Dear Dr Shaw

Re: Death of Michael Huggon – Regulation 28 Notice

Thank you for raising the matters of concern further to the investigation into the death of Michael Huggon.

We have had an opportunity to reflect on the circumstances of the death as a practice, and have also met with colleagues from Cumbria Health (formerly Cumbria Health on Call). We enclose our response below.

We have identified a number of themes including patient access, clinical capacity, patient safety and safe working practices, cross organisational working and human factors, which help structure our response.

Patient Access

Patient access to general practice services has been increasingly challenging in recent years with patient demand typically exceeding clinical capacity. In response to increasing patient demand and to try to operate safely, many practices, including Carlisle Healthcare had implemented a system focussing on same day access advising a patient to contact the practice from 8am to request a same day appointment. Once daily capacity was exceeded patients would be asked to “call back tomorrow”, unless the request was “urgent” in which case it would be triaged by a “duty doctor”. This system protected same day access to a degree, but significantly limited the ability to book ahead for non-urgent problems. The process led to a high number of people being asked to contact the practice again the following day. This did not provide a good experience of “making an appointment” and fuelled an “8am rush in the competition to get an appointment. It also disadvantaged people with non-urgent health problems.

From April 2023 NHS England instructed General Medical Practices to implement an “assessment of patient need” when a patient contacts the practice in person, on-line or via telephone. .This is illustrated in figure 1 overleaf.

Figure 1 – Modern General Practice Access Model 1

Carlisle Healthcare implemented “Modern General Practice Access” in June 2023. This aimed to improve patient experience of contacting the surgery, see and understand all expressed patient demand (removing the need to “call back tomorrow”), and respond to that need (to offer the right care with the most appropriate clinician or service in a safe time frame).

Approximately 70% of our current demand comes into the practice online via an approved third party provider “eConsult”2. The remainder of our patient requests are taken over the telephone or face to face via our receptions desks.

At Carlisle Healthcare, when a patient requests an appointment in person or on the phone, the trained call handler will ask the patient a series of structured questions to better understand the nature and urgency of the request. This request is passed to a central care navigation team within the practice. Each clinical request is viewed by a GP and a decision is made about the disposition of the request. This may include the offer of a face to face or telephone consultation within a specific time frame, signposting or referral to another appropriate service, or resolution of the case (e.g prescription or information issued). Some cases will be added to an urgent GP worklist for further clinical assessment/triage (e.g visit requests, or when there is lack of clarity from the original submission). Carlisle Healthcare receive about 600 appointment requests on a Monday and approximately 450 requests each day from Tuesday to Friday.

In general, implementation of Modern General Practice Access has been a positive experience. We no longer ask people to “call back tomorrow from 8am”. Patient experience has been positive with our June 2024 Friends and Family Test score currently at 93% satisfaction.

1 https://www.england.nhs.uk/gp/national-general-practice-improvement-programme/modern-general- practice-model/ 2 https://econsult.net/

Clinical Capacity

Workforce in general practice continues to change. There are now fewer GPs, a growing population, with an increasing number of people living longer lives with more complex health needs.

Carlisle Healthcare has a registered patient population of approx. 38,500 people. We have 6.6 whole time equivalent GP Partners and employ a further 9.6 whole time equivalent general medical practitioners. This equates to 0.4 whole time equivalent general practitioners per 1000 registered patients. This is in keeping with England average. Local and national trends show an increasing number of patients per whole time equivalent GP year on year.

We employ a wide range of health and care professionals within our general medical practice including nurses, health care assistants, care co-ordinators, advanced clinical practitioners, paramedic practitioners, social prescribing link worker, clinical pharmacists, physiotherapist, occupational therapist, mental health workers, and children and young people’s social prescribers. Some of these roles are supported by ring fenced and pre-defined NHS funds supported by the NHS England Primary Care Network Directed Enhanced Service. 3

We provide a number of functions within general practice and organise ourselves in teams fulfil these. They include preventative care, (immunisation campaigns, cancer screening and health checks), enhanced health in care homes, planned proactive care for people with long term health conditions and complex care needs, acute visiting and personalised proactive care for people living with frailty.

We strive to offer the capacity that we need to deliver a high quality service, but recognise that this often falls short. These workforce challenges are reflected nationally and are impacted by national policy.

Patient Safety and Safe Working Practices

The British Medical Association has published guidance for safe working in general practice.4 The BMA recommends no more than 25 substantive patient contacts per GP per day for a GP to deliver safe care. Whilst recognising the BMA guidance, we have not implemented this at Carlisle Healthcare as it would restrict patient access and add additional pressure to our already overstretched health and care partners. Despite this, we try to support our clinicians to work safely but recognise that they frequently go above and beyond their contracted working hours.

Approximately 2% of the population contact their general practice on a daily basis.

It’s important to appreciate that general practice is not an “emergency service”. We work closely with partners to ensure that when people contact us they get the care that they need (e.g. directing a patient with a suspected heart attack to 999). We have safeguards in place to screen for life threatening and emergency conditions when people contact the surgery to be able to direct them to the most appropriate service.

3 https://www.england.nhs.uk/gp/expanding-our-workforce/ 4 https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-in-general- practice

Cross Organisational Working

As a general practice we work closely with other health and care partners including Cumbria Health (out of hours), North Cumbria Integrated Care (acute and community services), Adult Social Care, Cumbria, Northumbria, Tyne & Wear Foundation Trust (mental health and learning disability), North West Ambulance Service and a variety of voluntary, community and social enterprise organisations.

Carlisle Healthcare provides core hours between 8am and 6.30pm Monday to Friday. Cumbria Health provides out of hours services via 111 when we are closed.

Some work will naturally flow between out of hours and in-hours services as one service closes and another opens. Requests for follow up from out of hours cases to in hours services are messaged electronically to the patient’s practice for further action. There is currently no consistent agreed pathway for the transfer of same day work from in-hours providers to Cumbria Health.

Human Factors

The initial request for a home visit for Mr Huggon was taken over the phone by one of our call handling staff at 2.15pm on 6th February. This request was passed to our care navigation team. Unfortunately a clinical decision to contact the patient to ascertain more information wasn’t made until 4.50pm and Mrs Huggon was contacted by a GP at 6.06pm that day, when a home visit was agreed but there was no clinical capacity to respond directly within core working hours. The home visit was completed by the out of hours service later that evening.

It is regrettable that it took over two hours to make a decision for a clinician to phone the patient to ascertain more details. This was in part due to the volume of work presented to the clinician that afternoon

It is also regrettable that once a decision had been made, it took a delay of a further hour or so before the patient was contacted by phone. Again workload contributed to this delay.

Our Response and Action Taken

We recognise that our response to the visit request was not adequate. Clinical capacity, workload and human factors played their part in this.

Following internal discussion within Carlisle Healthcare we have agreed to implement a performance indicator that all requests for acute home visits will be triaged by a clinician within 60 minutes.

Following discussion with Cumbria Health, we have agreed that any cases that have already been triaged and need same day clinical input after we have closed will be passed directly to Cumbria Health via telephone, instead of asking the patient to contact 111. This should improve the patient experience of care and reduce delay in response times.

Both of these changes will be put in place with immediate effect.

Clinical Director Carlisle Healthcare

Dear Dr Shaw

Prevention of Future Deaths Regulation 28

Thank you for raising the matters of concern further to the investigation into the death of Michael Huggon.

Cumbria Health has reviewed the case and reflected on the findings you have highlighted. As part of this review, we met with our colleagues from Carlisle Healthcare on the 14 August.

Our response is as below, and I have outlined them in two separate headings.

1. The systems in place currently Cumbria Health has for many years had processes in place to allow the exchange of clinical information between organisations that include not only daytime primary care but other organisations such as community nurses, hospice, and secondary care. We are very aware that communication issues are often the cause of situations where things could have gone better for patients and the measures, we already have in place are there to mitigate this risk. We also fully recognise the pressures on daytime practice which include capacity to address all the patient queries that arrive at the practice before the 18.30pm handover to Cumbria Health.

Currently we have in place:

• A dedicated number for health care professionals to contact Cumbria Health after the surgeries have closed (03000). This allows a clinician-to-clinician handover if necessary or a clinician to our “controller” to take the appropriate details and log onto the out of Hours patient system.
• A dedicated number (0300) that vulnerable patients have as part of their care package which allows then to contact Cumbria Health directly rather than go through NHS 111
e.g. palliative care patients.
• A special patient note template that can be completed by the practice and electronically gets uploaded in the patients Adastra record.
• E-mail inbox (choc.north) that allows transfer of information from practices to our control centre that is staffed 24/7.
• The control centre is staffed 24/7 anyway for any queries which could include passing over clinical cases of need at shoulder time in particular.

2. Action from the Regulation 28 request

• As discussed above, Cumbria Health has met with Carlisle Healthcare and completed a review of Mr Huggon’s case.
• The case will be discussed at our regular clinical forum with the emphasis on assessing capacity when patients decline an admission which was pertinent to Mr Huggon’s case but applies to any patient who declines or refuses treatment.
• We will put on educational sessions to update our clinicians on the mental capacity act, managing challenging scenarios with particular emphasis on how this is documented in a patient record (which is again pertinent to the case of Mr Huggon)
• We will ensure that the information in the section above is communicated to the GP practices through all of Cumbria on the options Cumbria Health has for discussing and handing over cases of concern if they are unable to manage them within the constraints of their capacity, particularly at that shoulder time period of when they close and the Cumbria Health opens. This will be achieved by a standalone communication and guidance will be entered onto our newly developed website for ease of access. After meeting with CHC I know that they have put in place some changes to the way they manage cases such as Mr Huggon and with our plan above to cascade the options we have in place to all practices. I hope the Coroner has gained assurance that the process are as robust as possible to prevent such cases as Mr Huggon’s from happening in the future.