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

6 Models of Care

Aim

The prime objective of the Models of Car Task Group was to advise on models of care including varying range of needs, remote and rural considerations, specific requirements and other groups. While there is a wide range of people with specific and distinct requirements, five were identified for preliminary examination during this review:

1. Palliative Care
2. Mental Health
3. Frail and Older People
4. Children
5. Health Inequalities

The work on people with specific needs (other than children) was largely taken forward in workshop format, with the support of the Royal College of Nursing, Scotland. The full report of the Models of Care Task Group is available on the Review website and includes specific examples of patient experience.

Recommendations 1-7 primarily relate to models of care and best use of OOH services

Background

The current model of OOH care has evolved from changes in the General Medical Services (GMS) contract in 2004, which allowed General Practitioners to opt out of providing OOH care. Prior to this there was a range of OOH provision, led by GPs, from large urban co-operatives through to remote practices providing their own OOH care with the support of NHS 24. Established in 2001, NHS 24 expanded to become an all-Scotland service by November 2004, providing telephone triage for people or carers seeking urgent primary care. Presently 45 GP practices (out of a Scottish total of 980) in remote and rural areas provide for the OOH care of their registered patients, representing 1.3% of the population.

Subsequent to this, there has been a significant rise in the demand for OOH primary care and an increasing ambiguity as to what the expectations are for the provision of OOH care. Currently such care is driven by patients or carers accessing care/medical help to deal with a care/medical crisis which cannot wait for a routine appointment. It is also no longer limited to OOH general practice services but includes access to other services like emergency departments, SAS, palliative care services, social care services and the third sector.

The increased demand and workforce challenges in daytime general practice have presented increasing day time access issues, resulting in some patients seeking routine care in the OOH period. This may also be about the personal choice of individuals as well - for example where people may no longer accept that they need to take time off work to access health and care services in a culture of 24/7 access to many other services.

The demands of daytime working along with flexible working practices have also seen fewer doctors being willing to provide OOH care. Changes in training for GPs has reduced the amount of time spent in the OOH period and this has resulted in doctors who may be competent but not confident in providing OOH care. As a consequence there are fewer doctors in the early stages of their careers providing OOH care. New models should improve the engagement of this group of doctors as part of the solution.

Over the past eleven years, NHS Boards have had to work creatively to secure OOH provision across Scotland. New models have emerged piecemeal across the country, many already based on a multi-disciplinary approach.

Methodology

Evidence considered

• The work of the National Unscheduled Care Programme - see Annex G for a diagram of the six essential actions for unscheduled care.
• The integration principles set out in the Public Bodies (Joint Working) (Scotland) Act 2014. These principles are included in Annex H.
• The rapid review of international literature and emerging findings from the public and professional engagement programme.
• A number of current models of OOH care were considered. A focus was made on identifying what models appeared to work well, whether there were any challenges/ barriers to wider implementation, whether they could work in remote and rural areas as well as urban settings, and whether they had the potential to be scaled up.

Scope of primary care OOH services

OOH primary care services provide care for people who have urgent health or care problems that cannot wait until regular daytime services are available

Issues which impact on future OOH models

• Those requiring OOH services should be able to access the services they need easily and swiftly
• Formal public sector services are only part of the solution to providing quality OOH care
• OOH services should work within a robust governance framework
• Multidisciplinary teams are key to ensuring integrated OOH service delivery for patients.

Core Elements of an Integrated OOH Model

For safe and effective OOH care 'one size doesn't fit all' - taking into consideration the geography of Scotland and the particular issues faced both in remote and rural as well as urban areas

A model is proposed which is based on principles that outline the core elements that should be in place in order to provide safe, effective and person-centred care and which support service providers to deliver.

• This model acknowledges that local variation and flexibility is essential.

• The exact configuration of commissioned OOH services including workforce requirements will be the responsibility of individual Health and Social Care Partnerships and IJBs
• A primary care OOH services should be built around the integration planning and delivery principles set out in the Public Bodies (Joint Working) (Scotland) Act 2014

Service Configuration for an OOH Model

The future model comprises OOH services delivering integrated care in a co-ordinated fashion requiring effective partnership working of multi-professional and multi-agency teams.

A quality service, improved outcomes and best value should be at the core of future OOH services. The patient journey of care should be as seamless as possible, ensuring that the patient is directed to the appropriate part of the service whilst using the fewest number of steps, services or interfaces. This includes fewer steps where information is asked for repeatedly (by NHS 24 and local OOH services) and ensuring patient knowledge is transferred and built upon throughout the patient pathway of care.

OOH services should aim to point patients to the service most suited to deliver the needs of patients and carers, and minimise access barriers. This means getting the right practitioner to assist care needs at the right place, in a timely fashion, according to need. That might be provided face-to-face or remotely by telephone call or video-link.

The present model of OOH services is illustrated on page 69. In describing a future model of OOH urgent care there are a range of functions with key inter-dependencies. These are outlined below and are also illustrated diagrammatically on page 70.

OOH 118 hours per week

NHS 24 function

• NHS 24 should continue to be the first point of entry to OOH services for the public. NHS 24 would continue to triage calls and stream referrals received to self-care, OOH services, A&E services and the Scottish Ambulance Service (SAS), as required. Going forward, better synergistic working between NHS 24 and SAS is essential.
• Following triage by NHS 24, patients requiring telephone advice and interventions, but requiring no onward referral, would be managed by NHS 24 through a range of in-house professionals.
• Access to clinical advice should be available, through effective professional-to-professional telephone/video-link services.
• Triage by NHS 24 and onward referral to Urgent Care Resource Hubs (as suggested below) should help to ensure timely onward referral of patients requiring urgent clinical care - to GPs and other clinicians, according to need. In addition, onward referral should involve a range of multi-disciplinary and multi-agency responses available within the locality. This will utilise the joint expertise of all OOH team members, in order to enhance patient experience and to ensure safe delivery of patient care and outcomes.

Community Co-ordination Function - Urgent Care Resource Hub

• OOH services would have a community health and social care co-ordination and dispatch centre where its function is to co-ordinate, mobilise and orchestrate the most appropriate care response. The term suggested for this is: Urgent Care Resource Hub.
• Integration authorities, either working independently or delivering economies of scale by collaborating with partner authorities to provide regional services, would have the responsibility for ensuring that there is this community co-ordination function within the OOH services they are responsible for providing.
• The size, configuration and location of this co-ordinating function would be determined by local circumstances. It would be supported by patient based information systems such as Key Information Summaries and electronic decision support as well as access to ALISS (A Local Information System for Scotland), the third sector database. All patient information from NHS 24 will go to the Urgent Care Resource Hub (for governance purposes and because it simplifies the process and ensures a focus for effective local co-ordination of care).
• This new model would see an increased number of multi-disciplinary/multi-agency patient disposition responses initiated via the co-ordinating centre, which would be responsible for matching patients to the most appropriate response to meet their needs. This would be to a range of community based health and care services including GP OOH services, paramedical practitioners, ANPs, community nursing teams (supporting home visits), community pharmacy, social services, third sector providers, community psychiatric nursing services; requests for patients to attend an OOH centre facility which in some areas might be co-located with this co-ordinating centre
• The community co-ordination function would also support access to local 'speak to doctor' and professional- to-professional calls - for example, if a telephone call is required between a district nurse, care home nurse or ambulance paramedic who needs to speak to the OOH doctor for further advice. This function is also required for OOH practitioners to be able to talk to a specialist physician, geriatrician or other specialist in order to aid in management decisions at the time when the OOH practitioner is present with the patient. This function enables professional-to-professional support for practitioners.

Urgent Care Centres

Urgent Care Centres (UCCs) - presently referred to as Primary Care Emergency Centres (PCECs) - would deliver urgent care within local communities. Their location and fitness for purpose would also need to take into account access issues - especially for patients living in remote and rural areas, and economies of scale. They should be configured as both service delivery and learning environments which are safe and secure for the wellbeing of patients and staff. Although primarily configured for OOH service delivery the infrastructural assets of Urgent Care Centres should be used to best purpose for local care needs on a 24/7 basis.

There may be merit in seeing more seriously unwell patients adjacent to A&E/acute services where they are likely to be referred or require investigation where this is an option to do so. This model, co-locating primary care and A&E/acute services is being developed in England. This model aims to minimise unnecessary transfers of acutely unwell patients. However, for some of our communities such an approach would restrict access and as a consequence, no prescriptive view has been taken. Co-location may be particularly appropriate for remote and rural locations, where demand and staffing levels of A&E and OOH services are lower and might provide additional resilience for local services. The merits/demerits of co-location of A&E and OOH services was also highlighted by the rapid literature research commissioned by the Review, which concluded that co-location and integration of services should be rigorously evaluated, including process evaluations, to understand the impact and challenges this brings to different professional groups.

People with Specific Needs

To inform the final recommendations of the Review Group, the Models of Care Task Group was asked to consider how to develop future services to deliver quality OOH care to four groups with specific needs: those with poor mental health; those with palliative care needs; those who are older and experiencing frailty, and those experiencing health inequalities (defined as those living in areas of multiple deprivation) for the purposes of this work.

A report was prepared, built on the outputs of four workshops intended to inform the general recommendations of the Models of Care Task Group and help to ensure they underpin a principle of equity of outcome in the OOH period for those with some of the greatest care needs in our communities. The report is available on the Review website.

In addition, further work was commissioned from Dr Kate McKay, Senior Medical Officer, Scottish Government, on the specific needs of children for OOH services. This will be considered separately, below. She submitted a paper which is available on the Review website. The Review also received specific assistance from Dr Zoe Dunhill MBE, former Consultant Paediatrician.

The workshops on people with poor mental health, with palliative care needs, who are older and experiencing frailty, or those experiencing health inequalities were designed to explore the core elements, strengths and challenges of existing models of services designed to meet the needs of the identified groups. In particular, issues of access, available advice and support were explored. Participants in each workshop were drawn from professional, public and third sector bodies with a stake in current service provision, as well as those representing service users.

Key generic themes

Five key generic themes were identified at the workshops:

1. Those requiring OOH services should be able to access the services they need easily and swiftly.

2. Formal, public sector services are only part of the solution to providing quality OOH care. Many third sector organisations, for example, are specifically set up to provide support to those with particular needs, such as those in mental health crisis, and already provide OOH services.

3. OOH services should work within a robust governance framework, particularly given that many of those working in these services are often isolated in their practice.

4. Multi-disciplinary teams are key to ensuring integrated OOH services deliver for patients.

5. OOH services should be able to demonstrate their effectiveness and value for money to ensure long-term sustainability into the future.

Key messages about frail older people, mental health, palliative care and health inequalities

In addition to these common themes there were also some very specific issues raised that relate to one or more of the groups with specific needs:

• There are too few places of safety for those who are under the influence of alcohol or drugs during the OOH period and who are unfit for psychiatric assessment. A&E and custody are frequently not the most appropriate place to provide quality care in these circumstances. In a similar vein, fewer frail older people would need to be admitted OOH inappropriately if there were improved "holding options" for support and clinical interventions in their place of residence. Improvements to person-centred and effective care would be possible with greater local investment in this area.
• The cost of calling some telephone services can mean that people living in poverty choose not to access OOH services appropriately. To deliver equity of outcome, phone access to all health care and support services should be free. This will require those advice and support lines provided by the third sector, in particular to be funded appropriately.
• Some crises, such as mental health crises, can be prevented by providing free and easy access to emotional support and practical advice during the night and at weekends. Investing in more local, first line services - particularly by building on those services already provided by the third sector - could greatly reduce the demand on specialist OOH care and provide better outcomes.
• 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.
• 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, frail people from the sector in the OOH period.
• Hospital-at-home care was recognised as a positive, multi-disciplinary contribution to improving care in the community and delivering the 2020 Vision. However provision should 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 clinical interventions in the community and, if this service is to be within the remit of OOH primary care team, it will also require those clinicians to have both the capacity and competence to deliver.
• All localities need 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.
• All localities should offer a comprehensive home environment assessment for those older people identified as frail to reduce the risk of falls, accident and injury. Those with chaotic lives, who often also have poor health outcomes, need better support to access core services rather than relying on crisis intervention through OOH services. The good work demonstrated in 'Deep End' practices should be extended, but not all those in need of healthcare will be registered with a general practice. Further walk-in, non-appointment sessions, should be considered to complement standard daytime general practice service provision. In addition, minor ailment services (MAS) provided by community pharmacists should be improved and extended as an additional local support to avoid urgent OOH interventions.

Key messages about children

Young children are presented frequently by parents/carers to both OOH and A&E services in Scotland, particularly, the under 1 year age group. Between 1 April 2014 and March 2015, under 1 year olds had a consultation rate of 743 per thousand of the population and under 5 year olds had an attendance rate of 433 per thousand of the population. Focusing on the under 1 year olds, of the total of 45070 seen over that one year period, 86% were seen at a Primary Care Emergency Centre whereas only 2% received a home visit.

In terms of OOH service outcomes, in 0.1% of cases, a 999 Ambulance was called; in 23% of cases the parent/carer was advised further contact with their own GP practice; in 56% of cases treatment was completed with no follow up planned; in 8% of cases an emergency admission was arranged to hospital; 2.6% of cases were referred to A&E services. The remaining 10% were classified as other dispositions. This is illustrated in the diagram below:

OOH Service Outcomes for Children under 1 year of age

A similar picture is seen for A&E service attendances. The under 1 year age group is a potentially high-risk subset of children, where attendance rates have been steadily increasing over the last 10 years. Following such attendances, there is a high proportion of 'zero day admissions' (duration of stay in hospital under 24 hours) suggesting many of these illnesses are short, self-limiting acute conditions, many of them viral illnesses.

More than 60% of children under 1 year of age presenting to A&E services are brought by their parent or carer. This is particularly true of more vulnerable populations, of lower socio-economic status, and in some ethnic groups.

Like other OOH care services, there is some parent/carer confusion about what is the right care pathway and the right service to access. Services are not uniform throughout Scotland - Health Boards have different systems in place, depending on whether there are facilities to observe or investigate young babies, for example, with fever.

The Royal College of Paediatrics and Child Health (RCPCH) published care standards in 2015: 'Facing the Future Together for Child Health'. This report includes a number of suggestions to enhance the collaboration between acute paediatric units and primary care services for the care of children who present with acute symptoms. This should be seen as complementary to the Scottish policy: 'Get it Right for Every Child'(GIRFEC), which is the national approach to improving the wellbeing of children and young people in Scotland.

There is therefore scope to improve OOH services for children and the following recommendations were considered:

• GPs, advanced nurse and paramedical practitioners should have rapid access to telephone advice from paediatric specialist staff during daytime and OOH periods
• GP, advanced nurse and paramedical practitioner training should include a strong focus on paediatric clinical skills.
• The NHS Inform (NHS 24) website should have a clearly signposted section on young children who become unwell with common causes and suggestions for parents as well as primary and secondary school staff and others caring for children. This should be extended to the development of appropriate mobile applications (see also Recommendation 21.9).
• NHS 24, territorial Health Boards, Local Authorities, Health and Social Care Partnerships and IJBs (where children's services are delegated) should continue to work together to develop local urgent care pathways for children, and to ensure they are effectively implemented in accordance with the principles of Get it Right for Every Child (GIRFEC).
• Regular local interactive multidisciplinary educational sessions - supported by consultants with paediatric responsibilities, should be encouraged and resourced to facilitate clinical quality improvement and service development.

Advanced Nurse Practitioner Team, Cumbrae