Integrated Urgent Care Services bombshell set to explode in April 2019

This is a long (3k) word blog post.

  • NHS England has ordered this new service to be up and running everywhere in England by April 2019. It is based on a revamped NHS 111 service that hands patients off to a phone- and digital-technology based Clinical Advice Service.  This aims to complete the consultation without referral to other services.
  • This Integrated Urgent Care Service (described as the “front door to the NHS” ) copies USA multi-partner urgent care services provided by Medicare and is key to the Accountable/Integrated Care drive to replace skilled NHS staff with the products of life sciences and digital technology companies.
  • The Integrated Urgent Care Service will fundamentally change how patients access NHS services and will benefit the corporate profits of digital technology companies – not patients or NHS staff.
  • There is little or no evidence from the West Yorkshire  Urgent and Emergency Care “Vanguard” that it will work.

The cost cutting “all hours” Integrated Urgent Care Service is the means of controlling and restricting patients’ access not only to A&E and ambulance services – but to their own primary and community health services. It fails to provide any continuity of care for patients, and focusses largely on phone consultations followed by self care.

A clinician told us,

“I cannot figure out the reason to justify the need for this change. Why is NHS England enforcing standardisation of out of hours? And it isn’t all out of hours – some bits point to access to same day appointments with a GP.

At our GP practice, we have 111 slots cropping up on our afternoon lists which are supposed to be emergency appointment triage. Now I’ve read the Integrated Urgent Care specification, I imagine this is why.

In my experience, patients booked in so far are not appropriate and one child was not even our patient had been booked with the wrong details as a totally different patient!”

The tender document for West Midlands Integrated Urgent Care Service (the first in the country) says the 24/7 service is:

“the ‘front door’ of the NHS providing access to both treatment and clinical advice. This will include NHS 111 providers and GP led OOH [out of hours] services with links to community services, ambulance services, emergency departments and social care.”

The West Midlands Integrated Urgent Care Service contract was awarded under an Alliance Agreement to Care UK (Urgent Care) Ltd, three other companies (Badger Group, Nestor Primecare and Vocare -since taken over by Totally Ltd), and other pre- existing local contracts).

The West Midlands Integrated Urgent Care Service is trialling the Ask NHS app
with £4.5m patients. This is a symptom checker designed to encourage patients to self assess rather than contact a health service.  It is seen as a way of reducing patients’ calls to 111 and other NHS services.

It’s shaping up to be bad for patients and NHS staff – and it’s a nightmare for commissioners

In the West Yorkshire and Harrogate Integrated Care System, the lead Commissioner for this huge Integrated Urgent Care service (which is to cover the whole of Yorkshire and the Humber) has admitted at a Joint Clinical Commissioning Committee meeting  they don’t know how to procure it they are paying an untold sum to the management consultants Attain to do it for them. And they are not the only ones.

This Integrated Urgent Care Service looks very much like an Accountable/Integrated Care System, with a capitated budget that has to cover the whole population – regardless of the number of people treated or the complexity of their care; a lead provider; and loads of subcontracts.

The Frimley Integrated Care System  could be a showcase model. There is a trial within it of ambulance response to home visit requests, as a way of freeing up the time of our GP’s (and with that removing the family doctor from the most vulnerable patients?). It details GP practices opening 8-8 and at weekends – but is this “GP practices” as we know it – or is it blurring the boundary between what is primary care and what is urgent care and working traditional GP practice into this new model framework?

A fundamental change to the way patients access health services

NHS England says these new phone and digital Integrated Urgent Care Services will fundamentally change the way patients access health services.

We are worried as we think it is a change for the worse.

This huge reconfiguration of patients’ access to NHS services is taking place as the government, its quangos and corporate and academic cronies in life sciences, pharma and digital technology are hijacking the NHS as a means of generating economic growth via feeding the profits of industries in these sectors.

In the process, they are selling out patients and NHS frontline staff.

All the extra £20bn NHS money promised by May is for high tech investment in the new primary care super hubs, and  for changing the workforce into a dumbed down cheap labour force.  Her speech about it at the Royal Free Hospital could have been written by Simon Stevens.

We desperately need to slap this whole Accountable Care gambit on the head with a big spade, through Allyson Pollock’s and Peter Roderick’s NHS Reinstatement Bill.

Revamped NHS 111 call handling

The new Integrated Urgent Care service is to combine:

  • a revamped NHS 111 call handling service
  • a new phone (and later online) Clinical Advisory Service, and
  • designated face-to-face Integrated Urgent Care treatment centres, located in primary care centres, Urgent Treatment Centres or streaming facilities in local A&E departments.

A patient who needs urgent health or social care will call NHS 111. A call handler – aka a Health Advisor – will follow a script that determines which kind of clinician in the Clinical Advisory Service the patient will be handed off to for a phone (or later, online) consultation.

At the moment, NHS 111 is an “assess and refer” service – patients phone NHS 111, and NHS 111 tells them where to go.

The new model of Integrated Urgent Care Service will be “consult and complete”. In other words, you phone NHS 111 and they hand you off to a phone Clinical Advice Service. Their mandatory target will be to complete at least 50% of phone consultations (driven by algorithms in the form of a Clinical Decisions Support System), without referring the patient elsewhere.

Phone-based Clinical Advice Service that uses a digital Clinical Decision Support System

The Clinical Advice Service will have a team of clinicians on the phone (and later, online) that includes Advanced Nurse Practitioners, pharmacists, dental nurses, mental health nurses and palliative care nurses, headed by a GP 24/7.

The clinical advisors will follow a standardised protocol or Clinical Decision Support System, with the aim of resolving the patient’s problem on the phone if possible.

A 2011 systematic review of the effectiveness of Clinical Decision Support Systems (doi:10.1371/journal.pmed.1000387) found that:

“There is a large gap between the postulated and empirically demonstrated benefits of [CDSS and other] eHealth technologies … their cost-effectiveness has yet to be demonstrated”.

It seems that Clinical Decision Support Systems are about tying clinical decisions to data about cost and outcomes that’s required for Accountable Care payment methods.

Resolution of the patient’s problem could include sending them self care information and/or remote prescribing to a local community pharmacy that is in the NHS 111 Directory of Services, via a new Electronic Prescription Service that NHS Digital is rolling out nationally to all integrated urgent care providers.

A clinician told us,

“Remote prescribing without the patient even being seen is much more risky. Risk management & managing antibiotic overprescribing is a tricky one if you take away examination & face to face assessment.

And there is big emphasis in the Integrated Urgent Care spec on access to full records which brings its own questions on the right to have full access.”

If the Clinical Advisory Service clinician cannot complete the consultation on the phone, they can refer the patient to a face to face appointment in an Integrated Urgent Care treatment centre. All under the one Integrated Urgent Care Service umbrella and with lots of technology and triage tools to standardise care.

The “consult and complete” requirement in the NHS England’s specification mentions reducing unnecessary questions, which probably means quick quick quick on the phone.

The Ask NHS app being trialled in the West Midlands Integrated Urgent Care System also links to NHS 111; so if the symptom checker app tells the patient to call 111, 111 will automatically receive the app’s symptom checker results.

Designated Integrated Urgent Care Service treatment centres

The “designated IUC treatment centres” could be located in:

  • Urgent Treatment Centres (standardised to a service specification),
  • Primary care – including new extended hours (evenings and weekends) which may well be provided by an out of hours provider
  • 24/7 services co-located at A&Es.

An April 2017 NHS England blog about Urgent Treatment Centres  explains:

“[W]e plan to standardise as many as possible [walk in centres, minor injuries units and urgent care centres] so they offer better and consistent opening times every day, and more tests and treatments – and all under the single banner of ‘Urgent Treatment Centre’ which NHS 111 can book you into.

“ ‘Urgent Treatment Centres’ …will be integrated with the existing strands of front line services in local communities. They will be open 12 hours a day, seven days a week, and offer patients who do not need to go to a main hospital A&E department treatment by clinicians with access to blood tests, ECGs and X-rays. They will offer booked appointments after calling NHS 111 or a GP, as well as those who walk-in with problems that can’t wait…

These will typically offer treatment for suspected broken limbs, strains and sprains, cuts and grazes, bites and stings, scalds and burns, minor head injuries and other ailments such as ear and throat infections, skin infections and eye problems.”

“Designated IUC treatment centres” are to be staffed by a GP or Advanced Nurse Practitioner or “appropriate equivalent health or social care professional.” (p 30, 5.3.6)

Home visits by a clinician from the designated Integrated Urgent Care treatment centre will also be made where necessary. But this will be an Integrated Urgent Care employee – not the patient’s GP or other known clinician.

What if the consultation can’t be completed by the Integrated Urgent Care service?

As well as issuing prescriptions electronically, sending the patient self-care information and directing them to a designated Integrated Urgent Care treatment centre, the Clinical Advisor can make an electronic appointment for a face to face consultation with an outside service, using a Directory of Services (IUC Specification s5.12, p64) This service could be ambulance, a GP out-of-hours or same day appointment, social care, palliative care etc.

Who benefits? Digital technology companies. Not the public or NHS staff

A clinician told us,

“Gone are the days where your family doctor oversees your medication and care.

I seriously can not see what the justification is for this – apart from cutting costs by diverting patients from GPs, out of hours urgent care services and A&E.

Their claims that this will simplify and improve patient access to urgent care are not new, but this design will not achieve their claims – it will set us back decades.”

It is intended to be cheaper than other NHS services, by reducing patient access (or “managing demand”) to GPs, A&Es and a host of other services including social care, mental health care and palliative care. But it will make a lot of money for digitech companies

An example of this is Coordinate My Care,  which was funded by the NHS Innovation Accelerator.  Coordinate My Care is a digital record of a palliative care plan, available electronically to all the various services that a patient or their carer calling 111 might need to be referred to. Its justification is that:

“70% of the time patients are treated and advised by other healthcare professionals [than their GPs] who do not known [sic] them”

A primary care clinician commented:

“Coordinate my Care is about selling an app if you ask me. It’s about promoting tech – how can this programme help to improve care without addressing care or capacity? It says it will help more people stay and die at home – how??

When I used to work in the rapid response teams we used to get palliative care handover forms from district nurses /GPs – these go to out of hours too . Patients have notes in the house. Advanced planning is on templates for dementia reviews for end of life care.

Gold standards pathways were all about individualising care around patients and improving quality. At end of life in Bradford they had a hospice at home team and the palliative care team was well staffed and each had their own case loads to visit and develop plans with. Now palliative care teams are doing more teaching roles (to justify grades apparently ) and less of the care.

I can’t for the life of me understand how a pretty computer programme will help . Education would help, stopping cutting palliative care nurses would help, stopping cutting district nurses would help and stopping care staff ticking stupid boxes and inputting unnecessary amounts of paperwork would help. This looks like a nice extra gadget as opposed to a necessity . Hardly what we need when we are suppose to be tightening our belts??”

With its reliance on algorithm-based remote consultations, the Integrated Urgent Care Service is not only de-personalising the relationship between patient and clinician, it is deskilling and deprofessionalising our clinicians, by reducing their role to ticking standardised care protocol boxes.

As well as depending on confidential patient data being widely shared, without a lot of clarity about information governance issues – which are huge, it pushes more responsibility for self care on patient, family and friends. This comes with considerable clinical risks.

There is no evidence that this will work for the NHS

The Integrated Urgent Care services specification is very like USA multi-partner urgent care services provided by Medicare.

But is the profiteering American urgent care system right for our NHS?

Under the headline “The Race Is On to Profit From Rise of Urgent Care”, in 2014 the New York Times reported …

“[O]ne of the fastest-growing segments of American health care [is] urgent care, a common category of walk-in clinics with uncommon interest from Wall Street. Once derided as “Doc in a Box” medicine, urgent care has mushroomed into an estimated $14.5 billion business, as investors try to profit from the shifting landscape in health care.”

The clinician we spoke to said,

“We are all set to base a massive restructure on little pockets of trial.

For example, NHS 111 are booking into GP slots already. And as part of the West Yorkshire Urgent and Emergency Care Vanguard, Yorkshire Ambulance Service set up a new Hear, See and Treat Clinical Advice Service – which was totally panned in a 2017 external evaluation by Yorkshire & Humber Academic Health Science Network.

Criticisms were tempered by the acknowledgement that the Clinical Advice Service was at a very early stage of development and had ‘significant…challenges in recruitment of clinical specialists.’

The evaluation was not very positive about the other elements of the West Yorkshire Urgent and Emergency Care Vanguard, either. It basically said there is no usable evidence from that Vanguard. So why not wait until there is some?”

The Integrated Urgent Care spec seems full of contradictions – it looks as if it’s aiming to replace a lot of GP care

One the one hand, it says that “the vast majority” of urgent care will continue to be provided by General Practice during their present opening hours. 100% of GPs will offer same day and pre-bookable evening and weekend appointments.

On the other, it claims that the new Integrated Urgent Care services will “fundamentally change the way patients access health services” and be open 24 hours a day.

The clinician said,

“The Integrated Urgent Care spec seems very sneaky. I think it’s more than we imagine urgent care to be. It looks as if it is aiming to replace a lot of GP care.”

This is borne out by the spec, which says (5.12.2, p65) that the Integrated Urgent Care Clinical Advice Service means that

“the distinction between GP delivery in and out of hours is evolving.”

The “generic” GP in the Clinical Advice Service must be able to access the telephone patient’s own GP practice appointments, in case the consultation can’t be completed on the phone and the patient’s own GP practice is open. Which raises the question, if the GP practice was open, why would the patient call 111?

The spec also says that although at the moment only 20% of NHS 111 calls are made when GP practices are open, the commissioner will work with local GP practices to figure out the demand for in hours appointment slots for the Integrated Urgent Care Clinical Advice Service.

So is NHS England thinking that GP practices would require patients seeking urgent care to call NHS 111 – rather than come to an urgent same day appointment with them?

At what point does the boundary cease to exist between an Integrated Urgent Care Treatment Centre and a Primary Care Home? (Which, confusingly, has nothing to do with residential care homes but is a new model of large scale GP practice, imported from the USA, that is displacing traditional family doctor practices.)

The blurring of the boundary between the Integrated Urgent Care Service and the new large scale Primary Care Home “locality” GP practices is confirmed by the spec’s requirement that the Integrated Urgent Care Clinical Advice Service must

“align” with “community based services, health and social care, Urgent Treatment Centres and A&E, and provide the access point for these face to face services via the NHS 111 number and appropriate clinical triage”.

And that the Integrated Urgent Care Clinical Advice Service must

“integrate and share common functions with locality based primary care centres, which…coordinate and provide a range of services… (such as extended access centres).”

What does this mean for patients’ access to known, familiar clinicians? And for face to face consultations?

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3 comments

  1. This is all about profit at the expense of patients. Who is going to be accountable when things go wrong and how can older people be expected to deal with these faceless “clinicians”with targets to meet on the ‘phone. The tories are only interested in making money and people are being forced to accept an inferior service which will have dire consequences. We are already seeing the destruction of the NHS for profit and this is another step towards that.

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  2. We have just had confirmed that the best results for patients – long healthy lives, come from being in the care of one doctor who knows and treats you over a long period and who is accountable to a public body for the standard of that care. This is a million miles away from the endless parade of ill considered schemes since 2012 which put patients’ needs well below the priority of financial success. The entire expensive fiasco must by now be driving the caring NHS trained clinicians insane with frustration. I recently met a retired consultant who was keen to see improvements in the NHS and joined his local CCG, gave his opinions and worked on difficult issues using his lifetime’s expertise. He soon found his efforts though politely received were ignored completely. The script had already been written. So he resigned and retired not wanting any part of the systematic destruction he was seeing. We are losing too many valuable professionals in this way.

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