Urgent and Emergency Care Programme Board Wednesday 25 November 2015

Urgent and Emergency Care Programme Board Wednesday 25 November 2015 Title: DRAFT U&EC Event Report Agenda item: 3 Paper: 3 Action requested: Executive summary: Endorse Following the U&EC event Implementing the Urgent and Emergency Care Vision in London - on 17 November an event report has been developed summarising content and discussion. Further to this the event feedback forms and challenge and idea cards have been analysed and findings are included. Workshop feedback will be further considered in detail to inform developments in each of the areas. Summary of recommendations: Reference to related documents: The Urgent and Emergency Care Programme Board is asked to note the next steps and endorse the report for publication alongside event materials. N/A Date paper completed: 20 November 2015 Other forums that have considered this paper: Author(s) name and title: None Tom Henderson, Project Manager, Healthy London Partnership

Implementing the U&EC Vision in London DRAFT Event report November 2015 3

Contents Executive summary 5 Page Introduction, purpose and structure of the event 6 Session One: The U&EC Vision and Responding to Patients Expectations - Discussion and Feedback 10 Session Two: Overcoming Implementation Challenges Workshop Sessions - Discussion and Feedback 15 Session Three: Mental Health Crisis Care and U&EC Vanguards - Discussion and Feedback 20 Delegate feedback and Next steps 22 4

Executive summary Professor Sir Bruce Keogh s comprehensive review of the Urgent and Emergency Care (U&EC) system in England called for clarity and transparency in the offering of U&EC services to the public. In response to this, commissioners in London have been working collaboratively to understand patient and public behaviours and expectations and develop consistent specifications for U&EC facilities to provide co-ordinated, consistent and clear services to meet these expectations. A pan London event was held by the Healthy London Partnership at Mary Ward House on the 17 November 2015 for commissioners, providers and service users to provide an opportunity for stakeholders to hear insights from research into Londoners experiences and expectations of U&EC services, how the clinically developed facilities and system specifications respond to this and begin to tackle some of the key challenges to implementation. 225 delegates attended the day with a mix of delegates consisting of commissioners, providers, clinicians, managers, local authorities and 44 service users/carers/lay and patient representatives. Feedback on the event was received from delegates via event evaluation forms and feedback cards; 30 responses were received. Overall, the event was largely well received with 96% feeling that the event was relevant to them and their organisation and 76% that felt the event met the objectives set. A consistent theme of dissatisfaction overall was with the venue. There was also a high level of satisfaction amongst delegates with most workshops; where workshops were more interactive delegates felt more engaged and satisfaction levels were higher. The poster display was also well received with 66% feeling that it provided them with fresh insight, common feedback was that there needed to be more time to view the posters and that the venue restricted the viewing of posters. Feedback from the event will be used to inform programme developments and will be shared with all delegates. 5

01 Introduction, purpose and structure of the event Transforming London s health and care together 6

Introduction and purpose The purpose of this paper is to provide a summary of the content and discussion from the Implementing the Urgent and Emergency Care Vision in London event held on Tuesday 17 th November 2015. The event was chaired by the two U&EC transformation programme chairs; Dr Andy Mitchell, Medical Director, NHS England (London) and Conor Burke, Chief Officer, Barking and Dagenham, Havering and Redbridge CCGs. The aims of the event were: To share insight from research into Londoners experiences and expectations of U&EC services To describe the vision for U&EC services, and how we re responding to patients expectations in London Begin to tackle some of the challenges of implementing this vision in workshop sessions focussed on workforce, interoperability, payment mechanisms and patient co-design To share and learn from poster presentations of good practice and innovation submitted from across London and beyond. The event was well attended with 225 delegates present; of which 44 were patient and public representatives (20%). There was also a good spread of representation from across all five of London s U&EC networks, as detailed below: Network: NCL NEL SEL SWL NWL Delegates represented: 30 52 28 36 28 7

Structure of event Session One: The U&EC Vision and Responding to Patients Expectations, chaired by Dr Andy Mitchell included presentation and discussion on: Urgent and Emergency Care: The new offer - Professor Keith Willett, Medical Director for Acute Episodes of Care, NHS England The patient perspective - Helena Kania, Patient Representative; Clare McDonald, Behaviour Change and Engagement Specialist; and Dr Rachel Wilson, BSc (hons), MBChB Responding to patients expectations the U&EC facilities specification U&EC Clinical Leadership Group Co-Chairs: Dr Tom Coffey OBE, GP Wandsworth CCG; and Dr Simon Eccles, Consultant in Emergency Medicine, St Thomas Hospital The session finished with a panel Q&A with the speakers chaired by Dr Andy Mitchell Session Two: Overcoming Implementation Challenges saw delegates break into groups to attend four workshops to discuss: A. Patient co-design Developing services together with patients and discussing principles of co-design for London s U&EC networks. B. Workforce development Identifying key workforce challenges in transforming U&EC systems and the steps to address them. C. Interoperability Identifying and agreeing the vision and principles for interoperable IT systems to support U&EC transformation. D. Payments Mechanisms - Developing and piloting new models within U&EC systems to transform care. 8

Structure of event Session Three: Mental Health Crisis Care and U&EC Vanguards, chaired by Conor Burke, included feedback from the chairs of the workshops sessions followed by presentations and discussion on: Mental Health Crisis Care - Dr Marilyn Plant, Clinical lead, Clinical Expert Group Chair & GP, Richmond CCG Barking & Dagenham, Havering and Redbridge CCGs Urgent and Emergency Care Vanguard - Alan Steward, Chief Operating Officer Havering CCG; and Dr Dan Harris, Clinical Director, Emergency Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust Conor Burke then summarised the day and next steps Sharing Good Practice and Innovation Poster Display Throughout the refreshment breaks and lunch break there was also opportunity for delegates to share and learn from poster displays in the U&EC Good Practice and Innovation Market Place. Posters were submitted in advance of the event from numerous stakeholders across London s U&EC system and were supplemented with examples from across the UK. In total 50 posters were displayed, each describing innovation that has improved the U&EC system and benefited patients. There were also poster displays from across London s U&EC networks describing their vision for the development of U&EC services. 9

02 Session One: The U&EC Vision and Responding to Patients Expectations Discussion and Feedback Transforming London s health and care together 10

Discussion and feedback Session One: The U&EC Vision and Responding to Patients Expectations Urgent and Emergency Care: The new offer - Professor Keith Willett, Medical Director for Acute Episodes of Care, NHS England Professor Keith Willett described the national vision as set out in the Urgent and Emergency Care Review with an update on the progress and support in implementing transformation across U&EC systems in England. This included key points around the current issues seen in Urgent and Emergency Care services and the need for transformation across systems to meet the patient need and expectations of care. The vision for the new offer and establishment of U&EC networks across England was described as well as the route map for implementation and four key national priorities for supporting delivery; payment system reform, information sharing, system measures and workforce. Following the presentation Professor Keith Willet took questions from delegates. Discussion included: Highlighting the importance of balancing the benefits of collaboration and locally driven change as well as the importance of primary care within the wider urgent and emergency care system. Professor Keith Willet agreed with the these important points. Specific issues around South Croydon were raised and Professor Keith Willet highlighted the importance of the role of U&EC Networks to ensure an affordable and sustainable U&EC system is put in place. Good practice in one locality was shared about a rapid response team developed to avoid admission and expedite discharge but it was highlighted that issues persisted between primary care and secondary care communicating. Dr Andy Mitchell highlighted the inter-operability workshop as the beginning of action to develop solutions to address this. Morale of the workforce in the system was also highlighted as an issue, with feelings of being understaffed and bogged down. Professor Keith Willet recognised this but also fed back how heartened he was during the summer when roadshows across England were undertaken and he experienced a huge amount of energy and enthusiasm to transform the system for patients. 11

Discussion and feedback Session One: The U&EC Vision and Responding to Patients Expectations The patient perspective - Helena Kania, Patient Representative; Clare McDonald, Behaviour Change and Engagement Specialist; and Dr Rachel Wilson, BSc (hons), MBChB The presenters showcased two complementary anlayses that have been undertaken; a survey of over a 1,000 Londoner s experiences and expectations of U&EC services and behavoiural insights research from 897 patient and staff interviews undertaken in A&E. Key messages included: The current public and professional confusion at the range urgent care services locally avaliable- 68% of Londoners don t know the difference between 'Urgent Care Centre', 'Walk in Centres', 'Minor Injury Units' and GP led health centres. The high number of young people who use A&E services within London, and the impact of populations who move regularly and hence may not be registered with a local GP. The strength of the brand of A&E whilst patients often wish to access an appropriate service for their need, the accessibility of A&E departments and confidence in the care they will receive means that patients are often willing to attend A&E even if there is a wait. Responding to patients expectations the U&EC facilities specification U&EC Clinical Leadership Group Co-Chairs: Dr Tom Coffey OBE, GP Wandsworth CCG; and Dr Simon Eccles, Consultant in Emergency Medicine, St Thomas Hospital Dr Tom Coffey described how the patient s expectations have been used to shape the vision for the U&EC system across London and updated on the developments underway in Primary Care and Integrated Urgent Care to support the transformation of U&EC systems. Dr Simon Eccles then described the breadth of engagement undertaken with the public and clinicians in developing a consistent U&EC facilities and systems specifications for London. The specification builds on the London Quality Standards, the achievements made in networking specialised care and ensures parity of esteem for patients in mental health crisis. 12

Discussion and feedback Session One: The U&EC Vision and Responding to Patients Expectations The session finished with a panel Q&A with speakers chaired by Dr Andy Mitchell. Discussion included: The next steps for changing the public s behaviour across London when accessing U&EC care. Claire McDonald highlighted that services need to be delivered consistently, in line with the specifications so there was a viable and consistent alternative offer to A&E; only then could widespread communications to the public take place to encourage the use of alternatives and begin to see behaviours change based on new and positive experiences. It was suggested that all junior doctor inductions should include familiarisation with the alternatives to A&E in the local area so that they could play their part in advising patients. It was also highlighted that for any member of staff to advise of alternatives they need to be confident that the alternative is accessible and able to treat the patient. The importance of ensuring safe and timely inter-hospital transfers across the system was raised. The importance of mental health and ensuring parity was highlighted by a number of speakers and delegates. A question was raised around dealing with alcohol issues in A&E. Dr Simon Eccles advised that this was certainly an issue at specific times and whilst some needed to sleep it off others with long standing issues need to be signposted or referred to support services and this was successful in some cases. Another delegate reiterated the success of the consolidation of specialist services such as stroke and trauma and suggested that others should also be looked at such as plastics and burns services. The issue of a high use of A&E for children was raised, and whilst it was recognised that there was often anxiety from parents and a risk averse attitude in A&E, it was also highlighted that this was reinforcing behaviours of the future generation regarding how urgent care should be accessed. Dr Tom Coffey responded that general practice in hours and out of hours needed to be developed to deal with this cohort of patients. 13

Discussion and feedback Session One: The U&EC Vision and Responding to Patients Expectations The session finished with a panel Q&A with speakers chaired by Dr Andy Mitchell. Discussion cont d: Discussion took place on the collocation of Urgent Care Centres with A&Es. Dr Tom Coffey responded that these often had the benefit of providing everything that was needed as there was speedy access to the back up services available in hospitals such as x-ray. However, it was also highlighted that there is a plethora of other facilities available in the community, such as, minor injuries units and GP led health centres, many of which have different offerings and different opening times. This causes confusion and U&EC Networks now needed to look at how Urgent Care Centres would be developed in the community in line with primary care developments. The importance of ensuring the workforce was available to deliver the vision was highlighted and it was noted that the workshops that day would focus on tackling these issues. 14

03 Session Two: Overcoming Implementation Challenges Workshop Sessions Discussion and Feedback Transforming London s health and care together 15

Discussion and feedback Workshop A Patient Co-design The workshop was chaired by Trevor Begg, lay member for Hillingdon CCG. The session covered examples of successful co-design and co-production of services with patients from across London, including: Health 1,000 in BHR CCGs Presented by Alan Steward, Chief Officer Havering CCG The Empowered Patient Programme and Community Outreach in Hillingdon CCG Presented by Radhika Howarth, Hillingdon CCG The discussion then focussed on answering 3 key questions in groups: Ensuring we use the co-design principles laid out in the five year forward view and learning from current good practice from across London when co-designing with all patient groups that use U&EC services. How we co-design effectively across network boundaries - what do we need to do to balance between achieving locally determined priorities and ensuring consistency of services? What can be done once across London to support co-design locally? E.g. education and consistent messaging to support changing patient behaviour. In the plenary feedback, Trevor Begg highlighted the following points: 1. The need to share good practice of patient co-design across London to support development of U&EC services 2. The need to co-design with all populations that use U&EC services especially with younger people. This could be supported across London with a focus on the means of engaging, e.g. via social media and how we listen and respond. 3. Strong support for a clear and consistent message across London to ensure patients understand the U&EC system. Particularly in relation to ensuring that the primary care extended hours is well communicated, so that people know about the alternatives to A&E. 16

Discussion and feedback Workshop B - Workforce The workshop was chaired by Paul Roche, HLP workforce programme lead and covered the following aims: Sharing an overview of the engagement currently sought to understand and develop key workforce priorities for U&EC. Validating of the 6 identified priorities with stakeholders ensuring they are consistent with what is experienced within networks and across London. Consideration against each workforce priority of the proposed actions and development with particular consideration of who across the system in London should lead on each action. In the plenary feedback, Paul Roche fed back that three common themes had come out of the workforce workshops: 1. The need for indemnity, contracts and incentives to be aligned to the vision for U&EC transformation; 2. The need for a shift in culture and behaviour to enable change across the system; 3. The need for a place to share solutions and learn from each other as many excellent examples had been shared in the workshops. 17

Discussion and feedback Workshop C - Interoperability The workshop was chaired by Eileen Sutton, HLP Integrated Urgent Care lead and Dr Simon Eccles, U&EC programme clinical lead and covered the progress made so far in developing interoperable services within NHS 111 across London and the proposed principles put forward by U&EC clinicians to develop interoperable solutions to support whole system transformation. The purpose of the discussion in the workshop was to seek validation of these principles from a wide range of U&EC stakeholders and patients from across the system. A summary of the proposed principles outlined is below: Citizen account and value A single process allowing patients to define their preferences in advance of care. The design of interoperable systems should allow participation with patients and to make care accessible for them. Including the ability to reschedule appointments and upload telemetry data to monitor care. Accessing and collating data Patient information held by different providers across London needs to be located and collated in real time, using a standards based approach, to support triage and the transfer of care between different providers across the pathway. Creating alerts Clinicians will be able to subscribe to specific alerts for circumstances and patients they define. Delivery of information through existing systems Patient information is communicated directly to the clinician to support decision making, and does not require accessing alternative systems. In the plenary feedback Mike Part, interoperability lead for HLP highlighted: That there had been agreement in all sessions for the proposed principles for interoperable systems to support the transformation of U&EC services. These principles would therefore be used as the basis on which to build solutions across London and be taken forward to support the national direction for development. Mike also fed back some of the concerns and challenges raised by workshop attendees regarding information governance and data sharing. He acknowledged these challenges and would continue to work with stakeholders to develop solutions and ensure that patients views are taken account of throughout the process. 18

Discussion and feedback Workshop D Payment Mechanisms This workshop introduced the new national payment approach for U&EC. Lily Tang from Monitor chaired alongside Stuart Saw from NHS England (London) and outlined the need for a new payment approach to support U&EC system transformation. Lily outlined the current challenges preventing a coordinated and consistent system, namely payment systems being institution focussed, differing incentives and the lack of robust activity, cost and quality data. The new payment approach was introduced, making use of three elements (see the proposed figure above). The aim of this approach is to have a coordinated and consistent payment approach across all parts of the UEC network not just the acute setting. How the model has been developed including the approach with stakeholders was outlined in the workshop as well as next steps and the plan going forward into 2017/2018. In the plenary feedback, Lily Tang highlighted the following points: Delegates had been broadly supportive of the principles but challenges had been highlighted around budget constraints; whilst the new payment approach would not be able to resolve this it was one reason why more intelligent payment approaches needed to be developed and adopted. Lily also outlined that the new payment approach may be mandatory in the future and welcomed people getting in touch to discuss further. 19

04 Session Three: Mental Health Crisis Care and U&EC Vanguards Discussion and Feedback Transforming London s health and care together 20

Discussion and feedback Session Three: Mental Health Crisis Care and U&EC Vanguards Mental Health Crisis Care - Dr Marilyn Plant, Clinical lead, Clinical Expert Group Chair & GP, Richmond CCG Dr Marilyn Plant described the variation currently seen for patients experiencing mental health crisis in our U&EC systems across London and the steps being taken to set standards that ensure parity of esteem for these patients in the development of U&EC services across London. Work to support U&EC Networks across London included understanding the current provision of health based place of safety and defining the ED crisis care pathway. A number of points were raised by delegates following Dr Marilyn Plant s presentation; issues included the lack of Child and Adolescent Mental Health (CAMHS) beds nationally and the impact in London and the S136 process, particularly the availability of Allied Mental Health Practitioners and the lack of appropriate beds. Marilyn agreed with these issues and that the focus on transforming care for those in a mental health crisis needed to be a priority to achieve parity of esteem. We have transformed care in London for those who have a stroke or a heart attack and now need to do the same for those in mental health crisis Dr Marilyn Plant Barking & Dagenham, Havering and Redbridge CCGs Urgent and Emergency Care Vanguard - Alan Steward, Chief Operating Officer Havering CCG; and Dr Dan Harris, Clinical Director, Emergency Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust The presentation detailed the aims, achievements to date and lessons learnt from the London U&EC Vanguard and how further challenges would be overcome to transform care across the system. This included the importance of developing a shared vision with all stakeholders that fits with the local context and population and the importance of patient co-design when developing plans. If we are to transform the Urgent and Emergency Care system then we need to leave our personal agendas at home. Some services may expand and some may shrink but we must accept this for the greater good. Dr Dan Harris 21

05 Delegate feedback and Next steps Transforming London s health and care together 22

Evaluation form feedback Overall responses 76% felt that the event met the objectives outlined 96 % felt that the event was relevant to them and their organisation 60% felt there was sufficient opportunity to learn from others o 26% neither agreed or disagreed and 6% disagreed 60% felt satisfied with the day overall o 26% were neither satisfied or dissatisfied and 3% felt dissatisfied Key themes Most helpful aspects of the day: 1. Networking and sharing of good practice 2. The workshop sessions 3. Setting the scene for U&EC and bringing delegates up to date Least useful aspects of the day: 1. Limited scope to develop ideas in workshops: A number of delegates commented they would have liked more time to develop ideas in the workshops 2. Logistical issues: Some delegates felt a larger venue would have been more suitable for the high turn out 3. The payments mechanism workshop: Some delegates found it difficult to follow the financial jargon of the workshop Session One: The U&EC Vision and Responding to Patients Expectations 70% felt the presentation on Urgent and Emergency Care: The new offer provided them with fresh insight 66% felt the presentation on The patient perspective provided them with fresh insight 16% were indifferent 6% did not feel that it provided them with fresh insight 66% felt the presentation on Responding to patients expectations provided them with fresh insight Session Three: Mental Health Crisis Care and U&EC Vanguards 53% felt that the presentation on Mental Health Crisis Care provide them with fresh insight 10% were indifferent 6% did not feel this way 63% felt that the presentation on BHR U&EC Vanguard provided them with insight Session two: workshop sessions Percentage of responses who agreed that workshop leads were engaging and the presentations were of a high quality: 73% - Patient co-design 63% - Interoperability 60% - Workforce 36% - Payments and funding Percentage of responses who felt the session was interactive and felt there were actions they could take to start putting this into action 53% - Patient co-design 46% - Workforce 43% - Interoperability 30% - Payments and funding Poster displays 66% of responses said the good practice market place provided them with fresh insight and the majority would have liked to spend more time viewing them 23

Challenge and lightbulb cards Delegates were encouraged to note their thoughts via the use of feedback cards which were available on the tables. Light bulb cards encouraged delegates to note down ideas and if and when solutions have become apparent that they feel empowered to take forward whereas challenge cards asked delegates to consider what they thing are the greatest challenges they will face in implementing this new model. The cards were completed anonymously and collected in post boxes at the venue. A total of X light bulb cards and XX challenge cards were completed. The themes from both these cards have been grouped together as new ideas were also posted on the challenge cards. Stick with one title for urgent care centres and stop tinkering A&E and GP are clear that s why people go there BHR story very inspiring Work with TV producers to create storylines on the various urgent care pathways Nationally need an overall re-procurement of suppliers, individual services are being ripped off Don t forget the patient/carer I feel empowered to link with the right bits of the system to develop networks I feel empowered following session to put over messages in Residents Association Magazines and eblasts I feel empowered to create co-client workshops Put ipads in waiting rooms to receive feedback, provide information and give feedback Cuts in social services and public health Successive governments telling patients to expect more and more rather than to respect and value and protect the NHS Consistent standard approach and communicating this to patients Getting the leadership right Motivating and inspiring the workforce Financial transparency Linking with existing networks such as stroke and trauma and building on relationships and pathways Communication between hospitals, GPs and community care IT working well between services Getting enough staff and valuing them 24

Follow up action Next steps include: Publishing event materials and the findings of the patient survey and behavioural insights research to share with all stakeholders and U&EC networks. Creating a compendium of good practice and innovation from the posters shared on the day and developing this to support networks in their development of the U&EC system. Continued engagement with all U&EC Networks to tailor support to their implementation of the U&EC vision and development of network delivery plans. Develop full reports of the workshop outputs to inform U&EC network developments and the support from HLP programmes, including: Workforce - highlighting agreed actions against identified priorities Interoperability development of data standards aligned to the agreed principles, development and testing of system design across London. Payments supporting networks to design and implement new payment models aligned to their local vision. Patient Co-design collation of good practice from across U&EC networks to specifically support co-design Ensure all feedback informs future programme events. The published event materials and U&EC facility and system specifications for London are available online via: https://www.myhealth.london.nhs.uk/healthy-london/urgent-emergency To get in touch with the U&EC programme please email: england.serviceredesign@nhs.net 25