Progress Update – Review of Access to GP, Urgent and Emergency Care - Appendix 2
No. / Recommendation / Responsibility / Anticipated Completion Date/ Completion Date / Q3&4 Progress UpdatePresented to Committee on 16 June 2015 / Q3&4 Assessment of progress
(Categories 1-4) / Quarter 1/2 evidence of progress
Presented to Committee on 15 December 2015 / Q1/2 Assessment of progress
1 / All GP Practices in the Borough should consider using a telephone triage (for example ‘Doctor 1st’) appointment system, particularly as a method of reducing non-attendance
at appointments. / Individual GP Practices as appropriate / Ongoing / 18 GP Practices responded to the Committee’s recommendations.
At the time of the Committee’s review, the ‘Doctor 1st’ system (GP-led telephone triage for all appointments) is used by Norton Medical, and has been considered by others or may be in future. There were mixed views across Practices relating to its potential impact, and some stated that it would depend on Practice size and type as to whether it would work.
Aside from Norton, all Practices provide either limited telephone triage, or in the majority of cases offer some form of telephone consultation in appropriate cases.
Update from CCG - All practices were offered the opportunity to be supported to implement a Doctor First System. The Roseberry Practice in Billingham are now operating a Doctor First system. However other practices are undertaking a telephone consultation approach following the principles of the Dr First system.
In addition the unplanned admissions Direct Enhanced Service (DES) aims to provide timely telephone access, via ex-directory or bypass number, to relevant clinicians and providers to support decisions relating to hospital transfers or admissions, in order to reduce avoidable hospital admissions or A&E attendances.
It proactively case manages vulnerable patients (both those with physical and mental health conditions) through developing, sharing and regularly reviewing personalised care plans. It includes identifying a named accountable GP and a care co-ordinator, improving access to telephone or, where required, consultation appointments for patients identified in this service who have urgent enquiries. / 2 / CCG - The situation with telephone triage is much as it was in June 2015 with two practices offering a ‘Doctor 1st’ system and other practices using a range of telephone triage systems as part of their patient access.
The CCG are also considering the ways that digital technology can help improve patient access and are appraising a range of options from online triage algorithms, improved online patient self-help and the use of online consultation forms to provide another type of access to ensure that patients can access relevant healthcare in a format that works for them.
It is planned that digital technologies to improve primary care access for patients in Stockton and Hartlepool will be available as part of a primary care quality improvement scheme from April 2016. / 1
2 / Practices should clearly publish whether they are currently accepting patients both on their websites and on practice premises. / Individual GP Practices
NHS England / Ongoing / In the initial response to the Committee’s work, the majority of Practices stated that online advertising of the status of their list takes place, primarily NHS Choices and individual Practice websites.
Four Practices agreed to investigate publicising the open status of their patient list on site/in reception. Others stated that posters on the premises would be used when the list was closed.
Practices who wish to close their list are required to make a formal application to NHS England. Upon receipt of the application NHSE will engage with all relevant stakeholders including the CCG (as co-commissioners).
The application would be given due consideration in relation to the applicant’s situation.
To date, one practice has applied to close their registered list for an agreed period of time. This is being reviewed by the CCG and NHSE, in light of co-commissioning responsibilities being introduced in Q1 of 15/16, this application will be reviewed by the Joint Co-commissioning committee. LA members are advisors to this committee. / 2 / NHS England - All practices must make available a practice leaflet to both its current patients and prospective patients. The leaflet is required to contain information on how to register as a patient, the practice boundary in which it registers patients and the rights and responsibilities of the patient, including keeping appointments. Where the practice has a website, the practice shall publish on the website details of the practice boundary area.
In addition patients are able to gain information on whether a practice is accepting new patients on NHS Choices, and practices may also publish this information on their web-site.
In addition practices must declare on an annual basis that they adhere to their contractual obligations. On reviewing the practice annual contractual declaration all practices in Stockton Borough adhere to making a practice leaflet available and reviewing this on a 12 month basis, it is not a contractual requirement to place on their web-site if the practice is accepting new patients, although this would be good practice. / 2
3 / Healthwatch Stockton be requested to encourage patients to make their registration application in writing (to ensure a written reason/response to any refusal is provided), and to encourage patients to report any ongoing issues to Healthwatch; / Healthwatch Stockton-on-Tees / Ongoing / Healthwatch have monitored feedback on this issue. Since the issue has been raised with NHS England, until recently no further intelligence had been received in relation GP registration.
However a patient contact in the last month has identified that some practices may be indicating they have closed lists when they are listed as being open on websites. / 2 / Healthwatch has received no further intelligence in the last six months.
All GP practices have been sent Healthwatch promotional info by post and in person with a request to display in the waiting areas.
In terms of the advice that may be provided if someone contacts them on this issue, we would usually provide a caller with a list of alternative GP practices as well as the details of NHS England. If the case is more complex we would provide additional signposting (for example, to an advocacy service) or if the person is vulnerable, we have made phone calls on their behalf.
We feed intelligence directly to NHS England when a caller highlights issues around registration. / 2
4 / The NHS England Area Team should review the current status of GP patient registration in Stockton Borough. / NHS England / Ongoing / NHS England act upon any evidence or information received with regards to patients who have been refused access to join a GP practice where the practice list is open. As at 5 June, there are no practices with a closed list in the Stockton Borough. / 2 / NHS England -NHS England act upon any evidence or information received with regards to patients who have been refused access to join a GP practice where the practice list is open. As at 30 November, there are no practices with a closed list in the Stockton Borough. NHS England did receive an application from Woodlands Family Medical Centre on 25 March 2015, however this was subsequently withdrawn by the practice. NHS England actively engages with practices in the Borough and we would encourage the OSC to let us know of any issues in the area.
In addition practices must declare on an annual basis that they adhere to their contractual obligations; this includes the requirement to demonstrate reasonable grounds where it has refused an application to register a patient and keeps a written record of refusals and the reasons for them.
All practices must also advertise and include information on how to make a complaint or comment on the provision of the service within the practice leaflet. Practices are also required to include the name and address of the Board
On reviewing the practice annual contractual declaration all practices in Stockton Borough adhere to advertising and including the complaints procedure to patients. / 2
7 / The Council and NHS partners should consider the role of education and communications to ensure that the local population gains a better
understanding of what constitutes an emergency versus more minor
ailments. / CCG
Public Health / April 2015 / The CCG have produced a 5 year Urgent Care Strategy (August 2014) in line with the strategic aims and objectives set out in the Clear and Credible plan.
In order to deliver the strategy we have sought views of the public through a street survey which was conducted (18th May-29th May) to gain an understanding of the experiences, views and needs of current and future services for Urgent Care with a focus on provision and access.
We expect the findings of this survey will support the development of a targeted campaign to inform and educate the public to ensure they receive the right care in the right place at the right time.
The CCG committed funding towards communications schemes in 14/15 as part of System Resilience Group (SRG) funding such as ‘talk before you walk’, children’s seasonal ailments booklets and campaigns regarding flu and GP opening hours.
The CCG are also involved in a regional communications campaign regarding better use of urgent care facilities / education of patients regarding urgent conditions being co-ordinated by the commissioning support unit (NECS) and have also set aside funding as part of 15/16 SRG plans to put in place enhanced local communication plans. This will be agreed by SRG members which includes the LA.
Public Health will be working with Communications to develop a range of public information messages using a variety of formats, and to include messages focussed on young people. Following changes in staff members, new staff member will be taking this forward when in post. / 2 / CCG - The Urgent Care Project Oversight Group (UCPOG) have reviewed the Commissioning Standards, undertaken a gap analysis and a revised procurement and mobilisation timetable has been developed to reflect extension of contracts and the procurement of a new integrated urgent care service.
We continue to encourage people to uses services appropriately. For 15/16, SRG plans are based around three key themes which cover general workforce capacity, admission avoidance and facilitating early discharge. This includes additional GP primary care cover over bank holiday weekends - plus the ability to mobilise any of the schemes that evaluated well in 14/15 when a trigger point in the system is reached that requires surge management. This includes a streaming nurse and GP in A&E.
There is a campaign being undertaken throughout winter 2015 to ensure patients are better informed regarding services to access – this has been developed nationally and led locally – national direction was received that all local communications should be in line with the national campaign
Public Health - Public Health and SBC Communications will be utilising the messages developed locally inline with the national campaign to inform patients through SBC communication channels, including KYIT and a future article in Stockton News.
Specific messages for young people will also be developed, once the national campaign is available to use by SBC. / 2
8 / The CCG and partners should increase publicity for NHS111 and when to use it. / CCG
Public Health / December 2014 (and ongoing) / See response in Q7 – the street survey undertaken is seeking views on the 111 service and is promoting the use of this as first point of contact aware of the current Urgent Care provision and how, when and where they could access these services including the use of 111. We expect the findings of this survey will support the development of a targeted campaign to inform and educate the public to ensure they receive the right care in the right place at the right time and this will include use of the 111 service.
Through SRG plans there were posters and leaflets that promoted the use of 111 as first point of contact during the winter period.
This is further supported through our communication channels as both Clinical leads provide regular health columns within the local media covering a range of health issues and promote the use of the 111 service.
To take forward as part of work outlined at rec 7. / 2 / CCG - The Directory of Services (DOS) is managed and maintained by the Commissioning Support Unit on behalf of the North East CCGs by a DOS Team and is the source of local information and services for call handlers in 111 services. The DOS Team work to improve the DOS through continuous engagement with Commissioners and Providers involving both the CCG NHS 111 Clinical Leads and Service Planning and Reform Teams. There is representation from the DOS Team at all Clinical Governance and NHS 111 Contract Review Meetings to ensure that issues are addressed and to promote service improvement.
The vision for the DoS is for it to include all of the services commissioned by the CCG. Local Authorities have provided extensive information to populate the stand-alone system and commissioning intentions have been identified for 2016/17 to support and progress this work.
In relation to communicating to the public, the integrated winter campaign is ‘Stay Well This Winter ‘and key elements are as follows:
•Targeted flu vaccine strand via radio, TV; Social media; on-line advertising and press ads.
•Stay well message strand will start with outdoor ads, TV , and door-drops . More outdoor ads will run in December, with pharmacy bags; radio and press ads; social, digital campaign.
•There is the ability to up-weight some of the advertising (especially digital) in response to some triggers (e.g. severe weather).
NHS England’s marketing objective for the Stay Well This Winter campaign is:
To ensure that people who are most at-risk of preventable emergency admission to hospital are aware of and, wherever possible, are motivated to take, those actions that may avoid admissions this winter.
The overarching objective is to reduce unnecessary emergency admissions amongst target groups, e.g. very young, very old (80+) and those with underlying conditions, including mental health.
Public Health - As outlined above in point 7, once the national campaign is available regarding emergency vs minor ailments, a more comprehensive plan of communications from Public Health/Comms will be developed.
Similar to the CCG, SBC have been actively promoting stay well this winter to SBC residents. / 2
11 / a) Healthwatch Stockton be requested to encourage feedback on
individual experiences of the ambulance service and to report its findings to the Committee,; / Natasha Judge / Healthwatch Stockton-on-Tees / Ongoing / Healthwatch has monitored the information it receives from local residents and collate experiences of ambulance care (positive/negative).
No recent intelligence has been received.
(To note, Healthwatch is also planning on undertaking separate work on hospital transport.) / 2 / Healthwatch have reported no issues in the previous six months.
[This will be an ongoing action] / 1
12 / North East Ambulance Service and CCGs consider how they can improve
the proportion of ambulance call outs appropriately dealt with in the community (‘at the scene’) / CCG
NEAS / End of 2014 / For Hartlepool and StocktonCCGthe indicative plan for “Hear and Treat” activity for 2014/15 was 1,049 cases. From a year end perspective a figure of 1,643 was achieved showing a circa 56% increase. This has been a success across the region, improving considerably the proportion of calls dealt with in the community
As part of the 2 year agreement with NEAS a significant sum of non-recurring resource was agreed via CQUIN (Commissioning for Quality and Innovation) to implement a transformation change within the organisation known as an ICAT Service (Integrated Care and Transport). This scheme aims to utilise a wide range of skilled staff and vehicles to ensure the most appropriate level of response is provided to patients. It is expected that this will enable paramedics to focus on the more serious emergency incidents.
Early indications of progress being made in the NEAS Quality Report for “hear and treat” patients. Development of enhanced-CARE paramedic training and advanced paramedic roles in 2015-16 now underway.
Quarterly CCG-level reports are being automated and will be available from Q2 2015-16 onwards. / 2 / CCG -The NHS 111 Directory of Services holds a significant number of services that are commissioned by CCG's, for example Rapid Response Services. In addition to this Paramedics are encouraged to contact General Practitioners to seek advice about patient conditions in order to empower paramedics to make the appropriate decision around the patients’ treatment plan. NEAS have been provided contact numbers for all GP practices across Stockton to contact for an urgent response to avoid admissions to hospital where appropriate.
Clinical Hubs are considered critical to the implementation of the North East Urgent and Emergency Care Vanguard. Commitment has been made as part of the Vanguard to implement 24/7 senior clinical decision support through an enhanced clinical hub, accessible by 111/999 and external clinicians.
Phased approach to expansion of clinical hub is underway, supported by resilience monies. This includes the development of specialist roles in the hub, such as mental health, pharmacy and dental. By having multiple specialists ‘in the room’ and integrated systems allowing for cross-boundary working patients and HCP can receive immediate support in terms of pathways of care for patients, provide expert advice, signposting and referral with the preferred ability to book directly with each care provider location.
In addition to this NEAS have a logistics desk in place to which Paramedics are able to contact in order to request information around alternative pathways within the Directory of Service. Trialling mobile Directory of Services (DoS) in December 2015 with the Emergency Clinical Care Managers, allowing crews to search for appropriate services on scene with patients as opposed to ringing NEAS Control Centre.
NEAS - The Integrated Care and Transport (ICaT) project aims to align the patient transport and emergency care services into one single operating model. It has already seen the introduction of Advanced Practitioners and ICaT crews.
It also entails a review of the job descriptions for Ambulance Care Assistants and Emergency Care Assistants, simplifying the roles across patient transport and emergency care.
New draft job descriptions have been created following feedback from recent staff roadshows.
As at the end of Quarter 2 2015/16, there have been 869 hear & treat cases in the HAST CCG area. / 1
13 / As part of the monitoring of the results of this review, NEAS and Cleveland
Police should report back to the Committee on operational relationships and partnership working. / NEAS
Cleveland Police / End of 2014 / NEAS and police continue to work together on an operational level. Feedback from NEAS staff indicates that that our working relationship with the police is currently very good.
We have a number of ongoing initiatives between the services and it is important that we continue to work closely with police locally and at a national level with the Association of Chief Police Officers, to explain the ongoing challenge we face in our service response and quality.
Seven and a half percent of all 999 incidents that NEAS attend come from calls by the Northumbria; Durham and Cleveland police services. This is the highest proportion of emergency incidents originating from the police of other ambulance trust in the country. All our calls are prioritised on the patients’ clinical need and requests from police officers do not take preference if other callers have a greater need.
NEAS meet regularly with all police services and are open and honest with all our partners about the issues we are facing. The national shortage of paramedics is particularly acute in the North East; [during 14-15] less serious cases have experienced delayed responses from us because of the increase in the number of potentially life threatening emergencies we are being called to, delays at hospitals mean that we have had fewer crews available to respond.
Further update from Police to be confirmed. / 2 / NEAS - A meeting between the three Police Chief Constables and the Trust’s Chief Executive took place on 21 August 2015. The Police and Crime Commissioners for Durham and Cleveland also attended alongside other representatives from the organisations.
As a result of the meeting it was agreed that Durham Police Chief Superintendent would be appointed lead, providing updates to the NEAS Chief executive and Durham Constabulary Chief Constable and overseeing a joint approach on a regional basis.
Durham Police Chief Superintendent would progress on-going initiatives focusing on demand reduction and partnership work to ensure the effective delivery of our services, police and ambulance alike.
Since August, a number of meetings between NEAS and the 3 Police forces have taken place, forming a ‘tactical’ group alongside an ‘operational’ group who will progress the various initiatives.
A report is currently being written for the Chief Officers and Chief Executive, scoping the main challenges and initiatives which will address these.
Cleveland Police – Cleveland Police agrees with the update provided by NEAS. / 1
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