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Urgent Treatment Centre Co-design Events

Engagement Report

November 2018

Helping to shape future health and social care in Mid Nottinghamshire

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1. Introduction Urgent and Emergency Care is one of the main national service improvement priorities for the NHS, with a focus on improving national Accident & Emergency (A&E) performance whilst making access to services clearer for patients. Research has shown that patients and the public are confused by the mix of walk-in centres, minor injuries units and urgent care centres, in addition to numerous GP health centres and surgeries offering varied levels of core and extended service. Within and between these services, there is a confusing variation in opening times, in the types of staff present and what diagnostics may be available. To end this confusion, NHS England have set out a core set of standards for urgent treatment centres (UTC) to establish as much commonality as possible. By December 2019 patients and the public will:

Be able to access urgent treatment centres that are open at least 12 hours a day, GP-led, staffed by GPs, nurses and other clinicians, with access to simple diagnostics, e.g. urinalysis, ECG and in some cases X-ray.

Have a consistent route to access urgent appointments offered within 4hrs and booked through NHS 111, ambulance services and general practice. A walk-in access option will also be retained.

Increasingly be able to access routine and same-day appointments, and out-of-hours general practice, for both urgent and routine appointments, at the same facility, where geographically appropriate.

Know that the urgent treatment centre is part of locally integrated urgent and emergency care services working in conjunction with the ambulance service, NHS111, local GPs, hospital A&E services and other local providers.

Newark Urgent Care Centre will change to become an Urgent Treatment Centre and the public, staff and other stakeholders are key to ensuring the service meets the needs of local people, hence a series of conversations to understand what local people believe are important factors for consideration in the development of this service. Engagement commenced on 17 January 2018 when NHS Newark & Sherwood Clinical Commissioning Group commenced a discussion with the public, staff and stakeholders to;

Raise awareness of the requirements of Urgent Treatment Centres

Provide registered patients with an opportunity to be listened to and their questions answered

Give staff the opportunity to be listened to and engage in the process Over 60 people participated in this engagement and provided positive comments. The local MP, Health Scrutiny Committee and Healthwatch have shown an interest in the proposals and have been updated on an ongoing basis. Further drop-in events took place on 8 and 21 March 2018. A co-design event took place on 30 July 2018 that was attended by 40 people including staff, public and stakeholders. The event began with a presentation delivered by Dr. Amanda Sullivan, Chief Officer, NHS Newark & Sherwood Clinical Commissioning Group. The presentation described how the plans for Newark Urgent Treatment Centre (UTC) formed part of the strategic vision for Newark Hospital as a centre of excellence for urgent and planned care delivering joined up services that are flexible for patients. Some of the national requirements relating to urgent treatment centres were described together with information about emerging models for urgent treatment centres that had differing opening hours depending on their location. For example a UTC located within the A&E department at QMC would open 24/7 whereas UTCs not co-located within an A&E Department opened 16/7.

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Key requirements for the Newark UTC were described as:

It should be part of integrated urgent and emergency care services working closely with the ambulance service, NHS111, local GPs, hospital A&E services and other local providers

Patients should be able to access more routine and same-day appointments for both urgent and routine appointments, at the same facility

Walk-in appointments should still be available at the UTC

We aim to offer people in Newark access to urgent appointments in the right setting for their illness or injury within four hours.

Presently Newark Urgent Care Centre sees on average 65 patients every 24 hours, but only around 2 patients between the hours of midnight and 8am A full copy of the presentation may be found in Appendix A. Further events were held on 11 September 2018 and 16 October 2018. The presentations at both events revisited the context around the establishment of Urgent Treatment Centres for the benefit of anyone who had not attended earlier events. The events sought to look in further detail, through presentation and/or discussion, at the key issues raised by participants during the course of the event held on 30 July 2018, including NHS 111, workforce, clinical pathways, future population growth and transport. On 11 September 2018 Dr. Christine Johnson, Clinical Lead, NHS 111, provided explanation of the current provision of NHS 111 and described how the clinical assessment service would develop to ensure the service delivered a consult and complete approach to care rather than assess and refer as at present. Explanation was provided that public health data analysis had been used to predict demand and plan for the future. Population growth was expected to be between 8,000 and 14,000 by 2026 due to housing growth with the majority occupied by families with young children with less residents aged 50 and over. This will create more demand for primary care services from this group than hospital care. The co-design event held on 16 October 2018, reviewed the issues raised at previous co-design events and captured the CCG’s response to these as detailed below;

Participants were reminded of the range of services available in Newark - GP Surgery, Pharmacy GP extended access appointments, NHS 111 Clinical Assessment Service and GP out-of-hours service including overnight visits. Data was also shared about the level of attendances and the range of services available to assist participants to consider possible solutions to deliver services going forward at Newark Urgent Treatment Centre during the workshop sessions.

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2. What did patients, staff and stakeholders tell us? Full details of the feedback provided at the three events in recorded in full in Appendices B, D and F. The key questions asked and the key themes raised during the discussion groups are summarised below; 30 July 2018 Co-Design Event During the co-design event held on 30 July, 2018, participants were asked to consider three key questions as follows;

How would people who live in Newark want to see services work together?

With a direct booking facility through 111, how could the UTC develop?

Could we make better use of the workforce round the clock, whilst ensuring access to urgent care clinical advice and assessments at all times of the day?

The key issues that emerged from the discussion groups may be summarised as:

People’s perception is that NHS 111 is not a good service as their experience or anecdotal evidence is that it doesn’t work for them.

Workforce capacity was a real concern in relation to GPs, Advanced Nurse Practitioners, and availability of an appropriately skilled workforce to deliver the NHS 111 clinical assessment service

Consideration should be given to the large elderly population to ensure equity of access to services and to ensure their access is not compromised due to availability of transport or IT solutions

The rurality of the area poses challenges in relation to urgent care provision and consideration needs to be given to ways to support people with urgent care needs at home

Consideration should be given to planned housing growth in the area and its impact on urgent care services

The impact and costs associated with increased ambulance service activity should be reviewed

There is a need to effectively communicate any changes to the way services are delivered to

enable the public to access the right care, first time

Whilst not directly relating to the development of an urgent treatment centre, it was highlighted that there would be a need to ensure appropriate clinical cover for in-patient beds at Newark Hospital.

11 September 2018 Co-Design Event During the co-design event held on 12 September 2018, participants were asked to consider three key questions as follows;

What would good look like for Newark Urgent Treatment Centre?

How could better use be made of the NHS 111 service?

How can we improve overnight services? The key issues that emerged from the discussion groups may be summarised as:

NHS 111 clinical assessment service should have clear protocols to follow and particular reference was made to end of life care and patients with complex health needs. The importance of sharing clinical records to inform appropriate treatment was also considered to be important in the overall delivery of services together with Special Patient Notes.

In determining workforce requirements consideration should be given to the impact of change on other services at Newark Hospital, eg. in-patient wards

Build workforce capacity through better use of pharmacists, Advanced Nurse Practitioners and encouraging self-care with a greater focus on health promotion to improve population health

When considering population growth account should also be taken of the number of people who travel into Newark to work

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16 October 2018 Co-Design Event During the co-design event held on 12 September 2018, participants were asked to consider three key questions as follows;

Based on the information provided about the level of attendances and the range of services available, what are the possible solutions to deliver services going forward?

We would be interested to hear of any different or innovative ideas regarding access to services.

What other considerations should be taken into account in the development of Newark Urgent Treatment Centre?

The key issues that emerged from the discussion groups may be summarised as:

Further clarification was requested regarding the data about current activity at the Newark Urgent Care Centre. It was suggested that the activity didn’t take into account the length of time patients may remain in the centre. In addition, it was suggested that many communities do not know about the service at Newark Urgent Care Centre and may attend elsewhere either conveyed by the ambulance service or using their own transport.

There were differing opinions regarding the opening times of the Urgent Treatment Centre going forward. Some participants were of the view that it should be available 24/7 whilst others, with a caveat regarding the accuracy of the data, were of the view that opening between 12 midnight and 8 am was not a good use of public money.

With regard to services provided within the Urgent Treatment Centre, access to mental health crisis intervention was considered important in addition to the provision of care closer to home or within the home, as appropriate.

There was a consistent thread through all the co-design events that related to communication. There was a view that there is a general lack of awareness of the range of services available in Newark and when it is appropriate to access those services. Provision of better information may support the Newark population to access the right care, first time. The Voice magazine was suggested as a good resource to cascade messages widely to the population.

3. Next steps Further data has been requested regarding the specific queries raised during the event held on 16 October 2018 and to inform the further targeted engagement with those patient groups defined as high users of Newark Urgent Care Centre. All feedback arising from the co-design events and the targeted engagement will be reviewed and analysed to inform the service specification for Newark Urgent Treatment Centre. An updated report will be made available on the CCG’s website at www.newarkandsherwoodccg.nhs.uk Any potential changes to services will be subject to appropriate communication and engagement.

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Appendix A

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Appendix B Feedback from 30 July 2018

Question; How would people who live in Newark want to see services work together?

Whenever the centre is open a GP should be available. Sometimes there are no appointments. People are not well enough informed about what can be carried out at the Urgent Care Centre. The plan needs to consider other issues such as ambulance transit time. If the UTC is not opened 24/7 will EMAS be able to cope with the extra demand? Who will pay for these extra ambulance journeys? The service needs to consider how in-patients will be cared for. It needs people qualified to care for patients who are acutely unwell. What happens if you are registered with GP out of the area? The centre is a long way away from people who live in remote areas. Need to think about ways to support people with urgent needs at home. The service needs to consider the larger proportion of elderly people who live in the area, particularly as they may be more isolated, living on their own with less access to public transport or a car. There is too much emphasis on internet when older people may not be online. IT solutions are not for everyone. Need alternatives and also need to build confidence in use of IT solutions Improved communication is required to achieve more efficient and effective use of services. Improvement communications should:

Enable health and social care to work in more integrated way

IT systems would be able to ‘talk to each other’ across pathways of care

information about changes in service provision would support more appropriate use and right care first time

The Voice is a good resource for sharing health information messages.

Question; With a direct booking facility through 111, how could the UTC develop?

The Urgent Care Centre did not show up when I called 111. The call handler didn’t know the hours it was open. Concerns re level of expertise in 111. What happens when people have an appointment but there is more urgent case that walks through the door? 111 staff need the right training to structure their questions when people have difficulty communicating. We need more awareness of where urgent stops and acute starts. Why not put the call handling clinicians in the centre rather than in another location? We need a proper electronic records system so that people can see your notes and history Would centralising services have an impact on footfall to the building? Can the car park cope with higher attendance? The main issue was around NHS 111 i.e. how people’s perception is that it not a good service as their experience or anecdotal evidence is that it doesn’t work. As we need to guide the public to use NHS 111 as their main access point into urgent care services, we need to change this perception, ideas were:

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Provide data (I will see if I can get data from Healthy London Partnership (HLP) who were the main driver for the clinical assessment service (CAS) incorporated into NHS 111

Have a NHS 111 SME who can give a “non-technical” presentation on the benefits of using this service going forward with the CAS fully established

Have some real life examples of where this service has worked Where will staff to deliver clinical assessment service come from? How can you build confidence in public to use NHS 111 service? Protocols required for clinical assessment service. How will NHS 111 clinical assessment service be able to respond to people living with complex needs who require routine care for example pain relief or dehydration?

Question; Could we make better use of the workforce round the clock, whilst ensuring access to urgent care clinical advice and assessments at all times of the day?

Even though the service is not used much overnight, it’s the most worrying time to be ill. People need to know they can get help when they need it. There is already a perception that the Urgent Care Centre is closed at night. Could we have GP appointments at night time for people who work shifts? Could Advance Nurse Practitioners provide appointments at night? There has been massive population growth in Newark as well as a large housing development. It needs a dedicated A&E department at Newark Hospital. There is a need to build workforce capacity – GPs, Advanced Nurse Practitioners, Pharmacists. More and more is being asked of a limited workforce. Need to embrace self-care. New housing developments planned therefore need to future proof any services.

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Appendix C

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Appendix D

Feedback from 11 September 2018

Key questions each themed workshop were asked to consider; What would good look like for Newark Urgent Treatment Centre? How could better use be made of the NHS 111 service? How can we improve overnight services?

NHS 111

Staff are overworked

Lessons should be learnt from other providers

End of Life Care Pathways – What happens if it doesn’t work?

Distress from distant relatives/parents/dementia carers – Need evidence of what we can do better

Will 111 be able to support the enhanced clinical assessment or are they too risk averse?

Clear protocols required for clinical assessment service.

NHS 111 – There are currently 8.4 million people in the geographical area for East Midlands and also Milton Keynes. Clinical call demands have increased over the years. The service is provided by a Derbyshire Call Centre. Invitations were extended for patients and members of the public to visit the Centre to understand how the calls work and what happens when patients dial 111 and clinical input.

Exampled provided – If patient calls with a complex issue then the clinician will ensure that the patient is assessed and provided with an appointment at a local setting where appropriate or alternative medical assistance will be sought.

Staff at the Call Centre is competent and confident to deal with calls and direct to a clinician as and when appropriate. There are triage pathways in place and relevant for the settings.

Will 111 be able to support this clinical assessment – are we too risk averse?

NHS 111 service where will staff make/judgement calls on clinical assessments

from? Protocols for clinical assessment service – upgrading of services

Workforce

Workforce should be specific to what could and would be treated

Ask staff currently working in the Urgent Care Centre what overnight services can be delivered safely

Recognise the impacts on other services

Counteract negative impacts

Building capacity – Pharmacist/self-care/GPs and ANPs

Asking more of workforce which is limited

Retirement and retention of staff needs to be address

Less overseas clinicians

Population Growth

Estimated number of properties = the actual number of people would be quite low

Need to consider the number of people from surrounding areas who travel into Newark for work

More emphasis on health promotion to improve population health and alleviate pressures

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Transport issues for rural areas

Future proofing for new housing developments

Clinical Pathways

Importance of sharing of clinical/medical record to inform appropriate treatment options.

Patients need to understand the role of partners and other organisations in relation to an integrated approach to delivery of care including NHS111 and GP Surgery

Is the Urgent Treatment Centre medical condition specific? When a patient is referred the condition would be treated upon arrival and thereafter referred to specific condition services as and when appropriate and at the right time.

How will UTC be able to respond to people with complex needs but especially pain and dehydration

NHS 111 service where will staff make/judgement calls on clinical assessments

from? Protocols for clinical assessment service – upgrading of services

General Comments;

Communications;

Communication needs to be issued and in line with the national media campaigns and communications. Key messages need to be joined up with all organisations and direct the right message for patients. Urgent Care/Urgent Treatment – People need to know what the meanings of specific areas are including Primary Care

Special Patient Notes –Patients need to know and understand more about Special Patient Notes – what they are and what they are used for.

What does Primary Care mean? This needs to be outlined specifically for patients as they don’t understand. The examples of primary care are GP led organisations such as pharmacists, Out of Hour Services, GP Practices.

Across health and social care – patients – healthcare professionals (hcp) hcp + hcp – hcp and carers

IT systems talking to each other across pathways

Voice – Good resource for messaging

Advertise extended access in surgeries. Engagement needs to continue to including local GPs and ensuring that they are on board with any changes in the area.

IT Solutions – not for everyone/ need alternatives. Also need to build confidence and support people

Financial considerations

Savings – how will this be achieved?

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Appendix E

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Appendix F

Feedback from 16 October 2018

Based on the information provided about the level of attendances and the range of services available, what are the possible solutions to deliver services going forward?

Dispute over data – Patients are accessing other services already

Few referrals to Newark – Data does not reflect reality

Figures don’t include patient already in

Figures don’t accurately capture all activity

What’s the percentage of EMAS journeys to 3 x big hospitals for non-clinical cases from Newark to KMH, Lincoln and NUH

Data only reflects who does attend – many communities don’t know that the UTC exits

More limited service if data correct

How many ambulance calls are from Newark? How many end up at Newark?

ED journey is 23 miles away

Uniform assessment process between different services

Disconnect over KMH/Newark Services

KMH: Default – How do we influence and prioritise

Data does this cover the current activity at the UTC and other services

12 midnight to 8am is not a good use of public money

Majority of people want to see the UTC open 24/7 but must be cost effective

Would like a 24hr service but understand that this might not be cost effective when looking at activity between midnight and 8am

A service should be available 24/7

There should be efficient use of services – There is little confidence in NHS 111

Staff requirements/availability must match the hours of operation

Spend the public purse efficiently

Ensure mental health crisis staff available

Communications on available services/alternatives

Not confident in NHS111 in its current format

Better understanding of what services are around both in the community and the hospital, that patients could use

Primary care in ED – NHS 111 to ensure DOS is well known.

We would be interested to hear of any different or innovative ideas regarding access to services.

Keep people at home

Access to services closer to home

Having the right number of clinicians and the right experience

What should the Newark Urgent Treatment Centre look like? • Open and available 24/7 • Appropriate skill mix needed • out of hours medic on call • Impact on medical cover for in-patient ward • Recruitment and retention impacts all areas (if closed overnight)

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General comments; Requires further information/analysis to get a true picture of demand including; • Activity • Staff mix • Average length of stay/time in department

Communication

More information on what staff are on in the UCC, what other clinical services are available in the hospital and other support services such as bus services

How can make sufficient use of services to prevent them from being cut or cancelled completely

General awareness of services and where to go for what is not good

Information about what is available? The answer isn’t more information it is better information

Need clarity on what the offer is Transport

Transport for rural communities