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Report for HOSC members on feasibility of potential for return of

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2 Feb 2010HOSC members requested a further progress report in the New Year and requested that a report on the feasibility of relocation of the Walk-in

REPORT FOR HOSC MEMBERS ON FEASIBILITY OF RETURN OF WiC SERVICE TO

    WiC BUILDING

Concerns were expressed by HOSC members at its October 2009 meeting about a

    number of service delivery issues that arose following the co-location of A & E and

    WiC in August 2009, which mainly related to:

    ? Change in flow patterns into the A & E/WiC

    ? Staffing

    ? Triage systems

    ? Space utilisation

    ? Communications

    ? Quality and patients views

A group of senior managers and clinicians from PAHT, the PCT and the community

    provider has since met every week to monitor these issues and the impact of the

    improvement actions taken.

A progress report was given to HOSC meeting in December 2009 which provided a

    number of assurances of the improvements that have been achieved.

HOSC members requested a further progress report in the New Year and

    requested that a report on the feasibility of relocation of the Walk-in Centre back to

    the old WiC building was also prepared.

This paper has therefore been developed to provide an analysis of the key factors

    that need to be considered in determining the feasibility of a return of the WiC

    service to the WiC building should this be deemed necessary in the future.

Members are reminded that the WiC/BARDOC/A & E Department co-location on

    the Rochdale Infirmary site is in line with implementation of Phase 1 of the Healthy

    Futures Urgent Care Centre model (which has been designed to provide high

    quality, responsive urgent care for the residents of the borough of Rochdale).

    Key factors

    1. Change in flow patterns into the A & E/WiC and 4 hour target

    performance

    During the period subject to HOSC scrutiny, the level of activity and arrival

    times by hour showed a change in flow of patient presentation per hour

    between 10.00 a.m. 5.00 p.m. compared to previous years. This had a

    significant effect on waiting times for patients and thus the 4 hour target was

    also breached.

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    Whilst the total patient attendance numbers are within the expected combined figure (for A&E and WiC activity), the profile of attendances by hour differed from the expected norm, and this seems to have been related to an unpredictable and unexplainable shift in the hourly attendance profile.

Recent Performance

    It is important to note that for the last 3 months of 2008 when the WiC was temporarily co-located within the Emergency Dept, there was no corresponding dip in performance. In fact performance improved despite an increased number of attendances and pressure on available space.

    Data analysis shows that since the more robust triage and streaming of patients to the right part of the service was implemented from November 2009, the previous flow problems have been greatly improved and the performance of the department with regard to the four hour access target has seen a significant improvement.

    An analysis of performance over the latest 2 week period this year from 4 to 17 January 2010 (in table below) shows that overall performance against the A&E target was at 98.3%.

    It is the view of the three organisations, therefore, that given the progress made and the recent achievement of the 98% A&E target, a relocation back

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    to the WIC building would not add any value, and thus is not seen to be required.

    2. Staffing

    The WiC staff rotas are now fully deployed with contingency cover in place.

    Nursing staff vacancies in A&E are being recruited to, and the most recent advertisements have attracted a number of successful applications which are being processed.

    The nursing staffing situation has improved, and the co-location has facilitated a more integrated model which enables nurses to work together more closely.

    There are some issues regarding medical cover, in part due to the national shortage of middle grade doctors available to work in A&E. A rolling programme of recruitment is in progress.

    It is felt that a re-location back to the WiC would not add any value to the staffing position and the benefits that are currently being derived from integration as described above would be lost.

    It is the view of the three organisations, therefore, that given the progress made, a relocation back to the WIC building would not improve the staffing situation, and could reduce available capacity

    3. Triage Systems

    At the point of co-location, the triage system was not sufficiently robust to ensure patients were seen as quickly as possible on arrival, or to direct patients to the right part of the system. A more integrated triage system has since been put in place which now directs patients as they arrive to the right

    part of the system. This has improved patient flow, space occupancy, waiting times, and the management of unpredictable surges in demand.

    It is the view of the three organisations, therefore, that given the progress made, a relocation back to the WIC building would not improve or add value to the triage system, and in fact would reduce available capacity. .

    4. Estate / Space availability

see Appendix 1

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5. Communication

    The PCT issued a communiqué to GPs and pharmacists to ensure that they

    were aware of the surges in demand and were asked to deflect as much

    primary care activity away from A & E/WiC as possible.

    Communication with the public was also supported by the launch of the The

    “Choose Well” campaign to encourage more appropriate use of A & E, WiC

    and primary care services.

    6. Quality and Patients Experience and Views

    The “one stop shop” model now in place since the co-location has

    generated a positive response from patients.

    Signage has been improved within the department, particularly to ensure

    that the children‟s waiting area remains designated for this purpose

    Prior to the actions outlined in this paper being implemented a post-service

    audit of patients accessing the co-located service was undertaken by the

    Patient‟s Council with 40 random patients on leaving the department. The

    results are shown below.

    The Patient‟s Council has agreed to conduct a re-audit in order that we

    continue to fully understand the patient‟s perspective of this service.

     How would you grade the New Service?

     25% 38%Better Same Poor 7%don‟t know/first visit

    30%

Conclusion

On a recent visit to Rochdale Infirmary by the Emergency Care Intensive Support

    Team it was acknowledged that a co-located WiC with an Emergency

    Department/Urgent Care Centre is the optimum model for quality urgent care.

    It is the view of the three organisations and the Healthy Futures Delivery Unit that

    this model is in line with implementation of Phase 1 of the Healthy Futures Urgent

    Care Centre model.

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    Appendix 1 contains more detail but it remains the view of the organisations involved that any relocation back to the WiC building would be disruptive to the new model, and to services currently located in the WiC building, and would be detrimental to the current service and the future development of integrated primary and secondary care.

    Any such move should therefore, only be considered as an absolute last resort, when all other improvement actions have failed, where the new arrangements are proved to be unsustainable, or where such a move would clearly add value to the overall urgent care system and to patient experience

    Whilst a number of improvements have been achieved, it is acknowledged that winter pressures much of which can be unpredictable - will have an impact on the

    performance of the RI site, as it will across the country. It will be important, therefore, for the team to continue to monitor performance on an ongoing basis, re-considering all of the factors above, as necessary. However, it is also important to note that for the last 2 weeks, performance at Rochdale Infirmary A&E Department has been above 98%.

    A further progress report will be prepared in the spring of 2010 for submission to HOSC, as requested.

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    Appendix 1.

    Feasibility of re-opening the WIC

    1. During the period under HOSC scrutiny the numbers of patients in the

    department exceeded the physical capacity of the department, despite the

    expansion provided prior to the co-location. As a result patients were waiting in

    less than ideal situations, and the department was under pressure for space to

    see patients in the most appropriate place. Since that time the waiting area

    seating has been increased, and the changes to the triage system has

    improved patient flow through the department, thus reducing the need to

    occupy space in the waiting area for long periods.

The department remains compact, but it is now able to function more

    effectively .It is less crowded even during peak times due to the new triage

    system. Patients are now seen more quickly and therefore spend less time in

    the waiting area.

Whilst it is the view of the three organisations that the changes made to the

    clinical treatment of patients renders a re-opening of the WIC unnecessary, the

    concerns raised by the HOSC around the capacity of the physical environment

    to cope at peak times are acknowledged. We have, therefore, considered the

    feasibility of reopening the WIC as a last resort, if it becomes apparent that the

    capacity available in the A&E is consistently inadequate to cope with demand.

The options considered further are:

    a. Full reinstatement of the WIC service in the original building

    b. Use of the WIC building as an „overflow‟ facility at times of significant

    pressure

    a) Full reinstatement of the WIC service in the original building.

    ? The co-location of A&E and WIC services is seen as best practice

    nationally, a point reinforced in a recent visit by the National Emergency

    Care Support Team.

    ? The benefits of co-locating the staff, given the different, complementary

    skills, are now beginning to be realised.

    ? The revised Triage system depends on staff from both A&E and WIC

    being available in the same place and involved in the process

    ? Shift patterns for WIC staff have been adjusted to ensure that there is

    increased cover in the department at peak times

    ? The WIC building now houses:

    ? Dental Access Centre

    ? Additional Treatment Room Clinic x 5 days

    ? Phlebotomy Service x 5 days per week

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    ? Diabetic Retinopathy screening (approx 10 weeks)

    and there are advanced plans for housing the IV Therapy Service on these premises.

    There would, therefore, be inadequate space to rehouse the WIC service in the building without significant disruption to these other services.

    In addition, the staff have put huge effort into making the new system work for the benefit of patients, and dismantling the system would result in a loss of these clinical benefits, which all of the organisations concerned would be reluctant to do.

b) Use of the WIC as an overflow facility

    The changes that have been made in the use of the building since the co-location with A&E are detailed above, and would make this option equally difficult in physical capacity terms.

    In addition,the use of any available space in the WiC building was considered by the team during the period under OSC scrutiny to potentially release prime clinical space in A & E/WiC , and to provide an additional clinical area. However this was seen to be potentially more disruptive than helpful, and would separate the staff who need to work together on a co-located basis to deliver the integrated model.

In conclusion:-

    - The relocation, either full or partial, of the WIC service to the original facility

    is neither physically feasible nor clinically desirable. However, the capacity and conditions within the waiting area, and the comfort and safety of patients will be kept under regular review.

    - Plans are in place to rename the WiC building as the Whitehall Street Clinic

    to ensure patients needing WiC services are directed to the correct location and thus to remove the confusion and consequent inconvenience to patients that has been reported.

    - It is the view of the three organisations, therefore, that it is neither necessary

    nor feasible to relocate the WiC service back to the WiC building in order to resolve the space factor. However, consideration will continue to be given to the utilisation of any available space at the Whitehall clinic to support delivery of additional services

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