Domain 3 – case studies

  1. Nottingham GP’s: Cardiology Discharge Project
  2. Rushcliffe: Urgent Community Support Service
  3. South East Staffordshire & Seisdon Peninsula: Vasectomy Services
  4. Stoke-on-Trent & North Staffordshire: Orthotics
  5. North Derbyshire: Patient Experience
  6. North East Essex: GP Urgent Visiting
  7. North East Essex: Surge Management Meetings
  8. West Essex: The Princess Alexandra Hospital trust-Urgent Ambulatory Care
  9. South London: Accident & Emergency Service Policy
  10. HomeFirst: Rapid Response Service
  11. East Anglia: Major Trauma
  12. Ipswich & East Suffolk: Unplanned Care emergency assessment unit
  13. Coventry & Rugby: NHS Referral support service
  14. South Worcestershire: GP Working with the ambulance Service
  15. South Warwickshire: Member Practice Engagement in Commissioning
  16. NHS England: My Shared Pathway

Nottingham GP’s: Cardiology Discharge Project

Nottingham GPs and cardiology consultants were concerned that too many cardiology patients were asked to attend hospital for unnecessary follow-up outpatient appointments.

A small-scale pilot project suggested that many cardiology patients currently on hospital lists could be safely and more appropriately monitored by their GP.

GPs and consultants agreed criteria for assessing whether patients could be safely discharged to their family doctors and produced discharge categories.

In order to assess patients to gauge which category they fell into, GPs and consultants needed to share patient information. This was done efficiently and safely using eHealthScope, a secure, password-controlled system developed by a local GP and only accessible via N3, the NHS IT network.

As a result, by the beginning of April 2013, 720 patients had been discharged from hospital outpatient systems. (eHealthScope was also used to monitor discharge numbers.)

This has enabled the provider Trust (Nottingham University Hospitals) to offer fewer cardiology outpatient slots, while reducing waiting times for those patients who do require hospital follow-up.

The initiative also led to a revised patient pathway for echocardiography, with reduced consultant involvement as GPs provide ongoing monitoring and valve checks are carried out by cardiac technicians at the hospital.

Rushcliffe: Urgent Community Support Service

Analysis of activity data at Rushcliffe Clinical Commissioning Group (RCCG) showed a high number of unnecessary admissions to secondary or residential care for people with long term conditions.

RCCG in partnership with Nottinghamshire County Council (NCC), and working with the Community Service, designed a rapid short term service to support people at risk of having an avoidable emergency admission to a hospital or care home due to medical deterioration and/or an inability to cope at home. The planned outcomes were:

  • better patient experience
  • cost savings due to a reduction in urgent admissions
  • understanding the impact of specific interventions on admission avoidance

Patient and carer comments:

“… if this service hadn’t been available I would have had to go into hospital”.

“ … the service was definitely needed and we couldn’t have managed without it”. (Carer)

Referring clinicians were asked what their clinical management would have been if UCSS had not been available.  The results for the first year demonstrated:

  • 134 of 177 patients avoided hospital admission
  • 76% of patients would have been admitted to the hospital or care home without the UCSS
  • 24% of patients would not have been admitted but the referrer believed that the UCSS assisted in their management of a potential crisis.

Net cost efficiencies of £208,745 (full year cost £143,476 including start up)

South East Staffordshire & Seisdon Peninsula: Vasectomy Services

Vasectomy services have been delivered in primary care for many years, largely by General Medical Practitioners (GPs). Such services have been commissioned in a variety of ways by current and previous NHS organisations. The latest NHS re-structure has provided the opportunity for a more widespread view of existing arrangements. The variation of commissioning and governance arrangements became apparent though the accreditation panels for Practitioners with a special interest (PwSI) following the formation Staffordshire and Shropshire Cluster of PCTs. They identified and discovered the sources and reasons for the existing variation in current vasectomy pathways commissioned by CCGs and the cluster identified wide variation in the quality of submissions for the re-accreditation of GPs with a special interest in vasectomy.

This review of community vasectomy services

  • identified variation in the governance of individuals and of  commissioned service specifications that in some cases fell below best practice
  • ensured that governance arrangements are clear
  • assisted in the reduction in cost of vasectomy for South East Staffordshire and Seisdon CCG from £604 to £250 per case
  • identified GPs who were not under the GPwSI umbrella and ensured they had appropriate governance.
  • identified a number of GPs who did not need accreditation as they were employed by another NHS body
  • the future PwSI policy at area team level will be manageable and effective.

Stoke-on-Trent & North Staffordshire: Orthotics

Historically, the orthotics service in North Staffordshire and Stoke on Trent had been provided by two separate organisations which had led to a fragmented and inefficient service for patients and their carers. This, together with long wait times, has been a source of much frustration to patients, so much so that a campaign group, North Staffs Orthotics Campaign (NSOC) was set up with the aim of improving the service.

North Staffordshire CCG commissioned an external review of the orthotics service in its entirety in June 2011, resulting in over one hundred recommendations to improve the service provision. The overarching recommendation from the review was that the service should be delivered by one provider to enable equity of access for all service users.

From September 2011, the CCG looked at redesigning the service within the existing budget, with a single provider alongside members from NSOC, hospital managers and orthotics staff who were working within the system at the time in order to:

  • Provide a community-based, cost effective, accessible specialist orthotics service which includes the diagnosis, treatment and fitting, maintaining and repairing of or thoses for children and adults in line with the agreed access criteria, responding to changing needs of the orthotics user.
  • Provide access to high quality, safe care that gives timely advice, appropriate support, assessment, diagnosis and treatment for patients according to their individual need
  • To ensure the service is delivered in line with current policy, learning and best evidence and provide appropriate governance and management for the service.

The key aim of the collaborative working was to ensure that a number of significant outcomes were achieved through the redesign of the service including:

  • Enhanced patient and carer experience, satisfaction and quality of life
  • Delivery of a service that enables patients and their carers to obtain information, knowledge and skills to facilitate self-care, wellbeing and to promote independence
  • Responsive and timely access to a service that supports patients to proactively access the service in a location of their choice
  • To provide a service that is equitable for all patients

Accessibility and locations are very important to service users and the CCG elected to commission a hub and spoke model to ensure that a number of community locations were utilised along with an in reach element to support the local acute trust. The hub of the model consists of a new building designed specifically for the provision of orthotics and both NSOC and the Orthotists were offered the opportunity to feed into the buildings plans to ensure that key elements such as hoists and a private gait walkway were incorporated. The spoke clinics have been mapped on existing patient postcodes to ensure that clinics are based in the most appropriate places.

The specification for the service focuses heavily on quality and patient experience, particularly around the areas of information for patients, waiting and fitting times and the delivery of orthoses. Strict Key Performance Indicators (KPIs) and a detailed Minimum Dataset have been developed to ensure that the provider is held to account for the delivery of the service as specified.

The service has been fully up and running since the beginning of October 2012 within the new building and the impact that the redesign has had on the service is already evident. Both the specification and the opportunity to work alongside the CCG to make the crucial improvements required has been praised by NSOC and the local LINK group who feel that the changes made will have a significant positive impact on patients experiences within the service. The changes have also been written about within the Daily Mail as a positive article regarding the CCG and  patient and public engagement.

North Derbyshire: Patient Experience

Prompted by concerns about the inappropriate use of the Emergency Department (ED) at Chesterfield Royal Hospital NHS Foundation Trust patient experience staff designed and undertook semi-structured interviews with patients in the ED waiting area.

The major issues identified were:

  • Despite knowledge of alternative services people opted to come to the ED for reassurance; access to specialist equipment such as x-ray; as a gateway to other specialists
  • There is not an understanding of the terms Emergency/Urgent/Non-Urgent
  • This may explain why they do not use 111, but also they do not understand what it provides
  • There were higher levels of confidence in ED than in other parts of the NHS
  • Long waiting times are not a deterrent to the convenience of an open access system but providing information on length of waits would make some people leave
  • People were cynical about the possible introduction of appointment systems
  • Lack of GP access was a significant reason for attendance
  • For some going to ED was ingrained behaviour

The information gleaned is being used by commissioners to inform the design of a new Urgent Care Village.

Pam Purdue, Head of Patient Experience

North East Essex: GP Urgent Visiting


North East Essex: Surge Management Meetings


West Essex: The Princess Alexandra Hospital trust-Urgent Ambulatory Care


South London: Accident & Emergency Service Policy

A multi disciplinary team comprising of NHS England London Region’s medical, nursing and patch assurance colleagues held in March a Risk Summit with the Croydon health economy. This summit was convened after careful discussion between NHS England, the National Trust Development Agency and the Care Quality Commission following joint concerns particularly on Accident and Emergency service quality. NHS England and partner agencies – along with independent experts – met with the Clinical Commissioning Group, the local acute and community provider, the independent Urgent Care Centre provider and 111 service provider. Engagement was positive and solution focussed and a number of further meetings were held and an overarching strategic urgent care recovery plan was developed as a result of the summit. Although it is early days, the local urgent care system has become more resilient, with over 95% of patients accessing Accident and Emergency services in Croydon waiting less than four hours consistently since the week commencing 5th May. Through the Recovery & Improvement Planning process the focus in now turning to long term sustainability and resilience of the urgent and emergency care system for the forthcoming winter. Again, this will be done collegiately with the local health economy but also in partnership between NHS England (South London patch team) and equivalent colleagues in Monitor and the National Trust Development Agency.

HomeFirst: Rapid Response Service

Mr PT an 87years old man lives alone and normally independent. Referred to HomeFirst as a Rapid Response by his GP after complaining of being unwell (‘off his feet’) for two weeks prior, poor appetite and vomiting. The GP diagnosed a chest infection and commenced antibiotics.

Mr PT was contacted by the HomeFirst clinician of the day by telephone within 15 minutes of receiving the referral to arrange a visit.

The initial joint assessment was carried out by the HomeFirst Case Matron and social worker within an hour. The following problems were identified:

  • Memory problems,
  • Poor compliance with medication
  • Poor mobility, unsteady on his feet.
  • Poor diet and appetite.
  • Unsafe environment due to lack of suitable equipment.

Post assessment the following interventions were put in place by HomeFirst

  • Bloods, medication review and regular observations and monitoring by the case management nurses liaising closely with his GP and the HomeFirst consultant.
  • Home care support workers to support ADL, diet, and medication prompts -3 daily visits.
  • Physiotherapy
  • OT -functional assessment and therapy
  • Equipment to enable him to continue to live in his home.

Mr PT was discharged from HomeFirst after 8 days. An urgent care admission had been prevented:

  • Infection cleared,
  • Mobility and nutrition status significantly improved,
  • Safer environment (appropriate equipment provided)
  • Maintenance care package put in place.

East Anglia: Major Trauma

Major trauma generally includes such life-threatening physical injuries as head injury, multiple injuries, bleeding from ruptured organs, spinal injury, amputation of limbs and severe knife or gunshot wounds.

East of England has over 3,000 patients annually involved in serious injuries. Three of every four of these patients normally survive to hospital, one will meet the criteria for life threatening major trauma, the most complex form of trauma, and two will have a potentially life changing severe injury.

What is the east of England trauma system?

The inclusive trauma system supports and facilitates joint working across all organisations treating or providing support for traumatically injured patients.

The aim of this network of care is to implement national and international best practice and evidence, to reduce death and disability, and to support patients and their families at each stage of treatment and recovery.

TEMPO (Trauma East Manual of Procedures and Operations) describes what should happen at each stage of care to ensure that the care of the patient is optimised.  Every organisation within the trauma system has signed up to its principles and standards.


  • Trauma system delivering evidence based care across a network of providers. Commissioners and lead clinicians worked together to develop a clear service specification with clinical standards and operating practices, to produce a clinically led commissioned service  model which includes the following features:
  • Rapid access to care through diagnosis and time critical transfer to appropriate facilities.
  • Network Co-ordination service provides 24/7 consultant advice (all specialties), and arranges immediate transfer.
  • Retrieval service supports fast retrieval of patients and transfer to Major Trauma centre
  • Trauma Co-ordinator starts to monitor and plan for rehabilitation requirements immediately
  • Major Trauma Centre also provides rapid rehabilitation and links to other services (e.g. Department of Work and Pensions) to deliver holistic patient care.

Region-wide data collection, audit and case review supported by enhanced training and development.

Outcomes and outputs

  • An ambition of at least 10% reduction in mortality
  • Improved inpatient outcomes following rehabilitation
  • Evidence of improved partnership working within health services and with partner agencies.
  • Cost effective system (based on Scharr report)
  • Improvements in data collection and audit to measure improvement, support change and future innovation
  • Clear understanding of best practice across providers and commissioners

Ipswich & East Suffolk: Unplanned Care emergency assessment unit

Why did we do it?

In 2011-12, the GPCCs were devolved responsibility for managing the budget for acute activity including unplanned hospital admissions.

A review of unplanned hospital admissions in 2010/11 identified the potential for 1 in 5 admissions to be managed at home or on an outpatient basis, contingent on:

  • access and availability to alternatives;
  • senior clinical advice;
  • integrated approach; and
  • professional and public behaviour

Strategic significance to CCG

This aligns with two CCGs clinical priorities to improve care for frail elderly individuals and high quality local services, where possible.

What did we do?

In 2011-12, the GPCCs were devolved responsibility for managing the budget for acute activity including unplanned hospital admissions.

A review of unplanned hospital admissions in 2010/11 identified the potential for 1 in 5 admissions to be managed at home or on an outpatient basis, contingent on:

  • access and availability to alternatives;
  • senior clinical advice;
  • integrated approach; and
  • professional and public behaviour

Strategic significance to CCG

This aligns with two CCGs’ clinical priorities to improve care for frail elderly individuals and high quality local services, where possible.

How was this achieved?

Clinical engagement

  • This initiative followed a pilot with one member practice with high emergency admission rates.  Member practices reviewed benchmarked practice level data of emergency admissions in locality groups. Benefits for GPs, patients and the reduction in admissions were so apparent that GPs and the hospital wanted to develop this as part of the CQUIN programme in 2011-12 for all practices.

Integration between acute and community care

  • The Ipswich hospital CQUIN involves the EAU consultant providing clinical telephone advice to the GP wanting to refer patients with urgent needs.
  • The community provider CQUIN involves increasing the Admissions Preventions Service to work with EAU as an urgent response team to support patients in the community.

If the GP and EAU consultant agree, the patient can safely be managed by:

  • Same/next day outpatient appointments
  • Community admissions preventions service
  • Advice about managing at home

What were the benefits?

  • Reducing unplanned admissions
  • Since May 2011, 20-25% of calls taken by the consultant result in an alternative outcome to admission.
  • Unplanned admissions overall have dropped 10% since the initiative began and this is sustained.
  • Improving integrated working
  • The service has improved joint working between GPs, A&E, EAU, Community Care and the ambulance service.  The opportunity for a GP to discuss a case with the consultant prior to making the referral increases GP confidence about the decision reached.  Confidence in the admission prevention service is improved with GPs making more direct referrals to this service.
  • Improved patient experience

There are benefits to patients of reduced admissions and increased support at home. The testimonial below shows this:

  • The team leader for the admission prevention said, “We provided a quick response for this patient in his own home.  We hydrated the patient at home before he went to hospital for his test the next day.  Ipswich Hospital had put all the necessary arrangements in place and he was seen within an hour of his arrival by the endoscopy department.  He was discharged home with our support after this test.  This is a good example of how we can support patients and improve their overall experience.”


The service saves £35,000 per month and has been a recurrent CQUIN scheme. It was substantively commissioned for 2013-14.

Coventry & Rugby: NHS Referral support service

The RSS service is led by GPs and supports our local GP colleagues to provide a better service for patients by ensuring referrals are sent to the right destination, first time. The service also provides a really useful point of contact for advice and support on referrals”

Dr S Allen, GP, Accountable Officer NHS Coventry and Rugby CCG

Reason for Change:

Coventry was a high spend area for outpatient activity and local GPs felt that this was an area that they were able to greatly influence and improve.

How was the change made?

A business case and cost/activity modelling undertaken using assumptions based on ‘average’ performance of other referral centres showed that we could benefit from triaging referrals. GP triagers were recruited to review referrals and redirect where appropriate.


Improved quality of referral letters (as noted by main provider consultants). 15% drop in GP referrals to secondary care from 2010/11 to 2011/12. More patients appropriately directed to 2week wait and rapid access clinics. Significant reduction in need for main provider to use Waiting List Initiative clinics.


  • Year one gross saving: £1,316,105.
  • Investment: £443,598.
  • Net saving: £872,507

This has been modelled as 75% of a full year effect. We anticipate net savings of £1,311,209 for the next full year.

South Worcestershire: GP Working with the ambulance Service

This was implemented on 5th October 2012 to reduce A&E attendances and avoid unnecessary admissions.  It was developed by a group of GPs who identified a range of situations (999 calls for generally ill older people, call from care homes, falls, breathing difficulties) where conveyance to A&E and admission could be avoided if an experienced GP could see the patient at the location of the emergency – typically their normal place of residence.

A single GP is available from noon to 8pm, 7 days a week.  More than local 50 GPs are on the rota – bringing an additional benefit of generally improving communications between practices and the ambulance service.  This has resulted in more direct contacts outside the scheme between the ambulance service and GPs to treat patients more effectively.

The GP is only deployed where the ambulance service would have no other choice than to convey the patient to hospital.  Since October, the GP has dealt with 1,221 calls, with only 20% being conveyed.  This has reduced pressure on A&E, avoided almost 500 admissions and saved £1.1m.  More importantly the scheme has improved quality with feedback showing patient being delighted that services have worked together to treat them safely in their own homes.

For more information contact:

Dr Nikki Burger
GP Lead for Urgent Care
South Worcestershire CCG
David Mehaffey
Director of Strategy
South Worcestershire CCG

South Warwickshire: Member Practice Engagement in Commissioning

We have created a number of initiatives to support our 36 member practices and enable their active involvement in our commissioning processes. In particular, these focus on the key challenges relating to urgent care and the role of our practices in supporting a range of projects aimed at reducing entry to the acute setting. Workstreams include promoting management of long term conditions, better self-management, admission avoidance and supporting discharge.


  • We adapted the bi-monthly CCG newsletter issued to all practices, to include funnel charts which compare activity rates and highlight variances.
  • ‘Buddy locality groups’, each led by an Executive member, serve to update groups of practices on CCG challenges and decisions, gauge the practices’ thoughts and concerns and generally engage them in the CCG’s development. It also enables the group to consider activity data by practice, share good practice and discuss / identify commissioning issues.
  • We hold monthly Members Council meetings to discuss and agree commissioning issues.

By working closely with practices using these tools, we have been able to tackle variances between practices, identify and share good practice in patient management which has resulted in a greater focus on commissioning alternatives to urgent care.

NHS England: My Shared Pathway

Secure Mental Health specialised services are commissioned by NHS England for patients who have either an offending history and /or require detention for the protection of others.

“My Shared Pathway” is a recovery/ outcome process with supporting tools which outlines collaborative approaches that clinicians and patients use to gain a shared understanding of the patient’s needs, including outcomes they need to meet in order to move along and through the secure pathway and how these outcomes will be met.

Pathway resources:-

  • My outcomes, plans and progress
  • A shared understanding
  • My relationships
  • Me and my recovery
  • My safety and risks
  • My health

The recovery approach supports patients to be in control of meeting their own outcomes along their pathway. The resources support a collaborative dialogue in difficult areas such as risk.

Secure services have moved closer to a recovery and outcomes-based approach to care delivery, with an agreed number of outcome areas providing a framework for care planning, care programme approach, and the possibility of performance reporting outcomes instead of inputs.

The heart of the programme is the patient who is engaged in every aspect of their care and planning for the future, taking control of their own recovery journey.

HSJ article: Increasing patient involvement in care pathways