Main Report of the National Review of Primary Care Out of Hours Services

Annex D: Evidence Submitted by Professional Groups and Organisations

Royal College of General Practitioners Scotland and the Scottish General Practitioners Committee of the BMA: Joint Submission

The Royal College of General Practitioners (RCGP) Scotland and the Scottish General Practitioners Committee (SGPC) of the British Medical Association (BMA) welcomed the Review and were very encouraged by the progress that had been made.

Separate additional submissions from RCGP Scotland and SGPC are available on the Review website. In considering what recommendations should be made, they jointly believed that the following principles should be considered:-

• There must be clarity on the scope and purpose of primary care OOH services
• Primary care OOH services should be seen as a valued core NHS service and must be resourced adequately
• OOH services should have a clear identity as the urgent 'green light' service as opposed to an emergency 'blue light' service
• Triage of patient demand should be optimised to ensure best use of available resources, with patients referred to self-care and non-urgent services when safe to do so
• OOH care should be delivered by a multidisciplinary team (MDT) of which the general practitioner is a key member
• All MDT members should be working up to the top of their skill set (licence to practise)
• As the senior clinical decision maker in primary care, fully trained GPs are vital and should, when clinically appropriate, be available to all patients with urgent OOH clinical needs
• Staff working in the OOH period should feel safe and supported, with adequate facilities
• Services involved in patient OOH care should have integrated IT systems that allow appropriate sharing of patient information in a secure environment
• The training of junior doctors to be general practitioners should include sufficient and well supported exposure to OOH to develop competence and should take place within a learning environment
• GPs in their first five years following completion of specialty training, should be enabled and encouraged to develop confidence working in the OOH period
• Doctors working in OOH services should have the opportunity to partake in local GP cluster quality activity and be able to influence service development through their IJB.

"It is a core professional value of general practice that GP driven care in the community is available at any time. RCGP Scotland and SGPC see it as essential that GPs remain a central part of the OOH service to ensure holistic, co-ordinated patient care".

Chief Nursing Submission endorsed by Scottish Executive Nurse Directors (SEND) and the Royal College of Nursing (RCN)

The submission from the Chief Nursing Officer Scotland (CNO), endorsed by SEND and RCN, made recommendations for addressing the future of care across the spectrum of health and social services, both daytime and OOH services, offering a number of examples of good practice.^1,2

1. http://www.rcn.org.uk/aboutus/scotland/professionalissues/nursinginnovations
2. http://www.rcn.org.uk/aboutus/scotland/professionalissues/remoteandruralscotland

The full submission from the CNO is available on the Review website.

The CNO indicated that:

"Nursing is already making a significant contribution in this context across primary, intermediate and acute care.... To maximise this potential we need to learn from and scale up on initiatives where we are seeing tangible benefit for our patients through enhanced nursing roles".

Her three key recommendations are as follows:

1. Advanced Nurse Practitioners: The potential of advanced nurse practitioners (ANPs) must be urgently realised

The CNO noted that: "The evolution of ANP roles has been local and organic resulting in inconsistencies of role and education as well as significant gaps in the availability of services ....the public, our professional colleagues and nurses themselves must have greater confidence in and better understanding of the ANP role in Scotland".

A further 13 recommendations were proposed for short term implementation and three for the medium term.

2. Community Nursing: Reducing OOH demand and improving outcomes through community nursing

The CNO noted that: "Splitting in (daytime) and OOH service development hinders a focus on joined-up services that improve patient outcomes'".

While community nursing service already offer an invaluable core health service across communities in Scotland, that service is not universally available on a 24/7 basis and the nursing workforce is ageing fast. The CNO's shared vision is for urgent action to ensure the sustainability of a vibrant, 24/7community nursing service able to coordinate round-the-clock community nursing. In order to secure that aim, the CNO has commissioned a review of district nursing which is already underway and due to report in April 2016.

A further five recommendations were made for short term implementation and eight for the medium term.

3. Nursing Staff Support: The right support must be provided for nurses to be competent, confident, informed and well resourced

The CNO noted that: "In the OOH period, where the primary focus will be on delivering complex, urgent care with significant amounts of lone-working there is a particular need to ensure nurses are well-supported to deliver safe, high quality care".

A further three recommendations are made for short term implementation and four for the medium term.

The CNO has established a Transforming Nursing Group which will act as the main governance body to ensure that these recommendations are implemented effectively and quickly.

Community Pharmacy Scotland, NHS Scotland Directors of Pharmacy and Royal Pharmaceutical Society of Scotland - Joint Submission

This is the first time that all the major professional Pharmacy organisations in Scotland have produced a joint Pharmacy statement, which proposed:

"The pharmacy profession welcomes the opportunity to contribute to the National OOH Review and to offer solutions to address the challenges of providing care both OOH and in hours. There is much to build on as pharmacy already contributes to primary care through the community pharmacy service, particularly the Minor Ailment and the Chronic Medication Services. In addition pharmacists providing services to GP practices are delivering direct patient care in this setting. Pharmacists are also working strategically in and across primary and secondary care to ensure effective pharmaceutical services…

….We consider that a collective response from Community Pharmacy Scotland (contractor body), the Royal Pharmaceutical Society Scotland (professional body) and Directors of Pharmacy (senior pharmacy leaders for NHS Boards) provides reassurance to the National Primary Care OOH Review that the profession is very much committed to playing a full and active part in improving health outcomes for the people of Scotland…"

The full submission from the Scottish pharmacy community is available on the Review website.

Key Pharmacy Recommendations

• Electronic Record Access: The principal enabler is to ensure available information is utilised effectively. This requires as a minimum, that community pharmacies are given universal access to the Emergency Care Summary (ECS) and the Key Information Summary (KIS), as appropriate. This will enable them to play their full part in patient care during the OOH period.
• Extending the Minor Ailment Service (MAS): There should be greater use of the Minor Ailment Service by the whole population, making pharmacy the first port of call for these conditions and a national awareness raising programme of this service. This would ease pressure on healthcare services both for daytime and OOH services.
• Resources to match extended roles: To appropriately resource increased contributions of pharmacists and pharmacies

Against these three key recommendations, the joint Pharmacy submission makes 15 further detailed recommendations for implementing in the short, medium and long term, in relation to:

• Enabling best electronic access to community pharmacies
• Extending the use of national community pharmacy patient group directions (PGDs)
• Maximising the use of the Minor Ailment Service (MAS)
• Strengthening use of the urgent care PGD for repeat medicines/appliance; pharmacists with additional skills to provide enhanced services in community pharmacies and the OOH services
• Engagement by pharmacists in anticipatory care planning
• Exploring extended hours opening, including weekend; develop a national direct referral and clinical handover framework
• Encouraging pharmacist prescriber input to GP practices daytime services reducing pressure on OOH services
• Examining potential roles for pharmacist prescribers in both OOH and A&E services
• Expanding pharmacist input into NHS 24
• Reducing negative impact of medicines shortages on patients, pharmacists and GPs
• Enhancing pharmacist assessment and management skills for common clinical conditions
• Ensuring robust workforce planning for the entire pharmacy workforce, to ensure future fitness for purpose.

National OOH Operations Group Submission

The National OOH Operations Group in their position statement offered the following recommendations:

• The OOH service should be valued as an essential element of the whole NHS
• Adequate resourcing including staff and finance
• A realistic workforce plan for now and the future
• Wrap around multidisciplinary team including both health and social care, with skill mix and encompassing robust arrangements to achieve this
• Structured involvement with the Integrated Joint Boards
• Standardised educational requirements and clinical competencies for nurses, pharmacists and extended role for paramedical practitioners working in an OOH setting
• Support of secondary care colleagues especially the Emergency Department
• A robust, effective and consistent entry point for patient care with accurate and pragmatic triage
• Fast and efficient IT systems to facilitate communication
• Appropriate buildings and facilities
• In-built quality improvement methodology
• A clear description of purpose and remit of the OOH services

The full submission of the National OOH Review Group is available on the Review website.

Allied Health Professionals' Submission

The following submission was provided by the National Allied Health Professions Advisory Committee:

• To support a linked daytime/OOH approach, it is essential to maximise the potential of planned care in order to pre-empt avoidable urgent care. This includes consolidation of integrated community rehabilitation teams. Such measures should help to enable Allied Health Professionals (AHPs) to work at the 'top of their licence'. This should also facilitate flexible access to services on an urgent basis, according to individual need.
• To inform the development of future OOH service models and the optimal contribution of AHPs it will be important to secure shared, reliable, secure and timely access to electronic patient records.
• Configuration of future OOH workforce development plans should include the contribution of AHPs, as a key integral component.
• Individuals who fall, requiring urgent assistance and future prevention are a key priority group. It is suggested that AHPs play a leading role in the implementation spread and sustainability of the Falls Up and About pathway, to aid early identification of triggers for repeat falls/attendees
• The revision of the General Medical Services contract (due to be implemented in 2017), should take account of the important impact of AHPs in their service contribution to the wider primary care team.
• AHPs should look to maximise additional skills and expertise, such as independent prescribing capability, in order to optimise their contribution to OOH and urgent care,

Summary of Clinical Professional Views

Drawing from individual and joint submissions from clinical professionals:

• Negative perception: In the past, OOH services have been regarded as overtime or 'bolt on' to the main business of the NHS.
• Identity and purpose: Going forward, they must have a clear identity, purpose and valued as being essential - at the heart of the care services in Scotland.
• Person-centred: They must be built on the needs of patients and be flexible - one size does not fit all.
• Expectations and best use: At a time when both in-hours GP and OOH services are under pressure, it is essential that best use of OOH services are made by the public and expectations are realistic.
• Access and triage: Have a robust and consistent point of access by patients whose needs are then effectively triaged.
• Integration: They must be clearly integrated with the wider health and social services, with strategic leadership from Health and Social Care Partnerships and IJBs.
• Care pathways: The interface between OOH and acute services is particularly crucial - local care pathways need to be developed in tandem, be understood and effectively implemented - this is particularly important for OOH and A&E services.
• Multi-professional contributions: Recognition of the contributions of individual professionals is key: GPs, nurses, pharmacists, mental health practitioners, allied health professionals, social services workers and other professionals providing care or support services, going forward, as new models of care are developed.
• Optimal working: Thee skills and expertise of all professionals working in OOH services must be optimised - with individual practitioners working to maximise use of their skills and the full scope of their practice.
• Non-medical prescribing: Should be extended and optimised.
• Teamwork and leadership: Effective 'wraparound' multidisciplinary teamwork and leadership are essential, including comprehensive induction programmes.
• Workforce planning: Robust workforce planning is required at national and local levels.
• Training environment: OOH services must be regarded as excellent training as well as delivery environments.
• Competencies: Standardised educational requirement and clinical competencies must be in place for all clinicians working in OOH services.
• Support staff: The contribution of non-clinical support staff is crucial and must be clearly valued and recognised.
• Quality improvement: Continuous quality improvement is necessary - delivering and assuring safe and high quality services.
• Facilities: OOH services should be housed in facilities that are fit for purpose - taking into account [1] clinical and educational requirements; [2] the safety and wellbeing of both the public and staff.
• eHealth: OOH services should be underpinned by robust IT systems, shared electronic records (including ECS and EKIS), and videoconference/ telemedicine infrastructure to facilitate communication and coordination of care.
• Contractual practice, terms and conditions: Good contractual practice should be shared nationally. Terms and conditions should fully reflect the specific requirements of OOH services, going forward.
• Resources: Robust resource planning and appropriate funding allocation.

Social Work Scotland Submission

Social Work Scotland welcomed the opportunity to have representation on the National Review Group. The review presents the opportunity to build on success where best practice exists through integrated multi-disciplinary health and social work/care teams (including OOH) providing 24/7 services in partnership with the third and independent sectors and carers. Health and Social Care Partnerships under the auspices of Integrated Joint Boards (IJBs) will require to have organisational development plans in place that support the delivery of future models of care. These will focus on supporting staff to integrate ways of working and increase mutual respect across professionals to ensure we deliver the best service we can in Scotland. Their full submission is available on the Review website.

Social Work Scotland indicated:

"The review of OOH primary care provision cannot be considered in isolation and service redesign has to link with in-hours service provision from both a primary care and acute perspective. In considering how the shape of urgent and emergency care might look on a 24/7 basis it is acknowledged that all those delivering health and care services via NHS, Local Authority, third sector, carers and the independent sector have had the opportunity to contribute to the review process. As we move forward towards the integration of health and social care, all of these stakeholders will have a key role to play in delivering person-centred services on a multidisciplinary/multi-sectoral basis."

Key Messages from Social Work Scotland

1. All health and social care services need to focus on building resilience and self care management among those services that care for people with health needs. This should include contingency arrangements for extraordinary circumstances. This may prevent the volume of crises interventions required.

2. Service users, carers, the workforce and members of the public need to be clear what constitutes urgent care which may require attention by OOH services. Therefore, there is a need to establish frameworks for use of these services wherein the detail of the provision of services needs to be clearly laid out and understood (including roles, responsibilities and functions of each agency).

3. An urgent move to assess the future need for roles to be developed to ensure better patient services, user outcomes and a more flexible service - for example, more work is needed to develop advanced nurse practitioners, to review and develop the role of the district nurse and community nursing teams and to capitalise on the contribution of pharmacists and paramedical practitioners. This has to be considered in the context of multi-disciplinary teams with social work and social care key partners.

4. Focusing on supporting staff to integrate cultures and ways of working and increase mutual respect between professions. Only by improving this will integrated working come to fruition. Joining up IT systems that ensure efficient, safe and timely communication between staff from different organisations will support positive outcomes for patients/service users OOH.

Links between Primary Care OOH Services and Local Authority OOH Provision

• It is recognised that currently primary care OOH provision and local authority OOH (emergency) social work provision could be better connected.
• Through integration of health and social care and the establishment of health and care partnerships there is an opportunity to consider, how in the future, social work and primary care OOH may be better integrated. It would be important to consider further the potential of co-location in terms of health and social care 'hubs' but this in itself will not bring about change. In considering how OOH provision might look in the future and also the daytime element, it would be important to design models of service delivery that improve outcomes for people who use services with integrated patient/service user pathways and support packages that reflect multi-agency working with greater flexibility to utilise resources more effectively.

Links between Primary Care OOH Services and Local Authority Care Home Provision

• The care home sector is an important area for OOH primary care provision as Local Authorities both provide and commission care home placements. This includes nursing care.
• There are positive aspects to the current OOH provision to care homes and the review provides the opportunity to build on this.
• The strengths and challenges in terms of current OOH provision to care homes from a local authority perspective can be summarised as below:-

Strengths

• Quality care requires a whole-system approach placing the service user/patient at the centre of all activity. Therefore the term "OOH" is not helpful as we work towards delivering person-centred care for vulnerable persons and their carers/family members across 24 hours.
• Within the care home environment, the staff skill mix ensures safe and effective care alongside appropriate, multi-disciplinary clinical decision making at all times throughout the 24 hour period. Staff are supported by experienced managers and professional colleagues to deliver safe and effective care.
• We have used service users' experience of OOH services and listened to their feedback and where necessary have acted to ensure services remain responsive and of a high quality.

Challenges

• A significant challenge will be to ensure the full spectrum of services needed are available at any given time, recognising that the current scope of within and out with hours are based on contractual definitions, rather than patient/service user health care needs. A frequent difficulty is effective communication and there are challenges to ensure that patient/service user information flows simply and securely between providers and professions across 24 hours.
• There needs to be a far greater emphasis on anticipatory care planning, as currently many of those accessing OOH services have long-term conditions where better planning for changes in known conditions could prevent urgent care intervention. Anticipatory care planning requires to be available to all key staff delivering services at all times and should remain the property of the patient/service user and not the provider of service.
• People at the end of life should be able to access services directly over the 24 hour period without recourse to NHS 24 to ensure swift and effective care. This should come with extended admission protocols to allow 24/7 admission to hospice care. Extending the practice of 'just in case' medicines and protocols would support service users/patients to remain within care homes.
• Palliative care patients should have extended access to community nursing and ANP support, with nurses able to verify expected deaths in the community
• Care homes should be able to access a wider set of community supports to reduce avoidable admissions of older people from the sector OOH.
• Hospital-at-home services were recognised as a positive, multi-disciplinary contribution to improving care in the community and delivering the 2020 vision. However provision must now be available in all areas of Scotland with extended hours of operation and the full involvement of social care services to provide effective, high quality and person-centred care for older people around the clock. This will also require clarity on who is accountable for acute medical interventions in the community and, if this service is to be within the remit of the OOH primary care team, it will also require those professionals to have both the capacity and underpinning knowledge to deliver.
• All localities require to have an effective falls response service to assist people in a crisis and avoid unnecessary admissions. They should also provide co-ordinated follow-up services to prevent further falls or injuries wherever possible.

Links across Primary Care Daytime and OOH Provision and Local Authority Community Based Services Operating 24/7

• There are a range of examples across local authority and health partnership areas of integrated health and social care teams who provide support to vulnerable people in both daytime and OOH services to keep people at home thus avoiding unnecessary hospital admissions. One of the challenges is raising awareness with GPs and other primary care clinicians that these services exist and building their confidence that these are credible alternatives to hospital admissions, particularly OOH where the default position is often hospital or care home admission. There is a need for better communication with primary care clinicians in order that they better understand the community based services that are available where social work, health and other partners have a range of community supports and early interventions in place with the aim of reducing unplanned emergency events. The benefits of such teams have to be positively accentuated, whereby nursing, AHP and social care staff work together to ensure that the person receiving the service is provided with a seamless service eliminating referrals and improving coordination between professionals both at the time of crisis and support following that crisis.
• When the model of care described above is provided over 24/7, it supports primary care clinicians both working in daytime and OOH to maintain people at home, avoiding potential hospital admissions. It has been recognised that factors within daytime general practice provision, such as lack of availability to appointments, impacts on other parts of the health care system (for example: OOH, NHS 24, A&E and acute hospital services). However there is also an impact on the social care sector in that if an individual cannot access the health care support they need this may impact on the level of support required from a local authority perspective for example: social care or mental health service provision.
• There has to be recognition that to widen the models of care described above across partnerships will require the appropriate resources. The issue of resources is both financial and people having the right levels of staff, with the right skills, in the right place. The dialogue has to continue in terms of shifting the balance of care and the balance of resources from acute hospital services to community based provision both in terms of professionals moving from a hospital setting as well as budget re-allocations. The role of other health care professionals including the Scottish Ambulance Service also have a pivotal role to play in such integrated community support teams and this requires further exploration in terms of role and functions.
• The development of the virtual ward model (hospital-at-home) is operational across a number of partnerships across the country and described above in terms of the benefits. In citing this as a model of good practice in maintaining people at home in a virtual ward model with clinical input, there is a caveat in that due cognisance has to be given to the cost/benefit analysis of this model of service compared to other models of integrated community support prior to any decision to introduce or expand.

Future Provision

• The establishment of Health and Social Care Partnerships and IJBs brings opportunities to determine future service provision across all sectors.
• This presents opportunities to further consider models of care for both daytime and OOH service provision. The Health and Social Care Partnerships and IJBs will be required to have in place a Strategic Commissioning Plan for Adult Health and Social Care and this will act as important leverage in terms of how future services are commissioned and delivered.
• Health and Social Care Partnerships and IJBs will have a key role in determining the financial profile across community based services and the unscheduled care element of acute described above. In order to further develop integrated multi-disciplinary teams that are designed to meet local need this will require budgets to be in the right place with potential disinvestment from some of the current arrangements to support reinvestment in community based services across local authority, NHS, third and independent sectors. This is as relevant for OOH care as it is for in daytime provision.
• The development of future models of care has to be predicated by the use of robust data across not just local authority and health but all stakeholders.
• Health and Social Care Partnerships and IJBs will require robust workforce planning in place and organisational development strategies in place that support the delivery of future models of care. This provides a real opportunity to have an organisational development (OD) approach that supports a better understanding of roles and functions across not just health and social work but the third and independent sectors. This will also allow for an examination of role/ task/location across professions/sectors to determine where there is a need to do thing differently. This would include a range of staff, for example GPs, AHPs, home care, district nursing, pharmacists with a view to ensuring that where there is the potential to up skill any sector of the workforce undertake more enhanced roles we train and support them to do so. This will enhance capacity to create teams that get the right services to people at the right time both daytime and OOH services. This extends to the role of the third and independent sectors in terms of the important contribution they make to delivering services. Effective integrated workforce planning is crucial.
• Joint organisational development plans have to focus on supporting staff to integrate cultures and ways of working and increase mutual respect between professions. There has to be learning and development strategies in place that support distributive leadership across professions/sectors. These are crucial factors if integrated working is to come to become embedded across all care sectors
• There is also an opportunity to look at undergraduate professional training and further integration of social work and health faculties in universities to ensure learning programmes promote an understanding of cross sector roles, function, and the need for integrated service provision in communities.
• Effective communication is a key area in future service provision and the work of the review group in looking at data and technology as integrated teams need to be supported effective linked and fit for purpose IT systems with information shared appropriately and seamlessly across health and social care as well as other stakeholders. This is crucial for safe and effective OOH provision.
• Future development and utilisation of telehealth and telecare will be important to supporting people to be more independent in their communities, promoting self management and reduce reliance on services which includes OOH provision.

Recommendations offered by Social Work Scotland

• 1. There is an opportunity to explore further local authority OOH services provision with that of NHS primary care OOH services to explore opportunities for co-located and integrated service provision. This should be part of the strategic planning process within Health and Social Care Partnerships and IJBs.
• 2. Strategic commissioning plans for adult health and social care require to be developed. This will act as important leverage in terms of how future services are commissioned and delivered. Future models of care have to meet local need and focus on early intervention and prevention. There is an opportunity to build on success where best practice exists in terms of integrated multi-disciplinary health and social work teams (including OOH) that provide 24/7 services often in partnership with the third and independent sectors and carers. A platform for shared learning across sectors would be beneficial.
• 3. Robust workforce planning needs to be in place and organisational development strategies that support the delivery of future models of care. There is an opportunity to have an organisational development approach that supports a better understanding of role/task across professions/sectors to determine where there is a need to doing things differently. This would support the development of multi disciplinary/sector teams with the potential to up skill the workforce to undertake more enhanced roles, where appropriate, and with the training and support to do so. This will enhance the capacity to create teams that get the right supports to people at the right time and this extends to the role of carers, third and independent sectors, given the important contribution they make to supporting people in communities.
• 4. Joint organisational development plans have to focus on supporting staff to integrate cultures and ways of work and increase mutual respect between professions. There is a need for learning and development strategies to be in place that support strong distributive leadership across professions/sectors. These are crucial factors if integrated working is to come to become embedded across care sectors.

Chief Officers of Integrated Joint Boards Submission

In their submission, the Chief Officers of Integrated Joint Boards (IJBs) indicated that Integration of health and social care has been a long term policy direction and in 2015/16 has been coming into reality across Scotland. By 31st March 2016 all partnerships will have brought together the planning and commissioning of health and social care under a joint arrangement (Body Corporate or Lead Agency). In many partnerships operational delivery will either be integrated or moving towards being integrated.

General Medical Services, including OOH services, are part of the delegated functions for all Bodies Corporate. Therefore OOH primary care services will be a component of all partnerships' strategic plans. In some cases operational management of OOH services will also be delegated to partnerships.

Some of the challenges facing OOH services (particularly medical recruitment and retention) are not always possible or desirable to address at a single partnership level since they require regional or national action. However some challenges, such as closer working with other care services, require local action at partnership level.

Proposed Principles

• The primary location of the planning for OOH GP services should be the IJBs. This should be balanced against the need for consistency within territorial Health Boards that have multiple partnerships and the need for solutions to problems that can only resolved on a national basis.
• OOH primary care services have important connections and opportunities for improvement with OOH social care services. We believe that the Review should recommend greater local integration with social care services and other NHS OOH services for example district nursing and mental health services.
• There has been an upward spiral and competition of pay rates set locally over the last few years. Payment rates for doctors working in OOH services should be set nationally. Consideration should also be given to the potential for variation locally (within nationally agreed limits) to address capacity in hard-to- fill areas.

Third Sector Contribution

Future caring systems must place a high value on improving the connectedness between individuals, systems and sectors. The third sector is a major provider of 24/7 health and social care services in Scotland; fifty-five per cent of the sector is employed in social care or health and the sector has collective annual income of £4.9 billion (Health and Social Care Alliance). One third (~£1.6 billion) of the sector's income is for activity in health and social care. It is therefore vital that the statutory and the third and independent sectors in Scotland pool resources, and co-produce the caring and efficient systems required for the future.

The full third sector contribution is available on the Review website.

The inclusive process adopted by the National Review of OOH Primary Care Services is a good example of the spirit of collaboration required to make sustainable improvement in health and social care services. The Review is an opportunity to celebrate the dedication and talent of people working in both the statutory and non statutory sectors, but also to consider opportunities for doing things in a different way. Key features of our future caring systems should be that they place a high value on inter-connectedness, which applies at all levels, between individuals, systems and sectors. There is untapped potential in developing a more reciprocal approach, where effort and benefits are equally shared between people living in our communities and those who provide care and support, no matter which sector they work for.

The Christie Commission made recommendations about managing demand and enabling people to do more for themselves and each other, which are relevant to improving OOH care. An important theme in the report was that effective services must be designed with and for people and communities - not delivered 'top down' for administrative convenience:

"Working closely with individuals and communities to understand their needs, maximise talents and resources, support self-reliance and build resilience and prioritising preventative measures, to reduce demand and lessen inequalities."

This is a good description of the type of services which the third sector have a long history of providing and which have an impact in OOH care.

There is an increasing awareness of the potential benefits of co-production and person-centred design in many areas of Scottish public services and the third sector through networks such as the Co-Production Network, movements such as ULab, the Scottish Council for Voluntary Organisations' (SCVO) Digital Participation programme, Health and Social Care Academy of the Health and Social Care Alliance, opportunities exist for different staff disciplines and sectors to develop joint approaches to improving health and wellbeing, promote prevention and self-management. Participation in its widest sense, is presently being discussed in Scotland through the National Conversation on Health and Social Care services in 2015. This has relevance for the Review, as it is an opportunity for people to put forward their views and ideas on how to sustain a 24/7 service which remains free at the point of delivery. Opportunities and strengthening existing relationships with the third sector should be harnessed and will enable solutions beyond traditional health service approaches to promote improvement of OOH services. These approaches will involve engaging people who use OOH services and strengthening multi-disciplinary, multi-professional and multi-sector collaboration.

The third sector plays a vital role in supporting the people of Scotland, particularly the most vulnerable individuals in our society, who are often frequent users of OOH services. Therefore improving these connections has potential to improve personal outcomes, safety and to have a positive impact on inequalities in health. The need to support and understand the contribution of the third sector is now more urgent, as IJBs and Scottish Government require information to make efficient use of all community resources and to develop the intelligence required to plan services. We suggest that developing the local and national collaborative infrastructures required can be addressed by implementation of the following recommendations which are considered in greater detail within the full Third Sector report submitted to the Review:

• Improve understanding and support for the role of the third sector in OOH services prevention and self management
• Improve national intelligence about the contribution of the third sector to Scotland's Health and wellbeing in both daytime and OOH services
• Explore models of governance in statutory and non statutory organisations to ensure a person-centred safe and effective service
• IJBs should explore models of funding to the third sector to ensure their contribution to both daytime and OOH services is secure
• Improve systems for communication and for connecting both statutory and non-statutory providers of care.

Independent Sector Contribution

This is an extract of a submission from Donald Macaskill, Joint National Workforce Lead for Scottish Care. (see: http://www.scottishcare.org/about/) The full submission is available online.

As the population of Scotland continues to age, more and more individuals will seek to use OOH services. The independent sector strongly believes that it has a positive role to play to ensure that the experience of care and support can be as person-centred, effective and holistic as possible. To achieve this, there needs to be much more co-ordinated and strategic partnership and working across the statutory third and independent sectors. The provision of OOH support is best delivered at a local community level, by integrated teams involving staff from all sectors, able to respond to local needs and circumstances. People are best supported as close to their home environment as possible and wherever possible that admission to hospital should be made as a clinical choice and not because it is the only resource available. We recognise that the success of OOH provision will necessitate a re-prioritisation of resources and a commitment at the point of planning, commissioning and procurement to enable local OOH provision and partnerships across all the sectors. We hope that the Review will contribute to this process.

The following recommendations were offered to the Review for consideration:

• It is important that care homes and care at home/housing support services are recognised as being part of 'primary care' in its widest sense and that they offer potential solutions to some existing and developing challenges.

This will be develop in importance as integration continues to take root and will necessitate joint local planning and review of local OOH provision which should of necessity include both the independent and third sector providers in an area. In particular IJBs should explore the distinct contribution which use of care homes and care at home/housing support could offer for local OOH provision.

• There is a significant lack of data on the independent sector's activity in the OOH period which makes it challenging if not impossible to capture the local and national contribution. Work needs to be undertaken to identify best practice and the lessons learnt from local work.

The establishment of appropriately funded local pilots to test the potential of using care homes and home care provision to contribute to ensuring a reduction in unnecessary hospital admission and reducing delayed discharge. Such testing would include the exploration of developing appropriate communication and data systems to enable GPs to have access to a wider range of options which are alternatives to hospital admission. As part of this the configuration of 'rapid response' care home beds and intensive home care for up to 48-72 hours offers both immediacy of access and local treatment. We believe that a responsive OOH provision requires that all care options, including step-up care homes and care at home provision should be available to those making decisions to place individuals

• Overall there needs to be a more robust improvement in anticipatory care planning and a sense of real partnership between the independent, third and statutory sectors.

There are some specific areas which impact most directly upon the independent sector, notably in relation to tissue viability; in awareness and treatment of delirium (there are still issues of misdiagnosis as dementia). All three would be aided by a more joined up, localised approach to OOH support and treatment which involved care at home and care homes and which would prevent unnecessary hospital admissions for some of the most vulnerable of our citizens. Related to this is a more comprehensive location of direct services, for example locating rehydration facilities in a care home to prevent unnecessary admission.

• Work should be undertaken to explore the strategic and routine use of telemedicine links between primary care, secondary care and social care,

This should assist the reduction of unnecessary duplication and intervention especially for older individuals who may have limited capacity and comprehensibility - for example: tests could be conducted by nursing staff in a care home and reviewed by a GP or consultant to avoid unnecessary movement of residents from care home to hospital.

• There is merit in exploring the potential use of existing models of personal information, for example One Page Profiles, already used by many care homes as a mechanism for personal information passports. The use of such person-centred information tools would assist in the reduction of unnecessary re-assessments and to ensure a more focused and holistic support of individuals as they navigate between different parts of primary care.

Related to this, the lack of any national and comprehensive system to pool data from statutory and non-statutory sectors, inhibits real collaborative working and creates yet more obstacles for people seeking support and care. Sharing common datasets between all sectors has potential to positively impact on OOH services.

Developing a reformed OOH provision will require the development of integrated information and data systems that ensure staff have access to all relevant information to ensure a seamless care pathway for individuals.

• The age of those we care for has increased significantly with an attendant complexity of medical conditions, as well as an increase in dementia. This will require greater professional support for care homes.

For care homes, this means residents coming in later, with higher levels of dependency and closer to end of life. For care at home and housing support, it means supporting people, with higher levels of need to live and die in their own homes, whilst maintaining as much quality of life as possible The provision of palliative and end of life care is OOH provision acknowledges the significant role care homes and care at home services play in palliative provision. In practice this will require a more robust OOH support to care homes and care at home providers in relation to palliative and end of life care, medical emergencies etc. in order to ensure the continuity of care plans and that individuals are able to exercise the maximum degree of control and choice in relation to their care and support in OOH periods.

• There requires to exploration as a matter of urgency with the regulatory bodies to ensure the ability of care home and care at home/housing support providers to engage in and develop new models of intermediate care, step up and step down provision.

Providers often make the observation that they would like to engage in much more innovation in regard to intermediate care but feel they are hampered by the legislation relating to registrations and changes to service provision through the Care Inspectorate.

• Greater co-working and collaboration will be essential going forward

It is important that work is undertaken to increase the awareness and training of clinical staff to include social care options and in particular the contribution of the third and independent sectors. This will necessitate a properly funded workforce development and planning strategy which involves all partners.

See also: Social Care - the voice of the independent care sector in Scotland website at: http://www.scottishcare.org/index/