Provision of unscheduled primary care and GP access

Dr Josip CarMedical Director & PEC Chair

NHS Hammersmith and Fulham

and Director of eHealth Unit

Imperial College London

A Framework for Action

1. The need to improve Londoners' health

2. The NHS is not meeting Londoners' expectations

3. One city, but big inequalities in health and healthcare

4. The hospital is not always the answer

5. The need for more specialised care

6. London should be at the cutting edge of medicine

7. Not using our workforce and buildings effectively

8. Making the best use of taxpayers money

PCTs are being asked to consider the following in their strategies:

• Preventing people from choosing to use or ending-up in unscheduled care

• Being more responsive to the patients’ needs and expectations

• Making the system easier for patients to understand and navigate

• Ensuring more consistent quality standards in community and hospital services

Hammersmith and Fulham Unscheduled Primary Care Tender

What’s Our History?

• Lack of access to GP practices• Confused map of services difficult for public and professionals to

navigate• Poor access to Community provider services• Under utilised Out of Hours• A&E the default option and heavily over-used compared to London

and National expectations

Hammersmith and Fulham Unscheduled Primary Care Tender

Why go out to Tender?

• Five year history of small, sometimes disjointed service improvement attempts

• Involved in NWLCRG and fully signed up to clinical recommendations for change

• Wanted to test and challenge the market in search of innovation• Keen to do business with a single umbrella provider to minimize

commissioning demands

Objective

Improved outcomes for residents across the area by developing a new service model, improving performance measures and addressing issues of equity, quality and access

Background

• The population is characterised by high mobility, high mortality rates for cancer and CHD and distinct pockets of deprivation

• Underdoctored• a third of patients under 45 were dissatisfied with

the lack of Evening and Weekend opening. • A quarter of respondents in the over +65 age

group were dissatisfied with the lack of lunchtime access to their GPs.

• 375 A&E attendances per 1 000 head of population (age and need weighted).

Patients attending A&E for what could be described as routine Primary Care conditions represent a growing cohort and present the PCT with a significant financial challenge due to:

•  the high cost of A&E services in terms of the number of patients attending

•  the high number of patients subsequently admitted to hospital for observation

•  the application of PbR tariffs to those patient episodes

The patients belong to a variety of groupings that can be categorised as those patients who are:

• not registered with a local GP or claim not to be registered with a local GP

• visiting the locality/or working on temporary contracts and so can’t access their own local GP

• unable to obtain a GP appointment at a time convenient to them

• attending with a perceived emergency which is considered by hospital as a Primary Care problem

• attending for a second opinion• out of hours attendees unaware or uninformed of the

local OOH provision by their GP practice• advised to attend A&E by NHS Direct

Current services• Charing Cross Hospital A&E (CXH A&E)• Charing Cross Hospital Urgent Care Centre

(CXH UCC)• Parson’s Green Walk-in Centre (PG WiC)• Hammersmith Hospital A&E (HH A&E)• Unscheduled Care GP provision• Out of Hours GP Services

Single Point of Access

There is currently no single point of access call number for the locality.

there are a wide range of community services that could be used on an unscheduled basis to avoid an A&E attendance. These include District Nursing, End of Life Care teams, Falls Teams, Respiratory Care, Diabetes Nurses, Catheter Care teams etc.

We know from our OOH provider that call handling can be extremely effective in reducing A&E demand and we need to replicate this in some form for in hours.

The key objectives of the project:• Develop and establish a new service model for

Hammersmith and Fulham, in partnership with key stakeholders and through competitive dialogue with potential provider organisations by April 2009.

• Procure a new service through formal a competitive tender commencing in Septemeber 2007 and completing in November 2008.

• Award a contract for the service to the preferred provider based on new service standards, performance measures, quality criteria and value for money to commence in April 2009 for five years, with an option to extend for a further five years.

• Ensure that the new contract and service are implemented by July 2009 and that robust contract management processes are established to ensure that the new service meets performance standards.

• Ensure that service users, their carers and other stakeholders, including the Local Authority, GPs and other clinicians, are involved in the development of the service specification and evaluation of tenders received.

• Ensure that the interests of staff affected by any change of contracts are protected under TUPE regulations throughout the procurement process and subsequently during implementation of the new contract.

Project approach• Competitive Dialogue procedure for tendering. • This procedure is particularly suited to services of

sufficient complexity that a precise service specification cannot be produced at the outset of the tender.

• The advantage of this procedure as opposed to an open or restricted tender is that it will allow a period of formal dialogue with providers to address issues of quality and service delivery, provide the opportunity for innovation within the development of the service specification.

The project includes the following services commissioned by Hammersmith and Fulham PCT:

• Unscheduled Walk-in self-referrals at Charing Cross and Hammersmith hospitals’ A&E departments

• GMS GP Provision• Extended Hours GP Provision• Out of Hours GP Provision• Single point of Access Telephone help and advice• Options for opportunistic Co-location of

Community Provider Services

Constraints• Lack of consistency in the collection and collation of

patient/service user information across provider organisations

• Lack of outcome measures to determine the effectiveness of services

• Lack of current performance measures relating to some aspects of unscheduled care

• Difficulty in establishing true service costs due to possible cross-subsidisation of services and unclear allocation of overhead costs

• Lack of previous knowledge of this tendering process• Commitment to innovation

• The project phases:• Project initiation – establishment of project team,

project management structure and initiation document, and Board approval to proceed

• Stakeholder involvement to develop an outline “vision” for the new service

• Advert inviting expressions of interest, development of Pre-Qualification Questionnaire and Memorandum of Information

• Evaluation and Short-listing following PQQ stage• Issue of Invitation to Participate Document• Evaluation of bids and short-list

• Competitive dialogue period and issue of final specification and invitation to tender

• Evaluation of final tenders and selection of preferred bidder

• Board approval to award contract• Implementation of new contract

Hammersmith and Fulham Unscheduled Primary Care Tender

Scope of the Tender?

• £45m Tender over five years• Create referral only A&E access• Deliver two “super surgeries” capable of interdicting all A&E self-

referrals containing two brand new GP Health Centres in-line with the current NHS London requirements based on current A&E sites

• Deliver OOH Service with 95% coverage• Deliver Single Point of Access telephone system• Provide cornerstone for future Polyclinic development• Create a single provider for the entire Unscheduled Care delivery

pathway and simplify Commissioning

Hammersmith and Fulham Unscheduled Primary Care Tender

Anything else?

• Significant investment in Extended Hours LES (3 x DES)• Creation of a range of co-located support services from Provider

Services such as Hospital at Home• Negotiation with Acute Trust for “space” and commitment to assist

with capital investment• Commitment to re-invest in Major A&E services to counter any

instability caused by removing “minors” – adjusting tariff

Hammersmith and Fulham Unscheduled Primary Care Tender

Why choose Competitive Dialogue?

• We don’t have a monopoly on good ideas• Innovation was a key driver for change• We wanted to “front load” the issues and challenges and thus make

actual contracting less protracted• We wanted to allow single bidders to develop consortia offering the

entire pathway rather than have them over-stretch themselves or end up with multiple providers across the pathway

Hammersmith and Fulham Unscheduled Primary Care Tender

Difficulties?

• New process for everyone and so required a protracted process• Very intensive in terms of time and commitment• Requires significant senior input and less options for delegation• Can be daunting in terms of performance managing and reporting a

“concept” rather than a concrete specification

Hammersmith and Fulham Unscheduled Primary Care Tender

Rewards?

• Evolution of a genuinely innovative and integrated care pathway• Significant scope for public and user involvement• Simplified commissioning with single provider

Hammersmith and Fulham Unscheduled Primary Care Tender

Tips?

• Don’t be shy about getting outside expertise in – we used a Consultancy firm with experience of Competitive Dialogue to help us as well as our solicitors

• Remain true to a process without a spec – it’s easy to fall into the trap of designing yourself what you set out not to design yourself

• Fully involve LMC and other powerful self-interest and lobby groups from the outset

• Genuinely win over Directors and CEO to the concept before beginning because the draw of traditional tendering is strong and can quickly undermine the opportunities for innovation that Competitive Tendering offers if your leaders lose the focus