Executive Summary: Commissioning Urgent Care
Commissioners have six central themes to consider. They need to:
- Build care around the patient not the existing services
- Simplify an often complicated and fragmented system
- Ensure the urgent care system works together rather than pulling apart
- Acknowledge prompt care is good care
- Focus on all the stages for effective commissioning
- Offer clear leadership across the system, while acknowledging its complexity Box ends
1. BUILD CARE AROUND THE PATIENT NOT THE EXISTING SERVICES
i) Attempts to define what is or isn’t urgent tend to be unhelpful and confusing. Patients tend to make good judgements about how to access care and will make their own mind up about whether something is urgent based on their understanding of their own health and the local healthcare system.
ii) Patients need to be seen at whatever point they access the healthcare system; for those with urgent needs, this is especially important because of the likelihood their condition is more acute.
iii) The variation in demand for urgent care services is predictable. By carefully matching available resources, in particular, clinical staff to the demand for services from patients, it is possible to reduce waits, increase productivity and reduce risks to patient safety.
iv) All services need to ensure they develop systematic processes for seeking and acting upon patient feedback. This involves both patient satisfaction data that can be directly compared with other similar services as well as a detailed understanding of individual patient experience.
2. SIMPLIFY AN OFTEN COMPLICATED AND FRAGMENTED SYSTEM
i) It is vital to make it easier for everyone to understand how to access urgent care. A national urgent care telephone number – 111 – is being tested and will soon be rolled out across the country. But, however, successful the use of a new, simple number to access services may be, it will only be as good as the network of local services underneath it.
ii) There is a need to simplify what is available between the GP surgery and the A&E department. Patients are confused about where to access care. In addition to NHS Direct, general practice, emergency departments and the ambulance service, a host of new facilities, including walk-in centres, urgent care centres, polyclinics, equitable access centres and GP-led health centres, all offer a slightly different range of services available at varying times.
iii) The evidence suggests opening new services is opening up new demand, only some of which is for urgent care. Careful examination of the case mix in many of these facilities indicates they are often delivering planned care with follow-up visits, such as changing dressings. Commissioners need to look at this objectively and consider if it is a service adding value to the local health economy.
iv) The fragmentation of services, with different organisations working alongside each other without any clear and shared agreement about governance, puts both staff and patients at risk. The governance regime and reporting must cover all patients and the whole of their episode of care. It is not acceptable if the information from different systems is not brought together to support the analysis required by proper governance.
v) It is critical to define who is responsible for care as patients move across organisational boundaries. Where two providers work together to deliver what is, for the patient, one service, commissioners should give prime contractual responsibility to one party, with the other acting as subcontractor; for example, if an out-of-hours provider is working with a walk-in centre to see some patients. Where a service works with many others, such as NHS Direct or 111, a mechanism needs to be put in place to promote direct feedback from the providers, so issues at the interface point are addressed.
vi) To support the delivery of integrated care commissioners might want to make clear that the service that refers a patient on to another provider is responsible for the hand-over. The lead clinician at the service where the patient first accesses the healthcare system needs to ensure that any referrals are appropriate and that the hand-over works as it should with the necessary information being made available in a timely fashion to the service taking on that patient.
3. ENSURE THE URGENT CARE SYSTEM WORKS TOGETHER RATHER THAN PULLING APART
i) The ability of services to work together is one of the most important features of an effective healthcare system. When systems fail or patient safety is compromised, the inability of services to transfer patients or share important information is often a key factor.
ii) There is a need to develop system-wide metrics, but it’s also essential to understand the performance of each part of the system. The quality of the overall urgent care system depends on the quality of each service, as well as how they join together to provide seamless care; it’s not one or the other but both.
iii) It is vital to support clinicians to work together to ensure best care is delivered both within and across organisational boundaries. We have found repeatedly that services supporting clinicians to work well together and use their range of skills and expertise in an integrated team, provide a better quality of care. This also involves acknowledging and addressing difficult or dysfunctional relationships, either between individuals or across organisations.
4. ACKNOWLEDGE PROMPT CARE IS GOOD CARE
i) There is clear evidence that patients with acute needs have better outcomes if treated rapidly, and that patients associate rapid care with good care. All services need to look carefully at how they can ensure patients are seen promptly; commissioning should focus on improved access to care across the whole urgent care system, rather than setting separate and differential standards across the urgent care pathway.
ii) Where patients are seen face to face It is much more effective for a service to be set up to see and treat patients straight away rather than relying heavily, as many do, on triage processes followed by a second ‘full’ consultation. All services need a contingency plan in case of a major emergency, but these are very rare events and not a good basis for the overall design of a service. Telephone assessment should also be carried out promptly but, where this meets the need of the patient for reassurance and advice, these may become consultations that are completed over the phone allowing the episode of care to be closed.
iii) A prompt response to potentially urgent requests for care is particularly important at the front end of the healthcare system. Many of the most urgent requests for care are received as calls for home visits in general practice. We urge clinical commissioners to ensure that all practices rapidly call back any request for a home visit so that those few cases requiring an immediate response are dealt with within a few minutes, allowing a community based response to be put in place as soon as possible or a rapid transfer to hospital for a specialist opinion, potentially avoiding a hospital admission.
5. FOCUS ON ALL THE STAGES FOR EFFECTIVE COMMISSIONING:
- the commissioning process can be thought of as a cycle, in which needs are assessed, plans are drawn up, contracts are let to deliver the plans, delivery is monitored and ideas are revised
i) Don’t expect to get the specification right in every detail. Commissioning is a largely incremental process: changes should happen during the life of a contract and the commissioner and provider need to work together towards this. The ideal is that the re-tendering or re-letting of a contract will only require the commissioner to formally consolidate many of the changes agreed over the life of the contract into one document.
ii) Commissioners play a key role in monitoring arrangements. To do this, they must:
- have a good working relationship with providers and a sound understanding of each service and how it works
- observe the services themselves – including ‘walking the floor’ and talking to patients, staff and clinicians
- apply a consistent set of measures across all urgent care services in order to understand how the different services compare and to recognise any migration of patients to or from an area
- ensure systems can track patients so the pathway can be followed from beginning to end to support an integrated governance process across organisations and services
iii) An over-simplistic focus on reducing cost, such as by avoiding tariffs, is misguided – despite the increasing financial pressures on public services. Any new currency in the NHS, or the development of shared tariffs to incentivise new ways of working, demands a high level of cooperation both at a senior level between organisations and between frontline clinicians, and requires proper accounting to be sure any planned savings are both achievable and delivered. Too often, commissioners fail to look at the overall cost to the health economy or taxpayer and instead focus on reducing cost to one party, or in one part of the system.
iv) Financial incentives need to be aligned to ensure commissioners stop paying more than once for the same service provided at different points in the system. One opportunity to do this is by bringing all costs for urgent care back to the practice budget, or collectively through the budgets of clinical commissioning groups (this would include out-of-hours services, all 999 or 111 calls, all visits to urgent or primary care centres and A&E). Patients should be free to choose how to access urgent care, but if the cost tracks back to the practice budget there is an incentive for the practice to deal with as many requests for urgent care as rapidly as possible. Whether or not costs can be routed back to the practice, it is vital information is promptly fed back about the usage of urgent care services by practice patients (for example, through a dashboard as highlighted in case study four).
v) There should be a greater emphasis on commissioning for quality, including making clear the ‘quality cost’. This involves identifying the service costs directly relating to improving the quality of care, including the cost of recruitment and induction processes, staff training, support and development, benchmarking and audit processes. We recommend commissioners should require providers to explicitly identify the ‘quality cost’ within any tender they submit.
vi) Urgent care appears to have become the test bed for a market-based system in the NHS: urgent care centres, GP-led health centres and in particular, out-of-hours services, have increasingly been subject to tender processes. We do not have a problem with increasing contestability, or the idea services can be tested if all other routes for improving services fail, however, it is less clear why tendering has become the default position for commissioners in urgent care, while hospital contracts remain unchallenged.
The tendering process is costly: it’s estimated the tender process costs in excess of £100,000 (plus the cost to the provider of bidding that has to be recovered). There is also a concern commissioners pay less attention to developing a clear commissioning strategy than to ensuring mistakes are not made in the procurement process. Better management of contracts by commissioners, armed with good information over a longer period than is typical, is the key to driving down costs and improving patient care.
6. OFFER CLEAR LEADERSHIP ACROSS THE SYSTEM, WHILE ACKNOWLEDGING ITS COMPLEXITY:
In the past, too many commissioners felt unable or unwilling to challenge existing arrangements and implement radical change: the challenge, as the title of this report says, is to break the mould without breaking the system
i) Given the current requirement for efficiency savings and greater value for money, all commissioners should take a fresh look at their urgent care strategy and the range of disparate services commissioned over the last ten years. Can all services really be justified? How do they add value to patient care? Are commissioners paying twice for the same service?
ii) General practice is the bedrock of any urgent healthcare system. There is a need for greater emphasis on ensuring individual practices respond rapidly and effectively to patients with an urgent need. If all practices improved the speed and effectiveness in responding to same day requests, there would be a substantial beneficial effect on the wider healthcare system; all commissioning strategies for urgent care should start by addressing the key role of general practice.
iii) Urgent and emergency care networks have an important role to play in leading local healthcare systems. Too often they have been seen as talking shops where no real decisions are taken, but if systems choose to give them real executive authority, for example in defining the clinical pathways and protocols for handover of care, then they can play a key role in improving care across organisational boundaries.
iv) Urgent care services need to develop a stronger culture of learning from mistakes. Commissioners should encourage providers to take part in wider initiatives that support rapid sharing and learning from incidents where patient safety was put at risk.
v) Commissioning is often seen as the passive partner within the urgent healthcare system, with staff perceived as too distant from the frontline services they commission. It is the responsibility of the new clinical commissioners to work with a poorly performing service and to insist on action being taken immediately. In every case of poor performance, there has been enough evidence to allow the commissioner to act and if necessary, terminate the contract early. We encourage all commissioners to manage their services closely enough to avoid terminations.