National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in

Rapid Review of Hospital Element of Unscheduled Care Services in North Wales: Profile of current unscheduled care services in North Wales Authors: Siobhan Jones and Claire Jones

Quality Assurance: Dr Rob Atenstaedt, Consultant in Public Health Medicine, NPHS (Local Public Health Director, Conwy & Denbighshire Local Health Boards)

Date: 10/6/09 Version: 2

Status: Final

Intended Audience: Expert and Stakeholder Groups in Feedback Session on 24th June 2009

Purpose and Summary of Document: This report forms part of a series of documents comprising elements of a rapid review of the hospital element of unscheduled care services performed by the National Public Health Service for Wales on behalf of the Unscheduled Care Services Project Team

Publication/Distribution: • Clinical Strategy Website

Author: Siobhan Jones/Claire Jones Date: 10/6/09 Status: Final Version: 2 Page 1 of 18 Intended Audience: Expert & Stakeholder Groups

National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Profile of current unscheduled care services in North Wales

Description of Current Services

1. Number and type of A&E Departments in North Wales

Table 1 and Map 1 detail the number and location of unscheduled care services in North Wales. North Wales residents also access unscheduled care services outside North Wales at Countess of Chester, Bronglais and Royal Shrewsbury Hospitals.

Table 1.Number of A&E, Minor Injuries Units and Out-of-Hours GP Units in North Wales, 2009

Number Hospitals with A&E Department 3 Hospitals with Minor Injury Units 15 Hospitals with GP Out of Hours Unit 10

2. Location of A&E Department in North Wales

Map 1. Location of North Wales A&E, Minor Injuries Units and Out-of-Hours GP Units*

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

* MIU services and GP out of hours services at Bron y Garth Hospital moved to Ysbyty Allt Wen in Penmorfa in March 2009

3. Minor Injuries Units

There are 15 Minor Injuries Units across North Wales. These are described in Table 2:

Table 2. MIU’s across North Wales

Community Hospital Colwyn Bay Llandudno Denbigh Ruthin Llangollen Mold Flint Holywell Chirk YsbytyAllt Wen Bryn Beryl Tywyn Memorial Dolgellau Ysbyty Penrhos Stanley

In Denbighshire, a minor injuries enhanced service is provided by primary care in the areas without Trust provision, primarily Rhyl and Prestatyn in the north and Corwen in the South (ref: Wales Audit Office (2009) Unscheduled Care: unplanned, urgent or emergency health and social care. Survey of Local Health Board Chief Executives (Denbighshire)).

Conwy – a minor injuries enhanced services is provided by primary care in the more rural areas, to provide a local service to this population (Betws y Coed, Llanrwst and Cerrigydrudion) (ref: Wales Audit Office (2009) Unscheduled Care: unplanned, urgent or emergency health and social care. Survey of Local Health Board Chief Executives).

There is a GP out of hours centre in Penrhos Stanley on Saturdays and some bank holidays

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

4. A&E Facilities

During March/April 2009 a service profile template was sent out, and completed by, senior staff from the Emergency Departments and/or Medical Directorate at Ysbyty Gwynedd (YG), Ysbyty Glan Clwyd (YGC) and Maelor (WM) Hospitals (see Appendix 1). The template provides an overview of the current service provision at the three main A&E departments in North Wales. This section of the report provides a summary of the information provided.

4.1 Size of A&E Departments

The A&E department at Ysbyty Gwynedd (YG) has 3 cubicles, 4 treatment rooms, 6 assessment bays and 4 resuscitation bays. Ysbyty Glan Clwyd (YGC) A&E department has 12 cubicles, 4 adult treatment rooms, 1 paediatric treatment room, 1 room for the assessment of mental health patients and 4 resuscitation bays. Wrexham Maelor (WM) A&E department has 8 cubicles for the treatment of minor illness and accidents, 9 cubicles for the treatment of major illness and accidents and 4 resuscitation bays.

4.2 A&E backup facilities

All of the three A&E departments have access to the facilities of an Acute Medical Assessment Unit (AMU/MAU) An AMU is a dedicated area for managing acutely ill medical patients who are being admitted. Ysbyty Glan Clwyd has a 30 bedded AMU and WM has 23 bedded AMU. None of the 3 A&E departments currently have a Clinical Decision Unit (CDU) for patients who require a period of specific investigation and active clinical management to allow early and safe discharge, although WM report that there are plans to set up a CDU next year. WM also has a Surgical Assessment Unit.

All three hospitals have Intensive Care Unit facilities. YG currently has 3 Level 2 Critical Care beds and 7 Level 3 Critical Care beds. Wrexham Maelor hospital has 12 Level 2 critical care beds and 5 Level 3 critical care beds. YGC currently has 8 level 3 critical care beds and reports that an expansion of critical care in the hospital is planned. YGC also 1 overnight intensive recovery bed (operated if staffing levels permit).

Currently, children requiring the facilities of a Paediatric Intensive Care Unit in North Wales are stabilised and then transferred, usually to the PICU at Alder Hey Hospital in Liverpool. Therefore, none of the three hospitals currently have PICU facilities. YG and YGC also have a HDU cubicle to stabilise children prior to transfer to PICU.

All three hospitals have Cardiac Care Unit facilities, with YG and YGC reporting that they have Rapid Access Chest Pain Clinic pathways in place, with paramedics being trained in the administration of thrombolysis for patients with suspected Acute Myocardial Infarction.

4.3 Models of care

All three hospitals use the Manchester Triage System to assess patients presenting at the A&E department and all departments currently employ Emergency Nurse Practitioners (ENP) to support with the assessment and treatment of patients. YG has ENP cover in the A&E department from 08.00 – 21.00, YGC has ENP cover for 8 hrs a day and WM has

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3.20 whole time equivalent (WTE) ENP’s working at one time, but has 7 WTE trained ENPs.

4.3.1 Trauma team

All three A&E departments have a trauma team in place led by a senior clinician. In YG a senior Emergency Department Doctor is the trauma team lead, in YGC it is the most senior Doctor available and in WM the trauma team lead is the Emergency Department Consultant. See appendix 2 for additional information from YGC on their trauma team arrangements out of hours.

4.3.2 Links to GP Out of Hours

Appendix 3 provides full details of the Out of Hours Service arrangements across North Wales. YGC currently have GP Out of Hours Services on the hospital site but not co- located with the A&E department. At YG the GP Out of Hours service is co-located next to the A&E dept, and patients are sent directly from A&E triage using agreed protocols (approx 350-400 patients a month). WM GP Out of Hours Service is currently provided from a portakabin on the hospital site, and there are plans to locate the GP OOH service within the A&E Department from April 2009.

In YGC, GP’s with Special Interest regularly support A&E staff and in YG GP’s from the OOH service are occasionally called upon to ‘queue bust’. GP’s do not work in the WM A&E department.

4.4 Elective & emergency workload arrangements

YG and YGC provided details on their arrangements for elective and emergency workload for individual specialities. In YG for all specialities (except trauma/orthopaedics and obstetrics/gynaecology) on call consultants are not free from their elective responsibilities during day time hours. In YGC, on call consultants are free from their elective responsibilities during day time hours for the following specialities: Trauma/Orthopaedics, Anaesthetics and Urology. On call consultants are not free from their elective work in Vascular, Maxillo-facial, ENT, and Paediatrics. For GI specialties some, but not all consultant are free from elective work when on call. Critical Care at YGC covers elective and emergency work. Obs/Gynae staff are not always free from their elective responsibilities while on call (see appendix 1)

4.5 Access to diagnostics

For YG and WM, access to MRI scanning is not available out of hours. In YGC MRI scanning is available out of hours on an on-call basis, via consultant request and for specific conditions. All three hospitals have out-of-hours access to CT scanning, Ultrasound scanning and laboratory investigations with immediate reporting.

4.6 Access to theatres

All hospitals reported that fully staffed emergency theatres are available 24/7. WM and YGC have emergency theatre staff on site 24/7 and YG has scrub staff and obstetric ODP

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales on site 24/7 with a further two ODP’s on call. In YG there is also one ENT scrub person available on call.

4.7 Arrangements for 24 hour consultant level medical/surgical cover

YG has an A&E consultant working in the department from 9.00 – 17.00 weekdays and for 4 hrs a day at weekends. This is to be increased to 6 hours a day at weekends. In YGC there is consultant cover from 09.00 to 17.00. There is evening consultant cover at YGC to 21.00 one night a week with occasional night shifts to cover service gaps. WM has consultant cover from 08.00 to 22.00 weekdays and 10.00 – 18.00 at weekends. The A&E Consultant is also available on call overnight.

4.8 Telemedicine/ telecare facilities

All three hospitals report having telemedicine facilities available. There is a telemedicine link between YG and the MIUs, and it is used by the MIU’s to get advice and support from YG A&E department. There is also a link between Bryn Beryl community hospital and YG, and a remote dermatology clinic is held. YGC also has telemedicine video conference links between the A&E department and the neighbouring MIU’s although it was reported that most of the MIU’s except Colwyn Bay are reluctant to use it. WM has links but they are not currently used.

5.0 A&E staffing levels

The template in Appendix 3 gives detailed information on the staffing levels in each of the three A&E departments. YG currently has 3 WTE A&E consultants, YGC has 2.2 and WM has 4. YGC reports vacancies for 5 full time equivalent middle grade doctors and 2 full time equivalent Consultants. YG and WM both have vacancies for 2 band 5 nurses and WM also has a vacancy for 1 administrative staff.

6.0 Time Spent in NHS Accident and Emergency Departments* (ref: Welsh Assembly Government (March 2009) First Release. Time Spent in NHS Wales Accident and Emergency Departments: February 2009. Available online http://wales.gov.uk/docs/statistics/2009/090319sdr372009en.pdf?lang=en)

The following data reports on Trust performance for major A&E departments, other A&E/minor injury units, and the average for all hospital emergency care facilities and covers the period beginning March 2008 through to the end of March 2009.

The Annual Operating Framework (AOF) for the NHS in Wales for 2008-09 includes a national target that states ‘95% of new patients (including paediatrics) spending no more than 4 hours in a major A&E department from arrival until admission, transfer or discharge. Patients spend no longer than 8 hours for admission, transfer or discharge’.

The chart below shows the total time spent in a Major A&E Department from arrival until admission, transfer or discharge for North Wales in March 2009.

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Major A&E Departments are defined as a consultant led service with appropriate resuscitation facilities and designated accommodation for the reception of accident and emergency patients. These departments must provide the resuscitation, assessment and treatment of acute illness and injury in patients of all ages, and services must be available continuously 24 hours a day.

Total time spent in a Major A&E Department from arrival until admission, transfer or discharge for North Wales in March 2009

Trust Total attendances % of patients who % of patients who spent less than 4 spent less than 8 hours in A&E hours in A&E North Wales 11,344 89.2 99.1 North West Wales 4,078 91.2 99.8 North Wales Region 15,422 89.7 99.3 Wales 74,070 88.1 97.7 Source: WAG 2009

The chart below shows the total time spent in a Minor A&E Department from arrival until admission, transfer or discharge for North Wales in March 2009.

Other A&E/Minor Injury Units are defined as other A&E/casualty/minor injury units which have designated accommodation for the reception of accident and emergency patients and can be routinely accessed without appointment, but which do not meet the criteria above for a Major A&E Department.

Total time spent in a Minor A&E Department from arrival until admission, transfer or discharge for North Wales in March 2009

Trust Total attendances % of patients who % of patients who spent less than 4 spent less than 8 hours in A&E hours in A&E North Wales 1,632 100.0 100.0 North West Wales 3,092 96.4 99.4 North Wales Region 4,724 97.7 99.6 Wales 23,128 95.8 98.9 Source: WAG 2009

*An additional technical document produced as part of the 90 day review of unscheduled care presents the North Wales trusts’ data on emergency admissions and A&E attendances for the last 5 years.

7.0 Key Messages

• There are 3 hospitals with major A&E departments, 15 hospitals with minor injury units and 10 hospitals with GP out of hours units in North Wales

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

• All 3 A&E departments in North Wales are supported by the facilities of an Acute Medical Assessment Unit. None of the 3 hospitals currently have a Clinical Decision Unit. There are plans to set up a CDU at Wrexham Maelor Hospital next year • The Manchester Triage system is currently used by all 3 A&E departments to assess patients, and Emergency Nurse Practitioners are employed in all 3 departments to support with the assessment and treatment of patients • All 3 A&E Departments in North Wales have a trauma team led by a senior clinician • All three hospitals have access to CT scanning, Ultrasound Scanning and laboratory investigations out of hours, with immediate reporting. Ysbyty Glan Clwyd does have some access to MRI scanning out of hours (on consultant request for specific conditions) • All 3 A&E departments have telemedicine links with the Minor Injury Units, however there is currently variability in the extent to which these are utilised • There are staff vacancies in all three A&E departments in North Wales, with YGC reporting a number of medical staffing vacancies • In March 2009, none of the 3 A&E departments in North Wales met the AOF target of ‘95% of new patients (including paediatrics) spending no more than 4 hours in a major A&E department from arrival until admission, transfer or discharge’ in March 2009. Less than 1% of patients waited longer than 8 hours in any A&E department during March 2009.

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Glossary of terms

A&E – Accident and Emergency

OOH – Out of hours

GP OOH – General Practitioner Out of Hours service

MIU – Minor Injury Units

YG – Ysbyty Gwynedd Hospital

YGC – Ysbyty

WM – Wrexham Maelor Hospital

AMU – Acute Medical Assessment Unit

CDU – Clinical Decision Unit

Level 2 - Critical Care – patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care, and those stepping down from higher levels of care.

Level 3 - Critical Care – patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

Manchester Triage System – a tool by which triage can be carried out effectively, in the same way and to the same standards. The National Triage Scale incorporates categories which are defined by number, colour, name and target time for treatment.

ENP – Emergency Nurse Practitioners

MRI – Magnetic Resonance Imaging

CT – Computersied Tomography

ENT – Ear Nose and throat

ODP’s – Operating Department Practitioners

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Appendix 1

90-Day Unscheduled Care Project - Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor Service Profile Template

Size of A&E Number of cubicles? 3 12 8 minors Number of resus / trauma beds? 4 resuscitation bays 4 resuscitation bays 4 resus Other rooms/beds (describe) 4 treatment or consulting rooms. 6 1 room for assessment of MH patients 9 majors assessment bays 4 Adult treatment rooms and 1 paediatric treatment room Does A&E have back up of; AMU - number of beds / trolley Yes 30 23 beds Clinical Decision Unit - number of beds / trolleys n/a No No - planned for next year Surgical Assess Unit - number of beds / trolleys n/a No Yes. 7 beds & 6 trolleys Overnight intesive recovery (OIR) - number of 0 1 if staffing permits No beds Level 2 critical care - number of beds 3 0 12 7 8 (Critical care expansion planned) 5 Level 3 critical care - number of beds PICU beds - bed numbers 1- HDU cubicle and resus bay to HDU cubicle on paediatric ward to No stabilise paeds prior to transfer stabilise paeds prior to transfer CCU - bed numbers Y - CCU 6 Beds 24/7 Rapid 6 beds 24/7 Rapid access chest Yes. 4 beds access chest pain clinic pathway place pain clinicpathway in place. Paramedics Paramedics trained to thrombolyse trained to thrombolyse

Medical Level 2 (high dependency beds if not 0 0 Yes - included in above included above) number of beds

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor Models of care in place Triage arrangements Manchester Triage System Manchester Triage System Manchester triage 24/7 Any specific patient assessment protocols in Streaming assessment and discharge place?, (e.g. see and treat) from triage Please describe how current staff skill mix is NP cover 8.00-21.00 ENP cover 8 hours 24/7 3.20wte ENPs working at one time,but deployed in the A&Edepartment (e.g. Nurse 7wte trained Practitioners / Emergency Care Practitioners) Is there a trauma team? Yes Yes Yes Who is on trauma team? senior E.D dr/plus senior nurse E.D/surg A&E consultant/associate specialist. ED/ortho/surgical/anaes. reg /ortho Ortho middle/junior grade. Gen surgery Consultant/Reg. middle/junior grade/ Anaesthetist SHO & middle/cons depends who available.

Who is trauma lead? senior ed.dr Most Senior Dr available ED Consultant Number of ATLS trained junior doctors approx 50% 6 out of 8 How is A&E linked to Primary care OOH? (e.g. Gwynedd and Anglesey OOH service Presently in a portakabin on site,will be OOH on site/integral with A&E dept/ off site) provide consultations, telephone advice within the department from April 27th 09 and home visits with NHSD call handling and triaging. Regarding Out of Hours there is one provider – Morfa Doc – who provide call handling, telephone triage, home visits and medical and nursing advice both over the telephone and at the centre. For those patients who are seen at Ysbyty Gwynedd, there is an electronic link between the two OOH providers. There is a protocol to support the transfer of primary care patients from YGC A&E and MorfaDoc (source: Welsh Audit Office Survey - Conwy LHB)

Do GP’s work in A&E? No No Yes GPswiSI regularly support A&E staff If so is it in capacity of A&E Dr or GP? on occasion called as g.p to que bust from out of hours

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor Staffing levels (by speciality): Nursing support

Nursing (by band) Band 5: 26.09 Band 6: 3.29 (of which 2 Band 5: 27 Band 6: 3.71 Band 7: 4.03 (of Band 5:32.50 Band 6:12.63 Band 7:5.46 are ENPs) Band 7: 7.0 (of which 2 are which 1.58 are ENPs) Band 8: 1.00. Of Band 2:2.80(ENPs included in Band 6/7 ENPs) Band 8: 1 these nurses 1.80 WTE are Registered wte)(2.6wte RSCNs included in Sick Children's Nurses B6/5wte)Based on 64,000 attendances.

Clinical Support Physiotherapist: 0.42 Physiotherepist 18hrs Junior Dr’s (by grade and specialty) 2 FY1, 2FY2, 2 GPVTS, 1 ACCS, 3 FTSTA medicine

Consultants (by specialty) 3 2.2 4 Associate Specialists 1 & 1 approved not funded 2 1 Staff grades 5 9.5 7 Clinical Assistants 0 2.4 2 sessions Trust grade/Clinical Fellow 2 0 1 0 Old style Specialty Registrars 0 1 0 Specialty Registrar, training grade (ST) year 4-6 in 1 1 EM ACCS (Acute Care Common Stem) ST1 in EM 1 1 Vocational Training Scheme (VTS) 3 3 2 Free Standing Training Appointments at ST1 2 1 3 FSTAs other? 0 1 0 Foundation year 2 2 2 2 Foundation year 1 0 1 2 Emergency Care Practitioners 4 0 0 Vacancies 2 Band 5 nursing vacancies 5 FTE middlegrades & 2 WTE 2 WTE band 5 & 1 x 12 hr office junior Consultant

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor Arrangement for elective vs. emergency workload for each specialty (e.g are on call consultants free from elective responsibilities during day time hours) Upper GI no Not all Information not provided Lower GI no Not all Information not provided Vascular no No Information not provided Trauma/orthopaedics yes yes Information not provided Maxillo facial n/a No Information not provided ENT no No Information not provided Urology no yes Information not provided Paediatrics no no Information not provided Anaesthetics no Yes Information not provided Critical Care no Crit Care necessarily cover both Information not provided Obs & GYnae yes not always Information not provided

24 hr Access to diagnostics (YES/NO?) MRI no yes on call. Consultant request only In hours only

CT yes - via on call yes on call yes USound yes - via on call yes on call yes Labs yes yes yes Is immediate reporting available yes yes yes

Access to theatres Number of Theatres (total) 8 (10 Oct onwards) plus 2 in ABH, 2 in 11 HMS ? 2 trauma theatres Are fully staffed emergency theatre/s available Yes during weekday staff are released 24/7 from various theatre, Yes Yes Are emergency thetare and obstetric theatre staff on call or are they on site 24/7? scrub staff on site24/7 Obstetric ODP on site 24/7 plus 2 ODP's on call 24/7 plus 1 ENT scrub person on call. On site On site

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Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor What Are the arrangements for 24 hr consultant level medical/surgical cover (Describe)

Details of medical rotas A&E consultant works(not on call) in Consultant cover daytime 0900-1700. Dept 9.00 - 17.00 weekday & 4 hrs/day Evening cover to 2100, one night pre A&E Consultant cover from 8.00- at weekends, to be increased to 6hrs at week. Occasional night shifts to cover 22.00hrs in dept M-F and 10.00-18.00 weekends service gaps Sat/Sun. On call over night Progress with EWTD compliance Junior posts compliant Information not provided Seniors rota - yes except for weekends if called in. Telemedicine / Telecare in AED Are there any facilities for telemedicince/ telecare available Yes Telemedicine V/C available between all AED 's & MIU's. Most MIU's except CB reluctant to use. Potential immense Yes but unrealised Yes If so, how are these used? MIU's to ED for advice and support. Community hospital Bryn Beryl to YG Dermatology remote clinic held. Not used

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Appendix 2 - Membership of Trauma team, Ysbyty Glan Clwyd

In hours if available ie not in Theatre

A&E consultant / Associate specialist Orthopaedic Middlegrade / Junior Grade General Surgery Middlegrade / Junior Grade Anaesthaesia SHO and Middlegrade / Cons depending on who available.

Evenings Week

A&E consultant / Associate specialist or staffgrade Orthopaedic Junior grade (may be FY2) Orthopaedic Middlegrade on call from home General Surgery Middlegrade on call from home General Surgery Junior Grade (may be FY2) Anaesthaesia SHO and Middlegrade depending on who available

Nights Mon to thurs

A&E consultant / Associate specialist on call from home A&E Junior (maybe FY2) Orthopaedic Junior grade (may be FY2) General Surgery Junior Grade (may be FY2) Orthopaedic Middlegrade on call from home General Surgery Middlegrade on call from home Anaesthaesia SHO and Middlegrade depending on who available

Weekend Days

A&E consultant / Associate specialist/Locum or staffgrade when in Department A&E Junior (maybe FY2) Orthopaedic Junior grade (may be FY2) General Surgery Junior Grade (may be FY2) Orthopaedic Middlegrade on call from home General Surgery Middlegrade on call from home Anaesthaesia SHO and Middlegrade depending on who available.

Weekend Nights A&E consultant / Associate specialist/Locum not routinely called will attend for complex cases or multiple major Trauma Cases as impossible within EWTD A&E Junior (maybe FY2) Orthopaedic Junior grade (may be FY2) General Surgery Junior Grade (may be FY2) Orthopaedic Middlegrade on call from home General Surgery Middlegrade on call from home Anaesthaesia SHO and Middlegrade depending on who available.

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

Appendix 3 - Out of Hours Service arrangements across North Wales (ref: Welsh Assembly Government (2009) Unscheduled Care Local Delivery Plan North Wales Health Community (Central, East and West))

Central Area

Morfa-Doc provide out of hours cover to a population of approximately 220,000 with a high number of elderly patients. The population can double during the summer period as the area is a popular destination for tourists from Liverpool, Manchester and Birmingham areas; it has been estimated that there are 40,000 static caravans along the coastal strip.

The main control centre is situated at Ysbyty Glan Clwyd (opposite A&E) where Morfa-Doc perform the call-handling, the telephone triage and face to face contacts with patients. Patients can also be directed to one of the satellite treatment centres at Ruthin or Llandudno hospitals.

60 local GPs support the service by working sessions. All doctors who work for the service are either current principles in the area or are recently retired from local practices. The service employs 35 nurses, 15 receptionists and 13 drivers. Morfa-Doc has a fleet of 4 vehicles which are well equipped and all have satellite navigation systems.

Morfa-Doc work in partnership with North Wales NHS Trust (Central) by providing the medical cover for 6 community hospitals and providing GPs to work within the A&E department at weekends. They also provide cover for 3 hospices.

Morfa-Doc has been working very closely with the adjacent Accident and Emergency Department to provide the most appropriate care for patients. A protocol has been developed in partnership to allow staff in both clinical areas to identify patients who would benefit more by being provided with care from the appropriate service.

Morfa-Doc employs a Community Nurse Practitioner who has district nursing experience to visit patients with blocked catheters to be treated at home if deemed necessary thus reducing inappropriate admissions to hospital. There is currently no district nursing service for patients after 11pm and these Community Nurse Practitioners are able to provide critical services such as palliative care.

East Area

Since 1st April 2008 Flintshire and Wrexham Local Health Boards has commissioned their out of hours service from NEWDOC. Prior to this Flintshire Local Health Board provided their own service for patients registered with Flintshire practices and Shropdoc (a private organisation based in Shrewsbury) provided the OOH service to patients registered with Wrexham practices. The total population covered is approximately 300,000.

NEWDOC provides its clinical service from two centres – one in Deeside Community Hospital in Flintshire and one on the site of Wrexham Maelor Hospital.

Whilst there is no District General Hospital in Flintshire, there are three Community Hospitals with Minor Injury Units, all of which refer patients to the OOH service. NEWDOC

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National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales provides cover for the inpatients within the Community Hospitals in Flintshire and Wrexham in partnership with the North Wales Trust (Eastern).

The service employs:

• 60 GPs, many of whom are local principals and regular local locums. • 34 nurses • 23 Receptionists / telephonists • Cars and drivers contracted in. All cars are equipped with satellite navigation systems and clinical software.

The current temporary base in Wrexham is contained in a Porta-cabin adjacent to the A&E unit at the Maelor General Hospital. This is a temporary measure whilst the development of the N.E. Wales Emergency Response area (NEW ERA) is completed. The first phase is due to be completed in March 2009 and NEWDOC will then be moving into the new build to be co-located with the A&E Department. Close working relationships have developed in order to ensure that the patients are seen by the most appropriate service during the Out of Hours period.

West Area

Gwynedd LHB hosts the out of hours service for both Gwynedd and Anglesey Local Health Boards. The call-handling and telephone triage component of the service is commissioned from NHS Direct Wales and Gwynedd LHB employs both clinical and non-clinical support staff.

Since October 2005 Powys LHB has commissioned the clinical component (face to face) of the service from Gwynedd LHB for patients registered with two practices in Machynlleth and Cemmaes Road.

The total population covered is approximately 200,000 and this population increases significantly as a result of visitors and tourist who stay in the area.

The service is currently provided from 7 treatment centres across Gwynedd and Anglesey, one of which is co-located adjacent to the Emergency Department in Ysbyty Gwynedd, Bangor; the other 6 treatment centres are co-located within Minor Injury Units in Community Hospitals.

The out of hours service provides cover for community hospital inpatients within the Community Hospitals and the GPs provide support to, and are supported by Clinical Practitioners working in the Minor Injury Units.

The Service Currently Employs:

• 4 Salaried GP’s • 90 “sessional” GPs, many of whom are local principals and regular local locums. The service has not used any doctors from locum agencies since April 2005 • 9 nurse practitioners to include a dedicated Palliative Care Nurse from 7:30 to 11:30pm every night.

Author: Siobhan Jones/Claire Jones Date: 10/6/09 Status: Final Version: 2 Page 17 of 18 Intended Audience: Expert & Stakeholder Groups

National Public Health Service for Wales Rapid Review of Hospital Element of Unscheduled Care Services in North Wales

• 8 Receptionists / telephonists • 9 dispatcher/drivers • 9 drivers • Full time manager with 3 part time support officers • Part time Medical Adviser

4 cars, fully equipped with computers and satellite navigation systems are available at all times.

Author: Siobhan Jones/Claire Jones Date: 10/6/09 Status: Final Version: 2 Page 18 of 18 Intended Audience: Expert & Stakeholder Groups