Care When I Need It. A Report on Urgent Care Services

Care When I Need It A Report on Urgent Care Services March 2013

Contents Foreword 1 Executive Summary 3 1.0 Introduction 5 2.0 Background 6 2.1 Policy 6 2.2 Current Provision 8 2.3 Activity and Waiting Times at Urgent Care Services 9 3.0 Our Approach 12 4.0 The People 14 5.0 Findings 15 5.1 The Emergency Department 17 5.2 GP Services 26 5.3 GP Out of Hours Services 28 5.4 Minor Injuries Units 36 6.0 Conclusion 42 7.0 Recommendations 44 Bibliography 46 Appendices 47

Foreword Access to high quality, compassionate and timely urgent care is a high priority for people across Northern Ireland. Provision of urgent care is a challenge for providers of services due to the high volumes of people attending and the range and severity of patients conditions. In the last 6 months we have spoken to over 4000 people to find out their experiences of urgent care. While some experiences have been positive, addressing concerns about poor communication, lengthy waiting times and access to and understanding of the services offered by GP Out of Hours and Minor Injuries Units are crucial if the over reliance on Emergency Departments is to be reduced. People are often unsure of the best place to go for treatment, with limited advice and information available. Patients are uncertain whether to contact a GP out of Hours service, visit a Minor Injuries Unit or to go directly to their main Emergency Department. Consequently, in the recommendations of this report the Patient and Client Council has called on Health and Social Care organisations to make better information available to patients and their families on where they can get the right treatment at the right time and in the right place. The on-going review of health and social care services Transforming Your Care describes changes required to the provision of urgent care in Northern Ireland. The experiences of people as described in this report should form an integral part of that debate to ensure that patient care and experience remains at the centre of care provision and planning. 1

I would like to extend my sincere thanks to all those who contributed to this project, particularly people who have shared their personal experiences. It is crucial that the experiences of patients and families who use urgent care services are central to any changes that are planned to the future delivery of services. Maeve Hully Chief Executive, Patient and Client Council. 2

Executive Summary This document records the views and experiences of people across Northern Ireland on urgent care services and makes recommendations to improve the existing services. Previous work done by the Patient and Client Council demonstrates that timely and effective access to urgent care services is a priority for people. A total of 4,160 people contributed to this project; 3,743 people completed a questionnaire, 305 people participated in focus groups and 72 patients took part in short interviews during site visits to 21 urgent care facilities. The stories of 40 patients and carers who contacted the Patient and Client Council s Accident and Emergency and GP Out of Hours Helpline in the period from 8 March to 31 August were also considered as part of this project. The report describes a number of key findings. The results of the questionnaire show that the Emergency Department is the most common choice of service for people in need of urgent care by a considerable margin, 67% of all respondents (2344). This is supported by focus group participants who agreed that the Emergency Department along with GP Services (in and out of hours) are the most common services they would go to for urgent care. In addition, people would welcome the introduction of a single telephone number to contact urgent care services. While the Emergency Department is many people s first choice for urgent care, a number of concerns about this service are raised in the report. The main issue for people is waiting time to see a doctor or for treatment. People also voiced concerns about the environment in which they had to wait, including safety, comfort, cleanliness and patient facilities. Waiting time is also an issue for people using the GP Out of Hours service. There is evidence in the report of good practice at GP Out of Hours services; 63% (1,229) of questionnaire respondents who had used the service within the past year rated it either good or excellent. However, waiting times for a call back 3

from the GP is a significant area of concern. 63% (2,310) of all questionnaire respondents said they would prefer a call back within 30 minutes. People appear to be well-informed about the GP Out of Hours service; 89% (3,285) of questionnaire respondents indicated that they knew how to contact this service. In comparison, public awareness of Minor Injuries Units is poor, with 35% (1,013) questionnaire respondents and almost half of all focus group participants unaware of the location of their nearest Minor Injuries Unit. People would like access to Minor Injuries Units that are accessible, located locally, open in evenings, more wide-ranging in the treatment and services it offers and staffed with experienced clinicians. A lack of consistency for patients accessing GP services for urgent care is also apparent. While many people said they find it difficult to get advice or an appointment with their GP when in need of urgent care, others spoke positively about the urgent appointment and ring back services available at their GP surgery. The situation appears to vary greatly between GP practices. Throughout the report, good communication is identified as crucial in an urgent care situation. Examples of caring and attentive staff working hard under difficult circumstances at urgent care facilities are very much in evidence. However, some people did report experiences of poor communication, negative staff attitudes, questionable treatment or misdiagnosis and a lack of dignity and respect, particularly at the Emergency Department and GP Out of Hours service. Accessibility is also an issue for some people when using GP Out of Hours services and Minor Injuries Units, especially older people, people living alone and those with no access to personal transport. There is evidence of positive experiences; however, people reported that urgent care services can be improved in a number of ways. The report concludes that information and education about how to use urgent care services during a period of change for health and social care services in Northern Ireland is essential. 4

1.0 Introduction People in Northern Ireland want timely, effective and accessible urgent care services. Over the past three years people have repeatedly told the Patient and Client Council that they are concerned about access to urgent health care. This is reflected in reports such as The People s Priorities and Rural Voices Matter. As a result of this evidence we undertook this project to gather people s views and experiences regarding urgent health care. Over 4000 people from across Northern Ireland, many of whom had recent experience of the service, contributed to the project in a variety of ways. The concerns regarding access to urgent care services are not new. In 2008, a Northern Ireland Audit Office (NIAO) report highlighted how a period of change within Northern Ireland s emergency care departments had resulted in: a disjointed and uncoordinated emergency care system which has been manifested in patients waiting too long in A&E and experiencing difficulty in getting the right service. (NIAO, 2008: 9) For the purposes of this report the term urgent care is used to focus on a number of services, such as Emergency Departments 1, GP services, GP Out of Hours services and Minor Injuries Units. 1 Please note that the term Emergency Department is used throughout the report (except when used in quotations) to denote A&E and casualty. 5

2.0 Background The following section provides some background on urgent care services in Northern Ireland. It describes current policy on urgent care, including a number of reviews of emergency care services that have been undertaken in recent years; current service provision for urgent care; and activity and waiting times at Emergency Departments, Minor Injuries Units and GP Services, including Out of Hours. 2.1 Policy In 2007, the Department of Health, Social Services and Public Safety (DHSSPS) commissioned Price Waterhouse Coopers (PwC) to undertake an independent review of emergency care activity. This review suggested that nearly one quarter (24%) of Emergency Department attendances in Northern Ireland were inappropriate and could be addressed by alternative healthcare services, such as Minor Injuries Units (PwC, 2007:139). The review noted that Emergency Departments are heavily used, with attendances that were 20-30% higher than in the rest of the UK (this was based on 2004 figures). It also indicated that some people attend Emergency Departments when they cannot get an appointment quickly enough with their GP during regular working hours. High use of Emergency Departments may be partly due to the lack of development of other types of unscheduled care services. For example, in Northern Ireland, out-ofhours centres do not allow open access and there are no walk-in primary care health facilities. The independent review made a number of recommendations including: increased availability of GPs working within or adjacent to Emergency Departments as well as reviewing the opening times of Minor Injuries Unit and the staff skill mix. The PwC review has formed the basis for subsequent work. In 2008, the NIAO referred to this report in its own review of unscheduled care in Northern Ireland, Transforming Emergency Care in Northern Ireland, which focused on performance and targets set for urgent care services. Since then Emergency Department 6

activity and performance has been published in bulletins produced on a monthly or quarterly basis by the DHSSPS. In 2012, the Minister of Health set up an Emergency Department Improvement Action Group with the aim of improving patient outcomes and the patient experience in Emergency Departments. This group was charged with reducing waiting times and ensuring that 12 hour waits are a rare occurrence. In recent months the Health and Social Care Board has consulted the public on a Strategic Framework for GP Out of Hours services. The consultation document made a number of suggestions to improve Out of Hours services such as simplifying access, improving operational efficiency and improving alignment with other healthcare services. The recommendations are currently being implemented. A wider review of health and social care services in Northern Ireland, Transforming Your Care, was published by the DHSSPS in November 2011. It found that performances against targets in emergency care were not being met, and that up to 50% of patients presenting to Emergency Departments are standard cases without immediate danger or distress (p.98). To further compound Emergency Department congestion, it is estimated that alcohol is a significant factor in 40% of all hospital admissions, rising to 70% of Emergency Department attendances at weekends (p.54). Transforming Your Care stated that options available to the public in dealing with emergency injuries and illnesses are not well known and getting the message across to the public about when to access Emergency Departments, Minor Injuries Units, and GP Out of Hours clinics requires further work (p103). It concluded: there is potential to do things differently and achieve consistent outcomes. Accident and Emergency Departments can and should be supported more locally through an integrated urgent care model. The urgent care model is not a one size fits all approach. It is an approach which looks at the needs of local people and tailors provision to meet their urgent care needs (HSCB,2011: 102) 7

2.2 Current Provision In Northern Ireland, urgent care is provided across a range of facilities. There are currently eighteen hospitals which provide some form of urgent care and five GP Out of Hours services. There are ten Emergency Departments for the most serious injuries and eight Minor Injuries Units. The types of hospital provision and GP services, including Out of Hours, are detailed in the following table: Type of facility and location Hospitals Mater Infirmorum Royal Group of Hospitals Antrim Area Causeway Ulster Craigavon Daisy Hill Altnagelvin South West Area Hospital Description of service Consultant-led service with designated accommodation for the reception of emergency care patients, providing both emergency medicine and surgical services on a round the clock basis Lagan Valley Downe (GP-led for part of the day) Minor Injuries Units Whiteabbey Mid Ulster Ards Community Bangor Community Armagh Community Hospital Tyrone Urgent Care and Treatment Centre, Tyrone County South Tyrone GP Out of Hours Located in designated towns across Northern Ireland (see map below) Providers: Belfast Health and Social Care Trust South Eastern Health and Social Care Trust Southern Health and Social Care Trust Western Urgent Care Dalriada Urgent Care GP Practices Consultant-led service with designated accommodation for the reception of emergency care patients, but which does not provide both emergency medicine and emergency surgical services and/or has time-limited opening hours A Minor Injuries Unit with designated accommodation for the reception of patients with a minor injury and/or illness. It may be doctor-led or nurse-led. A defining characteristic of this service is that it treats at least minor injuries and/or illnesses and can be routinely accessed without an appointment GP-led service providing urgent care when GP surgeries are closed which is generally between 6pm and 8am weekdays and all day Saturday, Sunday and public holidays 353 GP practices in Northern Ireland Table 1 Urgent Care Services Note: Definitions in the above table from DHSSPS and NISRA (January 2012) Emergency Care Waiting Time Statistics (October - December 2012), p.30. 8

The centres where people are seen by a GP Out of Hours are shown on the map below: Figure 1: GP Out Of Hours & Hospital Locations 2.3 Activity and Waiting Times for Urgent Care Services 2.3.1 Emergency Departments and Minor Injuries Units There were over 687,035 attendances at emergency care departments in Northern Ireland last year, of which 146,035 people waited for over 4 hours and 7,243 people for over 12 hours. Improving patient access to health services remains a top Ministerial priority the Ministerial target for Northern Ireland for 2012/13 requires that: 95% of patients attending A&E departments are either treated and discharged home, or admitted, within four hours of their arrival in the department, and; no patient attending any A&E department should wait longer than 12 hours either to be treated and discharged home, or admitted (NISRA, 2012: 1) 9

The 12-hour target has been in place since 2007 and the 4-hour target from 2008. It has, however, only been regularly achieved in two hospitals in relation to Emergency Departments. Minor Injuries Units usually achieve 100% turnaround in 4 hours. The DHSSPS has stated its aims for urgent care services very clearly: Uniform performance targets which are applicable to all HSC Trusts have been set and all Trusts are expected to meet the targets. How each HSC Trust realises the targets is an operational issue appropriate to them (Black, 2012: 7) 2.3.2 GP Out of Hours Services 605,507 patients used the GP Out of Hours service from 1 January 2012 to 31 December 2012. Statistics provided by the Health and Social Care Board relating to GP Out of Hours indicate that the vast majority (over 90%) of patients with an urgent health care need are triaged 2 within 20 minutes which meets the requirements of the Out of Hours services contract (see Appendix 1 for more detail). The remainder of all calls to the service are required to be triaged within 60 minutes. The following table shows the number of contacts with patients from January 2012 to December 2012. Out of Hours Provider Telephone Consultations Patient Visit to Out of Hours Centre Home Visit Total Dalriada Urgent Care 75,259 59,084 12,141 146,484 Southern HSC Trust 57,849 53,354 7,322 118,525 South Eastern HSC Trust 62,033 40,356 6,849 109,238 Western Urgent Care 49,489 59,015 6,960 115,464 Belfast HSC Trust 69,739 38,504 7,553 115,796 Total 314,369 250,313 40,825 605,507 Table 2: Contacts with GP Out of Hours 1 Jan 2012 31 Dec 2012 2 See Appendix 1 for more detail 10

2.3.3 GP Services (urgent care services during normal working hours) The General Medical Services (GMS) contract makes provision for GPs to provide a range of services including Out of Hours services. As it also enables opt outs and does not clearly define what should be provided; this has led to a lack of consistency in the service. Statistics are not available for waiting times for appointments with GPs for services provided from 8am to 6pm. 11

3.0 Our Approach The Patient and Client Council adopted a combined approach to this research project. Both quantitative and qualitative methods were employed to gain a wider understanding of people s views and experiences of urgent care. People could contribute to the project in four main ways: Questionnaire; Focus Group; On site visits to urgent care facilities by Patient and Client Council staff; Accident and Emergency and GP Out of Hours Helpline. A questionnaire was developed so as to capture attitudes towards urgent care services. The questionnaire was distributed at a number of public events, through community groups, and was available to complete online. The large number of people who responded to the questionnaire, 3,743 people, ensured that a variety of perspectives were obtained. A copy of the questionnaire can be found in Appendix 2. A number of focus groups took place to explore in more detail the issues surrounding urgent care. To attain a good geographical spread, focus groups were located in all five Health and Social Care Trust areas. Care was taken to involve a broad range of participants, including sections of the population that are sometimes under-represented in such studies, for example older people, adults with learning disability, ethnic minorities and men s health groups. A full list of focus group numbers and locations is available in Appendix 3. Patient and Client Council staff members made site visits to a number of urgent care facilities. This included at least one Emergency Department, one GP Out of Hours service and one Minor Injuries Unit (with the exception of Belfast) in each of the five Trust areas. At each site, staff made observations on location, environment and information provision. Additionally, patients took part in short interviews on-site and were offered the option of a follow-up call from the Patient 12

and Client Council to discuss their experience in more detail. For a list of site visits see Appendix 4. The Patient and Client Council launched the Accident and Emergency and GP Out of Hours Helpline (hereafter Helpline) on 8 March 2012. The free phone number was advertised in the local media and representatives from the Patient and Client Council took part in media interviews publicise the project and encourage people to share their experiences. Staff members were informed on the purpose of the helpline and protocols for dealing with different responses. Staff recorded individual responses onto a template and all responses were stored securely to ensure confidentiality was protected. Callers were briefed on the role of the Patient and Client Council and if appropriate were offered the opportunity to be referred onto a Patient and Client Support Officer for advice about making a complaint. Only the contacts made to the helpline between 8 March and 31 August 2012 are considered for this report, however the helpline is in operation until 31 March 2013. It is important to note that the comments made through the helpline that are contained in this report were made by patients and carers. The Patient and Client Council made no judgement nor sought to verify the veracity or otherwise what people told us. 13

% respondents 4.0 The People A total of 4,160 people offered their views and experiences of urgent care services in Northern Ireland. 3,743 people completed a questionnaire about urgent care (Appendix 2). The majority of respondents were female (2440 or 60%). Just over half of all respondents fell into the 36 to 65 years age range. Figures 2 and 3 reflect the gender and age profile of respondents. 30 20 Male 10 40% Female 60% 0 Under 18 18-35 36-49 50-65 Ages (years) Over 65 Figure 2: Gender of respondents Figure 3: Age of respondents 305 people took part in 27 focus groups across Northern Ireland. Participants discussed a range of issues, such as why people choose particular services for urgent care and how services might be improved for those in need of urgent care. Forty contacts were made to the Helpline in the period from 8 March to 31 August 2012. Of those, twenty-two were people who had personal experience of urgent care and 18 were carers who had accompanied a friend or family member at an urgent care facility. All experiences had taken place within three years of contact with the Patient and Client Council. However, the majority (68%) had occurred within the previous six weeks some within the previous twenty-four hours. In order to engage with people on the front-line receiving urgent care, twenty-one site visits to urgent care facilities across Northern Ireland were made. More than seventy patients took part in short interviews about their experience. During the site visits, Patient and Client Council staff made observations on location, waiting times, information provision, the waiting area and access to refreshments. 14

5.0 Findings The findings are reported under the four main services that people said they use for urgent care: The Emergency Department; GP Services; GP Out of Hour Services; Minor Injuries Units. These services were identified by those people who completed a questionnaire or took part in a focus group. In an introductory question, they were asked where they would go if they, or someone they cared for, were in need of urgent care. The 3,743 people who completed a questionnaire were given the opportunity to answer this question freely, rather than choose from a range of options. The most common response by a considerable margin was the Emergency Department, the first choice of more than two thirds of people (2,344 or 67%). Out of Hours 11% Call 999 4% GP 18% Emergency Department 67% Figure 4: Where would you go if you or someone you care for needed urgent care? It is interesting to note that young people (under 18 years) who completed a questionnaire were more likely to say they would go to an Emergency Department (130 or 77%) and less likely to indicate any alternative services. Response from older people (over 65 years) was in keeping with the averages given above. 15

There was also some regional variation in response to this question. As Figure 5 below shows, people living in the Belfast Trust were most likely to go to the Emergency Department (425 people or 72%) and least likely to use a GP Out of Hours service (43 or 7%). The percentage of people in the South Eastern Trust who said they would go to a GP Out of Hours service (43 or 8%) also fell below the regional average of 11% given in Figure 4 above. Figure 5 shows that the opposite was the case in the Western Trust. People living in the Western Trust were least likely to go to an Emergency Department (311 people or 57%), while the number of people who said they would see their GP (118 or 22%) or use a GP Out of Hours Service (92 or 17%) was higher than the other Trust areas. 100 80 Call 999 60 GP Out of Hours 40 GP 20 0 Belfast Northern South Eastern Southern Western Emergency Department Figure 5: Where would you go if you or someone you cared for needed urgent care? By Trust Area (% respondents) It is important to note that many people added that their choice of location when seeking urgent care very much depended on the circumstances involved and the type of care needed. This point was repeated throughout the project when people commented on accessing urgent care services. Depends on severity of condition or seriousness of injury Depends on type of care needed, I would contact GP or Out of Hours first to get their advice Depends on time of day - would go to GP first, or Out of Hours, and A&E if real emergency 16

When asked where they would go if they were in need of urgent care, the 305 focus group participants gave a more detailed response. The question was broken down further; participants were asked where they would go for urgent care between 9am and 5pm and after 5pm. Many people gave more than one answer to this question, explained by the fact that circumstances might influence their decision. Between 9am and 5pm the GP and the hospital Emergency Department were the most common services identified. Almost three quarters of focus group participants said they would contact their local GP surgery for urgent care during opening hours if they felt their illness or injury could be treated by the GP and if they could get an appointment at short notice. More than half said they would go to the Emergency Department, especially if the situation was considered serious. A smaller number of people identified the Minor Injuries Unit or the local Pharmacist as other services they would consider using if they were in need of urgent care (in both cases about 40 people). After 5pm there were just two common services identified; GP Out of Hours and the Emergency Department. Again it is important to note that most people agreed their choice of location would depend on the nature of the illness or injury. In a situation they considered to be serious, most said they would go straight to the Emergency Department day or night, weekday or weekend. 5.1 The Emergency Department The findings show that the Emergency Department is the most common choice of service for people in need of urgent care (see Figure 4 above). Comments about the Emergency Department centre on four main issues: Waiting times; Waiting area environment safety, facilities and cleanliness; Treatment; Staff. 17

It is worth noting that many of the more detailed comments on the Emergency Department come from people who contacted the Helpline. The more in-depth questions asked in both questionnaire and focus groups tended to concentrate on other urgent care services such as GP Out of Hours services and Minor Injuries Units. While most of the experiences described on the Helpline focus on people s concerns with the Emergency Department, it is important to remember that 67% (2,344) of questionnaire respondents said that the Emergency Department was their first choice of service for urgent care. Waiting Times Three quarters of contacts (30) made to the Helpline were about the hospital Emergency Department. Of those, 18 people complained about the length of time they had to wait in order to be seen by a doctor or to be treated. People spoke of waiting times of between 4 and 14 hours, despite being in considerable discomfort and pain. In one case, a patient stated that they waited more than 10 hours in an Emergency Department without seeing a doctor and finally left without treatment. In many instances patients were older people who were tired, upset and confused about having to wait so long. A carer for an older person with dementia described how her relative was confused, frantic and disturbing other patients during a 14 hour wait for treatment but was told she had to wait her turn like everyone else. Four people said they were frustrated that they, or the person they cared for, had to go through triage a second time and face a second long wait. This was despite being referred to the Emergency Department by another service for a specific treatment. One person stated that they spent 48 hours on a trolley in an Emergency Department before being admitted to hospital, even though he was referred there by his GP. 18

Why, when a professional has already made a diagnosis of what is needed in my mother s case a simple x-ray was this not accepted by those on duty in Emergency Department? Carer for 92 year old patient who had to wait several hours after being referred by their GP for an x-ray Communication was also an issue. Many people said that during waiting times of up to 12 hours in an Emergency Department they were never offered an update or information on how much longer they would have to wait. One person observed that a noticeboard that displayed the average waiting time to patients never changed from 3.5 hours in the eight hours she spent in the waiting area. A few people who had been referred on to the Emergency Department after contacting other services felt that they should have been informed about expected waiting times or possible alternatives. They suggested that urgent care facilities should communicate with one another to help people make an informed decision. Many focus group participants agreed in open discussion that previous experience of long waiting times at the Emergency Department made them reluctant to consider this service as the best option for urgent care. Never go to the hospital A&E is always so busy. People go to it for anything they think they can be seen quicker Patient and Client Council staff made site visits to six Emergency Departments across Northern Ireland. They found that waiting times at Emergency Departments appeared to be longer than those at GP Out of Hours facilities at the time the visits took place, especially in the Belfast and South Eastern Trust areas. While the majority of patients interviewed on-site said that the service and treatment they received was good, most commented on the length of time they had to wait and said they would like to be kept better informed about waiting times after triage. 19

Case Study One A 12 hour wait at the Emergency Department The carer for an older person with dementia recalled a visit to the Emergency Department which began at 5pm one afternoon and finished at 5am the following morning. The 12 hour experience consisted of: On arrival they had to wait for paramedics to hand patient over to nursing staff After triage and blood tests they waited several hours for the results At 1.30am, eight hours after arriving, the patient was taken to a cubicle 45 minutes later the patient was seen by a doctor for the first time Patient was sent for an x-ray, they waited 40 minutes in the x-ray department Again they waited for results Finally the doctor diagnosed the infection and said they could go home There was a two hour wait for an ambulance to transport them there At 5am this vulnerable older person and her carer were the last two people to leave the Emergency Department. Waiting Area Environment safety, facilities and cleanliness Almost everyone who contacted the Helpline about long waiting times at the Emergency Department said they were unhappy about the environment in which they had to wait. For some people this was a case of basic care and comfort during an anxious experience. People described having to stand when they first arrived because the waiting area was so busy, having no access to facilities for hot drinks or snacks and not being offered any refreshment while lying on trolleys for hours. Two people waited on trolleys between 19 and 48 hours in cold and draughty conditions. A few carers talked about the lack of dignity their relative experienced while being treated in the Emergency Department. A mother stated that her son lay on a trolley between a patient suffering a miscarriage on one side and a patient having an intimate examination on the other. One carer described the treatment area of the Emergency Department as overcrowded and uncomfortable for seriously ill patients. 20

Three people said that both the waiting and treatment areas of the Emergency Department were dirty, with rubbish on the floor, used or discarded medical instruments left out, unwashed floors and, in one case, unclean bed sheets and a kidney dish with another patient s vomit left by the bedside. Some raised questions of patient safety due to the number of people under the influence of alcohol and drugs in the Emergency Department. One person described how a busy waiting room, including children, had to watch intoxicated people urinate and fall about while young nurses struggled to lift them. It was suggested a number of times that individuals under the influence of alcohol were prioritised over more urgent cases in order to remove them from the waiting area. I felt that drunk people were given priority over my husband on this occasion Is A&E a hostel for drinkers to sleep off hangovers? During site visits to Emergency Departments, Patient and Client Council staff observed that most waiting areas were clean and functional and provided patients with televisions, vending machines for refreshments and posters and leaflets displaying information. In a small number of cases issues with the waiting area were noted, such as broken seats, waste left discarded and televisions and information screens turned off or out of order. A few patients interviewed at one Emergency Department questioned the safety of the waiting area at weekends and evenings due to the number of patients who appeared to be under the influence of alcohol and drugs. 21

Case Study Two The Emergency Department - I ve never experienced anything like it A carer who had just accompanied his seriously ill wife by ambulance to the Emergency Department contacted the Helpline to talk about the four hours she waited on a trolley to be examined by a doctor. The main examination area, where 20 to 30 people lay on trolleys waiting to be seen, he described as: Something like a bomb site the place is chaos The room was too small for the number of trolleys, so patients were constantly moved and shoved about so that medical staff could get to other patients. Very few comforts were afforded the patients: There was one toilet for all patients to use no blanket, no pillows available Other patients spoke to him of being there for almost 24 hours and not being offered any refreshment. With only one doctor on duty and minimal nursing staff, the service was under a lot of pressure: I don t feel that it is the doctor or nurses fault. They are stretched beyond capacity and are dealing with large volumes of patients Treatment Some people who contacted the Helpline had serious concerns about aspects of their treatment at urgent care services, such as misdiagnosis, poor communication, and lack of dignity and respect for patients. Many of these stories were very personal in nature and distressing for the patients or carers involved. Four people raised specific questions about medical treatment received at an Emergency Department. Two patients were discharged from the Emergency Department untreated, despite voicing their concerns. One, an older person, was quickly sent back to the Emergency Department later that day after being assessed by a GP Out of Hours. The other patient was contacted by a nurse at the local GP surgery two days later to say that an x-ray taken at the Emergency Department showed they had a fractured arm. It was two weeks before a member 22

of staff at the Emergency Department contacted the patient to advise there had been a mistake. Case Study Three I believe patient care starts before arrival and continues through departure A gentleman described how his experience of the excellent care his relative received at the Emergency Department was tainted when they returned to the car park in the early morning to find that the considerable car parking charge was payable only in change which they did not have: At 2.30 in the morning I was faced with trying to find change of a 20 note to pay to get my car out - no shop open, security staff couldn t help and the footfall of injured, drunken revellers was not a nice place to be looking for change. A very challenging 20 minutes in which staff had been most unhelpful Eventually, two of the drunken revellers, there because a relative had died in the hospital that night, helped him with change to pay the parking charge. I ve often wondered how I would ve felt scavenging in A&E for car park change if I d just left the bedside of a relative or child who d just passed away Staff Six people who contacted the Helpline said they were unhappy with the way in which Emergency Department staff approached them. Some felt that medical staff, especially during night shifts, were rude, tried to avoid or simply ignored patients. It seemed like they didn t want to know In one case reported to the Helpline it was claimed that a vulnerable adult was treated insensitively by medical staff. A carer who accompanied a patient with mental health illness said that, when treating her relative, doctors and nurses were rude, insensitive and lacking in any bedside manner. What is more, they failed to take any account of her particular care needs. 23

It is important to note that not everyone who contacted the Helpline had a wholly negative account of the Emergency Department; many had mixed experiences of the care they received. Four people specifically contacted the Helpline to describe the efficient and attentive treatment they received on a recent visit to the Emergency Department. The most common positive comment made related to staff, particularly nursing staff. Many people recognised that urgent care staff work hard under difficult circumstances and yet continue to be kind and attentive. Staff were run off their feet but they couldn t have been nicer The staff are wonderful, it s just the system A few people specifically mentioned the paramedics who treated them on the way to the Emergency Department. One patient, who waited an hour for an ambulance to arrive to take him 3 miles to hospital, commended the ambulance crew: I make no judgement as to whether this (waiting time) was reasonable or not I would say that when the ambulance crew arrived they acted promptly, efficiently and sensitively and I felt confident and happy to be in their care 24

Case Study Four It was a positive experience A lady attended her nearest Emergency Department after an accident with a kitchen utensil in which she nearly removed the tip of her thumb: When I went to reception the staff member was courteous and I was asked to have a seat in the waiting room. After approximately 10 mins a nurse assessed the damage and gave me a dressing to help stem the flow of blood. After about 1 hour 10 mins I was called to the treatment room where I was looked after by two extremely pleasant staff (nurses) I got paper stitches and supporting dressing and advised to go to my local medical centre in about seven days or if I felt I needed further help. It was a positive experience Many of the issues identified in this section were also raised in the recent Patient and Client Council report Emergency Admission to Hospitals in Northern Ireland (December, 2012). The report found that patients attending the Emergency Department are just as concerned about communication, being kept informed, dignity and respect as they are about being treated for their illness. Patients and carers value consideration and compassion from the people charged with their care. Case Study Five - Accessing Urgent Care Services A man, living on his own and with no access to transport, described an occasion where he was in need of urgent care but struggled to get to help. He did not consider his illness an emergency so did not want to ring an ambulance. Instead, he phoned a taxi to take him to the Emergency Department, but the taxi driver was reluctant to take him as he was very ill and vomiting. He eventually persuaded the taxi driver by using a sick bag on the way to the Emergency Department, where he was left at the door to make his own way in. 25

To Summarise The Emergency Department The main issue for people using this service are long waiting times; Communication is important to people attending the Emergency Department. People reported a lack of information about waiting times and examples of poor communication from Emergency Department staff; People have concerns about safety, comfort, cleanliness and patient facilities in some Emergency Department waiting areas; People spoke positively of caring staff working hard under difficult circumstances; and Some people raised issues with the treatment they received and the lack of dignity and respect they experienced while using this service. 5.2 GP Services (urgent care services during normal working hours) Almost a fifth of questionnaire respondents (615 or 18%) said they would contact the GP if they were in need of urgent care. However, a more detailed discussion within the focus groups found that more than three quarters of participants would go to the GP if they needed urgent care between 9am and 5pm. Discussion on GP services focused on one main issue: How do you get advice and appointments with your GP when you require urgent attention? It was very evident that experience varies across GP practices and as a result, focus group discussion around this issue was quite mixed. About a third of participants who commented further said that their local GP surgery was a reliable source of advice when they were in need of urgent care. They explained that emergency appointments were usually available, their clinic had a daily open surgery or that they could arrange a call back from the GP to discuss the problem. A few people said their doctor will do house visits if care was needed urgently. 26

In my GP surgery there is a doctor on duty to deal with urgent cases every day so always can get an appointment that way if it is serious However, the remaining two thirds of participants who commented on this issue said that they sometimes experience difficulties when they contact the GP for advice or an appointment in an urgent situation. Many people explained that it was hard to get a routine GP appointment within a reasonable timeframe, and particularly difficult at short notice. It was even more difficult to get an appointment with their own GP who knew their medical history. Chance would be a fine thing! Never get an appointment with your own doctor, have to wait at least 2 weeks Focus group participants identified other common difficulties they faced when accessing GP services. These included: having to phone the GP early to see if they could get a cancellation or speak to a doctor, which was not always possible; trying to get past receptionists perceived as blocking the path to the doctor, which was said to be stressful and off-putting; and difficulty getting through to the surgery or health centre as the phone line was so busy. Many groups agreed that there needs to be more consistency in this area. There is such a big difference in experience and that no-one should find it difficult to contact the GP for advice or an appointment when in need of urgent attention. To Summarise GP Services (urgent care services during normal working hours) Many people experience difficulties getting advice from or an appointment with their GP when they require urgent attention. While some people did compliment the appointment and ring back services at their GP practice, it is evident that there is no consistency for patients in this area; the situation varies greatly between GP practices. 27

5.3 GP Out of Hours service Public awareness of the GP Out of Hours service appears to be high; 89% of questionnaire respondents (3,285) indicated that they knew how to contact the GP Out of Hours. It is perhaps worth noting, however, that only 63% of young people (149) said they knew how to contact the GP Out of Hours service. Just 1 in 10 questionnaire respondents said that they would contact the GP Out of Hours service if they were in need of urgent care. In more detailed discussion within focus groups, the GP Out of Hours was identified along with the Emergency Department as the most common choice of service for participants after 5pm. Many people who had recent experience of the GP Out of Hours spoke positively of the service. Just over half of all questionnaire respondents (1,957 or 53%) said that they or someone they cared for had used a GP Out of Hours service in the past year. Of those, the majority of people (63%) rated the service highly, good (852 or 44%) and excellent (377 or 19%). I think it [GP Out of Hours] is an excellent service Would rather use Out of Hours as quicker than casualty and better response I mostly use the GP Out of Hours service. I had to use them at Christmas this year and had a very good outcome A total of 16% (303 people) rated the GP Out of Hours as either fair or poor, the remaining 21% (409 people) rated the service average. Comments about the GP Out of Hours service centre on four issues: Waiting times for a return call from the GP Out of Hours; Staff; Accessibility; Getting the necessary treatment and expertise in urgent care situation. 28

Waiting times for a return call from the GP Out of Hours The vast majority of respondents (3,347 or 92%) felt that people should not wait more than 1 hour for the GP Out of Hours to return their call, 63% (2,310 people) indicating under 30 minutes as a reasonable amount of time to wait and 29% (1,037 people) indicating 30 minutes to 1 hour. 3 Almost no-one thought it acceptable to wait more than 2 hours for the GP Out of Hours to return a call and less than 1% (41 people) expected an instant call back. 1 to 2 hours 30 mins to 1 hour Under 30 mins 0 10 20 30 40 50 60 70 % respondents Figure 6: How long do you think it is reasonable to wait for the GP Out of Hours service to return your call? However, when people who had used the GP Out of Hours service within the past year were asked if they would change anything about the service, more than half of those who responded (381 people or 54%) identified faster ring back times. No options were provided with this question and people were able to answer freely. As Figure 7 overleaf shows, faster ring back times was the most common response by a considerable margin. 3 The service specification requires all patients to receive a call back within 1 hour and those with an urgent need within 20 minutes 29

Chemist open as well Better follow up service Drop-in centre (no need to call first) Access to medical records More call outs by doctors More accessible Better staff attitudes Faster ring back time % respondents Figure 7: Is there anything about GP Out of Hours service you would change? 12% of all questionnaire respondents (486) said that long waits for the GP Out of Hours to ring back would discourage them from using this service when in need of urgent care. Waiting can be long especially if you re panicking Length of time it took for them to call back, ended up having to call ambulance A total of fifteen people contacted the Helpline to talk about an experience of GP Out of Hours service. Many of these questioned the amount of time they had to wait to receive a call back from the GP Out of Hours or until the doctor was able to see them at the clinic or to make a home visit. Staff When people who had used the service within the past year were asked what they would change about GP Out of Hours, 15% (102 people) identified improved attitudes from staff members at these facilities (see Figure 7 above). When commenting further, some respondents noted previous bad experiences of poor communication and treatment from GP Out of Hours staff which made them reluctant to use the service. 30

Attitude of staff terrible Really bad communication They make you feel like you re bothering them Fourteen people who contacted the Helpline to talk about an experience of the GP Out of Hours described an aspect of poor treatment they received at the service and half of these complaints related to negative staff attitudes. People said they had been made to feel like time wasters who had inconvenienced the doctor and misused the service. For example, two parents with sick children believed that the doctor on duty at the GP Out of Hours service immediately dismissed them as anxious parents, even though both children were later admitted to hospital for treatment. Only one person who contacted the Helpline made positive comments about the GP Out of Hours service. He described it as a useful service for older people in the locality, with staff who were helpful, kind and communicative. Case Study Six I left feeling that I was an inconvenience and a time waster On phoning the Out of Hours GP with a sudden pain in the kidney area, a patient was asked to visit the Out of Hours clinic at the local hospital: When I arrived I was the only patient there and was seen quickly (within ten minutes). However, the doctor appeared to be inconvenienced by seeing me. After treating me for a kidney infection he told me this was not an emergency, the service was only for emergencies and I should phone first, I cannot just drop in. I explained that I had phoned the Out of Hours doctor first. I left feeling that I was an inconvenience and a time waster Later at home her condition deteriorated and the pain increased dramatically, the patient phoned an ambulance and was taken to the Emergency Department where she was treated for kidney stones. I was very disappointed with the treatment I received from the [Out of Hours] doctor. He was rude and misdiagnosed me, which resulted in me requiring A&E attention 31

Accessibility The third most common aspect of the GP Out of Hours that questionnaire respondents with recent experience of the service would change is accessibility (81 people or 12%). People living in the Western Trust were most likely to suggest that the GP Out of Hours service should be made more accessible (27 people or 18%). More Out of Hours in local area to cut down on travel Have more out in rural areas In additional comments some people questioned the accessibility of their nearest GP Out of Hours service. They raised concerns about the distance they would have to travel when they needed urgent care and the transport costs involved in making that journey. This was considered all the more problematic to those people who commented that doctors rarely make home visits. 4 Cost of travel, can t afford taxi and Doctor never comes out Accessibility of GP Out of Hours facilities was also a concern for some of those who contacted the Helpline to talk about this service. A few people living in rural areas said that the GP Out of Hours Service was difficult to get to when they needed urgent care as it was so far from their home. One carer described a long taxi journey he made to the GP Out of Hours along with his wife, who was in considerable pain, at the cost of 40. He felt that provision should be made for people who do not drive or who live on their own. Getting the necessary expertise and treatment in an urgent care situation Almost two thirds of people (2,420 or 64%) said that the main reason they would not use GP Out of Hours services for urgent care was if the problem was considered too serious. In such a case they would go straight to the Emergency Department. Respondents were given a list of options to choose from and this 4 See Table 2 (page 9) for a breakdown of figures for contacts made to GP Out of Hours services January to December 2012, including the number of contacts that result in a home visit 32

was the most common answer by a considerable margin. The second most frequent response was related to this issue; 13% of respondents (531) felt they would get more expertise at the Emergency Department. If the problem was too serious I would go straight to the hospital More expertise at the Emergency Department 64% 13% Too long to wait 12% Poor previous experience 5% Don t know how to contact the facility 4% Wanted to see a consultant 2% Table 3: Reasons why people would NOT use GP Out of Hours services for urgent care In further comments many questionnaire respondents again wanted to make the point that their choice of service very much depended on the seriousness of the situation. In serious circumstances rapid access to a 24hr A&E is often essential Some were of the opinion that in a situation where someone required urgent care it was safer to go straight to the Emergency Department. Central to this decision was getting the most appropriate medical care as quickly as possible, which some felt was just not possible to achieve over the phone to an Out of Hours doctor. Feel safer at A&E rather than waiting on a phone call Difficulty of getting problem solved appropriately over the phone A few people went further to suggest that the GP Out of Hours service was not reliable in an emergency, as they did not have the necessary skills or expertise. For some, this comment was based on a previous poor experience of the service. 33

For a specialist condition you need expert advice Attended OOH with mum last year, told nothing was wrong and she was sent home. Mother admitted for emergency surgery the next day Four people who contacted the Helpline reported experiences where their condition was either misdiagnosed or undetected by the GP Out of Hours, which led them to seek further help from another service. All four described the doctor s behaviour on these occasions as rude, impatient or annoyed. In one particularly distressing case, a carer described how their relative tried to travel to the Out of Hours clinic but being in so much pain had to return home and wait for the doctor to make a home visit, was misdiagnosed and died a short time later. It is important to reassert that 63% of respondents (680) who had used a GP Out of Hours within the previous year rated the service either good or excellent. When asked to suggest reasons why they would not use the GP Out of Hours service for urgent care, many respondents took the opportunity to say they considered the service their first port of call for urgent care outside working hours. Contact GP Out of Hours for advice in the first instance Would go to Out of Hours before A&E Patients who talked to the Patient and Client Council on site visits to Out of Hours facilities across Northern Ireland were also positive about the service. They mentioned efficiency, helpful staff and shorter waiting times than the Emergency Department. 34

Case Study Seven - Our one crisis gave me two totally different experiences A carer explained how her husband s experience of two separate urgent care facilities left the couple with two completely different perspectives. When her husband suddenly became ill one evening - distressed, disorientated and confused his wife called the GP Out of Hours for advice. After a brief conversation, the doctor asked to speak to the patient and when the carer took the phone back the doctor was gone. Despite the fact it was the carer who phoned for advice, the doctor wrongly assumed the patient was lucid and coherent and offered the carer no instruction about how to assist her husband. At this stage I had no idea if the symptoms were life-threatening or not, I had no wish to waste anybody s time on something which would pass with time When his condition deteriorated later that night she took him to the Emergency Department, where she describes the care they received as outstanding. A junior doctor on duty saw my husband and myself enter the building and realised from a distance just how ill he was and had him brought through to triage immediately. After a speedy assessment and admission the situation was explained to me in great detail, I was reassured and given plenty of time to ask questions and was kept informed The patient was diagnosed with a brain haemorrhage and admitted to hospital. Our one crisis gave me 2 totally different experiences 35

To Summarise GP Out of Hours Service 92% of people said that they should not have to wait more than 1 hour for the GP Out of Hours to return their call, 63% would prefer a call back within 30 minutes; When people who had used the GP Out of Hours within the past year were asked to identify any aspect of the service they would change, 54% said faster call back times; There was evidence of good practice; 63% of questionnaire respondents who had used the GP Out of Hours within the past year rated it good or excellent ; Areas where people voiced concern - negative staff attitudes, lack of expertise and misdiagnosis, poor accessibility and lack of home visits by the doctor making the service problematic for people living alone or with no access to transport. 5.4 Minor Injuries Units Discussion about Minor Injuries Units focused on two main areas: Public awareness of Minor Injuries Units; Delivering a successful Minor Injuries Unit to patients. Public awareness of Minor Injuries Units When compared with the GP Out of Hours service, public awareness of Minor Injuries Units appears to be poor. More than a third of questionnaire respondents (1,013 or 35%) 5 said they did not know where their local Minor Injuries Unit was located. The percentage of respondents under 18 years of age who were unaware of their Minor Injuries Unit was even higher at 51% (122 people). It is perhaps telling that when asked where they would go if they needed urgent care as few as 4 people actually named the Minor Injuries Unit as a possible service (this was an open question in which respondents were able to answer freely). 5 Please note this number does not include respondents from the Belfast Health and Social Care Trust area as there are no stand-alone Minor Injuries Unit in Belfast. 36

It is important to note that there is currently no discrete Minor Injuries Unit in the Belfast Trust area; instead Minor Injuries Units are part of the hospital Emergency Department. This probably explains why half of respondents from the Belfast Trust area did not know the location of their local Minor Injuries Unit, (310 people or 51%). However, a large minority of respondents from the Western Trust were also unaware of the location of their Minor Injuries Unit, (246 people or 44%). People in the South Eastern and Southern Trust areas were most aware of their Minor Injuries Unit, 73% (446 people) and 70% (398 people) respectively knew of the service. Focus group participants showed an even greater lack of awareness of Minor Injuries Units. Around half of those who took part did not know where their local Minor Injuries Unit was located or guessed a location but were unsure. The focus groups discussed Minor Injuries Units in more detail. In general, participants agreed that a minor injury was something that was not critical, or non-lifethreatening, such as cuts, burns, sprains and fractures. Delivering urgent care in a Minor Injuries Unit When asked, only a small number of focus group participants, 23 out of 305 people, said they had actually used a Minor Injuries Unit for urgent care in the past. Most of these had positive experiences, the most frequent comment being that they were seen quickly and effectively, with very little waiting time for treatment. The triage system was also praised. A few people said they liked the fact that they were able to get diagnostics and treatment at one location. Efficient system at the time it wasn t at its peak, it was only started up yet now it s a very good system to have However, 8 people with first-hand experience of a Minor Injuries Unit had more negative comments to make. There were two common complaints about the service; first that it was limited in the kind of treatment it could provide and 37

therefore people were often sent on to the Emergency Department, and second that the nearest Minor Injuries Unit was too far to travel to for urgent care. All focus group participants, regardless of whether they had first-hand experience, were asked to suggest how a good Minor Injuries Unit should be delivered to patients. The suggestions made are listed in order of priority: More public awareness it was widely agreed that Minor Injuries Units are not well enough known. Information should be provided to make the public more aware of what a minor injury is, where it can be treated, where the service is located and when it is open. People suggested that community notice boards, GP surgeries, libraries, supermarkets, billboards and local newspapers should be used to promote the services that are available; Accessible a good Minor Injuries Unit should be easily accessible to the local population; After hours services extended opening hours, including weekends; Staff it should be adequately staffed with experienced clinicians; Located in already existing surgeries a Minor Injuries Unit should be based in a health centre or hospital or linked to GP surgeries/treatment rooms; Walk-in service or drop-in centre; Good access to other services from Minor Injuries Units if it is necessary to refer a patient on to another service, such as the Emergency Department, this should be straightforward and patients should not have to wait a second time; and Flexibility some groups want to see a more flexible service with doctors able to make home visits to treat minor injuries (this was particularly important to a focus group of older people and a learning disability group). Others felt there should be more provision for people in rural areas, such as mobile units or for the location of a Minor Injuries Unit in rural areas to be regularly rotated. 38

To Summarise Minor Injuries Units There appears to be a lack of awareness of Minor Injuries Units; People want to have a Minor Injuries Unit which is well publicised, accessible, located locally, open in evenings and at weekends, more wide-ranging in the types of service/treatment it offers and properly staffed with experienced clinicians. Additional comments from focus groups At each focus group, participants were given the opportunity to talk freely and to suggest ways in which services could improve for people in need of urgent health care. 1. A single telephone number for urgent care Focus group participants were asked for their thoughts on the proposal for a single telephone number for urgent care. This was recommended in the review of health of social care services, Transforming Your Care (HSCB: 2011). The majority of people supported the idea for a single telephone number for urgent care in theory, but voiced concerns about how the service would be delivered in reality. The proposal stimulated a lot of debate and further questioning. Most people agreed that how the phone line was organised and managed would be key to its success. The focus groups identified a number of qualifications or conditions on the delivery of this proposed urgent care telephone number. They are listed in order of priority: Phone line must be staffed by trained clinicians in order to assess effectively the urgency of the situation and to offer best advice to the patient; 39

It must be adequately staffed in terms of numbers so people in urgent need do not have to wait for their call to be answered; Human response, no automated phone systems. Operators should be pleasant, communicative, understanding and compassionate; Local service rather than regional, so they know what is available in area; The new telephone number must be well-publicised to avoid confusion; Freephone number; Operator should have access to medical records. The majority of people felt that, if it was delivered properly, a single telephone number for urgent care could cut down on the number of people going to their local GP surgery or Emergency Department; sometimes all that is needed is advice. Sure it s worth a try, the situation at the minute leaves a lot to be desired However, it is worth noting that a significant minority (about a quarter of all focus group participants) felt that the proposal was either unnecessary or a bad idea. The main reason given was that the 999 number was very ingrained in popular culture and a new number would be both inefficient and confusing. What is more, for older people or those with communication problems and difficulties using the phone it could present yet another barrier to accessing urgent care. Some people worried that the phone service would struggle with demand and consequently the line would be constantly busy. A few people questioned where the money to fund this proposal would come from, and whether it would be better spent staffing more out-of-hours facilities for people in need of urgent care. 2. More frontline staff people want to see more frontline staff at urgent care facilities to reduce waiting times and to allow staff more time with each patient; 3. Better communication people talked about poor communication in all areas of care; good communication was considered vital in an urgent care situation; 40

4. Emergency Department must change people want to see fast and effective treatment times, a more efficient triage system and better prioritisation of patients at hospital Emergency Departments; 5. Information people want more information about urgent care services available in each area and how to access them in an appropriate way; 6. More services for minor injury and after-hours care alternatives should be expanded to relieve the pressure on hospital Emergency Departments; suggestions included walk-in centres and extended out of hours services; 7. Access to medical records - all facilities should have access to medical records; 8. Accessibility the distance people have to travel to attend urgent care facilities should be considered and everyone should have reasonable access to services; 9. Better availability of GP services it should be less difficult to see or speak to your GP when in need of urgent care; suggestions included extended opening hours and daily open surgeries for urgent appointments. 41

6.0 Conclusion There is evidence in this report of positive experiences of urgent care, however, people reported that urgent care services can be improved in a number of ways. People want excellent care from compassionate staff. People would like to see a reduction in waiting time to see a doctor or to receive treatment at the Emergency Department. Many people expressed concern about the safety, cleanliness and comfort of the environment in which they have to wait for long periods of time. Waiting time for a call back from the GP Out of Hours was also identified as a concern with this service. The report finds that 92% of people believe that they should not have to wait more than one hour for the GP Out of Hours to return your call; 63% would prefer a call back within 30 minutes. When questionnaire respondents were asked what they would change about the GP Out of Hours service, faster call back times was the most common response by a considerable margin. Communication is also a central issue. People would appreciate being kept better informed particularly at the Emergency Department. Negative staff attitudes which include experiences of poor communication, rude and insensitive staff, lack of dignity and respect, and being made to feel like an inconvenience or time waster were key concerns. Good communication from compassionate staff was considered vital in an urgent care situation. Accessibility is also a priority for people, particularly in rural areas and for people who live alone with no access to personal transport. This was considered all the more problematic due to the lack of home visits made by GP Out of Hours. People also thought that Minor Injuries Units should be more accessible by extending opening hours and having a unit in every locality. 42

The Emergency Department remains the first choice of service for the majority of people in need of urgent care. However when focus group participants were asked to identify ways to improve urgent care services, most of their answers related to relieving the pressure on and usage of Emergency Departments. Expanding alternative services such as GP Out of Hours, Minor Injuries Units and GP services, and informing the public about the range of services that are available and how to access them appropriately was seen as central to achieving this. The findings of this report point to a lack of public awareness about the Minor Injuries Units, with almost a third of questionnaire respondents unaware of the location of this facility. Many people also said that they experience difficulty getting advice or an appointment with their GP at short notice when they require urgent care. There appears to be no consistency for patients in this area, but it was frequently suggested that daily open surgeries and evening hours at GP practices may encourage more people to access this service instead of the Emergency Department. Finally, it is evident from this report that more clarity is needed about the definition of urgent care. Throughout the project, when asked about their choice of service when in need of urgent care, people were often keen to stress that their decision very much depended on the seriousness of the illness or injury. Some people stated that they were unsure what was meant by urgent care or questioned how urgent care differed from emergency care. As focus group participants suggested, information and education about how to use urgent care services during a period of change for health and social care services in Northern Ireland is essential. 43

7.0 Recommendations Based on the evidence collected from patients and the public the Patient and Client Council makes the following recommendations: 1. The Health and Social Care Board should further develop work that has already commenced on Emergency Departments and GP Out of Hours services. This would include a review of the whole system of access to and discharge from emergency and urgent care services, including: GP services; Minor Injuries Units; advice and information; as well as good communication with patients and staff training to improve the overall patient experience; 2. The Health and Social Care Board and the Health and Social Care Trusts should continue to address the issue of lengthy waiting times for care and treatment in urgent care settings; this is one of the biggest areas of concern identified in this study; 3. The Health and Social Care Board should develop the range of treatments available in Minor Injury Units and GP Out of Hours; 4. The Health and Social Care Board and Public Health Agency should work to raise awareness among the public on how to access urgent care services, particularly Minor Injuries Units; 5. The Health and Social Care Board should further explore options which may reduce pressure on existing urgent care services, such as a Patient Information and Advice Service ; 6. Health and Social Care Trusts should ensure that all stages of the patient journey are underpinned by the five Patient and Client Experience standards Respect; Attitude; Behaviour; Communication; Privacy and Dignity Dignity (Improving the patient & client experience NIPEC in partnership with the RCN, for DHSSPS, 2008); 44

7. The Health and Social Care Board should ensure that patients are advised of the length of time they can expect to wait for a ring back call which should be within 30 minutes; 8. The Health and Social Care Board should ensure consistent standards for access to GP services in an urgent care situation. In particular: a. opening hours; b. availability of an urgent appointment; c. ring back services; and d. evening and weekend surgeries; 9. The Health and Social Care Trusts should provide a safe environment within Emergency Departments; 10. The Northern Ireland Electronic Care Record should be implemented as soon as possible so that people do not have to keep repeating their medical history. 45

Bibliography Appleby J. (2005) Independent review of health and social service care in Northern Ireland. Belfast: DHSSPS(Accessed on 28 November 2012) http://www.dhsspsni.gov.uk/appleby-report.pdf Black, L. (2012) Emergency Care (A&E). Northern Ireland Assembly. Research Paper 88/12. Belfast: Northern Ireland Assembly (Accessed 28 November 2012) http://www.niassembly.gov.uk/documents/raise/publications/2012/health/8812.p df Department of Health, Social Services and Public Safety (2005) Caring for people beyond tomorrow: a strategic framework for the development of primary health and social care for individuals, families and communities in Northern Ireland. Belfast: DHSSPS (Accessed on 28 November 2012) http://www.dhsspsni.gov.uk/primarycare05.pdf Department of Health and Social Services and Public Safety (2002) Developing Better Services. Belfast: DHSSPS (Accessed on 28 November 2012) http://www.setrust.hscni.net/involving/involving/developing%20better%20services.pdf Hallaran, F. and Robertson-Steel, I. (2008) A Guide to Good Practice: Unscheduled and Emergency Care Services. Cardiff: National Leadership and Innovation Agency for Healthcare (Accessed on 27 November 2012) http://www.wales.nhs.uk/sitesplus/documents/829/a%20guide%20to%20good%2 0Practice%20-20Unscheduled%20and%20Emergency%20Care%20Services.PDF NIAO (2008) Transforming emergency care in Northern Ireland. Report by the Comptroller & Auditor General. Belfast: NIAO NIPEC in partnership with the RCN (2008) Improving the patient & client experience. Belfast: DHSSPS. PwC (2007) DHSSPS Audit of Accident and Emergency Activity. Belfast: DHSSPS. (Accessed on 28 November 2012) www.dhsspsni.gov.uk/a_e-reportvolume-1.pdf p.6 Poots, E. (2012) http://www.dhsspsni.gov.uk/ec1_sept_12.pdf 46

Appendix 1 Service Specification for the provision of Urgent Primary Care Out-of-Hours in Northern Ireland The following extract is from the Service Specification for the Out of Hours service and details the standards for patient access to the service: Access 1. A single telephone number with sufficient telephone lines and call handlers available to answer all calls within 60 seconds after the end of any introductory message which should be no more than 30 seconds long with no more than 5% of calls abandoned. 2. Out-of-Hours services are available and accessible to patients and their representatives during the Out-of-Hours period. and any additional times agreed with the commissioner. 3. Patient contacts (either by telephone or walk-in) are assessed and responded to, based on clinical need and professional judgement with robust mechanisms to identify emergency calls and prioritise urgent contacts. Calls will be categorised on initial contact and must then be disposed of as follows: Triage: - Immediately life-threatening: these calls should be passed to 999 ambulance within 3 minutes. - Urgent: appointment given at initial contact or triage within 20 minutes by a health professional. - All other calls: triage within 1 hour by a health professional. Face-to-face consultation: The health professional will determine if a person needs a face-to-face consultation and the appropriate timescales. A face-to-face consultation, if required, usually takes place at an Out-of-Hours centre or occasionally at a patient s home or place of residence. - Urgent: face-to-face consultation within 1 hour if required after completion of triage. - Less urgent: face-to-face consultation within 2 hours if required after completion of triage. - Routine: face-to-face consultation within 6 hours if clinically appropriate after completion of triage. - Repeat callers: health professionals should ensure they are aware of and have read the notes of any previous contacts (with the respective Out-of-Hours Provider) concerning that patient particularly those over the 110 hours preceding the call. The health professional should ascertain the reason why the person phoned back. If the person is not seen there should be clear documentation of the reasons why the person is not seen. 47

4. The patient only needs to make one telephone call to the Out-of-Hours service and if a base face-to-face visit is required, should be able to attend the Out-of- Hours centre that is operational nearest to them if they so choose. Ideally they should be given an indication of the time they will be seen. 5. Patients are informed of approximate timescales at all stages in the patient journey and always contacted if an agreed home visit or appointment time is delayed. 6. Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Appropriate provision must be made for patients with impaired hearing or impaired sight to contact and use the service. 7. Patients will be issued with a prescription, if required, when a community pharmacy is accessible or the condition does not require immediate treatment. Out-of-Hours centres are expected to hold a stock of commonly required medicines for immediate supply should this be required. Out-of-Hours providers should generally not deal with repeat prescriptions unless in exceptional circumstances. Source: Service Specification for the provision of Urgent Primary Care Out-of- Hours in Northern Ireland. pp.11-12. 48

Appendix 2 Questionnaire Where do you go for Urgent Care? We want to learn about the services you would use in the case of a medical emergency (Urgent Care). Q1 Where would you go if you or someone you care for needed urgent care? Q2 Do you know where your local Minor Injuries Unit is? Yes No Not Sure Q3 Are you aware of how to contact the GP out of hours service? Yes No Q4 How long do you think is reasonable to wait for the GP out of hours service to return your call? Other: Under 30 Mins 30 Mins 1 Hour 1 2 Hours Q5 Have you, or someone you care for, used the GP out of hours service in the past year? Yes (Continue to Q6) No (Skip to Q8) Q6 How would you rate your overall experience of the GP out of hours 49

service? Poor Fair Average Good Excellent Q7 Is there anything about GP out of hours service you would change? Q8 Please indicate below any reason why you would NOT use GP out of hours services for Urgent Care (tick any that apply): Too long to wait Wanted to see a consultant Poor previous experience Other: Don t know how to contact facility If problem was too serious, would go straight to the hospital More expertise at A&E Department Q9 Would you like to be involved in a focus group around Urgent Care? Yes No Your Name: If YES, please provide: Your Address: Telephone: Email Address: 50

Q10 What is your gender? Male Female Q11 What are the first four digits of your postcode? (e.g. BT52) Q12 Which age range do you fall under? Under 18 18-35 36-49 50-65 Over 65 Q13 Which Health and Social Care Trust area do you live under? Northern Belfast South Eastern Southern Western Thank you for completing this questionnaire, please return in the FREEPOST envelope provided. Telephone 0800 917 0222 www.patientclientcouncil.hscni.net 51

Appendix 3 List of Focus Groups Lighthouse Hostel, Ballymena NHS Retirement Fellowship, Ballymena Rural Community Network, Cookstown Ballymena Inter-Ethnic Forum Rutledge Vocational Training Group Limavady Belcoo Day Care Centre, Fermanagh Edenballymore Sure Start, Creggan, Derry Newtownbutler Day Care Centre NHS Retirement Fellowship, Bangor Action Mental Health, Newtownards Atlas Women s Group, Lisburn HSC Graduate Students Lung Cancer Support Group, Belfast Older People s Group, St Mark s Church, Belfast Multiple Sclerosis Support Group, Belfast Chest, Heart and Stroke Support Group, Belfast Wade Training, Lurgan Newry and Mourne Deaf Club Support Group Learning Disability Group, Orchard Leisure Centre, Armagh Men s Mental Health Support Group, Dungannon TILII, Belfast Action Mental Health, Belfast Learning Disability Group, Banbridge Social Education Centre 52

Learning Disability Group, Cookstown Adult Centre TILII, Lisburn Ballymena Beacon Centre Focus Groups questionnaire participants Within the focus group questionnaire people had the opportunity to provide their personal contact details to take part in focus group work. Personal and Public Involvement Officers made the necessary arrangements in setting up the following engagements: Derg Valley Day Care Centre, Castlederg Six Mile Leisure Centre, Ballyclare Joey Dunlop Centre, Ballymoney Gortalowry House, Cookstown Omagh Library Skettrick House, Newtownards Belfast PCC Office 53

Appendix 4 List of On Site Visits Emergency Departments Antrim Area Hospital Accident and Emergency Department Altnagelvin Hospital Accident and Emergency Department Causeway Hospital Accident and Emergency Department Craigavon Area Hospital Emergency Department Downe Hospital Emergency Department Mater Hospital Emergency Department Royal Victoria Hospital Emergency Department Ulster Hospital Emergency Department Out of Hours Facilities Craigavon Area Hospital Out of Hours Dalriada Urgent Care Ballymena Downedoc Downe Hospital Knockbreda Out of Hours Lagandoc Lagan Valley Hospital Mater Hospital Out of Hours Moneymore Out of Hours Facility Strabane Health Centre Out of Hours South Tyrone Hospital, Dungannon Minor Injuries Units Ards Community Hospital Minor Injuries Unit Armagh Community Hospital - Minor Injuries Unit Tyrone County Hospital, Omagh - Minor Injuries Unit Whiteabbey Hospital Minor Injuries Unit 54

55 ISB NUMBER 978-0-9567172-9-0