REPORT FOR HOSC MEMBERS ON FEASIBILITY OF RETURN OF WiC SERVICE TO
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
? Triage systems
? Space utilisation
? 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).
1. Change in flow patterns into the A & E/WiC and 4 hour target
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
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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.
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.
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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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
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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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
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.
- 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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