Planning the Future of Urgent Care Services in Southend Public Discussion Document

Planning the Future of Urgent Care Services in Southend Public Discussion Document

Foreword GP-led walk-in services, like those based at St Luke s Health Centre in Southend, were originally designed to improve patient access to GP services. However GPs and nurses across the country have become increasingly concerned that such services are simply creating extra demand; some patients who may have waited to see their own GP, visited a local pharmacist, used an out of hours service or treated their condition with sensible selfcare are now attending their nearest walk-in service instead. NHS Southend Clinical Commissioning Group (CCG) has reviewed the way the St Luke s walk-in service is used and the evidence gathered locally reflects these national concerns. We asked more than 650 people who used the walk-in service a range of questions about why they attended and also collected data directly from Care UK which runs the centre. We have met with local people and ward councillors, and Healthwatch Southend held a public meeting on the issue and provided us with a summary of the discussions at that meeting. We have also been directed by new national guidance which shows that attempts to direct patients away from A&E have not worked and so rather than locating walk-in services away from A&E they should be co-located. Co-location would also give us the opportunity to develop an entirely new service at the hospital which would incorporate the A&E minors service. This would significantly reduce pressure on A&E by ensuring patients were routed to the best place for the care they need (potentially away from the hospital) and would also put more staff at the front line. We have looked at a number of different options and believe this is the best way forward for Southend. Therefore, when the current contract for the walk-in service ends we want to develop a new service co-located with A&E at Southend Hospital. This new service would focus on those patients who attend A&E with an urgent minor ailment or condition, that can be seen by a GP or nurse. This would free up capacity in A&E for those who need more specialised care. Please take a look at the information in this document and send us your thoughts. Because this affects the area previously covered by NHS South East Essex, our colleagues at NHS Castle Point and Rochford CCG are asking their residents the same questions. We look forward to hearing your views. Dr. José Garcia-Lobera GP, Governing Body Member and Chair of the CCG Melanie Craig Chief Officer

1 The Local Health System The health system in Southend is facing challenging times. It serves one of the UK s more densely populated areas and a population which is ageing; the over 65 age group is predicted to increase by 9.1% by 2018 and by 24% by 2025 and this will drive a much greater increase in demand. The borough has areas where there is a higher than average prevalence of a number of diseases and it is expected the prevalence of several chronic diseases will also significantly increase over the coming years. In addition our health system particularly the urgent care system is subject to additional pressure from more than six million visitors who come to the borough each year. GP Practices in Southend Over and again, patients tell us that when they fall ill or have a minor ailment their preference is to see their own GP at their local practice. With this in mind we are working with GPs in Southend to improve access locally. Most recently the Queensway Medical Centre and the Thorpe Bay Surgery have increased their opening hours to full core hours (8am to 6.30pm Monday to Friday, excluding bank holidays). There are 35 GP member practices in Southend of which; 11 are operated by a single GP 24 have a registered list of less than 5000 21 are fully open during core hours (60%) We are planning a number of important initiatives to support local GP practices to improve their access. This work is supported by NHS England. In its 2014 document Transforming Primary Care in Essex, it states one of the key aims is: Practices will not close during their core contracted hours of operation (8am to 6:30pm Monday to Friday) ensuring patients have access to their surgery during these hours. 1 Southend University Hospital NHS Foundation Trust (SUHFT) Southend Hospital serves a catchment area with a population of approximately 345,000. It has an accident and emergency department that deals with immediate and urgent threats to health. Southend s A&E department remains one of the best performing in Essex but, at times, staff face significant challenges in managing the amount of people who attend. There are two pathways for patients who are taken to or who choose to attend A&E. The Majors Pathway Patients who receive emergency treatment at A&E majors are most typically those brought to the hospital by ambulance. Majors deals with emergency, life-threatening conditions and this includes: loss of consciousness acute confused state and fits that are not stopping persistent, severe chest pain breathing difficulties severe bleeding that cannot be stopped 1 The Heart of Patient Care - Transforming Primary Care in Essex Published by NHS England 2014

The Minors Pathway This is for conditions which are not life threatening and which should not be self-managed or treated in the community. Typically such patients are treated for conditions like broken bones, burns and scalds, head injuries, eye injuries and injuries to the back, shoulder and chest. The A&E department has an average of 2,470 minors attendances each month. Through a payment by results contract at national tariff prices, this costs an average 187,664 a month even though a significant proportion of these patients received no treatment or minor treatment. Indeed many patients who attend A&E and use the minors pathway could have been more appropriately treated elsewhere including at their own GP practice or dentist, with advice and guidance from their local pharmacist, by using Southend s Out of Hours GP service (accessed by dialling NHS 111) or through self-care at home.

2. St Luke s Health Centre In October 2007, as part of his Next Stage Review, health minister Lord Darzi (pictured) announced new investment to develop approximately 150 GP-led health centres. These would open 8am and 8pm seven days a week offering both a listed GP practice and a walk-in service. The walk-in service would be open to any member of the public, including those registered at GP practices elsewhere or those not registered with any GP practice. Lord Darzi hoped the walk-in service would improve patient access to GP services. Each Primary Care Trust (PCT) was expected to commission at least one GP-led health centre in their area and NHS South East Essex PCT commissioned the St Luke s Health Centre in 2008 as part of this national programme. Although based in St Luke s ward in Southend, the walk-in service continues to serve the entire population previously covered by NHS South East Essex PCT; the borough of Southend as well as the districts of Castle Point and Rochford with a total population of approximately 345,000 people. The GP Practice The GP practice within St Luke s Health Centre inherited a small patient list of about 1600 when it opened in May 2009 from a previous practice that had closed. During the past five years that list size has grown to 6250 patients and is now capped at that level by the Care Quality Commission, largely due to the size of the premises. The practice is popular and there is a significant waiting list. The service is currently based in temporary accommodation and a project group, chaired by NHS Southend CCG, is pursuing local options for a permanent home for the GP practice. The group includes representatives from NHS England and NHS Property Services. There is very limited land availability within the St Luke s ward and a number of options are being progressed including The Cumberlege Centre, St Luke s Church, Temple Sutton School and Cecil Jones Lower School and St Edmund s Hall. As the walk-in service is co-located at the health centre, St Luke s registered patients currently receive extended opening hours locally (8am to 8pm, seven days a week). St Luke s is the only GP practice in Southend to have such opening hours. However a new contract for the GP practice is being re-procured by NHS England whilst the walk-in service has become the responsibility of the CCG. Going forward this means the GP practice and walk-in service will be delivered independently through two separate contracts and potentially by two different providers. Therefore the GP practice at St Luke s may no longer offer the same opening hours as the walk-in service, even if the walk-in service were to continue to be co-located there.

The contract for the walk-in service concludes at the end of March 2016 and planning permission on the temporary building runs out in February 2017. The Walk-In Service Why people attend the walk-in service My GP was closed My GP had no appointments Other There are national concerns that GP practices are not offering adequate access which means patients do not have continuity of care within the scope of their own registered surgery. The walk-in service manages an average of 1,681 attendances each month and, as the graph above shows, the majority of these say they attended the walk-in service because their own GP practice was closed or because they felt they were unable to get an appointment. These findings reflect national concerns that walk-in services have not improved patient access to their own GP services. The table below shows the majority of attendances at St Luke s by patients registered at other practices are for minor ailments such as coughs, colds, earaches, stomach and dental complaints. These are all complaints which can often be treated at a patient s own GP practice or dentist, through self-management or by seeing a pharmacist. Reasons for attending the walk-in service Other infections Ear, Urinary Tract etc Other Minor Illness Colds, sore throat (not Tonsillitis) Minor Injuries Ligament injuries, muscle strain / injury Other category Prescriptions, rashes, no reason given, contraception

3 The Case for Change Guidance at the time of the Darzi report was that out-of-town locations like St Luke s were preferred as they reduced the accumulation of health services in one area. However, more recently, there has been a change in national thinking around the location of primary care facilities and the management of the minors emergency pathway. The Royal College of Emergency Medicine states: Efforts to encourage patients to seek assistance over the phone or to go elsewhere over the past 15 years have not reduced the flow of people to A&E. So we believe the issue should be dealt with by positioning services where the patient is attending, by co-locating Primary Care facilities with A&E. This approach is supported by leading national bodies including the Royal College of Physicians, the Royal College of Surgeons, the NHS Confederation, NHS England and the Department of Health (England). Beyond this new guidance, the walk-in service has not supported the local health system in the way it was hoped. 1. Despite having the longest opening hours in the borough (8am to 8pm 365 days per year), patients registered at the St Luke s GP practice are higher than average users of the hospital s A&E department. On average there are 102 attendances per month at A&E minors for patients registered at the St Luke s GP practice. This costs NHS Southend CCG 7,780 on average per month through the national A&E tariff. 2. Patients visiting A&E may have to wait up to four hours to be seen. Those with minor ailments would be better served accessing their local GP or pharmacist. 3. Overall attendances at Southend Hospital s A&E department have continued to grow over the past five years whilst the walk-in service manages an additional 1,681 attendances each month, on average. Rather than diverting attendances from A&E, the walk-in service has resulted in an increase in overall activity. 4. The majority of patients who use the walk-in service tell us if the walk-in service did not exist they would not have attended A&E but used other services such as the outof-hours GP service, local pharmacist, NHS 111, their own GP practice or self-care. 5. In Southend 40% of GP practices are not fully open during core hours and many patients are referred to the walk-in service by their own practice, especially at times when they have closed during core hours. 6. The GP out-of-hours service is commissioned to see people outside core hours. A recent national study by the Royal College of Emergency Medicine suggests a third of people are not aware of the out-of-hours service. 7. The walk-in service has had some impact on the St Luke s GP practice patient list, which is capped at 6250. Without the walk-in service, the patient list would likely be able to grow to further as the practice would have had more physical space and so able to increase (for example) the number of consulting rooms.

4 The Options NHS Southend CCG initially shortlisted three options in response to the evidence we had gathered. These were: Option 1 The walk-in service would be maintained and remain in St Luke s with no change in service, co-located with the GP practice. It will relocate with the GP practice to another location within the ward. Option 2 The walk-in service would be maintained but relocated to Southend Hospital with no service change. Option 3 When the current contract for the walk-in service ends, a new service will be developed and this will be co-located with A&E at Southend Hospital. This new service would focus on those patients who attend A&E with an urgent minor ailment or condition, that can be seen by a GP or nurse. This would free up capacity in A&E for those who need more specialised care. Assessing the Options The options were initially assessed against five key criteria and analysed against the current contract values, activity flows and underlying workforce themes. Criteria/ option Option 1 Option 2 Option 3 Clinical viability and patient safety Accessibility Affordability and value Sustainability Implementation Option 3 was the only option to meet all five key criteria. We then carried out a review of the advantages and disadvantages of each option. Option 1 Advantages Familiarity for patients Service would be open to patients 84 hours per week. Disadvantages No improvement in access across the borough Pressure remains on the St Luke s GP practice patient list not to grow whilst sharing premises with the walk-in service Potential for two providers in same location which could increase overall costs and remove economies of scale and be confusing for patients Does not follow the national guidance on co-location of emergency care services

Option 2 Advantages Co-location with the hospital meets national guidance Service would be open to patients 84 hours per week Some pressure relieved on the St Luke s patient list allowing growth. Disadvantages No improvement in access across the borough Potential traffic issues Planning permission needs to be sought No integration with A&E therefore may not support improvements in A&E flow An unchanged service may see activity continuing to grow Option 3 Advantages A primary care led main assessment/treatment urgent care service Service would be open 24 hours a day, 365 days per year including bank holidays A redesigned minors pathway will ensure better availability and flow through the A&E department and better manage patients who need to be treated in A&E Minors redesign will support the hospital to achieve the 4-hour A&E standard in a sustainable way A Central Reception that would be the single point of patient registration for the whole of the minors pathway with a Triage clinician determining if patients should be seen in the UCC A navigation service safely redirects appropriate patients to other community based services Unregistered patients assisted to register with a GP Practice Consulting rooms utilised to facilitate privacy and confidentiality Access to the same diagnostics and investigations currently available in existing A&E department A safe, consistent primary and secondary care joint led minors service to all patients By 8am the next day a patient s GP will have details of the care provided by the UCC and any further information The development of the UCC will be linked to the CCG s work to improve access to GPs across the borough A multi-agency linked and sustained public information campaign about the appropriate use of healthcare services Continued support for an assessment/treatment area for children and this would then be integrated with Trust Paediatric process Patients could be able to book appointments for the follow up of certain conditions (to be prescribed later) Some pressure relieved on the St Luke s patient list allowing further growth whilst remaining in temporary buildings Meeting national guidance on co-location of urgent care services Disadvantages Potential traffic issues Planning permission needs to be sought

Our Key Aims Our governing body has supported option 3 as its preferred option and we are seeking your views to help create a full business case for this option. As this is developed we will be able to look at the detail of the new service to ensure it meets four key objectives: 1. To develop local health services to enable patients to access the right service in the right setting 2. To strengthen the provision of urgent care services across south east Essex 3. To ensure the continued clinical sustainability and safety of the service configuration 4. To address the underlying financial challenges in the unplanned care pathway 5 What Do You Think? When the current contract for the walk-in service ends, we want to develop a new service and this will be co-located with A&E at Southend Hospital. This new service would focus on those patients who attend A&E with an urgent minor ailment or condition, that can be seen by a GP or nurse. This would free up capacity in A&E for those who need more specialised care. We want to know your views and hope you will complete the survey included in this discussion document, or write to us using the contact details below. This consultation will run for 12 weeks until Friday 11 September 2015. You can complete the questionnaire and post it to us for free at: Urgent Care Services Consultation NHS Southend CCG Freepost RTBZ-GAKR-AECG Harcourt House 5-15 Harcourt Avenue Southend-on-Sea Essex SS2 6HE You can complete the same questionnaire online at: surveymonkey.com/r/southeastessex You can email your comments to: sccg.communications@nhs.net You can send your comments to us via the Patient Participation Group at your local GP practice. Please ask at your GP practice for details of your Patient Participation Group.

Questionnaire We welcome any feedback or ideas you have, but we are particularly interested in your answers to the following questions. You do not have to answer all questions and please use extra paper if necessary. Q1. Your GP Practice and Postcode. We would like to know this in order to monitor which respondents are from Southend and which are from Castle Point and Rochford. I am registered at a GP Practice I am not registered at a GP Practice Don t know/would rather not say The name and address of my GP practice Q2. My Postcode

Local health services We want to ask you a few questions about your awareness of local health services and how you use them. Q3. There are a number of ways that people seek treatment and advice for a minor ailment. Minor ailments include coughs, colds and a sore throat, aches or pains, toothache, a rash or a minor burn or injury. Which of the following are you aware of? Yes I am aware No I am not aware Self-care at home GP Practice Pharmacist Dentist NHS 111 The out-of-hours GP service The walk-in service A&E Other (please state)

Q4. If you were suffering from a minor ailment, which of the following would you consider? Yes No Don t Know Self-care at home GP Practice Pharmacist Dentist NHS 111 The out-of-hours GP service The walk-in service A&E Other (please state)

Q5. About 70% of people who use the walk-service were seeking advice or treatment for a minor ailment. What do you think would reduce such attendances? Agree Disagree Don t Know Better information and awareness of how to self-care at home Better use of local pharmacies Better use of NHS 111 Make it easier to book an appointment with a GP Better use of the out-of-ours GP service If you have any other suggestions, please write them here:

Q6. I am providing a response: In a personal capacity As a representative of a group (please give details below) Q7. Our preferred option is Option 3. Please let us know if you agree or disagree with this option. Option 3: When the current contract for the walk-in service ends, a new service will be developed and this will be co-located with A&E at Southend Hospital. This new service would focus on those patients who attend A&E with an urgent minor ailment or condition, that can be seen by a GP or nurse. This would free up capacity in A&E for those who need more specialised care. Agree Disagree Don t Know Q8. If you have any other comments about the issues in this discussion document, please include them in the box below.

Some basic information about you It would be useful to have some information about you, but you do not have to answer the following questions. Q9. Age 14 and under 15-24 25-44 45-64 65-74 75-84 85+ Q10. Gender Male Female Your own term

Q11. Ethnicity White: British Asian or Asian British: Pakistani White: Irish Asian or Asian British: Any other Asian background White: Any other White background Black/African/Caribbean or Black British: African Mixed/Multiple: White & Asian Black/African/Caribbean or Black British: Caribbean Mixed/Multiple: White & Black African Black/African/Caribbean or Black British: Any other Black background Mixed/Multiple: White & Black Caribbean Other ethnic group: Chinese Mixed/Multiple: Any other mixed background Any other ethnic group Asian or Asian British: Bangladeshi I d rather not say Asian or Asian British: Indian

Q12. Please select the option which best describes your sexuality Lesbian Gay Heterosexual Bisexual I d rather not say Q13. Which belief or religion, if any, do you most identify with? Agnostic Judaism Atheism Sikhism Buddhism Prefer not to say Christianity Other Hinduism I d rather not say Islam

Q14. Do you consider yourself to have a disability? Yes No I d rather not say

Q15. FOR RESIDENTS OF SOUTHEND-ON-SEA ONLY. New and permanent premises are being sought for the GP practice at St Luke s Health Centre. Please look at the options below and consider what your priorities are for new premises. Please decide which is the most important option and write the number 1 in the box next to that. Then decide which is the second most important and write the number 2 in the box next to that and so on, until you have listed each option from most to least important. It needs to be close by There needs to be adequate parking There need to be good public transport links It needs to be a brand new building It needs to be a large building Please add any other comments here:

Q16. FOR RESIDENTS OF SOUTHEND-ON-SEA ONLY. What health services would you like to see delivered from the new premises? NHS England will also survey patients of the St Luke s GP practice separately about the services available.