REPORT SUMMARY SHEET

Quality care for you, with you REPORT SUMMARY SHEET Meeting: Trust Board Meeting Date: 28 th May 2015 Title: Consultation Proposal to permanently close Armagh Minor Injuries Unit Lead Director: Debbie Burns, Interim Director of Acute Services Corporate Objective 5: Making Best Use of Objective: Resources Purpose: For Approval to commence local consultation Summary of Key Issues for Trust Board High level context: The Trust wants to achieve the best possible outcomes for people requiring urgent care services across the Southern Trust by providing access to appropriate acute services delivered by highly skilled and trained staff. Purpose of the document is to formally consult on a proposal to permanently close Armagh Minor Injuries Unit to seek to achieve this aim and ensure maximum value for money is achieved from public funds. Key issues/risks for discussion: Following temporary closure of Armagh MIU (November 2014) information analysis shows minimal impact on other urgent care services. Additional attendances at STH MIU have been picked up through existing resources with no adverse impact. Staff previously working in Armagh MIU have been successfully redeployed to alternative settings in either CAH ED or STH MIU Updated September 2014

Summary of SMT challenge/discussion: Paper tabled at SMT 20 th May 2015 Need to include comparison data re: impact on demand in CAH ED and STH MIU Reference to number of other service changes implemented as part of contingency to be removed Include reference to no clinical risk identified as direct result of additional travel aligned to minor injuries Further information on impact on individual staff / numbers to be clearly set out. Internal/External engagement: There has been wide engagement by the Trust with staff and key stakeholders regarding the Trusts intention to formally consult on proposed changes. Human Rights/Equality: An Equality Screening Template has been completed with the proposed changes deemed to be of a minor impact. Updated September 2014

Consultation Document Proposal for Closure of Armagh Minor Injuries Unit Consultation from Friday 29 th May 2015 until Friday 11 th September 2015 1

Have Your Say Electronic copies of the papers can be accessed via the Trust website: www.southerntrust.hscni.net/consultations The timeline for responses is 15 weeks commencing 29 th May 2015 ending 11 th September 2015. All enquiries regarding these documents should be directed to: Southern Health & Social Care Trust Director of Acute Services C/o Planning Department Brackens Craigavon Area Hospital 68 Lurgan Road BT63 5QQ Tel: 028 3836 6819/ 6879 E-mail: miu.consultation@southerntrust.hscni.net 2

What is this paper about? The Trust wants to achieve the best possible outcomes for people requiring urgent care services across the Southern Trust by providing access to appropriate acute services delivered by highly skilled and trained staff. The purpose of this document is to formally consult on a proposal to close Armagh Minor Injuries Unit to seek to achieve this aim and ensure maximum value for money is achieved from public funds. As part of the contingency measures required by the Minister to achieve financial breakeven by 31 st March 2015, the Southern Trust (the Trust) were asked to consider those services that could be temporarily stood down to ensure critical health and social care to the resident population of the Trust could be protected. Following this very careful assessment, Armagh MIU was identified as a service which the Trust believed could be safely stood down or reduced on a temporary basis until 31 st March 2015. It was agreed that Armagh Minor Injuries Unit (MIU) would be temporarily closed (with effect from 17 th November 2014 until 31 st March 2015) to release funds for critical health and social care provision. It should be noted that the decision to implement a temporary closure was made in the context of the Minister s announcement on 30 th October 2014 in which he makes it explicitly clear that should Trusts propose to make any significant service changes permanent, those proposals must be subject to consultation. As stated by the Trust in November 2014, should there be a need for this contingency measure to become permanent, the Trust will undertake normal consultation while paying due regard to its Section 75 equality duties, human rights obligations as well as its employment equality obligations in making any final decision. It is proposed that the permanent closure would be implemented following a (15 week) consultation period which is due to end on 11 th September 2015. 3

How do services currently operate? Within the Southern Trust there are two acute hospital sites, Craigavon Area Hospital (CAH) in Craigavon and Daisy Hill Hospital (DHH) in Newry providing full Emergency Department (ED) services. In addition there are MIUs provided in both Armagh and Dungannon. The MIU service is targeted at anyone over the age of five who has a minor injury as it is recognised that very young children should be treated in an Emergency Department that has full paediatric support on site. Conditions that can be treated in the MIU include: - Minor lacerations (cuts) Minor sprains/strains Minor bone injuries/fractures (where there are x-ray facilities available) Bites/stings Minor burns/scalds Minor eye problems. The following conditions should be treated at an Emergency Department: Asthma/shortness of breath Collapse Epileptic seizure Chest pain Abdominal pain Overdose Chest infection Serious cuts, breaks, fracture etc. 4

Table 1: MIU Service Provision Southern Trust South Tyrone Hospital (STH) Nurse Led 9am 9pm Monday to Friday and 10am 6pm Saturday and Sunday Armagh Community Hospital (ACH)* Nurse Led Monday Friday 9am 5pm *temporarily closed as at 17 th November 2015 South Tyrone Hospital MIU The South Tyrone Hospital Minor Injuries Service in Dungannon is a nurse-led service supported by auxiliary staff. The service has access to diagnostic services during opening hours. The service is operational 9am-9pm Monday to Friday and 10am 6pm Saturday and Sunday. Patients access the South Tyrone Minor Injuries Unit by: selfreferral, GP referral/out of Hours Service, Community Nursing Referral and other Hospitals. Armagh Community Hospital MIU The Armagh Community Hospital Minor Injuries Service is a nurse - led service supported by auxiliary staff. The service has access to diagnostic services during opening hours. The service is operational from 9am-5pm Monday to Friday. Patients access the Armagh Community Hospital Minor Injuries Unit by: self-referral, GP referral/out of Hours Service, Community Nursing Referral and other Hospitals. Since the 17 th November 2014 the service at Armagh MIU has been temporarily closed. (**the term diagnostics throughout the consultation documentation relates to availability of x-ray facilities). 5

Impact of Temporary Closure Between April 2014 and October 2014 the total attendances in Armagh MIU were 4,541 which is a 6% increase on the same period the previous year (4,312 attendances Apr Oct 2013). The average hourly attendances at Armagh MIU (Apr 2012 Oct 2014) were 3.4 contacts. The graph below shows the average hourly attendances at Armagh MIU from April 2012 until October 2014. Graph 1: Average Hourly attendances April 2012 October 2014 Since the temporary closure in November 2014 the Trust has undertaken an analysis of information to assess the impact on other unscheduled / urgent care services. The graph overleaf shows the average contacts per hour at CAH ED, STH MIU and Armagh MIU both pre and post temporary closure of Armagh MIU in November 2014. The graph shows that there has been no significant impact on the already increasing trend for CAH ED attendances. The attendances at STH MIU have increased since November 2014, however they have not yet reached the peak of 7 attendances per hour that was seen in July 2014. The existing workforce in STH MIU has been able to pick up the additional demand from within current resources. STH MIU 2013/14 Attendances = 21,159 2014/15 Attendances = 23,644 (12% increase) Minor Injury Attendances CAH ED 2013/14 Attendances = 15,911 2014/15 Attendances = 16,310 (2.5% increase) 6

Graph 2: Contacts per Hour across urgent care services April 13 March 15 7

The graph below shows the number of attendances at CAH ED who were categorised as a minor injury case (Category 4 & 5 of the Manchester Triage category). The graph shows that since the temporary closure of Armagh MIU in November 2014 there has been no change to the overall annual activity trend at CAH ED for minor injuries. Graph 3: Minor Injury Attendances at CAH ED April 13 March 15 The impact on local GPs in the Armagh locality is difficult to ascertain. Prior to the temporary closure patients attending the MIU may have been referred into the diagnostics service at Armagh Community Hospital for non-obstetric ultrasound or x-ray. An analysis of the number of diagnostic referrals from local GPs into the Armagh Community Hospital diagnostics service was completed to establish if lack of access to the MIU had increased demand for GPs. This analysis identified no increased referrals from Armagh locality GPs into ACH. Accessibility From the Trust analysis of activity there were a total of 22 wards within the Armagh LGD that were using Armagh MIU. The Analysis showed that people living in 17 of the 22 wards listed would be required to travel further to access their nearest alternative service (either MIU or ED). Those wards most affected are The Mall, Killeen, and The Demesne who 8

would have to travel a further 12 miles to CAH ED. Whilst some people may experience inconvenience associated with this additional travel, no clinical risk has been identified as a direct result of additional travel aligned to minor injuries. Why is there a need for Change? The demand for emergency (unscheduled) and urgent care services is ever increasing and in order to meet the needs of the local population the Trust have had to evolve and change the way in which urgent care services are delivered. The Trust has been working with local and regional commissioners to improve services for patients attending Emergency Departments. In addition to the Minor Injury services in Armagh and Dungannon, the Emergency Departments in Craigavon and Daisy Hill Hospitals also have well established minor Injury streams. Patients attending the Emergency Department with a minor injury can be managed through this dedicated stream. The Trust is also working with commissioners to expand the scope of practice for Emergency Nurse Practitioners (ENPs) to enable them to see a wider range of conditions including patients presenting with minor illnesses, supported by medical staff working in the Emergency Department. We need to ensure urgent care services are accessible and delivered in a responsive and timely manner. The main reasons why we believe we need to change the way we deliver urgent care is set out below:- Making best use of skilled staff to improve outcomes for the patient The Southern Trust currently has 13.2 whole time equivalent ENPs. The current staffing model within the Minor Injuries Department comprises Emergency Nurse Practitioners (ENPs). ENPs are experienced Registered Nurses with a minimum of 5 years experience in an Emergency Department who have undergone specialist training to gain the knowledge and skills to assess, diagnose and prescribe a management treatment plan for patients. All ENPs work to a set of clinical 9

protocols and all patients triaged to this service are assessed, diagnosed and treated within 4 hours. Within the ED the ENP service makes a significant contribution to improving the flow of patients through the department, enhancing the patients experience by enabling them to be seen in a timely manner as well as assisting in the release of senior Emergency Department medical staff to provide timely emergency care to patients with more acute needs. In 2014/15, attendances at our emergency Departments increased by 6% compared to 2013/14. From April 2012 to October 2014 average attendances at Armagh MIU remained at less than 4. To ensure delivery of safe, quality urgent care these skilled ENP resources must be fully utilised at our busiest sites. During April 2014 to October 2014 the average daily contacts in Armagh MIU was 32 which equates to an average attendance of 4 persons per hour; demand for MIU services in South Tyrone Hospital have been increasing along with demand for emergency care at Craigavon Area and Daisy Hill Hospitals. The challenge for the Trust in delivering high quality accessible services at a local level is also ensuring value for money is achieved. Recognising the financial pressures faced by the Trust It is well documented that health and social care services are under an unprecedented strain to deliver the level of services in line with demand and within the envelope of available funding. The current financial pressures and budgetary constraints has resulted in Trusts having to scrutinise the utilisation of services and ensure that all public funding being allocated to deliver health and social care is used to achieve the greatest outcomes. The initial Trust decision to temporarily close the MIU in Armagh was taken by Trust Board in response to the Ministers request to ensure service provision remains within budget. 10

Demand for Minor Injuries Services in Armagh During 2011 the Trust undertook a consultation on the Strategic Review of Minor Injuries Units in the Southern Trust area (28 th November 2011 until 24 th February 2012). The consultation considered a range of options across the MIUs at that time (Mullinure, Armagh Community Hospital and South Tyrone hospital MIUs). During the consultation period a pilot took place in Armagh Community Hospital MIU to extend the opening hours Monday to Friday from 5pm to 7pm (additional 2 hours per day). The pilot ran for over 12 months (5 th Dec 2011 31 st March 2013). Following a review of daily usage during this time it revealed that on an average day, less than 3 people attended the unit in the 2 hours between 5pm and 7pm. On the basis of the low demand the Southern Trust decided to cease the pilot and to reinstate the original opening hours (9am 5pm Monday to Friday). The more recent review of attendances at Armagh MIU (page 6 above) reinforces that average attendances fluctuates between 2.8 and 4.1 persons per hour (April 12 Oct 14) demonstrating a lower demand for this service in comparison to other minor injury and urgent care services across the Trust. 11

What does the Trust plan to change? The Trust s Vision The Trust wants to achieve the best possible outcomes for people requiring urgent care services across the Southern Trust by providing access to appropriate acute services delivered by highly skilled and trained staff. Proposals for Service Change The Trust proposes to:- Permanently close Armagh Minor Injuries Unit and redirect skilled staff to support appropriate care at South Tyrone Hospital Minor Injuries Unit and Emergency Departments at Craigavon Area and Daisy Hill Hospitals. What will be different after the change? Should a decision be made to permanently close the Armagh MIU service the local population of Armagh will continue to be able to access minor injury services in STH MIU as well as urgent care services at Craigavon Area and Daisy Hill Hospitals. The Trust will be able to ensure our existing highly skilled and qualified staff are best utilised to meet the demands of the local population across alternative urgent care services. Potential Implementation & Timescales Following consultation, should a decision be made to permanently close the MIU in Armagh the effect would be immediate. Proposals for Alternative Use or Disposal of Assets At present there are no plans to change any of the remaining services offered on the Armagh Community Hospital site; services include a wide range of outpatient clinics including 12

Speech and Language Therapy, Podiatry, Physiotherapy, Orthoptics and Audiology as well as maternity, mental health, radiology and an outreach ambulance base. If it is decided to close Armagh MIU permanently, the Trust will continue to provide a wide range of outpatient services and consider all opportunities to ensure the vacated space is maximised to its full potential. Management of Change The Trust s Management of Change Framework is the main vehicle for effecting change within the Trust. In order to manage and mitigate any potential differential impact on existing staff the Trust will adopt a project management approach. As part of this approach a project management group will include human resources and trade union representative(s) as to ensure robust, fair and agree human resources processes are in place to manage any future staff changes. Identified Staff working in Armagh MIU have already been successfully redeployed to similar roles within South Tyrone Hospital MIU and Craigavon Area Hospital ED following the temporary closure in November 2014. Any decision to implement a permanent closure would not further impact on these staff or result any further need for redeployment. Equality Screening - Section 75 Northern Ireland Act 1998 The Southern Health and Social Care Trust (the Trust) is committed to fulfilling its statutory equality duties set out in section 75 of the Northern Ireland Act 1998 (the Act) and has conducted an Equality Screening Template on the proposed changes in line with the Equality Commissions guidelines. The equality screening template was completed by Trust staff to provide clarity and agreement on the detail and outcome of the exercise. The Trust is also committed to the safeguarding and promotion of human rights in all aspects of its work, in particular Article 8 of the European Convention on Human Rights. The Trust fully accepts its obligation to take 13

appropriate steps to mitigate any adverse impact on current residents. Through the equality screening process the proposal was assessed to be of low impact due to the low demand for the service and minimal impact on accessibility; therefore it has been deemed not necessary to carry out a full Equality Impact Assessment. The full Equality Screening Document can be provided on request by contacting the Trust as detailed on page 2 and the document is also available on the Trusts website www.southerntrust.hscni.net. Rural Proofing The Department of Agriculture and Rural Development has published guidelines for rural proofing in the development of new policies or policy proposals. The Trust remains committed to the principles set out in these guidelines and routinely consider the impact of any of its service change proposals on staff, patients and the wider public. The Trust s Strategic Plan for the next 3 years provides an overview of the strategic direction of the Trust. Any specific service changes proposed will be subject to a formal public consultation process which will involve a review of specific information on those areas or communities which may be impacted by the proposal. Consideration will be given to any adverse differential impact that proposals may have on people living in rural areas, how any differential impact could be addressed and the costs and benefits of doing so. The Trust s Equality Impact Assessment which will be undertaken, where appropriate, for each specific service change proposal will identify any accessibility issues for staff and patients, including consideration of issues such as ease of access to services for service users and availability of transport and telecommunications infrastructures. Through the Equality screening process for this specific proposal to permanently close Armagh MIU, careful consideration was given to the impact on the local population. An accessibility analysis was undertaken which identified that 14

people living in 17 of the 22 wards listed would be required to travel further to access their nearest alternative service (either MIU or ED). Those wards most affected are The Mall, Killeen, and The Demesne who would have to travel a further 12 miles to CAH ED. As these people have minor injury issues this is not deemed to be a risk. 15

APPENDIX 1 Your chance to have your say Consultation Questionnaire The Trust wishes to consult as widely as possible on the proposal. Please use this consultation questionnaire to register your comments by 11 th September 2015. Page 2 of this document provides additional information on the Trust s communication, consultation and engagement processes and how you can be involved. Responses should be sent to: Email: Written: miu.consultation@southerntrust.hscni.net Southern Health & Social Care Trust Director of Acute Services C/O Planning Department Craigavon Hospital Site 68 Lurgan Road BT63 5QQ Tel: 028 3836 6819/6879 I am responding: as an individual On behalf of an organisation please tick box Name: Job Title: Organisation: Address: Tel: Email: 16

Question 1 Do you agree the Trust should deploy skilled staff to ensure they can respond to where demand is highest? YES NO Please give reasons for your response below: 17

Question 2 Do you agree that Trust resources should be directed to support demand within urgent care services? YES NO Please give reasons for your response below: 18

Question 3 Do you agree with the Trusts proposal to permanently close Armagh MIU service? YES NO Please give reasons for your response below: 19

Please include any other comments you wish to make on the proposals outlined within this document. 20

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