ANNEX 7 – Format of Cabinet Response to Audit Committee Report

Response to the Report of the National Assembly for Wales Public Accounts Committee Report on Primary Care Out of Hours Services

Provided by: Vaughan Gething AM, Minister for Health and Social Services

Date: September 2019

The Welsh Government welcomes the findings of the report and offers the following response to the 8 recommendations contained within it. While we recognise the leadership role of Welsh Government and that Out of Hours services form a part of the Primary Care Model for Wales and of unscheduled care services. It should be noted that the delivery of Out of Hours services remains the statutory responsibility of health boards.

A significant amount of work has been undertaken by Welsh Government and the NHS over the last two years to develop out of hours services. Much of this work responds directly to the recommendations of the original WAO Report and provides context to the recommendations contained in the PAC Report. A more detailed summary of this work can be seen at Annex 1.

Recommendation 1: We recommend the Welsh Government ensure there is capacity within the Out of Hours service to provide patients with reassurance and help them to access the services most appropriate to their needs.

Health Boards are responsible for providing out of hours services. Using a nationally developed model, they are currently undertaking a significant piece of work to analyse and understand the exact nature and timing of their demand. This will be used to ensure that rotas include the right balance of clinicians to meet this expected demand. We expect this model to be trialled over the coming winter and to be routinely in place in 2019/20.

Health boards actively manage shift fill for all out of hours staff groups, including but not confined to GPs. A submission of clinical staffing levels is shared with Welsh Government and other partners twice a week. This information is available to, and discussed on, the NHS Daily Executive Conference calls to assist in operational planning and resilience.

The development of one central Directory of Services (DoS), across Health, Local Authorities and third sector, remains a critical component in supporting urgent primary care – particularly when there is increasing range of health and well-being services working within and across organisational boundaries. This information is crucial in sign posting patients to the correct service whether this is by the patients themselves of through professionals or the 111 service. For example, a Health and Well-being App providing access to the DoS for professionals was launched in the summer, while the public have access to the DEWIS and NHS (D) W websites

Recommendation 2: We recommend the Welsh Government reviews the way it allocates funding to health boards for out of hours services to ensure that allocations more accurately reflect the current service needs and provide greater transparency in terms of investment and actual spend.

Reject

Funding for out of hours services are contained within the overall GMS allocation to health boards. The recommendation focuses on the allocation. It is for health boards to determine the appropriate level of investment in these services, using either the GMS allocation, or drawing on their substantial levels of discretionary funding, this does not therefore relate directly to central allocations. This blend of funding reflects the wider range of services now in place to support out of hours services. It is crucial that local organisations understand local services. Given this, we agree that it would be timely to review the current definition of expenditure to ensure funding is more transparent and reflects the wider range of services now in place to support out of hours access.

Recommendation 3: We recommend the Welsh Government share good practice across Health Boards in Wales in making out of hours services more attractive places to work, such as the approach taken in Aneurin Bevan University Health Board.

This is already well in train. A Peer Review was undertaken of each health board in the late autumn of 2018. Making out of hours a better place to work was a significant theme, while the review provided an opportunity to share best practice.

Following the review a summary report was produced that captured best practice from across Wales, this was shared with all health boards and WAST earlier this year. Further, the All Wales Quality and Safety OoHs / 111 Forum, a meeting of clinical and managerial leads has reorganised reinforcing the sharing of best practice relating to quality, safety and management. For example the clinical section shares and learns from clinical incidents and near misses, while the managerial section has helped delivered the new policy relating to Verification of Death training A new website will be launched in the September which aims to provide a range of information to help inform clinicians about the benefits of working in out of hours (see also Recommendation 4 below).

The peer review identified ‘isolation’ as a key factor in some clinicians’ decision not to work in the out of hours. There is still much work to do but the move to multi-disciplinary team working, the implementation of 111 and the embedding of out of hours in the 24 /7 model of primary care all help to reduce this feeling of isolation, making out of hours a much more attractive proposition for all staff.

Recommendation 4: We are concerned about the general decline in GP numbers not just for out of hours services but daytime services too across Wales. We recommend the Welsh Government actively develop policies to increase GP numbers.

The Train, Work, Live campaign is actively targeting GPs and GP trainees and is supported by 2 incentive schemes for GP trainees. The fill rate for GP training has improved significantly in recent years and as a result, we have increased the number of GP places from 136 to 160 this year, with the intention to further increase the number of places in the near future. We are also working with Health Education and Improvement Wales HEIW to further increase the number of GP training places from August 2021.

We have also introduced and continue to develop a number of tools to support primary care workforce sustainability, including establishing an all Wales Locum Register for locum GPs. This is a pivotal first step to structure the provision of sessional work to support our GP partners working in Wales.

HEIW have undertaken a project to address out of hours recruitment difficulties via a dedicated website development that is dedicated to Primary Care Out of Hours. The purpose of the website is to highlight opportunities in out of hours and attract potential and existing staff. The website is scheduled to launch in September 2019.

Recommendation 5: We recommend the Welsh Government resolve issues with the quality of data available on GP numbers as a matter of urgency as there needs to be better data available, including on out of hours care. If multidisciplinary teams are delivering the out of hours services, it is imperative to know who works in each team, where they are delivering the service to, and be able to track the staff numbers over years.

NHS Wales Shared Service Partnership (NWSSP) has been engaged by the Welsh Government to procure and implement the Wales National Workforce Reporting System (WNWRS), this provides a secure web based tool developed to capture all practice staff information for General Practices.

With the introduction of the WNWRS we hope to improve data quality across the board and we continue to work with all relevant stakeholders to ensure the data is of the highest quality. We are depending on GP practices providing as complete and accurate information as possible to support production of higher quality statistics.

We will explore the potential for further development of the WNWRS with NWSSP, to consider how information for clinicians working in out of hours can be captured and develop a proposal by the end of December 2019. If this development is not feasible, we will work with health boards and primary clusters to collect accurate and complete workforce data for GPs working in alternative settings, including out of hours

Recommendation 6: We are concerned that there appears to be a number of issues arising from the pay inequalities of GPs compared to England as well as taxation issues as reported to us in evidence. We recommend that the Welsh Government seek to address these issues and provide us with an update on any action taken to do so.

Reject

Although there appears to be some anecdote relating to pay inequalities in the east of Betsi Cadwaladr, we have no hard evidence of this and it doesn’t appear that this is a national issue. We are also aware of the issues with taxation in relation to HMRC IR 35 but these are non devolved issues. Health boards have acted collectively in response to these issues, while Welsh Government have tracked progress and impact. There are however bigger and more general concerns with pensions and the Minister for Health and Social Services is pursuing these with the UK Government.

Recommendation 7: We recommend the good practice at CVUHB in terms of strengthening its performance management is shared with other health boards and that the Welsh Government explore in more detail how it can enhance the sharing of good practice. The Welsh Government may wish to consider, where possible, to give greater direction on such practice and monitor compliance with any directions issued.

We are working with the Welsh out of hours community to strengthen the emphasis on understanding the nature of the demand within individual health boards both in terms of case mix and time of the day. This involves developing the good practice already developed in CVUHB around demand and capacity modelling so that it can be used across Wales. A ‘Once for Wales’ model has been developed and is being tested by each health board this winter with a view to rolling it out formally in readiness for use in 2019/20. We believe that developing the clinical model based on demand is the key. Once these building blocks are in place we will increase the emphasis on performance management.

Recommendation 8: We recommend that our successor committee of the sixth assembly examine the progress and success of the implementation of the 111 service following full roll out in 2021/22.

Noted

We are pleased to note that the Committee recognise the success of the 111 roll out to date and recognise the opportunities presented by the service. We would welcome the committee of the sixth assembly examining the progress and success of the111 service. This will continue to remain a key priority for NHS Wales in the future and we are actively supporting a number of initiatives to ensure its long term success.

Annex 1

Progress Following the WAO Report into Out of Hours Services – August 2018

Background

While we were pleased to note that the WAO report recognises that out of hours services are well regarded by the public, we accepted the recommendations contained within the report as being a helpful contribution to the delivery of an effective Out of Hours (OoH) service in Wales. In common with other parts of the UK there have been issues with recruiting clinical staff, in particular GPs in the OoHs period over the last few years.

Over the last 2 years, Welsh Government working closely with the NHS have been focusing on the areas highlighted in the WAO report delivering national and local actions that are making the system more resilient. At the same time the roll out of 111 has increased resilience and created opportunities for more and better regional and national working.

The WAO made 8 major recommendations and we believe a significant amount of work has been undertaken, much of which was underway prior to the Report’s publication, but due to the timing of the report and field work was not necessarily fully recognised in the final report.

In particular, we recognised the call for greater involvement and leadership from both the Welsh Government and the NHS and Judith Paget the Chief Executive of the Anuerin Bevan Health Board has been providing a strategic lead, chairing the Urgent Primary Care (OoHs) Group, which coordinates key actions on a journey to the greater integration of services as part of the Primary Care Model for Wales.

Our ambition is to bring greater consistency and equity to the delivery of Out of Hours services across Wales, learning from the best practice that already exists. However, it should be remembered that ultimately Health Boards remain responsible for the delivery of primary care services in the out of hours period.

The Primary Care Model for Wales

The Primary Care Model for Wales focusses on the delivery of Primary Care services over the 24/7 period of which OOHs is an important part. The resilience of, and access to, in hours services has a key bearing on Out of Hours (OoHs) services. Therefore, Out of Hours services in Wales are now being planned in the strategic context of the Primary Care Model for Wales.

The Model, which supports the vision set out in A Healthier Wales It is predicated on collaboration at a very local level through the primary care clusters to plan care and support to meet population need. Cluster led planning and delivery is about seamless and effective care from a multi professional team on a 24/7 basis, with priority for the sickest people.

In this context, our approach is embedded in a 24/7 service. We know services delivered during the in hours period can impact on demand for services out of hours. Some GP practices across Wales are facing challenges in terms of achieving sustainability and accessibility. We are working in close collaboration with health boards and GP practices to address the challenges of GP recruitment and introduce access to a wider range of health professionals and signpost people to other local services such as community pharmacies.

In terms of attracting more GPs and other health professionals to Wales, our national and international campaign “This is Wales: Train, Work, Live” was launched in October 2016 to market Wales and NHS Wales as an excellent place for doctors, including GPs. The campaign has resulted in a significant increase in the fill rate for GP training. Following all rounds of recruitment this year, 98% of GP training places have been filled - 134 from the 136 places available. It is positive that more doctors are choosing Wales to train as a GP.

Our strategy is for expansion of multi-disciplinary teams in primary care, including out of hours, led by GPs, by investing in a range of healthcare professionals, such as advanced practitioners, clinical pharmacists, mental health clinicians and physiotherapists.

We are also reforming the national contract for in hours primary care services to improve the way they are planned and delivered leading to more sustainable and accessible services.

Since the GP contract reform in 2004 that saw GP OOHs removed from the GMS contract, the delivery model for in and out of hours has been managed and delivered through different providers (i.e. OoHs directly delivered by Health Boards and Shropdoc, not-for-profit social enterprise in Powys). However, it is recognised that there is the ‘golden thread’ of urgent care that runs across in hours and out of hours services. It is clear that the management of urgent primary care in hours has an impact on urgent primary care services out of hours and vice versa. Therefore, we need to consider the 24/7 urgent primary care offer as a whole whilst recognising that service delivery will be slightly different in and out of hours.

As part of the implementation of the Primary Care Model for Wales, the Strategic Programme for Primary Care has five specific workstreams to progress actions on a national level to support implementation of the primary care model for Wales at a local level. A key workstream within this is the 24/7 Model work stream, intentionally labelled to ensure we consider what the overall offer is to the public. There is a recognition that across Wales the urgent care services offered to the public from Primary and Community Care are very different depending upon the time of day and often the location of the prospective patient. This work stream looks to ensure that as far as possible the service offer is consistent and appropriate in both time of day and geography. Whilst we recognise that service delivery will be slightly different in and out of hours, the overall principles and components of the model should be the same for example call-handling systems, the extended MDT and wider community service infrastructure (key components of the Primary Care Model for Wales).

The 24/7 work stream is focussed upon urgent care services within Primary and Community Care and should complement the work of the National Unscheduled Care Board. The work stream will pick up upon the actions associated with the recent OOHs Peer Reviews, investments in Primary and community services associated with the Winter period, escalation metrics and tools within primary care, access to and use of the totality of independent contractor footprint within a locality and the success of and options for the delivery of clinical triage through in hours GMS services. This work will have a watching brief on the development of the population segmentation and risk stratification at cluster level.

Leadership

The work of the Urgent Primary Care (OOHs) Group, chaired by Judith Paget continues to maintain the focus on specific issues for OOHs of services already identified. However, there is strong alignment with the Strategic Programme for Primary Care and, where appropriate, actions are being taken forward through the workstream of the Strategic Programme in order to ensure we deliver a ‘blended’ model going forward. For example:

- Winter Plans – the 24/7 workstream will consider all recent investments in primary and community care (across in hours and out of hours) to develop a guide to no more than 10 services/initiatives in primary and community care services that add significant value to the whole system in terms of demand management and supply capacity at times of peak demand.

- Escalation metrics and tools – again these are under developed in primary care compared to secondary care. An outcome of the 24/7 workstream is to ensure that there escalation tools in place which allows rapid assessment of capacity issues in primary care (in and out of hours) with resultant support mechanisms.

- Wider community services and pathways – a focus of the 24/7 workstream is a consistent and standardised community service response across health and social care which prevents avoidable emergency admission to hospital. We know that unscheduled social care needs is a pressure particularly out of hours so it is important that the focus is wider than just health.

It is planned that over the coming months, actions relating to OOH services will be aligned to the Strategic Programme. However, currently there is a need for the Urgent Primary Care (OOHs) Group to continue to ensure a focus and profile on some of the critical areas identified specific to OOH Services. (For noting, the over-arching governance for the Strategic Programme and the Urgent Primary Care Group is the National Primary Care Board).

The Peer Review process delivered in 2018 (and to be repeated in 2019), was a clinically led, data driven review of each health board’s OoH service, designed to act as a ‘critical friend’ in offering advice and support as part of development of a safe effective OoHs service.

The Peer Review Panel was led by an independent chair (Dr CDV Jones) with membership including Clinical Directors, operational leads, Associate Medical Directors, Directors of Primary Care, the 111 Programme, HEIW, RCGP and Welsh Government. The intended outcomes included:

Ø recognise good practice and shared learning;

Ø provide positive peer support for improvement;

Ø offer increased clarity of direction for NHS Wales regarding the wider transformation for urgent primary care and greater consistency of approach both in-hours and out of hours (24/7); and

Ø assist in the development of a clinically led, solution focussed, sustainable model for Wales

The output from each review was a summary report and action plan which was endorsed by local clinical leaders and the wider executive team.

Key summary messages arising from the Peer Review visits were:

Clinical teams and their wider organisations found the peer review visits constructive and assisted with wider learning and shared best practice.

· Local and national workforce plans need to be strengthened to ensure they support GPs leading and working within a wider multi-disciplinary team.

· Urgent Primary Care (OOHs) should adopt a more consistent approach to demand and capacity planning linked to workforce modelling

· Now that LHBs are all on the same version of Adastra, it should be possible to benchmark in a more consistent manner.

· Having effective non-clinical and clinical triage processes are critical to the effectiveness of the urgent care pathways. The 111 team are assisting the standardisation of these approaches across Wales and increasingly there will be greater scope for developing these at a regional or national level.

· The integration between 111, NHS Direct, and OOHs will increasingly offer significant opportunities for wider system resilience.

· The role of the 111 clinical hub (over time) could increasingly offer urgent care advice and support for a number of key clinical pathways such as mental health, dental, palliative care and paediatric advice.

· Maintaining and updating one central Directory of Services (across Health, Local Authorities and third sector) remains a critical component to support urgent primary care – particularly when there is an increasing range of services.

· The Peer Review identified variation in the reporting of Serious Incidents (SIs), Near Misses and Never Events. Processes should be reviewed and strengthened locally to ensure ongoing learning between clinical teams (both locally and nationally) and for wider clinical governance purposes. Urgent Primary Care Services/the OoHs Forum have reviewed their reporting mechanisms to ensure they are robust and effective and have linked to appropriate governance structures within each organisation.

· Local work environments are being reviewed to ensure that they are conducive to patient care and staff welfare and that where appropriate, they broadly have access to a similar range of services as in-hour colleagues.

· LHBs, 111 and Welsh Government actively supported a range of initiatives as part of winter planning in 2018/19. Particular focus was on wider MDT input including pharmacy support, mental health, palliative care, advanced paramedic practitioners (APPs), Health Care Support Workers (HCSW) and initiatives to support improved access to urgent dental care. All schemes have been evaluated and were actively supported (usually for 3- 6 months) to ensure the benefits of such schemes are fully understood. The majority of schemes were kept in place until post Easter as a minimum.

· Maintaining executive buy-in and oversight of the urgent primary care agenda is essential.

· A number of pilots have been instigated across organisations which reflect established (good) practice. It was agreed by executive and clinical teams that in most instances that subject to appropriate evaluation these should be mainstreamed and recognised as business as usual).

Overall, the Peer Review Panel was impressed by the ongoing dedication and commitment that was demonstrated by all staff and their continued focus on delivering high quality patient care. There was a evident ‘passion’ to deliver long term sustainable change aligned to the wider 24/7 urgent primary care agenda and the national 111 Programme.

It was recognised that Out of Hours can offer excellent working and training opportunities for staff. It can allow trainees and newly qualified professionals the opportunity to get a fuller understanding of the urgent and emergency care system and with a structured induction and ongoing mentorship programme are being put in place, to enhance future recruitment and retention.

Health boards have a new cohort of clinical leaders and operational staff in place who are often in the vanguard of developing new approach to urgent primary care both locally, regionally or nationally.

The new standards upgraded in consultation with clinicians and managers from the service are key to driving forward both the new delivery model and a high quality response to patients.

Staffing

Non devolved HMRC IR35 changes to the ‘off payroll working’ in the public sector has had an impact on the way GPs are taxed. From April 2017 any health board who engage GPs via a personal service company are responsible in deciding whether the IR35 rules apply for those GPs that they engage, and therefore whether they must deduct the appropriate amount of tax and NICs at source.

Furthermore, HMRC concluded that GPs working directly for LHBs, whether in OoH services or locum capacity should be treated within the scope of IR35 and therefore ‘on-payroll’ with a view to PAYE and NI deductions being deducted at source. This change came into effect on 1 November 2017.

Feedback from LHBs is that the impact of the ruling from HMRC has not been as a significant on shift fill or recruitment to out of hours services in NHS Wales as was first expected.

There are a wide variety of both national and local initiatives being undertaken to make OoHs a more attractive place to work. These are often aimed at reducing the general feeling of isolation by: creating a team culture, increasing its (OoHs) profile, and offering well defined roles for all staff by developing a cross cutting competency framework - clinical, managerial and administrative, better training and development opportunities, reducing the reliance on GPs and introducing new professionals/roles. For example:

· Demand/capacity work – compared to secondary care services the tools for supporting demand capacity work are under developed in primary care. As part of the Strategic Programme Workforce Group, demand capacity models are being considered in order to provide a ‘once for Wales’ approach for in hours and out of hours primary care. Out of Hours have been in the vanguard of this work and are close to implementing a single methodology for all Welsh LHBs.

· All Wales roles for urgent care – a sub-group of the Urgent Primary Care (OOHs) Group is looking at developing national roles and has developed a set of core competencies for urgent care. This work will be particularly important as we consider the use of the role of urgent care practitioners in and out of hours.

· Workforce plan – the demand/capacity modelling and the development of national urgent care roles are critical to inform workforce plans. The Strategic Programme Workforce Group is taking workforce planning forward for both in and out of hours services to provide clusters and Health Boards with the tools to develop more robust workforce plans and in turn inform IMTP plans going forward. HEIW is fully linked into the workforce group so any educational or training requirements can be considered as they arise.

· Website development – HEIW have undertaken a project to address Out of Hours recruitment difficulties via a website development that is dedicated to Primary Care Out of Hours for provision of a one stop shop for information, education and direct contact details of local out of hours services. The purpose of the website is to highlight opportunities in OoHs and attract and recruit potential staff. The launch of the website in September 2019 will coincide with an active social media campaign designed to raise awareness of out of hours as a viable career option and to support marketing of recruitment opportunities and will link to the new GP Wales website. The objectives are as follows:

Ø To make the Urgent Primary Care Out of Hours service more attractive to clinicians;

Ø To widen the pool of potential staff by offering information and support that can be easily accessed, encouraging interest in working in the Urgent Primary Care Out of Hours service; and

Ø To provide resources to facilitate effective recruitment and retention activities.

Standards

The previous (up until end of March 2019) Wales Quality and Monitoring Standards for the Delivery of Out of Hours Services, were developed and agreed in 2014, by the 111 / OoH Sub-Group of the Urgent & Emergency Care Board involving the NHS and Welsh Government. The service was given four years to achieve these, by 31 March 2018.

Following the roll out of 111, the OoH/111 community have been keen to create a single ‘universal’ suite of standards and quality indicators. The intention was to develop a set of measures that could be adopted, and used by all health boards, regardless of whether they are operating 111 or OoHs.

The new standards (introduced 1 April 2019) are based on the existing Wales Quality and Monitoring Standards for the Delivery of Out of Hours Services, and interim 111 standards, but in line with a strong evidence based clinical view, are consistent with, or been ‘relaxed’ slightly from the current standards. For example, home visits, where very low numbers can skew achievements of the total face to face measure, have been removed from the NHS Delivery Framework for 2019/20 and thus the measure now focusses on solely attendances at Primary Care Centres.

As noted, the new standards are based on the existing standards and have been refined in conjunction with key service stakeholders, drawing on expertise from both clinical colleagues, and those managing the OoH / 111 service. The refined standards have been through the information standards process and were presented for comment and discussion key stakeholder groups. All of these had an opportunity to play into the standards, including crucially the GP Out of Hours Forum and the WAST board.

While it is generally recognised that the Standards present a challenge to the current service, it was agreed that these ‘stretch’ standards would continue to drive the development of the delivery model for OoHs. They will also drive improvement, innovation, regional/ national working in a prudent manner. Internal reporting against these standards will start in July 2019 but will be captured in the 2019/20 Annual Report

Although the evidence base is still relatively small it appears that delivery of these clinically based standards will be better using the 111 model, making it easier to get the right clinician to the right person at the right time.

Performance

Measuring Out of Hours has been an on-going and continuing journey. Since 2004, OoHs services developed independently across Wales and despite using the same management system – Adastra, local configuration was such that there was no consistency, standards or equity of access to information. From this low base where little information was available to run or measure the service, much work has been undertaken on an all Wales basis to bring consistency to the information available to a point where:

Detailed work is being undertaken to measure and understand demand;

Capacity requirements and shift fill are captured in a more meaningful and consistent manner;

Both the previous and new OoHs standards can be measured and monitored on a more consistent basis (although there are still some issues);

The clinical outcomes available within the system are consistent and are increasingly useable for benchmarking purposes;

Information was at the core of the peer review exercise; and

Standards have been agreed and implemented.

Our latest performance shows improvement against the standards and evidence from out of hours services, gathered during the peer review and subsequently when reviewing winter demonstrate an increasingly resilient service. Although this remains difficult to demonstrate and we accept there remains much work to do in this area to meet the increasing demand for information on the 24/7 model. The delivery of a new model will be a major step forward and much of the dialogue to date has been about the data and information.

The Roll-out of 111

Where we are rolling out 111 in Wales, this is already making OOHs more resilient – this can be seen in ABMU, Hywel Dda, Powys and more recently Anuerin Bevan, where the 111 service which manages people with urgent needs in the out of hours period. The 111 programme roll out, to be completed by 2021/22, will initially support primary care out of hours and provides a significant opportunity by simplifying access to services for the public, providing greater national alignment for the call handling and clinical triage.

The 111 service is improving access by signposting people to local services and sources of help, using a free to call number. In due course this will be delivered using other multimedia / digital opportunities. There will be greater regional and national working to meet the demand for advice and treatment at peak times and to safely reduce the workforce at quiet times.

Contacts with patients will be increasing based around multi-disciplinary team working, these will be less reliant on GPs but place greater emphasis on their clinical leadership role. Good communication systems means professional teams have access to up-to-date clinical records, which is essential so people receive appropriate care, especially those with complex conditions and/or at the end of life.

Plans are in place to roll the service out in Cwm Taf Morgannwg health board later in 2019/20. The project will then instigate a ‘firebreak’ in autumn 2019/20 to introduce a new national 111 IT platform to support the service. Following the implementation of the IT system, roll out of the 111 service will be extended to Betsi Cadwaladr and Cardiff & Vale health boards.