Argyll & Bute CHP Cowal Community Hospital and Out of Hours Service Additional Activity Analysis May 212 Version 2. Cowal 24/7 Activity and Workforce Review Group Report
Introduction & Summary of Points to Consider Following a discussion at the last project group meeting in March 212 which included observations by the public representatives and comments by the co-chair with regard to difficulty in understanding activity information on the profile of out of hour s activity i.e. how many calls during the day and night, weekend shifts etc as well as information on hospital and casualty activity. Members also reflected that they need to consider the principles around the service requirement to inform the short listing and subsequent option refinement and subsequent appraisal process: This document attempts to answer some of these questions providing some further activity analysis and supporting information for the Cowal 24/7 review. Additional profile information is to follow on the inpatient and casualty activity audit currently underway for the May meeting. Out of Hours Base Whether the More rural areas (Strachur, Tighnabruaich, and Lochgoilhead) could be covered by a doctor based in the Cowal Community Hospital. The main workload issues in doing this is the number of new visits and the travelling time required to do them. The other issue is the response time to these rural areas. However because of their geographic diversity even a Rural Doctor may be a significant travelling time from the others and Dunoon may be as "central" a starting point as any. Equally if patients required to attend the PCEC for an appointment could the nearest surgery be used as a base or in fact it may be easier and more convenient for some patients in the Tighnabruaich catchment are to travel to Dunoon rather then Strachur. Out of Hours Activity Overnight (11pm-8am) If the visiting rate for Lochgoilhead negligible then this area is unlikely to receive a significantly faster service than that currently available at from Vale. What is the out of hours appointment and home visiting profile for Dunoon, Strachur, and Tighnabruaich patients per out of hours shift and what is the Doctor staffing implication o 6pm-11pm o 11pm-8am o Weekends and bank holidays o Could over night visits be reduced further using transport or ambulance service. What if the increased workload to Dunoon is relatively low and could be counterbalanced by a strategy to use taxi/ transport and ambulance service more appropriately. Home Visits what is the call for? What were the incidents of home visit requests occurring at the same time e.g a visit in Dunoon and one in Tighnabruaich at 11.pm at night? Page 2
Contents 1. PCEC Out of hours Call Centre Activity Page 4 2. A&E Activity Page 17 3. Community Hospital Inpatient Activity Performance/Profile Page 18 4. SAS Inter Hospital Transfer & Air Transfer Activity Page 2 5 Cowal Peninsular Inter-settlement Drive Times (minutes). Page 23 6. Cowal Community Hospital & OOH Medical Staff and Casualty Nursing Budget Page 25 Page 3
1. PCEC OUT OF HOURS CALL CENTRE ACTIVITY Figure 1a: Home visit response time to patients in GP practice area Home Visit Response Times - Tighnabruaich April 9 to Dec 211 Percentage Split Within 4 Hours, 28, 29% Within 1 Hour, 31, 32% Within 2 Hours, 38, 39% Home Visit Response Times - Strachur April 9 to Dec 211 Percentage Split Within 1 Hour, 11, 22% Within 4 Hours, 2, 4% Within 2 Hours, 19, Page 4
Home Visit Response Times - Dunoon & Kilmun April 9 to Dec 211 Percentage Split Within 4 Hours, 482, 38% Within 1 Hour, 283, 22% Within 2 Hours, 51, 4% 12 Lochgoilhead NHS24 - Type of Res pons e April 211 - January 212 1 Number of Patients 8 6 4 2 Attend PCEC Tel. Advice / GP to phone Home Visits Walk In (at VOL) No Action Source: NHS GG&C OOH Hub (Vale of Leven) Page 5
Figure 1b: Home visit requests at same time over 2 year period Dunoon and Tighnabruaich & Strachur 64 days with Home visits of 2 in a given hour over a 2 year period of which only 9 days involved either Tighnabruaich or Strachur (as graph below) 3 OOH Analysis - Number of Home Visits by Practice and Time (2 visits in hour) Ist January 21 to 31st December 211 Dunoon Strachur Tighnabruaich 2 N u m b er o f V isits 1 24-Jan-1 21-Feb-1 25-Apr-1 16-May-1 22-May-1 15-Aug-1 25-Sep-1 25-Jun-11 25-Sep-11 18: 7: 2: 19: 14: 1: 1: 9: 12: Date & Hour of Visit Page 6
Figure 1c: Home visit requests at same time over 2 year period Dunoon and Tighnabruaich & Strachur 8 days with Home visits of 3 or more in a given hour, over a 2 year period of which only 1 day involved either Tighnabruaich or Strachur (as graph below) 5 OOH Analysis - Number of Home Visits by Practice and Time (3 or more visits in hour) Ist January 21 to 31st December 211 Dunoon Strachur Tighnabruaich 4 N um ber of V isits 3 2 1 6-Feb-1 21-May-1 5-Jun-1 6-Jun-1 3-Aug-1 22-Jan-11 14-Aug-11 29-Oct-11 13: 18: 21: 8: 11: 12: 1: 2: Date & Hour of Visit Page 7
Figure 1d: Home Visit Breakdown by Day 16 14 Dunoon PCEC Service Home Visit Daily Profile Jan - Dec 11 (431 cases) Home Visit 128 132 12 1 Number 8 6 4 35 34 4 31 31 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 14 12 Dunoon PCEC Service Home Visit Daily Profile Apr1 - Jan11 (432 cases) Hom e Vis it 122 117 1 Number 8 6 57 4 33 32 38 33 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 8
Figure 1e: Tighnabruaich and Strachur GMS Service Type Tighnabruich and Strachur GMS Service Type of Response Jan 211 - Dec 211 Number 14 12 1 8 6 4 2 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 Time of Day (24 Hour Clock) Home Visit Advice Appointment CPN Advice MIU Appointment Number 3 25 2 15 1 5 Tighnabruaich and Strachur GMS Service Type of Response- March 28- Sept 21 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 Hour of Day- (24 hour clock) Visit Advice Appointment 999 Ambulance Dual Dr & 999 CPN Advice Page 9
Figure 1f GP out of hour s activity by shift period 211 Please note this table and the two following are copied from the OOH Workload sheet created on 1 th May 212. This version of the OOH workload incorporated patients with no registered practice data supplied into the Strachur figures. That is Tighnabruich relates to patient registered to the Kyles Practice and all other Strachur PCEC activity is recorded against Strachur. The activity data displayed is for the year 8: 1 st January 211 to 7:59 1 st January 212. Taking these times aligns the OOH activity workload with the Hospital shift patterns. For information there was one OOH appointment and one NHS 24 Advice after midnight 31 st December 211. Summary totals are as follows:- Dunoon PCEC Cowal OOH Appointments 722 Appointments 751 Home Visits 431 Home Vists 492 Total 1153 Total 1243 Strachur PCEC Tighnabruaich Appointments 9 Home Visits 34 Total 43 Strachur PCEC Strachur Appointments 2 Home Visits 27 Total 47 Page 1
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Figure 1g Dunoon PCEC GP out of hour s activity by day of week 211 These three tables show how the OOH activity is attributed across the days of the week. There is maximum activity on Fridays, Mondays and Tuesdays reflecting the bank holidays in 211, eg New Year and Easter. Note also the each of 3, 4, 5 or 6 Appointments happened on 9 Saturdays throughout the year. Note also there were 57 days (365 38) where there was NO GP OOH activity however none of there were a Saturday or Sunday Average figures use the Number of Days Available of the Year as the denominator for calculations, eg 129/52 = 2.48 Page 12
Figure 1h Cowal GP out of hour s activity by day of week 211 In this figure summary data from 1h is combined with similar data for Strachur PCEC. This latter data is divided into Tighnabruich registered patients and Strachur and other registered patients, as per explanation in figure 1f. Of note is that combining the two PCEC data there are still 51 days without any OOH activity however none are a Saturday or Sunday. By a small margin Tuesday is the least busy day. Page 13
Figure 1i Dunoon PCEC GP out of hour s frequency activity 211 18 16 14 NHS 24 OOH Activity - Frequency of Home Visits & Appointments - Dunoon PCEC 1st January to 31st December 211 Appointments Home Visits Appointments & Home Visits 12 Num ber of D ays 1 8 6 4 2 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 Frequency Range This graph is designed to display the frequency of activity of the Dunoon PCEC. The frequency range (x axis) is the number of each case type, so 1 equates to only 1 Home Visit or 1 Appointment during the day. The graph shows that there were 15 days with no Appointments and 157 days with no Home Visits. The combined column is normally taller for 2 or more Home Visits or Appointments as there will be many occasions when this happens on the same day. The data for the graph is stated:- Similarly for Strachur PCEC 35 NHS 24 OOH Activity - Frequency of Home Visits & Appointments - Strachur PCEC 1st January to 31st December 211 3 Tighnabruaich Strachur 25 Number of Days 2 15 1 5 Frequency Range 1 2 3 Page 14
Figure 1j Cowal PCEC GP out of hour s busiest days 211 Whereas the data in figure 1i tends to highlight the frequency when the PCEC are not busy this figure shows the busiest days. In this Appointment and Home Visit activity is combined for Dunoon and Strachur PCEC and those days when this combined activity occurred more than 1 times. Note that the OOH service is required to provide primary care access out with the normal Practice opening times of, roughly, 9 am to 5pm Monday to Friday. There were 18 occasions for more than 1 combined Home Visits and Appointments, Saturday is the most busiest of these 18 dates. Please note the bank holiday dates in 211 were :- 3 rd January (Monday) 4 th January (Tuesday) 22 nd April (Friday) 25 th April (Monday) 29 th April (Friday) 2 nd May (Monday) 11 th July ((Monday) 29 th August (Monday) 26 th September (Monday) 26 th December (Monday) 27 th December (Tuesday) The following graph translates all Home Visit and Appointment activity, stated below, to the days of the weeks. Page 15
45 NHS 24 OOH Activity (Home Visits & Appointments) by Day of Week - All Sites 1st January to 31st December 211 Number of Calls 4 35 3 25 2 15 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 5 Dunoon Strachur Tighnabruaich All Sites Page 16
2 A&E ACTIVITY Figure 2a: A & E Activity New and Return Attendances No of Attendances 9 8 7 6 5 4 3 2 1 Cowal Community Hospital Monthly Accident & Emergency Activity: New & Return Attendances Time Period: 1st April 28 to 29th February 212 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan-1 Feb-1 Mar-1 Apr-1 May-1 Jun-1 Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 New Return Linear (New) Linear (Return) Source: Information Services Page 17
3 Cowal Community Hospital Inpatient activity profile January 21- December 211 The information below illustrates the trend (red line) in bed use in the hospital which is showing number of beds occupied over the last 2 years. This has been matched with a reduction in the number of beds in use. The hospital will have a bed complement of 19 inpatient beds for GP Acute admission, 4 of which have been identified for palliative care use. Figure 3a: Cowal Community Hospital Maximum Daily Bed Occupancy Cowal Community Hospital: Occupied Bed Days; All Wards; Specialty (E12) Time Period: 1st January 21 to 31st December 211 3 25 GP Acute Occupied Beds Occupied Beds Trend N u m b e r o f B e d s 2 15 1 5 1 - J a n - 1 1 - F e b - 1 1 - M a r - 1 1 - A p r - 1 1 - M a y - 1 1 - J u n - 1 1 - J u l - 1 1 - A u g - 1 1 - S e p - 1 1 - O c t - 1 1 - N o v - 1 1 - D e c - 1 1 - J a n - 1 1 1 - F e b - 1 1 1 - M a r - 1 1 1 - A p r - 1 1 1 - M a y - 1 1 1 - J u n - 1 1 1 - J u l - 1 1 1 - A u g - 1 1 1 - S e p - 1 1 1 - O c t - 1 1 1 - N o v - 1 1 1 - D e c - 1 1 Source: Information Services 3 Cowal Community Hospital - Total Patient Discharges 1st April 211 to 31st March 212 257 25 N u m b e r o f D isc h arg e s 2 15 177 158 131 143 1 64 63 5 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 18
Figure 3b: Inpatient/Day Case Discharged Episode Activity Calendar Year 211 Practice Codes 84237 Drs Johnston, Hall & Brennan, 246 Argyll Street 84241 Church Street Surgery, 3 Church Street 84256 Drs Campbell & Thomson, 246 Argyll Street 84449 Dr P M R Von Kaehne, Lochgoilhead 84684 Dr Robert S B Coull, Strachur 84716 Dr Ian J D Hamilton, Kilmun 84773 Drs Carle & Partner, Tighnabruaich 81% of the inpatients in Cowal Community Hospital during 211 (749) benefited from being looked after by their own GP day time Monday to Friday Patients who are looked after by their own doctor - who knows them well - value this service immensely. The qualities and additional care that the patients own GP bring to patient s hospital stay is fundamental to holistic continuity of care and we are uniquely able to bridge the gap between secondary care and home and manage long term ongoing conditions with our extensive knowledge of our patients. 19% of the inpatients in Cowal Community Hospital during 211 (165) were not looked after by their own GP. These are looked after by 2 out of the 3 town practices Page 19
4 Scottish Ambulance Service Activity Figure 4A SAS Average Response Times (minutes) by Area- Rural Cowal 1st April 211 to 13th February 212 SAS 999 Call Categories: Cat A: response may be critical in saving life or improving the outcome for the patient, e.g. heart attack, serious bleeding, etc. Cat B: calls which need to be attended quickly but which will not deteriorate or suffer by a slightly slower response Cat C: assistance calls in which someone needs help - perhaps to get up following a fall where no injury has been sustained Urgent: Can only be requested by a doctor (usually a GP) or a midwife. The response is tailored to each individual patient's need as determined by the doctor requesting the ambulance Routine: are booked days, or even weeks, in advance. They are usually carried out by Patient Transport Services although 999 vehicles can be used PA21 2 (Tighnabruai PA22 3 (Glendaruel) PA27 8 (Strachur) Total Cat A Cat B Cat C Call Call Call Urgent Total No of Incidents 9 5 3 42 14 Average Response 34.8 42.44 42.62 111.37 69.68 No of Incidents 7 12 3 22 Average Response 3.31 25.52. 6.26 31.78 No of Incidents 7 29 11 22 69 Average Response 24.24 24.2 25.59 81.19 42.52 No of Incidents 23 91 14 67 195 Average Response 29.94 34.16 29.24 98.99 55.58 Page 2
Average Repsonse Times (minutes) by Area 14 Cat A Call Cat B Call Cat C Call Urgent 12 Average Number of Minutes 1 8 6 4 2 Tighnabruaich Glendaruel Strachur Source: Scottish Ambulance Service Figure 4e Number of Incidents by Area 1st April 211 to 13th February 212 Number of Incidents by Area 6 Cat A Call Cat B Call Cat C Call Urgent 5 4 Number of Incidents 3 2 1 Tighnabruaich Glendaruel Strachur Source: Scottish Ambulance Service Page 21
Figure 4b Area (postcode) demand by Call Type 1st April 211 to 13th February 212 Cat A Cat B Cat C Routine Urgent Total Call Call Call PA21 2 (Tighnabruai 9 4 3 9 61 PA22 3 (Glendaruel) 6 11 1 1 19 PA23 7 (Dunoon Sou 147 234 58 1 75 515 PA23 8 (Dunoon Nor 162 318 88 2 9 66 PA24 8 (Lochgoilhead) 1 1 2 PA25 8 (St. Catherine 1 2 3 PA26 8 (Cairndow) 1 1 2 PA27 8 (Strachur) 7 26 11 11 55 Total 332 633 163 3 186 1317 Area (postcode) Demand by Call Type Number of Calls 7 6 5 4 3 2 1 Routine Urgent Cat C Call Cat B Call Cat A Call Tighnabruaich Glendaruel Dunoon South Dunoon North Lochgoilhead St. Catherines Cairndow Strachur Source: Scottish Ambulance Service Page 22
5 Cowal Peninsular Inter-settlement Drive Times (minutes). Inveraray Dunoon Strachur Tighnabruaich Dunoon 6 Strachur 3 3 Tighnabruaich 65 4 4 Glendaruel 55 4 3 25 Kilfinan 6 45 35 15 25 Colintraive 6 35 35 25 2 3 Portavadie 75 5 45 1 3 15 3 Lephinmore 45 45 2 3 3 2 3 3 Ballimore 6 45 3 25 25 1 25 2 15 Invernoaden 4 25 1 4 35 4 4 5 2 35 Glendaruel Kilfinan Colintraive Portavadie Lephinmore Ballimore Source: The travel times are calculated using an ArcGIS add-in function that uses a comprehensive road network grid that includes all roads (not only single track but unclassified). Average speeds for types of road (Motorway, Trunk, A, B, Minor unclassified etc) are applied to the network length to calculate the area it is possible to travel within a given time. Adjustment is made to the travel distance that is possible depending on whether the road is running through urban or rural areas this is based upon us applying a land use layer as part of the calculation. There are some shortfalls things like one way systems etc are not programmed in this type of work. The strength of the GIS approach is that it provides an average picture for such work that can be systematically employed in lots of different situations. In extremes of conditions average times will not apply and it is obviously not possible to capture the difficulties of every individual journey. However, similar application has shown correlation between GIS estimates of travel times and patients reports of journey times to hospital. http://www.ij-healthgeographics.com/content/5/1/4 Page 23
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6. What is the Cost of the Current Service Cowal Medical Services Budget Type of Medical Staff/Service Budget ' Town GPs Hospital In-Patient Services Monday to Friday (8:- 18:) 159, CHP Employed Medical Staff Hospital Inpatient, Casualty & Dunoon l Out of Hours service 859, Rural GPs Tighnabruaich/Strachur Out of Hours Service 284, Total Cost 1,32, Note: Excludes Lochgoilhead as this is covered by an SLA with NHS GG&C Cowal Casualty Nursing Services Budget Casualty Staff Type ** Budget Number of Staff Emergency Nurse practitioner and other trained nursing staff 497, 12.7 Auxiliary 64,4 2.45 Total Cost 561,4 14.52 Note: ** Nursing staff also cover outpatient clinics & theatre sessions Page 25