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Urgent Care and GP Services at Hemel Hempstead Hospital Public Consultation

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Introduction

Herts Valleys Clinical Commissioning Group is developing a new approach to urgent care in west Hertfordshire that takes into account developments in health services nationally and locally.

In line with our Your Care, Your Future aims we are looking at how we can make the best use of NHS resources to ensure patients receive effective, timely care appropriate to their needs and make sure that care is delivered in the right place and as close to home as possible.

This consultation focuses on the future access to services at the urgent treatment centre and West Hertfordshire Medical Centre which are located in Hemel Hempstead Hospital.

We need to make a decision on future opening hours for the urgent treatment centre which has been operating on reduced hours since December 2016.  Difficulties with filling GP shifts overnight was resulting in ad hoc closures and led to the provider, West Herts Hospitals NHS Trust, notifying the CCG that they needed to temporarily reduce the contracted 24 hours and move to interim hours of 8am to 10pm. The urgent need to address patient safety issues did not allow time for consultation about this temporary change. We are seeking the views of patients and others on options for permanent hours in line with the previous commitment to consult on this issue.  

The West Herts Medical Centre operates on a fixed term alternative provider of medical services (APMS) contract which due for renewal in October 2018. We need to make a decision on the contract for services to registered patients and want to take account of people’s views.

This consultation is open to anyone with an interest in services provided at the Urgent Treatment Centre and West Herts Medical Centre at Hemel Hempstead Hospital.

This document provides more information about the future direction of urgent care and other services and explains the issues that need to be taken into account when making future decisions about services.

The following public meetings have taken place (use the hyperlink to see presentations from each meeting)

Monday 12 February, Berkhamsted (Dacorum area)

Wednesday 21 February, Hemel Hempstead (Dacorum area)

Tuesday 20 March, Borehamwood (Hertsmere area)

Wednesday 21 March, St Albans (St Albans and Harpenden area)

Thursday 22 March, Watford (Watford and Three Rivers area)

 

About us

Herts Valleys Clinical Commissioning Group (CCG) is the local NHS organisations that plans and pays for local health care and make sure that residents across west Hertfordshire receive good care. We are led by local doctors representing the needs of their patients and the views of their GP colleagues, as well as ‘lay’ members, who are not doctors and represent local communities.

The challenges we face

Across the NHS services are under pressure. We have to make sure that doctors’, nurses’ and other specialists’ time is used wisely and that patients get the right level of care for their needs in a timely way.

There is particular pressure on A&E services which should only be accessed for genuine emergencies where people’s lives or limbs are at risk or on the advice of a medical professional. All less serious problems can be dealt with by urgent care services including GPs, urgent treatment centres or minor injuries units and NHS111. We need to educate patients and others about the best place to go for particular problems.

Historically there has been a variation between the services available at urgent care or urgent treatment centres and minor injuries units which can be confusing for patients. Additionally some people aren’t fully aware of the help available through services such as the non-emergency NHS111 service. The CCG’s emerging approach to urgent care aims to address this by bringing together various parts of the NHS, including hospital and ambulance services, to create a more joined-up system that is easier to understand.

Our approach to urgent care is linked to our plans for GP extended access.

Whatever solution we agree has to be lasting and realistic and also fit with the overall direction for NHS services locally and nationally.

Urgent Care Services

What is the difference between emergency and urgent care? 

Urgent care services are available to treat people who need immediate attention for an illness or injury that isn’t life threatening. The chart below outlines the difference between urgent and emergency care and where to go with particular problems.

 Emergency
 Urgent
 Risk to life or limb
Immediate attention but no threat to life or limb  
 
  • Severe chest pain
 
  • Sprains, strains and muscular, back or joint pain
 
  • Suspected heart attack
 
  • Fractures or broken bones
 
  • Breathing difficulties
  • Cuts, wounds, bites and stings
 
 
  • Severe bleeding
 
  • Minor burns and scalds
 
  • A serious head injury
 
  • Minor head and eye injuries
  •  Suspected stroke including paralysis
  • Objects stuck in ears and noses
 
 
  • Skin complaints
 
  • Minor illnesses

In west Hertfordshire there are a number of non-emergency services that can offer rapid care or advice from health professional. 

Walk-in hospital services

Urgent Treatment Centre (UTC)

  •     Open 8am-10pm (temporary hours)
  •      GP led
  •     Walk-in services for all patients
  •     Able to test for and treat a wide range of urgent health issues
  •     Can offer x-rays, ultrasound, electrocardiograph, blood glucose monitoring, urine and pregnancy testing and urine monitoring

West Herts Medical Centre (WHMC)

  •    Open 8am-8pm
  •    GP led health centre adjacent to UTC with a shared   front desk
  •      Walk-in services for all patients (sees around 8,000 people a year) and has its own list of approximately 2,000 registered patients.
  •    Walk-in patients are assessed by a nurse and directed to either West Herts Medical Centre or the UTC.

Telephone service

NHS 111

  •      Free 24/7 NHS non-emergency number.
  •       Calls are answered by trained healthcare adviser, backed by a clinical assessment team including GPs, nurses, prescribing pharmacists and paramedics
  •     Provides advice on self-care or signposts to best service for patient’s assessed needs
  •     Can book people into appointments or arrange visits from GPs or nurses 24/7.
  •     Will call ambulances directly in serious cases.

Community-based services

GP

  •        Working towards all west Hertfordshire residents being able to see a GP locally outside of normal practice hours during evenings and at weekends.
  •       GP out-of-hours available via NHS111 or a redirect from a surgery phone number. May offer home visit if patients unable to get to walk-in centre

Pharmacists

  •       Free, confidential advice to help with many common illnesses and complaints.
  •       Late opening pharmacists in each area and many are open at weekends too.

Our plans for urgent care services

We are developing a new urgent care strategy for west Hertfordshire with the aim of ensuring that patients receive effective care first time, in the right place and in a timely way. Our urgent care strategy follows NHS England’s national plan for strengthening urgent care services so that more patients with non-emergency care needs can be treated locally to help release pressure on hospitals and particularly on A&E departments. This will allow hospital staff to focus on emergencies and life threatening situations and enable all who arrive at A&E to receive the appropriate level of treatment and care.

We are developing shared procedures with all local NHS services so that patients who are assessed as having a non-emergency condition are seen in urgent care services rather than in A&E.

Our plans have a number of key elements:

NHS 111

  • There will be a greater focus on the NHS 111 service – as the ‘front door’ into urgent care for everyone.
  • The local NHS 111 service has been enhanced to ensure that people calling the service have clinical assessments by a team of health professionals from different specialisms at the earliest possible stage.
  • The clinical assessment team can arrange for people to speak directly a GP, can book people into appointments or arrange visits from a GP or specialist nurse. They can also call ambulances if needed.

Urgent treatment centres (UTCs)

  • UTCs are a key part of the national plans and are designed to diagnose and deal with the most common ailments seen at A&E. They aim to provide a standardised service in place of the current mix of walk-in urgent care and minor injuries services.
  • On 1 December 2017 the urgent care centre at Hemel Hempstead Hospital became a UTC in the first wave of a national roll-out. The UTC provides an enhanced service including booked appointments through NHS 111 and increased on-site testing for conditions such as sepsis and thrombosis to provide patients with results from the centre itself, reducing waits at or trips to Watford General Hospital.
  • While anyone can use the Hemel Hempstead UTC we are developing urgent care services in other parts of west Hertfordshire, tailored to local needs. In keeping with our commitment to provide care close to home we will look at how we can increase local access to services such as diagnostic tests. We will consult separately on the development of these local services.

GP extended hours

  • We are increasing access to GP services outside normal practice hours across the patch.
  • We are making good progress on plans for all west Hertfordshire residents being able to see a GP locally during evenings and at weekends by 2019, making a significant difference to the ability of patients to access primary care services.
  • We will provide over 50% coverage of extended hours by March 2018

West Herts Medical Centre (WHMC)

  • As part of plans to streamline and simplify services for patients and make better use of the resources, we aim to merge walk-in services at the WHMC with the UTC.
  • Merging the services will give all patients the benefit of the enhanced services at the UTC and means we can make better use of available GPs.

Key factors in looking at future options  

In looking at future options for the Urgent Treatment Centre and West Herts Medical Centre at Hemel Hempstead Hospital we need to bear in mind the following considerations.

We need to make the best possible use of our limited clinical workforce

  • GPs are at the heart of urgent care service but they face huge demands on their time. The national shortage of GPs is reflected locally in west Hertfordshire where the number of GPs per patient is below the national average. The local and national work to address the shortfalls won’t deliver quick results and we need to assume our workforce challenges will be with us for years to come.
  • A GP who does shifts in an urgent treatment centre; A&E, NHS111 or in the out-of-hours GP service does this on top of their practice responsibilities which will increase with the move to seven day working. If a GP works overnight they cannot be in their practice seeing patients from 8am the next morning.
  • Activity levels in the UTC are significantly lower at night. The table below shows that when the urgent care centre at Hemel Hempstead hospital was open 24 hours few patients attended between 10pm and 8am. Demand during core hours has remained the same.
  APRtoMAR APRtoMAR APRtoMAR      

Average UCC/UTC attendance per day by the hour of the day

2015/2016

2016/2017 

2017/18 to date

Total Av 15/16 Total Av 16/17

Total Av 17/18

12am to 3am

2.4

1.7

0.0

7.2 5.3

0.0

>3am to 6am

1.8

1.2

0.0

>6am to 8am

3.1

2.4

0.0

>8am to 12pm

23.0

24.3

27.5

74.2 76.9

84.9

>12pm to 3pm

15.9

15.9

18.4

>3pm to 6pm

15.2

15.6

17.4

>6pm to 10pm

20.1

21.2

21.7

>10pm to 12am

3.7

2.8

0.0

3.7 2.8

0.0

The change in hours hasn’t led to a corresponding increase in A&E attendances at Watford General Hospital or other local hospitals or additional pressures on the out-of-hours service.

Access to urgent care

Irrespective of the future hours of the UTC, overnight services for people who need urgent care or who need to speak to or see a GP are available through NHS 111 and the out-of-hours service.

Patient safety

Patient safety is of paramount importance. We need to put in place a service that we know we can deliver and that patients can rely on. We need to avoid ad hoc closures of the service with little or no warning as has been the case when the UCC in Hemel was open overnight. 

Consultation

  1. Urgent Treatment Centre Opening Hours

We are seeking feedback on the following three options for opening hours for the UTC at Hemel Hempstead Hospital.

For each option access to the UTC will be in addition to the following other urgent care services:

  • NHS 111 - available 24/7
  • GPs out of hours service (via NHS 111)
  • GP extended hours
  • Walk-in services for emergencies at Watford General Hospital as well as at other nearby hospitals such as Luton and Dunstable and The Lister (Stevenage).
 

UTC Opening hours

Staffing

Comments

Option one

UTC open 8am – 10pm*; current temporary hours

UTC to be GP-led, with nursing, advanced nursing and reception support

1. GPs will cover the UTC opening hours as well as existing services such as NHS 111, the UTC and GP out-of-hours. Current opening times make it feasible for GPs to work in the UTC and still be available in surgery the following morning.

2. No walk-in  service overnight at the UTC

3. There is a possibility that people may go to Watford or other A&E departments out of hours for non-life threatening issues.

Option two

8am – midnight*; an additional two hours over and above current hours

GP-led, with nursing, advanced nursing and reception support.

Shift patterns to take into account  additional two hours

1. More convenient for patients to be able to attend the UTC until 12midnight.

2. We need to consider GPs’ ability to cover a shift that means them working until 1am* if they are due to see patients in their surgery from 8am the following day.

3. Demand and use of resources. The activity chart above shows that few patients arrived at the UCC after 10pm.  

Option three

24 hours a day.

As per substantive contract.

GP-led, with nursing, advanced nursing and reception support

1. Continued GP shortages means that difficulties with filling overnight shifts at the UTC could still be an issue. Staffing difficulties may increase in the context of GPs working extended hours in practices.  

2. If an inability to fill shifts leads to ad hoc closures this would be inconvenient for patients and could be detrimental if the service is withdrawn unexpectedly.

3. The table above shows that activity levels are very low overnight. We need to consider if this is the best use of professional staff time.

4. Having a 24 hour service in Hemel Hempstead might reduce the number of people going to A&E for help with non-life threatening problems

*Services stay open for an hour after the stated closing time to treat patients who are already there.

Consideration of a nurse-led service. The team has assessed a further option for an overnight nurse-led service to help overcome the issues around GP availability.  We concluded that this is not a viable option as it is not clinically sound. Low attendances (as shown below) would mean that nurses working the night shift at the UTC would have insufficient throughput of patients to maintain their competency and skill levels.  In addition, we have patient safety concerns about running a service that had a different skill mix at night from the service experienced by patients during the day. Overnight patients would receive a more limited service. 

  1. Future contract for services to West Herts Medical Centre registered patients

As stated previously, in order to streamline services and make better use of clinicians’ time we aim to merge the walk-in part of West Herts Medical Centre into the UTC to create a single service. The budget for treating non-registered patients will be reallocated to the UTC.

There are two options relating to the remaining service for the 2,000 patients who are registered with West Herts Medical Centre.

 

Description

Details

Considerations

Option one

Do not renew the contract and support patients to re-register with other practices

There would be a year’s transition payment for GP practices accepting the registered patients to allow them to take on any additional activity. This would be in addition to the payments made to practices in accordance with size of patient list.  

1.     There are a number of practices near to WHMC, one of which is very close.

2.     Other practices have indicated support for taking on WHMC patients.

3.     Patients would still be able to use the walk-in service at the UTC to see a GP – although walk-in appointments cannot be pre-booked.

4.     Other practices offering extended hours would mean that patients would still have access to appointments at evenings and weekends through their new practices.

5.     Patients would have to move to a new GP who would not be so familiar with their medical history.

Option two

Renew the contract when it expires in October 2018.

Put out the WHMC contract for registered patients to a commercial, competitive procurement.  This would be a new alternative provider of medical services (APMS) contract starting from November 2018. Again this would be time-limited (five years) with a decision needed at the end of the contract about whether to renew it.

1. This would be the least disruptive option (short-term) for patients registered with WHMC.

2. This would be a five year contract and the CCG would need to consult again at the end of that period about renewing the contract.

3. Having 2,000 registered patients would mean this is a small practice – the average practice has 9,000 patients. The number of patients affects how much funding a practice receives and this in turn affects the range of services they can provide. 

4. A small practice may find it more difficult to recruit and keep GPs and staff shortages may pose more of a problem than in larger practices.

5. We may not attract potential providers who are willing to invest time and money in bidding for a time-limited contract and taking on what is a small patient list size.

 

Consultation and decision making.

The above consultation ran between 31 January and 28 March 2018.

We have worked with patient participation groups and local community and voluntary organisations to make sure this consultation reaches as many local people as possible.

Thank you to everyone who took the time to attend a public meeting, to complete a questionnaire or to send your views in writing.

Your views will help inform our decisions about opening hours for Hemel Hempstead Urgent Treatment Centre and the contract for West Herts Medical Centre.

An independent research company is reviewing and analysing all the comments received from individuals and organisations, including verbal feedback at events as well as written responses. They will compile all feedback into a summary report. This will be presented to the Herts Valleys CCG board meeting in public in May when a decision on both issues will be made.

Suggestion box update

Comments placed inside the suggestion boxes at Hemel One and Apsley 2 from 23 May to 24 June were discussed by the staff involvement group. The Suggestion boxes update is here together with the outcomes of actions the staff involvement group asked to be taken forward.

August desk availability calendar

Staff can print the calendar for August to highlight any day/s when they will be out of the office. When applicable, the calendar should be attached to your desk monitor so the desk can be easily identified as being available for use. Please be respectful of others and be sure to leave the workstation area as you found it.

Staff awards

Some more details on these awards which will be launched soon. There will be two awards each quarter – one for an individual and one for a team. They will be based on our values. If you think there is someone/a team at Herts Valleys CCG who represents any of the values, you will be able to download and fill in a form from the intranet. A panel will then judge the winners. The first awards are due to be made in September. More details in future issues of this round-up.

Teams

Some teams that you may