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

Executive Summary

The National Review of Primary Care Out of Hours Services ('the Review') was asked to evaluate the effectiveness of the delivery of primary care out of hours (OOH) services in Scotland and to provide recommendations for improvement in the context of Health and Social Care Integration. This Report seeks to address the remit and makes 28 Recommendations.

Chapter 1 - Key Messages

Headline issues addressed by the Review are summarised and high level recommendations made.

Chapter 2 - Recommendations:

All of the recommendations are grouped into this chapter. These recommendations were synthesised from the views of the public, health and social care professionals, professional organisations and bodies, and from published literature and research commissioned by the Review - see Chapter 3. Recommendations are proposed about a new model of care; individuals with specific needs and access requirements; health inequalities; the future workforce and the roles of its multidisciplinary members; the roles of Health and Social Care Partnerships and Integrated Joint Boards (IJBs); Special Health Board and Public Bodies; the third and independent sectors and other statutory agencies. Recommendations are provided about supporting the public to promote prevention and self care, where appropriate and to seek the right OOH and urgent care service, when needed. National workforce, OOH service specification and implementation plans are recommended, with guidance for local translation. Proposals are also made about research, evaluation, affordability and best use of resources.

Chapter 3 - Review Purpose and Process

The background to the Review, its remit and process are described.

• The main Review Group led the process with multidisciplinary, multi-sectoral and public membership.
• An Executive Group was established to support the Review and distil all the evidence and recommendations arising from the process and engagement.
• Four thematic Task Groups were established: Models of Care, Workforce and Training, Quality and Safety, Data and Technology. These reported to the Executive Group.
• Workstreams were instigated for groups of people with specific needs and access requirements: Palliative Care, Mental Health, Frail and Older People, Children, and Health Inequalities. Support was provided by the Royal College of Nursing (RCN), Scotland.
• A virtual Reference Group was established with multidisciplinary, multi-sectoral, public and international representation, offering rapid external peer review to the Executive Group.
• A schematic for the Review structure is available at Figure 3.1.
• A Short Life Working Group was established to examine terms and conditions for GPs working in OOH services.
• A rapid systematic literature review and further research was commissioned from the Scottish School of Primary Care (Annex F) and on the Review section of the Scottish Government web site.
• Data, statistics and analyses were provided by Information Services Division (ISD) - see Key facts about services (Annex B).
• Financial data were provided by NHS Directors of Finance (Annex C).

Chapter 4 - Engagement and Consultation

This chapter describes the extensive engagement process for the Review, including visits to all Board Areas in Scotland, visits to, and communications with Special NHS Boards and Public Bodies. Figure 4.1 provides a schematic of the national engagement programme. Local public discussion groups were commissioned via the Scottish Health Council and took place throughout Scotland. The work of the Review was supported by a dedicated website and by intermittent press releases, requesting public and professional views. Wider consultation with many groups and agencies took place, including a national consultation event and a meeting with MSPs also took place. The process and interim progress of the Review were shared and discussed with many groups. Account was taken of relevant interfaces with other on-going Scottish Government workstreams and reviews.

Chapter 5 - Findings

Describes and summarises the views of the public on OOH services, supplemented by the Health and Experience Survey 2013/14. The discussion group work, analysis and report provided by the Scottish Health Council were central to this task. This work was supplemented by the national engagement visits to all Board areas and workshops, including one set up by the Health Care Alliance Scotland (Alliance), seeking views about how best to use and access services.

Views of health and social care professionals, the third and independent sectors were captured at meetings during the visitation programme to Board areas. Submissions were received from the Chief Nursing Officer, professional organisations and bodies. These are summarised in Annex D and available in full on the Review website. A requested submission from NHS Health Scotland, regarding health inequalities is summarised in Annex F and available in full on the Review website.

Chapter 6 - Models of Care

A new model of care is described where a multidisciplinary, multi-sectoral urgent care coordination and communication function will be provided at Urgent Care Resource Hubs, which would be configured for both service delivery and training purposes. They would be established primarily to coordinate urgent care for OOH services - but should be considered on a 24/7 basis. They would facilitate multidisciplinary co-location, co-working, co-production and co-learning. They would be able to provide best information about and for the people served in their localities and help deploy the most appropriate services and resources available in order to secure timely and optimal care and support, according to need. This would fit with the principles of a person-centred, intelligence-led, asset-optimised and outcomes-focused service. Modelling, piloting and evaluation will be required. Urgent Care Resource Hubs would be networked to local Urgent Care Centres, presently referred to as Primary Care Emergency Centres which should be fit for purpose and be located to maximise accessibility and service resilience. Figure 2.1 provides a high level schematic of the proposed model. Recommendations are also made about NHS 24 and SAS synergies and the requirements of some groups of people with specific care and access needs (Recommendations 1-7).

Chapter 7 - Workforce and Learning

The importance of valuing our workforce looms large in this Review. At the outset, person-centred was re-defined as applying to both the person receiving care or support and the person delivering it. In order to meet the needs of future OOH and urgent care services it is essential to develop a high calibre, high morale workforce of sufficient capacity and capability. The Review was established recognising that serious GP shortages were compromising the sustainability of OOH services, which remain fragile and may worsen without resolute and urgent action. Recommendations are made on: workforce planning at national and local levels, interdependent linkages between daytime and OOH services, the importance of the educational and working environment and an organisational development approach. The skills and expertise of all professional working in OOH services must be optimised - with individual practitioners working to maximise use of their skills and the full scope of their practice. Recommendations are made for the future contributions of the GP, nursing, pharmacy, paramedical, other allied health professionals, associate physician and social services workers. The importance of working and learning in professional partnership is stressed across the sectors, as is valuing the vital and unsung contribution of support workers. Strong and resolute professional leadership at all levels will be required to assess and implement the Review's recommendations. (Recommendations 8-19).

Chapter 8 - Quality and Safety

Quality and safety are central to ensuring care and support both for patients and their carers, to secure best results - an outcomes-focused service. Present quality governance arrangements reflect former systems established by individual providers rather than a more holistic, person-centred approach, going forward. The advent of health and social care integration provides an opportunity and obligation to develop robust integrated quality planning, quality improvement, assurance and accountability, across all sectors. Optimal urgent care is a pressing matter for the people of Scotland, a unifying cause and a clarion call to action.

The new model of care proposed by the Review, delivered by a growing multidisciplinary team drawn from all care sectors, requires to be underpinned by a clear and shared service specification which should be rapidly developed. Reflecting a truly person-centred approach, new standards and indicators should incorporate both patient/carer outcomes and staff experience and must also take account of health inequalities. Proportionate and risk based quality of care scrutiny reviews for OOH and urgent care services should be developed collaboratively by Healthcare Improvement Scotland and the Care Inspectorate. Proposals are made to undertake a scoping exercise for improvement support of OOH services at national and local levels. A national multi-sectoral Quality Governance Group is recommended to oversee quality and ensure that standards are being set, met and improved upon, including the sharing of best practice (Recommendation 20).

Chapter 9 - Data & Technology

Improved Information Technology (IT) and eHealth systems will help to deliver many of the recommendations made by the Review. This recommendation reflects the guiding principle that future models of OOH and urgent care should be intelligence-led. While IT systems have evolved and significant progress has been made, the huge potential of shared electronic records has yet to be fully realised. Individuals who may be sick and seriously ill may traverse from home through a number of care sectors in a very short space of time. Care providers may access a myriad of separate databases, along the journey of care. Care at interfaces with separate databases and recording systems or methods adversely impacts on safety and hampers effective communications and collaboration. Person-centred care requires reliable and accurate person-centred information, available at the right time and in the right place. The proposed Urgent Care Resource Hub model offers a potential opportunity to help coordinate and interpret information at area and locality levels - particularly in complex cases and those with enduring conditions. This person-centred intelligence function should help to optimise assets and care outcomes. Consistency in data sharing across sectors should be the rule, preserving security and confidentiality. A collective service review of OOH IT systems currently in use and related governance arrangements is urgently required in order to deliver national consistency in use and optimisation of individual patient care and information.

The deployment of high quality video-links remains patchy and further exploitation is required - connecting Urgent Care Resource Hubs with Urgent Care Centres, in remote and rural areas, in intermediate care settings such as residential homes and community hospitals, in the Scottish Prison Service and for mobile clinical decision support by SAS. Cultural barriers to effective deployment should be addressed as they often outweigh technical issues. Innovation, development, deployment and evaluation of mobile applications ('apps') are also recommended to support self care and best use/access to services (Recommendation 21).

Chapter 10 - Role of Health and Social Care Partnerships and Integrated Joint Boards

Strong strategic leadership will be required for implementing the recommendations made by the Review. Getting OOH services and urgent care right for the people of Scotland should be a compelling priority for all sectors. Excellent care should not be just reactive but be pro-active. Opportunities for prevention and pre-emption should be pursued to add to individual and community resilience (Recommendations 5,15,16). The view of the key leadership role and function of Health and Social care Partnerships and IJBs was commonly and consistently expressed throughout the Review process. Recommendations are made about strategic planning, quality and safety imperatives and promotion of inter-sectoral organisational development - to help erode cultural differences and to promote the common weal (Recommendation 22).

Chapter 11 - Role of Special Health Boards and Public Bodies

Special Health Boards and Public Bodies should play key supportive roles going forward for OOH services and urgent care, as they did during the course of the Review. Relevant Review recommendations are mapped onto each organisation, as are the guiding principles adopted by the Review: of person-centred, intelligence-led, assets optimised and outcomes-focused care. The complementary principles of desirable, sustainable, equitable and affordable services are also applicable to the functions of these Boards and Bodies - for example NHS Health provided advice on the impact and mitigation of health inequalities - mapping to the principle of equitable services. The synergistic collaboration of NHS 24 and SAS should be very important as they work together to ensure optimal triage and clinical care processes and dispositions. Equally the regulatory, scrutiny and improvement roles of Healthcare Improvement Scotland and the Care Inspectorate should combine in common cause to ensure the quality and safety of OOH and urgent care throughout Scotland. The imperative of health intelligence cannot be understated and NHS NSS should continue to develop its role and aspirations at national and local levels. The Scottish Health Council should continue to promote best engagement of the people of Scotland in participating and shaping future care services, including self care and best use of urgent and emergency care services. A further proposal was for the Scottish Government to carefully consider optimal governance arrangements for NHS 24, SAS and NHS NSS, in the light of the recommendations of the Review (Recommendation 23).

Chapter 12 - Role of the Third and Independent Sectors and other Agencies

Both the third and independent sectors are significant contributors to OOH care services. The third sector very often attends to particularly vulnerable members of society. The third sector submitted a paper for the Review as did the independent sector via Social Care and both offered recommendations. Many of the proposals by Social Care have been assimilated by generic OOH services recommendations made by the Review. The principles offered by the third sector, several of which were cross-cutting, were considered and with minor changes were assimilated into the Review recommendations - issues of role awareness, improved intelligence, better inter-sectoral governance, sustainable funding and enhanced inter-sectoral communications were raised.

The assets and future role of the Scottish Fire and Rescue Service should have more prominence in relation to health and social care provision, particularly in their prevention and first responder roles and co-responder roles, in close partnership with SAS. This has immediacy for community cardiac arrest events with cardiac defibrillator equipped vehicles.

Royal National Lifeboat Institution (RNLI) lifeboats may be deployed for evacuation of urgent cases from remote islands when alternative transport arrangements are unavailable or inappropriate, particularly in adverse weather conditions. Where there are working linkages between the RNLI, SAS and HM Coastguard, these should be supported by a formal Memorandum of Understanding.

The Review heard concerns about capacity and co-dependency of GP personnel across OOH primary care, prisoner care and forensic medical services. The Review was unable to pursue this further, in the available timeframe and therefore recommends that further work should be considered of the issues concerned. This would include better use of telehealth, linked electronic records, quality assurance of OOH services for prisoners, and exploration of the potential for advanced practitioners for clinical forensic services (Recommendation 24).

Chapter 13 - Promoting Person-Centred Care

The first guiding principle of the Review was that optimal OOH care should be person-centred in terms of those who receive care and those who deliver it. Much of the focus of the Review has been on valuing staff. It is appropriate that we return full circle to person-centred care for the people of Scotland. It is a compelling principle which must be heeded:

• Helping people and their carers to be informed and engaged through education, information sharing, addressing health literacy needs, emotional and psychological support
• Helping the professionals to be enabling and collaborative, through leadership, communication skills, training and reflective practice
• An organisational infrastructure that promotes continuity, ease of access, customises time according to need, IT support and service design
• Rich social support, relationships and sustained resources in our communities that keep people well.

There is an opportunity to develop OOH and urgent services that are responsive to the self-management and health literacy needs of people. The rationale and recommendations for these are set out in Scotland's national health literacy action plan Making it Easy and are wholly endorsed by the Review (Recommendations 25 and 5,6,7).

Chapter 14 - Research and Evaluation

The Review commissioned a rapid systematic review of the international literature, and focus group research from the Scottish School of Primary Care and undertook separate survey work (Annex F) and available in full on the Review website.

During the course of this systematic review yielding 274 research papers for scrutiny, a paucity of robust evaluation of models of OOH services was found.

The lack of relevant published literature and planned service evaluations in OOH services have significantly hampered understanding of best practice. Future research and development (R&D) support should inform and evaluate new models of OOH and urgent care services, including economic assessment (Recommendation 26).

Chapter 15 - National Implementation Plan and Local Guidance

The Review has proposed 28 recommendations covering new models of care, workforce - including increased multidisciplinary capacity and capability, quality and safety, data and technology, responsibilities and leadership and enhanced roles for statutory authorities, third and independent sectors and other agencies. These are ambitious - but reflect extant and looming challenges of demographic change, increasing multimorbidity, complexity and rising service demands. The recommendations offered reflect the imperative of transformational rather than incremental change. Careful reflection on the recommendations is therefore essential for all stakeholders at national and local levels. This is amplified by financial constraints and the need to maximise benefits, as discussed in Chapter 16. Set in the context of early and evolving health and social care integration, implementation of the recommendations in the Review will require inter-sectoral collaboration of a very high order. Careful, considered and resolute preparation of quality assured implementation planning is vital at both national and local levels (Recommendation 27).

Chapter 16 - Finance and Best Use of Resources

Recognising significant financial challenges in the next 10 years it will be particularly important that all services produce increased efficiency and productivity in order to deliver safe, high quality person-centred care. Increased investment in primary care OOH and urgent care services specifically will need to demonstrate best value for money and areas of disinvestment pursued. Particular areas for resource allocation are identified where maximising service benefits will be essential including: Urgent Care Resource Hubs, Urgent Care Centres, eHealth, workforce capacity and capability, SAS in synergistic working with NHS24 and SAS strategic aspirations (Recommendation 28).

Chapter 17 - Conclusions

28 recommendations and a number of sub-recommendations are presented for consideration and reflection. They embrace new models of care, the needs of specific groups, enablement and empowerment, accessibility, health literacy, inequalities and the promotion of person-centred care. Workforce issues occupy a number of our recommendations - capability, capacity, challenges and the need for unprecedented primary care workforce planning at national and local levels with a key focus on valuing and supporting staff throughout their careers. Better quality and safety are essential for optimising patient care and this will be underpinned by better use of and access to electronic records, telehealth, telecare and mobile applications caring for our patients and the people of Scotland, supporting self-care where appropriate and ensuring best access to services when needed. A number of recommendations are made about the future roles of the third and independent sectors and other agencies, the leadership roles of Health and Social Care Partnerships and Integrated Joint Board, and the support roles of Special Health Board and Boards. Recommendations for research and evaluation are mooted and there is a strong emphasis on shared inter-sectoral planning at both national and local levels with the key imperative of ownership. The final recommendation addresses finance and best use of resources.