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SERVICE SPECIFICATION
ST. MARY’S HOSPITAL URGENT CARE
CENTRE SERVICE
Version 1.1
Date Issued: 02/11/2015
NHS CENTRAL LONDON CLINICAL COMMISSIONING GROUP
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Service Specification No. TBC
Service The provision of a primary-care led urgent care
centre at St Mary’s Hospital, Paddington to
include the front desk supporting both the UCC
and Emergency Department of St Marys Hospital
The service will be open access and will operate
on the principle that all patients should receive a
consistent, rigorous assessment of the urgency of
their need and an appropriate and prompt
response
Commissioner Lead Holly Manktelow, Senior Delivery Manager for
Unscheduled Care, Central London Clinical
Commissioning Group
Provider Lead TBC
Period April 2016 for a period of 3-5 years.
Date of Review October 2015
1. Population Needs
1.1 National / local context
Within Central London and NW London, the vision is to create an urgent and emergency care system
(one system multiple facilities) that is capable of delivering equitable access to the right care, first
time for patients through a networked model with services provided along robust pathways 24/7.
Urgent Care Centres form an important access point on this network with key interdependencies
with general practice, NHS 111, London Ambulance Service (LAS), Community Independence Service
(CIS), GP Out of Hours service (GP OOH), GP extended hours’ hubs and hospital Emergency Centres.
This vision reflects the review of emergency, urgent and unscheduled care services across North
West London led by the 'Shaping a Healthier Future' programme.
The redesign of the unscheduled care pathway is a major objective for Central London Clinical
Commissioning Group and will lead to a re-alignment of current unscheduled care services into an
integrated 'referred-in' set of services that will guide patients to be seen at the appropriate health
care setting/service, with the appropriate level of urgency.
Critical to this pathway redesign will be the development and improvement of the Urgent Care
Centre at St Mary's Hospital which will improve patient access to urgent, unplanned care, whilst
ensuring that the patient's on-going healthcare needs are met in the most appropriate setting within
the community or primary care.
1.2 Introduction
The St Marys Urgent Care Centre (SMUCC) is a highly accessible community-based facility providing
care for a large population area. It is located within St Marys Hospital, Paddington and will operate a
24 hour a day service, 365 days a year, with no appointment necessary offering patients access to a
range of health professionals in order to respond to the varied needs across all ages and disabilities.
The UCC provider will also be responsible for the Emergency Department front desk, which will book,
assess and stream patients to either the ED or UCC according to their needs. The UCC service will
assess and treat patients during one visit and decrease the number of attendances to the ED for
those conditions considered non-emergency.
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It is important that SMH UCC is fully integrated with every other part of the local health community
and that it operates as part of the overall urgent and emergency care system for the local health
economy. Pathways from NHS 111, GP Out of Hours and into our Community Independence Service
are of key importance as are referral routes on to GP extended hours, the community and other
services. It is important to note that this document reflects the existing specifications, aims and
desired outcomes to date. These should be read in the context of the desire of the CCG to develop a
fully integrated unscheduled care system in the future.
1.3 Population covered
The population using the UCC generally comes from within North West London either resident or
transiting through the area via one of the major transport hubs and services. The UCC is used
primarily by the working age population, between 18 – 35, young children and their families and
some BME communities. The location of the UCC also means that the UCC may provide services to a
significant number of homeless and rough sleeping patients, patients with mental health conditions
and patients who are not ordinarily resident in the UK.
Patients may attend the UCC when suffering from both minor illnesses and minor injuries. The
interpretation of X-rays and other diagnostics / investigations is in scope as is the treatment of Minor
Fractures. Interventions that patients may require include:
• The management of uncomplicated fractures
• Non-complex regional anaesthesia for wound closure;
• Incision and drainage of abscesses not requiring general anaesthesia; and
• Minor ENT / Ophthalmic procedures
There are no age limits for UCC patients
1.4 Exclusion Criteria
Exclusion criteria for adults and children are listed in Appendix 1
1.5 Key Interdependencies
The UCC forms part of an overall non-acute / non-emergency strategy that supports healthcare
delivery in Central London. The UCC also has to integrate with services across North West London
and in non-health related areas.
Providers are required to work collaboratively with stakeholders in the local health economy and to
develop shared pathways and joint working across primary and secondary care. It is essential that the
UCC provider(s) develop strong relationships with:
• Primary care, particularly in Central London, West London, Brent and wider North West
London where the majority of UCC patients originate and also Hammersmith &Fulham and
Ealing.
• Acute secondary care, particularly the Emergency Department at St Mary's Hospital;
• Out of Hours Primary Care Services
• NHS 111 services
• Community Independence Service
• Extended hours primary care Out of Hospital services
• Community pharmacists;
• Public Health consultants and advisors
• Dentists;
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• Optometrists
• Mental Health services, including Children and Adolescent Mental Health Services (CAMHS);
• Homeless services, including providers of intermediate care services for homeless people;
• Third Sector services e.g. support groups and other support services; and
• Other community providers
1.5.1 Development of a single urgent care network
Work is underway to develop a single North West London Urgent Care Network (one network,
multiple facilities) and the UCC provider(s) will be expected to play an active role in this network and
in developing strong, working relationships with other providers (including attending network
meetings as required)
National pilot sites are exploring opportunities for NHS 111 to be authorised to directly refer and
book patients into Urgent Care Centres. Providers will be expected to be prepared to work with NHS
111 to develop these referral pathways. The local GP Out of Hours Service will make direct
appointments for patients to be seen at the UCC as will extended hours and weekend opening
General Practice.
Over time the UCC will be expected to ensure full integration with the NHS 111 service, both for
patients ‘referred in’ to the UCC, and when referring patients into community services and General
Practice. This will include access to the 111 Directory of Service. It is anticipated that a booking
option for NHS111 to book cases in to the UCC will be introduced by the Provider.
The UCC Provider will need to work closely with GP OOH services including joint assessments or
receiving referrals from OOH and will need to work with commissioners to develop clear pathways
with intermediate care services, including the Community Independence Service.
Finally, the Provider will have to work closely with local primary care, in particular in developing and
understanding how the UCC works in partnership with extended hours’ primary care and whole
systems models of integrated care.
1.5.2 Integration with secondary care
An integrated service model is fundamental to a UCC’s ability to deliver safe, high quality care. In
practice, this means close integration with EDs and other health services via formal governance
mechanisms and strong informal working relationships.
The key features of a genuinely integrated service model are:
• Clear lines of responsibility and accountability, both within and between provider
organisations;
• Clearly defined handovers of care between providers;
• An approach to review and continuous improvement that transcends organisational
boundaries;
• Clear policies aimed at managing risk and procedures to identify and remedy poor
professional performance.
In order to address these issues, providers will be expected to develop an operating model that
supports the following principles:
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◦ Partnership with the acute provider, including working together in periods of high and low
demand and developing appropriate access to specialist input ◦ A Joint Clinical Governance Group to foster joint working and drive continuous
improvement. Membership will include clinicians from the UCC provider, the hospital
trust and the appropriate CCG. In support of the principle of integrated clinical
governance, the Joint Clinical Governance Group will require Mental Health
representation in order to be quorate (in line with current ED practice). ◦ Working across organisational interfaces – including developing policies, processes and
procedures jointly between the UCC provider and ICHNT and developing strong informal
working relationships between ED and UCC managers. ◦ Ensures that IT systems between the UCC and Trust are interoperable so that patient
details will not have to be taken again in the event of streaming/transfer to ED ◦ Delivers appropriate access to diagnostics and specialities provided within the acute.
1.5.3 Integration with patients and the community
The UCC provider will be expected to continually engage with patients to improve their knowledge,
understanding and experience of the service being delivered. Improvements to patient experience
and outcomes when using the UCC service should be a key focus for the provider.
The Provider will make arrangements to carry out regular patient experience surveys, such as the
Friends & Family Test, in relation to the service and will co-operate with such surveys, including
surveys may be carried out by the Commissioner or hospital Trust.
The UCC provider will be expected to demonstrate evidence of having used patients’ experience of
using the service to make improvements to service delivery.
1.5.4 A child and family friendly environment
The CLCCG recognises that the provider does not have the ability to make alterations to the
premises, the UCC must accommodate the needs of children and accompanying families as far as is
reasonably possible within the limitations of the building and surrounds. CLCCG will work with the
Provider and the Acute Trust to pursue changes to the environment that may be possible within
these limitations.
The Provider will be expected to maintain sufficient child-friendly treatment rooms to meet the
expected annual level of child attendances at the UCC.
The Provider will be expected to organise the employment of play specialists at peak times to work
across within the UCC, where possible the Provider should work with the acute provider to share play
specialists across both the UCC and the ED.
The Provider will actively seek comments from children, young people and their carers to improve
the services and facilities.
1.6 Location of Service
The St Marys UCC is located at St Mary’s Hospital, Paddington in its own dedicated space. The
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booking, assessment and streaming of patients will be located within the ED; however, this function
will be managed by the UCC provider.
2. Outcomes
2.1 NHS Outcomes Framework domains & indicators
Domain 1
OUTCOME 1
Preventing people from dying prematurely
People are seen, assessed, treated (where clinically
appropriate) and discharged within the specified
timeframe by appropriately trained and qualified staff
leading to an appropriate clinical outcome.
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Domain 2
OUTCOME
Enhancing quality of life for people with long-term
conditions
Services provide reassurance to patients with long-term
conditions and the service works closely with other key
services, particularly the community independence
service, to ensure patients get the support they require to
remain independent for longer.
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Domain 3
OUTCOME
OUTCOME
Helping people to recover from episodes of ill-health or
following injury
Patients contacting the service receive timely,
comprehensive information regarding their condition.
The service provides health promotion, education and
self-care advice to patients on discharge from the service
to support people to remain independent and healthy
and to increase understanding of services available
locally to patients.
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Domain 4
OUTCOME
OUTCOME
OUTCOME
Ensuring people have a positive experience of care
Continual improvement through patient engagement
and review
Patients have a high level of satisfaction with the
services
The service is fully integrated into the local health
economy and efficiently run ensuring that patients
receive excellent care.
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Domain 5
OUTCOME
Treating and caring for people in safe environment and
protecting them from avoidable harm
The service must be accessible to all applicable patients
including children, those living with disabilities or mental
ill-health and vulnerable communities such as rough
sleepers and the homeless.
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2.2 Local defined outcomes
In addition to the NHS Outcomes Framework domains, NHS Central London CCG has worked with
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patients and clinicians to identify additional local outcome requirements.
• A high quality, safe, pro-active, patient-centred and responsive service delivered in an
environment that is primary care led.
• Timely and effective triage at the 1st
point of contact with the service.
• Deliver clinically effective, evidence based and value for money service consistent with NHS
operational framework, CQC requirements and safeguarding requirements and guidance.
• Services users, including minority ethnic groups, children and families have equitable access
to the service on the basis of need and experience. The service will be responsive to their
needs making reasonable adjustments when appropriate including when flagged in
SystmOne
• Works in collaboration with other local health care providers to ensure patients are
supported to understand how to access care most appropriate to their needs in the future.
3. Scope
3.1 Aims and objectives of service
The aim of the UCC service is threefold:
• To deliver excellent and sustainable clinical outcomes to patients including safe and effective
treatment for patients with a variety of non-life threatening health conditions, injuries or
illnesses within a community-based, primary care-led environment.
• To deliver an exceptional patient experience which includes good customer service, being
treated with dignity and respect, by polite and compassionate staff with efficient processes,
personalised care, pleasant and accessible surroundings, timely treatment and safe services.
• To deliver a value for money service where care is delivered efficiently as well as effectively.
The intended service objectives are:
• To operate a 24 hours a day, 7 days a week service which is integrated with current
provision delivered with the distinctive culture and approach of a primary care service
with experienced primary care clinicians and practitioners leading the service.
• To operate a single ED and UCC clinically-led triage service which ensures patients
receive a consistent and rigorous assessment of the urgency of their needs and an
appropriate and prompt response.
• To manage circa 60% of all A&E activity (including paediatric activity) within St Mary's
through the UCC if clinically appropriate. This equates to around 72,000 attendances to
the UCC per year.
• To ensure initial assessment and streaming is completed in 20 minutes for adults; and 15
minutes for paediatric patients.
• To make all 'see and treat' decisions within 60 minutes to enable the acute provider to
deliver their 4 hour A&E target if transfer to ED is required.
• To aim to 'assess, stream, see, treat and discharge' patients within two hours of arrival,
and no later than 3 hours of arrival.
• To ensure services are safe, age appropriate, service user-centred and delivered to
required quality standards.
• To ensure services are easily accessible and well known to residents and can adapt to
sudden fluctuations in the volume of patient presenting.
• To reduce re-attendance and unnecessary attendances to the UCC by ensuring patients
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attending with routine primary care needs are appropriately and actively referred into
core primary /community services for their future needs.
• To work closely with the acute provider to ensure integrated and seamless care
pathways and efficient services during periods of low demand.
• To ensure UCC Information and Communication Technology (ICT) processes are inter-
operable with both GP and Trust systems in order to facilitate effective information
sharing, including information on safeguarding (such as Child Protection Orders)
• To ensure safe and effective discharge of patients including communication of a patient's
episode of care to their GP practices within 12 hours of discharge and to their school
nurse or health visitor, where appropriate, by 08:00 the next day.
• To deliver health promotion, education and self-care advice on discharge to support
patients to remain independent and healthy and to improve knowledge and
understanding of the variety of unplanned care services available to patients.
• To deliver excellent patient experience measured through the friends and family test and
feedback gathered through the Provider.
• To work with, and across, the full spectrum of primary, secondary and acute providers to
develop and implement a single unscheduled care network.
Details of the required staffing competencies and levels can be found at Appendix 2. The provider is
required to have a child and adult safeguarding lead for the UCC.
3.2 Service description / Care pathway
The main elements of the UCC service will include:
A) Front desk, located within the Emergency Department, providing
registration, initial assessment and streaming to UCC or ED.
B) Diagnosis and treatment
C) Referral and discharge including support for patients to understand the
most appropriate services for their needs in the future including self-care options
A.) Registration, initial assessment and streaming key features
1. Single reception, located within the ED, for all ED and UCC patients
2. Patients will have an initial clinical assessment by a GP or a suitably trained nurse with primary
care experience (clinical streaming)
3. Patient registration on the appropriate IT system primarily SystmOne, Firstnet or Adastra as
appropriate.
4. Patients self-presenting with major emergencies will be identified immediately and streamed
into the ED.
5. Patients arriving by LAS will directly access the ED via the ambulance entrance. However patients
with minor complaints may be streamed to the UCC by the London Ambulance Service, or by the ED
nurse receiving the patient from the LAS
6. Timescales
7. Some aspects of treatment and diagnostic investigation could and should be provided at the
initial assessment stage (e.g. analgesia, ordering of x-ray).
8. Treat and support unregistered patients, including helping them to register with an appropriate
GP.
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9. Work in partnership with the ED to ensure plans are in place to deal with both unexpected surges
in demand, and to deliver efficiencies during low demand.
A1. Single reception
Due to the position of the UCC within the SMH site, a single ED and UCC reception will be located
within the ED. The UCC provider will manage this reception, initial assessment and streaming
function within the ED, operating the function within a distinct primary care ethos and culture.
As part of this process, all patients should be registered on the appropriate systems. All registrations
will take place at the registration desk.
Registration staff will provide a 24-hour registration service, directing and supporting patients
through the system, as appropriate, using a calm manner and treating patients with dignity and
respect.
An NHS number must be recorded on all patient records.
Registering children
Registration details for each child shall include the name and relationship of accompanying adult, and
school, health visitor, social worker if this is not already contained on the system.
A2. Clinical Streaming
Patients will be clinically streamed to appropriate areas by a Primary Care GP or Nurse using the
assessment guidelines owned by the Joint Clinical Governance Group. The provider will agree
protocols with the London Ambulance Service (LAS) to facilitate streaming.
The initial assessment of patients will be carried out by an experienced GP or clinician with primary
care experience. The Provider will be expected to develop a cohort of senior multi-disciplinary staff
to undertake this role in the medium and long term, based upon an agreed competency framework.
Clinicians with suitable competencies will include GPs, primary care nurses and other suitably
qualified clinicians to meet case-mix demands. The Provider will need to put in place mechanisms so
that a Local Medical Services Director will assume management responsibilities for all medical and
nursing staff. All staff will be assessed against a suitable competency framework owned by the
Provider and approved by the Joint Clinical Governance Group.
There should be a single assessment and steaming process for all UCC or ED walk-in patients –
patients requiring transfer to or from ED should not need to be assessed again on arrival. For the
avoidance of doubt the commissioners will not pay for both an UCC and ED episode of care therefore
the early and accurate assessment of need upon presentation to the UCC, via an ED front desk, is
required to ensure that multiple episodes of care do not occur unless there is deterioration which
necessitates transfer to the ED. In this event the deterioration could not have been reasonably
foreseen by the lead clinician responsible for the care of the service user.
Initial Assessment of Children
All children attending the UCC will be visually assessed on arrival to identify an unresponsive or
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critically ill child. The Provider shall ensure that the reception and clinical streaming staff have
received appropriate training so that they are able to direct patients immediately to the emergency
department where appropriate (see Appendix 3).
The initial assessment of paediatric patients shall include consideration of whether there are any
child protection concerns and whether the child protection register should be checked.
Redirection
At this time, commissioners wish for the UCC to 'see and treat' and do not wish patients to be
redirected to primary care or other services during initial assessment and streaming. However, the
Provider will be expected to engage in any pilots to test the impact of redirection or in any local or
national policy changes which require redirection to take place.
A3. IT
IT processes must be inter-operable with the Acute Trust system, other GP systems and the NHS
spine as appropriate to ensure that:
o Patient details will not have to be taken again in the event of streaming/transfer to
ED
o Child / vulnerable adult ‘Red Flags’ can be picked up by UCC staff.
o The UCC is able to communicate with, and access records on the GP system
(SystmOne).
o The UCC is able to access information from the Child Protection Information System
(CP-IS). This System is being rolled out nationally in stages and is due to go live across
the London Borough of Hammersmith and Fulham and Westminster at the end of
2015. The Provider will be expected to sign up to the implementation of this system
with NHS England.
The use of SystmOne will enable rapid access to patient details for those registered with the majority
of local practices. Patients should not be expected to re-supply basic demographic information upon
arrival where this information is available electronically from a referring service.
A4. Major Emergencies
Patients self-presenting at UCC with major emergencies will be identified immediately by the
assessing clinician and, when appropriate, accompanied to Majors by an appropriate clinician, where
prioritisation and full assessment will take place. Non-ambulant patients will be transferred to
Majors via existing transfer protocols and escalation procedures.
Protocols shall be in place to ensure direct referral and transfer of care, as appropriate. Triaging
within urgent care will be conducted using a common approach to assessment and common
standards. The protocol underpinning this immediate assessment/triaging decision will have been
agreed by the Joint Clinical Governance Group.
The commissioner has established and maintains a list of conditions which should be triaged directly
to ED Majors or resuscitation areas; this is attached at Appendix 3. This list will have been agreed by
the Joint Clinical Governance Group.
A5. Ambulances
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The default pathway for ambulance patients is direct to the ED via the ambulance entrance.
However, patients with minor complaints may be streamed to the UCC by the London Ambulance
Service, or by the ED nurse receiving the patient from the LAS. At no time is a suspected medical
emergency to be streamed to the UCC if there is any doubt as to the level of care required. The
Provider will be expected to develop appropriate pathways with LAS.
A6. Timeframes
UCC patient streaming should be complete within 20 minutes (adults) or 15 minutes (paediatric
patients) of registration.
In accordance with Healthcare for London guidance, the UCC is expected to make all ‘see and treat’
decisions within 60 minutes; that is to say, the UCC is expected to identify and pass all appropriate
patients through to ED within 60 minutes from the time of registration, so the 4-hour target remains
achievable for the ED.
A7. Diagnostics at initial assessment
Some aspects of treatment and diagnostic investigation could and should be provided at the initial
assessment stage (e.g. analgesia, ordering of x-ray). Clinicians providing the initial assessment will
require the skill set necessary to provide this treatment.
A8. Un-registered patients
Patients who attend the UCC who are not registered with a GP will be treated by the UCC according
to the same criteria as a registered patient. In addition, they will be supported by the staff in the
centre to register with a local practice of their choice. The Provider will need to work closely with
relevant GP practices, particularly those within Central London, West London and Brent so that UCC
staff are able to support patients with registration.
Unregistered patients from outside the area will be supported to contact the registration department
of their local CCG.
A9. Working with the ED
Joint Contingency plans should be put in place with the ED to deal with unexpected surges in demand
in order to ensure that waiting times are kept under control. These plans should minimise the
volume of clinically inappropriate transfers to ED. These plans should include how resources will be
obtained to meet unexpected demand and any expected cost implications for the commissioners of
the service.
The Provider will also be expected to work with the ED to identify the most efficient way to operate a
24//7 service during periods of low demand such as between midnight and 8am.
B.) DIAGNOSTICS AND TREATMENT KEY FEATURES
1. Access to diagnostics
2. Appropriate use of diagnostics
3. Performance standards
4. Interpretation and Reporting
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5. Specialist input
6. Paediatric care
7. Mental Health care
B1. Access to diagnostic
The UCC will have access to diagnostics and investigations run by ICHNT from the SMH site. The costs
for all access to diagnostics and investigations charged by the Trust will be billed to the UCC provider
directly, and this should be taken into account in the tender price.
Generally, diagnostics and investigations will be available to the UCC on the same day, and within a
defined time period which will allow the result of the diagnostic / investigation to inform a treatment
decision before the patient returns home.
The following investigations and diagnostics should be available to UCC clinicians
Diagnostic area Diagnostic tests available to UCC
Electrocardiogram (ECG)
Haematology • Full blood count (FBC)
• D-Dimer
Biochemistry • Blood Glucose
• Pregnancy Test
• Urea & Electrolytes
Microbiology • Urine
• Stool
• Throat, wound swabs etc.
Radiology • Plain film for limbs and chest
Ophthalmology (optional) • Slit lamp
B2. Appropriate use of diagnostics
Only urgent diagnostic action will be initiated. It is therefore not anticipated that the level of
diagnostics provided will exceed that provided in a standard GP surgery, other than the additional
diagnostics that may be required for minor injuries (e.g. X-ray). Requests for diagnostic testing
should be audited by the Provider on a regular basis.
For any diagnostic tests which could be considered to be routine, the patient should be referred back
to their GP. Patients should not be able to see the UCC as a route to getting tests quickly and
bypassing primary care
B3. Performance standards
The UCC is expected to make all “see and treat” decisions within 60 minutes of the patient arriving at
the UCC.
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In some cases, UCC patients may require access to diagnostics where this would contribute to a
decision regarding the patient’s immediate treatment or referral. It is therefore recommended that,
with the exception of tests requested as part of an onward referral to a specialist clinic, all test
results should be available within one hour.
B4. Interpretation and Reporting
The UCC is expected to interpret all diagnostics and investigations it requests; except for those it
requests as part of an onward referral to a specialist clinic. This applies to radiology and pathology.
For radiology, the UCC is required to develop a process through which X-rays can be subject to a
medical interpretation, as part of the episode of care, and that these are formally reported on. No
arrangement for 'instant' X-ray interpretations as part of an episode of care has yet been made with
ICHNT.
It will be for the Provider to demonstrate that the process defined is safe and effective and these
measures must include having an abnormal results review process.
B5. Specialist input
UCC clinicians should be able to access input from a range of specialists, including ED consultants,
orthopaedic specialists, paediatric specialists and radiologists. The principle is that access to a
specialist opinion should be no different to that available at a GP surgery. Where specialist input has
been sought, clinical responsibility for the patient remains with the UCC clinician unless and until the
patient is formally transferred to an alternative service.
B6. Paediatric treatment
The provider must deliver appropriate and responsive care to all children attending the UCC. This
must be in accordance with the standards set out in the Children Act 2004, National Service
Framework for Children and any local protocol within North West London Health economy. Children
under the age of 2 years suitable for the UCC will be seen by a suitably qualified clinician.
The Provider shall ensure that:
• Their staff have relevant professional registration, indemnity and have undergone enhanced
Disclosure and Barring Service C checks;
• All staff caring for children shall have appropriate paediatric experience, including core
paediatric competencies (see appendix 2); and
• Staff know who to contact for advice on child protection matters at all times. This includes
having a clear lead named within the UCC and staff being aware of the contact details of
social care leads in relevant local authorities.
The UCC shall be equipped with an appropriate range of drugs and equipment.
All provider staff shall be trained in paediatric basic life support. At least one member of the UCC
team at every shift should have training in advanced paediatric life support (ALPS) training, to be
funded by the provider.
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The UCC shall have a named paediatrician with designated responsibility for UCC liaison.
B7. Mental Health treatment
Mental Health presentations account for at least 20% of primary care attendances1. UCCs require
24/7 direct access to the psychiatric Liaison team. Local psychiatric liaison teams will be responsible
for ensuring consistent levels of cover for the SMH UCC and to the Mental Health Crisis Team if one is
available on-site.
All UCCs have access to a Mental Health assessment room that is compliant with the relevant Royal
College of Psychiatrics safety standards2
C: REFERRAL AND DISCHARGE KEY FEATURES
1. Communication of the episode of care
2. Health promotion, education and self-care
3. Follow-up Care
4. Onward Referral
5. Medicines Management
C1. Communication of the episode of care
A discharge summary is to be offered to the patient by the person discharging them. This is a
summary record of the patient’s visit to the UCC outlining what happened to them.
The UCC Provider will issue discharge summaries to GP practices within 24 hours, providing relevant
clinical and treatment information, medication and any necessary follow-up care. The Provider will
also be responsible for communicating the episode of care to school nurses and health visitors where
relevant by 08:00 the next working day.
It remains the requesting clinician’s responsibility to ensure that all abnormal diagnostic results are
followed up appropriately.
C2. Health promotion, education and self-care
Service users should be provided with timely and appropriate health promotion and education as
1 'Guidance for commissioning integrated urgent and emergency care. A 'whole system'
approach – Dr Agnelo Fernandes, RCGP Centre for Commissioning, August 2010
2 Psychiatric services to accident and emergency departments, Council Report CR118, Feb
2004
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well as health information materials to enhance health knowledge, skills and behaviours, and to
enable informed health decisions. The service must use education to promote the use of patient self-
care and the use of alternative unplanned care services which may be relevant to the patient. If
appropriate, the provide may wish to review the reason for the current attendance with the patient
and provide information to the patient on the other urgent care services which may have been more
appropriate.
The Provider should develop or signpost patients, carers and healthcare professionals to educational
tools, such as information leaflets, videos, telephone support, exercise information and signposting
to health and wellbeing services e.g. smoking cessation, NHS Health Checks, health trainers and
community champions. Any materials should be patient friendly, written in plain language, with
translation services and easy read available when required.
The Provider should consider the best way to encourage health behaviour change through the
discharge process within the UCC including linking with community-based public health services, such
as community champions, or with voluntary and community organisations in the area which could
provide appropriate support to patients.
C3. Follow-up Care
If further follow-up care is required, the UCC should transfer the patient appropriately, for example,
back to their GP, care at home or other intermediate care services, and will need to agree processes
for this to happen. A STARRS nurse pilot is underway within ICHNT and the Provider will be
responsible for establish a pathway with this pilot to facilitate access to integrated health and social
care where appropriate for the patient.
The UCC will need to establish referral mechanisms for patients requiring community physiotherapy
as a part of their on-going care, should this be considered to be appropriate and where access to full
SystmONe notes is available.
The UCC provider will also be responsible for arranging any patient transport deemed necessary at
the time of their discharge. A pilot, provided by St James Ambulance, is underway in St Mary’s
Hospital to support A&E patients with transport home if they are at risk of admission due to difficulty
in returning home. The UCC will be responsible for establishing a pathway with this pilot.
The Provider shall ensure that systems are in place to ensure safe discharge of children, including
advice to families on when and where to access further care if necessary.
C4. Onward Referral
The UCC ability to refer to outpatient services directly is defined by local commissioners and should
follow the locally agreed protocols. For Central London CCG this is for patients to be advised to
contact their registered practice for further treatment, investigation or referral into secondary care.
With the exceptions below, clinicians in the UCC will NOT refer patients for first outpatient
appointments. Exceptions are:
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• Suspected cancer (the patient needs to know that this is an urgent 2 week wait appointment)
• Referral to the Rapid Access Chest Pain clinic
• Referral to Early Pregnancy Assessment Unit
• Referral to Fracture Clinic
• Ophthalmology out-patient clinic where patients can access community services in the Tri-
Borough which will have urgent 48-hour access.
Referral guidelines and protocols regarding referral to these services will be drawn up and adhered
to. The UCC Provider will be expected to agree direct referral pathways to additional specialist
services and clinics including specialist gynaecology services and genito-urinary medicine. Where an
admission is required this will be made directly to the specialty concerned. Patients will not be
referred back to ED for diagnostics or admission
UCC patients may be referred to community based services, including general dental services,
pharmacy services, community nursing and social and voluntary services.
The UCC will, in time, be fully integrated with the Directory of Services both for patients 'referred in'
to the UCC, and when referring patients into community services and General Practice.
C5. Medicines Management
The main mechanism for medication supply at the UCC will be either using:
• A FP10 prescription form suitably controlled and issued.
• A pre-pack medication using a patient group direction (PGD) for use out of hours when local
pharmacies may be closed. The cost of procuring any stock or pre packs will be the
responsibility of the UCC.
The Provider is expected to:
• Comply with the North West London Integrated Formulary and the local Management of
Infections Guidelines and any other relevant guidelines that the CCG will provide as
appropriate and relevant to the services.
• Use the locally-agreed antibiotic guidelines and formulary, and not to prescribe drugs from
the locally-agreed 'Red Drugs' list.
• Have a mechanism available through which a full course of medicines can be
provided/administered out of hours, where clinically appropriate, without returning to the
UCC, hospital pharmacy or GP practice.
• Observe the Carson review recommendation that where a patient needs to start at course of
medicine without delay (e.g. for pain relief) or because delay could compromise care they
should receive the full course at the same place as the consultation.
Where the Provider prescribes using FP10s these costs will be met by the Commissioner's UCC FP10
prescribing budget. This budget will be closely monitored by both the UCC management and the
Commissioner's medicines management team to establish patterns of prescribing at the UCC
ensuring any anomalies are identified.
The UCC should not issue repeat prescriptions, except for at risk patients, as determined by clinical
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assessment and then for a maximum of one week except oral contraceptive pill where 28 days’
supply may be given.
Medicines Use reviews for patients with complex medicines regimes which are the reason for or have
contributed to attendance at the UCC should be initiated by the UCC.
When nurses prescribe medication for children, they shall have the necessary, experience,
qualifications and certificated knowledge of paediatric pharmacology.
Providers are responsible for clinical governance and compliance with applicable national guidance
for all aspects of medicines management, including prescribing and providing / administering drugs.
Any incidents must be investigated by the Provider, with outcomes reported following the local
incident reporting process.
Providers will need to comply with Misuse of Drugs Regulations 2001. In additional, regulations made
under the Health Act 2006 require each healthcare organisation to appoint an Accountable Officer,
responsible for the safe and effective use of Controlled Drugs in their organisations. The regulations
also introduce standard operating procedures (SOPs) for the use and management of controlled
drugs. Providers will need to have the appropriate processes in place to agree and adopt SOPs for
their use.
4. Applicable Service Standards
4.1 Applicable national standards (e.g. NICE)
The UCC service is expected to comply with the following standards
• National standards for Urgent and Emergency Care Facilities
• Department for Health Standards for Better Health
• National Quality Standards (NQRs),
• NICE Technology Appraisals;
• NICE clinical guidelines and Interventional Procedures
• Care Quality Commission, Essential Standards of Quality and Safety
• Standards set out by the Information Standard Board (ISB) for health and social care, ISB
0160 Clinical Risk Management (its application in the deployment and use of health IT
systems) and other relevant requirements set out in guidance or standards issued by a
competent body.
• Other national or local standards relevant to the provision or urgent care within a
community-based, primary care led facility.
This is not an exhaustive list and relevant and appropriate standards being introduced will also apply
by agreement with commissioners.
4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal
Colleges)
• Royal College of Paediatrics and Child Health 2012 Standards for Children in Emergency Care
Settings
• Healthcare for London 2010: A Service Model for Urgent Care Centres: commissioning advice
for PCTS
• College of Emergency Medicine 2011, Emergency Medicine: the way ahead
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• London Safeguarding Children Board 2015 London Child Protection Procedures
• SCIE. Protecting adults at risk: London multi-agency policy and procedures to safeguard
adults from abuse. Published: August 2011
• Faculty of Emergency Nursing Competency Framework
• Mental Health Crisis Concordant
• All other relevant Royal College standards and in accordance with Professional Bodies (GMC,
NMC)
It is recommended that the provider also ensures that they adopt any guidance or standards that
are:
• Issued by the Care Quality Commission, e.g. Essential Standards of Quality and Safety
• Issued by the National Institute of Clinical Excellence from time to time
• Issued by any relevant professional body and agreed between the parties
• Connected with the reporting or audit of Serious Incidents
• Included within locally or nationally agreed service specifications, guidance or protocols
• Issued by the DH that cover urgent or emergency care
• Takes account of any guidance issued by Monitor
• Local safeguarding adults’ procedures including prevent
1.3 Applicable local standards
The UCC must meet the requirements for Urgent Care Centres developed as part of the Shaping a
Healthier Future Programme and set out in the attachment below.
5. Applicable quality requirements
Drawing on recommendations made by Healthcare for London3, College of Emergency Medicine
4,
London Health Programmes, the UCC service will be expected to meet the following clinical
standards (subject to change but used for reference in this version of the specification.)
5.1 Minimum levels of cover
UCC must be staffed by at least one doctor and at least one nurse at all times
UCCs must develop a staffing model able to manage peaks and troughs in demand, exploring
potential synergies with ED and GP OOH services
5.2 Governance
Each urgent care service is to have a formal written policy for providing urgent care. This policy is
to adhere to the urgent care clinical quality standards. This policy is to be ratified by the service’s
3 ‘A service model for urgent care centres – commissioning advice for PCTs’ – Healthcare for London; January 2010 4 CEM (2011) Emergency Medicine The Way Ahead
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provider board and reviewed annually
All urgent care services are to be within an urgent and emergency care network with integrated
governance structures
All urgent care services to participate in national and local audit, including the use of the Urgent
and Emergency Care Clinical Audit Tool Kit to review individual clinician consultations
5.3 Core Service
During the hours that they are open all urgent care services to be staff by multidisciplinary teams,
including: at least one registered medical practitioner (either a registered GP or doctor with
appropriate competencies for primary and emergency care), and at least on other registered
healthcare practitioner
An escalation protocol is to be in place to ensure that seriously ill / high risk patients presenting to
the urgent care service are seen immediately on arrive by a registered healthcare practitioner
All patients are to be seen and receive an initial clinical assessment by a registered healthcare
practitioner within 15 minutes of the time of arrival at the urgent care centre
Within 90 minutes of the time of arrival at the urgent care service 95 per cent of all patients are to
have a clinical decision made that they will be treated in the urgent care service and discharged, or
arrangements made to transfer them to another service5
At least 95 per cent of patients who present at an urgent care service to be seen, treated if
appropriate, and discharged, in under 3 hours of the time of arrival at the urgent care service
During all hours that the urgent care service is open it is to provide guidance and support on how
to register with a local GP.
The service is to have a clear pathway in place for patients who arrive outside of opening hours to
ensure safe care is delivered elsewhere
Access to minimum key diagnostics during hours the urgent care service is open, with real time
access to images and results:
- Plain film x-ray: immediate on-site access with formal report received by the urgent care
service within 24 hours of examination
- Blood testing: immediate on-site access with formal report received by urgent care service
within one hour of the sample being taken
Clinical staff to have the competencies to assess the need for, and order, diagnostics and imaging,
and interpret the results
Appropriate equipment to be available onsite
- A fully resuscitation trolley
- An automated external defibrillator
- Oxygen
- Suction and
- Emergency drugs
All urgent care service to be equipped with a range of medications necessary for immediate
treatment
Urgent care services to have appropriate waiting rooms, treatment rooms and equipment
according to the workload and patient’s needs
All patients to have an episode of care summary communicated to the patient’s GP practice by
5 This is guidance only; the provider will be expected to meet the 60-minute target as appropriate.
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08:00 on the next working day. For children the episode of care to be communicated by their
health visitor or school nurse, where known and appropriate, no later than 08:00 on the second
working day
5.4 Supporting Services
Urgent care services to have arrangements in place for staff to access support and advice from
experienced doctors (ST4 and above or equivalent) in both adult and paediatric emergency
medicine or other specialities without necessarily requiring patients to be transferred to an
emergency department or other service
Single call access for mental health referrals to be available during hours the urgent care service is
open, with a maximum response time of 30 minutes
5.5 Patient Experience
Patient experience data to be captured recorded and routinely analysed and acted on. Data is to be
regularly reviewed by the board of the urgent care provider and findings are to be disseminated to
all staff and patients
All patients to be supported to understand their diagnosis, relevant treatment options, ongoing
care and support by an appropriate clinician.
Where appropriate, patients to be provided with health and wellbeing advice and sign-posting to
local community services where they can self-refer (for example, smoking cessation services and
sexual health, alcohol and drug services)
5.6 Training
Urgent care services to provide appropriate supervision for training purposes including both:
- Educational supervision
- Clinical supervision
All healthcare practitioners to receive training in the principles of safeguarding children, vulnerable
and older adults, mental health capacity act and prevent, and identification and management of
child protection issues. All registered medical practitioners working independently to have a
minimum of safeguarding training level 3
6. Location of Provider Premises
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Appendix 1: Clinical Exclusions (Adults and Children)
Adults
The following criteria should be applied by the UCC when considering whether an adult patient is
suitable for treatment by the UCC. Many of the clinical exclusion criteria listed in the table below will
only be identified after clinical assessment. As a result, it will not always be possible to apply these
criteria at the point of streaming. Some patients may therefore be identified as unsuitable for UCC
care during assessment or treatment.
In addition, patients referred to (and accepted by) on-call hospital specialties by their GP will be
streamed directly to Majors or the Assessment Unit for onward transfer to the hospital as
appropriate.
Exclusion criterion Additional information
Markedly abnormal
baseline signs
• tachycardia > 110 beats per minute
• bradycardia < 40 beats per minute
• hypotension < 100 mm Hg systolic (unless known to be normal for
that individual)
• respiratory rate <10 or >=25 breaths per minute (adults)
• oxygen saturation <92%
• hypoglycaemia
Chest Pain • Nature of the pain is consistent with ischemia
• Chest pain associated with tachycardia > 110 beats per minute
• Chest pain associated with tachypnoea > 25 respirations per
minute
• Central chest pain or left sided pain with radiation to the neck or
arm
• Chest pain associated with nausea, shortness of breath or
sweating
• A previous history of heart disease if relevant
• History of Cocaine use within the previous 48 hours
Complex fractures • For example, (but not limited to):
• Long bone fracture of legs
• Open fractures
• Spinal injury
Patients receiving
oncological therapy
• Patients receiving oncological therapy should be transferred to a
hospital with an Acute Oncology Service. All Major Acute
Hospitals have Acute Oncology services.
Sickle cell crisis
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Shortness of Breath • "Severe" shortness of breath compared to normal
• Cyanosis
• Increased peripheral oedema
• Impaired consciousness or acute confusion
• Rapid rate of onset
• Associated with tachycardia > 110 beats per minute
• Inability to speak in sentences
• Shortness of breath associated with chest pain
• Shortness of breath associated with pallor and cold sweats
• Respiratory rate greater than 25 per minute
• Oxygen saturation < 95% in a previously healthy individual [E:e]
• History of severe asthma or recent emergency admission or a
single ITU admission.
• Shortness of breath associated with chest trauma.
Adults with signs of
severe or life
threatening asthma
• cannot complete sentences
• pulse ≥ 110 beats per minute
• respiration ≥ 25 breaths a minute
• peak flow ≤ 50% predicted or best
• silent chest
• cyanosis
• bradycardia (heart rate < 40 bpm)
• exhaustion
Airway compromise
• stridor
• quinsy
• oedema of tongue
• unable to swallow
• saliva/ drooling
Acute exacerbation of
Heart Failure
Burns • >5%
• Facial/ eye involvement
• Inhalation injury
• Chemical/ electrical involvement
New CVA
Significant DVT • Patients with suspected DVT associated with chest pain/SOB or
HR > 110
Haematemesis /
Haemoptysis
Overdose / Intoxicated
and not able to mobilise
• Are experiencing acute alcohol withdrawal or delirium tremens
• Are a danger to themselves or others
• Acute mental health presentation compromised by alcohol/drugs
• Unaccompanied by other responsible adult and need a period of
observation
• Have taken any drug overdose
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Significant head injuries • Clinical concerns about a Cervical Spine injury:
• Neck pain or midline bony tenderness
• Focal neurological deficit
• Paraesthesia in the extremities
• Any other clinical suspicion of cervical spine injury
• Head injury associated with GCS < 13 at presentation
• GCS < 15 when assessed 2 hours after the injury
• History of significant Loss of Consciousness
• More than one episode of vomiting
• Persistent headache
• Suspected open or depressed skull fracture
• Sign of basal skull fracture
• haemotympanum, ‘panda’ eyes, cerebrospinal fluid otorrhoea,
Battle’s sign
• Post traumatic seizure
• Focal neurological deficit
• Significant amnesia
• Dangerous Mechanism of injury
• pedestrian/cyclist stuck by a car, ejection from vehicle, fall from
over 1 metre or 5 stairs
Mental health • Overdose
• Other significant self-harm (adults). NB. Mental Health Trust
advice is that this criterion should be open-ended and subject to
clinical judgment. For example, a ‘simple laceration’ would be in-
scope for the UCC.
• Any self-harm (children)
• Severe withdrawal, delirium tremens and withdrawal seizures (as
these are very likely to require medical admission)
• Acute psychosis with disturbed behaviour.
• Acute confused state/ delirium
• Require a secure environment (i.e. the main Emergency Dept.) for
assessment including suicide risk using current screening tool
Levels of consciousness • Patients with fluctuating levels of consciousness or reduced GCS.
Obstetric Emergencies • Pregnant patients with Per Vaginam (PV) bleeding (heavy)
(pregnancy less than 20 weeks to ED and more than 20 weeks to
obstetrics);
• Pregnant patients with abdominal trauma;
Clinical Exclusions (children)
In addition to the exclusion criteria set out above, the following exclusion criteria will apply to
paediatric patients:
Exclusion criterion Additional information
Acutely ill children • All children identified as ‘acutely ill’ using Paediatric Early Warning
System (PEWS)
Children with signs
of severe or life
• too breathless to talk or feed
• respiration ≥ 40 breaths a minute in children over 5 years or > 50
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threatening asthma breaths per min <5 years
• pulse ≥ 120 beats per minute in children over 5 years or > 140 beats
per minute < 5 years
• use of accessory muscles of breathing
• peak flow ≤ 50% predicted or best in older children
Paediatric head
injury
• Witnessed loss of consciousness
• Amnesia (antegrade or retrograde) lasting > 5 minutes
• Abnormal drowsiness
• 2 or more discrete episodes of vomiting
• Clinical suspicion of non-accidental injury
• Post-traumatic seizure
• Use AVPU to assess level of alertness.
• Suspicion of skull injury or tense fontanelle
• Any sign of basal skull fracture
o haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage
from ears or nose, Battle’s sign
• Focal neurological deficit
• Age < 1 year: presence of bruise, swelling or laceration > 3 cm on the
head or any-sized bruise if pre-mobile
• Dangerous mechanism of injury
o high-speed road traffic accident either as pedestrian, cyclist
or vehicle occupant, fall from > 3 m, more than 5 stairs, high-
speed injury
Procedure requiring
sedation
Multiple pathologies
deemed to be
complex
Repeat attendances • Paediatric patients attending the UCC in excess of three times in
three months should be referred to the paediatric team at a Major
Acute Hospital. This criterion is also standard in NW London EDs and
is intended to reduce repeat admissions.
Fever with non-
blanching rash
Fitting
History of decreased
or varying
consciousness
• See paediatric head injury guidance above
Headache, fever and
vomiting
• For clarity, this exclusion only applies if all three symptoms occur in
combination.
Any infant with a
history of lethargy or
floppiness
Levels of
consciousness
Patients with fluctuating levels of consciousness or reduced GCS.
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Appendix 2: Required staffing Competences and Standards
Drawing on recommendations made by Healthcare for London6, College of Emergency Medicine
7,
London Health Programmes, the UCC service will be expected to meet the following clinical
standards (subject to change but used for reference in this version of the specification.)
Area Competence
Standard clinical
competences
• All staff (including receptionists) should have the ability to carry out basic
life support for adults
Minimum staff education and competency requirements for all clinical staff
working in urgent care services include:
• Recognition of serious illness;
• Intermediate Life Support training;
• Pain assessment;
• History taking, examination, formulation of a diagnosis and treatment
plan;
• Prescribing or Patient Group Directives (PGD);
• Competence in the recognition of acutely ill patients and as a first
responder;
• Identification of vulnerable patients and their multidisciplinary pathways
of care (‘vulnerable groups’ include but are not limited to: frail elderly,
adolescents and children, people with mental health issues).
• Recognition of adults at risk, the ability to identify when safeguarding
procedures are necessary, and the ability to implement adult
safeguarding policy and London Adult
• At least one clinical member of staff must have intermediate life support
training.
Minor Injuries
competences
Clinical staff dealing with minor injuries must possess the practical skills
necessary to identify and manage non-complex soft tissue and bone injuries,
for example:
• Wound closure
• Plaster casting
• Assessment of burns
Paediatric
competences
All UCCs receiving children must have a minimum level of competence, skills
and experience for treating young people, including:
• Paediatric Intermediate Life Support training
• All discharging clinicians/ main deliverers of care need to have level 3
6 ‘A service model for urgent care centres – commissioning advice for PCTs’ – Healthcare for London; January 2010 7 CEM (2011) Emergency Medicine The Way Ahead
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child protection
• Recognition of sick children, including Paediatric Early Warning System
Diagnostic
competences
• For those non-radiology diagnostic services which are available to them,
clinical staff must be able to assess the need for, and order, diagnostics
and interpret results.
• For those radiology diagnostic services which are available to them,
clinical staff must be able to assess the need for, and order, diagnostics.
They must also possess the ability to interpret simple X-rays (e.g.
uncomplicated fractures)
Training and
Education
• Urgent care services must be able to ensure that trainees can be
supervised to the appropriate GMC standards.
In addition to the standards set out above, UCC clinical staff should have experience of working
within a primary-care led environment. At all times the UCC must have staff on duty who can
demonstrate the following:
• Assessing the legal capacities of patients to consent
• Managing uncooperative patients including those with mental health problems
• Assessing and managing imminent violence
• Recognising the symptoms of depression and anxiety
• Being capable of providing treatment to service users with mental health problems who are
presenting with issues to the UCC which require treatment not directly related to the mental
health diagnosis.
• Assessing the suicidal patient
• Assessing and advising those who have experienced domestic violence
• Understanding the child protection aspects of working with adults with mental health
problems
• Assessing substance dependence and substance related problems.
• Recognition of adults at risk
Additional Staff requirements relating to paediatric care.
The provider will have a named paediatrician with designated responsibility for UCC liaison.
All clinical staff caring for sick and injured children shall have the same basic competencies in caring
for children as they do for adults, e.g. recognition of serious illness, basic life support, pain
assessment, an identification of vulnerable patients.
Nurses caring for sick and injured children in the UCC shall have at least basic competence in both
emergency nursing skills and in the care of children. Nurses caring for children in the UCC shall be
competent in:
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• Communicating with children and their families;
• The assessment and recognition of the sick child;
• Basic life support skills;
• Anaphylaxis training;
• Recognition of vulnerable children, the ability to identify when safeguarding procedures are
necessary, and the ability to implement child protection policy and Pan London Child
Protection Procedures;
• Pain assessment and management;
• Administration of medication, ideally by Patient Group Directives (PGDs) for analgesia;
• The current legal and ethical issues pertaining to children, including consent and
confidentiality issues.
Minimum competencies in relation to care for children and young people have been defined by:
• Skills for Health8
• The Department for Education and Skills9
• Royal College of Nursing10
; and
• The Faculty of Emergency Nursing11
Where emergency nurse practitioners (ENPs) work autonomously to see and treat children in the
UCC, the Provider will ensure that the nurses have received specific education in the anatomical,
physiological and psychological differences of children. They must also have specific training in
history-taking, examination skills and diagnostic reasoning in children, including interpretation of
investigations.
8 Skills for Health, www.skillsforhealth.org.uk
9 Department for Education and Skills 2004, Common core skills and knowledge for the
Children's Workforce
10 Royal College of Nursing 2004, Services for Children and young people; preparing nurses for
future roles.
11 Faculty of Emergency Nursing 2009 Competency Framework.
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Appendix 3: Major Emergencies Direct Transfer Conditions
The following conditions should be referred directly to the ED:
• Patient with GP letter referring them directly to an inpatient speciality;
• Patient presenting within 30 days of discharge from Hospital with the same problem, e.g.
post-operative infections;
• Patient repeat attending within 72 hours with the same presenting complaint and seen by
ED or hospital speciality;
• Patient with a direct access agreement to the relevant speciality;
• Patients with life or limb threatening injuries;
• All major trauma / Road Traffic Accidents / victims of serious assault;
• Ay patient presenting with acute collapse or confusion;
• Patients needing antiretroviral post-exposure prophylaxis (after need stick injury or sexual
exposure);
• Patient requiring parenteral / opioid analgesia for pain, or requires sedation;
• Intoxicated with impairment of consciousness, aggression or complex health needs;
• Attempted suicide / actively suicidal patients;
• Fracture with clinical deformity, or dislocated joint (or refer to orthopaedics if appropriate);
• Suspected pulmonary embolism (or refer to medical team / ambulatory care unit if
appropriate);
• Acute abdomen (or refer to surgeons);
• History of unconsciousness or altered consciousness;
• Acute anaphylaxis (after initial treatment in UCC and resuscitation team called);
• Alleged rape;
• Colles fracture;
• Currently having seizure;
• Stroke or Cerebral Vascular Accident (CVA) / Transient ischaemic attach (TIA) (separate
pathway);
• Deep vein thrombosis (DVT) or suspected DVT (or use ambulatory pathway if appropriate)
• Electrical injuries / history of electrocution;
• Haematuria post abdominal injury;
• Inhalation of smoke or fumes;
• Mandible dislocation;
• Meningitis or suspected Meningitis;
• Multiple injury / trauma;
• Penetrating eye injury;
• Per Vaginam (PV) bleeding (heavy) (pregnancy less than 20 weeks to ED and more than 20
weeks to obstetrics);
• Pregnant with abdominal trauma;
• Renal colic (or refer to ambulatory care unit if appropriate);
• Gunshot injury;
• Stab wound;
• Uncontrollable haemorrhage / epistaxis;
• Any patient that an experienced clinician has a 'bad gut feeling about'
