Download urgent care navigation service (pilot)

Agenda item 11
Part 1 meeting of the Castle Point and Rochford CCG
Governing Body held on 31st March 2016
URGENT CARE NAVIGATION SERVICE (PILOT)
Submitted by:
Robert Shaw, Joint Director of Acute Commissioning and
Contracting
Prepared by:
Matt Fassihi, Project Manager
Status:
For Approval
Executive Summary
i)
Recommendations
Members of the Governing Body are asked to consider and approve the
commissioning case for the Urgent Care Navigation Service pilot.
ii)
Overview
Accident & Emergency (A&E) departments throughout the country are experiencing
unprecedented levels of attendances, which is having a negative impact on how
quickly patients with genuine medical emergencies can be seen and general patient
flow throughout the acute setting.
Compared to the previous year, attendances at Southend University Hospital
Foundation Trust (SUHFT) A&E department rose 6% over the 12 months ending
June 2015. This is a far greater increase compared with the national average of
1.1% and attendances at SUHFT now regularly top 8000 patients per month.
With increasing attendances placing significant challenges on the local A&E
department, predominantly from people attending during the day with minor
illnesses, the consultation around St. Luke’s Walk in Centre (WIC) offered an
opportunity to re-think how urgent care is provided in the area.
1
The Urgent Care Navigation Service will be situated at the front door of SUHFT A&E
department and will provide a clinical team to stream all walk-in patients and
appropriate ambulance arrivals to the most appropriate part of the hospital. The
Streaming Clinician will have the ability to stream patients into the core A&E
services, to more appropriate services outside A&E via the Navigator or discharge
the patient as their clinical need dictates.
Patient’s presenting with a minor illness with National Early Warning Score (NEWS)
≤ 1 that require follow up at services outside of A&E such as Primary Care, will be
referred to the Navigator. The Navigator will initially be a clinical role that will support
patients to access the most appropriate services outside of A&E such as GP Primary
Care, pharmacy, self-care and dental services, by booking appointments and
providing details of local services.
The ‘streaming’ element of the service will be in place from 8:00 – 23:00, 365 days a
year. Outside of these hours, patients will follow the same pathway but with
streaming and navigation taking place within the core A&E services. The ‘navigation’
element of the service will be available from 08:00 until 00:00, 365 days a year.
The service differs from the current service model in two distinct ways. Firstly, the
introduction of a ‘Navigator’ role will focus the service more on redirecting minor
illness patients to appropriate services outside of A&E and making better use of
existing Primary Care capacity. Secondly, the service will no longer perform a ‘see
and treat’ function for these patients, thus reducing the appeal of A&E as an
alternative route to access Primary Care services.
Based on evidence from other areas that have trialed a similar model, it is expected
that the new service will result in 20% of minor illness patients being redirected away
from A&E to more appropriate care options. This will result in 13,813 fewer A&E
attendances and a net saving of £1.3m across both CCGs, inclusive of the closure of
the walk in centre.
The impact on primary care is expected to be low as not all patients being redirected
from A&E will require a GP appointment. Those that do will be spread across core
Primary Care provision, Out of Hours (OOH) and the Primary Care Hubs. The
linking of IT systems between A&E and GP practices will further improve the
management and flow of those patients requiring an appointment in GP Primary
Care.
iii)
Key issues
The following risks have been identified for the Urgent Care project and will continue
to be closely monitored during the pilot period.
2
3
Initial Risk
Rating
15
Protocols for referral back to
own GP or GP hubs or OOH GP
will be enhanced with direct
booking into GP surgery
(SystmOne) and/or telephone
booking by receptionist.
Current
Risk
Rating
5
Current Controls in Place
Likelihood
Waiting times in
A&E increase,
ECS
performance
worsens, -ve
patient
experience,
delays to
treatment and -ve
Trust reputation
Current Risk
Rating
Impact
1
The volume of
patients
accessing the
new service is
significantly
higher than
anticipated
Consequence
Likelihood
Risk
Impact
Initial Risk
Rating
4
2
8
5
2
10
3
2
6
Role descriptions for staff
working in the service will be
focussed on re-direction and
patient education. Use of
redirection pathway will be
monitored.
New service
fails to re-direct
activity
Waiting times in
A&E increase,
ECS
performance
worsens, -ve
patient
experience,
delays to
treatment and -ve
Trust reputation
3
SUHFT unable
to find suitable
physical space
to co-locate the
new service
New service is
based elsewhere
and therefore
less effective in
directing patients
to more
appropriate forms
of treatment
4
3
12
Location of service will remain
where it is. Navigator will be a
floating role with access to the
front desk.
4
SUHFT & new
service provider
are unable to
agree
acceptance
criteria for the
new service
There is no
change to the
current service
being provided
3
2
6
Clinical Decision group has
developed and agreed a criteria
for A&E / GP minors.
3
1
3
5
Higher than
anticipated
patient volumes
affect local
traffic / parking
arrangements
9
The redirection model should
reduce volumes attending A&E
over time. A communications
plan is in place so that the public
are aware of the changes and
what services are available
should they have urgent care
needs.
3
2
6
9
Of those who expressed a
preferred option during the
public consultation, 61% were in
favour and 39% were against.
There will continue to be
significant user involvement
sought regarding
implementation of the new
service.
3
2
6
2
6
There is public
opposition to
the new
proposals
Traffic builds up
in the area,
parking becomes
more limited for
patients
Amendments are
required to the
original plans
causing delays to
implementation
5
3
15
There is no Seeing GP within
new service spec to remove the
appeal of primary care
treatments in A&E. As above,
S1 booking will support redirection.
3
3
3
3
3
7
8
9
10
There is no new
service in place
on 1st April
2016 when St
Luke’s WIC is
set to close
Patients may
perceive their
experience as
negative if they
are referred
onto a more
appropriate (but
different) care
provider.
There is no
change to the
current service
being provided
Some patients
may express their
frustration with
staff. Patient
experience
survey data may
be negatively
affected.
4
3
4
4
16
Interim plans have been
developed for both CCGs.
Contract negotiations underway
to ensure service starts on time.
4
4
16
12
A communications plan is in
place so that the public are
aware of the changes and what
services are available should
they have urgent care needs.
3
4
12
2
2
4
4
3
12
The need for the current SEEDs
service to sit behind the new
service is expected to reduce
meaning no impact on the
system.
Adding a GP
service in A&E
may put greater
strain on an
already
stretched
resource across
the localities
Fewer GPs
available to
provide the GP
Primary Care
slots that patients
are redirected
into
4
Trust unable to
remove costs
from within A&E
to match
income
reduction from
redirected
activity
Trust unable to
support cost
saving of £1.3m.
Scheme would
no longer have
positive financial
impact
4
3
12
The navigator service will be
nursing and allied professionals
rather than a GP. The triage GP
will be through the existing
SEEDs service.
4
16
iv) Associated papers
Appendix 1 – Full Commissioning Case
Appendix 2 – Service Specification
4
Trust have identified some
savings and discussions
continue with the Trust
Governing Body monitoring information
Internal governance
This commissioning case was approved by the CCG Senior Leadership Team on 9 th
March 2016 and the Joint Clinical Executive Committee on 17th March 2016.
Stakeholder and community engagement
A public consultation was undertaken over the future of urgent care servicesin south
east Essex. The project board overseeing the development of this service includes
lead clinicians from the CCGs and Southend University Hospital NHS Foundation
Trust, along with executive management. A full communications and engagement is
in place.
Resource implications
Financial and resource implications are outlined within the commissioning case.
Legal implications
Legal implications are considered within the commissioning case.
NHS Constitution
This commissioning case supports the following NHS Constitution principles:
Principle 1 – The NHS provides a comprehensive service available to all
Principle 2 – Access to NHS services is based on clinical need, not an individual’s
ability to pay
Principle 5 – The NHS works across organisational boundaries and in partnership
with other organisations in the interest of patients, local communities and the wider
population.
Principle 6 – The NHS is committed to providing best value for taxpayers’ money and
the most effective, fair and sustainable use of finite resources
Equality and diversity implications
A full Equality & Diversity Impact Assessment has been completed and returned an
overall impact of ‘None’.
Further information
For further information about this report, please contact: Robert Shaw, Joint Director
of Acute Commissioning and Contracting, NHS Castle Point & Rochford CCG and
NHS Southend CCG.
5
APPENDIX 1
COMMISSIONING CASE :
URGENT CARE NAVIGTION SERVICE (PILOT)
1.
Background
In October 2007, as part of his Next Stage Review health minister Lord Darzi
announced new investment to develop approximately 150 GP‐led health centres
across the UK. St Luke’s Health Centre in Southend is open 365 days a year from
8am-8pm, with a registered list size of ~6000 patients and also offering walk in
appointments for patients registered with other practices (or unregistered).
From 1st April 2015, NHS England retained commissioning responsibility for the
registered patient provision but the walk-in provision became the responsibility of the
Clinical Commissioning Groups (CCGs). The contract for both elements of St Luke’s
was extended to 31 March 2016 to enable a full public consultation and future
commissioning decisions to be made.
With increasing attendances, predominantly from patients attending with minor
illnesses, placing significant challenges on the local Accident and Emergency (A&E)
department, the consultation around St. Luke’s offered an opportunity to re-think how
urgent care is provided in the area. For example, national guidance now
recommends co-locating urgent care services alongside A&E departments to
manage minors patients (NHSE, 2015).
Following the public consultation, both NHS Southend CCG and NHS Castle Point &
Rochford CCG Governing Bodies approved at their meetings on 24 th September
2015, a recommendation to close the walk-in element of St. Luke’s and charged the
Urgent Care Pathway Project Board with developing a new urgent care pathway.
This decision provides an opportunity to pilot an entirely new service at the front door
of A&E and better manage the minors stream, which would not only significantly
reduce pressure on the A&E department but also ensure patients are routed to the
best place for the care they need, not necessarily within A&E.
6
2.
Outline of the Service
The Urgent Care Navigation Service (‘The Service’), situated at the front door of
Southend University Hospital NHS Foundation Trust (SUHFT) A&E, will provide a
clinical team to stream all walk-in patients and appropriate ambulance arrivals to the
most appropriate part of the hospital. It should be noted that the Trust will continue
with the SEEDs Service during this pilot. This will be kept under review throughout
and it is expected that the need for this service will reduce during the pilot period.
The service model is designed to ensure patients are assessed quickly and
effectively in the early part of their journey by a highly qualified and experienced
‘Streaming Clinician’ and to ensure they are on the appropriate treatment pathway
from the start.
This Streaming Clinician will have the ability to stream patients into the core A&E
services, stream to more appropriate services outside A&E via the Navigator or
discharge the patient as their clinical need dictates. The Navigator will initially be a
clinical role and a key component within the model who will support patients to
access services such as GP Primary Care, Pharmacy and Dental Services by
booking appointments and providing details of local services.
In providing Clinicians and Navigators to stream out and support minor illness
patients attending A&E to access more appropriate provision, the service will help
support patient flows through the hospital during its busiest periods, whilst
recognising very poorly patients who need to be fast-tracked into core A&E services.
The ‘streaming’ element of the service will be in place from 8:00 – 23:00, 365 days a
year. Outside of these hours, patients will follow the same pathway but with
streaming and navigation taking place within the core A&E services. The ‘navigation’
element of the service will be available from 08:00 until 00:00, 365 days a year.
Educating and supporting patients to make appropriate use of healthcare services
will be an important part of the service model and a consistent theme as patients
move through the pathway. This will include, for example, helping unregistered
patients register with a GP Practice or providing leaflets to patients on local
pharmacy or dental services.
The service design supports new and emerging models of urgent care through its
focus on early assessment, providing care that is proportional to need, supporting
patients to navigate the urgent care system and promoting integration between the
hospital Trust, Primary Care and other providers.
The service differs from the current service model in two distinct ways. Firstly, the
introduction of a ‘Navigator’ role will focus the service more on redirecting minor
illness patients to appropriate services outside of A&E and making better use of
7
existing Primary Care capacity. Secondly, the service will no longer perform a ‘see
and treat’ function, thus reducing the appeal of A&E as an alternative route to access
Primary Care services.
3.
Service Description
Following registration, all walk-in patients and those deemed appropriate following
ambulance assessment and transport to the department, will have an assessment
completed by a suitably qualified Streaming Clinician to understand the nature of
their presentation (injury or illness) and to determine a National Early Warning Score
(NEWS). The purpose of streaming will be to identify and direct patients to the right
place for the right care and also identify any potential emergencies, keeping the
patient safe at all times.
Staff undertaking this Streaming Clinician role will be a combination of GPs and
experienced nurses who will have the skill and experience to quickly and accurately
assess a patient’s clinical need and have the authority and confidence to direct
patients to the services they need or discharge the patient as clinical need dictates.
After this initial assessment, patients will be managed in the following ways
depending on their presentation;
1) Any injury or an illness with a NEWS >1 will be streamed directly into core A&E
services and be appropriately managed under pre-existing protocols.
2) An illness with NEWS ≤ 1 that requires follow up at services outside of A&E such
as Primary Care, will be referred to the Navigator. The Navigator will provide direct
support to patients streamed to other services by booking appointments, providing
local knowledge of the services available and also assisting unregistered patients to
register with a GP Practice.
It should be noted that the streaming clinicians will be expected to use their clinical
judgement so if there are patients that have a NEWS score ≤ 1 but in their view they
need Accident & Emergency Care then they will still be sent through the minors
pathway.
At the outset there will be six “redirection” pathway options:
 GP Practice (own GP practice or a GP practice that is commissioned to
provide services to patients who are unregistered or registered elsewhere)
 Primary Care Hubs
 Pharmacy
 Out of Hours (OOH)
 Dental Practice
 Self-management
8
The redirection aspect of the model described here will be used at service
commencement. However, it is anticipated that this will be the subject of ongoing
scrutiny and will expand to provide a broader range of treatment and patient support
options, in order to ensure the best possible outcomes for patients, the Provider and
the Commissioner.
4.
Alignment to CCG Priorities
This project links to the following CCG corporate objectives for Castle Point &
Rochford:
 We will deliver our constitutional standards and manage the delivery of health
services within our available budget over the next five years
 We will embark on a programme of transformation that delivers new models of
care through a reinvigorated primary care provision that places the patient at
the centre of an integrated care pathway working with local partners and
resource following the patient
 We will involve local people in deciding what we do
 We will ensure that those services we commission for the population are safe,
of a high quality and improve the health of our population
 We will improve capacity, capability and access to primary, urgent and
emergency care
 We will ensure there is greater involvement with our member practices and
strong clinical leadership is provided
This project links to the following CCG priorities for Southend:
 Clinically led services for patients that supports accessing the right care in the
right place.
 Quality and safety will be maintained throughout the pilot.
 Centre on patients, families and carers with education and support in
accessing other services as part of the redirection process.
 Best use of public money – we are currently paying twice for patients who
attend A&E when they should be accessing primary care.
 Working across organisations in partnership – this pilot works across
organisational boundaries with two commissioning groups, the Trust and
primary care.
5.
Context and Supporting Analysis
Accident & Emergency departments throughout the country are experiencing
unprecedented levels of attendances, with ‘winter pressures’ being felt all year round
in some areas. Compared to the previous year, attendances at SUHFT A&E
department rose 6% over the 12 months ending June 2015 which equates to 14
9
extra patients per day. This is a far greater increase compared with the national
average of 1.1% and attendances at SUHFT now regularly top 8000 patients per
month. The knock on effect to the 4-hour Emergency Care Standard is such that the
95% target has only been achieved once in the year to date and performance is
consistently below that achieved in 2014-15.
An analysis completed in August 2015 by The Boston Consulting Group showed that
the additional 14 patients per day are predominantly a result of non-major
presentations (9 non-major vs 5 major). The growth in non-major attendances was
analysed further and a clear profile of this patient group emerged:






The growth is wholly experienced in-hours on all days of the week
Patients are of working age or children (Under 30s = 66%, 30-64 = 33%)
Demand is from walk-in presentations
With medical diagnoses
From Southend CCG (56%) and CP&R CCG (22%)
94% of whom are registered with 14 GP practices covering 37% of the
population
A survey of patients attending the current model at SUHFT A&E was also carried out
and indicated that 16% of patients had tried to get an appointment with their GP but
were not able to be seen quickly enough. This is supported by results from a
national survey showing that patient’s ability to see or speak with their GP in
Southend and CP&R had worsened in 2014-15 compared with the year before,
whereas national trends reported a small improvement. Also of significance was the
finding that 23% of patients had not considered contacting their GP at all before
attending the A&E department.
6.
Stakeholder & Service User Engagement
The public consultation over the future of urgent care services in south east Essex
was promoted throughout the consultation period through local media, social media,
patient groups, and other organisations such as Healthwatch Southend &
Healthwatch Essex, via local authorities and Southend Association of Voluntary
Services (SAVS).
During the consultation period a series of public events and meetings took place in
both Southend and Castle Point & Rochford to explain the CCG’s preferred option;
being to decommission the walk in service and design a new service which
incorporates A&E minors in one co-located unit at Southend University Hospital. A
discussion document with accompanying paper and online survey were made
available for local people to have their say.
10
In all 152 surveys were completed which is reflective of the response rates other
CCGs have achieved with similar consultations, and of those who expressed a view
on the preferred option 61% were in favour and 39% were against.
Following the decision by the Governing Bodies not to recommission the walk-in
service at the St. Luke’s Health Centre, the Urgent Care Pathway project board has
charged its Communications & Engagement group with developing a plan for
consulting with patients on how the new service can be successfully
implemented. The plan also outlines the communications activities that will take
place leading up to the launch of the new service and beyond, so that the local
population are better informed of the changes and how to navigate the urgent care
system at times of need.
The Chief Operating Officer and Clinical Director for A&E at SUHFT, as well as other
key staff, have been involved throughout the development of the new service with
attendance at project board and clinical design meetings. We continue to pursue a
close working relationship with the Trust to ensure the service is implemented
effectively and learning is maximised during the pilot period.
This commissioning case has been approved at both Southend and Castle Point &
Rochford CCG Senior Management Teams as well as the Joint CCG Clinical
Executive Committee on 17th March 2016.
7.
Activity & Financial Analysis
Of the 13 HRG codes covering Accident and Emergency, clinicians on the Urgent
Care Project Board deemed three codes, VB08Z, VB09Z and VB11Z, would be
those most likely to contain patients who may be appropriate for redirection i.e.
presenting with a minor illness with NEWS ≤ 1. Volumes of activity occurring during
the proposed hours of the service over the last three years are show below (relevant
HRG codes highlighted in purple).
11
Using actual activity up to month 9 2015/16 and forecasting months 10 to 12 based
on the seasonal variation seen in previous years, this gives a projected outturn for
2015/16 of 63,356 attendances.
In the year to date 2015/16, there has been a growth in A&E attendances of 5%
when compared with the previous year. Assuming this trajectory in attendances
continues and adding a potential rise in attendances as a result of the closure of St.
Luke’s Walk in Centre (WIC), it was agreed at the Urgent Care Project Board that a
rate of growth of 9% would be assumed for modelling 2016/17 activity for these three
HRGs.
With regards to volumes of patients that could realistically be redirected to other
services outside A&E, examples of similar services from other parts of the country
were considered and an analysis of A&E treatments and investigations undertaken
at SUHFT was completed. Both pieces of work point to a realistic target for
redirection of around 20% for patients falling into these three HRG categories,
equating to 13,813 redirected attendances. As outlined in the table below, achieving
20% redirection will yield savings of £1,320,452, when including the savings relating
to closure of St. Luke’s WIC.
Castle Point &
Rochford CCG
548,886
119,571
(288,201)
380,256
Saving from redirected activity
Saving from 2015/16 cost of St Luke’s WIC
Cost of implementation incl. Triage Service
Net Savings
Southend
CCG
824,130
478,284
(362,218)
940,196
Total
1,373,016
597,855
(650,419)
1,320,452
By definition all patients that are redirected will not require emergency treatment and
will be redirected and most importantly supported to access the most appropriate
care;
Primary Care
Evidence from Princess Alexandra Hospital suggests that around half of the
redirected patients from A&E will require a GP appointment in Primary Care. This
would equate to an average of;


1 per practice per week for CP&R
3 per practice per week for Southend
These averages are based on 24 hrs and therefore given access to Out Of Hours the
impact on practices will be even less.
12
An analysis of GP Primary Care capacity has been undertaken in both Southend and
Castle Point & Rochford to identify or make available sufficient Primary Care
capacity and Out of Hours for the Navigator in A&E to make direct bookings into.
Within Southend there was deemed to be no spare capacity within GP Primary Care.
In addition Southend are currently reviewing their options for neighbourhoods / hubs
and therefore they do not have the hub infrastructure that exists within CP&R.
Therefore the Clinical Executive approved a Local Enhanced Service (LES) which
has been offered to GP practices in order to facilitate sharing across practices to
provide the capacity in a similar way to the hub model in CP&R.
Within Castle Point & Rochford, in view of the small numbers that are potentially redirected to primary care and individual practices each day, there is sufficient capacity
within the emergency slots already available to manage this activity. In Castle Point
& Rochford there is also the opportunity to access the 2 x Primary Care Hubs that
operate on Saturday, Sunday and Bank Holidays. Beyond this it is not felt that
additional specific capacity is required, however, this will be closely monitored and if
the position changes then this will be duly costed and rolled out to GP practices as
required.
In addition to both these approaches in primary care there will be the ability to direct
book into the Out Of Hours Service.
Pharmacy
Discussions through the CP&R Locality Commissioning Groups also highlighted the
opportunities to develop more opportunities for patients to access care through a
pharmacist. These will continue to be developed during the early stage of the pilot.
8.
Expected Outcomes and Performance Measures
The aims of the Urgent Care Navigation Service (‘The Service’) are to:
 Reduce the number of patients attending the A&E department for Primary
Care and other conditions that do not require A&E services
 Improve overall performance against the 4 hour A&E standard.
 Improve patient care by ensuring patients are redirected to the right service.
The objectives of the service are to:
 Ensure that only those patients who need A&E services are seen within core
A&E.
 Maximise the use of existing human resources in terms of skills, knowledge
and competencies.
 Ensure all patients can access the service and have their clinical episode
assessed within 4 hours in line with the national A&E waiting time standard.
13









Ensure all patients are streamed by a suitably qualified Clinician and receive a
disposition that is appropriate for their clinical need.
Redirect patients presenting with a minor illness into Primary Care and other
services to receive care that is appropriate to their clinical need or support with
self-management advice and printed materials where this is clinically
appropriate.
Assist patients presenting with a minor illness to book appointments in Primary
Care, access alternative services and/or confidently self-manage their illness.
Ensure patients and their GP are fully informed of the outcome of their clinical
assessment and treatment plan and where clinically appropriate, receive
advice on self-care.
Educate patients on the appropriate use of urgent and emergency care
services to encourage and support behaviour change.
Provide a more cost-effective service for managing those patients who present
at the A&E department with a minor illness.
Connect urgent care services together more effectively to improve navigation
of a system that can be complex and confusing to patients.
Improve the satisfaction of patients presenting with a minor illness by
supporting access to alternative treatment options.
Transform urgent care services in line with current NHS guidance and
recommendation (NHSE, 2015).
The service is expected to have additional benefits which include;
 Improving access for patients requiring emergency treatment through the
reduction of people being treated inappropriately for minor illnesses in A&E.
 Improving the integration of primary, community, Out-of-Hours (OOH),
secondary and mental health services in the local area and streamline care
pathways.
 Improving satisfaction for all patients presenting at the A&E department.
 Facilitating the registration of unregistered patients with a GP Practice.
 Identifying GP practices where access is difficult, enabling the local CCGs to
direct resources/assistance.
14
National Standards:
Title
Description
Target
Time to initial
assessment
Total time from arrival to start of full
initial assessment.
95th percentile time to
assessment <15
minutes
Total time spent
in the A&E
department
Total time spent in the A&E
department.
95th percentile wait <4
hours for admitted
patients and the same
threshold for nonadmitted
Left without
being seen
Percentage of people who leave the A rate < 5%
A&E department without being seen
for assessment.
Unplanned reattendance rate
Percentage of unplanned reA rate < 5%
attendances at A&E within 7 days of
original attendance (including if
referred back by another health
professional).
Local Standards:






Patients requiring Majors, Minors or Paediatrics will be assessed and rerouted
within 15 minutes. Target 95%
Patients not requiring core A&E services will reach their outcome disposition
within 60 minutes of arrival eg decision to redirect to primary care. Target 95%.
Patients requiring support in accessing alternative services will receive this
from a dedicated member of staff, including support to book appointments and
provision of written information. Target 100%
All patients that are unregistered with a GP will be offered support to register
with a local GP practice. Target 100%
A summary of the patient’s episode of care will be communicated to their GP
Practice, where IT systems permit, by 8am on the next working day if time of
arrival is before 23:00. Target 100%
Provider will collect and report patient experience data specific to the service
e.g. where possible, Friends and Family Test (FFT) data specifically for the
navigation service separate to A&E.
15
9.
Procurement Route
The proposed service will be a 12 month pilot; therefore there will be no procurement
process to undertake at this stage. This will be subject to approval from the relevant
Committees. Procurement routes following the pilot will begin to be addressed
during the pilot year and will also be subject to approval from the relevant
Committees.
10.
Implementation Timetable & Resources
Timetable:
Nov
2015
Action
Governance Approvals
Dec
2015
Jan
2016
Feb
2016
GB
Contracting
Mobilisation / IT
Primary Care Capacity
Service Launch
Mar
2016
CEC/G
B
Apr 2016
1st Apr
Resources:
Resource
Name/Role (if known)
Role in Scheme
Level of resource
Finance
Viv Molulu & Steve Downing
Finance & activity
modelling
From within current
resources
Commissioning
Robert Shaw & Emily
Hughes
Contract negotiation
& agreement
From within current
resources
Contract
Management
Mark Emanuele
Contract
management
From within current
resources
Project
Management
Matt Fassihi
Project Management
From within current
resources
IM&T
Dave Allen-Smith
IT interoperability
From within current
resources
Clinical
Drs Mike Saad, Sharon
Hadley, Jose Garcia &
Roger Gardiner
Clinical leadership
From within current
resources
Quality
Linda Dowse & Tricia Dorsi
Quality assurance
From within current
resources
16
11.
Quality Assessment
A full Quality Impact Assessment (QIA) has been completed with the project Clinical
Leads and has satisfied the Quality Teams at both NHS Southend CCG and NHS
Castle Point & Rochford CCG.
Possible indicators
Positive impact on quality and
safety
No impact
Potential negative impact on
quality and safety
47
20
26
1
Indicator(s) with
negative impact
Nature of the risk
Mitigation
Monitoring panel
Patient
Experience
Patients may perceive their
experience as negative if they
are referred onto a more
appropriate (but different) care
provider.
A communications plan is in
place so that the public are
aware of the changes and
what services are available
should they have urgent
care needs.
Clinical Design Group
The QIA will be continually revisited throughout the duration of the project. A full QIA
is available on request.
12.
Equality & Diversity Impact Assessment
A full Equality & Diversity Impact Assessment (EIA) has been completed with the
project Clinical Leads and has satisfied the Quality Teams at both NHS Southend
CCG and NHS Castle Point & Rochford CCG.
Age
Disability
Gender
Pregnancy
Marital
Status
Race
Sexual
Orientation
Religion
Human
Rights
Total Points:
0
0
0
0
0
0
0
0
0
0
Impact Score:
3 – this area has a high
relevance to equalities
2 – this area has a
medium relevance to
equalities
1 – this area has a low
relevance to equalities
0 – this area has no
relevance to equalities
Overall Impact
Irrespective of the total score calculated above, the overall impact is af f ected by the f ollow ing: If
any one or more of the equality groups has scored 2 then the overall impact is MEDIUM. If any one
or more of the equality groups has scored 3 then the overall impact is HIGH.
NONE
The EIA will be continually revisited throughout the duration of the project. A full EIA
is available on request.
17
APPENDIX 2
URGENT CARE NAVIGATION SERVICE –
SERVICE SPECIFICATION
Service Specification No.
Service
Commissioner Lead
Provider Lead
Period
Date of Review
Urgent Care Navigation Service (pilot)
Robert Shaw, Joint Director of Acute Commissioning
and Contracting, NHS Castle Point and Rochford
CCG and NHS Southend CCG
Jon Findlay, Chief Operating Officer, SUHFT
1st April 2016-31st March 2017
1.
Population Needs
1.1
National context and evidence base
1.1.1 National Context
This specification is produced at a time of considerable challenge for urgent and emergency
care. Over recent years, the number of people attending A&E departments across the
country has increased to unprecedented levels, with ‘winter pressures’ being felt throughout
the year in many areas.
The scale of change needed to meet increasing demands on services whilst achieving
financial sustainability for future generations is considerable. Over the next five years, the
system needs to become more efficient and reduce the number of people who attend or are
admitted to hospital when they could be better cared for in the community or at home.
For those patients with urgent but non-life threatening needs, there must be effective and
personalised services outside of hospital that can deliver highly responsive care, close to
people’s homes. For those with life threatening emergency needs, there must be specialist
centres and facilities supported with the very best expertise to maximise chances of survival
and recovery.
The appropriate use and navigation of urgent and emergency care services is key to
ensuring both quality of patient care and financial sustainability.
1.1.2 Evidence Base
The evidence base for this service includes:

Five Year Forward View (NHS, 2014)

Transforming Urgent and Emergency Care Services in England (NHSE, 2015)

Commissioning Standards: Integrated Urgent Care (NHSE, 2015)

A&E Clinical Quality Indicators (DH, 2011)

Internal A&E Audit (BCG, 2015)
18
1.2
Local context
The recently jointly commissioned audit of attendances at A&E clearly indicated the
following;

6% year-on-year rise in A&E attendances at SUHFT

Rise in A&E attendances is predominantly minors patients made up of children and
working age adults, arriving during normal working hours.

Planned closure of St Luke’s walk in centre

Perceived lack of availability of primary care appointments
This audit together with the closure of the St Luke’s walk in service has necessitated a
review and revised model for walk-in patients at the front door of A&E. Following discussions
between the Trust and commissioners, the clinical design group has established a revised
model which will see relevant patients redirected to appropriate care organisations if they
don’t clinically require A&E services.
This specification provides the detail of this redesigned service.
2.
Outcomes
2.1
NHS Outcomes Framework Domains & Indicators
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
2.2
Preventing people from dying prematurely
Enhancing quality of life for people with long-term
conditions
Helping people to recover from episodes of ill-health or
following injury
Ensuring people have a positive experience of care
Treating and caring for people in safe environment and
protecting them from avoidable harm



Local defined outcomes

Prompt identification and assessment of patients within 15 minutes of arrival.

All patients requiring core A&E services or admission will be rerouted within 60 minutes
of arrival.

All patients requiring support in accessing alternative services will receive this from a
dedicated member of staff.

All patients presenting with a complaint that can be self-managed will be supported in
doing so.

Patients, their families and carers will report positively of their experience within the
service.

Attendance and re-attendance rates will be reduced through better and more
appropriate use of alternative services, including Primary Care.

Improved integration of urgent care services across the health economy.
19
3.
Scope
3.1
Aims and objectives of service
The aims of the Urgent Care Navigation Service (‘The Service’) are to:
 Reduce the number of patients attending the A&E department for Primary Care and
other conditions that do not require A&E services

Improve overall performance against the 4 hour A&E standard.

Improve patient care by ensuring patients are redirected to the right service.
The objectives of the service are to:
 Ensure that only those patients who need A&E services are seen within core A&E.

Maximise the use of existing human resources in terms of skills, knowledge and
competencies.

Ensure all patients can access the service and have their clinical episode assessed
within 4 hours in line with the national A&E waiting time standard.

Ensure all patients are streamed by a suitably qualified Clinician and receive a
disposition that is appropriate for their clinical need.

Redirect patients presenting with a minor illness into Primary Care and other
services to receive care that is appropriate to their clinical need or support with selfmanagement advice and printed materials where this is clinically appropriate.

Assist patients presenting with a minor illness to book appointments in Primary
Care, access alternative services and/or confidently self-manage their illness.

Ensure patients and their GP are fully informed of the outcome of their clinical
assessment and treatment plan and where clinically appropriate, receive advice on
self-care.

Educate patients on the appropriate use of urgent and emergency care services to
encourage and support behaviour change.

Provide a more cost-effective service for managing those patients who present at
the A&E department with a minor illness.

Connect urgent care services together more effectively to improve navigation of a
system that can be complex and confusing to patients.

Improve the satisfaction of patients presenting with a minor illness by supporting
access to alternative treatment options.

Transform urgent care services in line with current NHS guidance and
recommendation (NHSE, 2015).
The service is expected to have additional benefits which include;
 Improving access for patients requiring emergency treatment through the reduction
of people being treated inappropriately for minor illnesses in A&E.

Improving the integration of primary, community, Out-of-Hours (OOH), secondary
and mental health services in the local area and streamline care pathways.

Improving patient satisfaction for all patients presenting at the A&E department.
20

Facilitating the registration of unregistered patients with a GP Practice.

Identifying GP practices where access is difficult, enabling the local CCGs to direct
resources/assistance.
3.2
Service model
For the purposes of this service specification Accident & Emergency is the term used to
describe the whole department and incorporates the following elements;

Reception

The Urgent Care Navigation Service (‘The Service’)

Core A&E Services (Resus, Majors/Minors, Paediatrics)
This service specification details the Urgent Care Navigation Service. The other elements of
the A&E department are commissioned outside of this specification.
The service model (Appendix A) is designed to ensure patients are safely and effectively
assessed within A&E by a suitably qualified Clinician, with the ability to stream into core A&E
services, other services outside the hospital or discharge the patient as their clinical need
dictates.
The service design supports new and emerging models of urgent care through its focus on
early assessment, care proportional to need, support in navigating the urgent care system,
interoperability and integration between the Trust, Primary Care and other providers.
Providers should be aware of their wider role within the urgent care system and adaptable to
emerging models of care.
In providing Clinicians and Navigators to stream out and support minor illness patients
attending A&E to access more appropriate provision, the service will help support patient
flows through the department and the wider hospital during its busiest periods. It will also
benefit all patients by supporting those who do not need to be in A&E to access alternative
services and recognising very poorly patients who need to be fast-tracked into core A&E
services early.
Educating patients about the appropriate use of healthcare services will be an important part
of the service model and will be a consistent theme as patients move through the pathway.
This will include, for example, helping unregistered patients register with a GP Practice or
providing leaflets to patients on local pharmacy or dental services.
The service will not provide clinical advice over the telephone to patients. Patients calling
the service will be advised to contact their GP Practice or NHS 111.
The service will not provide pre-booked first appointments to patients. Use of the service by
patients as an alternative to Primary Care should be actively discouraged by the Provider as
part of the education of patients, rather the service will facilitate access by the patient of their
usual GP or an alternative GP who has agreed to see patients urgently who are not on their
registered list.
There will not be a “see and treat’’ model (i.e. seeing patients when they arrive, assessing
their needs, and providing treatment), although “see and advise” (e.g. “you need to see a
dentist”) is within the scope of the service.
21
3.3 Service Description
3.3.1 Registration
The registration process is not part of the Urgent Care Navigation Service and therefore sits
outside of this service specification. Patients arriving at SUHFT A&E will register on arrival at
the reception following pre-existing protocols.
3.3.2 Streaming
The purpose of streaming will be to identify and direct patients to the right place for the right
care and also identify any potential emergencies, keeping the patient safe at all times.
All walk-in patients arriving at A&E and those deemed appropriate following ambulance
assessment and transport to the department, will have an assessment completed by a
suitably qualified Clinician to understand the nature of their presentation (injury or illness)
and to determine a NEWS score. Staff undertaking the Streaming Clinician role will be a
combination of GPs and experienced nurses who will have the skill and experience to
quickly and accurately assess a patient’s clinical need and have the authority and
confidence to direct patients to alternative services where clinically safe to do so.
Following the assessment, patients presenting with any injury or an illness with NEWS score
>1 will be streamed directly into core A&E services and be appropriately managed under
pre-existing protocols. Patients presenting with an illness with NEWS score ≤1 (and who do
not fall within the list of exclusions in the streaming flowchart – Appendix A), will be directed
to the Navigator for support in accessing other services.
3.3.3 Navigation
Patients assessed as not requiring the services of the core A&E department will be
redirected to Primary Care or other services more appropriate for their clinical need. The
Navigator will provide direct support and assistance to patients in accessing such services
which may involve booking appointments for the patient, providing local knowledge of the
services available and also assisting unregistered patients to register with a GP Practice.
At the outset there will be six “redirection” pathway options:

GP Practice (own GP practice or a GP practice that is commissioned to provide
services to patients who are unregistered or registered elsewhere)

Primary Care Hubs

Pharmacy

Out of Hours (OOH)

Dental Practice

Self-management
The streaming and redirection aspect of the model described here will be used at service
commencement. However it is anticipated that this will be the subject of on-going scrutiny
and will expand to provide a broader range of treatment and patient support options, in order
to ensure the best possible outcomes for patients, the Provider and the Commissioner.
The Navigator is a crucial role in supporting patients who are identified for redirection by the
streaming process and will be undertaken by a clinical member of the team. In order to fulfil
this role effectively, the Navigator will not only have up-to-date and detailed knowledge of
local health services but an ability to build and maintain strong local partnerships with these
and other key services such as; welfare rights advice, social services, drug and alcohol
advice services, virtual wards and voluntary services.
22
The Navigator will also assist patients in self-managing their condition through direct nonclinical advice to the patient or carer, offering printed materials and sign-posting to various
sources of on-going support including patient education programmes, support groups and
internet-based information e.g. NHS Choices.
The Navigator will be responsible for recording details of all help and advice they provide. In
particular they will be responsible for recording details (e.g. time, date, name, age,
presenting complaint, GP Practice, the reason why a GP Practice appointment could not be
made) of all successful and unsuccessful attempts to book a GP Practice appointment.
These details will be collated on a monthly basis and fed back to the Commissioner.
3.3.4 Discharge
On each occasion that a patient is discharged directly from the service or redirected to more
appropriate provision, the service will be responsible, where IT systems permit, for providing
relevant information (for example, the need for the GP to follow up with the patient and/or
prescribe medication) and detail of the attendance to the patient’s own GP Practice by 8am
the next day if time of arrival is before 23:00.
In the case of self-management, patients should also be provided with printed materials
relating to their specific condition. If a patient has any questions once they have been
discharged from the service they should call their own GP Practice or NHS 111. The patient
will be advised on discharge of what to do if their symptoms persist beyond the time that
they were advised to expect resolution, or worsen.
3.4 Service Delivery
The ‘streaming’ element of the service will be in place from 8:00 – 23:00, 365 days a year.
Outside of these hours, patients will follow the same pathway but with streaming taking
place within the core A&E services. The ‘navigation’ element of the service will be available
from 08:00 until 00:00, 365 days a year.
3.4.1 Staffing
The Provider’s staffing model for the service will reflect the need for a strong understanding
of services available in Primary Care, from the Clinicians completing assessments, to the
Navigator providing advice and redirecting to primary and community services.
All clinical and non-clinical staff shall have appropriate line management, professional
development and supervision arrangements in place. Appropriate records must be kept of all
staff registration including, membership of professional bodies which are appropriate to their
disciplines and evidence of annual life support training.
Staff involved in the service must be able to demonstrate a good knowledge of local health
services and local health and care strategy and be aware of local issues and need.
3.4.2 Specific Patient Groups
3.4.2(i) Mental Health
The assessment carried out by the Streaming Clinician will inform the prioritisation of mental
health patients. In such cases that it is known or suspected that the patient is presenting with
a mental health problem, the patient will be directed into core A&E services where they will
be assessed in more detail before deciding whether referral to the Liaison Psychiatry team
(RAID) is required.
23
3.4.2(ii) Unregistered Patients
All patients will be asked at their assessment if they are registered with a GP Practice. Any
unregistered patients will be encouraged by the Navigator to contact relevant authorities,
such as Healthwatch, who will support the patient to register with a GP Practice.
Unregistered patients from outside the Southend CCG and Castle Point & Rochford CCG
localities will be asked to contact the registration department of their CCG.
3.4.2(iii) Out of Area Patients
Patients attending A&E from out of area will be supported by the Navigator to book an
appointment with their own GP or will be supported to access a local GP accepting
temporary residents / OOH services as required.
3.4.2(iv) Flagged Patients
The Commissioners and other organisations will provide the Provider with a list of “flagged
patients” via the IT system (for example, frequent attenders, registered mental health
patients, safeguarding, end of life, Special Allocation Scheme, those referred to in alerts in
the previous 6 months) along with guidance as to what action should be taken for each
flagged patient that presents at the service. At patient registration the IT system will have the
ability to flag up these patients and the appropriate action to be taken.
3.4.3 Diagnostics
The Streaming Clinician and Navigator will not require access to diagnostic tests as part of
their roles within the service. Any patients where it is felt diagnostic tests are required
should be directed to the appropriate core A&E services, or where appropriate, referred to
specialty services during the streaming phase.
3.4.4 Supply of Medicines
Medication will not be provided by Clinicians working within the service. Where prescribed
medication is indicated, patients will be supported by the Navigator to access an
appointment with Primary Care and their GP informed of the recommended course of
treatment (see section 3.3.5 Discharge). Where over-the-counter medication is indicated,
patients will be advised as to the location of pharmacies that will be most convenient for
them to access.
3.4.5 Patient Records
GP and Community patient records will be accessed by the service and read by clinical staff
who have been granted access rights.
3.4.6 Communication
Information sharing and systems play a crucial role in the service model. It is essential that
information on any patient seen by any Clinician/Practitioner within the model is passed to
their registered Practice. There must be the commitment to information sharing with agreed
protocols by all professionals involved in this model of care. A record of the patient’s
presenting need, clinical intervention and follow up requirements, will be communicated to
the patient’s GP practice, where IT systems permit, by 08.00 the next working day if time of
arrival is before 23:00.
The Provider is expected to develop a consistent framework for the recording of clinical
intervention details and the communication of this to the relevant GP Practice via the IT
system.
24
3.4.7 Data Reporting
The Provider will record, monitor and report activity and performance data with the required
level of granularity as described in Appendix B.
3.4.8 Quality Standards and Clinical Governance
The Commissioner requires that the quality of the service to be provided is of a consistently
high standard and all professionals abide by the guidance of their professional selfregulatory body. The Provider will be expected to outline clinical governance mechanisms to
be applied when concerns about the quality of the service is raised. The service will be an
integrated part of the A&E department and operate within a common framework of standards
and governance.
The Provider will comply with all clinical standards, recommendations, policies, procedures
and legislation as set out in the Contract. The Provider will implement mechanisms for
managing risk, including disaster recovery, contingency and business continuity plans as set
out in the Contract. All incidents (both clinical and non-clinical) will be reported by staff
(using Datix) and managed appropriately as set out in the Contract.
3.5
Population covered
The population served is all walk-in patients arriving at SUHFT A&E front door, and those
deemed appropriate following ambulance assessment and transport to the department.
3.6
Any acceptance and exclusion criteria and thresholds
Exclusion Criteria;

Patients arriving by ambulance who have any form of injury or an illness with NEWS
score >1.
3.7
Interdependence with other services/providers
The service, as part of the wider unscheduled care system, will be expected to develop
strong links and referral pathways with existing services, including but not limited to;







Primary Care
EEAST
SEPT Community Nursing
SEPT Mental Health
CP&R Hubs
Essex County Council
Southend-on-Sea Borough
Council







NHS 111
Community Geriatrician
OOH
IC24
Dental services
The voluntary and community sector
Care Homes Pilot service (Southend CCG)
These close working relationships will support the new service to deliver the required
benefits to patients. The provider will be expected to liaise with other service providers on a
case management basis where particular individual patients continue to attend
inappropriately.
25
4.
Applicable Service Standards
4.1
Applicable standards set out in Guidance and/or issued by a competent body
Title
Description
Target
Time to initial
assessment
Total time from arrival to start of full
initial assessment.
95th percentile time to
assessment <15 minutes
Total time spent in
the A&E
department
Total time spent in the A&E
department.
95th percentile wait <4
hours for admitted patients
and the same threshold for
non-admitted
Left without being
seen
Percentage of people who leave the
A&E department without being seen
for assessment.
A rate < 5%
Unplanned reattendance rate
Percentage of unplanned reattendances at A&E within 7 days of
original attendance (including if
referred back by another health
professional).
A rate < 5%
4.2
Applicable local standards
The Provider will need to develop the systems for collecting and reporting the following
standards;

Patients requiring Majors, Minors or Paediatrics will be assessed and rerouted within
15 minutes. Target 95%

Patients not requiring core A&E services will reach their outcome disposition within
60 minutes of arrival e.g. decision to redirect to primary care. Target 95%.

Patients requiring support in accessing alternative services will receive this from a
dedicated member of staff, including support to book appointments and provision of
written information. Target 100%

All patients that are unregistered with a GP will be offered support to register with a
local GP practice. Target 100%

A summary of the patient’s episode of care will be communicated to their GP
Practice, where IT systems permit, by 8am on the next working day if time of arrival
is before 23:00. Target 100%

Provider will collect and report patient experience data specific to the service e.g.
where possible, Friends and Family Test (FFT) data specifically for the navigation
service separate to A&E.
5.
Applicable quality requirements and CQUIN goals
5.1
Applicable Quality Requirements: See Schedule 4 Parts [A-D]
5.2
Applicable CQUIN goals: See Schedule 4 Part [E]
6.
Location of Provider Premises
The service shall be delivered from the A&E Department at Southend University Hospital
NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY.
26
Appendix A - The Model
27
Appendix B – Data Reporting
Activity

Attendance volumes by presenting condition and patient demographics.

Attendance time, date and discharge time and date

Patient destination following streaming, by General Practitioner, presenting condition and time
of decision to stream. For example;
o
Core Services (+ Resus, Majors, Minors, Paediatrics)
o
Direct admission (+ Destination)
o
Other (+ Primary Care, OOH, Dental, Self-Management, Pharmacy).

Volume of patient contacts by Navigator, by presenting condition.

Volume of non-registered patients supported to register with a GP.

Identification and attendance summary of frequent attenders (patients attending more than
once a month).

Weekly attendance reports by GP practice of their patients attending the service to be issued
to Southend and CP&R practices.
Effectiveness of Care

Total time in the Urgent Care Navigation Service. The median, 95th percentile and single
longest total time spent by patients in the service, for all, redirected, admitted and nonadmitted patients.

Total time in the A&E department: The median, 95th percentile and single longest total time
spent by patients in the A&E department, for all, admitted and non-admitted patients.

Unplanned re-attendance rate: Unplanned re-attendance at A&E within 7 days of original
attendance (including if referred back by another health professional).

Ambulatory care for emergency conditions: the percentage of A&E attendances for cellulitis
and DVT that end in admission.

Ambulatory care sensitive conditions: the number of admissions for cellulitis and deep vein
thrombosis (DVT) per head of weighted population.
Patient Experience

Proportion of patients who require a Primary Care appointment that are successfully booked
into an appointment slot directly by the service, by practitioner and tabulated separately for
those booked with their own practice and those booked elsewhere.

Proportion of unregistered patients from the Southend and Castle Point & Rochford areas that
are provided relevant details for registering with a GP Practice.

Left without being seen: The percentage of people who leave the A&E department without
being seen for treatment.

Service Experience: Qualitative description of what has been done to assess the experience
of patients using A&E services, their carers and staff, what the results were, and what has
been done to improve services in light of the results. Provider will collect and report patient
experience data specific to the service e.g. where possible, Friends and Family Test (FFT)
data specifically for the navigation service separate to A&E.
Patient Safety

Proportion of patients for whom a summary episode of care is communicated to the patient’s
GP Practice, where IT systems permit, by 8am on the next working day if time or arrival is
before 23:00.
28

Time to Initial Assessment: The median, 95th percentile and single longest total time spent by
patients from arrival to start of full initial assessment.

Time to Treatment: The median, 95th percentile and single longest total time spent by
patients from arrival to the start of definitive treatment.

Consultant sign-off: The percentage of patients presenting at type 1 and 2 (major) A&E
departments in certain high-risk patient groups (adults with non-traumatic chest pain, febrile
children less than 1 year old and patients making an unscheduled return visit with the same
condition within 72 hours of discharge) who are reviewed by an emergency medicine
consultant before being discharged.
29