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Business Case - Public
Project Name NHS111 and GP Out of Hours
Programme Manager Clare Kapoor
Programme SRO Liz Wise
Document Date 05/03/2015 Document Version 2.0
Project Impact
Financial Year 2016/17 2017/18 2018/19 2019/20
Source of savings
Demand Management
☐ De-commissioning
☐ Change in Care Setting
☐ Other
Provider Impact
Secondary Care Primary Care
Community Services
☐ Other
1. Summary of Proposal
The purpose of this Business Case is to seek approval of the clinical model principles and associated budget for the integrated NHS 111 and Out-of hours (OOH) service across NCL prior to proceeding with the procurement process.
Enfield CCG, as Lead for Urgent Care across North Central London (NCL) Clinical Commissioning Groups (Barnet, Camden, Enfield, Haringey, Islington CCGs), is procuring an integrated NHS111 and General Practitioner (GP) out of hours (OOHs) service for NCL due to the need for contract renewal and changes to the way urgent care is provided.
To enable the successful delivery of the programme all five CCGs have supported the proposals set out in the business case by:
Endorsing the recommended model of an integrated, single contract between NHS
111 and OOH for the group to begin developing a detailed business case;
Agreeing to a contract extension with the existing NHS 111 and GPOOH providers in
NCL; LCW, Barndoc and Care UK to 31 March 2016, to allow additional time to
properly implement the new service model;
Agreeing the SRO for the programme to represent the best interests of the CCGs
involved in this programme; and
Agreeing to fund the additional resources required to support this programme.
These decisions were approved by the 5 Governing Bodies on the dates set out below:
Barnet GB – 28 August 2014
Camden GB – 10 September 2014
Enfield GB – 20 August 2014
Haringey GB – 30 July 2014
Islington GB – 2 July 2014
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The approval of the clinical model principles and budget model is now being sought in order to commence the procurement process of an integrated 111/GPOOHs service across NCL which will have quality and financial benefits in that we should be able to procure an improved service that will better meet the needs of patients living in the five CCG Boroughs for the same investment.
The other areas of focus under the proposed Urgent Care Programme are out of scope for this business case.
2. Background & Context
2.1. NHS 111
NHS 111 is a free telephone number to help people with urgent, but not life-threatening, conditions get advice and access the most appropriate service to meet their needs. In North Central London NHS 111 is currently provided by London Central & West Unscheduled Care Collaborative (LCW).
NHS 111 is a key feature of the Urgent and Emergency Care System in England.
2.2. GP Out-of-Hours
GP Out of Hours services are a vital part of the urgent care system in England, and an important partner to the NHS 111 service and busy Emergency Departments. The services are available so that people can access a GP, for urgent conditions, when their own GP surgery is closed at night, weekends or public holidays. It is an urgent care service which aims to provide patients with a more clinically appropriate alternative to Emergency Departments
In Barnet, Enfield and Haringey, the GP out of hours service is currently provided by Barndoc. In Camden and Islington, the service is provided by Care UK.
3. Project Proposal
3.1. Options Appraisal
Following a review of unscheduled care across North Central London in March 2014, an options appraisal on the future model of unscheduled care was carried out. Each CCG considered the options; seven options in total were considered:
1. Do nothing and extend current contract arrangements;
2. Commission one provider across the five CCGs for all three urgent care services e.g. NHS111, OOH and UCCs;
3. Commission one provider across the five CCGs for NHS 111 and OOH only;
4. Commission one provider across the five CCGs for UCC provision only;
5. Commission one provider for urgent care services for Barnet, Enfield and Haringey and one provider for urgent care services for Camden and Islington;
6. Commission one provider for NHS 111 and OOH for Barnet, Enfield & Haringey and one provider for NHS 111 and OOH for Camden and Islington; and
7. Each borough to commission all urgent care services individually.
The group identified option three as the most viable with the possibility of integrating urgent care centres into the model (option two) at a future date.
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3.2. Governance
The project is directed by the NCL NHS111/OOH Steering Group, which will is governed by the NCL CCGs Urgent Care Programme Board. A number of specialist sub-groups inform the working group to inform different aspects of the project. The system of governance is illustrated in Appendix 1.
3.3. Procurement
The contract for the combined NHS111 and OOH service will need to be awarded through a competitive tender in order to ensure that the provider is selected following a fair and transparent process.
The Phase 1 model would be for a single contract with a lead provider, not necessarily a single provider, enabling a collaboration of providers to deliver services under a single contractual framework for NHS 111 and GPOOHs. This approach allows flexibility for localisation of the service dependent on local requirements and has been agreed by all five CCG Governing Bodies and Enfield CCG nominated to lead this project with Enfield Chief Officer as SRO.
3.4. Clinical Model
3.4.1. Principles
The principles for the clinical model have been drawn from:-
- London 111 Learning Programme - NHS 111 Phase 1 Learning and Development Programme - Primary Care Foundation review of GP Out of Hours in Camden and Islington - Care Quality Commission inspection findings from GP Out of Hours - NCL Clinical Quality Review Group recommendations and actions (111 and OOH) - London Winter (System) Resilience Programme - Out-of-hours GP services in England (National Audit Office Report) - Health Select Committee proceedings - Local clinical activity and data analysis - NHS 111 Commissioning Standards
NHS England learning and development programme and has been used to inform the model. However it is important to note that public clinical and market engagement will continue during the lifetime of this project and, more specifically, during the development of the clinical service specification; therefore the detailed model is subject to engagement activities and outcomes. The principles proposed at the time of writing the business case are:
Access to the service to include online mechanisms and Interactive Voice
Recognition telephony for more efficient triage
Clinical assessment to be enhanced for ambulance and ED referrals as well as
patients presenting with complex conditions
Clinical call backs to be prioritised locally for self-care cases
GP telephone consultations and direct booking to base visits / home visits from NHS
111 - this is a substitution of the first triage and removal of the need for a second
clinical assessment
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Prescribing capability will be offered from the NHS 111- OOH setting and enhanced
with the use of EPS as available
GP OOH base locations will be accessible across NCL from a range of locations and
not restricted by borough of patient GP registration
Electronic health record sharing will be built into the service model so that it can be
enabled in the future in order to improve patient experience and outcomes
Inclusion of pharmacist within the delivery model to manage patients that do not
require a GP
Access to mental health trained clinicians to manage specific cases
3.4.2. Components of the service
Telephone based triage 24 hours a day – NHS 111
Access to 24 hour clinical advice through a skill mix model: nurse, paramedic,
pharmacist, GP
Out of hours: base or home visiting (outside of GP in-hours time periods)
Figure 1: Proposed NHS111 and GP Out of Hours Delivery Model
The model of care is being developed to support outcomes that are most appropriate for patients and the way they use services. The proposed new service will include the use of skill mix including nurses, paramedics and pharmacists as well as GPs. The specification is unlikely to state ratios of staff as this will vary for different times of the day and different periods in the year. However any provider will be monitored in their ability to manage their case load. The aim is to reduce the number of unnecessary separate patient contacts, which means integrating services.
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Access
Telephone
Users could phone the service as they do at present. Added features will include interactive voice recognition (IVR) to stream certain calls.
Online
Users could access services via the web and would either be directed to a service or would receive a call back – this is currently being developed by NHS England, NCL is already a test site for this functionality.
Triage
Use of a clinical decision support tool is essential for the non-clinical triage, NHS Pathways is the only accredited clinical decision support tool that is available for use within NHS 111.
As a result of the NHS England learning and development programme and other local evaluations, changes have been made to the existing model of delivery and a clinical assessment stage has been included to optimise triage outcomes following initial Pathways assessment for certain cases.
The NCL model will still use an accredited triage tool but will supplement this with clinical assessment for defined cases, including:
Ambulance calls
Certain ED referrals
Certain GP OOH cases
Referral
NHS 111 will continue to refer to other services via the NHS Directory of Services. The Directory of Services will continue to require ongoing development and maintenance.
GP OOH and most other OOH services will receive cases using ITK and electronic transfer.
Online services will use this same ITK standards, which will also be used for referral to ambulance services.
Information Technology
Information technology platforms in health have developed individually, however integration between IT platforms remain a challenge. The integrated service will have to meet interoperability standards that allow integration and the ability to track the entire patient journey between NHS 111 and OOH services.
With the development of GP 0800 – 2000 working, it is proposed that the provider of 111 and OOH is able to directly book appointments with registered GP’s. Integration with other urgent and emergency care services will be promoted through the use of the directory of services and using the NHS IT standards.
The principle of record sharing is supported as it allows personalisation of care.
Out of Hours
Out of Hours services will still be expected to continue to offer a range of base locations as they currently do. At this stage the base locations will not change, however a new provider will be expected to work with the CCGs to develop additional bases as indicated by ongoing needs assessment and service evaluation. Whilst it will be outside of the scope of this
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programme, some of those base locations may also be offered through UCC locations – this will increase choice for patients and resolve some of the issues of inequitable access.
The service will be expected to dispense medication as it does at present, however it is not expected that the service will provide any diagnostics or special investigations.
3.4.3. Potential impact and demand changes resulting from the proposed changes
Population growth and the ageing population will mean that the activity is likely to
increase and the case complexity will continue to increase.
The new model will result in a more acute case mix being referred to the Out of
Hours service as a result of the clinical assessment that has been included in this
model; this will also result in diversion from acute services such as Ambulance, ED
and UCC.
Online users will be able to ‘self-assess’ but will also receive a call back from a
clinician where indicated, the NHS 111 phase 1 Learning would suggest that this will
result in a channel shift from patients currently accessing other parts of the health
system as well as some of those currently phoning NHS 111.
The integrated model between NHS 111-OOH model can be more rapidly modified in
response to any surge in demand within the urgent care system.
Pharmacists will be able to reduce onward referral by providing medication advice
through a telephone consultation.
Prescribing capability within NHS 111 is also expected to reduce unnecessary
transfer of cases between 111, OOH and other providers.
The proposed skill mix model combined with more timely access to a GP will help support the urgent care system and in the longer term is expected to help manage demand for urgent and emergency care.
4. Project Aims & Objectives
The key aims of changing the service model include the following:
Improvement of the patient experience;
Better integration between NHS111 and OOH GP services to deliver
a more streamlined patient pathway;
Improved information sharing to benefit the patient experience and outcome;
Better use of urgent care services;
Improved use of resources;
More streamlined contract and performance management across NCL whilst
maintaining a local service; and
A more consistent model of care across NCL
4.1. Integration
This has many benefits from both an operational and clinical standpoint and to enhance the patient experience. The NHS 111 London Learning Programme has reviewed the various operating models in use across London, from full or partial integration to stand-alone urgent care service and stand-alone NHS 111 services. The findings to date suggest that the
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integration of NHS 111 and OOH derives the greatest benefits from an operational and clinical standpoint. This is due to the fact that approximately 35% of calls across London receive an OOH disposition at the end of their assessment. In NCL approximately 47%of calls to the local NHS 111 provider are referred on to OOH service providers across the country. The current service model does not support prescribing and definitive case management within a 111 setting, however integration of 111 with OOH will allow clinicians to utilise their full range of skills including the ability to prescribe without onward referral to a subsequent service.
4.2. Streamlined Patient Pathway
The patient journey will be streamlined with call operators able to book patients directly into the OOH service, a noted core requirement in an NHS 111 service model1. The handoff will be smoother and better communicated to the patient and the staff, thereby decreasing the risk of the patient being ‘bounced’ around the system, and also leading to increased patient compliance with a direct booking. Due to integrated systems and audits the patient journey will be easier to track through the two services and this can lead to improvements, efficiencies and innovations.
It is envisioned that over the course of the next five years new technological developments will be introduced to NHS 111. Serving a larger area will allow the provider to manage the financial costs to the organisation in having to roll out these anticipated changes. Proposed future developments to NHS 111 include an increased online presence including web-chat with clinicians, on-line symptom checker, follow up texts and emails from the service and integration with tele-health and tele-care monitoring2.
4.3. Consistent Model of Care
Currently each OOH service provider has different referral criteria leading to inconsistent patient experience across the NCL footprint. An integrated, single contract model for NHS 111 and OOH will reduce the variation in clinical services and improve equity for patients across NCL. This would ensure the population has equitable access to the OOH service.
The current service differs across North Central London with variable access to GP consultations at different times of the out-of-hours period. The changes in the 111 operational model including clinical re-assessment has meant that the need for access to a GP during the out-of-hours period has increased. In order to avoid onward referral to ED and ambulance for patients that can be managed in primary care, greater access to a GP is now indicated. The case reviews, end-to-end audits as well as review of complaints and incidents would suggest that the differential access to a GP during the out-of-hours period is resulting in avoidable presentations within the emergency care settings.
Commissioning a single OOH service across NCL would also reduce the current inequity experienced by patients as a result of administrative boundaries which are causing inequalities in access for patients. The ability to access the OOH service would be further streamlined, improving the patient experience.
4.4. Improved Information Sharing
Sharing of information will be facilitated with ease when both services are provided by a single contract model. In areas where there is an integrated, single provider model between OOH and NHS 111 the sharing of patient information, such as Special Patient Notes (SPNs),
1 NHS 111Commissioning Standards (draft) v0.1, section 3.6, page 9.
2 NHS 111Commissioning Standards (draft) v0.1, section 3.20, page 14
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held by the out of hours provider, is more easily achieved. The sharing of patient records is a core requirement of the NHS 111 service model.
The sharing of SPNs and other records, such as Coordinate my Care (CMC), will ensure the patient is dealt with in the most efficient and effective way possible, is referred on to the most clinically appropriate service for their needs and has a heightened experience of the care received as they would not have to repeat themselves when explaining their reasons for seeking care.
Improved health information sharing combined with an enhanced clinical model will help reduce the demand for ambulance and acute services. The integrated, single contract model also simplifies the arrangements required to work with local GPs for sharing information with practices.
4.5. Improved Management of Workflow and Staffing
Both services being overseen by the same management team will lead to better visibility of activity into the services, allowing resources to be adjusted accordingly to better manage the workflow. The integrated service model is also more able to respond and collaborate quickly and with ease to any issues that may arise from inappropriate referrals to the OOH service or surges in demand. The staff in both services will also have a better understanding of how the other service operates and this can increase efficiencies and confidence, especially for OOH. This addresses the major concern highlighted by NCL GPs during the initial rollout of NHS 111 that OOH services could be overwhelmed by inappropriate referrals from NHS 111.
In the proposed integrated service model, the operational risk for inappropriate referrals to OOH will be primarily assessed internally with reporting and oversight through clinical governance mechanisms.
Staff will also be better utilised, for example, GPs that traditionally provided telephone consultations in an OOH setting will directly support the NHS 111 service by managing specific cases and also by providing floor walking and management of complex cases.
The GPs can add further value by assisting with training and supervising clinicians and undertaking audits in the NHS 111 service, helping to improve patient safety. Utilising GPs, in the NHS 111 service was piloted within the NHS England 111 Futures Programme.
4.6. Improved use of resources
Integration under a single contractor allows for economies of scale, with both services sharing the cost of the management and administration and back office functions such as estates, IT, telephony and facilities. The integrated model also has more flexibility to respond to service challenges, utilising the combined internal resources in times of surge to ensure the services’ performance are not undermined. The provider(s) will also have more resilience to be able to adapt to service changes and development over the course of the contract. In drafting the national service specification for NHS 111 the NHS England team want to
ensure that the service is commissioned in a way that will allow it to continually adapt to new
developments. These efficiency savings are good for both the provider of the services, and the commissioners.
As local services develop in the future, there may be reason to move some activity away from one of the services, and a provider or consortium of providers would be more resilient to these kinds of changes and less likely to be destabilised as a result. It is important to note that in commissioning an integrated model across the five CCGs, good channels of communication between commissioners and the provider(s) would be required to ensure that local service developments take into consideration any impact on the commissioned service.
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4.7. Streamline Contract and Performance Management
Currently there are three Contract and Performance Management Group (CPMG) meetings and three Clinical Quality Review Group (CQRG) meetings to manage the separate NHS 111 and OOH services in NCL, and one joint NHS 111 and OOH meeting to ensure collaboration between the providers. In an integrated, single contract model these meetings could be streamlined requiring only two meetings to manage the contract and clinical aspects of the integrated service. By coming together to commission the integrated service and support across the five, the CCGs would be able share the contract management support costs.
5. Scope of the service
5.1. In and out of scope
In Scope Out of Scope
NHS 111 services Planned Care
GP OOH Outpatient Services
Tertiary Services
5.2. Key relationships:
GP in-hours services
GP Extended Hours (8-8)
Urgent Care Centres
Walk-in centres
Emergency Departments
London Ambulance Service
Mental Health Services
Dental Services
Pharmacies
Community Services
6. Team Resources
The NHS111/GPOOHs Project will need a team of decision makers who will be required to work autonomously, reporting to the NCL Collaboration Board or the five Individual Governing Bodies. We recommend the following, as outlined in the Terms of Reference3:
Senior Responsible Officer – NCL Chief Officer and Chair
Senior Responsible Clinician
Clinical Champion – NCL GP Governing Body Member
CCG Urgent Care Clinical Leads
CCG Urgent Care Management Leads
CSU Contract and Procurement Managers
NHS England
Provider (when the implementation phase is reached)
3 North Central London CCGs NHS 111/OOHs Working Group Draft Terms of Reference, v2.1
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Patient representative
Healthwatch representative
An overall Programme Manager will be required to coordinate the work streams and report into the NCL Collaboration Board. The first priority for this post will be the NHS 111 and the GPOOHs procurement whilst at the same time commencing the phase 2 element of the strategy (NCL Urgent Care Review).
The senior responsible clinician will lead the clinical work group, and undertake the clinical aspects of both the Programme and the commissioning project. A Clinical Champion who is a GB board member will be recruited to work alongside the clinical lead.
Resources will be required for communications, financial planning, contracting and procurement, which should come from business as usual resources in discussion with the CSU. Expert procurement support has been agreed at 80 days for the project. However, there is a need for additional funding to cover the detailed activity and financial modelling required for the 111 and GPOOHs procurement.
We will also require additional administration to support the Enfield CCG PMO who will provide the process management.
7. Financial Summary
The financial models below show current contract value, the cost of continuing with current services for a further 5 years and the cost of the integrated 111 and OoH model for a 5 year period.
7.1 Current activity and cost
Commercially confidential information.
7.2 Activity and cost with the continuation of the current 3 contracts across NCL
Commercially confidential information.
7.3 Activity and cost with integrated 111 and OOH service and 1 contract across NCL
Commercially confidential information.
8. Case for Change
8.1. National drive for reconfiguration of urgent and emergency care
8.1.1. Increasing pressure on urgent and emergency care
The urgent and emergency care system is under pressure and there is local agreement that the system needs to respond to the significant challenges it is facing. The recent Emergency
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and Urgent Care review report by Sir Bruce Keogh has highlighted that the majority of patients seeking care in Emergency Departments could be better cared for closer to home4.
Figure 5: Emergency Department Attendances in North Central London, by CCG
Approximately 40% of patients seeking care in Emergency Departments are discharged without treatment and there were over 1 million avoidable emergency hospital admissions in England last year. This is true for NCL and was further evidenced earlier this year by the review undertaken in Camden and Islington CCGs5 highlighted that of the 191,188 Emergency Department attendances approximately 18.5% were discharged without treatment. These numbers suggest that change is needed in the way urgent care services are organised and delivered to provide patients with better quality of care in a more appropriate care setting.
8.1.2. Accessing the Right Care, First Time
The wide variety of urgent care services and lack of clarity on what each service can treat causes a lot of confusion. It seems inevitable that patients will often choose to attend Emergency Departments when they have an urgent care need, because they know what to expect from this service. This confusion over where urgent care can be sought is not helpful to patients, healthcare professionals, providers or commissioners. If patients are to be supported in making the right decision, first time, there needs to be clarity and simplicity in the urgent care system and this will require a streamlining of urgent care services.
One of the key aims of NHS 111 is to make it easier for patients and the public to access urgent healthcare and drive improvements in the way the NHS delivers that care6. One of the key recommendations in the Emergency and Urgent Care review report is ensuring that people with urgent care needs are given the right advice in the right place, first time to ensure they then seek care in the setting most appropriate for their needs, rather than defaulting to Emergency Department. To achieve this NHS 111 needs to be enhanced and marketed as the ‘smart call to make7’ creating a 24-hour personalised priority contact point.
4 Urgent and Emergency care review report, Sir Bruce Keogh, November 2013, page 5
5 Camden and Islington Urgent Care Review Finance and activity modelling, January 2014
6 NHS 111Commissioning Standards (draft) v0.1, section 2.1, page 5.
7 Urgent and Emergency care review report, Sir Bruce Keogh, November 2013, page 8
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The report also notes the benefits of NHS 111 being at the heart of an integrated care network8.
8.2. National Learning from the NHS 111 Pilots
NHS 111 services have now been commissioned throughout England and after some initial performance challenges in some parts of England the service is now stable, supporting the delivery of high quality urgent and emergency care. Although NHS 111 providers are operating to a national specification, they have all incorporated local innovation, which means we have a platform that can be used to understand what has worked and what hasn’t. Six pilots have been closely monitored by the NHS 111 Learning and Development Programme to provide:
an evidence based response to the national U&EC review;
further development of NHS 111 commissioning standards; and
the continual development, design and delivery of local NHS 111 and GPOOH
services by CCGS and providers.
8.2.1. Phase 1 pilots – key findings relevant to this service
1. GP early intervention pilot: Compared to Clinical Advisors, GPs in NHS 111 reduced the number of ambulance dispositions. Small increase in ED dispositions. GPs increased the use of self-care advice and reduced the urgency of primary care dispositions. This was completed without increasing call length.
2. Clinical assessment of green ambulance dispositions pilot: Further clinical (NHS 111 nurse / paramedic) assessment of urgent (green) ambulance dispositions led to a high proportion of changed dispositions (61%–70%), largely in the direction of reduced urgency or diversion to ED or GP OOH. Size of this effect was consistent between pilot NHS 111 centres. Important learnings regarding the competencies and skill set of clinicians conducting the clinical re-assessment.
3. Developing a Digital NHS 111 service – Access to and sharing electronic crisis records pilot: Callers with a SPN crisis record available in NHS 111 received lower urgency dispositions compared to callers without this additional information. Particularly significant for older patients where people aged 85 and over were 5 times as likely to have their enquiry completed by NHS 111 (36%/1002 with an SPN, 7%/1365 without an SPN). London providers successfully attached SPN/ crisis records using ITK, as part of the 111 referral to providers across U&EC system.
4. Developing a Digital NHS 111 service – online access to clinical assessment pilot:
Pilot tested the impact of a GP OOH call back service on people who used the Digital Assessment Service (DAS)* via the NHS Choices website. This was restricted to 2 clinical pathways (diarrhoea & vomiting, colds and flu) linked to 2 GP OOH areas in London (NE & Central London, NW London). Findings are useful as a ‘proof of concept’ to inform further developments through the online access channel.
The outcomes of this programme will continue to be monitored and inform design principles for re-procurement of NHS 111 in London.
8 NHS 111London learning programme, chapter 2, page 18
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8.3. Need for integrating the NHS 111 and GP OOH services
8.3.1. Patient flows
The patient flows demonstrate that the majority of NHS 111 and OOH patient flows are within the North Central London but not necessarily within their borough of residence. Integrating services will enable patients to access services that are most appropriate.
Figure 6: Map of North Central London showing location of service users at the time of call
8.3.2. Clinical Activity
The majority of referrals are currently made to GP OOH services during based on the clinical needs of patients. Access to GPs and other clinicians should be more timely, reducing the number of handovers. The integrated service will enable clinicians to prescribe without the need for duplication or unnecessary referral. Prescribing cannot be offered within the NHS 111 service.
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Figure 7: Top Ten Referrals from NHS 111
8.3.3. Skill Mix – Workforce
Workforce has been identified as a focus for urgent care development by NHS England. An
NCL-wide model with integration of OOH and NHS 111 will offer the flexibility to move staff
to where they are most needed to meet changes in patient use throughout the day/year.
Workforce to include: health advisors, nurses, paramedics, pharmacists, dental nurses and
GPs
8.3.4. Urgent Care System Resilience
As part of wider support for the urgent and emergency care system the NHS 111 and OOH
services need the ability to respond to changes in demand in the rest of the system. The
current model allows organisations to respond individually but still results in duplication for
patients and inefficiencies in operational delivery that can result in delays. An integrated
model is proposed as a collaboration of providers would have to operate collectively and
respond jointly to system wide changes.
8.4. Issues with the current configuration of GP Out of Hours Services
8.4.1. Variation in current commissioning of out of hours GP services
A National Audit Office (NAO) report, published in September 20149 found that, while some GPs achieved value for money with their out-of-hours GP services, others did not, and there was significant variation in cost and performance across the country.
9 National Audit Office (2014) Out-of-hours GP services in England document
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“To achieve value for money, NHS England, either directly itself or in partnership with clinical commissioning groups, needs to: understand the variation in cost and performance, and
secure improvements in some localities; improve oversight of opted-in services where GP practices have retained responsibility for out-of-hours care; and strengthen national assurance arrangements. As it implements the vision outlined in its urgent and emergency care review, NHS England must oversee an increase in awareness of out-of-hours GP services and ensure that these services are integrated effectively with other parts of the urgent care system”10.
The Primary Care Foundation11 called for more robust performance management and quality monitoring of services by commissioners. The proposal outlined in this business case will help ensure that out of hours GP services are aligned with other London services and commissioned consistently across the five boroughs.
8.4.2. Recent reduction in Out of Hours GP activity
The number of cases handled by out-of-hours GP services has fallen significantly, from an estimated 8.6 million in 2007-08 to 5.8 million in 2013-1412. This is partly because of the introduction of NHS 111. The NAO estimates that out-of-hours GP services also cost less now, in real terms, than they did in 2005-06. However ongoing changes to the urgent care landscape, illustrated by the NHS 111 roadmap below, makes true cost comparison difficult.
Figure 8: NHS England’s future vision for NHS111
The unpredictable nature of GP out of hours activity means that commissioning arrangements need to be refreshed.
10 Out-of-hours GP services in England, NAO, September 2014
11 Colin-Thomé D, Field S. General Practice Out-of-Hours Services: Project to consider and assess current
arrangements. Primary Care Foundation. January 2010 12
National Audit Office (2014) Out-of-hours GP services in England document
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8.4.3. Public Awareness of GP Out of Hours services
Public awareness of GP Out of Hours services is poor, particularly among certain groups, including younger people and people from black and minority ethnic communities. People who are unfamiliar with GP out-of-hours services are more likely to go to Emergency Departments or call 999 if they or their family feel unwell during the night or at the weekend.
9. Links to Strategic Goals
The NCL CCGs have agreed founding values on which their vision13 is built. These values centre upon delivering best value for patients, in the most efficient and effective manner. We are pioneering a Value-based Commissioning approach as we believe that commissioning for outcomes is imperative to drive the delivery of a high quality and compassionate healthcare system.
The NCL CCGs have agreed key principles of collaboration between themselves, with a principle focus on openness, honesty and transparency. This has been agreed within the NCL Clinical Commissioning Committee, of which, each CCGs Chief Officer and Chair is a member. Together the NCL CCGs will lead the development of the local healthcare system with our partners and the people of North Central London, to ensure access to and the delivery of safe, effective and responsive services that reduce inequalities, meet identified needs and ensure maximum positive health impact within the resources available, through:
Honesty;
Integrity;
Courage;
Patient Sighted;
Competency;
Transparency;
Collaboration; and
Adherence to NHS Founding Principles.
These are reflected throughout the strategy and operating plans through our continued commitment to improve services for patients by achieving our ambitions to meet the seven system objectives.
Our plans seek to maximise our total return on investment in services to ensure that our services continuously improve outcomes for our population through our Value-based Commissioning approach. We are actively working to build effective relationships with providers to enable a collaborative approach to ensure services meet patient need and to continuously improve quality. As a group of CCGs we are taking the approach of collaborating where its adds value and localising where necessary. The following table outlines the impact of this project on the five NCL Clinical Commissioning Groups Vision and Values:
NCL Clinical Commissioning Groups Vision and Values
High Impact
Medium Impact
Low Impact
Working in partnership with individuals and patients groups to ensure they are central to our work
☐ ☐
13 NCL SPG – 5 Year Strategic Plan, 20 June 2014
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Improving quality and access to Primary and Community services
☐ ☐
Improving integration and coordination of all health and social services
☐ ☐
Ensuring the optimum use of all available resources ☐ ☐
Ensuring we work in an open and transparent way with our public and all partners
☐ ☐
An integrated NHS 111 and OOH GP service is a key intervention in the strategic plan for the NCL health economy. Attainment of the Emergency Department performance target ensures all patients who need it are seen quickly. Access to primary care is also a key issue here, ensuring Emergency Department resource is available to those who need it most. Extension of primary care access to 8am-8pm can assist to see many patients quickly and in a more streamlined way. The CCGs will support the delivery of the following strategic vision:
Support self-care – we will provide easily accessible information about self-care
options through schemes such as the ‘choose well campaign’;
Help people with urgent care needs to get the right advice or treatment in the right
place, first time;
Approach NHS 111 and Out of Hours procurement strategically across NCL;
Ensure that people with more serious or life threatening emergency needs receive
treatment in centres with the right facilities and expertise to maximise chances of
survival and a good recovery;
Ensure connectivity throughout the whole urgent and emergency care system;
Recent self-assessment by providers in meeting the London Quality Standards
demonstrated that overall in NCL there are gaps in:
consultant led services, especially at weekends;
24 hour provision of diagnostic / interventional services
mental health access at the point of emergency admission; and
timely discharge planning.
The objective is to meet the London Quality standards by 2018/19 and to ensure greater collaboration between providers to address current gaps. The London Quality Standards have been included in the proposed KPIs for acute providers and will be monitored through the contractual process.
10. Milestones
Milestone Descriptor
Milestone Date
NCLUC1 Agree resources, governance structures and ToRs 19/12/2014
NCLUC2 Project Steering Group resourced and first meeting arranged
24/11/2014
NCLUC3 Business case for 111 and GPOOHs developed for Feb 15
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approval across the 5 CCGs
NCLUC4 Clinical Service Specification approved across the 5 CCGs
May 2015
NCLUC5 Procurement of NHS111/GPOOHs commenced April 15
NCLUC6 Procurement completed and mobilisation of NHS111/GPOOHs commenced
Oct 15
NCLUC7 New NHS111/GPOOHs service commenced Apr 16
11. Engagement Plan
Key stakeholders will need to be involved including; patients, Care UK, LCW, local GPs, LAS, UCLH, RFHT, WH, NMHT, CCGs and Las to develop the new service pathways and the resources required. More engagement will be needed with a wider group of stakeholders as part of the implementation and this will be coordinated with support from the CSU and a detailed Communication and Engagement Plan.
Stakeholder Impact (H/M/L)
Concerns / issues / resistance
Benefits / what’s good about proposed change?
Acute Hospitals L Develop new patient pathways where the DoS changes to reflect more out of hospital service provision
Reduction in patients attending hospital at higher tariffs
Patients managed closer to home
OOH GP Providers
H More changes for GPs in a time of change fatigue
Impact on extended hours and resources
GPs lack of trust in trust in triage process
Patients maintained within the community
Shorter waiting times and right care, first time
Reducing additional triage and assessment process
NHS 111 Providers
H Integration with OOH services to enable a streamlined pathway (up to now GPs have added an additional layer of assessment)
One call to make – right care, first time
More streamlined service and better commissioner intelligence on services
Local GPs M Impact with extending primary care hours in a phased approach across NCL.
Streamlined pathways and greater access
Community Providers
M Changes to integration, coding and DoS may impact on current services
Current services may need to extend hours to
More integration, streamlined pathways and right care first time
Reduction in hand-offs therefore a reduction in clinical risk
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meet pathway demands
LAS M Interoperability – does the LAS have the technical expertise and willingness?
Single call with reduced hand-offs, faster response and better support
Local Authority Teams
L Changes to integration, coding and DoS may impact on current services
More integration, streamlined pathways and right care, first time
Voluntary Sector Organisations
L Changes to the DoS may increase outcome volumes to local third sector providers
Better and more appropriate care and support
Carers more involved with their treatment and care
HealthWatch M Resources to meet the needs of involvement within the sub groups
Change to service leading to improved care and outcomes
Carer’s groups L Way service is configured and provided – will service meet patients’ needs?
Change to service leading to improved care and outcomes
Patient Groups L Way service is configured and provided – will service meet patients’ needs?
Change to service leading to improved care and outcomes
12. Critical Success Factors
Critical Success Factor
Measurement of Success
Action Target date for completion
All CCGs to adopt the new specification
Agreement from all 5 CCG Boards
Written confirmation received
May 2015
CSU have available resources and skills to support the project
Procurement, data analysis, financial planning and contract outputs delivered
Contract and procurement requests provided
January 2015
Interoperability Single patient call All stakeholders must improve their IM&T systems to ensure objective is achieved
December 2015
Single contract for whole system
One contract developed to provide
CSU to provide contract
October 2015
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provision all services needed from one or multiple providers
The provider to integrate with other local services to support a coherent urgent care system
Specified within service specification and contract
Accurate Directory of Services management
April 2016
Resources available to provide support and expertise to project
Project Board and sub groups have required resources and expertise
Stakeholders to provide subject matter experts
September 2014 and ongoing
13. Risks
Risk Description Impact Likelihood Total Risk Score
Mitigation
Specification agreement Delay
4 3 12 SRO to canvass COs
Funding not available 5 2 10 SRO to obtain agreement
Full resources unavailable
4 2 8 Use external and CSU resources
Change in clinical scope
5 2 10
Ensure Clinical Commissioning GPs are fully engaged
Change in clinical scope
5 2 10 Ensure GPs are fully engaged
Failure to involve all stakeholders
4 2 8
Programme Board established a.s.a.p. with appropriate stakeholders
Current Providers unwilling to negotiate contract extension
5 1 5 Favourable discussions already underway
Failure to manage activities to programme
5 3 15
Ensure experienced Programme Manager is utilised
1 = low, 5 = high
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14. Assumptions
14.1. Commissioning
All 5 CCGs in agreement to the new specification for an integrated
NHS111/GPOOHs service
All 5 CCGs are in agreement with the 111/GPOOHs project, costs and the scope
Clinical Commissioning Leads are available and empowered
Commissioning resources have been identified and are available
14.2. Finances
Resourcing budget will be agreed
Financial planning support available
Identified outcomes and benefits are pragmatic and achievable
14.3. Governance
Programme Board ToRs agreed
Project Steering Group ToRs agreed
Subject Matter Experts are available and have the necessary time to devote to the
project
The use of the Enfield PMO is assured and appropriately resourced
The Steering group and sub groups have robust leadership
External skills have been highlighted and commissioned
14.4. Contract and Procurement
Procurement resources are available from CSU
Contract methodology agreed
CSU has necessary skills to formulate an appropriate contract
Contract is aligned to the London Learning Programme and NHSE guidance
14.5. Data
Baseline data is accurate and comparable
CSU can provide data analysts with the skills to mine the data appropriately
14.6. Technical
CSU has the right technical expertise to facilitate the tasks require to meet the
service specification, i.e. interoperability, DoS manipulation, coding, telephony, etc.
15. Monitoring
The Urgent Care Review will be monitored by the Programme Board using a Performance sub-group, which will also monitor savings against the financial assumptions in parallel with the Finance sub-group for the 111/GPOOHs project.
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Monthly highlight reports will be discussed and any data that exceeds agreed financial or performance parameters will be rectified by the Programme Board and reported to the NCL Collaboration Board and an improvement plan initiated.
A performance dashboard will be developed as a tool to monitor compliance against standards and levels of savings the new model will generate against plan.
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Appendix 1 – NHS 111/GP OOHs Project Steering Group Governance
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Appendix 2 - Cost of continuation with current contracts for a 5 year period – per year
Commercially confidential information
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Appendix 3 – cost of the integrated service for a 5 year period – per year
Commercially confidential information
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Appendix 4 – Document History and Approval List
Document History:
Date Version Author Changes
24/11/14 1 Mark Featherstone Initial draft
29/12/2014 1.1 Clare Kapoor Incorporate Islington comments
27/01/2015 1.2 Clare Kapoor Add clinical model
04/02/2015 1.3 Clare Kapoor Revisions following comments from Haringey and Islington
04/02/2015 1.4 Clare Kapoor Finance section
06/02/2015 1.5 Leo Minnion General changes to flow throughout document
11/02/2015 1.6 Sam Shah General changes throughout the document
12/02/2015 1.7 Sam Shah General changes throughout the document
12/02/2015 1.8 Clare Kapoor Confidential watermark removed
23/02/2015 1.9 Camden comments
05/03/2015 2.0 Sam Shah General changes throughout the document
Document Approvals:
Named leads that have approved this document prior to submission for approval
Date Area Name
Programme SRO Liz Wise
Clinical Lead Dr Samit Shah
Finance Lead Robert Whiteford
Contract Lead Bernhard Crede
Procurement Lead Jeanetta Nelson