Urgent care strategy: 2014/ /20

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1 Urgent care strategy: 2014/ /20 1

2 Version control Date Version Discussed at 11 th November Urgent care strategy task and finish group: sections 1, 2 and 3. Urgent care board: sections 1, 2, and 3. 5 th December Minor wording changes, inclusion of additional information in sections 1, 2 and 3 including updating of some tables to include more up to date information. Sections 4, 5 and 6 finalised. For discussion at next task and finish group meeting (17 th December). 19 th December Final amendments made following task and finish group meeting. Greater clarity on purpose of document, additional service mapping information, minor adjustments and additions to priorities. Inclusion of mental health information. 14 th January Some tables and figures updated. Final proof reading and addition of executive summary and summary. 22 nd January 2015 CCG Governing Body seminar 26 th January 2015 Urgent Care Board 29 th January 1.4 Inclusion of amendments requested through GB and UCB. Additional mental health priorities included from section 4 onwards. Some minor changes to quality and outcome standards, metrics and measuring progress and section on workforce in section 8. 7 th May 1.5 Final amendment and adaption following stakeholder engagement programme which ran through April and discussion at April UCB on extent to which strategy is updated and amended. See accompanying engagement report for full detail of amendments. 21 st May Approved by Commissioning and Finance committee. Acknowledgements With thanks to Worcestershire and Croydon CCGs, on whose document template this strategy is derived from. 2

3 Table of contents Introduction/Executive Summary Introduction Purpose What is urgent care? Vision Principles/objectives Strategic aims The current urgent care system Self-care NHS Community pharmacy GP practices GP out of hours services Minor Injury Units (MIUs) Accident and Emergency Department emergency ambulance service Mental health services Other community services Summary of key factors facing the urgent care system and conclusions Urgent care contracts and costs Patient experience of urgent care Self-care NHS Community pharmacy GP practices GP out of hours services Minor injury units Accident and Emergency (A&E) emergency ambulance service Mental health services Summary/conclusions Principles and objectives

4 5. Priorities for system change What good looks like quality and outcomes Measuring progress Associated developments/considerations The five year work plan emerging work streams Summary/conclusions References/Bibliography Appendix 1 Community pharmacy location map Appendix 2 Map showing percentage of population without access to a car or van Appendix 3 Key themes relating to urgent care from the community services engagement events Appendix 4 Suggested urgent care quality and outcome standards List of figures and tables Figure 1: The vision for Urgent and Emergency Care Figure 2: Map of urgent care services in South Devon and Torbay Figure 3: Urgent care services in South Devon and Torbay Figure 4: Early results from Pharmacy First schemes Figure 5: General practice consultation rate per person per year Figure 6: A&E attendance per head of population against patient satisfaction Figure 7: GP out of hours contacts by age range Figure 8: Services connected to the Torbay Hospital A&E department Figure 9: Number of A&E attendances: Figure 10: A&E attendance by age: % change and per 1000 population Figure 11: A&E/MIU attendance by age and locality Figure 12: Percentage of A&E/MIU attendance not receiving treatment Figure 13: A&E attendance per 1000 population by GP practice Figure 14: A&E attendance by LSOA (Torquay) Figure 15: Ambulance station locations in South Devon and Torbay Figure 16: Ambulance calls by month managed and unmanaged Figure 18: Conveyance rates to A&E by Ambulance Trust Figure 19: A&E Friends and Family test: SDHCFT % recommends Figure 20: Interim findings from local Is A&E for me? survey Figure 21: Commissioning urgent care: key principles Figure 22: CCG outcome indicators relevant to urgent and emergency care Figure 23: Quality and outcome standards for urgent care services in South Devon and Torbay 62 Figure 24: Specific quality and outcome standards by service: A&E, in hours primary care and MIUs/UCCs

5 Table 1: Calls per 1000 patients to the Devon 111 service: Table 2: NHS Devon 111: national quality requirement achievement in Table 3: Location of GP OOH treatment centres across South Devon and Torbay Table 4: Number of GP OOH contacts by type and treatment centre location, Oct 2013-Oct Table 5: GP out of hours contacts by year Table 6: MIU attendance by site: Table 7: MIU attendance by site, by Index of Multiple Deprivation Table 8: MIU attendance by site, by age Table 9: MIU performance information Table 10: Nurse staffing levels - Accident and emergency services August Table 11: Quality indicators for A&E: South Devon Healthcare performance and achievement of A&E four hour wait Table 12: Number of 999 calls and performance achievement in Table 13: Overview of community services provided in South Devon and Torbay and availability. 41 Table 14: Urgent care contracts and costs by service Table 15: GP patient survey results: patient satisfaction with access Table 16: CQC A&E survey results: South Devon Healthcare Table 17: Work streams to implement the recommendations of the strategy

6 Introduction/Executive Summary The purpose of this urgent care strategy is to set out, in a single document, the CCG s future plans for commissioning urgent care across South Devon and Torbay. Underpinning this strategy will be an implementation plan that outlines the steps we will take in order to make the strategy a reality for the local population. The strategy will run from April 2014 through to March 2020, by which time we intend to have made radical changes to the way in which urgent care services are accessed in South Devon and Torbay. The vision for urgent care in South Devon and Torbay is that: The vision for the urgent care system in South Devon and Torbay over the next five years is that: People with urgent but non-life threatening needs should be treated by services as close to home as possible, leaving emergency departments free to concentrate on more serious and life threatening emergency needs. Urgent care is important in terms of patient contacts and resources; nationally, urgent or unplanned care leads to at least 100 million calls or visits each year, representing around a third of NHS activity, and accounts for more than half the costs (NHS England, 2013). Producing the strategy, we are mindful of the national strategic direction set by the Urgent and Emergency Care Review, led by Professor Sir Bruce Keogh (NHS England, 2013). The review set out proposals for a fundamental shift in how and where the NHS meets urgent and emergency care needs. Urgent Care for the purpose of the strategy is defined as the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly for needs that are not considered life threatening. The strategy excludes emergency care, defined here as immediate or life threatening conditions, or serious injuries or illnesses. As such, within scope is consideration of the self-care, NHS 111, primary care in and out of hours, minor injury units/urgent care centres and community pharmacy. We have also included 999 and A&E, which may be more appropriately defined as emergency services, acknowledging that at present a number of patients will use these services to meet urgent needs, and this has an impact on the way the services are able to operate. The strategy comprises a number of sections including vision/aims/objectives, a description and analysis of the urgent care system by service, a review of patient experience by service, definition of commissioning principles and objectives, priorities for system change, suggested quality and outcome standards to define what good looks like, suggested metrics for measuring progress, associated developments/considerations and a work plan to take the strategy forward. A key part of the strategy has been to undertake a comprehensive services review of the urgent care system. The review has shown that there is a complex picture, with a number of providers offering 6

7 different services which can be confusing. The strategy aims to address this. Key findings from the service review include: We need to reduce reliance on services and support self-care. There is a wide range of support tools and services available, although uptake and usage locally is limited or unknown. Promotion of existing services and resources, including NHS Choices, should be a priority as should promotion of the NHS 111 number for advice. We are well served by community pharmacies, with extended opening times. They have a wide range of skills including support for self-care and sign-posting to other services (including 111) and potential to do more, including managing minor ailments and emergency supply. GP consultation rates are continuing to rise. Telephone consultation is increasingly offered by all practices in South Devon and Torbay for urgent conditions, with most patients getting a call back within an hour (although this varies by practice). There is some evidence GP visits in the middle of the day has an impact on patients attending A&E later. The GP out-of-hours service performs well and is highly regarded by patients and professionals. However, nationally and locally the number of cases seen by out of hours is falling, a trend we are keen to reverse. The service currently sees large numbers of very young children and the Newton Abbot and Torquay treatment centres are busiest. NHS 111 is a relatively new service in Devon. There have been some difficulties locally with achievement of some of the quality requirements including time taken to answer calls and call length, which we need to continue to address to improve patient experience. Calls needing a service are most commonly referred to primary care with a proportion also receiving an ambulance dispatch or referral to ED. Referrals to other services and those receiving advice are currently low. We have not seen the increase in 999 calls from patients reported nationally, however the number of health care professional calls has increased. Most calls come from Torbay and there is little variation in and out of hours. Conveyance rates to emergency departments are good, with the provider treating many patients at the scene. Our rate of A&E attendance is above the national average and increasing and we need to halt this rise. We are seeing increases in attendance from those living in Torquay, very young children and those in the middle age ranges so need to ensure that there are other urgent care services available to these groups which will better meet their needs. The overall rate of attendance in A&E continues to be highest amongst young children and those aged 80+ years, suggesting a need for clear pathway for these patients. There have been some difficulties in waiting times in the A&E department this year, although a turnaround plan is likely to improve this. Consultant cover in the week is good, although it drops below the national recommendation at weekends. Opening hours and services offered by our minor injury units vary by location which can be confusing and services need to be comprehensive and consistent to provide a viable alternative to A&E attendance. Newton Abbot stands out as the service most used by patients. A high proportion of patients are aged 5-9 years and Paignton and Teignmouth are used by patients from more deprived areas. A wide range of community and social care services are provided locally, but not all are available six or seven days a week. Of those that are, there are differences in provision 7

8 between Torbay and south Devon and the overall picture of services available to patients with urgent needs is complex. Further improvements need to be made to the multi-agency system of care and support so people in crisis because of a mental health condition are able to access the support and treatment they require at time of need and that support and treatment is consistent across 24/7. As part of the strategy, we have compiled a supplementary report on patient experience of urgent care services which brings together findings from specific engagement undertaken for this strategy as well as utilising information from other sources including HealthWatch, national surveys, the Patient Opinion website and Friends and Family tests. Although it is difficult to capture patient experience for urgent and emergency care we have found the following: We know only a little about the use of self-care, although patients do report that they would like more help and support to manage their own conditions. There are varying levels of awareness of NHS 111, nationally and locally, and more information needs to be made available to explain the service, targeted as appropriate. Community pharmacy is felt to be an under-utilised resource and some unable to get a GP appointment will use their pharmacy as an alternative. We know most about patients views on access to GP services although findings vary from generally positive quantitative survey results and more critical qualitative feedback and results vary significantly by practice and locality. Critical comments include wanting longer opening times, simpler appointment systems, shorter waiting times, convenient appointments and ability to be seen on the day. In comparison to the national picture, fewer patients locally would attend A&E if they could not get a GP appointment and we are not yet seeing a link between rising A&E attendance and patient satisfaction. Satisfaction with out of hours services locally is very good. However, over a third of our population are not sure how to contact a GP out of hours, better than the national figure, but still a concern. Raising awareness of local services and how to access them therefore emerges as a priority, targeting younger people, BME groups and those practices were fewer patients in the GP survey were aware of out-of-hours services. MIU services have been reported positively, with patients wanting to know more about them. The Friends and Family scores indicate a high level of satisfaction, although response rates are low. Nationally, a number of patients use A&E in non-emergency situations if they cannot get a convenient GP appointment. We are not seeing quite the same level of usage locally, but this is likely to vary by patient group and practice, suggesting more targeted work with particular practices and by location is useful. The 2014 CQC survey showed that the A&E department was rated similar to other trusts for most measures, although scored worse for waiting times. The Friends and Family test scores for the local A&E are below the national average although there are early signs this may be improving. 999 services are generally rated highly by patients, with patients appreciating prompt and professional care. 8

9 Urgent mental health service priorities are similar to priorities for other services including high quality services, simplifying services, person-centred care, third sector support and right care first time. Taking the service review and patient experience results into account, we have arrived at a set of commissioning principles for all services which will take us forward over the next five years. Services should be available seven days a week and provide good value for money; the right care will be available first time, every time; there will be high quality evidence based care with clear standards; services will be complementary and interoperable accessed through a single source; and services will operate in an integrated network which minimise handover and delay. Our priorities for change over the next five years will be: More actively promote self-care and make it much easier for patients to access high quality, reliable information and services. This will include promotion of existing services. Make NHS 111 the smart call to make, as the gateway to the urgent care system. This will include ensuring a high quality service, with calls answered promptly, more advice offered and referral to services other than A&E and 999. Ensure primary care in hours and out of hours services is the default service of choice for patients to meet their urgent care needs. This will include a set of quality standards for urgent primary care services, high quality out of hours services and as many patients as possible using the out of hours service in preference to alternatives. Ensure there is an option locally for patients to access an urgent care centre, as envisaged in the urgent and emergency care review. We will need to be mindful of the emerging specification for UCCs and factor in the on-going MIU review process to ensure a consistent range of high quality services is available. Continue to reduce ambulance conveyance rates, through Right Care Initiatives. Develop community pharmacies into urgent care providers as they are readily accessible. Reduce ED attendance rates and 999 calls for urgent conditions through the above priorities. For urgent mental health care, achieve parity with physical health care through the redesign of the acute urgent care pathway. High quality, accessible urgent care services, including the development locally of a set of quality and outcome standards for all urgent care services and service specific measures. Shared clinical records across urgent care providers. Some of this work will need to be targeted to particular locations and patient groups as we have seen variation in use of services by age, particularly children and the elderly; and, by area with higher levels of activity from those living in Torquay, Paignton and Brixham. A number of work streams emerge from strategy which will need to be assigned to lead individuals and groups to progress through the life of the strategy. The strategy will be mainstreamed by incorporating the work streams into the CCG work-plans and this, together with the metrics for measuring progress, will allow regular monitoring of progress on delivery. As there are a number of work-streams, it will be necessary to prioritise them, as we are on a five year approach to change. Some, by their nature, will also take longer than a year to implement and for us to see the effect of change. Year one priorities, including those which are already underway include minor injury unit 9

10 review/reconfiguration, patient record information sharing, urgent care community pharmacies and frail elderly pathway. The CCG s integrated plan is clear about the approach to financial management, which will apply to this strategy. Planned spending on the current main healthcare provider services will remain at the same level as planned except where organisations can demonstrate that by spending more than this, savings will be made for other healthcare providers and that this can be agreed with those organisations. This means that we will not see additional resources available for urgent care over the next five years; the priority will need to be on working within the existing resource envelope and improving service efficiency by, for example, reducing the number of multiple attendances that occur through system confusion, reducing reliance on the more expensive services such as 999 and A&E and, increasing the use of GP out of hours, MIUs and 111. We will also need to review the value for money of all of our urgent care service contracts to ensure we are getting best value. The CCG as a commissioner is committed to working in partnership with our providers, particularly the new Integrated Care Organisation (ICO) which will bring together acute and community services and a shift in resources from acute care to care provided closer to people s homes. As a clinically lead commissioning organisation, it is one of our quality standards to develop and maintain good working relationship and develop a good understanding of services including walking the floor and talking to patients and staff. 1. Introduction 1.1. Purpose The purpose of the urgent care strategy is to set out, in a single document, our future plans for commissioning urgent care across South Devon and Torbay. Whatever the urgent need is and in whatever location, our aim is to ensure that our population has access to the best care from the right person in the best place and at the right time. The strategy document is intended to be easily navigated by the reader with judicious use of headings, figures and tables to enable the reader to either read the whole document or easily find the section they need, summarised as follows: 1. Introduction: defines the purpose of the strategy, defines urgent care and the scope, describes the vision, principles/objectives and strategic aims 2. The current urgent care system: provides a service map of the current urgent care services, describing each in detail and with relevant activity, quality and performance information. 3. Patient experience of urgent care: provides an overview of patient experience of urgent care, by service, summarising the findings from an accompanying report to the strategy Patient Experience (Urgent Care): What are people telling us? 4. Principles and objectives: this section follows from the review of the current system in sections two and three, re-visiting the vision, principles and objectives and, strategic 10

11 aims described in section one to assess how closely our current services and system match what we are aiming for. 5. Priorities for system change: specifies our priorities for change, having considered how closely the current services match the vision and objectives for re-design. 6. What good looks like quality and outcomes: identifies the relevant measures from the CCG outcomes framework and identifies local quality and outcome standards that we will be looking to include in contracts. 7. Measuring progress: identifies metrics that will enable us to measure the success of the strategy, which will be reported monthly to the urgent care board. 8. Associated developments/considerations: includes the approach to financial management, impact of proposed changes to funding flows, the Integrated Care Organisation (ICO), development of Local Multi-Agency Teams (LMATs), workforce development and estates. 9. The five year work plan emerging work streams: workstreams are identified and leads. Implementation plans will be needed for each workstream and we intended to pursue a programme management style approach to implementation to ensure delivery. The scope of the strategy covers self-care, NHS 111, primary care, minor injury units, community pharmacy, mental health services, community services, A&E and 999. We have not attempted to replicate work already underway in other strategies; however the strategy is complementary to existing strategies on prevention and self-care and mental health, and will influence the development of emerging commissioning strategies including those for primary care. Existing work programmes including end of life care and children s services will also need to be influenced by the strategic direction set. The priorities for the strategy are complementary to the Joint Strategic Needs Assessment (JSNA) including improving the urgent care experience for children and providing care away from hospital wherever possible (starting and developing well), ensuring those of working age understand how to access urgent care when they need it and receive care promptly (living and working well) and improving the urgent care experience and providing care away from hospital where possible for older and frail people (ageing and dying well). The quality and outcome standards emphasize patient safety and experience. The development of a local integrated care organisation is also important as it will deliver a number of our urgent care services going forward. We have not covered services currently commissioned by NHS England, including emergency dental services; however we would wish to continue to work in partnership with colleagues to ensure the best services are available locally and integrated with other urgent care services. The document is a strategic document and, as such, does not include specific recommendations for particular services to be provided or locations for the same. However, the stakeholder engagement exercise did produce a number of comments in this area and we will ensure that the feedback is available to work stream leads to capture in implementation plans. In producing the strategy, we are mindful of the strategic direction set by the Urgent and Emergency Care Review, led by Professor Sir Bruce Keogh (NHS England, 2013). The review was designed to review how the NHS organises and provides urgent and emergency care services in England, recognising that across the country, hospital services that support and sit behind A&E and 11

12 ambulance services are under intense, growing and unsustainable pressure. The review set out proposals for a fundamental shift in how and where the NHS meets urgent and emergency care needs. The strategic direction for the national review was underpinned by a review of the urgent and emergency care system in England and the evidence to illustrate the main challenges faced. The Five Year Forward View (NHS England, 2014) identifies the importance of transforming urgent care over the next five years including much better support for self-care, breaking down barriers between services, new care delivery models, much better integration between urgent and emergency care services, and strengthening and investing in primary care. All these aspects of change feature in the strategy. The planning guidance that accompanies the document identifies a key priority for commissioners and providers to prioritise the major strategic and operational task of how they will be implementing the urgent and emergency care review. This strategy describes our approach to implementation. The strategy was developed in 2014 by a task and finish group which included CCG, patient and provider representation. The final draft of the strategy went out for stakeholder feedback in March 2015 and this version has been adapted in light of the feedback from the consultation. The full stakeholder engagement report is available as an accompanying document to the strategy What is urgent care? Urgent care is largely without an agreed definition however we offer the following definition for the purpose of the strategy. Urgent Care is the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly for needs that are not considered life threatening. (Immediate or life threatening conditions, or serious injuries or illnesses, would normally be deemed emergencies). It is important in terms of patient contacts and resources; nationally, urgent or unplanned care leads to at least 100 million calls or visits each year, representing around a third of NHS activity, and accounts for more than half the costs (NHS England, 2013). This strategy is predominantly focused on urgent care, using the definition above. Within scope is consideration of the following service areas: Self-care NHS 111 Primary care in and out of hours Minor injury units/urgent care centres Community pharmacy Mental health services Community services 12

13 We have also included the following emergency services, acknowledging that at present a number of patients will use these services to meet urgent rather than emergency care needs, and this has an impact on the way the services are able to operate. In addition, ambulance services are increasingly developing appropriate responses to urgent care needs, for example, specialist paramedics. 999 A&E Emergency services not in the scope of the strategy are trauma and major trauma services and, admitted patient care including surgery and intensive care Vision The two part vision adopted locally is articulated in the Urgent and Emergency Care Review (2013). 1. People with urgent but non-life threatening needs should be treated by highly responsive, effective and personalised services outside of hospital. These services should deliver care in or as close to people s homes as possible. 2. People with more serious or life threatening emergency needs should be treated in centres with the very best expertise and facilities in order to reduce risk and maximise chances of survival and a good recovery. Getting the first part right will relieve hospital based emergency services, to deliver the second part of the vision. A more detailed schematic of the vision is described in the review and shown in figure 1. The CCG agrees with the two part vision and the figure describes the overall approach to the strategy, notwithstanding that the aim of our local strategy is about the local interpretation of the national vision and priorities. 13

14 Figure 1: The vision for Urgent and Emergency Care Source: NHS England (2013) 1.4. Principles/objectives The principles describe HOW we intend to work, whereas the strategic aims identify what we will be doing. The principles for good urgent and emergency have been described in the U&EC review and will be adopted locally. Services should: Provide consistently high quality and safe care, across all seven days of the week. Be simple and guide good, informed choices by patients, their carers and clinicians. Provide access to the right care in the right place, by those with the right skills, the first time. Be efficient and effective in the delivery of care and services for patients. The U&EC review defined a number of patient focused objectives for system change, following a national patient engagement and consultation process. These will be incorporated into our five year priorities for change and tested out for local relevance through on-going patient engagement. 14

15 Make it clear how I or my family/carer access and navigate the urgent and emergency care system quickly, when needed. Provide me or my family/carer with information on early detection and options for self-care, and enable me to manage my acute or long-term physical or mental condition. Increase my or my family/carer s awareness and publicise the benefits of phone first. When my need is urgent, provide me with guaranteed same day access to a primary care team that is integrated with my GP practice and my hospital specialist team. Improve my care, experience and outcome by ensuring the early input of a senior clinician in the urgent and emergency care pathway. Wherever appropriate, care for and treat me where I present (including at home and over the telephone). If it's not appropriate to care for and treat me where I present, take or direct me to a place of definitive treatment within a safe amount of time; ensure I have rapid access to highly specialist care if needed. Ensure all urgent and emergency care facilities can transfer me urgently, and that the transport is capable, appropriate and approved. Real time information, essential to my care, is available to all those treating me. Where I need wider support for my mental, physical and social needs ensure it is co-ordinated and available. Each of my clinical experiences should be part of programme to develop and train clinical staff and ensure development of their competence and the future quality of services. The quality and experience of my care should be measured and acted upon to ensure continuing improvement Strategic aims There are five strategic priorities for system change which are derived from the U&EC review, and supported by the CCG through this strategy. 1. To provide better support for self-care. 2. To help people with urgent care needs get the right advice in the right place, first time. 3. To provide highly responsive urgent care services outside of hospital, so people no longer choose to queue in A&E. 4. To ensure that those people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery. 5. To connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts. Better support for people to self-care can be achieved by providing better and more available information about self-treatment so that people can manage their situation with more confidence. A second component of support for self-care focuses on comprehensive and standardised care planning. The role the voluntary sector is important and we will need to understand in more detail the nature and scope of these services. 15

16 It is important to help people with urgent needs get the right advice in the right place at the right time, first time. The NHS 111 service will develop further to ensure prompt access to high quality health advice and referral to appropriate services. Responsive urgent care services outside of hospital will ensure that people no longer need to choose to attend A&E. These services will incorporate pharmacy, primary care, new urgent care centres and mobile treatment maximising the role and contribution of each to reduce A&E attendance. The new urgent care centres will provide access to walk-in minor illness and injury services and be part of wider primary care services including out-of hours GP services. There are national plans to introduce two levels of hospital emergency department under the current working titles of Emergency Centres and Major Emergency Centres to ensure people with more serious or life threatening needs receive treatment with the right facilities and expertise. Finally, all urgent and emergency care services will need to connect together to ensure the system is more than a sum of its parts. 2. The current urgent care system This section is intended to provide a service map of the urgent care services currently in South Devon and Torbay. It includes self-care, NHS 111, community pharmacy, primary care (in and out of hours), minor injury units, A&E, 999 ambulances, mental health and community services. Each service is described and relevant activity, quality and performance information shown where available. The current urgent care system in South Devon and Torbay is complex, with a number of providers running different services. This does need to be simplified and this strategy aims to achieve this. The services are shown by location on the map in figure 2 and summarised in figure 3. The map excludes ambulance stations however it is worth noting at this point that these are located in Ashburton, Totnes, Dartmouth, Brixham, Paignton, Torquay, Newton Abbot and Dawlish. 16

17 Figure 2: Map of urgent care services in South Devon and Torbay Source: SD&TCCG (2014) Figure 3: Urgent care services in South Devon and Torbay 69 pharmacies, with 6 open 100 hours/week 35 GP practices One GP out of hours service, with treatment centres provided from five locations One NHS 111 urgent medical advice service, which also handles GP out of hours calls Nine minor injury units (MIUs) based in community hospitals, with a range of opening times and services on offer One 999 ambulance service One Accident and Emergency (A&E) department Source: SD&TCCG (2014) 2.1. Self-care NHS resources which support self-care include the NHS Choices website ( which has a wealth of information on conditions and treatments. It also includes the symptom checker, which is also available in app form, and allows users to check symptoms if they are feeling unwell to get an assessment and information about their illness and advice on what to do and where to go. 17

18 NHS 111 can provide support and advice for self-care, as well as signposting patients to the most appropriate health service if applicable. In South Devon and Torbay, Devon Partnership Trust, working in partnership a local GP practice and Know Your Own Health, provide supported self-care service (branded Live Well, Feel Better ). Referrals from GP practices are managed in line with the Unplanned Admissions DES. South Devon Healthcare FT also provides cardiac and pulmonary rehab support. Torbay and Southern Devon Health and Care Trust provide diabetes education, accessible for those eligible. Patients Know Best is work on-going in South Devon Healthcare for certain specialties ( This is a web based tool designed to put patients in control of their medical records. Key message There are a range of self-care support tools and services available, nationally and locally, although uptake and usage locally is limited or unknown NHS 111 South Western Ambulance Services Foundation Trust has been running the Devon NHS 111 number since September NHS 111 is a national initiative that is being rolled out across the country. It is a free to use telephone number that has been introduced to make it easier for patients to access local health services. The number should be used when there is an urgent medical need but the condition does not warrant a 999 call. It is available 24-hours-a-day, 365 days a year. In Devon, those requiring a GP out of hours need to call 111. When patients call 111 they are assessed by trained call handlers who are supported in their role by clinicians. The call handlers and clinicians will then provide healthcare advice and direct people to the relevant local service that best suits their needs. If an emergency ambulance is required then this will be arranged automatically during the call. The 111 service locally is fairly new so we are not able to track activity year on year. However, when comparing the number of calls per 1000 patients in South Devon and Torbay to those in the rest of Devon, the rate is broadly similar (see table 1). 18

19 Table 1: Calls per 1000 patients to the Devon 111 service: NHS 111 Datasource M144B Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Total SDT Number of Triaged Cases 6,884 7,294 6,273 6,530 6,661 5,574 6,051 45,267 Rate per 1k Pop North 3,433 3,653 3,226 2,993 3,178 2,729 3,053 22,265 East 7,769 8,071 7,071 7,217 7,240 6,409 6,706 50,483 Number of Triaged Cases West 7,974 8,656 7,468 7,346 7,503 6,503 7,095 52,545 Other 2,653 2,538 2,307 3,026 3,795 2,223 2,265 18,807 Total 21,829 22,918 20,072 20,582 21,716 17,864 19, ,100 Rate per 1k Pop For , the average number of calls per month in South Devon and Torbay is Of these, the majority of calls where the caller needs referral (acknowledging that around 15% do not need a service) are referred to primary care the GP out of hours service (49%), in-hours primary care (5%) and community pharmacy (0.5%). Levels of referral to emergency services including 999 and the Emergency Department are around 10% and 5% respectively which are within national and local tolerances. However, we would wish to continue these rates further as part of the strategy. Across Devon, less than 0.5% currently receive health advice from the service and very few callers are directed to MIUs (in August 2014, only 23 callers were referred to MIUs). Table 2 shows the achievement of the national quality requirements for Devon NHS 111 for the first quarter of The areas where the provider continues to experience difficulties are around calls answered in 60 seconds and call backs within 10 minutes. The provider has worked hard to improve performance in these areas by better matching shifts to known demand however as the demand peaks are significant and occur for short periods of time usually at weekends - this does continue to cause difficulties. Joint work continues to rectify this and improve patient experience. Table 2: NHS Devon 111: national quality requirement achievement in NQR Q Target Providers must report regularly to CCGs on their compliance with the Quality Requirements Monthly Providers must send details of all consultations (including appropriate clinical information) to the practice where the patient is registered by 8.00 a.m. the next working day % 95% Providers must regularly audit a random sample of patient contacts and appropriate action will be taken on the results of those audits. 0.34% Providers must regularly audit a random sample of patients experiences of the service and appropriate action must be taken on the results of those audits. 0.90% 1% No more than 5% of calls should be abandoned 2.88% <5% 100% of calls should be answered within 60 seconds of the end of any recorded message (which should be no longer than 30 seconds) 85.18% 95% 100% of life-threatening calls should be passed to the ambulance service within 3 minutes of the life-threatening status being identified % 95% Patient callbacks must be achieved within 10 minutes 31.84% 95% Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Provided a month in arrears % 95% 19

20 Key message NHS 111 is a relatively new service which has been running for a just over a year locally which takes GP calls out of hours in Devon. This service has struggled to meet call answering and call back standards although work is underway to improve this. Most callers are currently referred to primary care and there is scope to reduce rates of referral to 999 and ED and increase to other services Community pharmacy There are 69 community pharmacies in South Devon and Torbay situated in high-street locations, supermarkets and in residential neighbourhoods. A map showing the location of community pharmacies in South Devon and Torbay is included in appendix 1. Pharmacies open a minimum of 40 hours a week. Six pharmacies in the area are open for 100 hours a week and a considerable number are open for extended hours including Saturdays. The majority have a private consultation room and patients can have access to a health care professional without the need for an appointment. Community pharmacies provide a convenient and less formal environment for those who cannot easily access or do not choose to access other kinds of health service. Nationally, 99% of the population can get to a pharmacy within 20 minutes by car and 96% by walking or using public transport, even in the most deprived areas. Eighty-four per cent of adults visit a pharmacy at least once a year and on average an adult visits a pharmacy 16 times a year. Over 75 per cent of adults use the same pharmacy all the time and the footfall into a community pharmacy is approximately three and a half times more than general practice. Under their contractual arrangements with the NHS, community pharmacies provide a range of core services including dispensing medicines, repeat dispensing, disposal of unwanted medicines, healthy lifestyles, signposting and support for self-care. Community pharmacists as experts in medicine are also commissioned to provide medicines adherence support through Medicines Use Reviews and the New Medicines Service. Both services support patients in getting the most benefit from their medicines. Community pharmacy services can play an important role in enabling self-care particularly amongst patients with minor ailments and long term conditions. Pharmacy First services are being trialled in South Devon and Torbay to promote community pharmacy as the first access point for people with certain common ailments, together with emergency supply of repeat medicines if the patient has run out of their regular medication. The schemes, which are funded by the Prime Minister s Challenge Fund, is showing early positive results as indicated in figure 4. 20

21 Figure 4: Early results from Pharmacy First schemes 669 patients seen in 4 weeks: Torbay 113 patients, South Devon 153 patients, North and East localities 403 patients. 357 seen for minor (winter) ailments, 205 patients seen for PGD services and 107 seen for emergency repeat supply service. Estimated 378 GP of appointments saved ( 17,100 forecast savings of GP time) and 12 Accident and Emergency appointments saved (saving estimated 1,380). Source: SD&TCCG (2014) Key message South Devon and Torbay is well served by numbers of community pharmacy with extended opening times including evenings and weekends. There is potential to make much better use of their skills as part of the urgent care system including promotion of healthy lifestyles, sign-posting, support for self-care and medicines use reviews. There is also scope to consider their enhanced role in managing minor ailments and emergency supply of medicines out of hours GP practices Over ninety per cent of all NHS patient contacts are thought to take place within primary care. There is a lack of available, up-to-date, data on general practice consultation activity, but levels have increased steadily over the last 10 years, with an estimated 340 million taking place in 2012/13 (NHSE, 2013). Figure 5 shows the increasing rate per person per year. Figure 5: General practice consultation rate per person per year 21

22 L83637 L83122 L83146 L83013 L83029 L83666 L83120 L83032 L83045 L83118 L83126 L83607 L83014 L83657 L83034 L83094 L83005 L83055 L83145 Source: NHS England (2013) There are 35 GP practice partnerships in South Devon and Torbay who provide primary medical services from 8am to 6.30pm. All practices provide essential services, for people who are ill or believe themselves to be ill, immediately necessary treatment, additional services and a wide range of enhanced GP services. At present, contracting responsibility for GP services lies with NHS England but the CCG has expressed an interest to take greater responsibility for primary care commissioning going forward. All GP practices in the South Devon and Torbay CCG area offer daily urgent (with some offering nonurgent) telephone consultations with a GP. Depending on what clinical details the patient will disclose, patients are either transferred immediately to a GP, transferred in-between other consultations, transferred to the duty doctor or a GP calls the patient after surgery. Call back times do vary across the patch, ranging from 5-10minutes to 4 hours in some practices. There appears to be no average although the most common is within the hour for an urgent request. Regarding face to face consultation, patients at some practices are also offered same day face to face consultations or, most commonly, as soon as possible. Nationally, there is also thought to be a link between satisfaction with access to GPs and attendance at A&E departments although we are not seeing such a link locally yet, as figure 6 shows. Figure 6: A&E attendance per head of population against patient satisfaction % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% A&E attendances per head of population against patient satisfaction Satisfaction AE Rate Pearson correlation coefficient (where 1 = total positive correlation, -1 = total inverse correlation and 0 = no correlation) Source: SD&TCCG (2014) 22

23 The Urgent and Emergency Care Review highlights an issue with GP visiting times impacting on A&E attendance, with those requiring a home visit presenting at hospital later in the afternoon when A&E departments are at the busiest and staffing and support services are reduced. This is when GP visits are undertaken after morning surgery and before afternoon surgery, usually between the times of 11am and 2pm. There is some evidence locally that these visiting times do lead to higher rates of attendance from those GPs have visited later in the day. Key message GP practices are the most frequent provider of urgent care services and GP consultation rates are continuing to rise. All practices in South Devon and Torbay encourage telephone consultation for urgent conditions, with most calling patients back within an hour (although this does vary). Although an issue nationally, locally, there is no statistical link between poor patient satisfaction with services and A&E use. Arrangements for GP visits in the middle of the day has an impact on patients attending A&E later when the department is particularly busy and some support services are reduced GP out of hours services GP out of hours services are provided across Devon by Devon Doctors Ltd, across the county of Devon. The services run from 6.30pm to 8am on weekdays, weekends and bank holidays when GP practices are closed. The service is for patients with urgent conditions that cannot wait until their GP practice is next open. Access to the services is via NHS 111. If following a series of questions, the caller is deemed to need primary care their details will be transferred to the GP out of hours service. At this point, a GP will call the patient to take further details and offer advice as appropriate. Following the phone consultation with GP, the caller may also be advised to attend a treatment centre or a GP may undertake a home visit. A caller may also be referred to another service, depending on their needs. GP OOHs treatment centres are currently located at the following Community Hospitals (table 3). Table 3: Location of GP OOH treatment centres across South Devon and Torbay Location Weekdays Weekends/Bank holidays Overnight Newton Abbot Hospital X X X Paignton Hospital X Teignmouth Hospital X Torbay Hospital (ED) X X Totnes Hospital X X X Source: SD&T CCG (2014) As table 4, shows Newton Abbot is the busiest treatment centre; indeed, it is one of the busiest in Devon. The next busiest base is Torquay, followed by Totnes. The total number of contacts last year was about 195/1000 patients. Of these, 52% were dealt with by GP advice on the phone, 31% by attendance at a treatment centre and 16% received a home visit. Of the total seen, approximately 23

24 10% went towards hospital. The times that most people access out of hours services are from 7pm to 9pm on weekdays and 8am to 1pm on weekends and bank holidays. Table 4: Number of GP OOH contacts by type and treatment centre location, Oct 2013-Oct 2014 Sum of Total Final Cons Type name GP Advice GP TC GP Visit Ward Visit Grand Total Newton Paignton Teignmouth Torquay Totnes Grand Total Source: Devon Doctors (2014) Figure 7 shows the number of out of hours services contacts by age range; as can be seen, a large proportion of those in contact with the service are aged 0-5 years, with the largest peak in very young children, aged 0-2 years. Figure 7: GP out of hours contacts by age range Source: Primary Care Foundation (2014) Locally, we are seeing a change in activity levels for GP out of hours services contacts in the south, as shown in table 5. This decreasing trend is mirrored nationally and the National Audit Office s report identified that the number of cases dealt with by the services had fallen in recent years, from 8.6 million in to 5.8 million in This has been partly attributed to the roll-out of NHS 111 and locally there have been changes in the numbers and case mix for the service. 24

25 Table 5: GP out of hours contacts by year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total 14/15 4,593 4,873 4,057 4,150 4,750 3,728 4,146 4,205 5,085 52,783 13/14 5,350 5,832 5,239 4,890 4,211 4,669 4,517 4,772 5,398 4,619 4,390 4,793 58,680 12/13 6,181 5,588 6,316 5,384 5,212 5,294 4,820 4,785 6,540 5,419 5,120 6,627 67,286 11/12 6,632 5,674 4,908 5,541 5,174 4,489 5,490 4,869 6,631 5,422 5,587 5,933 66,350 July actual figure missing, average taken of rest of year End of year total taken on average of available data Source: Devon Doctors (2014) Achievement of the national quality requirements for out of hours by Devon Doctors is generally very good. Over 90% of urgent cases are clinically assessed on the phone in 20 minutes and routine cases within 60 minutes. For those requiring face to face assessment, over 90% of urgent cases are seen in two hours and nearly 100% of those assessed as routine are seen in six hours. These strong results are supported by high levels of patient satisfaction, described in more detail in the next section. The Public Accounts Committee recently published a report into the out of hours GP service in England. There have been criticisms around variable quality and value for money of these services. As described above, Devon Doctors provide a high quality service which is well regarded by patients, which is monitored quarterly through contract review meetings. The Committee report mentioned variable value for money, with the cost per case ranging from less than 29 to more than 134 in The cost per case for South Devon and Torbay is 54, which is below average. Key message The GP out of hours service in Devon performs well and is highly regarded by patients and professionals alike. It also provides good value for money. However, the number of cases seen by the service is falling, since the introduction of 111, a trend which has also been found nationally. The number of contacts for young children is high, as are contacts in Newton Abbot and Torquay treatment centres. A good proportion of cases are dealt with by telephone advice Minor Injury Units (MIUs) There are eight MIUs in South Devon and Torbay, with services provided by Torbay and Southern Devon Health and Care Trust. Most minor injuries units can treat: Sprains and strains Insect and animal bites Broken bones Minor eye injuries Wound infections Minor burns and scalds Injuries to the back, shoulder and chest Minor head injuries Minor illnesses are not generally treated through MIUs although some sites do offer services for mild 25

26 abdominal discomfort, sore throat, ear pain and urinary tract infection for children over the ages of 2-3 years. Units are located at Newton Abbot, Totnes, Teignmouth, Dartmouth, Dawlish, Ashburton, Brixham and Paignton. Opening hours and services do vary. Most units open at 8am, but closing times are variable. In and out of hours medical support is available at most, but not all, sites. Similarly, x-ray is available at most sites, but not all the time. There are diagnostic management links between the community MIUs and ED, who provide minor patient advice and X-ray review. Recognising the variation in attendance and services, a minor injury unit review is currently underway to review the location, opening times and service offerings. This will help to ensure they are consistent and provide patients with a sound alternative to A&E attendance for certain minor injuries and illnesses. Considering attendance at the MIUs in our area, as can be seen from table 6, the MIU with the consistently highest numbers of attendance is Newton Abbot, followed by Totnes, Brixham and Teignmouth. Table 6: MIU attendance by site: Sum of atts Ashburton Bovey Tracey Brixham Dartmouth Dawlish Newton Abbot Paignton Teignmouth Totnes Grand Total 2008/ / / / / / Grand Total Source: SD&TCCG (2014) Table 7 shows MIU attendance by Index of Multiple Deprivation at Local Super Output Area. With 1 being the most deprived and 5 the least, Paignton and Teignmouth MIUs are seeing a large proportion of patients from areas of higher deprivation. Table 8 shows MIU attendance by age. Considering attendance by four year age band, the highest level of attendance in all MIUs by age is amongst children aged 5-9 years. Table 7: MIU attendance by site, by Index of Multiple Deprivation IMD Quintile Hospital Grand Tota Paignton 22.41% 36.77% 24.05% 16.05% 0.72% % Teignmouth 15.40% 23.37% 14.98% 40.04% 6.21% % Dartmouth 13.61% 2.44% 42.15% 23.75% 18.06% % Dawlish 12.38% 24.14% 41.42% 20.73% 1.33% % Grand Total 7.80% 22.91% 36.32% 25.88% 7.09% % Newton Abbot 4.30% 20.23% 33.13% 30.81% 11.52% % Totnes 2.21% 18.84% 58.13% 19.78% 1.04% % Brixham 1.02% 48.81% 35.30% 14.62% 0.25% % Ashburton 0.35% 11.25% 69.20% 18.17% 1.04% % Note: Quintile 1 = Most Deprived, Quintile 5 = Least Deprived 26

27 Source: SD&TCCG (2014) Table 8: MIU attendance by site, by age Ashburton Brixham Dartmouth Dawlish Newton Abbot Paignton Teignmouth Totnes age 0-4 4% 4% 3% 4% 7% 5% 6% 6% age % 15% 16% 14% 17% 17% 17% 18% age % 6% 5% 7% 8% 7% 7% 7% age % 6% 4% 5% 8% 6% 6% 9% age % 7% 4% 5% 7% 7% 6% 6% age % 5% 4% 4% 6% 5% 4% 5% age % 4% 3% 5% 6% 5% 3% 5% age % 3% 3% 4% 4% 4% 4% 5% age % 4% 4% 6% 6% 4% 4% 6% age % 5% 4% 6% 7% 5% 6% 7% age % 7% 5% 6% 5% 6% 7% 6% age % 8% 9% 7% 5% 6% 7% 7% age % 7% 7% 6% 4% 5% 6% 4% age % 7% 7% 8% 3% 8% 6% 4% age % 6% 9% 6% 3% 4% 7% 3% age % 4% 8% 3% 2% 5% 4% 3% age % 3% 3% 2% 1% 2% 1% 1% Grand Total 100% 100% 100% 100% 100% 100% 100% 100% Source: SD&TCCG (2014) MIU performance is generally very good, with low average waiting times around 30 minutes with very few patients waiting over two hours as table 9 shows. Table 9: MIU performance information Minor Injury Units MIU - Average waiting time (95th percentile) HI MIU - No. of attendances HI ,084 4,160 4,478 4,647 5,393 4,950 Torbay Locality Total HI , Brixham MIU HI , Paignton MIU HI , Southern Devon Locality Total HI ,939 3,622 3,943 3,977 4,602 4,352 Southern Devon & Torbay CCG Total HI ,542 2,742 3,051 3,194 3,494 2,930 NEW Devon CCG Total HI , Other CCG Total HI , ,207 MIU - No. of new attendances (patients) MI ,876 3,375 3,608 3,780 4,433 4,062 MIU - No. of follow-up attendances - planned & unplanned (patients) MI , MIU - No. of 4 hour breaches HI MIU - % patients waiitng > 2 hours HI % 1.3% 1.3% 1.9% 2.9% 1.7% Source: SD&TCCG (2014) Key message There are eight MIUs across South Devon and Torbay, although opening hours and services offered do vary by location. This can be confusing and we have seen attendance from 2012 plateau at around 35,000. Attendance varies by site with Newton Abbot seeing nearly 15,000 people per year whereas the average at the other sites is around Considering age and level of deprivation, the units are seeing a high proportion of patients aged 5-6 years and in Paignton and Teignmouth, higher proportions of patients from the more deprived areas attend. Performance in terms of waiting times across the MIUs is generally very good. Title 27

28 2.7. Accident and Emergency Department There is one Accident and Emergency Department in the CCG footprint. South Devon Healthcare NHS Foundation Trust runs the Emergency Department at Torbay Hospital in Torquay. It is a 24/7 service seeing all acute and emergency care patients. It is a designated trauma unit, liaising with Derriford Hospital in Plymouth as the Trauma Centre. There are a number of other services connected to and run from the department as described in figure 8. Figure 8: Services connected to the Torbay Hospital A&E department Minor injuries service Arrhythmia team GP out of hours treatment centre Dementia team Consultant review follow-up clinics Stroke team Dressings clinics Rapid access DVT clinics (nurse-led) Short stay paediatric assessment unit (SSPAU) Speciality nurses Emergency Assessment Unit (EAU) Chest pain team Liaison psychiatry service Source: SDHCFT (2014) The department includes child friendly facilities including a section of the waiting area and there is a child friendly treatment area. Baby change facilities are available in the toilets. At this point in time, patients referred by GPs Torbay Hospital go through the normal A&E system, including a triage nurse, prior to onward direction to a specialty team. Connected to the department is a multispecialty Emergency Assessment Unit (EAU) which has 49 beds. Following a pilot last year, the newly refurbished short stay paediatric assessment unit started in November The unit is based on the Louisa Cary Children s Ward and will be consultant paediatrician led. The aim is improve the urgent and emergency care pathway for children and young people. There will be direct access for GP referrals (avoiding A&E), where children can be assessed in a more timely manner and in a child-friendly environment. The unit will open from , Monday to Friday, with the last referral at GPs contacting the hospital have direct access to a consultant paediatrician 9am-9pm, Monday to Friday, who can also provide direct advice and guidance. The urgent and emergency care review identifies issues that staffing is probably the single most important factors in providing a high quality, timely and clinically effective service to patients. (pp. 49). There are national concerns about the number of doctors wanting to train in emergency medicine and difficulties recruiting and retaining staff, particularly senior doctors and consultants whom are considered to improve patient outcomes. The review is clear that consultant delivered care is the model for the future, with 24 hour presence or ready availability, but notes concerns about variation in the number of hours that consultants are present in A&E departments with variation between weekdays and weekends. 28

29 Locally, in November 2014, there are six consultants in the department, with interviews for a 7 th underway. Currently, none of the consultants have sub-specialty training in paediatrics, which is nationally recommended for EDs with more than 16,000 annual paediatric visits (Torbay sees just over 21,000 children per year) however, the SSPAU provides urgent and emergency access to paediatricians. The shop floor coverage of consultants in A&E in Torbay is 14 hours per day, Monday to Friday and 6 hours/day over weekends. The national recommendation is shop floor coverage for at least 12 hours per day. The review also identifies designating nursing staff is important with national concerns being raised about high rates of vacancy and inadequate skill mix. Information from NHS Choices, show in table 10, shows some difficulties filling registered nurse day hours up until August although the situation is better with unregistered day and night staff, and registered night staff. Table 10: Nurse staffing levels - Accident and emergency services August 2014 Ward name % of registered nurse day hours filled as planned (Ward) % of Unregistered care staff day hours filled as planned (Ward) % of registered nurse night hours filled as planned (Ward) % of Unregistered care staff night hours filled as planned (Ward) EAU 89% 3 of planned level 128% of planned level 98% of planned level 126% of planned level EAU 84% 4 of planned level 144% of planned level 100% of planned level 105% of planned level Source: NHS Choices (2014) Accident and Emergency Quality Indicators (QIs) are published nationally by the Health and Social Care Information Centre. Reports are published quarterly from Hospital Episode Statistics (HES) A&E data for the following five A&E indicators: Left department before being seen for treatment rate Re-attendance rate Time to initial assessment Time to treatment Total time in A&E Table 11: Quality indicators for A&E: South Devon Healthcare performance and achievement of A&E four hour wait Quality Indicator ENGLAND SDHCFT Left department before being seen for treatment 2.88% 4.48% Re-attendance rate within 7 days 7.62% 7.13% Median - Time to initial assessment [emergency ambulance cases only] - minutes Median - Time to Treatment, minutes Median - Total Time in A&E (minutes) - admitted patients only Median - Total Time in A&E (minutes) [Non-admitted patients only] Median - Total Time in A&E (Performance; minutes) Source: HSCIC (2014) 29

30 DataSource: UCB Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Emergency Care 4hr wait standard 82.2% 84.8% 84.2% 82.0% 90.6% 93.9% 95.4% 90.8% 83.8% Source: SD&TCCG (2014) Table 11 shows the local position. As can be seen, in June there were some difficulties experienced in the department with above national rates for those leaving the department, times to assessment for ambulance patients and total time in A&E. There have also been some difficulties achieving the four hour wait. This has predominantly only been an issue locally since the start of 2014, with the Trust previously showing high levels of performance. As a result of the difficulties in meeting the quality standards, the acute trust and CCG have agreed an action plan to turn this around, and in July the Emergency Care Intensive Support Team (ECIST) visited the Trust and suggested a number of areas for improvement which are now being included in the turnaround plan. We are confident that these figures will improve with future releases of information. In common with other areas, we have seen a rise in A&E attendance over the last five years as seen in figure 9. Our rate of A&E attendance is above the national average: 39,419/100,000 population, compared with 30,041/100,000 in England. Figure 9: Number of A&E attendances: / / / / / /14 Sum of Atts 65,955 66,042 67,983 70,504 71,659 72,956 % change 0.13% 2.94% 3.71% 1.64% 1.81% Source: SDT&CCG (2014) 30

31 00 to to to to to to to to to to to to to to to to to to Considering the use of A&E by age, figure 10 shows large increases in attendance amongst very young children and those in the middle age ranges. However, when considering total attendances, the highest users continue to be those aged 80+ years. Figure 10: A&E attendance by age: % change and per 1000 population Age Band 2010/ /14 % Change 00 to % 05 to % 10 to % 15 to % 20 to % 25 to % 30 to % 35 to % 40 to % 45 to % 50 to % 55 to % 60 to % 65 to % 70 to % 75 to % 80 to % 85 to % % Attendances per 1,000 population by age 2010/ /14 Source: SD&TCCG (2014) 31

32 Over the last two years, we have seen a change in the time of attendance at A&E. More people are now attending later, from 8pm to 8am. We have also seen changes in the day of attendance at A&E, with particular increases being experienced on Monday and Tuesday. When considering who attends A&E (and MIUs), as can be seen in figure 11, the largest number of patients are from the Torquay and, Paignton and Brixham localities. Figure 11: A&E/MIU attendance by age and locality A&E / MIU Attendances All Providers 2013/14 By Age Group & Locality over_65 adult child Coastal Moor To Sea Newton Abbot Torquay Paignton and Brixham Source: SD&T CCG (2014) Nationally, the rate of those attending A&E not needing treatment (although the patient may receive advice and guidance) is around 40%. Locally, as can be seen in figure 12, our rate is lower however it does vary by location. As can be seen in the figure, a large number of patients attending A&E/MIUs from the Torquay locality did not receive any treatment. 32

33 Abbey and Shiphay Barton (Torquay) Southover Old Farm Buckland Croft Hall Brunel Chilcote Chelston Hall Parkhill Corner Place Grosvenor Road Mayfield Withycombe Bishops Place Pembroke House Devon Square Cricketfield St Lukes Albany Richmond House Kingskerswell Catherine House Cherrybrook Kingsteignton Teign Estuary Compass House Greenswood Teignmouth Buckfastleigh Bovey and Chudleigh Channel View Barton (Dawlish) Leatside Ashburton Dartmouth Chillington Percentage Of All 2013/14 Attendances Figure 12: Percentage of A&E/MIU attendance not receiving treatment 14% Percentage Of Attendances Receiving No A&E / MIU Treatment All Providers 2013/14 12% 10% 8% 6% 4% 2% 0% Coastal Moor to Sea Newton Abbot Paignton and Brixham Torquay Locality CCG Source: SD&TCCG (2014) Proximity to A&E and levels of deprivation are known to influence attendance. Considering the profile of attendance by GP practice, shown in figure 13, this appears to be the case locally with higher rates of attendance from practices in more deprived areas. Figure 13: A&E attendance per 1000 population by GP practice Attendances per 1,000 population by practice fy_2012_13 fy_2013_ Source: SD&T CCG (2014) To look at A&E attendance in more detail, it is possible to map attendance by Lower Super Output Area (LSOA). LSOAs are derived from census data and each contains 1500 persons. Figure 14 shows attendance across Torquay; of particular note the two LSOAs with dots on them have respectively 990 attendances and 1030 attendances over the last twelve months. 33

34 Figure 14: A&E attendance by LSOA (Torquay) Source: SD&T CCG (2014) Key messages There is one Accident and Emergency Department in the CCG footprint offering a wide range of acute and emergency care services including trauma services, minor injuries, rapid access DVT clinics (nurse-led), speciality nurses and teams and a paediatric assessment unit. Connected to the department is a multi-specialty Emergency Assessment Unit (EAU). Consultant cover is good in the department, with 16 hours Monday to Friday, well in excess of the national recommendation of 12 hours per day. However, this drops to 6 hours/day over the weekend. At present, none of the consultants have paediatric sub-specialty training, which is recommended in departments with over 16k paediatric attendances. However, locally the shortstay paediatric assessment unit allows urgent access to paediatricians. The department has experienced some difficulties achieving the national quality requirements and four hour wait standard although a turnaround plan should show significant improvements in this area as the year progresses. The rate of A&E attendance in South Devon and Torbay is above the national average and increasing with particular increases in attendance from those living in Torquay, very young children and those in the middle age ranges. Location and deprivation is also influencing attendance with higher rates of attendance from GP practices in deprived areas and there are two LSOAs in Torquay with particularly high numbers of attendance. A large proportion of those from Torquay leave receiving no treatment (although advice may be given). The overall rate of attendance in A&E continues to be highest amongst young children and those aged 80+ years. 34

35 emergency ambulance service South Western Ambulance Service NHS Foundation Trust provides accident and emergency services throughout the South West region. The 999 telephone number and response is their main service. The 999 ambulance service is generally for use in emergencies, that is if a patient has a serious or life threatening emergency need. Callers are connected to an ambulance 999 operator or call handler who asks a series of questions to establish what is wrong. Calls are categorised as: Immediately life threatening (category A) An emergency response will reach 75% of these calls within eight minutes (Red 1 and Red 2 calls). Where onward transport is required, 95% of life-threatening calls will receive an ambulance vehicle capable of transporting the patient safely within 19 minutes of the request for transport being made (A19). These calls are defined as category A Green 2 (Emergency Treatment and/or Transport to Emergency Department) - Presenting conditions, which though serious are not immediately life threatening, must receive a response within 30 minutes, in 95% of cases Green 4 (999/Urgent) - Calls can be categorised as Green 4 and will receive a response in 60 minutes, in 90% and 70% of all cases respectively. Patients will always be taken to hospital when there is a medical need for this. However, ambulance crews increasingly carry out more diagnostic tests and do basic procedures at the scene. Crews also refer patients to social services, directly admit patients to specialist units and administer a wide range of drugs to deal with conditions such as diabetes, asthma, allergic reactions, overdoses and heart failure. The Ambulance Trust has a number of stations across the CCG area, shown in figure 15. Patients are not treated at these locations however they are strategically important and there is potential to develop their use into the future. Figure 15: Ambulance station locations in South Devon and Torbay Ashburton Totnes Dartmouth Brixham Paignton Torquay Newton Abbot Dawlish Source: SWASFT (2014) The number of 999 calls, categories and performance is summarised in table 12. This shows that a large number of calls are for immediately life threatening and life threatening conditions (R1-A19). 35

36 However, there are still a number of calls for serious but not life threatening conditions and urgent conditions which could be managed in another way. Table 12: Number of 999 calls and performance achievement in SWAST Number of Calls April May June July Aug Sep Oct Nov R1(8) R2(8) 1,598 1,600 1,579 1,714 1,670 1,616 1,463 1,547 A19 1,670 1,678 1,665 1,794 1,747 1,690 1,545 1,614 G2(30) 1,892 1,867 1,861 2,146 2,106 1,781 1,944 1,914 G4(999) G4(URG) Performance April May June July Aug Sep Oct Nov R1(8) 87.50% 79.49% 81.61% 82.72% 75.32% 85.14% 84.15% 82.35% R2(8) 80.54% 79.88% 79.73% 79.05% 76.77% 81.37% 77.44% 74.34% A % 97.02% 97.00% 96.43% 95.94% 97.40% 95.79% 95.72% G2(30) 94.45% 92.29% 92.53% 90.82% 89.70% 92.14% 90.12% 88.98% G4(999) 84.09% 87.36% 84.34% 90.65% 80.28% 89.81% 85.53% 82.81% G4(URG) 60.11% 64.84% 66.49% 57.45% 61.94% 67.96% 61.02% 65.93% Source: SWASFT (2014) As can be seen in figure 16, there has been a steady rise in the number of ambulance calls per month, most notably health care professional calls, with a small decrease for calls from patients. Figure 16: Ambulance calls by month managed and unmanaged 36

37 Source: SD&T CCG (2014) % change (HCP) % change (999) % change (Total) HCP /12 12,178 40, /13 12,490 43, % 6.6% 5.7% 2013/14 11,842 38, % -12.0% -10.5% 2014/15 YTD 10,159 21,494 Within our localities, the number of calls from each area does vary with most calls coming from Torquay and, Paignton and Brixham as can be seen in figure 17. Figure 17: Managed 999 calls by age and locality Managed SWAST Calls 2013/14 by Age Group & Locality Of Pickup Location Coastal Moor to Sea Newton Abbot Paignton and Brixham Torquay to 64 0 to 19 Source: SD&T CCG (2014) The South Western Ambulance Services Trust has the lowest rate of conveyance in the country, with more patients treated at the scene and not conveyed to A&Es as figure 18, taken from the U&EC review shows. 37

38 Figure 18: Conveyance rates to A&E by Ambulance Trust Source: NHS England (2013) Interestingly, there is very little variation locally between the numbers of ambulance calls in and out of hours, with a near 50:50 split between in and out of hours. This picture is mirrored across most localities, except Torquay when around 54% call out of hours. Key message Although the number of 999 calls from patients has remained relatively stable locally, in comparison with national rises, the number of health care professional calls has increased. The highest number of calls in the CCG comes from Torbay, with little variation in and out of hours. A number of calls are for immediately life threatening and life threatening conditions, although there are still a number for serious and urgent conditions which could be alternatively managed. The ambulance provider has one of the lowest rates of conveyance to emergency departments, treating many patients at the scene Mental health services Community Mental Health Services: Community mental health services for South Devon and Torbay, provided by Devon Partnership NHS Trust, have duty systems in place so that people who are in receipt of mental health services requiring urgent advice and support can access help quickly or be supported to access the correct service, for example the Crisis Resolution and Home Treatment Service. The community mental health services run between 9am and 5pm, Monday to Friday. Devon Doctors Community Mental Health Practitioners: The Devon Doctors Service provides urgent out-of-hours healthcare for patients when GP practices are closed; people access the service through the 111 service described earlier. Community Mental Health Practitioners work between 38

39 10am and 10pm at weekends and Bank Holidays; the Community Mental Health Practitioners conduct telephone assessments with callers and, dependent on the needs of the person, provide telephone advice, signposting to mental health services including Crisis Resolution and Home Treatment or a home visit by the GP. Crisis Resolution and Home Treatment Services: Devon Partnership NHS Trust (DPT) provides two Crisis Resolution and Home Treatment (CRHT) Teams locally, one in Teignbridge and one in Torbay, the teams employ Mental Health Practitioners, including Consultant Psychiatrists and operate from 8am to 9pm, 7 days a week. There are standards in place regarding response times. Referrals to the team are triaged and people with the most urgent presentations are contacted within 4 hours and all other people referred are contacted within 24 hours. After 9pm the CRHT function is provided by a Mental Health Nurse Practitioner. The Mental Health Nurse Practitioner works between 7.30pm and 7.30am, 7 days a week and during these hours provides telephone advice and support and a mental health assessment service within A&E; they are supported by junior doctors and the on-call Consultant Psychiatrist. Rapid re-referral to mental health services: At the point of discharge from mental health services, as part of discharge planning, rapid re-referral to Devon Partnership NHS Trust mental health services is discussed with individuals. Contingencies regarding rapid re-access at times when people need urgent advice or intervention are in place to enable people to access the service that previously provided care avoiding the need for access via the Mental Health Assessment Teams. Rapid rereferral plans are individual to the person and are time limited. Liaison Psychiatry Services: The Urgent and Emergency Care Review identifies that approximately 5% of A&E attendance relates to mental health disorders and re-attendance is linked to untreated mental health problems. The review identifies a need to ensure that patients attending A&E have a mental health assessment within the same timescale as those with physical health problems. Devon Partnership NHS Trust provides a Liaison Psychiatry Service to the A&E Department and wards of Torbay Hospital. The service operated between 9am and 10pm, Monday to Friday, and from January will extend to weekends. There are standards in place regarding response times. Those referred to the Liaison Psychiatry Service from A&E are seen within one hour and those referred from the Emergency Assessment Units are seen within four hours with referrals from the wards seen within 24 hours. A&E is given priority in order to manage the flow and capacity through the Department. Outside the working hours of the Liaison Psychiatry Service a Mental Health Nurse Practitioner, supported by junior doctors and the on-call Consultant Psychiatrist, provides support and advice to A&E and hospital wards as well as conducting urgent mental health assessments. The demand for urgent mental health services is increasing from 6pm on a Friday to Monday morning (ECIST). The peak hour for admission to A&E is 8pm and Mondays are the busiest day of the week closely followed by Friday and Saturday. The Emergency Duty Team: Anyone requiring urgent attention outside of Social Services office opening hours can contact the Emergency Duty Team (EDT); the team responds out of hours to a range of calls including requests for advice and signposting for mental health problems and requests for assessments under the Mental Health Act. The team operates Monday to Thursday 4.30pm to 9am and Friday to Monday, 4pm to 9am. 39

40 Place of Safety: People who are detained by the police under Section136 of the Mental Health Act because they are believed by police to be in need of care should be conveyed to a Place of Safety for assessment as outlined in the Mental Health Act Code of Practice. The local Place of Safety is on the Haytor Unit at Torbay Hospital. The Place of Safety is available 24 hours a day, 7 days a week. An enhanced service will operate from March 2015 to include additional nurse practitioners and assistant practitioners, available 24/7. The redesign of the urgent care pathway has included the provision of a local enhanced section 12 approved doctor rota within 9 to 5 working hours; these enhancements are currently being evaluated with a planned roll out to out of hours in April 2015 subject to the findings. Other service developments for urgent mental health care include: psychiatric assessment and management service for out of hours and weekends, volunteer peer support, out of hours sanctuart support, volunteer/peer support mental health helpline 8pm to 11pm, 7 seven days a week and 24 hour telephone access to mental health professionals There are also developments to raise awareness of urgent mental health care needs in other services including a training programme for 111 staff and practice standards and key working principles for A&E. There is also a Devon wide pilot service providing mental health information and clinical support to NHS 111. NHS ambulance services in England are planning to introduce a single national protocol for the transportation of section 136 patients, which will provide agreed response times and a standard specification for use by clinical commissioning groups. Key message Out of hours services need to be of the same consistency and quality as those provided during 9 to 5 hours with regard to staffing levels and range of options available. Opportunities for joined up, flexible working across services need to be maximised Other community services Table 13 shows the availability of community services and those which are available seven days a week. As can be seen, there is a wide range of community and social care services provided locally, with varying five to seven day availability. Services not currently available into weekends and bank holidays include early stroke discharge and neuro team, ME/CFS, MSK physiotherapy, older peoples mental health, health visiting, school nursing, alcohol and drug services and social work. Services that area available seven days a week, across Torbay and south Devon, includes district nursing, lifestyles, community hospitals and the emergency duty services for social care. The child and adolescent mental health services (CAMHS) are available via the EDS. Services currently available in Torbay include intermediate care, discharge co-ordinators, intensive home support and, crisis response for domiciliary care, although it should be noted that for the latter three services there is a different service available in south Devon through Devon County Council. 40

41 It makes for a complex picture of provision across Torbay and south Devon, with some potential for confusion for patients involved with these services needing to access care urgently. Going forward, more of this information needs to be available through 111 to ensure patients can be signposted to the most appropriate service, including some of these services. However, we do recognise that not all services are necessary to be delivered seven days a week and so local pilots are informing which additional services would be needed both to meet the needs of the population and to facilitate patient flow. Table 13: Overview of community services provided in South Devon and Torbay and availability Service Torbay 7 day service Southern Devon 7 day service Comments Hospital discharge Discharge Coordinators cover A&E sat /sun No provided by DCC in SD CAMHS emergency duty service plus protocols with A&E emergency duty service plus protocols with A&E Care direct plus N/A No provided by DCC in SD Rapid response (dom care) N/A Yes Different service commissioned in Torbay therefore N/A Early stroke discharge and neuro team No No ME/CFS No No MSK physio No No Older peoples mental health No No Health Visitors no no School nurses no no Alcohol and drug services no no Social Work No No See EDS Social care reablement Provided by IHSS Provided by DCC District Nursing Yes Yes Intermediate care Yes No Intensive Home Support Service (service in early pilot stages) Crisis Response Team (dom care) Lifestyles / Public Health Promotion Yes Yes Community hospitals Yes Yes Yes N/A - Different service commissioned in SD N/A - Different service commissioned in SD Yes but no therapy service in SD hospitals, apart from Teign ward which has 7 day cover St Kilda Yes N/A No 7 day therapy cover Intermediate care minimum level service at the weekend in Torbay. Staff also cover Paignton and Brixham hospitals for new therapy referrals or people at risk of deterioration. Weekend working sat am for smoking cessation and other times if events are on Emergency Duty Service (out of hours) Yes Yes provides out of hours Social Work and provided by DCC in SD Source: T&SDHCT (2014) Summary of key factors facing the urgent care system and conclusions Taken from the key messages through this section, the key issues relating to the urgent care system are as follows. We need to reduce public reliance on services and support self-care. Although there is a wide range of support tools and services available, uptake and usage locally is limited or unknown. Promotion of existing services and resources, including NHS Choices, should be a priority as should promotion of the NHS 111 number for advice. We are well served by community pharmacy, with extended opening times including evenings and weekends. They have a wide range of skills including support for self-care and 41

42 sign-posting to other services (including 111) and potential to do more, including managing minor ailments and emergency supply. GP consultation rates are continuing to rise. Nearly all practices in South Devon and Torbay encourage telephone consultation for urgent conditions, with most getting a call back within an hour (although this varies by practice). There is some evidence GP visits in the middle of the day has an impact on patients attending A&E later. The local GP out-of-hours service performs well and is highly regarded by patients and professionals. However, nationally and locally the number of cases seen by out of hours services is falling, a trend we are keen to reverse. Large numbers of very young children are seen by the service those who are seen, are mostly seen in Newton Abbot and Torquay. NHS 111 is a relatively new service in Devon. There have been some difficulties locally with achievement of some of the quality requirements for time taken to answer calls and call length, which we need to continue to address to improve patient experience. Most patients are referred to primary care, following by an ambulance dispatch or referral to ED. Referrals to other services including pharmacy and MIUs are low as are the numbers of those receiving advice from the service. We need to increase the numbers of patients referred to services other than 999 and ED, particularly out of hours services and MIUs. We have not seen the increase in 999 calls from patients reported nationally, however the number of health care professional calls has increased. Most calls come from residents in Torbay and there is little variation in and out of hours. Conveyance rates to emergency departments are low, with the provider treating many patients at the scene. There have been some difficulties in waiting times in the A&E department this year, although a turnaround plan is likely to improve this. Consultant cover in the week is good, at 16 hours per day, although drops below the national recommendation for 12 hours a day at weekends. Our rate of A&E attendance is above the national average and increasing and we need to halt this rise. We are seeing increases in attendance from those living in Torquay, very young children and those in the middle age ranges so need to ensure that there are other urgent care services available to these groups which will better meet their needs. The overall rate of attendance in A&E continues to be highest amongst young children and those aged 80+ years, suggesting a need for clear pathways for these patients. The opening hours and services offered by our minor injury units vary by location which can be confusing. The service offering, including location, needs to be comprehensive and consistent to provide a viable alternative to A&E attendance and we want to see the numbers seen by the services rise year on year. Newton Abbot stands out as the service most used by patients. A high proportion of patients aged 5-9 years use all the units and considering levels of deprivation, Paignton and Teignmouth are used by patients from more deprived areas. A wide range of community and social care services are provided locally, but not all are available six or seven days a week. Of those that are, there are often differences in provision between Torbay and south Devon and the overall picture of services available to patients with urgent needs is complex and not uniform. Further improvements need to be made to the multi-agency system of care and support so people in crisis because of a mental health condition are able to access the support and treatment they require at time of need and that support and treatment is consistent across 24/7. Agencies across the South West region have signed up to the recommendations of the 42

43 Mental Health Crisis Concordat (HM Government February 2014); these standards relate to access to support before crisis point, urgent and emergency access to crisis care, quality of treatment and care when in crisis and recovery and staying well to prevent future crises. The regional declaration can be found at Considering the use of urgent care services and location, variation emerges across the CCG area with lower levels of activity seen in the more rural localities which can be some distance from the nearest centre, for example A&E or an MIU. Much higher levels of activity are seen in the Torbay localities, A&E, MIU and 999 activity with some parts of the towns showing very high rates. As well as rurality the ability to access services, is also important. Appendix 2 includes a map which shows the percentage of households without access to a car or van. In central Torquay and Paignton, there are wards where 30-35% of households do not have access to transport and areas in Torquay, Teignmouth and Newton Abbot where 20-25% of households have no access Urgent care contracts and costs Table 14 show the urgent care services described in this strategy, the cost of each and the contract type. In some instances, it is not possible to separate out the cost of the urgent care services, particularly in primary care, but this provides an overview of the cost of services. The table shows the most expensive services are 999 and Accident and Emergency, with lower values attributable to the GP out of hours, MIU and 111 services. Where available, cost/case figures are included and more work will need to be done to assess the value for money offered by the various contracts. 43

44 Table 14: Urgent care contracts and costs by service Service Ambulance service (999) Accident and Emergency GP out of hours services Minor injury units NHS 111 Primary care (community pharmacy) Primary care (GP practices) Cost of services, based on contract values The cost of the 999 contract to in South Devon and Torbay is 10,376,760. The contract is a block contract. The estimated cost of the A&E service at Torbay Hospital is 7,228,626. The South Devon Healthcare contract is a block contract. The cost of the GP out-of-hours contract in South Devon and Torbay is 2,847,637. The contract is a block and the average cost per case is 54. The estimated total cost of the MIU services across South Devon and Torbay are 1,363,199 (staff and non-pay only). The Torbay and Southern Devon Health and Care Trust contract is a block contract. The cost of the 111 contract to in South Devon and Torbay is 615,544, based on a cost per call of The contract is 90% block and 10% marginal with penalties for achievement of quality requirements. There are 339 Community Pharmacies in Devon, Cornwall and the Isles of Scilly, of these 69 (20%) are in the SD&T CCG area. The proportion of the budget that relates to pharmacies in South Devon and Torbay (gross expenditure minus prescription charge revenue) is 10,161,000. Pharmacies are paid with a combination of establishment payment, practice payment, and fees linked to items dispensed against prescriptions Sixteen per-cent of patients in Devon, Cornwall and the Isles of Scilly are registered with a GP in SD&T CCG. The cost of these services is (including dispensing payments) is 34,375,000. The contract is based on a fee per patient and specific fees and allowances. Source: SD&T CCG (2014) As described previously, the current urgent care system is complex and this can lead to patients having to access multiple services to find the right one for them which can lead to unnecessary attendance and cost in the system. This does suggest that urgent care services may not be being used most efficiently or effectively, with some default to the more expensive services including A&E and 999. Our ambition is to drive a significant shift in the focus of resources on urgent care away from emergency ambulance and acute care towards care in the local community, where it is safe to do so. Acute hospital care will only be used for the patients for whom it would not be possible to care for safely and appropriately in other environments. 44

45 3. Patient experience of urgent care The evidence base for the Urgent and Emergency Care review identifies that quality of care can significantly impact on the way that patients choose to access services (NHS England, 2013). An assessment of quality of services, where available, has been made in the previous section. The review also notes that it is difficult to capture patient experience for this type of health care as many patients are children or the elderly and they may also be experiencing fear, pain or stress. Despite this, we are able to draw some conclusions about patient experience of the various urgent care services. This section is a synopsis of an accompanying report to the strategy, Patient Experience (Urgent Care): What are people telling us? The report gives us a good understanding of patient understanding and experience of urgent care from the CCG community services engagement events in 2013 and urgent care engagement in It also draws on information from other sources including Healthwatch surveys, the national GP patient survey (repeated every six months), the website Patient Opinion, the Friends and Family tests and other specific national and local reports. Specific engagement to inform this strategy has been undertaken through road shows, surveys and patient story telling. The development of the strategy, implementation plans and priorities will be subject to further engagement. A summary of the key issues relevant to urgent care from the community services engagement is included in appendix 3. Reference is made to the findings from the engagement through this section where applicable Self-care We know a little locally about the use of self-care, mostly from the engagement events where patients reported that they would like more help and support to manage their own conditions. The evidence base for the urgent and emergency care review reported a study which showed that the NHS Choices symptom checker, for on-line support and advice about illnesses and conditions, was most frequently used by those aged 45 years and under and females NHS 111 At CCG engagement road shows through September and October, we specifically asked patients about their use of urgent care services and awareness of 111. A number of those questioned were aware of 111 (33), and nearly two thirds had used it (24). There were mixed views on the service with positive comments including the phone was answered quickly and the response was good. Negative comments included lots of questions were asked, long waiting times and some concern over the response received e.g. ambulance dispatch or suggested attend A&E anyway. As part of their on-going commitment to gauging and acting upon patient experience, SWASFT run quarterly patient surveys. Numbers are still small at the moment, with 34 responses in the last quarter, but the most recent survey shows generally good results. Over 60% are very likely to 45

46 recommend the service to family and friends and most found the advice very helpful. When asked who they would have contacted if 111 were not available, most respondents said A&E, followed by the GP practice and then 999. Three formal and informal complaints were received in the last quarter in the CCG regarding 111. The key themes were large amounts of questions and particularly, long waiting times for call backs. In the HealthWatch England survey, 4 out 5 surveyed were aware of NHS 111 although only 1 in 5 reported using it. Responses suggest that more information needs to be made available to the public to explain the 111 Service. Taking an extract from the Patient Opinion website on 111, using national information, patients like the following about 111: call handlers, care, friendly staff, helpful and nurses. They think the following could be improved: computer system, diagnosis, investigation, quick diagnosis and rudeness Community pharmacy Pharmacies were identified in the engagement events as an under-utilised resource, for advice and signposting and supporting reductions in wastage GP practices Patient access to GP services was a recurring theme through the CCG community service engagement process and emerged as the key concern from the whole process. Across all five localities, patients wanted longer opening times and simpler appointment systems. It was also noted that some people visit A&E because they cannot get a GP appointment when they feel they need one. GPs co-located with other services were also felt to be a good idea, in community hubs and in A&E/MIUs. Over the last year, HealthWatch Devon has been collecting experiences and views from patients, carers and the public about local health services. It appears that there are an increasing number of negative experiences coming through regarding access to GP services, waiting times, difficulties getting same day appointments and getting convenient appointments. However, their survey earlier this year showed that more than three-quarters of those surveyed found it easy to make a GP appointment. Those who had experienced difficulties reported rigid booking systems, not being able to get through on the phone, not being able to see the GP of choice and long waiting times for named GPs. Some concern was also reported with reception staff attitudes. For those unable to make a GP appointment, most would visit their pharmacy. Smaller proportions would call 111 or do nothing. The ability to walk in and by seen by a medical professional, without the need for an appointment was praised. The national GP patient survey, repeated every six months, provides a wealth of information on patient satisfaction with local services. A summary of the most recent survey, from July 2014, is included in table 15 and shows that that across the CCG, there are above average levels of satisfaction with access although this does vary by locality. Also derived from the patient survey, there is some useful information on what patients do if they cannot see the GP at the time they wanted to. At present, most patients would accept the alternative appointment or would contact 46

47 the surgery another day. Nationally, 9% would go to A&E; locally only 5% would. An increasing proportion who may have wanted to see someone would also accept a telephone consultation: 14% in comparison to 5% nationally. Table 15: GP patient survey results: patient satisfaction with access Question England CCG Moor to Sea Coastal Newton Abbot Paignton/Brixham Torquay Q3 - easy/fairly easy to get through on phone 73% 78% 81% 67% 77% 81% 80% Q12 - easy to get appointment/speak to someone 73% 80% 82% 75% 80% 80% 81% Q18 - good/fairly good experience of making an appointment 75% 83% 85% 76% 81% 85% 85% Q20 - Don't normally have to wait too long 58% 67% 61% 64% 60% 73% 70% Source: NHS England (2014) Extended GP opening hours are a national and local priority. According to the GP patient survey, 80% are satisfied with GP opening times locally in comparison with 75% nationally. Additional opening times that would make it easier for patients to see their GP would be Saturdays (74% preference) and after 6.30pm (69% preference). This indicates the local priorities for extended opening and we need to make sure that these preferences are factored into future extended access arrangements. In the evidence base for the urgent and emergency care review, research is cited regarding patient access to GPs on the telephone which shows that patients who were very unsatisfied with telephone access waited, on average, 129 minutes to speak to a GP whilst those who were very satisfied waited on average 46 minutes. The average length of time to speak to a GP on the phone locally for an urgent condition is around 60 minutes suggesting that the majority of patients are likely to be satisfied with call back times however, this will vary by practice GP out of hours services The national GP patient survey shows that locally around 35% do not know how to contact a GP out of hours; this is better than the national figure of 44% but over a third of the population still do not know how to access services when their surgery is closed. Results vary considerably between practices, with a range between 45% and 20% not knowing how to contact an out-of-hours doctor. There are fourteen practices with above CCG average rates, from across the localities. For those who have used the out-of-hours services, satisfaction is very good with the Devon Doctors service consistently appearing in the top ten. All aspects of the service score well above the England average rates: ease of contacting the service, promptness of service, confidence and trust in the clinician and are all above average. Overall satisfaction is 78% compared with 66% nationally. This year, the National Audit Office undertook a poll of nearly 900 people regarding GP out-of-hours services. Those who had not heard of out-of-hours GP services were almost five times more likely to call 999 at night than those who had heard of the out-of-hours GP services. Awareness amongst certain groups, such as younger people and those from black and minority ethnic communities, was lower than among others. 47

48 One formal complaint about Devon Doctors has been received in the CCG in the last quarter. It relates to missed diagnosis of appendicitis, which resulted in an admission and operation for a child. It was identified at the locality events, that Devon Doctors should be able to access patient details Minor injury units Patients agreed across the locality engagement events that extended MIU opening times and services would be advantageous and that these should be well advertised. In February 2013, Torbay and Southern Devon HCT began rolling out the Friends and Family Test to Minor Injury Unit (MIU) patients. The patient experience questionnaire includes the test question: How likely are you to recommend our ward/miu/service to friends and family if the needed similar care or treatment? Although the trust is not required to provide any data nationally until December 2014, they have published the results from April 2013 to February 2014 on their website and have advertised them locally on posters in wards and MIU s. Response rates have varied throughout the year and there have been periods when it has been difficult to maintain the required response rates. The net promoter score for the MIU friends and family test shows a large percentage of people using the service would recommend it to F&F: the year to date figure to October 2014 shows 88% would recommend. One formal/informal complaint has been received in the CCG in the last quarter regarding MIUs, focusing on the need to extend the hours of opening at Newton Abbot MIU given the growth in population predicted in Newton Abbot. A positive review of the Teignmouth MIU was posted on the Patient Opinion website, praising nursing and reception staff Accident and Emergency (A&E) During 2014, the Care Quality Commission (CQC) sent out a questionnaire was sent to people who had attended South Devon Healthcare NHS Foundation Trust accident and emergency department (A&E), as part of a national survey. A questionnaire was sent to 850 people who had attended during January, February or March Responses were received from 333 patients at South Devon Healthcare NHS Foundation Trust. Table 16 shows the trust scored about the same for most measures, with the exception of waiting times which scored worse when compared with other trusts. Table 16: CQC A&E survey results: South Devon Healthcare 2014 Patient survey measure Score Compared with other Trusts Arrival at A&E 7.8/10 About the same Waiting times 5.2/10 Worse Doctors and nurses 7.9/10 About the same Care and treatment 7.3/10 About the same Tests 8.3/10 About the same Hospital environment and facilities 8.2/10 About the same Leaving A&E 5.8/10 About the same Experience overall 7.89/10 About the same Source: CQC (2014) 48

49 The Friends and Family for A&E services is a one question survey that aims to assess a patient s experience of NHS services. The question is worded How likely are you to recommend our A&E department to friends and family if they needed similar care or treatment. A graph analysing the position of SDHFT from April 2013 to October 2014 is included in figure 20. As can be seen, there is a downward trend from a peak in May 2013 to the lowest score for the Trust in July 2014, although there are promising early signs of an upward trend from then. At present, the Trust scores of 83% are below the national average of 87%. Figure 19: A&E Friends and Family test: SDHCFT % recommends Source: SD&T CCG (2014) Two formal/informal complaints about A&E were received in the last quarter in the CCG. The key themes include concerns about nurse staffing at night, noise, lack of pain relief offered and ineffective management of condition, including early discharge (to be re-admitted). The Patient Opinion website allows patients to feedback their experience of health services. There were six reviews posted recently, one praising the service and nurses. The others were negative about waiting times, unhelpful staff, perceived understaffing and inappropriate referrals from GPs. The reviews also mentioned out of date information, lack of toilet facilities and a shabby look to the department. One area of particular interest to the CCG is gaining a greater understanding patient behaviour in using A&E services. A survey was carried out in 2011 to survey self-presenters (excluding those brought in by ambulance); 63 people were self-presenters at the time of the survey. Over half (37) felt that A&E was needed for their condition or that an A&E accessed service could only be provided through Torbay Hospital. Other relevant factors included GP access (17), proximity to the hospital (13) and advice from another (11), most commonly a friend or relative. GP access concerns could be characterised as a perception of being seen more quickly (6), could not get an appointment (6) and in too much pain to wait for a GP (5). Regarding proximity to hospital, this included living or working nearby (5) and being in the hospital with a friend or relative (5). In March 2014, Healthwatch England commissioned YouGov to survey 1,762 people to find out why patients go to A&E and what could be done to ease pressure on frontline services. Eighteen per cent admit to knowingly using A&E for a non-emergency at some point in their lives and 1 in 4 said it 49

50 they would use A&E in the future if they were unable to get a GP appointment in a reasonable timeframe, with 1 in 3 also stating that they would do so if the non-emergency situation occurred out of hours. The survey results also identified poor awareness of alternatives, with around a third not knowing where their nearest MIU or equivalent or what services it offered. Specific engagement has been undertaken by the CCG on the use of A&E and urgent care alternatives, via an on-line survey Is A&E for me? which ran in November and December of The results are currently being analysed and will be reported in full in the accompanying patient experience report; however interim results in mid-december showed the results in figure 20. Figure 20: Interim findings from local Is A&E for me? survey 147 responses received as at 16 th December; Nearly two-thirds had attended A&E in the last two years, over two thirds had not attended an MIU; Most had attended for a problem they had, closely followed by problems with a child they cared for; Nearly two-thirds expected to see a doctor in A&E; Well over three-quarters attended because they felt they needed immediate treatment; The three most highly rated factors when choosing an urgent care service were: seeing a professional face to face, seeing someone quickly and access by car. Most patients would contact their GP in-hours if they had an urgent care need and out of hours most would call 111; For a child with a high temperature, most would call 111 or attempt to contact a GP out of hours; For acute back pain, most would call 111 or wait to see their GP the next day; Nearly two thirds had heard of NHS Choices; Regarding home medicine cabinets, over half had pain relief, sticking plasters/bandages, antihistamine/sting relief, anti-septic, anti-diarrhoea tablets and thermometer. Source: SD&T CCG (2014) emergency ambulance service At CCG engagement events through September and October, we specifically asked patients about their use of urgent care services. There were many positive comments about 999 when people had used them for urgent/emergency reasons people were generally impressed with the promptness of the response they received and professional service. Most people would use it if they perceived they were dealing with a sudden, serious issue. Of all those questions, most people would use or had used 999 to meet an urgent/emergency need (21); this was followed by A&E (14) and GP practice (10). SWASFT have received three patient reviews on the Patient Opinion website, all of which were positive citing speed of the service and quality. Patients have also posted on NHS Choices regarding the service, with 11 positive reviews out of 18. The overall user rating is 4 out of 5. 50

51 3.9. Mental health services Through engagement events held across South Devon and Torbay attended by over 500 people the following themes for improvement were identified related to access to urgent and crisis support: The need for the person experiencing crisis to be at the centre of the process with services working flexibly and in a joined up way For out of hours services to be of the same consistency and quality as those provided during 9 to 5 hours with regard to staffing levels and range of options available To eradicate the need for the use of police custody as a Place of Safety For there to be greater clarity regarding which services do what and when so that people can access the right service at the right time when support is most needed To improve access to the range of options that help prevent crisis in particular residential or sanctuary type options To embed in the clinical pathway access to those with lived experience in peer support roles at times of urgent need To improve access to third sector support provision to extend the range of choice at times of urgent need To maximise opportunities for communication with carers during every step of urgent and crisis care To reduce the number of points of access to services to improve ease of access and referral For as many services as possible to have open access at times of urgent need For people with lived experience to have an integral part in service development At engagement events across South Devon and Torbay people have told the CCG that there needs to be more consistency in the provision of out-of-hours urgent care and greater choice for those experiencing mental health crises. This important feedback, together with the publication of the Crisis Care Concordat, has informed the redesign of urgent mental health care services Summary/conclusions Summarising the above, drawing on the community services engagement events, Healthwatch surveys, the national GP patient survey, Patient Opinion, the Friends and Family tests and other reports, we can draw the following conclusions at this stage. It is difficult to capture patient experience for urgent and emergency care as many patients are children or the elderly and they may also be experiencing fear, pain or stress. We know only a little about the use of self-care, mostly from the engagement events where patients reported that they would like more help and support to manage their own conditions. It would be advantageous to know more about this, and promote existing selfcare services. Nationally, a number of those surveyed were aware of NHS 111 although fewer patients had used it. Responses suggested that more information needs to be made available to the public to explain the 111 Service, targeted to similar cohorts as those unaware of GP out-ofhours services. 51

52 In the engagement events, community pharmacy was felt to be an under-utilised resource and some of those surveyed locally who were unable to get a GP appointment would consider going to a pharmacy. Consideration could be given to maximising their role including referral from 111. We know most about patients views on access to GP services, although findings vary from generally positive quantitative survey results and more critical qualitative feedback. Patients at the engagement events wanting longer opening times, simpler appointment systems, shorter waiting times, convenient appointments and ability to be seen on the day, if necessary. The GP patient survey shows generally good levels of satisfaction locally, although it varies significantly by practices. In comparison to the national picture, fewer patients locally would attend A&E if they could not get an appointment and we are not yet seeing a link between A&E attendance and patient satisfaction. More people in the GP survey locally are satisfied with opening times; those who would find extended hours more convenient indicated a preference for Saturday and evening opening. Nearly all surgeries now offer telephone consultations for urgent cases, with most called back within the hour which suggests it would be satisfactory to patients in this timescale. This suggests a mixed picture of satisfaction with services, with surveys showing generally higher levels of satisfaction that the more qualitative approaches to seeking patient views. There may still however be unwarranted variation in experience, with poorer access in some practices and longer call back times. Over a third of our population are not sure how to contact a GP out of hours, which is better than the national figure but still a concern. Nationally, it has been identified that younger people and those from black and minority ethnic communities are less likely to be aware of services. Raising awareness of local services and how to access them therefore emerges as a priority, targeting younger people, BME groups and those practices were fewer patients in the GP survey were aware of out-of-hours services. Satisfaction with services locally is very good, with the provider consistently in the top ten providers nationally. MIU services were reported positively in the engagement events, with more patients wanting to know about them. The Friends and Family scores from the provider indicate a high level of satisfaction, although there have been some difficulties with response rates. It would be advantageous to know more about patient experience and understanding of the services, and promote them more widely. Nationally, a number of patients use A&E in non-emergency situations and if they cannot get a convenient GP appointment. We are not seeing quite the same level of usage locally, but this is likely to vary by patient group and practice, suggesting more targeted work with particular practices is useful. Regarding local services, the 2014 CQC survey showed that the A&E department was rated similar to other trusts for most measures, although scored worse for waiting times. The Friends and Family test scores for the local A&E are below the national average and have been on a downward trend; however, there are early signs that this is improving from July. 999 services are generally rated highly by patients, with patients appreciating prompt and professional care. Urgent mental health service priorities are similar to priorities for other services including high quality services, simplifying services, person-centered care, third sector support and 52

53 right care first time. Consistency in the provision of out-of-hours urgent care and greater choice for those experiencing mental health crises is important. 4. Principles and objectives Having reviewed the current urgent care system and patient perspectives and priorities, it is timely to re-visit the vision, principles and objectives and, strategic aims described in section one to assess how closely our current services and system match what we are aiming for. The vision for the urgent care system in South Devon and Torbay over the next five years is that: People with urgent but non-life threatening needs should be treated by services as close to home as possible, leaving emergency departments free to concentrate on more serious and life threatening emergency needs. In developing services to achieve the vision, we need to ensure the principles shown in figure 21 guide our decisions to ensure a simple and straight forward network of high quality urgent services are routinely available. We will increasingly articulate what good looks like, including outcomes and quality standards for all our urgent care services, to ensure we are able to monitor and assess quality. These will be evidence-based, incorporate patient experience and draw on the expertise of local providers. Most, but not all, urgent care services are available seven days a week. The corner stone services, which are available seven days a week, are NHS Choices, NHS 111, 999, some community pharmacies and urgent primary care services (a combination of in-hours GP practices and out-of-hours service). At present, we therefore have a gap in terms of minor injury unit/urgent care centre facilities. There is also scope to more closely integrate in and out of hours GP services, to provide a more seamless primary care service to patients. 53

54 Figure 21: Commissioning urgent care: key principles Urgent care services are available and accessible seven days a week. High quality, evidence based care with clear standards for what good looks like. Services should provide good value for money. Complementary and interoperable services that meet urgent care needs, accessed through a single source. The right care should be available first time, every time, in a place that best meets patient need. Integrated, networked services which minimise handover and delay. It is important that this strategy is patient focused. Reviewing the patient focused objectives for system change from section 1 we need to ensure we focus on the following as described here. Make it clear how I or my family/carer access and navigate the urgent and emergency care system quickly, when needed. Increase my or my family/carer s awareness and publicise the benefits of phone first. More needs to be done to promote NHS 111 and to make available other use to use material to assist patients to do this, for example, advice and signposting apps. Support for self-care is vitally important both to enable patients to access information when an urgent condition presents, but also to provide additional support to those already living with long term issues or conditions. We need to ensure that there is greater awareness of advice and support tools (including NHS Choices and 111) and ensure that those with specific long term issues have support and advice. This can involve greater use of the voluntary sector and mapping resources and capability is likely to be necessary. We also want to make sure that during urgent care consultations, patients receive appropriate health and wellbeing advice. When my need is urgent, provide me with guaranteed same day access to a primary care team that is integrated with my GP practice and my hospital specialist team. Provide me or my family/carer with information on early detection and options for self-care, and enable me to manage my acute or long-term physical or mental condition. All GP practices in our CCG offer same day access to those with urgent conditions, usually on the telephone. However, experience of access does vary across practices and more work needs to be done to define standards for same day access to primary care in particular. 54

55 This standard is often attributed to emergency departments, and it is very important here, but it can equally well apply to the wide range of other urgent care services too. Wherever appropriate, care for and treat me where I present (including at home and over the telephone). The urgent and emergency care review introduces the concept of emergency centre and major emergency centre. It is likely that the A&E department at Torbay Hospital will be classified as an emergency centre, initially assess all patients with more serious or life threatening emergency needs (as the CCG is predominantly a remote and rural community ). Most patients will be managed by Torbay Hospital, although those needing specialist treatment will be transferred to a major emergency centre. The timing of any such transfers, including from urgent facilities to emergency facilities and from ECs to MECs will be critical. Continued achievement of ambulance response times will be important. Real time information, essential to my care, is available to all those treating me. Improve my care, experience and outcome by ensuring the early input of a senior clinician in the urgent and emergency care pathway. The use of the telephone to access services, including urgent care advice, has increased dramatically over the last few years including the NHS 111 service and practices offering telephone advice/consultation for urgent conditions. This trend looks set to continue. However, some patients also want to be able to walk in and use services and options need to be available to allow this to happen. At present, the only services offering walk in services are community pharmacy, minor injury units and A&E with the latter being most commonly used. An increasing range of walk-in options may be required including a primary care offering in and out of hours. If it's not appropriate to care for and treat me where I present, take or direct me to a place of definitive treatment within a safe amount of time; ensure I have rapid access to highly specialist care if needed. Ensure all urgent and emergency care facilities can transfer me urgently, and that the transport is capable, appropriate and approved. There is work underway locally to move towards a shared clinical record, using the GP practice record as the vehicle for this. Whilst accepting that due diligence is needed to ensure appropriate governance processes are in place, patients core details should be available to all urgent care providers. An early priority will be sharing between in and out of hours GP care. In advance of this, locally special patient notes are applied to the Adastra urgent care system which is available to NHS 111 and the GP out-of-hours service. 55

56 Very often, the initial urgent contact is only the start of the journey, particularly for older people and those with long term conditions. The follow up and support care they need is just as important as the initial contact and could prevent them having to access urgent care if properly co-ordinated. Although not the prime aim of this strategy, it is important that associated strategies for the development of community services and social care are able to handle patients associated needs. Where I need wider support for my mental, physical and social needs ensure it is co-ordinated and available. Each of my clinical experiences should be part of programme to develop and train clinical staff and ensure development of their competence and the future quality of services. The quality and experience of my care should be measured and acted upon to ensure continuing improvement. Patient experience has been critical to the development of this strategy and we expect that on-going monitoring of patient experience, using both qualitative and quantitative methods, is a routine part of all urgent care providers continuous quality improvement. 5. Priorities for system change Considering the map of current services and use of the same suggests we have more to do in the next five years to develop a clearer and more comprehensive range of urgent care services away from A&E at Torbay Hospital. To do this, we need to focus on our priorities for change described below, which incorporate the five strategic priorities for change described in the first chapter: support for self-care; right advice, right place, first time; highly responsive services available outside of hospital; those with life threatening emergency needs receive care in more specialist centres; and, urgent and emergency care services are connected. Our priorities for change over the next five years are as follows; these priorities are intended to deliver an urgent care system that has the design characteristics described in figure 23. More actively promote self-care and make it much easier for patients to access high quality, reliable information and services. This can include making best use of the web including NHS Choices, peer support and voluntary sector support. We also want all providers to provide consistent messages about self-care are given and sign-post to other appropriate services, including the third sector. With our partners, including Healthwatch, We will explore evidence based approaches including social marketing to ensure messages are targeted accordingly and supported self-management for particular groups, as part of their care pathway 56

57 Make NHS 111 the smart call to make, as the gateway to the urgent care system. This will need to include promoting the service more widely and to specific target groups and, ensuring that the service is able to offer a high quality, prompt response. This will include improving call answering times and reducing average call length. The service will increasingly offer patients advice and refer to the most relevant local urgent care service with referrals to ED and 999 the last resort. The service will also increasingly be able to book appointments for patients. In developing the service, the CCG will pay due attention to the national 2014 commissioning standards for 111 services. Ensure primary care in hours and out of hours services is the default service of choice for patients to meet their urgent care needs. Most patients see primary care, particularly GP practices, as their main urgent care provider. We need to ensure that this continues to happen and that patients get prompt access to high quality services when they most need them. Consistent, same day access to primary care will become the norm. Many practices are already able to see patients the same day for an urgent issue however this is not always available. A more timely approach to requests for home visits is also important, so patients with urgent conditions are assessed and seen promptly and to avoid the mid-afternoon/late evening bulge of attendance at A&E. We have a highly regarded GP out-of-hours service, with good levels of patient satisfaction; however, in the last couple of years we have seen a drop in activity and we need to ensure that the service is able to see more patients out of hours. Develop options locally for patients to access an urgent care centre, as envisaged in the urgent and emergency care review. The guide specifications for these services are still in development however it seems likely that they will need to include access to walk-in minor illness and injury services and be part of wider primary care services including out-of hours GP services. Urgent Care Centres may also be advantaged by co-location with hospital services, particularly in urban areas. We will need to consider the best location for such services and the extent to which some of our minor injury unit services could develop into such facilities. Our priority for reconfiguration will be to ensure a high quality, consistent and safe service can be provided and this is likely to mean economies of scale are necessary. Continue to reduce ambulance conveyance rates. Under the Right Care initiatives, the South Western Ambulance Service is already working hard to reduce conveyance to hospital. Right Care 2 will take this further and we want to continue to work with the trust to provide care and treatment at the scene, wherever necessary, or convey patients to alternative services including urgent care centres as they develop. Across the SWASFT footprint there are an exciting range of initiatives running which can reduce conveyance to ED or improve patient experience. These include the use of other professionals such as GPs and mental health workers in hubs, rapid response vehicles and direct access pathways. SWASFT are currently participating in a national pilot for dispatch on disposition which is producing promising results in terms of improvements in hear and treat rates and responses to red calls. Develop community pharmacies into urgent care providers. We have a wide network of community pharmacy services locally, with extended opening hours. They are well placed to offer more enhanced urgent care services and we will be exploring this in more detail including advice for minor ailments, medication, emergency supply of medicines and advice and support for long term conditions. They will increasingly become part of the urgent care network and there is scope for trialling roles for pharmacists in locations where urgent care is provided. 57

58 Reduce ED attendance rates and 999 calls for urgent conditions. In delivering all the above, we need to halt the year on year rise in attendance at our A&E department so it is fully able to become an Emergency Centre dedicated to more serious and life threatening conditions. Reducing the number of 999 calls will also be important, and we need to include in this halting the rise in health care professional calls to 999. For urgent mental health care, achieve parity with physical health care. People in crisis because of a mental health condition are kept safe and helped to find the support they need, whatever the circumstances in which they first need help, and from whichever service they turn to first. No one in mental health crisis will be turned away or find themselves alone in their distress. Wherever possible, crisis will be prevented from happening through planned prevention work and early intervention. Thinking back to the needs assessment, a high proportion of those using urgent care services are children, particularly pre-school children. This suggests a need to ensure that there are suitable urgent care services available for children and that all services are child friendly. In some instances, there may be a need to ensure that speciality paediatric trained doctors and nurses are available. The GP out-of-hours service and A&E in particular both currently see large numbers of young children; it is likely that this picture is mirrored in in-hours general practice too, although we do not have figures for this. There is a need to publicise urgent care services to parents of young children, in particular the NHS 111 number and provide support for self-care and advice for common childhood illnesses. There is the potential to work with the emerging Torquay children s hub to achieve this, signposting parents and providing supportive information on managing common illnesses in children. Given the high proportion of young children using the services a priority recommendation would be to develop a paediatric urgent care pathway, with the emphasis on pre-hospital care, avoiding the need in most instances for children to have to receive hospital care. At the other end of the spectrum, the highest attendance rate per 1000 patients in A&E continues to be amongst older people, particularly those aged 80 years and over. Very often, a busy A&E department is not an appropriate place for a frail older person to be. A priority recommendation therefore is to develop a frail elderly urgent care pathway, with the emphasis on pre-hospital care, avoiding the need in most instances for the frail elderly to receive acute hospital care. This is currently part of the ICO project, based around the frailty pathways in Newton Abbot with a focus on timely assessment, reduced length of stay (if hospital is necessary), multi-disciplinary input and care home links. Considering need by location, we are seeing high numbers of 999 calls and A&E attendances from patients in Torquay, closely followed by Paignton/Brixham, and it is likely a number of these contacts are for urgent, rather than emergency conditions, and could be dealt with by other services. We need to increase awareness of other services already available in Torquay and Paignton/Brixham, including NHS 111, primary care (in and out of hours) and the MIUs. To be most effective, this will be targeted to patients of practices where there are lower rates of awareness of GP out of hours services (and 111) and areas where there higher rates of A&E 58

59 attendance by lower supper output area (LSOA). There is the opportunity to work with the emerging Torquay children s hub to do this. We will also need to consider the accessibility of these services, including how easily patients are able to access their GP service and the variable services offered by the two MIUs. Using information from the July 2014 GP patient survey, in Torquay shows that on average 85% are satisfied with their experience of making an appointment and 70% feel they don t normally have to wait too long. In Paignton and Brixham, on average 85% are satisfied with their experience of making an appointment and 73% feel they don t normally have to wait too long. Both rates are above the CCG average. There is also a potential issue of a gap in service in Torquay, for meeting urgent care needs with no minor injury unit service. The minor injury unit (MIU) services in terms of what will be seen, age range and hours of availability varies by location. This can be confusing to patients and attendance varies significantly by location, from around 15,000 in Newton Abbot to under 1000 in Ashburton. The MIU review started the process of moving towards fewer, more consistent services, with longer hours of opening and enhanced services. This process is continuing through locality discussions on what will work by area. Looking forward, we need to be mindful of the need to move towards the development of Urgent Care Centres, building on the recommendations of the MIU review. The final specifications for urgent care centres have not yet been issued, but there has been some communication with national leads (EF October 2014 conversation with Professor Benger, national clinical lead for urgent care centres). The final specification is expected soon, and is likely to contain the following key components: Available and operational for sixteen hours per day: 8am to midnight suggested. Staffed and led by primary care; the clinical teams must be multidisciplinary and have available to it at all times general practice care. Plain x-ray films must be available at all times. Access and link with emergency departments, including aligned governance processes and communication routes. Urgent care centres must be hubs of integrated urgent care which are successful in avoiding attendance at ED where not necessary. In addition, locally it is felt important to ensure that there is ready access to pathology (point of care testing or phlebotomy) and radiology, where plain films could potentially be used for more than trauma cases. The national view is that where there is insufficient capacity for urgent care centres to be delivered as per core plan, variations should not be designed which create problems and uncertainty for patients: an urgent care centre must be clearly that. Alternative services may be provided by innovative options considering the role of primary care, ambulance services and pharmacies and others, but should not attempt to offer a low level urgent care centre. It is important that in the development of UCC type facilities locally the offering is strong enough to provide patients with a viable alternative to attending A&E. Our patient engagement shows us that patients attend A&E 59

60 wanting to see a doctor and seeking immediate treatment so UCC facilities need to have a medical presence the ability to see and treat a wide range of urgent conditions. We will need to continue to work on the correct configuration of urgent care centre facilities bearing in mind the national recommendation for co-location with Emergency Departments and building on the success of already popular MIU facilities, such as those in Newton Abbot. 6. What good looks like quality and outcomes Appropriate and timely access to urgent care influences outcomes. We have reviewed the CCG outcomes framework and figure 22 shows an adapted version of the framework including the outcomes where urgent care services can contribute, including support for self-care, avoidable admissions and improving patient experience. We will increasingly include these outcome standards in contracts with urgent care providers, ensuring that as far as possible the same standards apply across different contracts to encourage providers to work together to meet shared aims. Figure 23 begins to scope out local quality and outcome standards that we will be looking for across the urgent care system. Broadly, these can be categorised as system design standards and those for service delivery, clinical governance and workforce, and commissioning arrangements. A more detailed description of the standard for service delivery, clinical governance and workforce and commissioning arrangements are included in appendix 4. These will be subject to amendment and development but will form the basis for a discussion with patients and professionals on developing a comprehensive network of fit for the future urgent care services. These are high level at this stage, and focus predominantly on the system and service delivery standards applicable to all urgent care providers. The standards are derived from work by the Kings Fund (2013), the Primary Care Foundation (2011) and the London Health Programmes ( ) on transforming the health system and commissioning standards for urgent care. 60

61 Figure 22: CCG outcome indicators relevant to urgent and emergency care 1. Preventing People from Dying Prematurely 2. Enhancing Quality of Life for People with Long-Term Conditions Overarching Indicator Potential years of life lost from causes Health-related quality of life for considered amenable to healthcare: adults, people with long-term conditions children and young people (NHS OF 1a i & ii) (NHS OF 2) ^ Improvement Areas Mortality within 30 days of hospital admission for stroke Emergency admissions for alcohol related liver disease Cancer: diagnosis via emergency routes Source: SD&T CCG (2014) 3. Helping People to Recover from Episodes of Ill Health or Following Emergency admissions for acute conditions that should not usually require hospital admission (NHS OF 3a) Emergency readmissions within 30 days of discharge from hospital (NHS People feeling supported to manage Emergency admissions for children their condition (NHS OF 2.1) with lower respiratory tract infections People with COPD & Medical Research People who have had a stroke who are Council Dyspnoea scale 3 referred to admitted to an acute stroke unit pulmonary rehabilitation programme within four hours of arrival to hospital People with diabetes diagnosed less Alcohol admissions and readmissions than one year referred to structured Unplanned hospitalisation for chronic Mental health readmissions within 30 ambulatory care sensitive conditions days of discharge (adults) (NHS OF 2.3.i) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s (NHS OF 2.3.ii) Complications associated with diabetes inc emergency admission for diabetic ketoacidosis and lower limb 4. Ensuring that People have a Positive Experience of Care Patient experience of GP out of hours services (NHS OF 4a ii) Patient experience of hospital care (NHS OF 4 b) Friends and family test for acute inpatient care and A&E (NHS OF 4c) Patient experience of A&E services (NHS OF 4.3) 5. Treating and Caring for People in a Safe Environment and Protecting them from Patient safety incidents reported (NHS OF 5a) 61

62 Figure 23: Quality and outcome standards for urgent care services in South Devon and Torbay Service delivery: System design: The patient will be seen by the right person with the right skills to manage their needs, first time. The patient knows how to access information and guidance in the event of needing urgent or emergency care. Prompt care is good care, and the emphasis should be on access across the whole system. Delays and handoffs between urgent care providers should be minimised ; all providers will work together to ensure that if a patient has previously been clinically assessed as needing another service, they can be fast-tracked for treatment elsewhere. General practice is the bedrock of any urgent healthcare system; all commissioning strategies for urgent care should start by addressing the key role of general practice. If all practices improve the speed and effectiveness in responding to same day urgent requests, there would be a substantial beneficial effect on the wider healthcare system. Best practice is adopted across urgent care services, including early senior review and see and treat for minor illness and injury. There is greater integration between services, to reduce confusion and duplication. Patients are involved in their care and treatment and in the design and delivery of services, with an emphasis across all providers on patient engagement and experience, and adapting services to meet patient preferences. Services are of a standard that people would recommend them to family and friends. Information is shared across urgent care providers to improve patient care and outcomes, with complementary and interoperable solutions. Urgent care services are networked to an emergency department professional support, clinical supervision and advice on clinical standards. Out of hours urgent care services are co-located as far as possible, with reciprocal arrangements for advice and support and to pick up each other s caseload when either team has no waiting patients. Physical environment, demand and capacity, clear information, initial clinical assessment, see and treat, health and wellbeing advice, care of children away from hospital and prompt initial visual assessment, initial mental health assessment, liaison psychiatry, services for pregnant women, rapid response for end of life patients, mental health care. Clinical governance and workforce: Named clinical governance lead, patient involvement including children and young people, shared governance, safeguarding policies and procedures, dignity and respect, competencies to assess paediatric, maternity and mental health needs and refer as appropriate, first responder skills in caring for the acutely ill. Commissioning arrangements: The CCG will be a highly effective commissioner of urgent care through good working relationships with providers, a sound understanding of services, observing services including walking the floor and talking to patients, staff and clinicians, performance monitoring and early recognition of issues. 62

63 In addition to these, we need to do more work locally defining outcomes and quality standards for A&E, primary care and MIUs/urgent care centres. These will need to draw on existing quality indicators and other relevant standards including the A&E quality indicators, the London Outcome Standards for urgent and emergency care and the Primary Care Foundation primary care access standards. These are summarised in figure 24. Figure 24: Specific quality and outcome standards by service: A&E, in hours primary care and MIUs/UCCs A&E Primary care (in hours GP) MIUs/Urgent Care Centres Shop floor consultant cover at least 12 hours per day,, including weekends and bank holidays; Local achievement against the A&E quality indicators to be at least as good as the national average and move towards top 25% achievement; Consistent achievement of the 4 hour wait standard; Improvements in patient satisfaction with A&E services. Patients contacting their surgery with an urgent condition should receive clinical assessment, which can be over the telephone, within one hour; Those needing to be seen for an urgent condition will be seen the same day; Those requesting an urgent home visit are promptly clinically assessed, on the phone, and visited as quickly as possible after assessment (PCF recommend 20 minutes for phone assessment and a visit within one hour of assessment); We also need to explore a move towards seven day services with GP practices and the out-of-hours provider, making primary care more easily identifiably available 7 days a week. Available and operational for at least 12 hours per day (with 16 the optimum); Clinical multi-disciplinary team available at all times Initial clinical assessment within 15 minutes; Overall waiting and treatment time should be no more than 3 hours (with two the optimum). Although there is a set of clear quality and access standards for out-of-hours primary care, there are currently no nationally defined access standards for in-hours general practice. Although rates of satisfaction with general practice locally are very good across the CCG, we do see high rates of variation by practice. Working with NHS England, who holds the contracts for general practice, we do want to progress the development of local access standards, particularly for patients seeking help with urgent needs. We need to do more work on this locally to agree a set of reasonable and realistic standards starting with those described above. In order to reduce attendance at A&E, patients need to be able to access a viable alternative service that they trust will be provide them with the right service, first time. The move towards urgent care 63

64 centres, as introduced in the urgent and emergency care review, is a key development here. These new services, which may develop from a smaller number of minor injury units, will need to have a clear service offering and more work will be needed to define quality standards for these services. 7. Measuring progress The measures of success that will be monitored during the implementation of this strategy and are likely to include the following, including relevant CCG outcome indicators. It will be the intention to include these metrics in the performance dashboard that the urgent care board receive monthly, to monitor progress. Priorities for change Increase in self-care, reducing reliance on services Increase the use of NHS 111, it is the the smart call to make High quality, accessible urgent primary care services Suggested measures Increase in patient awareness of NHS Choices Increase in number of patients in supported self-programmes Number of patients signposted to voluntary sector support People feeling supported to manage their condition (CCG OI) People with COPD referred to pulmonary rehab (CCG OI) People with diabetes referred to structure self-care (CCG OI) Increase in the number of calls overall Increase in number of calls answered in 60 seconds, particularly at weekends and on bank holidays Average call length reduces Patient awareness increases Patient satisfaction increases Low call abandonment rate More patients receive advice Reduced number of calls where ED is the disposition Reduced number of calls where 999 is the disposition Increase in calls where primary care is the disposition (in and out of hours) Increase in calls where minor injury units or equivalent are the disposition Practices offering same day access for urgent conditions Patients calling primary care with an urgent condition receive a call back within one hour Urgent requests for home visits are assessed within 20 minutes and seen within an hour of assessment Increase in patient satisfaction with primary care access Maintain or increase patient satisfaction with GP out of hours services More patients are aware of how to access GP out of hours services Increase in patients in contact with GP out of hours service Increase in children using GP out of hours services Increase in those aged 80 + using GP out of hours services Reduced onward referral of urgent patients to other services 64

65 Development of urgent care Increase in number of MIU attendances centres Increase in number of children using MIU services Increase in number of ambulances who convey to MIUs Number of sites able to offer specified urgent care centre services (to be defined as national specification becomes available) Reduced onward referral of urgent patients to other services Development of mobile Reduced conveyance rates to hospital treatment Reduced number of ambulance handover breaches centres/paramedic at home Reduced conveyance rates for children services Reduced conveyance rates for those aged 80+ Additional measures to be defined Development of urgent care Increase in 111 calls referred to community pharmacy community pharmacies Number of pharmacies participating in CCG commissioned local urgent care services Number of patients using pharmacy urgent care services Services that patient would have used instead of pharmacy (activity saved) Reduced numbers onward referred to other urgent care service Reduction in acute hospital Reduced number of 999 calls ED attendance Reduced number of ED attendances Reduced number of ED attendances for children Reduced number of ED attendances for those aged 80+ Reduced number of ED attendances for end of life patients Reduced number of repeat attenders Consistent 7 day services for urgent needs Numbers and range of urgent care services available 7 days a week Number and range of urgent care services not yet available 7 days a week Shared clinical records Increase in number of special patient notes (SPNs) available to 111 and GP out of hours Increase in number of urgent care providers able to access the patient s full clinical record High quality services for all Achievement of national quality requirements for OOH services Number of urgent care services networked to an ED Number of urgent care services co-located Number of initial clinical assessments in 20 minutes (not ED) % of transfers to emergency centre and major emergency centres in a time to be defined. Hours per day of consultant cover in ED, across seven days. Consistent achievement of A&E standard for 95% seen in 4 hours Improvements in A&E quality indicators reduced average waiting time, reduced total time, reduced re-attendance. Improvements in patient satisfaction with A&E (CCG OI) Serious incidents and complaints by services Patient satisfaction information by service As available, CQC reports 65

66 Patient experience will continue to be important in monitoring the successful implementation of the strategy and we will continue to work with colleagues in Healthwatch and the patient experience team. This will ensure that patient experience not only contributed to the development of the strategy but also its on-going monitoring and evaluation. 8. Associated developments/considerations The CCG s integrated plan is clear about the approach to financial management, which will apply to this strategy. Planned spending on the current main healthcare provider services will remain at the same level as planned except where organisations can demonstrate that by spending more than this, savings will be made for other healthcare providers and that this can be agreed with those organisations. This means that we are unlikely to see additional resources available for urgent care priorities over the next five years, the priority will need to be on working within the existing resource envelope and improving service efficiency by, for example, reducing the number of multiple attendances that occur through system confusion and reducing reliance on the more expensive services: 999 and A&E in particular. Nationally, to support the recommendations of the urgent and emergency care review, Monitor have proposed to reform the reimbursement of urgent and emergency care as follows: A substantial proportion will be fixed core funding, to reflect the always-on nature of the services and to concentrate providers and commissioners attention on planning capacity across the system to specified minimum access and quality standards, in line with the UEC Review vision. A proportion will be volume-based funding, to make it possible for individual providers across the system to manage unpredictable fluctuations in demand and to share in the financial impacts of their actions on the system as a whole, as well as to enable risk to be allocated between providers and commissioners in a way that supports the behaviours needed to achieve the UEC Review vision. Provider-specific and system-wide quality metrics will be used as eligibility criteria for different rates of fixed and volume-based funding, and as the basis for bonuses and penalties, to support service change and promote quality improvement. The new Integrated Care Organisation (ICO), bringing together hospital and community services, is a major step towards achieving a joined-up system in South Devon and Torbay. This may involve the planned acquisition by South Devon Healthcare NHS Foundation Trust of Torbay and Southern Devon Health and Care NHS Trust. The ICO will provide acute, community and social care services, and through this we expect to see resources shift from acute care to high-quality, value-for-money care provided closer to and in people s homes. Services will be developed in a way that links closely with community hubs and the move to six/seven day services. This links to the Urgent and Emergency Care vision to provide services away from Emergency Centres in acute hospitals, with urgent care centres and primary care providing services closer to people s homes. There may also be possibilities to link community hubs with urgent care centre type facilities. We will see a shift in the current workforce configuration to more community-based teams, delivering seven-days-a-week services. Our integrated business plan includes working towards fully 66

67 joined up 7 day provision, of which Primary Care is a key element. The plan to deliver seven day services is included in the service development and improvement plans for our acute and community providers and this will be further progressed with the contract with the integrated care organisation. The work to develop GP practice federations can support seven day working, so that care will be provided to a population rather than to the registered Practice list. This will enable a federation of practices to work together to provide different care models, including extension of existing services into periods of the week where General Practice is currently restricted or unavailable. As part of this collaborative approach we will optimise the current workforce capacity by exploring technology based solutions that complement traditional face to face consultations, so that not only is access extended in terms of timings but also in terms of styles. The CCG is actively working with its Local Education Training Board (LETB) to ensure a steady supply of appropriate medical and non-medical staff over the next five years, aligned to our integration intentions. This, in turn, is informed by the national strategic work being led by Health Education England (HEE) to provide a workforce plan aligned to the Five Year Forward View through a newlyformed Workforce Advisory Board. For the first time, it is anticipated that the historic pressure peaks and troughs inherent in workforce planning will be smoothed out by more cohesive forwardplanning. Whilst there are recognised shortages in specialities which are directly involved in the delivery of urgent and emergency care (including General Practice), it is anticipated that this national work will pay more attention to creative solutions to these workforce pressures, and this is certainly playing out in the South West. For example the newly-accredited Physician s Associate programme has recently been accredited by Plymouth University and in two years will produce a new breed of practitioner capable of delivering a medical (as opposed to a nursing) model of care in and out of hospital. Advanced Practitioners in nursing enable us to flexibly plug the gap between the non-registered and registered workforce, with reflective practitioners capable of working in any setting (including mental health). Finally through our community hubs we are developing the notion of the community professional ; care coaches who will be able to make a discernible reduction in attendance through the emergency pathways by guiding our most vulnerable people through conversations, self-care options and even social prescriptions. It is important that we work with our providers and representative organisations on developing approaches to securing the future workforce, and be mindful of the requirements of professional bodies. As part of the ICO development, work is on-going on the development of a joint estates strategy that fits with and facilitates the emerging joined up service model around four pillars : an excellent quality environment, economical and efficient estate, safe well maintained and responsive and transformed innovative estate portfolio. The strategy for the community estate will centre on the need and type of health and care services to be provided in local communities in the future. Consideration needs to be given specifically to the future services provided in the community and what facilities will be required including the provision of care closer to home. By working in partnership with other agencies and councils on joined up care services, and by collaborating on estate ownership, it may be possible to rationalise leases across the combined estate. Investment in the future will be required in the estates infrastructure for change of use as part of a combined whole system investment plan. By combining support services through the integration, some savings on leased accommodation will be realised. The future of community estate will be the provision of sustainable, fit for purpose and quality buildings in the right place to support healthy communities and the needs of the combined health and social care system. This will include 67

68 community centres with GPs co-located with multi-disciplinary teams and Local Multi-agency Teams (LMATs) and larger MIUs with longer opening hours and enhanced radiological input. IM&T strategies will play an important role in supporting the transformation of urgent care. This will need to involve integrated and shared records across providers and support to allow patients to make better use of technology to meet their urgent care needs. Increasingly patients will be able to view their GP records on-line, in addition to existing technology which allows them to book appointments and repeat prescriptions. Improving access to health information and advice on-line and better information on local services will allow patients to better self-care and make decisions about which services will suit their needs. Increasingly apps or similar will make this easier. As well as patients being able to book appointments, it is increasingly clear that this be extended to NHS 111 who will be able to directly book appointments with a range of urgent care providers to improve the patient pathway. New IT systems being implemented in A&E and MIUs will further enable IM&T to support high quality, more integrated patient care. The ambulance service are also making innovative use of IM&T with mobile technology and access to the DOS, as well as ambulance arrival screens in EDs to speed up patient handover. 9. The five year work plan emerging work streams Considering the priorities identified through the previous sections, we now need to describe how to take the work of the strategy forward, to implement it. The priorities are wide ranging and will require teams from across the CCG and partner organisations to work together in a productive way to deliver change and new models of care. The emerging work streams from the strategy are described in table 17, together with a description of the group who will be responsible for overseeing the work and the lead manager(s) responsible for delivering the work stream. We will ensure the strategy is mainstreamed by incorporating the work-streams into the CCG work-plans. This, together with the metrics for measuring progress described in section 7, will allow regular monitoring of progress on delivery. As there are a number of work-streams, it will be necessary to prioritise them, as we are on a five year approach to change. Some, by their nature, will also take longer than a year to implement and for us to see the effect of change. Following final approval of the strategy, it will be important to move swiftly to implementation. The aim will be for project plans to be developed for each work stream with clear actions, outcomes, leads and timescales attached. Given the scale and scope of the strategy, the programme management approach to overview and implementation is likely to be implemented to ensure the benefits of service transformation described in the strategy can be realised. 68

69 Table 17: Work streams to implement the recommendations of the strategy Work streams Minor injury re-configuration/ development of urgent care centre(s) Patient record information sharing Development of the role of community pharmacy to improve access to urgent care services Development of frail elderly urgent care pathway Redesign of acute mental healthcare pathway Development and mainstream of urgent care quality and outcome standards including: Physical environment Clinical governance and workforce Emergency Department Primary care Urgent care centres Improving urgent access to primary care in and out of hours, including co-location Improving support for self-care including enhanced and targeted provision of information on services and maximising the role of the voluntary sector Enhancing the NHS 111 service improving experience and alternative dispositions On-going development of emergency centres and links with major emergency centres Improving understanding of patient experience of urgent care and service development Reducing ambulance conveyance rates (Right Care 2) and enhancing urgent care provision Responsible group Urgent Care Board (UCB), overseeing locality plans Information sharing group To be advised Integrated Care Organisation (ICO) work stream 3 Acute care pathway steering group, reporting to Mental Health and Learning Disability Redesign Board Task and finish group(s) of UCB Primary care redesign board (PRCB) Task and finish group of UCB NHS 111 integrated performance assurance meeting (IPAM) UCB To be advised UCB, through Right Care 2 Lead(s) Deputy Director of Commissioning Deputy Director of Corporate Affairs/Clinical Lead for IM&T Governance Medicines Optimisation Pharmacist/Head of Unplanned Care Head of Integration/System s Manager (Acute and Community Care) Head of Mental Health Commissioning Head of Quality/Head of Unplanned Care Deputy Director of Commissioning Head of Patient Engagement/Head of Unplanned Care Head of Unplanned Care Clinical Lead for Urgent Care Head of Quality/Head of Unplanned Care Deputy Director of Commissioning First year priority? Yes, already underway Yes, already underway Yes, already underway as part of PMCF Yes, already underway through ICO Yes, already underway 69

70 Development of paediatric urgent care pathway Torbay locality specific work including promotion of alternatives to ED and addressing service gaps Inclusion of CCG outcome standards and local quality standards into contracts Integrated governance and network arrangements across urgent care UCB UCB, through locality groups To be advised UCB, through task and finish group if necessary Clinical Lead for Urgent Care/Head of Quality Head of Unplanned Care/Locality Leads Head of Unplanned Care/Head of Contracting and Procurement Governance leads for provider organisations 10. Summary/conclusions This strategy focuses on the topic of urgent care, important for patients, professionals and commissioners to get right, to ensure high quality services meet needs, and offer good value for money. To address the issue we have undertaken a thorough review of all urgent care services locally to better understand existing use of services and the quality of the services offered which shows us that the national picture of increasing use of A&E to meet urgent needs is mirrored locally. We also see that there are a range of other services but the offering is variable and activity for some services which can provide a viable alternative to A&E is decreasing. We have undertaken a thorough analysis too of patient experience of services which shows variation in understanding of what services do and experience, with some concerns emerging over access and waiting in particular. Using this information, we then consider how we can implement the findings of the national urgent and emergency care review and a number of priorities for service change emerge and principles which will guide our commissioning decisions. We have also included a section on what good looks like starting to scope out a set of quality and outcome standards to apply to urgent care contracts. Priority work streams and metrics for improvement are included, to ensure the strategy can progress from document to implementation. 70

71 References/Bibliography Professor Benger (2014) EF conversation with Professor Benger, national clinical lead for urgent care centres Care UK (2014) Urgent and important: A future for urgent care in a 24/7 NHS Commissioning Support for London (2010) A service delivery model for urgent care centres: Commissioning advice for PCTs Emergency Care Intensive Support Team (2011) House of Commons, Committee of Public Accounts (2014) Out of hours GP services in England: Twenty-second Report of Sessions Kings Fund (2010) Avoiding Hospital Admission: what does the research evidence say? Kings Fund (2013), Transforming our health care system London Health Programmes (2013) London Quality Standards for Acute Emergency and Maternity Services Monitor (2014) Reimbursement of urgent and emergency care: discussion document on options for reform National Audit Office (2014) Out of hours GP services in England NHS England (2013) The Evidence Base from the Urgent and Emergency Care Review NHS England (2013) Urgent and Emergency Care Review: End of phase one report NHS England (2014) CCG outcomes indicators set NHS England (2014) Five year forward view NHS England (2014) The Forward View into Action: Planning for Primary Care Foundation (2011) Commissioning Urgent Care 71

72 Appendix 1 Community pharmacy location map Source: SD&T CCG (2014) 72

73 Appendix 2 Map showing percentage of population without access to a car or van 73

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