Item 3 – Appendix 1

Health Scrutiny Committee – 23rd June 2010

Update on the Urgent Care Centre(UCC) programme in the wider context of the review of unplanned care service provision in Hertfordshire

1. Introduction

This report is intended to give members an update on the work underway to review the provision of unplanned care services in Hertfordshire with particular reference to the implementation of the urgent care centre programme.

Unplanned care covers a spectrum of services including self care support; advice from pharmacists and NHS Direct, surgery consultations with GPs and nurses plus out of hours’ services; treatment in minor injury units and urgent care centres and for more serious conditions, specialist emergency care inA&E departments and acute admission units.

A review is being undertaken now to take account of a very different financial climate compared to that which prevailed when the urgent care programme was agreed in 2007 as part of NHS service reconfiguration in the county.

In this new context the health economy faces a challenging situation. We are experiencing an ever-increasing demand for health care. This has to be set against a background of little or no growth monies being available over the next five years. We therefore have to make the best possible use of the resources we have to drive up quality and improve the patient experience. It will mean making difficult decisions with GP colleagues and with the involvement of patients.

It is proposed to bring an interim paper to the July board meeting of NHS Hertfordshire including recommendations on St Albans and Herts and Essex Minor Injury Units (MIU) and a further full report on the review of unplanned care services to aBoard meeting in the autumn.

2. Urgent Care Centres – Implementation

The original planning for urgent care centres covered four different types of settings

  1. Replacing existing A&E departments such as the UCC in Hemel Hempstead and the planned UCC for Welwyn Hatfield
  2. Integrating UCCs within the larger A&E departments - as planned for The Lister Hospital in Stevenage and WatfordGeneralHospital
  3. Developing new services as pilots in two communities - Cheshunt and Hertford
  4. Offering additional services in two communities which already have minor injury units – St Albans and Herts and Essex, Bishop’s Stortford

3. So what has been experienced to date?

  • Dacorum Urgent Care Centre

The opening of Dacorum UCC in October 2008 and the transfer of major A&E services to Watfordin March 2009 has been successful. And it is seeing a good and appropriate case mix of patients as planned which has resulted in an overall net decrease of A&E attendances in West Hertfordshire of 5%.

The performance figures for Dacorum UCC show that it is working within the parameters set by the contract agreed between the PCT and the provider organisation (a partnership between West Herts Hospitals Trust and Herts Urgent Care – Dacorum Urgent Care Centre Partnership).

Patients needing minor illness care are channelled (triaged) to the GP Health Centre (open between 8am to 8pm) which is also co-located within the urgent care centre; patients with less serious injuries not requiring specialist care are channelled to the urgent care centre.

  • Cheshunt and Hertford Urgent Care Centres

New urgent care centres opened in Cheshunt and Hertford in October 2009.The services are provided by a partnership of East & North Herts Trust and Assura Lea Valley LLP. These were launched as pilots with the intention to evaluate their performance and determine whether they attract patients with minor injuries and illnesses who would otherwise have made unnecessary visits to A&E departments. As part of the evaluation process, detailed information and patient feedback is being collected.

Both centres are well used particularly the one at Cheshunt.The evidence, and it is acknowledged that the pilot period has still some months to run, appears to demonstrate that approx 50% ofpeople are attending who otherwise would have self managed or would have visited their GP. There has been a very slight reduction in A&E attendances at Barnet and ChaseFarmHospital.

There also appears to be a strong correlation between patient perceptions of GP access as evidenced in the quarterly patients survey, and increased minor illness attendance at UCCs.

Further testing of these early findings is needed before we can reach more definite conclusions; however, itappears that the NHS has duplicated services and incurred additional costs.

  • St Albans and Herts & Essex

There have been two attempts to enhance the model of care for the existing minor injuries units; the first was a full blown procurement process and the second an attempt to extend the service with the existing providers. Neither approach has come up with an enhanced service at a price commissioners could afford.

With the benefit ofexperience and hindsight, we have concludedthat the failure of the procurement process for the proposed St Albans and Herts and Essex Urgent Care Centres was due to the lack of commercialand financial viability of a doctor/nurse led service model. The cost of a patient attendance was working out much more than the cost of an average attendance at an A&E Department.

4. High Level Reviewof Unplanned Care Services

NHS Hertfordshire is using the learning from the procurement of urgent care centres at Hemel Hempstead, Hertford and Cheshunt and the failure to do so in St Albans and Herts and Essex in planning the next stages.

The new NHS Hertfordshire Board has requested that a high level review of unplanned care services be carried out. This is taking into account:

  • the experience of the local urgent care programme to date;
  • the nationally introduced changes that have been taking place with the establishment of GP led health centres in June 2009;and,
  • increased access to primary care through extended GP working hours (74% of GP practicesoffer morning, evening or weekend surgeries).

The review is adopting a number of key principles:

  • Appropriate care for people with unplanned care needs

The development of the urgent care network is now taking place in a new context with a wider range of options available for people to access unplanned care. The public needs clarity on the options available for the services to be used appropriately.

  • Cost effectiveness& value for money

There is a need to ensure that services provide the best value for money, address PCT priorities and maximise the best use of reducing resources. To this end the unplanned care services review will be comparing local expenditure on unplanned care with regional and national information. If more money is to be invested in these services there has to be a benefit in terms of patient experience and clinical outcomes.

  • Accessible care closer to home

There is the need to understand how investments in the urgent care centres and other new services are helping patients to have easier access and if they are helping GPs to manage people’s conditionsbetter. It is important that existing activity is redirected and the PCT isnot creating new supply-led demand through developing additional urgent care access points.

5.Work in Progress

To date the unplanned care review has mapped the activity and costs (where known) of unplanned care service provision ranging from self care including supported self care e.g. pharmacy to short stay admissions in acute hospitals.

The next phase of work is to fully understand why up to 20% of patients attend both A&Es and the pilot urgent care centres with routine minor illnesses that do not require the expertise of A&E or the UCC clinical staff.

There are a number of work streams currently underway:

  • Working with clinicians in A&E departments and UCCs to pilot primary care initiatives.
  • Launching a communication campaign at the end of June with the public. The aim of the campaign is to reinforce the options available to patients so that they choose the right service at the outset.
  • A retrospective audit underway in West Herts to analyse the needs of those patients who required less than a day’s length of stay.
  • Work has started on the cellulitis (Skin infection) pathway as there appears to be high number of hospital attendances for this, when in the majority of cases care can be provided locally by the patient’s GP.
  • At Cheshunt UCC, work is in progress with local GPs and the UCC to manage more appropriately those patients who attend for routine minor illness conditions.

6. St Albans and Herts & Essex Minor Injuries Units

Following the halting of the procurement processa great deal of work has been undertaken with existing providers and with local GPs to see if a workable solution can be found. The PCT Board firmly believes that any proposals must secure best value for moneyand be sustainable.

Herts and Essex MIU

Work has included looking at the possibility of extending the opening hours of the MIU but the results of a detailed analysis forecast that there would be insufficient attendances to justify additional opening hours. Discussions are taking place with the GPs in the area, which is covered by the East Locality Practice Based Commissioning Group. GPs have asked for more details from the current providers and the PCT on the operation of the current MIU. The outcome of these discussions will be incorporated in the Board paper in July.

St Albans MIU

Discussions are ongoing with GPs in St Albans PBC on the development of the St Albans MIU. They value the current service very highly and are currently exploring the possibility of improving access to some tests and investigations that are not available at the weekend.The views of the PBC group will be incorporated into the recommendations for the Board paper to be presented in July.

The Board paper will focus on ensuring greater clarity around the outcomes expected of the current services at St Albans and Herts and Essex, to ensure high quality, good patient experience and best value for money. This may also include some additional business case developments as requested by local GPs.

7. Conclusion

All the work streams previously outlined will inform how the PCT takes forward any unplanned care initiatives, including the UCC programme. The timetable for this is:

2012 /13

A 24 –hour integrated Urgent Care Centre at ListerHospital, Stevenage

A 24-hour standalone urgent care centre in QE11 Hospital, Welwyn Garden City

2014

A 24-hour integrated Urgent Care Centre at WatfordGeneralHospital, Watfordin line with campus development.

The PCT Board will receive proposals at its July Board relating to the future of the St Albans and Herts and Essex Minor Injury Units and a progress report on the unplanned care strategy, and a further full report on the review of unplanned care services to aBoard meeting in the autumn.

Denise Boardman

Assistant Director Service Redesign

Andrew Parker – Director of Primary Care Development

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