Integrated Care Partnership

Transcription

1 Appendix 1 Integrated Care Partnership Full Business Case Development of a New Urgent Care Service for Salford Francine Thorpe Project Lead, SCH Nadine Armitage Project Lead, SRFT

2 Development of a New urgent Care Service for Salford Table of Contents Index No. Page No. LIST OF FIGURES 4 Updates from Draft to Final Version 5 1. SUMMARY 1.1 Purpose 1.2 Model of Care 1.3 Benefits and Risks 1.4 Summary 2. STRATEGIC CONTEXT 2.1 Problems/Opportunity 2.2 Current Service Position 2.3 Summary 3. PROJECT DESCRIPTION 3.1 Purpose 3.2 Project Description 3.3 Objectives 3.4 Scope 3.5 Risks 3.6 Anticipated Outcomes 3.7 Stakeholders 3.8 Public Engagement 3.9 Strategic Alignment 4. MODEL DEVELOPMENT 4.1 Purpose 4.2 Defining the Urgent Care Centre and Trauma & Resuscitation Centre 4.3 Design of the UCC & RTC 4.4 Proposed organisational model of UCC 4.5 Activity Modelling 4.6 Equality Impact Assessment 4.7 Workforce Modelling 5. FINANCIAL APPRAISAL 5.1 Finance Baseline 5.2 Full Cost Analysis 5.3 Implementation Costs 5.4 Commissioner Finance 6. RECOMMENDED OPTION 6.1 Proposal 6.2 Implications of the Proposal 6.3 IM&T Implications 6.4 Economic Case 6.5 Value for Money 6.6 Project Risk Assessment 6.7 Financial Risk 7. PROJECT MANAGEMENT ARRANGEMENT 7.1 Purpose 7.2 Leadership 7.3 Project Plan Page of 127

3 Development of a New urgent Care Service for Salford 7.4 Implementation Strategy 7.5 Monitoring 7.6 Reporting 7.7 Benefit realisation plan 7.8 Post Project Evaluation 7.9 Communication Strategy 7.10 Contingencies 8. CONCLUSIONS AND RECOMMENDATION 8.1 Description 8.2 Recommendations 8.3 Project Responsibility 8.4 Project Accountability 8.5 Implementation Plan 8.6 Business Case Approval and sign off 9. SERVICE CHANGE FLOW MODEL APPENDICES 10.1 A&E Presenting Complaints and Patient Outcomes 10.2 A&E Activity Levels on an Hourly and Daily Basis 10.3 A&E Attendance Trends 10.4 Admission Rates from A&E Departments in the North West 10.5 Entry Points to Intermediate Care and Community Services 10.6 Stakeholder Analysis 10.7 PDSA Cycles 10.8 Full Options Appraisal for Organisational Model 10.9 Walk In Centre Patient Survey Outcome of Scenario Modelling Activity Model for Best Case Scenario Activity By Day and Hour UCC and TRC Staff Rotas Full Cost Analysis for Phase 1 and Phase Equality Impact Assessment Public Engagement Responses and Actions Page of 127

4 Development of a New urgent Care Service for Salford Figure No. LIST OF FIGURES Page No Proposed restructure of urgent care services in Salford Unscheduled Care Demand in Salford Urgent Care Services Activity Data for 2009/10 Urgent Care Activity and Costs for 2009/10 Patient Flow in Existing Urgent Care Mode Project Scope Development of Urgent Care Centre and Trauma and Resuscitation Centre The Challenge Development of Urgent Care Model Proposed Draft Model for UCC and R&TC Activity Data for 2009/10 at Urgent Care Services in Salford Revised Activity Data for 2009/10 at Urgent Care Services in Salford Scenario Models for Best, Base and Worst Case Daily Averages for Best, Base and Worst Case Best Case Attendance Distribution and Reductions Base Case Attendance Distribution and Reductions Patient Arrivals at the UCC and TRC Staff and Patient Numbers in UCC and TRC GPOOH Staffing Numbers Summary of Work Force Options Phase 1: WTE for Existing and Proposed Model (Base Case staff levels) Phase 2: WTE for Existing and Proposed Model (Stretch Case staff levels) Provider Forecast Baseline Costs for 10/11 Summary of Cost Analysis for Phase 1 and 2 NHS Salford Contract Forecast & Plan Contracting Scenario 1- Impact on Commissioners Contracting Scenario 2- Impact on Commissioners NHS Salford Affordability Proposed Urgent Care Model Patient Flows in the Proposed Mode Page of 127

5 Development of a New urgent Care Service for Salford Updates from DRAFT to Final Version This is the final version of the Developing an Urgent Care Service in Salford Business Case. Further work is needed to refine the UCC and TRC using the PDSA approach that has been adopted for an adaptive approach to the design of the urgent care system. Since the draft business case was submitted in November 2010 the following amendments have been made to the business case: o Work Force Workshop held to challenge work force plan modifications made o Costs revised based upon work force session and includes Phase 1 and Phase 2 costs o Amended to consider Equality Impact Assessment and Investment Review Panel comments o Implementation plan proposed o Communication Messages defined o Benefits Realisation outlined o PDSA sessions scheduled to progress with the design of the UCC and TRC Page of 127

6 Development of a New urgent Care Service for Salford 1 Executive Summary 1.1 Purpose In May 2010, Members of the Integrated Care Partnership approved in principle a project proposal outlining the development of an Urgent Care Centre on the SRFT site. The original proposal outlined the integration of a range of community unscheduled care facilities into the Urgent Care Centre and suggested that this new facility would deflect activity from the current A&E Department. In supporting this proposal to be developed into a full business case the Partnership requested the following to be included as part of this work: The business case to include the development of a Trauma and Resuscitation Centre on the SRFT site The remit of the proposed Urgent Care Centre to be expanded to include all patients currently attending A&E that would not require trauma and resuscitation facilities. The scope of the business case to include the PANDA unit (previously considered out of scope) The business case therefore focuses on the development of existing services into adjacent facilities on the SRFT site comprising an Urgent Care Centre (UCC) and a Trauma and Resuscitation Centre (TRC) collectively described as a new Urgent Care Service for Salford. There is a high level of clinical consensus across primary, community and secondary care on the outlined proposals. The objectives of this proposal are summarised as: 1. Reduce the cost of Unscheduled Care across Salford in a two stage approach 2. Reduce urgent care attendances in a two stage approach 3. Prevent avoidable admissions 4. Provide a cohesive, seamless model of unscheduled care delivering a consistent service that minimises clinical risk Savings and activity reductions will be achieved in two phases as follows: Phase Savings ( ) Reduction in Activity Phase 1 - Closure of Walk in Centres 1.05m 34,795 Phase 2 Reduction in Attendances 0.62m 23,235 Total (Phase 1 & 2) 1.67m 58,030 In order to deliver savings this proposal seeks to ensure that patients receive the right care, at the right place, at the right time by the right health care professional. To achieve this vision the following issues need to be addressed: Page of 127

7 Development of a New urgent Care Service for Salford Ensure patients who do not have urgent secondary care needs are managed in other settings, this includes promotion of self care and ensuring patients with urgent primary care needs are managed in primary care Minimise duplicated urgent care services Reduce access points to urgent care services Consistent urgent care messages across the Salford Health Economy Collaborative working across primary and secondary care The project team is clear that A&E attendances will only reduce over time if inappropriate attendances are re-directed to primary care, community pharmacy and self care is promoted 1.2 Model of Care The Trauma & Resuscitation Centre (TRC) will provide specialist urgent care services for patients with a high level of intervention and need, for example, patients requiring resuscitation, cardiac arrest and unconscious patients. There is broad consensus on the cohort of patient appropriate for the TRC. Salford Integrated Care Programme Board has supported the proposal that elements of community unscheduled care will be integrated into an Urgent Care Centre (UCC) as outlined in figure 1. In addition, other community based services that offer urgent care interventions are to have access points integrated and develop clear pathways between their services and the UCC. This will streamline care ensuring that the patient accesses the right health professional to address their needs in the most effective and efficient way. Figure 1 Proposed restructure of urgent care services in Salford Canalside WIC Pendleton WIC Little Hulton WIC Urgent Care Centre A&E Including PANDA Trauma and Resus Centre GP OoH PANDA Key: Current Provision: BLUE Future Provision: RED An activity model for the UCC and TRC is included that uses a number of assumptions in defining how existing urgent care activity will be re-distributed in the new service model. In understanding the activity model there are several terms that require definition in particular: Page of 127

8 Development of a New urgent Care Service for Salford Streaming - simple protocols are used for a rapid decision to channel a patient to a defined urgent care stream. Deflection are patients that currently attend secondary care with a minor selflimiting illness or primary care need that require a resource to redirect them to primary care The proposal should be considered in two distinct phases: Phase 1: UCC and TRC opens in Autumn 2011 staffed to manage the assumed activity levels this includes patients that will need to be deflected as their needs would be better managed in alternative services. For phase 1 footfall will be high, following relocation of the Walk In Centres, and resources will need to be focused on streaming patients, promoting self care and deflecting patients to primary care and pharmacy. Phase 2: Whilst deflection rates will increase during phase 1, following walk in centre closures, work will be on going to embed thresholds for identifying primary care patients and ensure consistent messages are given to patients. Consistently re-directing patients to the most appropriate services is anticipated to affect patient behaviour leading to fewer attendances at the UCC and TRC. A step change in UCC and TRC attendances is req8uired to further modify the work force plans as demand reduces. To enable further costs to be released the reduction in attendances in phase 2 must materialise. 1.3 Benefits and Risks The benefits of this proposal are: The financial assessment indicates a range between 1.05m and 1.67m Improved quality of care for patients with urgent care needs Reduction in overall demand for urgent care Reduction in unnecessary non-elective admissions The risks of this proposal are: Not achieving the activity reductions and continued rise in demand and costs Delay in implementation impacting upon ability to achieve savings Inability to integrate IM&T systems to support the proposal Changes in national or regional policy impacting negatively on the proposal The risks have been considered and mitigating actions are outlined within the proposal. 1.4 Summary This business case fully underpins the objectives outlined by Salford s Integrated Care Partnership Board. It proposes a fully integrated model of urgent care within the city that reduces costs whilst maintaining the quality of service provision. It has been supported by clinical leaders and seeks to ensure that patients receive the right care in the right place, when required. Page of 127

9 Development of a New urgent Care Service for Salford 2 Strategic Context 2.1 Problem/Opportunity Salford has recently embarked upon a New Approach to Managing and Delivering Unscheduled Care and Chronic Disease Management. This is to be achieved though local partnership arrangements to improve the quality of healthcare against the context of constrained public spending. To this end a Joint Programme Board has been established to drive forward the changes required to meet this challenging agenda. A Clinical Re-design Workshop was held in March 2010 to agree a range of projects that will achieve the necessary efficiency savings as well as supporting service re-design. These projects were reviewed at a subsequent workshop in May 2010 and approved for development into full business cases. This business case has been developed as part of this programme of work. The scale of the financial savings required is unprecedented when in recent years despite increased spending on a range of additional unscheduled care services demand has continued to rise. The target cost reduction was initially 6.4 million but was later revised to 7.2 million due to the zero length of stay project being included in the target. The projects that contribute to this target are as follows: Directly managed by the programme: - UCC, Resus and Trauma - Optimising Services and Pathways (Phase 1 &2) - GP Access Not managed by the programme: - Zero length of stay - Assertive outreach - A&E assessment areas Precise details of the scope will be determined once the risk sharing contract is finalised. Whilst savings have not been apportioned to each of the 3 projects there is an expectation that the urgent care programme overall will deliver 7.2m in savings. A summary paper will identify the overall level of savings and implementation costs associated with the 3 business cases National Context In 2008 Lord Darzi produced High Quality Care for All, NHS next stage review. Themes from this review are that the NHS is to provide safe and effective care for patients closer to home with timely access to appropriate services and diagnostics. To support this there should be innovative work to prevent ill health, provide personal care and give more control to the patients. The report outlines the challenges to the NHS in the 21 st Century focusing on the six main areas: Page of 127

10 Development of a New urgent Care Service for Salford Rising expectation Demand driven by demographics The continuing development of information Advances in treatment The changing nature of disease Changing expectation of the health work place When this report was written the NHS budget was close to the European Union average with 9% of the GDP spent on health. With the economic down turn the NHS must use the resources available efficiently, effectively and economically in the face of: Increasing expectations, An ageing population, A rise in lifestyle disease, and The cost of new treatments. Over recent years there has been significant attention by the Government to urgent and unscheduled care services; that include the introduction of a range of targets and service development in an attempt to improve access and performance. Despite the measures that have been implemented, or possibly as a direct result of them there continues to be an annual increase in the attendances at A&E, Walk-in Centres (WIC s), and Urgent Care Centres with increasing pressure on the 999 ambulance service, the GP OOH services and NHS Direct on top of the urgent cases seen by GP s and Practice nurses. There is a widely held belief that WIC s in particular have not had any impact upon A&E attendances they have merely provided an alternative source of access for patients with minor illness that could be managed by primary care or selfmanagement. National studies confirm this view. 1 In addition there is also a perception that a significant proportion of patients that attend A&E departments could be managed within primary care or in a community setting. Evidence to support this view is presented in a recent report from the Primary Care Foundation which found in a literature review that the proportion of patients attending emergency departments that could be classified as primary care cases to be between 10% and 30%. Despite this being the case and a range of initiatives being introduced across England where Primary Care Clinicians have been based within or alongside emergency departments the report concluded that there was a paucity of evidence on which to base policy and local system design 2 The recent NHS White Paper Equity and Excellence: Liberating the NHS 3 in recognizing the financial challenges faced by the NHS reinforced the role that improvements in Quality Innovation Productivity and Prevention (QIPP) will play in identifying efficiencies whilst improving quality. To this end twelve national work streams have been established to deliver this quality and productivity challenge. One of these work streams focuses on Urgent Care and aims to maximise the 1 National Evaluation of NHS Walk In Centres; Salisbury et al; University of Bristol, July Primary Care and Emergency Departments; Report for the Primary Care Foundation, David Carson, Henry Clay, Rick Stern; March Equity and Excellence: Liberating the NHS; DH July 2010 Page of 127

11 Development of a New urgent Care Service for Salford number of instances when the right care is given by the right person at the right place and right time for patients. The emphasis is on designing simple systems that that guide patients to the most appropriate place for them to receive the support they require. It is evident that current systems do not deliver this requirement therefore changes are required to address these issues Local Context Over the next Comprehensive Spending Review period it is anticipated that in real terms the NHS budget will contract. Urgent care is an area of significant expenditure within the Salford health economy, 45% of all acute core contract expenditure is allocated to urgent care 4. In recognition of the anticipated economic position key partners within Salford have agreed to make savings of 6.4m across the urgent care pathway by 2013/ Local Population Salford s population in 2008 was 221,300 and included a growing number of young people, the population increased by 1% from There is also a changing age structure within the city s population with the number of under 5 s projected to increase by 10% over the next decade. The projected changes in the population of older people living in Salford, although increasing are lower that the proportion for England from However linked to the high levels of deprivation, Salford s older citizens experience higher rates of long term conditions, disability and chronic illness 5. Salford s health profile is generally worse than the England average. It is a city affected by inequality with the rest of the country and other cities with high levels of deprivation, unemployment, teenage pregnancy; crime; smoking; alcohol and drug abuse. 6 The main causes of excess deaths in Salford are 7 : Coronary Heart Disease Respiratory Disease Lung Cancer Chronic Liver Disease The health profile and the inequalities within Salford contribute to a high level of A&E attendances and non-elective admissions. National productivity indicators issued by the NHS Institute for Innovation and Improvement, continue to indicate that, on a capitation basis, Salford experiences significantly more emergency hospital admissions than the England average for a selection of 19 common conditions. In Quarter /09, this resulted in the PCT being ranked 131 out of 152 PCTs nationally, with an indicator score of , 4 NHS Salford A&E Attendance Pack NHS Salford Trust Board Paper Joint Strategic Needs Assessment; Acting Director of Public Health, May NHS Salford Strategic Plan ; 7 NHS Salford Commissioning Board Paper Life Expectancy & All Age All Cause Mortality in Salford: Dr. Gunjit Bandesha, July 2010 Page of 127

12 Development of a New urgent Care Service for Salford which means that the rate of emergency admissions is 44% higher than expected. If the PCT were to achieve a level of performance in line with the quartile of trusts that had the best level of performance, this would result in a productivity saving of 6.5m. The reasons for these inefficiencies are multi factorial and could relate to a number of factors: Variable quality of chronic disease management Perverse incentives of the tariff system Inefficiencies in handover arrangements Lack of adherence to care pathways Confusion within care pathways Flow inefficiencies within care pathways Variable ability to manage risk within unscheduled care Poor sharing of clinical datasets and information Variable access to core primary care services Current Service Provision The range of services offering unscheduled care within Salford has increased over the past few years. As each service has developed a new point of access for service users and referrers has emerged. This has resulted in confusion for patients and health professionals in relation to which service to use. There are elements of overlap and duplication as well as additional work generated as patients move between services resulting in inefficiencies and unnecessary cost. In keeping with the national picture, the demand for Unscheduled Care Services in Salford continues to rise as illustrated in the chart below (Figure 2): Figure 2 Unscheduled Care Demand in Salford Increase in urgent care attendances A&E attendances A&E and Walk in Centre attendances Walk in Centre attendances Number of attendances Month 8 NHS Salford Trust Board Paper A New Approach to Managing & Delivering Unscheduled Care and Chronic Disease Management in Salford: Dr M Burrows, October 2009 Page of 127

13 Development of a New urgent Care Service for Salford There is a range of services that patients can directly access for their urgent care needs within Salford; the activity delivered in each of the services during 2009/10 is outlined in figure 3 below: Figure 3: Urgent Care Services Activity Data for 2009/10 9 Urgent Care Service Number of Patients Attending Units of Measure SRFT A&E 64,444 Attendances PANDA 18,485 Attendances Little Hulton Walk In Centre 11,230 Attendances Pendleton Walk In Centre 19,640 Attendances GP Out of Hours 31,506 Contacts / Telephone Triage Primary Care Centre 12,549 Attendances Total 157, Accident & Emergency (A&E) Department The A&E Department at Salford Royal was attended by 82,929 patients in 2009/10. A quarter of all A&E arrivals were via an ambulance with the remaining patients arriving as walk in patients. The department successfully achieved the 4 hour wait in 2009/10 with 98.04% of all patients discharged or admitted within 4 hours. All walk in patients are initially registered at the A&E reception desk prior to triage. If patients are under 16 years old they are referred directly to the Paediatric Assessment and Observation Area (PANDA unit). Following registration all patients are triaged by a nurse who uses the internationally used tool Manchester Triage System (MTS). This tool identifies which A&E area, such as Resuscitation, Majors or Minors, should manage and treat the patient or alternatively, if the patient has primary care needs and could be managed by the Primary Care Centre. In 2009/10 11% of all patients attending A&E were referred to the Primary Care Centre for treatment. The MTS tool also prioritises all patients using a colour coding system, the prioritisation is based upon the degree of urgency with which the patient must be assessed and treated. Work has been ongoing to modify the triage system to deflect attendances and identify primary care patients. The A&E department is staffed by A&E Consultants, Senior Registrars, Senior House Officers, Advance Nurse Practitioners, Emergency Nurse Practitioners and a range of nursing and clinical support staff. Patient assessment is undertaken, supported by diagnostics. A dedicated A&E x-ray unit is available for plain film diagnostics to support rapid access to diagnostics. Patients are discharged or admitted in line with the national 4 hour A&E waiting time. In 2009/10 28% of all A&E attendances were admitted, appendix 10.1 gives details of the patient outcomes and the most common presenting conditions. Patients admitted are either admitted directly to an inpatient ward or admitted to an assessment area: 9 Data provided by NHS Salford, A.Atcha, (2010) Page of 127

14 Development of a New urgent Care Service for Salford Emergency Clinical Decision Unit, Emergency Assessment Unit or Surgical Assessment Unit. Analysis of the A&E attendances shows that Mondays are the busiest days of the week with weekends having the lowest attendance levels. Attendance patterns during the day show attendances peaking at 10am, which remain high until 7pm when the attendance figures start to fall markedly, see appendix These trends follow national patterns for A&E attendances and suggest some predictability in A&E Attendances. In 2009/10 attendances at A&E and subsequent non-elective admissions for Salford registered patients equated to 54.4m worth of activity under the Payment by Results (PbR) system. Almost 75% of this activity occurred at Salford Royal Foundation Trust (SRFT) as illustrated below in figure 4. Figure 4: Urgent Care Activity and Costs for 2009/10 Urgent Care Activity All Salford Registered SRFT Patients Patients Activity 09/10 Activity 09/10 A&E Attendances 91, m 64, m Non-elective Admissions from A&E 31, m 10 23, m There is a clear trend that A&E attendances and non-elective admission from A&E have increased year on year. Whilst the percentage increase in attendances from 2008/09 to 2009/10 rose by 7.7%, the percentage increase in non-elective admissions rose by 19% during the same period (appendix 10.3). A key measure for the A&E department is the admission rate from A&E. The admission rate has risen from 24.0% in March 2007 to 29.1% in March This represents a 5.1% higher rate than the recommended admission rate from A&E of 24%proposed by Darzi (2008). It is anticipated that by changing the model of unscheduled care within the A&E department it will contribute to reducing the number of admissions into SRFT. The impact of this is likely to contribute to cost reduction and improving the quality of care provided to patients. When comparing SRFT admission rates to other neighbouring Trusts in the North West there are significant differences in admission rates. Data for 2009/10 for all acute trusts in the North West shows that SRFT s admission rate of 28% is the fourth highest rate compared to all 20 Trusts in the North West. Fourteen of the twenty trusts have an admission rate of 24% or lower, as illustrated in appendix This information suggests there is scope to safely reduce admission rates. A recent report published by the Primary Care Foundation having been commissioned by the Department of Health to carry out a study across England of the different models of primary care operating within or alongside emergency 10 Admissions data includes 6.1m worth of Excess Bed Day charges Page of 127

15 Development of a New urgent Care Service for Salford departments; indicated that in a literature review of primary care clinicians working within or alongside emergency highlighted: When we used a consistent definition and a consistent denominator of all emergency department cases we found that the proportion that could be classified as primary care cases (types that are regularly seen in general practice) was between 10% and 30% 11 Based on data available locally as well as this national evidence it is clear that there is scope to review the flow of these patients into the A&E department and more appropriately address their management within a primary care setting PANDA Unit The Paediatric Assessment and Decision Area, PANDA, opened in April 2008 and is a specialist unit for managing paediatric patients. PANDA is supported by a similar clinical team to A&E, however, a community nurse team also support the PANDA unit, which enables patients to be followed up in the community after discharge and provides continuity of care. PANDA provides the following services: Management of all patients within 4 hours An observation area for admitted paediatric patients for up to 24 hour observation Direct admission to Royal Manchester Childrens Hospital (RMCH) for appropriate patients Since PANDA opened, the referral rates for admissions external to SRFT hospital have reduced from 12 % to 4%. As a result, 96 per cent of patients are now managed within the PANDA unit and the community Walk In Centres (WiC s) There are two nurse led Walk-In Centres within Salford, Little Hulton WiC & Pendleton WiC. These facilities were established following national directives to improve access and choice for patients. The WiC s provide a drop-in service for the resident and transient population of Salford, whether or not they are registered with a local GP. Activity within the WiC s has grown steadily since opening; there are currently on average 2,500 patient attendances per month across the 2 sites. A third WiC (GP led) opened in Monton in April 2010 as part of Salford s Equitable Access arrangements. This is part of a practice providing a drop-in and prebooked appointment service for both registered and non-registered patients. The walk in element of this practice was relocated to the SRFT site on 1 st September 2010 in order to maintain the opportunity of primary care clinicians working alongside A&E consultants to support the clinical redesign process outlined within this business case. 11 Primary Care and Emergency Departments, Report from the Primary Care Foundation, March 2010 Page of 127

16 Development of a New urgent Care Service for Salford Data gathered from the WiC s indicates that a proportion of patients present because they state that they unable to get timely access to their GP practice. However, many patients choose to return for care in preference to attending their own GP. The majority of consultations are for: Upper Respiratory Tract Infection Skin Infections Medication requested (requests for prescriptions) Urinary Tract Infection Approximately 30% of those presenting (snapshot analysis) 12 have minor selflimiting aliments that could be safely managed with advice from pharmacists or by simple self-management. In addition there are patients that attend the WiC s whose needs would be better met by a consultation within their own GP practice as they may have ongoing long-term health needs. It is anticipated that by changing the model of unscheduled care within the city to support primary care access and self management a proportion of these patients would not require access to unscheduled care services. This will result in a reduction in cost as well as unnecessary attendances for patients GP Out of Hours (GPOOH) Salford s GP Out of Hours Service is provided by Salford Community Health. It offers clinical assessment and advice to the Salford population when their GP service is closed. Telephone calls are routed either directly from General Practice phone systems or via answer phone message to a Call Handling facility provided by Wigan PCT OOH service. The service operates from the Cavendish Building on the SRFT site, close to the A&E Department and is provided by an integrated GP and Nurse Practitioner workforce. Following telephone triage, patients that require a GP appointment out of hours attend for an appointment within this facility or may be advised to attend a local Walk In Centre. Alternatively patients may be offered a Home Visit. These are carried out by a GP supported by a North West Ambulance Service (NWAS) paramedic who acts as driver in an NWAS car. The types of conditions that patients present to the GPOOH Service mirror the WiC presentations which are predominantly: Upper Respiratory Tract Infection Skin Infections Medication requested (requests for prescriptions) Urinary Tract Infection Since June 1 st 2010, all patients requesting advice out of hours have been triaged by a clinician within service, offering self care advice, an appointment at the centre or a home visit. This has reduced the number of unnecessary attendances at the centre by 40% with no auditable adverse impact on A&E numbers. Approximately 6% of OOH consultations lead to referral to hospital specialty for further treatment or investigation. On national benchmark data, this is at the lower 12 Audit of attendances at Little Hulton & Pendleton WIC July 2010 Page of 127

17 Development of a New urgent Care Service for Salford end of referral rates. A small number of patients will represent to A&E for a second opinion following OOH assessment. This duplication in activity would be eliminated by merging services Intermediate Care and Other Community Services Intermediate Care Services also provide elements of unscheduled care, in particular the Enhanced Rapid Response Team, which offers assessment and short term intervention for patients with a range of urgent care needs to support them being maintained within their own homes. IN addition to providing community assessment and support for patients in their own homes, the team assesses patients within the A&E Department as to their suitability to return home. The Intermediate Care Service will then provide up to two weeks community support to these patients off-setting admission to hospital. Whist this way of working currently impacts upon hospital admissions from A&E there is scope to develop care pathways further in order to reduce the numbers of non-elective admissions. There are a number of other community services that support patients with urgent care needs in response to the national drive to deliver care closer to home. The District Nursing Evening and Overnight Service is an example of this in that they respond to urgent calls from patients to address problems that may have previously required a visit to A&E (e.g. blocked catheter). In addition to this element of their caseload a significant proportion of their work is considered to be planned care supporting people to be maintained within their own homes, in particular caring for people at the end of their life who wish to die at home. The range of services offering unscheduled care within the community has increased over the past few years. As each service has developed a new point of access for service users and referrers has emerged. This has resulted in confusion for patients and health professionals in relation to which service to use. There are elements of overlap and duplication as well as additional work generated as patients move between services resulting in inefficiencies and unnecessary cost. A map of the entry points into these services is included as appendix It is anticipated that improvements in patient experience and increased efficiency through reduction in duplication will be gained by streamlining these entry points. 2.3 Summary Integration and co-location of the services outlined above has the potential to reduce cost through economies of scale and more efficient working practices. The quality of service delivery would also be improved by integration and streamlining of services so that patients are seen by the health professional with the right skills. Figure 5 illustrates the patient flows in the existing urgent care system. An emphasis on self management and better use of primary care services has to underpin any element of service redesign in order to reduce the overall demand for urgent care. Service redesign needs to be congruent with national QIPP Urgent Care work stream aiming to ensure that the patient receives the right service from the right person in the right place at the right time. Page of 127

18 Figure 5 Patient Flow in Existing Urgent Care Model Existing Urgent Care Model 11,230 Walk in Centre Little Hulton 1,696 8, ,966 No Follow Up Refer to GP/Dentist Refer to A&E Refer to Community Service No Follow Up 679 A&E Patients via WiCs 82,929 A&E 30,730 24,347 Discharged - No Follow Up -Refer to HCP -Refer to GP -Other Admission 19,640 Walk in Centre Pendleton 15, Refer to GP/Dentist Refer to A&E 18,485 PANDA 0 Walk in Centre Canalside 1,198 0 Refer to Community Service 9,367 31,506 17,044 10,284 GP Out of Advice Base Visit Hours 3,979 (Telephone Triage) Home Visit 199 Other Notes: 1: All data relates to 09/10 activity. 2: The split of patient outcomes from GP OoH uses the proportion splits for 10/11 data following the new telephone triage implementation. 3: Canalside Walk in Centre had no activity for 09/10. 2,580 3,182 12,549 (Walk Ins) A&E Patients via GP OoH Key: Baseline Data for Activity Model: ### Duplications ### A&E Ambulance Arrivals 09/10: 19,222 A&E Other Arrivals 09/10: 72,332 Primary Care Centre , No Follow Up Refer to GP/Dentist Refer to A&E Refer to Community Service Page of 127

19 3 Project Description 3.1 Purpose This proposal has been developed as one of three projects approved as part of the unscheduled care redesign process within Salford. It is anticipated that the combination of these projects will support partner organisations to safely reduce costs, reduce duplication, maximise efficiency whilst maintaining patient safety and minimising risk. The two other projects are outlined as follows: Optimizing Care Pathways GP Access There are clear links across the three project areas and these have been fully considered in developing this business case. This proposal fully underpins the work of the Optimizing Care Pathways project offering timely access to urgent care as well as supporting the management of patients at the end of their life in the most appropriate setting, preventing unnecessary hospital admission. The GP Access Project supports the overall philosophy that patients with primary care needs are better managed by their own GP. The successful implementation of the GP Access project will be required to support the proposals outlined within this business case This business case focuses on the integration of key elements of unscheduled care that are provided across Salford. The scope of the services included as part of this work is highlighted in section 3.3; however relationships with other services are considered and included. The three main areas that this business case supports are to: Reduce the overall cost of unscheduled care Reduce unnecessary unscheduled care attendances Reduce unnecessary hospital admissions This proposal will support the delivery of the objectives outlined above, however, this needs to be viewed as part of a series of reforms that will contribute towards the financial savings required across the health economy. For the purposes of this proposal it is helpful to define a number of key terms that are used throughout the business to provide clarity and an shared understanding of the objectives. Definitions of the key terms are as follows: Page of 127

20 Deflection - Dispersal - Reduction - Duplication - Deflections are patients attending secondary care with minor self limiting conditions or primary care needs, that require a resource to be redirected to primary care, self care or community pharmacy services Dispersed patients are patients who previously accessed urgent care services but it is assumed they will not use the new UCC and TRC facilities, for a variety of reasons. Resources are not required for managing these patients. Reductions are considered as patients who do not attend the UCC or TRC and therefore resources are not required for managing these patients. Also referred to as Non Attenders or Non Arrivals. Duplications are patients accessing several urgent care services which will be prevented by the co-located and integrated model proposed Streaming - Simple protocols are used for a rapid decision to stream a patient to a defined urgent care stream 3.2 Project Description There are a range of unscheduled care services provided within the Salford health economy that could be delivered more efficiently and effectively through an integrated model of care. The key areas that this proposal seeks to address in order to improve service delivery in terms of quality and cost reduction are highlighted as follows: Promotion of self care for self limiting conditions Promotion of primary care for patients with minor illness Promote the use of relevant community services for patients with non-urgent needs Reduce the number of access points to minimise duplication or omission of care Reduce the numbers of patients that are admitted from A&E to align with national benchmarks Support the development of a health economy wide consistent approach to the management of patients that present in unscheduled care services to avoid duplication of presentation to alternative providers Maintain of a timely response to patients that present with serious or life threatening urgent care needs 3.3 Objectives 3.1 The objectives of this proposal are summarised as: 1. Reduce the cost of Unscheduled Care across Salford in a two stage approach 2. Reduce urgent care attendances in a two stage approach 3. Prevent avoidable admissions 4. Provide a cohesive, seamless model of unscheduled care delivering a consistent service that minimises clinical risk Page of 127

21 In order to deliver savings this proposal seeks to ensure that patients receive the right care, at the right place, at the right time by the right health care professional. To achieve this vision the following issues need to be addressed: Ensure patients who do not have urgent secondary care needs are managed in other settings, this includes promotion of self care and ensuring patients with urgent primary care needs are managed in primary care Minimise duplicated urgent care services Reduce access points to urgent care services Consistent urgent care messages across the Salford Health Economy Collaborative working across primary and secondary care The project team is clear that A&E attendances will only reduce over time if inappropriate attendances are re-directed to primary care and community pharmacy or through the promotion of self care. 3.4 Scope In order to clearly define the remit of the proposal the scope of services to be included was considered by the project team and is outlined below. The decision for inclusion within scope was based upon the: Identified objectives Proportion of Unscheduled Care activity delivered within the service Scope of other Unscheduled Care projects. The discussion highlighted that a number of services whilst out of scope of the project have key relationships and may impact upon this proposal. It was agreed that these would need to be considered as part of the options appraisal In Scope The scope relates to all patients using these services including adults and children, people registered with a Salford GP, those registered elsewhere and nonregistered patients that present to the services outlined. A&E Department All arrivals (ambulance and walk in patients) Canalside Non-registered element of this practice GP Out of Hours All patients including advice only and home and base visits PANDA Unit Pendleton Walk In Centre Little Hulton Walk In Centre Out of Scope but has key relationship/may impact Primary Care Services District Nursing Evening & Overnight Service District Nursing Day Services Community Matrons A&E Assessment Units Page of 127

22 Rapid Response, Single Entry Point and other elements of Intermediate Care Alcohol Outreach Team Mental Health Liaison Children s Community Nursing Service Ambulance Service Salford Care Homes Practice Pharmacies SRFT In Patient Specialities Diagnostic Services Out of Scope Nursing Homes Intermediate Care Bedded Units Canalside Registered Activity Other Community Services In summary the scope of this proposal in relation to major service redesign is represented in figure 6 below. Figure 6: Project Scope Community Unscheduled Care SRFT Unscheduled Care GPOOH Pendleton WIC A&E Department Including PANDA Little Hulton WIC Canalside WIC Page of 127

23 3.5 Risks The overall risks to the health and social care economy in not proceeding with this proposal are outlined as follows: Risk Continued rise in demand for unscheduled care services Risk to the credibility of the organisations involved in the Integrated Care Partnership in not achieving the objectives outlined Reduced opportunity to make improvements in the Health Inequalities in Salford as the available resources are diminished by an increased spend on unscheduled care Threat to the success of the Optimizing Care Pathways proposal due to the inter-dependency of this proposal Continued in consistent approach to the management of unscheduled care needs negatively impacting upon the quality of patient care and experience Consequence Cost of unscheduled care continues to rise and causes unplanned spending cuts to services. Risk to reputation of partner organisation at a local/national level Lack of action taken to address the unscheduled care demand locally may result in changes being imposed centrally Impact on available budget for preventative interventions and planned care if urgent care system costs do not reduce Potential savings at risk for other urgent care projects Fragmented urgent care system with efficiency opportunities neglected 3.6 Anticipated Outcomes The benefits of this proposed new model of care are outlined within the draft Full Business Case. A high level summary is presented below: Benefit Description Potential Savings Between 1.05m and 1.67m Quality Improvements Consistent approach to the assessment, treatment and ongoing management of patients accessing unscheduled care Reduction in duplication or omission of care Right care provided at first time of presentation Reduction in overall Promotion of self care for minor ailments demand for Patients with primary care needs being managed in unscheduled care primary care Reduction in nonelective admissions Reduction in Unscheduled Care attendances Co-location and integration of services will lead to a reduced non-elective admissions. The number to be quantified once the PDSA cycles are completed and proposed pathways developed Page of 127

24 The anticipated outcomes and benefits are presented below with suggested measurement criteria. Anticipated Outcome / Benefit Cost savings for both Provider and Commissioner Improvements in patient experience Consistent approach to the assessment, treatment and ongoing management of patients accessing unscheduled care Overall reduction in unscheduled care attendances Changing patterns of treatment seeking behaviour for minor self-limiting conditions Reduction in duplication/omission of service to patients Consistent achievement of national quality standards and targets for unscheduled care 3.7 Stakeholders Suggested Measurement Criteria Current spend versus future spend Number of non-elective admissions Number of attendances Number of Hand-offs between services Number of patients presenting at different points within the system Monitoring of complaints Audit and monitoring of standards of practice using nationally agreed tools Monitoring of attendances Monitoring attendances Regular Audit of casenotes Review of outcome data Audit Feedback from complaints Regular monitoring against national and local criteria A range of stakeholders has been engaged during the development of the business case. A core group, the project steering team, was formed to progress the business case from SRFT, Salford Community Health, Salford Practice Based Commissioning and NHS Salford. Wider engagement has been sought throughout the development of the business case as illustrated by appendix 10.6, which shows that more than fifty representatives from a variety of disciplines and organisations have been involved in the development of the UCC and RTC. There has been strong clinical leadership for the project with two clinical leads: the PBC Urgent Care clinical lead and the A&E clinical director. Furthermore there has been extensive involvement from consultants and clinical leads from PBC, A&E, PANDA and EAU. Clinical leadership can be demonstrated by involvement in project teams, development of Plan Do Study Act work, development of the UCC and RTC model and a high level of engagement in a clinical workshop that defined the underpinning principles of collaborative working in the UCC and RTC. Wide engagement must continue throughout the implementation phase to ensure the UCC and R&TC operate as an integrated model. It is suggested that briefing sessions are held with key staff to share the work to date in developing the business case, in particular a briefing session for staff at SRFT where supporting departments will interact with the UCC and RTC such as diagnostics, surgery and pharmacy. Page of 127

25 3.8 Public Engagement It was agreed that a substantial engagement with the population of Salford was necessary to support and guide the business cases for the Integrated Care Programme. The engagement ran from 13 September 2010 to 13 December The engagement was in the form of a document with an explanation of the current position and the options for change followed by a questionnaire. This came in 2 forms, the full document and a summary document, both of these were place on the NHS Salford Internet site with 1000 of the full document and 20,000 for the summary document printed and circulated. Two advertisements were placed in the local paper inviting the public to apply for the documents and directing people to the web site where the forms could be filled in electronically. Results were positive with only 16% not agreeing to overall proposals, specifically when asked Do you agree with our vision set out in the document to provide, safe, cost-effective and joined-up urgent care services that reduce unnecessary costs?, the results were as follows: Yes, completely 48% Yes, to some extent 35% No 16% Don t know -10% Some of the positive comments o o o There is a need to streamline medical services. This is a credible vision which minimises risk. Makes sense and will secure the long-term stability of the NHS. Issues Identified Access to Salford Royal. - Location (Little Hulton residents) - Parking - Long waits in A & E Difficulties accessing GP appointments Possibility of increased use of ambulance services Appendix contains further details of the findings together with response and actions to address the comments. 3.9 Strategic Alignment Alignment with National Strategy The recent government White Paper Equity and Excellence: liberating the NHS outlines the intention to develop a coherent 24/7urgent care service in every area Page of 127

26 of England 13 This business case is consistent with that aim and outlines how this will be achieved in Salford. In addition the White Paper highlights a requirement to ensure that redesign of patient pathways is clinically led and based on dialogue and partnership between GP s and hospital specialists, these groups of staff have been instrumental in shaping and developing this proposal for Salford. Members of Salford s Practice Based Commissioning Consortium have played a major role in developing this proposal, through membership of the project steering group and attendance at the clinical workshop events. This is consistent with the strategic intentions outlined within the DH publication to devolve commissioning arrangements to GP consortia. Local implementation of the national guidance on transforming community services as outlined in the revision to the Operating Framework; 14 will result in the majority of Salford Community Health Services being transferred to SRFT. This proposal is congruent with these plans for vertical integration as all services that are within the scope of this proposal are planned to transition to SRFT which will support the proposed redesign. In establishing accountability arrangements as part of the recent NHS reforms, the national consultation document 15 emphasises the need to focus on the outcomes of care. Five domains of an NHS outcomes framework are proposed: Preventing people from dying prematurely Enhancing the quality of life for people with long term conditions Helping people to recover from episodes of ill health or following injury Ensuring people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm This business case is predicated on the integration of services across organisational boundaries, ensuring a consistent approach to the management of patients that present with urgent care needs, many of whom have long term conditions. This consistent approach will assist in minimising risk and offer a positive experience of care and is therefore coherent with the domains as outlined above. The national Urgent Care QIPP work stream in aiming to maximise the number of instances when the right care is delivered in the right place at the right time has identified the following improvement areas: Consistency of offer Single point of entry Service reconfiguration Establishing service directories Development of NHS pathways This business case is consistent with these key themes and the proposed re-design has been developed in line with the evidence emerging as part of this work stream. 13 Equity and Excellence: Liberating the NHS; DH July Revision to the Operating Framework for the NHS in England 2010/11; DH June Transparency in outcomes a framework for the NHS; DH July 2010 Page of 127

27 3.9.2 Alignment with Regional Strategy Recent guidance issued by NHS North West indicates that proposed service changes must meet their assurance tests in the following four areas: Support from GP Commissioners Strengthened public and patient engagement Clarity on the clinical evidence base Consistency with current and prospective patient choice Evidence of support from GP Commissioners is presented within section 3.7 Information on public and patient engagement and reference to patient choice is outlined within section 3.8. Engagement with a wide range of clinical stakeholders is demonstrated and reference is made where applicable to the available evidence base throughout the document. Salford has been actively involved in the NHS North West Campaign Choose Well to manage the demand for A&E and 999 services. The principles underpinning this campaign include: encouraging patients to manage minor self-limiting illness increased use of local pharmacy and primary care services The principles fully underpin the proposals outlined in this business case and will require a consistent approach from all partners to support a reduction in demand for unscheduled care Alignment within the Local Strategic Partnership This proposal has been developed as part of a larger work programme established by Salford s Integrated Care Partnership. It aligns with the strategic intent outlined by key partners in the original proposal A New Approach to Managing and Delivering Unscheduled Care and Chronic Disease Management in Salford 16 Relevant Stakeholders from organisations within the partnership have been involved in the development of this proposal as outlined in section 3.7 In developing the proposal consideration has been given to ongoing testing and refinement of the triage tool used within the North West Ambulance Service (NWAS). Clinicians involved in the development of this business case have also been involved in the pilot projects to support the refinement of the NWAS tool. This business case is congruent with the NWAS plans for implementation of this tool across their services. 16 NHS Salford Trust Board Paper A New Approach to Managing & Delivering Unscheduled Care and Chronic Disease Management in Salford: Dr M Burrows, October 2009 Page of 127

28 4 Model Development 4.1 Purpose In May 2010, Members of the Integrated Care Partnership approved in principle a project proposal outlining the development of an Urgent Care Centre on the SRFT site. The original proposal outlined the integration of a range of community unscheduled care facilities into the Urgent Care Centre and suggested that this new facility would deflect activity from the current A&E Department. In supporting this proposal to be developed into a full business case the Partnership requested the following to be included as part of this work: The business case to include the development of a Trauma and Resuscitation Centre on the SRFT site The remit of the proposed Urgent Care Centre to be expanded to include all patients currently attending A&E that would not require trauma and resuscitation facilities. The scope of the business case to include the PANDA unit (previously considered out of scope) This business case therefore focuses on the development of existing services into adjacent facilities on the SRFT site comprising an Urgent Care Centre (UCC) and a Trauma and Resuscitation Centre (TRC) collectively described as a new Urgent Care Service for Salford. Consequently this model is the preferred option and has been developed for this business case. The option development for the Urgent Care Centre can be found in the project proposal for the original Rationalising Access project. This section outlines the following aspects of the new Urgent Care Service: Defining the activity to be undertaken within the proposed Resuscitation and Trauma Centre Defining the activity to be undertaken within the proposed Urgent Care Centre including the streaming tools and underpinning principles The organisational form of the proposed Urgent Care Centre The proposed changes to the urgent care system are illustrated by figure 7 overleaf. Page of 127

29 Figure 7: Development of Urgent Care Centre and Trauma and Resuscitation Centre The Challenge Community Unscheduled Care Urgent Care Centre A+E Dept Including PANDA Canalside WIC Pendleton WIC Trauma and Resus Centre Little Hulton WIC PANDA GP OOH KEY: Current Provision: BLUE Future Provision: RED Page of 127

30 4.2 Defining the Urgent Care Centre and the Resuscitation & Trauma Centre Salford Integrated Care Programme Board has supported the proposal that the following elements of community unscheduled care will be integrated into an Urgent Care Centre: Canalside Walk In Centre Little Hulton Walk In Centre Pendleton Walk In Centre GP Out of Hours Services In addition, other community based services that offer unscheduled care interventions are to have access points integrated and develop clear pathways between their services and the UCC. This will streamline care ensuring that the patient accesses the right health professional to address their needs in the most effective and efficient way. Further definition of the proposed UCC model has focussed on the activity currently undertaken within SRFT A&E Department to identify what proportion of this activity will transfer into the UCC and what proportion of activity will be managed within the Trauma and Resuscitation Centre. Defining the model of care to be provided within these two areas has been achieved through: A clinical redesign event attended by GP s,consultants and Nurses Regular project team meetings Ongoing clinical dialogue between GPs and secondary care clinicians In defining the Resuscitation and Trauma Centre there was consensus that this facility will focus on managing patients with a high level of need, for example, patients requiring resuscitation, cardiac arrest and unconscious patients, particularly those patients that would require admission. This would lead to a specialist centre that provided emergency care for patients requiring high level interventions. There was agreement that the majority of patients suitable for the RTC would be easily defined, however, there would be a cohort of patients where there would need to be a flexible approach in identifying the appropriate centre. In defining the UCC there is broad consensus amongst the clinical community that whilst the direction of travel is understood; the final design of the UCC has not been fully defined. There is agreement that an action learning approach, underpinned by a Plan Do Study Act (PDSA) cycle, will be used to clarify the final model of care provided within this facility. The process is an iterative one therefore a step-wise model is required as illustrated by figure 8 below. Page of 127

31 Figure 8: Development of Urgent Care Model Development of Urgent Care Model Possible Urgent Care Models Action Learning Approach to Develop Urgent Care Model Direction of Travel Current Urgent Care Model (A&E, Walk In Centres, GP OoH) A key principle that underpins this iterative approach to the development of the UCC is collaborative working Principles of Collaborative Working The key factor is the need to build a culture of trust and integrated working within the UCC; this will be underpinned by the following: Direct relationships between senior clinicians Primary Care and Secondary Care Clinicians working side by side to ensure that discussions take place in relation to decision making about specific patients. This will include real time discussion as well as retrospective audit and review. It was acknowledged that the patient population would be a hybrid from a mixture of primary care patients along with the types of patients that are currently managed within the A&E Department. There was agreement therefore that the service provided within the UCC should be Primary Care Facing i.e. working from the premise that asks: Is self-management the best option for this patient? Does this patient need to be seen within UCC today, seen by their GP today or can they wait to see their GP? Page of 127

32 Are there community services that could address this patient s needs? It is recognised that the following is required to underpin this model of care: consistent approach to patient management across the health economy regular feedback to GP s on their patients use of UCC access to same day GP appointments where appropriate In order to achieve the level of trust and collaboration that is required, the group proposed an action learning approach is in progress with senior GPs working alongside A&E Consultants. A Plan Do Study Act (PDSA) methodology is being used to test assumptions and develop consistent streaming. The final model of the proposed UCC will be informed by this work. The UCC will be fully operational on a 24/7 basis 365 days a year Integration and Relocation of Services In order to fully realise the new model of urgent care for Salford a stepped process of integration of the Walk In Centres into the developing Urgent Care Centre forms part of this proposal. The timeline for this is outlined within the implementation plan. In addition full integration of the GP Out of Hours service is included along with the integration of access points for other community services. 4.3 Design of the UCC and RTC The design of the integrated Urgent Care Centre and Resuscitation and Trauma Centre, in particular the role of primary care, is critical in delivering savings for urgent care activity. A key aim of the model is to ensure consistent management of patients who access urgent care services. In the design of the UCC and R&TC model feasibility and affordability are key factors considered when designing patient streaming models, delivery of clinical treatment and patient flow. The model informs the subsequent work force plans by identifying the role of primary care, in particular GPs, within the UCC and also in shaping the purpose of the Plan Do Study Act cycles. Primary and Secondary care clinicians have developed a model for the UCC and R&TC, which has been approved by the Integrated Care Partnership for further development. The model is illustrated in figure The following are important design features to highlight: All walk in patients and telephone calls will be received by the main reception desk, this includes GP OOH calls A consistent decision making tool will be used to stream patients to either self care, primary care, the UCC or R&TC The reception area will also manage bookings for GP OOH visits and arranging urgent GP appointments Ambulance patients will be directed to the UCC or R&TC potential for streaming refinement Further deflection of patients from the UCC to self care and primary care will be promoted 17 Proposal for the UCC and R&TC Model, E.Tamkin and M.Smith (Sept, 2010) Page of 127

33 Figure 9 Proposed Draft Model for UCC and R&TC Proposed Draft Model for UCC and R&TC Key Deflected Patients UCC R&TC/PANDA Patient Flow Patient Access Options Reception Streaming Outcomes Reception Description: Salford GP Deflected Patients: Telephone Walk In Multiple reception staff (clinical and non-clinical) registering and streaming patients arriving at the UCC/R&TC and receiving calls for GP OoH. Decision making tool to be agreed. Patients are streamed to R&TC, UCC, Self Care, Pharmacy or Salford GP appointments. For appropriate patients reception staff will book appointments with GPs. Self Care Pharmacy UCC ANPs MH Liaison ANPs ANPs Out of Hours Services ANPs ANPs Rapid Response ANPs Patients deflected by redirecting to alternative services or self care promoted. Salford GP urgent appointments booked if appropriate UCC Description: Multiple staff within UCC to assess and treat minor illness and minor injury patients. Area is staffed by AMPs. GP supervision provided by GP OoH, existing GP presence in A&E and supplementary GPs from Salford PBC (e.g. 1.5 days per week). One consideration is to have bookable appointments as well as a waiting arrangement (to be agreed). Further deflection of patients from UCC to self care will be a key role for UCC staff. Assumption is that the 4 hr target will apply to UCC patients. UCC to include: Out of Hours Services Mental Health Liaison Team Rapid Response PANDA 1 o ANP PANDA Description: Arrangements for managing children to be the focus of PDSA work. Proposal is to have primary care in reach into PANDA unit. Ambulance R&TC Triage Treatment R&TC Description: R&TC staffed to manage Trauma and Resus patients, triage required within R&TC. Assumption that 4 hr target applies to R&TC patients. Page 33 of 127

34 4.3.1 Streaming The integrated reception area can receive all walk in patient attendances and telephone queries for out of hours services such as GP OoH calls. It was agreed that senior clinicians, such as a consultant or senior GP, streaming patients would not be a cost effective way of managing attendances and patient flow. There is agreement from primary and secondary care clinicians that the streaming of patients will utilise a decision-making tool as patients arrive at the UCC, this could include using a computer based streaming tool such as NHS Pathways or the NWAS tool. Work is on going to agree who is most appropriate to stream patients. Further agreement has been established that the streaming will be based upon a decision making tool that supports consistent streaming decisions. A tool for streaming patients has not been agreed, however, proposed options are: NWAS Tool NHS Pathways Manchester Triage System It is acknowledged that which ever tool is used further work is needed to refine the tool to increase the level of deflections. This will be the basis of PDSA work. For the purposes of costing the new model it is assumed that the triage is undertaken by a band 7 nurse on a 24/7 basis as per the existing arrangement Role of GP The role of the GP within the UCC will be fully defined by PDSA work to understand the most effective way of using GP skills. The role of GPs within the UCC is not to provide GP consultation sessions in hours as this could stimulate demand within the UCC with patients accessing the UCC GP instead of attending their own practice. As such all primary care patients suitable for GP appointments in hours will be redirected to their own practice, with the option of UCC staff contacting Salford practices to arrange GP consultation, if there is an urgent primary care need. The mechanism for deflecting patients back to primary care is to be agreed with all Salford practices through Practice Based Commissioning forums. A potential risk is that demand for GP OOH is stimulated at 6.30pm if thresholds for appointments are inconsistent with in hour arrangements. The Programme Board has agreed that in order to address this potential risk the following principles would underpin the integration of GPOOH within the UCC 18 : The development of a clear communication strategy to patients. The emphasis of this should be to promote a telephone contact with either In Hours General Practice or OOH Service as the first step prior to actually making a journey. The same rigour in considering alternative provision is applied to patients accessing the GPOOH service as is applied within normal working hours. 18 Relationship Between GPOOH Service and the Proposed Urgent Care Centre P. Fink, F.Thorpe (Sept; 2010) Page of 127

35 The appropriate use of the skill mixed team within the UCC for patients presenting to the GPOOH Service The role of GPs within the UCC will focus on: providing support UCC staff to deflect appropriate patients to self care, community pharmacy and GP practices developing the streaming tool to define appropriate thresholds building relationships between the UCC and Salford GP practices leading on PDSA work Embedding the new working practices in the UCC and R&TC will be a key role for the GP. Whilst a GP presence must be maintained within the UCC there is the potential for the presence to be reduced over time as new working practices embed and patient behaviour adapts to the new thresholds. This could reduce costs, for example, after 6 months operation. The GP role within the UCC will compliment the existing primary care presence within A&E. As such additional GP resource requirements will be limited to 1 day per week, as support from GP OOH s will be provided on weekends and in the evenings. The cost of the GP will be considered as an implementation cost only Plan Do Study Act (PDSA) Cycles The focus of the Plan Do Study Act (PDSA) activities will focus upon the following four areas: Agreeing the decision making tool for streaming patients Increasing deflections from the UCC to self care and primary care Defining appropriate thresholds for admission to assessment areas Developing a working model for managing paediatric patients The PDSA work will emphasise deflections to self care and the adoption of patient education for all appropriate attendances. The first set of PDSA cycles was completed in November 2010 with involvement from secondary and primary care clinicians. The outlined PDSA cycles are shown in appendix Further cycles have been planned for January and February 2011 and have been included within the implementation plan. 4.4 Proposed Organisational Model of the UCC In order to further develop the UCC model clinicians indicated that defining a preferred organisational model would assist in enabling them to develop the clinical model of service provision within the UCC facility. The organisational model relates only to the governance arrangements of the UCC, when assessing each organisational model the services provided by the UCC would be the same for each case. Five organisational models were proposed for consideration. They included: Joint Venture Mutual System Partnership Existing provider (SRFT) as sole provider Page of 127

36 GP Consortia as sole provider Third party/independent ` A description of each model can be found in the briefing paper Urgent Care Centre Proposed Organisational Model 19. The defining characteristics of each model are level of partnership involvement and the legal robustness of governance arrangements for each model. A set of weighted benefit criteria was used to assess each organisational model that included: ability to achieve savings; feasibility; clinical effectiveness; future proofing; and patient experience. There was wide engagement in assessing the options from: GPs Secondary Care Clinicians NHS Salford Executives and Senior Managers SRFT Executives and Senior Managers Fourteen responses were received from a total of 24 stakeholders that were invited to participate in the exercise, as shown in appendix The outcome of the option appraisal supports the underpinning principles for the Urgent Care Centre. There is strong support for collaborative arrangements whereby primary care and secondary care jointly lead the development of the Urgent Care Centre, such as the partnership and joint venture options. The support for collaborative models over rides the models where providers operate independently. Furthermore the option of a third party is deemed untenable and therefore a tendering exercise has been disregarded. In practical terms the Joint Venture model is currently unfeasible as a legal GP Provider arm in Salford does not exist. As such the joint venture model is unable to develop in line with the Urgent Care Centre implementation timescales: closer inspection of the option appraisal results suggests that feasibility is the reason for the joint venture model being the second option overall. However, securing robust accountability arrangements is essential for the UCC. The Integrated Care Partnership approved the recommendation to develop a partnership model in the short to medium term to progress the development of the UCC. The ICP also approved the recommendation, in principle, that the long term solution is to transition to a Joint Venture, subject to legal and regulatory approvals. As such the implementation plan for the UCC and R&TC identifies key steps in developing accountability arrangements and establishing a partnership board. The accountability arrangements that will be in place during the first phase of implementation are described in section Activity Modelling In order to develop the Urgent Care Centre and Resuscitation and Trauma Centre an understanding of levels of activity in each centre must be established. It is assumed that the existing urgent care facilities across Salford will be consolidated 19 Urgent Care Centre Proposed Organisation Model, N.Armitage & F.Thorpe (Sept, 2010) Page of 127

37 at Salford Royal FT (SRFT). As such the activity that must be considered as part of this project comprises: A&E PANDA Unit All Walk In Centres GP Out of Hours (OOH): contacts and activity Primary Care Centre: A&E deflections and walk in attendances This paper examines a number of scenarios to determine likely activity levels within the UCC and R&TC. To do this historic activity for 09/10 has been analysed and a number of assumptions have been made to develop three potential scenarios: A base case - expected levels of activity A best case lowest levels of activity in R&TC and UCC A worst case - highest levels of activity in R&TC and UCC Activity Data for 2009/10 The activity model was based upon historic activity from 2009/10 and included adult and paediatric activity, as illustrated by figure 10, the total urgent care activity was 157,854 patient contacts across the six urgent care services. However, this data included some duplication in activity for patients accessing multiple services such as GP OoH and A&E or Walk In Centres and A&E. Where possible corrections have been made to remove duplicated patient activity as the integrated UCC and GP OoH model will minimise duplicated contacts. Figure 11 illustrates the modified baseline activity data that accounts for Primary Care Centre and GP OoH duplicated patient contacts Figure 10: Activity Data for 2009/10 at Urgent Care Services in Salford Urgent Care Service Number of Patients Attending Units of Measure SRFT A&E 82,929 Attendances (18,485 PANDA) Little Hulton Walk In Centre 11,230 Attendances Pendleton Walk In Centre 19,640 Attendances Canalside Walk In Centre 0 Attendances GP Out of Hours 31,506 Contacts (Telephone Triage) Primary Care Centre 12,549 Attendances Total 157, Note that a correction for patients attending both the Walk In Centre and A&E has not been made as patients details are not recorded within the Walk In Centres 21 Review of GP OoH and A&E Attendances Briefing Paper, NA (2010) 22 Urgent Care Centre and Resuscitation and Trauma Centre Activity Model and Sensitivity Study: HG and NA (2010) Page of 127

38 Figure 11 Revised Activity Data for 2009/10 at Urgent Care Services in Salford Urgent Care Service Number of Patients Attending Units of Measure SRFT A&E 81,984 Attendances (18,485 PANDA) Little Hulton Walk In Centre 11,230 Attendances Pendleton Walk In Centre 19,640 Attendances Canalside Walk In Centre 0 Attendances GP Out of Hours 31,506 Contacts (Telephone Triage) Primary Care Centre 3,182 Attendances Total 147, Activity Model Assumptions The activity model uses a number of assumptions to estimate the level of activity within the UCC and RTC and also the number of patients that will access other services or self care should the Walk In Centres relocate. The following assumptions underpin the activity model, which have been agreed by the project steering group. Activity data set used is for 09/10 financial year provided by NHS Salford All patients attending SRFT and Walk In Centres are considered (i.e. Salford and non-salford registered patients) Year on year rise in attendances is 0% Canalside attendances are assumed to be zero as the service commenced in April 2010 but was not actively promoted. The service has not reached full capacity yet. The R&TC will manage all patients attending A&E who, in 09/10, had a disposal code 23 listed as: Died in Department Dead on Arrival Admitted Hope/Other Activity in the R&TC is assumed to be 20% greater than the activity from the 3 disposal codes above to account for patients deteriorating in the UCC Walk In Centre and deflected patients who do not attend the UCC or R&TC are grouped as Other this means patients could present at: a neighbouring Acute Trust; a local Walk In Centre provided by neighbouring PCTs; GP practices; pharmacies; or self manage their complaint. 33% 24 of all patients currently attending the Walk In Centres would attend A&E as an alternative to the Walk In Centre 55% of patients in Little Hulton will use Salford urgent care services whilst 45% will use Bolton urgent care services This principle was agreed at the Clinical Workshop on 16 th July Based upon a snapshot sample of patients attending Pendleton and Little Hulton WICs over 1 week in July 2010, MW, SCH. Acknowledgement that seasonal trends are not reflected by this snapshot, see appendix CQC assume 55:45 split for attributing performance of the Little Hulton Walk In Centre to Salford and Bolton respectively for the 4 hr wait target. Page of 127

39 GP OoH activity to be unaffected by UCC model current activity levels assumed constant in UCC 90% of all patients 16 years and under will be managed within the PANDA unit, the remaining 10% could be managed within the UCC Scenarios A number of factors will influence the capacity of the UCC and R&TC including: 1. Dispersal of patients currently attending Walk In Centres 2. Management of paediatric patients 3. Thresholds for managing patients within the UCC These three factors have been modelled to develop the base, best and worst case which are illustrated in figure Appendix shows the cases modelled using the sensitivity figures outlined. In addition the activity model used for developing the three scenarios is shown in appendix Figure 12 Scenario Models for Best, Base and Worst Case Urgent Care Service Best Case Base Case Worst Case R&TC 29,216 29,216 29,216 PANDA 16,637 16,637 18,485 UCC 38,846 45,701 57,807 GP OoH 31,506 31,506 31,506 Other 31,338 24,482 15,783 Total 147, , ,797 The three cases shown have been used to underpin the work force plan and cost model. Three cases were developed to help identify the tipping points for stepped costs. Whilst the TRC activity was fixed at 29,216 for the three cases it was proposed that the best case also considered a 20% reduction in activity to 24,500 to understand if there was a stepped cost in staff levels by reducing TRC activity. However, assessment of the daily averages, shown in figure 13, demonstrate that the step changes between the base case and best case are of the order of 1 patient per hour, for both the TRC and UCC. Consequently the base case has been used for developing the work force plans. In order to identify the staff requirements within the UCC and RTC the activity levels on a daily and hourly basis have been identified. It is assumed that the arrival times at the UCC and RTC will reflect the current pattern of arrival times in A&E. As such the arrival times have been scaled depending upon the activity levels within each scenario. This information is shown in appendix Cost analysis of paediatrics seen in PANDA vs UCC to be determined. Staff requirements in treating paediatrics e.g. safe guarding, paediatric training to be reviewed to assess if managing PANDA patients in UCC is cost effective. 27 Details can be found in the paper Urgent Care Centre and Resuscitation and Trauma Centre Activity Model and Sensitivity Study: HG and NA (2010) Page of 127

40 Figure 13 Daily Averages for Best, Base and Worst Case Urgent Care Service Daily Average Best Case Base Case Worst Case R&TC 80 (67*) PANDA UCC GP OOH Telephone Contacts 28 Conversion to Base Visits Conversion to Home Visits Total Activity (All attendances, visits and contacts) Total Footfall in UCC * Attendances if TRC activity was 24,500 pa Impact of Other Urgent Care Projects It is acknowledged that the activity model data will be affected by on going work in other projects including the other Integrated Care Programme projects and also other projects that have inter dependencies with urgent care. Consideration has been given to the impact of these projects which is outlined as follows: Optimising Pathways Project This project is progressing in two phases. At present only estimates for the impact of Phase 1 are available. Phase 1 seeks to reduce the unscheduled care spend on people in their last year of life by 20%. The estimated reduction in A&E attendances and admissions via A&E are estimated 29 at: 908 fewer A&E attendance 716 fewer admissions via A&E GP Access Project The GP Access project will, through improved efficiencies, provide greater capacity in GP practices and will also improve the utilisation of GP appointments. This project is an enabler for the UCC and R&TC project and will support the UCC to deflect patients to primary care. As such reductions in A&E attendances have not been allocated to this project. Mental Health Liaison Team The Mental Health Liaison Team has recently been commissioned to provide a comprehensive service to A&E, the assessment areas and the inpatient specialty wards. It is anticipated that the team will improve the response time to patients in A&E who require an assessment. As the team has recently been commissioned there is limited data to inform the activity model. It is unclear whether the Mental Health Liaison Team will reduce A&E attendances as such when the activity and performance data for this service is reviewed after several months operation this can inform the UCC and R&TC activity model. 28 All patients contacting GPOoH receive telephone triage and a proportion of these patients will either receive a home visit or base visit in addition to the telephone contact 29 Estimates provided by KP and RG (19 th August 2010) for the Optimising Pathways project Page of 127

41 Intermediate Care Commissioning Best Value Project NHS Salford clarified that the Intermediate Care Commissioning Best Value project delivered savings in 2009/10 from a 433 reduction in admissions 30. This reduction in attendances and admissions is captured within the 2009/10 data. The project is expected to deliver the same level of savings in 2010/11. Given that the admissions have been captured in the data that underpins the activity model there is no risk of overlap of savings or reductions in activity within the TRC. If there are further reductions in attendances and admissions due to the Intermediate Care project it is unlikely that these changes will exceed the tolerances for the worst, best and base cases given the magnitude of existing reductions. The Christie at Salford Project The development of the Christie at Salford satellite radiotherapy centre opens in Summer 2011 and roll out of solid tumour chemotherapy in Winter 2011/12. It is anticipated that the number of emergency attendances will increase as cancer patients accessing the radiotherapy services at The Christie at Salford and the chemotherapy service will naturally go to Salford s emergency village albeit that the cancer centre will only operate in hours (it will be 9-5 Monday to Friday). A smaller cohort of patients attending Salford will be suspected Neutropenic patients, however, since The Christie will be providing palliative radiotherapy patients SRFT may see an increase in patients presenting acutely with progression of their disease. Attempts to estimate the numbers of Neutropeonic patients is difficult as many of the suspected Neutropeonic patients who are admitted for treatment do not transpire to be truly febrile Neutropeonic. Activity data shows that there are currently patients attending SRFT A&E with a cancer diagnosis in each month. With the opening of The Christie centre this figure is likely to increase but it is difficult to estimate the increase, following the opening of The Christie centre it is proposed that A&E activity for The Christie patients is monitored to understand the impact on urgent care usage and care pathways developed to ensure patients are directed appropriately in case of emergency. Summary To summarise, it is anticipated that the net effect of the projects outlined above is within the tolerances of the activity model and therefore within the capacity of the proposed work force plans. Where it is unclear what the impact of the project will be on the UCC and TRC then risks have been captured in section 6 with mitigations outlined Deflections and Reductions Summary The project team was asked to consider the best case as the most likely case for the UCC and RTC. Using the best case scenario the distribution of patients within the existing urgent care system to the new urgent care system is shown in figure 14. However, the best case assumes a reduction in attendances following a consistent approach to deflecting patients that influence patient behaviour. The affect of this will only materialise after a period of time. As such, the cost savings and activity levels must be considered in two distinct phases as described: Phase 1: UCC and TRC opens in Autumn 2011 staffed to manage the assumed activity levels this includes patients that will need to be deflected as their needs 30 Information from Intermediate Care Review, Dec 2010, PBC Operational Board Paper Page of 127

42 would be better managed in alternative services. For phase 1 footfall will be high, following relocation of the Walk In Centres, and resources will need to be focused on streaming patients, promoting self care and deflecting patients to primary care and pharmacy. Phase 2: Whilst deflection rates will increase during phase 1, as thresholds are embedded, it is anticipated that patient behaviour will change leading to fewer attendances at the UCC and TRC. A step change in UCC and TRC attendances is required to further modify the work force plans as demand reduces. The activity and staff model is highly dependent on the number of deflections achieved therefore increased deflections will lead to a reduction in attendances at the UCC and TRC, and ultimately reduced staff resource and costs, which is the primary aim of this proposal. Figure 14 Best Case Attendance Distribution and Reductions Existing Service Activity for 09/10 Patient Changes in Proposed Model RTC UCC PANDA GP OoH Reductions Patients Duplicated SRFT A&E (adults) 64,444 29,216 29, , PANDA 18,485-1,571 16, Little Hulton WIC 11,230-1, ,497 - Pendleton WIC 19,640-5, ,131 - GPOOH 31, , PCC 12, ,289 9,367 Canal Side WIC Total 157,854 29,216 38,845 16,637 31,506 31,338 10,312 The base case is more reflective of activity levels in phase 1, illustrated in figure 15, and is used for the purposes of the work force plan and subsequent cost schedules. In addition, the annual activity levels within the UCC varied by 15% between the Best and Base Cases the impact practically was one attendance less per hour. Consequently this magnitude of change in activity does not impact on the stepped costs for the UCC, which has been explored in the development of the UCC work force plan. A greater step change in activity and increased deflections is required to release further costs in Phase 2. From a total of 158,000 patient contacts in the urgent care system 10,300 duplicated attendances will be removed and 24,500 attendances at Walk In Centres are expected to disperse to primary care and self care. The financial analysis is also based on this model. Page of 127

43 Figure 15 Base Case Attendance Distribution and Reductions Existing Service Activity for 09/10 Patient Distribution for Proposed Model GP TRC UCC PANDA Reductions OoH Patients Duplicated SRFT A&E (adults) 64,444 29,216 34, PANDA 18,485-1,849 16, Little Hulton WIC 11,230-2, ,192 - Pendleton WIC 19,640-6, ,159 - GPOOH 31, , PCC 12,549-1, ,132 9,367 Canal Side WIC Total 157,854 29,216 45,700 16,637 31,506 24,483 10,312 There is some evidence to suggest that the actual need of Walk In Centre patients is more appropriate for primary care than secondary care. However, the activity model assumes a proportion of patients will attend the UCC and TRC based upon patient feedback. The intention is to further increase deflections in phase 2 by considering the primary care cohort of patients. Further reductions indicated would only be realised with the following interventions: Consistent deflection of patients to primary care Shift of paediatric activity to the UCC/primary care intervention Reduction in GP OOH contacts following a consistent approach of redirecting patients both in hours and out of hours GP Access A proportion of patients will be deflected to primary care as a result of relocating the Walk In Centres to SRFT and there will also be the cohort of patients who will access primary care as a result of being deflected from the UCC. Based upon feedback from Walk In Centre patients (see appendix 10.9) 47.1% of patients said they would access GP practices instead of the Walk In Centre. Assuming this to be true for all Walk In Centre patients then this equates to approximately 14,500 patients. This is equivalent to one patient per Salford practice requesting a GP appointment every week day. This anticipated demand for primary care appointments does not include those patients who will be referred back to their GP from the UCC and GP OoH for routine and urgent appointments. To ensure the primary care patients are deflected from the UCC there must be confidence that practices will have urgent slots available for these patients. It is proposed that each practice in Salford has at least two urgent appointment slots per day: a slot available in the morning and another in the afternoon. Practices will be contacted by the UCC where patients require a urgent primary care appointment following clinical assessment at the UCC. Providing two urgent slots per day equates to 28,600 appointments in primary care. Note that this is an average and some practices may have a higher, or lower, demand for urgent primary care appointments. Page of 127

44 4.6 Equality Impact Assessment An Equality Impact Assessment was carried out for the UCC and TRC. The assessment considered how the proposed changes to the urgent care services would impact patient cohorts from the seven strands of diversity. An action plan identified issues and actions required where there was the potential that equalities groups and communities could be affected by the proposal. In addition wider issues and actions were raised an included. The project team has considered the identified actions and where they are directly related to this proposal have identified measures to be taken to managed and address the issues, further details can be found in appendix Workforce Modelling This workforce plan is based upon the UCC and TRC activity levels anticipated in the Base Case, as detailed in section 4.5. Whilst the annual activity levels within the UCC varied by 15% between the Best and Base Cases the impact practically was one attendance less per hour. Consequently this magnitude of change in activity does not impact on the stepped costs for the UCC. A greater step change in activity and increased deflections is required to release further costs in Phase 2. The workforce plans have been developed inline with the activity shown in figure15, the base case. As detailed in section 4.5 above reductions in patient demand and the assumed deflections will initially require workforce resource in order to register, stream and assess for appropriate deflection. Critically the key risk of this workforce plan, and associated cost savings, is that the anticipated reduction in attendances and deflections are not achieved and attendances remain stable or continue to rise. A peer review of the work force plans identified core posts that remain fixed regardless of activity. Posts related to surges in activity were also identified that could be removed should activity levels reduce further. This has been identified as a stretch case and is highly dependent upon further reductions in attendances. This stretch case has been described in section to demonstrate the stepped costs should further reductions materialise Overview The workforce plan for the UCC and TRC demonstrates a fully integrated model with integrated workforce skills and the flexibility to meet patient demand across both centres. A significant amount of work has been undertaken to map the new service activities and identify the skills, types and number of staff needed to meet the assumed demand. Consideration has been given to which types of staff would be best to carry out particular roles in order to reduce costs and improve the patient experience. Positive benchmarking exercises have been undertaken to compare staffing levels in Trusts with similar activity levels. However, the benchmarking exercises are comparing A&E Departments but the proposal within this business case describes a new model of care and therefore thinking and working differently is needed. Page of 127

45 As previously indicated anticipated deflections may take time to achieve and therefore a phased approach to staff reductions may be needed, with short term temporary contacts being offered which then could be released when demand decreases. Staffing numbers/skills/shifts have been reviewed in line with demand, however, there are a number of considerations that need to be taken into account within the planning: All Medical staff are subject to compliance with the European Working Time Directives which has strict guidance on out of hours working, required time off etc. The Deanery requires different levels of medical staff to attend weekly afternoon training sessions which considerably depletes staffing numbers at particularly high levels of patient activity. Specialist Registrar (SpR) and Senior House Officer (SHO) posts are fully funded by the Deanery and therefore the only cost commitment is for the banding payment, which relates to the percentage of out of hours work undertaken. There is no protected time for formal nurse training sessions and as education is vital to staff development, training sessions are scheduled during shift overlap where there is a duplication of staff. This overlap also allows for required staff breaks to be taken. Nursing staff need to comply with cleaning schedules and infection control policies at the beginning of each shift. They are also required to undertake preparation duties including equipping and safety checking of all equipment in patient areas To secure seamless services for patients the availability of supporting and specialist services out of hours need to be factored into the work force plans as during these hours there is less Trust demand on certain aspects of service such as diagnostics, no elective work, access to specialist reviews etc which generates more availability to unscheduled care services. Staffing levels during these periods have been modified to account for this and the variation in patient flows through the hospital. Despite different daily averages of patient arrivals there is a recommended minimum staffing level for the R&TC designed to ensure that they can meet patient demand and dependency as well as having the ability to send an EMAT (Emergency Medical Assistance Team) group out should the need arise. There are areas of the workforce plan which need further development and this will occur as the proposed model is progressed. One of the areas still under review is the streaming tool to be used. This plays a vital role within both the Urgent Care Centre and Resus & Trauma Centre and has yet to be decided. Once agreed appropriate staffing levels can be apportioned, however, in the meantime a draft allocation of cost has been included Organisational Model The UCC and TRC will both operate 24 hours a day. The proposed workforce is flexible enabling staff to be moved between areas to meet any peaks in demand. Page of 127

46 The TRC has 24 hour activity but with the majority of arrivals between the hours of a.m. and 1.00 a.m. Due to the severity of presentations some patients can remain in this area for long periods of time and require more nursing, medical and diagnostic time. The nursing role within this area requires a higher level of clinical knowledge and skill base than in other areas due to the dependency and complexity of this patient group. The UCC will predominantly see minor injury and urgent minor illness. Levels in demand are different than the Resus and Trauma Centre with peak arrival times being between a.m. and p.m. The expected length of stay for patients in this area is much lower than in the TRC. Each medical staff member will on average have a turnaround of between 3 and 4 patients per hour however this can vary dependant on severity of presentations. The medical staff, Emergency Nurse Practitioners (ENP s) and Advanced Nurse Practitioners (ANP s) in this area will be supported by nursing and clinical support staff to prepare patients and provide a variety of treatments including suturing, plastering, medications etc. Figure 16 shows the times of patient arrival for both UCC and TRC by day of week Figure 16 shows the times of patient arrival for both UCC and TRC by day of week A rapid assessment service will be provided between the hours of a.m. and p.m. staffed by a clinical support worker. This service will provide rapid access to bloods, ECG s and diagnostics where required for patients direct from triage. Figure 16 Patient Arrivals at the UCC and TRC Number of Patients Arriving at UCC and TRC by Hour and Day of the Week Number of Staff & Patients Monday Tuesday Wednesday Thursday Friday Saturday Sunday TIme of Day Roles and Responsibilities The UCC and TRC are supported by an integrated medic and nursing team. The roles and responsibilities of each clinician are outlined in this section. Page of 127

47 Consultants - This is the most senior group of medical staff who will be medically responsible for both areas. The Consultants operate a three shift system working within all elements of the Unscheduled Care footprint, including considerable commitments to provide resource to the assessment areas (costs removed). There is an overlap of Consultant presence in the afternoons and this provides senior cover for the mandatory teaching sessions which take place throughout the week. Alongside these training sessions the Consultant body have an obligation to provide in hours on the job training for all junior medical staff to satisfy the Deanery training requirements. The Consultants support all medical and nursing staff, have senior input to a large number of patients per day and provide trauma support and senior cover for the Panda Unit alongside the Panda Consultant when involved with complicated cases. The Consultants provide on call cover overnight and job diaries also demonstrate considerable time spent outside timetabled hours and this is recognised in the flexibility contracts. The College of Emergency Medicine Consultant Workforce Guidance document, April 2010 recommends 10 WTE consultant staff for between 50,000 and 80,000 attendances. Senior Registrars - SpRs are regarded as senior clinical decision makers across all areas of Unscheduled Care and they provide 24 hour seven day cover. There is a Deanery requirement that they all attend the mandatory training sessions on Thursday afternoons. The SpRs rotation is annual and therefore because of the length of time spent in this area their skill levels and competences are enhanced. Majority workload is in the Resus and Trauma Centre however they will flex into the UCC to meet demand and contribute to training and supervision of junior medical and senior nursing personnel. Foundation Year/GPVTS/Trust Clinical Fellows/SHO s - Junior training grade medical staff work in all areas of the Department and again provide 24 hour seven day cover. They have a fixed training session on Wednesday afternoons and receive support and on the job training from both the SpRs and Consultants throughout the week. The training grades rotate every 4-6 months so significant variation in competency throughout the year is a recurrent observation requiring cycling of teaching curriculum. GPs - The role of the GPs is being defined by the PDSA work, however, their role will be to bring a primary care perspective to the management of the UCC. Their key responsibilities will be embedding thresholds for streaming patients, providing advice and clinical supervision to the UCC staff, educate, providing feedback to primary care. In hours the GPs will not be responsible for treating patients as the intention is for all primary care needs to be treated in primary care. The Out of Hours GPs will continue to provide out of hours cover, however, the delivery of Out of Hours will be integrated with the UCC and thresholds for managing patients will be aligned with in hours arrangements. Advanced Nurse Practitioners - The ANPs will work across all areas of the new model, providing clinical assessment and support to the care and treatment of a diverse and undetermined caseload of patients. Many of these patients have highly complex acute presentation from the very sick/seriously ill or injured patient to the more common/minor illnesses and injury. The ANP s will be expected to contribute to telephone triage, handling calls for the GPOOH Service, which involves a level of assessment and advice over the telephone. These nurses demonstrate advanced skills and competencies, practicing at the highest levels of freedom to act, determining clinical diagnosis and treatments indicated, and maintaining records as an autonomous practitioner. On the job teaching and support is provided by Consultant and SpR staff and formal teaching is held on Friday afternoons Page of 127

48 Emergency Nurse Practitioners - ENP s are senior nurses Band 6 & 7 who have undergone academic and practice assessment in the management of minor injury/illness. Their role within the Urgent Care Centre would include assessment, diagnosis, management and discharge of patients with a wide variety of minor illness/minor injury presentations. This group of staff are skilled nurses in emergency care and therefore can work across all areas of the service Lead Nurse - Overall responsibility for senior nursing management and leadership to the department ensuring high quality care, staff with the appropriate clinical skills to a level which ensures fitness to practice, incident and complaints management, recruitment and retention of staff. Strategic lead for the development of nursing services within emergency medicine ensuring that policies and protocols are adhered to in order to provide safe and effective care. Band 7 Nurses As the senior and most experienced member of the clinical nursing team they undertake the Nurse in Charge role which provides shift leadership and supervision to all areas, maintains correct staffing levels and skill mix, maximises patient flow and ensures flexibility of the staff to meet patient demand in all areas. As well as being a senior triage nurse, these staff members can work clinically in all areas of the proposed model. Band 6 Nurses - Deputy shift leaders who manage patient flow, treatment and care in each area of the department. They liaise with speciality areas of the Trust to ensure appropriate and timely patient care. They have the ability to triage and to work in all areas of the model. They mentor and develop the junior nursing staff and take lead roles in service development projects. Band 5 Nurses - Able to assess, plan, implement and evaluate patient care in all areas of the department, ability to coordinate in each area in the absence of a more senior member of the nursing team. Clinical Support Workers - provide essential care to all patients. Those with extended skills are able to perform tasks which ensure patients results are ready timely, to assist in appropriate patient management, as well as provide prescribed treatment to those with minor injuries UCC and TRC Staff Levels The integrated work force model for the UCC and TRC is illustrated in figure 17, which shows the staff to patient ratio by hour for the UCC and TRC. Further detail is shown in appendix 10.13, which outlines the shift rotas for the UCC and TRC. Page of 127

49 Figure 17 Staff and Patient Numbers in UCC and TRC GP Out of Hours This workforce plan includes GP s that will undertake home visits to patients where this is required following an initial telephone triage assessment. The plan assumes that all patients requiring a home visit will be unable to attend the UCC for treatment and their urgent care needs require the input of a GP. In order to ensure that this resource is available, there will be at least one GP working from the UCC between the hours of 6.30pm and 8.00am Monday to Friday and from 8.00am Saturday until 8.00am Monday. Bank holidays will be staffed as per weekends. Current levels of activity suggest that more that one GP is required at peak times over the weekend to meet the demand for home visits. When the GP s are not out on visits they will form part of the integrated workforce within the UCC undertaking telephone triage or treating patients that attend. Economies of scale have been realised by the integration of the administrative staff currently supporting GPOOH into the admin/reception staff pool of the UCC. In addition Advanced Practice Nurses (ANP s) that currently support the GPOOH Service, by undertaking telephone triage and treating patients that attend for a face to face consultation, have been integrated into the overall workforce plan for the UCC. The table overleaf (figure 18) indicates the staff required. This level of staff is based on the assumption that telephone triage and treatment of patients that present to the UCC following triage will be undertaken by the wider pool of staff available within the UCC. This assumption holds for week days only, on weekends additional resource is required for supporting the telephone triage which has been captured within the UCC nursing plan. Page of 127

50 Figure 18 GPOOH Staffing Numbers Days of the week Hours Covered GP ANP Monday to Friday 6.30pm am 1 Monday to Friday 6.30pm pm 1 Saturday, Sunday & Bank Holiday 8.00am 10.00pm 2 Saturday, Sunday & Bank Holiday 10.00pm 8.00am 1 Saturday, Sunday & Bank Holiday 8.00am 8.00pm PANDA Consideration has been given to training requirements that GP OOH have for Specialist Training for year 2 and 3 medical doctors. The additional cost pressures of providing this training have been captured within the financial section, however, the training will impact on how GP OOH services are provided as a GP presence will be needed at the UCC for training purposes. PANDA has currently been excluded from this workforce plan until the PDSA work is undertaken. Once results are known the PANDA workforce will be mapped Support Services The Unscheduled Care services rely on a variety of staff to support the delivery of care. These staffing groups are detailed below. Lecturer Practitioner - The Lecturer Practitioner role provides educational/training support to all levels of nursing staff along with supervision, providing specialist intervention and education. The LP leads on the introduction and continuous development of key roles and responsibilities that improve the patient experience/service delivery i.e. Advanced Practitioners, Emergency Nurse Practitioners, and Triage Nurses. Staff development both skill based and academic study is coordinated by the LP to ensure safe and effective practice and achievement of standards for urgent care. Secretarial Support - Secretarial staff support the Consultants and senior nursing team from all areas including Panda. Their duties are varied and include management of medical rotas, police statements, attendance letters, complaints, child protection reports and meeting organisation/ minute taking. Staffing levels and grades have been mapped to meet workload demands Reception - The reception staff will support all areas of the service including the GP OOH provision. There is a lot of duplication in the areas based on the number current access points and therefore staffing numbers can be reduced with the proposed new model. Support Manager and reception supervisors will also provide 7 day cover to provide all relevant reporting information, maintain rotas, deal with difficult situations and provide backup cover for reception at times of surge. Portering Support - Due to the close proximity of the Assessment Area and Diagnostic Facilities in the new build it is not anticipated that an increase to the current Portering facility will be required. Portering staff will need to based in the Department at all times and support all areas including PANDA Page of 127

51 Housekeepers Provide a vital service in ordering and maintaining stock levels, patient support, organisation of deep cleans etc, and general upkeep and maintenance of the department. Domestics Support Provide 24 hour cleaning and hygiene support to the patient areas Security/Police - Security do not provide dedicated support to A&E. As A&E is the main access point for the hospital after lock down there is a guard based in the area from 9.00 p.m. to 8.00 a.m. However if they are needed to respond to any incident in the hospital they will leave the Department - indirect costs proportioned, no change anticipated. There is Police presence in the Department between 22:00 and 04:00 on every Friday and Saturday night and on the first and last Sunday nights each month. This initiative has significantly reduced the number of violent episodes against staff and provided the general public with reassurance and a feeling of safety Transport Support to GP OOH - GP OOH Service requires a driver and vehicle to be available during OOH to attend home visits with the GP on shift. Current cost is 114,000 and is provided by St Johns Ambulance. Initial costs for Trust to provide service would be 84,500 Call Centre Support to GP OOH - SCH currently commission a call centre function to support the GP OOH. This call centre receives the initial telephone contact and records the patient s demographics before transferring the call to the GP OOH staff. Further work is to be undertaken in this area to ascertain what resource/costs can be saved Alternative Approaches to Work Force Planning and Work Force Plan Peer Review To ensure the work force plans were rigorously scrutinised analysis of the work force plans was undertaken that was then followed by a Peer Review workshop. Alternative Work Force Planning Approaches The approach adopted for developing the work force plans was to determine staffing levels through engagement of appropriate clinical and support service staff with the anticipated activity levels as the basis for each work force plan. To benchmark these bottom up work force plans two alternative approaches were also used as follows: 1. A 15% imposed reduction across all three staff groups is proposed to align savings with the savings target for the programme as well as the proposed activity deflections 2. Minimum daily staff levels within the current A&E Department following workforce analysis have been replicated for each day of the week, suggesting work force savings in addition to those in Option 1 of 6.3 % in the TRC and 12.3% in the UCC. The second approach considers the patient to staff ratios during the week and is described in further detail. The number of patients expected to attend and the number of staff on each unit has been compared for each day of the week. A simple ratio of daily staff hours per patient for each day of the week has been calculated (taking no account of skill mix, etc.) The staff / patient ratio is lowest on Mondays and this ratio has been applied to all the other days of the week. In other words activity modelling suggests on average Page of 127

52 approximately 11% fewer patients will attend the RTC on Tuesdays than on Mondays, yet the initial workforce plan shows the same staffing rotas for both days Tuesday s revised workforce plan shows a 11% reduction in staffing. The same calculation has been made for both units and each day of the week. This analysis suggests a 7% reduction in the RTC staffing (compared to the initial workforce pan) should be achievable, and a 14% reduction in the UCC staffing. At this stage no attempt has been made to understand how these reductions could be achieved in terms of changes to shift patterns, etc. GPOOH staff have been excluded from this analysis. As such three financial options were costed for comparison, as illustrated in figure 19. The different approaches show a consistent level of savings, which reinforces the bottom up approach taken in the work force planning process. The options suggest that the order of magnitude of savings is approximately 1m. Figure 19 Summary of Work Force Options Option Provider Provider Savings ( ) Savings (WTE) 1 Work Force Plan 1,054k % Reduction 1,069k Minimum Patient/Staff Ratios 992k Work Force Peer Review A work force workshop was held with representatives from each of the work force planning groups. A detailed discussion of the work force plans provided clarity on the integrated model and a number of challenges were raised to build understanding of the model and to dispute the level of savings. The constraining factors were also considered, in particular training requirements for medical staff which limits the level of savings achievable within the TRC due to the high level of interdependency between SpR, SHO and consultant capacity. A finalised and agreed work force plan emerged from the workshop for the base case activity levels. A key objective of the work shop was to identify further savings that could be released if activity levels reduced further. Core staff and activity related posts were identified for each work force plan and assumptions have been made to determine the reduction in attendances that would be needed to release these additional posts. This is considered to be the stretch case Stretch Case The stretch case has been developed based upon assumptions made in the work force workshop regarding activity related posts. The stretch case includes the reductions in attendances identified in the best case and forms the basis for determining further savings in Phase 2 of the project. The following posts have been identified as activity related posts which manage surges in demand: Band 8A 1pm to 9pm Page of 127

53 Band 7 (ENP) 10 am to 6pm Band 5 10am - 6pm & 6pm 2am : Assumptions have been made regarding the additional capacity these posts provide, which are listed in the assumptions in section 5.2. It is estimated that these posts manage approximately 16,380 patients. Consequently for the stretch case a reduction in attendances of 23,235 is required to release further costs, this includes the reductions from the best case activity model. Administration support could also be reduced if activity levels reduce to stretch case levels Work Force Summary The work force plan defines the staff requirements for the integrated UCC and TRC model and assumes the base case levels of activity. The resources outlined are for phase 1 of the project, however, to secure further savings attendance reductions, exceeding the level anticipated in the best case, must materialise in phase 2 of the project. It should be noted that the work force plan identifies staff reductions, however, the actual activity within the UCC, TRC and PANDA exceeds existing A&E activity levels. Therefore, the staff reductions outlined have been achieved with the increase in activity and will also support a 24/7 service. The outcomes of the PDSA work will help to identify anticipated deflections. For Phase 1 of the proposal the WTE for the existing services and proposed services are shown in figure 20. For phase 2 of the project the reductions in attendances identified in the best case must materialize and the attendance reduction estimated for the stretch case (as described in section 4.7.9), only when the stretch case activity levels are reached could a further layer of staff be released as shown in figure 21. The figures illustrate the changes in WTE and the basis for the finance model. Each set of rotas for the various staffing groups have been agreed with HR and therefore meet EWTD guidelines and have been also been agreed with the staff. Page of 127

54 Figure 20 Phase 1: WTE for Existing and Proposed Model (Base Case staff levels) Staff Group Proposed WTE Total Existing WTE Total A&E WiC GP OOH Medical Consultant SpR SHO GP Total Change %) -5.3 Nursing Band 8A Band Band Band Band Band Band Edcuation Posts Total Change (%) Admin/Support Reception Reception Reception Medical Secretary Medical Secretary Domestic Total Change (%) GP OOH GP Band Total Change (%) Page of 127

55 Figure 21 Phase 2: WTE for Existing and Proposed Model (Stretch Case staff levels) Staff Group Proposed WTE Total Existing WTE Total A&E WiC GP OOH Medical Consultant SpR SHO GP Total Change %) -5.3 Nursing Band 8A Band Band Band Band Band Band Edcuation Posts Total Change (%) Admin/Support Reception Reception Reception Medical Secretary Medical Secretary Domestic Total Change (%) GP OOH GP Band Total Change (%) Page of 127

56 5 Financial Appraisal The financial appraisal describes the level of savings anticipated for the UCC and RTC project. Savings have been expressed as provider savings and commissioner savings. To determine the level of savings for the project the existing cost of the urgent care systems as outlined in the virtual budget has been used as a baseline. Savings have been identified for the two phases of the project using the two work force plans described in section 4. A number of assumptions have been listed to illustrate the basis for the savings and areas where further refinement is required. In addition implementation costs have been captured which will support the implementation phase of the project. The summary tables outlined in the section are supported by detailed information in appendix Finance Baseline The table below shows the baseline cost of operating both the current Accident & Emergency department at SRFT and the Walk In Centres / GP Out of Hours Services across the Salford health economy (as referenced in the virtual budget which supports the commissioner and provider intentions for financial arrangements in the future). Figure 22 Provider Forecast Baseline Costs for 10/11 Provider Service / Department Direct costs SRFT SRFT SCH SCH SCH Emergency Medicine Providers - Forecast Costs 10/11 Indirect costs Overheads TOTAL A&E 4,564,315 2,803,354 1,690,513 9,058,182 Panda Unit 2,140, , ,510 2,898,674 GP Out of Hours 1,353, , ,642 1,725,345 Walk in centres - Pendleton & Little Hulton 752,304 56, , ,188 Darzi Walk in Centre Canalside 362,500 27,188 72, ,188 Sub Total Emergency Medicine 9,173,046 3,282,905 2,647,626 15,103,577 Page of 127

57 5.2 Full Cost Analysis A summary of the savings for Phase 1 and 2 of the project are shown in figure 23. Direct and indirect costs have been considered in the cost analysis, however, overhead costs have been excluded as these are being reviewed by other organisation wide initiatives The activity levels for each phase are included within the summary table which highlights the reduction in attendances required in order to deliver the savings outlined. For Phase 1 of the project 1.05m of savings are identified which correlates with a reduction in attendances of 34,795 if the best case activity levels are assumed. To move from Phase 1 to Phase 2 there would need to be a further reduction of 23,235 attendances within the UCC and TRC to enable a further 620k to be released. If the stretch case in Phase 2 is realised then the project could deliver 1.67m savings. This represents 13.34% of the indirect and direct cost baseline. Figure 23 Summary of Cost Analysis for Phase 1 and 2 PROPOSED CONTRACTING METHODOLOGY - UNSCHEDULED CARE BASELINE - PROJECT COSTS 2010/11 Provider Service / Department Direct costs Indirect costs Overheads TOTAL ACTIVITY (including GP OoH)** ACTIVITY (excluding GP OoH)** SRFT A&E - Adults only 4,609,543 2,848,582 1,690,513 9,148, SRFT A&E - PANDA 2,140, , ,510 2,898, SCH GP Out of Hours 1,353, , ,642 1,725, SCH Walk in centres - Pendleton & Little Hulton 752,304 56, , , SCH Darzi Walk in Centre Canalside / PCC 362,500 27,188 72, , TOTAL BASELINE COST 9,218,274 3,328,132 2,647,626 15,194, PHASE 1 - REVISED MODEL OF UCC / R&TC* 8,164,714 3,328,132 2,647,626 14,140, SAVING AGAINST BASELINE 1,053, ,053, PHASE 2 - REVISED MODEL OF UCC / R&TC 7,621,061 3,251,609 2,647,626 13,520, SAVING AGAINST BASELINE 1,597,213 76,523-1,673, PHASE 2 - ADDITIONAL SAVINGS TO PHASE 1 543,653 76, , PHASE 2 : SAVING - AGAINST BASELINE DIRECT & INDIRECT COSTS 13.34% Capacity - full REVISED MODEL OF UCC / R&TC - COST AT FULL CAPACITY 8,164,714 3,362,286 2,647,626 14,174, based on costs above The full cost analysis is based upon the following assumptions: Assumptions 1. No change to PANDA costs 2. Indirect costs for all providers remain the same for Phase 1 3. Overheads relating to WICs and GP OOH are non releasable except for 11,640 rental charge for Pendleton WIC Page of 127

58 4. Triage remains as present with Band 7 nurse present at all times (24/7 and 365 days per year) 5. Activity levels for the activity related posts are based upon the following assumptions: a. ENP role sees patients 5hrs per day at 3 patients per hour = 5,460 patients pa b. ANP activity is linked to band 5 activity and both band 8A and 5 posts will see patients 10 hrs per day at 3 patients per hour = 10, 920 Therefore capacity reduction is estimated at 16,380 patients per year. 6. Call Centre support from Ashton, Leigh and Wigan in relation to GP OOH remains unchanged 7. Non pay for new UCC and R&TC is proportional to current attendances at A&E and WICs 8. Management costs for all areas are currently unchanged 9. No additional security costs required to those presently paid for A&E cover at SRFT 10. The resource identified is modelled on the activity levels at base case. Further savings have been identified based upon identification of core posts and activity related posts during the Work Force Workshop. However, moving from Phase 1 to Phase 2 staffing structures is dependent upon deflections converting to reductions in attendances 5.3 Implementation Costs In order to facilitate the development of the UCC and TRC and realise the potential savings there are a number of implementation costs. IM&T Implementation Costs The costs outlined are for the interim IM&T solution. The costs for a long term have not been included in this business case and will be subject to a future IM&T business case. o The bespoke work required to develop the Medisec form is 10,000 however this is current included within an existing project so would be at no additional cost. o Additional IM&T support is not required due to the transfer of support from NHS Salford as part of the TCS changes. o Additional storage capacity to support the increase in activity is dependant on another project so no additional funding is required to support this. o 5 additional PCs will be required within the UCC to support the interim solution at a cost of per PC. Total IM&T Costs = Training Implementation Costs To ensure staff are trained in providing the new urgent care service and articulating consistent urgent care messages across Salford staff training will be required. Whilst much of this training will be delivered in house by the Trusts Learning and Development team and through shadowing and cross organisational working, it is anticipated that some external courses will be required. Initial costs include: o Prescribing course for UCC staff = 25,000 (25 staff at 1k per member of staff) o Conflict Resolution style training = 7,500 Page of 127

59 Communication Material Supporting literature will be required to reinforce the deflection messages. A budget of approximately 10k will be needed to provide material locally in collaboration with the NHS Salford Communication team. Triage Costs During the first few months of the project commencing with the closure of the WiCs and the opening of the new UCC and TRC facilities it is prudent to ensure there are sufficient staff triaging patients at the front door of the UCC. As such an additional band 7 triage nurse has been proposed to support triaging and deflection of patients on the front door for the first 6 months. This resource may require review during the first few months, however, if there is a surge in attendances the additional resource will be needed to ensure deflection rates remain sufficiently high. The cost of providing 6 months of a 24/7 triage nurse is 170k. Alternatively, a band 7 triage nurse could provide support in the UCC during peak hours only 7 days per week at a reduced cost. GP Costs Similarly, during the first few months of the project input from Salford GPs in developing and embedding thresholds and supporting the UCC development. Assuming a GP supports the UCC 1 day per week (and 8hrs per day) for the first 6 months operation then the cost would be 15,600. Signage and Estate Costs These costs are to be confirmed during the implementation stage. Implementation Project Manager The cost of a project manager has been included in the implementation costs as whilst existing operational staff will continue to be involved in the project it is acknowledged that a dedicated post is needed to implement the new model. A band 7 project manager for 12 months would cost 43,275. It should be noted that the implementation costs do not include any HR costs that may arise from the development of the UCC and TRC. The total implementation costs are estimated at 275k. 5.4 Commissioner Finance This section provides information on NHS Salford spend on current services and the impact of future redesign for those services within the scope of this project. So this specifically excludes current unscheduled care services at other Trusts but includes the cost impact of redesign on all services where known. Current Contracting Arrangements - Baseline Figure 24 shows NHS Salford s budget for those services within the scope of this business case and contracted activity levels. The A & E contract is based on PbR national tariff with a local tariff in operation for patients receiving triage only and the PANDA contract is a cost per case contract. Page of 127

60 The SCH contracts are all on a block basis i.e. a set financial envelope. The funds identified from the relocation of the Canalside walk in service have been transferred to the unscheduled care budget. Figure 24 NHS Salford Contract Forecast & Plan Urgent Care Services Activity Plan 2010/11 Budget 2010/11 000s Forecast Activity 2010/11 Forecast Actual 2010/11 000s SRFT A&E (Adults) - HCA 15,591 1,930 22,585 2,795 - STDA 28,210 2,596 10, MIA , A & E Triage 11, , Subtotal A & E 55,487 4,677 53,795 4,818 PANDA Attendances 18,000 2,707 16,902 2,541 WICs 30, , GPOOH 31,506 1,563 31,506 1,563 PCC/UCC phase Canal Side Walk in Facility (to 31/8/10) Total 135,863 10, ,073 10,290 Note Forecasts are based on month 7 data. No contract activity information is available for SCH services so forecast has been assumed as plan. HCA=High cost attendance, STDA=Standard attendance, MIA=Minor Attendance PCC budgetrecurrent includes non recurrent funding of 182k Current Financial Performance The PCT is currently forecasting over performance on these budget areas of approximately 59k for the year mainly. The annual budget for the PCC includes 211k non recurrent funding, recurrently funding has been assigned to the urgent care centre phase 1 from the relocation of the Canalside walk in facility and NHS Salford has added 71k to the recurrent budget to fund the budget deficit. It should be noted that there are some case mix variances against plan. Some explanation for this is that plan was based on 2009/10 out-turn; and it was recognised that a sizeable volume of attendance activity that was coded as standard in 2009/10 should have been coded as minors Future Contracting Arrangements The intention is to introduce a new contracting structure from 1 st April 2011 which will span the financial years 2011/12 to 2013/14. The contract proposal is a commitment based contract agreement (core block) with clear rules around adherence to pathways, thresholds and demand management. Page of 127

61 The services in the scope of this business case would be included in this block arrangement and the commissioning assumption is that the PCT core payment would be based on the plan less its share of expected provider savings. Agreement needs to be reached on the distribution of the provider cost reductions between the partner organisations. Work is in progress to: Calculate the core staff and the staff that are activity related, i.e. w.t.e. could be increased or reduced to match capacity requirements, by grade and service. Produce stepped costs for each change in physical capacity and calculate the activity that can be delivered within each of these steps. This work will provide the detail towards the agreement required to manage and share financial risks. As there is no firm agreement on this proposal, two scenarios for commissioner savings have been used in the business case. These are explained in Impact of Service Redesign on Commissioner Costs Scenario 1 shows the impact should the contract with SRFT retain PbR for the activity within the scope of this business case i.e. based upon an activity X tariff methodology. It should be noted that the operating framework for 2011/12 has been published recently which mandates an overall reduction in the 2011/12 national tariff by 1.5% and HRG 4 will be used for A & E. These changes have not been assessed and therefore have not been factored into the savings figures, which may be overstated. Scenario 2 is based on the principles of the proposed local contracting methodology for those service areas within the scope of the Integrated Care Redesign Partnership Board. The contract proposal is a commitment based contract where parties agree to planned levels of activity within a set funding envelope, share the financial risk of increasing activity and costs and work together to implement more efficient and effective pathways; treating patients in the most clinically appropriate and cost effective setting. The assumption in this scenario is that the core payment will relate to a given capacity for those services within the redesign programme and that stepped costs are calculated to provide thresholds which trigger additional physical capacity and cost. The detail on how the financial risks would be mitigated and shared is still to be agreed so no assumptions have been in this regard. There is an assumption that the commissioner will realise cost reductions relating to these redesign cases as the actual costs are released. No agreement has been made with regard to how these cost reductions will be shared between partner organisations. So in the absence of any agreement scenario 2 estimates the NHS Salford share of cost reduction savings at 25%, 50%, 75% and 100% of saving. It is also assumed that other PCT commissioners will continue to pay under PbR however this will change as PCT organisations and functions reconfigure. Page of 127

62 Contract Scenario 1 Current contracting within PbR Figure 25 below shows the anticipated activity in each of the new service areas using the most likely, best and worst case activity modelling. Figure 25 Contracting Scenario 1- Impact on Commissioners Scenario 1 - Tariff Based Approach All activity Most Likely Case Best Case Worst Case Activity Cost Activity Cost Activity Cost R&TC - HCA 26,134 3,234,326 26,134 3,234,326 26,134 3,234,326 - STDA 3, ,619 3, ,619 3, ,619 Subtotal 29,216 3,517,945 29,216 3,517,945 29,216 3,517,945 PANDA 16,637 2,500,874 16,637 2,500,874 18,485 2,778,665 UCC - STDA 10, ,921 10, ,921 10, ,921 - MIA 34,146 2,131,044 27,291 1,703,224 46,252 2,886,580 - A & E Triage only - MH Liaison 1,080 13,662 1,080 13,662 1,080 13,662 Subtotal 45,701 3,108,627 38,846 2,680,806 57,807 3,864,162 GPOOH 31,506 1,734,672 31,506 1,734,672 31,506 1,734,672 Subtotal SRFT based services 123,060 10,862, ,205 10,434, ,014 11,895,444 A & E (Bolton) - MIA 1, ,100 1, ,100 3, ,713 General Practice 16, , ,887 0 Pharmacy 1, , Other 4, , ,222 0 Self Care 1, , Dental 49 1, , Total 147,543 10,967, ,542 10,539, ,797 12,094,860 NHS Salford impact 82% estimate SRFT activity 9,664,102 9,313,289 10,631,750 Projected cost /(saving) ( 567,234) ( 918,047) 400,414 The optimising pathways project has identified the A & E resource usage for patients in the scope of its project, these amount to 357k p.a. This project is assuming a 35% reduction in activity by the third full year, but these savings have been excluded from that project to avoid double counting. These would be in the region of 125k in addition to those above. Assumptions 1. Trauma and resuscitation activity assumes majors will be same as 2009/10 and balance will be standard. (NHS Salford activity case mix is based on 2010/11 month 7 forecast.) 2. Urgent care centre activity assumes the same level of standard attendances as 2009/10 less those seen in T & RC. (NHS Salford activity case mix is based on 2010/11 month 7 forecast.) 3. The number of anticipated MH Liaison patients that are now triage only has been estimated at 90 per month and shown separately. The balance is minors. 4. Case mix detail by commissioner hasn t been provided so this is a blanket estimate based on current proportion of total activity. Page of 127

63 5. The activity modelling assumes that a percentage of Little Hulton activity will access Bolton A & E services so these have been assumed as minors. 6. PANDA as 2009/10 for all commissioners less 10% in best and most likely assumed will take place in UCC. (NHS Salford activity forecast) 7. All GPOOH activity is NHS Salford. Contract Scenario 2 Proposed contracting framework Figure 26 below shows the estimated provider cost reduction in phase 1 of 1,054k and phase 2 of 1,638k with scenarios for the potential NHS Salford share of savings at 100%, 75%, 50% and 25% share of savings. This is the gross saving as there is also a cost impact on other non SCH services of phase 1 199k and phase 2 105k (mainly Bolton A & E). That gives a best case scenario saving of 949k in phase 1 and 1,439k in phase 2 with 100% share of savings; at 50% share this would reduce to 527k at phase 1 and 819k at phase 2. Figure 26: Contracting Scenario 2- Impact on Commissioners NHS Salford Impact - Scenario 2 - Contracting Proposal (commitment based contract) Phase 1 Phase 2 000s 000s Provider Planned Cost Reduction (1,054) (1,638) Increased Commissioner costs Net projected cost / (savings) (949) (1,439) NHS Salford share of planned provider savings 100% (1,054) (1,638) 75% (791) (1,229) 50% (527) (819) 25% NHS Salford Affordability (264) (410) Figure 27 below summarises the available funding and impact of each of the contracting scenarios showing the current position and the impact of the redesign by best, most likely and worst case impact. The 2010/11 forecast position for NHS Salford is 59k over budget. Page of 127

64 Figure 27 NHS Salford Affordability Current 2010/11 000s Best Case 000s Most Likely Case 000s Worst Case 000s NHS Salford Affordability Funding NHS Salford Budget 10,231 10,231 10,231 10,231 Contracting Scenario 1 Projected costs 10,290 9,313 9,664 10,632 Projected pressure/ (surplus) 59 (918) (567) 400 Contracting Scenario 2 Projected costs 10,337 10,337 10,431 Share of Provider Savings (1,638) (819) (264) Projected pressure/ (surplus) (1,533) (714) (64) This table shows the surplus that may be achieved in each activity scenario: best, most likely and worst case for each contracting scenario. For contract scenario 1: the current contracting regime. It shows a maximum surplus of 918k at phase 2 activity levels i.e. best case. On contracting scenario 2 the share of actual savings between each organisation hasn t been agreed so these are estimated. Best case is shown at 100% of phase 2 savings, most likely is shown as 50% share on phase 2 savings; and worst case is 25% of phase 1 savings. The overall target cost reduction for the integrated care redesign programme was 15%; the best case scenario is estimated to achieve a provider cost reduction of 1,638k with a net saving of 1.533k i.e % overall savings on the total NHS Salford plan. The best case scenario achieves the target 15% reduction, but contractual agreement still needs to be reached on the distribution of these savings. Page of 127

65 6 Recommended Option 6.1 Proposal The proposal is to implement a co-located and integrated UCC and TRC that can respond to the urgent secondary care needs of local patients. The model seeks to reduce attendances within the urgent care system by challenging existing thresholds for managing patients and ensuring patients with self limiting minor conditions and primary care needs are deflected to primary care and self care. 6.2 Implications of the Proposal The proposal will affect a number of stakeholder groups including patients, staff, clinical services and supporting infrastructure. Patients Staff Improved pathways of care as services are integrated therefore less risk of communication breakdown between services Access to the most appropriate Health professional according to need Opportunity to have their urgent care needs met and be followed up if required at home by an integrated team of health professionals Reduced numbers of access point for Walk In patients may inconvenience patients in some parts of the city, however this may be off-set by improved access to Primary Care All elements of Community Unscheduled Care delivered and managed from a single point therefore less confusion for patients and referrers. Need to ensure a robust education and communication plan is developed for patients to change their behaviour in managing minor self-limiting ailments Possibility of redeployment or redundancy issues for some staff Opportunities for staff to extend their skills Re-design of service would impact upon their current working arrangements Need to ensure that the Clinicians have and continue to maintain a primary care focus and are encouraged to signpost patients to their own GP and where possible to self-management Need to ensure that staff are appropriately skilled in the recognition of urgent care needs that may need more specialist input from secondary care Need to ensure that all staff involved in triaging and streaming of patients have the necessary training to ensure consistency. Training for patients facing staff to support them in deflecting patients to self care, pharmacy or primary care. Other Clinical Services Integration of some elements of community services into this facility may impact upon key relationships with other services (e.g. Rapid Response relationship with other areas of Intermediate Care) Page 65 of 127

66 Potential for increased referrals into other services as patients are deflected from secondary care into community services. This will require robust care pathways to be agreed Reduced admissions to secondary care Care pathways and relationships with Specialist Services e.g. Palliative Care and Community Matrons would need to be developed to maximise deflections Care pathways into secondary care services will need to be developed to ensure that patients requiring more specialist input are transferred without disruption or delay Clinicians working within the Urgent Care Centre will need to be able to access diagnostics Direct Booking of patients into appointment slots with their own GP is required to support this model Other Stakeholders Relationships with Salford City Council need to be considered in relation to Social Care services that are provided to the client group served. Protocols and pathways need to be developed with the ambulance service to maximise deflections Protocols and pathways need to be developed with secondary care to prevent any delay in patients accessing the appropriate treatment Care pathways and protocols will need to be developed with GM West Mental Health Trust for relevant patients The impact of this project on A&E attendances at hospitals outside Salford will need to be monitored, especially at Bolton as removing the Little Hulton Walk In Centre may impact on this activity and have financial implications for Commissioners Approximately 18% of SRFT A&E attendances are patients that are not registered with a Salford GP. Mechanisms for cross border charging for these patients will need to be established Continuity of Service During the implementation phase of this project dual running of services may be required to ensure a smooth transition; this would have a financial impact. A phased approach to the closure of the Walk In Centres will be required to coincide with improvements in GP access Care pathways agreed as part of the other Unscheduled Care projects (Frail Elderly, Palliative Care, Frequent Flyers) will need to be phased into the service redesign process so that this additional activity can be fully accommodated Pathways and protocols for referral between the Urgent Care Centre into SRFT will need to be agreed IM&T The Urgent Care Centre will need a fully integrated Community and primary care IT systems as well as SRFT systems. Access to Social Care IT systems would also be of benefit The ability to transfer information electronically to GP s will be required Page 66 of 127

67 The information governance issues related to this data sharing will need to be agreed Telephony A call handling facility for telephone triage and advice is required. The amalgamation of a number of telephone access points for Community Unscheduled Care is required Estates The availability of suitable accommodation on the SRFT site is crucial to the success of this project. The current redevelopment of the site may therefore impact upon the timescales. Closure of the Walk In Centres will realise savings on Estate costs. 6.3 IM&T Implications The IM&T project requirements have been captured by the IM&T sub group. An IM&T Requirements Specification has been developed that captures requirements for all of the Urgent Care projects but focuses on the development of the UCC and R&TC. In order to meet the pressing timescales of the UCC and TRC the development of an IM&T solution has been phased as an interim solution and a long term solution. The former has been assessed with the long term solution to be progressed in early The functionality of existing solutions available within the partner organisations has been reviewed. A series of options based on these existing systems were developed and assessed against the requirements specification and process maps. o Option 1 isoft s Patient Centre A&E Module (PAS) & Medisec Electronic Documents Utilisation of existing isoft Patient Centre (PAS) supported by the paper CAS card process currently in operation in SRFT A&E. Expansion of user base by 18.3 WTE and an increase in activity by 53,000 patient s attendances per year. Development of Medisec Electronic Documents to enable electronic transfer of documents to GP practises. Booking of GP appointments to be made by telephone to GP practises. GP Out of Hours to continue using Adastra in line with current model. o Option 2 Advancing Care Adastra Expansion of the existing Adastra system currently in operation in SCH Walk-in- Centres and GP Out of Hours to include the Urgent Care Centre and Resus & Trauma Centre. o Option 3 Do Nothing Make no change to current systems. A full analysis of the three options 31 was carried out with Option 1 identified as the recommended option. Following assessment against the requirements specification and process maps option 1 isoft s Patient Centre A&E (PAS) module has been identified as the most appropriate of the existing solutions available in the organisation. 31 Integrated Care Partnership, IM&T Options Appraisal, (M Neve, 2010) Page 67 of 127

68 Alternative existing solutions have been considered but rejected due to the lack of integration to SRFT s current PAS system which would require significant staffing resource and financial cost to interface additional systems to the SRFT PAS and EPR. The isoft A&E Patient Centre (PAS) software is already deployed at SRFT with a modular licence so no additional licences are required to expand the user base. Associated IM&T Risks isoft Patient Centre (PAS) currently has limited data storage capacity there is a risk that increased record in isoft Patient Centre (PAS) might result in increased utilisation of current available storage capacity. If this exceeds current capacity isoft Patient Centre will cease to be able to operate. Further storage capacity and resilience will be implemented as part of the Itanium project which is currently awaiting additional funding approval and is expected to be delivered by July Development of a new electronic UCC discharge letter is dependant on Medisec delivering the requested configuration changes to Medisec on schedule as part of the GP Communications project this work is scheduled to be delivered by April Should unforeseen changes be made to the current triage process additional configuration within isoft Patient Centre/PAS may be required which could result in additional financial costs. 6.4 Economic Case The NHS is tasked with releasing billion of efficiency savings over the next four years through the QIPP programme. The level of these savings is unprecedented in recent times and follows a background of financial growth and investment in a demand led environment. Locally Salford has invested in extra capacity within unscheduled care services, but demand continues to rise and capacity filled. NHS Salford must achieve its required efficiency savings to be able to meet its financial targets and be able to invest in prevention programmes that address the longer term economic problems. This business case aims to release actual costs that will go towards the overall programme target of 7.2m; and importantly educate patients in self care and when it is appropriate to see a health professional. Revenue implications for the full implementation of the business case are detailed in section 5, financial. No trajectories have been done for future years growth. The background to the programme is given in the paper A new approach to managing and delivering unscheduled care and chronic disease management within Salford Dr M.Burrows. 6.5 Value for Money Current VFM Currently the majority of spend within the scope of this business case is under the PbR tariff and as such may be deemed as VFM when benchmarking against other acute spend. However patients are being seen in secondary care when it would be more appropriate for them to be directed to other services or to self care. In this Page 68 of 127

69 respect current services do not deliver optimum value for money. The PANDA service is on a cost per attendance local tariff, further work will be done on this within the programme to integrate workforce and achieve the most effective use of resources possible. The SCH urgent care services are delivered under a block contract; however the WIC on a pure price per contact basis seems to deliver VFM; and GPOOH has been benchmarked favourably alongside other PCT commissioned out of hours services. The former primary care centre pilot was funded on a non recurrent basis and has not reached the levels that would make the service cost effective. Within the past twelve months levels of triage have dropped further and this service cannot be deemed to be VFM. Future VFM The future model reduces the number of access points and capacity removing possible patient duplications in the system, thereby reducing activity. The communications work stream will support the programme in promoting long term change in patient behaviour which is key to future delivery of urgent care services i.e. laying foundations for further work in the future in other areas by managing patient expectations. It will implement changes to the current triage system developed from the combined knowledge and experience of primary and secondary care clinicians. This aims to ensure that only those patients who are clinically appropriate to be seen in the hospital urgent care services are triaged through and others are referred to the most appropriate service or given self help advice. Phase 2 of the programme is achievable and can deliver significant savings towards the QIPP programme. If this redesign did not go ahead the only other alternative would be to close access points in a less managed and integrated way. 6.6 Project Risk Assessment The risks to the project have been rated as to the potential impact and likelihood of occurrence. They are presented overleaf along with the mitigating actions to minimise the risks identified. Page 69 of 127

70 Project Risk Assessment Risk The project will not deliver the required activity reductions and demand for urgent care will continue to rise. Influencing Factor Inability to sustain collaborative working across Primary and Secondary care. Inability to secure sign up of all health professionals to a consistent message of self management and use of alternatives. Likelihood (H,M,L) L L Impact (H,M,L) H H Mitigation Organisational sign up to the Partnership Board Collaborative Organisational Model agreed (Mutual System Partnership Joint Venture) Education Programmes PDSA Cycles to monitor and embed this practice. Inability to influence public behaviour on self management of minor ailments. H H Public education programme Education of staff Inconsistencies in Primary Care provision M H Primary Care Access Project GP Sign up to deflecting urgent primary care patients to GP practices M H Work with GP access project to secure support PBC support to ensure that this is facilitated Community Services capacity to respond to patients urgent care needs. M M Engagement of clinical and service leads to ensure access is available. PBC influence on revising service specifications for community services Activity is deflected to neighbouring secondary care M M Establish a collaborative approach across Greater Manchester through the Urgent Care Page 70 of 127

71 organisations network. Establish baseline and monitor impact, taking action if this issue is realised Telephone Triage of GP OOH patients by wider pool of staff creates inconsistencies and increases home and base visits M M Staff training in GP OoH telephone triage Consistent triage for GP OoH and UCC to identify primary care routine/urgent patients Early integration of GP OoH into A&E to support collaboration and establish consistent approach for primary care patients Year on year rise is modelled at 0% H M Surge in activity at UCC anticipated on closure of WiCs: staged approach, consistent messages, collaborative working and additional triage resources will be used to manage peaks in demand Existing staff are managing any increase in year in year demand The Christie at Salford patients attend SRFT A&E, increasing activity for TRC compared with 09/10 baseline M L The Christie patient activity in A&E to be monitored Patients to be provided with after care information for emergencies The triage tool is risk averse and does not deflect patients to the most appropriate services e.g. primary care. This will increase the activity and put pressure on capacity. It will also fail to address the longer term self care education. L H Primary care and secondary care agreement on the appropriate triage tool and modifications to tool. PDSA work to set and review at frequent intervals. Performance indicators to monitor triage outcomes Delay in implementing the Inability to retain sufficient L M Communication mechanisms established Page 71 of 127

72 new service delivery model will impact upon the ability to achieve savings numbers of experienced staff. Constraints of existing accommodation. M M Skills sharing programmes developed HR involvement to support Amendments can be made to existing working practices prior to accommodation becoming available. Capacity of the IM&T Departments to provide the necessary support to integrate IT systems. H H IM&T workshop to prioritise this activity. On-going development of long-term solution Managerial capacity for implementing the business case. L M Build capacity into the implementation plan. Early engagement with relevant service managers to secure their full support. Implementation of the new model will impact negatively on organisational reputation Capacity of the Estates and IM&T Departments to support the development of a call centre facility. Public perception in relation to Walk In Centre closures. L M M M IM&T workshop Early engagement with relevant managers to secure their support and build into existing work programmes Patient engagement plan Patient education and communication strategy Potential to fail on national targets during the transition phase. M H Robust performance monitoring arrangements in place. Additional triage support identified Phased implementation Changes in local, national or regional policy may impact Quality of care adversely affected during period of change L M National directives in relation to the responsibility for M M Robust performance monitoring arrangements in place. Work with PBC to secure support that minimises the impact that this may have on Page 72 of 127

73 upon the proposed service delivery model and reduce the ability to maximise efficiency savings. delivering GP Out of Hours Services being returned to local GPs. Developments in regional trauma centre plans L L the new service delivery model. Co-ordination of urgent care plans across the region to be led by key partner organisations and to ensure changes are discussed at a GM level using existing urgent care networks. Rationalisation of urgent care services in Greater Manchester M M Engagement with GM trusts through urgent care networks Page 73 of 127

74 6.7 Financial Risk The high level financial risks are outlined: Risk Provider cost reductions will not be achieved Additional costs are required for implementation and will impact on savings for year 1. The partner organisations do not reach agreement on the contracting proposal and/or estimated stepped costs do not accurately reflect actual. Workforce plans have reductions in staff and may incur HR and learning and development costs Mitigation Assumptions on activity deflections linked to workforce requirements have been reviewed. Further work is planned to scrutinise assumptions with patient behaviour reviewed following staged service changes IM&T scoping will identify any IM&T costs Project Implementation costs identified in the business case Partners working closely on the detailed costs and impacts of the scheme. Directors of Finance of each organisation to lead. Workforce plans to incorporate the planned changes and appropriate training for alternative posts to be provided. Page 74 of 127

75 7 Project Management Arrangements 7.1 Purpose In order to progress the proposals outlined within the business case it is necessary to establish the Governance structures to oversee the implementation plan and to move into full operational management of the service. The Integrated Care Programme Board has previously approved the establishment of a Mutual Systems Partnership arrangement as the organisational model. This includes the establishment of Committee structure. The Committee will have representation from: SRFT(clinical and operational management representatives) Salford Community Health (clinical and operational management representatives) Salford GP S (2 representatives) The committee will in the first instance oversee the implementation of the business case for the development of the Urgent Care Service and as the service becomes fully operational will oversee the operational management. It is proposed that this Committee is identified as the Operational Steering Group for Salford Urgent care Service. It will ensure that Salford s new Urgent Care Service operates within the spirit of the Partnership agreement established in relation to delivery of unscheduled care services between: Salford Royal Foundation Trust Salford Community Health Salford GPs NHS Salford Salford City Council North West Ambulance Service Greater Manchester West Mental Health Trust The Operational Steering Group will report by exception to the current Integrated Care Programme Board for as long as the partnership remains in existence Members of the Programme Board will nominate relevant representatives to attend and the current Project Steering Group will take responsibility for developing the Terms of Reference and drafting a memorandum of understanding. The Operational Steering Group will be established by the end of January Leadership The development of this business case has been sponsored by the Managing Director of Salford Community Health as Executive Sponsor and developed jointly by the Associate Director of Partnerships, Salford Community Health and Commissioning and Business Development Manager, Salford Royal Foundation Trust. A Project Steering Group comprising of representatives from all partner organisations has been instrumental in supporting the development of the business case. Clinical Leadership for the project has been provided by the A&E Clinical Director and the Practice Based Commissioning Lead for Urgent Care. It is anticipated that Page 75 of 127

76 this level of Clinical Leadership will be sustained throughout the implementation of the proposal to ensure full clinical commitment. Leadership to ensure full Implementation of the business case will be provided on collective basis by the Operational Steering Group outlined above. Implementation will require actions to be completed by a range of personnel currently employed across the Urgent Care System. Ideally a nominated Project Lead is required to co-ordinate and monitor implementation of the business case. Additional costs for this role have been included in the implementation costs. However a secondment opportunity for an individual to undertake this role may be a more cost effective option. 7.3Project Plan The implementation strategy, approved by the Integrated Care Partnership in July 2010, is a stepped approach supported by iterative Plan Do Study Act cycles. In the development of the business case a number of PDSA cycles have been designed and scheduled to take place from the end of October The implementation relies upon the existing providers working collaboratively to have a joint approach to realising the proposed work force plan. A key underpinning principle for implementation plan is to sustain any positive changes that develop from the PDSA work. It is essential that new working practices are embedded over the next 12 months to ensure the move to the new Emergency Village building at SRFT is not exposed to any operational risks Outlined below is a summary of the actions required to fully implement the new Urgent Care Service for Salford. Further detail to underpin these actions is included in the timeline for implementation (overleaf). Develop and implement streaming tools, care pathways and thresholds for referral Relocation of current community facilities Implement the IM&T requirements Implement the Estates requirements Establish the Organisational Model for the UCC Establish the operational arrangements to support implementation of the organisational model Develop the Workforce Public and Stakeholder communication plans Page 76 of 127

77 Proposed Timeline for Implementation of the Urgent Care Service Business Case Month/ Year Milestones Preparation Communications December th Public Engagement Closes Prepare for GP OoH move to Agree high level A&E Design process for managing patient messages with project leads GP deflections Identify training needs Develop response to and resources engagement January th for 2 weeks PDSA Cycles to review paediatric attendances Develop PDSA work Business Case approval stages Briefing sessions for relevant staff groups February 2011 PDSA meetings to plan further cycles 9 th Review of Business Case PBC Operations Board 23 rd NHS Salford Commissioning Board Business Case approval stages Establish baseline data Develop PDSA work Implement process for managing GP deflections Gain ICP & PBC approval for deflections 24 th Business Case Approval by ICP March 2011 Duplication audit of patients accessing multiple entry points for urgent care access Review PDSA cycles and develop plans for amending/ reviewing care pathways Review feasibility for GP OoH integration with A&E Agree process for managing GP deflections and criteria for requesting urgent appointments Plan for closure of WiC s April st Vertical Integration SRFT & SCH Provide crib sheet information for staff Training for staff on deflections & conflict resolution Commence Public Communication Promote deflection messages to GPs, A&E, GP OoH and WiCs Communicate key messages to the Page 77 of 127

78 Month/ Year Milestones Preparation Communications Develop PDSA work public Develop care pathway work Targeted Prepare for closure of WiC s communications within Urgent Care services May 2011 June st Commence deflections from WiC, PCC, GP OoH and A&E 1 st Closure PCC WiC Review progress in the development of care pathways, amending protocols as required. Monitor patient behaviour Prepare for closure of PCC/Canalside Identify and plan for any associated staff training arising for new care pathways Prepare for closure of Little Hulton WiC Staff training Promote deflection messages to GPs, A&E, GP OoH and WiCs Communicate Key messages to Public Staff training Feedback to GPs on success of Urgent care deflections Promote deflection messages to GPs, A&E, GP OoH and WiCs Feedback to GPs on impact of PCC/Canalside closure Target Key messages to Little Hulton residents re: impending closure Staff training July st Closure Little Hulton WiC* Monitor patient behaviour Promote deflection messages to GPs, A&E, GP OoH and WiCs Page 78 of 127

79 Month/ Year Milestones Preparation Communications Feedback to GPs on impact of WiC closures August 2011 September 2011 September/October 2011 November 2011 April 2012 September 2012 Commence Planning for move to New Build** Review impact of closure of Little Hulton WiC 1 st Closure Pendleton WiC* Duplication audit of patients accessing urgent care services through different entry points Open Emergency Village** Complete integration of GPOOH with A&E Review impact of integration 6 month review of triage role 5 month evaluation Work force review Phase 2 Evaluation Work force review Monitor the impact of implementing new care pathways Monitor patient behaviour Prepare for closure of Pendleton WiC Promote deflection messages to GPs, A&E, GP OoH and WiCs Feedback to GPs on impact of Little Hulton closure Targeted key messages to Public re: Pendleton closure Monitor patient behaviour Promote deflection messages to GPs, A&E, GP OoH and WiCs Monitor patient behaviour Feedback to GPs on impact of Pendleton closure Collate data to monitor impact Make relevant adjustments to the model following this review Complete evaluation report and identify whether further stepped costs can come out of the service. Project Steering Team to lead evaluation Continue with Key messages to the Public Continue with regular feedback to GPs Continue with Key messages to the Public Continue with regular feedback to GPs Page 79 of 127

80 * The exact date for closure of the Walk in Centres is dependent upon the level of deflections and reduction in attendances materialising. The existing A&E department is constrained by available accommodation and will be unable to manage significant surges in attendances, therefore the closure of the WiCs must be staged and informed by patient behaviour. Note that all dates are proposed dates and subject to the outcomes of the public engagement, business case approval and approval from NHS Salford regarding Walk in Centre arrangements **Dates yet to be confirmed for commissioning of new build and opening of Emergency Village on SRFT site Page 80 of 127

81 7.5 Monitoring Implementation of the business case will be monitored by the Operational Steering Group as outlined in section 7.1. The main function of this group in the first instance will be to ensure that the new Urgent Care Service for Salford is implemented according to the agreed implementation plan. The Operational Steering Group will establish smaller working groups to ensure that all aspects of the implementation plan are delivered to the agreed timescales. The Chair of each group will be required to report by exception to the Steering Group within an agreed timescale. In addition, the Operational Steering Group will establish mechanisms to monitor all aspects of performance relating to the Urgent Care Service, ensuring that relevant national and local targets are met. The suggested benefits criteria in relation to this business case are outlined in section 7.7, the Operational Steering Group will ensure that mechanisms to monitor these criteria are established and receive regular reports on progress. 7.6 Reporting The Operational Steering Group will report by exception to the Integrated Care Programme Board for as long as this Board remains in situ. Members of the Operational Steering Group will establish reporting arrangements within their own organisations to ensure that relevant stakeholders are fully informed of progress. It is anticipated that regular progress reports will be required by Practice Based Commissioners, the frequency and process for this will be identified following approval of the business case 7.7 Benefit Realisation Plan The benefits realisation plan is presented overleaf. Page 81 of 127

82 Desired Benefit (include reference to Strategic Plan if applicable) Reduction in cost of Urgent Care Services Stakeholders Impacted Commissioners Providers Salford population Enablers required to realise benefit Establishing the new Urgent Care Service for Salford GP Access project Communication messages promoted by all providers Outcomes displayed if benefit realised Reduced cost of Urgent care Reduced attendances Cashreleasing or noncashreleasing? Value? Phased release of savings over first 12 months as part of Phase 1 and further savings released in Phase2 Current baseline measure Current cost of: A&E Services WiC s GPOOH Who is responsible (must be agreed with person identified) Operational Steering Group Target date (if phased delivery of benefit, please specify Phased savings through 11/12 and 12/13 Maximise capacity of Urgent Care Services by reducing duplication Commissioners Providers Salford population Integrated Urgent Care Service Appropriate IM&T GP Access Reduction in duplicated appointments audit to monitor Non cash releasing Numbers of duplicate presentations across the system Operational Steering Group September 2011 Page 82 of 127

83 Patients seen in the most appropriate place for their medical condition at first presentation. Consistent approach to the assessment, treatment and ongoing management of patients accessing unscheduled care Fewer patients with primary care needs accessing Urgent Care Services Patients Patients Patients Commissioners Single point of entry into the Urgent Care Service Appropriate IM&T GP Access Agreed care pathways to support new Urgent Care Service Patient education Primary Care Access Increased numbers of patients receiving the right care at first presentation. Reduction in complaints Reduced deflections and attendances Improvements in the management of patients ongoing needs. Operational Steering Group? Reduction in the numbers of patients being deflected or redirected Attendances reduce Non cash releasing Non cash releasing Non cash releasing Number of patients presenting at different points within the system. Numbers of complaints Deflection rates decrease as primary care attendances reduce Compliance with pathways monitored by clinical audits Numbers of agreed pathways Current numbers of deflections and redirections Operational Steering Group Operational Steering Group Operational Steering Group November 2011 evaluation To be confirmed April 2012 Evaluation Page 83 of 127

84 7.8 Post Project Evaluation The staged approach to implementation of this business case requires ongoing monitoring of the numbers of patients presenting at A&E following the closure of each element of Community Unscheduled Care Services. The numbers of patients presenting with primary care needs and being deflected back to GP s for their needs to be addressed will be carefully monitored as part of implementation. Mechanisms to feed this information back to GP s will be developed as part of the implementation plan. Evaluation is therefore seen as a fundamental element of the implementation process. It is anticipated that the new service model will facilitate changes in public behavior as patients learn to seek care from their GP in the first instance for primary care needs. A formal evaluation is therefore planned for 6 months after full implementation of the new Urgent Care Service. This is outlined in the Implementation Plan. This evaluation will inform stage 2 of the business case and identify whether activity has reduced sufficiently to enable further stepped costs to come out of the service. Implementation plans to achieve these further savings will then be developed. 7.9 Communication strategy Communication with the Public and wider stakeholders is a key feature which will impact on the successful implementation of this business case. Reference is made in the implementation plan as to how communication underpins each element. Public education and communication of key messages will commence two months prior to any significant changes being made to the urgent care system. The messages will be consistent with the Choose Well campaign that is currently running, however they will be targeted at relevant sections of the local community. The key messages are outlined below: Key Messages for Patients/Public Promotion of self-care options. A&E not for primary care needs. Patient attending A&E who have primary care needs will be re-directed to primary care to ensure resources are dedicated to those who need emergency services. Walk In Centres will close as patients with minor illness will be able to see their own GP. A new Urgent Care Centre will open on the SRFT site for patients that have minor injuries or urgent care needs. Clear explanations and examples as to what constitutes urgent care needs. Key Messages for Staff Walk In Centre Staff and GPOOH Staff Promotion of self-care for minor self-limiting ailments Patients to be re-directed to their GP practice as appropriate Only offer treatment if urgent care need that cannot wait Page 84 of 127

85 GP s and Practice Staff WiCs and A&E are not to be promoted by practices to enable demand management of patients using these facilities. Acceptance of re-directed patients from WiC s and A&E for urgent appointments. Follow up of patients that continue to turn up at WiC s and A&E inappropriately A&E Staff Promote self-care Do not offer treatment for patients with primary care needs Deflect patients to primary care as appropriate Timeline for Communications Timeline to Target Audience Messages Rationale Commence December 2010 Salford population Choose Well Campaign Raise awareness of appropriate use of services January 2011 onwards Salford Population As outlined in section Prepare for changes in service March 2011 onwards Salford GPs & Practice Staff Staff working in A&E, WiC s, GPOOH As outlined in section May 2011 onwards GP s Feedback on success of deflections from WiC s and A&E May June 2011 June 2011 July 2011 July 2011 August 2011 November 2011 onwards Patients using Canalside WiC/PCC Patients using Little Hulton WiC. GP s in Little Hulton & Walkden Patients using Pendleton WiC GP s in surrounding areas Salford population Salford GP s As outlined above As outlined above As outlined above Key messages arising from evaluation of service change. Link to campaigns such as Choose Well Prepare for changes in service To enable GP s to target their patients. Reinforce messages that closure is imminent Reinforce messages that closure is imminent Reinforce messages that closure is imminent Reinforce messages on appropriate use of services Page 85 of 127

86 7.9.3 Communication Mechanisms The methods of communicating the key messages outlined above will consist of the following: Leaflets, posters and written material Press and media releases Public forums e.g. Community Committees Face to face individual discussions Staff briefing & training sessions 7.10 Contingencies The risks to this project have been outlined in section 6.6 and mitigating actions identified. The Operational Steering Group will be responsible for reviewing any risks as part of overseeing the implementation plan. Where necessary any operational issues will be escalated internally for the relevant organization to resolve. If necessary, issues will be escalated to the Integrated Care Programme Board for resolution by the members of the partnership. The constraining factor in the implementation of this business case relates to the ability to successfully re-direct and deflect patients that do not require urgent care. The staged approach to the closure of community urgent care facilities puts contingency plans in place to monitor patient behaviour at each step in the process. Relevant feedback mechanisms will be implemented and reinforced by targeted communication mechanisms to ensure that demand is managed appropriately to successfully achieved the outcomes identified. The timetable for staged closure of community facilities can be accelerated or put back depending upon the success of the reduction in activity levels. Page 86 of 127

87 8 Conclusions and Recommendation 8.1 Description There has been significant progress to date in developing the model for the new Urgent Care Service in Salford. In particular the development of collaborative working arrangements between primary and secondary care and the level of clinical commitment in developing the proposal. The proposal outlined defines a co-located and integrated UCC and TRC that can respond to the urgent secondary care needs of local patients. The model seeks to reduce attendances within the urgent care system by challenging existing thresholds for managing patients and ensuring patients with self limiting minor conditions and primary care needs are deflected to primary care and self care. The project will have staged savings that will be released on closure of the Walk In Centre facilities and a reduction in UCC and TRC attendances once patient behaviour is influenced through consistent urgent care messages. 8.2 Recommendations The board is asked to approve the implementation of the business case. The items that require approval are: Development of co-located and integrated UCC and TRC service model Staged closure of the Walk In Centres Development of governance structures for the UCC Two phase approach for delivering savings 8.3 Project Responsibility To be confirmed 8.4 Project Accountability To be confirmed 8.5 Implementation Plan The implementation plan shows the high level steps required to deliver the UCC and TRC model. The project will have a phased implementation as the PDSA work is embracing a continuous learning approach that is defining the UCC and TRC model. Furthermore the savings will be released in two stages as the project is phased in two steps. The first step is managing the re-distribution of patients across the urgent care system given the new urgent care service model. Once the model and working practices are embedded further savings are anticipated, however, the additional savings are dependent upon deflections translating to reductions in attendances. Page 87 of 127

88 8.6 Business Case Approval and Sign-off Business Case approval is sought from: Investment and Review Panel, NHS Salford Salford PBC Operational Board Commissioning Board, NHS Salford Salford Integrated Care Partnership Page 88 of 127

89 9 Service Change Flow Model The proposed model for the Urgent Care Centre and Trauma and Resuscitation Centre is illustrated in figure 28. This shows the patient outcomes anticipated within the two centres. The activity data shown in the model is activity data from the Best Case activity model. The purpose of the PDSA work is to provide evidence that supports the assumptions for patient flow to the UCC and TRC and to estimate deflection rates to self care and primary care. Figure 28 Proposed Urgent Care Model Urgent Care Patient Management Level of Patient Need Existing Proposed Resus Majors Trauma & Resus Centre Minor Injury Accident & Emergency Urgent Care Centre Minor Illness Minor Self Limiting Conditions PCC WiCs Primary Care - GP Practices - Pharmacy -Self Care Threshold adjustment Page 89 of 127

90 Figure 29 Patient Flows in the Proposed Model Proposed Urgent Care Model 17,044 (GP OoH) Self Care Primary Care Community Pharmacy Urgent GP Appointment 91,553 Attendances 31,506 GP OoH Calls Attendance Arrival Mode: Ambulance: 19,222* Other: 72,332 Reception & Streaming 45,700 14,462 Urgent Care Centre GP OoH Self Care / Primary Care / Pharmacy Urgent GP Appointment Discharge Follow Up Admission 29,216 Resuscitation & Trauma Centre Discharge Follow Up Admission Self Care / Primary Care / Pharmacy 16,637 PANDA Urgent GP Appointment Discharge Other : 24,482 - Other A&Es -Other WiCs - GP/Dental Practices - Community Pharmacies -Self Care Key: Deflections to Self Care/Primary Care/Community Pharmacy Note: * Number of Ambulance arrivals in 09/10 assumed the same in future years Admission Page 90 of 127

91 10 Appendices Appendix 10.1 A&E Presenting Complaints and Patient Outcomes Table 1 shows the outcomes for patients attending SRFT in 2009/ A&E Attendance Disposal Description % of Patients Brought in Dead 0.01 Did Not Wait 3.09 Died in Department 0.17 Direct Admission to SRFT 0.00 Discharged did not require follow up Inpatient SRFT Inpatient other 0.84 Inpatient RMCH/Boothall 0.43 Other 0.09 Referred to A&E Clinic 1.69 Refer to A&E Fracture Clinic 5.61 Refer to GP Refer to Other Health Care Professional 5.83 Refer to Outpatient Clinic 3.91 Refused Treatment 0.21 Sum: Table 2 highlights the presenting conditions with the highest admissions. Presenting Condition Number of Patients Admitted % of Patients Admitted Overall % of Attendances that are Admitted Unwell Adult % Chest Pain % Abdominal Pain % Limb Problems % 8% Shortness of Breath % Collapsed Adult % Total 14, % 32 Data provided by SRFT IM&T Page 91 of 127

92 Appendix 10.2 A&E Activity Levels on an Hourly and Daily Basis for 2009/10 A&E Attendances by Day and Hour in 2009/10 Number of A&E Attendances (09/10) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 92 of 127

93 Appendix 10.3 A&E Attendance Trends 9000 Monthly A&E Attendances at SRFT for 07/08, 08/09 and 09/ Number of Attendances / / /10 0 April May June July August September October November December January February March 2007/ / / Month Page 93 of 127

94 Appendix 10.4 Admission Rates from A&E Departments in the North West 40% 35% 30% 25% 20% 15% 10% 5% 0% Percentage of Patients Attending A&E who are Admitted to Hospital for all North West Acute Trusts in 09/10 % of Patients Attending A&E who are Admitted CENTRAL MANCHESTER LANCASHIRE TEACHING HOSPITALS BOLTON SOUTHPORT AND ORMSKIRK HOSPITAL BLACKPOOL, FYLDE AND WYRE HOSPITALS WWL MORECAMBE BAY HOSPITALS WIRRAL HOSPITAL TAMESIDE AND GLOSSOP ST HELENS AND KNOWSLEY HOSPITALS PENNINE ACUTE ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITAL NORTH CUMBRIA ACUTE EAST LANCASHIRE HOSPITALS STOCKPORT NORTH CHESHIRE HOSPITALS SALFORD ROYAL SOUTH MANCHESTER THE MID CHESHIRE HOSPITALS AINTREE HOSPITALS NW Acute Trust Admitted to Hospital Proposed Target Admission Rate Page 94 of 127

95 Appendix 10.5 Entry Points to Intermediate Care and Community Services SCH Community Unscheduled Care Mapping Existing Provision DN Evening & Weekends 5.00pm 7.00am Referrals and requests for patients Known to caseload (links to GPOOH for call handling) GPOOH 6.30pm 8.00am weekdays 24hours weekend & BH Call handled by Wigan Call back from Clinician to advise, Give appointment or arrange visit Care Home Practice Advice Line for Care Home Staff managing patients Already on caseload 8.00am 7.00pm SEP Intermediate Care 8.00am Midnight Hospital & Community Referrals Screen & Triage Patient / Referrer Emergency Dental service 6.00pm pm M-F 10.00am 10.00pm Weekends & BH Children SEP for new referrals & those on caseload 8.00am 8.00pm ACM Duty Desk Hospice 8.00am 6.00pm M-F For patients known to Specialist Palliative Care Patients on existing caseload Hospice Advice line for staff Teams (Hosp & Community) 8.30am 4.30pm 7 days NHS Direct, Dial 999, Present at A&E, Present at at WIC Page 95 of 127

96 Appendix 10.6 Stakeholder Analysis Table illustrates the range of stakeholders engaged in the development of the UCC and RTC model. Stakeholder Organisation Stakeholder Representative(s) Rationale Engagement method Salford Royal NHS Foundation Trust Clinical: Martin Smith A&E Clinical Director Richard Warner EAU Clinical Director Richard Lea EAU Consultant Anu Trehan EAU Consultant Martin Thomas A&E Consultant Colin Bernstein PANDA Unit Consultant Jonathan Vickers Surgery Clinical Director Ruth Clay PANDA Unit Consultant Margaret Israel Clinical Lead Nurse Gabby Lomas - Jill Windle - Operations: Janelle Holmes Director of Operations Medicine Caroline Ryan A&E Senior Manager Gaynor White A&E Lead Manager Leigh Latham Surgery Senior Manager Elaine Quick Diagnostics Senior Manager Finance: Kate Whiting Business Accountant IM&T: Jon Lawton Gill Caine Estates: Lindsay McCluskie PFI Lead A&E, PANDA, EAU and SAU will be directly impacted by the proposed UCC and R&TC model Key role in implementing services changes and informing development of UCC and RTC model. Quantification of savings and determining cost of new services. New cost structures for urgent care proposed for consideration. Members of project steering group Leads and engaged in work streams Participation in Clinical workshop Engaged in the development of the business case Involvement in Plan Do Study Act cycles Members of project steering group Leads and engaged in work streams Engaged in the development of the business case Members of project steering group Engaged in the development of the business case IM&T support for data queries Requests and queries submitted to IM&T UCC and RTC will be located in New build timescales and layout the new building discussed Cancer Services: The Christie centre at Salford Engaged in the development of Page 96 of 127

97 Stakeholder Organisation Stakeholder Representative(s) Rationale Engagement method Salford Practice Based Commissioning NHS Salford Salford Community Health Leah Robins Service Improvement Lead may affect A&E attendance levels Pharmacy: Pharmacy services required to Justine Scanlan Director of Pharmacy support UCC and R&TC and development of Clinicians: Elaine Tamkin PBC Urgent Care Lead & Vice Chair Hamish Stedman PBC Chair Clive Boyce PBC Vice Chair Jeremy Tankel PBC GP Colin Malcolmson PBC Cluster Lead Commissioning: Harry Golby Mike Smith Finance: Joanne Camilleri Head of Finance Commissioning Chris Kevill Head of Contracting Executive Sponsor: Michael Gibbs Chief Executive SCH Operations: Kim Scanlon General Manager Pauline Law General Manager John Quinn Operations Manager Victoria Thorne Rapid Response Lead PBC have a key role as commissioners. The role of GPs as primary care providers is also a critical access point to urgent care services and also in deflecting activity from secondary care. Commissioner of existing service Quantification of savings and determining cost of new services. New cost structures for urgent care proposed for consideration. Sponsor for project Key role in implementing services changes and informing development of UCC and RTC model. the business case Engaged in work stream on prescribing protocols To be involved in pharmacy requirements Members of project steering group Leads and engaged in work streams Participation in Clinical workshop Engaged in development of business case Members of project steering group Engaged in the development of the business case Members of project steering group Engaged in the development of the business case Members of project steering group Leads and engaged in work streams Engaged in the development of the business case Clinical: Peter Fink GP OoH Michelle Ward Advanced Nurse Practitioner Amanda Jones - Advanced Nurse GP OoH and WIC will be directly impacted by the proposed UCC and R&TC model Members of project steering group Participation in Clinical workshop Engaged in the development of the business case Involvement in Plan Do Study Act Page 97 of 127

98 Stakeholder Organisation Stakeholder Representative(s) Rationale Engagement method Salford City Council Greater Manchester West Mental Health Trust Practitioner Finance: Malcolm Semp Head of Finance SCH Jennifer McGovern Associate Director of Joint Commissioning Gill Heaps Mental Health Liaison Team Lead Ross Overshot - Mental Health Liaison Team: Clinical Lead Penny Evans Director of Operations Quantification of savings and determining cost of new services. New cost structures for urgent care proposed for consideration. Integrated service model will include health and social care needs for patients Mental Health Liaison Team are a key supporting service for UCC, RTC and Assessment Areas. NWAS Mark Newton NWAS Lead NWAS developing tools for triaging patients that will impact UCC and RTC Various Organisations Urgent Care Leads: Karen Proctor Optimising Pathways Robin Gene Optimising Pathways Laura Sidall - Optimising Pathways Melanie Walters Optimising Pathways Richard Freeman: GP Access Interdependencies with other urgent care project to be defined and accounted for in savings cycles Engaged in the development of the business case Invitation to project team Leads and engaged in work streams Engaged in the development of the business case Involvement in Plan Do Study Act cycles Engaged in the development of the business case Page 98 of 127

99 Appendix 10.7 PDSA Cycles The three PDSA cycles that have been agreed and developed are outlined as follows: 1) Deflections 1. Project Work Stream PDSA Increasing Deflections to Primary Care, Self Care and Pharmacy Stakeholders GPs, ANPs, ENPs, A&E Consultants, Triage Nurses, wider Salford GP practices 2. Objectives Increase the number of patients deflected to primary care, self care and pharmacy Test the streaming tools: Manchester Triage System, NHS Pathways and the NWAS tool Identify conditions that should be seen in primary care Identify number of A&E patients that require urgent and routine GP appointment Identify training needs of ANP staff Define criteria for accessing GP urgent appointments Build understanding of alternative services to support patient deflections 3. Description The PDSA cycle will be split into 3 phases as follows: 1) Identify patients appropriate for the UCC and also patients appropriate for deflection to primary care, self care and pharmacy 2) Identify patients appropriate for urgent and routine GP appointments 3) Identify patients appropriate for the UCC and deflected patients using the 3 streaming tools: Manchester Triage System, NHS Pathways and the NWAS tool Phase 1) Patient Identification The triage nurse in A&E will code patients as being appropriate for the UCC and deflections by identify them with coloured stickers on the patients CAS cards (blue for UCC and green for deflections). These patients will be directed to the quasi UCC clinical team who will assess and treat the patient and will also identify the patients for appropriateness for management within the UCC or deflection to primary care using the coloured stickers. The GP will review patient notes on an individual basis and again identify if the patient is appropriate for deflection or UCC. The role of the GP will be to provide advice and support to the ANPs and review individual case notes providing feedback to the ANPs if it is felt that patients could have been deflected to primary care. The GP will be responsible for developing a checklist to support decision making for deflecting patients to primary care, self care or pharmacy. The PDSA clinical team will comprise: 2 ANPs (from Walk In Centres) 2 ANPs (from A&E) Salford GP Page of 127

100 A&E Consultant support For the duration of the PDSA work the Primary Care Centre (PCC) ANPs will be relocated to A&E patients will not be deflected to the PCC but instead flow to a ANP stream supported by a Salford GP. During this period the PCC ANPs and lead Walk In Centre ANPs will treat patients deemed appropriate for the UCC and deflected primary care patients. The cohort of patients to be managed within the PDSA clinical team will include minor injury, minor illness and deflected patients. Phase 2) Criteria for GP Appointments The second phase of this PDSA cycle will be identifying which primary care patients require urgent appointments and those requiring routine appointments. Appointments would only be made for patients requiring urgent appointments. For patients identified as primary care the GPs role is to assess the patient to identify who requires an urgent or routine appointment. The GP is to develop criteria for distinguishing between routine and urgent appointment patients. Administration staff to contact practices to obtain an urgent appointment and note if this is possible and also the practice contacted this will indicate both demand and capacity or appointments. Phase 3) NWAS Tool Phases 1 and 2 above are to be repeated with alternative streaming tools. This will allow comparison of the tools and identify weaknesses and strengths of each tool prior to selecting a streaming tool. Phase 4) NHS Pathways Tool Phases 1 and 2 above are to be repeated with alternative streaming tools. This will allow comparison of the tools and identify weaknesses and strengths of each tool prior to selecting a streaming tool. 4. Success Criteria The cycle of activities will be deemed successful if: Number of patients identified for deflection to primary care/self care/pharmacy can be increased above the baseline for 09/10 Agreement of patients appropriate for UCC and deflection between ANPs, GPs and triage nurses Identify areas of training for UCC staff to develop training programme e.g. condition based such as abdominal pain and headaches and build understanding of community services Develop criteria for urgent GP appointments Identify demand for urgent GP appointments and routine appointments Develop checklist for identifying patients appropriate for deflecting patients to primary care 5. Timescales EACH PDSA CYCLE WILL COMPRISE A 3 HOUR CLINICAL SESSION FOLLOWED BY A 1 Page of 127

101 HOUR REVIEW. IT IS ANTICIPATED THAT THE PDSA CYCLES WILL BE ON A 5 SESSION BASIS, THAT IS: PHASE 1: MANCHESTER TRIAGE 5 SESSIONS PHASE 2: CRITERIA GP APPOINTMENTS 5 SESSIONS PHASE 3: NWAS TOOL 5 SESSIONS PHASE 4: NHS PATHWAYS 5 SESSIONS A DRAFT TIMETABLE FOR THE PDSA ACTIVITIES IS SHOWN IN THE ATTACHED DOCUMENT DRAFT PDSA Cycle Schedule Rev 1 6. Data Collection The following pieces of data must be recorded as part of the trial: Patient activity streamed as UCC and Deflections by Triage Patient activity streamed as UCC and Deflections by ANPs/ENPs Patient activity streamed as UCC and Deflections by GPs Patient demand for GP urgent and routine appointments Availability of urgent GP appointments Salford practices of primary care patients Training Themes for UCC staff Themes to inform project implementation 7. PDSA Costs 8. Actions 1) Identify available GP sessions: Elaine Tamkin 2) Gain support from Salford GPs to provide urgent appointments during PDSA cycles: Elaine Tamkin 3) Confirm if NHS Pathways can be trialed Nadine Armitage 4) Draft and arrange briefing for staff Clinical leads Page of 127

102 2) Thresholds 1. Project Work Stream PDSA Refining Thresholds for admissions and patient transfers 1) Admission from UCC to Assessment Areas 2) Admission from RTC to Assessment Areas 3) Transfer from UCC to RTC 4) Admission to Assessment Areas via Single Entry Point Lead TBC Stakeholders GPs, ANPs, Consultants Intermediate Care, Care Homes practice, Rapid Response, District Nurse evening service, Assessment Units 2. Objective Reduce admissions to assessment areas by accessing community services Reduce activity with the RTC Increase knowledge of, and confidence levels, in community services 3. Description Acknowledgement that this is a more complex area with complex cases and greater stakeholders. Potential approaches for refining admission thresholds: Multi-Discipline Team (MDT) review of case notes to identify different ways of managing patients MDT morning ward rounds to review over night patients (ECDU and EAU) GP and Consultant review of Single Entry Point admissions and then feedback to practices Observation sessions in resus and majors by community service staff (build on PANDA unit mode?) 4. Success Criteria Reduce Non-elective admissions Reduce Length of Stay on ECDU and EAU Identify barriers that lead to inappropriate admissions Feed back on Single Entry Point admission to Salford GP practices by GPs 5. Timescales TBC 6. Data Collection TBC 7. PDSA Costs TBC Page of 127

103 3) Paediatrics 1. Project Work Stream PDSA Managing Paediatric Patients Lead TBC Stakeholders GPs 2. Objective Increase the number of patients deflected to primary care, self care and pharmacy Test the streaming tools: Manchester Triage System, NHS Pathways and the NWAS tool Identify conditions that should be seen in primary care Identify number of A&E patients that require urgent and routine GP appointment Identify training needs of ANP staff Define criteria for accessing GP urgent appointments Build understanding of alternative services to support patient deflections 3. Description This PDSA cycle will replicate the activity in the PDSA cycle relating to deflections to primary care, self management and pharmacy. 4. Success Criteria The cycle of activities will be deemed successful if: Number of patients identified for deflection to primary care/self care/pharmacy can be increased above the baseline for 09/10 Agreement of patients appropriate for UCC (in reach in PANDA) and deflection between ANPs, GPs and triage nurses Identify areas of training for UCC/PANDA staff to develop training programme e.g. condition based such as abdominal pain and headaches and build understanding of community services Develop criteria for urgent GP appointments Identify demand for urgent GP appointments and routine appointments Develop checklist for identifying patients appropriate for deflecting patients to primary care 5. Timescales TBC 6. Data Collection TBC 7. PDSA Costs TBC Page of 127

104 Appendix 10.8 Full Options Appraisal for Organisational Model Benefit Criteria used to assess the five organisational models is shown below: Benefit Criteria Description Weighting Comments BC 1 Ability to achieve savings 30 BC 2 Feasibility 25 BC 3 Clinical Effectiveness 25 BC 4 Future Proofing 10 BC 5 Patient Experience 10 Total 100 Potential to realize economies of scale by reducing duplication. Savings realized by reduction in activity Considers time to implement and practical arrangements around governance Level of clinical risk (consider the risk incurred in patients moving between services or not presenting in the right place) Local fit and alignment with strategic objectives of the programme as well as regional and national context Patient expectations and patient experience considered including receiving the right service at the right time on initial presentation The outcome of the options appraisal is detailed below for the five options. The five options are: Ranking Order Weighted Score First Mutual System Partnership Second Joint Venture Third SRFT only 87.1 Fourth GP only 74.0 Fifth Third Party 46.2 Page of 127

105 Appendix 10.9 Walk In Centre Patient Survey A 1 week survey of Walk In Centre (WIC) patients revealed that almost half of patients would access their GP or Dentist instead of the WIC, with a further 33% choosing A&E and the remainder accessing self help options. Patients were asked on arrival which service they would use if the WIC was not an option. Alternative Services Number % GP A&E Pharmacy Other Self Care Dentist Total It has been noted that the proportion of patients who would respond with self care will be low as patients are unlikely, after travelling to a WIC, then respond that their need could be managed without clinical advice and treatment. Page of 127

106 Appendix Outcome of Scenario Modelling Nine activity scenarios were modelling using the following sensitivity factors: Dispersal of Walk In Centre Patients Best Case: 23% of WiC patients attend UCC Most Likely Case: 33% of WiC patients attend UCC Worst Case: 63% of WiC patients attend UCC Management of Paediatric Patients Best Case: 10% of PANDA patients managed by UCC no evidence to support higher proportion of patients managed by UCC Most Likely Case: 10% of PANDA patients managed by UCC Worst Case: 0% of PANDA patients managed by UCC Thresholds for Managing UCC Patients Best Case: 15% decrease in activity from 09/10 Most Likely Case: 0% change in activity from 09/10 Worst Case: 10% increase in activity from 09/10 The table below shows the scenarios modelled and the chart shows the impact on activity within the UCC, R&TC, PANDA, GP OoH and activity in other service providers. Factor Scenario Upside Case Downsi de Case 1: Dispersal 2: Paediatrics 3: Thresholds Upside -10% Downside 30% Upside 0% Downside -10% Upside -15% Downside +10% Page of 127

107 Appendix Activity Model for Best Case Scenario Page of 127

108 Appendix Activity By Day and Hour 1) Anticipated Activity Levels in the TRC Activity in the TRC is based upon activity trends in 09/10 using the following data: All patients with the disposal codes: dead on arrival, died in department, inpatient Hope Activity data in 09/10 scaled proportionately for TRC activity of 29,216 per annum Page of 127

109 2) Anticipated Activity Levels in UCC Activity in the UCC is based upon activity trends in 09/10 using the following data: All patients arrival times and days excluding those with the disposal codes: dead on arrival, died in department, inpatient Hope/Other Activity data in 09/10 scaled proportionately for UCC activity of 45,701 per annum Maximum represents Worst Case figures Minimum represents Best Case figures Average represents average attendance for the Most Likely Case Page of 127

110 3) Activity Levels for Streaming in UCC Activity in requiring streaming is based upon activity trends in 09/10 using the following data: All patients arrival times and days Activity data in 09/10 scaled proportionately for UCC, TRC and PANDA activity of 91,554 per annum Maximum represents Worst Case figures Minimum represents Best Case figures Average represents average attendance for the Most Likely Case Page of 127