Urgent Care services in Warwickshire North Andrea Green Warwickshire North Clinical Commissioning Group
Emergency and Urgent Care The big picture in Warwickshire North
Growing demand and 48,000 attendances population has led to huge at George Eliot pressure on hospital hospital A&E in emergency and urgent care 2014/15 – up to 50% services. of these people Growing & ageing population. could have possibly In Warwickshire North the been treated population +65 years is expected to increase effectively elsewhere by 60% by 2030. In Nuneaton & Bedworth increase expected at 43% by 2030.
Emergency and Urgent Care The big picture in Warwickshire North • All 28 GP practices in Warwickshire North provide at least 8 hours of service a day
• 18 of those GP practices offer extended hours access – more than 8 hours a day
• GP led walk-in service at Camp Hill - 8am to 8pm seven days a week
• Urgent Care Centre at George Eliot Hospital - 10am to 6.30pm seven days a week – pilot service opened October 2014
• NHS 111 – 24 hour, 365 day, free telephone service
• Out-of-Hours Primary Care Service – weekdays 6.30pm to 8am, but weekends and Bank Holidays open 24 hours at George Eliot Hospital site.
We do not have enough GPs! Ratio of GP to registered population shows that each GP has around 200 extra patients compared with national average
Extract from NHS England Primary Care Strategy 2014 Patient Feedback Informing Vision for Quality and feedback from pre-engagement: • Vision for Quality feedback developed over 12 months
• Preference for face to face consultations, not telephone advice
• Confusion about how to access the right services quickly - this results in patients going to A&E when they can be treated elsewhere
• Variability in patient satisfaction with access to GPs.
• Pre-engagement feedback (277 responses)
• Need for longer GP opening hours
• People were prepared to travel to get the urgent care they needed
• People wanted same-day access to primary care as part of an urgent care system
• People wanted access to a GP
• People wanted to be streamed to appropriate urgent care.
Why review the urgent care services?
• We also have a growing and ageing population whose needs have changed. Older people often have more than one healthcare problem
• Confusion about what local services are available and when for both public and professionals
• Some difficulty accessing primary care
• Need to streamline care and ensure it is the best possible and offers equality of access across Warwickshire North
• Need a sustainable, well trained urgent care workforce that works seamlessly with primary and emergency care. How many people attend urgent care services? • Walk-in service at Camp Hill – c 6,200 walk-in patients, April 2014 - March 2015
• George Eliot Hospital urgent care – growing numbers with 926 in the month of March 2015
• George Eliot Hospital A&E attendances from the boroughs of North Warwickshire, Nuneaton and Bedworth rising – 45,649 in 2013, 47,233 in 2014.
Across our population some people attend UHCW and some people may present at GUH from neighbouring CCG localities Walk-in service at Camp Hill The graph below illustrates the number of monthly walk-in attendances during 2011/12, 2012/13, 2013/14 and 2014/15 (10 months). (Source: Camp Hill Health Centre Practice data). It clearly demonstrates the increased activity in 2014/2015.
Comparison of Monthly Activity by Year
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300 Activity 200
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0 April May June July Aug Sept Oct Nov Dec Jan Feb Mar Month
11/12 12/13 13/14 14/15 Who uses Camp Hill Walk-in Service? Average walk-in presentations by postcode per day 10/2012 - 9/2013 10/2013 - 9/2014 10/2014 - 1/2015 CV7 0.3 0.3 0.4 CV8 0.0 0.0 0.0 CV9 0.5 0.7 1.1 CV10 7.2 8.3 11.0 CV11 2.7 2.8 3.7 CV12 0.7 0.8 1.5 CV13 0.1 0.1 0.1 other 1.8 2.0 3.4 This map illustrates that the Camp Hill Walk-in Service is accessed by patients from all areas of North Warwickshire, not just Camp Hill residents. Key 0-499
500-2499
2500-4999
5000-7499 Camp Hill Walk-in Service - most common health problems patients attend with: • Ear, nose and throat
• Respiratory problems
• Stomach problems
• Skin problems
• Urinary tract infections
– Source: manual audit for the calendar month of January 2015
Walk-in attendance by hour and age at Camp Hill Urgent Care Centre at George Eliot Hospital The data below illustrates monthly attendances from the commencement of the Urgent Care Centre and clearly illustrates an upward trajectory. (Source A&E data George Eliot Hospital). 1000 Month Activity seen Month Activity seen 800 2014 by Urgent 2015 by Urgent Care Care Centre Centre 600 400 October 359 (10.50%) January 385 (13.66%) 200 Activity November 518 (16.02%) February 628 (19.53%) 0 December 489 (16.61%) March 926 (31.67%) April 1,454 (43.7% May 1,595 (45.38%)
The top ten presenting complaints attending the Urgent Care Centre are illustrated below with upper and lower limb injury being by far the most frequent:
Number of Patients % of Number of Complaint % of Patients Complaint Patients Patients Upper Limb 16.10% 532 RTC 4.56% 151 Lower limb injury 14.26% 471 Headache 2.52% 83 Abdo Pain 7.08% 234 Pregnancy-related 2.42% 80 Back pain/injury 4.66% 154 Chest Pain 1.45% 48 Unwell 4.56% 151 Allergic Reaction 1.16% 38 A&E Attendances at George Eliot Hospital
A&E Attends
20145 2012-13 2013-14 2011-12
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4000 April May June July Aug Sep Oct Nov Dec Jan Feb Mar
Increases in A&E attendances can be seen throughout the majority of 2014-15. There is a definite increase in the number of attenders based on 2013-14 data. T^he graph illustrates a 6.8% increase in A&E attendances. Attendance by hour A&E 2014/15
GEH A&E Attendances by Arrival Hour 3,500
3,000
2,500
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500
- What’s happened since
We carried out extensive engagement during summer 2015 with local patients, members of the public, the voluntary sector and partner bodies. More than 200 people (total 274) completed a questionnaire to let Warwickshire North CCG hear their views. What people told us
• For most people the urgent care service they were most likely to use for an urgent care need was same day access at the patient’s own GP surgery.
• Some respondents also commented on the difficulty experienced when trying to access a GP appointment.
The survey also told us that:
More local service If you are ill, you simply based at GP surgeries want to be seen by a with access to doctor. It’s helpful to be My GP closed for lunch, my son had patients own records able to see a doctor out of injured his foot, I had to use A&E and experienced GPs your working hours.
• The survey also told us that when people have an urgent care need they are most likely to seek a same day urgent care appointment from their registered GP practice. However we also know that some people have expressed concern about access at their local GP practice.
Doctors appointments are terrible to I don’t mind where I you get told call back at 2pm or use Need better access to go as long as I get online appointments – useless! I tried trained staff - who know what I need – flexible today and found I would have to wait how to deal with urgent times 19 days for an appointment care issues What people told us
• The people of Warwickshire North would like an urgent care service that is seamless with better streaming where people are seen and treated in the right place at the right time first time, with access to a doctor.
• Good access is essential to people with the request that consideration is given to location, travel times, transport and waiting times. The survey also told us that: Used the Camp Hill Walk-In service at Walk in …was dealt Camphill is not responsive, with very quickly waited ended up at A&E with excellent care. anyway My experience of Walk-in service was poor – complete waste of NHS money
• Most people who responded were prepared to travel between 5 &10 miles and between 20 and 30 minutes to access urgent care
• For a significant number of people public transport was very important whilst for others parking was very important.
• 93% of respondents accessing the GP led urgent care service at George Eliot hospital felt the service met their requirements to a good or satisfactory level
• 65% of respondents who had accessed the Camp hill urgent Care walk in service expressed that the service met their requirements to a good or satisfactory level
Equal access for all not just for the not everyone can get If walk –in is based on population of Nuneaton the hospital site, patients to Nuneaton - no I Have to rely on transport by taxi, public transport. Lots can be easily transferred after 6pm. to A&E or admitted more of people don't have Camp Hill, how would people who access to a car. effectively if necessary. don't drive get there? But what about same day access to primary care?
• Theme from pre-engagement – people would prefer their GP
• Challenge GP workforce
• CCG submitted a bid for Prime Ministers Challenge Fund
We do not have enough GPs! Ratio of GP to registered population shows that each GP has around 200 extra patients compared with national average
Extract from NHS England Primary Care Strategy 2014 We considered access and location
We looked at national evidence as guidance National Urgent and Emergency Care reviewed by Professor Sir Bruce Keogh (2013) Having an urgent care centre in the grounds of a hospital means that people can be easily redirected to urgent care from A&E where an urgent care service is more appropriate We considered a more flexible system
Reducing hours of access would clearly not be a feasible choice for patients and members of the public who want a more flexible system. The survey told us that the following things were important to the public when making decisions about urgent care services:
Took farther to walk-in waited and GP service at A&E would Keep AE for then ended up going to A&E any be great - patients can be Keep A&E for way! triaged down right route. Emergencies only !
Being treated in the right place at the right time Services that take pressure off A&E so only the people who need it use it Urgent care services working together and more joined up Access to urgent care without having to make an appointment Access to a doctor Pointless having Camp Hill which is only 5 mins away from Urgent care ‘fragmented and In an ideal world all George Eliot. complicated …Base whole service at urgent care services Camp Hill is deprived George Eliot Hospital make it easy would be in one place areas in North for patients and carers, awareness of Warwickshire too a single point of access We considered cost
The most efficient way of working will provide accessible care to the greatest number of people.
It therefore needs to be located in a place where patients can be directed to the most appropriate urgent care and any further treatment they need is easily available. Stakeholder Group
The stakeholder group had patient representatives, members of the public, public health representation, and provider representation. Stakeholder Group
Session one: 15 June 2015
• What they did - Helped to design the critical success factors - Agreed the weighting for each CSF - Scored the scenarios'
• Outcome - The critical success factors were used to help score possible scenarios
Scenarios
Scenario Description Location Staffing Opening times
To retain the current walk-in provision, location, staffing and Current One opening hours. Camp Hill GP Led 08:00 -20:00 7 days a week To retain the current walk-in provision, location and staffing Reduced Two but reduce the opening hours of the service. Camp Hill GP Led Opening Times 7 days a week To retain the current walk-in provision, location and opening Current Three hours, but change the staffing to Advanced Nurse Camp Hill Nurse Led 08:00 – 20:00 Practitioner (including non-medical prescribing 7 days a week
To retain the current walk-in provision and location but Reduced Four change the staffing to Advanced Nurse Practitioner (including Camp Hill Nurse Led Opening times non-medical prescribing) and offer reduced opening hours. 11:00 – 19:00 7 days a week To relocate the walk-in provision and redirect current activity Five to GP led urgent care on GEH site. This would be a GEH Urgent Care GP Led 24/7 NHS 111 & existing Urgent Care Centre co-located 2.5 miles Pathway adjacent away on the GEH site to A&E
A GP led walk in service to be provided at another primary To be Six care location within Warwickshire North CCG area. Another Location GP Led determined This scenario is for an Advanced Nurse Practitioner (including To be Seven non-medical prescribing) led walk-in service to be provided Another Location Nurse Led determined at another location to be confirmed within the Warwickshire North CCG area Critical success factors - scoring criteria
No Weighting Criteria 1 15 Conditions appropriately managed in an urgent care setting or appropriately redirected 2 15 I will get the right professional with the right skills and competencies to manage my diagnosis / condition (Supports sustainable Urgent Care workforce)
3 15 Relieve pressure on A&E to facilitate to best quality experience for our patients 4 10 Improve access by simplifying and making it clearer where to go for urgent care (Supports the single point of entry into single care)
5 13 Ability to organise / refer patients for diagnostics or deliver on site 6 12 Accessible parking Public transport / direct bus route 7 10 Promote continuity of care with patients own GP 8 5 Promote Accessibility for the most vulnerable groups of our population
9 5 Remove duplication of urgent care services Stakeholder Group
Session two: 25 June 2015
• What they did - Reviewed the scores to identify the scenarios that scored highest and agree short list of options
- considered the benefits and disadvantages for each of the shortlisted options
Key Findings
• Scenario 5 scored highest – Redirect walk-in activity to GP-led urgent care service on GEH site
• Scenario 1 was the second most popular - leave Camp Hill service as currently stands – issue of affordability
• Lowest scoring scenario was scenario 7
• Scores for scenarios were broadly consistent
• All options which were nurse-led scored the least.
Options Appraisal of Scenarios
The two top choices were shortlisted:
• Scenario One, Do nothing
• Scenario Five, relocate the Camp Hill Walk-In activity to an urgent care service at George Eliot Hospital Stakeholder Group Session three: 14 September 2015
Following the pre-consultation engagement new representatives for BME communities and parents with young children were asked to join the group and attended this session
• What they did - considered pre consultation feedback and & key message re same day access at GP practice for urgent care
- Helped to design future consultation engagement plan Stakeholder Group Recommendations: to address feedback on same day access at own GP for urgent care.
• Take forward action and response through developing primary care strategy and proposals on out of hospital community services
• Undertake further engagement with the public as these plans and proposals are developed.
• The group confirmed their recommended options for consultation
The consultation
The CCG would therefore like to consult publicly on two options:
Option 1: To Do nothing.
Option 2 :To relocate the walk-in activity from Camp Hill to GP- led urgent care service at GEH site.
Revised Consultation Timeline
October 2015 • Launch of full consultation
• Monitor of progress against action plan and amend if necessary
• Information gathering with early analysis of data to assess response
November 2015 • Collate feedback and begin to identify themes
• Hold consultation meetings
• Continue to publicise the public consultation
December 2015 • Public consultation closes