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

1 Key Messages

Overarching

• The Scottish Government recognises the importance of primary care as the first point of contact in health care for most people - including the out of hours (OOH) period when people need urgent care.
• Putting the person at the centre of care is a fundamental principle of the Scottish Government's future vision for the people of Scotland. In this Review, the 'person' refers both to those who need services - their carers and families - and those who provide services. Urgent care services should be more easily accessible and navigable for all.
• During the one year period 1 May 2014 to 30 April 2015, almost one million contacts were made with primary care OOH services. Over the same period, NHS 24 dealt with ~1.3 million calls. This compares with ~900,000 emergency department/A&E attendances in the OOH period, amounting to 56% of their total workload. The Scottish Ambulance Service (SAS) dealt with ~500,000, '999' and general practice urgent calls in the OOH period.
• The demand for urgent care is growing - particularly for rapidly increasing numbers of frail older people with multiple long-term conditions and complex care needs.
• Currently the over 75 years age group and the under 1 year age group are high volume users of OOH services. Patients aged over 75 years presently represent 8% of the Scottish population and account for nearly 20% of patients treated. The over 75 age group is projected to increase by ~32% by the year 2024 and ~66% by the year 2034.
• The annual cost of delivering primary care OOH services reported by Scotland's territorial Boards in 2014/2015 was £81.8 million. NHS 24 incurred costs of £40.4 million, giving a total of £122.2 million invested by the NHS in supporting OOH services across Scotland, excluding Scottish Ambulance Service costs, which are not demarcated by time.
• Following the introduction of the 2004 General Medical Services Contract, the responsibility for delivery of general practice services during the OOH period transferred from GPs to territorial Health Boards. This has resulted in a number of unforeseen and adverse consequences - including insufficient participation of GPs in OOH services.
• The present situation for OOH services is fragile, not sustainable and will worsen, unless immediate and robust measures are taken to promote the recruitment and retention of sufficient numbers of GPs working in both daytime and OOH services.
• Future urgent care will be delivered by well-led and trained multidisciplinary and multi-sectoral teams. GPs will no longer be the default health care professionals to see patients for urgent care, but they must continue to be an essential part of multidisciplinary 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 multidisciplinary OOH workforce should be rapidly built up, including: advanced nurse practitioners, community nursing staff, paramedical staff and other allied health practitioners (AHPs), clinical pharmacists, physician associates and social services staff. The contribution of administrative and support staff is crucial and must be clearly valued and recognised.
• Future provision of OOH and urgent care services should not be constrained by traditional boundaries or demarcations.
• Going forward, this should include a more prominent role for the third, independent sectors and other agencies, including the Scottish Fire and Rescue Service.

Enabling Person-Centred Support and Services

• Future service design and delivery should be based on best meeting the needs of the public and those who deliver services, taking full account of individual requirements, irrespective of circumstance. This should enable tailored advice, support and self care, and where required, direction to the right service, at the right time.

Workforce

• Workforce planning, recruitment and retention should be accorded high priority and urgency for both daytime and OOH services - particularly for GPs and district nurses, given the aging profile of both workforces and the serious impact of imminent retiral or withdrawal from service.
• Moving to a sustainable and multi-disciplinary OOH workforce will require new thinking, different ways of working and investment across the workforce using best organisational development practice.

• National workforce planning for OOH services should be rapidly configured and translated to support integrated workforce planning to meet the needs of areas and local communities.
• The collection of systematic and comprehensive primary care workforce data is essential on an ongoing basis.
• The effectiveness of OOH services will rely on strong leadership, provided by the most appropriate professional, in relation to local circumstances and requirements.
• Staff working in OOH services deal with many difficult pressures - particularly delivering care during unsocial hours and through the night. This involves caring for patients who may be seriously unwell, often working in isolation from colleagues. To ensure a sustainable and well supported workforce, OOH services should prioritise embedding induction, supervision for all staff and decision- making support for all clinicians.
• GPs undergoing their specialist postgraduate training should receive increased exposure to high quality training in OOH services. After completion of training, GPs should be encouraged, enabled and supported to participate in the delivery of OOH services to meet the health care needs of the Scottish people.

Quality and Safety

• The quality and safety of OOH services should be underpinned by a clear service model specification of revised quality standards and quality indicators. A national Quality Governance Group should be established to oversee and support continuous quality improvement and promote good practice.
• OOH services should be regarded as a core component of services requiring robust support at Board area level. Healthcare Improvement Scotland should be commissioned to scope out how best local, regional and national improvement support may be required, in collaboration with the Care Inspectorate.

Infrastructure and Technology

• A new model of urgent care is proposed by developing Urgent Care Resource Hubs. These hubs would provide a coordinating function for multidisciplinary and multi-sectoral urgent care and should provide patient and service intelligence, supporting multidisciplinary teams. While primarily established for OOH services, they should be considered for 24/7 urgent care coordination. Piloting and evaluation will be important, to inform future progress.
• Existing Primary Care Emergency Centres should be considered as a future network of Urgent Care Centres. These should be fit for purpose for service delivery and training, and appropriately located to facilitate patient access and service resilience. Community pharmacies should play a more prominent future role in the OOH period, providing advice and treatment for minor ailments. Day time requirements for NHS urgent care in the community would normally continue via direct access to general practice services, community pharmacies and with NHS 24.
• Digital infrastructure should be further developed, to enable better electronic records, information and knowledge exchange - which should lead to improved communications, decision making and better patient outcomes. This should also include enhanced use of video-conference technology, telehealth and telecare - and the development of mobile applications 'apps', to promote self care and to assist best use and access to urgent care services. Good communications are particularly critical for remote and rural areas where inadequate mobile and broadband infrastructure compromises care delivery.

Leadership

• Health and Social Care Partnerships and Integrated Joint Boards (IJBs) will be required to provide strong leadership for OOH and urgent care services, going forward. They must place sufficient priority on the delivery, improvement and monitoring of quality and safety for these services working with NHS Boards, Local Authorities, the third and independent sectors.
• The strategic planning process of Health and Social Care Partnerships and IJBs should look for opportunities for integrated OOH service provision from Local Authorities and the NHS, including co-location opportunities, and the provision of optimal urgent care services on a 24/7 basis.

Finance

• Over the next decade it is unlikely that health funding will grow at the same rate as the increase on demand for services. All of our services will therefore need to deliver increased efficiency and productivity in order to deliver the safe, high quality care required. Increased investment in OOH and urgent care services will need to demonstrate best value for money.