Delivering integrated urgent care – the clinical advice service

Lynne Heald, Senior Manager at Attain, talks about delivering a clinical advice service as part of an integrated urgent care model

In the second of a three part series on integrated urgent care, Lynne Heald from Attain considers the role of clinical advice services (CAS) to support effective decision making, the expected benefits to patients and the system as a whole, and the implications for technology and the workforce.

A central component of integrated urgent care (IUC) services will be the provision of a clinical advice service (previously referred to as ‘hubs’) to support patients and importantly other healthcare professionals in clinical decision making to deliver right care, right place, right time, first time. The requirement on all Clinical Commissioning Groups (CCGs) is to ensure there is a clinical advice service available to their population (patients and healthcare professionals); however one clinical advice service could cover multiple CCGs.

NHS England has developed some guidance around the clinical advice service but the document remains in draft form at this time and although it has been shared with CCGs but is not available more widely as a resource as yet. NHS England have stopped short of providing a national specification for the clinical advice service and maintain that the model should be for local determination whilst following the national Commissioning Standards for IUC.

There are however some clear expectations of the services which include ensuring that it is:

  • available 24/7 365 days year
  • made up of a multi-disciplinary clinical team that will include GPs
  • capable of taking calls from NHS 111 and 999
  • capable of taking calls from other healthcare professionals to provide specialist advice and support

There is also an expectation that there will be robust integrated governance across the patient pathway – building on the excellent governance principles and processes implemented with the NHS 111 services.

There should also be links to consultants/specialists and technology such as videoconferencing will enable consultations with specialist to be done ‘remotely’ which will improve access considerably and with clinical decision making.

In a joint letter to all providers, CCGs and LAs from Simon Stevens and Jim Mackey on the 9th March 2017 they reaffirm the need to ensure that the access to clinical assessment for NHS 111 is increased in order to help manage the flow of patients and reduce the pressure in A&E. They make particular mention of care home and the need for this sector to have access to clinical assessment via NHS 111.

Expected impact of the clinical advice service on patients:

  • Improved care navigation with access to sound clinical advice which will result in an improved patient journey/experience, i.e. right place first time for patients
  • Patients will receive urgent care provision closer to home whenever this is appropriate
  • Increase in appropriateness of referrals to A&E and better use of alternative care settings such as e.g. community, urgent care centres, primary care, pharmacy
  • Increased levels of self-care
  • Improved patient outcomes and mortality
  • Increased patient satisfaction

Expected impact on the system:

  • Reduction in the number of unnecessary conveyances by ambulance to A&E
  • Reduction in avoidable A&E attendances and subsequent admissions
  • Increased levels of self-care
  • Improved specialist support for front line colleagues and therefore more effective clinical decision making.
  • Increased staff satisfaction

Determining the ‘model’ for the clinical advice service

CCGs across the country are looking at their local geographies and working with providers and NHS England to design a model for the clinical advice service that works for their population. Clearly there has been a great focus on the vanguards and accelerator sites to be leading the way in developing these models but other areas are also moving forward with this. The guidance document from NHS England gives some very useful insight into how to set up this service and is being updated as more is learned. The development of the clinical advice service will be an evolutionary exercise and the ‘model of service’ is bound to develop over time.

One of the key components to developing the model is determining which calls from NHS 111 should go through to the clinical advice service. Currently the national average of NHS 111 calls going to existing ‘clinical advisors’ is circa 22% and there is a desire to increase this. The initial ask of accelerator sites was to increase this to 30%. These early implementer sites are identifying calls that could benefit from this timely clinical intervention but NHS E have suggested some particular call ‘categories’ that may benefit from further assessment by the clinical assessment service (Table 1). The NHS Pathways team is also carrying out some work to enable earlier identification of the calls which would benefit from further telephone clinical advice. If all of these calls were to be referred to the clinical advice service it could be dealing with circa 60% of the NHS 111 call volume.

Table 1 – Potential calls to the clinical advice hub

Interim disposition%
Transferred to a clinical advisor in NHS 111 (current)22%
Speak to GP 8.1%
Green ambulance codes3.75%
A&E referral4.8%
Streaming of mental health, pharmacy and dental calls6.8%
Complex calls, refused dispositions and pre-determined call plans6.7%
Patients > 80yrs6.2%
Patients < 5yrs 2.15%
Total61%

The accelerator sites are working hard to reach the initial 30% target however this hasn’t been achieved as yet.

Workforce

The clinical advice service is likely in many areas to be a ‘virtual’ model comprised of some clinicians working from the main contact centre and some working from other environments such as primary care centres, other clinical environments and even home. Resourcing in health and social care is becoming an increasing challenge so this sort of flexibility is going to be critical in maximising resource capacity. These resources whilst providing the ‘clinical advice service’ do not have to be employed by a single organisation.

Skill sets thought to add benefit in the clinical advice service include GP’s, advanced nurse practitioners, advanced paramedics, pharmacists, mental health professionals and palliative care nurse specialists. Some areas are also looking at other specialists such as emergency department consultants and midwives and the vision is to have a ‘network’ of specialist available ‘remotely’ for advice and support.

The technology exists to enable this type of model but there will need to be a willingness amongst organisations and their staff to do this and to deploy robust governance structures and processes to ensure that this is a safe practice for patients and for staff. It is likely that areas will look at innovative employment models such as rotational posts and ‘work passports’ to help facilitate this.

Modelling the workforce requirement in terms of numbers needed is also a significant challenge but imperative to get right. There are lots of variables to be considered in the modelling including the volume of each call type by time of day and day of week, the required skill set to meet the needs of that call and the urgency (i.e. warm transfer or call back appropriate and if call back the range of the call back time). This will provide a basic requirement but that needs to be then overlaid with the usual contingency factors for sickness and absence, training and performance management support and surges in demand. The level of analysis required therefore becomes quite a complicated and needs to be resourced effectively by commissioners and providers making decisions regarding the design, procurement and mobilisation of the clinical advice service.

Technology

The clinical advice service provider will need to be fully compliant with the NHS 111 IM&T standards (soon to be updated and will be published with the title Integrated Urgent Care Technical Standards).

Some aspects of the IUC technical architecture can and should be defined centrally to ensure there is a seamless service across the country, and this will include nationally provided services such as the repeat caller service but other aspects of the architecture will be dependent on services, systems and processes in place within particular regions. For these areas NHS England will provide information and advice to commissioners on the technical capabilities that will be required and therefore need to be included.
Additionally, commissioners need to be mindful of their local digital roadmaps (LDR’s) and ensure that what is developed is in line with and complimentary to (or at least not at odds with) the strategic plan for technology for the area.

Clinical governance

The existing NHS 111 clinical governance guidance has been reviewed and developed (Led by Dr Helen Thompson) to cover the wider integrated urgent care service including therefore the clinical advice service.

In summary

Increasing access to clinical advice via NHS 111 and 999 does make sense for certain cohorts of patients that could benefit from additional discussion with a suitably skilled clinician to determine the best course of action, whilst taking into account a number of variables including the patient’s history and agreed care plan.

There is not, however, going to be sufficient clinical capacity in the system to provide this level of input to all calls, so identifying the calls that would benefit most is absolutely crucial. The learning from the early implementers of clinical advice service needs to be shared so that perhaps a ‘core model’ can be developed as a foundation but allow for some local variation to meet the needs of the local population. This model will undoubtedly evolve over coming months or even years alongside other developments in integrated urgent and emergency care, so both commissioners and providers of this service must be visionary and agile to accommodate this.

What we mustn’t do is add any unnecessary complexity into the patient journey. Patients who need a 999 response must be identified as early in the process as possible and not be subject to a further ‘unnecessary’ clinical assessment if a red response is triggered within the initial triage. The clinical advice if used must enhance the patient journey and not just add another step in the process or hurdle to be jumped.

If done well, the model will a) refer the ‘right’ cohorts of patients for clinical advice and b) ensure that clinical advice is provided by skilled and knowledgeable practitioners who can offer support and advice to promote self-care or work with patients to identify appropriate care outcomes through having access to multiple care pathways and resources.

Attain experience

Attain have experienced clinicians and project management practitioners who have experience in urgent and emergency care and in particular remote clinical triage as providers and commissioners.

Attain have supported the procurement of a number of integrated urgent care services. This has involved managing the procurement end to end including development of service specifications, quality schedules and KPI’s. We have been instrumental in supporting commissioner’s particular through procurement and implementation and to manage gateways and checkpoints.

We have supported implementation and mobilisation of a new integrated urgent care service (prior to introduction of CAS) ensuring that the service (NHS 111 and OOH across 7 CCGs) went live on time and without incident. We were commended by NHSE for the level of detail within the plan and the rigour applied to the delivery.

Most recently Attain have worked with a group of CCGs in London to support the development of their ‘model’ and the service specification to support that. We also developed a dynamic modelling tool to look at the resource requirement for the CAS using different scenarios to include/exclude various patient cohorts.