HYWEL DDA UNIVERSITY HEALTH BOARD’S RESPONSE PUBLIC ACCOUNTS COMMITTEE

Primary Care Out-of-Hours (OOH) Services

Patient Experience

· Since the 111 service was fully rolled out to all areas of Hywel Dda University Health Board (the Health Board) (October 2018), there has been in the region of 20,000 contacts made from patients within the region.  To date, there have not been any notifications of significant events relating to the care received by service users.

· Patients are able to access care from GPs and non-medical clinicians at five treatment centres located throughout the Health Board region: Prince Philip in Llanelli; Glangwili in Carmarthen; Withybush in Haverfordwest; Llyn Y Fran surgery in Llandysul; and Bronglais in Aberystwyth. 

· In addition to face-to-face clinicians, there are advice GPs who operate as a part of the clinical model.  In addition, as a part of the 111 provision, GPs, Pharmacists and senior nurses operate within the Clinical Support Hub; the aim of which is to undertake consultations with the more complex patient demographic.

· Following the launch of 111 in Carmarthenshire in May 2017, Hywel Dda Community Health Council (the CHC) undertook a survey (supported by the Health Board) and have produced a patient experience report.   Whilst some important themes key to improvement were identified, the response and hence sample size was disappointingly small with only 36 patients completing the survey.  Some of the themes included:

o Assessment of the success of the Health Board communications strategy in relation to 111;

o Monitoring of 111 standards and response times;

o Continued efforts to be made by the Health Board to strengthen the GP OOH provision so that patient direction and NHS capacity is maintained;

o Reports of positive experiences to be shared with staff;

o Feedback from service users to be discussed and any opportunity to improve the services be observed;and

o Feedback from service users to then be shared and details of how it influences the 111 service to be made available.

· Discussions are now underway to commence a Health Board wide survey since 111 was rolled out across the remainder of the Health Board in October 2018; this is provisionally planned for quarter 1 in 2019/20.

· At time of reporting, there is also a CHC Wales-wide survey-monkey under way, which aims to assess patient experience within the broader OOH service.

Financial and Clinical Sustainability

· The Health Board spans a significantly large and challenging geographical area.  There are pockets of urbanised communities surrounded by vast swathes of rural which is a mix of urban and rural by nature. 

· The Health Board operates five OOH bases across its area of responsibility; four are co-located with secondary care emergency services, and the fifth is affiliated to a GP practice in south Ceredigion. 

· The Health Board has experienced a number of cost pressures, including:

o Ad hoc pay enhancements offered and taken up in efforts to improve shift fill status when cover drops below what the service considered a critical level. This measure has not served the service well as there was little evidence to support claims that patients have significantly increased access to services as a consequence.

o When shifts are not filled, there is sometimes a financial benefit but there is a corresponding negative impact in the wider system.  On the other hand, when the rota gap stems from salaried staff absence, there is no saving and securing locum cover means the service pays twice for such sessions.

o The service stands out as the highest cost service in Wales per head of population, which is driven by the rural nature of the service that impacts on the number of bases in operation.

· HMRC cost pressures arising from the employer’s duty to pay NI contributions (2017) are in the region of £300k per annum.  The service has had to meet this cost from patient care monies.

· The impact of HMRC’s changed viewpoint on the self-employed status of GPs has resulted in some sessions being withdrawn.  Other service changes, such as the rollout of 111, has also had a negative impact on GP availability, albeit transiently.  Acceptance of the new models has been an issue and been subject to significant engagement work.

· As a part of service redesign and succession planning, there is now a requirement for investment opportunities (advanced practice/alternative models) to prepare for the future.  This could be considered an investment, which could produce a yield in 5-10 years’ time given the periods required to train and develop advanced practitioners adequately.  These timescales allow experienced GPs to provide support and supervision to new advanced practitioner recruits, prior to retirement.

· Vacant shifts due to lack of GP interest is not an uncommon feature in the service.  These most frequently occur at weekends when the service faces its highest demand.  This is exacerbated by a lack of uptake in salaried posts. A rolling recruitment has resulted in five successful employments, but three have been from GPs who were in locum positions and were able to change their employment arrangements due to varying personal circumstances. Therefore, there has been no real net gain in the workforce position.   For many GPs, the flexibility in locum work is attractive and is a factor in the poor uptake in salaried recruitment.

· Since 111 was rolled out into Pembrokeshire and Ceredigion (October 2018), the Health Board has provided an additional advice GP resource.  Assessment of its  efficiency and the impact on how it may have diverted advice work away from GPs who need to see patients face to face, will soon be undertaken in conjunction with the 111 team; this will inform the decision as to whether additional advice resource is a justified investment. 

· The Health Board’s broader financial position is presently not conducive to supporting the long-term OOHs strategy, given that an increased run rate will exist for temporary period. Accommodating this, at least in the medium term is a challenge for the Health Board. 

Information and Performance Management

· The Health Board submits monthly returns to Welsh Government against the OOH standards.  There is a hiatus in the flow of data from October 2018 to date, which is attributable to determining reporting criteria as a part of the 111 system. However, the new (interim) standards are being launched on 1 April 2019, which take account of the service changes brought about by 111.  

· Reporting is to be completed by the Welsh Ambulance Services NHS Trust (WAST) as a part of the data sharing agreement. Discussions are underway to discuss content and local requirements.  The Health Board will retain access to the data set and organisational reports are set to continue.

· There is a data sharing protocol in place between the Health Board, Abertawe Bro Morgannwg University Health Board and WAST, which allows the production of full end-to-end analysis of OOH activity in the West Wales Region. 

· The Health Board has access to software and is developing individualised reports that highlight its activity.  A meeting has been arranged for 5 March 2019 to support development of the reporting mechanisms.

Peer Review

· The Health Board’s OOH service took part in the inaugural peer review exercise in 2018 (chaired by Dr Chris Jones, Chair of Health Education and Improvement Wales (HEIW)).

· The review looked at all aspects of service provision and discussed issues affecting the service with managers, clinicians and administrators involved in the OOH service in order to better understand the underlying local service issues. 

· It was at the Peer review that previous work to train administrators as Health Care Support Workers (HCSW) was shared with the review team.  This has resulted in a pilot, funded by the 111 program, which is promoting the expansion of the operational team that have contact with patients. 

· The Health Board is running a pilot where drivers double up as HCSWs and join GPs during house calls, in addition to base working.   Through this interaction, HCSWs carry out basic observations and other tasks relevant to their training and competence; work which would otherwise have to be done by a GP.  A review of the pilot is to be carried out at its conclusion, during quarter 1 of 2019/20.

Integration of OOH with Other Services

· The Health Board sees the development of a supervisory GP role, which will assume on-shift responsibility and carry empowerment to direct other clinicians to manage the workload in a live scenario as central to the future model.  This will support further development of non-medical clinicians, such as enhancement of the current and innovative advanced practitioner collaboration.

· Since November 2018, the OOH service has formed a collaboration with WAST to bring two Advanced Paramedic Practitioners (APPs) into the service.  Over a three month period, the APPs have undertaken approximately one in five home visits across the locality and are beginning to make a significant contribution within the service treatment centres.

· In addition, WAST has increased the numbers of clinicians they are able to train in advanced practice. This bodes well for the service and can only have a positive impact on the wider unscheduled care system. 

· Discussions are now under way to increase the model significantly, but this requires substantial long-term investment (discussed earlier).

Staff Engagement

· The Health Board has established a select GP Advisory Panel (chaired by the Director of Operations/Deputy Chief Executive) which includes senior GPs with a long history on the OOH service locally, which helps resolve issues and supports with advice on complex issues.

· The focus of the Advisory Panel has been centred on identifying and addressing reasons behind poor shift fill rates, development of Standard Operating Procedures, and discussions around escalation and actions that can be taken. Additionally a Memorandum of Understanding is due to be signed off by the group, with valuable contributions made by the clinical membership. 

· In the coming weeks and months, the Advisory Panel will have a key role in discussions associated with potential service model changes.

· Other related groups have helped with the wider GP workforce issues with the Deputy CE opening individual conversations and holding meetings with staff to address issues at executive level.  This is in addition to site visits and meetings held by the management team, which appear to be well received. 

· The service manager has improved lines of communication with many of the staff and this provides support when the service has been under strain. This endeavour extends to non-clinical members of the team, such as receptionists, drivers, call handlers and shift organisers.  These valuable members of the staff are regularly consulted and actions and ideas generated are fed back to relevant parties to include OOHs service management and 111 on a regional working basis.

· In respect of the locum GP workforce, the Health Board commissioned expert advice (along with its peer organisations) for GPs affected by the HMRC’s decision to vary its interpretation about the self-employed status of GPs.  The Health Board also facilitated three dedicated meetings so that GPs could hear first-hand the expert advice and opinion as it applied to their personal circumstances.

· There was a detailed and lengthy engagement process with medical staff ahead of the 111 rollout in October 2018. These sessions continue but medical attendance has waned.  

· Extraordinary meetings were held with the 111 project team and concerned members of staff ahead of launch that were invaluable.

Resilience

· Weekday shift fill has improved overall and this generates little cause for concern presently.  Weekend shift fill remains variable in all areas but there are particular issues in the Llanelli region. 

· In Llanelli, the OOH team is working with the local Minor Injuries Unit (MIU) to better understand the demand profile, particularly when there is no OOH clinician present.  At this early stage, there have been no significant impacts on MIU attendances, suggesting that other clinicians are able to make effective decisions about patient care remotely. Carmarthen’s base is far more resilient by comparison.

· Ceredigion is usually covered with only short notice leave (e.g. sickness) giving rise to uncovered shifts in the majority of occasions.  This is different to Carmarthenshire where shifts are not filled despite being available.

· Pembrokeshire (60% salaried) has a relatively stable evening and overnight rota, though long term sickness has impacted this on times.  The weekend is subject to the availability of locum GPs and on occasion, there are significant shortfalls.  The service is also able to call on Advanced Nurse Practitioners (ANP) on a bank basis, which affords resilience to weekend cover when needed. The difference with Pembrokeshire is that (overnight) there is only one clinician in attendance, whereas the other counties have two.  There is therefore little in the way of resilience if the Pembrokeshire clinician is unable to work at any point.  The new APP model has mitigated this significantly.

24-hour Working

· In order to achieve a “care closer to home model”, the service needs to fully understand the potential benefit in the improvement of relationships with daytime primary care. 

· Discussions about developing a 24-hour vision have begun and a strategic direction of clinical bias is presently being sought, which will align with the Health Board’s Clinical Strategy. 

· Collaboration and discussions with the Primary Care Directorate have also commenced and as a part of these, the service is looking to see how it can support PT4L (education days) for general practice.

The Scope of OOH Services

· There is a clear need to define the scope of operation for OOHs.

· The OOH standards relate to the presentation of patients with “Urgent Primary Care” needs.  However, the service often sees cases with lower acuity and is able to defer to alternative pathways as a result, including daytime practice.

· In an area where access to daytime services is challenged and capacity reduced, there is an inevitable knock-on effect on OOH demand.  But with that, there appears to be no recognition with much of the wider public of the core remit of the service and it is felt that there is now an opportunity to clearly re-define and re-design the service to facilitate a more appropriate level of access to services.  Patient education, by means of a clear communications strategy, may be one way to achieve this.

· Within any re-design lies the potential to extend support of urgent presentations to the 24-hour period and not be limited to the current OOH operating times.  Again, establishment of a stable workforce (and a sufficient supplementary recruitment) will also be an essential element of any service modernisation.

National Standards

· Interim 111 standards are due to be launched on 1 April 2019.

· Fully staffed bases within the current establishment level should assist in meeting these standards, but frequent weekend gaps in rotas will detrimentally affect overall performance. 

· Monitoring of NHS Direct (WAST) performance and allocation of priorities will continue to ensure appropriateness of clinical priorities and ensure clinical staff are not overwhelmed by demand.

· The standards will be shared with clinical colleagues so they are fully appraised.

Workforce Planning

· At a meeting on 18 February 2019, the future model was debated in some detail. 

· The service will next move to a scoping phase in order to evaluate how the service can evolve and what numbers and types of clinicians will be required for the future. 

· Current staffing levels i.e. having frequent gaps, allows the service to invest in APPs within its current resource level but, when taking into account retirement options available to many GPs in the coming 5 years, the invest to save model of finance will become more a necessity as additional monies to support enhanced run rates will be required for limited periods.  This includes a potential £600k in terms of further development of the APP model (to include additional funding for educational opportunities), with another similar amount for Advanced Nurse Practitioners (ANPs). 

· This level of investment could lead to 20 additional advanced practitioners being qualified in the next 2 years, which would make a real difference to our patients.

Quality Assessments

· Complaints and concerns management and learning from events is an important functional and strategic element in the management of the service. 

· In 2018, there were 70 incidents and concerns raised in connection with the service; ten have been upheld following investigation.  There was one serious incident (which involved multiple service providers that was subject to a Grade 4 investigation led by the Health Board).  In addition, there were two Coroner’s investigations (no individual was identified to be at fault) and two Ombudsman investigations (no ruling against the service).

· The National OOH Forum is collating information on events for sharing on a national scale, so that learning from events can be widely disseminated.  Furthermore, any potential change to policy can be identified at this level and contributions can be made from GP leads across Wales.

· In recent months, the clinical supervision requirements of the service have increased in order to support the APPs who are now operational.  In terms of demand, they are contributing to the home visiting activity on a substantial scale, with approximately 20% of activity being completed by an APP.  The next stage of audit and review of the project will include case reviews and looking at patient journeys post admission, ensuring appropriate skill sets are maximised. 

· It should be noted that the Emergency Department and 999 referral numbers from OOH remain consistent and stable despite the inclusion of this new group of practitioners.

Spreading Innovative Practice

· The APP model has provided significant additional winter resilience to the OOH service and will now be further developed as the clinicians are moved into all aspects of OOH care, to include face-to-face consultation in one of the treatment centres.

· The ANPs, currently engaged on bank arrangements, will be the subject of a scoping exercise to better understand the feasibility/potential derived from creating substantive (salaried) posts.

· In the wider context of workforce development, and on the premise that shift offerings can only be offered during unsocial hour’s periods, recruitment is potentially adversely affected.  Expansion of the service to operate on a 24-hour basis may create opportunities to address and reverse this issue through the production of a full rotational (24-hour) shift system.  However, clinicians and experience is in short supply across all departments and service providers.  For service modernisation to be feasible, careful scoping of recruitment potential needs to be undertaken.

· In terms of service modernisation, the Health Board has senior representation at the National 111 Programme Board, with the Deputy Director of Operations in regular attendance.  Furthermore, the Board has invited its service leads to present evidence in support of the rollout and has approved the risk assessments and mitigations.

National Leadership Arrangements

· The Deputy Chief Executive/Director of Operations is the executive lead for the service; this has provided support, focus and stability in challenging workforce issues. 

· In addition, the Deputy Medical Director holds a portfolio for OOH on a national basis and has developed a close working relationship and understanding of the Health Board’s service.

· The Clinical Director and Service Manager are frequent contributors to the national OOH forum. 

· Collectively, service leads have been able to influence the rollout of the 111 system, especially in terms of rurality; the standardisation brought about by the 111 model has been adapted for rural settings.  An example would be the requirement to retain access to a higher number of home visits in support of the demographic variances seen in the rural setting.

The 111 Service

· Full integration of the 111 model across the Health Board was achieved on 31 October 2018. 

· In four months, the combined 111/OOH service has dealt with in excess of 20,000 patient contacts. 

· To date, there have been no reported serious/untoward incidents.  This gives assurance that the model is clinically safe based on current activity and assessment of concerns. 

· In terms of operational oversight, there are frequent joint operational group meetings with WAST, 111 and service leads from Health Boards who are currently within 111.  This provides a platform to address operational concerns in an open and clinically supported atmosphere.

· The 111 National Programme team has supported the Health Board through its journey, which culminated in roll out of the model into Pembrokeshire and Ceredigion in October 2018.  It also provided financial assistance to the OOH service to support various related issues most of which have already been noted in this briefing.   This is in addition to the support from Welsh Government in respect of winter allocations, which has funded an expansion of the dedicated telephone based Advice GP.