Engagement Document
Proposed Changes to Urgent Care Services in ABMU Health Board
1. Introduction
Our strategic plan, Changing for the Better (C4B) - which was published in 2010 - set out an ambitious programme to improve the quality of the health care services we offer. Making sure patients have rapid access to the services they need, only admitting people to hospital beds who can’t have their needs met in other ways and extending our range of community services are key priorities.
Abertawe Bro Morgannwg University Health Board is therefore continually checking the way we provide services to our patients, to ensure we offer the highest quality, most appropriate and safest services we can within the resources we have.
We have identified that patients and their families find some of our urgent care services difficult to access and understand. Some of these services can’t operate in the way they were intended because the required staff are not always available, which can also cause difficulties for services and confusion for the public.
Therefore we have been developing ideas about how we believe these services could change in future in order to simplify the services, making them easier for the public to understand, and reduce the length of time people have to wait for treatment.
We are keen to hear your views and ideas on the proposals outlined in this document. Details of how you can let us know your views are outlined at the end of the document. These will form part of a formal engagement process being carried out by the Health Board in conjunction with Abertawe Bro Morgannwg Community Health Council from Monday 12th December 2016 to Friday 10th February 2017. In March 2017 the outcomes of the engagement process will be considered by the Health Board and the Community Health Council in order to decide the next steps for these services.
2. Current Urgent Care Services
This document focuses on our urgent, unscheduled care services. These are services for patients who are not 999 emergencies, but who still need care straight away. These include:
· Minor Injury Unit patients;
· Patients referred urgently to hospital by their GP;
· Other patients who need an assessment to decide if they should be admitted to a ward or cared for in another way.
Outlined below are brief details of the urgent care services we provide at Singleton and Neath Port Talbot Hospitals, which form part of a wider range of services that support the emergency services provided at Morriston and Princess of Wales Hospitals.
Singleton Hospital
The four existing urgent care services at Singleton Hospital are:
· The Acute GP Unit (AGPU) Open 8.30am-5.30pm, Monday to Friday. This is led by a group of Swansea GPs who on top of their usual practice work, also work here. AGPU offers fast-track access to hospital scans and tests; as well as to hospital consultants. The Unit receives all calls from GPs requesting hospital admission and also some referrals from paramedics from the Welsh Ambulance Service for patients who would otherwise be transported to and admitted via the Accident and Emergency Department at Morriston Hospital. The unit’s early interventions help to avoid a third or more of unnecessary hospital admissions. If the GPs feel a patient needs to be admitted, they refer them to the Singleton Assessment Unit. Unfortunately, the Acute GP Unit’s current 5.30pm closure time coincides when demand is at the highest. It deals with around 35 calls each weekday.
· The Singleton Assessment Unit (SAU) Open 24 hours a day, 7 days a week. Access is via the Acute GP Unit when that is open – 8.30am-5.30pm on weekdays. Outside these hours and at weekends patients arrive by referral only, usually from GPs. The Assessment Unit is led by hospital doctors, and patients are assessed by a medical team who admit the most serious cases. Out of hours and on weekends there is additional pressure on the SAU as their Acute GP Unit colleagues are not there to triage and assist, and this can lead to delays. The Singleton Assessment Unit sees 23-24 patients a day.
· The Minor Injury Unit (MIU) Open 8am-8pm, seven days a week. The MIU is staffed by GPs. However, these are GPs who are part of the ABMU GP out-of-hours service, which runs from Neath Port Talbot, Morriston and the Princess of Wales hospitals. This means that at weekends, the MIU at Singleton Hospital sometimes closes early if there is a shortage of out of hours GPs to cover the ABMU area. Singleton’s MIU does not deal with as many conditions as the MIU at Neath Port Talbot Hospital - particularly fractures – as it has does not have the appropriate staff to read X-rays. It sees about 30 patients a day, mainly between 9am and 6pm.
· Ambulatory Emergency Care (AEC) Opens weekday afternoons between 1pm and 5pm. This is the newest service, launched last year. It is consultant led, but works closely with the Acute GP Unit. It offers direct access to a Consultant who is supported by a wide range of specialists, therapists, and social services staff and has access to same-day tests. During a pilot last autumn, it proved to be extremely effective in treating patients so they didn’t need to be admitted, or cutting down their length of stay in hospital. It currently sees 2-3 patients a day and 90% go home. In common with the Acute GP Unit, it isn’t open in the early evening, after 6pm. However, it has been closed a quarter of the time over recent months due to consultant unavailability.
Neath Port Talbot Hospital
Neath Port Talbot Hospital’s Minor Injury Unit (MIU) is currently open 24 hours a day, 7 days a week, 365 days a year. The MIU is led by a consultant nurse with offsite support by a Consultant in Emergency Medicine. The service is delivered by highly skilled emergency nurse practitioners, triage nurses, healthcare support workers and receptionists. The MIU is designed to diagnose and treat patients with minor injuries and provide ambulatory care for patients with lower limb deep vein thrombosis. Some patients attend MIU who are assessed and redirected to other services that are more appropriate to meet their health needs (e.g. General Practitioner, GP out of hours service or the Emergency Department) or advised to self-care. The Unit does not see children under the age of 1, these are treated in the Emergency Department at Morriston or Princess of Wales Hospitals because of the specialist nature of the care required. This will not change as a result of these proposals.
The MIU has a reputation for seeing and treating patients quickly and effectively. Patient attendances have increased year on year and the majority of patients attend the MIU between 9am and 8pm. This means that about 120 patients can attend each day, equivalent to about 9 patients attending each hour. Patients presenting between these times are having to wait longer periods for treatment. This demand also places additional pressure on staff. Sometimes delays in treatment mean that we are not meeting the Welsh Government target of 95% of patients being seen, diagnosed, treated and discharged within 4 hours. There has also been an increase in the numbers of patients who attend the MIU but who then decide the wait is too long when the department is busy and leave.
Some of this increase in patients is because we have been actively encouraging appropriate patients to attend the MIU as a quicker alternative to receive treatment. This involves redirecting patients from across the area to the Neath Port Talbot Hospital MIU in order to reduce pressure on the major Emergency Departments at Princess of Wales Hospital, Bridgend and Morriston Hospital, Swansea. Many patients also prefer to attend MIU because of the timeliness and quality of care delivered. We have data which shows that patients travel from as far as Llanelli and Caerphilly to access care at the MIU due to its reputation for quality and efficiency.
Conversely, from 8pm until midnight the number of patients turning up reduces to an average of 4 patients per hour. Then from midnight to 7am very few patients turn up – about 3 each night. Between 7am and 9am an average of 3 patients attend each hour.
Overall demand for the MIU is increasing year on year. Between September 2012 and August 2013 there were 31,325 new attendances, but for September 2015 to August 2016 they had increased to over 40,777; with the vast majority attending during the day and early evening.
The MIU is run by a small team of highly skilled staff. At times of unplanned sickness, both short and long term, we have limited alternative staff available to make sure we have enough staff to operate the service fully. It is difficult to find replacements at short notice. In this situation the service runs with less staff than desirable to meet patient demand, which can cause longer waits for patients and puts pressure on the team. The current staffing position is fragile due to current vacancies to which we are recruiting.
In October 2016 the new 111 service was introduced for patients across Bridgend, Neath Port Talbot and Swansea. This means that patients can ring 111, a free to call phone number for people to access the right care from the correct professional in the quickest time possible. Instead of having to ring different numbers to contact NHS Direct Wales or GP out-of-hours services, they can now call 111 to reach both. The 111 model being trialled here is completely different to that in England, instead of replacing NHS Direct Wales and GP out-of-hours, it is bringing them together and taking on additional staff. A team of experienced GPs, nurses and pharmacists is available during evenings and weekends to expertly assess patients and refer them for the most appropriate treatment. Community based health professionals including district nurses and paramedics can also access this team for advice. We are encouraging our patients to contact 111 when they have a significant health problem but are unsure which service across our area would best meet their needs.
Proposed Changes to Urgent Care Services
Clinicians and managers at both Singleton and Neath Port Talbot hospitals have now come up with ideas on how to streamline and improve urgent care services. This will also help with demands on Morriston and Princess of Wales hospitals’ Accident and Emergency Departments by providing clearer options for patients whose care is urgent but not an emergency. Here’s an outline of the ideas so far for improvement being discussed for each of the hospitals:
Singleton Hospital
Singleton Hospital currently has the four different systems in place for urgent, unscheduled care patients as outlined above. These have evolved over time, but separately, often as a result of successful pilot schemes.
The idea now is to merge these four systems into a single service with a larger team of different clinicians working from one urgent care centre at Singleton Hospital, which will be open for longer, be able to cope with more patients and will have more staff in place when the demand on the service is highest.
Merging these services would not mean any staff losses or loss of resources. In fact these will be enhanced with two new additional advanced nurse practitioners being appointed to boost the new centre’s team.
The proposal is for this new integrated urgent care centre at Singleton to be open from 8am till 8pm Monday to Friday as well as 8am to 1pm on weekends and bank holidays. The Health Board believes it can staff this service consistently at levels which will meet patient demand and reduce waiting times for treatment. It will also mean that the unplanned unavailability of services will stop.
The extra opening hours and additional staff, working as a single integrated team, would mean urgent cases being assessed and treated more quickly. Not only do we believe this would reduce waiting times for patients, but it would relieve pressure on the Emergency Department at Morriston Hospital, reducing waits there too. These changes would also free up the SAU staff to focus on the acutely unwell patients who need admission to hospital 24/7.
Walk-in patients could access the same services now available at Singleton’s current MIU; but there would be a change in access times. It will remain in place 8am till 8pm Monday to Friday but would close at 1pm instead of 8pm on weekends. This is because the GP out-of-hours doctors would then be concentrating on supporting the fast track assessment of urgent patients at weekends rather than treating minor injuries.
The MIU at Singleton currently sees about 12-15 patients on a Saturday or Sunday afternoon, which include a mix of people with minor injuries, eye problems and some who could see their GP instead. In future these people would be directed to the Minor Injury Unit at Neath Port Talbot Hospital, which has more facilities. This already increasingly happens by default now, when GP out-of-hours doctors are unavailable at Singleton, but this is on an unplanned basis and so patients only find out when they attend if this is the case.