Primary Care Out of Hours Service Review Option Appraisal 4th November Workshop Report

Primary Care Out of Hours Service Review Option Appraisal 4th November 2014 Workshop Report

Primary Care Out of Hours Service Review

Contents 1 Context...4 1.1 Scottish Government s Vision for Health...4 1.2 NHS Lanarkshire s Strategic Health Planning Framework...4 1.3 Primary Care Out-Of-Hours in Lanarkshire...5 1.4 What is Emergency and Urgent Care...6 1.5 Case For Change...7 1.6 NHS Lanarkshire Challenges...8 1.7 National Challenges...8 2 Current Service Background...9 2.1 Summary of Out-Of-Hours Review...9 3 Option Appraisal...11 3.1 Options Appraisal...11 3.2 Benefits Criteria...12 3.3 Ranking and Weighting the Criteria...15 3.4 Summary of the Final Ranking and Weighting...16 4. Workshop Approach and Methodology...17 4.1 Presentations from Key Informants...17 4.2 Scoring Process and Methodology...20 5 Results...22 5.1 Scoring the Service Models...22 5.2 Scoring the Service Configuration...24 5.3 Population Flow Drive Times...25 5.4 Workforce...26 5.5 Supporting Analysis Service Model...27 5.6 Scoring Analysis Service Configuration...27 5.7 Sensitivity Testing...30 6 Evaluation...32 Appendix 1 Participants Briefing Paper for Option Appraisal...34 Appendix 2 Event Programme...37 Appendix 3 & 4 Participants Scoring Sheets AM & PM...38 Appendix 5 Benefits Guide...40 Appendix 6 List of Participants...41 Primary Care Out of Hours Service Review

1. Context 1.1 Scottish Government s Vision for Health The Scottish Government published their 2020 Vision in September 2011. This set out the actions required to achieve sustainable quality in Scotland s Healthcare system. This strategic narrative, which was set out by the Cabinet Secretary for Health, Wellbeing and Cities, provided the context for taking forward the implementation of the Scottish Government s Healthcare Quality Strategy (2010) and the actions required to improve efficiency and achieve financial sustainability. 1.2 NHS Lanarkshire s Strategic Health Planning Framework NHS Lanarkshire developed the framework A Healthier Future published in 2012 to support future strategic health planning and to gain a shared understanding of the actions required to achieve the Scottish Government s 2020 Vision. We have identified strategic aims to achieve this vision, which are set in the context of delivering a healthier future for all from cradle to grave. Transforming Patient Safety and Quality of Care in NHS Lanarkshire, Healthcare Quality Assurance and Improvement Strategy 2014-17 supports the on-going implementation of A Healthier Future with its four strategic aims: 1. To reduce health inequalities and improve health and healthy life expectancy 2. To support people to live independently at home through integrated health and social care working 3. For hospital day case treatment to be the norm, avoiding admissions where possible 4. To improve palliative care and supported end of life services NHS Lanarkshire s quality vision is to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. We are committed to transforming the quality of health care in Lanarkshire to be the safest health and care system in Scotland. We will accomplish our quality vision by: setting and delivering ambitious quality goals to support the provision of high quality services to the people we serve engaging staff, patients and the public to improve our quality of care ensuring that everyone in the organisation understands their accountability for quality and are clear about the standards expected of them, embedding our organisational values of Fairness, Respect, Working Together and Quality 1 http://www.nhslanarkshire.org.uk/boards/2014-board-papers/documents/june/quality-assurance-and-improvement- Strategy-2014-2017--June-2014-Board.pdf 4 Primary Care Out of Hours Service Review

gaining insight and assurance on the quality of our care managing risk to quality 1.3 Primary Care Out of Hours in Lanarkshire The General Medical Services (GMS) contract came into force in April 2004. It gave General Practitioners (GPs) the opportunity to opt out of providing out-of-hours care for their patients. The GMS contract means that NHS Lanarkshire is responsible for ensuring all patients can get out-of-hours care. Each NHS Board in Scotland has developed a service for the people living in their area. This means there is no consistent model or standardised practice for the provision of GP Out-of-Hours Services in Scotland creating a market place that results in competing demands for the available staff and thus each NHS Board area might have a slightly different model of service. NHS Lanarkshire commissioned a comprehensive review of Primary Care Out-of- Hours Services (PC OOHs) in September 2013. A structured programme management and robust service change process to support informed decision making has been objectively facilitated by the Change & Innovation function of NHS Lanarkshire. The process has closely followed the guidance and policy set out below: NHS Boards have a statutory duty to involve patients and the public in the planning and development of health services, and in decisions which will significantly affect the operation of those services. Scottish Government s Guidance sets out how NHS Boards should inform, engage with, and consult their local communities. Involving Patients, Carers and the Public in Option Appraisal for Major Health Service Changes, Scottish Health Council (March 2010) All new policies, programmes and projects, whether revenue, capital or regulatory, should be subject to comprehensive but proportionate assessment, wherever it is practicable, so as best to promote the public interest. Core guidance is contained in The Green Book. The Scottish Health Council is a member of the Review Board and has been in attendance to observe and advise on the process and to conduct an independent evaluation. 2 National Health Service Reform (Scotland) Act 2004, section 7, http://www.opsi.gov.uk/legislation/scotland/acts2004/20040007.htm 3 Informing, Engaging and Consulting People in Developing Health and Community Care Services CEL 4 (2010), Scottish Government 4 Involving Patients, Carers and the Public in Option Appraisal for Major Health Service Changes http://scottishhealthcouncil.org 5 The Green Book - Appraisal and Evaluation in Central Government, HM Treasury available at http://www.hm-treasury.gov.uk/data_greenbook_index.htm Primary Care Out of Hours Service Review 5

Phase 1 (Jan- April 2014) the review board overseen a comprehensive review of the current service including; all activity and demand, workforce capacity and review of the current clinical model with a search and exploration of how GP out-of-hours services are delivered in other NHS Board areas, in the UK and any other evidence to draw on. Throughout phase one extensive communication and engagement was carried out through a range of communication mechanisms to capture the views of staff, service users and the public. Phase one concluded in April 2014 with all information obtained in the diagnostic phase presented to the review board for information and planning of the next phase of work. Working closely with the OOHs staff and review board members a full in-depth analysis provided specific data and rigorous undisputable evidence that reinforced the need to explore options for change and associated improvement to address the increasing patient safety issues emerging as the number of doctors available to work in the service is reducing. 1.4 What is Emergency and Urgent Care There is often confusion about the terminology referred to by service users and providers of urgent and emergency care. Terms such as unscheduled care, unplanned care, emergency care and urgent care are often used interchangeably. Unscheduled care is defined as:...care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is out with the core working period of NHS Scotland. It follows that such demand can occur at any time and that service to meet this demand must be available 24 hours a day. Urgent care is the response before the next in hours or routine (primary care) service is available. The work of the Primary Care Out-of-Hours Review (PC OOHs) review should also been seen in context of allowing the patient to be seen by the right professional in the right place, at the right time. Continuous review and recently published documents which contain quality statements and indicators have contributed to our thinking and planning for future provision of PC OOHs across NHS Lanarkshire. To enable service improvements to go forward agreement must be reached on the best clinical model and service configuration of PC OOHs to ensure the service is above all clinically safe, delivers the most appropriate treatments and interventions, and that support and services will be provided at the right time and in the right place by the right person. The reasons and rationale for the review and the case for change and improvement are set out below. 6 Primary Care Out of Hours Service Review

1.5 Case for Change The current service is under consistent pressure due to the lack of availability of GP s willing to participate in the PC OOHs service. This is exacerbated at holiday periods including summer and during winter with high levels of demand particularly in the busiest centres and at the busiest times. A recent calculation of the number of slots available weekly taking into consideration that the overnight doctors carry out a dual role reported 1474 GP appointments are available however the availability of staff to cover in the areas of highest demand is low and on many occasions can go below core staffing levels. The service demand can go up or down in any given week or month. Frequently the staff availability is extremely unpredictable, therefore the planning can be very reactive with changes to service delivery and locations staff are asked to relocate at short notice which can result in centres being closed to deliver a safe service. The constant unpredictability has an impact on the morale of staff working in the service and creates a constant fragility within the planning of service provision. A recent example (May, 2014) highlighted this fragility as a significant issue and one that impacts on key performance areas such as Out-of-Hours centre appointments breaching the triage time allocated of 1 or 2 hours. In this example people required to be directed to go to an already busy Emergency Department and the 4 hour home visits were under constant assessment resulting in some appointments being allocated 12 hours in advance. The overall activity for this period was comparable to that of previous years however the delays were caused by the shortfall in staffing being insufficient to meet patient demand. This level of demand with limited resources (GP availability) resulted in Business Continuity Plan (BCP) arrangements being put in place to ensure the service could be delivered. Throughout 2014 BCPs have been commonplace, with the service regularly having to operate from three, two or on occasion a single site. This is exemplified in, increased patient safety risks. In recognition of the risk associated with the reduced numbers of doctors available, the NHS Lanarkshire Corporate Risk Register has been updated to include the OOHs service as it currently exists. In recognition of the fragility of the service, the risk level is regularly reviewed and is currently rated as a red risk given the continued shortfall in the numbers of doctors available and the need to regularly invoke BCP arrangements. Primary Care Out of Hours Service Review 7

1.6 NHS Lanarkshire challenges Significant difficulties in maintaining the current service model for the provision of Primary Care Out-Of-Hours services due to the availability of clinicians to cover all shifts in all centres. Covering the Out-Of-Hours service across five centres creates inefficiencies GPs and support staff report a degree of isolation from colleagues at times Activity levels in each centre have differing levels of demand varying from very high to low demand across the OOH spectrum. A reduction in the pool of GP s prepared to work on weekends and public holidays. Changes in GP working practices make it increasingly difficult to recruit GPs to work in the OOH period. A high number of people appear to be using the PC OOH Service as their means of choice to access health care. Current service configuration requires consideration as accommodation is problematic with insufficient space and equipment stored at Law House which is not accessible at weekends. The management team based in Law House work predominately in hours and the HUB where the calls are received operates out-of-hours and is based at Hairmyres. This makes communication and co-ordination challenging. The service has 6 vehicles stored at different locations making cover for breakdown difficult. 1.7 National issues There is a growing concern nationally around the sustainability of PC OOH services in their current form with a number of Boards experiencing problems filling rotas. The lack of a consistent workforce model or pay arrangements for the group of sessional GPs who make up approx 90% of the NHS Lanarkshire OOH workforce. There is no consistent contracted status nationally for sessional GPs, leaving the market open and vulnerable to GP availability to cover the appointment slots. This makes the current arrangements unsustainable and open to further destabilisation without review and redesign. The current HUB accommodation is subject to operational demands requiring relocation and disruption on Public Holidays when GPs are not working and the rest of the NHS is working a normal day. This is also less than ideal when patients are redirected to the temporary centres resulting in the potential for confusion for the public. 8 Primary Care Out of Hours Service Review

2. Current Service Background Primary Care out-of-hours services in Lanarkshire currently include the following: NHS 24 as the national 24-hour phone service on the new number 111, provide a first line assessment, health information and nurse advice through telephone consultations and triage (assessment of how urgent the medical problem is) as an important part of all out-of-hours care. Where necessary, NHS 24 assessment refers onto a local Primary Care OOHs HUB where a home visit, doctor s advice call or an appointment is allocated at one of the current 5 centres either at a core hospital based OOHs centre or within a health centre located in the outlying areas in the community. General Practioners within the Out-of-Hours Service provide an advice service. Face to face consultation by appointment at one of the current 5 centres. Provision of a professional to professional consultation by telephone. A domiciliary service where doctors carry out home visits to people who are too unwell or incapacitated to attend an out of hours centre. Day-to-day management of the service is provided from the base at Law House. The HUB (control centre) is based at Hairmyres Hospital As a result of ever decreasing numbers of GPs available or willing to work in the service Business Continuity Plans (BCP) designed to consolidate resources and mitigate risk have been in place since June 2014. This has resulted in reducing the service to Level 1 BCP consolidating to three centres to manage the demand. On a number of occasions this has been reduced to Level 2 consolidating to two centres where urgent 1hr and 2 hr appointments have been passed to Emergency Departments. Level 3- consolidation to 1 centre. Activated on a number of occasions overnight (impact on home visits) and also on one occasion Sat pm one GP supported by 4 nurse practitioner. 2.1 Summary of Review timeline The review was commissioned in September 2013 and to date has completed the following work. All meetings, events and workshops within the review engage all stakeholders to ensure a representative and truly collaborative output. The output from each meeting event is circulated and distributed widely with a feedback mechanism. Primary Care Out of Hours Service Review 9

Engagement, Involvement and Influencing Stage Phase I Commissioning and Diagnostic Phase I included: Commissioning dedicated and specialist service change and improvement resources Change & Innovation (September 2013) Setting up the Review Board structure and membership - set up phase (October 2013) Strategic Analysis (October 2013-Jan 2014) Diagnostic phase (Jan 2013 April 2014) to assess and review: All aspects of the current service provision The current service by undertaking face-to-face and on-line Communication and Engagement with staff and service users The current clinical and workforce model Phase II Options Development and Appraisal Phase II has included: Undertake Options Development process from scratch to create a Long-List of Options (8 May 2014) Plan, design and carry out an Options Appraisal of Long-List to inform short-listing options (27 June, 2014) Plan, design and carry out an Options Appraisal of Short-List to inform recommendations to the NHS Board (4 November, 2014) Pre Event Briefings All lay representatives who had signed up to the event were invited to a preevent briefing session on Monday 27 th October, 2014 hosted by Kate Bell, Senior Manager Change & Innovation and Calvin Brown, Primary Care Communications Manager. The session was planned to go over the rationale for change, the current service arrangements and the option appraisal pack content. The pack included all strategic background, the case for change, service change methodology and process explanations, scoring methods and process as well as specific guidance on scoring both morning and afternoon sessions. All facilitators were invited and attended a number of sessions leading up to the event to cover all aspects of background, process and methodology. NHS Lanarkshire does not have a dedicated service improvement team to oversee, lead and manage major, complex service change so facilitators from other departments are sourced on a good will and ad-hoc basis. In turn they are briefed on the detailed approach and methodology and asked to be objective in the process. For continuity the same facilitators were engaged in both appraisal events to maximise effort and knowledge and minimise risk of errors in the process. 10 Primary Care Out of Hours Service Review

3. Option Appraisal 3.1 Short-list of Models The output from the first Options Appraisal event (June 27, 2014) created a short-list of models regarding the future service model. At the Review Board meeting on 20 th August a challenging and detailed workplan was set out for the second Option Appraisal (subject of this report). This included scoping out the deliverability of each of the short-listed/viable models and developing geographic locations to appraise the best service configuration for the OOH service in future. Feedback from the event on the 27 th June supported the development of a few givens to be applied across all proposed models: A workforce model to ensure the right levels of staff were available to provide a safe service; All future locations will have the specified capacity to provide fit for purpose accommodation Consideration and research will go into planning the necessary skill mix to enable new ways of working. The four proposed models below were presented to the Programme Board meeting on 20 th October, 2014. Primary Care Out of Hours Service Review 11

Table1. Short List of Options The models selected for in-depth appraisal at the event included a baseline or benchmark option. The status quo model was considered and scored at the event although the current model is not considered to be a viable or deliverable model in future. The purpose of including the Status Quo model was to provide a benchmark so that the value of the alternative models below may be judged by reference to current service provision. Status Quo/Do Minimum The current service would remain the same, working across the Five Primary Care Out-of-Hours centres. 1. One Out-of-Hours Centre for Lanarkshire One Out-of-Hours Primary Care centre consolidating all aspects of the service within one reachable location for the Lanarkshire population. 2. Two Centres: One in North and One in South Lanarkshire Two Out-of-Hours Primary Care centres one North one South Lanarkshire based within a Health Centre environment. 3. Three Primary Care Out-of-Hours Centres based in Community Health Centres Three Primary Care Out-of-Hours centres in community based facilities in locations across Lanarkshire to meet population demand. 4. Three Primary Care Out-of-Hours Centres within the (Acute Hospitals/Emergency Departments) Hospital based Out-of-Hours centres sites working on the current co-location with the District General Hospitals. This final step in the engagement stage of the review has been to carry out an appraisal of all proposed models utilising the benefits criteria below. 3.2 Benefits Criteria The benefits criteria adopted are the six quality dimensions set out below, recognised as key indicators of what quality means in the delivery of services to patients in healthcare settings. These have been utilised by NHS Lanarkshire for many years in service improvement processes. They are adopted from the dimensions of quality established by the Institute of Medicine (2001) and include the Quality ambitions as set out in the Scottish Government s Healthcare Quality Strategy, 2010 and reflected in NHS Lanarkshire s planning framework. Although pre-chosen, the criteria were reviewed (with opportunity for correction or adjustment), discussed and agreed by the Review Board as relevant and sufficiently rigorous to support the right outcome for future provision of PC OOHs service. 12 Primary Care Out of Hours Service Review

Table 2 - Benefits Criteria Quality Attributes Key Features Reduced Clinical Risk and avoiding harm to patients from care that is intended to help them. A safe Primary Care Out-of-hours service would therefore provide: The environment is safe for the patients/staff Staff are appropriately trained to deal with presenting conditions or refer on seamlessly Access to specialist advice is available if required Appropriate facilities are available to meet the urgent care needs of the patient in the out-of-hours period Evidenced based clinical and quality standards are in place to avoid/prevent significant events Increased patient safety is achieved due to team based working Higher number of staff working together in the same place brings improved compliance with governance, greater opportunity for peer support and increased accountability Safe storage, monitoring and supply of medication Service is delivered and monitored against National Clinical Quality Standards for OOH Services. Providing services based on scientific knowledge and best clinical standards and improved quality of Care and outcomes An effective Primary Care Out-of-hours service would therefore provide: Sufficient staff working together in teams to ensure a responsive and flexible service The range of staff with the right skills available to meet all expected urgent clinical conditions A fit for purpose clinical environment to deliver evidence based care Training opportunities are available for the multi-skilled workforce Access to assessment/medication/urgent treatment (where indicated) Structures and mechanisms in place to utilise and deploy staff and resources effectively. Improved linkage with integrated health and social care teams. Greater opportunities for Peer Support within the workplace Primary Care Out of Hours Service Review 13

Quality Attributes Key Features Care is responsive and appropriate to patients needs and patient is included in clinical decisions. A patient-centred Primary Care Out-of-hours service would therefore provide: Improved access to urgent primary care service Support provided through availability of transport where clinical need is established Care is delivered within the timeframe triaged by NHS 24 Will improve the experience of patients and service users Patients are seen by the right person in the right place within the right timeframe Patients are not rushed through consultation and value is placed on the patients views Patients are listen to and treated with respect and dignity Avoidance of waste including energy, supplies, equipment, resources including staff and ensuring a seamless journey through services An efficient Primary Care Out-of-hours service would therefore provide: A service configured to meet evidence based demand Better utilisation of mobile units. (home visiting) The available workforce has a range of knowledge and skills responsive to the urgent care needs of all patient groups Efficient deployment of skills and knowledge Informed deployment of the workforce and resources to allow faster access to assessment, care and treatment. The service is well resourced, financially viable and deliverable 14 Primary Care Out of Hours Service Review

Quality Attributes Key Features Providing care that does not vary in quality because of geography, location or socio-economic status. All patients have access to a range of service provision An equitable Primary Care Out-of-hours service would therefore provide: Access to urgent Primary Care service in the out-of-hours period Access to a workforce who are suitably trained to meet the needs of urgent care, can reduce any risk of harm and manage the care and treatment effectively Access to interpretation services Equitable application of clinical criteria to access transport to support attendance to primary care centre in out-of-hours period. Reduction of harmful delays for those who give and receive care A timely Primary Care Out-of-hours service would ensure: Patients are assessed and treated within the timeframe triaged by NHS 24 i.e. 1hr, 2hr, 4hr Patients are seen at the appointment time given. Sufficient workforce available to ensure timely access to the right person first time. 3.3 Ranking and Weighting the Criteria The weighting and scoring method, is a form of multi-attribute or multi-criterion analysis. This involved identification of all the non-monetary factors (or attributes ) that are relevant to the service change process; the ranking and allocation of weights to each attribute to reflect their relative importance; as it relates to the Out of Hours service change. This is then used at the event to allocate scores to each option to reflect how it performs in relation to each of the benefit criterion The Review Board (29th May 2014) confirmed the list of benefit attributes above and agreed to delegate the ranking and weighting to a sub-group of the Board. A group of staff and lay people met to establish and assess the relative importance of the benefits criteria The group of subject matter experts (OOHs service staff) and lay group members (Patient Partnership Forum) met on the 10 th June, 2014 to agree the ranking and weighting of the benefits criteria. Those present reported this to be a transparent, rigorous and robust process of exploring the case for change and the rationale behind each criterion as it applied to the OOH service change and the aims of the Option Appraisal process. The meeting was chaired by an objective service change facilitator (Kate Bell). Primary Care Out of Hours Service Review 15

3.4 Summary of the Final Ranking and Weighting This process was split into two stages: The sub-group of the Programme Board ranked the benefits criterion in order of importance which was shared with the participants at the event. The sub-group gave a weighting to each of the benefit attributes in line with the ranking. Table 3 Ranking and Weighting Benefits Criteria Attributes Final Ranking Final Weighting Safe 1 40 Effective 2 20 Person-Centred 3 16 Efficient 4 14 Equitable 5 5 Timely 6 5 16 Primary Care Out of Hours Service Review

4. Workshop Approach and Methodology The aim of the event was to measure all five models, including the status quo against the benefits criteria and scoring process to reach viable, feasible and deliverable service models and service configuration. 4.1. Presentations Service Change Process Kate Bell, Senior Manager, Change & Innovation at NHS Lanarkshire Participants were welcomed by Kate who recognised the commitment of all stakeholders who had given their time so far in meetings, workshops and events as part of the ongoing engagement process to support NHS Lanarkshire to develop improvements in the out-of-hours service. She expressed her thanks to the significant numbers of public representatives present. Kate described the stakeholder event as an opportunity to: Assess the potential benefits of different models against the information provided and presented. Assess models objectively using agreed benefits criteria and scoring methodology. Assess information provided and presented on models, location and combinations to inform the best fit to the essential, desirable and important factors for service configuration. Kate sign-posted participants to the contents of delegate s pack a significant amount of reference material. The event pack contained a hard copy of the Option Appraisal pack which had been circulated electronically seven days in advance of the event for pre-reading included: Strategic context and background information Notification of the programme, an explanation of the option appraisal methodology, the vision, constraints and limitations, Proposed service models information covering the benefits, risk and opportunities for improvement and Service configuration information and materials on location combinations covering workforce capacity, out-of-hours accommodation specification, mapping of driving times to determine population flow and consideration for deprivation. Primary Care Out of Hours Service Review 17

On the day of the event a number of key presentations were delivered to cover: The Rationale for Change Craig Cunningham, Head of South Lanarkshire Community Health Partnership Craig, who is the Executive Sponsor for the Review presented the strategic context and the need for improvement within the Primary Care Out- of-hours service. He stressed that patient safety was his over-riding concern and that currently, the service was unable to provide that on a predictable and systematic basis. He had met with the GPs who worked in the service who had reinforced their experience of the difficulties of lone working, of the subsequent reluctance of GPs to work on those shifts and the resulting patient safety issues arising when less than 50% of patients deemed as requiring an urgent appointment within 1 hour were receiving that level of response. Indeed, in September, that had dropped to no more than 1 in 4 of the 1 hour people receiving an appointment in that time frame. Accordingly, he described NHS Lanarkshire s responsibility to seek to review the service in such a way that it would make it more attractive to GPs to work in the service and that maximum scope was available to use a wide range of staff to ensure a service which was safe for patients whilst still having the service accessible. Communications and Engagement process Colin Angus, a Public Partnership Forum (PPF) member of the Review Board, Calvin Brown, Primary Care Communications Manager An overview of the Communications and Engagement process from a PPF perspective was delivered by Colin who listed the relevant pieces of work he has been involved in designing and developing. He also talked about how he has felt he has been able to influence the format and content of surveys and contribute to the development and appraisal of models for improvement at review board level and through collaborative working within the comms and engagement process. Calvin, gave an overview of our approach and the communications strategy describing the process as a planned open, honest and inclusive process. He noted that the process had followed closely national guidance (CEL 4 Informing, Engaging and Consulting). The establishment of a Communications and Engagement Sub Group was viewed as key to the two way engagement and feedback approach to utilise this sub groups as for reference, approval and validation. Key members of this group include PPF, carers, voluntary organisations, service improvement & staff side. From the earliest point NHS Lanarkshire has been working with Scottish Health Council and commissioned NHS Health Scotland to provide additional resources and expertise to engage hard to reach and out of reach groups of excluded population. As well as a comprehensive communications plan which has reached tens of thousands of stakeholders, a proactive approach has been taken to ensure an inclusive service change process representative of all key service users. An Equality and Diversity Impact Assessment of the review process has informed this process and is being reviewed and reported to ensure the future service model and configuration is informed by the need and views of all. 18 Primary Care Out of Hours Service Review

Colin indicated that the process helped him think in a Lanarkshire wide perspective as the location options were left until the end of the process. He felt that the journey that the review is taking has been a very positive experience and, although, at first, he felt a bit disappointed that two of the four short list options were discounted at the BioCity stakeholders event, the fact that the current service was a high risk due to staff shortages helped him understand the logic of the situation. Current Service and Business Continuity Process Lena Collins, Head of Planning, South Lanarkshire Community Health Partnership Lena, gave a description of the current service delivery and past and present challenges to service delivery. She explained in some detail the Business Continuity arrangements and described the circumstances that lead to invoking these. Business Continuity replaced business as usual arrangements in June, 2013 to ensure a safe, effective and person centred service could be predictably delivered at all times. In her presentation Lena also gave an overview of the work that been undertaken by the review board with regard to developing an evidenced based clinical model and devising an accommodation specification for each of the proposed models. Models for Improvement Dr Chris Mackintosh, Associate Medical Director for South CHP and GP in East Kilbride Dr Mackintosh described in detail each proposed service model. Chris covered key areas of the case for change and sign posted to the quality criterion when describing each of the models. He also referred to the option appraisal pack (pages 16-21) where the benefits, risks and opportunities for improvement were described. In setting out the models for improvement, Dr Mackintosh highlighted the following areas as general issues which were common to all but with variable impact are: 1. Redirection policy: as yet unproven in Lanarkshire and a developing process by which patients presenting at ED are assessed and then redirected to appropriate services, including self care. This is national policy. 2. Co located with ED or on independent site: colocation reduces the travel time between OOH service and hospital admission. Colocation also reduces the risk to ED service by reducing the possibility that patients will choose to go straight to ED as it is closer than an OOH service. Any provision of OOH on a non hospital location will increase the pressures on ED 3. Single centre or more than one centre: Ideal for patients is a doctor at the end of every street, and for efficiency of service ideal is one location. The more locations that are used reduce the variety of services that can be provided at any location. This includes a variety of nurses, pharmacy support, mental health input. Fewer centres will reduce the risks associated with lone working both for clinicians and patients. Primary Care Out of Hours Service Review 19

4. Accommodation: This is a GP OOH service and the accommodation should reflect this. This includes rooms with windows, waiting area, treatment room, storage etc. There is a significant stress associated with providing this type of service, and the wrong accommodation will simply exacerbate the issues. 5. Access: This refers to access to services. If reconfigured well, patients will have access to more services. 6. Location: this relates to travel time, car parking etc. Data about this presented later. 4.2 Scoring Process and Methodology An explanation of the decision-making methodology and scoring process was covered by Kate Bell, Senior Manager, Change & Innovation. All stakeholders were identified through the Programme Board and invited to the event with no less than 6 weeks notice. The event was attended by 59 people with a total of 51 people eligible to score. As described in the event briefing paper which had been distributed in advance of the event and presented on the day, the facilitated groupwork process enabled each proposed model and service configuration to be discussed in turn by the five mixed stakeholder groups. All attendees were allocated to one of five groups pre-event to ensure equal representation. This also ensured a mixed representation of expertise and knowledge across all groups. The participants remained in the same groups for both the morning and afternoon session. The groups were facilitated by experienced facilitators not involved in the delivery of the Out-of-Hours service. 20 Primary Care Out of Hours Service Review

a. Scoring the service model AM The morning session gave an opportunity for further interrogation of the benefits, risks and opportunities for improvement before individual scores were applied to represent the value of each of the benefits criterion as it applied to the options and to the PC OOHs service. (See Appendix 3 Participants Score Card) b. Scoring the service configuration PM The afternoon session concentrated assessing the service configuration combinations using information and materials on location combinations covering workforce capacity, out-of-hours accommodation specification, mapping of driving times to determine population flow and consideration for deprivation. An individual scoring sheet was completed by participants. (See Appendix 4) A presentation was delivered to the full group by Kate Bell, covering the format and content of the maps giving a brief analysis of the mapped combinations to provide information to promote discussion and comparisons of locations. c. A Gallery Walk A Gallery Walk presented A1 size maps of all models and all combinations to enable a close look at the maps provided by the Scottish Government Geographic Information Science & Analysis Team as well as detailed Workforce and accommodation capacity information. Members of the Review Board were on-hand to answer any questions from participants. d. Groupwork session PM Participants went into previously allocated groups for a facilitated groupwork discussion before participants individual scores were applied to represent the essential, desirable and important factors for future delivery of the out-of-hours service. (See appendix 4 PM participants scoring chart) Primary Care Out of Hours Service Review 21

5. Overall Results 5.1 Scoring Service Model Table 4 All Models, all Groups - Ranking and Scoring AM Session Models All groups All groups ranking total scores Model 2 - Two centre PC OOHs centres North/South 1 12208 Model 1 - One consolidated PC OOH s 2 11665 Model 3 - Three PC OOHs centres in health centres 3 7990 Model 4 - PC OOHs centres co-located within 3 DGH s 4 6248 Status Quo - baseline model 5 2064 PLEASE NOTE: The function of including the Status Quo do nothing model is to provide a benchmark so that the value of the alternative do something models may be judged by reference to current service provision. Table 5 - All groups breakdown All groups - Status quo - baseline model Status quo - baseline model Total Weighting Weighted total 1 Safe 16 40.0 640 2 Effective 18 20.0 360 3 Patient-centred 42 16.0 672 4 Efficient 13 14.0 182 5 Equitable 30 5.0 150 6 Timely 12 5.0 60 Total for option 1 = 2064 22 Primary Care Out of Hours Service Review

Model 1 - One consolidated PC OOH s Total Weighting Weighted total 1 Safe 123 40.0 4920 2 Effective 130 20.0 2600 3 Patient-centred 83 16.0 1328 4 Efficient 133 14.0 1862 5 Equitable 83 5.0 415 6 Timely 108 5.0 540 Total for option 2 = 11665 Model 2 - Two centre PC OOHs centres North/South Total Weighting Weighted total 1 Safe 130 40.0 5200 2 Effective 121 20.0 2420 3 Patient-centred 119 16.0 1904 4 Efficient 111 14.0 1554 5 Equitable 114 5.0 570 6 Timely 112 5.0 560 Total for option 3 = 12208 Model 3 - Three PC OOHs centres in health centres Total Weighting Weighted total 1 Safe 78 40.0 3120 2 Effective 72 20.0 1440 3 Patient-centred 105 16.0 1680 4 Efficient 60 14.0 840 5 Equitable 101 5.0 505 6 Timely 81 5.0 405 Total for option 4 = 7990 Primary Care Out of Hours Service Review 23

Model 4 - PC OOHs centres co-located within 3 DGH s Total Weighting Weighted total 1 Safe 69 40.0 2760 2 Effective 49 20.0 980 3 Patient-centred 75 16.0 1200 4 Efficient 47 14.0 658 5 Equitable 73 5.0 365 6 Timely 57 5.0 285 Total for option 5 = 6248 5.2 Groupwork Session - Appraisal of Service Configuration The preferred locations were considered using the methodology described below. The approach required the out-of-hours review board and key stakeholders to reflect the key elements from the Case for Change in the essential, important and desirable factors for the Safe, Effective and Person Centred delivery of the out-ofhours service. Groupwork Process Each group was asked to discuss and consider each of the factors in turn and using the individual score cards place an x next to the option that delivered this best. Scoring Process Primary Analysis - The scores from the morning session were entered into a master score sheet by NHS Lanarkshire IM & T staff independent who were not involved in the review. See table 5 above As a result of the morning scores only two models were deemed viable and deliverable in accordance with service model criterion as specified in relation to workforce and accommodation capacity. The models appraised for best fit for service configuration which were considered in the afternoon are described below: One Centre Model One Primary Care Out-Of-Hours Centre located in Community Health Facilities in Lanarkshire Option 1 Motherwell Health Centre, ML1 1TA Option 2 Douglas Street Clinic, Hamilton, ML3 0BP 24 Primary Care Out of Hours Service Review

Two Centre Model: Two Primary Health Care Centres located in Community Health Facilities in Lanarkshire Combination 1 Airdrie Health Centre ML6 6DB AND Douglas Street Community Clinic ML3 0BP Combination 2 Motherwell Health Centre ML1 1TA AND Hunter Health Centre G74 1AD Combination 3 Wishaw Health Centre ML2 7BQ AND Hunter Health Centre G74 1AD 5.3 Drive Times Population Flow Option 1 Motherwell Health Centre Option 2 Douglas Street Clinic Graph 1 demonstrates population flow and drive times for Model 1. Graph 2 below shows the drives times for Model 2 and with each of the combinations. Primary Care Out of Hours Service Review 25

5.4 Workforce The case for change and thus the need for a comprehensive review is predicated on the continuing reduction in the number of GPs available to work in the service now and potentially in the future. The workforce modelling was carried out on the basis of a 60/40 ratio between GP and Nurses. With the planning assumptions arrived at using appointment times and allocation of staff. The staff team includes GPs, Nurses, Healthcare Support Workers, Receptionists and Drivers. The chart below shows the indicative numbers of GP hours required to operate each of the proposed models measured against the baseline of the current five centre model. Example of the maps displayed is shown below: 26 Primary Care Out of Hours Service Review

Table 6 - GP hourly requirement per Model Model Configuration No of GP hours GP Resource Status quo/ Baseline 27870 100% Current state Business continuity 22296 20% less Model 1 One centre 15474 44% less Model 2 Two centres 20892 25% less Model 3 Three centres 25500 9% less Model 4 Three centres of the District General Hospitals 25500 9% less 5.5 Supporting Analysis Service Model According to the evidence gathered Model 1 One Primary Healthcare Out-Of- Hours Centre delivers a more predictable workforce model and has the potential to improve opportunities for recruitment and retention. Model 2 Two Primary Care Out-Of-Hours centres will also promote recruitment and retention and is a good fit for workforce capacity, scores highest in relation to the Safe attributes of the model, with Airdrie Health Centre and Douglas Street Clinic combination performing better in relation to deprivation, population flow, accommodation capacity and areas for improvement. (See appendix 5) 5.6 Scoring Analysis Service Configuration The decision making approach utilised in the afternoon session required the out-ofhours staff and key stakeholders to suggest some factors they consider to be either essential or important or desirable for the OOHs centres part of the service. For example, an essential factor would likely be adequate and fit for purpose clinical space. An important factor might be increases the recruitment and retention of GPs. A desirable factor might be... etc. The analysis of the method works as follows: (Step 1) First consider if a clear preference emerges after consideration of the feedback on essential factors. If yes, then we have a preferred model! If not, move to Step 2. (Step 2) Consider if a clear preference emerges after consideration of the feedback on important factors. If yes, then we have a preferred model! If not, move to Step 3. (Step 3) Consider if a clear preference emerges after consideration of the feedback on desirable factors. If yes, then we have a preferred model! Primary Care Out of Hours Service Review 27

Table 10 Score for all Groups PM Scoring summary - Afternoon Model 1 Model 2 (one centre) (two centre) Essential - the model provides 1. Sufficient GPs available to work in the service - Workforce 42 37 2. Sufficient staff working in multi-disciplinary teams to provide the service? (Nursing, MH pharmacy) - Workforce 41 38 3. Best evidenced practice and a reduction in clinical risk - Quality 41 43 4. Recruitment and retention of all staff groups - Effective 34 44 5. Peer support, training & development opportunities - Effective teams 40 37 Totals 198 199 Table 10 above is a record of the scores across all groups in relation to the Essential factors to design and deliver a Safe, Effective and Person centred Primary Care Out-of-Hours Service in Lanarkshire. The total scores illustrate overall there is little to differentiate the models. Table 11 The scoring sheet analysis below is a summary of all participants scores. This analysis alongside the information available on population flow and drive times indicates that: 1. If a one Primary Health Care Out-Of-Hours Centre was the preferred model best fit would be in Douglas Street Clinic Hamilton. 2. If a two Primary Health Care Out-Of-Hours Centre model was the preferred model, best fit would be the combination of Airdrie Health Centre and Douglas Street Clinic Hamilton. 28 Primary Care Out of Hours Service Review

Table 11 - Scoring sheet totals for Options/combinations Model 1 Model 2 Factors/Criterion option 1 option 2 combination 1 combination 2 combination 3 (Motherwell (Douglas (Airdrie (Motherwell (Wishaw Health Centre) Street) Health Centre Health Centre Health Centre and and Hunter and Hunter Douglas Street) Health Centre) Health Centre) Essential 1. Capacity - accommodation is fit for purpose? (Clinic rooms/waiting areas/separate and co-located reception areas) 34 41 40 23 30 2. Accessibility - population flow and utilisation 21 37 37 14 14 55 78 77 37 44 Important 1. Accessible parking for staff and public 30 40 36 25 23 2. Support provided through availability of transport where clinical need is established 33 38 36 26 27 3. Opportunities for co-location of management and hub 5 13 13 4 4 4. Opportunity for further service improvements 23 38 33 17 22 91 129 118 72 76 Desirable 1. Access to other services simultaneously, e.g. Health improvement, public health. 17 18 17 12 14 2. A range of shift patterns to support recruitment and retention 33 32 TOTAL NUMBER OF PARTICIPANTS WAS 49 Primary Care Out of Hours Service Review 29

5.7 Sensitivity Testing In order to test the robustness of the results of the option appraisal an assessment of the sensitivity of the ranking of the scores to key variables and assumptions was carried out. Table 7 - below recorded the outcome of the scoring exercise for each individual group (by group), by combination and what the outcome/ranking would have been. The afternoon session methodology has sensitivity built in as scoring is facto based with less room for strategic or self interest scoring. Table 7 - Group Score AM All Group Summary Morning Session Service Model Models Group Group Group Group Group All All 1 2 3 4 5 groups groups total scores Status quo - baseline model 5 5 5 5 5 5 2064 Model 1 - One consolidated PC OOH s 2 2 2 2 1 2 11665 Model 2 - Two centre PC OOHs centres North/South 1 1 1 1 2 1 12208 Model 3 - Three PC OOHs centres in health centres 3 3 3 3 3 3 7990 Model 4 - PC OOHs centres co-located within 3 District General Hospitals 4 4 4 4 4 4 6248 Groups 1, 2, 3 and 4 ranked Model 2 as the highest with group 5 ranking model 1 as the highest. 30 Primary Care Out of Hours Service Review