Clinical Governance Framework

Norfolk and Wisbech (excluding Great Yarmouth) Integrated NHS 111 and OOH Service Clinical Governance Framework (Final Draft Version 1.0) SRO: Nicola Cocks Clinical Leads: Dr Victoria Stanley (NHS Norwich CCG) Dr Penny Ayling (NHS North Norfolk CCG) Dr Keeva Rogers (NHS South Norfolk CCG) Dr Imran Ahmed (NHS West Norfolk CCG) Dr Andrew Wordsworth (NHS Cambridgeshire and Peterborough CCG representing Wisbech)

Approved By: SRO: Nicola Cocks ------------------------------------------------------------------ Clinical Leads: ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- 2

1. Introduction This framework details the Clinical Governance arrangements that are in place to ensure a safe and effective Integrated NHS 111 and Primary Care OOH Service is provided to the population of Norfolk and Wisbech (excluding Great Yarmouth). It provides the evidence on which the Senior Responsible Officer and the respective CCG Clinical Leads have assured themselves that robust clinical governance arrangements are in place for the new service. It draws on the experience and lessons learned from delivering the NHS 111 and OOH service over the past 3 years The new Integrated NHS 111 and Primary Care OOH Services is scheduled to go live on 1 st September 2015. The provider of these integrated services is IC24 The current provider of these services is East of England Ambulance Service (EEAST). Commissioners, EEAST and the incoming provider IC24 have worked diligently and professionally to ensure a safe hand over of the services with minimum disruption to patients, staff and other health professionals and services. Patients dialling 111 following handover should see no disruption in service. The service is still being provided in the local area and many of the staff delivering the service will remain the same as the roles are protected under TUPE Patients requiring an OOH GP who contact their own GP will hear an answerphone message directing them to call 111 who will help them. Patients directly dialling the previous OOH number will also hear a recorded message advising this service is no longer operating and directing them to call 111. Patients on the borders of the covered area may on dialling 111 get through to a neighbouring NHS 111 service. All NHS 111 service providers are obliged to provide a service to Out of Area callers that meet the NHS 111 specification regardless of where they are calling from. The Integrated NHS 111 and Primary Care OOH Service Project SRO and the Clinical leads for North Norfolk, Norwich, South Norfolk, West Norfolk and Cambs & Peterborough (Wisbech) have assured themselves that the service is safe and effective. Assurance Letters (Refer to appendix 1, 2 and 3) 2. Local Context 2.1 Local population and commissioning arrangements The commissioned service covers the Norfolk and Wisbech population, excluding Great Yarmouth. Great Yarmouth and Waveney services are provided by IC24 under a separate contract. The estimated population for this service is 830,0000 patients and are the responsibility of 4 CCGs and 1 LCG in the area to be covered and these areas are broken down in terms of GP practice and population as follows: CCG No of GP Practices Approx. patient population Norwich CCG 22 213,000 North Norfolk CCG 20 169,000 South Norfolk CCG 26 229,000 3

West Norfolk CCG 23 169,000 Wisbech LCG 4 50,000 There are also 3 prisons in the local area which will be covered for urgent OOH care by IC24 under the terms of this contract. These are: HMP Norwich HMP Bure HMP Wayland 2.2 Local emergency and Urgent Care services 2.2.1 999 Service is provided by: East of England Ambulance Service (EEAST) provides the 999 service in the locality. 2.2.2 Acute Care in the area is provided by: The Norfolk and Norwich University NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY http://www.nnuh.nhs.uk/ The Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust, Gayton Road, King's Lynn, Norfolk, PE30 4ET http://www.qehkl.nhs.uk/ 2.2.3 Community Care in the area is provided by: Community Care in the Norfolk contract area is provided by Norfolk Community Health and Care NHS Trust (NCH&C), Elliot House, 130 Ber Street, Norwich, Norfolk, NR1 3FR http://www.norfolkcommunityhealthandcare.nhs.uk/ This provider also has a number of community hospital beds who s out of hours medical cover will be now be provided by IC24 as the Primary Care OOHs Provider Community Care in the Wisbech area is provided Uniting Care Partnership (UCP), Block 2, Ida Darwin Hospital, Fulbourn, Cambridgeshire, CB21 5EE http://www.unitingcare.co.uk/ Community hospital beds for the Wisbech area are provided at North Cambridgeshire Hospital, The Park, Wisbech, Cambridgeshire, PE13 3AB http://www.cambscommunityservices.nhs.uk/ 2.2.4 Mental Health Care is provided by: The Mental Health provider for the Norfolk contract area is Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Drayton High Road, Norwich, Norfolk, NR6 5BE http://www.nsft.nhs.uk/ The Mental Health provider for older people in Wisbech is UCP, Block 2, Ida Darwin Hospital, Fulbourn, Cambridgeshire, CB21 5EE http://www.unitingcare.co.uk/and for adults, young people and children is Cambridgeshire and Peterborough Foundation Trust (CPFT). Elizabeth House, Fulbourn Hospital, Fulbourn, Cambridge, CB21 5EF http://www.cpft.nhs.uk/ 3. The local approach to the overall governance and clinical governance of NHS 111 and Primary Care OOH Service 3.1 How the local approach was developed North Norfolk, Norwich, South Norfolk, West Norfolk and Cambs & Peterborough (Wisbech) have commissioned a fully integrated NHS 111 and Primary Care OOH Service. There was scope within the procurement for multiple providers to work together to tender to provide the service however no such bids were received. The selected provider IC24 tendered to provide the whole service and to manage it as a fully integrated service. 4

At the pre procurement stage a Project Team was set up to develop service specifications and to help with market engagement for this new integrated service. On procurement of the service a full Project Board was set up to lead the mobilisation and implementation of this service as well as decommissioning and transitioning of the existing services to the new provider. EEAST is the main incumbent provider so this service decommissioning and transition was also part of this project. Additionally as Wisbech is also part of this procurement there is an element of decommissioning of Herts Urgent Care (HUC) as the NHS 111 provider responsible for Wisbech and Urgent Care Cambridgeshire (UCC) as the OOH provider for Wisbech. The Project Board had a series of individual work-streams of which clinical was one. This included a clinical governance process to cover the mobilisation and decommissioning but also to hold providers to account regards clinical safety and effectiveness on an ongoing basis through the life of the contract. A number of stakeholders were identified and involved in this process The stakeholders included: Norwich CCG (Coordinating Commissioner) South Norfolk CCG North Norfolk CCG West Norfolk CCG Wisbech LCG East of England Ambulance Service Trust incumbent provider of NHS 111 and OOH in Norfolk East of England Ambulance Service Trust as 999 service provider UCC OOH Provider in Wisbech HUC NHS 111 provider in Wisbech Norfolk and Norwich University Hospital Foundation Trust Queen Elizabeth Hospital Foundation Trust Cambridgeshire Community services (Community Services Luton) Norfolk Community Health and Care Norfolk & Suffolk Foundation Trust Norfolk & Waveney LMC Health Watch As NHS Norwich CCG is coordinating commissioner for this service Dr Victoria Stanley was selected as the area Clinical Lead for NHS 111 and Primary Care OOH. She is supported by Clinical Leads in each of the CCGs covered and, in Wisbech case, LCG covered. The approach has been slightly different than the initial launch back in 2012 as this is an existing functioning service. The DoS is well established and although the provider organisations will change the staff delivering the service in many case will remain the same so the emphasis is on transitioning rather than launching a brand new services Dr Stanley has thus far led the clinical work-stream and is working very closely with the outgoing and incoming providers to ensure a seamless and clinically safe hand over of patients, staff and service. The Clinical Leads and Quality Leads have met on a regular basis to develop the assurance framework for the mobilisation and develop a Joint Clinical Governance structure and process that will ensure that this service is properly managed and monitored and is developed to continually to improve services and outcomes for patients NHS England have produced some new guidance for NHS 111 Clinical Governance http://www.england.nhs.uk/wp-content/uploads/2015/03/nhs111-clincl-govrnce-tool-kit.pdf 5

which we have used as a reference point throughout this process and in developing this document but the Clinical Work-stream have enhanced this further to encompass the OOH element of the service to ensure that the service is indeed fully integrated. See Appendix 5 for the Terms of Reference 3.2 Stakeholder engagement in the development of the arrangements IC24 and commissioners have been committed to stakeholder engagement and have utilised as many existing fora to continue this process following procurement. The Clinical Leads are working GP s from the local area providing a direct link and voice in these local areas. The Clinical leads and IC24 have worked collaboratively to develop this Clinical Governance framework which takes into account national guidance as well as the local clinical commissioners requirements. A communications strategy was developed collaboratively across all CCGs and is found in Appendix 4 The Regional NHS 111 lead in the area has been kept fully appraised of the activity in this area. IC24 have a robust stakeholder engagement plan that includes the development of a Stakeholder Project Board (SPB) which will have the following objectives pre and post Go Live of the service: Create an environment for all key Stakeholders to recognise, discuss and review the needs of the local community and pressures within the system; Understand and appreciate the reasons and rationale for what is working well and not so well and suggest and implement solutions; Review service effectiveness; Development of local pathways; Understand the use of resources and ascertain appropriate levels of use and evaluate outcomes of patients; Whole system approach to service provision reducing duplication and improving efficiency and effectiveness of services; and Communication between all key Stakeholders. This Board will create an environment where the expertise of key partners within urgent care services can be utilised and will be used to support communication and engagement with all colleagues including those who perhaps have not engaged with the service. We will actively work with all key Stakeholders and encourage them to be involved or represented at the SPB to promote communication and engagement of all key partners. This will enable the service to grow and develop to meet the needs of patients, carers, families and to commissioning intentions. To ensure an inclusive and active SPB is achieved IC24 have developed a stakeholder engagement plan also found at Appendix 4 that runs in parallel to the mobilisation and implementation plans of the service. 3.3 On-going stakeholder engagement in the governance of the service Following the launch of the service on 1 st September 2015 there will continue to be engagement with all stakeholders. The new guidance referred to previously has reduced the number of stakeholders required at ongoing Clinical Governance meetings however there is a commitment with this service to always have CCG leads, Provider (IC24), 999 Provider 6

(EEAST) regularly with others invited dependent on the call reviews or issues being looked at i.e. Community, Mental Health, Dental etc In addition to clinical governance group IC24 are establishing a Stakeholder Project Board to maintain ongoing dialogue regards the service and service development with local stakeholders. 3.4 Defining the scope of the clinical governance group The Clinical Governance and Operations Group reporting to the Integrated NHS 111 and Primary Care OOH Programme Board, has an overview of: Clinical governance Operations, Performance, Directory of Service (DoS). Quality Clinical Governance reporting will include clinical incident reviews, serious incidents learning and action plans, themes and learning from complaints, End-to-End service reviews and health professional feedback. The Clinical Governance and Operations Group will also discuss patient, staff and stakeholder experience of the service. This Clinical Governance Framework Document contributes to the assurance that the Provider is compliant in meeting its statutory duties. 3.5 Learning that influenced development of the Operations and Clinical governance regime Over the course of current contract with EEAST to provide the NHS 111 and OOH service there have been consistent ongoing clinical and operational quality review meetings between the commissioner and the provider. This has at times involved other providers such as acute hospitals. In addition to these quality review meetings Call Review meetings have also been held regularly to review the NHS 111 calls made. All have agreed that the meetings need to continue as this has been a very positive part of the process and has helped identify issues and move the service forward. The clinical and operational people responsible for the Integrated NHS 111 and OOH service from within the commissioning team and IC24 as the service provider are extremely keen to build on this and re-establish the group taking the opportunity to refresh the ToR including membership and aims and objectives. Having been through the experience of re-procurement with the need to re-look at service specifications has highlighted that it would be pertinent to build into the process going forward ongoing review of the service and specification to ensure it continues to evolve and develop in terms of patient care and treatment. In looking at the longer term picture a 5yr Clinical Governance plan has also been put forward see section 15 and Appendix 30 3.6 Re-establishing the identity of the Clinical Governance and Operations Group The Integrated NHS 111 and Primary Care OOH service has a key role to play within the Urgent Care System. When working appropriately it will direct patients to the right care, first time and helping them navigate through the most appropriate service for their symptoms. 7

Through the clinical governance group there is potentially wide ranging stakeholder community and access to significant daily patient flow data. This can provide real insight to patient and stakeholder behaviours to identify trends and, commissioning gaps and work with stakeholders to enhance appropriate local service provision and address local needs. It is important that this group is re-established at the launch of the new service to ensure that all involved follow the principles, ToR etc of the new group and therefore move the service forward rather than continue to follow the current plan without refreshing it 4. Clinical Governance Structure 4.1 The role of the NHS 111 and Primary Care OOH clinical leads The Job description for the role is found at Appendix 7. NHS England provided a template JD for this role in draft form but this was relating just to the NHS 111 element so this has been adapted to incorporate the OOH element also. The Head of Quality, Improvement and Assurance for Norwich will take the deputy role. 4.2 The role of the Clinical Governance and Operations Group The Clinical Governance and Operations Group provides assurance regards the clinical safety and effectiveness of the service to the CCGs as commissioners and partner organisations. The service is an integrated 111 and OOHs service and is provided by the same provider with overarching clinical and operational leadership embedded within it to ensure cohesive working practices and governance across the whole organisation. It is important however that this partnership working transcends the NHS 111 and OOH service and that this integration in terms of working together for the benefit of patients and to ensure good clinical governance across the whole patient journey. A key function of Clinical Governance and Operations Group is to consider how the Integrated NHS 111 and Primary Care OOH Service performs as part of the wider urgent care pathway. Where possible therefore the whole patient journey/experience will be reviewed. The group will co-opt in other providers and health care professionals when specific areas not covered by the core membership are being explored (e.g. Mental Health Crisis Teams, Midwifery, Paediatrics) It is expected that GP s and 999 Provider (EEAST) will be part of the core membership. End-to-end call reviews are part of the responsibility of this group and will be reported to this group (or undertaken as part of the work of this group). The Group is chaired by the NHS 111 and OOH Clinical Lead for Norwich CCG as coordinating commissioner. The group will: Review and manage operational progress made by the service provider and stakeholders (e.g. KPI s, activity management, interoperability and information management). Provide overarching Clinical Governance (CG) partnership forum for discussion, resolution, learning and trend analysis of the Norfolk and Wisbech Integrated NHS 111 and Primary Care OOH Service (e.g. audit, HPF management, CGI analysis) Ensure the service adheres to the level of clinical governance standards required Be responsible for DoS management and development 8

4.3 Terms of reference of the Integrated NHS 111 and Primary Care OOH Clinical Governance and Operations Group These are included in draft at appendix 5 4.4 Reporting and accountability of the Integrated NHS 111 and Primary Care OOH Service 4.4.1 The review of End to End calls will be carried out monthly. They will review calls from the service, the disposition and the onward treatment of that patient. Calls are chosen from HPF, Complaints and other call types as directed by the Clinical Governance and Operations Group. There will be a formal record of calls reviewed and actions required that will be followed up as part of the meetings. 4.4.2 The Clinical Governance and Operations Group meets monthly to manage operational and clinical governance issues and to review reporting from the service covering clinical risk, system impact, performance for other health care services (e.g. EEAST 999 service or acute hospitals) disposition analysis, audit, summary of DoS, trend analysis around HPF and Complaints, This group will ensure that it provides a written report for the Patient Safety and Quality Committee that will include details from the Call Review Sessions 4.4.3 The Norfolk and Wisbech (excluding Great Yarmouth) Integrated NHS 111 and Primary Care OOH Service Programme Board was set up to oversee the successful mobilisation and implementation of the new Integrated NHS 111 and Primary Care OOH Service and consequent demobilisation of the services provided by EEAST, HUC and UCC. The Programme Board Meets monthly and is led by the SRO (see Appendix 10 for ToR). The remit of this board was to safely procure, mobilise and implement the new Integrated NHS 111 and Primary Care OOH Service. It is anticipated that this board will continue to be in place for a short time to ensure that the service is fully stable and handed over to BAU in terms of Quality and Contract management 4.4.4 The National NHS 111 Programme Board receives monthly to look at provision of NHS 111 nationally to look at clinical safety, effectiveness and governance and includes review of Directory of Services. 4.4.5 The National NHS 111 Clinical Governance Group The Regional NHS 111 Clinical Lead for this area and attends this meeting to represent amongst other areas Norfolk and Wisbech NHS 111 Clinical Lead will provide a written report every 6 weeks to the regional lead to apprise him of the status of the Norfolk and Wisbech NHS 111.The RCL will use this report to update nationally on the status of Norfolk and Wisbech NHS 111 Service. 4.5 Responsibilities for safe governance of the service The provider (IC24) are clearly responsible for the provision of a safe and clinically effective service but will be held to account to do this by the commissioners of the service. In order to hold the provider to account the commissioner will have appropriate checks and balances in place to assure them that the service is a) safe and ready to go live and then b) to continue to be assured of the safety and quality of services provided 9

The group also has responsibility to ensure that any learning from incidents, serious incidents, complaints or feedback is appropriately shared so that likelihood of recurrence is reduced. This will involve at times sharing this detail anonymously internally and externally even nationally if required IC24 both also have to adhere to the Duty of Candour and have demonstrated their policies and processes that reflect this 4.6 Dealing with Incidents, Serious Incidents (SI s), Complaints and Feedback Overview Serious incidents, complaints or issues raised by healthcare professionals should be managed through the relevant process. Complaints and incidents may be highlighted by an organisation that did not provide the aspect of care where the incident occurred. The management of Incidents and Complaints is primarily the responsibility of the organisations in which the incident has occurred and therefore a robust mechanism for receiving complaints reports of incidents (including those where the complaint is not primarily the concern of the receiving organisation) is required. These need to be logged in a transparent and open way using a system that is capable of holding this information and reporting on them and then responded to in a time appropriate to the priority of the issue. The commissioning Clinical Lead must be made aware of all feedback, complaints through an agreed reporting process. SI s will be reported to the commissioner and the Clinical Lead at the earliest opportunity. <Flow chart will be inserted here when finalised at CG group 24.07.2015> 4.7 Serious Incidents A serious incident (SI) can be defined as any event that causes, or has the potential to cause, a serious damage or loss, injury, mental trauma, or unexpected death, or where there could be external agency involvement, major litigation and or media interest. When an incident, feedback or complaint is raised and assessment should be done to assess if this can/should be categorised as an SI s in line with National guidelines for SI s as described in CCG and provider policies. If an SI is raised the coordinating commissioner and Clinical Lead must be informed at the earliest opportunity as well as putting in to motion the full SI process NEL CSU administers the SI process on behalf of the CCG s. Where the SI does involve NHS 111 the NHS 111 SI process will also be initiated in addition and linked to the SI process already in place for the service provider involved. Wider learning from SI s is described in the work of the Clinical Governance and Operations Group later in the document See Appendix 10 and 11 for SI policies Summary of Reporting Requirements Severity level Frequency of reporting required (note: day = working days) 10

Grade 0 Incident form then further information within 3 working days Level 1 Level 2 Incident form then 7 day update report then 45 (working) day investigation report with action plan Notification to Norwich Clinical Commissioning Group ASAP and Incident form within 24 hours, then 72 hour update report, then 7- day update report then 60 (working) day* investigation report with action plan SI Process <Workflow to be inserted here> 4.8 Dealing with complaints A complaint is critical feedback and an expression of dissatisfaction from a service user. This service user could be a patient, a patient s representative or a healthcare professional. A complaint relating to the service may be made at a number of different locations, e.g. A&E, a Pharmacy, or a GP Surgery including the service being complained about. All CCGs websites give clear instructions on how to make a comment or complaint as does the website of the service provider IC24. Patient leaflets are also available. CCG complaints are managed via NEL CSU and will be directed to NEL via (email address). All complaints will be managed according to CCG and Provider policies which have been reviewed to ensure they are aligned. This includes assigning lead responsibilities and timelines for responses e.g. acknowledgement within 3 working days and final response within a reasonable timescale agreed with the complainant. All compliments, complaints, incidents, feedbacks and SI s are reported to the CCG s Individual Quality Committees. <Complaints workflow to be inserted here> See appendix 21 and 22 for details of provider and CCG Complaints Policy: Complaints received by the CCG will be sent to the NHS 111 and Primary Care OOH clinical lead, who will handle in accordance with their policy. Complaints may also be received from other NHS 111 providers. These should be investigated and dealt with as normal if the patient is from the area. If the patient is from outside the area the provider will need to liaise with the appropriate CCG in regards to this and this will not be the responsibility of the local CCGs 4.9 Investigating issues and sharing learning with partner organisations All incidents, feedback, complaints and SIs are opportunities to review processes and systems and learn from them organisationally and even nationally. IC24 will provide monthly reports that will detail compliments, HPF s, incidents, serious incidents and complaints and how they were resolved. These are reviewed and discussed in the Clinical Governance and Operations Group meetings with relevant partner stakeholders and learning/development points taken on board. Where the group feels the learning will 11

enhance the service these changes will be embedded within the service model. Any national learning will be fed back through agreed national processes Scheduled end-to-end service reviews will focus on issues identified from HPF s incidents and complaints or areas where it is felt the overall patient pathway can be improved. Health Care Professionals will be invited to be involved e.g. Mental Health Crisis team to review calls from Patients with acute mental health issues to improve access via NHS 111 and DoS to crisis team. These follow the same review process detailed above. 5. Special Patient Notes/Share My Care (SMC) 5.1 Requirement The term Special Patient Note is used to describe information recorded about patients with complex healthcare needs who may be at risk to themselves or others, or who cannot safely manage their healthcare themselves. SPN s have usually been created by the patient s own Primary Care Provider to provide some continuity of care between providers especially in the OOHs environment. Summary Care Records (SCR) and the Enhanced SCR is helping to improve availability of patient information to relevant care providers but it is not a complete solution. Call handlers taking the initial call need to be able to quickly determine if a particular patient has a specific care plan in place so that they know before launching module 0 something different needs to happen with this patient. In many cases where patients have a long term condition or end of life care plan in place an assessment using module 0 would result in an inappropriate ambulance dispatch. SMC provides a locally owned special patient notes system that can hold anticipatory care plans and end of life instructions that can be viewed by all clinicians involved in a patient s care enabling continuity of care for patients delivered by a highly skilled and informed workforce. SMC has been adopted by the Pilgrims Hospice and is used as their End of Life (EoL) register An explanation of Share My Care and user guides can be found in Appendix 25 and 26 5.2 Administration of Share My Care notes Full user guides are available to support the practices in administering ShareMyCare and these are being shared now and support offered to practices to understand the processes. The user guides can be found in Appendix 26 6. Integrated NHS 111 and Primary Care OOH Service Resilience 6.1 Resilience plans in place for the NHS 111 service IC24 as a provider of NHS 111 services ensure that service reliance and the service has planned the appropriate systems are in place to safeguard patient safety and service quality. Business continuity is a core component of risk management and the emergency planning and resilience needed for a service such as this is vital to minimise interruptions to the service. Interruptions to NHS 111 service provision will have an immediate knock on effect to the other health services such as 999 and ED therefore the service must be maintained. The CCG evaluation team and subsequently the IM&T work-stream lead, Operational Lead and Programme Lead have reviewed IC24 Business Resilience around the NHS 111 service and are satisfied it meets the requirements. 12

Additionally all resilience and backup process are scheduled to be thoroughly tested through the mobilisation period in assessing the services readiness to go live. Enough time has been built into this schedule to allow for remedial actions to be taken should these be required. A desktop exercise to test the people component of these processes is scheduled to be held on the 29 th July 2015 again leaving enough time for remedial actions to be taken if issues are identified. These back-up systems are scheduled to be checked regularly throughout the life of this contract. IC24 have local business continuity provided by having 3 separate contact centres that can all deal with all NHS 111 services they deliver. Therefore if the Norwich contact centre is not available for any reason the calls will route through to and be picked up by the Ipswich and Ashford contact centres DOS failure The Call Advisors will be notified of the DOS failure and this will affect the ITK and the ability to transfer patient details to the most appropriate settings of care. In this situation the clinical supervisor on duty will inform all the staff to inform the callers that a referral will be made and they will be contacted with confirmation. The Dispatch Controller will activate the manual DOS in CLEO (Patient Management System) and will complete the referrals through secondary community channels such as safe haven faxing. Unanticipated Staff Shortage or Peaks in Demand Within IC24 s service model there is a service dispatcher who will proactively review real time demand on the service and staffing requirements to enable proactive, responsive management. These staff receive advanced training in managing all our systems and in disaster and contingency management at each alert level. In the instance where there is an increase in demand or staff shortages the following actions are taken: Use assignments to add additional short term Call Advisor capacity to the affected service Clinical skill sets assign to frontline duties Review all off line activity and cancel, bringing staff back on line where appropriate All suitably trained first line managers & learning and development teams to be allocated to front line duties, whilst ensuring adequate supervision for the increased staff All short notice annual leave and TOIL to be cancelled Routine call reviews postponed Break management reviewed Appropriately trained bank and agency staff called in Front line staff approached and asked to extend their shift if appropriate Dependent on the duration, front line staff may be approached and asked to extend the length of their shift, or contacted at home via the cascade process and asked to attend for their shift early On call Director informed of increased call demand and actions taken On call Director to establish communications with commissioner s appointed person as appropriate If disruption is greater than 24 hours, IC24 will make additional necessary arrangements across its 111 estate to ensure continued availability of the 111 service. Industrial Action 13

IC24 is a non-unionised organisation. However they do work closely with key stakeholders who can be affected by industrial action to ensure that we are aware of any planed action (NB this will also apply to OOH in the section below). Pandemic flu or other major incident As a NHS 111 provider IC24 are prepared for pandemic flu and have the NHS Pathways dealing with pandemic flu in place. National NHS 111 Resilience Nationally there is an element of resilience in that a proportion of all calls in normal operations are distributed to out of area NHS 111 providers are required to be able to respond to these calls by providing appropriate assessment, interrogating the DoS and providing an appropriate outcome for the patient including where it is necessary autodispatch of an ambulance. Because of this other providers are able to deal with out of area calls in the event of an emergency where calls may need to be distributed nationally for a time in response to an unexpected emergency. This contingency can only be invoked by the National NHS 111 team. 6.2 Resilience plans in place for the Primary Care OOH Service Loss of base IC24 will deliver the OOH service from eight bases dispersed across the Norfolk and Wisbech area. Through IC24 s relationships with two GP Federations Iceni and Norwich Practices Ltd they will identify beta sites that can be used in emergency situations. Where a service has to be delivered from alternative bases they will have a robust communication and escalation plan that ensures that the NHS 111 Call Advisors are providing accurate information to the patients. Pandemic Flu and Other Major Incidents As a provider of OOH primary care IC24 are members of Resilience fora and work closely with the Heads of Emergency preparedness response and Business Continuity within the Public Health departments of the county councils. This ensures IC24 can provide a whole system response to business continuity. For example; Working with In-hours services identifying at risk patients in adverse weather: Review demand, pressures and service response across the whole system; o Fully contribute mass casualties, evacuation and emergency response/recovery plans. 6.3 Reporting of contingency usage and mitigating action plans Should a contingency be invoked the provider will alert the commissioners including the Clinical Lead. In accordance with contractual requirements an exception may be required dependent on level of contingency used or the impact it has on quality or performance 6.4 Resilience of the clinical governance regime itself The clinical governance group is made up of Clinical Leads and Clinical Quality Leads from all areas along with the providers clinical leads. Commitment is being sought from the CCGs to support the clinicians in this and it is felt that with all CCGs involved the group is robust and has resilience to accommodate short term absence however this will remain under review and will be escalated if there are any issues 7. Clinical engagement 14

7.1 Clinicians engaged in the development of the Integrated NHS 111 and Primary Care OOH Service. Communication and Engagement has been completed, through meetings and workshops involving a number of stakeholders. Commissioners and the incoming provider have been equally involved in this engagement process and to an extent the incoming provider has been encouraged to forge ahead with this engagement arranging meetings themselves and being proactive in this area Stakeholders include: Norwich CCG (Coordinating Commissioner) Dr Victoria Stanley South Norfolk CCG Dr Keeva Rogers North Norfolk CCG Dr Penny Ayling West Norfolk CCG Dr Imran Ahmed Wisbech LCG Dr Andrew Wordsworth East of England Ambulance Service Trust incumbent provider of NHS 111 and OOH in Norfolk East of England Ambulance Service Trust as 999 service provider UCC OOH Provider in Wisbech HUC NHS 111 provider in Wisbech Cambridgeshire Community services (Community Services Luton) Norfolk & Suffolk Foundation Trust Norfolk & Waveney LMC Health Watch Communications leads Patient Safety and Quality leads across all areas The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust Norfolk and Norwich University Hospitals NHS Foundation Trust Norwich and Central Norfolk Mind Norfolk County Council FutureEast Voluntary Norfolk Health & Wellbeing Boards West Norfolk Voluntary & Community Action Norfolk Drug & Alcohol Partnership Age UK Norfolk Norfolk Safeguarding Adults Board Social Care Patient involvement groups Community Trust Norfolk Community Health & Care NHS Trust Mental Health Trust - Norfolk Community Health & Care NHS Trust 7.2 Engagement activities planned post launch IC24 representatives will be engaged at all SRGs and other local strategic fora to enable them to be a responsive provider and seen as part of the solution. IC24 have a local management and clinical team who will be leading communications supported by a Norfolk Communications Officer. 8. Health professional feedback process 15

8.1 Health professional feedback form and reporting (QIR) Health Professional Feedback (HPF) is an accolade, comment, observation complaint or suggestion from another health professional. In the Norfolk and Wisbech area these are commonly referred to as Quality Incident Reviews (QIR) and we are proposing that we continue to use this established process. Health professionals are encouraged to provide feedback on their experience of the Integrated NHS 111 and Primary Care OOH Service delivery, especially where they identify areas where the service can be improved. The forms will be available on both CCG websites, the provider website. They will be shared with all stakeholders and available to call centre and OOH staff should a healthcare professional call in with feedback to the service. 8.2 How feedback will be used Issues raised under an HPF will be acknowledged and shared with the Clinical leads as detailed in the above diagram. The HPF s will be categorised using DATIX and where they are of a medium or high risk will be reviewed personally by the clinical lead. This approach will enable further discussion with the healthcare professional and is a further opportunity for clinical engagement. Issues and concerns raised by the HPF s will be considered as a standing agenda item for the Clinical Governance and Operations Group in terms of future learning and/or actions to amend current processes. Where required issues may be escalated for discussion with the provider within contract management meetings. The group anticipate that the initial numbers of HPF s (QIR s) received will be higher and more frequent within the first 3 months of launch while the service is embedding. Close attention to these will demonstrate the willingness of the service to receive feedback and encourage on-going use of this process in the future. 8.3 How the service will respond to issues that have been raised Once the HPF has been received and acknowledged the HPF risk/issue is considered using the DATIX risk matrix. Experience shows that a number of HPF s are for operational reasons e.g. wrong patient telephone number/address but there are a number of HPF s that are of a higher clinical nature and it is important to be able to identify these easily. All HPF s are investigated regardless of level of risk. It is anticipated that in all cases the outcome/resolution will be made to the originator within a maximum of 21 days. All HPF s will be reported and monitored by the Clinical Governance and Operations Group through trend analysis 8.4 Encouraging feedback in the early days after launch of the new service Through regular communications and the wide dissemination of the HPF s to all stakeholders the aim is to encourage the feedback, both positive and negative, to support the smooth transition of the service from incumbent provider to new provider and also the ongoing development of the service. Healthcare professionals will only continue to feedback and engage with this process if they feel they have a voice that is listened to, acknowledged and acted upon where appropriate. The service will therefore ensure that where an HPF has been received and has identified a gap/weakness the required measures are taken to address this and very importantly are communicated as widely as possible to encourage further regular feedback. 16

This message will continue to be given and all stakeholders will be asked to encourage staff in their respective organisations to provide feedback. 9. Clinical data 9.1 Agreements in place for sharing clinical data IM&T systems issues and Information Governance requirements are identified and addressed through the appropriate governance structures in line with guidance received for the Integrated NHS 111 and Primary Care OOH Service. Each provider organisation has signed an information sharing agreement, which will be monitored by the CCG Information Governance support which is provided by NEL CSU. The CCGs work within the National Information Governance Framework and Caldicott, ensuring all requirements of information governance are met within the organisations. The named leads are included in the contract between IC24 and the CCGs. 9.2 Clinical and operational data to be used by the clinical governance group The data set is being agreed to accommodate the requirements across this integrated Service. The agreed reporting template will be included in this document when finalised on 24.07.2015 9.3 Report format and frequency The Clinical governance data pack is produced monthly and covers the following areas as detailed above: a) Operational data b) Clinical data An example report is shown in <a link will be inserted here when final> During launch and for the first 7 days of operation the Clinical Lead will join the programme group and chair the daily sit rep call. A summary of these calls will be fed back to the OCGG during initial meetings and the summary operational and Clinical data will be reported weekly for the first 4 weeks of the service. In addition to this the group will see reports on any SI when it has been closed 9.4 Reviewing the data the group receives The monthly reports are circulated to the Clinical Governance and Operations Group a week in advance of the meeting and will be reviewed by the group. The Clinical Governance and Operations Group will review for overall activity in Operational and clinical data and through effective monitoring may highlight service provision gaps/duplication/missing services to feed into the commissioning cycle and the redesign of services and clinical pathways Realistically it is anticipated that three months of data should be available and assessed before a view can be taken if the data is enough or too much to satisfy the requirements of the group and should be reviewed at this time. This should remain under regular review to ensure that data continues to inform commissioners, providers and users of the service insight into the service quality and performance. 17

There will be separate Contract management group responsible for the formal contract and performance management of the service. 10. Staff and patient experience 10.1 Patient experience of the service There are a number of ways that we will gain feedback from patients experience of the service: Patient feedback: IC24 will periodically survey, at least quarterly, a random sample of 2% all calls received and in line with the contract review - see Appendix 20. This information will also be reviewed within the contract review meeting to ensure quality of service is measured and monitored Clinical Governance and Operations Group: A monthly review of complaints, compliments and incidents focussing on impact on the patient pathway. This will include robust risk assessment and management. Representation: There is a patient representative included in the membership of the Clinical Governance and Operations Group. Friends and family test will be incorporated into all patient satisfaction surveys Working with statutory organisations such as Healthwatch Presentations to PPG s for practices within the commissioned areas 10.2 Staff experience of the service IC24 undertakes annual staff survey for its entire workforce. This is part of the national staff survey process and forms part of national benchmarking monitoring. Staff will be encouraged to feedback their experiences on a daily basis to the Shift Lead. Staff will also be asked to undertake a simple quarterly staff survey to record their experience, training and levels of satisfaction in the daily working routine. To enhance the staff feedback process IC24 have suggestion boxes within all their working environments and have an open door policy across all levels of management. There will also be local monitoring of the staff experience via existing partner organisation procedures including: Health Advisor audit Incident reporting process and HPF Individual performance review NHS Pathways clinical supervision and mentoring Staff forums and other existing feedback routes Stakeholder Management KPI The Clinical Governance and Operations Group, through the inclusion on its monthly meeting agenda, will seek ways to expand Clinical Engagement (e.g. through use of Clinical Forums, 360 degree appraisal of Service, compiling and distribution of data, etc). 10.3 Using staff and patient experience information to improve the service All patient and staff experience information will be reported in to the Clinical Governance and Operations Group and where it involves NHS 111 the National 111 Programme Board when appropriate to do so to ensure national learning. Similarly learning regards OOH service will be communicated through to GP s and other GP services using appropriate forums where this is identified as required. 18

10.4 Reporting Information to the Clinical Governance and Operations Group The provider will submit a monthly report to the Clinical Governance and Operations Group in line with the overall governance diagram detailed in section 4 <example report to be inserted here> 10.5 Gathering feedback in the early days of the service During go-live staff will be encouraged to feedback their experiences on a daily basis to their line managers. This will be recorded on the Shift Manager Report and summarised for inclusion in the daily/weekly SITREP process and to the NHS 111 and Primary Care OOH Contract Manager through their daily contacts with the provider. In addition IC24 utilise the survey monkey website to encourage staff to feedback in real time. HPF s are also being encouraged to feedback experiences as described in the HPF section 9.4 11. Clinical decision support system and DOS 11.1 NHS Pathways NHS Pathways is an assessment system for triaging telephone calls from the public, based on the symptoms they report when they call. It is integrated with the Pathways Directory of Services, which identifies appropriate services for the patient s care if an ambulance is not required. NHS Pathways is under constant review and direction the independent National Clinical Governance Group and is supported by Royal Colleges. NHS Pathways is a tried and tested system in wide use across the NHS. 11.2 Population of DoS The Directory of Services (DoS) is a central directory - which is integrated with NHS Pathways and provides the call handler with real time information about services available to support a particular patient. The population of the DoS is co-ordinated by the local DoS Manager and there is a Standard Operating Practice (SOP) in place to support this see appendix 20 The comprehensive DoS covers health and social care services in the Norfolk and Wisbech areas. The DoS underpins the delivery of the NHS 111 service, and service information is to be kept up to date and maintained in line with NHS Pathways releases and service developments. Dedicated resource will be identified to ensure that information is extracted from the DoS to support commissioning intelligence and to action changes to the DoS as a result. The DoS Project Manager coordinates DoS population, clinical validation, development and clinical sign-off. Each CCG and Wisbech LCG has a clinical lead in place who takes responsibility for the clinical sign off the Dos in their respective areas. There are close working links with the national Pathways / DoS teams and other DoS managers. The DoS Manager attends the Regional DoS leads meetings which feed into the national NHS 111 Clinical Governance meetings. The DoS manager attends the Clinical Governance and Operations Group and provides monthly progress reports regards the DoS 19

11.3 Going Live and DoS sign off process The DoS is already up and running as NHS 111 is already operating however changes are required when the services transition to the new provider on 1 st September 2015. In readiness of this Clinical Leads, the DoS manager and the incoming provider have worked together to validate the DoS and look for any gaps and opportunities to improve outcomes. IC24 have met with a number of other providers and CCGs to ensure that where possible the DoS reflects the availability of services and that where appropriate local area pathways are agreed and embedded in the DoS or in CLEO. The ultimate sign off if the DoS for Go Live will be given by the Integrated NHS 111 and Primary Care OOH Clinical Lead. In line with updates to Pathways system, the DoS has been updated to Version 3.2, or the latest applicable service. The process for updating is to initially ensure clinical sign-off by clinical leads, and then work with individual providers to ensure service profiles properly reflect the work of the service. The work of updating is an on-going process as to ensure any national system or local service changes are captured. 11.4 GP and OOH messaging In addition to Demographic and Clinical Details the DoS lists each GP endpoints for electronic messaging. Most GPs messages (PEMs) from NHS111 will now be received through ITK enabled systems as this is now available across the whole footprint. IC24 are working closely with practices to make sure all GP endpoints are in the system on Go Live. In addition IC24 have communicated with Practices to ensure that they do enable the required mechanisms within their systems to receive messaging from both the NHS 111 and OOH elements of the service. The systems within IC24 send an automated post event message 30 minutes on closing the patient traction. 12. Call advisors and clinicians working in the Integrated NHS 111 and Primary Care OOH service 12.1 Recruitment, selection and training of staff IC24 already operate the NHS 111 and OOH services on behalf of a number of other CCG s and therefore have an ongoing systematic recruitment plan. This has been adjusted to take into account the Norfolk and Wisbech service. The Norfolk and Wisbech NHS 111 service calls will be handled, predominantly in Norwich but with the ability to handle calls also at Ipswich and Ashworth contact centres to provide greater resilience. IC24 have used existing agreed models to calculate additional required capacity and staff have been recruited along with additional staff lost through natural attrition and this modelling has been further reviewed and validated at CCG level. All staff receive a robust training programme and competency assessments in relation to their role. This includes both system training such as NHS Pathways where relevant and enhanced training and CPD as relevant to their role. IC24 have a training team who are supported by the HR department to ensure that training, education and learning is continued through a career within IC24. 111 staff 20