SIUC Integrated Governance Framework

Introduction

This document sets out the governance framework for integrated working between BrisDoc Healthcare Services and Practice Plus Group (PPG) as Severnside Integrated Urgent Care (SIUC). The purpose is to provide NHS 111, the Clinical Assessment Services (CAS) and Out of Hours primary care face to face consultations, for Bristol, North Somerset, and South Gloucestershire (BNSSG) from 2nd April 2019. This includes any subsequent changes to the provision as agreed via contract variations for the service from this date forward.

This framework describes the principles adopted by Severnside partners to deliver, monitor, and evolve Integrated Urgent Care (IUC), delivering high quality patient care, and best use of all resources.

The delivery of IUC by SIUC is a collaborative partnership, built on values of high quality and safe care for patients, and the workforce, within budget. This collaborative partnership is set out using the IUC bid process, and NHS Standard Sub-Contract frameworks.

This framework articulates:

• The respective roles and responsibilities of individuals and organisations within the framework
• Parity of esteem between the partner organisations in relation to prioritisation within each other’s business, in relation to service design, improvement and change needs
• How service change will be managed
• How the evolvement of patient care IT delivery systems will be realised
• The policies and procedures adopted to secure good governance of the SIUC service

Severnside Model of Care

SIUC’s 24/7 model of care is based on optimising “consult and complete”, combining the following core elements:

• NHS111 (Interactive Voice Response (IVR), Pathways, ED/999 validation)
• Clinical Assessment Service (CAS)
• “Out of Hours” (OOH) face-to-face (F2F) (treatment centres (TC) and home visiting)
• Severnside Professional Line (in hours’ professional advice regarding acute medical admissions as well as Out of Hours interface with colleagues)
• System Clinical Assessment Service (SCAS) (ETC and 999 disposition management)

 

At the core of the service is a commitment to ensure care is equitable and that “patient care by people who care” is demonstrated. A key principle of these services will be to optimise the capability of the first clinical contact to deliver the highest rate of “most appropriate care” by “Right Clinician, First Time”, recognising the importance of “consult and complete”. This will be facilitated by the experience and expertise of clinicians, and the dynamic oversight of the whole team.

The service model will focus on the following three critical features for success:

• Quality Care – Patients are at the heart of everything we do

 

• Resource Care – optimising the use of all resources across the local health economy
• Workforce Care – every person counts

PPG Workforce

The team will include Service Advisors (SA), Health Advisors (HA), Clinical Advisors (CA), and Clinical Navigators (CN):

 

•               Role	•               Level	•               Tasks
•               SA	•               2	•               Manage non-symptomatic/repeat calls •               Identify symptomatic calls and appropriately transfer call to an HA •               Request an update on a previous call •               Refer into the CAS via the Directory of Service (DoS) e.g., for medication queries. •               Focus on customer service, local signposting, and courtesy calls. •               Process NHS 111 online cases on receipt.
•               HA	•               3/4	•               Focus on patients requiring full assessment utilising NHS Pathways •               Transfer calls appropriately to a CA •               Directly book appointments as defined by NHS Pathways (where possible) •               Close selected calls with self-help advice Refer onwards using the DoS
•               CA	•               5/6	•               Nurses and Allied Health Professionals (AHPs) working within NHS Pathways (and/or other CDSS Tools) •               Undertake telephone triage •               Optimise “consult and complete” •               Close calls with self-help advice •               Work seamlessly as part of the wider CAS team •               Validate ambulance/ED dispositions
•               CN	7	•               Dynamic management of the 111 queue •               Clinical risk assessment of cases awaiting call back in the 111 clinical queue •               Monitoring the live provision of ambulance and emergency treatment centre validation •               Escalation strategies based on an agreed plan, acting as initial point of contact for all contact centres for any service impacting issues posing a clinical risk •               Movement of clinical resource across services •               Responsibility for KPI monitoring such as Warm Transfer (WT), Call Back in 10 minutes for P1 cases (CB10), ambulance/ETC validation and Combined Clinical Contact (CCC), reacting as appropriate to network demand

NHS 111

Within SIUC, PPG will deliver the NHS 111 service, 24/7/365 to meet required national and local standards. PPG will be part of the national NHS 111 network, the expectations of which will be included within the Severnside contractual arrangements.

Patients will contact NHS 111 via telephone or an on-line functionality using agreed protocols. The on-line service will give patients the option to talk to an Advisor. An IVR will welcome patients to NHS 111 and offer options for selection.

A Service or Health Advisor will manage the call determining urgency, following a standard system. The patient will be asked to provide demographics, special requirements e.g., translation, and consent for the health professionals involved in their care to access their patient record. Advisors will identify if the call has a Special Patient Note (SPN) or alert, allowing them to determine the immediacy of next steps.

NHS 111 Online

Access to NHS 111 via the NHS 111 website online link or the NHS App is available in BNSSG. Online referrals will be received by a Service Advisor and made live within Adastra. The case is transferred via ITK to the CAS if required.

Clinical Navigation – The Clinical Delivery Team

The Clinical Delivery Team (Real Time Team) consists of Clinical Navigators (CN) who are paramedics and nurses with experience in critical thinking, deductive reasoning, prioritisation, streaming and telephone triage, enabling the service to remain safe.

The Bridge will continually review, risk assess and amend cases as appropriate, or adjust a queue if, for example, a particular clinician is delayed with other cases. The dynamic management of call handling times, case prioritisation, navigation, capacity, and escalation will be supported by The Bridge. It will also manage telephone and IT platforms to optimise patient service, thus maintaining clinical safety and providing service resilience.

Direct Booking

Directly booked appointments may be made to BNSSG GP practices on a phased basis, as per national protocols.

CAS

The ‘free-form’ part of the CAS will be managed by BrisDoc and will operate 24/7/365 utilising a multi-professional team of GPs and Allied Health Professionals including Advanced Clinical Practitioners, Clinical Practitioners, Mental Health Practitioners and Pharmacists. The primary function of the CAS will be to triage, assess and consult patients and other HCPs and provide a suitable outcome or referral for their health and care needs.

Severnside Professional Line (SPL)

Out-of-Hours period (OOHs)

The SPL, within the CAS, is designed to provide Health Care Professionals in the community with additional clinical support in real time. A key aspect of the success of the SPL is admission avoidance and management of clinical risk. Specific groups of professionals for whom a target timeframe for call-back is agreed are detailed below:

• Paramedics and District on scene will receive a call-back within a target of 30 minutes

In Hours period

The in hours SPL was commissioned, as a variation to the IUC contract, with effect from 1st April 2020. The service provides support to BNSSG GPs and other community HCPs for the management of patients for whom acute medical admission may be needed to the local acute trusts. The SPL clinicians are responsible for discussing clinical management of the patient with the referring GP, with the intention to explore if there are safe alternatives to an admission. Where admission is agreed, the SPL will arrange the handover of the patient to the relevant acute trust.

The arrangements for joint working between the SPL Team and each of the Trusts are set out in a separate governance framework which is aligned to this document.

Patient Line

SIUC will use BrisDoc’s patient line, which provides a direct link to a Call Handler located in the CAS. It is used at the discretion of individual clinicians in cases where there is an active management plan, or safety-netting option, to allow swift re-connection to a clinician. This is highly regarded by patients and their families, and has proved very valuable in supporting selected patients and/ or their carers to speak with a clinician if symptoms deteriorate, minimising unnecessary additional contacts. It should be used during the current ‘open’ OOH period, most usually over a weekend.

Face to Face Consultations

During the OOH period, F2F contact will be delivered through Treatment Centres (TCs) or home visiting (HV). A TC or HV appointment will be booked following a CAS consultation if appropriate. This will ensure that any clinician conducting a F2F contact has full up-to-date information and can provide high quality safe patient care in the context of any risks to the patient or clinicians.

Subject to changes made during the COVID-19 outbreak, direct booking for 111 to F2F appointments has been ceased to ensure safety of clinicians, all patients now receive a remote assessment prior to a F2F appointment, approved by the clinical co-ordinator when operational.

System Clinical Assessment Service (SCAS) and Validation

PPG Clinical Advisors are responsible for validating 999 and ED dispositions with the intention to ensure these Pathways assessments have derived the most appropriate disposition for the patient.

To complement PPGs validation process, and support maximising impact for the local healthcare system, the SCAS also receives ED and 999 dispositions during operating hours.  The SCAS initially ran a pilot from December 2021-March 2022.  This has been extended for a further twelve months. The SCAS is a co-located hub with a multi-speciality skill mix including ED clinicians, paediatrics, Mental Health and GPs, nurse and AHPs from general practice and Severnside. Amongst other things the SCAS receives ED and 999 cases for a full remote assessment to ensure only those where ED/999 are the only option use emergency services/ED.  Alternatives to ED/999 include UTC, MIU, general practice, Severnside, and importantly consult and complete when no onward referral is needed.

Contractual and Medical Leadership Model

The NHS standard contract for the BNSSG IUC service is held between the BNSSG Clinical Commissioning Group (CCG) and BrisDoc Healthcare Services as the prime contractor. The delivery of the NHS 111 service by PPG will be governed by a sub-contract of the NHS standard contract between BrisDoc and PPG. Between the sub-contract, the Heads of Terms, and this framework the collaborative behaviours and standards for delivering IUC by Severnside will be described.

The PPG Contract Group, reporting to the Urgent Care Services Leadership Oversight Board (UCSLOB) will oversee all contract arrangements and any resolution requirements.

BrisDoc’s Medical Director has the over-arching responsibility for leading SIUC patient care and service delivery. Therefore, assurance must be given that patient and staff safety is maintained in all elements of the IUC service, and that the safety culture within both organisations is exemplary.

SIUC Governance Management Framework

The Severnside governance framework will be underpinned by the BrisDoc meeting and reporting structure (figure 2) that oversees the delivery of safe, effective integrated urgent care. All meetings will have comprehensive terms of reference with delivery objectives, so all members are clear as to their purpose and function, and their individual role/responsibility as a member.

BrisDoc and PPG have established Governance and Patient Experience Teams. These teams will work collaboratively to ensure there is a seamless approach to governance. Within SIUC they will be collectively known as the Severnside Governance Team. The Team comprises:

BrisDoc	PPG
Director of Nursing, AHPs and Governance	Contact Centre Manager
Governance Manager	Clinical Lead & Deputy Contact Centre Manager
Quality Manager	Regional Governance Lead
Patient Safety Co-ordinator	National Administration Manager
Patient Safety Administrator	Patient Experience Team

 

The Severnside Governance Team will support the SIUC Quality Group Meetings at which all governance matters will be reported, reviewed, and monitored. The SIUC Quality meeting will report to BrisDoc’s Quality Board at which assurance and scrutiny will be applied.  Representation from both SIUC partners will be present. Similarly, SIUC service development and improvement will be managed in BrisDoc’s Service Delivery and Improvement Board. The Terms of Reference (TOR) for these meetings set out the requirement for Patient and Stakeholder engagement thereby ensuring experience, involvement and needs are triangulated with performance.

Robust contract management through BrisDoc’s PPG Contract Group and IUC Contract meeting with commissions will ensure all SIUC service elements deliver against volume, value, and quality. PPG Contract Group meetings will monitor and evaluate the NHS 111 service and review the effectiveness and performance of the interface of NHS 111 with the CAS and face to face services within SIUC. These meetings will be held in advance of, and in preparation for contract meetings with the CCG.

Severnside representation will be negotiated as required for any additional governance meetings as required and requested by BNSSG CCG.

Figure 2 BrisDoc Meeting and Reporting Structure

Governance Management Systems

Both BrisDoc and PPG have established governance management systems which are not appropriate to change for the purposes of SIUC and neither of which allow for an integrated management system for use by SIUC. BrisDoc uses bespoke databases to record learning events (LERIS), complaints/compliments (BOB) and information requests. PPG uses Datix.

Both systems fulfil the needs of the user and will therefore continue to be used until/unless other opportunities for a new integrated system for SIUC arise. This means both organisations will continue to record governance matters (learning events, Serious Incidents, complaints, Health Care Professional Feedback, and compliments) in their respective management systems.

Governance Management Systems will as a minimum capture the following details as relevant to the type of record being created and the circumstance of the event/feedback:

• Event unique identifier
• Date of the event
• Patient identifier (minimum detail and numerical if possible)
• Staff identifier
• Type of learning event e.g., near miss, severe harm
• Category of learning event e.g., abuse/violence/aggression, communication
• Location of the event
• Service involved
• Staff group involved
• Investigatory Manager
• Risk score
• Description of the event
• Description of the investigation and findings
• Description of learning and actions taken
• Status
• Date closed

 

These systems will generate reports that allow for a full analysis of all learning events, their outcomes and management.

In addition, there will be a SIUC Quality Database (SQD) that will record and report on the overall number of different types of governance issues being reported e.g., learning events, complaints, accidents. Key managers will have data entry rights to this database.

BrisDoc’s Governance Manager will have access to PPG Datix system in the interest of robust, transparent governance.

Primary communication with SIUC for all governance matters will be via the severnside.governance@nhs.net email account managed by the Severnside Governance Team.

Corporate Governance

Performance Management and Reporting

The national IUC specification and NHS Standard Contract set out a suite of key performance and quality indicators providers are required to meet through collaborative and effective service delivery. In addition to these, there will be local quality requirements agreed with the Commissioner. The responsibility for each indicator will be assigned to BrisDoc, PPG or both to deliver, and report on in the format agreed.

BrisDoc is accountable to the CCG for the delivery of the IUC service in accordance with the contract requirements for cost, volume, and quality. As the sub-contractor, PPG will be accountable to BrisDoc for delivering the NHS 111 service, including the Real Time Team, in accordance with the contract requirements, for cost, volume and quality; service delivery improvement plans; and data quality improvement plans.

In accordance with the information sharing agreement and the SIUC sub-contract, PPG will provide to BrisDoc, at the required time, the relevant accurate and complete performance data for their SIUC BNSSG activity. PPG will prepare performance data and narrative in the SIUC Quality and Performance report, to be submitted in advance of the meeting, in accordance with agreed timescales, which will evidence performance and exception analysis for all relevant requirements.

BrisDoc will be responsible for leading the preparation and delivery of the contract performance and quality report to the CCG in accordance with the agreed timescales. This will include accurate and complete performance data and exception analysis for all contractual requirements. Data, evidence of learning and exception reporting will be provided by both PPG and BrisDoc in accordance with agreed timescales. BrisDoc will represent SIUC at CCG contract meetings. If required, PPG representatives will attend on request.

If required, the annual Severnside Annual Quality Account will be developed jointly by BrisDoc and PPG.

The IUC service performance and quality report will be presented at the IUC Contract meeting with commissioners.

Commissioning for Quality and Innovation (CQUINS)

CQUINS for the IUC service will be agreed collaboratively within Severnside and with the CCG as part of contract negotiation, thereby ensuring all BNSSG patients benefit from initiatives to improve the quality of the local IUC service. CQUINS will apply to both the NHS Standard Contract and the Sub-Contract.

Risk Management

The effective management of risk is integral to the delivery of safe services to patients and a safe work environment for staff. There should be no cause for deliberate harm to arise from services delivered by SIUC or the way it operates. BrisDoc and PPG will identify and assess risk, ensuring it is managed, reduced, eliminated, transferred, reviewed and communicated on a regular basis.

SIUC will hold an integrated risk register for all elements of its model of care, which will be routinely reviewed at the UCSLOB and reported to the CCG via the Performance and Quality Report (where score is 15+). Risks will include clinical, operational, financial, governance, and ergonomic hazards. Management of the risk register will be the responsibility of BrisDoc’s Director of Corporate Services. All SIUC managers have the responsibility to identify risk, complete a risk assessment and action plan; and submit the risk for inclusion in the risk register. Risk owners will be responsible for reviewing their risks whenever service circumstances change and on a routine basis (quarterly), as requested by the Director of Corporate Services.

System Interface

Capacity and demand planning will form an integral part of SIUC operational management, particularly in preparation for managing the bank holiday periods. Peaks in demand will be anticipated and staffing mapped accordingly. If there is an unexpected peak, resilience measures, such as calling upon additional remote triage clinicians, will be enacted. Business continuity plans are well-developed and robust, with clear escalation processes and communication channels between branches of the service, whilst also reflecting the position of NHS 111 services within a national resilience context.

Severnside will participate in system conference calls and provide capacity management data as required. In escalation, Severnside will be a proactive partner in supporting the delivery of safe and effective patient care and, where appropriate, support other BNSSG health and social care organisations deliver safe patient care.

In situations where workload peaks to potentially unsafe levels and/or Severnside must implement any business continuity measures, other organisations will be notified so they can contribute to the ongoing delivery safe patient care until business as usual is resumed.

Communication will be with the Shift Manager (BrisDoc)/ Operational Team Manager (PPG) and equivalent managers in the other organisations.

Policies and Procedures

It is recognised that both BrisDoc and PPG have organisational policies to which staff are required to adhere in accordance with the terms and conditions of their employment. This has not changed under SIUC. Where applicable to an integrated urgent care pathway or process, SIUC policies will be developed collaboratively by the relevant senior managers, with patient involvement if appropriate.

Both organisations will have comprehensive business continuity plans, setting out tactical control measures, that sustain and then recover all core and supporting business processes, thereby maintaining patient care 24/7.

SIUC policies and Standard Operating Procedures (for interoperable processes within SIUC) will be approved by the SIUC Service Delivery and Improvement Board, with review as required by the UCSLOB. All SOPs and policies will be routinely reviewed as per the period prescribed at approval. Mid-term changes will be made in accordance with service changes/updates.

SIUC policies will be available to staff via BrisDoc and PPG intranets. Self-employed clinicians will be able to access them via the BrisDoc clinical toolkit.

SIUC processes will be monitored for compliance against policies and procedures through an audit programme agreed by the SIUC Quality Group.

Care Quality Commission (CQC) Registration

SIUC is not a legal entity; therefore; both BrisDoc and PPG will maintain their individual registration(s) with CQC to provide the regulated activities respectively, and at the relevant locations. Each organisation is responsible for paying its own fees to CQC. Each organisation’s Statement of Purpose will describe the scope of their integrated urgent care services provided by SIUC.

As prime contractor, BrisDoc wishes to be informed of all PPG-end SIUC CQC inspections. Inspection reports and any associated action plans will be presented to the SIUC Quality Group meeting and UCSLOB. BrisDoc and PPG will ensure their inspection reports are available through the relevant website/s and are shared with staff.

Health & Safety

SIUC recognises its duty to ensure the health, safety and welfare of its employees, contractors, and anyone else who may be affected by its activities, so far as is reasonably practicable. BrisDoc and PPG will comply with the provisions of the Health and Safety at Work Act 1974, and all relevant subsidiary regulations.

SIUC will complete assessments to identify internal and external risks and will learn from any accidents, learning events and near misses that may occur. Necessary changes will be implemented to reduce risk. Employees will be provided with access to health and safety advice and relevant information and training. Risks specific to certain employees, such as new and expectant mothers or the young, will be assessed separately.

SIUC management teams will consult with staff with regards to health and safety issues and work with them to eliminate them where possible and promote a positive health and safety culture. All staff are responsible for their own health and safety and that of others who may be affected by their actions.

Any member of staff who experiences a workplace accident will report it in accordance with the relevant accident reporting policy.

BrisDoc and PPG will have their own organisational Health and Safety Groups as required by the Health and Safety at Work Act. Health and safety learning events and all accidents will be reported and recorded in that organisation’s learning event Management System.

PPG’s Regional Governance and Quality Lead will be responsible for ensuring a report on health and safety learning event and accidents is provided for any quality and performance report and, if necessary, discussed at the PPG Contract meetings.

Arrangements for Managing Change

Throughout the duration of the contract there will be opportunities and drivers for service change, be they a national directive as the specification for IUC evolves or identified within Severnside and the local urgent care system that support service improvement.

It is recognised that change can present challenges at organisational, service, and individual levels. Change requires good leadership to effect a successful outcome.

Change and service redesign will be managed through the BrisDoc Service Delivery and Improvement Board, where appropriate additional stakeholders may be involved in service redesign.

Wherever practicable, changes to patient care pathways or other patient journeys will be piloted to inform the final model which will be formalised through a contract variation.

Pilots will be undertaken in accordance with robust project management principles and methodology. Project initiation documents and plans will be jointly developed and agreed within Severnside and will set out the clear expectations of both BrisDoc and PPG to deliver the pilot on time, to cost, and to the agreed standards. Pilots will be fully evaluated to capture the benefits for patients/staff, and to inform the impact on SIUC systems, processes, and individual organisations.

Implementation of redesigned or new service delivery following a pilot will also be managed in accordance with project management methodology through to go live and project closure.

Throughout these processes each partner organisation will commit to, and honour, the provision of resources to deliver project milestones and go live on time. To this end each partner organisation will afford Severnside parity of esteem with respect to other organisational projects/initiatives. Accountability for delivering this will be set out in the IUC sub-contract.

Clinical Governance

Clinical governance is a framework through which patient care organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. This framework embodies four key attributes:

• recognisably high standards of care
• transparent responsibility and accountability for those standards
• a constant dynamic of improvement
• application of the seven pillars of clinical governance (figure 3)

 

Figure 3 Pillars of Clinical Governance

There will be a collaborative, joint approach to investigating any learning events, Serious Incidents, complaints, Health Professional Feedback, and compliments between and within partner organisations.

The oversight of learning events, Serious Incidents, complaints, Health Professional Feedback, and compliments management in SIUC will be held by BrisDoc’s Director of Nursing, AHPs and Governance and PPG’s Regional Governance and Quality Lead on behalf of the partner organisations. They will be responsible for identifying performance issues for raising at the Quality Board.

SIUC learning events, Serious Incidents, complaints, Health Professional Feedback, and compliments will be included in organisational learning event management systems and reported on internally, as well as to the SQG, which will routinely review complaint numbers, themes, outcomes and investigation performance. An overview of all SIUC learning events, numbers and categories will be held in the SIUC Quality Database (SQD) and the Quality Board will receive a highlight report on these matters from the SQG.

Duty of Candour

SIUC will fully adhere to “Being Open” with patients and families when things go wrong, BrisDoc supports an open learning culture in which candour is the norm. As regards the formal ‘Duty of Candour’, duty of candour will be conducted by the senior clinician leading the investigation, with advice and support from SIUC’s Medical Director and others as appropriate. Duty of Candour will be undertaken within 10 days of the learning event being known.

Patients/families will be approached by a telephone call and offered the opportunity of a meeting. The date, time, medium and venue will be their choice and will be accommodated insofar as is possible. A meeting will be followed up with a written letter that recounts the discussion and actions agreed. As part of the duty of candour process families will be offered support to understand and review the investigation report.

Learning Event Management

As providers of patient care services, both BrisDoc and PPG uphold the principles for delivering safe and effective care and minimising the potential for harm to all. SIUC will evidence a culture where patient safety is paramount, and reporting is driven by integrity and improvement.

Within SIUC a learning event is any event from which learning could arise, including those which caused harm or had the potential to cause harm. This will include near misses where an unexpected/unintended occurrence did not cause harm but had the potential to do so. Harm may be caused to a patient, member of the public, member of staff, the organisation, or a combination thereof.

The target timeframe within which a leaning event will be explored and concluded is one calendar month. Each learning event will have an investigatory manager (clinician and/or managerial) who, working with colleagues as required, will be responsible for leading the exploration into the learning event, identifying issues for remedial action, preparing a learning event management plan, and capturing and sharing learning.

In most situations there is scope for learning from an event whether at individual, team, organisation, or pan-health community level. Shared learning will be a feature of learning event management in SIUC. This may be in the form of shared learning emails, in newsletters, in team meetings or at educational forums.

Service and clinical managers will be responsible for ensuring timely, robust, and complete exploration of any leaning event relating to their service, including:

• identification of root causes and remedial problems
• formulation and delivery of an action plan
• management of individual staff learning
• managing and monitoring change
• risk assessment
• sharing learning within the service
• signing off a learning event as complete
• working in accordance with the agreed learning event management timescales
• providing exception reporting where timescales are not met
• completing workflow reports in the learning event management system
• identifying relevant learning events for shared learning as part of quality review processes

Serious/Significant/Never Events

SIUC will manage any event which meets the definition of a ‘Serious Incident’ (SI) in accordance with the National SI Framework (due to be updated as the Patient Safety Incident Response Framework – PSIRF). This framework defines serious incidents as adverse events where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. In BrisDoc, these incidents are referred to as ‘Significant Events’.

With respect to SIUC, examples of SIs from the NHS SI framework which could occur include:

• Acts and/or omissions occurring as part of NHS-funded healthcare that result in:
  • Unexpected or avoidable death of one or more people
  • Unexpected or avoidable injury to one or more people that has resulted in serious harm
  • Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional to prevent:
    • the death of the service user
    • serious harm

• An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:

• • Failures in the security, integrity, accuracy, or availability of information often described as data loss and/or information governance related
  • Property damage
  • Security breach/concern
• “Never Events” are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. The list of official “never events” is managed by NHS Improvement and reporting is a contractual requirement through the NHS Standard Contract
  • The nature of services provided by SIUC means it is impossible to conceive that a “never event” will occur. However, if one should occur, it will be managed in accordance with the Severnside learning event management process
• Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation

 

Any event declared as an SI requires:

• Submission to Strategic Executive Information System (STEIS)
• Reporting to Commissioners
• Reporting to the CQC
• Reporting to Insurer including NHS Resolution
• Investigating in accordance with NHS Improvement patient safety Root Cause Analysis (RCA) framework and tools.
• The final report into the investigation of a SI to be submitted by the 60^th working day following the incident being identified as a SI, unless exceptional circumstances prevail, in which case an extension will be sought.

Multi-agency SI

Where a multi-agency SI investigation is convened in BNSSG, SIUC will participate in accordance with the wishes of the lead investigating organisation. Where SIUC is the lead investigating service for a multi-agency SI, it will operate with integrity and in a manner that supports partner organisations to participate in a timely and collaborative way.

A lead investigatory manager and clinician will be appointed in discussion with the SIUC Medical Director (and others as appropriate). This team will be supported by the Severnside Governance Team, with BrisDoc’s Director of Nursing, AHPs and Governance overseeing the process, providing support and guidance to the investigatory manager and reporting to the SIUC Medical Director.

The process to determine whether an SI is declared or not, and how the SI is managed is described in the Event Management Process diagram. The decision to declare an SI is made jointly, subject to a conference call with representatives from both organisations. The SI will then be led subject to agreement in that call.

SI Monitoring

The SQG will be responsible for overseeing and monitoring the completion of RCA action plans. The CCG will assure itself an action plan has been completed and authorise final sign off. SI reporting will be to the BrisDoc Quality Board and UCSLOB, with updates being provided to the SIUC Medical Director as required.

Complaints

As providers of patient care services both BrisDoc and PPG uphold the principles for delivering a high-quality service to patients that is efficient, clinically effective and meets their needs at all times. SIUC will evidence a culture that, when provided with adverse feedback, is:

• receptive and listening
• open to review, learning and sharing
• ready to offer an apology

 

Complaints will be received by the route which best suits the patient’s, or their representative’s approach to communication.

Where the complainant is not the patient and the response will include personal health information, patient consent will be sought prior to a response being shared with the complainant. In the case of a child (<18yrs) a parent/legal guardian may receive the response. Evidence of power of attorney/guardianship will be sought prior to a response being sent. Complainants will receive an explanation, and whenever appropriate, evidence of learning and improvement and an apology.

Wherever a complaint is received it will be acknowledged in writing, within three working days, giving the complainant an indication of when they can expect to receive a response, a point of contact, who will be investigating the concerns they have raised, and a copy of the Severnside complaints leaflet.

All complainants will receive a response from SIUC, irrespective of whether the complaint relates to purely NHS 111 or not. Where the complaint relates to NHS 111 only, PPG will manage the complaint process but correspondence will be via SevernSide headed documentation. SIUC aims to ensure patients receive a response to their complaint within 25 working days and are kept up to date with progress if this is not achievable. Monitoring and managing timescales with investigatory managers will be undertaken by the Severnside Governance Team.

Response timeframes will be monitored via complaint reports from relevant governance systems and reviewed by the SQG.

Service and clinical managers will be responsible for ensuring the robust and complete investigation of any complaint relating to their service including:

• reviewing the care pathway and evidence (e.g., case records, voice recordings) across all SIUC services
• obtaining a written reflective account from the staff involved, or writing an account of an interview with a member of staff
• identifying learning
• sharing learning within the service
• drafting a response to the complainant either on behalf of the SIUC Medical Director or Service Director or themselves
• managing and monitoring change/improvement in individuals/team
• working in accordance with the agreed complaint management timescales
• providing exception reporting where timescales are not met
• completing workflow reports in the complaint management system
• identifying relevant complaints for shared learning as part of quality review processes

 

The SIUC managers who may respond directly to a complaint include PPG’s local Medical and Clinical Leads, and Call Centre Deputy/Manager; and BrisDoc’s Deputy Medical Directors, Head of IUC and Head of IUC Nursing. “Low level” or more minor complaints can be responded to by the Governance Manager, Quality Manager or IUC Operational Manager.

All complaint responses will guide the complainant about where they may go should they be unhappy with the response. Ideally, when a complainant is unhappy with their response and wants to take it to a second stage, resolution will be within SIUC by someone independent to the initial investigation such as the SIUC Medical Director. Otherwise, the complainant may be directed to a commissioned advocacy service or the Public & Health Service Ombudsman.

Compliments

When a compliment or a thank you is directed personally to a member of staff the message will be forwarded to them with a “thank you” from SIUC via line management arrangements. When staff can be identified from information provided by the feedback giver, the feedback will also be shared with them.

Health Professional Feedback

Healthcare professionals often provide feedback to the providers of integrated urgent care to raise awareness that systems/processes may not have operated as planned, or outcomes for the patient been as expected.

Feedback from professionals or organisations to Severnside will be managed as health professional feedback (HPF) by the Severnside Governance Team. HPF should be received via the SIUC Governance Team via severnside.governance@nhs.net.

Receipt of feedback will be acknowledged to the sender and, following an investigation, the sender will receive a report that shares the findings of the investigation. The response to any HPF will be from SIUC and not from individual organisations.

• The investigation into HPF about an NHS 111 call will comprise a review of NHS Pathways including audit of the voice recording, discussions with the staff involved where appropriate, professional assessment of the findings and preparation of a response by the investigatory manager. These will be led by PPG
• The investigation into HPF about a CAS or face to face contact will comprise review of the case record and any voice recording, review of the shift report, discussion with clinicians/staff involved when appropriate, professional assessment of the findings and preparation of a response by the investigatory manager. These will be led by BrisDoc
• Any HPF which refers to both NHS 111 and CAS or Face to face contact will be led by BrisDoc with relevant contribution from PPG
• Health professional feedback, raised by a SIUC member of staff about an external organisation will be sent from SIUC by the SIUC Governance Team who will share the response with the reporter

Event Management Process

Safeguarding, Capacity, Prevent, CP-IS, Child Death Review

BNSSG Safeguarding Overview

Well established processes exist in BNSSG for reporting vulnerability for management by specialist teams. Each Local Authority has its own arrangements/teams for managing vulnerable adults and children, and a Partnership Board that provides joint health and social care oversight for their area. During working hours, referrals are made to the Local Authority responsible for the patient. During out of hours there is a single referral point for BNSSG into the Emergency Duty Team (EDT) for both adults and children.

SIUC service named professionals will ensure SIUC is represented at the BNSSG Safeguarding Professionals meeting.

SIUC will actively participate in serious case reviews and domestic homicide reviews for patients who have been in contact with NHS 111, CAS and/or Face to Face services. This will be co-ordinated through BrisDoc’s Director of Nursing, AHPs and Governance.

It is recognised that both BrisDoc and PPG have organisational policies to which staff are responsible, in accordance with the terms and conditions of their employment. Each organisation has safeguarding policies for adults and children. This has not changed under SIUC.

Named Professionals

SIUC’s Head of Severnside Nursing and Allied Health Professionals will be the named Safeguarding Lead for Adults and Children for SIUC. The SIUC Head of Severnside Nursing and Allied Health Professionals will report safeguarding issues to relevant SIUC Board Directors. Each service (NHS 111, CAS/Face to Face) will have a separate named professional lead. The leads will regularly review cases where safeguarding concerns were present, and liaise with the patient’s usual clinician, to capture outcomes and learning for sharing. The SevernSide Medical Director holds oversight of Safeguarding matters.

Monitoring

Safeguarding referrals will be reviewed at the SQG meeting and reported to the BrisDoc Quality Board.

Training and Learning

All SIUC staff will participate in safeguarding training in accordance with the expectations of the IUC NHS Standard Contract requirements. Training performance will be monitored in the SQG and BrisDoc Quality Board.

Mental Capacity Act

All clinical staff will receive Mental Capacity Act training that equips them with the knowledge to assess a vulnerable adult patient’s capability to make an informed and reasoned decision, and the skills to support a vulnerable adult who lacks capacity and their “decision-maker”.

Child Protection Information Sharing

The CP-IS project allows health and social care staff to share information safely to better protect society’s most vulnerable children. CP-IS ensures unscheduled health care settings are alerted if a child is on a child protection plan or is a looked after child if they attend a service. It provides their social care contact and a record of their previous unscheduled care attendances whilst also notifying social care of this new attendance.

Currently within BNSSG the acute trusts, Bristol and South Gloucestershire LAs and BrisDoc are not part of the project. Adastra upgrades have taken place to provide access to CP-IS.

All SIUC services will use CP-IS when it is available to ensure the ongoing protection of vulnerable children.

Child Death Review

When asked by the Child Death Enquiry Office (CDEO) Severnside will investigate whether the child (or representative) had contact with an NHS 111, CAS, or face to face service, and respond accordingly. Such requests will be managed as an information request and recorded in the relevant governance management system. Where there has been contact, completion of Form b will be undertaken by the Severnside Governance Team, working with a relevant clinical lead. Severnside will participate in and ensure appropriate representation at case review meetings. Learning from a case review will be disseminated in accordance with Severnside’s approach to shared learning. The Director of Nursing, Allied Health Professionals and Governance will be informed of all such enquiries and will inform the SIUC Medical Director as needed.

Prevent

It is recognised that both BrisDoc and PPG have organisational Prevent policies to which staff are responsible in accordance with the terms and conditions of their employment. This has not changed under SIUC.

Prevent concerns will be discussed with both services’ Prevent Leads (usually the safeguarding Lead) and a decision made as to whether an alert will be made in accordance with local BNSSG arrangements. Alerts will be logged in LERIS and Datix. Prevent alerts will be reported to and reviewed at the SQG meeting.

Audit

Audit will be routinely undertaken to assure high quality care is being provided. This will be in accordance with the expectations of NHS Pathways licence requirements in NHS 111, and BrisDoc’s audit framework which includes clinicians’ telephone and face to face consultations (typically using Clinical Guardian) and telephone calls made by/to non-clinicians.

SIUC will agree a programme of audit for the IUC service that will inform services’ performance. Audit reports will be presented to the BrisDoc Quality Board.

End to End Reviews

End to end reviews comprise a review of a patient’s journey from point of referral/contact with SIUC through to the outcome of their contact, including with another service. End to end reviews have multiple aims:

• identify processes and practices that
  • constrain or do not add value to the patient’s journey, both within SIUC and other organisations
  • do not meet service expectations/standards
• provide a thematic e.g., end of life care, overview of SIUC services
• identify service/system change needs
• identify learning and sharing opportunities
• agree feedback to staff, other organisations
• improved customer service

 

As part of routine quality monitoring and service improvement/redesign arrangements SIUC will undertake end to end reviews of patient journeys through integrated urgent care.

SIUC will actively participate in and contribute case examples to BNSSG End to End Reviews in accordance with contractual requirements of the urgent care system.

Topic Audits

As part of complying with the expectations of the NHS standard contract SIUC will undertake clinical audits relevant to the services provided. The purpose of clinical audit, as a quality improvement cycle, will be to check that clinical care meets defined quality standards and monitor improvements to address any shortfalls identified.

Any clinical audit will factor in the requirements of the Royal College of General Practice (RCGP) Emergency and Urgent Care criteria which include the comprehensiveness of documentation of a consultation.

All audits will have a report prepared which will be presented to the SQG, shared internally within BrisDoc and PPG, and reported to the BrisDoc Quality Board.

Arrangements for Monitoring Experience

Seeking feedback from patients and their carers about their experience of services is integral to the way SIUC works. Patient feedback is a key contributor to understanding how well the services are meeting people’s needs and to what standard. Patient experience will be proactively captured in several ways:

• survey questionnaires posted to patients (and others as set out in the SIUC NHS Standard Contract)
• via digital link scanned in a treatment centre or from text
• text calls/messages
• via patient participation and involvement

 

Feedback will be sought to understand patient’s experience of their journey through SIUC as well as within the individual services. SIUC will seek patient feedback about consultations in each service.

Service	Target
NHS 111	5% return of all calls taken each month (contractual 200 per month)
CAS	5% of a weeks’ consultations (excluding death verification) in each fortnight period
F2F	5% of a weeks’ consultations (excluding death verification) in each fortnight period

 

The CAS is the route through which healthcare professionals can access out of hours face to face services, and multi-disciplinary advice for their patients. Understanding their experience of SIUC services is key to the ongoing refinement and development of the CAS. Healthcare professionals’ feedback of their personal experience of using the CAS and that on behalf of their patient will be sought.

Professionals’ experience will be monitored through:

• an analysis of submitted Healthcare Professional Feedback forms (e.g., quantity, issues raised)
• call reviews through audit.

 

Stakeholder experience will be reported to the SQG and shared with the BrisDoc Quality Board. Patient experience will be reported to the SIUC Patient Reference Group with service design issues being shared with the SIUC Service Development and Improvement Board.

Record Keeping Best Practice

Professional standards require that patient records document the clinician’s work clearly, accurately, and legibly. The case record provides a reminder of what happened during the consultation, actions, steps taken and outcomes. It also informs colleagues who may subsequently have contact with the patient to provide/support continuity of care. It provides evidence of the standard of care given particularly if that is called into question.

The integrity of the case record is paramount. SIUC clinicians will therefore ensure their case records are:

• Complete
• Contemporaneous
• Clear and legible
• Entered for the correct patient
• Include no ambiguous abbreviations
• Avoid inappropriate comments e.g., offensive, personal, humorous remarks
• Not tampered with
• Checked

 

Best practice suggests that new notes should not be inserted, or an entry deleted. Computerised entries should not be changed once the post event message (PEM) has been sent. If a clinician realises their mistake prior to the PEM being sent the case record may be edited with correct information being substituted for the incorrect. If the mistake is realised once the PEM is sent the record may only be edited in accordance with the SIUC Best Practice Guidelines Policy.

In written notes, errors should be scored out with a single line, so the original text is still legible, and the corrected entry written alongside with the date, time, and signature. In retrospect if something is remembered an additional note should be made, clearly stating when the information is added and why.

To fulfil their primary purpose of supporting patient care, case record notes should be made during the consultation (or as soon as practicable) and include the following details:

• relevant history and examination findings (both normal and abnormal)
• differential diagnosis and any steps taken to exclude it
• decisions made and agreed actions
• information given to patients, including the different treatment options and risks explained during the consent discussion
• the patient’s concerns, preferences and expressed wishes (this will also be valuable should they lose capacity)
• drugs or other treatment prescribed, and advice given
• investigations or referrals made
• the date and time of each entry and the clinician’s identity.

 

The quality of documentation will be routinely audited through clinical audit (see 6.8).

Research

SIUC will participate in research projects appropriate to its business purpose and availability of capacity. Potential research partners will need to be able to provide an approved proposal, protocol, and ethics approval (if ready) when approaching SIUC about participation. All proposals and protocols will be reviewed by the SIUC Medical Director prior to final agreement to participate. The BrisDoc Quality Board will be informed about all research projects and receive the findings and reports.

Research partners will be required to enter into Third Party Confidentiality Agreements individually with SIUC partner organisations as SIUC is not a legal identity. Appropriate Information Sharing Agreements will be set up and approved by BrisDoc’s Programme and Service Director, and PPG’s Primary Care Medical Director prior to data being accessed and released.

Research partners will need to include costs within their proposals that are adequate to cover SIUC’s participation costs.

There will be formal agreement between the SIUC partner organisations and the research partner setting out participation arrangements, expectations, and resources.

Where SIUC intends to conduct its own research project an appropriate research governance framework will be put into place that provides assurance to any Host NHS Organisation (for funding flow/management) and to the SIUC Directors.

Infectious Disease Notifications

SIUC clinicians (working in the CAS and face to face services) have a statutory duty to notify the local Health Protection Team of suspected cases of certain infectious diseases. This is to support Public Health England (PHE) detect and manage outbreaks of disease and epidemics as soon as possible. The list of infectious diseases that are notifiable to PHE will be accessible to all clinicians working in SIUC on BrisDoc’s Clinical Toolkit and PPG’s intranet. Reporting will be by way of PHE’s notification form sent to the local Health Protection Unit.

Coroner’s Cases

SIUC cases for which the Avon Coroner requests a statement(s) from either/both BrisDoc and PPG staff will be submitted from SIUC, having been appropriately reviewed by respective legal/indemnity teams and the SIUC Medical Director.

Where SIUC is requested to attend an inquest to give evidence following the submission of an investigation report, consideration will be given as to who is most appropriate to attend to speak to an RCA report. This may be a single representative, or it may be representatives from both BrisDoc and PPG.

Where SIUC is requested to attend an inquest to speak to a statement this will be by the individual who provided the statement.

Special Patient Note Management

Special Patient Notes, created within the Adastra system, have typically provided NHS 111 and Out of Hours staff information to support patient care in accordance with a pre-agreed management plan e.g., a SWAST frequent caller contract or GP’s care/treatment plan. An SPN may also be raised to alert other care staff about potential risks in the patient’s environment e.g., risk of aggression and violence. NHS 111 can see any SPN within Adastra that has been created by an IUC service. NHS 111 HAs will not have access to view EMIS records.

In hours’ primary care services “flagged” treatment plans, including end of life care (RESPECT) plans and DNAR information, are within EMIS and may be accessed directly by CAS and face to face clinicians in SIUC. The need for sharing a management plan for inclusion as an SPN in Adastra is therefore becoming less frequent. When a management plan is received for inclusion as an SPN it is sent to brisdoc.careplan@nhs.net and entered Adastra by BrisDoc’s Central Rota Team. Updates are provided by a patient’s own GP surgery. Where there has been a learning event, the patient’s surgery may be contacted and asked to update their management plan with advice as to how clinicians, working out of hours, can best support the surgery’s management plan for their patient.

Workforce Governance

Good workforce governance makes sure that everyone working in SIUC knows what good performance looks like and has the support they need to deliver excellent care. The core purpose of workforce governance is to ensure visible, transparent standards for workforce care through robust recruitment processes, and supervision, training, development, and support to staff working in SIUC services. It relies on good, experienced management with relevant leadership skills and attributes.

BrisDoc and PPG have established organisational processes for developing the competencies and knowledge of their leaders and staff, which will apply to SIUC staff and from which they will benefit.

BrisDoc and PPG maximise the opportunities available to develop their workforce, to ensure there is career progression and development opportunities that help develop and retain staff and be a good employer in their local community. This includes taking the opportunity to work with the Apprenticeship Scheme, NHS Leadership Academy, local Universities, West of England Academic Health Science Network, and the Community Education Provider Network. These opportunities will apply to SIUC as a service within the partner organisations. BrisDoc has a track record of developing an accredited evidence work based learning module with the University of the West of England to develop clinical skills in urgent care.

Workforce performance will be reported to the UCSLOB and reported in the PPG Contract Meeting.

Requirements for education, training, and competencies

Competencies

The Integrated Urgent Care / NHS 111 Workforce Blueprint, (finalised by Health Education England in 2018) sets out a career framework and competencies for Skills for Health (S4H) levels 2-9 and provides workforce governance guidance. The blueprint reflects the national IUC service specification and thereby supports providers ensure its workforce is capable and competent to deliver IUC services and care.

SIUC will review and embrace the good practice examples set out in the workforce governance blueprint to ensure its workforce is able and facilitated to provide high quality patient care based on competencies.

SIUC roles will be aligned to this blueprint.

Education and Training

Both BrisDoc and PPG will have in place training matrices that ensure staff in the SIUC partner organisations are equipped with the knowledge and skills required to provide safe and effective patient care, and to do the job they have been employed to do. As a minimum this will include:

• All aspects of health and safety e.g., fire, COSHH, manual handling
• Information Governance
• Safeguarding and associated topics e.g., FGM
• Equality and Diversity
• Infection Control
• Use of relevant clinical systems and assessment tools

 

Accredited training providers providing health related training will be used e.g., e-LFH, Avon LMC courses, NB Medical – Hot Topics programme. Training is also provided via topic specific Clinical Forums for urgent care clinicians. Self-employed clinicians will evidence required training as set out in BrisDoc’s policy for the recruitment and induction of self-employed and agency staff. Where cross site working arrangements are in place, staff who work at both Nicholson House and Osprey Court in the CAS will undergo all induction and training appropriate for working in hosted premises. Staff will be familiar with all protocols that cover joint working in the CAS across the patient assessment journey. Training performance will be reported to and monitored by the UCSLOB.

Staff Line Management

All SIUC Line Managers will have received information from their organisation’s HR team in their main areas of HR responsibilities. This may include for example managing:

• sickness/absence,
• underperformance,
• personal development and training,
• special leave including maternity etc.,
• disciplinary procedures

 

All SIUC staff will know who their line manager is and how to contact them. All staff will have the opportunity of regular 1:1 contact with their line manager in a format that best suits their work situation.

Where staff may work across both BrisDoc and PPG elements of the SIUC services their line manager and service manager will both contribute to their personal development reviews. These managers will liaise on a regular basis to ensure staff are supported to and deliver optimal patient care services.

Honorary Contracts

The Oxford dictionary definition of an honorary contract, since the 1940s, has been “A legal agreement entitling a person whose primary employer is not the National Health Service to work directly with NHS patients on an unpaid basis, especially for the purposes of research or training”.  NHS honorary contracts are in the main for research activities or provision of specialist care. They provide for access to patient records and indemnity.

A contract given on an honorary basis is one that is held or given in an honour (rather than legal agreement), is without payment, and is without the normal privileges and duties.

Honorary engagement can be described as performing work for the benefit of an organisation (i.e., to meet its role and purpose) without remuneration. Where an individual is conducting activities under an honorary engagement that will have a direct impact on the care of patients or involve direct contact with them, the individual will be accountable to the NHS organisation concerned for this work. Accountability means there needs to be clear statements about the individual’s reporting arrangements, and about the procedures, codes of practice and other rules and regulations that apply to the work in question. An honorary contract can clarify and confirm this accountability and ensure an individual understands that they are subject to the organisations policies and procedures.

As IUC services develop there will be non-SIUC staff working within a SIUC setting. For example, clinicians from a mental health service provider based in the CAS delivering mental health care for people who call/use online NHS 111 or need to contact their mental health professional. In this context honorary contracts will be used to set out and manage the governance arrangements and working practices of these staff within SIUC.

Professional Registration and Revalidation, Fitness to Practise

All clinicians working within SIUC will be registered with a professional body that is the General Medical Council, Nursing & Midwifery Council, Healthcare Practitioners Council, General Pharmaceutical Council, and participate in revalidation and appraisal to secure their ongoing fitness to practise.

All new clinicians will have their fitness to practise confirmed on commencement with the service, and this will be routinely checked through their employers HR processes to ensure registration and fitness to practice is being maintained. Employed clinicians are checked annually. Self-employed checked as part of on-boarding process and informed they have a responsibility to inform us of any changes.

Oversight of a clinician’s performance will be held by the SIUC Medical Director in conjunction with SIUC clinical leads and PPG’s Regional Medical Director, using data from Datix and the LERIS/BOB/Clinical Guardian clinician dashboards.

Issues where fitness to practise is of concern will be managed by a Performance Advisory Group chaired by the SIUC Medical Director.

Recruitment, Induction & Personal Development Reviews

All recruitment of employed and sessional staff for SIUC services will be to the standards set out in NHS Safer Recruitment Guidelines.

It is recognised that both BrisDoc and PPG have organisational policies to which staff are responsible in accordance with the terms and conditions of their employment. Each organisation has recruitment and induction policies. This will not change under SIUC.

Where a member of staff works across BrisDoc and PPG elements of the IUC services their line managers will collaborate to ensure the PDR reflects the integrated care and support the member of staff provides for SIUC.

Whistleblowing

SIUC strives for a culture of openness and transparency involving all members of staff and all workers from senior management down. The SIUC partner organisations recognise the utmost importance of enabling employees to safely raise concerns of malpractice, negligence, criminal activity, fraud, misconduct, or wrongdoing by anyone in the workforce. Those who do raise such concerns, known as “whistle-blowers” or “those speaking out”, are considered an asset to the organisation and not a threat.

 

It is the duty of every member of staff to speak up about genuine concerns. SIUC is therefore committed to ensuring that any staff concerns of this nature will be taken seriously and investigated. A disclosure raised within SIUC will be protected if the member of staff has an honest and reasonable suspicion that malpractice has occurred, is occurring or is likely to occur. Staff who raise concerns reasonably and responsibly will not be penalised in any way.

There will be named “Freedom to Speak Up Guardians” in BrisDoc and PPG, in accordance with the recommendations made by the Francis Inquiry in “Freedom to Speak Up” 2015, whose role is to ensure SIUC has an appropriate whistleblowing policy in place, that staff know where to go to raise a concern, and offer advice and support to staff that have concerns they do not feel they can raise or escalate within their organisation.

It is recognised that both BrisDoc and PPG have organisational whistleblowing policies to which staff are responsible in accordance with the terms and conditions of their employment. This will not change under SIUC.

Staff Experience

SIUC highly values feedback from staff to constantly improve working environment culture, and conditions. Sub-optimal staff well-being can have significant impact on individual performance and attendance which impacts on service delivery objectives.

Staff experience will be measured annually in SIUC through a survey. Results will be collated by teams and shared with managers for dissemination and action planning for improvements. Results and action plan outcomes will be discussed at the SQG meeting and reported to the UCSLOB.

Workforce Modelling

Within SIUC the workforce model will be reviewed to ensure the knowledge, skills and competencies of staff enable the services to meet patients’ needs flexibly and responsively. This may include diversifying the workforce’s professional skill mix that enhances career opportunity for individuals and filling harder to recruit to roles, whilst providing an enriching multi-professional environment for staff to work in. An example of this has been the development of the Clinical Navigator role for the CAS.

Information Governance

Information Governance (IG) will be managed via the BrisDoc IG group and Quality Board where Information Governance will be a standing item.

Information Governance learning events will be reported through the standard learning event management processes.

In line with the contract schedule the respective IG leads within Severnside will develop a reporting and escalation framework that reviews the following;

• Register of staff in key Information Governance roles e.g., Caldicott Guardian, SIRO, ISM, DPO
• Register of Data Sharing agreements
• Confirmation of ICO registration
• Review Subject Access Requests
• Data Protection Security Tool status and compliance (annually)
• Identifying the need for development of new policy or changes to existing where required
• Review of learning events or themes, with recommendation for change or learning to be shared
• Review of the Privacy Impact Assessments annually or on change of significant service design
• Review “Fair Processing Information”/ “Privacy Notices” provided to patients annually or on change of significant service design, Data Management and Flows

All patient data will be managed in accordance with the General Data Protection Regulations 2018, Access to Health Records Act 1990, and Data Protection Act 2018.

It is recognised that both BrisDoc and PPG have organisational policies to which staff are responsible in accordance with the terms and conditions of their employment. Each organisation has information governance policies. This will not change under SIUC.

Within SIUC an Information Sharing Agreement will describe the flow of all data internally across the patient journey, and externally from SIUC to the relevant organisations managing the patient e.g., the patient’s own GP, a receiving organisation of an emergency referral.

The NHS number will be the consistent BNSSG patient identifier within SIUC.

No patient identifiable data will be emailed other than via nhs.net email.

Freedom of Information

The Freedom of Information Act 2000 provides public access to information held by public authorities in two ways:

• public authorities are obliged to publish certain information about their activities; and
• members of the public are entitled to request information from public authorities.

 

The Act covers any recorded information that is held by a public authority in England, Wales and Northern Ireland, and by UK-wide public authorities based in Scotland.

Public authorities include government departments, local authorities, the NHS, state schools and police forces. However, the Act does not necessarily cover every organisation that receives public money. For example, it does not cover some charities that receive grants and certain private sector organisations that perform public functions. As BrisDoc is an employee owned trust and social enterprise and PPG is a limited company, they therefore not obliged to provide data under the FOI Act however have opted to work collaboratively with the CCG to provide information where there is no conflict with commercial sensitivity/confidence. However, where it is in accordance with a contractual requirement, or is in the interest of improving patient care services, SIUC will provide the requested information if it is not commercially sensitive.

Commercially sensitive data might include for example financial information.

Recorded information includes printed documents, computer files, letters, emails, photographs, and sound or video recordings.

The Act does not give people access to their own personal data (information about themselves) such as their health records or credit reference file. If a member of the public wants to see information that a public authority holds about them, they should make a subject access request under the Data Protection Act 2018.

FOI requests will be monitored and reviewed at the SIUC Contract and Performance Board.

Subject Access Requests

It is recognised that both BrisDoc and PPG have organisational policies to which staff are responsible in accordance with the terms and conditions of their employment. Each organisation has a policy for the management of subject access requests. This will not change under SIUC. However, so as not to inconvenience a patient where it is relevant to their journey within SIUC, a single request may be accepted for records that span NHS 111/CAS and face to face services.

Responding to such requests will be managed by SIUC’s Governance Team. These requests will be recorded in Datix and/or the information request database by the receiving organisation as an information request and included in the SIUC governance dashboard.

Subject access requests will be monitored and reviewed at the SIUC Contract and Performance Board.

Information Commissioner’s Office

The ICO is the UK’s independent body set up to uphold information rights in the public interest and promote openness by public bodies and data privacy for individuals.

The Data Protection Regulations 2018 require every organisation that processes personal information to pay a fee to the ICO.

BrisDoc and PPG will be registered at the appropriate tier with the ICO, pay their annual fee and be able to produce their registration certificate on request.

Patient Confidentiality

SIUC will have established working practices that effectively deliver patient confidentiality. This is required by law, ethics, and policy.

It is recognised that both BrisDoc and PPG have organisational policies to which staff are responsible in accordance with the terms and conditions of their employment. Each organisation has data protection policies that include securing and maintaining patient confidentiality. This will not change under SIUC.

SIUC is committed to the delivery of a first-class confidential service. This means ensuring that all patient information is processed fairly, lawfully, and as transparently as possible so that the public:

• understand the reasons for processing personal information
• give their consent for the disclosure and use of their personal information
• gain trust in the way SIUC handles information and
• understand their rights to access information held about them

 

A duty of confidence arises when one person discloses information to another (e.g., patient to clinician / health advisor or call handler to clinician). All SIUC staff will work in accordance with this duty of confidence and be appropriately trained in information governance, so they understand their duties.

SIUC processes for managing patient information will ensure it upholds the requirements of the confidentiality model.

• PROTECT – look after the patient’s information
• INFORM – ensure that patients are aware of how their information is used
• PROVIDE CHOICE – allow patients to decide whether their information can be disclosed or used in particular ways.
• IMPROVE – always look for better ways to protect, inform, and provide choice

 

To achieve the secure communication within SIUC of patient identifiable data only NHS.net email will be used. Predominantly this will be within the Severnside Governance Team using severnside.governance@nhs.net.

Breaches to Patient Confidentiality

Any breach to patient confidentiality will be reported as a learning event and included in the Datix/LERIS and investigated in accordance with PPG and BrisDoc disciplinary processes. Consideration will be given to whether a breach of patient confidentiality is declarable in accordance with the learning event management process. Monitoring of patient confidentiality learning event numbers will take place in the SQG meeting.

NHS Pathways Licence

As prime contractor BrisDoc is responsible to NHS England for providing assurance of PPG’s compliance with its NHS Pathways Licence. A SIUC NHS Pathways Assurance Process has been approved by NHSE and compliance performance is managed at the monthly PPG Contract meeting and by the SQG.

Financial Governance

Contract and Payment Terms

The value and payment terms of the IUC contract for BNSSG will be set out in the NHS Standard Contract for IUC between the Commissioner and BrisDoc, as the prime contractor.

The value and payment terms of the NHS 111 (including the Real Time Team) element of the IUC Contract will be agreed between BrisDoc and PPG and will be set out in the sub-contract of the IUC NHS Standard Contract between BrisDoc (prime contractor) and PPG (sub-contractor).

There will be no uplift to either BrisDoc or PPG agreed share of the IUC contract value unless there is an uplift in the budget from the Commissioner. It is recognised that there may be changes to activity proportions in NHS 111, the CAS and face to face services as IUC services develop and progress during the contract term, for example with the introduction of NHS 111 online/First. Consequent activity changes will be mirrored by a change in flow of resources between the ICU service elements be that monetary or workforce. This will include where service improvement changes shift the balance of patient flow, the principle being that resource will follow the patient within SIUC.

Clinical and Professional Negligence Claims

Each organisation is responsible for managing any claims for negligence and ensuring their insurer/ NHS Resolution Clinical Negligence Scheme for GPs (CNSGP) is notified of any potential claim in a timely manner.

PPG will inform BrisDoc of any potential claim raised about their NHS 111 management of a BNSSG patient.

Claims will be reported and monitored at the PPG Contract meeting and escalated to the SIUC Directors.

Insurance

Employers & Public Liability

BrisDoc and PPG will be individually responsible for securing adequate employers and public and products liability insurance to cover the public, the number of staff employed, and the premises worked from.

Medical Indemnity

The NHS Resolution Clinical Negligence Scheme for GPs (CNSGP) was launched in March 2019. This replaces medical defence organisation indemnity cover for GPs with respect to NHS funded primary medical services. The scheme covers liabilities:

1. a) incurred on or after 1 April 2019; and
2. b) arising from an act (or an omission to act) on the part of a GP or any other person working in a general practice setting where that act (or omission):

• is connected to the diagnosis, care, or treatment of a patient; and
• results in personal injury or loss to the patient.

 

Severnside, having an NHS Standard Contract, fulfils all the following requirements to be eligible to be covered under the scheme:

• the carrying out of an activity that consists of, or is in connection with, the provision of NHS services
• the NHS services being provided by, or under a contract with, a person or organisation whose principal activities are to provide primary medical services (i.e., the NHS services are provided as part of general practice)
• the activity in question is connected to the diagnosis, care, or treatment of a patient.

 

CNSGP does not cover all primary medical services activities. Activities and services not covered by the scheme include non-NHS or private work, inquests, regulatory and disciplinary proceedings, employment and contractual disputes, and non-clinical liabilities such as those relating to defamation. Complaints (unless there is a formal claim for compensation for clinical negligence as well) are not covered by CNSGP.

All staff providing NHS funded primary medical services will be covered by the CNSGP. This includes GPs and other healthcare professionals. All beneficiaries under the scheme are responsible for knowing, understanding, and adhering to the rules of the scheme.

GPs working in SIUC will work in accordance with the requirements of the scheme as set out by NHS Resolution which includes maintaining separate indemnity cover for legal support and advice, coroner’s cases and complaints etc. known as non-NHS activity; and making appropriate notifications.

Evidence of indemnity cover for non-NHS activity will be checked at recruitment. Independent GPs will accept BrisDoc’s terms of engagement through which they commit to adhering to the requirements of being on an NHS England Performers List. This assures BrisDoc of their fitness to provide services to SIUC.

Professional Medical Malpractice

All Severnside non-doctor clinicians and support staff providing NHS primary medical services will also be covered by CNSGP. This includes NHS 111, CAS, and face to face services.

BrisDoc and PPG will maintain medical malpractice insurance cover for legal support and advice associated with potential claims, coroner’s cases and complaints etc. known as non-NHS activity for these staff.

BrisDoc and PPG will ensure their respective insurers are kept up to date, during the policy year, of any service and workforce changes that might affect the level of cover required, and are notified accordingly of any issues that may give rise to the need for legal support etc.

BrisDoc and PPG will, via the Severnside Governance Team, ensure that any Significant incident/learning event/complaint where harm was caused will be notified to NHS Resolution/the insurer, in the event a claim should arise in the future.

If, during the SIUC contract, either organisation changes their Medical Malpractice insurer it will arrange and purchase appropriate run off cover.

Monitoring & Review

Collation and monitoring of SIUC’s governance performance will be via the relevant governance management systems and SQD which are co-ordinated by BrisDoc’s Governance Manager. This tool will be used in the BrisDoc Quality Board to provide an overarching view of SIUC governance performance. The SQG meeting will be responsible for reviewing the detail with respect to governance performance and holding managers to account for their actions. The chair of the BrisDoc Quality Board will report to the BrisDoc Corporate Leadership Board.

This framework will be reviewed as part of the contract renegotiation process to ensure its currency and fitness to govern how SIUC is delivered and refined.

Escalation process

The design and delivery of integrated urgent care by SUIC will be a collaborative process that has high quality patient care and most effective use of the public purse at its heart. In any event where there is an impasse to resolving an issue the SIUC Directors will secure resolution.

Prior to escalation to the SIUC Directors attempts at resolution will have been undertaken at:

• service design level
• through service delivery monitoring
• through sub-contract management.

Change Register

Date	Version	Author	Comments
31.1.2019	2.0	CLN	Updated to include feedback from Commissioner as part of mobilisation assurance process for NHS England.
19.3.2019	3.0	CLN	Updated to include feedback from NHSE as part of the assurance process, further feedback from the CCG and the new CNSGP launched March 2019.
25.11.2020	4.0	CLN	Updated to change use of the DAC in BrisDoc to bespoke databases i.e., IRIS/BOB, “cloud-based” database to a governance database, risk reporting from Service & Quality Board to SQG, alerts to referrals with respect to safeguarding. To include new SIUC Governance team member titles, reference to BrisDoc’s terms of engagement for independent GPs. Removal of reference to SIUC Board replaced by BrisDoc Urgent Care Services Leadership and Operational Board (UCSLOB) and SIUC Directors, glossary. New section 2.1.2 NHS 111 online New section 2.1.3 on validation New section 2.1.4 on direct booking Inclusion in 2.2.1 acute trust admission requests, NHS 111 online, EPS2 use, direct booking. Section 4 included new SIUC governance structure. New section 8.6 on NHS Pathways Licence assurance processes. Change PPG to Practice Plus Group (PPG) throughout
XX.XX.2022	5.0	Rhys Hancock	Update and Review – New Template