Item 8 - Primary Care Out of Hours GP Service
North Lanarkshire Council · 21 September 2022
Back to Health and Social Care Integration Joint Board — 21 September 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 8 SUBJECT: Lanarkshire Primary Care Out of Hours Service – Key Challenges and Next Steps TO: North Lanarkshire Integration Joint Board Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Soumen Sengupta, Chief Officer South HSCP Ian Beattie, Head of Health & Social Care (South Lanarkshire) Dr Linda Findlay, Medical Director (South Lanarkshire) DATE: 21st September 2022 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval For endorsement X To note 2. ROUTE TO THE BOARD This paper has been: Prepared Chief Officer, South Lanarkshire IJB Reviewed Chief Officer Endorsed NHS Lanarkshire Population Health & Primary and Community Services Governance Committee 2.1 One of the challenges of partnership working is that not always possible to discuss issues and share papers with everyone at the same time. Therefore, we ask members of the IJB to be understanding and respectful of the fact that due to the scheduling of meetings, South Lanarkshire IJB (as host) is scheduled to be presented with the substance of this report at its meeting of 20th September 2022.
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2 3. RECOMMENDATIONS 3.1 IJB members are asked to: Note the position, performance and challenges facing the Primary Care Out of Hours Service in Lanarkshire, reflective of the issues Scotland-wide. Note the activities to progress the previously confirmed refreshed clinical model and supporting project. Endorse the development of an updated whole system Urgent Care Model. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES Context 5.1 The Main Report of the National Review of Primary Care Out of Hours Services highlighted that across Scotland: The introduction of the 2004 General Medical Services Contract – where the responsibility for delivery of general practice services during the Out of Hours period transferred from GPs to territorial Health Boards - resulted in a number of unforeseen and adverse consequences, including insufficient participation of GPs in Out of Hours services. The demand for urgent care was growing - particularly for rapidly increasing numbers of frail older people with multiple long-term conditions and complex care needs. The (then) present situation for Primary Care Out of Hours services was fragile, not sustainable and would worsen, unless immediate and robust measures were taken to promote the recruitment and retention of sufficient numbers of GPs working in both daytime and Out of Hours services. 5.2 The Review’s proposals included that: Future urgent care be delivered by well-led and trained multi-disciplinary and multi-sectoral teams. GPs would no longer be the default health care professionals to see patients for urgent care, but they must continue to be an essential part of multi-disciplinary urgent care teams, providing clinical leadership and expertise, particularly for complex cases. People seeking help need to see the right professional at the right time, according to need. An enhanced capacity multi-disciplinary Primary Care Out of Hours workforce should be rapidly built up, including advanced nurse practitioners (ANPs), community nursing staff, paramedics and other allied health practitioners (AHPs), clinical pharmacists, and social care staff. The contribution of administrative and support staff is crucial and must be clearly valued and recognised. Future provision of Primary Care Out of Hours and urgent care services should not be constrained by traditional boundaries or demarcations. Yes No X N/A
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3 NHSL Primary Care Out of Hours (PCOOH) 5.3 The NHSL Primary Care Out of Hours (PCOOH) service is hosted within South Lanarkshire Health & Social Care Partnership (SLHSCP). The PCOOH Hub is based in the Primary Care Centre, Douglas Street Community Clinic, Hamilton. 5.4 Clinical services are provided at: The main primary care centre (PCC) at Douglas Street, Hamilton (as above) Airdrie Community Health Centre when safe staffing levels allow, with telephone contact via the PCOOH Hub. 5.5 The PCOOH service covers a population of around 580000 (i.e. all of Lanarkshire excluding Rutherglen/Cambuslang locality and the Northern Corridor) between the hours of 6pm until 8am Monday to Thursday; and between 6pm on Fridays and 8am on Mondays at weekends. 5.6 Ninety percent of calls to the PCOOH service are referred by NHS 24, with the remainder being professional-to-professional calls from community nursing, the Scottish Ambulance Service, community pharmacy and community hospitals. 5.7 Calls from NHS 24 are received as three case types: PCC (approx. 50% of cases) Doctor Advice (approximately 45% of cases) Home Visit (approximately 5% of cases) 5.8 Each call is allocated to one of three time dispositions by NHS24: within 1 hour; 2 hours; or 4 hours. 5.9 Approximately 23% of calls from NHS 24 are for the more urgent 1 and 2 hour dispositions. National targets are set for each case type and time disposition. 5.10 Professional-to-professional calls are also given standard time dispositions: 4 hours for community pharmacy; and 1 hour for other callers. 5.11 The service operates with the Adastra IT system. We are currently moving to an updated and cloud-based version of the system. 5.12 Most calls are received electronically from NHS 24 via Adastra; and professional-to-professional calls are logged in Adastra by the Hub dispatchers. Following NHS24 triage the service will conduct clinical consultations, which with additional local knowledge frequently change the disposition of those referrals (approximately 50% of PCC calls and 67% of home visits). 5.13 Following clinical consultation many are closed but some are forwarded to face-to-face assessment at either the main PCC in Hamilton or (when staffing
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4 allows) in Airdrie, both operating a timed appointment system. A minority of cases require home visits (HV). 5.14 Call volumes at peak periods during weekends are around 35 to 40 calls per hour, with occasional peaks of 50 calls per hour. On public holidays, call volumes tend to be higher with around 50 calls per hour at peak periods. The peak period at weekends and public holidays is between 8am and 2pm, with a slow decline in demand up until 9pm to 10pm (by which time demand usually drops below 20 calls per hour). Lowest demand is between 3am and 5am both weekdays and weekends. 5.15 The average weekly call volumes in 2022 thus far (excluding public holidays) are 1343, with weekend call volumes being 883 on average. This is on par with levels pre-pandemic, although there is a rising trend in demand notably at the weekends. 5.16 As with other areas of primary and urgent care there is an ongoing need to engage with public to raise awareness of the role of the service; and where and when to seek support for their health care needs. 5.17 The service performance against targets is broadly positively, but workforce availability and more consistently high levels of referrals have proven challenging. I was given an appointment with the out of hours service on a Saturday afternoon in April, with a suspected bad bout of tonsillitis. I was seen very promptly by an Advanced nurse practitioner who was fantastic, checking me over making sure she hadn’t missed anything. She then got a second opinion from the doctor who was working at this time. He made me feel comfortable during his examination and ensured he explained everything in depth to me before explaining the next steps. His bedside manner was next to none and his calm attitude put me at ease. He was actually finished his shift but decided to stay extra to ensure I was checked over before referring me for hospital treatment. This was a very daunting time and
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5 the staff made sure I felt as comfortable as possible and really went above and beyond in terms of my care. Just a few of a very hard-working team over at NHS Lanarkshire's Out of Hours. 5.18 The median duration of PCC consultations is 20 minutes. The median duration of GP advice calls is 15 minutes. 5.19 Home visiting is time consuming, taking 1 hour on average (including travel time). Home visits for mental health cases requiring emergency detention are particularly time consuming and can take 3 to 4 hours (or more). 5.20 At present PCOOH clinical staffing is based on a ratio of 70% GPs to 30% other clinicians. 1 HOUR PRIMARY CARE CASES 2 HOUR PRIMARY CARE CASES 1 HOUR HOME VISITS 2 HOUR HOME VISITS
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6 Challenges 5.21 It may be helpful to picture the PCOOH service as a medium scaled GP practice with a list of circa 570,000 patients. At the peak demand periods the available appointments are quickly filled and a queue builds within the virtual waiting room with call rate of 35-50 new patients per hour at peak times. The median duration of GP advice calls is 15 minutes; and the median duration of PCC cases is 20 minutes. Therefore, at peak times the optimum workforce of (12 - 14 GPs/ANPs on weekdays; and 18 at weekends) is required to match capacity with demand. Like a GP practice, PCOOH has a closing time business and the service endeavours to see all patients they can within the session. 5.22 For a considerable period, and similar to most Scottish OOH services, the NHSL service has had to operate with fewer GP’s than is desirable, due to the challenges of recruiting either into salaried or sessional posts. The Service is typically unable to fill 25% to 30% of GP sessions over each month based on the current clinical model. This issue is most prevalent at weekends and over public holidays. 5.23 The intention has been work towards a rebalanced multi-disciplinary workforce model (as per the recommendations of the National Review) by: Seeking to employ a greater proportion of salaried GP’s who can be rostered over all of the shifts (noting that given the national shortage of GPs, that this will take time to achieve) and so reduce the reliance on the number of sessional GPs required (who understandably opt into shifts which suit their circumstances). Moving to a revised ratio of 50% GPs to 50% other clinicians (50:50 ratio), initially by seeking to increase ANP capacity. 5.24 In the PCOOH, ANPs provide assessment, clinical care and management of both the stable and acutely unwell patient and their family. They are trained to make complex and autonomous decisions using advanced skill and knowledge; and have overall responsibility for the assessment of care needs and the delivery of advanced care. They are able to assess patients face-to- face, remotely (telephone and video consultations) and during house visits. 5.25 Due to legislative and competency-based limitations, ANP practice is restricted in the following areas: Low age paediatric presentation (age might vary between ANPs due to individual stages of development and dependence on access to support/overview by senior clinician when there is need for indirect supervision) – starting with under 4-year olds Capacity assessment (Adults with Incapacity – AWI) Mental Health Detention Acute Mental Health Certification of Death Obstetrics (maternity and pregnancy related presentations)
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7 5.26 In circumstances where competency or legislative restrictions limit the ANPs practice, care of patients is navigated or escalated accordingly and in line with locally agreed processes to a relevant professional with the required competency, whether Senior ANP, GP or relevant acute care speciality. 5.27 As a senior clinician within the PCOOH the Senior ANPs play an important part in leadership and teaching for both AHP, nursing and junior medical staff, making appropriate referrals to, and co-ordination the contribution of other members of the multi-disciplinary team. The Senior ANPs participate in the GP rota as appropriate, with indirect consultant / GP or advanced care practitioner lead supervision as appropriate. 5.28 Realising the potential of Senior ANPs as senior clinical decision makers and Clinical Service Duty Holders aligns with workforce modernisation and strategic workforce planning and the overall aim of NHSL to maximise the potential of resources, ensuring excellence in care and better outcomes. NHSL has developed and maintains robust organisational processes and governance in relation to Advanced Practice roles. These governance processes are guided and informed by the West of Scotland Advanced Practice Academy. Assurance around Advanced Practice roles is outlined in NHSL Advanced Practice Governance framework. 5.29 The existing ANP workforce working with PCOOH have their core roles in daytime General Practice; and are pivotal to the implementation of the Primary Care Improvement Plan (PCIP). Consequently, for example, they cannot be secured on a Sunday night as they are already rostered for the Monday in their core role. It is also important to ensure the wellbeing of this scarce ANP workforce to ensure there is good retention and future recruitment to these posts which support a considerable amount of urgent care activity across the system. These posts are critical to and focused on the delivery of the PCIP and contributing to the sustainability of General Practice (which is another risk area within NHSL). Their support to PCOOH cannot therefore be to the detriment of their core function; and from a recruitment perspective, the PCOOH requirement for the role is a further demand into a limited supply line. 5.30 Strengthening the multi-disciplinary workforce is dependent not only on nursing but the development of an advanced practice strategy for Lanarkshire - incorporating AHPs, paramedics and pharmacists, amongst others. 5.31 There are already approvals in place for a new clinical model and supporting project which will move the PCOOH service to a more multi-disciplinary workforce and competency-based model of care. A clinical lead for a session may therefore be a doctor, nurse/AHP consultant, or a senior ANP who possess the agreed competencies to provide safe and effective patient care. This approach to care continues to support best practice where patients receive person-centred, safe, high-quality care and enhances the traditional medical/GP leadership model of service delivery.
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8 5.32 Given the realities of workforce availability, it continues to be challenging to routinely operate from two centres, so and the imperative for safe service delivery has necessarily limited the scope to operate from the Airdrie PCC. 5.33 There has also been increasing need to invoke the redirection procedure whereby patients are directed to attend the emergency department (ED) at one of the three main NHSL acute sites. This occurs for two reasons: either there are rota gaps for particular clinicians (e.g. GP or ANP), and for example children under four cannot be seen by the service; or there is an increase in demand during a session and the waiting times become unsafe requiring a redirection of some patients. 5.34 Redirections will be requested when the queue builds to the extent that: Further patients referred in will not be seen before the service closes The queue has built up to a level where the capacity to manage them safely at even the subsequent session is compromised, i.e. the available capacity is already fully committed and the waiting list continues to grow with new referrals (noting that there will be fewer staff on a weekend overnight for example relative to the day shift) 5.35 When the redirection procedure is invoked, new referrals are directed to EDs allowing PCOOH to work through the existing queue. Redirected patients who do not attend ED will refer themselves to PCOOH on a subsequent shift; some go to their GP; and a cohort do not present anywhere immediately. 5.36 It should be noted that when redirection is invoked, the majority of patients (on average 76%) do not present at their local ED. Where there is a redirection, the number of patients who present at an individual acute site are in (typically low) single figures. The redirections occur over the weekend period. Of the 76% who do not present to ED, approximately half of these patients do not go anywhere; and the other half either recall NHS 24 or call their in-hours practice. 5.37 As with other parts of the NHSL system, PCOOH are frequently presented with patients with low acuity; and about matters that should have been addressed earlier in the day /week. Similar to ED, PCOOH is not always used appropriately. An example was over one of the recent public holidays where there were numerous calls about prescriptions that patients had not dealt with via their local pharmacy or GP practice. 5.38 In common with other services which receive referrals from NHS 24, the PCOOH service has concerns about some of the unintended outcomes of the current model of and algorithms used for NHS 24 triage. When patients are reviewed through telephone consultation by our PCOOH service, up to 50% of PCC cases and up to 67% of home visit cases can be managed by means other than a face-to-face assessment. Engagement with NHS24 is planned. 5.39 The current identified risk is that there could be sessions where it is not possible to operate due to workforce availability. As noted in this report the
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9 risk arises at weekends and is subject to active mitigation as has been separately reported within the Health Board risk register: by the ongoing review of workforce capacity; the concentration on the main PCC; the escalation process for redirections; and the programme plan which support the Horizon 1 and 2 (see below). Meeting the Challenges 5.40 Pre-pandemic, a Project Board – with a project plan - had been established to strengthen the PCOOH service. Given the ongoing challenges in running the service and as endorsed by the Health Board in autumn 2021, SLHSCP undertook a further process to seek external feedback on the nature and currency of the work undertaken to-date; and identify areas for potential learning from other Health Boards. The PCOOH management team and members of SLHSCP Senior Management Team engaged with colleagues from other Health Boards and the Scottish Government Primary Care team who agreed to be ‘critical friends’, offering an informed external perspective on the content and vision of the project plan to ensure that it was realistic and representative of a contemporary service. 5.41 Overall, the feedback was positive and supportive of the work that has been completed and was planned by the PCOOH team. The discussions noted that the challenges in Lanarkshire reflect those of other Health Board areas; that we the PCOOH are following best practice; and have demonstrated innovative thinking. 5.42 These engagements have reinforced the importance of investing in multi- disciplinary clinical leadership; staff wellbeing; communication; and positive marketing of the service. These are all elements which are currently being addressed - as far as it possible and realistic - within Horizons 1 and 2. For example, work is underway with the NHSL Communications team to improve the marketing of roles in PCOOH. The embedded video clip is an example of this: https://vimeo.com/699727148/1aca2c9bd9 5.43 Fundamentally though – and looking forward - a more ambitious (and potentially Scotland-leading) “solution” is required. Urgent Care 5.44 Urgent care in the community is that which requires a response before the next routine care service (or appointment). The over-riding principle is “right care, in the right place, at the right time”. 5.45 Nationally, urgent care is being redesigned - phase one of this saw the introduction of Flow Centres in December 2020. 5.46 At a time when there is increasing demand on primary care (where it is estimated 90% of urgent care is delivered), workforce challenges and GP sustainability issues, we need to look to radically change urgent care delivery to ensure sustainable services in Lanarkshire.
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10 5.47 There is much to commend a model which would bring together the co- ordination of a number of existing urgent care services together under the auspices of an overall co-ordinating multi-disciplinary hubs. Such an approach should incorporate consideration of primary care out of hours provision, to reinforce and strengthen its important contribution to a whole system approach to delivering urgent care for local people. 5.48 Given the above then, a three horizons approach - as illustrated below - is proposed for moving the service forward: Horizon 1 - Stabilisation Horizon 2 - Implementing a new Clinical Model Horizon 3 - Developing an updated whole system Urgent Care Model Horizons 1 and 2 are broadly described though the existing project plan for moving the service forward; and via the new Clinical Model and workforce modelling which supports this intention. A future paper will be brought forward setting out proposed destinations for Horizon 3, taking into account the role of PCOOH within the wider approaches to GP sustainability and urgent care redesign. Horizon 1 5.49 As noted throughout this report, Horizon 1 needs to continue a focus on stabilising the service – with key actions being to: Deliver a safe and urgent primary care service for patients Ensure that the PCOOH team are appropriately supported as part of the wider NHSL system Strengthen the interface with the wider system Focus on the main PCC, with Airdrie PCC opened when safe and when possible to do so Continue public communication and engagement about the role and use of the service Engage with NHS24 in respect of the triage algorithms
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11 Horizon 2 5.50 Horizon 2 is about fully establishing the rebalanced multi-disciplinary clinical model, notably: Develop the competency-based clinical leadership model Recruit to the rebalanced multi-disciplinary team clinical model Horizon 3 factors in the timeline to recruit and fully train an ANP/Senior ANP workforce; and having the competency-based clinical leadership model fully up and running. Horizon 3 5.51 Horizon 3 is about developing, consulting upon, agreeing and then establishing an updated Urgent Care Model, within which primary care out of hours delivery would be a key and integrated element. This is required to more substantially address the current and growing risks to the delivery of PCOOH; and contribute to mitigating the significant risks to general practice sustainability. 5.52 In terms of proceeding with Horizon 3, an immediate action would be to establish a New Urgent Care Model workstream within the Urgent Care Recovery structures; and thereafter to update the NHSL Board and both South and North Lanarkshire IJBs accordingly of the issues within this report and the developmental work to be progressed. 6. CONCLUSIONS 6.1 The paper has provided an overview of the Lanarkshire PCOOH; the challenges it faces; its positive performance despite these challenges; the summary feedback from the review of the existing project plan; and next steps proposed to manage these challenges moving forward. 6.2 A three horizons approach is proposed for moving the service forward: Horizon 1 - Stabilisation Horizon 2 - Implementing a new Clinical Model Horizon 3 - Developing an updated whole system Urgent Care Model 6.3 In terms of proceeding with Horizon 3, IJB members are asked to endorse the proposal to establish an Urgent Care Model Development workstream within the NHSL Urgent Care Recovery structures subject to approval from the South Lanarkshire IJB (as host). 6.4 Further reports will be provided to South and North Lanarkshire IJBs and the Board of NHS Lanarkshire of the issues within this report and the developmental work being progressed. 7. IMPLICATIONS
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12 7.1 NATIONAL OUTCOMES People who use Health and Social Care Services have positive experiences of those services, and have their dignity respected Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services People who use Health and Social Care Services are safe from harm People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide Resources are used effectively and efficiently in the provision of Health and Social Care Services 7.2 ASSOCIATED MEASURE(S) 7.2.1 Performance Measures are reported weekly and monthly on 1, 2 hours and 4 hours targets (as described above). 7.3 FINANCIAL This paper has been reviewed by Finance: Yes X No N/A 7.3.1 For Horizon 2, the additional posts and required spend plan to support the growth and development of the rebalanced multi-disciplinary clinical model will be managed within the existing budget. 7.4 RISK ASSESSMENT/RISK MANAGEMENT 7.4.1 This report concerns – and the proposals would contribute to the further mitigation of – the following items on the NHSL Corporate Risk Register: 2126 – Sustaining Out of Hours Primary Care Service (Current Risk Very High – Target Medium) 2150 – Sustaining GP Services (Current Risk Level High – Target Medium) 7.5 PEOPLE 7.5.1 This report has reinforced the importance of investing in multi-disciplinary clinical leadership; staff wellbeing; communication; and positive marketing of the service. As described, these are all elements which are currently being addressed - as far as it possible and realistic - within Horizons 1 and 2. For example, work is underway with the NHSL Communications team to improve the marketing of roles in PCOOH. The embedded video clip is an example of this: https://vimeo.com/699727148/1aca2c9bd9 7.5.2 Communication support will be enlisted in respect of the three horizon approach, notably: In relation to Horizon 1 the Communication team are devising and distributing ongoing public messaging to encourage people to engage with PCOOH appropriately. Work is ongoing - both locally and nationally - to target
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13 audiences; support ‘right care, right place’ messaging; and encourage personal responsibility (for matters such as having adequate medication supplies before bank holiday periods, for example). In relation to Horizon 2, the Communication team are progressing work to improve the marketing of roles in PCOOH. In relation to Horizon 3, a comprehensive communication plan would be required to be developed to support consultation and engagement activities. This would seek to ensure optimised stakeholder awareness and involvement whilst, crucially, also ensuring the requirements of the national Planning with People guidance are met. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed: Yes No N/A X 7.6.1 EIAs will be undertaken as part of Horizon 3, to inform on-going developments. 8. BACKGROUND PAPERS Main Report of the National Review of Primary Care Out of Hours Services https://www.gov.scot/publications/main-report-national-review-primary-care- out-hours-services/ 9. APPENDICES None. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following: Soumen Sengupta, Chief Officer - South Lanarkshire Integration Joint Board on telephone number 01698 453700.