1 Note on Health Overview Panel Visit to Teddington Walk in Centre on 10

Note on Health Overview Panel visit to Teddington Walk in Centre on 10 February 2016

Attendance: Councillors Andrew Day (Chair), Raju Pandya (Vice Chair), Maria Netley and Linsey Cottington, and Marian Morrison (Democratic Services Officer)

Purpose: the Health Overview Panel has considered proposals to relocate the GP led Clinic (appointment service - not walk in) from Gosbury Hill Health Centre to Surbiton Health Centre but to provide a walk in service initially Saturday to Monday 8am-8pm. The Panel has heard about the successful Teddington WIC and agreed to visit this and pass on views and suggestions to the CCG ahead of the Board Meeting on 3 March 2015 where the final decision on the proposals would be made.

Visit: The visit took place at 10.00am – 11.30 am on Wednesday 10 February. We were met by Tracy Mahoney, Walk-in Centre Lead Nurse. The WIC was exceptionally quiet with only 3-4 patients seen in the waiting area. Monday on the other had had been very busy. At weekends, many patients have to wait and there is insufficient seating. The imminent closure of the Pharmacy may present an opportunity to extend seating areas. We also heard that more substantial changes were being considered for the WIC waiting areas. We were shown round the clinical areas and nursing office.

Background: The Walk in Centre (WIC) is operated by Hounslow and Richmond Community Health Care (a health provider) and is co-located at Teddington Memorial Service alongside two inpatient wards (rehab), outpatient service, X-ray, Occupational Therapy, Physiotherapy, Audiology services as well as the appointment only GP out of hours (OOH) service run by East Berkshire NHS Trust.

The WIC has been in place since 2005 but there had previously been an established minor injuries service at the Hospital.

The WIC is independent from these other services with the exception of X-ray. A Pharmacy is currently on site but this will close at the end of March as it is not cost effective and there are two high street pharmacies close by.

Opening times: WIC X-ray GP attendance Monday to Friday 8am to 10pm 9am to 7pm 6.30pm to 10pm Weekends and Bank Holidays 8am to 9pm 12pm to 5 pm 8am to 9pm

Wider health services – This part of West and South West London is well provided by hospitals and the needs arising from Heathrow are provided mainly at Hillingdon Hospital. West Middlesex Hospital has a 24/7 GP led urgent care centre enabling more appropriate care delivery for patients attending A&E. There is a similar WIC (to Teddington’s) at Queen Mary’s Hospital, Roehampton. In the Twickenham area there are a number of GP hubs which were reported as providing an effective approach to primary care delivery (details not explored).

1 Staffing - The WIC is Nurse practitioner led with 2-5 Nurse practitioners in place depending on the time of day. Some Nurse practitioners are able to prescribe under nurse prescribing arrangements and all are able to dispense under agreed Patient Group Directives for a limited number of drugs which are held on the premises. One Nurse Practitioner has advanced training in paediatrics and this has enabled a significant reduction in paediatric attendances at nearby A&E (West Middx).

One GP is present at weekday evenings and two are in place at the weekends. GPs are provided under contract and some are local.

Attendances – weekends and Mondays are busiest. The average number of attendances is 140 per weekday, 180-190 on weekend days but on Boxing Day 2016 there were 242. It draws patients primarily from Hounslow and Richmond but also from Kingston and Surbiton and increasingly from further afield eg Surrey Downs. There are attempts to try and draw more patients from Richmond and Twickenham alleviating pressures on West Middlesex and Kingston A&Es.

Generally patients attend appropriately for their condition but the WIC is seeing a proportion of patients for wound dressings which should really be seen in their local primary care settings. Some patients receive wound dressings for several weeks or months. The WIC picks up the cost of any necessary dressings and there is effectively double charging for this care (as GPs are paid for this service). It was thought that a shortage of practice nurses was a factor in this trend.

Patient Pathway – All patients are given a brief assessment of the urgency of their condition and then seen by a nurse practitioner. (A longer more formalised triage assessment would increase the overall waiting time.) Patients will then be seen by the attending GP when present if required. 80% of patients are discharged within 2 hours, waiting times vary, usually 1 to 1.5 hours weekdays increasing to at weekends 1.5 to 2 hours at weekends.

Arrangements are made with the London Ambulance on a case by case basis where patients present with serious conditions such as chest pains and will be “bluelighted” to an appropriate provider eg St George’s. Ambulances generally arrive within 15 minutes or sooner. Nurse practitioners are able to provide immediate basic life support in the meantime.

On average 7% of patients will be redirected to other services eg Surgical Medical specialties, sexual health, dental services.

Cost: Cost per patient for being seen at the WIC is £37 (compared to A&E attendance which is around £75).

Information – there is a well-designed leaflet explaining the services and the kind of conditions which can be seen at the WIC (minor injuries and illnesses). It also lists a range of conditions for which advice cannot be given and patients need to seek advice from elsewhere eg their GP or possibly A&E. Posters in the waiting area also explained this.

2 Possible suggestions for improving services locally in Kingston:

Members were very impressed by the overall service and recognised that it does represent a good standard of care which they would wish to see replicated in Kingston. The WIC has the advantage of being provided by a substantial health provider operating across two London boroughs – Hounslow and Richmond and costs of out of borough attendances are supported by cross charging other CCGs.

Health Overview Panel Members recognise that CCG is developing final proposals for the new service at Surbiton Health Centre for consideration by the Board on 1 March 2016 and request that the following suggestions are taken into consideration:

1. The Nurse Practitioner model in conjunction with GPs at Teddington WIC appears to be very successful and we wonder whether the model at Surbiton should include Nurse Practitioners, particularly if the hours are extended subsequently.

2. Additional skills of nurse prescribing (and the use of Group Patient Directives) and advanced paediatric training could also be considered as part of the Surbiton WIC service model.

3. In due course, if budgets permit and the new service is well used, we would suggest that consideration is given to providing additional hours at Surbiton Health Centre WIC when possible particularly from 4.00pm to 8.00pm on weekdays to respond to both needs of children at the close of school and those of local people returning home after work. 7.00am to 10.00am may also be desirable.

4. With the additional CCG co-commissioning role related to primary care we would recommend a review about the role of the practice nurse in providing wound care including dressings and stitch removal at GP surgeries as we understand that this service may not be so readily available due to shortages of practice nurses even though there is a budget element to fund this within GP practice payment arrangements. It may be possible to better provide practice nurse support and wound care in grouped practices or GP hubs.

Marian Morrison Democratic Services Officer 22 February 2016

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