13 NHS Ayrshire & Arran 366,860 4, ,029 4, ,174 4, NHS Borders 112,870 3, ,559 3, ,268 3, NHS Dumfries & Galloway 148,190 3, ,237 3, ,295 3, NHS Fife 364,945 4, ,954 4, ,122 4, NHS Forth Valley 293,386 3, ,193 3, ,055 3, NHS Grampian 550,620 7, ,085 7, ,941 7, NHS Greater Glasgow & Clyde 1,203,870 13, ,206,846 12, ,210,337 12, NHS Highland 310,830 9, ,385 9, ,067 9, NHS Lanarkshire 562,477 7, ,039 7, ,612 6, NHS Lothian 836,711 8, ,104 9, ,071 8, NHS Orkney 20, ,250 1, ,390 1, NHS Shetland 22, , , NHS Tayside 402,641 6, ,500 5, ,540 6, NHS Western Isles 26, ,197 1, ,196 1, Totals 5,222,100 75,445 5,250,894 75,275 5,281,693 74,302 11

12 Another cost guide often used for benchmarking purposes is the cost per patient contact (see Table 2). For 2012/13 this was 67.92, which is the lowest cost for any board in Scotland using this measure and a reduction from in 2010/11 or 4.8%. However these costs may have been impacted in 2013/14 when compared nationally given the NHS Lothian pay uplift of 15.2% for GP and ad hoc GP pay rates, the first pay uplift in 10 years. TABLE 2: OOH Cost per contact per board Cost Totals /11 Contacts 2010/11 Cost 000s Cost per contact 2010/ /12 Contacts 2011/12 Cost 000s Cost per contact 2011/ /13 Contacts 2012/13 Cost 000s Cost per contact 2012/13 NHS Ayrshire & Arran 55,929 4, ,555 4, ,953 4, NHS Borders 0 3, ,363 3,020 - NHS Dumfries & Galloway 22,325 3, ,040 3, ,693 3, NHS Fife 52,520 4, ,262 4, ,191 4, NHS Forth Valley 46,243 3, ,555 3, ,056 3, NHS Grampian 90,522 7, ,290 7, ,394 7, NHS Greater Glasgow & Clyde 175,825 13, ,124 12, ,598 12, NHS Highland 42,597 9, ,780 9, ,325 9, NHS Lanarkshire 79,316 7, ,741 7, ,487 6, NHS Lothian 121,645 8, ,712 9, ,632 8, NHS Orkney 1, ,530 1,791 1, ,400 1,741 1, NHS Shetland , NHS Tayside 0 6, ,853 6,451 - NHS Western Isles 6, , ,151 - Totals 695,028 75, ,589 65, ,433 74,302 NB1. Where there is no contacts figure and thus no contact figure, this is because the board did not gather figures about the number of contacts. NB2. Notice that NHS Lothian have the lowest cost per contact figure for two of the last three years and are second lowest in the other year. 12

13 Cost Comparisons from 2010 Review (Ref 2) The above review reported some internal cost comparisons which complement the national data (Table 3). This data was used to offer a snapshot of unscheduled care services costs. From this the key cost to target would be to reduce the cost per home visit. The imminent roll out of a fleet management system aligned to Sat Nav technology could have efficiency effects on these costs. Redesigning the geographic coverage and deployment of cars, drivers and doctors may also help and is discussed later in the report. TABLE 3: Activity Cost Original table info 2008/ /13 LUCS cost per PCEC Contract LUCS cost per Home Visit LUCS cost per phone advice RIE cost per A&E Attendance SJH cost per A&E Attendance WGH Minor Injuries cost per Attendance S ource NHS Lothian Finance 6.2 Patient Experience The National Health and Care Experience Survey 2013/14 (Ref 4) compares public views on Primary Care and OOHs care results with the previous survey in 2011/12. This shows overall patients are slightly less positive about their experiences and that positive ratings for access to GPs and GP care may have Scotland wide root causes. Out of Hours care had similarly reported less positively than 2011/12 the overall rating reduced from 72% positive to 71% positive. The figures for NHS Lothian and each of the 4 CHPs are set out in Table 4. Staff expressed a good deal of pride in the quality of service provided and the ability to focus on the individual patients. 13

14 TABLE 4 R ating overall care provided Out of Hours:- Positive Responses Difference From Difference 2011/12 From Scotland NHS Lothian East CHP Midlothian Edinburgh West Note: the question includes aspects of care provided by NHS24, SAS, A&E with only 27% of those who used an OOH s accessing a PC OOH service On this indicator, although limited specificity for PC OOH s and LUCS, NHS Lothian is 2% above the Scottish average which is statistically significant. 6.3 Quality Quality Indicators for Primary Care Out of Hours Services were published in March 2014 (Ref 3). There are 6 indicators of which only one is reported locally. All the others will require additional clinical time, to put in place manual audit systems. Some rely on the improvements to the functionality of ADASTRA (national OOH s IT system) and most will be reported by an ISD data mart. The Indicators are:- 1) Response times NHS24, home visit, hour visit. 2) Appropriateness of triage for home visits clinically appropriate hour visits. 3) Effective information exchange. 4) Implementing national clinical standards and guidelines; tracer condition asthma. 5) Antimicrobial prescribing (PRIMS + GP 10 data) x 4 groups antimicrobials. 6) Patient experience the patient experience, positive outcome, number of complaints. Given the recent pressures on the system much of the preparatory work needed is not as far advanced as the service would wish. However the actions suggested in the LUCS service Improvement 14

15 Plan will help realise the clinical infrastructure needed for this small team to deliver these national standards. Of the above the performance against 1, 2 and 4 hour home visits is reported by LUCS and Table 5 shows the performance between 2008/9 and 2013/14. Table 5 1 Hour Visits 2 Hour Visits 4 Hour Visits % 1 hour %1 hour 15 %2 hour %2 hour 15 % 4 hour mins mins Overall performance has been reasonably maintained with a fall of 4% on 1 and 2 visits achieved with >15 mins. Given increasing activity and complexity in care this may be acceptable. There is an active Quality Improvement Team which will lead the implementation and delivery of the national quality indicators. Critical incidents and complaints are already being reviewed and patient experience local survey tools are being tested. Actions 1. The clinical leadership capacity for doctors and nurses needs increased to support quality, clinical and staff governance in the PC OOH s service 2. A target of 90% achievement of % 1 hour and 2 hour should be set and priority given to reporting regularly on the appropriateness of home visit triage by NHS24 3. Performance against the National indictors should be reported to the Unscheduled Care Board;- Interim report by Winte r 2014 Full report Spring/Summe r

16 7. Reviewing LUCS Activity 7.1 Core Activity Tables 6 & 7 show changes and smoothing in activity over a 4 year period and the changes in the mix of that activity. Did not attend (DNA) rates are problematic in Primary Care and OutPatient settings. Although not shown the DNA rates for LUCS are very small: 343 in 2009/10 and 480 in 2013/14. Table 6: Core Activity Core LUCS Activity 2010/ / /12 % Incr 2012/13 % Incr 2013/14 % Incr Primary Care Emergency Centre visits 75, ,798 1% 78,096 3% 69,845 (11%) Home Visits 20, Doctor 26,293 Telephone Advice ,475 2% 21,569 5% 20,215 (6%) 25,429 (3%) 26,967 6% 24,645 (9%) Calls transferred for District Nurse Action 8, ,249 18% 12,640 23% 13,058 3% Total LUCS contacts Total NHS 24 Lothian Calls NHS 24 Nurse advice (includes A & E and SAS) 121,645 1, ,267 2, , ,702 0% 126,632 4% 114,705 (9%) 203,313 2% 216,578 7% 207,209 (4%) 71,362 2% 77,306 8% 79,446 3% Overall activity has changed s ince 2010:- - Total NHS Lothian calls has by 3.5% - Total LUCS contacts has by 5.7%. - NHS24 has increased the number of calls from Lothian it manages by 3%. - Overall most LUCS activity is down from 2012/13 but up overall - Total LUCS activity in 2008/9 was 114,215 and in 2013/14 114,

17 Table 7: Core activity as a Percentage of calls Core LUCS Activity 2009/10 % of Total Calls Primary Care Emergency Centre visits 2013/14 % of Total Calls 82,807 39% 69,845 34% Home Visits 20,739 10% 20,215 10% Doctor Telephone Advice 32,801 15% 24,645 12% Total LUCS contacts 136, ,705 Calls transferred for District Nurse 8,899 4% 13,058 6% Action NHS 24 Nurse advice (incl A&E, 67,688 31% 66,806 32% SAS outcomes) Total Lothian Calls (NHS24 & LUCS) 215, % 207, % Of these total the % mix (Table 7) shows - Attendance at a PCEC as a % of total calls has decreased from 39-34%. - Home visits as a percentage of total calls has remained relatively stable. - There has been a small percentage decrease in doctor advice calls as a percentage of the total calls. - NHS24 completes the call percentage has increased from 31% to 32% meaning 68% of all NHS Lothian calls are currently dealt with by LUCS (Table 8 ). Table 8 Outcome of NHS24 Calls 2009/10 % of total 2013/14 % of total not transferred to LUCS Lothian Calls Lothian Calls NHS24 Nurse advice only 45,963 21% 47,371 23% NHS24 outcome to A&E 10,597 5% 10,597 5% NHS24 outcome to SAS 11,128 5% 8,838 4% Total 67,688 31% 66,806 32% 17

18 7.2 Reviewing Additional LUCS Activity Table 9 sets out service development activity which has evolved since LUCS started. For some this is seen as non core activity but that would certainly appear to be an outdated view. It does however paint an interesting snapshot of the way the service and mix of activity is changing. Each of these is reviewed in more detail. Table 9 Additional activity Additional LUCS Activity 2009/ / / / /14 Untriaged Calls diverted 28,590 22,840 20,329 19,070 15,598 from NHS24 Patients seen on referral from A&E (RIE & St John s 4,172 5,677 4,683 4,062 3,284 Professional to 7,964 7,312 8,196 9,166 9,686 Professional referrals Planned Review Service Self Referral Untriaged calls Untriaged calls diverted from NHS24 shows a decrease of 45%. This trend is welcomed and given current pressures in all OOH s services. There may however be perceived benefits to the service as these calls offer local control but have decreased as staffing problems increase. Action 4. The national group should review with NHS24 the volume of calls which need to be triaged locally and continue to reduce this activity flow, except during periods of peak activity A&E Referrals Patients seen as referred from A&E at RIE or St. John s has also decreased by 27%, 91% of these referrals are discharged home by LUCS (2013/14). Action 5. Protocols exist to manage this flow and it should be kept under review by the relevant Clinical Directors (A&E + LUCS) 18

19 7.2.3 Profession to Profession (P2P) Referrals This is a direct phone line to LUCS hub at WGH and on to Doctor advice. Its activity has grown by 5% in the last year and 32% from 2010/11. While classed as additional activity it is replicated in other OOH s services and is clearly important to a range of health professionals. The percentage usage is set out in Table 10. TABLE /2014 %of total Change since 2010/11 Laboratories % Up 69% District Nurses % Up 20% Pharmacists % Up 27% SAS 913 9% Up 15% The scale of the increase in laboratories phoning LUCS doctors with abnormal (mainly blood) results needs further investigation. Key to this would be:- - assuring the right protocols for escalation are in place based on assessed significant patient safety in OOH s; - assuring systems maximise calls to in hours GPs; - assuring in hours GPs are requesting or identifying those blood test results which they are particularly concerned and would wish to see escalated and actioned and that OOH s are informed and clear about what action is expected. These factors are important as GPs in OOH are frequently phoned with abnormal results to act on in the absence of other forms of detailed patient information. Consideration should also be given to look at models of laboratory nurses in other countries to see if there is a potential service development model. The following actions are recommended:- Actions 6. The Service Manager and Clinical Director in conjunction with the Laboratories should review all protocols for escalation to an OOH s doctor and ensure these are for urgent patient safety concerns only. This should include clinical assessment at the lab before calls to LUCS. 19

20 7. The Clinical Nurse Manager should with the CHP Chief Nurses, review the nature of calls made by District Nurses to OOH s Doctors and act on the findings. It is likely that this growth is reflective of demographic changes, frailty and co-morbidities of elderly people. 8. The calls from Pharmacists should also be reviewed and it is suggested a 2 week audit for all calls to P2P line would be sufficient to understand the call reason and disposition. 9. The calls from SAS also need to be understood and consideration (based on the audit) given to see if this is a service chargeable to SAS. 10. Protocols should be developed for planned service reviews as this is likely to be an area of increased activity Self Referrals Self referrals are people who attend one of the PCEC sites without firstly calling NHS24. They are therefore not triaged or assessed for the urgency of their health care need. LUCS has protocols for deciding with walk-in patients or those who attend without an appointment how quickly they will be seen. Two types of appointment are offered next available following assessment and by protocol where the wait may be up to 4 hours, and early where a speedier response is needed and a clinician may be asked to advise. Two other key categories of patients who self refer are people not registered with a GP and visitors to the area. The reasons why people turn up at the PCEC sites is poorly understood from the patients perspective. There are also geographic variations with the highest number of walkins at W.G.H and Mid Lothian Community Hospital. A summary of the trends in self referrals is set out in Tables 12a and 12b. Table 11 Walk-in trends 20

21 The number of walkin at each site overall have remained fairly static over the period with the exception of WGH which has peaks during August as a result of the Festival Centre. The number of walkins at the WGH are a lot higher than at the other sites which is may be as a result of the perceived open door at the WGH as it is located beside the Minor Injuries Unit reception. However, the overall figures mask a trend in increasing number of walkins at the WGH on a Saturday & Sunday. A similar but a lot smaller trend is also seen at the MCH on a Saturday & Sunday. This Saturday & Sunday trend appears in 2014 after a drop in walkins during 2013 at MCH, while the MCH Weekday trend is in the opposite. TABLE 12a TABLE 12b There may be a historical legacy at WGH of having had an A&E, being able to do X-rays and co-location with Minor Injuries Unit. Conversely in Midlothian Community Hospital it may be there is a new public awareness of new services:- a type of minor injuries, minor illness 21

22 service, neither of which have been put in place by the CHP. Easy parking and location at MCH may also encourage opportunistic use. It may also be related to the relative deprivation of the local areas around each of these sites. For LUCS people who walk in directly pose a clinical risk (as they can sometimes be very ill) and a service risk as they may not appreciate being redirected or asked to wait. On a more positive note the overall number is reducing but trends of increasing activity at weekends are emerging. The potential move of PCEC from it s current location in WGH may help manage an open door perception but it will need monitored and may need further protocols between MIU, ARU Ambulatory Care and PC out of hours. Actions 11. A public survey of those attending WGH and MCH should be undertaken in partnership with the CHP and Public Partnership Foras, to understand why people attend. 12. LUCS should review the Policy and Procedure for self referrals written in 2010 and consider asking people to phone NHS24 instead of a next available appointment. 13. The Communication Team should be involved in the findings of the public surveys and address routing issues which arise. They should consider making the Right Care, Right Time, Right Place (2011) leaflet more locally relevant, at the CHP level addressing and reinforcing the local access routes in Out of Hours Care Services Protected Learning Time (PLT) Since LUCS has been providing in hours cover for PLT from to X 6 per year. Each CHP is cross charged 25% of the cost i.e. 12,200 There are historic staffing levels and 4 sites open, charging is an equal percentage for each CHP with no relationship for activity to cost. There is no SLA in place. Actions 14. There should be a review of PLT activity to ensure cost effective service provision. Consideration should be given to reducing number of centres open and or staffing model related to West Lothian and rest of Lothian cover. 15. If staffing and cost pressures on LUCS continue then consideration must be given to handing this back to Practices or negotiate an alternative model. 22

23 7.2.6 Services for NHS Borders LUCS has an informal agreement to cover the West Linton Practice in NHS Borders. A cross charge is in place with an uplift annually of 2.5%. The charge this year was 32, However on 2012/13 head of population costs of this income should be higher. Action 16. An SLA should be put in place between NHS Lothian and NHS Borders, which agrees the costing model and uplift agreements for the PC OOH s cover of West Linton Practice population. 23

24 8. GP and ENP Recruitment and Retention 8.1 Current Issues LUCS is experiencing significant difficulties in recruiting and retaining GP s to fill its OOH s shifts. No data for % of unfilled hours or retention figures were available. However, although there is no regular reporting of unfilled shifts the following data was made available for the review:- Unfilled shifts in 2014 (note hours and shifts vary considerably in length). Easter 9.8%, summer 4.5% of which June 4%, July 6.7% and August 3.2%. LUCS is not alone and of the 3 other Boards contacted 2 are escalating concerns to executive level meetings. The pay uplift of 15.2% awarded in 2013 to GP s in LUCS has had no discernable positive impact on recruitment and retention. It has however had an impact on other boards where anecdotally some doctors have moved to ad hoc shifts in NHS Lothian. There is currently no formal reporting of unmet shifts, nor an agreed escalation process for managing the shortfall. The staffing pressures have meant centres have been closed to manage patient safety. Roodlands has closed twice due to staff shortages and MCH closed on Easter Sunday for the same reason. These pressures continue with regular threats to service delivery due to unfilled shifts. Although pressures are exceptionally problematic historically during summer school holidays, Easter, Christmas and 4 day Public Holidays, it is now becoming a year long problem. Some other Boards use locum doctors from agencies. NHS Lothian and some other larger boards do not. 8.2 Salaried and ad hoc GPs NHS Lothian has a mix of salaried GP s and ad hoc doctors. Ad hoc doctors are GP s on a NHS Board list, mainly NHS Lothian, who are paid a fee for hours worked. They are not NHS Lothian employees and attract no leave entitlements. NHS Lanarkshire was audited by HMRC and changes to this arrangement are required to ensure legal payments of National Insurance and Income Tax. Based on the model developed and agreed in Partnership (with BMA in NHS Lanarkshire) NHS Lothian is moving to implement the required changes. This will mean within the next 3 months > 220 ad hoc doctors will be paid via NHS Lothian payroll with National Insurance and Income Tax being taken off at source. NHS Lothian has had variable mix of ad hoc to salaried GP s in a range of 40% to 60%. The current level is around 50% of hours covered. Not all Boards have salaried GP s and NHS Greater Glasgow and Clyde run the service predominantly on ad hoc GP s. 24

25 While it is attractive to suggest increasing the percentage of salaried GP s as a solution to this, formalised contracts with shifts all within the OOH are largely unattractive. There is currently 240 ad hoc GP s supplying WTE and 58 salaried GP s supplying WTE. More salaried GPs have resulted in a reduction of the WTE contribution in recent years. 8.3 Sickness absence Medical and nursing staff sickness is having a significant impact on rota management and attracting other doctors to cover shifts. In 2013/14 the financial impacts were - 96,000 Medical cover put in place to cover unfilled, paramedic and nursin g shifts ,000 increase in salaried and ad hoc pay for medical cove r - 43,000 medical cover for long term salaried GP sickness - 99,000 medical cover for unfilled vacancies TABLE 13 Sickness absence Sickness Absence 2013/2014 By job Doctors 2.38% 11 ENP s 6.09% 9 Drivers 2.4% 8 Receptionists 4.47% 11 HUB 3.71% 2 Management 3.74% 3 District Nurses 4.99% 8 No. over 4% The Table 13 represents the sickness absence by job. There are clearly actions needed to manage this especially in the nursing groups. Of the headcount of nearly 20% of the staff have sickness higher than 4%. This must be addressed in the Service Improvement Plan. The doctor and dentist average sickness absence rate in NHS Lothian was 0.97% in-2013/14 and 2.38% in LUCS. Action 17. The Service Improvement Plan includes actions to address sickness absence management. 25

26 8.4 Shift Patterns and Rota Management Rotas are managed by an IT system called Rotamaster which is not used elsewhere in NHS Lothian but is used in the majority of OOHs nationally. The Service Improvement Plan makes recommendations for a review of systems and process to be undertaken by the Staff Bank Manager to explore efficiencies. It is also likely NHS Lothian will implement a rota management system in the next months and LUCS should be integrated to a pan Lothian system subject to the other systems interdependencies. Web enabled access, phone and text are all used in a targeted and generic way to try and fill shifts. Currently Rotamaster is an effective IT system. Shifts are also managed by a range of consortia the largest of which is Midlothian. These are groups of GP s who come together to commit to covering certain shifts. In Midlothian this is all the shifts at MCH and shifts are rarely handed back to LUCS to fill. In total there are 4 consortia filling shifts. Day shift lengths vary from around 4 hours to hours per night. This flexibility is needed to meet peaks in activity and encourage doctors to work in the service. 8.5 W hat doctors said about working in LUCS - Focus on giving high quality person centred care - Sites varied, different practices in some, very different workload in some. - In general shifts much busier, patient needs more complex care. - For many GP s there is no financial incentive to pay more as tax and pension negatively impacted as pay is increased - Doctors working as GP s in the day job are working flat out - demands have increased markedly within the last 2-5 years. - Shift patterns, length and start times are good for some and difficult for others. - Doctors recognise the different expertise of doctors good at telephone triage or expert at managing risk - Doctors needing OOH s experience. - Doctors needing to recognise and develop the contribution OOH practitioners make to their patient population care need s - Productivity differences between Doctors and ENP s Team working and mix of clinical colleagues positive When asked how more doctors could be attracted to work in OOH s services some of the themes which emerged were:- There is a lack of local and community ownership the co-ops worked for some and unclear if there was an appetite to go back. 26

27 There is a national shortage of GP s at the route of the problem. The day job has changed so much more GP s have no enthusiasm or energy to do more in OOH s. The day job doesn t finish until or later. Attracting partners to GP Practices is also difficult. Finding locums is very difficult and shifts are often covered internally in practice s In seeking to find potential actions to address some of these issues a review of the national workforce data was undertaken to ascertain NHS Lothian position compared to other boards. 8.6 Primary Care Workforce Survey, Sept (Ref5) The summary key findings from the ISD publication (noting data may not be complete as 68% of Practices responded). To the year ending 01/01/13 - NHS Lothian had 271 GP s contributing to OOH s. - The percentage split between salaried and ad hoc was 60-40%. - NHS Lothian, Tayside and Dumfries and Galloway had only between 10-20% of GPs in post contributing to OOH s while Borders had the lowest at 10%. All other boards had higher % of GPs contri buting. - Female doctors under 35 were the largest group (head count) contributing to OOH s. - GP s aged under 35 input average 3.5 hours per week in Scotland, 2.5 hours in NHS Lothian. - Older male doctors (over 55 years) in Scotland contributed 19% of the total hours and 16.3% in NHS Lothian. - Doctors aged between contribute over 65% of the total hours, but the female contribution is highest between the ages of % of GP retainers (often but not always female GP s returning to work on a part-time basis after an extended period of leave) had a session commitment of 1-4 hours per week. - NHS Lothian has 17.1% of GP s in Practice (N=89) doing 1-4 sessions per week, in Scotland this is 13. 4%. Summary This is a complex picture with National and local dimensions. There are also a number of issues that may negatively impact the current arrangements:- - re-negotiation of GP contract in Scotland. - shortages of GP s and nursing vacancy rates. - implementing HMRC changes for ad hoc GP s may disenfranchise more GP s from O OH s. 27

28 - threats of permanent closure of East or Midlothian sites will anger local GP s and reduce their likelihood to contribute to OOH s care. - different pay rates, terms and conditions for salaried GP s across Scot land. - perception of a fixed service model in NHS24 with a budget of approximately 73m (2013/14) and a further 74m in Scotland GP OOH s (2012/13); and questions of effectiveness. - the continued access demands on in hours service and patient routing to other services e.g. LUCS, walk-ins. In all the interviews and discussions there were very few positive concrete examples of how this picture could change for the better. 8.7 Addressing the Issues The following are a range of potential actions which may help NHS Lothian address some of the issues it can control. Actions 18. Differentiate NHS Lothian:- develop attractive Terms and Conditions for salaried GPs. develop attractive training and education opportunities. Packages for wider medical workforce to learn OOH s care e.g. in paediatrics and mental health. Offer joint posts for individuals within specific career paths potentially in unscheduled care. Create training for GP s and ENPs in telephone triage and doctor advice calls. Create links with medical schools for research opportunities and specialised module development e.g. risk taking in GP OOH s care or an Academic Primary Care Consortia with a Research infrastructure. Improve the culture and perception of the service and increase the clinical management. Support the above by undertaking further fact finding with GPs in Lothian about what would attract them to contribute, however limitedly, to OOH s care 19. Target Younger female doctors and GP retainers who currently work under 4 sessions a week. GP ST3/registrars with attractive and individualised fellowships similar or aligned to A&E fellows. Selling the uniqueness/importance of the professional development opportunities GP OOH care o ffers. Identify at GP ST3 stage those individuals who, with training, could offer sustainability to the service. 28

29 GP s who have never worked in OOH and offer taster/ refresher sessions. Develop a targeted recruitment plan assisted by the Head of Recruitment NHS Lothi an. 20. Consider These are some examples being considered under OOH s core delivery to address potential problems with GP recruitment. Using medical locums in a targete d way. Training ENPs or develop ANP role for home visits. Introducing stand-by shifts or on call for clinica l staff. Have doctors working from home with appropriate IT and telephone and privacy arrangements. Band 5 nurses to undertake diagnostic/arrange referrals and support doctor in peak times. Community paramedic role in home visits. 8.8 National GP Training GP ST1 and 3 do part of their training in LUCS. Not all services in Scotland provide this opportunity. Trainers need:- a) Training to undertake this rol e. b) Extra time while on duty to access/advise/support/supervise. c) Paid an additional element. Action 21. Currently LUCS GP s provide this support on a good will basis with no additional funding or recognition. This needs rectified and should be addressed in two ways:- - By the development of Terms and Conditions for salaried GP s. - By the Executive Medical Director investigating if monies are transferred to NHS Lothian for this post graduate national programme and take appropriate action to fund. 8.9 Addressing ENP Issues The review found significant professional and contractual concerns in this staff group. They were critical with historic and current management and partnership actions in respect of a range of issues, most noticeably A f C banding. The outcome of the final review held in May /June 2014 is still not known (July 2014).Some expressed a strong belief that they were working as Advanced Nurse Practitioners and were upset that the service continued to undervalue their role. 29

30 The appointment of a Clinical Nurse Manager who is also Lead for Advanced Nurse Practice and non medical prescribing is very welcome even for only 2 days per week. It is also clear that there were a range of professional issues which needed urgently addressed. It was also observed that especially at East and Mid Lothian sites there were anecdotal reports of high levels of patients for whom minor injuries were the presenting cause but that ADASTRA had no data code for these presentations. This adds to the need for clarity in the clinical model and the training and skills needed for the role. The Service Improvement Plan sets out a range of actions needed to address the following:- 1. Professional isol ation 2. Need to underpin professional practice with clinical protocols, assessed clinical competencies, clinical supervision and effective Personal Development Plans 3. Address workforce issues e.g. succession planning, skill mix, and educational preparation standards 4. Align the nursing contribution to service needs and strengthen clinical leadership and management 9. Improving Safety and Effectiveness 9.1 Clinical models Mid and East Lothian Managing clinical risk is an important consideration of East and Midlothian sites as currently ENP s can be left relatively isolated of medical or hospital cover. They are also geographically isolated. The staffing model on both sites is one doctor, driver, receptionist and 2 ENP s. Actions 22. The analysis of the activity at the Roodlands and MCH sites would suggest the following changes to the hours of service and clinical staffing; both Roodlands and MCH should close at instead of i.e. Monday to Friday opening from to hours. Both Roodlands and MCH should close at on Saturday, Sunday and Public Holidays i.e. open from to hours. One car, driver and doctor should cover the 2 geographic areas with support from car based at RIE when necessary. Each base should have a receptionist and doctor as core staffing Consider substituting a band 5 registered nurse for the receptionist at each site to support, record, manage, assess patients prior to doctor consultation. 30

31 9.1.1 CLINICAL MODELS - S T JOHN S, WGH AND RIE SITES The activity levels (excluding visits) at the other 3 sites are significant and comparable. Based on 2013/14 data:- St. John s Mon-Fri needs appointments for 3-5 patients WGH Mon-Fri needs appointments for 4 patients to RIE Mon-Fri needs appointments for 4-5 patients to Sat-Sun needs appointments for 8 patients to Sat-Sun needs appointments for 8-10 patients to Sat-Sun needs appointments for 8-10 patients to Actions 23. The Clinical Director and Service Manager will review the staffing for the 3 sites based on 2013/14 activity analysis which shows only very small variation to previous years activity and is reasonably stable in days of week and weekend site attendance yet there are staffing differences. 24. There should be an increase in the available appointments by health profession to 4 appointment slots for GP s (an increase from 3) and 3 appointment slots for ENPs (an increase from 2)and consideration of trialling of appointments for doctor advice calls. 25. ENPs should be concentrated at the above 3 sites and the CNM should review competencies, team working and potential skill mix. 26. Consider introducing: on call or Saturday arrangements for peaks in activity and clinical advising Doctors based in their own home with supporting technology/telephone to provide triage/doctor advice supplementary provision. Clinical Models - Summary Two clinical models are emerging driven by safety and activity:- M odel 1 East and Midlothian (Roodlands & MCH) - GP delivered service (No ENPs) and receptionist. - One car and driver for geographic area in the even ing i.e. East and Mid Lothian Support from RIE car when needed - Opening hours reduced Mon-Fri to 22.00/ Sat-Sun to Increased appointment numbers for Doctors from 3 to 4 per hou r - CHP s to agree what if any Minor Injuries service. - Locally relevant public information re access to a range of OOH care. 31

32 - Doctor advice calls distributed to the least busy base at the time, not necessarily the most geographically relevan t Model 2 RIE, ST Johns and WGH - Multidisciplinary teams with ENPs working to competency. Increased appointment numbers for Doctors as above a nd ENPs increase from 2 to 3 appointments per hour - Sites to be maintained if staffing shortages and escalation procedure agreed - Majority of cars dispatched from two of the 3 sites St Johns and RIE as currently happens overnight after midnight. - Doctor advice calls distributed to the least busy base at the time, not necessarily the most geographically relevan t 9.2 OOHs Services for Children and Young People There is a not unsurprising number of children attending an OOH s site every month (LUCS very rarely provides a home visit). 22% of LUCS contacts are for children and young people from 0 14 years. NHS24 refers approximately 75% of all children to OOHs services for a face to face consultation. Average numbers October 2013 May 2014 by site MCH RGH RIE STJ WGH AVERAGE Age Age A focus of the review was to ensure safety of patient care and that there was a supporting competency and training framework especially for children s care. Based on the investigative findings where GPs and ENPs see children who are not triaged and have undifferentiated presentations and noting the difficulty in telephone triage of children and absence of robust clinical protocols it is recommended that the service:- Actions 27. Appoint a named Clinical Lead Professional Adviser(s) in the care of children and young people; 28. The Clinical Nurse Manager and Chief Nurse (East and Midlothian) provide evidence of ENP competency to the Executive Nurse Director of the current level of expertise and professional updates completed in the last 3 years to assure that competency in the care of sick children, especially those under 5 years; 32