technical document – emergency and urgent care august 2012 · 2012-09-12 · technical document -...

Technical Document - Emergency and Urgent Care Final August 2012

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Technical Document – Emergency and Urgent Care August 2012


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CONTENTS ..................................................................................................2 TABLE OF FIGURES................................................................................... 3 1. INTRODUCTION .....................................................................................4 2. HEALTH NEED........................................................................................5

2.1 Hywel Dda Health Board Demography ............................................5 2.2 Levels of Deprivation........................................................................7 2.3 Population Projections for Hywel Dda Health Board ........................8

3. STANDARDS, POLICIES AND GUIDANCE.........................................12........................................................................................................................ 4. CURRENT SERVICES .........................................................................15 5. SERVICE PROFILE..............................................................................16 6. HOW WE COMPARE AGAINST THE STANDARDS` ..........................34 7. OPTION APPRAISAL SEPTEMBER 2011 – PRE LISTENING & ENGAGEMENT STAGE .......................................................................36 ........................................................................................................................ 8. LISTENING & ENGAGEMENT PROCESS...........................................51 9. CONCLUSION AND RECOMMENDATIONS .......................................52 10. BIBLIOGRAPHY ..................................................................................53


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TABLE OF FIGURES FIGURES TITLE PAGE1. Hywel Dda Health Board Demography 5 2. Population Pyramid for Hywel Dda Health Board and Wales 6 3. General Fertility Rate Trend, Wales & Hywel Dda LHB 7 4. Overall Welsh Index of Multiple Deprivation 2008 8 5. Population Projections for Hywel Dda Health Board 9 6. Hywel Dda Health Board 10 7. Travel Times to Hywel Dda Health Board Hospitals 12 8. Demand for Emergency Care at each Hospital Emergency Dept 17 9. ED Attendance, Split into Major/Minor Condition for each

Hospital ED Site 18

10. Ages of Attendance Across all Hospital ED’s 19 11 Emergency Department Attendances by County of Residence 19 12. Numbers of Hywel Dda Residents by Locality that Attend Major

ED’s within Abertawe Bro Morgannwg UHB 20

13. Number of Emergency Attendances a the Minor Injury Units in Community Hospitals within Hywel Dda

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14 Monthly Profile of MIU Attendances 22 15. Attendances by time of day at Tenby and South Pembrokeshire

Hospitals 22

16. Total Numbers of Incidents in Hywel Dda Area 23 17. As Incident by Hour 25 18. Hospital Transfers Undertaken by WAST 26 19. Number of Inter Hospital Transfers Undertaken as 999 Calls 30 20. Hywel Dda Patients taken Directly to an Out of Area Hospital 31 21. Demand for Urgent Care at GP Out of Hours Service Providers

within each County 32

22. Medical Staffing Rotas 33 23. College of Emergency Medicine Guidelines Compliance 35 24. Results from Clinical Options Appraisal Workshop 13 September

2011 48

25. Statistics for Emergency Departments 49 26. Weighted Results 50


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Emergency and Urgent Care 1. Introduction This technical document provides information on the current services delivered for emergency and urgent care by Hywel Dda Health Board.

The technical document will be used to evidence the need for change and develop our services for emergency and urgent care. As such, the following areas are explored:

The health needs for the Hywel Dda area: a needs assessment for

Hywel Dda highlighting key issues for emergency and urgent care An overview of current services: provides a snapshot of our current

services for emergency and urgent care. More detailed information is then provided on attendances at emergency departments and minor injury units across Hywel Dda.

Analysis: statistical information on activity for emergency and urgent

care’s services is provided for. Information about our current workforce is also provided.

Standards and the Case for Change: key national standards, policies

and guidance are listed for emergency and urgent care’s services. These standards are used to justify the Case for Change.

Benchmarks: our performance against key standards is summarised.


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2. Health Need

2.1 Hywel Dda Health Board Demography Hywel Dda Health Board covers the three counties of Carmarthenshire, Ceredigion and Pembrokeshire. Around 375,000 people live within the Hywel Dda Health Board area, however around 388,700 people are registered with GPs in the area. The catchment population for our services extends into South Gwynedd, Powys and Swansea. The geographical boundaries of the Health Board are shown in the map below.

. Figure 1: Hywel Dda Local Health Board area

Hywel Dda Health Board Borth

Aberystwyth

Llanilar

Tregaron

AberaeronNewquay

Cardigan

NCELlandysul

Llanbydder

Lampeter

NewportFishguard

Solva

Haverfordwest

Milford Haven Neyland

Pembroke Dock

Narberth43

Whitland St Clears

Carmarthen

FerrysideKidwelly

Burry Port

Trimsaran

Llanelli

LlangennechPontyates

Pontyberem

Tumble

PenygroesAmmanford

Llandeilo

Llandovery

Saundersfoot

Tenby

- GP practices

- Hospitals with A&E

Hywel Dda Health Board covers a quarter of the land mass of Wales but contains only 13% of Wales’ population. It is the second most sparsely populated health board area. 31.4%, 47.9% and 20.7% of the population live in the local authority areas of Pembrokeshire, Carmarthenshire and Ceredigion respectively.

With 30% of Wales’ population the area’s age and sex profile is similar to that of Wales as a whole (Figure 2), but there are notable differences with fewer people aged 25-44 and more people aged 55-79.


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Figure 2. Population Pyramid for Hywel Dda Health Board and Wales

Across Wales and the UK the general fertility rate, the number of births per 1000 women of child bearing age, has been falling until 2001/2002. However it has been slowly rising since (Figure 3). The Hywel Dda Health Board area general fertility rate is lower than the Wales rate but closely reflects the Welsh pattern.


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Figure 3

2.2 Levels of Deprivation Geographically based deprivation measures can be used to show inequality in health and suggest areas likely to most need measures to improve health and manage ill health. The Welsh Index of Multiple Deprivation, 2008, is produced at small area levels called lower super output areas (LSOA), and is derived from a broad range of factors. In Hywel Dda LHB there are areas of deprivation including parts of Llanelli, Pembroke Dock and Cardigan (Figure 4).


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Figure 4. Overall Welsh Index of Multiple Deprivation 2008

0 10 20

miles

Carmarthen

Aberystwyth

Llandovery

Llandeilo

LlanelliBurry Port

Pembroke Dock

Milford Haven

Fishguard

Haverfordwest

Lampeter

Cardigan

St David's

Overall Welsh Index of Multiple Deprivation 2008Fifths of deprivation, Low er Super Output Areas, Data source: WAG

Most deprived (22)Next most deprived (41)Median (90)Next least deprived (66)Least deprived (11)

Motorway

A Roads

Local authority boundary

This map is reproduced from Ordnance Survey material with the permission of Ordnance Survey on behalf of the Controller of Her Majesty's Stationery Office © Crown copyright. Unauthorised reproduction infringes Crown copyright and may lead to prosecution or civil proceedings. Wales Centre for Health. Licence Number: 100044810. 2009

22 out of 230 LSOAs in the Health Board (10%) are among the most deprived fifth in Wales with 11 out of 230 (5%) in the least deprived fifth. However, within less deprived areas there are often pockets of hidden deprivation. 2.3 Population projections for Hywel Dda Health Board The latest projections indicate that if current trends continue, the number of persons aged 65 and over resident in Hywel Dda Health Board will increase by 67 per cent between 2008 and 2033. The proportion aged 75 and over is projected to increase from around 10 per cent at local authority level to around 16 to 18 per cent over this period, the sharpest increases being in Ceredigion and Pembrokeshire. The percentage aged 85 and over is projected to more than double from around three per cent to six to seven per cent by 2033. (Figure 5).


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Figure 5. Population Projections for Hywel Dda Health Board

-20

-10

0

10

20

30

40

50

60

70

80

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

2032

2033

Perc

en

tage c

han

ge fro

m 2

00

8

0-15 16-24 25-44 45-64 65+

Produced by the Public Health Wales Observatory, using data from the Welsh Assembly Government

2008-based population projections for Hywel Dda Health Board, persons: 2008 to 2033

These estimates are based on assumptions about births, deaths and migration. The increase in the number of older people is likely to cause a rise in chronic conditions such as circulatory and respiratory diseases and cancers. Meeting the needs of these individuals will be a key challenge of the Health Board. In the current economic climate the relative (and absolute) increase in the economically dependent and, in some cases, case dependent populations will pose particular challenges to communities. Hywel Dda Health Board Organisation Hywel Dda Health Board’s acute and community services are currently delivered by four main district general hospitals, eight community hospitals, eleven health centres and other accommodation. Additionally there are numerous settings across the three counties from which mental health, learning disabilities, rehabilitation, psychotherapy and neurophysiology services are provided.


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Figure 6. Hywel Dda Health Board

The four main district general hospitals serving the Hywel Dda Health Board area are Glangwili General Hospital in Carmarthen, Prince Philip Hospital in Llanelli, Withybush General Hospital in Haverfordwest and Bronglais General Hospital in Aberystwyth. The eight community hospitals comprise Mynydd Mawr Hospital, Amman Valley Hospital and Llandovery Hospital in Carmarthenshire, Tenby Hospital and South Pembrokeshire Hospital in Pembrokeshire and Cardigan Hospital, Aberaeron Hospital and Tregaron Hospital in Ceredigion. Hywel Dda Health Board in addition to providing care for residents of Carmarthenshire, Ceredigion and Pembrokeshire also provides care for some residents of Powys, South Gwynedd and Swansea whilst some Hywel Dda Health Board residents also receive care at Abertawe Bro Morgannwg University Health Board Hospitals.


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Primary care services are delivered by 55 GP practices (main sites) where GPs provide essential services to their registered population including people with long term diseases. They also provide vaccination and immunisation, minor surgery procedures and enhanced services such as diabetes and sexual health. There are also 51 dental practices, 100 community pharmacies and 52 optometry premises. The vast majority of the Hywel Dda population live within a relatively short travelling time of some form of healthcare facility. This may be their GP surgery or a community hospital. Within Hywel Dda 97% of residents live within 30 minutes and 100% within 35 minutes from a District General Hospital or Community Hospital.

Number and proportion of Hywel DdaHealth Board residents in each traveltime band to any hospital

Travel time (minutes)

Number %

<15 218,780 58.415 - 29 145,754 38.930 - 35* 10,058 2.7

Produced by Public Health Wales Observatory, using MYE 2009 (ONS), MapInfo Drivetime * maximum travel time

(NB: These times are based on travel by car)


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Figure 7: Travel Times to Hywel Dda Health Board Hospitals

In relation to GP surgeries the position is even stronger with 99% of the Hywel Dda population living within 30 minutes of their GP practice.

3. Standards, Policies and Guidance This section looks at the standards and policies that guide the planning and delivery of emergency and urgent care. As with all the evidence it is not always unequivocal and much of it is based on expert opinion and available information rather than detailed research trials. However, there are many pieces of evidence that point to similar conclusions and as such gives sufficient weight for us to consider this in the planning of services. The following documents outlining the recommended quality standards are the ones mainly considered in this section.

- The College of Emergency Medicine – The Way Ahead - 2008-2012. Strategy and Guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland;


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- College of Emergency Medicine British Association for Emergency Medicine – The Reorganisation of Emergency Services (England) July 2007;

- Setting the Direction – Primary and community services strategic delivery programme;

- Setting the Direction (Hywel Dda) ABC of Community Services; - Ten High Impact Steps to Transform Unscheduled Care; - Urgent Care, a practical guide to transforming same-day care in

General Practice; - RCGP Guidance for Commissioning Integrated Urgent and

Emergency Care – ‘A Whole System’ approach; and - Unscheduled Care Maturity Matrix (Draft - September 2011).

With regard to trauma and emergency care the standards and the discussions of the evidence across Wales makes these significant points;

Major Trauma - There is evidence that there are significant outcome benefits for patients with major trauma when treated in a dedicated major trauma centre. The Royal College of Surgeons (RCS) have also stated the view that, as a minimum, major trauma centres should admit more than 250 critically injured patients per year.

The RCS cites a number of pieces of evidence in support of major trauma centres:

Regionalisation of care to specialist trauma centres reduces mortality by 25% and length of stay by 4 days.

High volume trauma centres reduce death from major injury by up to 50%.

Time from injury to definitive surgery is the primary determinant of outcome in major trauma (Not time to arrival in the nearest emergency department).

Major trauma patients managed initially in local hospitals are 1.5 to 5 times more likely to die than patients transported directly to trauma centres.

There is an average delay of 6 hours in transferring patients from a local hospital to a specialist centre. Delays of 12 hours or more are not uncommon.

Long pre-hospital times have a minimal effect on trauma mortality or morbidity – even in very rural areas such as the West of Scotland.

None of the emergency departments in Hywel Dda Health Board are major trauma centres. Patients with major trauma are currently transported to the major trauma units at Morriston Hospital, Swansea or the University Hospital of Wales, Cardiff.

General Trauma and Emergency Care –There is evidence for some patients (such as patients with ruptured abdominal aortic aneurysms) of outcomes improving as unit size increases, but it is not statistically significant. Services


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that meet clinical standards and consistently follow recommended pathways make the most difference, whatever the size of the unit. There is increasing evidence that outcomes are better when there are more senior doctors on site 24/7 and this is becoming increasingly difficult to achieve in smaller units.

The Royal College of Physicians and the Royal College of Surgeons have stated that high-quality emergency medicine and surgery services need a critical mass of medical consultants and a minimum amount of immediately available diagnostic equipment and treatment facilities. The Royal College of Surgeons recommends that a safe major Accident and Emergency department should service a population of no fewer than 300,000 (Royal College of Surgeons, 2008). This is on the basis that it would enable the provision of clinically viable accident and emergency departments with a minimum of 8 - 12 consultants, working in multi-disciplinary teams with experienced nurses and therapists, to provide 24 hour coverage. The College states that teams should experience sufficient volume to maintain a high skill level, noting that if this is not the case then it is increasingly likely that people with life threatening conditions are treated by someone who is not fully trained, particularly out of hours The Royal College of Physicians (RCP) has also highlighted a need for greater senior medical input 24 hours a day, 7 days a week, citing mounting evidence of substandard care delivered to patients who are admitted to hospital in the evening and at the weekend. The College believes that this is related to the difficulties in providing sufficient input to these patients from consultants. The RCP has also found that the supervision and training of junior doctors is also adversely affected by a lack of senior input at these times. As a result, the RCP has recommended an urgent review of rotas and the structure of the entire medical team to ensure that medical inpatients receive direct input from consultant physicians on a 7 day a week basis (Royal College of Physicians 2010). The College of Emergency Medicine in their document “The Way Ahead” make recommendations of the resources required in all emergency departments;

The presence of a doctor (ST4 or above) trained and experienced in emergency medicine 24 hours a day

Up-to-date facilities for resuscitation, emergency care and ambulatory care

The ED should be supported by the seven key specialties (general medicine, anaesthesia /ITU, surgery, orthopaedics, paediatrics, radiology and laboratory services).

24/7 access to x-rays, ultrasound and computed tomography (CT) Timely support from inpatient teams and efficient procedures for

admission to hospital A clinical decision unit (CDU)/observation ward Information and records system linked to the hospital and

community care records


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Educational and administrative space

4. Current Services There are Emergency Departments and Urgent Care provision in all counties together with minor injury services provided in some Community hospitals and the majority of General Practices (GPs). The definitions for Emergency Departments are as follows:

• A Major Emergency Department (Type I ) – is defined as a consultant led service with appropriate resuscitation facilities available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. A major ED should be supported by the seven key specialties; Medicine, Surgery, Orthopaedics, Paediatrics, Anaesthetics and Critical Care, Imaging and Laboratory support.

• An ED (Type 2) is defined as all 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.

Ref. (WHC (2006) 034) Within Hywel Dda, there are:

• Three major Emergency Departments(EDs) (Type 1) in: o Carmarthenshire at Glangwili General Hospital o Ceredigion at Bronglais General Hospital o Pembrokeshire at Withybush General Hospital

• One ED (Type 2) within Carmarthenshire at Prince Philip Hospital – this is currently ‘signposted’ as an Accident and Emergency department it, however, does not meet the criteria of a Major Type 1 facility as it can not mange surgical or paediatric emergencies. This leads to confusion about what care is available at Prince Philip Hospital, which will require additional clarification in the future.

• Minor Injury Units in: o Carmarthenshire at Llandovery Community Hospital o Ceredigion at Cardigan Community Hospital o Pembrokeshire at South Pembrokeshire Hospital and Tenby

Hospital • GP Minor Injury Services in 53 of the 55 GP practices across Hywel

Dda. • Out of Hours (OoH) GP services providing access to Urgent Care are

provided within each of the 3 Counties.

New Major Emergency Departments (Type 1) have recently opened (2010) at Glangwili General Hospital and Withybush General Hospital. Building work has recently commenced at Bronglais General Hospital to establish a new ED (Type 1) and Clinical Decision Unit, due to open May 2013. An Adult Clinical Decision Unit is under construction at Glangwili General Hospital, due to open


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in August 2012. All three Emergency Departments have/will have access to a full range of supporting services. At Prince Philip Hospital the medical support (Type 2) is delivered differently from the major EDs, the support is provided as follows

- 8am-10pm , seven days per week by Consultant, Middle Grades and Junior Doctors

- 10pm -8am by GPs.

Complex cases are stabilised and transferred from Prince Philip Hospital to Glangwili General Hospital or, for a number of patients with specific conditions, to other hospitals in neighbouring Health Boards. Protocols are in place, with the Welsh Ambulance Service NHS Trust (WAST) for this transfer. Within Hywel Dda, all surgical emergency and Paediatric services for the Llanelli area are currently provided in Glangwili General Hospital. Prince Philip Hospital only undertakes elective general surgery. The decision to split emergency and elective surgery in Carmarthenshire was made in 2006 following a Royal College of Surgeons independent review and a recommendation that emergency and elective surgery should be split. A public consultation followed and the decision taken that all emergency general surgery should be undertaken at Glangwili Hospital due to the inability to sustain services on both sites. Hywel Dda Health Board is not re-visiting this decision as all of the reasons for the change are still relevant. 5. Service Profile Activity profiles for access to Emergency and Urgent Care services are described below. Whilst activity data is available for a number of years only the last or last two years have been provided in this report:


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Figure 8 illustrates the demand for Emergency Care at each Hospital Emergency Department.

County Hospital Total Emergency Department Attendees

Attendances by Emergency

Ambulance

Self Referrals

Glangwili General Hospital

38,857 (24% admitted)

10,530 (52.9%

admitted)

28,073 (13.2%

admitted)

Carmarthenshire

Prince Philip Hospital

33,601 (10.4%

admitted)

3,869 (51.2%

admitted)

29,429 (5.0%

admitted)

Ceredigion Bronglais General Hospital

26,577 (19.4%

admitted)

5,237 (52% admitted)

20,836 (11.5%

admitted)

Pembrokeshire Withybush General Hospital

35,972 (22.4%

admitted)

8,412 (57.7%

admitted)

27,131 (11.6%

admitted) Source: Myrddin CiS 2011/12 The table details:

- numbers of people who self refer; - those who attend the ED by emergency ambulance services and - Percentage of the attendees who subsequently need admission into an

inpatient bed Figure 8 above demonstrates:

- At Prince Philip Hospital, a lower percentage of the total ED attendees (10.4%) and the self referral attendees (5%) are admitted.

- At Bronglais General Hospital, Glangwili General Hospital and Withybush General Hospital the percentages of ED attendances that are admitted are broadly similar (within a 3% differential)

- At Prince Philip Hospital, there is a lower number of attendees who are brought in by emergency ambulance services. (All surgical emergency cases and paediatric cases are currently seen in Glangwili General Hospital for Llanelli residents.)


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Figure 9 illustrates the ED attendance, split into major/minor condition for each of the Hospital ED sites:

2010/2011 2011/12 Hospital Patient Condition Total

numbersPatient Condition

Total Numbers

Major Minor Major Minor Bronglais General Hospital

25,940* 25,940 4384 22194 26578

Llandovery Hospital

260 260 1 254 255


6,419 27,155 33,574 6674 26927 33601

South Pembrokeshire Hospital

14 4,112 4,126 20 2988 3008

Tenby Cottage Hospital (New)

- 5,324 5,324 57 4635 4692


13,041 24,827 37,868 13041 25816 38857

Withybush General Hospital

8,801 26,882 35,683 11828 24144 35972

Cardigan Hospital 2, 173* 2,173 2123* 2123 Source: Myrddin CiS 2012 * Bronglais General Hospital and Cardigan Hospital did not have the ability to split attendances between minor and major during 2010/11 due to system limitations. Figure 9 demonstrates;

- A large proportion (80%) of the attendances at Prince Philip Hospital are classified as Minor cases. Prince Philip Hospital is classified as a Type 2 Emergency Department as there is not the full range of support services on site. This reflects the fact that surgical emergencies are already managed for Carmarthenshire at Glangwili General Hospital and should not present at Prince Philip Hospital.

- 19% of total ED attendances at Prince Philip Hospital are Major cases, 25% at Withybush General Hospital and 34% at Glangwili General Hospital.

- In Prince Philip Hospital these attendees categorised as major will be predominantly medical cases


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Figure 10 illustrates the ages of attendances across all hospital EDs:

Source: Myrddin CiS 2012 Figure 10 above demonstrates the pattern of demand, split into various age group bands, for Hospital ED services are broadly similar across Hywel Dda. The large number of attendances aged 20-24 years of age at Bronglais General Hospital is indicative of the student population at Aberystwyth University. Figure 11 illustrates Emergency Department attendances by County of Residence

Unitary Authority Bronglais



Withybush General Hospital

Grand Total

Carmarthenshire 200 30,130 29,486 461 60,277Ceredigion 19,709 4,595 60 293 24,657English UA 1,937 1,118 359 2,066 5,480Gwynedd 1,608 13 4 11 1,636Neath Port Talbot 36 238 442 95 811Pembrokeshire 67 1,536 39 31,624 33,266Powys 2,409 164 27 35 2,635Scottish UA 22 27 8 44 101Swansea 44 309 2,899 107 3,359Torfaen 12 21 4 23 60Unknown UA 155 88 44 406 692Welsh Other UA 391 639 233 830 1Grand Total 26,578 38,857 33,601 35,972 135,008Source: Myrddin CiS 2011/12


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Figure 11 demonstrates: - 15% of the total attendances at Bronglais General Hospital are

Gwynedd and Powys residents - 9% of the total attendances at Prince Philip Hospital are Swansea

residents - 16% of the total attendances at Glangwili General Hospital are

Ceredigion and Pembrokeshire residents - Within Withybush General Hospital, services are mostly accessed by

residents of Pembrokeshire Figure 12 illustrates the numbers of Hywel Dda residents, by locality, that attend major EDs within Abertawe Bro Morgannwg UHB Hywel Dda Locality Morriston Princess of Wales Amman/Gwendraeth 1,122 19 Llanelli 1,153 16 North Ceredigion 46 3 North Pembrokeshire 103 14 South Ceredigion 82 7 South Pembrokeshire 111 22 Taf/Teifi/Tywi 194 18 Non Hywel Dda Practice 808 60 Grand Total 3,619 159 Source: Myrddin CiS 2011 Figures 11 and 12 above demonstrates:

- A total of 3,619 Hywel Dda residents attend Morriston Hospital ED, this equates to 2.7% of total ED attendances within Hywel Dda. Morriston Hospital (ABMUHB) provides tertiary services to Hywel Dda, for example Burns and Plastics;

- 40% of Amman/Gwendraeth Locality emergency attendances go to Glangwili General Hospital and 52% go to Prince Philip Hospital;

- 86% of Llanelli Locality emergency attendances go to Prince Philip Hospital and 11% go to Glangwili General Hospital with 4% attending at Moriston

- The majority of the Taf/Teifi/Tywi locality emergency attendances (92%) go to Glangwili General Hospital.

- The majority of South Ceredigion locality go to Glangwili General Hospital to access emergency department services


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Figure 13: denotes the number of Emergency Attendances at the Minor Injury Units (MIUs) in Community Hospitals within Hywel Dda:

County Minor Injury Unit Hours of Service Total 10/11

Total 11/12

Carmarthenshire Llandovery Hospital Mon-Fri 0900 – 1700 260 255

Ceredigion Cardigan Hospital

Mon-Fri 0900-1800 Sat 00900-1200

2,173 2123

South Pembrokeshire Hospital

0900-1700 daily including weekends

4,126 3,008 Pembrokeshire

Tenby Hospital 0800-2200 daily including weekends

5,324 4,692

Grand Total 11,883 10,078

Source: Myrddin CiS Figure 13 illustrates:

- Very small numbers, an average of approximately 4 per week, attend the MIU at Llandovery

- Approximate attendances per day are: 6 per day at Cardigan, 11 per day at South Pembrokeshire and 15 per day at Tenby.

It is to be noted that 838 of the 11,883 (7%) total Emergency Attendances at Minor Injury Units with Hywel Dda, are followed up at an ED within the same day. Tenby and South Pembrokeshire minor injury units closed temporarily from 3rd January 2012 to 1st April 2012. The figures above show the impact of attendances during the closure. For the period January 2011 to April 2011 attendances at the minor injuries units in South Pembrokeshire and Tenby hospitals represented 22.8% of the total emergency department activity for Pembrokeshire. During the time that the units closed in 2012, attendances at the emergency department at Withybush General Hospital increased by 3.8%. This demonstrates that the closure of the two units had very minimal impact on the department at Withybush Hospital and reflects the fact that those attending Tenby and South Pembrokeshire hospitals only do so for very minor injuries or illnesses that can either be dealt with by self-care or by contacting the primary healthcare team such as the GP, practice nurse or pharmacist.


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Figure 14 illustrates the monthly profile of MIU attendances

Source: Myrddin CiS 2010/11 Figure 14 demonstrates a small seasonal fluctuation in attendances with a peak in August in Tenby averaging 25 per day and a smaller fluctuation in South Pembrokeshire of 15 per day. Cardigan attendances have only minor variations throughout the year and Llandovery has very similar attendances month on month. Figure 15 denotes attendances by time of day at Tenby and South Pembrokeshire Hospitals:

Source: Myrddin CiS 2011/12


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Figure 15 denotes:

- Increased attendance between 10am and 12 midday - Increased attendance between 3pm and 4pm - Significantly decreased attendance between 6pm and 9am

GP provision of Minor Injury and Wound Care services: 53 out of the 55 GP practices in Hywel Dda,) are commissioned to provide minor injury services. All 55 GP practices (24 within Carmarthenshire, 16 within Ceredigion, 15 within Pembrokeshire) provide wound care services. It can be seen that;

- The number of minor injury and wound care attendances are reflective of the GP practice catchment population and the Practice proximity to a Hospital Emergency Department /Minor Injury Unit at a Community Hospital i.e. the numbers are higher the further the distance and travelling time from Hospital EDs/Minor Injury Units.

- This would indicate a duplication of service provision in some areas and would suggest rationalisation of Minor Injury Unit Provision is possible if access can be maximised to GP provision.

Ambulance Information Figure 16 below shows the total number of incidents that Welsh Ambulance NHS Trust (WAST) responded to in the Hywel Dda area in 2010/11 and 2011/12. AS1 refers to 999 calls. AS2 doctor requesting urgent transport and AS3 are routine journeys. Figure 16 Total Numbers of Incidents in Hywel Dda Area

2010‐2011 Count of ID

AS1 Incident 26068 AS2 Doctors Urgent 6586 AS3 Routine 892 Grand Total 33546

2011‐2012 Count of ID

AS1 Incident 28934 AS2 Doctors Urgent 4799 AS3 Routine 1153 Grand Total 34886


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The next table and graph, figure 17 shows the 2011/12 incidents split by the time of day that the ambulance attended. These figures show how the number of AS1 and AS2 calls in particular peak late morning continuing into early afternoon


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Figure 17 AS Incident by Hour

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Total AS1 998 858 742 628 546 525 578 836 1175 1591 1620 1679 1699 1648 1693 1560 1405 1502 1385 1414 1307 1290 1179 1076 28934

AS2 81 64 43 41 42 27 42 61 103 282 352 370 474 540 527 386 330 245 237 152 114 124 91 71 4799

AS3 23 24 23 15 14 10 6 15 31 78 53 66 89 80 93 79 109 97 63 44 34 37 38 32 1153

Total 1102 946 808 684 602 562 626 912 1309 1951 2025 2115 2262 2268 2313 2025 1844 1844 1685 1610 1455 1451 1308 1179 34886 Figure 18 below shows the inter hospital transfers undertaken by WAST from hospitals in Hywel Dda Health Board, including community hospitals and the hospital that they were taken to during 2011/12.


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Figure 18: Hospital Transfers undertaken by WAST


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From this it can be seen that the majority of the transfers were to Glangwili Hospital and Morriston Hospital. 359 patients were transported from Prince Philip Accident and Emergency department to Glangwili which illustrates that Prince Philip cannot provide the full range of specialities and is not a full A&E. From all hospitals within Hywel Dda Health Board, 817 patients were taken to Morriston Hospital. This will be largely for services not provided in Hywel Dda Health Board with a large proportion being specialist cardiac services. Analysis of June and November attendance in Prince Phillip A&E unit An analysis has been undertaken of the June 2012 and November 2011 attendances at the A&E unit at Prince Philip Hospital with the following observations; The total number of patients who presented to the A&E Unit in June was 2929 and 2683 in November 2011 The analysis below is of patients who arrived at the unit by between 01.06.2012 and 30.06.2012. and 01.11.12 and 30.11.2012 and were coded as having arrived by either 999 or non 999 Ambulance. 1. June 2012 999 45 Patients arrived by 999 Ambulance

• Of the 45 Ambulance arrivals 19 were admitted 23 were discharged 2 did not wait and 1 died. Of those admitted 10 were over 70 years of age of those discharged 5 were over 70 years of age.

• Of the 19 patients arriving by 999 Ambulance and admitted 12 were

from SA15, 4 from SA 18 but only 1 from SA14, SA7 and SA4

• Of the 23 patients arriving by 999 Ambulance and discharged 7 were from the SA 14 and 10 from SA15, a further 2 were from SA18 1 from SA4 1 from SA32 and 2 unknown.

• Of the 19 patients admitted 12 presented between 08.00-18.30 and 7

between 18.30 and 08.00 ( 2 arrived between 18.30 and 19.00)

• Of the 23 patients discharged 7 presented between 08.00-18.30 and 14 between 18.30 and 08.00 (2 arrived between 18.30 and 19.00)

Non 999

• 306 patients were brought in by non 999 Ambulance of which


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o 155 were admitted o 135 discharged o 1 died o 10 did not wait o 1 A&E follow up o 2 became outpatients o 1 follow up with other provider (Out of area) o 1 further investigation

• Of the 155 admitted 106 were 70 years of age or older, of the 151

patients not admitted 50 were 70 years of age or older. • Of the 155 admitted 90 were admitted between 08.00-18.30 and 65

between 18.30 -08.00 • Of the patients discharged 67 presented between 08.00 and 18.30 and

91 between 18.30-08.00 • Of the total number of patients brought in by non 999 Ambulance the

given addresses are:

o SA14 – 86 o SA15 – 107 o SA16 – 23 o SA17 – 15 o SA18 – 50 o SA4 – 10 o Other 15

2. November 2011 999 52 Patients arrived by 999 Ambulance

• Of the 52 999 Ambulance arrivals 26 were admitted 25 were discharged and 1 did not wait. Of those admitted 14 were over 70 years of age of those discharged 9 were over 70 years of age.

• Of the 26 patients arriving by 999 Ambulance and admitted 14 were

from SA15, 4 from SA 14, 3 from SA18, 2 from SA16 and 2 from SA4.

• Of the 25 patients arriving by 999 Ambulance and discharged 5 were from the SA 14 and 9 from SA15, a further 7 were from SA18, 2 From SA 16 and 1 each from SA4, SA13and SA17.

• Of the 26 patients admitted 12 presented between 08.00-18.30 and 14

between 18.30 and 08.00.


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• Of the 25 patients discharged 13 presented between 08.00-18.30 and 12 between 18.30 and 08.00.

Non 999

• 249 patients were brought in by non 999 Ambulance of which

o 134 were admitted o 107 discharged o 2 died o 4 did not wait o 1 became outpatients o 1 follow up with another provider

• Of the 134 admitted 89 were 70 years of age or older, of the 151 patients not admitted 40 were 70 years of age or older.

• Of the 134 admitted 69 were admitted between 08.00-18.30 and 65

between 18.30 -08.00

• Of the patients discharged 55 presented between 08.00 and 18.30 and 51 between 18.30-08.00

• Of the total number of patients brought in by non 999 Ambulance the

given addresses are:

o SA14 – 40 o SA15 – 112 o SA16 – 20 o SA17 – 12 o SA18 –41 o SA4 – 11 o Other 13

Figure 19 shows the number of inter hospital tranfers undertaken as a 999 or 998 (ie emergency transfer) Of the patients transferred betweeh hospitals in figure 19, 624 almost 25% were transferred by 999 or 998 call. 71 of these patients were transferred from Bronglais General Hospital, 113 from Prince Philip Hospital, 105 from Glangwili General Hospital and 135 from Withybush General Hospital


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Figure 19: Number of Inter Hospital Transfers Undertaken as 999 Calls


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Figure 20 below shows the AS1 emergency patients taken directly to a hospital outside of the Hywel Dda Health Board area. Figure 20 Hywel Dda Patients Taken Directly to an Out of Area Hospital - AS1 Incidents Only 2011‐2012 Count of ID MORRISTON HOSPITAL SWANSEA 1024UNIVERSITY HOSPITAL OF WALES 176SINGLETON HOSPITAL SWANSEA 118PRINCESS OF WALES BRIDGEND 14NEVILL HALL HOSP ABERGAVENNY 8ROYAL SHREWSBURY HOSPITAL 5GLAN CLWYD HOSP BODELWYDDAN 4CHILDRENS HOSP WALES CARDIFF 4HEREFORD COUNTY HOSPITAL 4SOUTHMEAD HOSPITAL BRISTOL 4NEATH AND PORT TALBOT HOSPITAL 4QUEEN ELIZABETH HSP BIRMINGHAM 3ROYAL GWENT HOSPITAL NEWPORT 3ROYAL GLAMORGAN HOSP PONTYCLUN 3PRINCE CHARLES HOSP MERTHYR 2UNIVERSITY DENTAL HOSP CARDIFF 2BRISTOL ROYAL INFIRMARY 1BRISTOL ROYAL HSP FOR CHILDREN 1GLOUCESTERSHIRE ROYAL HOSPITAL 1DERRIFORD HOSPITAL PLYMOUTH 1LLANDOUGH HOSPITAL 1FRENCHAY HOSPITAL BRISTOL 1MAELOR GENERAL HOSP WRECSAM 1BISHOPS CASTLE HOSP SHROPSHIRE 1ADDENBROOKES HOSP CAMBRIDGE 1Grand Total 1387


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Figure 21 illustrates the demand for Urgent Care at GP Out of Hours (OoHs) service providers within each county. Figure 21: GP Out of Hours Activity 2010/11

County GP OoH Service Provider

GP OoH Contacts

GP OoH Treatment

Attendances

GP OoH Home Visits

Ceredigion Bronglais and Llandysul

14,752 (9.9%

admitted)

3,973 (7.2% admitted)

2,394 (6.1%

admitted)

Glangwili 6,202 (5.7% admitted)

2267 (8.8%

admitted) Carmarthens

hire Prince Philip

30,150* (4% admitted) 7941

(6% admitted)

2142 (8.4%

admitted)

Pembrokeshire

Withybush and South

Pembrokeshire

24,476 (12.7%

admitted)

9,397 (12.3%

admitted)

3,040 (13.3%

admitted) Source: Myrddin CiS 2011 *GP OoH initial contacts within Carmarthenshire, are taken by telephone and are, therefore, available on a county not hospital basis The following information is provided:

- total number of people who make telephone contact with the GP Out of hours service;

- those who are seen at one of the treatment centres; - the number of people who receive a home visit; - the percentage of people who are admitted into an inpatient bed in

hospital following the GP OoH; and consultation is also demonstrated Note about this information

- There are some issues with the direct comparison of the data across the three counties due to anomalies in the definitions. For example, a contact in Pembrokeshire may refer to either a telephone triage or face to face consultations undertaken by a GP, whereas in Carmarthenshire it only refers to a patient actually seen by the GP.

- Also differences in the proportion of patient seen in home visits may be due to a number of external factors including for example, availability of other care providers in the community, geography, concentration of population living in close proximity to a treatment centre and indeed the type of treatment centre.

- The Three Counties GP Triage Consultation Group is looking into the data and how it actually relates to performance.


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Workforce The key workforce issues are summarised as follows:

- Difficulty in recruiting to some clinical roles , currently, out of all the Consultant posts within Hywel Dda, there are only three posts which are occupied by substantive consultants and for the remainder there are locum arrangements in place;

- There are currently four Emergency Departments requiring medical support which is ‘spread thinly’. This results in services which are difficult to maintain, due to the inability to recruit to all the posts that are required to run the four rotas, further details appear later in this section;

- There is a specific problem with recruitment of Consultant and Staff Grade and Associate Specialist (SAS) doctors within Withybush General Hospital;

- The current Enhanced Nurse Practitioner (ENP) staff could and should use their higher level knowledge and skills to better effect using their advanced skills which is cost effective as it releases medical staff time for more complex cases; and

- There are benefits and opportunities for the current workforce in terms of integration through new clinical leadership models, which may include specialist ENP and Advanced Practice roles within urgent care services and Primary and Community based services which will ensure services to provide optimum care for patients. Similarly, during out of daytime working hours (out of hours), there are opportunities for integration of emergency and urgent care services.

There are currently four Emergency Department teams operating individual on-call rotas as follows: Figure 22: Medical Staffing Rotas

Speciality: Emergency Departments Tier of On call Bronglais Glangwili Prince Philip Withybush

Consultant Consultant 9-5 (no on call)

Consultant cover is 1:4 Consultant - 1:3

Tier 2: Higher Grade (ST3 & above and middle grade)

Middle Grades - 1:3 shift

Middle Grades - 1:5 shift pattern

CT/GP - 1:7 shifts At night Prince Philip is covered by Enhance Role A&E GPs

Middle Grades - 1: 6 Full shift pattern

Tier 1: Core training/ Foundation 2

Juniors F2 1:5 shift pattern

Foundation F1s

F1 – (training post ) shift pattern

CT/GP /FP2 & FP1 - 1:7 full shift pattern


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Hywel Dda is working with the Deanery to examine the training programme and to improve the quality of training and the sustainability of our training posts. The situation in Hywel Dda is reflected in the following:

• Recruitment issues have been extremely severe in this speciality for 2 years

• Recruitment issues are worsening and as from September 2011 it is anticipated approximately 50% of higher training posts will be vacant

• Recruitment gaps have caused serious issues with the quality of training in some centres

• Sir John Temple’s Report (2010) recommends that to ensure EWTD compliant rotas deliver adequate training there is a minimum requirement of 10-11 personnel

New GMC standards explicitly state FY2 trainees cannot work out of hours without on site supervision. This is currently not the case in some EM departments in Wales 6. How We Compare Against the Standards None of the current EDs are compliant with the Royal College staffing standards as follows:

- Across Hywel Dda, there are severe Consultant medical staffing recruitment and retention difficulties within all the Emergency Departments, resulting in delayed access to senior clinical opinion and decision making. This lack of senior staff leads to long waiting times when departments are busy, resulting in severe pressures within the whole system to meet the Accident and Emergency 4 hour wait 95% target and the 8 hour 99% target. Although Hywel Dda is one of the better performing Health Board within Wales in regard to the 15 minute handover target from Welsh Ambulance Services NHS Trust, the 100% target is never achieved. The current service configuration resulting in severely under staffed departments is not attractive to staff seeking high profile, professional development opportunities as a trainee or as a qualified clinician. The ‘thinly spread’ professional knowledge makes it difficult to share clinical expertise when, for example, a second opinion is needed.

- Within Hywel Dda, the current model for Emergency Care service

provision is not sustainable as none of our Hospital Emergency Departments (EDs) comply with the College of Emergency Medicine Guidelines as detailed in Figure 23 below:


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Figure 23: College of Emergency Medicine Guidelines Compliance

College of Emergency Medicine Guidelines

Hywel Dda Compliance with the Guidelines

Presence of a doctor (ST4 or above) trained and experienced in Emergency Medicine 24 hours a day

EDs in Bronglais General Hospital, Glangwili General Hospital and Prince Philip Hospital do not have medical cover, trained to the recommended level, overnight

ED should be supported by 7 key specialities

Prince Philip Hospital ED is not supported by the seven key specialities

Timely support from inpatient teams and efficient procedures for admission to hospital

Prince Philip Hospital ED is not supported by the seven key specialities which occasionally result in presenting patients at Prince Philip Hospital needing to be transferred to Glangwili General Hospital

Support of an Clinical Decision Unit(CDU)/observation ward

At Withybush General Hospital there are adjacent CDU/ED facilities. Integrated CDU/ED facilities are planned to become operational mid 2012 in Glangwili General Hospital and mid 2013 in Bronglais General Hospital as part of the ‘Front of House’ Scheme. At Prince Philip Hospital there are not adjacent CDU/ED facilities

Up-to-date information technology (IT) and records system linked to the hospital and community care records

Integrated IT systems are in development

Within Hywel Dda full compliance against with standards would mean the establishment of a single Emergency Department. Given the geography of Hywel Dda and the travel times the current view is this could only be possible if there was 24/7 helicopter medical retrieval, which is not available at this time. A summary of the current problems within Hospital EDs include the following:

• Chronic recruitment and retention challenges; • Delayed access to senior clinical opinion and decision making; • Clinical governance challenge e.g.

- key specialty support not available on all sites - misleading signposting at Prince Philip Hospital - lack of clarity of service provision at Prince Philip Hospital;

• Long waiting times at busy periods; • Too many patients waiting too long in ambulances; • Inconsistent assessment processes; and • Compliance with National targets.


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The 10 High Impact Steps to Transform Unscheduled Care recommend there is a need for the Out of Hours GP services to be integrated with Type 1 Emergency Departments, to facilitate a coordinated approach to managing patients with emergency and urgent care needs over the 24 hour period, ensuring that patients are assessed, and transferred appropriately between OoH services, EDs, ambulance crews or other services. Within Hywel Dda, Minor Injury Services are provided by 53 out of the 55 GP practices, located closely to the population they serve. Analysis of the attendances at GP practices Minor Injury Units demonstrates:

- The number of minor injury and wound care attendances are reflective of the GP practice catchment population and the Practice proximity to a Hospital Emergency Department /Minor Injury Unit at a Community Hospital i.e. the numbers are higher the further the distance and travelling time from Hospital EDs/Minor Injury Units.

This would indicate a duplication of service provision in some areas and would suggest rationalisation of Minor Injury Unit Provision is possible if access can be maximised to GP provision. The current and ongoing development within Community Services, Local Authorities, Primary Care and the Third Sector of the ‘virtual ward’ concept- care closer to home, will support Unscheduled Care (Emergency and Urgent care) services. This will integrate many streams of work ongoing within the community to predict the dependency of the population, to assist in the prevention of patients with known chronic conditions attending Emergency Departments inappropriately, to develop management plans for the ‘frequent flyer’ patients and development of the Community Resource Teams within each locality. The communication campaign of ‘Choose Well’ will support and educate the public in making the Right Choice first time so that they contact the service that will best meet their needs.

7. Option Appraisal 2011 - Pre ‘Listening and Engagement’ Stage There are a number of factors to be aware of when considering the attached option appraisal:

1. The option appraisal process was undertaken for a range of services in August/September 2011

2. It reflected the clinical and management engagement processes that had been undertaken to that time and the shortlisted options identified to that point.

3. It was a clinically led development process that included; • Speciality ‘Think Tanks’. • A two day planning event in May 2011 with circa 120 people

including 50 medical staff.


37

• A multi stakeholder benefits criteria and criteria ‘weighting’ workshop (August 2011).

• An option appraisal workshop (Health Board Executives and Clinical Leaders) applying benefits criteria to short listed options.

• Feedback to key stakeholders including the Community Health Council.

4. It formed the basis for the service models discussed in the public listening and engagement stage between December 2011 and April 2012

5. The Emergency and Urgent Care component of the appraisal was based on evidence and ‘in-room’ discussion and is attached as a record to show completeness of the process prior to the listening and engagement stage.

NOTE

This work has since been influenced through the listening and engagement stage with the public, stakeholders and clinical staff and the option appraisal below no longer reflects the Health Board’s preferred option. For the service options now being formally considered please see the Health Board’s consultation document ‘Your Health, Your Future: consulting our communities’ and the consultation questionnaire.


38

The Option Appraisal 2011 – Pre Listening and Engagement Stage is detailed below

Emergency and Urgent Care

Options A long list of options for Emergency Services, generated by clinical staff at a series of events and are shortlisted below

Options Description Short Listed Option 1 – Standards Model One Major Emergency Department at Glangwili General Hospital, supported by 3 Urgent Care Centres

One Major Emergency Department at Glangwili General Hospital. This department will provide a Consultant led service with services available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. Re-configure both the non-compliant the A & E at Prince Philip Hospital and the A&E departments at Bronglais and Withybush General Hospitals to develop Emergency Nurse Practitioner - delivered Urgent Care Centres (UCCs).

Yes

Option 2– Standards Model One Major Emergency Department at Withybush General Hospital, supported by 3 UCCs

One Major Emergency Department at Withybush General Hospital. This department will provide a Consultant led service with services available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. Re-configure both the non-compliant A & E at Prince Philip Hospital and the A&E departments at Bronglais and Withybush General Hospitals to develop Emergency Nurse Practitioner - delivered Urgent Care Centres (UCCs)

Yes

Option 3 – Within Hywel Dda, three Major

Three Major Emergency Departments within Glangwili General Hospital in Carmarthenshire, Bronglais General Hospital in Ceredigion and Withybush

Yes


39

Emergency Departments co-located with new clinical decision units (Bronglais, Glangwili and Withybush General Hospitals) and one Urgent Care Centre co-located with ambulatory acute medical services (Prince Philip Hospital)

General Hospital in Pembrokeshire to be maintained. These departments will each provide a Consultant led service with services available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. Configure the non-compliant A & E at Prince Philip Hospital to develop to an Emergency Nurse Practitioner - delivered Urgent Care Centre (UCC).

Option 4 – Within Hywel Dda, two Major Emergency Departments, one in the north and one in the south balanced with ABM UHB

Two Major Emergency Departments, one in the north (Bronglais General Hospital) and one in the south (Withybush General Hospital) balanced with Morriston General Hospital Mayor Emergency Department in ABM UHB.

• Largest % of Hywel Dda’s population live in Carmarthenshire and, therefore, travel times would be increased for people in an emergency situation.

Option 5 – Within Hywel Dda, Four Major Emergency Departments with full range of emergency back up services

Four Major Emergency Departments with full range of emergency back up services (Orthopaedic, Surgical, Critical Care, Anaesthesia, Paediatrics, Obstetrics, and Medicine). This would entail Prince Philip Hospital being developed to a mayor emergency department specification.

• Hywel Dda population size doesn’t require four mayor Type 1 Emergency Departments

• Prince Philip Hospital would need extensive refurbishment and additional staffing to reconfigure to a Type I ED facility

• Prince Philip Hospital is only 8miles from the Regional trauma centre for


40

(NB For the Health Board’s preferred option being consulted on August 2012 refer to the consultation document)

SW Wales at Morriston General Hospital.

Option 6 - Status Quo – Three Major Emergency Departments within Carmarthen, Ceredigion and Pembrokeshire and one A & E at Prince Philip Hospital.

The three Major Emergency Departments at Carmarthenshire (Glangwili General Hospital), Ceredigion (Bronglais General Hospital) and Pembrokeshire (Withybush General Hospital) would be maintained. Prince Philip Hospital has not the range of emergency support services including acute surgery, paediatrics or obstetric services to meet the criteria of a Type 1 Mayor Emergency Department as per (WHC (2006) 034). If the current configuration is to continue, the local community will need to be fully aware of the limitations within the department - e.g. part of the ‘Choose Well Campaign’.

• Non compliance with standards • Delayed access to senior clinical

opinion and decision making • Clinical Governance risks due to

misleading signposting and public perception of the A&E at Prince Philip Hospital

• Prince Phillip Hospital does not meet the criteria of a Type 1 ED - which 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. The ED should be supported by the 7 key specialties

• Significant recruitment and retention problems


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Emergency Departments

Establish a sustainable model for Emergency Services for Hywel Dda Criteria

Safety Workforce Accessibility Deliverability Strategic Fit Impact

• Quality • Outcomes • Standards • Accreditation • Resilience

• Sustainability (locum/agency) • Recruitment / retention • Deanery • Capacity for change

• Transport • Adjacency to alternative treatment • Demography • Waiting/Access Times

• Site configuration • Capital availability • Speed/ease • Welsh Government Support • Relevance to need • Flexibility

• Maximising integration benefits • Care closer to home • Economies of Scale • Alignment with partnerships

• Socio/economic • Health Impact Assessment • Equality Impact Assessment

Short-listed Site Option Option 1 One Major Emergency Department (ED) at Glangwili General Hospital. This

• Compliance with standards and Royal College Guidelines as follows: -The presence of a doctor (ST4 or above) trained

• Improved staffing as workforce would be shared across 1 ED and 3 Urgent Care Centres (UCCs) -Current staffing requirement is 4

Car Travel Times to Glangwili General Hospital:

Time

(mins)

% of population of

Cuml. %

• Significant resources will be required by WAST to transport larger numbers of patients to main ED. • Insufficient

• Not a strategic fit with upgrade of EDs in Withybush General Hospital and new build plans for Bronglais General Hospital.

• Potential negative socio/economic impact in Pembrokeshire and Ceredigion • Health Impact assessment has both positive ( i.e. higher quality of urgent care, potential improved outcomes) and negative aspects (i.e. increased travel times for patients and


42

department will provide a Consultant led service, with services available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. Re-configure the non-compliant A & E at Prince Philip Hospital and reconfigure A&E departments at Bronglais and Withybush

and experienced in EM 24 hours a day -ED supported by 7 key specialities -Timely support from inpatient teams and efficient procedures for admission to hospital -Supported by a Clinical Decision Unit (CDU)/observation ward -An up-to-date information technology (IT) and records system linked to the hospital and community care records -Educational and administrative space within the department

Consultants per hospital site –16 for Hywel Dda. • The transfer of clinicians /resources from other sites would allow a more sustainable and less onerous rota at the remaining main Emergency Department. • Due to the critical mass of medical staff in Carmarthenshire, this model would improve the medical staffing position in potentially attracting suitably qualified applicants. • Improved quality in the Junior Doctor training

Hywel

Dda <30 24.3 24.330-59

53.8 78.1

60-89

21.4 99.5

90+ 0.5 100 Source: Public Health Wales Observatory, 2011 • Would require significant improvements in emergency retrieval and transfer including air ambulance services. Inadequate road infrastructure.

infrastructure to support central emergency take i.e. emergency department, assessment facilities, beds, diagnostics and supporting facilities •Potential need to relocate helipad adjacent to main Glangwili General Hospital site

• Compliant with the following: The College of Emergency Medicine – The Way Ahead 2008-2012. Delivering Emergency Care Services Strategy (DECS)-(right person in the right place etc) Ten High Impact Steps to Transform Unscheduled Care (centralisation of services)

relatives)


43

General Hospitals to develop Emergency Nurse Practitioner - delivered Urgent Care Centres (UCCs).

• Current clinical resources would be redistributed to the 1 Major ED. This would enable the Health Board to increase the availability of senior opinion at the ‘front door’ and enable improvements in emergency care. • Potential inability to achieve ‘the golden hour’ for 21.9% of Hywel Dda population

experience

Option 2 One Major Emergency Department at Withybush General Hospital. This department will provide

• Compliance with standards and Royal College Guidelines as follows: -The presence of a doctor (ST4 or above) trained and experienced in EM 24 hours a

• Improved staffing as workforce would be shared across 1 ED and 3 Urgent Care Centres (UCCs) -Current staffing requirement is 4 Consultants per hospital site –16

Car Travel Times to Withybush General Hospital:

• Significant resources will be required by WAST to transport larger numbers of patients. • Insufficient infrastructure to support central emergency take

• Not a strategic fit with upgrade of EDs in Glangwili General Hospital and new build plans for Bronglais General Hospital • Compliant with the following:

• Increased patient flow to ABM UHB services. • Potential negative socio/economic impact in Carmarthenshire and Ceredigion • Health Impact assessment has both positive ( i.e. higher quality of urgent care, potential improved outcomes) and negative aspects (i.e. increased


44

a Consultant led service with services available continuously 24 hours a day for resuscitation, assessment and treatment of acute illness and injury in patients of all ages. Re-configure the non-compliant A & E at Prince Philip Hospital and reconfigure A&E departments at Bronglais and Glangwili General Hospitals to

day -ED supported by 7 key specialities -Timely support from inpatient teams and efficient procedures for admission to hospital -Supported by a Clinical Decision Unit(CDU)/observation ward -An up-to-date information technology (IT) and records system linked to the hospital and community care records -Educational and administrative space within the department • Current clinical resources would be redistributed

for Hywel Dda. • The transfer of clinicians/resources from other sites would allow a more sustainable and less onerous rota at the remaining main ED. • Due to the critical mass of medical staff this model would improve the medical staffing position in potentially attracting suitably qualified applicants. • Historically recruitment of medical staff has been more difficult further west and north of Carmarthen. • Improved

Time

(mins)

% of population of

Hywel

Cuml. %

<30 21 21 30-59

23.8 44.8

60-89

40.4 85.2

90+ 14.8 100 Source: Public Health Wales Observatory, 2011 Would require significant improvements in emergency retrieval and transfer including air ambulance services. Inadequate road infrastructure

i.e. emergency department, assessment facilities, beds, diagnostics and supporting facilities

The College of Emergency Medicine – The Way Ahead 2008-2012. Delivering Emergency Care Services Strategy (DECS)-(right person in the right place etc) Ten High Impact Steps to Transform Unscheduled Care (-centralisation of services)

travel times for patients and relatives )


45

develop Emergency Nurse Practitioner - delivered Urgent Care Centres (UCCs).

to the 1 Major ED. This would enable the Health Board to increase the availability of senior opinion at the ‘front door’ and enable improvements in emergency care. • Potential inability to achieve ‘the golden hour’ for 55.2% of Hywel Dda population

quality in the Junior Doctor training experience

Option 3 Within Hywel Dda, three Emergency Departments co-located with new clinical decision units (Bronglais General Hospital,

• Improved compliance against standards and Royal College Guidelines. -The presence of a doctor (ST4 or above) trained and experienced in EM 24 hours a day -ED supported by 7 key

• Improved staffing as workforce would be shared across three Major Emergency Departments and one Urgent Care Centre • The transfer of clinicians/resources from Prince Philip Hospital

• No change in service provision for residents in Ceredigion and Pembrokeshire. Travel times - 90% of Carmarthenshire residents can access Glangwili General Hospital within 30 minutes Car Travel Times to Glangwili General Hospital:

• Infrastructure -Realistic in terms of deliverability as 2 new EDs in Glangwili General Hospital and Withybush General Hospital and new build in Bronglais General Hospital has commenced. • The transfer of 999 emergencies

• Access to safe services by provision of one Major ED in each of the three Counties. • Compliant with the following: The College of Emergency Medicine – The Way Ahead 2008-2012. Delivering

• Clinical impact –patients will be taken to the most appropriate service. Improve safety of service in Carmarthenshire, less confusion re Prince Philip Hospital emergency care provision. • Impact of change for Llanelli will be mitigated through services remaining available at PPH, proximity of Carmarthen and ABMU Emergency Services, and introduction of new community care initiatives.


46

Glangwili General Hospital, and Withybush General Hospital) and one Urgent Care Centre at Prince Philip Hospital.

specialities -Timely support from inpatient teams and efficient procedures for admission to hospital -Supported by a Clinical Decision Unit(CDU)/observation ward -An up-to-date information technology (IT) and records system linked to the hospital and community care records -Educational and administrative space within the department • Prince Philip Hospital currently does not fulfil the criteria of a Major Emergency Department as it

would allow more sustainable and less onerous rotas to the 3 remaining EDs. • Due to the critical mass of medical staff in Carmarthenshire, this model would improve the medical staffing position in potentially attracting suitably qualified applicants. • Improved quality in the Junior Doctor training experience as training would be confined to the Major EDs. • Emergency Nurse Practitioner (ENP) and other

Time

(mins)

% of population of

Hywel

Dda

Cuml. %

<30 24.3 24.330-59

53.8 78.1

60-89

21.4 99.5

90+ 0.5 100 Source: Public Health Wales Observatory, 2011 • Glangwili General Hospital is relatively central for Carmarthenshire residents • Proportion of residents of Llanelli currently travel to Carmarthen or ABMU for unscheduled surgical and paediatric care.

and GP referrals from Prince Philip Hospital to Glangwili General Hospital may require increased ED capacity at Glangwili General Hospital if the current model of care is unchanged. However, with the developments in community (virtual ward, ambulatory care , choose well, Primary care) this demand will need to be monitored closely • The inpatient configuration to support the EDs will be dependent on the Levels of Care Audit

Emergency Care Services Strategy (DECS) Ten High Impact Steps to Transform Unscheduled Care

• Increased patient flow to ABMU services. This to be mitigated through WAST protocols.


47

does not have the full support as dictated by the COEM. • Prince Philip Hospital is currently signposted and perceived by the general public as an A&E Department. This poses a significant risk to the Health Board and to the general public when their expectations of service delivery are not met. In practice operating as a minor injuries unit • Current resources would be redistributed to the Three Major Emergency Departments.

enhanced posts will need to be strengthened with ongoing specialist professional training. (Staffing norm of 4 consultants per hospital site)

recommendations and implementation within Hywel Dda. • ART and WAST services will be embedded in the support of this care model. • The Non Emergency Transport improvement project (ICARHS) will need to continue to address the discharge delays attributed to transport.


48

This would enable the Health Board to increase the availability of senior opinion at the ‘front door’ and enable improvements in emergency care. • Ability to achieve ‘golden hour’ for 100% of population of Hywel Dda

The weighting and scoring of the shortlisted options is shown in the following section: Short listed Options Option 1: 1 Major Emergency Department at Glangwili General Hospital with 3 Emergency Nurse Practitioner delivered Urgent Care Centres (UCCs) in Bronglais, Prince Philip & Withybush Hospitals. Option 2: 1 Major Emergency Department at Withybush General Hospital with 3 Emergency Nurse Practitioner delivered Urgent Care Centres (UCCs) in Bronglais, Glangwili and Prince Philip Hospitals. Option 3: 3 Emergency Departments co-located with new clinical decision units (Bronglais, Glangwili & Withybush Hospitals) and 1 Urgent Care Centre at Prince Philip Hospital. Figure 24: Results from Clinical Options Appraisal Workshop 13th September 2011 Option 1 Option 2 Option 3 Average 24.77 21.97 44.03 Weighted Average 4.26 3.78 7.32


49

Figure25: Statistics for Emergency Departments


50

Figure 26: Weighted Results Weighted Results

Benefit Criteria Option 1

1 ED at Glangwili General Hospital

Option 2

1 ED at Withybush General Hospital

Option 3 3 EDs and 1 UCC at Prince Philip Hospital

% Differential over next best option

Safety 1.06 0.96 1.70 60.0% Workforce 1.18 1.07 1.17 0% Accessibility 0.59 0.48 1.39 0.32% Deliverability 0.49 0.41 1.11 0.26% Strategic Fit 0.51 0.45 1.07 0.10% Impact 0.52 0.41 0.88 0.10% Total Score 4.26 3.78 7.32 In four of the categories, ‘Accessibility’, ‘Deliverability’, ‘Strategic Fit’ and impact, the preferred option for three EDs scored more than twice as well as the next best alternative. Safety scored 60% better than the next best. Only in the Workforce category did three EDs and a single ED at Glangwili scored equally well, reflecting both the difficulties in staffing and the potential recruitment opportunities associated with one unit. Preferred Option September 2011 The preferred option at September 2011 Maximise the opportunities for Primary Care Minor Injury services and improve integration of Community, Social and Primary Care as part of the unscheduled care pathway. Configure non-compliant A&E at Prince Philip Hospital to develop an in-hours Consultant led ‘Hot’ Clinic (medicine & diagnostics) and nurse led Urgent Care Centre. Major Emergency & Urgent Care Departments (Bronglais General Hospital, Withybush General Hospital, Glangwili General Hospital) – to include paediatric assessment facilities, with enhanced, co located adult clinical decision units and diagnostic and multi specialty support. (The Emergency Floor)


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8. Listening and Engagement Process From December 2011 to April 2012, Hywel Dda Health Board undertook a listening and engagement process to explain the need for service change across the Health Board and to seek views. This process showed that the majority of people agreed with the need to ensure that services meet quality and safety standards and that the best use should be made of scarce resources. The Health Board’s aim to provide 80% of NHS services locally, through integrated primary, community and social care teams working together was supported as was the aim for service planning to treat the ageing population who suffer from long-term chronic conditions as a priority. The need to improve transport services was endorsed. However, respondent views were divided on the remaining principles, as fewer than half agree and more than two fifths disagree with specialising some services into fewer, fully equipped centres (45% agree; 41% disagree). The principle of developing specialised services, meaning that some patients will have to travel further for some hospital services, (48% agree; 42% disagree) divided views in a similar manner. Further comments provided through questionnaire analysis and other submissions revealed that, in general, respondents are most concerned about: • Hospital closures and downgrading (especially with regards to

Bronglais Hospital), travel time to get to hospital (both as a patient and a visitor) due to closures and downgrades, and whether transport will be improved and how the costs of implementing any changes will be funded and whether it will impact on patients directly.

• Local access to Women’s and children’s services, planned care cancellations, timely access to fully resourced A&E departments and the need for additional investment in mental health care and treatment.

• Many did not always understand the nature of their local services: some were surprised to learn of the limited nature of what they had supposed was a full A&E service at Prince Philip Hospital and local residents were especially concerned with the status of Prince Philip Hospital and the future of its A&E unit. Participants in Aberystwyth were concerned that Bronglais Hospital has already suffered the loss of some services and felt strongly that its strategic location in relation to Gwynedd and Powys must be taken into account

The main points from the public focus groups showed concern about hospitals being run down and travelling times to get to hospital. Residents living close to Bronglais and Prince Philip Hospitals were particularly concerned about the role of these hospitals. As a result of the listening and engagement process Hywel Dda Health Board had further discussions with clinical leaders, managers and the Board and refined the possible options for the delivery of emergency and urgent care. These options consider the need to deliver the required standards for emergency and urgent care across the rural communities.


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9. Conclusions and Recommendations None of the emergency departments in Hywel Dda Health Board currently meet recommended standards. The department at Prince Philip Hospital does not have the full back-up specialities required and hence what it is able to deliver is not an A&E service. 80% of patients who do attend at Prince Philip Hospital are categorised as minor. Small numbers of patients attend minor injury units and the majority of GP practices provide minor injury services. This is potential duplication of services. In a rural area, especially when there is an undifferentiated take there is a need to ensure access to senior assessment is balanced with the time taken to definitive care. In order to address these deficiencies, the Health Board has taken into account the outcome of the Option Appraisal exercise that was undertaken in 2011 (detailed above) and has also given full consideration to the Listening and Engagement Exercise that took place earlier this year, the outcome of which is summarised in the ORS Report that was issued in June 2012. Having taken on board all of the views expressed by patients, staff including key clinicians, members of the public and organisations with an interest in the shape of future services, the Health Board has recommended options for change for emergency and urgent care within the section on Hospital Services – Emergency Departments and Unplanned Care in the Consultation Document. The preferred option, among a number of recommendations for change, would retain acute medical services on all 4 hospital sites, acute surgery and trauma on the same 3 sites as they currently are, emergency departments in Bronglais, Glangwili and Withybush Hospitals and a Local Accident Centre at Prince Philip Hospital. For the full option description and specific consultation questions please refer to the Hywel Dda Health Board consultation document ‘Your Health, Your Future: consulting our communities’ and the associated consultation questionnaire


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10. Bibliography

- The College of Emergency Medicine – The Way Ahead - 2008-2012.

Strategy and Guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland;

- College of Emergency Medicine British Association for Emergency

Medicine – The Reorganisation of Emergency Services (England) July 2007;

- Setting the Direction – Primary and community services strategic

delivery programme; - Setting the Direction (Hywel Dda) ABC of Community Services; - Ten High Impact Steps to Transform Unscheduled Care; - Urgent Care, a practical guide to transforming same-day care in

General Practice; - RCGP Guidance for Commissioning Integrated Urgent and

Emergency Care – ‘A Whole System’ approach; and - Unscheduled Care Maturity Matrix (Draft - September 2011).

technical document – emergency and urgent care august 2012 · 2012-09-12 · technical document -...

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