Ealing Urgent Care Centre Procurement Scheme ITT Vol 3 ...€¦ · 1 Ealing Urgent Care Centre –...

Draft Ealing Urgent Care Centre Service Specification

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Ealing Urgent Care Centre Procurement Scheme ITT Vol 3

Ealing Urgent Care Centre Draft Service Specification

13 November 2015

As the model for networked urgent care services for North West London develops, there will be a need to refine the service specification for the

Ealing UCC. Ealing CCG reserves the right to make necessary changes during the procurement process and subsequently in discussion with the

preferred provider.

Section 1

Ealing Urgent Care Centre – Introduction Draft Ealing Urgent Care Centre Service Specification

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Contents 1 Ealing Urgent Care Centre – Introduction ..................................................... 3

1.1 Population covered .......................................................................... 3 1.2 Exclusion criteria ............................................................................ 4 1.3 Key interdependencies ...................................................................... 4 1.4 Location of service .......................................................................... 4 1.5 Applicable service standards ............................................................... 4 1.6 IMT requirements ............................................................................ 4 1.7 Key Principles ................................................................................ 5

2 The Ealing UCC operating model ............................................................... 7 2.1 Intended service outcomes ................................................................. 8 2.2 Clinical scope ................................................................................ 9

3 Registration and streaming ..................................................................... 10 4 See and treat ..................................................................................... 14

4.1 Diagnostic scope ............................................................................ 14 Diagnostic Interpretation and Reporting ..................................................... 16 Performance Standards ......................................................................... 16

5 Onward referral and discharge ................................................................. 20 6 Governance ....................................................................................... 24

6.1 Accountability ............................................................................... 24 6.2 Clinical leadership .......................................................................... 24 6.3 Integrated clinical governance ........................................................... 24

Partnership with Ealing ED ..................................................................... 25 Joint Clinical Governance ...................................................................... 25

6.4 Patient transfers ............................................................................ 25 6.5 Specialist input.............................................................................. 26 6.6 Shift handovers ............................................................................. 26 6.7 Patient Engagement and Involvement ................................................... 26 6.8 Incident Reporting .......................................................................... 27 6.9 .................................................................................................... 27 6.9 Complaints ................................................................................... 27 6.10 Safeguarding of Children .................................................................. 27 6.11 Protection of Vulnerable Adults .......................................................... 28

7 UCC integration with primary care ............................................................ 29 7.1 Minimum standards for integration with primary care ................................ 29

8 UCC workforce standards and workforce development .................................... 30 8.1 Training and continuous professional development ................................... 30 8.2 UCC minimum staff competences ........................................................ 30 8.3 UCC minimum levels of cover ............................................................. 32

9 Premises and services ........................................................................... 33 10 Contract, performance and working with the Provider .................................. 34

10.1 Contract term ............................................................................... 34 10.2 Open Book approach ....................................................................... 34 10.3 Performance expectations ................................................................ 35

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1 Ealing Urgent Care Centre – Introduction The Ealing Urgent Care Centre (EUCC) is a highly accessible community-based facility providing care for a large population area. The UCC has been in operation since 2011 and is co-located with the hospital Emergency Department (ED) at Ealing Hospital, London North West Healthcare NHS Trust (LNWHT). The UCC operates 24/7 throughout the year.

In 2014-2015, some 66,000 patients were assessed at the UCC representing about 60% of the patients presenting for urgent and emergency care at the Ealing Hospital site.

Within Ealing and NW London, the vision is to create an urgent and emergency care system (one system multiple facilities) that is capable of delivering equitable access to the right care first time for the majority of patients through a networked model with services provided along robust pathways 24/7. As this model develops, there will be a need to refine the service specification for the Ealing UCC. Ealing CCG reserves the right to make necessary changes during the procurement process and subsequently in discussion with the preferred provider.

Ealing CCG continues to implement the whole systems integrated programme which covers North West London and is also actively working with commissioners and providers to consider what accountable care partnership/s could look like. The provider of the UCC would be expected to participate in the discussions to develop this model of care and consider how they could operate within this. Alignment to this vision of healthcare delivery is critical for Ealing CCG.

Urgent Care Centres form an important access point on the urgent care network with key interdependencies with general practice, NHS 111, London Ambulance Service (LAS), the Homeward service (formerly referred to as Ealing Integrated Intermediate Care Services EIICS), GP Out of Hours service (GP OOH), GP extended hours hubs and hospital Emergency Centres.

It is important that Ealing UCC is fully integrated with every other part of the local health community and that it operates as part of the overall evolving urgent and emergency care strategy for the local health economy. Pathways from NHS 111, GP OOH and into Homeward are of key importance as are referral routes on to GP extended hours and community and other services. The Ealing UCC Provider will be expected to be a full and active participant in the Urgent Care Board.

Important changes to paediatric services in Ealing with the moving of in-patient paediatrics from Ealing Hospital (as part of Shaping a Healthy Future) in June 2016, mean that Ealing CCG must be assured that all other support for young children remains robust during this transition period. The Ealing UCC Provider will need to work closely with Ealing Hospital and other providers in NW London and the CCG to ensure pathways are clear.

1.1 Population covered Like EDs, treatment at an NHS UCC is provided on the basis of someone being ‘ordinarily resident’ in the UK. The population using the UCC generally comes from within the London Borough of Ealing. Of all the UCCs in North West London, Ealing has the greatest proportion of attendances by people who live within the host CCG area. The numbers of attendances at Ealing UCC by people from other CCG areas and from outside NW London are relatively small. This means the UCC can develop very close relationships with Ealing practices and other services operating for Ealing residents eg the Homeward service. Of the other NW London UCCs used by Ealing residents in 2014-15 Central Middlesex (9,732 attendances) had the highest use and St Mary’s (1,289 attendances) had the lowest use.

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1.2 Exclusion criteria The scope of the Ealing UCC will include both minor illnesses and injuries. There will be no age limit for UCC patients. Details are set out at Section 2.2 below. Specific clinical exclusions for both adults and children are set out at Appendix 2.

1.3 Key interdependencies The Ealing UCC provider will be expected to work closely with the 79 GP practices in Ealing, community pharmacists and a wide range of other services including:

Ealing Hospital ED. On-call specialisms at within London North West Healthcare NHS Trust (Ealing Hospital and

Northwick Park Hospital) and other specialist services elsewhere including those supporting the changes in paediatric and maternity services.

London Ambulance Service Extended hours primary care and other Out of Hospital primary care services Homeward Ealing GP Out of Hours services Community services including district nursing, community specialist nurses etc.

National pilots are looking specifically at how NHS 111 can and should be authorised to directly refer and book patients into Urgent Care Centres. Providers will be expected to be prepared to work with NHS 111 in the foreseeable future to ensure this is facilitated. The local GP Out of Hours Service will make direct appointments for patients to be seen by the UCC.

In future, it is expected that the Ealing UCC will be able to offer clinical support to NHS111 in instances where a medical opinion is required.

1.4 Location of service The Ealing UCC is located at Ealing Hospital adjoining the Ealing Hospital ED (LNWHT) on the Uxbridge Road, Southall.

1.5 Applicable service standards The Ealing UCC Provider will be expected to comply fully with relevant DH Standards for Better Health, National Quality Requirements (NQRs), NICE Technology Appraisals, Clinical Guidelines and Interventional Procedures and the London and Clinical Implementation Groups Standards where appropriate.

The Provider will meet the standards set out by the Information Standard Board (ISB) for health and social care, ISB 0160 Clinical Risk Management (its application in the deployment and use of health IT systems) and other relevant requirements set out in guidance or standards issued by a competent body. The Provider will be required to practice in accordance with relevant Royal College standards and in accordance with Professional Bodies (GMC, NMC).

1.6 IMT requirements The CCG’s strategic intent is to have a single patient record or interoperability between providers to enable access to the single record as clinically appropriate. To facilitate this, the CCG has invested in SystmOne across its primary and community care services.

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The CCG expects to receive proposals that support this strategic intent. Whilst the use of SystmOne is not mandatory, proposals for alternative systems will be required to demonstrate full interoperability with SystmOne, with no loss of functionality and no additional administrative burden on other SystmOne users or the CCG and paying due regard to information governance principles and regulations.

1.7 Key Principles Ealing UCC shall act as the first point of contact for all ambulatory Patients presenting at Ealing

Hospital with unscheduled care needs. It will also be the first point of entry to Ealing Hospital for Patients brought to Ealing Hospital by ambulance except in relation to those Patients that are required to be transferred directly to the Emergency Department in accordance with the London Ambulance Service referral criteria.

As a general principle, adults and children should be assessed and treated at the first point of contact capable of meeting their immediate needs. Redirection may lead to assessments being duplicated, patients inconvenienced and necessary care delayed.

The UCC has an essential role in managing people with minor illnesses to avoid inappropriate pressure on Ealing Hospital ED.

Patients attending who do not have urgent care needs must be supported by UCC staff to access advice and care from their local community pharmacist or to make an appointment with their own GP practice within the target timescales. The use of UCCs as an alternative to General Practice results in service duplication and undermines the sustainability of the system.

The best practice is to use a ‘see and treat’ approach where possible, with protocols to ensure that those waiting for treatment are fast tracked where necessary1. Triage is generally inappropriate in UCCs.

Service providers of the UCC and the ED will be required to work in partnership to ensure integrated and seamless care pathways for patients. There are agreed pathways from UCC streaming to ED clinical triage and from ED triage and assessment functions to UCC should this be more appropriate for treatment. Patients assessed in UCC as requiring treatment in the ED will be transferred within agreed timescales.

However, UCC and ED processes will generally operate separately with minimal interference to each other, although some flexibility is required (for example, in specific circumstances such as a major incident, excess demand or in the quieter times at night).

The following time standards must be adhered to in the UCC.

Patients must be assessed treated and discharged within the national 4 hour limit. In accordance with Healthcare for London guidance, the UCC is expected to make all ‘see and treat’ decisions within 60 minutes. Allowing for a further 60 minutes for return of image and diagnostics results, this will enable the UCC to identify and pass all appropriate patients through to ED within 120 minutes from the time of registration, so the 4-hour target remains achievable for ED. The 4 hour limit applies from the point of first registration so the time that ED has to treat and discharge transferred patients is limited by any time spent in the UCC.

Time between arrival and streaming (20 minutes for adults, 15 minutes for children). Time for return of X-ray and diagnostic results (1 hour from the image being taken).

1 Single point of triage for co-located Urgent Care Centres and Emergency Departments August 2015 Urgent and Emergency Care Clinical Leadership Group

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Time for the transfer of information to patient’s own practice (increasingly achieved in real time through the use of a system that is interoperable with SystmOne).

The UCC Provider will focus on maintaining the required patient flow going through:

Understanding demand and having the flexibility to balance capacity with predictable demand and less predictable spikes in demand.

Managing interfaces and handovers and having agreements in place that facilitate these. Working with the CCG to functionally integrate the service with all other components – this

includes having the ability to take direct referrals from NHS111 and GP OOH.

The UCC Provider will have a key role in working with patients to help them use primary care more effectively. At the streaming stage and at discharge, there is a key role in informing and reassuring patients to help them make appropriate decisions in seeking care in the future.

Section 2

The Ealing UCC operating model Draft Ealing Urgent Care Centre Service Specification

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2 The Ealing UCC operating model The model is set out in the diagram below.

The main elements of the UCC service will include:

Streaming and registration ( see Section 3 below)

See and treat (Section 4)

Referral and discharge (Section 5).

Strong informal working relationships between ED and UCC managers and clinicians are a necessary pre-condition for effective joint working2. Ealing UCC is expected to work in close collaboration with

2 Primary Care and Emergency Department Primary Care Foundation 2010

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Ealing Hospital ED. Transfers from UCC to ED and from ED to UCC will be facilitated by clear protocols. Joint Governance arrangements must be maintained (see section 6 below).

All policies, processes and procedures relating to organisational interfaces must be developed jointly between the Ealing UCC provider and Ealing Hospital prior to implementation. These interfaces should be kept under review and regularly discussed at Joint Governance Group meetings.

Ealing CCG expects the UCC Provider to initiate staff rotations with Ealing Hospital ED and to engage in joint training with ED staff.

Ealing CCG is open to proposals for sharing resources between the two services. Any proposal to share staffing eg at reception or on night shifts will require prior commissioner approval.

The UCC provider will be expected to work closely with Ealing Hospital through the period of transition for in-patient paediatric services to ensure clear pathways are agreed.

2.1 Intended service outcomes The aims and intended service outcomes are:

Access to urgent, unplanned care, while ensuring that the patient’s ongoing healthcare needs are met in the most appropriate setting within the community or primary care. This may involve streaming patients back into services (e.g. GP practices, community services, GP extended hours services) via a process of positive re-direction.

Patients receive a consistent and rigorous assessment of the urgency of their needs and an appropriate and prompt response.

The UCC will act as a single point of access to on-site emergency and urgent care services for all walk-in patients. The UCC operates over twenty four hours, seven days a week, and has an adjoining reception with Ealing ED.

The UCC will integrate with current service provision on the Ealing Hospital site but will have the distinctive culture and approach of a primary care service, with experienced and appropriately skilled primary care clinicians leading the service, working alongside other healthcare professionals.

The UCC service provider will work with Ealing Hospital to ensure integrated and seamless care pathways.

To reiterate, the CCG's strategic intent is to have a single patient record or interoperability between providers to enable access to the single patient record as clinically appropriate. SystmOne which is in use by all but two Ealing practices, GP OOH as well as in the Homeward service and the UCC systems must be completely interoperable with this. For Ealing registered patients, this interoperability means that the UCC clinician will have access to key information about previous history. The patient record including Information relating to the UCC contact will be promptly available to the practice.

To help educate patients and promote appropriate decision making for future urgent care needs. Navigation Patient experience and some clinical outcomes are contingent on the public’s ability to navigate the system effectively

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Patients attending the UCC who do not have urgent care needs will be supported by UCC staff to access advice and care from local community pharmacists, or to make an appointment with their own GP within the target timescales. The UCC will not constitute an additional access point in the local health economy for routine NHS care. The ability to direct book (ie potentially through NHS 111) should not be used as a means to allow patients to bypass their GPs. Pre-booked appointments (through NHS111 or through the Out of Hours GP) cannot take precedence over more urgent cases presenting at that time at the UCC. Patients who are not registered will be assisted by the UCC to register with a local practice.

The UCC Provider will work with NHS 111 to ensure effective referral.

The UCC Provider is responsible for ensuring access to language telephone services.

2.2 Clinical scope The scope of the Ealing UCC will include both Minor Illnesses and Minor Injuries. There will be no age restriction for UCC patients.

Interventions considered in-scope include:

Management of uncomplicated fractures Non-complex regional anaesthesia for wound closure and local anaesthesia Incision and drainage of abscesses not requiring general anaesthesia Minor ENT/ophthalmic procedures (e.g. packing noses; removing foreign bodies from eyes, ears

and noses). The interpretation of X-rays and other diagnostics/ investigations. Pain management. Issues with early pregnancy. Rapid onward referral for any case which might potentially be cancer (fully informing patient’s

GP but not reverting back for referral) subject to agreement with acute providers.

Clinical exclusion criteria for both adult and paediatric patients are set out at Appendix 1. Many of these clinical exclusion criteria will only be identified after clinical assessment. It will not always be possible to apply these criteria at the point of streaming. Some patients may therefore be identified as unsuitable for UCC care during assessment or treatment. The UCC Provider will be responsible for ensuring clear protocols are in place to ensure prompt transfer to ED. All exclusions will be reviewed periodically in the Joint Governance Meetings and in consultation with the Commissioners.

Section 3

Registration and streaming Draft Ealing Urgent Care Centre Service Specification

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3 Registration and streaming This section focuses on the stage of the model outlined in the yellow dashed box.

Registration and streaming

Patients, who will attend the UCC, include:

Walk-in patients Patients who have contacted a service such as NHS 111, OOH, their GP or other referring service

and have been asked to attend Those with the 20 presenting conditions that have been agreed with the London Ambulance

Service. The UCC should be able to receive patient referrals from differentiated ambulances within network agreed protocols and pathways of care

Patients brought in by ambulance with minor illnesses and injury in wheelchairs, or on a trolley

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but who are capable of walking or being moved to a wheelchair. These patients are taken to the UCC reception and dealt with in the UCC rather than going to the Emergency Department (ED)

On arrival at the UCC:

All patients attending will be recorded on the UCC IT system even though they may be positively redirected to a more appropriate service. IT processes must be inter-operable with both Ealing Hospital and GP systems to ensure that:

Patient details will not have to be taken again in the event of streaming/ transfer to ED

Child/ vulnerable adult ‘Red Flags’ can be picked up by UCC staff Registration details for each child seen at the UCC shall include name and relationship

of accompanying adult, and school, health visitor, social worker if this is not already contained on SystmOne.

In recording details and taking initial information, the Provider must take into account the need for privacy.

The use of a system that is fully interoperable with SystmOne will enable rapid access to patient details for those registered with the majority of Ealing practices. Patients should not be expected to re-supply basic demographic information upon arrival where this information is available electronically from a referring service.

Patients have told us that the way they are received and the way they are kept informed is extremely important to them.

Please refer to the key clinical competences set out at section 8.2.

A clinician competent and experienced in urgent care will carry out the assessment of patients attending the UCC. Clinicians with suitable competencies will include GPs, emergency nurses and other suitably qualified clinicians to meet case-mix demands.

At all times the UCC must have staff on duty who can demonstrate and evidence the following competencies:

Assessing the legal capacities of patients to consent

Managing uncooperative patients including those with mental health problems

Assessing and managing imminent violence

Recognising the symptoms of depression and anxiety

Assessing the suicidal patient

Assessing and advising those who have experienced domestic violence

Understanding the child protection aspects of working with adults with mental health problems

Assessing substance dependence and substance related problems.

Clinicians providing initial assessment should possess the skill set necessary to initiate the necessary

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diagnostic tests or analgesia.

Those attending will be streamed by an appropriately trained clinician to ensure:

Patients who present with a genuinely urgent need are streamed for assessment and treatment. Walk-in patients, who attend the UCC unannounced, will be seen in chronological order, subject to clinical-priority considerations.

Patients self-presenting with major emergencies are identified immediately and accompanied to the ED by a doctor or nurse. (The UCC Provider will have an agreed UCC to ED transfer protocol).

Patients attending with routine primary care needs are appropriately and positively redirected back into core primary /community services. They will be supported by the staff in the centre to access advice and care from their local community pharmacist, or to make an appointment with their own GP practice. Where appropriate, this will be achieved through NHS 111.

Patients who perceive a level of urgency greater than the UCC would classify are given appropriate education and advice in addition to redirection or help in navigation to other services.

Diagnostics are initiated by the streaming clinician where deemed necessary for the immediate treatment of the patient or where they are likely to prevent a subsequent admission to the acute hospital.

Analgesia is initiated if required -, the Provider shall ensure that treatment of pain is delivered within 20 minutes of the Initial Assessment.

The Rapid Response element of the Homeward service is called to assist in joint assessment for patients for whom there is a risk of an avoidable admission occurring and where Homeward is likely to be able to help ensure timely discharge from the UCC.

For children, there are any child protection concerns and whether the child protection register should be checked.

The UCC will not be used as a holding facility for patients who are likely to be admitted to hospital. Such patients should where possible be taken direct to the relevant Assessment Unit, ward or ED.

Any periods of observation of patients will take account of the 4 hour limit, bearing in mind the impact of late decisions to transfer to ED.

The Ealing UCC will have the ability to accept referrals GP Out of Hours Service to booked assessments and will be able to extend this to NHS111 patients in the future.

Patients attending the UCC who are not registered with a GP will be treated by the UCC according to the same criteria as a registered patient. In addition, they will be supported by the staff in the centre to register with a local practice of their choice.

UCC patient streaming should be complete within 20 minutes of arrival (adults) or 15 minutes (paeds). In accordance with Healthcare for London guidance, the UCC is expected to make all ‘see and treat’ decisions within 60 minutes; that is to say, the UCC is expected to identify and pass all appropriate patients through to ED within 60 minutes from the time of registration, so the 4-hour target remains achievable for the ED.

There will be a single initial assessment for all UCC/ED walk-in patients – patients requiring transfer

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to ED or from ED to UCC should not need to be assessed again on arrival.

The service will have full access to the NHS 111 Directory of Services and will be responsible for ensuring that all information relating to the UCC is fully up to date. Patients may be referred to community based services, including general dental services. Ealing UCC reception staff will have up-to-date details of all community and primary care based services and will be able to provide patients with contact numbers/service details and opening times in order that they are redirected to core primary care service provision.

Contingency plans should be put in place to deal with unexpected surges in demand in order to ensure that waiting times are kept under control. These plans should minimise the volume of clinically inappropriate transfers to ED.

The UCC Provider will have systems in place to ensure identification of patients who regularly present for the same condition and will work with the patient’s GP in review of care plans.

Section 4

See and treat Draft Ealing Urgent Care Centre Service Specification

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4 See and treat This section describes the stages of the model outlined in the yellow dashed box. For many patients, a see and treat approach will be the most appropriate so that initial assessment and treatment stages are effectively combined. For others after streaming and initial assessment will lead to a need for diagnostics or other opinion being sought. The Rapid Response element of the Homeward service may assist in jointly assessing for home care options and for other aspects of social care. Please refer to key clinical competences in section 8.2 below.

•

4.1 Diagnostic scope The UCC will have access to diagnostics and investigations at Ealing Hospital.

UCC patients may require access to diagnostics where this would contribute to a decision regarding the patient’s immediate treatment or referral. Diagnostics should only be provided where they are

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deemed necessary for the immediate treatment of the patient or where they are likely to prevent a subsequent admission to the acute hospital. All diagnostic intervention will be undertaken via an agreed protocol, which will be subject to regular audit.

All UCC clinicians with the designated competency will have access to the agreed diagnostic spectrum set out below.

It is therefore required that, with the exception of tests requested as part of an onward referral to a specialist clinic, all test results should be available within one hour. X-rays will be interpreted within one hour with reading by a radiologist within 24 hours. Results will be posted via the Diagnostic Cloud and SystmOne summary record.

Whilst the UCC is responsible for initiating the diagnostic test, the GP practice is responsible for any subsequent follow up.

The following investigations and diagnostics must be available to Ealing UCC clinicians:

Diagnostic area Diagnostic tests to be available to UCC

Electrocardiogram (ECG)

Pulse oximetry

Blood and other tests with turnaround within the episode/ real time access to results:

Full blood count (FBC) D-Dimer ESR (erythrocyte sedimentation rate) CRP - C-Reactive Protein LFT – Liver Function tests INR - Coagulation tests Urea and electrolytes Blood Glucose Pregnancy Test

LFTs & Gamma GT

Urate

Amylase

Bone Profile

Culture Aspirates

Test with longer turnaround Urine Stool Throat, wound swabs etc.

Radiology – initial report back in 1 hour/ radiologist review within 24 hours

Real time access to images

Plain film for limbs and chest (Ultrasound including gynaecology) X-ray for kidney stones

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Ophthalmology Slit lamp assessment

In addition, the UCC will have the ability to book other diagnostic tests as part of specific onward referral pathways eg, DVT ultrasound.

Diagnostic Interpretation and Reporting The UCC is expected to interpret all diagnostics and investigations it requests, except for those which it requests as part of an onward referral to a specialist clinic. This applies to Radiology as well as Pathology.

Performance Standards The UCC is expected to make all ‘see and treat’ decisions within 60 minutes.

This means that the UCC is expected to identify and pass all appropriate patients through to the ED within 120 minutes from the time of registration, so the 4-hour target remains achievable for the ED.

In some cases, a diagnostic or investigation will be required before this decision can be made. Therefore, in order for the UCC to comply with the 120-minute hand over standard, the outcome of all diagnostics and investigations will be returned to the UCC within an hour.

See and treat key features

Minor illness/ injury

All self-referred patients will be seen in order of arrival unless the streamer or consulting clinician feels they should be seen more urgently. Children will be prioritised.

The order in which any booked appointments (from OOH doctors or from NHS111) will be seen may be affected by the above prioritisation.

Specialist input

UCC clinicians should be able to access input from a range of on call specialists, including ED consultants, orthopaedic specialists, paediatric specialists and radiologists. Access to other specialist opinion should be no different to that available at a GP surgery. The UCC provider will ensure this access to clinicians at Ealing Hospital or elsewhere as necessary.

Where specialist input has been sought, clinical responsibility for the patient remains with the UCC clinician unless and until the patient is formally transferred to an alternate service. The Joint Governance Group will agree arrangements for when patients are waiting to see a specialist in the ED area.

Paediatric care delivery

The Provider will have a named paediatrician with designated responsibility for UCC liaison. The UCC shall have an RN (Children) lead nurse responsible for the care of children and a

lead nurse responsible for safeguarding children. The Provider shall ensure that all Clinical Staff fulfilling these roles shall liaise closely with their counterparts at the emergency department at the hospital for the purpose of ensuring that there are consistent processes

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across both the UCC and Ealing ED.

Children under 16 years will wait in the designated paediatrics waiting area. The Provider must accommodate the needs of children and accompanying families as far as

is reasonably possible. The Provider must give consideration to security issues, availability of food and drink, breast-feeding areas, and hygienic, safe play facilities.

The Provider will be expected to maintain sufficient child-friendly treatment rooms, clinical cubicles, etc. to meeting the expected annual level of child attendances at the UCC.

The Provider must deliver appropriate and responsive care to all children. This must be in accordance with the standards set out in the Children Act 2004 and local protocols within North West London Health economy.

Children under the age of 2 years suitable for the UCC will be seen by a clinician with core paediatric competencies.

The Provider shall ensure that the UCC will comply with the requirements of their Local Safeguarding Children Board and the London Child Protection Procedures.

The Provider shall ensure that the UCC will comply with the requirements of Ealing Safeguarding Children Board and the London Child Protection Procedures.

All UCC staff must know pathways of how to refer child protection concerns to the relevant local authority for advice on child protection matters at all times.

The Provider shall ensure that access to child protection and/or safeguarding advice is available from a Consultant Paediatrician or Named Doctor for Safeguarding and Children Social Care 24-hours). The Provider shall ensure that they have direct or indirect access to a regularly updated list of children subject to protection plans provided by the local authority.

All discharging clinicians/main deliverers of care need to be trained to level 3 child protection competence.

All Provider Staff shall be annually trained in paediatric basic life support in accordance with national guidelines. At least one member of the UCC team should have training in advanced paediatric life support (APLS) and the Provider shall establish and monitor guidelines and protocols to ensure the safe transfer of any child from the UCC to Ealing ED or an appropriate Emergency Centre.

For children and young people, the episode of care should be communicated to their health visitor or school nurse no later than 8am on the second working day following the child or young person’s episode of care.

Mental health referrals for those 16 years and under will be to CAMHS via ED. Patients who are 16 and 17 years with mental health issues will be referred to Psychiatric Liaison.

Mental Health care delivery

All UCC staff will have training on how to manage patients with mental health issues and understand the requirements for supporting people with dementia.

The UCC Provider will work with West London Mental Health NHS Trust to develop clear

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pathways to and from the Mental Health Single Point of Access which is currently being implemented.

The UCC will maintain 24/7 direct access to the Ealing Psychiatric Liaison Teams currently provided by West London Mental Health NHS Trust.

Working closely with the Ealing Psychiatric Liaison service, the Provider will agree the circumstances under which mental health needs should be streamed to the ED. Patients who present with acute self harm will be streamed directly to ED.

The UCC clinician will determine whether the patient’s condition requires specialist input from the psychiatric liaison team, transfer to ED, or referral back to their GP. In the majority of cases the patient can be seen and treated by a UCC clinician.

. A patient whose clinical condition deteriorates significantly would be transferred to the ED (as for any other type of patient).

The Ealing Psychiatric Liaison Team will be responsible for ensuring consistent levels of cover for the UCC. The role of the Psychiatric Liaison Team will be to:

To provide specialist input (NB. As with other specialist input, the psychiatric liaison team will be responsible for the advice they provide, but responsibility for the overall care of the patient will remain with the UCC).

To provide advice on onward referral of psychiatric patients and support UCCs to manage this process.

To provide UCC clinicians with training designed to improve their ability to identify and treat psychiatric patients.

The UCC will have access to a Mental Health assessment room that is compliant with the relevant Royal College of Psychiatrists safety standards3.

In support of the principle of integrated clinical governance, the Ealing Urgent Care Joint Governance Group will require Mental Health representation in order to be quorate (in line with current ED practice).

Drug and alcohol issues

UCC Clinicians will have the competence to recognise drug and alcohol issues and their impact on other health issues.

The UCC will liaise with the local pathways drug and alcohol services and will signpost to relevant agencies.

Learning disability

UCC Clinicians will have the competence to recognise the particular issues faced by people with learning disabilities in seeking urgent care.

Patients who are on the case load of the Community Team for People with Learning Disabilities should have a discharge summary sent to the team by 8am on the second working day.

3 “Psychiatric services to accident and emergency departments; Council Report CR118, Feb 2004”

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Sexual health and GUM

UCC Clinicians will have the competence to signpost and navigate patients to appropriate services.

Transfer to/from UCC

Following clinical streaming to the UCC any patient found, on detailed examination, to require more complex care will be referred directly to the ED.

A ‘Patient Transfer’ protocol for establishing an appropriate time to transfer patients between services will be agreed between the Ealing UCC Provider and Ealing Hospital prior to service commencement.

This protocol will support both services in delivering the 4 hour Standard. The four hour clinical standard will commence from the patients arrival to the UCC and NOT from the time of their transfer.

As part of this process the patient’s details will be transferred from the Ealing UCC clinical system to the Ealing ED IT system by staff without the need for the patient to re-register. The UCC will work with the ED to ensure that at least one terminal in ED is able to access SystmOne.

Information will be transferred electronically between the Ealing OOH service and the UCC.

Where appropriate, the Ealing UCC provider will be accountable for having and monitoring robust and cohesive policies for inter-hospital transfers (IHTs) that encompass the agreed pan-London standards eg for paediatric cases.

Section 5

Onward referral and discharge Draft Ealing Urgent Care Centre Service Specification

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5 Onward referral and discharge This section describes the stages outline in the yellow dashed box in the diagram below.

Many UCC patients will be seen, treated and discharged from the UCC with no further support services required. However, a proportion of UCC patients will need to be assessed to ensure they can be safely returned to their usual community setting with the appropriate community support (or a temporary alternative such as an intermediate care facility.

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Referral and discharge key features

Referral

Where an admission is required this referral will be made directly to the specialty concerned. Patients will then be transferred directly to suitable admitting/assessment units. Patients will not be referred back to the ED for diagnostics or admission.

The Provider is expected to make direct referrals to the planned care services offered by primary care in Ealing eg wound care.

Where appropriate, the Ealing UCC will refer patients to community based services, including general dental services, pharmacy services, and community nursing, and social and voluntary services.

Referrals for first Outpatient Appointments With the exceptions below, clinicians in the UCC will NOT refer patients for first outpatient appointments. Exceptions are currently for: • Suspected cancer • Referral to Oncology specialties • Referral to the Rapid Access Chest Pain clinic • Referral to Fracture Clinic • Early Pregnancy Unit • ECG – irregular pulse Referrals will be through routes agreed with London North West Health Care NHS Trust or other providers as appropriate. For other patients for whom the UCC GP has identified the need for an Outpatient appointment, the UCC clinician will ensure the patient’s GP is informed of concerns so that a referral can be made. The above list will be kept under review and may be extended following further discussion with local practices and the provider.

The Ealing UCC Provider will ensure patients are contacted about results which are only available after the episode.

The UCC will need to ensure full access for its clinicians to the Directory of Services.

Discharge

A discharge summary is to be provided to the patient by the person discharging them. This is a summary record of the patient’s visit to the UCC outlining what happened to them.

The Ealing UCC Provider will issue discharge summaries to GP practices by 8am the following day, providing relevant clinical and treatment information, medication and any necessary follow-up care.

It remains the requesting clinician’s responsibility to ensure that all abnormal diagnostic results are followed up appropriately – this may involve sending a ‘task’ to the patient’s practice via SystmOne or other arrangement to be agreed with local practices.

The CCG will work with the Provider and its member practices to develop the ability for the provider to book appointments at a patient’s practice.

For children and young people, the episode of care should be communicated to their health visitor or school nurse no later than 8am on the second working day following the child or

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young person’s episode of care.

There are also other services who may need to be informed or referred to such as: Community matrons Ambulance clinical support desk Social services Paediatric Liaison Nurses Paediatric asthma nurse School Nurses Health Visitors CHD nurses District Nurses The UCC provider is responsible for agreeing referral routes and raising issues where appropriate with the commissioner.

Medicines Management

The main mechanism for medication supply at the UCC will be either using: An FP10 prescription A pre-pack medication using a patient group direction (PGD). The cost of procuring any stock or

pre packs will be the responsibility of the UCC Provider.

The Provider is expected to: Have a mechanism available through which a full course of medicines can be

provided/administered to patients out of hours, where clinically appropriate, without patients returning to the UCC, hospital pharmacy or GP practice.

Observe the Carson review recommendation that where a patient needs to start at course of medicine without delay (eg for pain relief) or because delay could compromise care, they should receive the full course at the same place as the consultation.

Work to the national formulary for GP OOH services. The Provider will be expected to use the locally-agreed antibiotic guidelines and formulary, prescribe generic drugs wherever possible and not to prescribe drugs from the locally-agreed (NWL sector) agreed Red Drugs list.

Patients will be expected to fill prescriptions at retail pharmacists in the community between the hours of 8am and 6pm on weekdays and Saturdays and 10am to 4 pm on Sundays and pay a dispensing fee where appropriate. Outside these hours, the UCC Provider will maintain adequate stocks of pre-pack medicines for dispensing. If a PGD for a medication is not available and if clinically appropriate, an FP10 prescription will need to be supplied. A prescription supplied during out of hours will be the exception rather than the norm. The cost of FP10 prescriptions will be charged back to the UCC provider so allowance for both stock items and likely FP10 prescriptions will need to be made. These costs will be closely monitored by both the UCC management and the Commissioner's medicines management team to establish patterns of prescribing at the UCC ensuring any anomalies are identified. The UCC should not issue repeat prescriptions, except for at risk patients, as determined by clinical

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assessment and then for a maximum of one week. The provider is expected to refer patients to a pharmacy that is commissioned to provide urgent repeat medicines as a local NHS service. Medicines Use reviews for patients with complex medicines regimes which are the reason for or have contributed to attendance at the UCC should be initiated by the UCC. When nurses prescribe medication for children, they shall have the necessary knowledge of paediatric pharmacology.

Section 6

Governance Draft Ealing Urgent Care Centre Service Specification

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6 Governance The Ealing UCC should have a formal written policy for providing urgent care in place. The policy is to adhere to the urgent care clinical quality standards and is to be ratified by the service’s provider board and the U&EC Network annually.

The Ealing UCC should have an identified clinical lead, and participates in clinical and non-clinical audit, demonstrating effective engagement in a programme of continuous quality improvement.

The UCC Governance policy must be aligned to the Urgent Care Clinical Quality Standards (London Quality Standards http://www.londonhp.nhs.uk/wp-content/uploads/2013/03/Urgent-care-standards_FINAL-Feb2013.pdf)) through a structure integrated with that of the co-located ED.

6.1 Accountability The Ealing UCC Provider will be accountable to Ealing Clinical Commissioning Group as commissioners of the service.

The Ealing UCC Provider will be responsible for performance, clinical and financial management of the service.

The Ealing UCC Provider will be expected to be a full and active participant in the Urgent Care Board.

Nested integrated governance arrangements under strong clinical leadership are key to ensuring the UCC works effectively within the broader urgent care system.

6.2 Clinical leadership The Provider will be expected to develop a model for clinical leadership and clinical governance. As part of this, a local, designated Clinical Director will be assigned by the Provider.

The designated Clinical Director will take responsibility for the practice of all staff that treat patients autonomously. The Clinical Director also will take responsibility for the development, approval and implementation of developed care pathways and protocols.

6.3 Integrated clinical governance An integrated service model is fundamental to the Ealing UCC’s ability to deliver safe, high quality care. In practice, this means close integration with EDs and other health services via formal governance mechanisms and strong informal working relationships.

The key features of a genuinely integrated service model are:

• Clear lines of responsibility and accountability, both within and between provider organisations;

• Clearly defined handovers of care between providers;

• An approach to review and continuous improvement that transcends organisational boundaries;

• Clear policies aimed at managing risk and procedures to identify and remedy poor professional performance.

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In order to address these issues, providers will be expected to develop an operating model that supports the following principles:

Partnership with Ealing ED The partnership between Ealing UCC and Ealing Hospital ED is key and this includes oversight through a single Joint Governance Group that meets at least monthly.

The UCC provider will work with Clinicians in Ealing Hospital ED to agree clear plans on how integrated clinical governance will work across the UCC and the Ealing Hospital ED.

Joint Clinical Governance A Joint Governance Group will foster joint working and drive continuous improvement and develop good working relationships with specialties, especially paediatrics and orthopaedics. Membership will include clinicians from Ealing UCC, Ealing Hospital and Ealing CCG and West London Mental Health NHS Trust.

Terms of reference for the group will include:

1. Creation and regular review of the Joint Clinical Policy, including:

a. assessment guidelines for Clinical Streamers

b. staff competency framework

2. Service audit focussing on outcome based quality care including:

a. On a case by case basis, the appropriateness of the initial clinical navigation where a patient’s treatment is begun in the UCC and subsequently transferred to ED

b. On a case by case basis, the appropriateness of the initial clinical navigation where a patient’s treatment is begun in ED and subsequently transferred to the UCC

c. At overview level, patient case mixes will be reviewed regularly to assure clinical governance and standards and retain confidence in both services

d. On a regular basis, audit against staff competency framework

e. Patient experience data, SUIs, complaints and professional feedback

f. Review of re-directions back to primary care

g. Review of diagnostic tests/investigations

h. Review of prescribing.

3. Review and learning from all outcome data, incidents and complaints to improve quality of care.

6.4 Patient transfers Where patients are transferred from the UCC to another provider organisation, it is essential that there is clarity with regard to governance arrangements. Both organisations have a responsibility to ensure that there are appropriate systems in place to ensure patient safety. Individual clinicians also have a personal professional responsibility to ensure safe, high quality care. During any transfer, it will be necessary to:

• Be clear about who retains overall responsibility for the patient

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• Provide for a comprehensive transfer of information relating to the patient’s condition and investigations already conducted. Minimum standards for information provided on transfer should be agreed between providers.

A proportion of transfers to ED will involve high acuity patients who have presented with conditions that are out of scope for the UCC. It is therefore important that Ealing UCC staff possess the training, equipment and facilities required to stabilise patients in the event that their condition deteriorates before transfer can take place (e.g. resuscitation training and equipment). This will include stabilisation of any patients that will need to be transferred to other Emergency Centres.

6.5 Specialist input The provider is responsible for working with clinicians at Ealing Hospital or elsewhere within LNWHT to put in place arrangements for remote specialist input. This may require a contractual arrangement in the event that specialist advice is provided by a separate organisation.

Where a patient is not moved, but expertise is given by another organisation (e.g. expert wound management by an ED consultant or a radiology report) it is important that there is clarity as to who retains overall responsibility for the patient. The GMC guidance ‘Good Medical Practice’ on working with colleagues is relevant here.

6.6 Shift handovers The nature of the service is that staff will be on overlapping shifts and so team handovers are not appropriate. However, handover processes including communication and documentation, must be standardised over the week and subject to regular audit.

6.7 Patient Engagement and Involvement Patients, and where appropriate carers, must be actively involved in shared decision making and supported by clear information from health and social care professionals to make fully informed choices about investigations, treatment and on-going care that reflects what is important to them. This should happen consistently seven days a week (National Seven Day Services Forum Clinical Standard).

The UCC provider will ensure that patient privacy and dignity is maintained at all times and take steps to ensure that this always applies in waiting and consulting areas including areas used by children. The UCC provider will ensure that patients and carers who have sensory impairments are communicated with effectively including while waiting and being called for consultation eg through the use of electronic boards, pagers etc.

All patients are to be supported to understand their diagnosis, relevant treatment options, and ongoing care by an appropriate clinician. The UCC must make allowance for the needs of those whose first language is not English and those with sensory impairments The UCC provider will take into account any additional information included on the Summary Care Record (with the previous agreement of the patient and GP) concerning sensory, mobility or any other needs. Where appropriate, patients are to be provided with health and wellbeing advice and signposted to local community services where they can self-refer.

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The UCC provider is expected to capture data on patient experience, routinely analyse this and act on findings. Analysis is to be disseminated to staff and patients and shared with Commissioners.

The Ealing UCC provider will make arrangements to carry out regular patient experience surveys in relation to the service and will co-operate with such surveys, including surveys of the ED that may be carried out by Ealing CCG or London North West Healthcare NHS Trust taking due regard to any Department of Health guidance relating to patient experience.

The Ealing UCC provider will be expected to demonstrate evidence of having used patients’ experience of using the service to make improvements to service delivery.

The Provider should seek comments from children, young people and their carers to improve services and facilities.

The CCG will engage a patient/public representative in regular contract monitoring meetings.

6.8 Incident Reporting All incidents (both clinical and non-clinical) must be reported. The service will ensure that there are appropriate reporting mechanisms for all incidents and that these reports feed into the relevant monitoring and reporting systems already set up by the Commissioner and DOH. There will also be effective procedures for the management of all Serious Untoward Incidents (SUI) which are reported to the CWHHE Director of Nursing, Quality and Patient Safety. These will align with existing ED protocols and NHS London requirements for reporting and investigating SUIs. 6.9 Complaints The Ealing UCC Provider must adhere to the NHS Complaints process. The Lead Clinician of the UCC should deal with all complaints in line with the provider’s complaints policy. The complaints should be given to the most relevant lead to respond to depending on the issue (nursing, medical or admin staff). All complaints should be logged, and escalated to the Joint Governance group where appropriate.

The volume and content of complaints should be regularly analysed and used to inform internal continuous improvement processes with themes distilled and learning evidenced.

6.10 Safeguarding of Children [Section to be further developed with Safeguarding leads]

(Please see section 4 paediatric care delivery for full details of Child Safeguarding requirements).

The UCC must provide at least the same level of service as currently provided by an ED to ensure appropriate safeguarding of children and must adhere strictly to current national safeguarding policy4.

The Ealing UCC IT system must be able to identify safeguarding ‘Red Flags’ present on Trust and GP systems (the Provider must work with local practices to ensure this information is appropriately recorded)

4 Working Together to Safeguard Children (2010), Department of Children, Schools and Families.

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6.11 Protection of Vulnerable Adults [Section to be further developed with Safeguarding leads]

The UCC must provide at least the same level of service as currently provided by an ED to ensure appropriate protection of vulnerable adults and must adhere strictly to current national policy on the protection of vulnerable adults5.

The Ealing UCC IT system must be able to identify safeguarding ‘Red Flags’ present on Trust and GP systems.

5 Clinical Governance and Adult Safeguarding (2010), DH; No Secrets (2000), DH.

Section 7

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7 UCC integration with primary care

The Ealing UCC is required to develop the distinctive culture and approach of a primary care service. With this in mind, a key element of the UCC operating model is effective integration with local primary care services in general, and General Practice in particular.

This section summarises the steps the UCC provider must take to integrate with primary care.

7.1 Minimum standards for integration with primary care The provider will be expected to use an information system that is completely interoperable

with SystmOne which is in use in the vast majority of Ealing practices, GP OOH as well as in the Homeward service.

The UCC will develop the distinctive culture and approach of a primary care service working with hospital and secondary care clinicians, with experienced and appropriately skilled primary care clinicians leading the service.

The UCC will ensure full integration with the NHS 111 service, both for patients ‘referred in’ to the UCC, and when referring patients into community services and General Practice. This will include access to the 111 Directory of Service. It is anticipated that a booking option for NHS111 to book cases in to the UCC will be introduced by the Provider.

The UCC will be prepared to provide GP support to call handling at NHS111 when there is capacity to do so.

The UCC will work closely with the Rapid Response team from the Homeward service and with community services operated by LNWHT.

The UCC will work closely with GP OOH services including joint assessments or receiving referrals from OOH.

Patients attending who do not have urgent care needs will be supported by the staff in the centre to access advice and care from their local community pharmacist, or to make an appointment with their own GP practice or advised of extended hours services. Where appropriate, this will be achieved using the ‘111’ service.

Patients attending the UCC who are not registered with a GP will be treated by the UCC according to the same criteria as a registered patient. In addition, they will be supported by the staff in the centre to register with a local practice of their choice.

Patients may be referred to community based services, including general dental services, pharmacy services, community nursing, and social and voluntary services. UCC reception staff will have up-to-date details of all community and primary care based services and will be able to provide patients with contact numbers/service details and opening times in order that they are redirected to core primary care service provision.

The Provider will issue discharge summaries to GP practices by 8am the following day, providing relevant clinical and treatment information, medication and any necessary follow-up care.

Section 8

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8 UCC workforce standards and workforce development

The provider may engage a range of staff with appropriate skills including emergency care practitioners, nurse practitioner, extended scope practitioner (ESP) physiotherapists and pharmacists. All UCC clinical staff should have relevant professional and regulatory registration, indemnity and have undergone enhanced DBS checks.

8.1 Training and continuous professional development

The UCC provider must ensure all staff have access to appropriate clinical supervision for training purposes.

Ealing CCG expects the UCC Provider to initiate staff rotations with Ealing Hospital ED and to engage in joint training with ED staff to facilitate mutual understanding of services and the transfer of skills.

The provider would be expected to ensure GPs working in the centre attend UCC specific training where available.

Appropriate competency frameworks should be used for staff development and training and annual appraisals conducted.

In accordance with its responsibilities to support medical training, the CCG we will be looking to discuss with the provider how training sessions for local GPSTRs supervised by LETB trained and approved clinical supervisors can be delivered.

The demand and any additional costs have not been quantified at this stage. These will be subject to further discussion with the UCC provider.

8.2 UCC minimum staff competences

Area Competence

Standard clinical competences

All staff (including receptionists) should have the ability to carry out basic life support for adults

Minimum staff education and competency requirements for all clinical staff working in urgent care services include:

Recognition of serious illness.

Pain assessment.

History taking, examination, formulation of a diagnosis and treatment plan.

Prescribing or Patient Group Directives (PGD).

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Area Competence Competence in the recognition of acutely ill patients and as a

first responder.

Identification of vulnerable patients and their multidisciplinary pathways of care (‘vulnerable groups’ include but are not limited to: frail elderly, adolescents and children, people with mental health issues).

Ability to recognise that someone may be experiencing a mental health problem and to respond appropriately. At least one clinical member of staff on a shift must have intermediate life support training.

Clinical staff dealing with minor injuries must possess the practical skills necessary to identify and manage non-complex soft tissue and bone injuries, for example:

Wound closure

Plaster casting

Assessment of burns

Paediatric competences

All UCCs receiving children must have a minimum level of competence, skills and experience for treating young people, including:

Paediatric Intermediate Life Support training All discharging clinicians/ main deliverers of care need to have

level 3 child protection Recognition of sick children, including Paediatric Early Warning

System Communicating with children and their families; The assessment and recognition of the sick child; Basic life support skills Anaphylaxis training Recognition of vulnerable children, the ability to identify when

safeguarding procedures are necessary, and the ability to implement the emergency department at the hospital’s child protection policy and the Pan London Child Protection Procedures’

Pain assessment and management Administration of medication, ideally by Patient Group

Directives (PGDs) for analgesia The current legal and ethical issues pertaining to children,

including consent and confidentiality issues.

Diagnostic For those non-radiology diagnostic services which are available to them, clinical staff must be able to assess the

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Area Competence competences

need for, and order, diagnostics and interpret results.

For those radiology diagnostic services which are available to them, clinical staff must be able to assess the need for, and order, diagnostics. They must also possess the ability to interpret simple X-rays (e.g. uncomplicated fractures).

Training and Education Urgent care services must be able to ensure that trainees can be supervised to the appropriate GMC standards.

Maintaining and developing skills

The Provider must ensure skill are maintained and regularly updated and clear records of this are kept in accordance with professional and regulatory requirements and guidelines.

8.3 UCC minimum levels of cover

Standard Notes

UCC must be staffed by at least one doctor and at least one emergency nurse practitioner or emergency care practitioner at all times

As per London Health Programmes UCC standards.

UCCs must develop a staffing model able to manage peaks and troughs in demand, exploring potential synergies with ED and GP OOH services

During periods of low activity, an ‘assess and treat’ model is viable – no requirement to have separate clinicians for assessment and treatment.

Section 9

Premises and services Draft Ealing Urgent Care Centre Service Specification

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9 Premises and services

The UCC Provider will be expected to agree a lease with London North West Healthcare NHS Trust for use of the existing UCC premises at Ealing Hospital.

The provider will have in place a service level agreement with LNWHT for the supply of a number of support services to be provided to the UCC, including:

• Diagnostic services

• Clinical and non-clinical support services

• IT/telephony

• Other general facilities management services such as cleaning, clinical waste and porterage.

The UCC provider shall ensure in the use of the facilities that privacy and dignity are maintained at all times. Adequate waiting space should be allocated and distinct areas (with audio and visual separation) for children and young people who have to wait should be maintained.

The UCC provider will ensure that patients and carers who have sensory impairments are communicated with effectively including while waiting and being called for consultation eg through the use of electronic boards, pagers etc.

Section 10

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10 Contract, performance and working with the Provider 10.1 Contract term Ealing CCG intends to contract with a Provider/Lead provider for this service for a total contract period of 5 years. However, the CCG believes the environment is a changing one and that the nature of the relationship of the UCC with the other services that make up the North West London Urgent Care system including Emergency Centres will evolve over this period. For this reason, a break clause at 3 years will be included in the contract. The overall level of activity will be reviewed on a regular basis. The contract is for a range of activity and provision is made for demand in excess of this range and also where demand falls short of the expected level.

10.2 Open Book approach An open approach to activity and finance between Commissioner and Provider will enable a productive level of understanding to develop rapidly. This understanding will inform the activity levels and outcomes from the end of Year 3 to Year 5.

The Provider will participate in monthly contract review meetings (these may be more frequent in the early stages of the contract). The CCG will engage a patient/public representative to participate on a regular basis in these review meetings.

Scope of open book • All activity for the service from lead and other providers. • Details of activity related to patients (anonymised but tagged in order to link experience in this

and other services in compliance with Information Governance regulations). • Clear understanding of staff rotas and the link between capacity and variable demand. • Activity in other services (from commissioners) that informs evaluation of impact of service • Operating costs of lead provider and other providers. • Ready sharing of all feedback and experience including in case studies and case by case audit. Outside the arrangement • Corporate costs and profits of lead and other providers. • Costs and contract values of other services from Commissioners. The table below summarises the Open Book approach. It is about: It’s not about: Focusing on broader outcomes for the health and social care economy and which benefit patients.

NOT simply focusing on KPIs which are only part of the picture and taken in isolation may not explain what is happening

Understanding how patients are flowing through, where things are impeded and why.

NOT micromanaging the service

Understanding how the service is having an impact on the whole system and how this is sustained.

NOT treating the Provider in the isolation of a single contract

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Understanding where the Commissioners can facilitate other elements in the system to ensure that the Lead Provider can achieve the most effective response

NOT assuming the Provider is wholly responsible for all outcomes – it means being realistic and open about where responsibility lies

10.3 Performance expectations The Provider will be expected to meet demand within +/-5% of outturn total attendances for Ealing UCC in 2014/15 (66,880) ie 63,536 to 70,224 pa. Validated attendances in excess of this figure over a minimum of two consecutive quarters will trigger a discussion with Commissioners +that may lead to the application of marginal rates agreed as part of the procurement. Likewise activity falling below the minimum figure for a minimum of two consecutive quarters will trigger discussion over reduction in payment in line with terms agreed at the procurement stage.

Discussion will start with a comprehensive audit of patient activity which will also take into account, where appropriate, comparisons with activity in ED.

As part of the Open Book approach a patient audit – agreed with the Local Governance Board - will be undertaken at the end of the first quarter of the contract and at the end of the first 6 months. Thereafter, there will be at least an annual audit undertaken.

A mixture of quality and performance outcome based KPIs will form the basis of monthly reporting and review and will inform the Open Book approach.

[KPIs to be confirmed – the following based on existing reporting practice]

KPI Description

Performance band

A B C Adult Clinical Assessment

Percentage of adult patients who are streamed within 20 mins. >98%>90% <90%

Child Clinical Assessment

Percentage of children who are streamed within 15 mins. >98%>90% <90%

Appointment Length (Non Diagnostic)

Percentage of patients who do not require diagnostics seen treated and discharged within 2 hour of booked arrival time at UCC

>95%>90% <90%

Appointment Length (Diagnostic)

Percentage of patients who do require diagnostics who are referred for diagnostics within 2 hours of booked arrival time at UCC

>95%>90% <90%

Patient redirection

Percentage of patients assessed for one stream who are then redirected to the other <5% <10% >10%

GP Information Transfer

Percentage of GPs who receive information (by electronic transfer) about their patients accessing UCCby 8 a.m. the next working day

>98%>90% <90%

Health Visitor / School Nurse Info Transfer

Percentage of Health Visitors/ School Nurses who receive information (by electronic transfer) about their patients accessing UCS by 8 a.m. the 2nd working day

>98%>90% <90%

A&E 4 Hour Wait

Number of UCC referrals to ED that breach the max 4 hour wait standard for A&E (%) <2% N/A N/A

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KPI Description Performance band

UCC 4 hour wait Number of UCC attenders that breach the max 4 hour wait standard (%)

Dataset Information

Collection of Clinical Dataset Information as required in Annexes 2 or 3 of Schedule 7 and Schedule 5 >98%>95% <95%

Specialist Referral

Access to specialist referral in Acute hospital (including ED) within 120 mins (excluding any such failures which are solely attributed to any third party provider of such specialist referral services)

>90%>80% <80%

Mental Health Referral

Access to mental health assessment for a person with acute mental health problems within 60 mins (excluding any such failures which are solely attributed to the third party provider of such mental health assessments)

>90%>80% <80%

Unregistered Re attenders Percentage of re attenders not registered with a GP <10%<15% >15%

Unregistered Patient Assistance to Register

Percentage of non-registered patients helped to register with a GP >98%>90% <90%

Generic Prescribing Percentage of generic items prescribed >80%>77% <77%

Appendix 1

Sources for this specification Draft Ealing Urgent Care Centre Service Specification

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Appendix 1 Sources for this specification

This specification reflects:

A common core specification developed as a result of public consultation and detailed clinical discussions of the NW London Emergency and Urgent Care Clinical Implementation and Planning Group (E&UC CIG) of the Shaping a Healthier Future Programme.

Local requirements as developed through the Ealing CCG Task and Finish Group. The key aims set out in Transforming urgent and emergency care services in England -

Safer, faster, better: good practice in delivering urgent and emergency care - A guide for local health and social care communities, September 2015.

London-wide principles for UCCs as set out in the document Developing Urgent and Emergency Care Facilities and Systems Specifications (Draft) - Healthy London Partnership, July 2015/Updated draft October 2015 setting out a specification to which transition will be envisaged over 3-5 years

Recommendations made by Healthcare for London , College of Emergency Medicine and London Health Programmes for minimum competences for UCC staff.

Single Point of Triage for Co-located Urgent Care Centres and Emergency Departments August 2015 Urgent and Emergency Care Clinical Leadership Group.

London Urgent and Emergency Care Commissioning Intentions 2016/17.

Appendix 2

Exclusion criteria Draft Ealing Urgent Care Centre Service Specification

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Appendix 2 Exclusion criteria

Ealing UCC clinical exclusion criteria (adults)

Exclusion criterion Additional information

Markedly abnormal baseline signs

tachycardia > 110 beats per minute bradycardia < 40 beats per minute hypotension < 100 mm Hg systolic (unless known to be

normal for that individual) respiratory rate <10 or >=25 breaths per minute (adults) oxygen saturation <92% hypoglycaemia

Chest Pain Nature of the pain is consistent with ischaemia Chest pain associated with tachycardia > 110 beats per

minute Chest pain associated with tachypnoea > 25 respirations

per minute Central chest pain or left sided pain with radiation to the

neck or arm Chest pain associated with nausea, shortness of breath or

sweating A previous history of heart disease if relevant History of Cocaine use within the previous 48 hours

Complex fractures For example (but not limited to): Long bone fracture of legs Open fractures Spinal injury

Patients receiving oncological therapy

Patients receiving oncological therapy should be transferred to a hospital with an Acute Oncology Service. All Major Acute Hospitals have Acute Oncology services.

Sickle cell crisis

Shortness of Breath "Severe" shortness of breath compared to normal Cyanosis Increased peripheral oedema Impaired consciousness or acute confusion Rapid rate of onset Associated with tachycardia > 110 beats per minute Inability to speak in sentences Shortness of breath associated with chest pain Shortness of breath associated with pallor and cold sweats Respiratory rate greater than 25 per minute Oxygen saturation < 95% in a previously healthy individual

[E:e] History of severe asthma or recent emergency admission

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or a single ITU admission. Shortness of breath associated with chest trauma.

Adults with signs of severe or life

threatening asthma

cannot complete sentences pulse 110 beats per minute respiration 25 breaths a minute peak flow 50% predicted or best silent chest cyanosis bradycardia (heart rate < 40 bpm) exhaustion

Airway compromise

stridor quinsy oedema of tongue unable to swallow saliva/ drooling

Acute exacerbation of Heart Failure

Burns >5% Facial/ eye involvement Inhalation injury Chemical/ electrical involvement

New CVA

Significant DVT Patients with suspected DVT associated with chest pain/SOB or HR > 110

Haematemesis / Haemoptysis

Overdose / Intoxicated and not able to mobilise

Are experiencing acute alcohol withdrawal or delirium tremens

Are a danger to themselves or others Acute mental health presentation compromised by

alcohol/drugs Unaccompanied by other responsible adult and need a

period of observation Have taken any drug overdose

Significant head injuries Clinical concerns about a Cervical Spine injury: o Neck pain or midline boney tenderness o Focal neurological deficit o Paraesthesia in the extremities o Any other clinical suspicion of cervical spine injury

Head injury associated with GCS < 13 at presentation GCS < 15 when assessed 2 hours after the injury History of significant Loss of Consciousness

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More than one episode of vomiting Persistent headache Suspected open or depressed skull fracture Sign of basal skull fracture

o haemotympanum, ‘panda’ eyes, cerebrospinal fluid otorrhoea, Battle’s sign

Post traumatic seizure Focal neurological deficit Significant amnesia Dangerous Mechanism of injury pedestrian/cyclist stuck by a car, ejection from vehicle, fall

from over 1 meter or 5 stairs

Mental health Overdose Other significant self harm (adults). NB. Mental Health

Trust advice is that this criterion should be open-ended and subject to clinical judgment. For example, a ‘simple laceration’ would be in-scope for the UCC.

Any self harm (children) Severe withdrawal, delirium tremens and withdrawal

seizures (as these are very likely to require medical admission)

Acute psychosis with disturbed behaviour. Acute confused state/ delirium Require a secure environment (ie ED) for assessment

including suicide risk using current screening tool

Ealing UCC clinical exclusion criteria (children)

In addition to the exclusion criteria set out above, the following exclusion criteria will apply to paediatric patients:


Acutely ill children All children identified as ‘acutely ill’ using Paediatric Early Warning System (PEWS)

Children with signs of severe or life

threatening asthma

too breathless to talk or feed respiration 40 breaths a minute in children over 5 years

or > 50 breaths per min <5 years pulse 120 beats per minute in children over 5 years or

140 beats per minute < 5 years use of accessory muscles of breathing

Appendix 2


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peak flow 50% predicted or best in older children

Paediatric head injury Witnessed loss of consciousness Amnesia (antegrade or retrograde) lasting > 5 minutes Abnormal drowsiness 2 or more discrete episodes of vomiting Clinical suspicion of non-accidental injury Post-traumatic seizure Use AVPU to assess level of alertness. Suspicion of skull injury or tense fontanelle Any sign of basal skull fracture

o haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from ears or nose, Battle’s sign

Focal neurological deficit Age < 1 year: presence of bruise, swelling or laceration > 3

cm on the head or any-sized bruise if pre-mobile Dangerous mechanism of injury

o high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from > 3 m, more than 5 stairs, high-speed injury

Procedure requiring sedation

Multiple pathologies deemed to be complex

Repeat attendances Paediatric patients attending the UCC in excess of three times in three months should be referred to the paediatric team at a Major Acute Hospital. This criterion is also standard in NW London EDs and is intended to reduce repeat admissions.

Fever with non-blanching rash

Fitting

History of decreased or varying consciousness

See paediatric head injury guidance above

Headache, fever and vomiting

For clarity, this exclusion only applies if all three symptoms occur in combination.

Any infant with a history of lethargy or

floppiness

Appendix 3

London Ambulance Service UCC list Draft Ealing Urgent Care Centre Service Specification

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Appendix 3 London Ambulance Service UCC list

The following are presenting conditions that will be taken directly to the UCC on arrival by ambulance at Ealing Hospital.

Appendix 4

Draft Key Performance Indicators Draft Ealing Urgent Care Centre Service Specification

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Appendix 4 Draft Key Performance Indicators

11.1 Ambulance Handovers Percentage UCS handovers by Ambulance Service

taking over 15 mins≤ 5

1.2 Adult Clinical streaming Percentage of adult patients who are streamed (initial brief clinical assessment and navigation) within 20 mins.

≥ 98

1.3 Child clinical streaming Percentage of children who are streamed (have their initial brief clinical assessment and navigation) within 15 mins.

≥ 98

1.4 Appointment Length (Non Diagnostic)

Percentage of patients who do not require diagnostics who are discharged within 2 hour of booked arrival time at UCC

≥ 95

1.5 Appointment Length (Diagnostic)

Percentage of patients requiring diagnostics who are referred for diagnostics within 1 hour of booked arrival time at UCC

≥ 95

1.6 A&E 4 Hour Wait Number/percentage of patients redirected from UCC to ED with no diagnostic test within 1 hour ≥ 98

1.7 A&E 4 Hour Wait Number/percentage of patients redirected from UCC to ED with diagnostic test(s) within 2 hours. Target of 70% to allow for complex patients to be managed longer in UCC

≥ 70

1.8 A&E 4 Hour Wait Number/percentage of patients treated and discharged from UCC within 4 hours.

≥ 98

1.9 A&E 4 Hour Wait Number of UCS referrals to ED that breach the max 4hour wait standard for A&E (%)

≤ 2

1.10 Patient Redirection Redirection rate - percentage of patients assessed for one stream who are then redirected to the other

≤ 5

1.11 Specialist Referral Access to specialist referral to acute hospital specialists (including ED) within 120 mins (excluding any such failures which are solely attributed to any third party provider of such specialist referral services)

≥ 90

1.12 Mental health assessment Access to mental health assessment for a personwith acute mental health problems within 60 mins(excluding any such failures which are solelyattributed to the third party provider of such mentalhealth assessments)

≥ 90

1.13 Health Visitor / School Nurse Information Transfer

Percentage of Health Visitors/ School Nurses whoreceive information (by electronic transfer) about theirpatients accessing UCS by 8 a.m. the 2nd workingday

≥ 98

1.14 Dataset Information Collection of Clinical Dataset Information as required ≥ 981.15 Prescribing Adherence with the agreed UCC Formulary including

use of generic drugs1.16 Non registered patients Percentage of non-registered patients helped to

register with a GP≥ 98

No KPI Description

Process

Target

Appendix 4


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Additional measures to be developed:

Reporting requirements around new pathways, including to and from Homeward and to and from Mental Health SPA will be agreed with the Commissioner.

Patient satisfaction surveys to be developed to target specific age groups etc and to test satisfaction at first contact, streaming, treatment, referral on and navigation. Attention will also be given to the level and quality of information given to users.

Testing through audit of the clinician’s responsibility to ensure that all abnormal diagnostic results are followed up appropriately.

Shared Decision Making.

22.1 Patient discharge summary Percentage of patients for whom a discharge

summary is offered by the person discharging them.This is a summary record of the patient’s visit to theUCC outlining what happened to them.

100

2.2 GP Information Transfer Percentage of GPs who receive information (byelectronic transfer) about their patients accessingUCS by 8 a.m. the next working day

≥ 98

2.3 Falls Percentage of attenders age 55 years and over who present as a result of a fall receive a falls assessment and are referred into the appropriate local service.

≥ 98

2.4 Asthma Percentage of patients with asthma that have a set of baseline observations that include pulse, oxygen saturation rate, peak flow and respiratory rate (as a minimum) which should then form part of the information (received by electronic transfer) by GPs/Health Visitors and School Nurses (see above)

100

2.5 Alcohol The percentage of patients with an alcohol related attendance who receive a Paddington Alcohol Test (% to follow)

≥ 90

2.6 Child protection Number of patient contacts for patients with known child protection plans notified to social services by 8am the next working day

100

2.7 Vulnerable adults Percentage of patients attending identified as Vulnerable Adults notified to Safe Guarding Adults Coordinator

100

2.8 Diabetes Percentage of patients with a diabetic associated attendance (aged between 13 and 19 years) referred onto the Adolescent Diabetic Specialist Nurse

100

2.9 Learning Disabilities Percentage of patients with a learning disability that have information (a discharge summary) sent to the Community Team for People with Learning Disabilities by 8 a.m. the 2nd working day

100

2.10 Smoking Status Percentage of patients asked smoking status ≥ 982.11 Smoking Intervention Percentage of patients following a positive response

to the above offered a brief intervention and referral opportunity

≥ 98

2.12 Patient Satisfaction outcomes See note below - these measures will be prioritised and will be developed with user involvement.

≥ 90

Quality

No KPI Description Target

Appendix 4


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Education about future care decisions. Percentage of complaints that result in themed learning being evidenced.

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