Health, Housing and Adult Social Care Scrutiny Committee	6 November 2024
Report of Assistant Director of Pathways, York Place, Humber and North Yorkshire Integrated Care Board

Urgent Care Delivery Review in York and the East Coast - an Update on the Emerging Integrated Model and Next Steps

1.    Summary

This report updates committee members on progress regarding the Integrated Urgent Care Service model which was commissioned across North Yorkshire and York Places within the ICB from April 2024.

2.      Introduction

Building on the NHS Five Year Forward View, in 2017 NHS England and NHS Improvement published the Next Steps to this plan which highlighted the importance of delivering functionally integrated urgent care services. It stated that patients with less severe conditions should be offered convenient services including newly designated Urgent Treatment Centres and/or GP appointments, with more clinicians handling calls to NHS 111. The aim was to provide the best possible care closer to people’s homes and help tackle the rising pressures on urgent care services in both primary care and hospital.

In 2021, NHS England published an updated national service specification for the provision of integrated urgent care. This provided the framework and foundation for a new model of integrated urgent care across North Yorkshire and York Places, broadly covering minor injury and minor illness.

The Integrated Urgent Care Service (IUCS) will be available 24 hours a day (minimum 12hrs for "walk in" attendances), 7 days a week to respond to people’s urgent health care needs (minor illness and minor injury) when it's not an emergency but treatment, information or reassurance are required.

York and Scarborough Teaching Hospitals NHS Foundation Trust (the Trust) received a request from Humber and North Yorkshire Integrated Care Board (ICB) on 4 May 2023 to become the Prime Provider for Integrated Urgent Care services across the Trust's geographical footprint, commencing 1st April 2024 subject to due diligence from both parties. This request was accepted by the Trust.

The Urgent Care service at the time was not provided on an integrated basis - some elements were provided by the Trust directly, while the ICB had contracts (ending September 2023) with Totally, a private organisation, with the elements of streaming, minor injury, minor illness and Out of Hours provided separately.

3.      Objectives

The ICB’s intention was that by integrating these elements of Urgent Care there would be improvements in quality of care for patients, integration with other local services, and financial efficiencies.

The aim of the IUCS is to provide consistent, high quality, seamless and responsive services as close to service users' normal place of residence (or current location if a visitor to the North Yorkshire and York area) as possible.

The ask is that across York Place and North Yorkshire Place patients will:

· Be able to access an IUCS 24 hrs per day which is working to a consistent service specification, is led by a GP or consultant, and is staffed by a multi-disciplinary team sufficient in number and skill to meet the expected patient demand profile, with access to simple diagnostics.

· Have a consistent route to access urgent appointments through NHS 111, ambulance services and general practice. A walk-in option will also be retained for a minimum of 12hrs per day, 7 days per week including bank holidays.

· Understand that these services work in conjunction with the ambulance service, NHS111, local GPs, hospital emergency departments and other local providers.

This would be achieved by the IUC service:

· Delivering high quality, evidence-based, joined up healthcare that meets the requirements of national and local guidance, underpinned by shared computer systems and agreed governance.

· Providing patients with a complete episode of care (within the scope of the IUCS) concluding with either advice, a prescription, or an appointment for further assessment or treatment where required.

· Utilising innovative approaches to self-care and health promotion.

· Providing advice, treatment and signposting to appropriate services to prevent unnecessary Emergency Department (ED) attendances and hospital admissions.

· Ensuring appropriate referral pathways are in place to facilitate the timely and safe transfer of seriously ill patients to ED.

· Enabling the secure transfer of information about patients being initially assessed by NHS111 then attending the IUCS.

· Agreeing practical actions and timescales to increase integration of services with local primary care, local secondary care, ambulance services, social care provision, voluntary sector organisations and mental health services to reduce any duplication and improve patient experiences.

· Providing equitable and safe access to all service users.

· Educating the public and service users on the availability and appropriate use of self-care and alternative services.

· Actively working with other providers of health and social care across York and North Yorkshire Places to support improved communication, including communications to avoid admissions and reduce duplication.

The integrated urgent care service should not be an alternative to planned primary care or for service users who do not need urgent care. These service users will be provided with information about appropriate services.

4.      Engagement

With support from Healthwatch, York and North Yorkshire Places carried out engagement activities to help shape the IUCS specification. Three main themes emerged:

i) People are often unsure about when to use the NHS 111 service, when to call a GP or when to go to ED.

ii) If people have an urgent medical condition that needs treating on the same day, people will choose between their GP surgery, attending ED, ringing 999 or 111 (phone or online) – the pattern varies and is often dependent on ease of access.

iii) There is a lack of knowledge about Urgent Treatments Centres (UTCs), out of hours care, what these services offer, and when and how it is appropriate to access them.

The engagement activities identified the need to develop a 24/7 Integrated Urgent Care Service (IUCS) that is understood, consistent, easily accessible, and well signposted.

Use of our current Emergency Care services (A&E / 999) also highlights a strong driver for change. Attendances to ED have increased and continue to increase, with an upward trend in patient acuity. This changing demand profile has further increased pressure on services – 999 and EDs are no longer just for "emergencies".

As a consequence, performance standards across most aspects of urgent and emergency care have fallen, with growing evidence for resulting harm and increase in avoidable deaths as a result of delays in accessing the care.

5.      Progress to date

Selby Urgent Treatment Centre

Selby UTC transferred from Harrogate and District NHS Foundation Trust to York and Scarborough Teaching Hospitals NHS Foundation Trust in October 2023. The UTC has a history of working in collaboration with Selby Town Primary Care Network (PCN) to support the delivery of urgent care to the local population. The Trust has continued this partnership and works with Selby Town PCN to deliver urgent care services, through honorary contracts and a service level agreement.

A shared vision has been developed for the service, with priorities including (but not limited to):

· Recruiting two new practitioners and working on strengthening the governance around Selby. 

· Specialist paramedic practitioners training at both Selby and York UTC to improve minor injury skills so they can then support the patients of Selby. 

· Planning a case mix audit to review the types of patients that attend Selby so we can cross-reference this with the skills of the practitioners to looks to see if we can provide a service to meet the needs of the population.

Malton Urgent Treatment Centre

Malton UTC staff came across to the Trust on a TUPE arrangement on 1 April 2024 after a month of preparation and training. Since this date Malton UTC has had a more consistent level of provision.

A working group involving local system partners in Malton has undertaken audit work to understand the opportunities for improving local support where it is most needed.

We have successfully recruited an additional practitioner starting in December 2024 and are considering succession planning for the service.

As in Selby, we are working with local partners on a plan for a case mix audit to ensure we are meeting the health needs of the people of Malton.

Out of Hours (OOHs)

The Trust subcontracts the OOHs service. Following a thorough tender process, the contract was awarded to Nimbuscare in January 2024 and the service commenced in April 2024.The Trust and Nimbuscare meet monthly to review quality metrics and key performance indicators. Both organisations are active members of the York Health and Care Partnership.

Since April, OOHs provision has shown marked improvement in shift fill rates and call back times. Shift fill rates have now reached 98%, compared to below 50% in 2023. This improvement provides greater reliability for patients and helps reduce unnecessary visits to York and Scarborough Emergency Departments. The OOHs service has also achieved a 97% call-back target for patients referred by 111. This means that 97% of the time, patients receive a call back within the target time allocated by 111 (1hr, 2hrs or 6hrs). This has significantly enhanced patient experience and is reflected in patient feedback surveys.

The OOHs services in York, Scarborough, Selby, and Malton are co-located with the Urgent Treatment Centres (UTCs). This arrangement enables OOHs GPs to support nurse practitioners in the UTCs with more complex cases, fostering a more integrated approach to patient care.

IT system

In April 2024, Nimbuscare introduced SystmOne as the digital platform for the OOHs service. This widely-used NHS system provides clinicians with access to patient records and electronic prescribing capabilities, promoting more informed and streamlined care. With the majority of GP practices in our area already using SystmOne, this transition represents a positive step toward enhanced integration with primary care. This integration will also enable GPs to book patients directly into the UTCs, a key next step.

As of September, York and Scarborough Minor Illness services have adopted SystmOne, meaning OOHs and UTC clinicians now operate from a shared system, allowing them to work collaboratively across both services. This integrated approach is expected to enhance continuity of care, improve operational efficiency, and support the objectives outlined in the Integrated Urgent Care Service (IUCS) specification.

Further work is planned to extend SystmOne access to minor injury services at York and Scarborough, as well as Malton and Selby UTCs, to further align with regional integration goals.

Access

Malton and Selby UTCs are open 8am-8pm and patients can walk-in, with the last arrival time of 7:30pm to enable the last patients to be seen and the service to be closed at 8pm.

York and Scarborough UTCs are co-located with ED. Patients can walk-in to the Emergency Department and be streamed to the UTC by a Clinical Navigator at the front door of ED.

We are progressing toward a model where patients can be referred to any of our UTCs by a GP or via 111. SystmOne offers a feature that allows GPs and 111 colleagues to “book patients in” directly to the UTC. The clinical and operational benefits and limitations of this feature are being carefully evaluated before full implementation of this functionality.

Optimal Care Service

In July 2024 the Trust launched the Optimal Care Service (OCS) at York and Scarborough sites. The principle of OCS is that some resource is moved from ED Majors to ‘boost’ the UTC capability, effectively using the combined resource of these services in a more integrated way.

Minor illness + Minor injuries = UTC

Minor illness + Minor injuries + ED resource dealing with non-Majors = OCS

Use and effectiveness of OCS is being proactively monitored and senior clinicians are involved in embedding this service. Since launching, the number of complaints relating to long waits for non-admitted patients has reduced. 

6.    Next Steps

Data from ED attendances suggests there is good potential to improve local support for Heart Failure patients and for patients with musculoskeletal issues in Malton, through specialist clinics. The working group continues to meet and develop plans to support more patients locally to Malton.

The new Scarborough Urgent and Emergency Care Centre is due to open in the coming month; which is expected to bring benefits to patients and staff (including partners such as paramedics).

We are in the final stages of applying for funding to support estate reconfiguration at York. One of the planned changes is for the minor injuries service to move to be part of the ED footprint as part of the IUC service, along with a primary care led 24/7 Urgent Treatment Centre. One key advantage for patients is that they will no longer have to walk around the hospital building and navigate a different entrance and waiting area. The full estate reconfiguration within the existing footprint at York has commenced (ward moves) and is hoped to be concluded at the end of the financial year.

The work to date has all been made possible through local clinicians working together to make meaningful changes to services, which will have a lasting positive impact on patients and the workforce. All System partners are committed to continuing to work in this collaborative way, sharing experiences and ideas which will benefit the communities we serve, so we are optimistic about the future of Integrated Urgent Care Services across our patch as a way to improve patient care.

7.      Recommendation

It is recommended that the committee note and comment upon the report.

Contact Details Chief Officer Responsible for the report:
Shaun Macey Assistant Director of Pathways, York Place, Humber & N Yorks ICB
Report Approved	ü	Date	30/10/24

Wards Affected:  List wards or tick box to indicate all

All

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Annexes

None

Abbreviations

ED              Emergency Department

ICB             Humber and North Yorkshire Integrated Care Board

IUCS           Integrated Urgent Care Service

OCS           Optimal Care Service

OOHs        Out of Hours      

PCN           Primary Care Network

UTC           Urgent Treatment Centre