Cardiff & Vale University Health Board

Response to the Public Accounts Committee inquiry into Primary Care Out-of-Hours Services

Introduction

1. Cardiff and Vale University Health Board (UHB) welcomes the opportunity to contribute to the Public Accounts Committee inquiry into Primary Care out-of-hours (OOHs) services. This paper provides the Health Board’s written response to the areas highlighted by the Committee as part of their inquiry, namely:

· Performance and patient experience

· Financial and clinical sustainability

· Information and performance management

· Integration of out-of-hours with other services

Background to Primary Care OOH services in Cardiff and Vale University Health Board

2. The service is currently provided from three bases: Cardiff Royal Infirmary (CRI), Barry Hospital and University Hospital of Wales (UHW). CRI is the main operational base. Opening times for appointments are outlined below:

Base	Monday to Friday	Saturday/Sunday and Bank Holidays
CRI	20.00-23.00	08.00-23.00
Barry Hospital	19.30-22.00	08.00-21.00
UHW	19.30-24.00	08.00-23.00

3. Detailed demand capacity work has been undertaken and staffing rotas are developed to best meet the demands for the service. Significant work has been undertaken to determine the most appropriate clinical mix within the team. In general during the overnight period there are two GPs, a triaging nurse and a Clinical Practitioner working.

4. Based on the last six years’ worth of data, the service receives on average more than 120,000 calls per year. 53% of these calls are taken during a Saturday and Sunday. Typically 30% of patients are provided with a primary care face to face appointment, 30% are provided with telephone advice, 25% are referred onto other services, 7% are provided with a home visit and 8% relate to dental calls.

Performance and Patient Experience

5. The table below highlights performance for the last 3 years.

Table 1 – Primary Care OOH performance April 2016 to January 2019

	April 16- Mar 17		April 17- Mar 18		April 18- Jan 19
Standard	Total	Average %	Total	Average%	Total	Average %
Urgent Triage	30599	69.00	30549	74.32	24175	80.17
Routine Triage	43870	76.00	46905	77.36	39725	84.16
HV P1 (Emergency)	287	70.00	202	65.15	111	76.08
HV P2 (Urgent)	2085	74.00	2346	74.1	1878	77.57
HV P6 (Less Urgent)	4147	73.00	4229	70.46	3376	76.12
PCC P1 (Emergency)	336	71.00	251	68	159	76.21
PCC P2 (Urgent)	3675	80.00	4059	77.34	2417	83.8
PCC P6 (Less Urgent)	23400	95.00	25589	97.43	22277	97.87

6. The table generally shows year on year improvement across all performance measures. Performance is reviewed in detail on a monthly basis but is made available to the team on a daily basis, so action can be taken in response to any issues highlighted.

7. The most recent patient survey was undertaken in October 2018, the findings were compared to a similar survey carried out in April 2017.  Key results show:

· 72% of patients that completed the patient satisfaction survey have used the service before.

· 87% of patients rated their overall experience as excellent or good, this was a 29% increase from the previous survey.

· 14% of patients did note that they were dissatisfied with the time it took for a clinician to telephone them.

· 31% felt that they waited too long to see the clinician once in a clinical setting.

8. Actions taken to address the results of this survey include:

· Working continually to improve shift fill rates.

· Ensuring ‘comfort calls’ are kept up to date so the patient is aware of the latest position.

· Hub Shift leads work closely with the reception team to ensure messages are sent to  staff regarding waiting times at Primary Care Centres.

· Clinicians advise of waiting times when booking appointments.

· Receptionists advise on waiting times when a patient arrives.

Financial and Clinical Sustainability

9. The Welsh Audit Office report noted the following: Notional funding across Wales for OOHs funding was noted to have fallen in real terms Cardiff was referenced as spending the least on OOHs services at approximately £8,000 per 1,000 populations compared with Powys who spend £19,000.  However, the report noted that they had not analysed the reason for the variation and they recognised that a fair comparison of the costs between HBs is complicated due to geography and population.  It also noted that Powys OOHs service is different to the rest of Wales as it is run from a private ‘not for profit’ doctors co-operative called Shropdoc.

10. Work has been undertaken within the Health Board to ensure there is sufficient funding in the service to meet demand.  In the last two years, the funding has been increased by 17%. This has helped secure additional resource in the overnight period to include a second GP. This had an impact on staff morale and has helped improve shift fill rates and the ability to deliver a better service for patients.

11. Also, during the last 12 months the structure has been reviewed and additional managerial roles have been introduced. This has included a Deputy Clinical Lead and an Operational Manager.

12. The Health Board has also been developing a workforce plan using a clinically coded case mix to determine the numbers of hours per week required across a range of clinical roles.  The Health Board already has a multidisciplinary approach to OOHs with GPs working alongside Advanced Nurse Practitioners and Advanced Paramedics, Minor Illness nurses, Triage and Dental nurses.   Detailed demand capacity work has been undertaken to inform this work and some examples of the output are included in Annex 1. A workforce plan has been developed to ensure there is a robust structure and also a development plan for staff working within OOHs which provides the opportunity to progress within the service, and learn and develop new skills.  This is underpinned by a robust training and competency programme.  It is anticipated that this will improve retention and increase recruitment into the service.

Information and Performance

13. The Welsh Audit Office Report notes that the Welsh Government is currently reviewing the OOHs targets.  This is currently with WASPI and Welsh Government, the new targets will be published in April 2019

14. As outlined in Table 1, there have been improvements in performance within the Health Board over the last few years and there is regularly review of data and information to help inform decision about the service.  The service has changed quite dramatically over time and has in many ways led the way across Wales in nurse and advanced practice recruitment, education and training.  The workforce plan gives the OOHs service an opportunity to start to further change the workforce in a controlled and measured way, and will enable the service to train, recruit and retain the workforce for the future. This in turn will ensure the provision of better quality care to people who need to use the service. 

Integration of OOHs with other Services

15. The 111 roll out plan is for Cardiff and Vale UHB to go live in 2020; however this may be subject to change. 111 have decided on a “soft launch” which means that 111 will provide the call handling facilities for patients requiring assistance.  Patients would then be triaged by 111, and passed back to OOHs for; a further triage, a home visit or a primary care face to face  appointment.

16. Teams from Cwm Taf UHB, Aneurin Bevan UHB and Cardiff and Vale UHB have been meeting on a regional basis for a period of time. During recent months, the group has been looking at the data to support an overnight model, where triage could be provided on a regional basis rather than locally, especially during times of escalation.

17. We are also currently piloting a GP cluster model to support the OOHs service by triaging and offering appointments to patients within the practice/cluster by offering appointments  earlier in the morning and later in the evening Monday to Friday, and also on Saturday mornings.  This is still in its early stages and a full analysis and evaluation of this pilot will be undertaken (results are not available at this stage).

18. In addition, the OOHs team work closely with colleagues in the Emergency Unit, Primary Care, WAST, Frequent Attender Nurse and engage with colleagues regularly to agree pathways. There are also various multi-agency meetings that include staff from the Emergency Unit, OOHs, Primary Care, Police, Wales Ambulance Services Trust, Social Care, Drug and Alcohol, Mental Health, Housing etc. to support individuals who may be using emergency services regularly for a variety of reasons.  A great deal of work has been done with partners to address the needs of these people and to support a change in behaviour, whilst also aiming to resolve the reasons for the regular use of the emergency services.  This not only reduces demand on the service, but importantly aims to resolve the issues that can be extremely complex for the individual.

Summary and key messages

19. There has been a significant focus on OOHs during the last year which has involved both clinical and non-clinical teams. We have seen a steady improvement in performance over the period and this is closely monitored and reviewed on a regular basis so that appropriate action can be taken.

20. There has been additional investment in the service to improve service delivery.

21. Detailed demand and capacity work has been undertaken. This has informed the development of the workforce model to ensure it is aligned to the needs of people using the service.

22. Whilst recognising the challenges in Urgent Primary Care/OOH we are pleased with the progress made within the Health Board but we are not complacent and are keen to learn from others. We welcome the feedback from the national peer review which recognised:

· Our approach to workforce planning and the MDT model as best practice across Wales (this has been cascaded to others).

· The development of the remote working protocol as best practice in Wales and the protocol on death certification (again these have been shared with the All Wales OOH forum).

· The work undertaken on demand capacity analysis which is also being used as a model for implementation in other Health Boards.

· The escalation protocols and arrangements for on call and out of hours which will be suggested to other Health Boards as good practice.

· The good culture and excellent management and leadership within the Health Board.

Annex 1: PCC Casemix

This work was used to determine the skill mix required which is outlined below: