7. transforming urgent care in north tyneside

Urgent Care: Case for Change

NHS North Tyneside CCG

NHS North Tyneside CCG: Case for Change

Change Record Date Author Version Summary of Changes 21/10/15 Carole

Wardrope 0.21 • Remove 9.1 add paragraphs at end of 9.1

• Amendment to 7.3.4 These changes are reflect feedback provided by Healthwatch North Tyneside

NB: This is, by nature, an iterative document. It will be important to note the change record of this document as it moves through its various iterations. Key milestones for publication of this document will link to the phases of consultation: Phase 2: May 2015 (see Outline Case for Change) Phase 3: October 2015

Contributors

Project title: Urgent Care: Case for Change

Author: Ed Hutton

Owner: Mathew Crowther

Customer: NHS North Tyneside CCG

Date: 2nd October 2015

Version: V0.19

Name Position

Mathew Crowther Commissioning Manager, NHS North Tyneside CCG

Shaun Lackey Clinical Lead for Urgent Care, NHS North Tyneside CCG

Helen Steadman Commissioning Manager, NHS North Tyneside CCG

Carole Wardrope Commissioning Support Officer, NECS

Caroline Latta Senior Communications and Engagement Locality Manager, NECS

Helen Fox Senior Communications Manager, NECS

Kate Simpson The Newcastle-upon-Tyne Hospitals NHS Foundation Trust

Richard Curless Northumbria Healthcare Foundation Trust

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Reviewers:

Name Title Date of issue

Date of initial review

Date of final review

Ed Hutton Author

Mathew Crowther

Commissioning Lead

Shaun Lackey Clinical Lead

Helen Fox Communications and Engagement Lead

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1. EXECUTIVE SUMMARY .............................................................................................. 7

1.1 Why do we need to think differently about urgent care? ................................................................... 7

1.2 Process for developing this document and preparing for consultation ........................................... 8

1.3 The future clinical model and scenarios for change ........................................................................... 9

2. INTRODUCTION ........................................................................................................ 11

2.1 Purpose .................................................................................................................................................. 11

2.2 The outline case for change (OCFC) – May 2015 ............................................................................... 12

3. NATIONAL STRATEGIC CONTEXT – UPDATE ....................................................... 13

3.1 Urgent and Emergency Care Networks .............................................................................................. 13

3.2 Integrated Urgent Care Services ......................................................................................................... 14

3.3 Seven-day working ............................................................................................................................... 16

3.4 Primary and Acute Care Systems ....................................................................................................... 17

4. LOCAL STRATEGIC CONTEXT – UPDATE ............................................................. 18

4.1 North Tyneside urgent care strategy – a reminder............................................................................ 18

4.2 Northumbria Specialist Emergency Care Hospital (NSECH) ............................................................ 19

4.3 Primary care – models of care ............................................................................................................. 19

4.4 Financial context ................................................................................................................................... 21

4.5 Drivers for change ................................................................................................................................ 22

5. CURRENT SERVICE INFRASTRUCTURE – AN OVERVIEW .................................. 23

5.1 Map of current provision ...................................................................................................................... 23

5.2 Health profile of patients in North Tyneside ...................................................................................... 24

5.3 Local activity data ................................................................................................................................. 25 5.3.1 North Tyneside General Hospital ................................................................................................... 27 5.3.2 Great North Trauma and Emergency Centre (GNTEC) ................................................................. 31 5.3.3 Battle Hill Health Centre ................................................................................................................. 33 5.3.4 Shiremoor Paediatric Minor Injuries Unit ........................................................................................ 34 5.3.5 GP out-of-hours services................................................................................................................ 35 5.3.6 Current cost of urgent and emergency care in North Tyneside ..................................................... 36 5.3.7 Conclusions from the data.............................................................................................................. 36

6. PRE-CONSULTATION ENGAGEMENT .................................................................... 38

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6.1 Early engagement ................................................................................................................................. 38

6.2 Pre-consultation engagement process (May 2015 – July 2015) ....................................................... 39 6.2.1 Key findings from the pre-consultation engagement ...................................................................... 39

6.3 Developing the scenarios for consultation (August 2015 – October 2015) .................................... 40 6.3.1 Scenario development workshop ................................................................................................... 40 6.3.2 Desktop review of the draft scenarios (August 2015) .................................................................... 42 6.3.3 The viable scenarios for consultation ............................................................................................. 44

7. TRANSFORMING URGENT CARE IN NORTH TYNESIDE ...................................... 44

7.1 North Tyneside CCG’s urgent care commissioning intention – what is going to change? .......... 44 7.1.1 Decommissioning the current urgent care infrastructure ............................................................... 45

7.2 How would the scenarios be different from current urgent care services ..................................... 47 7.2.1 Service principles ........................................................................................................................... 47 7.2.2 Streaming and triage ...................................................................................................................... 48 7.2.3 Bookable appointments .................................................................................................................. 48 7.2.4 Integration opportunities for GP out-of-hours services .................................................................. 49

7.3 What is likely to stay the same? .......................................................................................................... 50 7.3.1 A&E services .................................................................................................................................. 50 7.3.2 Ambulance services ....................................................................................................................... 50 7.3.3 NHS111 .......................................................................................................................................... 50 7.3.4 General Practices (linked to models of care section 4.3) ............................................................... 51 7.3.5 Community pharmacy .................................................................................................................... 53

8. THE CLINICAL MODEL OF CARE ............................................................................ 53

8.1 The Urgent Care Centre (UCC) concept ............................................................................................. 53

8.2 Service description ............................................................................................................................... 54 8.2.1 How does this link up with General Practice? ................................................................................ 55 8.2.2 A focus on paediatric pathways ..................................................................................................... 55

8.3 Workforce .............................................................................................................................................. 56

8.4 Diagnostics ............................................................................................................................................ 57

8.5 Acceptance criteria ............................................................................................................................... 57

8.6 Streaming / triage .................................................................................................................................. 58

8.7 Redirection to other community or primary care services ............................................................... 58

8.8 Redirection to emergency services .................................................................................................... 59

8.9 Redirection to major trauma centre (GNTEC at the RVI) .................................................................. 60

8.10 Information sharing .......................................................................................................................... 60

8.11 Care navigation ................................................................................................................................. 60

8.12 The evidence base for urgent care centres ................................................................................... 60

8.13 Clinical model diagrams .................................................................................................................. 61 8.13.1 Single site UCC .......................................................................................................................... 61

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8.13.2 UCC and locality spokes ............................................................................................................ 62

9. THE SCENARIOS FOR CHANGE ............................................................................. 63

9.1 What we learnt through pre-consultation engagement that supports these scenarios ................ 63

9.2 Estates considerations ......................................................................................................................... 65

9.3 Equalities impact analysis ................................................................................................................... 65

9.4 Scenario 1: Single North Tyneside Urgent Care Centre (located at the existing North Tyneside General Hospital (Rake Lane) site) .............................................................................................................. 66

9.5 Scenario 2: Single North Tyneside Urgent Care Centre (located at the existing site at Battle Hill Health Centre) ................................................................................................................................................ 67

9.6 Scenario 3: Single urgent care hub supported by local ‘spoke’ services (urgent care hub located at the existing NTGH site at Rake Lane)...................................................................................................... 68

9.7 Scenario 4: Single urgent care hub supported by local ‘spoke’ services (urgent care hub located at the existing site at Battle Hill Health Centre) .......................................................................................... 69

9.8 What we have considered and ruled out ............................................................................................ 70 9.8.1 Maintaining the current service configuration ................................................................................ 71 9.8.2 Establishing multiple urgent care centres ...................................................................................... 71

10. NEXT STEPS – FORMAL CONSULTATION ......................................................... 72

10.1 Transport analysis ............................................................................................................................ 72

10.2 Financial analysis ............................................................................................................................. 72

10.3 Workforce review .............................................................................................................................. 72

10.4 Estates review ................................................................................................................................... 73

10.5 NHS England – Clinical Senate Review .......................................................................................... 73

10.6 Equalities analysis............................................................................................................................ 73

10.7 Procurement planning...................................................................................................................... 73

10.8 Post consultation .............................................................................................................................. 73

APPENDIX 1: STAKEHOLDER MAPPING ...................................................................... 75

APPENDIX 2: SUMMARY OF KEY MEETINGS AND WORKSHOPS ............................. 77

APPENDIX 3: EVIDENCE BASE ...................................................................................... 81

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1. Executive summary This Case for Change document will inform a consultation with the public and all stakeholders in health and social care about what the future state of urgent care provision should look like in North Tyneside. This consultation is intended to provide an opportunity for everybody in North Tyneside to contribute to a debate on the relative benefits and challenges of the clinical model and the different service configuration proposals set out in this document, and to put forward ideas to help improve the concepts that will define how urgent care services will be delivered from 2017. All of the engagement, discussion and feedback obtained through the consultation process will help the CCG to make a decision about what the future urgent care provision will look like. This will be translated into a business case and service specification in the early stages of 2016/17, with potential procurement activity taking place later in that year.

1.1 Why do we need to think differently about urgent care? North Tyneside Clinical Commissioning Group (CCG) is undertaking this consultation in recognition of several key drivers for change. These include: National policy direction

• Implementing models of care in the Five Year Forward View

• Urgent and emergency care networks

• Integrated urgent care services (NHS111 and out-of-hours GP services) Local strategic vision and developments

• North Tyneside Urgent Care Strategy – the vision set out in the strategy includes the establishment of an urgent care centre for the people of North Tyneside

• Northumbria Specialist Emergency Care Hospital (NSECH) – the introduction of a new hospital in Cramlington designed to manage the emergency care needs of the patients of Northumberland and North Tyneside. Emergency need includes, for example:

o Suspected stroke o Loss of consciousness o Persistent and severe chest pain o Sudden shortness of breath o Severe abdominal pain o Severe blood loss

This means that this need is no longer met for North Tyneside residents at the North Tyneside General Hospital site, which is now designated for the management of urgent care. There is a service at Battle Hill Health Centre which is also designated for this purpose, and now that there is plurality of

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provision in this respect, we need to consider the most optimal configuration of these services

• Primary care developments – new ways of working in General Practices will have an impact on capacity for urgent care management

Financial pressure • The CCG cannot afford to purchase duplicate urgent care services for the

population of North Tyneside. Services at Battle Hill and North Tyneside General Hospital provide a very similar service and are located only a few miles apart. This is the current situation after the introduction of the NSECH.

1.2 Process for developing this document and preparing for consultation The CCG has undertaken a pre-consultation engagement process to understand what people think about the current configuration of services and how they might be improved. This took place between 19th May 2015 and 10th July and included

• Surveys (general public) (N=774); completed on-street through quota sampling (to map the participant profile to that of North Tyneside) and online

• Focus groups (hard-to-reach and protected groups) (N=174); individuals attending the groups were supported to complete the same survey used within the on-street engagement

• Participatory events (N=34); a total of three events were held, one with each of the Urgent Care Working Group (N=15), members of the public (N=7), and community and voluntary sector representatives (N=12)

The results and analysis of this pre-consultation engagement activity are set out in the Right care, time and place: North Tyneside Urgent Care Listening and Engagement – Final Report, which is available on the CCG website here. This feedback has been instrumental in framing the consideration and development of the clinical model and scenarios set out in this document. The CCG has been working closely with colleagues in NHS England in order to provide assurance as to the robustness of the consultation process and associated documents. This will continue throughout the consultation process and will provide opportunity for independent clinical engagement via the NHS England Clinical Senate and a specially appointed clinical panel, which will provide critical analysis and challenge to the concepts described in this document. This will provide detailed clinical feedback, particularly in terms of the clinical model, which will be critical to enable the CCG to make the best possible decision at the end of the consultation process. In addition, the CCG has enlisted the support of the Consultation Institute (tCI), who has been a critical partner through the process of consultation planning. Their expert advice has been critical to ensuring the CCG has taken all necessary steps to mitigate the risk of legal challenge through the consultation process.

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1.3 The future clinical model and scenarios for change This document sets out a clinical model for the provision of an Urgent Care Centre (UCC). This service would be specifically designed to provide two core functions:

• Primary care response for medical presentations The philosophy behind this service component is about providing quick, simple access to a primary care service that can address urgent primary care need.

• Minor injury response This could range from simple cuts and scrapes to fractures. The service would therefore be furnished with the necessary diagnostic capability to assess these presentations (e.g. x-ray).

Emergency care need would be delivered by the new NSECH facility at Cramlington, or by the Great Northern Trauma and Emergency Centre (GNTEC) in Newcastle. Major Trauma (the most acute level of emergency need, most of which is conveyed directly by ambulance) would continue to be provided at the GNTEC. It is the view of the CCG that the best way to ensure that people can access the right care in the right place, first time, is by streamlining these services into a 24/7 single point of urgent care access and delivery. This new service would be able to provide the same capacity and clinical expertise as existing urgent care services but from a single location. It is therefore important to note that these proposals are not based on a principle of reducing or restricting access to urgent care provision in North Tyneside. This new service has the potential to improve the urgent care offer to the people of North Tyneside by:

• At the UCC, both the primary care response and the minor injury response would be accessible at any time of day, and be staffed appropriately to manage peaks in demand through the day and week.

• Both the primary care response and the minor injury response would be accessible to all ages. This is especially pertinent to paediatric pathways, where the necessary skills and experience to manage poorly/injured children must be available at all times.

• There is also potential for this model of delivery to be supported by locality based services designed to meet primary urgent care need, specifically around minor ailments. This would provide the primary care response (defined above) closer to home.

The mechanisms by which this clinical model could be implemented are set out in a number of scenarios. In essence, these describe the geographical location of services, as well as the inclusion or omission of a level of locality based community support services for the management of urgent (non-injury) primary care need. In summary these scenarios can be described as follows:

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The consultation process will provide the CCG with insights into the benefits and challenges of implementing these scenarios as perceived by the public, providers and by all partners and stakeholders involved in the planning and delivery of health and social care services in North Tyneside. There will be other pieces of work that the CCG will undertake to complement the feedback from the consultation. These include:

• Transport analysis

• Estates review – supported by NHS Property Services

• Workforce review

• Financial modelling

• Equalities analysis – although an outline analysis has been completed, the CCG acknowledges that this will be an iterative document and welcomes feedback from the public consultation as to the equalities impact of the scenarios in this document. This will feature as part of the consultation questionnaire.

The CCG will ensure that there is sufficient time for all of the above to be taken into consideration following the completion of consultation activity. It is envisaged that a decision will be reached on the future configuration of urgent care services by April 2016.

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2. Introduction

2.1 Purpose This Case for Change document builds on the Outline Case for Change (OCFC), which was published in May 2015 and provided a review and analysis of the urgent care system in North Tyneside, and why it will need to change to respond to local and national context. This document should be read in conjunction with the OCFC and the North Tyneside Urgent Care Strategy, which are published on the North Tyneside CCG website, along with a range of supporting material and information. Since the OCFC was published, the CCG have undertaken a pre-consultation engagement process to learn more about what the public, service users and key stakeholders think about the current services and what could be improved or done differently to support the objectives of the North Tyneside Urgent Care Strategy. The primary purpose of this Case for Change document is to:

• Reflect on the insights gained through this pre-consultation engagement exercise

• Summarise relevant national and local context that has come to light since the OCFC was published

• Outline some potential scenarios for change, including a clinical model and an options appraisal of these scenarios – these scenarios and the drivers for change are summarised in the Executive Summary, and set out in detail in section 9 (scenarios) and section 4.5 (drivers for change)

o This Case for Change is NOT a business case for what the future will be. It is about informing people as part of a consultation process to help us decide what the future provision of urgent care services should look like.

o Through the consultation process, the CCG is seeking feedback and ideas on the clinical model and scenarios contained within this document to help improve and refine the concepts for future urgent care commissioning.

This document (and associated supporting documentation), the OCFC and the North Tyneside Urgent Care Strategy provide the main repository of information to inform the public through the consultation period, scheduled to be launched on 7th October 2015. The consultation has been planned in line with a stakeholder mapping exercise (see Appendix 1). The consultation process will provide the CCG with the insights needed to help deliver the objectives of the North Tyneside Urgent Care Strategy, which was developed in collaboration with key partners and stakeholders via the North Tyneside Urgent Care Working Group (UCWG). The UCWG was also involved in the development of the clinical model and the scenarios for change set out in this document.

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2.2 The outline case for change (OCFC) – May 2015 The executive summary of the OCFC document outlines the argument for why we need to think differently about how the urgent care system is designed, configured and integrated. It also acknowledges that there are two important considerations that underpin the case for change in urgent care: 1) The urgent care system is changing around us – in June, the new Specialist Emergency Care Hospital opened in Cramlington, which has required consideration of how other urgent care services will integrate with this new landscape. Prior to the launch of the Northumbria Specialist Emergency Care Hospital (NSECH), there was a consultant led A&E department at North Tyneside General Hospital (NTGH). The walk-in-services at Battle Hill and Shiremoor provided an urgent primary care alternative to A&E. Since the NSECH launched, there is now a situation in North Tyneside where patients have three services only a few miles apart which essentially provide the same level of care, with some differences in terms of workforce, opening hours and access to diagnostics. This configuration of urgent care provision is not optimal and duplicates resources and it is right that the CCG seeks to address this issue. 2) The financial position of the CCG indicates that we are already living beyond our means (see section 4.4 for financial context). The OCFC concludes that we cannot afford not to change within the context of an already changing landscape. But, even if those two important factors did not exist, there would still be a robust argument for thinking differently about how we organise urgent healthcare provision in North Tyneside. This is clear by listening to the national policy direction and by reviewing the current pattern of healthcare usage, which is set out in the OCFC (and refreshed in this document). This Outline Case for Change assesses the current situation in the context of the seven key objectives identified in the North Tyneside Urgent Care Strategy. Some pertinent questions emerge from this Outline Case for Change, which include:

• How do services interact with each other, and how do community services engage with patients and carers to maximise the role and impact they can have?

• How do we realise the potential of NHS111 as a navigator of urgent care resources?

• Why are people choosing to attend A&E with relatively minor, primary care problems and why is this different in different areas, and for people of different ages?

The OCFC was developed with reference to a range of supporting documentation, including early engagement activity with the Urgent Care Working Group and the Council of Practices. It also draws on patient insights from a variety of perspectives. The OCFC and supporting documentation is available here.

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3. National strategic context – update Since publication of the Outline Case for Change, there have been some important developments in national health policy relating to urgent care. The Five Year Forward View and Sir Bruce Keogh’s Review of Urgent and Emergency Care remain the central policy documents, but sections 3.1-4 below provide some useful context in terms of how this work is progressing and an assessment of how this is likely to impact on local developments.

3.1 Urgent and Emergency Care Networks As part of the implementation of Sir Bruce Keogh’s review of urgent and emergency care, NHS England have invited applications from urgent care networks across the country to become one of a small number of Urgent and Emergency Care Vanguard sites. These Vanguard sites will be tasked with changing the way in which all organisations work together to provide care in a more joined up way for patients. The North East submitted a regional bid, which was approved in July 2015. The key areas of delivery for the North East Urgent Care Network (NEUCN) are outlined in the table below:

Delivery Area By April 2016 we will By April 2017 we will

System Leadership

- Create an overarching framework to deliver the objectives of the UEC review, including a stock take of services, regional action plan and implementation of revised NHS 111 Commissioning Standards.

- Address fragmentation and nomenclature of UEC services.

- Implement standardised system wide metrics, supported by academic partners to ensure rigour and benefits realisation.

- Ensure consistent delivery of High Impact Interventions by SRGs.

- Deliver improved intelligence and modelling via the ‘flight deck’.

- Undertake baseline assessment to inform proposed new costing models and agree scenarios for shadow monitoring.

- Implement outcomes of the regional UEC review stock take.

- Outcome of payment reform shadow monitoring implemented.

Self-Care - Promote self-care for minor ailments and self-management for long term conditions through the development of online health tools, initially focusing on parents of children under 5 years.

- Extend personal health budgets to support Integrated Personal Commissioning

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Primary Care - Increase direct booking into GP appointments, in and out of hours, to 50% of practices.

- Standardise minor ailment schemes in pharmacies.

- Further increase direct booking into GP appointments and expand direct booking to other UEC services.

Integration - Expand the Directory of Services (DoS) to

include social care. - Implement information sharing between

providers, allowing analysis of pathways and outcomes, by linking NHS identifiers from 111, 999, A&E and admission data. This will inform future pathway changes and payment reform.

- Enhance Summary Care Records in association with HSCIC.

- Achieve greater integration between 111 and OOH provision.

Out of Hospital - Implement 24/7 early clinical assessment of green ambulance and ED dispositions.

- Implement 24/7 senior clinical decision Support through an enhanced clinical hub, accessible by 111/999 and external clinicians, including GPs, pharmacists, mental health, dental and social care professionals.

- Improve See & Treat and Hear & Treat. - Enhance mental health integration through

rollout of 24/7 triage services, psychiatric liaison, 7 day MH consultant working and 7 day street triage with mobile access to health records.

- Utilise ambulance trauma consultants to enhance secondary care treatment in the community.

- Mobile access to DoS for all services.

It is clear from the stated objectives of the NEUCN that this work will have an impact on all local urgent care provision. It will oversee developments in NHS111 and 999 services, facilitate direct booking of urgent care appointments in all parts of the urgent care system and seek to connect together urgent and emergency services via technology, information and pathways. As this work gathers momentum through the next two years, the implications for all these developments on how local services are organised will become clear.

3.2 Integrated Urgent Care Services Sir Bruce Keogh’s Urgent Care Review, and more recently, the Five Year Forward View, both advocate a fundamental redesign of the urgent care ‘front door’ - including a more coherent ‘all hours’ telephone, ‘consult and treatment’ and clinical advice service for patients and health professionals alike. There is now national

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focus on the implementation of this vision and the first step is to set out, or ‘specify’ the key components of such a service. At present, the NHS 111 Commissioning Standards (available at http://www.england.nhs.uk/wp-content/uploads/2014/06/nhs111-coms-stand.pdf) describes the core requirements and standards for the NHS 111 service and repeats that commissioners may wish to enhance and add to these requirements to ensure that local specifications for NHS 111 are comprehensive and appropriate for their local area. In addition the National Quality Requirements (NQRs) specify how local OOH services should be performance assessed by local commissioners (available at http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4137271 There is work underway nationally to develop a new service specification that should be applied by local commissioners to provide a fully integrated service. This new service specification for call handling and ‘consult and treatment’ services would also allow commissioners to specify a further enhancement – namely a 24/7urgent care clinical advice service - ‘hub’. If the service is commissioned in this way it would move us away from the rather outdated notion of ‘in’ and ‘out-of-hours’ services. Consultation with commissioners, providers and other stakeholders is currently underway across the country on the appropriateness of the following enhancements (these will be in addition to those core standards described by the 111 and OOH service requirements):

• At the heart of the integrated urgent care system will be a 24/7 NHS 111 access line working together with ‘all hours’ primary care services;

• Patients will normally speak first to a call advisor who will use the clinical decision support system to triage symptoms. Complex patients needing to speak to a clinician will be identified quickly and receive a clinical assessment following direct “warm” transfer;

• To ensure a more comprehensive 24/7urgent care access, treatment and clinical advice service, commissioners should also provide access to a wider range of clinical expertise. This will include GPs, pharmacists, mental health workers and dental nurses. Clinical expertise may be available within NHS111 call centres, or accessed by direct transfer to a ‘clinical hub’. Patient experience will be enhanced by the early identification of calls that would benefit from access to this level of clinical expertise e.g. dental pain.

• All providers, or combination of providers, must commit to adherence with the Commissioning Standards and contractual framework.

• Special Patient Notes, including End-of-Life Care Plans, will be available at the point in the patient pathway which ensures appropriate care. In addition, patient records including the Summary Care Record will be available to all clinicians.

The Outline Case for Change highlighted the need for improvement in both NHS111 and OOH services, with integration and better use of clinically led triage being central to the improvements needed. This need has been echoed by the

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http://www.england.nhs.uk/wp-content/uploads/2014/06/nhs111-coms-stand.pdf

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4137271




feedback from our pre-engagement process (see section 6.2.1, as well as the Pre-consultation Report). The CCG will be seeking to fully integrate OOH services with the rest of the urgent care system. This would mean that all access to urgent primary care services, regardless of the time of day, is co-ordinated through the same point of access and delivery. For example, all of the current OOH telephone contacts might in the future be delivered through the NHS111 service itself, without the need to refer on to separate services. All face-to-face OOH contacts could be provided by the urgent care services set out in this document, and this could also include the co-ordination and delivery of home-visits. It is our expectation that these integrated services will be defined by the national and regional work that is currently underway. Therefore, North Tyneside CCG is obliged to wait for the revised commissioning standards and service specification to be issued by NHS England, and then to work in collaboration with the NEUCN, fellow CCGs, Out-of-Hours providers and the NHS111 service provider across the region in the implementation of the improvements identified. However, should the national/regional developments not mandate the level of integration between OOH and other urgent care services, as described above, then the CCG will be seeking to affect this change locally through this process of reforming urgent care services.

3.3 Seven-day working The NHS Services, Seven Days a Week Forum, chaired by the National Medical Director, was established in February 2013 to consider how NHS services can be improved to provide a more responsive and patient centred service across the seven day week. The Forum was asked by NHS England to focus, as a first stage, on urgent and emergency care services and their supporting diagnostic services The Forum’s review points to significant variation in outcomes for patients admitted to our hospitals at the weekend across the NHS in England. This variation is seen in mortality rates, patient experience, length of hospital stay and re-admission rates. The Forum also acknowledged the importance of whole system compliance with seven day working principles. 2014/15 saw the development of pilots to explore extended, seven day access to primary care (via the Prime Ministers Challenge Fund). The learning from these pilots is expected to inform policy in 2015/16 about seven-day working, which has already been signalled by the Secretary of State as a priority development. Both Northumbria Healthcare NHS Foundation Trust and Newcastle Hospitals NHS Foundation Trust are recognised as pioneers for implementing seven day working, and urgent care provision in North Tyneside is already reaping the benefits of this approach. We await further guidance from NHS England on how learning from the Prime Ministers Challenge Fund might be rolled out across the country, and in particular in primary and community care services. Our consideration of scenarios for change must be cognisant of developments in this area.

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3.4 Primary and Acute Care Systems As part of implementing the models of care described in the Five Year Forward View NHS England has awarded ‘vanguard status’ to a number of sites around the country. This is in recognition that there are some health economies that are already working on developments that will deliver the aspirations of these models of care, and this advanced position will help to inform the rest of the NHS about how these models of care might be implemented across the country. Northumberland was named a ‘vanguard’ site in March this year for implementation of the Integrated Primary and Acute Care Systems (PACS) model of care. This work is being driven by lead partners Northumbria Healthcare NHS Foundation Trust and NHS Northumberland Clinical Commissioning Group (CCG) working with Northumberland County Council, local GPs, mental health services and the ambulance service. Local people and Northumberland Healthwatch will also be involved from the outset. The collective ambition is to create a single ‘accountable care organisation’ (ACO) for the whole of Northumberland from 2017. This would bring together health and social care partners and combine general practice and primary care with hospital, community, adult social care, as well as mental health services, without the organisational boundaries which have historically prevented real transformation in care. The stated aims for this development include:

• Better access to care seven days a week – both for serious emergencies and for primary care services such as GP appointments

• Better use of technology to empower people to take control of their own health and wellbeing, live independently at home and stay healthy

• Care delivered by an aligned, integrated workforce, operating as one team, in one system with joined-up IT systems and processes

• One unified patient record, reducing the need for patients to repeat ‘their story’ to different health professionals and different parts of ‘the system’

In North Tyneside, we must be mindful of these developments and their implications for how we might seek to redesign urgent care services – there will be developments in Northumberland in terms of whole system integration from which we can learn. We should also be sighted on what this innovative work could mean for the future configuration of, and relationship between, commissioner and provider organisations, and whether this will pave the way for the configuration of NHS services across the region/country.

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4. Local strategic context – update The Outline Case for Change provides plenty of context in terms of local urgent care services. For ease of reference, it is useful to include in this document a reminder of the aims and objectives of the urgent care strategy and a reminder of the current infrastructure for urgent care. In addition, there is a section below providing insight into the developments taking place in primary care, which will be a critical piece of service context for the development of urgent care services.

4.1 North Tyneside urgent care strategy – a reminder The high level vision described in the North Tyneside Urgent Care Strategy can be summarised as follows: For people with urgent but non-life threatening needs:

• We should provide highly responsive, effective, personalised services out of hospital,

• Deliver care in or as close to people’s homes as possible. For people with more serious or life threatening emergency needs:

• We should ensure they are treated in centres with the very best expertise and facilities to reduce risk and maximize chances of survival and good recovery.

To realise the vision and move from the current to the future system of urgent and emergency care, the strategy proposes seven central objectives within which the requirement for change can be articulated. These are described as follows:

• Better support for people to self care

• Right advice first time

• Responsive urgent care services out of hospital

• Specialist centres to maximise recovery

• Connecting urgent and emergency care services

• High quality and affordable care within the resources available

• Integrating care along the pathway The strategy is available on the CCG website by clicking here.

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http://northtynesideccg.nhs.uk/news-media/publications/strategies/


4.2 Northumbria Specialist Emergency Care Hospital (NSECH) In June, the new Specialist Emergency Care Hospital opened in Cramlington, which has required consideration of how other urgent care services will integrate with this new landscape. This transformation was informed by a public consultation process that took place in 2009. This consultation is summarised in the report published by Northumbria Healthcare NHS Foundation Trust titled ‘Building a Caring Future,’ which included consideration of the impact that the new hospital would have on other services, including the North Tyneside General Hospital. It concluded that people will continue to be able to walk in for treatment of routine illness and injury and that the departments will continue to be medically-led and will have doctors and nurse-practitioners working in them. This work also concluded that people with minor injuries should not present to the new hospital – anyone presenting at one of the existing district general hospitals with a serious illness would be transferred to the new hospital, usually by emergency ambulance. Prior to the launch of the Northumbria Specialist Emergency Care Hospital (NSECH), all A&E services in North Tyneside were located at the North Tyneside General Hospital (NTGH). The walk-in-services at Battle Hill and Shiremoor provided an urgent primary care alternative to A&E. Since the NSECH launched, the service at NTGH is being re-classified as a 24/7 walk-in-service for urgent (non-life threatening or ’minor’) needs, such as:

• Minor head, ear or eye problems

• Broken nose or nose bleed

• Sprains, strains, cuts and bites

• Children's minor injuries and ailments

• Minor fractures or broken bones

• Abscesses and wound infections Patients with potentially life threatening conditions (Type 1) will be redirected to the NSECH should they present at NTGH. This is a transitionary process which will be reviewed by the end of December 2015 and fully implemented (depending on the outcome of the review) by April 2016. This means that, once the NSECH/NTGH transition is complete, there will be services only a few miles apart at NTGH and Battle Hill that are designed to manage the same level of care for the same patients in North Tyneside (with some differences in terms of workforce, opening hours and access to diagnostics). This configuration of urgent care provision is not optimal and duplicates resources and it is right that the CCG seeks to address this issue. This is explored in more detail in section 7.1.

4.3 Primary care – models of care New Models of Care is about looking after North Tyneside patients with the greatest needs in a different way. Patients with multiple/ poly-chronic long term

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https://www.northumbria.nhs.uk/emergency/sites/default/files/end-of-engagement-report-detailed-original-1.pdf


conditions will be offered an enhanced care package which is based on wrapping services around the patient, rather than patients being dictated to by the proviso of the system – ‘a pull system rather than the current push system’. The main objective of the new models of care programme is to deliver high quality, cost effective care for the residents of North Tyneside. This objective will be underpinned by three key components:

• Coordination of Care – to ensure patients actually receive the care they need and to eliminate waste and duplication

• Standardised Care – to drive consistency and high quality while leveraging systems that encourage clinicians to find the most cost effective solutions to patient needs.

• Matching patients need with the care model and clinical skills – patients with chronic diseases need a different kind of care than patients with injuries or simple episodic diseases and therefore the philosophy of directing patients into the right care model or delivery channel applies to clinicians as well.

The New Models of Care programme is very much aligned to both local and national strategy. That includes the implementation of the urgent care strategy, as well as other initiatives such as the Better Care Fund and the Older Persons Pathway. The New Models of Care programme aims to build on some of the excellent work already being undertaken, both within these work streams and within GP locality working groups, with a clear focus on:

• Ensuring that health and social care work more effectively together – through better sharing of information so people only need to explain their problems once;

• Intervening early so that older and disabled people can stay healthy and independent at home - avoiding unnecessary hospital admissions and reducing A&E visits;

• Delivering care that is centred on the individual needs, rather than what the system wants to provide – social care and NHS staff working together, with families and carers, to ensure people can leave hospital as soon as they are ready; and

• Provision of integrated support to carers so that they don’t feel they are struggling to cope alone and can take a break from their caring responsibilities.

It is important to understand these developments in primary care, as they will have a bearing on the capacity within general practice for the management of primary urgent care need. For example, if patients with long term conditions are receiving more comprehensive support from general practice, they may be less likely to deteriorate and experience exacerbations of their conditions that require an urgent response. This would have a positive effect on the amount of capacity available in general practice to manage urgent primary care need. The CCG is also committed to supporting the principles of the Urgent and Emergency Care Network in terms of the role of primary care. This includes expanding the scope and availability of directly bookable appointments. Over the

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next 18 months, the CCG expects there to be a focus on enabling NHS111 to book appointments with GP services. This will help to reduce the burden on GP administration, whilst also providing an opportunity to further standardise the approach to triage across the urgent care system. It could also provide opportunities to clarify the interface between GP services and the locality ‘spoke’ services set out in scenarios 3 and 4 (section 9). As these new primary care models become more established, we will learn more about the relationship between general practice and other parts of the urgent care system to ensure that the right level of capacity is identified and commissioned. However, at this point in time, we are not including any assumptions about the effect of models of care on the total amount of capacity available in primary care to manage urgent care need.

4.4 Financial context The CCG warned in March 2015 that it was experiencing financial pressures. Despite close monitoring and measures to manage the pressures, it reported a deficit of £6.4 million in 2014/15. The CCG has an annual funding allocation of £300m and this deficit represents just over 2% of its annual budget. This follows a small financial surplus reported in 2013/14. Further pressures in the new financial year 2015/16, including repayment of the previous year’s deficit, have resulted in a forecast deficit of £14.3m for 2015/16. The CCG has put in place a detailed financial review and a series of measures to save up to £17m in 2015/16. In the meantime, the pressures have continued to grow, due to a combination of issues including an increased number of patients attending our local hospitals and receiving care which is higher than other areas nationally, as well as a growing elderly population who need additional community-based care for complex health needs. This means that we are spending more money than we have allocated for the needs of our local population and not getting the best value for taxpayers’ money. The CCG has been proactive in working with GP members to develop a financial recovery plan, and NHS England is working with us to monitor our plans more closely so that together we can ensure we achieve financial balance. An important part of the solution is to make more use of existing community and primary care services and to develop these as an alternative to attending hospital – these changes will bring substantial cost savings, but they are a longer term solution and will take time to implement. Reconfiguring urgent care services as outlined in this Case for Change document will be a critical part of this process. However, it must be noted that, even if we were free of these financial concerns, we would still be striving to transform our local urgent care services so that they are more responsive and efficient. The next chapter summarises all of the drivers for change and puts the financial pressures in this context.

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4.5 Drivers for change In summary of sections 3 and 4 of this document, there are several important factors which require the whole health economy in North Tyneside to think differently about how urgent care services are configured and delivered. These are:

• National policy direction o Implementing models of care in the Five Year Forward View o Urgent and emergency care networks o Integrated urgent care services (NHS111 and out-of-hours GP

services)

• Local strategic vision and developments o North Tyneside Urgent Care Strategy – the vision set out in the

strategy includes the establishment of an urgent care centre for the people of North Tyneside

o NSECH – the introduction of the new specialist emergency hospital in Cramlington requires the review and reform of other urgent care services in the borough

o Primary care developments – new ways of working in General Practices will have an impact on capacity for urgent care management

• Financial pressure o The CCG cannot afford to purchase duplicate urgent care services

for the population of North Tyneside. Services at Battle Hill and North Tyneside General Hospital provide a very similar service and are located only a few miles apart. This is the current situation after the introduction of the NSECH and the CCG, in line with the pressures set out in section 4.4, needs to identify areas of efficiency in all health care expenditure

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5. Current service infrastructure – an overview Section 7 of the Outline Case for Change provides a comprehensive overview of the current infrastructure of services providing access for urgent care needs in North Tyneside. A quick list of the current service infrastructure is provided below for reference. There have been some changes since publication of the Outline Case for Change, and these are indicated where relevant in the list below:

• GP services • Walk-in-services

o Battle Hill Health Centre o Shiremoor Paediatric Minor Injuries Unit o 24 hour walk-in-service – this is the service that has been set up at

the North Tyneside General Hospital site after A&E services transferred to the new Northumbria Specialist Emergency Care Hospital (NSECH) – it is designed to manage urgent (non-emergency) care

o Non-local walk-in-services (e.g. Ponteland Road Walk-in-Centre and Mollineux Primary Care Centre)

• Community pharmacy (including Think Pharmacy First services)

• GP out-of-hours – there are local developments planned in this area (see sections 3.2 and 7.2.4 of this document for more detail)

• A&E o The majority of A&E activity for North Tyneside residents previously

took place at North Tyneside General Hospital (NTGH) – after NSECH opened in June 2015 the previously located A&E services at NTGH were transferred

o A smaller proportion of North Tyneside patients attend the Great North Trauma and Emergency Centre (located at the Royal Victoria Infirmary (RVI) in Newcastle). This is our nearest Major Trauma Centre, although we know that patients from North Tyneside do attend this service for relatively minor illness and injury.

• NHS111 – there are local developments planned in this area (see sections 3.2 and 7.3.3 of this document for more detail)

5.1 Map of current provision To inform understanding of the current service infrastructure, the map below illustrates the number and location of GP services, community pharmacies, walk-in-centres and hospitals.

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Other services (indicated by black dots) include:

• Ponteland Road Medical Centre

• Molineux Street Primary Care Centre

• Northern Doctors Urgent Care (GP out-of-hours service) – NTGH site

• Northern Doctors Urgent Care (GP out-of-hours service) – Balliol Business Park

5.2 Health profile of patients in North Tyneside The OCFC (link) provides some detailed information about the public health of North Tyneside residents. This can be found in section 6.4 of the OCFC. As a reminder of some of the key issues affecting North Tyneside, the map below provides a summary of the locality populations and some of the prevailing health concerns in those areas.

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5.3 Local activity data In the context of developing this Case for Change document, it is important that The CCG is well sighted on intelligence that reveals how patients are using different urgent and emergency care services. This analysis needs to include A&E and walk-in-centre activity for all patients resident to, or registered with a GP in North Tyneside, regardless of whether they attended services in North Tyneside, Newcastle or further afield. In light of the emerging national and local context, and the nature of the scenarios for change (see section 9), it is critical that we review some of the key pieces of information about current service activity so that we can understand the level of capacity that must be re-provided in the new system and gather an understanding of how patient flow in, and out of the borough might be affected by the changes proposed in this document. Figure 1: shows the total attendance at A&E departments and walk-in-services for patients of North Tyneside CCG. Many of these services are not located in North Tyneside, but are close by on our borders with Newcastle and Northumberland.

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It is clear from this chart that the majority of activity for North Tyneside patients has been taking place at NTGH, the walk-in-service at Battle Hill Health Centre and the GNTEC at the RVI. The table below shows the average activity volumes attending these services during the months of April 2014 – May 2015.

Service Average monthly attendance North Tyneside General Hospital 4,368

Battle Hill Health Centre (walk-in-service) 3,325

Great North Trauma and Emergency Centre (RVI) 1,060 (NB: this does not include eye casualty)

All other services 1,489

Total 10,242 Figure 1 also begins to describe the impact of the NSECH in June and July 2015. As the NSECH becomes more established, we can see a corresponding decrease in the activity presenting at NTGH. From May 2015 to July 2015, the activity levels have reduced at NTGH by around 43%. This trend is expected to continue and will be closely monitored on an ongoing basis to ensure that the full impact of NSECH is understood and considered as part of this consultation process. This is explored further in section 5.3.1.1. In the first six weeks since the launch of the NSECH, there was an increase of around 19% in A&E attendances for North Tyneside patients to the GNTEC at the RVI. It is important to note that this increase from North Tyneside is off-set by reductions from other areas. So the net change in A&E attendance to the GNTEC at the RVI is actually an overall reduction of around 1.8% since the NSECH launched in June. It is important to understand, however, that this level of reduction could be a part of normal seasonal fluctuation. Six weeks is a very short amount of time from which to draw too many conclusions. The full impact of the NSECH on surrounding services will be analysed on an ongoing basis over the next 12 months.

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It is thought that the shift in patient flow from North Tyneside is a simple reflection of patients choosing to attend Newcastle based services after A&E services were re-located to Cramlington, rather than travelling to the NSECH or utilising local urgent care services. The heat maps in sections 5.3.1-3 indicate where this flow is most likely to originate. However, this will be part of ongoing and rigorous analysis as to the impact of the NSECH on the rest of the local urgent and emergency care system. The following sections provide specific insights into local services, which are most relevant to review in terms of the scenarios for change set out in this document. These include:

• North Tyneside General Hospital – 24 hour walk-in-service (previously an A&E department)

• GNTEC (located at the RVI)

• Walk-in-service at Battle Hill Health Centre

• Shiremoor Paediatric Minor Injuries Unit

• GP out-of-hours services – provided by NDUC

5.3.1 North Tyneside General Hospital

5.3.1.1 Understanding the impact of the NSECH Analysis has been undertaken on A&E attendance activity after NSECH opened in June. As of July 2015, the data indicates a reduction at the NTGH site of circa 43% (based on an average monthly NTGH A&E attendance of 4,368). This reduction is illustrated in figure 3 in this section. This reflects a transitionary phase of the reconfiguration, and we would expect this reduction in NTGH activity to continue as NSECH services become more firmly established. There will be ongoing analysis of activity as it becomes available to clarify our understanding of the impact of NSECH, as this will be critical to planning the right level of capacity and resource in future urgent care services. Figure 2: shows the A&E attendances by North Tyneside patients at the NSECH after the service opened on June 16th 2015. This activity is only for first six weeks after NSECH launched. This data is being reviewed continuously.

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Figure 3: Shows a corresponding reduction in NTGH activity for patients in North Tyneside after the NSECH was opened.

Figure 4: This line graph shows the overall A&E attendances for patients in North Tyneside to the NTGH

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This chart provides an indication of the trend in usage of the NTGH A&E service over the last four years. There are some obvious surges in demand, but the general trend appears to be downward. This data helps to plan the level of resource that will be required in the future urgent care system. Figure 5: This pie chart shows the breakdown of the outcome that patients from North Tyneside received having attended NTGH A&E department in 2014/15.

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This data demonstrates the volume of attendance to NTGH A&E services that were discharged without requiring any follow up treatment (38%) and the patients discharged to the care of their GP (8%) and patients referred to the fracture clinic (6%). It is not possible to be definitive in the interpretation of these numbers, but it is reasonable to suggest that this activity could have been served by a primary care and minor injury service, as set out in the clinical model (section 8). Figure 6: provides an indication of the flow of patients from North Tyneside to the NTGH A&E service during 2014/15. We know that patients living closest to the hospital site are more likely to use the services, and that patients to the west of the borough use the service least of all, preferring to travel into Newcastle based services.

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5.3.2 Great North Trauma and Emergency Centre (GNTEC) This service is located at the Royal Victoria Infirmary (RVI) in Newcastle. The RVI GNTEC is designated as a Level 1 Major Trauma Centre (MTC). It is also one of twelve MTCs in the UK which treat both adult and paediatric patients. 15 -20% of those attending this service are children. The centre is one of two serving the Northern Trauma Network which extends from the Scottish Borders to Yorkshire (the other being the James Cook University Hospital in Middlesborough). A trauma system is a model of care designed to care for patients with multiple serious injuries that could result in death or serious disability, including head injuries, life-threatening wounds and multiple fractures. Major trauma centres are set up to provide this specialised care. They are hubs that work closely with a series of local emergency services. Major trauma centres operate 24 hours a day, seven days a week. They are staffed by consultant-led specialist teams with access to the best diagnostic and treatment facilities, including orthopaedics, neurosurgery and radiology teams. Figure 7: is a line graph showing the overall A&E attendances for patients in North Tyneside to the GNTEC at the RVI

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Figure 8: This pie chart shows the breakdown of the outcome that patients from North Tyneside received having attended the GNTEC at the RVI during 2014/15.

This data indicates that there many of the patients attending this service were discharged without requiring follow-up (35%) or to the care of their GP (20%). As per the analysis of the NTGH data, this could indicate a significant volume of patients that could be managed in an alternative setting.

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Figure 9: illustrates the flow of patients from North Tyneside into the RVI in Newcastle. Predictably, this originates most from the west, and Longbenton in particular. Areas west of Killingworth generate minimal amounts of activity. It is important, however, that this is kept under review following the introduction of NSECH, which may change people’s behaviour and preferences about where they will go for urgent and emergency care.

5.3.3 Battle Hill Health Centre Figure 10: Total number of attendances at the walk-in-service at the Battle Hill Health Centre, for all patients, regardless of where they are from (the vast majority of these attendances will be for North Tyneside residents.

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This illustrates the increased utilisation of the walk-in-service at the Battle Hill Health Centre over the past six years. Understanding these activity levels, and the increasing trend, will help the CCG to understand the capacity required in the future urgent care system. We also know that people tend to access the walk-in-service at Battle Hill Health Centre more frequently at the weekend, which indicates potential issues with access to alternative primary care options out-of-hours. Figure 11: This illustrates the flow of patients from North Tyneside attending the Battle Hill Health Centre. This information indicates that the majority of attendance to this service comes from the areas closest to it. There are fewer ‘hot-spots’ in this illustration than there are for the NTGH service (figure 6). This is in part a reflection of the higher level of acuity that was managed by the A&E service NTGH in 2014/15. It may also be that people further away from Battle Hill are using their own GP, as well as the NTGH and RVI A&E services, for the primary urgent care needs.

5.3.4 Shiremoor Paediatric Minor Injuries Unit The data available from this service is not as comprehensive as that available for the other services above, but the activity data since April 2014 is provided in Figure 12 below. It indicates that an average of 148 patients per month, or 34 patients per week are seen in this unit.

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Because of the limitations on the data, it is not possible to provide a heat map for how the Shiremoor Paediatric Unit is utilised by the population of North Tyneside.

5.3.5 GP out-of-hours services Northern Doctors Urgent Care provide out-of-hours GP services in North Tyneside and operate Monday to Friday 6.30pm till 8am and 24 hours throughout Saturday, Sunday and Bank Holidays. The service was re-procured in 2014 for a three year contract, due to expire in April 2017. Figure 13: The chart below indicates the activity being delivered for North Tyneside residents by Northern Doctors Urgent Care (NDUC) from August 2014 – June 2015.

On average, there are:

• 672 telephone advice contacts per month

• 544 face-to-face out-of-hours appointments per month

• 202 home visits per month

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5.3.6 Current cost of urgent and emergency care in North Tyneside

An analysis of the North Tyneside CCG expenditure on urgent care services in 2014/15 is provided in the table below.

Service Total spend in 2014/15

Payment mechanism

A&E – Northumbria Healthcare NHS Foundation Trust

£5,867,615 Tariff

A&E – Newcastle-upon-Tyne Hospitals NHS Foundation Trust

£1,606,592 Tariff

NHS 111 £597,469 Block

NEAS – 999 £5,702,956 Block

Battle Hill Health Centre (walk-in-service) £1,146,000 Block

GP out-of-hours £1,519,900 Block

Pharmacy (Think Pharmacy First) £90,000 Local tariff

Shiremoor Paediatric MIU £130,000 Block

Admissions Avoidance Resource Team and Emergency Care Practitioners

£884,003 Block

Emergency Medicine Service £3,000 Local tariff

Mental Health Crisis Team £1,310,755 Block

Total £18,655,321 This data is also referred to in section 7.1, which explores the future commissioning intentions of the CCG in terms of service reconfiguration.

5.3.7 Conclusions from the data It is critical that the CCG understands the level of activity that is currently accessing the current services providing urgent care to North Tyneside residents. New service configurations will have an impact on the existing flows of activity both inside and outside the borough for North Tyneside patients. It is fair to consider that the current activity being seen in local urgent care services represent a minimum quotient of activity that must be catered for in any future service configuration. Dependent on the urgent care scenario that is ultimately deployed in the future, there may be an impact on patient flows into the GNTEC and other Newcastle based walk-in-services. For example, should services be configured around a single urgent care centre located in the east of the borough, more patients might choose to travel to services in Newcastle. However, the CCG believes that this affect will be minimal, as the geographical options for the scenarios are very near to each other. Patients choosing to travel to Newcastle for urgent care need tend to live in the West of the North Tyneside, and it is unlikely that new service configurations will tempt this patient flow back into the borough.

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Based on this data in this chapter, we believe that the minimum amount of capacity that would need to be commissioned from future urgent care services is described by the activity currently attending the three services below:

• NTGH A&E – average monthly attendance = 4,368 (40% = 1,747) o It is thought that, once the NSCEH is fully established and activity

flows are more settled, it will be managing approximately 60% of the emergency activity previously managed at NTGH. This means that around 40% of the urgent (but non-emergency) activity will need to be re-provided for in local urgent care services. This is a working assumption that will need to be kept under review.

• Battle Hill Health Centre – average monthly attendance = 3,226

• Shiremoor Paediatric MIU – average monthly attendance = 148

• Out-of-Hours GP service o Average monthly face-to-face contacts = 544 o Average monthly home visits = 202

This means that we can estimate that future urgent care services in North Tyneside would need to accommodate at least 5,867 attendances per month, 70,404 attendances per year. NB – consideration of OOH may be affected by the national/regional changes set out in section 3.2 (i.e. this activity may be organised differently in the future). However, the figures are included here for completeness. Integration between urgent care services and GP out-of-hours services is explored in more detail in section 7.2.4. The clinical model set out in section 8 places a strong emphasis on triage and streaming into appropriate services. Through robustness of triage, the CCG does expect that there will be a proportion of this activity that can be appropriately managed by other, non-urgent community based services, and the services proposed in this document would be empowered to facilitate this re-direction into alternate services wherever possible. The impact of the NSECH on patterns of service use is an important consideration, and the CCG will ensure that more comprehensive intelligence in this respect is incorporated into this analysis as soon as it is available.

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6. Pre-consultation engagement A detailed summary of the pre-engagement phase of the consultation process, including a list of key meetings, agreed actions, and participants, can be found in Appendix 1.

6.1 Early engagement North Tyneside CCG first set out its commitment to reform the delivery of urgent care service in its Urgent & Emergency Care Strategy, 2014 – 2019. Some early public engagement work was then carried out to begin to assess the potential impact of any future changes and develop a better understanding of how the residents of North Tyneside were using existing urgent care services. These activities included:

• The CCG’s Council of Practice was invited to deliberate on the future configuration of urgent care services.

• The CCG’s Patient Forum took part in a workshop at which they were invited to discuss how they would prioritise different components of the urgent care system for allocations of finite funding.

• A survey of 62 patients attending the walk-in-service at the Battle Hill Health Centre in April 2014, using face to face structured interviews to understand their reasons for choosing this service.

• A similar survey of 69 patients attending the A&E at North Tyneside General Hospital in May and June 2014.

• A survey of 109 patients and members of the public to gather their views about self-care through on-line surveys, face-to-face interviews and focus groups.

Members of the public and the North Tyneside Urgent Care Working Group were then invited to attend an improvement workshop in January 2015. The purpose of this workshop was to review the information we had gathered from the public and begin to develop possible future scenarios for the delivery of urgent care. Attendees were asked to envisage how urgent care might be delivered in an ideal world, without being unduly constrained by practical questions of deliverability or cost. At the end of this process the group developed three possible future scenarios for delivering urgent care:

• Scenario 1 – A single urgent care centre

• Scenario 2 – A single urgent care hub supported by GP practices • Scenario 3 – An urgent care hub in each of the CCG’s localities

Further details of each of the scenarios which were developed in January 2015 can be seen in the chart below.

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6.2 Pre-consultation engagement process (May 2015 – July 2015) During the period 19th May – 10th July 2015, individuals were invited to take part in a listening and engagement exercise to share their experiences, opinions and suggestions for how urgent care services are delivered in North Tyneside. The methods by which individuals could get involved included:

• Right care, time and place: North Tyneside Urgent Care Listening and Engagement. 774 residents of North Tyneside were surveyed on the provision of urgent care services in the borough.

• Spending the Urgent Care Pound in North Tyneside. Stakeholders and members of the public were invited to attend 3 participatory budgeting workshops to discuss how they would invest in urgent care services.

• Participatory events (N=34); a total of three events were held, one with each of the Urgent Care Working Group (N=15), members of the public (N=7), and community and voluntary sector representatives (N=12)

• The Community Health Care Forum (CHCF) were requested by NHS North Tyneside CCG to consult with hard-to-reach and protected groups. The CHCF met with established groups and invited members to focus groups, totalling 174 people. Within these meetings, individuals were supported to complete the same survey that was used during the on-street engagement.

6.2.1 Key findings from the pre-consultation engagement The report provides an overview of some of the key themes that arose from the listening and engagement exercises, undertaken to understand the experiences and opinions of North Tyneside residents with regards to the local health services in their area. In addition, the exercise has enabled a greater understanding of what local people want from different services, and how they feel their delivery can be improved to ensure that patients are receiving the right advice or treatment in the right place. In summary, the most important factors when choosing which urgent and emergency care services are:

• The convenience of services is very important; whether it be travel accessibility or a choice between appointments or flexible consulting times. You want the ability to gain access to care whenever you need it and in a location which is suitable

• Improved access to all services through longer opening hours of GP practices including evening and weekend appointments and 24/7 access to pharmacies and walk-in centres.

• More medically trained professionals, who speak good English, in all services.

• Shorter waiting times in all services / quicker referral processes • Improved public awareness of all healthcare services and how to use them

appropriately, through information booklets/leaflets, social media, posters, education in schools and online information

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• Improved care within the community through greater availability of home visits, more district nurses, improved and quicker access to mental health services and better end-of-life care

• Targeted interventions are used to educate those who repeatedly use services inappropriately e.g. identify those who attend the GP/A&E unnecessarily and spend time explaining the different options that are available to them.

• There is greater flexibility in how patients can access advice; for example online support and consultations, drop-in clinics, one-stop shops, telephone appointments and helplines for non-urgent conditions.

• The Think Pharmacy First scheme is an effective method of enabling people to access urgent care with convenience

• Public want pharmacies that are open longer, private consultation areas in all practices, cheaper or free prescriptions for all.

• Pharmacists should become more involved in the provision of urgent care due to its low costs combined with the convenience and potential for the service.

• Greater access to the services through longer opening hours.

• The current GP out-of-hours contract is re-examined to establish whether it really meets the needs of local people, and whether in the future a new model of care should be established away from a long tradition of appointment-based access to a General Practitioner.

• Definitions of urgent and emergency care – patients find these terms confusing

• The service is made more efficient by reducing the number of patients attending with minor ailment through fines, warning letters, and public campaigns, and by redirecting patients to other services through a triage system undertaken by health professionals, or by advising patients if their condition could have been treated more appropriately at an alternative service after receiving treatment.

• Patients are kept informed of waiting times and delays.

6.3 Developing the scenarios for consultation (August 2015 – October 2015)

6.3.1 Scenario development workshop In August 2015 members of the Urgent Care Working Group and other stakeholders were invited to attend another improvement workshop in order to review the evidence gathered during the pre-engagement phase and further refine the future scenarios for urgent care which had been developed in January 2015. Once again, the group was encouraged to think creatively and not be unduly concerned with the practicalities associated with the scenarios they were developing.

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By the end of the workshop six future scenarios for delivering urgent care services in North Tyneside had been discussed:

• Scenario 1 – Maintain the status quo

• Scenario 2a – A single urgent care centre based at North Tyneside General Hospital (Rake Lane)

• Scenario 2b – A single urgent care centre based at Battle Hill Health Centre

• Scenario 3a – A single urgent care hub based at North Tyneside General Hospital (Rake Lane) supported by GP cluster ‘spokes’ in the other three CCG localities

• Scenario 3b - A single urgent care hub based at Battle Hill Health Centre supported by GP cluster ‘spokes’ in the other three CCG localities

• Scenario 4 – An urgent care centre in each of the CCG’s four localities The following chart illustrates the development of the scenarios prior to the launch of the consultation.

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6.3.2 Desktop review of the draft scenarios (August 2015) A panel made up of CCG clinical leads, commissioning managers and external clinical experts from outside the organisation, was convened to review the six scenarios that had been developed by the Urgent Care Working Group and its stakeholders. The panel was asked to assess each of the scenarios against the following criteria in order to determine whether they could realistically be delivered and were therefore suitable to be put forward for public consultation: 1. Strategic alignment This criterion is best described in the context of the North Tyneside Urgent Care Strategy http://northtynesideccg.nhs.uk/urgent-care-strategy/ which sets out seven key priorities that should be the focus of urgent care service redesign.

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http://northtynesideccg.nhs.uk/urgent-care-strategy/


These are also listed in section 4.1 of this document, but for reference they are summarised as: 1. Better support for people to self-care 2. Right advice, first time 3. Responsive urgent care services out of hospital 4. Specialist Centres to maximise recovery 5. Connecting urgent and emergency care services 6. High quality and affordable care within the resources available 7. Integrating care along the pathway Service integration and affordability are clarified in the next two sections, but in terms of overall capacity to conform with the North Tyneside Urgent Care Strategy, our thinking in terms of developing the scenarios in this Case for Change document is guided by reference to these seven principles, which is captured in the phrase ‘right care, right place, right time.’ 2. Integration Service integration is a central theme in national urgent care policy, and is a central theme to our North Tyneside Urgent Care Strategy. Specifically, principles five and seven refer to clear expectations around integration, best described in the objective that the urgent and emergency elements of the system join up and operate together ‘dissolving’ traditional boundaries between hospital and community based services to achieve a consistent approach to service delivery. The consideration of options in this Case for Change has included reference to this principle. The CCG is looking for solutions to service fragmentation and opportunities to bring services together. 3. Affordability As set out in section 4.4, the CCG is under considerable financial pressure. The Outline Case for Change illustrates the level of service duplication inherent in the current service infrastructure. The financial drivers for change are not the only drivers for change, but they are an important consideration and require us to explore all opportunities to remove duplication of service provision. This will be the clearest way in which the consideration of affordability will be determined. 4. Deliverability This criteria is simply a consideration of whether a scenario is deliverable. This could be in terms of whether the CCG has commissioning responsibility or control over the contractual levers or incentives in order to implement a particular solution. It could also be a reflection on the readiness, willingness and capability of various parts of the urgent care system to deliver care differently. It is acknowledged that assessment of deliverability may change over time, especially as markets develop and the regional/national urgent care agenda progresses. This is a criteria that would benefit from regular re-assessment.

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6.3.3 The viable scenarios for consultation

The CCG determined that the outputs from the UCWG scenario workshop could be described as per the left-hand column in the table below. This reflects the different geographical variance of each scenario, relevant to the capable estates that exist in North Tyneside.

The panel considered the scenarios involving a single North Tyneside Primary Care Centre (located either at the existing Rake Lane or Battle Hill sites) as being viable. In addition, they agreed that the option of a single urgent care hub supported by local ‘spoke’ services was deliverable but that it could have cost implications in terms of setting up multiple services in different locality settings, although it is possible that this would be offset by reductions in this demand to the ‘hub’ service. This would need to be explored fully in terms of a business case for future services.

7. Transforming urgent care in North Tyneside

7.1 North Tyneside CCG’s urgent care commissioning intention – what is going to change? At North Tyneside CCG we are committed to providing the best possible patient care to our community. The CCG wants to develop lasting, effective healthcare services both inside and outside of hospital and make it easier for our community to get the right advice or treatment in the right place, first time. To achieve this, the CCG has identified a number of key service principles which would underpin future urgent care services. These principles reflect the pre-

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consultation feedback, as well as the views from local commissioners, clinicians and other stakeholders. These principles are set out in section 7.2.1 below. Prior to the launch of the Northumbria Specialist Emergency Care Hospital (NSECH), there was a full A&E department at North Tyneside General Hospital (NTGH). The walk-in-services at Battle Hill and Shiremoor provided an urgent primary care alternative to A&E. Since the NSECH launched, there is now a situation in North Tyneside where patients have three services only a few miles apart which essentially provide the same level of care, with some differences in terms of workforce, opening hours and access to diagnostics. It is the view of the CCG that the best way to ensure that people can access the right care in the right place, first time, is by streamlining these services into a 24/7 single point of urgent care access and delivery. There is also potential for this model of delivery to be supported by locality based services designed to meet primary urgent care need, specifically around minor ailments. There is also an implication for the future of out-of-hours provision. This is set out in section 7.2.4 of this document, but in essence there is potential for the distinction between in and out-of-hours care to become less significant, as urgent access to primary care will be available 24/7 via the proposed Urgent Care Centre (see section 8). This could extend to co-ordination of home visiting services as well as face-to-face primary care contact.

7.1.1 Decommissioning the current urgent care infrastructure To enable this to happen, there will be some elements of current service infrastructure that would have to be decommissioned in order to provide the space within which the new services can be established. There are some services to which this will not apply – typically, services which are delivered across the region and which are intended to provide critical emergency services (A&E services, ambulance services and NHS111). It also does not apply to services that are not commissioned by the CCG, such as General Practice and pharmacies. The services that would be decommissioned are:

• The Urgent Care Walk-in-Service (situated at North Tyneside General Hospital, Rake Lane)

• Walk-in-service at the Battle Hill Health Centre

• The Shiremoor Paediatric Minor Injuries Unit In addition, consideration will be given to the North Tyneside contract for GP out-of-hours services, provided by Northern Doctors Urgent Care. The CCG will assess the emerging commissioning guidance on Integrated Urgent Care Services (see section 3.2) against its aspirations for ensuring a fully integrated urgent care system in North Tyneside. These aspirations are set out in section 5.3.5 and 7.2.4. Should the national/regional developments not mandate the level of integration between OOH and other urgent care services that we aspire to, the CCG will be seeking to affect this change locally through this process of reforming urgent care

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services. The current OOH contract is due to expire in 2017. The CCG will therefore take a view on whether to serve notice on this contract and to include re-provision of these services within the scope of local urgent care services. These services would be decommissioned in a planned way to be replaced by one of the scenarios set out in section 9. The consultation will provide an opportunity for the CCG to obtain feedback on these ideas from all local stakeholders. This will help to inform the final delivery model. An analysis of the North Tyneside CCG expenditure on urgent care services in 2014/15 is provided in the table below.

Service Total spend in 2014/15

Payment mechanism

A&E – Northumbria Healthcare NHS Foundation Trust (emergency activity)*

£3,520,569 Tariff

A&E – Northumbria Healthcare NHS Foundation Trust (urgent activity)*

£2,347,046 Tariff

A&E – Newcastle-upon-Tyne Hospitals NHS Foundation Trust

£1,606,592 Tariff

NHS 111 £597,469 Block

NEAS – 999 £5,702,956 Block

Battle Hill Health Centre (walk-in-service)

£1,146,000 Block

GP out-of-hours £1,519,900 Block

Pharmacy (Think Pharmacy First) £90,000 Local tariff

Shiremoor Paediatric MIU £130,000 Block

Admissions Avoidance Resource Team and Emergency Care Practitioners

£884,003 Block

Emergency Medicine Service £3,000 Local tariff

Mental Health Crisis Team £1,310,755 Block

Total £18,655,321 *The CCG is anticipating that approximately 40% of activity recorded in A&E services during 2014/15 will be retained in the walk-in-service in 2015/16 after the launch of the NSECH in Cramlington in June this year. The two figures for Northumbria Healthcare NHS Foundation trust represent 60% and 40% of the total A&E activity that was observed in 2014/15. The three rows highlighted green reflect the service areas that would be decommissioned under the proposed scenarios set out in this consultation, replaced by services described in the scenarios in section 9. OOH services are highlighted in orange, reflecting that these are potentially services that would be re-provided through the services set out in sections 8 and 9. The distinction between this and the areas highlighted green is that the

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inclusion of these services in our de-commissioning plans is dependent on the outcome of on-going national and regional work. Therefore, the total amount of funding made available via decommissioning would be in the region of £3,623,046. If OOH services are included, this figure increases to £5,142,946, although a significant proportion of the current expenditure on OOH services may need to be re-deployed into the NHS111 contract, if this is how the future telephone contacts will be delivered. This reflects the maximum financial envelope for commissioning new services. However, the CCG is expecting to release efficiencies through removing duplicated services. The precise funding requirements for new services would be dependent on procurement method and contractual mechanism. The options for contracting are expected to include the following:

• National tariff

• Locally agreed tariff

• Block contract

• New contract models (developed through the UEC Vanguard – see section 3.1)

Procurement options will be explored at a later date after consultation is complete and a decision has been made on how urgent care services will be transformed. This could include either full competitive tender or single tender action. This will be dependent on engagement with current providers and legal advice where necessary.

7.2 How would the scenarios be different from current urgent care services Essentially, the scenarios are designed to comply with and deliver the four criteria of strategic alignment, integration, affordability and deliverability (as set out in section 6.3.2). In doing so, there are a number of specific differences between the way services are currently configured, and the potential future configuration set out in the scenarios. These differences are captured in the sections 7.2.1-4 below.

7.2.1 Service principles • 24/7 walk-in-service, with medical cover at all times (NB: medical cover may

be arranged virtually at times of reduced need, such as from midnight to 6.00am – i.e. via telehealth solutions or through integration with the emerging Integrated Urgent Care Services concept described in section 3.2)

• Open to all ages, and staffed accordingly with the necessary professionals and skills to manage paediatric attendance

• Triage before access – all patients, whether they call NHS111 or self-present, will be initially assessed using a consistent triage system

• The offer of an appointment for all patients, regardless of whether they walk in or are referred

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• Integrating previously fragmented services through co-location of services and professionals wherever possible (and via seamless onward referral where co-location is not possible)

• Full access to the necessary patient information

• Avoiding service duplication

• Provision of information and education to patients about how to access the right service for their need

7.2.2 Streaming and triage The streaming function is critical to the success of this clinical model. It is the mechanism that will ensure that the service is being used appropriately and will be the point at which some patients are referred into other community based services. This could include providing direct booking into other services, such as GPs, meaning that patients do not have to wait in queues when they reach the right place for their care. In addition, and given that there will be no co-located A&E service, more complex and serious presentations must be identified quickly and referred, with transport if necessary, to a specialist emergency unit at either Cramlington (NESECH) or Newcastle (GNTEC at the RVI). The streaming function will be responsible for organising this onward referral. A principle of service delivery will be to ensure a standardised approach to triage. The CCG wants to ensure a consistent outcome for triage decisions across the system, and this will mean utilising a triage support tool that is consistent with those used in other parts of the system. The most obvious example of this is NHS Pathways, which is used by out-of-hours services, NHS111 and 999 services.

7.2.3 Bookable appointments The CCG intends that new services should be able to offer bookable appointments for all patients that need to access the service, for both walk-in patients and patients referred from elsewhere (e.g. NHS111). This would apply equally to both the primary care and minor injury pathways (see section 8.2). This would mean, for example, that NHS111 could offer an appointment time so that patients will know when to present, with confidence that they will not need to wait to be seen. Patients that walk in without being referred could be offered an appointment later in the day, meaning that they do not have to wait in the department to be seen. This will help to reduce the length of time all patients need to wait, improving the patient experience. It will also help the service to achieve a more even flow of patients through the day, maximising under utilised capacity at times of reduced demand. However, if there is immediately available capacity, this should be used to avoid any delays what-so-ever for patients that walk-in to the service. In line with the new emphasis on streaming and triage, should patients be assessed as being more appropriately managed by their own GP, the CCG wants to enable the new urgent care service to help patients book appointments with those services. This would mean that, wherever possible, patients will leave the department having been treated, or with an appointment to be treated.

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The CCG acknowledges that there are some issues with access to primary care (see section 7.3.4). As such, if it is genuinely not possible to secure an appointment for the patient with their own GP (or any other community service), the urgent care service will offer the patient an appointment at an appropriate time to come in and be managed by the service directly. This may be the same day, or later in the evening, or maybe later in the week, depending on the level of urgency and capacity. Scenarios 3 and 4 (see section 9) describe a ‘hub and spoke’ service model. It is envisaged that the ‘spoke’ services that could be set up in locality settings and that these would be accessible solely via booked appointments organised via NHS111. This would ensure that a virtual assessment and triage takes place prior to access. This will also provide valuable information to the CCG about access issues in other services, helping to target other improvement initiatives.

7.2.4 Integration opportunities for GP out-of-hours services Within North Tyneside, the current provider has a base at North Tyneside General Hospital at which patients can be booked an appointment following triage by NHS 111. The service also offers telephone assessment and provides home visits where appropriate. In the financial year 2014/15, the Out of Hours service managed 43.1% of its total throughput via telephone advice, 40.3% via face-to-face consultations, and 16.6% of patients received a home visit. As explained in section 3.2, we are expecting new commissioning guidance in the near future which will affect the way out-of-hours services are configured. We must be mindful of this emerging guidance, but it is important that the CCG sets out the expectation of what this is likely to mean to the way OOH services are configured and integrated with the rest of the urgent care system. In transforming local urgent care services, there is an opportunity to bring together the resources for managing primary urgent care need into a single point of access, helping to simplify urgent care access at any time of the day or week. The CCG is committed to ensuring that there is as much integration and collaboration between urgent care services as possible and there is a clear opportunity to bring together services designed to meet urgent primary care need in a 24/7 service. In the future state, it would be the intention for all patients who are identified as requiring an out-of-hours GP appointment to be directed to attend the UCC. This could mean that, in the future, face-to-face out-of-hours GP access is provided exclusively via the clinical model and scenarios set out in sections 8 and 9 (see also section 7.1.1) of this document. Capacity planning would need to account for this potential integration. Opportunities may also exist to integrate delivery of home visiting with this concept so that it is organised from the same single point of access out-of-hours, and potentially in-hours as well, providing additional support and resource for GPs to manage house calls through the day. It may be possible to utilise the fleet of cars that the current out-of-hours service uses for providing this role both in and out of GP opening times. In the future, access to GP advice and assessment over the phone may be possible by the NHS111 provider, whether in or out of hours, meaning that a

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patient would not need to be transferred from NHS111 to another clinical service to benefit from this telephone contact with a GP. This development is reflected in the emerging concept for Integrated Urgent Care Services as set out in section 3.2 of this document.

7.3 What is likely to stay the same? As explained in section 7.1, there are some elements of the current urgent care configuration that the CCG envisages will remain as they are currently configured. Some of these areas are subject to current or planned development, which will benefit the urgent care system, but this will be organised under separate workstreams and will be out with the scope of this consultation. So, described below are the essential service foundations with which the scenarios set out in section 9 will need to integrate.

7.3.1 A&E services On 16th June 2015, Northumbria Healthcare NHS Foundation Trust (NHCFT) launched the Northumbria Specialist Emergency Care Hospital (NSECH). This meant a broader re-configuration of urgent and emergency care services, which included designating the North Tyneside General Hospital site as a 24 hour walk-in-service (see section 4.2). As of 16th June 2015, NHCFT will be managing all of the serious emergency and illness activity at the NSECH in Cramlington. There are, therefore, no emergency/A&E services provided locally in North Tyneside. The Great North Trauma and Emergency Centre (GNTEC) at the Royal Victoria Infirmary, provided by Newcastle Hospitals NHS Foundation Trust (NUTHFT) is to the west of the borough, attracting patient flow from this part of North Tyneside for a range of urgent and emergency care need, as well as being the most local major trauma centre. Developments in A&E services are best articulated by the intentions set out in the UEC Vanguard – see section 3.1.

7.3.2 Ambulance services Ambulance services will continue to exist as they are currently configured, subject to the developments and improvements set out in the UEC Vanguard – section 3.1. Once we agree the service model and scenario that will be commissioned in North Tyneside in the future, there will be an opportunity to explore the role that local services can play as a point of destination for ambulance conveyance, helping to ensure that patients are in the right place, at the right time.

7.3.3 NHS111 Section 3.2 sets out the national approach to the development of NHS111, with the intention to integrate it with elements of out-of-hours services. The commissioning standards for this new integrated urgent care service are expected at the end of September 2015, which will clarify the direction of travel. This initiative supports the UEC Vanguard (see section 3.1), through which progress on implementing the commissioning standards is expected to be

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accelerated. As such, it is reasonable to expect that we will see changes to the way NHS111 and Out of Hours services (see section 7.2.4) are organised and integrated in 2016/17. It is critical, therefore, that the clinical model and scenarios set out in this document are cognisant of this important development so that local urgent care services can dovetail with newly developed and improved NHS111 services.

7.3.4 General Practices (linked to models of care section 4.3) The level of difficulty the public experiences when trying to access their local GP practice is often cited as one of the main reasons that demand for urgent and emergency care services has been rapidly rising in recent years. The media and other commentators have speculated that people are increasingly turning to their local urgent and emergency care services because they are not able to obtain an appointment to see their GP quickly and at a time that is convenient to them. This message was reflected to some extent in the findings of the pre-engagement exercise, with 7% of the people we surveyed reporting that they had experienced difficulties when trying to make an appointment to see their GP. Speed of access was also identified as an issue, with only 25% of those surveyed indicating that they had been able to obtain an appointment to see their GP on the same day. Healthwatch North Tyneside has also shared patient experience data with North Tyneside CCG which indicates that some residents of North Tyneside experience difficulties when trying to access their GP at a convenient time. Healthwatch recorded 20 complaints on this issue from North Tyneside residents in the period between May 2015 and October 2015. Healthwatch also published a report in March 2015 which suggested that an inability to access GP services urgently was causing some parents of children under 4 to rely on urgent and emergency care services as an alternative. This picture is contrasted by patient experience data collected within GP practices nationally, which suggests that residents of North Tyneside were, on average, more likely to rate their access to local GP services as ‘good’ or ‘very good’ when compared with other parts of England and the North East.

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The CCG has attempted to address perceived problems of access to GP services in the past by providing funding to increase the number of appointments available to the public. In 2014 the CCG paid for an extra 560 GP appointments for the residents of North Tyneside, covering the busy period between 26th and 29th December. However, it subsequently transpired that only 210 of these new appointment slots (38%) had been filled by patients and the rest had remained unused. It may therefore be the case that access itself is not an issue but that too many people are being unnecessarily referred on to an urgent or emergency care centre after seeing their GP. Data contained within the NHS England Primary Care Web tool indicates that GP practices in North Tyneside are more likely to refer their patients to an urgent care centre than those outside the borough. The data in section 5.3.1 also indicates that a significant proportion of the North Tyneside residents who attended an urgent or emergency care service were discharged without further follow-up. This indicates that they may have been experiencing minor injuries or ailments which could have been managed as effectively in primary care. North Tyneside CCG is currently attempting to understand why a small number of local practices have higher than average rates of referral to urgent and emergency care services. Early indications are this is being caused by a mixture of issues, including difficulties recruiting GPs to work in certain practices and operational issues which result in some GPs opting to minimise risk by referring patients on for further treatment or diagnostic investigation in an urgent care setting. In addition, the North Tyneside GP Federation is a new development that seeks to bring practices together at scale to identify opportunities for service improvement and efficiency. It will continue to develop and mature through 2015/16 and may be

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in a position to support enhanced primary care access for urgent care need as we move into mobilising a new urgent care landscape in North Tyneside in 2017.

7.3.5 Community pharmacy All of the 53 pharmacies in North Tyneside are currently signed up to deliver the Minor Ailments Scheme, which provides free advice and treatments for specified conditions to patients who are eligible for free prescriptions, or their children under 16 years old. The CCG is committed to developing the role of community pharmacy, initially via introducing enhancements to the existing minor ailment’s scheme, which will extend eligibility and access into these services. Through continued dialogue with pharmacy colleagues and the Local Pharmacy Committee, the CCG expects pharmacies to play an increasingly pro-active role in the management of urgent care in the community.

8. The clinical model of care In order for the scenarios set out in section 9 to be clear and understandable, it is vital that the clinical model that underpins the new service offer is also clearly set out. It is also important that the totality of urgent care provision is understood. Section 7.1 outlines the decommissioning process and also explains that there are several components of urgent care provision that will be retained in their current form. These are set out in section 7.3 as they form the essential foundations for urgent care provision. As explained in sections 3 and 4 of this document, there are a number of national and local developments that will move forward in parallel to the urgent care developments described in this Case for Change. These developments will help further improvements in the urgent care service infrastructure in North Tyneside.

8.1 The Urgent Care Centre (UCC) concept The CCG recognises the importance of establishing services locally that provide a real alternative to attending A&E services, and this is a message that came out of the pre-engagement feedback. Following the establishment of the NSECH in June 21015 and the transfer of acute emergency care services from North Tyneside General Hospital (Rake Lane) to that new unit, there is an opportunity to specify what clinical model should exist to meet the urgent (but non-emergency) care needs for people in North Tyneside. The concept that has been developed and is set out in this section is referred to as a Urgent Care Centre (UCC). The scenarios set out in section 9 indicate the potential for a single UCC ‘hub’ to be supported by locality based ‘spoke’ services. These would be locally based minor ailments services, located in each of the localities not served by the presence of the UCC ‘hub.’ These services would be designed to provide the primary care response (see section 8.2 below), but not the minor injury response. It is accepted that it will not be viable to keep the spoke services open 24/7 and to furnish them with the same diagnostic capabilities as the ‘hub.’ This will mean

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some limitations in the acceptance criteria, especially given that spoke services will not be able to provide the full compliment of staff skill mix that will be available at the UCC ‘hub,’ whilst opening times will most likely need to reflect key pressure points in primary care demand. It is also the intention that the ‘spoke’ services operate exclusively on an appointments system accessible via NHS111. This means that patients would not be able to walk-in to these services. Apart from the 24/7 walk-in principle, all the other service principles set out in section 7.2.1 would apply. For the purpose of this section, the term UCC will be used to refer to both the single service model and the ‘hub and spoke’ model. Both clinical models are illustrated in section 8.11.

8.2 Service description The proposed clinical service model is essentially in recognition of the large volumes of patients who have historically attended A&E departments for health concerns that are most appropriately managed in a primary care setting, for example, by a GP, primary care nurse or a pharmacist. For these medical presentations, most can be managed by assessment, prescribing and self-care advice and information, and potentially via referral to other community services. A smaller number of presentations may require some investigation (e.g. rapid, simple blood analysis) in order to identify more serious presentations which may require referral to more specialist emergency services. The model also recognises the importance of local access to a service that can manage uncomplicated minor injuries. The service offer would therefore be designed to provide two core functions:

• Primary care response for medical presentations The philosophy behind this service component is about providing quick, simple access to a primary care service that can address urgent primary care need. As such, the mindset in this service component will be to provide nothing that is not available in a routine primary care setting. Any complex presentation that requires more significant assessment and investigation will be referred on to the most appropriate service. Similarly, this service component will not seek to duplicate services provided in routine primary care services. There will be an emphasis therefore on redirecting patients whose primary care need is not urgent to other routine services that are more appropriate. At this point, there will be a clear opportunity for the service to provide information and education to patients about the services that are available and when/how to access them. In the delivery of this service, it is envisaged that there will be opportunity to integrate with other routine primary care services in order that patient redirection can be as seamless as possible. For example, out-of-hours services could be fully integrated with the 24/7 UCC (see section 7.2.4).

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• Minor injury response This could range from simple cuts and scrapes to fractures. The service must therefore be furnished with the necessary diagnostic capability to assess these presentations (e.g. x-ray).

Both of the primary care response and the minor injury response must be accessible at any time of day, and be staffed appropriately to manage peaks in demand through the day and week. Both the primary care response and the minor injury response must be accessible to all ages. This is especially pertinent to paediatric pathways, where the necessary skills and experience to manage poorly/injured children must be available at all times.

8.2.1 How does this link up with General Practice? It is important to understand that the UCC model set out in this section is NOT designed to replace the role of GPs in the management of urgent primary care need for their patients. GPs will continue to do all that they can to provide capacity for managing the full range of primary care need for their patients, planned or urgent. Section 7.3.4 of this document acknowledges that there are some issues in North Tyneside around GP access. It is also true that the current capacity within General Practice would not be able to cope with all of the historic attendances at A&E services that could have been managed within a primary care setting. Therefore, the model set out below should be considered as an additional resource and capacity for the management of primary urgent care need in North Tyneside. There will be a strong emphasis on ensuring that, wherever possible, patients do access their own GP for routine (non-urgent) primary care need, and the UCC will help as much as possible to facilitate this should these patients present at the UCC (see section 8.7). The UCC will provide vital intelligence on local issues in General Practices and will quickly identify if, for example, it is regularly or increasingly seeing patients from certain parts of the borough. This will help identify and address access issues in primary care.

8.2.2 A focus on paediatric pathways The CCG recognises the importance of providing comprehensive urgent care access for children. We know that children generate more A&E attendance relative to their population size than any other age group apart from people aged 70 and over. This is especially the case for children under the age of 5 years old. We also know that a large proportion of this A&E attendance is discharged from A&E services having received no significant investigation or treatment. When parents seek help for acute illness or injury in their children, there is a greater urgency to their need compared with seeking help for their own illness or that of an adult; this is determined by both worry, and convenience (trying to balance the needs of the whole family). We also recognise that the commissioning intentions (section 7.1) include decommissioning existing urgent care provision, including the Shiremoor

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Paediatric MIU. Therefore, we will need to reassure North Tyneside residents that they can expect at least the same dedicated and specialist response in the UCC for managing the urgent care needs of children. In recognition of this, the UCC concept will include the following:

• 24/7 cover by a paediatric nurse practitioner o This role would provide telephone advice and support to GPs on

request and to any ‘spoke’ services developed in localities

• Paediatric area specifically for observation – enabling children presenting with diagnostic uncertainty to be observed for a safe period before either discharging home or referring on to emergency services

NB: this may not apply to the locality ‘spoke’ services set out in scenarios 3 and 4 (section 9)

8.3 Workforce The CCG recognises that the details of service delivery in terms of the necessary workforce will be ultimately determined by the Provider of the service. However, it is clear from the pre-engagement feedback that there are some core skills and inputs that the future service model will need to incorporate. It is also clear that there is currently a wide range of excellent staff currently deployed in the delivery of urgent care services in North Tyneside. The CCG envisages that all of these staff groups would be deployed in the future service configuration. TUPE implications for staff will be thought through in detail after the consultation is completed and once a decision has been made about the future configuration of urgent care services. Potential workforce for urgent care services in the future includes the following (this list is not exhaustive):

• GPs

• Urgent care doctors (SPR and specialty doctors)

• Nurses (of all bands, from HCA to modern matron)

• Prescribing nurses

• Nurse practitioners, specialising in (for example): o Emergency care o Paediatrics o Minor injuries

• Radiographers

• Administrative staff, e.g. o Receptionists o Ward clerks

The clinical model describes a single site scenario as well as a ‘hub and spoke’ scenario. The same resource would be available to establish both scenarios, and

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as such, with the ‘hub and spoke’ model, the resource would be spread more thinly across a number of locations. Therefore, it should be noted that it will not be viable to establish the full compliment of staff described above in every point of delivery. For example, the ‘spokes’ will not provide a full range of specialist nurse practitioners or radiographers. This skill mix would be centralised at the ‘hub.’ The CCG is committed to undertaking a detailed assessment of workforce skills and capacity in terms of what is currently available and what will be needed to service the future configuration of urgent care. This review will be made available to help inform the CCG’s decision on what the future urgent care configuration should be.

8.4 Diagnostics The service must have access to:

• Plain film x-ray

• Rapid simple blood analysis Should any additional diagnostic tests be required, these will be managed through onward referral to the appropriate specialist emergency service.

8.5 Acceptance criteria It must be noted that at this stage, the clinical model is in a formative stage. However, it is useful to provide an indication of the sorts of presentations that could be managed within this kind of service model. The conditions listed below are not exhaustive – a more comprehensive list of conditions/interventions will be worked through as part of ongoing development of the clinical model. All patients would be streamed by an experienced Clinician and should the patient’s condition be outside the agreed acceptance criteria (i.e. the presentation is of a high acuity or complexity, the patient will be directed to the most appropriate alternative service (e.g. to specialist emergency services for very serious presentations or back to the patients GP for more complex management such as long term conditions). Conditions to be streamed directly into the UCC

• HEENT: Headache, ears, eyes, throat, cold, flu

• RESPIRATORY: Breathing problems, cough, asthma

• INFECTIOUS DISEASES: Chickenpox, mumps, measles, virus (facilities to isolate patient required), shingles, threadworms, head lice

• CONTRACEPTION: Emergency & routine contraception issues

• ALLERGIC REACTIONS

• ABDOMEN: stomach pain, dyspepsia, nausea, vomiting, diarrhoea, food poisoning, constipation, haemorrhoids

• UROGENITAL: cystitis and simple UTIs, period pain, vaginal thrush/discharge

• MUSCULO-SKELETAL: muscular aches and pains, back pain

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• SKIN: lumps, rashes, warts, verrucae, impetigo, athletes foot, fungal skin infections, nappy rash, scabies, contact dermatitis/atopic eczema

• PREGNANCY: including vaginal bleeding in early pregnancy

• MENTAL HEALTH: including alcohol abuse & homelessness, suicidal ideation, learning difficulties

• ORAL CARE: mouth ulcers, oral thrush, teething, toothache Conditions to be streamed directly into minor injuries

• MINOR INJURIES: o Minor head, ear or eye problems o Broken nose or nose bleed o Sprains, strains, cuts and bites o Children's minor injuries and ailments o Minor fractures or broken bones o Abscesses and wound infections

8.6 Streaming / triage See section 7.2.2.

8.7 Redirection to other community or primary care services Examples of where a patient should be re-directed to other services include:

• Patients with non-urgent problems which will be more appropriately managed by community services, such as:

o Dentist o Optometrist o Pharmacist o Social worker (or any other agency that can help with non-clinical

issues)

• To in-hours primary care services: o For patients who present with non-urgent primary care need

(potentially because they have experienced difficulty in obtaining an appointment with their own GP)

o Patients with an unchanged chronic condition, which is likely to be more appropriately managed by their own GP

o Patients who require a repeat prescription or a sick note o Patients who are not registered with a GP (e.g. temporary residents)

• If the Clinical Streamer determines that a patient should be redirected back to their own GP, the UCC service should make every effort to arrange an

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appointment with their GP Practice (electronically wherever possible, or over the phone if necessary).

• As set out in section 7.3.4, the CCG acknowledges that there are some issues with access to primary care. As such, if it is genuinely not possible to secure an appointment for the patient with their own GP (or any other community service), the urgent care service will offer the patient an appointment at an appropriate time (commensurate to the assessment of need) to come in and be managed by the service directly.

Patients which should NOT be re-directed to other routine primary care or community services include:

• Patients aged 65 or over

• Children aged 15 or under

• Patients with: o Dementia o Learning difficulties o Mental health problems o Substance misuse issues

• Patients requiring analgesia for pain

• Patients who speak little or no English This list is indicative only – the Clinical Streamer would be required at all times exercise their own clinical judgement to ensure patients are managed in the most appropriate setting.

8.8 Redirection to emergency services There will inevitably be presentations to this sort of service that actually require more specialist emergency response. This is why the clinical streaming role is so critical. An indicative list of the things that would potentially be referred on to specialist emergency centres is provided below.

• Suspected stroke

• Loss of consciousness

• Persistent and severe chest pain

• Sudden shortness of breath

• Severe abdominal pain

• Severe blood loss

• Ambulatory care

• Complex elderly assessment

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8.9 Redirection to major trauma centre (GNTEC at the RVI) Most patients that require the services of a major trauma centre will be taken there by ambulance, as the level of severity and urgency associated with these cases is extremely high. Some will be transferred from other emergency services having initially presented at an A&E department. Should any patients present at the UCC that require major trauma services, they will be very quickly identified and transported to the GNTEC at the RVI.

8.10 Information sharing It is crucial that departmental computer systems and patient information systems are aligned and communicate effectively with each other to reduce risk across patient journey. Lack of clinical information in urgent and emergency care consultations is often an issue that can lead to over-admission to hospital. Lack of information is also frequently cited as a cause of over-referral to secondary care from local urgent care providers to emergency departments. It is critical therefore that the UCC is able to view relevant and up to date patient information. At the very least, the Summary Care Record should be available, but the service should be exploring opportunities to access the full patient record, as is the case in the Gateshead Emergency Care Centre.

8.11 Care navigation The CCG recognises the importance of supporting patients in the navigation of local services. In particular, the CCG believes there is an important role that could be played by local voluntary sector organisations, especially in terms of patient advocacy and helping people to navigate a changing urgent care system. The CCG is committed to engaging with partners in the voluntary sector to explore these opportunities as part of the development of this clinical model.

8.12 The evidence base for urgent care centres Recent proposals for improving urgent and emergency care services in England indicate that a model which supports self-care, helps people with urgent care needs to get the right advice or treatment in the right place, first time and provides a highly responsive urgent care service outside of hospital so people no longer choose to queue in A&E are key to ensuring that we have a successful and long-lasting urgent care model. 1 Only by building the right system, and better supporting patients and the public to use it effectively, will we achieve improved outcomes for urgent and emergency care in the NHS and truly deliver high quality care for all, and ensure the same for future generations. 2 Appendix 3 provides key references for urgent care service development.

1 Transforming urgent and emergency care services in England, NHS England, 2013 2 Transforming urgent and emergency care services in England, NHS England, 2013

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8.13 Clinical model diagrams There are two variants of the clinical model relevant to whether the scenarios describe a single UCC site serving the whole borough, or whether they refer to a single UCC site, supported by locality ‘spokes’ that would provide a primary urgent care response (as defined in section 8.1-10 above). The essential characteristics of the service model would remain the same, although there would need to be careful consideration of the referral pathways and interplay between the ‘spokes’ and the ‘hub.’ The consultation process will be seeking views on these proposed models to enable the CCG, in partnership with key stakeholders, to refine the final clinical model that will be used in the future urgent care service configuration.

8.13.1 Single site UCC

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8.13.2 UCC and locality spokes

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9. The scenarios for change This section describes four potential scenarios in which the clinical model set out in section 8 could be implemented. These scenarios fall into two categories:

• Scenarios 1 & 2 – both describe a single point of delivery via the Urgent Care Centre (UCC), serving the needs of the whole borough. The distinction between scenarios 1 & 2 are purely geographical in terms of where the UCC is located.

• Scenarios 3 & 4 – both describe a ‘hub and spoke’ model, with the central UCC supported by locality ‘spokes’ at which there is provision of urgent primary care services, but with the minor injury element retained in the central UCC. The distinction between scenarios 3 & 4 is, as above, purely geographical in terms of where the UCC ‘hub’ is located.

So, in essence, these options are all about deciding between a single site model, or a hub and spoke model, and also taking a view on what should be the geographical location for the UCC. The affordability criterion for decision making acknowledges that the CCG is working with limited financial resources. This means that the CCG cannot afford to consider an option that would require any capital investment, for example designing and building a new purpose built unit at a new location in the borough. Therefore, we must consider options where there are existing buildings that would be fit for purpose in the delivery of the clinical model. The CCG has determined that there are two locations that meet this criterion, and these are:

• North Tyneside General Hospital (Rake Lane, North Shields)

• Battle Hill Health Centre (Wallsend) These options, and the clinical model which underpins them, have been scrutinised by NHS England.

9.1 What we learnt through pre-consultation engagement that supports these scenarios The box below provides some of the key messages that we received through the pre-consultation engagement activity that support the proposed clinical model and the single-site scenarios (1 & 3) for a single point of delivery for urgent care services in North Tyneside.

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In addition, it is clear from the feedback received through the pre-consultation activity that there are many people in North Tyneside who would prefer to have a full complement of urgent care services close to where they live. Some of this feedback is provided in the box below:

The introduction of local urgent access to primary care would clearly appeal to people that would prefer to have more locally based services. However, there are challenges that this may present for patients to understand the right place to go at

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the right time. Patients would need to discern when to use their own GP services, or the local spoke service, or the urgent care hub service. The CCG and provider services would need to inform people about how to navigate this complex system, but we know from pre-consultation engagement that people already find the existing system confusing. The participatory budget events, which formed part of the pre-consultation activity, provided some specific insights about which services people value in the current context of urgent care. Feedback from the events also concluded that the GP out of hours system needs rethinking in terms of access and delivery. Participants really valued the Walk in Centres that can be found in North Tyneside, citing the convenience and the efficiency of them. The “Think Pharmacy First” scheme was also really popular because of its easy and free access for those on low incomes. The event also highlighted that Rake Lane was more popular than Battle Hill to the participants present.

9.2 Estates considerations It is important that, in the consideration of the scenarios in sections 8.3-6, we have confidence that the estates at both NTGH and Battle Hill are capable of accommodating the projected demand on the services. We know that the NTGH site is capable of seeing double the numbers that are currently going through the department, as this was the case just two months ago prior to the NSECH launch. The land and buildings are owned by the Northumbria Healthcare Foundation Trust and as such there are no issues with lease holdings and expiration of tenancy contracts. The Battle Hill buildings are comprised of pre-fabricated mobile units. This means that there is a degree of flexibility in the site to adjust and develop capabilities in line with demand. The land is currently owned by Newcastle City Council, and the Newcastle Hospitals Foundation Trust have a lease-hold on this land, which is due to expire in 2019. During the consultation period, the CCG will arrange for a full estates review to be undertaken that will provide a definitive view on the relative benefits and challenges of each site in the context of future urgent care provision. NHS Property Services will support the completion of this estates review, which will be prepared in time to inform the CCG decision on what the future configuration of urgent care services will look like.

9.3 Equalities impact analysis The CCG has produced an indicative analysis of the potential impact that these scenarios may have on the population of North Tyneside. It is available on the CCG website and contains a detailed health and equalities profile of the population of the borough. It is the view of the CCG that urgent care services affect everyone equally. As such, we do not believe that there is any one scenario described in the

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http://northtynesideccg.nhs.uk/get-involved/your-views/urgentcare/case-for-change/


subsequent sections that would adversely affect one specific community or group of individuals more than another. However, the CCG also recognises that there may be people in North Tyneside who do not share this view, or think that we have not identified an important equality impact that could be linked to the scenarios below. This equalities analysis will continue to evolve as we move through the consultation process. The CCG will be asking specific questions about equalities through the consultation process, and will ensure that there is always an open invitation for anyone to tell us about any concerns they have regarding our equalities analysis.

9.4 Scenario 1: Single North Tyneside Urgent Care Centre (located at the existing North Tyneside General Hospital (Rake Lane) site) In this scenario, the single point of access located at NTGH (Rake Lane) would serve the entire urgent primary care and minor injury needs for the whole borough. Regardless of which locality patients are from, they would need to attend this location for all minor injuries and minor ailments. This scenario helps address people’s desire for simple urgent care system that is easy to navigate. This is different to scenarios 3 and 4 in that the entire resource available for this service is focused in one place, which means greater utilisation of staff and diagnostic services and potentially increased access and reduced waiting times. The other key difference is that there is not the same locality based services for minor ailments as in scenarios 3 and 4.

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9.5 Scenario 2: Single North Tyneside Urgent Care Centre (located at the existing site at Battle Hill Health Centre) In this scenario, the single point of access located at the current site of the walk-in-service at Battle Hill Health Centre and would serve the entire urgent primary care and minor injury needs for the whole borough. Regardless of which locality patients are from, they would need to attend this location for all minor injuries and minor ailments. This scenario helps address people’s desire for simple urgent care system that is easy to navigate. This is different to scenarios 3 and 4 in that the entire resource available for this service is focused in one place, which means greater utilisation of staff and diagnostic services and potentially increased access and reduced waiting times. The other key difference is that there is not the same locality based services for minor ailments as in scenarios 3 and 4.

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9.6 Scenario 3: Single urgent care hub supported by local ‘spoke’ services (urgent care hub located at the existing NTGH site at Rake Lane) In this scenario, the ‘urgent care hub’ will provide a different level of service to the single UCC in scenarios 1 and 2. The hub would be commissioned to provide minor injuries services to the whole of North Tyneside. It will also provide minor ailments services for the locality of Whitley Bay. This minor ailments element of the service would be delivered by local minor ailments services in the other three localities. The opening hours for the spoke services are likely to be focused specific peaks in demand for minor ailments, linked to capacity pressures in routine general practice services. When locality based minor ailments services close, the hub will then be available to serve the needs of the whole of North Tyneside for both minor ailments and injury, as it will be open 24/7. The difference between this scenario and scenarios 1 and 2 is that the available resource is spread more thinly across the four localities, enabling more local services, but reducing the level of capacity at the hub. In addition, the simplicity of the service is reduced for patients presenting with minor ailments. At certain times of the day, this could result in patients outside of the Whitely Bay locality attending

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the urgent care hub and being referred back to locality based minor ailments services.

9.7 Scenario 4: Single urgent care hub supported by local ‘spoke’ services (urgent care hub located at the existing site at Battle Hill Health Centre) In this scenario, the ‘urgent care hub’ will provide a different level of service to the single UCC in scenarios 1 and 2. The hub would be commissioned to provide minor injuries services to the whole of North Tyneside. It will also provide minor ailments services for the locality of Wallsend. This minor ailments element of the service would be delivered by locally based minor ailments services in the other three localities. The opening hours for the spoke services are likely to be focused specific peaks in demand for minor ailments, linked to capacity pressures in routine general practice services. When locality based minor ailments services close, the hub will then be available to serve the needs of the whole of North Tyneside for both minor ailments and injury, as it will be open 24/7. The difference between this scenario and scenarios 1 and 2 is that the available resource is spread more thinly across the four localities, enabling more local

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services, but reducing the level of capacity at the hub. In addition, the simplicity of the service is reduced for patients presenting with minor ailments. At certain times of the day, this could result in patients outside of the Wallsend locality attending the urgent care hub and being referred back to locality based minor ailments services.

9.8 What we have considered and ruled out In the consideration of options, the CCG has explored the potential for retaining the current service configuration as well as delivering urgent care centres in multiple points of delivery. These options are detailed in the following sections, along with a rationale for why the CCG does not believe these are viable options for the future state of urgent care services in North Tyneside.

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9.8.1 Maintaining the current service configuration

9.8.2 Establishing multiple urgent care centres The CCG has also considered an option to introduce four urgent care centres (as defined in the scenarios 1 and 2), one in each locality of North Tyneside. This was in response to the prevalence of feedback in pre-consultation around wanting a full compliment of services close to home. It was quickly clear that this would not be affordable, and as such the CCG have ruled this out.

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10. Next steps – formal consultation Clearly, the most significant next step is for the formal consultation process to run its course. This document will be published on the 7th October, coinciding with a lunch event to raise awareness of the consultation process. Through a wide variety of media, the CCG will be informing people in North Tyneside about the consultation and how they can get involved. The CCG will also be undertaking a number of activities to help provide detailed insights into the potential impact of service reconfiguration. Identified examples of this work are provided below, although it is likely that the consultation will identify further areas that the CCG will want to explore in more detail. It is the intention to ensure that all of the following work is completed by Spring 2016.

10.1 Transport analysis The CCG has commissioned an independent analysis of the transport implications of the scenarios above, especially in terms of whether there are sufficient transport links to manage patient journeys across the borough, and also to provide an assessment of the parking capabilities for each site. This is due to report on 5th October and will be published along with this document to inform the consultation.

10.2 Financial analysis It is critical that the future configuration of urgent care is affordable within the financial envelope stipulated in section 5.3.7. The clinical model and scenarios set out in this document will be subject to ongoing refinement as we move through the consultation process, and as such there are many variables that we will need to incorporate into an assessment of affordability. The CCG will undertake a detailed financial modelling process to inform its post-consultation decision on what the future urgent care provision should look like. This will be based partly on how current services are contracted and funded, but will also explore a range of contractual and financial mechanisms which could be deployed in the future. Activity data will be critical to this analysis. Analysis of urgent and emergency care service utilisation is a continuous process and will feed this financial review.

10.3 Workforce review The CCG will undertake an assessment of workforce skills and capacity in terms of what is currently available and what will be needed to service the future configuration of urgent care. The CCG is confident that the staff currently deployed in the provision of local urgent care services are the same staff that would be required in the future, but it is important that we carry out this assessment to ascertain whether there are any gaps that need to be addressed. This could be in terms of actual numbers of staff, or linked to training needs, and it will link very closely to the financial review in terms of the costs associated with filling any potential workforce gaps. This review will be made available to help inform the CCG’s decision on what the future urgent care configuration should be.

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10.4 Estates review The CCG will undertake, with support from NHS Property Services, a detailed review of the current estates in North Tyneside, including those at North Tyneside General Hospital and at Battle Hill Health Centre. This is to provide insights into whether any improvements or refinement to either estate would be necessary in order to deliver the new clinical model and the associated capacity. This will be available to inform the CCGs decision on a preferred option in April 2016.

10.5 NHS England – Clinical Senate Review The CCG has been working closely with NHS England throughout the development of this Case for Change document to ensure it complies with their assurance process for consultation planning. As we move into the formal consultation phase, as part of ongoing clinical engagement the CCG will invite a clinical panel of external, independent clinicians to interrogate the clinical model and scenarios. The panel will be made up of GPs, A&E Consultants, Paediatricians and Elderly Care Consultants and their assessment of our plans will include a desk-top review and presentation, as well as site visits.

10.6 Equalities analysis As referenced in section 9.3, the CCG will continue to review the equalities analysis as we move through the consultation process. This will inform a comprehensive equalities impact assessment after the consultation is complete, which will be critical in helping the CCG decide what the future urgent care configuration will look like.

10.7 Procurement planning After the CCG makes its decision about what the future urgent care provision will look like (in April 2016), it will need to begin considering how those services will be implemented. This will include developing a clear procurement plan, with an understanding of the implications on choice and competition. We will be engaging with procurement experts over the next few months so that they are informed about the consultation process and are best placed to advise us on the development of our procurement plan after April next year.

10.8 Post consultation After the consultation period draws to a close in January, the CCG will begin a process of gathering all the feedback from the wide range of engagement methodologies, which include public meetings, surveys and social media. It will also include an ongoing dialogue with our local NHS and social care partners, facilitated through the North Tyneside Urgent Care Working Group. The CCG will ensure that it has sufficient time to take all of this feedback into account, through a careful, structured and transparent process. The CCG expects to make a final decision on the future configuration of urgent care services by April

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2016, which means that there will be a four month period for this intelligent consideration to take place.

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Appendix 1: Stakeholder mapping

Stakeholder group

Stakeholder Stakeholder prioritisation category

Communication method(s)

Internal GP practices (member practices)

Key player Meetings & presentations at clinical council/ regular briefings

Internal CCG governing body Key player Face to face meetings and regular updates

Political audience Local councilors Key player Regular updates Partners Northumbria NHS Foundation

Trust Key player Briefings as required/

engagement and listening documents

Partners Newcastle Hospitals Key player Briefings as required/ engagement and listening documents

Partners Freeman Clinic Key player Briefings as required/ engagement and listening documents

Partners NEAS Key player Briefings as required/ engagement and listening documents

Partners Northern Doctors Key player Briefings as required/ engagement and listening documents

Governance and regulators

Health and wellbeing board Key player Meetings & presentations/ regular briefings


North Tyneside OSC Key player Meetings & presentations/ regular briefings

Partners North Tyneside Council – senior offices

Key player Regular updates and briefings

Partners Local Pharmaceutical Committee

Active engagement and consultation

Meetings and briefing

Partners Local Medical Committee Active engagement and consultation


Partners NHS independent providers, third sector




NHS England Active engagement and consultation


Patients and the public

Patients, carers and families Active engagement and consultation

Public meetings/ media releases/ website/information stands/ posters/info distributed at prime settings/consultation and engagement documents

Partners Community healthcare forum (CHCF)


Meetings and presentations /ongoing briefings and updates/ engagement and listening documents


Patients forum Active engagement and consultation

Meetings and presentations /ongoing briefings and updates/ engagement and listening

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documents

Partners Healthwatch North Tyneside Active engagement and consultation

Meetings and presentations /ongoing briefings and updates/ engagement and listening documents


Hard to reach, easy to overlook groups


Meetings with identified groups/ engagement events/ consultation events


GP patient participation groups Active engagement and consultation

Meetings/briefings

VODA Inform Briefings Other community and

voluntary sector Inform Briefings

Political audience Local MPs Keep informed and engage

Regular briefings/letters/ meetings (if required)


Local media Keep informed and engage

Pro-active and re-active press releases and statements/ interviews / briefings/ paid-for advertorials and supplements

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Appendix 2: summary of key meetings and workshops This section contains a chronological summary of the key meetings, workshops and other events which took place prior to the launch of the public consultation in October 2015. It has been included here in an effort to provide a clear summary of how the final consultation scenarios were developed and who was involved at each stage of this process.

Self-care Workshop, 8 Jan 2015 (developing the scenarios) Name Organisation

Steve Adams NEAS

Jean Banks Local Pharmacy Committee

Dr Mathew Beattie NHS North Tyneside CCG NHS 111 Clinical Lead

Helen Bedford Health Watch North Tyneside

Liz Brittlebank Practice Manager/Self-care subgroup

Anne Carlile Patient Forum member

Phil Clow NHS North Tyneside CCG

Susan Dowson Patient Forum Member

Tom Dunkerton NHS North Tyneside CCG

Michele Spencer North Tyneside Community and Healthcare Forum

Dr Susannah Thompson Freeman Clinics, Battle Hill Health Centre

Dr Dave Tomson NHS North Tyneside CCG, Clinical Lead

Barbara Toland Northumbria, Tyne and Wear NHS FT

Eileen Turner Patient Forum Member

Linda van Zwanenbe Health Watch North Tyneside

Dr Caroline Sprake NTCCG Clinical Director

Mariette Evans North Tyneside Council

Helen Fox NECS

Neil Frankland NECS

Ann Gunning Local Pharmacy Committee

Suzanne Joyce Northumbria Healthcare NHS FT

Janet Kelly Northumbria Healthcare NHS FT

Jane Kenny Northumbria Healthcare NHS FT

Nicole Mclean North Tyneside CCG

Vicky Peacock Patient Forum Member

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Jenny Rasmussen Northumbria NHS FT

Steve Rundle NHS North Tyneside CCG

Dr Riaan Swanepoel NHS North Tyneside CCG

Gill Sharrock Northumbria Tyne and Wear NHS FT

Primary Care Workshop, 25 Jan 2015 (developing the scenarios) Name Organisation Anya Paradis NTCCG

Carol Proctor NHCFT

Dr Andy Jones NHCFT

Linda van Zwanenberg Healthwatch

Lindsay Perks NT Healthwatch CCG Patient Forum

Maureen Taylor NDUC

Michele Spencer CHCF

Neil Frankland NECS

Phil Clow NTCCG

Sandra Gillings Priory Medical Group

Steve Adams NEAS

Dr John Matthews NTCCG

Dr Jonathan Cardwell NHCFT

Dr Mathew Beattie NTCCG

Dr Nicole Mclean NTCCG

Dr Susannah Thompson Battle Hill Health Centre

Gary Charlton NTCCG

Diane Wilcox NTW FT

Jean Banks LPC

Jennie Rasmussen NHCFT

Kevin Allen North Tyneside Council/NTCCG

Sue Wood North Tyneside Council

Teresa Creighton Newcastle Hospitals

Spending the Urgent Care Pound, 02 July 2015 (prioritising future delivery) Name Organisation

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Dr Matthew Beattie NHS North Tyneside CCG NHS 111 Clinical lead

Eleanor Binks North Tyneside Council

Wendy Burke North Tyneside Council

Dr Richard Curless Northumbria Healthcare NHS FT

Sue Graham North Tyneside Council

Julie Green Northumberland Tyne and Wear NHS FT

Nichola Kenny NEAS

Dot Kyle Newcastle upon Tyne Hospitals NHS FT

Rachel Shakir Freeman Clinics

Kate Simpson Newcastle upon Tyne Hospitals NHS FT

Maureen Taylor NDUC

Dr Jane Weatherstone Northumbria Healthcare NHS FT

Linda Van Zwanenberg North Tyneside Healthwatch

Carole Wardrope NECS

Andrew Satissi NTCCG

Caroline Latta NECS

Sheena Mcgeorge NECS

Jeremy Bruce Freeman Clinics

Urgent Care Working Group Meeting, 06 August 2015 (review the data gathered at the pre-engagement events and further refine the scenarios) Maureen Taylor Northern Doctors

Jacqui Old North Tyneside Local Authority

Kevin Allen (Joint CCG/NT Local authority)

Caroline Latta NECS

Helen Fox NECS

Ed Hutton NECS

Julie Danskin Northumbria HealthCare FT

Kate Simpson Newcastle Hospitals

Linda Van Zwanenberg HealthWatch

Dr Mathew Beattie NHS 111

Rachel Shakir Battle Hill Health Centre

Dr Shaun Lackey North Tyneside CCG

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Helen Steadman North Tyneside CCG

Marina Yaseen NECS

Paula Peart CHCF

Mathew Crowther NTCCG

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Appendix 3: Evidence Base

• Healthcare for London: A Framework for Action (2008)

• Primary Care and Emergency Departments, Report from the Primary Care Foundation (2010)

• Guidance for Commissioning Integrated Urgent and Emergency Care ‘A Whole System Approach‘ Royal College of GP’s Centre for Commissioning (2011)

• Urgent Care Centres: What works best? Primary Care Foundation (2012)

• Transforming urgent and emergency care services in England, NHS England (2013)

• Transforming our health care system, The Kings Fund (2013)

• Urgent and Emergency Care: A Review for NHS South of England, The Kings Fund (2013)

• Evidence to inform urgent and emergency care systems, Centre for Reviews and Dissemination (2014)

• Reforming Emergency Care (DH, 2001)

• 10 High Impact Changes for Service Development (DH, 2004)

• National Standards, Local Action: Health and Social Care Standard and Planning Framework 2005/06-2007/08 (DH, 2004)

• The Direction of Travel for Urgent Care, a discussion document (DH 2006)

• Services for Children in Emergency Departments (Report of the Intercollegiate Committee for Services for Children in Emergency Departments, 2007)

• The Department of Health White Paper – Our Health, Our Care, Our Say; a new direction for community services

• Commissioning Framework for Health and Well Being (DH, 2007)

• Delivery of national key targets for Urgent Care: Health Care Commission

• Effectiveness of GP’s in accident and emergency departments (Boeke Van Radnwijk-Jacobze, de Lange-Klerk et al, 2010)

• Urgent Care Centres: What works best? (Primary Care Foundation, 2012)

• Evidence to inform urgent and emergency care systems (Centre for Reviews and Dissemination, 2014)

• The Carson Report: “Raising Standards for Patients New Partnerships in Out-of-Hours Care”

• The Francis Report: “Final Report Of The Independent Inquiry Into Care Provided By Mid Staffordshire NHS Foundation Trust”

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• Everyone Counts: Planning For Patients 2013/14 - Offer One describes a review of Seven Days A Week services, starting with Urgent and Emergency Care

• The Urgent and Emergency Care Review; (NHS England June 2013)

• National quality requirements in the delivery of Out of Hours services (DOH 2004)

• Out of Hours services: A commissioning handbook (Primary Care commissioning, August 2012)

• Getting to grips with integrated 24/7 emergency and urgent care (NHS Alliance October 2012)

• The confidential inquiry into the deaths of people with learning disabilities (CIPOLD) July 2013

• Transforming Care: A national response to Winterbourne View Hospital

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7. transforming urgent care in north tyneside

Documents