proposal to change the opening hours of the minor injuries...

Proposal to change the opening hours of the Minor Injuries

Units at Sir Robert Peel and Samuel Johnson Hospitals

Final Case for Change

Version Control

Revision Date Description

V1 12.11.15 Initial draft

V2 – final draft 17.11.15 Comments incorporated

Final 18.11.15 Approved by Executive Management Team

Contents 1. Executive Summary ..................................................................................................................... 3

2. Background and Context ............................................................................................................. 4

3. Case for Change .......................................................................................................................... 7

4. Pre-consultation Options ............................................................................................................ 8

5. Consultation and Engagement .................................................................................................. 12

6. Post consultation option consideration .................................................................................... 16

7. Risks and mitigation .................................................................................................................. 18

8. Financial Appraisal .................................................................................................................... 20

9. Self assessment against the Secretary of State for Health “four tests” ................................... 21

10. Quality Impact Assessment ....................................................................................................... 24

11. Equality Impact & Risk Assessment (EI&RA) ............................................................................. 24

12. Conclusions and Recommendations ......................................................................................... 25

13. Appendix A – MIU Data Analysis ............................................................................................... 27

14. Appendix B – Consultation and Engagement Report ................................................................ 30

1. Executive Summary

Every day the NHS saves lives and helps people stay well, but the service is operating under

increasing pressure, both locally and nationally. Increasing life expectancy is leading to more long

term and multiple conditions which increase demand for services constrained by funding and

recruitment challenges.

It is therefore vitally important that the Clinical Commissioning Group (CCG) ensures that the money

it spends offers the greatest value and highest quality possible and meets statutory obligations to

balance our budget each year.

We have for some time been considering many options to help us achieve these objectives and

reviewing our urgent care provision is one of a number of Quality, Innovation, Productivity and

Prevention (QIPP) initiatives designed to reduce duplication, maximise efficiencies and to ensure

patients get to the right place, first time. This paper proposes some minor changes to the way our

urgent care services are delivered that will achieve a reduction in duplication of service provision,

help patients see the right person first time and deliver cost efficiencies to the health economy, with

minimal impact on service users.

Significant ongoing engagement has been undertaken regarding urgent and emergency care across

South East Staffordshire and Seisdon Peninsula CCG, which is summarised in this paper, and this has

fed into the development of the proposals. Public events, targeted engagement and discussions

across the local health and social care economy during 2014 and 2015 provided the CCG with a

wealth of knowledge. Patients, the public, staff, stakeholders and councillors have told us that they

want us to reduce waste and become more efficient to save precious resources and ensure that

local services are sustainable.

Our detailed analysis of activity at the Minor Injuries Units (MIUs) at Sir Robert Peel and Samuel

Johnson Hospitals has shown that many attendances are for conditions that are often treated, more

cost effectively, in primary care and that there is duplication in services commissioned for patients’

urgent care needs. It also clearly showed that there are very low numbers of patients attending

during the overnight period.

This paper describes how we developed and considered options for the future in the context of the

current service provision, national guidelines, clinical best practice and the recommendations of the

Keogh report ‘Transforming urgent and emergency care services in England, safer, faster, better:

good practice in delivering urgent and emergency care’ (August 2015).

We developed a number of options that aimed to match patient requirements and expectations

with the commissioning of appropriate, high quality, clinically and financially sustainable services.

We consulted widely with our communities about these proposals, as described in section 5 and the

feedback from the public consultation process has been fully considered prior to the conclusions

being drawn and final recommendations made.

Our conclusions have resulted in the following proposal:

Divert patients currently attending the Minor Injury Units (MIUs) in the Out of Hours (OOH) period to alternative, already commissioned services such as NHS 111, the GP OOH service or a main A&E department as needed and change the opening hours of the unit at Sir Robert Peel Hospital to 8am to 10pm and the unit at Samuel Johnson Hospital to 8am to 9pm.

This will result in reduced service duplication, facilitate patients being seen in the right place, first

time for their urgent care needs and deliver recurring annual savings of circa £317k to the health

economy and £230k for South East Staffordshire & Seisdon Peninsula CCG.

There were a number of issues identified during the public consultation that require resolution prior

to the implementation of this change and these are described in section 7 together with the planned

mitigating actions.

It is recognised by the CCG, that these minor changes will only go so far to improve services. To

ensure that locally we have an urgent and emergency care system that is reflective of the needs of

our local health economy and is simple, safe and effective, a full urgent care review is underway as

part of the Stafford wide approach to managing urgent care. The minor changes in this case for

change will lead the way locally in ensuring that patients see the right person, first time.

2. Background and Context

2.1 Urgent Care Context

The NHS Five Year Forward View (5YFV) explains the need to redesign urgent and emergency care

services in England for people of all ages with physical and mental health problems, and sets out the

new models of care needed to do so. The urgent and emergency care review (the review) details

how these models of care can be achieved through a fundamental shift in the way urgent and

emergency care services are provided to all ages, improving out-of-hospital services so that we

deliver more care closer to home and reduce hospital attendances and admissions. We need a

system that is safe, sustainable and that provides high quality care consistently. The vision of the

review is simple:

For adults and children with urgent care needs, we should provide a highly responsive

service that delivers care as close to home as possible, minimising disruption and

inconvenience for patients, carers and families.

For those people with more serious or life-threatening emergency care needs, we should

ensure they are treated in centres with the right expertise, processes and facilities to

maximise the prospects of survival and a good recovery. (Keogh Review, 2015)

In response to the review, urgent and emergency care services across the country are changing to

make them easier for patients to see the right person, first time when they need healthcare quickly.

Sir Bruce Keogh’s review ‘Transforming Urgent and Emergency Care Services in England, End of

Phase 1 Report (August 2014) describes how all health economies should develop urgent care

systems which are simpler and easier to navigate. It also states that ‘we must recognise that we

cannot rely on spending increasing amounts of money on a system that needs to be improved, and

which is already approaching its limits. We have to be more radical than this if we are to deliver

lasting solutions’.

The review highlights the need for the future system to:

• Provide better support to self care; • Help people with urgent care needs to get the right advice, in the right place, first

time; • Provide highly responsive urgent care services outside of hospital so people no longer

choose to queue in A&E; • Ensure that those people with more serious or life threatening emergency needs

receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery;

• Connect urgent and emergency care services so the overall system becomes more than just the sum of its parts.

To do this, a longer term solution must be developed to ensure that locally we have an urgent and

emergency care system that is reflective of the needs of our local health economy.

Through our discussions locally with stakeholders, patients and the public we recognise that our

urgent and emergency care systems within and outside the CCG need to change in order to deliver a

safe, effective urgent and emergency service, 7 days a week. A county wide strategy development is

underway and is expected to take at least 18 months therefore we have identified changes that can

be considered more quickly without compromising the long term vision.

There are many positives about the services commissioned in the local area but more people are

waiting longer to be seen, treated and discharged at A&E departments and ambulances are taking

longer to reach people in an emergency. The workforce locally is changing with gaps in GP

recruitment and some highly skilled nursing staff nearing retirement so we must make changes to

ensure the short term service delivery is sustained whilst we also focus on the longer term

workforce requirements that reflect local need.

Locally, urgent care services continue to experience unsustainable pressure due to rising demand, an

increase in complex healthcare needs and service limitations due to our local geography. Making

the changes proposed in this paper will help us move towards the new, national model and design

an effective system that delivers sustainable, high quality Urgent and Emergency Care services.

Along with our partners in the local healthcare economy, there is also a pressing financial imperative

to reduce waste in the system and increase efficiencies, so it is vital to look to implement quick wins

as well as long term solutions.

South East Staffordshire and Seisdon Pennisula CCG has one of the highest rates of A&E attendance

in the country when A&E and MIU activity is combined, which varies significantly by practice and

Locality. It is believed that elements of the demand are driven by actual or perceived access

problems to primary care, confusion in service offerings and a lack of integration across the urgent

care system. We are actively working with our GP locality teams to fully understand the access

issues and put measures in place to resolve them.

2.2 Minor Injuries Units (MIUs) background and data analysis

The MIUs at Sir Robert Peel and Samuel Johnson Hospitals are part of the Community Hospitals

provided by Burton Hospitals NHS Foundation Trust. The MIU nurse led services were set up with

the primary intention of seeing, treating and discharging patients without an appointment who have

minor injuries 24 hours a day, seven days a week and 365 days a year.

Patients attending the services are assessed and treated by Emergency Nurse Practitioners (ENPs).

There is no on-site Doctor within the units however local GPs currently support the service through

minimal input (11.30am to 1pm) during planned sessions Monday to Friday.

The MIU service can access x-ray facilities between the hours of 9am to 5pm Monday to Friday and

from 9am to 12pm on Saturdays. During the remaining time, patients are either assessed and

invited back to the service or redirected to A&E services locally when an xray is required.

Additionally, where patients attend inappropriately or need a high level of medical input, patients

are re-directed to their GP, the GP Out of Hours service or to Accident and Emergency, as

appropriate for their condition.

The service also currently offers the following inclusions/exclusions;

• ENPs can X-ray limbs under agreed protocols in patients aged two years and older; • ENPs are trained to treat minor fractures and in the application of casts; • Nursing staff are not trained in the manipulation of serious deformities; • Patients mainly self-refer to the unit but can be referred by other health care

practitioner such as doctors, practice nurses, radiographers; • Staff are currently able to refer patients to other health care providers including

district nurses, health visitors, the community intervention team, physiotherapists, the community falls team, the GP out of hours service or accident and emergency;

• Once assessed a plan of care is decided which could include further treatment, discharge or referral to other health care providers;

• Nursing staff can assess and treat a variety of eye injuries and complaints; • Telephone triage and advice is given; • There is a policy in place to receive ambulances but this is at the discretion of the

nurse in charge.

Over time the service has experienced increasing numbers of patients who are attending the MIU

with minor illness as well as minor injuries.

Our analysis has shown that over 50% of the patients are visiting the MIUs for conditions which are

normally managed in primary care, for example through an appointment with their GP, a

consultation in a Pharmacy or through self-management. There are also a number of attendances

for conditions for which there are alternatively commissioned, and more cost effective services

elsewhere such as emergency contraception, chlamydia screening and follow up dressings.

In addition, feedback from the consultation suggests that because the MIUs are local and open 24/7,

patients are attending for serious and life threatening problems. This poses a significant clinical risk

for patients who chose to attend the MIUs for emergency needs, particularly during the out of hours

period, as the MIUs are not equipped or staffed to deal with such cases and rely on calling the

emergency services resulting in the transfer of patients to A&E. This in turn, results in an MIU

attendance, ambulance conveyance and A&E attendance which not only adds additional activity, it

also adds duplicated assessments and delay in patients receiving the emergency treatment that they

need.

There is much evidence that addressing the needs of patients with more acute conditions quickly

means that they are likely to enjoy better clinical outcomes.

3. Case for Change

The CCG has one of the highest rates of A&E attendance in the country when the attendances at the

Minor Injuries Units (a type 3 A&E department) are included in this metric. Approximately 48,000

(73%) of the 66,000 attendances in the year 2014/15 were patients from South East Staffordshire

with the remaining 23% of patients using the service from Cannock Chase CCG, North Warwickshire

CCG and a wider geographical area.

Data analysis also shows that there are very low numbers of attendances at both of the MIUs during

the out of hours (OOH) period, with less than one patient attending every hour after midnight at

either site and a significant drop off in attendances after 9pm as illustrated in appendix A.

During the out of hours period which is defined as 6.30pm until 8am, the CCG currently

commissions a range of services to support urgent care needs. The GP ‘Out of Hours’ service

(OOH) operates from both Samuel Johnson and Sir Robert Peel Hospitals and is provided by

Staffordshire Doctors Urgent Care Ltd (SDUC) from 6:30pm until 8am Monday to Friday and 24

hours a day on Saturday, Sunday and Bank holidays. The service is accessed via the NHS111

telephone service that is operational 24 hours per day.

In addition, there are also full Accident and Emergency (A&E) departments serving the local

population at Queen’s Hospital in Burton and Good Hope Hospital in Sutton Coldfield. The current

services are summarised in the chart below:

As shown above, other services are already in place to cover the out of hours period to provide

healthcare when it is needed urgently.

Current Access to Urgent Care Services

8am 10am 12pm 2pm 4pm 6pm 8pm 10pm Midnight 2am 4am 6am

Primary Care 8am to 6.30pm Mon to Fri

GP Out of Hours service 6.30pm to 8am Mon to Fri and 24 hours on Sat, Sun and Bank holidays

Minor Injuries Units at Sir Robert Peel and Samuel Johnson, 24 hours a day, 7 days a week

A&E at Queen’s Hospital Burton and Good Hope Hospital, Sutton Coldfield, 24 hours a day, 7 days a week

NHS 111 service, 24 hours a day, 7 days a week

The Keogh report ‘Transforming urgent and emergency care services in England, safer, faster,

better: good practice in delivering urgent and emergency care’ (August 2015) states that “adults

and children should generally be assessed and treated at the first point of NHS contact capable of

meeting their immediate needs. Redirection may lead to assessments being duplicated, patients

inconvenienced and necessary care delayed.”

The CCG recognises that the MIUs provide a highly regarded, highly responsive service with most

patients being seen and treated quickly. Anecdotally, the long opening hours and short response

times are felt likely to encourage repeat attendance and fuel demand. However, the diagnostic

and medical support available, particularly during the out of hours period is limited so patients

who require an Xray, other test or medical review need to either go back to the MIU when the

Xray department is open or when there is a GP on site (during limited sessions Monday to Friday

only), be referred back to their own GP practice or to the GP Out of Hours service or visit one of

the A&E departments. This means that patients can be seen in two different places unnecessarily

and, as well as being inconvenient for the patients, it leads to duplication of service provision and

therefore costs for the CCG.

4. Pre-consultation Options

Various options have been considered to meet the CCG’s aims of providing sustainable, high

quality services and timely access to patients, whilst achieving its obligations to ensure that the

money it spends offers the greatest value. A variety of data analysis has been undertaken which is

summarised in a range of charts and tables, included in Appendix A. This informed the option

design and review process.

Regardless of which, if any, option is implemented, the CCG will initiate public education

campaigns to encourage patients to choose the appropriate access point for their urgent care

needs including self-care, Pharmacies for minor ailments, NHS 111, MIUs, GP OOH and A&E, so

that more patients are seen in the right place, first time and do not have to attend for repeat visits

thus ensuring better value for money than the current situation.

4.1 OPTION 1 – DO NOTHING

Description of current service

The Minor Injury Units are currently staffed by nurses and administrative staff. Patients are seen

and treated (where possible) or signposted on to other more appropriate settings (such as A&E) or

transferred if emergency treatment is required.

Opening hours are 24 hours a day, seven days per week, with access to diagnostics Monday to

Friday 9am to 5pm and Saturday mornings. A mix of minor injuries and minor illnesses are treated.

The units have minimal medical cover (11.30am to 1pm, Mon – Fri, Samuel Johnson only) and no

access to any specialised clinics.

Benefits

No change for patients, they will continue to receive the same service in the same location.

No implications for staff.

Risks

The current service is unaffordable in its current form.

The activity during the out of hours period is unsustainable due to the extremely low activity

overnight.

There is no access to x-ray for a significant proportion of the current opening hours resulting in

duplication (inviting patients back when x-ray is open) or redirection to other services such as

NHS111, GP OOH or Accident and Emergency departments.

The CCG is currently commissioning other services offering urgent care during the out of hours

period including GP OOH, NHS111 and A&E services.

The current MIU services have evolved over time to reflect the usage of patients. This means

that the current service is not specified accurately and does not necessarily reflect the existing

or future needs of patients.

Approximately 50% of activity is for minor illness which the service was not originally set up to

deliver and that can be seen in other healthcare settings such as a pharmacy or GP practice.

The CCG is not able to demonstrate effective use of its resources.

The MIU model does not reflect the national direction of travel for urgent and emergency care.

MIU is a costly resource as the public are currently accessing the services for minor illness not

just minor injury, which incurs extra costs and the CCG being charged twice for patients

returning or being sent elsewhere to be x-rayed (e.g. to A&E).

4.2 OPTION 2 – DE-COMMISSION THE SERVICE

Description The MIUs would be de-commissioned and close. The services could potentially be replaced at some

point in the future (at least two years) with a more appropriate ‘Urgent Care Centre’ (UCC) in line

with requirements and advice emerging from the Keogh Review into Emergency and Urgent Care.

Patients who currently attend the MIU would have to be seen elsewhere, i.e. wait for a GP

appointment; attend A&E; access GP out of hours services through NHS111 or self-care with the

support of pharmacies.

Benefits

The CCG could realise significant efficiencies as well as supporting primary care needs in a

primary care setting, rather than a hospital setting. This approach would be more cost effective

and gain best value from taxpayers’ resources.

Patients will be redirected to use the most appropriate service already commissioned such as

pharmacy services, NHS111, GP practices, GP Out of Hours and A&E services depending on their

clinical need

Risks

Extra pressures would be placed on already stretched GP and A&E capacity for the patients

requiring treatment for minor illness and injury

Increase in the use of the GP OOH, service at an increased cost, as the numbers of patients are

outside of accepted tolerances within this contract

Increase in attendances to A&E for patients requiring treatment for minor injuries and minor

illness may impact the performance at A&E departments. Given that the attendance at MIUs is

at a national tariff for MIUs, cost increases would be limited although would have to be

considered

Increase in 999 ambulance service calls for patients requiring treatment for minor injuries and

minor illness may impact the ambulance service performance. This may increase costs

minimally, however the ambulance service have a triage system in place to ensure minor illness

and injury are dealt with at appropriately commissioned services

The future model of urgent and emergency care is unclear locally and the de-commissioning of

MIU services may have a detrimental and de-stabilising impact on the existing Community

Hospitals until a longer term solution is identified.

4.3 OPTION 3 – REDUCED HOURS MIU

a) Open the MIUs from 8am to 6pm, 365 days a year

Description

The MIUs would remain open during the period from 8am to 6pm when most (approximately 72%)

patients attend. Patients requiring urgent care outside of these hours would be able to access

advice from NHS 111, use the GP OOH service or attend an A&E department.

It is also recognised that this option will require further work to reduce activity during the in hours

period for patients who require urgent treatment for minor illness.

Benefits

There would be no change for 72% of patients as they are currently seen during these core

hours

Services at the MIU would be more reflective of the diagnostic x-ray services available during

the Monday to Friday period (Monday to Friday 9am to 5pm and Saturday morning)

The CCG could realise significant savings as supporting primary care needs in a primary care

setting, rather than a hospital setting, is more cost effective

Patients will be redirected to use services already commissioned such as pharmacy services,

NHS111, GP practices, GP Out of Hours and A&E services ensuring that patients see the right

person, at the right time

Service continuity in maintaining the core, busy, opening hours for the MIU services will provide

stability to the Community Hospitals until the longer term model for Urgent and Emergency

Care locally is designed and understood

Risks

Approximately 17 % of out of hours activity attends during the hours of 6pm to 9pm

The GP OOH service does not open until 6.30pm Monday to Friday

Possible increase in attendances to A&E for patients requiring treatment for minor injuries and

minor illness may impact the performance at A&E departments. However numbers are low

during the out of hours period and as the MIU service currently has no access to x-ray during

this period, those requiring treatment for minor injuries may already be redirected to an

alternative service or asked to re-attend. Given that the attendance at MIUs is at a national

tariff, cost increases would be limited.



minimally, however the ambulance service have a triage system in place to ensure minor illness

and injury are dealt with at appropriately commissioned services therefore this risk is mitigated

b) Open the MIUs from 8am to 9pm, 365 days a year

The MIUs would remain open during the period from 8am to 9pm when the majority of patients

(90%) attend. Patients requiring urgent care outside of these hours would still be able to access

advice from NHS 111, use the GP OOH service or attend an A&E department.

It is also recognised that this option will require further work to reduce activity during the in hours

period for patients who require urgent treatment for minor illness.

Benefits

There would be no change for the majority of patients (90%+) as they are currently seen during

these hours

There will be a reduction in duplication of services available at times of very low activity.

The CCG and Hospital Trust will be able to realise efficiencies as supporting primary care needs

in a primary care setting, rather than a hospital setting, is more cost effective

Patients will be redirected to use services already commissioned such as pharmacy services,

NHS111, GP practices, GP Out of Hours and A&E services ensuring that patients see the right

person, at the right time

Service continuity in the maintaining the core, busy opening hours of the MIU services will

provide stability to the Community Hospitals until the longer term model for Urgent and

Emergency Care locally is designed and understood

Risks

Possible increase in attendances to A&E for patients requiring treatment for minor injuries and

minor illness may impact the performance at A&E departments. However numbers are

extremely low during the out of hours period and as the service currently has no access to xray

during this period, those requiring treatment for minor injuries may already be redirected to an

alternative service. Given that the attendance at MIUs is at a national tariff, cost increases

would be limited



minimally however the ambulance service have a triage system in place to ensure minor illness

and injury are dealt with at appropriately commissioned services therefore this risk is mitigated

5. Consultation and Engagement

South East Staffordshire and Seisdon Peninsula CCG regard engagement and consultation highly in

the commissioning of services locally. In order to arrive at the proposals, significant urgent care

engagement has been undertaken with residents, stakeholders and our GP members and will remain

an ongoing process.

The pre-consultation engagement undertaken included:

Minor Injury Unit Surveys at Samuel Johnson Hospital, Lichfield & Sir Robert Peel Hospital,

Tamworth, commissioned from Healthwatch/Engaging Communities Staffordshire, June

2014;

Talk about Health events summer 2015;

Discussions with GP members at Locality Boards;

Discussions with Burton Hospitals NHS Foundation Trust – including MIU staff, management

and Executives;

Discussion at the CCG’s Patient Council and through the formation of an Urgent Care Patient

Reference Group – summer 2015 and ongoing.

The proposals have been developed with East Staffordshire CCG as lead commissioner, Burton

Hospitals NHS Foundation Trust, our GP members and with the views of our local councillors and

patients at the heart of the proposals.

Together with our Governing Body, our GPs understand and support the rationale for change and

there is a consensus that doing nothing is not an option due to the clinical risks associated with

inappropriate attendance at the MIUs and the duplication of services which contributes to the

significant financial challenge that we face as a local health economy.

Advice was sought from The Healthy Staffordshire Select Committee about how best to fulfil the

CCG’s obligation to consult more widely with the public about the proposed minor change in

opening hours. A six week consultation period was supported and the methodology and findings are

described in detail in appendix B and summarised below.

5.1 Consultation Response Summary

There was significant engagement throughout the consultation with a wide range of individuals and

organisations which can be quantified as follows:

501 survey responses, gathered through the website, in hard copy and via face-to-face interviews at drop-in events;

Many questions and comments – these give us a sense of the concerns of respondents;

There were 30 direct communications sent to the CCG, including letters and emails.

The key questions posed sought to quantify the level of understanding of, and agreement with, the

proposals. The survey also offered the opportunity for respondents to provide further feedback

through free text comments.

5.2 Summary Quantitative and Qualitative findings

The survey was designed to gauge the opinions of local people about the proposed changes to the

opening hours at the MIUs in Tamworth and Lichfield.

5.2.1 Take up and profiling

In total 501 people completed a survey form, though not all questions were answered in every case.

In terms of the gender of people who completed the survey, 66% of respondents described

themselves as female, 32.7% described themselves as male, 0.21% described themselves as

transgender and 0.42% preferred not to say.

The ethnicity profile was made up of a majority of White British respondents (94%) with small numbers of people from other ethnic backgrounds completing the survey. However this does reflect the proportion of people from minority ethnic groups within Tamworth and Lichfield being lower than the national average (5% and 5.4% respectively compared to 20.2% nationally).

Respondents were asked to volunteer the first four characters of their postcode. Of the 501

respondents, 456 shared this data. The majority of the respondents who disclosed their location

came from Tamworth, making up 65% of the survey responses which is believed to be reflective of

the interest amongst Tamworth residents in the proposed change.

The survey was completed by a broad spread of age groups with the majority of respondents aged

between 25-74 years of age. In addition, it was pleasing to note that 18% of respondents were aged

between 25 and 34 years of age which is an age group that tends to not participate in survey activity.

This response rate enhances the quality of the overall data. A breakdown in terms of the ages of

respondents is displayed below:

5.2.2 Understanding the Proposal

Respondents were asked to express if they understood the rationale for the proposed changes to

the MIU opening hours and a variety of tools were used to help this understanding including a

narrated presentation available on line and used at all events and face to face discussions with CCG

clinicians and staff.

As can be seen in the illustration below, around 93% of respondents stated that they understood the

rationale for the proposed changes, with only 7% stating that they did not.

It can therefore be safely assumed that the majority of people who completed the survey were able

to understand what was proposed and why the CCG is proposing the change, which adds validity to

the data.

5.2.3 Support for the proposals

As can be seen below, more people disagreed with the proposals than agreed with 27% agreeing

and 64.3% disagreeing. A minority of people (circa 8.6%) expressed neither agreement nor

disagreement.

5.2.4 Choice of Alternative Urgent Care Service

Respondents were asked what alternative service they would use in the event of the MIU not being

available during the overnight period. As can be seen below, the survey responses to this particular

question are wide ranging, with 28.3% of people stating that they would attend A&E if the MIU was

unavailable overnight and a not dissimilar number saying they would call NHS 111 (25.7%).

Respondents stating “Other” generally described how the decision as to which service they would

elect to use in the event of MIU being unavailable overnight would depend on the circumstances.

Smaller numbers would elect to use either GP Out of Hours services, dialling 999 or waiting until the

following day.

5.2.5 Qualitative feedback

The survey responses provided significant qualitative feedback through the free text comments and

a number of themes emerged, as detailed in the consultation report (appendix B) and as

summarised below:

Current MIU and Community Hospital provision is highly valued by the local population and

there is a desire to maintain the current opening hours or at least shorten the proposed

closure period;

Concern about how the alternative services e.g. NHS 111, GP OOHs, A&E and mental health

services, will cope if the MIUs are closed overnight;

Questions about the validity of the data presented in terms of the numbers and types of

patients attending and the financial benefits of the proposal, including whether cost savings

from non front line services have been considered;

A lack of understanding and need for better education/communication regarding the total

urgent care system, its access points and where to go to see the right person, first time, for

a particular urgent care need;

Potential transport and travel difficulties if services had to be accessed at a more distant

location;

Wider concerns about the future of the Community Hospitals and the current and future

health needs of the local area, particularly in respect of Tamworth.

6. Post consultation option consideration

Having analysed and reflected on the feedback from the consultation report the preferred option

was reconsidered in light of the findings and consideration was given to whether alternative options

could meet the aim and objectives described in this paper i.e. to match patient requirements and

expectations with the commissioning of appropriate, high quality, clinically and financially

sustainable services, whilst addressing some of the themes and concerns raised during the

consultation.

A modified version of option 3b) has been developed which slightly extends the opening hours at the

Sir Robert Peel MIU to 10pm to better accommodate the average of three to four patients a night

attending this site between 9pm and 10pm, before a significant tailing off in attendances after

10pm. The benefits and risks of this option remain as shown for option 3b) on page 11 apart from a

reduction in the number of patients affected, with 92.3% being unaffected.

6.1 Views from the Urgent Care Patient Reference Group

As can be seen from the Consultation and Engagement Report, an Urgent Care Patient Reference

Group was formed and has contributed throughout the process. Having reviewed the themes and

patient reach from the MIU consultation, members of the Group who were available to review

themes, summarised their views as follows:

The out of hours service must be fit for purpose;

Patients must be provided with knowledge of where to go;

The CCG must monitor the impact of any implementation;

‘Personal thank you to the CCG for including us in the process from start to

finish’. Representatives found it useful to be involved.

The CCG would like to express our thanks to the Urgent Care Patient Reference Group members for

their support in this process.

7. Risks and mitigation

Risks associated with the themes arising from the consultation have been defined with mitigation

and actions identified and planned, as described below.

Theme Risk Mitigation/Actions

Concern about the ability of

alternative services to cope with

additional demand:

GP Out of Hours service Current service has a number of

actual and perceived gaps in

provision, especially after 9pm.

If the use of the service increases

then more patients will need to

travel to Burton for a centre visit in

the overnight period.

Suitability of the current OOH

location if the MIUs are closed

overnight.

Quality issues identified through

the consultation are being

addressed with the provider.

The service is being re-specified

to include the need to have a GP

based in a centre within

Tamworth overnight. This will be

implemented prior to, or

concurrently with the proposed

changes to MIU opening hours.

The OOH specification will

require the provider to ensure

that suitable premises are

available.

The low numbers of potential

additional patients are within

existing contract tolerances so no

adverse impact on costs are

anticipated.

NHS 111 NHS 111 direct more patients to

A&E in the absence of an overnight

MIU service resulting in

inconvenience to patients and

increased costs to the CCG,

The Directory of Services (DOS)

which underpins the 111 service

is being updated to ensure all

suitable sources of urgent care

advice and treatment are

correctly detailed to enable

patients to be directed to the

correct service for their needs.

A&E at Burton and Good Hope

Hospitals

These services are already

overstretched so more patients

attending if MIU is closed may

adversely impact performance.

Based on the analysis of the

types of patients attending MIU

overnight it is anticipated that a

very small number would need to

attend A&E so the impact will be

minimal. Some patients are

already being diverted to A&E in

the OOH period due to the MIU

not being equipped or staffed to

deal with medical emergencies.

Mental Health Services Anecdotal feedback has identified

apparent issues with the mental

health pathway whereby patients

in crisis attending the George

Bryant unit out of hours are

referred to the MIU which is

inappropriate.

The commissioner for mental

health services will be required

to review the pathway and

ensure that there are no gaps in

service provision particularly for

patients who have a mental

health crisis.

Validity of Data

Numbers of patients attending

Acuity of patients attending

Financial analysis

Developing and implementing

proposals based on flawed data in

relation to patient numbers,

patient acuity and financial

benefits.

During the public consultation,

the data has been refreshed,

found to be correct and has been

agreed with Burton Hospitals

NHS Trust, as the provider. The

year on year and seasonal

variances have also been

analysed and are shown in

appendix A.

In response to concerns by the

MIU staff, an observational audit

was undertaken as an additional

sense check on the numbers and

types of patients attending in the

overnight period.

The financial analysis has been

refreshed and reviewed

independently by a second

analyst and found to be sound.

Need for the public to better

understand the urgent care system

and how to access what they need

when they need it

Patients won’t get the right care

first time if they do not understand

the system and how to access it

appropriately.

The Directory of Service for 111 is

being reviewed and updated.

A public engagement and

education programme will be

undertaken by the MIUs and the

CCG prior to any change being

implemented and on an ongoing

basis to ensure patients, GPs and

other stakeholders know what to

do when there is an urgent care

need. Targeted communications

will be undertaken for protected

groups to improve knowledge

and understanding of available

services.

Transport and travel difficulties if

attendance at more distant

locations is required

Risk that more patients will call an

ambulance if they are unable to

travel to A&E at Burton or Good

The messaging and education

around use of NHS 111 to triage

patients will be key.

Hope Hospitals. Analysis has shown that the

number of patients needing A&E

for minor injuries in the

overnight period will be very low.

Concern about the future of

community hospitals and local

health provision generally

Risk that the proposal will

jeopardise the future of the

community hospitals.

Risk that the provision for the

health needs of the increasing

Tamworth population will not be

met by reducing services.

It is not felt that the minor

change proposed will impact the

overall sustainability of the

community hospitals.

The feedback received during the

consultation in relation to these

broader issues will be fed into

the ongoing strategy

development for the health

needs of the local populations.

8. Financial Appraisal

It is important to remember that this proposal aims to prevent unnecessary service duplication and

ensure that patients are seen in the most appropriate clinical setting for their needs, first time, as

well as identifying opportunities to increase value for money.

The financial assessment of both versions of options 3b), shown below, indicates the following best

case scenario savings to the health economy, spread across all the CCGs whose patients attend the

MIU. Approximately 72% of attendances, and hence the savings, are from residents of South East

Staffordshire and Seisdon Peninsula CCG. The savings shown do not take into account any potential

additional costs of alternative service provision. However, these are expected to be minimal for both

options as currently one in four patients attending the service in the overnight period are already

referred onto an alternative service. Due to contracting arrangements, any minimal increase in

activity will be absorbed into existing contracts.

Option 3b) – Open both sites 8am to 9pm

MIU Night Closure Impact (Contracted)

CCG Activity Finance Activity Finance Activity Finance

Total 2,622 £152,076 4,112 £238,496 6,734 £390,572

Open Close Open Close

Enter 24 Hour Parameters >> 8 21 8 21 1.89%

Non CSU CCG Proportion

The data below is MIU activity from 2014-15 costed at 2015-16 tariff of £58.

Lichfield Tamworth Total

Option 3b) revised – Open Sir Robert Peel MIU 8am to 10pm and Samuel Johnson 8am to 9pm

MIU Night Closure Impact (Contracted)

CCG Activity Finance Activity Finance Activity Finance

Total 2,622 £152,076 2,852 £165,416 5,474 £317,492

Open Close Open Close

Enter 24 Hour Parameters >> 8 21 8 22 1.89%

Non CSU CCG Proportion

The data below is MIU activity from 2014-15 costed at 2015-16 tariff of £58.

Lichfield Tamworth Total

9. Self assessment against the Secretary of State for Health “four

tests”

NHS bodies proposing change to service provision are required to assess the proposal against the Department of Health ‘four tests’. The table below summarises our position against these requirements.

Test Requirement CCG Activity

Support from GP

commissioners Commissioners will need to consider the

engagement / involvement that may

need to take place with practices whose

patients will be significantly affected by

the case for change, inviting views and

facilitating a full dialogue where

necessary. Local commissioners will need

to demonstrate the nature of the

discussion with consortia or with other

appropriate bodies as a proxy. For

example, the commissioner could obtain

written sign off from relevant local

consortia representative.

GP members value the service provided

by the MIUs but recognise and support

the need for change in the short term to

ensure patients are seen by the right

person, first time and that there is good

utilisation of available resources. They

are also supportive of the need to

develop a longer term solution.

The short term MIU proposals have been

clinically led with options designed and

reviewed together with GP clinical leads.

The preferred option consulted on was

supported by CCG GP members through

GP Locality Boards and the CCG Governing

Body. Wider members practices were

also engaged as part of the Protected

Learning Time for GP Practice in SES&SP

CCG.

Strengthened public

and patient

engagement

The National Health Service Act 2006

requires local health organisations to

make arrangements in respect of health

services, to ensure that users of those

services such as the public, patients and

staff are involved in the planning,

development, consultation and decision-

making in respect of the proposals. Local

commissioners should engage

Healthwatch and Health Overview and

Scrutiny Committees to seek their views.

Public, patient and staff views were

included in the development of the

proposals through the significant

engagement exercises undertaken in

SES&SP CCG regarding urgent care.

The good response to the public

consultation has enabled the views of a

wide range of individuals and

organisations to be captured and

considered as final proposals were

defined.

An Urgent Care patient stakeholder group

was established to be involved in the

development of the long term strategy for

Urgent Care provision. This group has

representation from Healthwatch and

other interested parties. A sub set of this

group has been involved in the design and

review of the consultation materials and

their views post consultation are included

in the consultation report.

The views of the local and county Health

Overview and Scrutiny Committees has

actively been sought.

Clarity on the clinical

evidence base It is recommended that clinicians should

lead in gathering this evidence,

considering current services and how

they fit with the latest developments in

clinical practice, and current and future

needs of patients.

The Keogh report ‘ Transforming urgent

and emergency care services in England’,

Safer, faster, better: good practice in

delivering urgent and emergency care

(August 2015) states that “adults and

children should generally be assessed and

treated at the first point of NHS contact

capable of meeting their immediate

needs. Redirection may lead to

assessments being duplicated, patients

inconvenienced and necessary care

delayed.” As explained in this document

the current MIU service can involve

redirection and duplicated attendances as

patients requiring diagnostic treatment

such as xray or medical review when

these MIU support services are not

available are being diverted to another

service such as the GP out of hours

services or A&E or are invited back to the

service when xray is open. This is not a

good clinical model, is a poor use of

resources and is inconvenient for

patients.

The clinical lead for Urgent Care has been

instrumental in reviewing the national

guidelines for Urgent Care and how the

needs of the CCGs patients can be best

met, now and in the future.

Patients are currently inappropriately

attending the MIUs for emergency needs..

This is not in line with best clinical

practice and does not always result in

patients being seen by the right person,

first time. Redirecting patients to more

appropriate services and re-specifying the

MIU service will enable us to better meet

the latest developments in clinical

practice in the short term, whilst we

move towards the longer term clinical

model for urgent care delivery.

Consistency with

current and

prospective patient

choice

Local commissioners will need to

consider how the proposed service

reconfiguration affects choice of

provider, setting and intervention; and

the choice this presents the patient

compared with the current model of

provision. Commissioners will need to

ensure this consideration is part of any

dialogue with local clinicians,

Healthwatch and Scrutiny Committees. In

meeting the choice test, commissioners

will want to make a strong case for the

quality of proposed services and

improvements in the patient experience.

Locally, patients currently have a wide

choice of services catering for their urgent

care needs. Sometimes this choice means

that patients do not know which services

to attend for their needs and are

inconvenienced by having a repeat

attendance, duplicated assessment or by

being re-directed elsewhere. This

proposal affects a small number of

patients who will be re-directed to the

most appropriate service through NHS111

during the out of hours period such as the

GP OOH service, or if an xray is needed,

through access to a service that offers

xray during the out of hours period which

the existing service does not offer. We

will also help patients make the right

choice through the Stay Well campaign.

10. Quality Impact Assessment

A full quality impact assessment has been undertaken by the Quality Improvement Manager which

has been reviewed by the CCG’s Quality Impact Assessment Sub Group. As can been seen from the

summary table below, it was concluded that there was a positive impact on six out of the nine

parameters. The sub group felt that the potential negative impacts were satisfactorily mitigated and

offset by the positive impacts of the proposal.

Duty of Quality: Compliance with the NHS Constitution, partnerships, safeguarding children or adults and the duty to promote equality?

Positive / Negative

Patient Experience: Positive survey results from patients, patient choice, personalised & compassionate care?

Positive / Negative

Patient Safety: Safety, systems in place to safeguard patients to prevent harm, including infections?

Positive / Negative

Clinical Effectiveness: Evidence based practice, clinical leadership, clinical engagement and/or high quality standards?

Positive / Negative

Prevention: Promotion of self-care and health inequality? Positive / Negative

Productivity and Innovation: The best setting to deliver best clinical and cost effective care; eliminating any resource inefficiencies; low carbon pathway; improved care pathway?

Positive / Negative

Patient Choice: Everyone who is cared for by the NHS in England has formal rights to make choices about the service that they receive

Positive / Negative

Access: Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health.

Positive / Negative

Integration: Integrated care involves providers collaborating, but it may also entail integration between commissioners

Positive / Negative

11. Equality Impact & Risk Assessment (EI&RA)

The existing MIU service has been reviewed in order to identify the protected groups who might be

adversely affected by any proposed change to the MIU opening hours. As a result, significant

targeted engagement has been undertaken with service users from the protected characteristics

groups, as described in the Consultation and Engagement Report (appendix B). The feedback

received formed part of the consultation outcomes report and was extremely helpful in assessing

the equality impact and was used in addition to the review of data, complaints reporting and soft

intelligence.

Overall it appears that many of the protected groups were in broad support of the proposals but

mainly as they perceive A&E as the place that they would go to if they had a minor injury and do not

routinely consider MIU as a place to go for urgent healthcare needs.

After a review of the EI&RA it has been confirmed that the EI&RA is a fairly comprehensive scrutiny

of any adverse impacts from CCG healthcare changes. It has been noted that the CCG ‘have made a

record of gathering evidence, of taking ‘due regard’ or deliberate consideration of local protected

groups according to the Brown Principles (PSED 2011). This is incorporated into the EI&RA

document, along with key embedded support documentation’.

Further to the EI&RA, the conclusions drawn are as follows:

Should a Governing Body decision be made for the proposed changes to be implemented, a detailed

implementation plan will be required in order to mitigate any issues for all patients including those

who are vulnerable or are from one of the protected characteristic groups. In particular, it is

important for the CCG to consider wider health inequalities for protected groups and also to ensure

the increased knowledge and awareness of services for patients to provide reassurance and

direction about which service to access for their urgent healthcare needs. The implementation plan

should also ensure that the CCG puts processes in place to routinely monitor and respond to any

adverse impact on protected groups through the usual contracting processes.

Further to the EI&RA, service improvements relating to NHS111 and GP OOH are required to ensure

that vulnerable groups are able to access healthcare from a GP in the out of hours period locally,

either through assurance over the telephone, a face to face appointment or a home visit.

12. Conclusions and Recommendations

The local health economy is experiencing significant financial pressures and in order to commission

local services that are responsive to patients’ needs as well as being clinically and financially

sustainable, the CCG must minimise service duplication and ensure that patients receive the right

care in the right place, first time, through safe, high quality services that offer the best possible value

for money.

Following a thorough review of the data and in response to the consultation findings, the CCG

recommends that the refined option 3b) is implemented with effect from 1st April 2016, i.e. that the

opening hours of the Minor Injuries Unit at Sir Robert Peel Hospital be changed to 8am to 10pm and

at Samuel Johnson to 8am to 9pm.

The small numbers of patients currently attending outside of these periods, on average 0.76 per

hour at Sir Robert Peel and 0.6 per hour at Samuel Johnson would be served by alternative, already

commissioned services such as NHS 111, GP OOH, A&E, in hours MIUs or Pharmacies.

This option is preferred as it offers the least disruption to patients using the MIU services in

Tamworth and Lichfield, ensures that duplication of service offering is reduced and releases a

modest level of recurring savings to the health economy. It also aligns with the goals and values of

the CCG, ensures there is service continuity for patients and supports the continued stabilisation

of community hospitals while a longer term solution is identified.

As described in this paper, the implementation of any change in opening hours will also involve

proactive campaigns to help patients choose the most appropriate service access point for their

urgent care needs, at all times of the day, so that more patients are seen in the right place, first

time.

Should the proposal for a change to the opening hours at the MIUs be agreed, a detailed

implementation plan will be required in order to inform patients of the changes and to ensure

that protected groups are aware of the wider services available for urgent healthcare needs at all

times of the day and night.

13. Appendix A – MIU Data Analysis

Total MIU activity by site showing total attendances by hour per year.

Source: 2014/15 SUS. Red line indicates an average of 1 patient per hour

Total 14/15 MIU Activity shown as average attendance by hour

Year on year variances for April – September from 13/14 to 15/16

Source: SUS.

Seasonal variances, quarter by quarter 1st April 2013 to 30th September 2015

Source: SUS.

14. Appendix B – Consultation and Engagement Report

proposal to change the opening hours of the minor injuries...

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