Business Case

1 / PBC Lead Manager: Paul Wike, Michelle Wilde
PBC Lead Clinician: Drs Read, Hooson, Hart and O’Connor
Lead Director: Simon Kirk
Lead Clinician (s):
Lead Manager(s): Robert Carter, Lisa Shackleton
Senior Finance Officer: Dianne Mason, Sam Lindop
2 / Title of proposed service/development:
Central Sheffield PBC Consortium wishes to commission a Roving GP Service to be provided for the period October – March 2010.
The service will, in the first instance, be a pilot service and following pilot evaluation a decision will be made about whether to extend the service.
Section A: the problem
3 / The problem you are trying to tackle. Include your Health Needs Assessment here.
Central Consortium are trying to reduce the number of avoidablenon-elective admissions to Secondary Care and improve care at home for patients. Because of long waits for in-hours GP visits, acutely unwell patients sometimes end up in hospital byeither self-referral, referral by their relativesor because the GP who visits finds that they have deteriorated and require admission. Often admission is the only safe option because the visiting GP does not have sufficient time to coordinate the various community nursing and intermediate care services necessary for the patient to remain safely in their own home.
Section B: the solution
4
Performance measu / Your proposal Describe how it fits with the Planned Care Framework or Unscheduled Care Strategy. If your proposal concern a LTC please also briefly describe what is being done to manage the overall pathway in terms prevention; identifying need; other service developments.
Central PBC Consortium are seeking to establish on a experimental pilot basis, a ‘specialist’ roving GP service with the specific brief to provide a rapid response service to address the immediate health needs of those patients contacting the GP practice and describing symptoms which, when reviewed against the agreed pathway algorithm (Appendix I), are deemed to indicate that the alternative to rapid specialist intervention would bea hospital attendance
The Roving GP service will be provided byGPs with a background in urgent care and/or
older people’s medicine, providingrapid response and necessary support to elderly or vulnerable patients on behalf of agroup of Practices. The aim of the service is to help GPs provide better and more prompt and responsive care for elderly people in theirown homes of a scope beyond contractual GMS services and prevent avoidable admissions to hospital. The aim of the pilot is to test out this initiativeand evaluate the evidence which will then be used to inform a decision as to whether Central Consortium extend the pilot and work towards a citywide service.
The GP will not only triage and treat but will also coordinate the different elements of Community Nursing and Intermediate Careserving Central Consortium Practices. The GP will be a conduit between Practices and other services and disciplines who are trying to reduce non-elective admissions allowing patients the opportunity to be treated at home without having to be admitted.
The Service will not undertake routine visiting on behalf of Practices. The purpose of the pilot is not to reduce the visiting burden of Practices but to utilise freed up resources in order to reduce non-elective admissions and enhance the care provided to patients of Consortium Practices.
Service objectives
  • To provide prompt high quality safe and appropriate care in patients’ homes.
  • To improve patients’ experiences.
  • To reduce avoidable hospital admissions.
  • To generate evidence about the viability of the service.
The proposal fits with the Unscheduled Care Strategy and has the support of the Unscheduled Care Strategy and Service Manager, D Mason.
All Practices are working towards Urgent Care – a practical guide to transforming same-day care in General Practice
Lives saved. Detail impact on health – reduced inequalities/unmet need etc.
All acute and urgent visits logged with Practices within Central Sheffield PBC will be triaged by Practice clinicians and if appropriate will be passed on to the Roving GP.
It is envisaged that these requests for visits will be seen within 1 hour of the call being received. Patients will have better access to a clinician and this should ultimately reduce avoidable
non-elective admissions and potential lives lost.
Improved quality. Detail patient/clinical improvements/reduced unmet need etc.
Patients will have better access to a rapid clinical assessment when they need it most, leading to better clinical outcomes.
Referral processes
Currentlypatients who request visits on the day are usually visited after morning surgeryand can wait up to 5 hours.
The Roving GP will be contacted promptly when a patientdeemed appropriate following triage per the prescribed pathway detailed at Appendix I calls for a visit or is in a crisis. The Roving GP will not maintain a patient list, however they will assume medico-legal responsibility for patients referred to them from the time they are referred to them until they are discharged from their care.
Where patients have been discharged by the Medical Assessment Unit and require follow up care which can be provided at home, MAU will provide a discharge report to the patient’s own GPadvising them of the follow up care that is needed. In circumstances where the discharge report suggests that immediate care and support is deemed advantageous to avoid possible re-admission, the Roving GP service will be contacted by the GP practice and be requested to provide the necessary immediate care
A third strand to be incorporated within the Roving GP service during the life of the pilot involves liaison with YAS to seek the productive engagement withParamedic Practitioners (PP) responding to emergency calls. In circumstances where the clinical condition observed is of a nature and complexity which falls beyond the scope of a routine GP visit but could be managed by the more specialist Roving GP service, the PP will be encouraged to contact the patients GP practice and seek mobilisation of the roving GP as an alternative to seeking transfer of the patient to hospital.
It will be the responsibility of the roving GP to notify the patients own GP that a visit has been carried out and about the care provided. The Roving GP will notify the patients own GP of the care that is provided and ongoing input that is needed, following the assessment of the patient.
Where a Practice receives a call from a patient requesting an urgent home visit, the GP will call the patient back within 20 minutes to assess whether an urgent visit is required ie immediately, or whether the patient could wait until the time the Practice has allocated to conduct home visits. If an immediate home visit is required the GP will call the Roving GP requesting a home visit. If the Roving GP is unable to attend within an hour, the patient’s own GP will make their own arrangements to visit the patient urgently or to admit the patient as they consider appropriate. The Roving GP will notify the patient’s own GP, as soon as possible, of the care that has been provided and ongoing input that is needed.
Where patients contact the out of hours service requesting an urgent home visit and it is not possible for the visit to be carried out by the OOH service because the call has come in at the end of OOH period, the OOHService will make the referral to the roving GP service via SPA (Single Point Access). SPA will contact the roving GP. The Roving GP will notify the patients own GP, as soon as possible, of the care that is provided and ongoing input that is needed.
In all cases the Roving GP should endeavour to call, fax or email the patients own GP with both discharge reports and ongoing progress as soon as is possible.
The Roving GP will liaise with Community Nurses, Social Care, CART, Hospital at Home, Specialist Nurses, Intensive Home Nursing and Palliative Care, as appropriate, and co-ordinate the patient’s care at home.
These referral processes will be refined and developed as the Service develops.
Operational
The service will be available Monday – Friday, 9.00am – 6.00pm for the duration of the pilot phase with the exception of bank holidays. The Roving GP should have access to a vehicle, should be contactable by mobile phone and have access to email and fax facilities at all times.
At times when referrals are sparse, the GP will have a list of Nursing Home patients at risk of admission that the GP can visit for checks or reviews.
Staffing
The number of staff providing the service will be a matter for the provider to determine. The following criteria are essential for the GPs assigned to providing the service:
  • at least two years core GMS experience in general practice;
  • at least 4 months experience as an SHO in A&Ein the past 10 years
  • excellent communication skills;
  • excellent interpersonal skills and ability to develop and sustain; professional relationships; and
  • the ability to work in a multi disciplinary team environment.
The following criteria are desirable skills for the GPs assigned to the project
  • experience as a senior house officer in elderly care medicine in the last 10 years
  • experience as a senior house officer in general medicine in the last 10 years
Relationships
The service provider and the GPs assigned to the project will be expected to develop a working relationship with consultants in the Medical Assessment Unit, the Rapid Access Clinic for Older People and the paramedic practitioners, Community Nursing and Intermediate Care Services.
In addition it will be critical to the success of the pilot to establish relationships and clear lines of communication with the practices taking part in the pilot.
Training
The service provider will deliver training to the practices taking part in the pilot, to the paramedic practitioners, to the out of hours providers, Community Nurses and MAU staff, about the referral processes and service protocols
Communications materials
The Roving GPs will develop appropriate materials for users of the service such as referral checklists etc.
Inappropriate use of the service
The service provider will be expected to ensure that the service is not used inappropriately by healthcare professionals.
Clinical governance
The service provider will be responsible for ensuring appropriate clinical governance arrangements are in place.
Service provider requirements
The service provider will be expected to be able to demonstrate the following requirements:
  • the commitment and the ability to develop a responsive, flexible and cost effective service;
  • a clear understanding of the specific challenges that patients, entering the service, can experience;
  • the service provider will ensure that waiting times for access are kept to a minimum. It is expected that patients will be visited within 1 hour of referral to the service;
  • evidence of providing a GP home visiting services;
  • evidence that sufficient management and clinical leadership time will be devoted to ensure the effective development of this service;
  • evidence that the education and training needs of the staff providing the service and the practices referring into the service can be met;
  • evidence that they comply with statutory employment legislation, e.g. equal opportunities legislation; and
  • evidence that they will be able to address issues relating to electronic storage and appropriate sharing of patient data, ensuring confidentiality.
  • It is also essential that the roving GP has access to the appropriate equipment to carry out patient assessment and administer preventative care to the patient at home.
  • that protocols are in place to ensure the service is not used inappropriately.
Record keeping
The provider organisation must have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose for which it was collected for and disposes of the information appropriately when no longer required.
Safe records and information management processes and procedures comply with the NHSIA information governance toolkit and all staff are aware of them.
The provider has effective systems for managing clinical records in accordance with Records management: NHS code of practice (Department of Health, April 2006)
The provider complies with the Data Protection Act 1998 and the Freedom of Information Act.
5 / Estimated minimum and maximum number of patients the service is likely to cover.
In central consortium with its population of 135,000 patients approximately 200 requests are received for home visits per day. It is anticipated that of these, between 30 & 40 patients per day would be appropriate for management by the 3 Roving GPs
6 / Evidence to support clinical effectiveness of the proposed service.
Similar services have been implemented in various parts of the country. The Central proposal has been drawn up following consideration of the schemes in place in the following areas
CambridgeCity and South Cambridgeshire PBC Consortium
NHS Brighton and Hove
North Manchester PBC Consortium
Halton and St Helens PCT
St Helens PBC Consortium, United League Commissioning (winner NHS Alliance Acorn Award for PBC)
7 / Evidence of patient support, including consultation with patients and users.
A survey has been undertaken at some Practices within Central Consortium – Dovercourt Surgery, Northern Ave Surgery, Manor Park Surgery – where patients who have requested home visits have been asked to comment on a service that would guarantee a home visit within 1 hour.
All patients canvassed for their opinions stated the service would improve on the current long waits for home visits.
8 / Evidence of stakeholder support. Include evidence of consultation with other relevant professionals and, where applicable, other providers.
All 27 Practices of Central Sheffield PBC Consortium
PCT Finance and Strategy Directorates
Patients
9 / Finance. Complete with SFO, who will normally describe this in an appendix. Summarise
current and future costs, making clear how much new investment you need, if any; whether the money is in IPCS or FUR or hasn’t been identified; whether you will generate net savings; or whether savings will be wholly reinvested in delivering the service (break even. Use the checklist in the guidelines to ensure all possible new costs have been considered, including any additional funding that may be required for another service on which this reform impacts.
Central Sheffield PBC Consortium Non-Elective Budget / Activity (09/10)
The service will run from 9am – 6pm (5 days per week).
Cost of Pilot – to be funded from Freed up Resources
It is anticipated that one non-elective admission will be saved per day. Over the 26 week period of the pilot, this is expected to save approximately £274,040 (130 avoided admissions @ an average cost of £2,108).
10 / Have the informatics implications been identified and funding/resources agreed?Are additional devices, licences, training required? Will the service introduce or change any information flows? Has software been tested for compatibility with existing infrastructure?
The Theservice will ensure that the IM&T systems and processes comply with statutory obligations for the management and operation of IM&T within the NHS, including, but not exclusively:
  • Common law duty of confidence;
  • Data Protection Act 1998;
  • Access to Health Records Act 1990;
  • Freedom of Information Act 2000;
  • Computer Misuse Act 1990; and
  • Health and Social Care Act 2001.
There is a statutory obligation to protect patient identifiable data against potential
breach of confidence when sharing with other parties.
The provider must meet prevailing national standards and follow appropriate NHS good practice guidelines for information governance and security, including, but not exclusively:
  • NHS Confidentiality Code of Practice;
  • Registration under ISO/IEC 17799-2005 and ISO 27001-2005 or other appropriate information security standards;
  • Use of the Caldicott principles and guidelines;
  • Appointment of a Caldicott Guardian;
  • Policies on security and confidentiality of patient information;
  • Achievement of the data accreditation requirements of the IM&T Directly Enhanced Service;
  • Clinical governance in line with the NHS Information Governance Toolkit; and
  • Risk and incident management system.
Equipment
3 Laptops with 3G card and access to SystemOne and EMIS hosted systems – to enable the GPs to access patient specific information. An opportunity to explore the use of Tuffbooks sa being piloted with a number of DNs may be considered
Data
The roving GP will be expected to submit monthly activity reports. An indicative list of data requirement is provided:
Minimum data requirements
  • Activity rates
  • Referral sources
  • Referral time
  • Referral to visit waiting times
  • Patient outcomes
  • Patient satisfaction
  • Number of referrals requiring further information due to incomplete fax template by practice
  • Number of patients requiring social care input
  • Number of patients referred back to the patients GP
  • Number of readmissions to service within three days
  • Number of readmissions to the service within 30 days
  • Number/proportion of patients admitted to hospital within 48hrs of consultation
  • Proportion of patients seen by the roving GP service who are admitted to hospital for the presenting condition compared to proportion of patients admitted to hospital for a similar condition from a control population not accessing a roving GP service
  • Number of inappropriate referral by practice
  • Discharge destination

11 / Assessment of the risks of implementing this.
Ensuring financial viability and cost-effectiveness
Ensuring the delivery of quick, responsive, quality patient care
Ensuring GP is currently registered and practising and has personal indemnity insurance
Evaluation
The service will informally be subject to detailed scrutiny on a weekly basis. Dr Amir Alfal, GP at Duke Medical Centre and service reviewer for Primecare will, on a weekly basis, review all referrals received by the service & provide a report indicating the referring practice and, based on the noted actions taken by the Roving GP, provide a judgement on the appropriateness of referral for Roving GP management. A report of the findings will be provided to the consortium and, should it be requested, to the PCT.