1

Urgent care – the case for change Urgent care: “The range of responses that health and social care services provide to people who require (or perceive the need for) urgent advice, care, treatment or diagnosis”

Direction of Travel for Urgent Care, Department of Health Introduction

The Barking and Dagenham CCG officially becomes responsible for commissioning most local healthcare services from April 2013. We have already identified the redesign of urgent care as a key priority. We want to work in partnership with the London Borough of Barking and Dagenham and the Health and Wellbeing Board, to take on the challenge of delivering excellent health care services in our borough.

Despite the progress in health and social care made over the past few years, we need to change. Our understanding of urgent care is growing and we know that we cannot simply continue providing services the way we do now. If we don’t, we are not only failing to meet the needs of our community effectively now, but we will also not be able to cope with patient demand and challenges we expect in the future.

We are considering how to improve our urgent care service “to ensure patients and the public have access to convenient, high quality, timely and cost effective urgent and emergency care services and know how to access these services effectively”.

This document sets out the CCG’s reasons for considering changes to the current system. It is intended as a discussion document with which to engage stakeholders in developing a local urgent care strategy which transforms the quality of services in the borough. Please take a look and give us your thoughts, so we can develop services of which we can all be proud1.

Dr Waseem Mohi, Clinical Director and Chair

Dr Richard Burack, Clinical Lead, Urgent Care

Dr Gurkirit Kalkat, Clinical Lead, Primary Care

Dr Arun Sharma, Clinical Lead, Locality Model

Commissioners need to focus on six themes to develop integrated urgent care services:

1. Build care around the patient not the existing services

2. Simplify an often complicated and fragmented system

3. Ensure the urgent care system works together rather than pulling apart

4. Acknowledge prompt care is good care

5. Focus on all the stages for effective commissioning

6. Offer clear leadership across the system, while acknowledging its complexity

Breaking the mould without breaking the system, Primary Care Foundation and NHS Alliance, 2011

1 You may prefer to look at the case for change slide pack which illustrates and highlights key points. Details are on the back page

2

Context

In 2010 Barking and Dagenham’s population was estimated to be around 187,000. The population has increased by 14% since 2001. Within Greater London, Barking and Dagenham had the biggest percentage population increase (2.4%) of all London boroughs between 2009 and 2010. This equates to a 12% in children. This is mainly due to increasing births and children aged under four, as well as more people aged between 20 and 50 living in the borough. The population is expected to continue to rise by about 2,600 per year2.

The local population is one of the most deprived in the country and life expectancy for both men and women is lower than the England average. About 10% of the population has caring responsibilities for someone who is ill, frail or disabled.

Clinical Commissioning Groups (CCG) From April 2013, the GPs leading Barking and Dagenham CCG will be responsible for commissioning the majority of healthcare services. This new arrangement will be a unique opportunity to improve and integrate services as GPs will be able to provide more clinical input into service planning than has previously been available and focus on developing integrated care that improves the quality of care for all patients

Primary care The borough has 40 GP practices, 38 community pharmacies and 19 general dental practices as well as 45 general opticians and an orthodontist3.

The borough has a registered GP patient population of 209,000 – 20,000 more than the resident population.

2 Joint Strategic Needs Assessment, London Borough of Barking and Dagenham and NHS Outer North East London, 2011; and Health Profiles, English Public Health Observatories, 2011

3 A dentist specialising in the prevention and correction of teeth irregularities.

3

111 111 is an easy to remember phone number that will be available from February 2013. It is for less urgent calls than 999. It will be staffed 24/7 (24 hours a day and night) by health advisers and call handlers with local knowledge at their fingertips, who will be able to direct you to the right treatment at the right time in the right place. In future they will be able to book GP appointments.

King George Hospital and Queen’s Hospital King George Hospital will have an important role in meeting the health needs of local residents as well as providing some specialist services for a wider population. Key services will include 24/7 urgent care and GP services: with 12 hour a day walk-in GP practice; booked appointments; better access to tests; GP out-of-hours service and telephone advice; and access to a range of specifically targeted diagnostics and urgent care support.

Queen’s Hospital is the major acute hospital for the sector and in future will provide all A&E services for the area4.

Both hospitals have urgent care centres where more patients who have primary urgent care needs will be seen. Patients whose needs do not need immediate attention will be referred back to their own GP practice wherever clinically appropriate.

Current urgent care activity

In its Commissioning Strategy Plan 2012-155, Barking and Dagenham CCG identified urgent care as a priority area for improvement within the overall direction of the commissioning strategy plan to build on quality improvement, increase productivity and move care and services closer to people’s homes.

Local people can access urgent care in a variety of ways, for instance: through a visit to the pharmacy: an urgent or booked appointment at their GP, dentist or optician; through the out of hours service; a walk-in or minor injuries unit or an A&E.

In May 2011, we undertook a study of urgent care activity for Barking and Dagenham residents at:

The Out of Hours service Walk in centres at Broad Street and Upney Lane as well as for B&D patients attending the neighbouring Loxford polyclinic The urgent care centres at King George and Queen’s Hospitals Accident & Emergency at King George and Queen’s Hospitals

This study did not include services provided by pharmacies or on weekends or in working hours by GPs. We know that a lot of urgent and “immediately necessary” treatment is seen at GP practices. In addition, people managing their own care, including using community pharmacies. We are looking in more detail into all of these services to understand their impact on the overall urgent care offer to patients and to consider options for a future service.

4 Health for NEL summary of decisions at www.healthfornel.nhs.uk 5 http://www.onel.nhs.uk/downloads/News-and-publications/Strategies-and-plans/CSP-BD-2012-15.pdf

4

The study showed that, in the last four years there has been a steady increase of 9.17% in the activity at these services (the activity counts each visit or call to these service so includes for example multiple visits from the same person), as shown in Graph 1 below:

170,000

Graph 1: B&D Total urgent care activity in out of hours, walk-in, urgent care centres and A&E for 2008/09 to 2011/12

160,000

150,000 Total Activity

140,000 Year 08/09 Year 09/10 Year 10/11 Year 11/12

Looking at the trends in further detail in Graph 2 below, however, we see that activity decreased between 2008/09 and 2011/12 in:

The out of hours service – activity decreased by 9.3% in that time, much of it caused by a steep drop in activity in 2009-10. We need to understand the reasons for this.

The urgent care centre at King George Hospital. In addition, there was no significant activity shift between A&E and the urgent care centres at either King George Hospital or Queen’s. Primary care type activity is estimated to make up 50% of all A&E activity at King George and Queen’s Hospitals – yet we are not seeing the shift to more appropriate services we would expect. A process called a ‘redirection order’ has recently been put in place to divert these types of patients away from A&E.

Broad Street and Upney Lane walk-in centre each see 19% of total urgent care activity, or a combined total of 38%. Of this, we know that that approximately 10% is activity from outside of Barking and Dagenham. Equally, Barking and Dagenham patients are also using other walk in services outside the borough, in particular, at the Loxford and Harold Wood polyclinics.6

70,000

Graph 2: Activity in various services for 2008/09 to 2011/12

60,000

50,000

40,000

30,000

20,000

10,000

Accident & Emergency

KGH UCC Queen's

UCC Loxford WIC

Upney Lane WIC

Broad Street WIC

Out of Hours

-

Year 08/09 Year 09/10 Year 10/11 Year 11/12

6 http://www.onel.nhs.uk/health-services

5

Current performance

We are reviewing our performance in more detail drawing on the Royal College of GPs Guidance for commissioning Urgent and Emergency Care, together with its accompanying toolkit7 8. In this way, we aim to develop a whole system approach based around the patient. To do this, we know we also need to look at primary care activity.

Primary care The national GP patient survey 2011/129 relates to all GP services and not just urgent care services offered by the practices. The response rate was low, but it indicated that almost half (19) of GP practices score below the national GP average score, nine practices have an overall score about the same as the national average and 13 practices have an overall score above the national average.

Key issues across Barking and Dagenham that met or were above the national average patient score are:

Indicator B&D average

National average

Helpfulness of receptionists at GP surgery 89% 89% Satisfaction with opening hours 81% 83% Overall experience of making an appointment 79% 79% Ease of getting through to someone at GP surgery 78% 82%

There are, however, more issues that score significantly below the national average:

Indicator B&D average

National average

Impression of waiting time at surgery 53% 61% In last 6 months, had enough support from local services or organisations to help manage long term condition(s)

58% 64%

Rating of nurse involving you in decisions about your care 62% 68% Overall experience of out-of-hours services 64% 71% Rating of nurse treating you with care and concern 69% 79% Rating of nurse explaining tests and treatments 69% 78% Rating of nurse giving you enough time 71% 81% Rating of GP involving you in decisions about your care 71% 76% Rating of nurse listening to you 72% 80% Confidence and trust in nurse 77% 86% Rating of GP treating you with care can and concern 77% 84% Recommending GP surgery 74% 82% Rating of GP giving you enough time 81% 87%

7 Guidance for commissioning integrated urgent and emergency care: a 'whole system' approach, Dr Agnelo Fernandes, RCGP, 2011 www.rcgp.org.uk/pdf/Urgent_emergency_care_whole_system_approach.pdf

8 www.rcgp.org.uk/pdf/Toolkit_Content_Final.pdf 9 Ipsos MORI GP patient survey 2011/12

6

Walk-in services

In our Commissioning Strategy Plan, we made a commitment to review activity at our walk in centres. In November the Barking and Dagenham LINk, the walk-in centres and the CCG worked together to undertake a joint survey and audit of a full week’s activity:

The LINk was commissioned to do a patient survey to understand:

People’s motivations for using the walk-in centres

If and where they seek help before and after using the centres

How they feel about the care they receive (a 10% sample)

The CCG will report on this and on the walk-in centres’ audit of:

The medical reasons why people use the walk-in centres

The clinicians’ diagnosis, active management and referrals.

Case for change

What do the issues facing the NHS, the urgent care activity and performance in Barking and Dagenham tell us?

There is a need to improve the quality of services, redesign how we deliver urgent care in the borough to ensure services are of a uniformly high standard

We need to help people to look after themselves, to understand and trust our services and make it easy to access them

Managing emergency activity and

urgent care is one of the King’s

Fund’s top 10 priorities for

commissioners. It highlights that:

Urgent care services are currently

often highly fragmented and

generate confusion among

patients about how and where to access care (Lattimer et al 2010).

Poor sharing of information as

patients move between different

providers of care in an emergency

is a cause of many significant

failures of care (Gandhi 2005).

The quality of out-of-hours care is

highly variable, particularly in terms of continuity of care,

leading to variable patient

experiences (NAO 2006).

The growth of new forms of

urgent care has failed to reduce

A&E attendances (Cooke et al

2004). Emergency attendances in

England rose by 46 per cent

between 2003/4 and 2009/10, (Department of Health 2011c).

Walk-in centres do not appear to

have led to shorter waits in general practice or lower

admission rates at other health

care providers (Salisbury 2003). Transforming our healthcare system: 10 priorities for commissioners, King’s Fund 2011.

The system is inefficient and not good value for money. It will struggle with demand in future. We are seeing an increase in urgent care activity overall and are not seeing a reduction in A&E activity despite the provision of Walk in Services and Urgent Care Centres. We are spending far too much money on treating people in walk in centres and in A&E with primary care type conditions which could be managed by the GP practice. If we manage this better, this will reduce the demand for urgent care and mean more resources to invest in preventing ill health and helping people live healthier, longer lives.

7

A need to improve the quality of services, redesign how we deliver urgent care in the borough to ensure services are of a uniformly high standard.

1. Increased integration will enable GP practices to reinforce their role as the first point of

access for patient care and their accountability for all care. Better primary care which is integrated with specialist health and social care provision is particularly important for older people and those with long term conditions. There is an ever increasing rise in the number of people with long term conditions: they make up 80% of all GP consultations and around 70 per cent of NHS resources10. Continuity of care with a GP helps avoid hospital admissions11. If they are not managed patients can deteriorate/need urgent care.

2. Improve the quality of general practice by raising the bar for all GPs and targeted

work with those practices where patients are less satisfied to reduce the differences between patient experiences.

3. Improve referral practices and pathways in urgent care which are highly variable and

inconsistent across the borough. We need to look at effective pathways which ensure the patient is seen in the right place, first time, every time.

4. Improving urgent care: We believe we can significantly improve services for patients

and reduce pressure on A&E services. The changes will ensure that A&E services are able to concentrate on patients who most need specialist care.

We need to help people to look after themselves, to understand and trust our services and make it easy to access them

5. Self care: Around 80% of all care in the UK is self care. The majority of people feel

comfortable managing everyday minor ailments like coughs and colds themselves; particularly when they feel confident in recognising the symptoms and have successfully treated using an over-the-counter medicine before12. More work needs to be done to enable people to feel confident to self-manage a wider range of their conditions with the right support from existing services, particularly community pharmacies.

6. Registering with a GP: Not everyone is aware of how to register with a GP or their role in

the health service, including providing urgent care. Once someone has decided they need to see a health professional, for example if self-care or advice from the community pharmacy isn’t sufficient to meet their needs, we want the GP to be accessible as the first point of contact for all health care which isn’t an emergency.

7. Making appointments: Often a patient doesn’t need urgent care. But they don’t know

how to get a planned appointment or the right care. Some patients don’t know how and when – this can mean they don’t go to the best place to treat their condition. Not all patients are satisfied they can get the appointment they need or enough time once in a surgery with the nurse or GP.

10 NHS 2010-2015: From Good to Great, Department of Health, Dec 2009 11 Breaking the mould not the system, Primary Care Foundation and NHS Alliance, 2011 12 http://www.selfcareforum.org/

8

8. Unregistered patients: Patients who are not registered receive “episodic care” and miss out on the holistic care that a GP provides such as immunisations and health checks. Walk-in centres in particular tend to discourage people from registering with a GP – around 10% of patients attending Upney Lane walk-in centre are not registered.

9. Many ways to access care. The current system is complex with different access routes

depending on the time of day. Some services are excellent and easy to access, but not enough people think about them to provide the care they need, for instance pharmacies.

10. Out of hours: GP services are not always accessible or sufficiently fast. In recent years

the use of the dedicated out of hours service has reduced. This suggests more patients are going to a walk-in centre, using an ambulance or attending A&E – perhaps because these services are considered better or easier to use.

a. Using an ambulance can put pressure on real emergencies and A&Es b. Using a walk-in centre, an ambulance or A&E is costly c. If people use a walk-in centre or A&E to treat urgent conditions, underlying

causes of illness (for instance substance addictions) may not be picked up or treated early – leading to more severe illness in future

d. Some illnesses are not best treated in hospital or A&E settings, for instance mental health problems.

11. A&E and urgent care services are under severe pressure. Clinicians believe key

reasons for this include: Staff are stretched too thinly across too many sites, making it more difficult to provide a 24/7 service and manage peaks and troughs in attendances;

A lack of availability of specialist staff (sometimes driven by increasing sub- specialisation of clinical practice); A&Es full of patients requiring urgent care but not emergency or complex care; Too many patients being admitted to hospitals because there are no alternative treatment options13.

13 Health for NEL summary of decisions at www.healthfornel.nhs.uk

9

The system is inefficient and not good value for money. It will struggle with demand in future

12. Services are often duplicated – with different services open at the same time – as

shown in the timeline illustration below. This leads to both patient confusion about where to seek urgent care and to variation in the ways in which patients enter and are referred through the health system. For instance, research suggests that walk-in centres do not appear to have led to shorter waits in general practice or lower admission rates at other health care providers14. Walk-in centres are rapidly closing across the country, with figures recently suggesting a quarter have closed in the past year15.

13. Demand is growing: walk-in services, urgent care centres and A&E departments

continue to see year on year increase, much of it primary care related. Somehow we need to maintain and improve quality whilst coping with more demand and with resources that are not increasing at the same rate as the requirements for care.

14. Capacity needs to be closely matched to demand: Some services can be over-run at peak times (for example A&E) while others are underutilised.

15. The system is complex to manage, with a lack of clarity on who does what and how

contracts for services are monitored and payments are apportioned.

16. Telephone health services are changing. The NHS Direct Service will cease in its current form and a new 111 telephone service is being rolled out nationally by 2013-14.

17. Variation in quality and accessibility of premises: A great many of the premises being

used for primary care across outer north east London are not up to standard – we need to make better use generally of our premises.

14 http://www.kingsfund.org.uk/projects/gp-commissioning/ten-priorities-for-commissioners/urgent-care 15 www.bbc.co.uk/news/uk-politics-18503034

10

Our commitment

The need to change urgent care services has been recognised by the CCG and others:

1. The Barking and Dagenham Health and Wellbeing Strategy 2012-1516 sets out how the

council, the NHS and other organisations aim to prevent, protect, improve and personalise services to:

increase the life expectancy of people living in Barking and Dagenham close the gap between the life expectancy in Barking and Dagenham and the London average

improve health and social care outcomes through integrated services

Our plans aim to deliver the ambition of the Health and Wellbeing Strategy: “More children and families have access to urgent care community services which meet their needs.”

2. Barking and Dagenham’s Commissioning Strategy Plan 2012-1517 has also identified the

need to redesign urgent care services and particularly highlighted the requirement to:

increase productivity and move care and services closer to people’s homes reduce variation in performance across providers reduce inappropriate use of A&E deliver high quality, equitable and value for money care from fit for purpose estate

3. The Joint Strategic Needs Assessment (JSNA) for 2012 is being finalised. The 2011 JSNA recommended18:

Every child the best start in life:

Consider a more detailed review of accident and emergency, walk-in centre and GP out of hours attendances due to accidental injuries, particularly in the under 5’s

Children and young people: Learn from the partnership work around Delayed Transfer of Care to review the Urgent Care Pathways for children and young people; CCGs should work with strategic partners to improve management of non-emergency child health issues in the community; and all urgent care settings should have appropriate child protection training and policies in place

Ill health prevention for adults

Preventing ill health and helping people live healthier lives and live longer.

16http://moderngov.barkingdagenham.gov.uk/documents/s61216/Joint%20Health%20and%20Wellbeing%20strat egy%20V.7.pdf

17 http://www.onel.nhs.uk/downloads/News-and-publications/Strategies-and-plans/CSP-BD-2012-15.pdf 18 http://www.barkingdagenhampartnership.org.uk/news-archive/Pages/jsna2011.aspx

11

Our principles for the urgent care service

No confusion of what to do, who to call or where to go A joined up and co-ordinated urgent and emergency care system Consistent, responsive and high quality service A consistent, standard offer throughout Barking and Dagenham - within and between each of the localities.

We want to provide urgent care services that are timely, trusted, easy to understand, comprehensive, are of a uniformly high standard, are integrated with secondary, community and social services and are efficient – so taxpayers’ money is used wisely

Our proposals

The CCG wishes to develop a strategy to better integrate urgent and emergency care – a whole system approach19 20 based around the patient. We want to commission coherent 24/7 urgent care services to support easy and appropriate access to the right level of service and provide responsive services for children, frail older people and those with mental health needs that integrate effectively with primary, community and other services designed to keep people well and out of hospital.

GP practices should be arranged in primary care localities, based largely on the

existing clusters. We will know how many localities when we have developed the model further, but sites would be chosen to provide services that would otherwise have to be provided in hospital. Patients will be able to access most services they need from their own GP practice. By working together GP practices will be able to:

Offer a greater range of services Share knowledge and expertise Better manage resources and patients (e.g. offer appointments at different surgeries). The current system has the potential for GPs to collaborate and share GP capacity21.

The mechanism for establishing this is described in the Royal College of GPs Toolkit for the development of primary care federations. These groups of practices would share responsibility for developing and delivering high quality, patient focused services for their local communities22. This will enable GP practices to re-establish themselves as the first point of contact for urgent (and planned) care. The service would work alongside the integrated care service which is already being established in six clusters and generally be accessed through usual GP surgery numbers or 111.

The NHS 111 telephone number goes live in Barking and Dagenham in 2013. The service is staffed by a team of fully trained advisers, supported by experienced nurses. They will ask questions to assess symptoms, then give healthcare advice or direct patients straightaway to the local service that can help them best. 111’s Directory of Service provides a new opportunity to support self care at pharmacies and share health service information. We will ensure that a new urgent care service integrates with 111.

19 Guidance for commissioning integrated urgent and emergency care: a 'whole system' approach, Dr Agnelo Fernandes, RCGP, 2011 www.rcgp.org.uk/pdf/Urgent_emergency_care_whole_system_approach.pdf

20 www.rcgp.org.uk/pdf/Urgent_emergency_care_whole_system_approach.pdf 21 The number of GPs per 1,000 patients for B&D is in the lower quartile nationally 22 www.rcgp.org.uk/pdf/Toolkit_Content_Final.pdf

12

An urgent care service needs to be developed for when seeing a practice GP is not an option (e.g. out of hours and for unregistered patients). This would be integrated, and would work in conjunction with current walk-in services – although these would probably require some reconfiguration (along with extended hours services).

We need to ensure we utilise high quality estates. There has been good investment in

estate and we need to maximise its potential use.

There needs to be a shift of resources and funding from hospitals to primary and secondary prevention in order to avoid unnecessary urgent care and hospital admissions. We need to work with partners to seek incentives that encourage partnership working and delivery of the best possible care rather than redirecting activity or encouraging perverse activity.

The benefits These proposals aim to transform the way services are delivered to:

improve access – with the GP as the first point of access - we would be looking to develop a model that shift resources into improving primary care capacity and access improve patient outcomes and experience of general practice assist primary care teams in improving the way they work increase service integration reduce duplication reduce the variation in services maximise the efficiency of the health service

Frequently Asked Questions (FAQs)

Question 1: What would happen to current patterns of service for the 999 ambulance, A&E and specialist care for emergencies/more complex cases?

Answer: They would remain – the focus is on making sure this level of care is targeted for patients in need. The expectation is that the pressure on 999 and A&E would be relieved by better access to primary care.

Question 2: Are you reviewing A&E and all types of urgent care?

Answer: This case for change focuses on primary urgent care and how we can design GP localities to maximise the GP’s central role in managing patients’ needs. We are keen to understand the impact that has and would have on all urgent care services. Decisions about changes to A&E in north east London have already been made. This work will ensure that the improvements needed in primary care will support the overall plans for the area.

Barking and Dagenham CCG Barking Community Hospital Upney Lane, Barking Essex IG 11 9LX Telephone: 020 8532 6314 http://www.barkingdagenhamccg.nhs.uk/