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

3 Review Purpose and Process

Purpose

The National Review of Primary Care OOH Services ('the Review') was asked to evaluate the effectiveness of the delivery of primary care OOH (OOH) services in Scotland. This evaluation involved reviewing the current delivery landscape and recommending action to ensure primary care OOH services:

• Are person-centred, sustainable, high quality, safe and effective care
• Provide access to relevant urgent care where needed
• Deliver the right skill mix of professional support for patients during the OOH period

The Review was established by Scottish Government in response to a consistent range of issues for OOH services. These include: recruitment and retention of sufficient GPs to work in OOH services, particularly in busier OOH centres and during peak holiday times such as Christmas and Easter. This is exacerbated by:

• Shifting attitudes in relation to achieving a work/life balance and the preparedness or willingness of doctors to cover OOH sessions
• Busier and more complex day-time general practice reducing the inclination or ability of GPs to work additional OOH sessions
• Proximity of some doctors' earnings to key pensionable thresholds

In addition:

• Staff availability is unpredictable making it difficult for Health Boards to forecast and plan staffing rotas and achieve necessary balance of skills mix.
• Demand can be difficult to predict leading to difficulty in delivering a consistent service which leads to difficulties in managing public expectation.
• Perceived unreliability of OOH services, increasing demand and inconsistency can cause pressure on other services such as emergency departments and acute hospital services.
• NHS Boards may be required to adjust their service delivery at short notice. Measures to deliver safe services now regularly include: increased session rate payments to attract GPs and secure sessions (with territorial Health Boards often competing with each other to secure GPs and other clinicians) and running the service from fewer local Primary Care Emergency Centre sites.

Review Process

The Review established a programme management structure in order to try to secure an open, interactive and inclusive process. The Review commenced in February 2015 and reported to the Cabinet Secretary for Health and Wellbeing in November 2015.

The Review structure as illustrated in Figure 3.1 below. Membership details for each of the Review groups, is provided at Annex A.

Figure 3.1 - Review Group Structure

Review Group

The Review Group was chaired by Sir Lewis Ritchie and comprised membership from a range of health and social care professionals, including stakeholders from the statutory services, third sector and public representatives. Its purpose was to provide overall direction and guidance to the Review process, ensuring that recommendations met the aims and objectives of the Review remit.

Executive Group

The Executive Group membership comprised chairs of the four themed Task Groups, the Reference Group and other colleagues providing specific support, including information, finance and academic input. It was also led by the Review Group Chair. Its purpose was to provide overall support for the Review through interfacing with and supporting the themed task groups in their development of recommendations.

Reference Group

The Reference Group was co-chaired by Dr John Gillies, former Chair Royal College of General Practitioners Scotland and by Eileen Moir, former Nurse Executive Director, Healthcare Improvement Scotland. The Reference Group performed the function of external peer review to the Executive Group and offered critique on emerging findings and recommendations. The group operated virtually - using email communication and included multidisciplinary, multi-sectoral and public involvement. Membership was drawn from Scotland, England, Northern Ireland and Wales, New Zealand and Canada in order to provide a broad perspective.

Task Groups

The following themed Task Groups were established with chairs and deputy chairs, who were all subject matter experts:

Models of Care

This Task Group was chaired by Dr Andrew Russell, Medical Director, NHS Tayside. Ellen Hudson, Associate Director, Royal College of Nursing Scotland, acted as deputy chair. The prime objective of the Models of Care Task Group was to advise on models of care including varying range of needs, remote and rural considerations, specific requirements and other groups. Whilst there is a wide range of people with specific and distinct requirements, five were identified for preliminary examination during this review:

a. Palliative Care

b. Mental Health

c. Frail and Older People

d. Children

e. Health Inequalities

The work on people with specific needs was taken forward by Ellen Hudson, largely in workshop format, with the support of the Royal College of Nursing, Scotland.

Workforce and Training

This Task Group was chaired by Professor David Bruce, Director of Postgraduate GP Education, NHS Education Scotland. Mike Sabin, Associate Director of Nursing and Midwifery, NHS Education Scotland, acted as Deputy Chair. The prime objective of the Workforce and Training Task Group was to develop options for recommendations, particularly in relation to the key aim of the Review to deliver the right skill mix of professional support for patients during the OOH period.

Quality and Safety

This Task Group was chaired by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland. Alison McDonald, Chief Nurse East and Mid Lothian, NHS Lothian acted as deputy chair. The prime objective of the Quality and Safety Task Group was to develop options for recommendations as to how the quality and safety of OOH services can be best measured, assessed and improved.

Data and Technology

This Task Group was chaired by Libby Morris, GP NHS Lothian and clinical adviser eHealth, Scottish Government. Christine Hoy, Health and Social Care Alliance Scotland, acted as deputy chair.

The prime objective of the Data and Technology Task Group was to develop recommendations for improved functionality for:

• Communications and data flows to support new ways of working in OOH services.
• Requirements for clinical records, decision support and integrated records

Working Group on GP Terms and Conditions

In addition to these Task Groups, a Short Life Working Group was established to consider and advise on terms and conditions for the employment of general practitioners working in OOH Services. This Group was chaired by Ian Reid, formerly Executive Director of Human Resources, NHS Greater Glasgow and Clyde.

Information Input

Information Services Division (ISD), NHS National Service Scotland provided data and statistical support to the Executive and Task Groups throughout the Review process. This work was led by Fiona Mackenzie.

Finance Input

On behalf of Health Board Directors of Finance, Katy Lewis, Finance Director of NHS Dumfries and Galloway, assisted by Margo McGurk, Finance Director NHS 24, provided a financial analysis of NHS costs of the current OOH services. These costs are summarised in Annex C.

Research Input

The Review requested Healthcare Improvement Scotland to commission a rapid systematic international literature review of OOH services and qualitative research from the Scottish School of Primary Care. This was undertaken by Professor Katherine O'Donnell and colleagues, General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow and is summarised in Annex F. This systematic review considered 274 papers:

Key areas identified in the systematic literature review as being crucial in the development of high quality OOH services were:

• Good communication and information technology, both across out-of-hours service providers but also across the daytime and OOH interfaces.
• Better understanding of how patients view OOH services and the decisions they make in relation to which service they choose to attend.
• Development and evaluation of new professional roles in OOH care, in particular pharmacy, but also other organisations out with health care
• Better engagement with early career GPs, with trainees and with undergraduate medical students to promote the value and professionalism of providing OOH care.
• Improvement in career development and training for other professional groups.
• Single, centralised systems have to be 'future proofed' to address the contextual realities of different areas, for example patients in remote and rural areas have different needs and capacity to respond compared to those in urban areas. This is also true in relation to socioeconomic deprivation.
• Co-location and integration of services will have to be rigorously evaluated, including process evaluations to understand the impact and challenges this brings to different professional groups.

The results of this literature review informed the working of the Task Groups and formulation of the Recommendations in Chapter 2.

Multidisciplinary team at Mid-Argyll Community Hospital and Integrated Care Centre co-located with Scottish Ambulance Service