Implementation of a core minimum specification across eight North West London urgent community response services serving a population of 2m

Introduction: North West London Integrated Care System supports a diverse population of 2m and has an ambition to reduce inequalities, increase quality of life and achieve outcomes on a par with the best of global cities.

The System includes place-based partnerships in eight municipal boroughs, and involves collaboration between commissioners, primary care, and secondary care NHS Trusts representing acute hospitals, community and mental health providers. There are four community health providers working across the geography.

Historically each local area commissioned community services independently, resulting in heterogeneous service models with differing levels of workforce and investment and contracted activity, presenting challenges for providers caring for patients across geographical boundaries including hospitals and ambulance services, and potentially undermining ambitions to maximise community-based care.

Aims: We undertook collaborative work 2019-2022 to agree and implement core minimum specification for one pathway – 2 hour Rapid Response – to level-up service provision to a consistent clinical and operational level.

We describe the challenges faced during the project, related to pathway interfaces in a complex out-of-hospital care system involving multiple parties.

The importance of avoiding unnecessary hospital attendances increased during the Covid pandemic and this necessarily accelerated our work, supported by the release of national investment to support care pathways as part an Ageing Well Programme.

Key Findings: We undertook gap analysis which illustrated the different clinical and operational models that predated our work.

Ambitions and definitions: we identified the need to use the terminology “core minimum” rather than single standardised service specification due to a desire among some partners to ensure that mature services did not see a levelling-down as a result of this work. Eg: all areas agreed to minimum operating hours 0800 – 2200, 7-days, but some services already exceeded this. The value of local variation was accepted.

Interfacing services: the heterogeneity in our teams was also apparent in interfacing services in each borough, with historical variation in community nursing, geriatrics, primary care, end-of-life care and hospital frailty pathways, requiring flexibility of implementation to prevent duplication.

Workforce: changing operating hours required formal consultation with staff and recruitment, which introduced delays to implementation.

Clinical interventions: an ambition to ensure we offer a consistent range of clinical interventions required agreement around clinical risk appetite and review of staff competencies and training eg: providing IV antibiotics required agreement around indications, responsibilities and protocols for venous catheterisation, first and subsequent administration precautions, prescribing and antimicrobial stewardship; similarly falls provision required definitions for non-injurious falls and appropriate thresholds for conveyance for investigations. We worked with other parts of the Urgent Care System to improve understanding of can be offered out-of-hospital.

Productivity: aligning service models provided opportunities for routinely benchmarking service productivity across teams.

Conclusions: We successfully developed and implemented a core minimum offer for Urgent Community Response services across our geography, which exceeds national recommendations.

Implications: Learning from this initiative will inform our plans in future to level-up other pathways including Community Nursing and rehabilitation.

There is transferrable learning for other places and partnerships seeking to transform services.