Appendix 5.5 MEETING: Haringey Clinical Commissioning Group Governing Body Meeting DATE Wednesday, 30 July 2014 TITLE: North Central London (NCL) NHS 111 and GP Out of Hours LEAD GOVERNING Jill Shattock, Director of Commissioning BODY MEMBER AUTHOR & POSITION: Jill Shattock, Director of Commissioning CONTACT DETAILS: Jill.Shattock@haringeyccg.nhs.uk SUMMARY: NHS 111 is a telephone and internet service our patients can access when they need medical help or advice, but when it is not a 999 emergency. It has been in place within North Central London (NCL) for just over a year; commencing in April 2013, with the current contract coming to an end in March 2015. The current GP Out of Hours (OoH) service contract is also due to end in March 2015 which presents an ideal opportunity to review both the services and seek to develop a new more streamlined service model. Recent evaluations across England have highlighted substantial duplication between these two services. The 5 CCGs across North Central London have been working together to look at options to reduce duplication between the two services, ensuring that people with urgent care needs are given the right advice in the right place, first time. This report presents a range of options for Haringey CCG to consider when looking at the future provision of NHS 111 and GP Out of Hours services locally. The options presented aim to drive forward our CCG vision for integrating services, making the care provided more efficient and more effective whilst offering greater value. SUPPORTING PAPERS: None RECOMMENDED ACTION: The Governing Body is asked to; NOTE the contents of this report SUPPORT the recommendations detailed below
Objective(s) / Plans supported by this paper: A global transformation of services and service providers A greater range as well as more integration of providers Patient and Public Involvement (PPI): Draft Communications and Engagement Plan in place. Full engagement process to be led by the programme Communications and Engagement Working Group. Equality Impact Analysis: To be completed with full business case. Risks: Slippage in the national NHS 111 programme (Publication of Commissioning Standards for NHS 111) could affect the timescale for local implementation of the service. Resource Implications: The development of the service specification and business case for the combined service has been confirmed as a collaborative priority by all 5 CCG s in North Central London. Audit Trail: The report has been developed by the monthly North Central London Unscheduled Care Commissioning Group. The group has an appointed SRO Chief Officer, NHS Enfield CCG Next Steps: Development of the full service specification and business case for a North Central London NHS 111 and GP Out of Hours service. 2
North Central London NHS 111 and Out of Hours Service 1. EXECUTIVE SUMMARY The urgent and emergency care system is under pressure and there is local agreement that the system needs to respond to the significant challenges it is facing. The recent Emergency and Urgent Care Review report by Sir Bruce Keogh has highlighted that the majority of patients seeking care in A&E departments could be better cared for closer to home. Approximately 40% of patients seeking care at A&E are discharged without treatment and there were over 1 million avoidable emergency hospital admissions in England last year. These numbers suggest that change is needed in the way urgent care services are organised and delivered to provide patients with better quality of care in a more appropriate care setting away from an acute hospital. The wide variety of urgent care services and the lack of clarity on what each service can treat, causes a lot of confusion. It therefore seems inevitable that patients will often choose to attend A&E when they have an urgent care need, because they know what to expect from this service. This confusion over where urgent care can be sought is not helpful to patients, healthcare professionals, providers or commissioners. If patients are to be supported in making the right decision, first time, there needs to be clarity and simplicity in the urgent care system and this will require a streamlining of urgent care services. One of the key aims of NHS 111 is to make it easier for patients and the public to access urgent healthcare and drive improvements in the way the NHS delivers that care. One of the key recommendations in the Emergency and Urgent Care Review Report is ensuring that people with urgent care needs are given the right advice in the right place, first time to ensure they then seek care in the setting most appropriate for their needs, rather than defaulting to A&E. To achieve this, the report recommends that NHS 111 is enhanced and marketed as the smart call to make, creating a 24 hour personalised priority contact point. The report also notes the benefits of NHS 111 being at the heart of an integrated care network. The Five Borough Unscheduled Care Commissioning Group wants to build on these recommendations in commissioning an integrated NHS 111 and GP Out of Hours (OOH) service, delivered by a single provider, to create a more streamlined service giving advice to patients on where to access urgent care in times of crisis. The integration of NHS 111 and OOH is a recommended service model in the NHS 111 London Learning Programme report for helping to respond to these challenges, and the main paper 1 seeks to build the case for an integrated, single provider model for NHS 111 and OOH across the 5 CCGs of North Central London (NCL), and following a review of the evidence the Governing Body is asked to approve the recommended development of an integrated single provider service model between out of hours and NHS 111 in NCL. 1 North Central London NHS 111 and Out of Hours report. The case for an integrated NHS 111 and Out of Hours Service across North Central London 3
2. Options Appraisal on the future of unscheduled care The five CCGs in NCL are undertaking a review of unscheduled care across the patch. As part of this work the options for the future model of unscheduled care are being considered. Seven options have been identified and are listed below: 1. Do nothing and extend current contract arrangements; 2. Commission one system across the 5 CCGs for all three urgent care services e.g. NHS 111, OOH and Urgent Care Centres; 3. Commission one system across the 5 CCGs for NHS 111 and OOH only; 4. Commission one system across the 5 CCGs for UCC provision only 5. Commission one system for urgent care services for Barnet, Enfield and Haringey and one provider for urgent care services for Camden and Islington; 6. Commission one system for NHS 111 and OOH for Barnet, Enfield and Haringey and one provider for NHS 111 and OOH for Camden and Islington; and 7. Each borough to commission all urgent care services individually. The Five Borough Unscheduled Care Commissioning Group considered each option in turn with their respective advantages and disadvantages. The group identified option three as the most viable with the possibility of integrating urgent care centres into the model (option two) at a future date. This would entail one commissioning process with one specification, albeit there may be local elements to the specification which might vary from borough to borough. The next step in this process is to develop the preferred option, including finance and activity modelling to be included in a detailed business case for presentation to each CCG governing body. 3. Benefits of an integrated single model for OOH s and 111 Integration between NHS 111 and OOHs is created by a single organisation providing both services; this could also be achieved via the lead provider model. This has many benefits from both an operational and clinical standpoint and to enhance the patient experience. The NHS 111 London Learning Programme has reviewed the various operating models in use across London, from full or partial integration to stand-alone urgent care service and stand-alone NHS 111 services. Though the programme requires further research and analysis to be conducted before recommending the optimum model, the findings to date suggest that the integration of NHS 111 and OOH derives the greatest benefits from an operational and clinical standpoint. This is due to the fact that approximately 35% of calls across London receive an OOH disposition at the end of their assessment. In NCL approximately 47% of calls to the local NHS 111 provider are referred on to OOH service providers across the country. The proportion of calls to the local OOH providers, Harmoni and Barndoc, are 13% and 27% respectively. In other areas of the London, where the OOH and NHS 111 are delivered by the same provider, there are demonstrable operational benefits. This includes Outer North East London where the Partnership of East London Cooperatives (PELC) is the provider and Inner North West London where LCW are the provider. The patient journey is streamlined with call operators able to book patients directly into the OOHs service, a noted core requirement in an NHS 111 service model. The hand-off can be smoother and better communicated to the patient and the staff, thereby decreasing the risk of the patient being bounced around the system, and also leading to increased patient 4
compliance with a direct booking. Due to integrated systems and audits the patient journey is easier to track through the two services and this can lead to improvements, efficiencies and innovations. 4. Improved efficiencies Integration under a single system allows for economies of scale, with both services sharing the cost of the management and administration and back office functions such as estates, IT, telephony and facilities. The integrated model also has more flexibility to respond to service challenges, utilising the combined internal resources in times of surge to ensure the services performance are not undermined. The provider will also have more resilience to be able to adapt to service changes and development over the course of the contract. In drafting the national service specification for NHS 111 the NHS England team want to ensure that the service is commissioned in a way that will allow it to continually adapt to new developments. These efficiency savings are good for both the provider of the services and the commissioners. As local services develop in the future, there may be reason to move some activity away from one of the services, and a large single provider would be more resilient to these kinds of changes and less likely to be destabilised as a result. 5. Service model and specification A full service specification will be developed for a combined service model, taking into account advice gleaned via the NHS 111 London Learning Programme and core standards that will be produced. With both services (111 and OOHs) potentially being provided by one organisation, tracking the patient journey through the OOH system will be streamlined and service utilisation information will aid better understanding of population needs, immediate outcomes and cost effectiveness of the system. The sharing of information can be facilitated with ease when both services are provided by one organisation and the sharing of patient information, such as Special Patient Notes (SPNs), held by the out of hours provider, is more easily achieved. The sharing of patient records will be a core requirement of the new NHS 111 service model 2. 6. Governance Over the length of the programme there would need to be an over-arching programme board and working groups for Procurement and Contracting, Clinical Governance, Data and Analytics and Communications and Engagement. During the mobilisation phase further working groups would need to be organised to look at specific areas such as telephony, technology, operations and the DoS. A potential structure is shown below: 2 NHS 111 Commissioning Standards (draft) v0.3, section 3.1, page 11. 5
To ensure robust oversight and management of the programme it is recommended that membership of the programme board includes the following representatives: Senior Responsible Officer (SRO) for the programme; CCG Clinical Leads for unscheduled care; NHS 111 Clinical Lead; Senior Commissioning leads; Contract and Performance Managers; Communications Lead; Programme Director; Programme Manager; Patient representative; and Provider (once appointed). The above proposed programme structure would ensure sufficient support for each area of the programme while creating a streamlined reporting process. 7. Contracting and Procurement There are a number of procurement options available to us as commissioners. The NEL CSU Clinical Procurement Team will provide technical advice on the most appropriate option. Contracting options need to be flexible enough to allow local providers to work at scale, potentially with larger, more robust providers. The model/contracting solution may take various forms, however the diagram below sets out the main contracting models along a scale of how formalised and tight the contractual structure for integration is 3 : 3 Contracting for Outcomes A Value Based Approach, Outcomes Based Healthcare, July 2014 6
8. Recommendations There are overwhelming benefits to jointly commissioning an integrated, single system service model incorporating OOH and NHS 111 across North Central London. The recommendation of an integrated, single service provider model between NHS 111 and OOH is the optimum model to deliver the benefits of integrated care. This model would deliver a seamless journey for the patient and access GP advice via the assessment in NHS 111. The model will need to take account of the developing primary care environment with some CCGs planning extended access 8am-8pm seven days a week. This would impact on the service model over time which would need to be flexible to accommodate changes. The recommended model would also provide clarity to the urgent care system in NCL with the new service sitting at the heart of integrated care in the area, directing patients through to the right service, first time. These improvements will enhance the patient experience and could lead to increased patient compliance. The economies of scale that could be delivered by the new service model proposed would also deliver savings to the commissioner through increased efficiencies and innovative working practices by the provider and streamlined management of the contract. To enable the successful delivery of the programme the 5 CCG Governing Bodies are asked to consider the following recommendations: Support Option three - the recommendation for the development of an integrated NHS 111 and OOH provider model. This will allow the 5 North Central London CCGs to begin the development of a detailed service specification and business case and begin engagement with clinicians and patients; Acknowledge that the current model for NHS 111 and GP Out of Hours will require extension to March 2016, to allow additional time to properly implement the new service model. 7