S.Evans 26/08/16 Page 1

A proposal for a secure, sustainable and consistent Minor Injuries Unit service for Wiltshire.

Background

The two MIUs in Wiltshire have been experiencing issues with maintaining appropriate skilled staffing levels. This is due to a variety of factors including the age profile of the workforce giving rise to not only more retirements but also some increased sickness levels; in addition there is a general shortage of qualified nurses entering this arm of the profession. Whilst in Chippenham this has mostly been manageable due to their opening 18 hours a day, although there has been need for some early closures; in Trowbridge this has caused an increased incidence of overnight closure to enable safe delivery of care, but also to effectively use the staffing resource efficiently in the hours of the day when the most attendances occur.

Since 1st April 2016, Trowbridge MIU has had to close on 28 occasions to date until 1st Sept (6 months). Although 2 of these occasions were for facilities maintenance issues, the remainder were due to lack of suitable staffing cover on the overnight shift. 5 of these closures were at weekends.

An initial paper was sent to Wiltshire CCG on 1 July 2016 and demonstrated that in Q4 of 15/16 at Trowbridge MIU there was an average of total attendances overnight of 2.3 patients per night between 00:00 -08:00 (this includes minor illness for which the unit is not commissioned).This equates to 0.3 patients per hour between midnight and 08:00; when CQC acceptable standard is 2 qualified staff as a minimum on duty during these hours. Hence current operations allocate 2 qualified staff to what is currently a 10 hour overnight shift when on average only 2.3 patients attend the department. A full data set and patient attendance map are attached as appendices to this paper for ease of reference.

While these issues are immediate and operational in nature, they will be relevant to separate work to examine the provision of Minor Injury Units in future. Wiltshire Health and Care has committed during 2016/17 to be a key strategic partner in the process to design and develop proposals for what urgent care centre provision could look like in Wiltshire the future. There is emerging national guidance which suggests that urgent care centres are unlikely to need to be available 24 hours, but should be available for at least 16 hours a day. The suggested hours in this national guidance is 08:00 -00:00. In Wiltshire however, from the data set attached, it can be seen that 16 hours opening for Wiltshire MIU’s would be best set at 07:00 – 23:00 for the service to be open when more of the public currently access the units.

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Impacts related to current hours of opening.

(24hrs at Trowbridge & 08:00 -01:00 at Chippenham.)

Potential frequent unplanned closures due to staff shortage. This results in the public being unsure when MIU’s are open to enable the individual to make an informed decision of where to attend for healthcare attention overnight. (The default when Trowbridge is closed is either Out of Hours or RUH urgent care centre or A&E for urgent need or accessing Primary Care on the next working day.)

Staff, especially ENPs ( Emergency Nurse Practitioners) having to work many additional shifts to cover the 24 hour period, resulting in a further increase in sickness levels staff resignations or options for retirement taken earlier than previously considered due to work place pressure.

Poor use of resources: the requirement for 2 qualified staff, one being an ENP, to work every night when only 86 patients with an ‘injury presentation’ are attending for the whole of Q4 between the hours of 23:00- 07:00 at Trowbridge MIU, (187 total attendances in this time frame.) This equates to a cost of £386 per person attending with a minor injury overnight with the required level of staffing, or for all attendances this is £117 per attendance compared to £21 per attendance during the day.

Staffing in the day is spread thinner, when most of the attendances occur, to enable the staffing to be available to cover the night shifts. This results in longer waits during the day due to lower staff levels.

Reliance on agency and bank to bolster the staffing across the 24 hour period, with a potential impact on quality.

Continuity of the present arrangement is not sustainable or efficient and effective use of valuable and rare resources even in the short term as illustrated in the impacts above.

Proposal: Planned overnight closure from 23:00 -07:00 7 days per week at both Chippenham & Trowbridge MIUs

Impactso Clearer public communication – leading to clarity and consistency on opening

hours of both MIUs, reducing potential confusion for patients, the public and other urgent care professionals.

o Maintaining quality standards and patient safety levels which are currently at risk.

o Greater resilience in current staffing levels to cover across a 16 hr day period, leading to reduced sickness levels and an opportunity to bolster recruitment to near to full establishment for the revised opening hours with a more robust skill mix to meet demand.

o It would increase the operational resilience of the unit, ensuring consistent availability of the MIU service 7 days a week.

o Reduced waits for treatment during day time hours due to shift in staffing resource from nights.

o Subject to a review at the end of 2016/17, it would mean that harmonised hours, in line with national guidance, would have been tested and be ready for adoption by any future urgent care centre model in line with emerging National Guidance.

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Wiltshire Health & Care would not anticipate any financial savings to be realised from these changes as any resource savings will be reinvested back into community services as follows:

Recruit to vacancies to return the MIU service to a capacity and skill set to meet current demand that includes activity not currently contracted i.e. minor illness, more complex medical conditions and mental health presentations.

To enable recruitment and existing staff development to flex to changes in future demand that will be brought about by the current and planned increase in the population of Wiltshire from the large increase in housing development especially centred in the areas around Chippenham, Trowbridge & Melksham.

Scoping of provision of overnight services delivered in the community via the core community teams. Such service could deliver overnight nursing interventions for urgent cases such as pain management for end of life patients and blocked catheter management, both of which may often result in acute admission.

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Appendix 1: data on patient flow

Graph 1: Attendances for Trowbridge MIU Q4 15/16. Days of the week

Graph 2: Attendance 20:00-08:00 broken down by presentation type

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Graph 3: Attendance 20:00-08:00 broken down by days of the week

Table 1: Average of attendances per day per hour between 20:00 - 08:00 Q4 15/16 and part Q1 16/17

M o nday T ues day Wednes day T hurs day F r iday Sat urday Sunday T o t a l

20 0.44 0.42 0.41 0.37 0.33 0.28 0.43 2.6921 0.25 0.25 0.26 0.35 0.32 0.14 0.33 1.8922 0.16 0.13 0.16 0.20 0.17 0.18 0.16 1.1623 0.10 0.09 0.11 0.08 0.07 0.11 0.07 0.62

A rr iv a l H o ur 0 0.03 0.02 0.05 0.05 0.06 0.10 0.06 0.371 0.02 0.01 0.03 0.04 0.05 0.03 0.06 0.242 0.02 0.04 0.01 0.04 0.01 0.05 0.06 0.233 0.01 0.00 0.01 0.02 0.03 0.02 0.04 0.134 0.00 0.01 0.04 0.01 0.01 0.00 0.03 0.105 0.01 0.02 0.02 0.03 0.01 0.02 0.03 0.146 0.05 0.04 0.07 0.03 0.02 0.07 0.06 0.357 0.17 0.13 0.14 0.11 0.16 0.11 0.19 1.028 0.50 0.50 0.50 0.39 0.60 0.47 0.52 3.48

T OT A L 1.76 1.66 1.80 1.71 1.84 1.60 2.04 12.41

A rr iv a l D ay o f Week

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Table 2: Arrival day of week Q4 15/16 total (83 days total)

M o nday T ues day Wednes day T hurs day F r iday Sat urday SundayWeek T o t a l f o r who le Q415/ 16

F r i - Sun T o t a l Q4

F r i -Sun % o f t he t o a l

week

20 48 34 32 28 22 24 31 219 77 35

21 17 19 14 20 18 11 21 120 50 41.6

22 14 15 11 15 15 17 12 99 44 44

23 7 13 5 5 5 8 5 48 18 37.5

A rr iv a l H o ur 0 3 2 5 3 4 8 6 31 18 58

1 4 2 4 2 6 3 4 25 13 52

2 2 4 1 3 6 7 23 15 65

3 1 2 3 4 1 5 16 10 62.5

4 2 3 1 4 10 5 50

5 1 1 4 2 1 3 12 6 50

6 3 1 5 2 1 6 4 22 11 50

7 12 6 17 10 15 11 12 83 38 45.8

8 39 34 37 33 53 36 33 265 122 46

2015/ 16 Q4

A rr iv a l D ay o f Week (83 days )

N.B blank spaces in table indicate no attendances on this time and day of the week for the whole of quarter 4 (83 days)

Table 3: Arrival day of week Q4 15/16 total (83 days total) for minor injury presentation only

M o nday T ues day Wednes day T hurs day F r iday Sat urday Sunday T o t a l

Fri -Sun % of week

20 11 23 14 20 8 15 15 106 38 36

21 3 12 7 13 12 8 11 66 31 47

22 2 12 5 7 9 3 3 41 15 36.6

23 4 9 4 1 2 6 1 27 9 33

0 1 1 4 1 4 1 2 14 7 50

1 1 1 1 4 2 3 12 9 75

2 1 1 1 1 3 3 10 6 60

3 1 3 1 1 2 8 4 50

4 1 2 3 2 66.66

5 1 1 2 4 2 50

6 2 1 2 2 1 8 1 12.5

7 10 6 16 8 8 4 1 53 13 24.5

8 34 28 30 24 45 15 18 194 78 40

2015/ 16 Q4

A rr iv a l D ay o f Week

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Appendix 2: Opening hours of other units

Table 5: MIU & Urgent Care Centres opening times within a 50 miles radius of Trowbridge MIU

Hospital Opening Times Facility

Chippenham Community 0700 - 0100 MIU

Trowbridge Community 24hrs MIU

Frome Community 0800 - 2230 MIU

Paulton Memorial 0800 - 2130 MIU

Tetbury 0830 - 1630 MIU

South Bristol Community 0800 - 2000 Urgent Care

Southmead 24hrs MIU

GWH 24hrs Urgent Care

Royal United Bath 24hrs Urgent Care

Vale Community, Glouc 0800 - 2000 MIU

West Berkshire Community 0800 - 2200 MIU

Bridgwater Community 0700 - 2300 MIU

Witney Community 1000 - 2230 MIU

Tewkesbury Community 0800 - 2000 MIU

Victoria, Wimbourne 0830 - 1630 MIU

Abingdon Community 1000 - 2230 MIU

North Cotswolds 0800 - 2000 MIU

Royal South Hants 0730 - 2200 MIU

John Radcliffe 24hrs MIU

Evesham Community 0900 2100 MIU

Lymington New Forest 0800 - 2100 MIU

Shepton Mallet Community 0800 - 2000 MIU

Cirencester 24hrs MIU

Westminster Memorial 0900 - 1800 MIU

Lydney & District 0800 - 2300 MIU

West Mendip Community 0700 - 2300 MIU

Clevedon Community 0800- 2100 MIU

Andover War Memorial 0830 - 1730 MIU

Duke Memorial 0800 - 2300 MIU

Yeatman, Sherbourne 0900 - 1800 MIU

Blandford Community 0900 - 1800 MIU

Burnham on Sea Memorial 1000 - 1800 MIU

Malvern Community 0900 - 2100 MIU

Ellen Badger, Sth Warwickshire 0800 - 2000 MIU

Bridport Community 0900 - 1800 MIU

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Big circles depict an approximate 10 mile radius from both Trowbridge and Chippenham MIUs

Small purple circles show postcode areas and numbers of patients visiting Chippenham MIU

Small green circles show postcode areas and numbers of patients visiting Trowbridge MIU

Trowbridge MIU

Total Overnight Patient Visits in 91 days of 16/17 (Jan/Feb/Mar)

Between 2300hrs and 0700hrs = 205

Total patient visits from areas covered on Map – 191 (93%)

Chippenham MIU

Total Overnight Patient Visits in 91 days of16/17 (Jan/Feb/Mar)

Between 2300hrs and 0100hrs = 54

Total patient visits from areas covered on Map – 48 (89%)

26

23

8

19

4

10

1

9

1

3

3

1

1

124

Appendix 3: Trowbridge and Chippenham MIU Overnight Patient Visits Map

Total Overnight Patient Visits in Q4 16/17 (Jan/Feb/Mar) - between 2300hrs and 0700hrs

4

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205 patients affected on average between 11pm and 7am - approximately 2.3 patients per night at a cost of £117 per patient. Day time cost approx £21 per patient

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54 patients affected on average between 11pm and 7am - approximately 0.6 patients per night at a cost of £54 per patient. Day time cost approx £20 per patient.