Urgent and Emergency Care Strategy 2013/ /17. Delivering High Quality Urgent and Emergency Care

Urgent and Emergency Care Strategy 2013/14 2016/17 Delivering High Quality Urgent and Emergency Care Working together to deliver sustainable high quality, safe, efficient and patient centred Urgent and Emergency Care for all the people in Croydon Integrated UECPB Strategy: Version 12 Page 1 of 113

Date Version Notes 15/07/2013 Version 10 Major refresh for Urgent and Emergency pathways board 19/07/2013 Version 11 Addition of standards, tightening of direction Draft (Circulated to U&EC Board and SMT) Draft 22/07/2013 Version 11.2 Draft (To be circulated to UECP Board and SMT and Clinical Network Leads for comments back 8 th August) 13/09/2013 Version 12 Incorporated comments from SMT/UECPB/Clinical Leads Integrated UECPB Strategy: Version 12 Page 2 of 113

Contents 1. National Context... 5 1.1. Local Context... 6 1.2. Our Population Challenges... 6 1.3. Our Service Challenges... 12 1.4. Our priorities to improve our service challenges and meet the needs of our Population.. 12 2. Overall Strategic Aim... 13 2.1. The overall Urgent and Emergency Care Strategy... 14 3. Definition of Urgent and Emergency Care... 15 3.1. Hyper-Specialist Emergency Care... 15 3.2. Emergency Care... 15 3.3. Urgent Care... 15 4. Current Landscape... 16 4.1. Level 5 Highly Specialised Services... 18 4.1.1. London Ambulance Service Conveyance to sites... 18 4.2. Level 4 Emergency Departments... 19 4.2.1. ED Admission and Non-Admission Attendances... 20 4.2.2. ED Attendances by HRG CHS 2012/13... 22 4.2.3. London Ambulance Service Conveyance to sites... 22 4.3. Level 3 24 hour Urgent Care Centres attached to ED.... 23 4.3.1. Virgin Urgent Care attendances By Days... 23 4.3.2. Virgin Urgent Care attendances - By Hours... 24 4.3.3. 2012/13 Data Virgin Care By Network... 24 4.3.4. London Ambulance Service Conveyance to sites... 25 4.3.5. Ambulatory Care Pathways... 25 4.4. Level 2a - Community (non-ambulatory patients)... 26 4.5. Level 2b - Primary and Community (ambulatory patients)... 27 4.5.1. Minor Injuries at Parkway (MIA) and Purley (PUC)... 27 4.5.2. Attendances by Day of the Week... 27 4.5.3. Top Clinical Presentations... 28 4.5.4. London Ambulance Service Conveyance to sites... 29 4.6. GP-Led Health Centre at Edridge Road with Walk In... 29 4.6.1. Registered Patients... 30 4.6.2. Walk-in Patients... 31 4.7. GP Practices... 31 4.7.1. GP Out-of-Hours... 32 4.7.2. 111 Directed Activity... 32 4.8. Pharmacies... 33 4.9. Level 1 Self Care... 34 Integrated UECPB Strategy: Version 12 Page 3 of 113

5. 4.9.1. 111 Current Performance... 34 4.9.2. 111 In-hours / Out-of-Hours... 36 4.9.3. Percentage of 111 calls referred to LAS (including treat and transfer + 999 emergency Red ambulances)... 37 Overall Activity... 38 5.1. Hours of the Day... 39 5.2. Days of the Week... 40 5.3. Out-of-Hours Total Activity... 44 6. Improving Our Services... 45 6.1. Whole System Pathway... 46 6.2. Elderly Frail Pathway... 47 6.3. Children s Pathway... 48 6.4. Whole System Service Provision... 49 6.5. Improving Quality... 50 7. Appendices... 54 7.1. Appendix A1: Urgent and Emergency Care Pathways Board Governance Structure... 54 7.2. Appendix A2: Urgent and Emergency Care Pathways Board Governance Membership 55 7.3. Appendix B1: NHS London Adult Emergency Care Commissioning Standards... 58 7.4. Appendix B2: London Urgent Care Operational Standards... 61 7.5. Appendix B3: Emergency Department Clinical Quality Indicators... 63 7.6. Appendix B4: National Quality Requirements OOH... 64 7.7. Appendix B5: Social Care Performance Indicators - Hospital Discharge... 65 7.8. Appendix B6: Quality and Performance Metric... 66 7.9. Appendix C: Map of Top 6 ED s by attendances... 70 7.10. Appendix D: Map of UCC s, MIU s and Walk in Centre... 71 7.11. Appendix E: Ambulatory Care Pathways... 72 7.12. Appendix F1: Virgin Care Urgent Care Centre Alternative Care Pathway... 73 7.13. Appendix F2: Purley War Memorial Hospital Urgent Care Centre Pathway... 75 7.14. Appendix F3: Parkway Emergency Minor Treatment Centre Care Pathway... 77 7.15. Appendix F4: Edridge Rd Community Health Centre Care Pathway... 78 7.16. Appendix G: GP Map... 80 7.17. Appendix H: Map of Croydon Pharmacies... 81 7.18. Appendix H1: Pharmacy First - Ailments included in the scheme:... 82 7.19. Appendix I: Draft Urgent and Emergency Care Action Plan... 83 7.20. Appendix J: GP and Pharmacy Opening Hours... 95 Integrated UECPB Strategy: Version 12 Page 4 of 113

1. National Context NHS England is leading on the development of a national framework for Urgent and Emergency Care which will be available for clinical commissioning groups in 2015/16. It is proposed that the Framework will help clinical commissioning groups commission consistent, high quality urgent and emergency care services across the country and within the resources available. To develop the Framework, NHS England is leading on the Urgent and Emergency Care Review (High quality care for all, now and for future generations: transforming urgent and emergency care services in England). In June 2013 the review has identified four emerging principles for an improved urgent and emergency care system in England, these are: 1. Provision of consistently high quality and safe care, across all seven days of the week 2. Simple and guides good choices by patients and clinicians 3. Provision of the right care in the right place, by those with the right skills, the first time 4. Efficiency in the delivery of care and services From these principles 12 system design objectives have also been outlined (table 1 below). These are the suggested outcomes which should be delivered by any future urgent and emergency care system: No Design Objectives 1 Make it simpler for me or my family/carer to access and navigate urgent and emergency care services and advice. 2 Increase my or my family/carer s awareness of early detection and options for self-care and support me to manage my acute or long term physical or mental condition. 3 Increase my or my family/carer s awareness of and publicise the benefits of phone before you go. 4 If my need is urgent, provide me with guaranteed same day access to a primary care team that is integrated with my GP practice and my hospital specialist team. 5 Improve my care, experience and outcome by ensuring early senior clinical input in the urgent and emergency care pathway. 6 Wherever appropriate, manage me where I present (including at home and over the telephone). 7 If It's not appropriate to manage me where I present (including at home and over the telephone), take or direct me to a place of definitive treatment within a safe amount of time; ensure I have rapid access to a highly specialist centre if needed. 8 Ensure all urgent and emergency care facilities are capable of transferring me urgently and that the mode of transport is capable, appropriate and authorised. Integrated UECPB Strategy: Version 12 Page 5 of 113

No Design Objectives 9 Information, critical for my care, is available to all those treating me. 10 Where I need wider support for my mental, physical and social needs ensure it is available. 11 Each of my clinical experiences should be part of a programme to develop and train the clinical staff and ensure their competence and the future quality of the service is being constantly developed. 12 The quality of my care should be measured in a way that reflects the urgency and complexity of my illness. Table 1: System Design Objectives 1.1. Local Context The Urgent and Emergency Care Strategy represents a whole systems strategy that has been developed with members of the Urgent and Emergency Care Pathways Board. The Board has recently refreshed its Terms of Reference and Membership so that it has new senior representation from all organisations. (See Appendix A2 for membership and Appendix A1 for Governance Structure). The Urgent and Emergency Care Pathways Board recognises that demand for Urgent and Emergency care services are predictable, based on activity trends and demographic changes. Hot spots in demand for services at the main acute service provider Croydon University Hospital and, in particular, in the Emergency Department is a symptom of the system not managing demand in other service areas, example community health services, primary care and community social care. 1.2. Our Population Challenges Population as at March 2011 was 363,400, making Croydon the largest Local Authority in London. Croydon's population has grown at a faster rate than the rest of England. Over the last ten years Croydon has seen an increase of 28,300 people since the 2001 census (335,100) which represents a 8.4% increase, 1.3 percentage points higher than the national average. Croydon has an ethnically diverse population with a high proportion of both young and elderly residents; it faces a significant future challenge as both the very young and the very old require more care. Croydon has the 5th highest proportion of children aged 0-19 years (26.9%) across all the London boroughs. It is anticipated that the number of births will rise by around 10% over the next 5 years. Integrated UECPB Strategy: Version 12 Page 6 of 113

Older people aged 65 years and over make up 13.8% of the Croydon population and residents aged 85 years and over make up 1.9%. These proportions are projected to increase to 16.27% and 2.91% respectively by 2030. Both the very young and the very old need more care. The analysis in Figures 1 and 2 show the projected attendances for future years based on the assumption that the configuration of current services and rate of use of services by age group/ward remains the same as in 2012/13. To cope with the projected demand our Urgent and Emergency care services needs to include different options of service delivery including an emphasis where appropriate for people to manage their own care. Figures 1 and 2 show a higher projected increase in attendances at CUH ED than for other urgent care services over the next 10 years. This is owing to: Higher population growth is expected in Fairfield ward than other wards and residents in Fairfield ward are more likely to use Croydon ED. Users of alternative urgent care services to CUH ED such as urgent care centres have a younger age profile than users of CUH ED. The GLA projection shows growth in the numbers of older people living in Croydon which will have a greater impact on CUH ED than other urgent care services. Figure 1: Projeced number of attendances at Urgent Care Services Integrated UECPB Strategy: Version 12 Page 7 of 113

Figure 2: Attendances at Urgent care Services in 2012/13 by age group Long Term Condition (LTC) is a major cause of ill health and in presenting cause for emergency attendances and admissions. Figure 3 shows the projected number of long term conditions in Croydon s population, 2012-2021 Integrated UECPB Strategy: Version 12 Page 8 of 113

The projections in Figure 3,4 and 5 show projected urgent care activity to 2022/23, using 2012/13 data as a baseline, based on the underlying projected changes in the age structure and deprivation levels in Croydon s population. The projections use latest GLA population projections and trends in the Index of Multiple Deprivation to project urgent care activity taking account of age and deprivation changes in Croydon s population. The assumptions made in creating these projections should be noted when interpreting them: The configuration of urgent care services is assumed to remain the same as 2012/13. The level of demand for urgent care services is assumed to vary only with regard to age and deprivation and to remain at 2012/13 levels with regard to any other factors. At lower super output area level, Croydon is assumed to continue to become more deprived or more affluent in comparison with the rest of England, at the same rate as between 2001 and 2008. The low scenario uses projections that are linked to housing development trajectories from the Strategic Housing Land Availability Assessment (SHLAA). The high scenario uses a trend-based projection that does not take dwellings into account. Figure 3 shows a higher projected increase in attendances at CUH ED than for other urgent care services over the next 10 years based on the high scenario. Figure 3: Projection of Urgent Care Activity by type or Urgent Care Provider Integrated UECPB Strategy: Version 12 Page 9 of 113

Figure 4 shows that East Croydon and Mayday have the highest projections of Urgent care activity. Figure 4: Projection of Urgent Care Activity by GP Network Figure 5 shows that 25 34 years olds have the highest projections of Urgent care activity. Figure 5: Projection of Urgent Care Activity by age group Integrated UECPB Strategy: Version 12 Page 10 of 113

Number Figure 6 shows the projected number of long term conditions in Croydon s population, 2012-2021 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Year Chronic kidney disease (total) Chronic kidney disease (diagnosed) COPD (total) COPD (diagnosed) Dementia (total) Dementia (diagnosed) Diabetes (total) Diabetes (diagnosed) Stroke/TIA (total) Stroke/TIA (diagnosed) Figure 6: Source: Projections based on data from Croydon general practices Figure 7 shows numbers of long term conditions by age and sex, showing that with older age the number of conditions a person has increases. Figure 7: Number of long term conditions by age and sex Integrated UECPB Strategy: Version 12 Page 11 of 113

Croydon has a number of service challenges that need addressing. 1.3. Our Service Challenges In delivering high quality Urgent and Emergency Care for all, we know that we face the following challenges: Bottom 10% of lowest satisfaction rates to see a GP quickly Bottom percentile for patient experience at Croydon University Hospital for last 3 years Rates for emergency admissions are higher when comparing Croydon with London Boroughs. Croydon is close to the England average and the rate is increasing faster than other local authorities. Rates of emergency readmissions to hospital within 28 days of discharge is significantly higher in Croydon than the national average Variable performance in meeting the Emergency Department, 4 hour waiting target Public are unclear about which services to best access and when Public reliance on services, when self-care would have been more appropriate Difficulties presented by the current Emergency Department and Urgent Care Department infrastructure for example, original capacity not designed for current demand. integrated quality and performance metrics have been developed which will capture performance and quality standards and also local priority areas that we are committed to meeting for London Commissioning, London Urgent Care Operating Standards, Clinical Quality Indicators, Social Care and Out of Hours standards (see Appendix B). The metrics will be presented to the Urgent and Emergency Care Pathways Board monthly where members will recommend immediate actions for improvement on negative downward trends. 1.4. Our priorities to improve our service challenges and meet the needs of our Population The Urgent and Emergency Care Pathways Board have a whole systems agreed action plan to improve our service challenges and meet the needs of our population. If we keep services the same we will not cope with projected demand. The introduction of ambulatory care pathways offer people the options and support to manage their own Long Term Condition other than an ED or Urgent Care Centre attendance. Our 5 key themes for our recovery and improvement plan are outlined in Figure 8 with the top service actions to: Improve self-care. Improve system access. Improve care and flow in hospital. Integrated UECPB Strategy: Version 12 Page 12 of 113

Appropriate flow on discharge and improving care options in the community. Improving care/clarifying options when returning to the community Figure 8: Top 5 Priorities 2. Overall Strategic Aim The overall aim of the Urgent and Emergency Care Strategy is to deliver high quality in the right place, right time, first time and to work to manage demand and meet this as required. To do this we understand that we need to emphasise a shift in current service use with more urgent care delivered at Level 1 and 2 and 3. Our integrated action plan (Appendix I works towards this shift and will be regularly evaluated to ensure that the increase in service delivery at level 1, 2 and 3 impacts positively on acute hospital demand. Our Prevention of Ill Health, Self-Care and Shared Decision Making Strategy and Primary and Community Strategy will help to facilitate this shift. Integrated UECPB Strategy: Version 12 Page 13 of 113

2.1. The overall Urgent and Emergency Care Strategy Figure 9: The Overall Urgent and Emergency Care Strategy Integrated UECPB Strategy: Version 12 Page 14 of 113

3. Definition of Urgent and Emergency Care 3.1. Hyper-Specialist Emergency Care There are three main Specialist Units that Croydon residents use if they suffer a stroke or a complex major trauma. These units are located at King s Hospital, St Georges and South London Trust and patients may be stabilised there before transfer on to their local hospital for further treatment or rehabilitation. If a Croydon resident suffers a severe rapid onset mental health condition, the main specialist unit is provided by The South London and Maudsley Mental Health Trust (SLAM). 3.2. Emergency Care Croydon residents use a range of local Emergency Departments for life-threatening conditions / illness or injury. Emergency Departments assess and treat patients with serious injuries or illnesses such as: loss of consciousness acute confused state and fits that are not stopping persistent, severe chest pain breathing difficulties severe bleeding that cannot be stopped The predominant Emergency Department used by Croydon residents is Croydon Health Services (CUH) with King s Hospital, St Georges and Epsom and St Helier Hospitals also used. 3.3. Urgent Care Urgent Care is defined as the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly. In practice this will mean that people, whatever their urgent need, whatever the location, get the best care from the right person, in the right place, at the right time, first time. The 111 service gives access to reassurance and directs to services that can help these include urgent care centre at the front end of Croydon Health Services (CUH), services providing out of hours care, GP Practices same day appointments, Pharmacies (including minor ailments services), a walk in centre at Edridge Road, a minor injury unit at Parkway New Addington and an urgent treatment centre at Purley. In addition there is also a single point of access for social and community services for people who are unable to leave their homes and which directs services needed for example rapid community response. Integrated UECPB Strategy: Version 12 Page 15 of 113

4. Current Landscape In practice, urgent care services across Croydon are fragmented providing a confusing picture for Croydon residents on opening times, who the service is for and what the services provide. For the most part, the default position is that Croydon residents use services located at Croydon Health Services (CHS) e.g. Emergency Department and Virgin Care, Urgent Care Centre, Edridge Road Walk-in Centre and GP Out-of-Hours where they know that they will be seen and treated. Evidence shows that the London Ambulance Service disposal of a high proportion of patients to CHS either to the Emergency Department or the Urgent Care Centre. Figure 10: Current Landscape Integrated UECPB Strategy: Version 12 Page 16 of 113

Figure 11: Current Landscape Integrated UECPB Strategy: Version 12 Page 17 of 113

4.1. Level 5 Highly Specialised Services There are 3 main Specialist Units that Croydon residents use if they suffer a stroke or a complex major trauma, these units are Kings Hospital, St Georges and South London Trust and patients may be stabilised there before transfer on their local hospital. If a Croydon resident suffers a severe onset mental health condition, the main specialist unit is South Maudsley Mental Health Trust (SLAM). (Awaiting validated data on use by Croydon residents of Hyper-acute Stroke Units and major trauma). 4.1.1. London Ambulance Service Conveyance to sites We know from 2012/13 London Ambulance Conveyance figures that 796 people were conveyed with the following conditions: Catheter Laboratory - 203 Major Trauma - 161 Hyperacute Stroke Unit 432 Total - 796 Figure 12 shows the breakdown of where Croydon residents were conveyed to. Figure 12: Level 5 LAS Conveyance Integrated E&UC Strategy: Version 12 Page 18 of 113

4.2. Level 4 Emergency Departments Figure 13 shows the total number of Croydon residents All ED attendances All Trusts 2010/11, 2011/12, 2012/13 and 2013/14 (May YTD) and for CHS ED for the same years (Based on SUS data). Appendix C shows the location of Level 4 Services. Figure 13: Level 4 All ED Attendances Figure 14 shows the annual costs for CHS and surrounding areas. Figure 15 shows the number of ED attendances by age group. 2010/11 2011/12 2012/13 2013/14 YTD MAY Total ED Costs All Trusts 12,507,818 14,214,272 11,855,207 2,043,767 Croydon Health Services ED Cost 10,594,447 10,840,724 8,005,127 1,408,744 Figure 14: ED Costs 2012/13 Attendances (Admitted) Attendances (Not Admitted) Total Admitted % 0-18 4,378 19,851 24,229 18 19-64 13,077 45,794 58,871 22 65-74 3,377 4,869 8,246 41 75-84 4,544 3,764 8,307 55 85+ 3,842 1,792 5,635 68 Total 29,218 76,070 105,288 28 Figure 15: ED Attendances by Age Integrated E&UC Strategy: Version 12 Page 19 of 113

4.2.1. ED Admission and Non-Admission Attendances Figure 16 shows for 2010/11, 2011/12, 2012/13 and 2013/14 May YTD (Based on SUS data) the proportion of attendances admitted and not admitted across All ED All Trusts. Figure 16: ED Admission and Non Admission Attendances Integrated UECPB Strategy: Version 12 Page 20 of 113

Figure 17 and 18 show the total activity by network to all ED - it shows that Purley and New Addington / Selsdon have the highest rates per 1000. Figure 17: ED Attendances by Network ED Attendances - All Ages as per 1000 of network population MDY THN WSS NAS PRY ECR ED all Attendances 252 253 263 339 273 267 Figure 18: ED attendances by Network Key: MDY: Mayday, THN: Thornton Heath, WSS: Woodside and Shirley, NAS: New Addington and Selsdon, PRY: Purley, ECR: East Croydon Integrated UECPB Strategy: Version 12 Page 21 of 113

4.2.2. ED Attendances by HRG CHS 2012/13 Figure 19: ED Attendances by HRG 4.2.3. London Ambulance Service Conveyance to sites Figure 20: Level 4 LAS Conveyance Integrated UECPB Strategy: Version 12 Page 22 of 113

4.3. Level 3 24 hour Urgent Care Centres attached to ED. Appendix D shows a map of the locations of Level 3 and Level 2 services. 4.3.1. Virgin Urgent Care attendances By Days Total Attendances: 41,072 Figure 21: Virgin Urgent Care Attendances By Days Integrated UECPB Strategy: Version 12 Page 23 of 113

4.3.2. Virgin Urgent Care attendances - By Hours Croydon CCG - 2012/13 All Days Hours Attended (Based on SUS data) Figure 22: Virgin Urgent Care Attendances By Hours 4.3.3. 2012/13 Data Virgin Care By Network Total Attendances to Urgent Care Centre by Croydon residents 2012/13-38,539 (Please note that the difference in values is attributable to attendances not being assigned to a Network) Figure 23: Virgin Urgent Care Attendances by Network Integrated UECPB Strategy: Version 12 Page 24 of 113

4.3.4. London Ambulance Service Conveyance to sites Figure 24 shows the number of patients taken to a Level 3 Co-located Urgent Care Centre. The highest numbers are taken to Croydon University Virgin UCC followed by Princess Royal. Figure 24: Level 3 UCC LAS Conveyance 4.3.5. Ambulatory Care Pathways Ambulatory Care Pathways have been developed and people attending the ED and the Urgent Care Centre at CHS will be directed to these pathways as appropriate (see Appendix E) Integrated UECPB Strategy: Version 12 Page 25 of 113

4.4. Level 2a - Community (non-ambulatory patients) The main focus of the Primary and Community Strategy is to provide care closer to home and to avoid (where clinically safe to do so), people attending ED and subsequently being admitted as an emergency. Services in the community are planned to include Rapid Response Teams to people at home or in Care Homes (see Figure 26 showing higher levels of non-elective admissions from Purley and East Croydon network and Case Management of people with complex needs including people with unstable long term conditions). Members of the social and health infrastructure will be able to access these services through a single point of assessment (SPA). Figure 25: Level 2a Emergency Admissions Usual Place of Residence Usual place of residence all ages as per 1000 of network population MDY THN WSS NAS PRY ECR Care Home Other Place of Residence Figure 26: Usual Place of Residence 3 4 4 3 115 110 110 107 87 120 Key: MDY: Mayday, THN: Thornton Heath, WSS: Woodside and Shirley, NAS: New Addington and Selsdon, PRY: Purley, ECR: East Croydon 7 6 Integrated UECPB Strategy: Version 12 Page 26 of 113

4.5. Level 2b - Primary and Community (ambulatory patients) 4.5.1. Minor Injuries at Parkway (MIA) and Purley (PUC) Table 2 shows activity for 2011/12 and 2012/13 and attendances to month 2 for 2013/14 2011/12 Attendances 2011/12 Cost 2012/13 Attendances 2012/13 Cost 2013/14 Attendances 2013/14 Cost MIA 6,464 398,350 5,947 217,069 1,014 35,146 PUC 5,643 347,696 5,393 223,903 874 30,466 Table 2: MIA and PUC Activity 4.5.2. Attendances by Day of the Week Figure 27: Attendances by Day of the Week Integrated UECPB Strategy: Version 12 Page 27 of 113

4.5.3. Top Clinical Presentations Figure 28: PUC Top 5 Presentations 2012/13 Figure 29: MIA Top 5 Presentations 2012/13 Integrated UECPB Strategy: Version 12 Page 28 of 113

4.5.4. London Ambulance Service Conveyance to sites Figure 30: Level 2 LAS Conveyance 4.6. GP-Led Health Centre at Edridge Road with Walk In Year Total Registered Patients with Appointments Total Walk-ins 2011-12 9,602 36,600 2012-13 12,865 35,774 Table 3: Edridge Road Activity Integrated UECPB Strategy: Version 12 Page 29 of 113

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 4.6.1. Registered Patients Registered Patients with Appointments 1600 1400 1200 1000 800 600 400 200 0 436 462 510 645 1009 992 960 878 852 821 852 1185 1038 1049 947 1436 1373 1386 1245 1228 1051 1095 1017 1048 1086 1095 1099 Reg Pts with Appointments Figure 31: Edridge Road Registered Patients with Appointments Trend of Registered Patients with Appointments 1600 1400 1200 1000 800 600 400 200 0 Reg Pts with Appointments Attendance Trend Figure 32: Edridge Road Registered Patients with Appointments Trend Integrated UECPB Strategy: Version 12 Page 30 of 113

Date Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 4.6.2. Walk-in Patients Walk-In Patients 5000 4000 3000 3549 3445 3194 3351 3426 3700 3323 3478 3012 2957 2879 2931 2912 2987 3035 3005 3078 3041 3156 3075 3249 3303 3321 2897 2940 3103 2694 2000 1000 0 Walk-ins Figure 33: Edridge Road Walk in Patients % split of Walk-In Vs. Registered Patients with Appointments 100% 80% 60% 40% 20% 0% Reg Pts with Appointments Walk-ins Figure 34: Edridge Road Walk-In Vs. Registered Patients 4.7. GP Practices There are 61 practices (see Appendix G) signed up to Personal Medical Services. Most practices offer extended hours and same day appointments. The emphasis within the Primary and Community Strategy is to ensure that same day appointments are standardised across practices and that networks regularly monitor the numbers for people attending ED and not admitted (see Appendix J). In addition there is an emphasis for urgent care centres to see by network if responsiveness can be improved to avoid these attendances from happening. Integrated UECPB Strategy: Version 12 Page 31 of 113

4.7.1. GP Out-of-Hours GP out of hours is located at CHS. Figure 35 below shows for 2012/13 the numbers of patients assessed by telephone advice, the numbers of people coming to base and the numbers of people seen at home. Figure 35: GP Out of Hours 4.7.2. 111 Directed Activity Figure 36 shows the numbers of Out of hours activity directed by 111 and the number of activity non 111. Figure 36: 111 directed activity Integrated UECPB Strategy: Version 12 Page 32 of 113

4.8. Pharmacies There are 73 Pharmacies in Croydon, with all offering minor ailments advice (see Appendix H for locations and Appendix H1 for a list of minor ailments as seen by participating pharmacies). Figure 37 shows that the number of consultations is highest in July. Figure 37: Pharmacy 1 st Number of Consultations Figure 38 shows 1 months data (April) the top 4 ailments treated. Figure 38: Pharmacy Top 4 Ailments Integrated UECPB Strategy: Version 12 Page 33 of 113

4.9. Level 1 Self Care Emphasis in the Prevention and Self - Managed and Shared Decision making is a move towards educating the public to manage their own conditions. Minor Injuries Marketing campaigns and managing minor burns/stings etc Long term conditions - Education around managing long term conditions 111 Reassurance Croydon residents can call 111 for reassurance and advice of selftreatment 4.9.1. 111 Current Performance Total number of patients with a Croydon CCG GP NACs code for this period is 20,877 Data from Jan 2013 until the end of June Data Source: South London Commissioning Support Unit Figure 39: 111 Callers Split by Age Group Integrated UECPB Strategy: Version 12 Page 34 of 113

Figure 40: Top Symptom Groups Referred to ED Figure 41: Top 10 Services 111 Callers Signposted To Integrated UECPB Strategy: Version 12 Page 35 of 113

4.9.2. 111 In-hours / Out-of-Hours Figure 42: Croydon in and out of hours calls Feb to Jun 30 th Integrated UECPB Strategy: Version 12 Page 36 of 113

4.9.3. Percentage of 111 calls referred to LAS (including treat and transfer + 999 emergency Red ambulances) Figure 43: LAS Calls Referred by 111 to 999 Integrated UECPB Strategy: Version 12 Page 37 of 113

5. Overall Activity The activity in Table 4 relates to all Croydon Resident activity to the following access points. Overall Activity 2011/12 2012/13 Total Emergency Department activity across all Trusts e.g CUH / St Georges / Kings for Croydon Residents 140,563 106,419 Total Emergency Department activity CUH 115,204 66,385 (55,144 ) Co-located Virgin Care UCC at CHS - 52,287 (41,072) WIC Edridge Rd 36,600 35,774 MIU Parkway 7,546 (6,464) 7,013 (5,947) MIU Purley 6,907 (5,643) 6,755 (5,393) Note: In brackets = Croydon Resident Activity 2012/13 Table 4: Overall Activity Integrated UECPB Strategy: Version 12 Page 38 of 113

5.1. Hours of the Day Figure 44 shows 2012/13 overall activity by hours of the day for the following locations: Hours of the Day: Attendances by Croydon residents to ED (CHS), UCC, MIU for Croydon CCG during 2012/13 (All Days) 4000 3500 3000 2500 2000 1500 1000 Main ED Virgin MAE MEU MIA PUC VIR 500 0 Main Eye Unit Purley Parkway 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours of Day / Site 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Total All Attend. MAE 1,551 1,329 995 891 824 790 700 1,147 1,688 2,598 3,245 3,581 3,604 3,452 3,319 3,216 3,218 3,128 3,104 3,129 2,878 2,498 2,346 1,913 55,144 MEU 189 1248 607 294 54 400 1,285 209 28 1 1 4,316 MIA 420 204 1,505 777 744 615 666 579 410 27 5,947 PUC 6 386 530 560 549 509 440 438 474 536 441 397 127 5,393 VIR 924 685 544 510 399 435 498 824 1,468 2,373 2,609 2,542 2,538 2,454 2,301 2,269 2,332 2,440 2,544 2,629 2,525 2,143 1,774 1,312 41,072 Total 2,475 2,014 1,539 1,401 1,223 1,225 1,198 1,977 3,731 6,749 7,021 6,966 7,125 6,950 8,848 6,945 6,858 6,625 6,711 6,464 5,814 4,668 4,120 3,225 111,872 Figure 44: Hours of the Day Integrated UECPB Strategy: Version 12 Page 39 of 113

5.2. Days of the Week Days of the Week: Attendances by Croydon residents for ED (CHS), UCC, MIU for Croydon CCG during 2012/13 Main A&E Virgin Main Eye Unit Parkway Purley Days Of Week / Monday Tuesday Wednesday Thursday Friday Saturday Sunday Grand Total Site MAE 8,376 7,959 7,873 7,880 7,978 7,446 7,632 55,144 MEU 949 844 868 836 817 2 4,316 MIA 890 874 887 813 800 862 821 5,947 PUC 999 776 772 732 743 743 628 5,393 VIR 6,255 5,760 5,782 5,629 5,439 5,932 6,275 41,072 Grand Total 17,469 16,213 16,182 15,890 15,777 14,985 15,356 111,872 Figure 45: Days of the Week Integrated UECPB Strategy: Version 12 Page 40 of 113

CUH A&E attendances by hour of the day Figure 46 shows all activity by hour of the day Croydon residents and Non-Croydon residents. Figure 46: CUH ED Attendances by Hour of the Day 2012/13 Integrated UECPB Strategy: Version 12 Page 41 of 113

AE Attendance Location 0 1 2 3 4 5 6 7 8 9 10 11 MAE - CUH - A&E 2,006 1,717 1,323 1,161 1,050 1,016 873 1,391 1,999 3,108 3,785 4,162 UCC - VIRGIN CARE 1,283 926 719 682 561 552 636 1,012 1,828 2,901 3,203 3,263 MEU - CUH - EYE UNIT 225 1,438 745 352 MIA - MINOR INJURIES PARKWAY 3 PUC - PURLEY URGENT CARE 7 477 662 692 679 AE Attendance Location 12 13 14 15 16 17 18 19 20 21 22 23 MAE - CUH - A&E 4,290 4,088 3,963 3,826 3,848 3,821 3,718 3,805 3,486 3,107 2,891 2,419 UCC - VIRGIN CARE 3,162 3,102 2,971 2,923 2,940 3,094 3,186 3,316 3,205 2,738 2,329 1,717 MEU - CUH - EYE UNIT 66 463 1,523 264 36 2 - - 1 MIA - MINOR INJURIES PARKWAY 496 249 1,739 916 860 729 792 692 507 30 PUC - PURLEY URGENT CARE 648 587 563 576 651 552 505 156 Table 5: CUH ED Attendances by Hour of the Day 2012/13 Integrated UECPB Strategy: Version 12 Page 42 of 113

CUH A&E attendances by day of the week Figure 47 shows all activity by hour of the day Croydon residents and Non-Croydon residents. AE Attendance Location Monday Tuesday Wednesday Thursday Friday Saturday Sunday MAE - CUH - A&E 10,059 9,595 9,501 9,429 9,596 9,199 9,474 UCC - VIRGIN CARE 7,947 7,372 7,295 7,088 6,910 7,593 8,044 MEU - CUH - EYE UNIT 1,119 1,016 1,007 988 982 2 1 MIA - MINOR INJURIES PARKWAY 1,037 1,016 1,043 968 924 1,045 980 PUC - PURLEY URGENT CARE 1,230 966 994 932 911 939 783 Figure 47: CUH ED Attednacnes by Day of the Week Croydon Residents and Non Croydon Residents Integrated UECPB Strategy: Version 12 Page 43 of 113

5.3. Out-of-Hours Total Activity Out-of-hours Total Activity YR1 YR2 YR3 Speak to GP 22,100 19,500 18,400 Visit GP 17,751 17,751 17,751 Home Visit 5,259 5,259 5,259 Total Out of Hours 45,110 42,510 41,410 Table 6: Out of Hours Total Activity Integrated UECPB Strategy: Version 12 Page 44 of 113

6. Improving Our Services Our aim is to ensure that our pathways are seamless and that we work in an integrated manner. The current system is fragmented with walk-in centres, minor injury units and urgent care centres offering a variety of treatments, and with a variety of opening times. London Ambulance Service redirect very few people to Walk-in-Centres and Minor Injury Units, alternative care pathways are to be reviewed and additional alternative care pathways will be developed to ensure that newly introduced community provision will be maximised Meeting the national time standard of 4 hours in the ED and 2 hours in the co-located UCC is a critical measure on whole system efficiencies which includes patient flows from the ED back to Primary and or Community Services and from ED through to an inpatient spell and discharge back to Primary and /or Community services. Integrated Health and Social Care Pathways to avoid unnecessary attendance at ED and to facilitate timely discharge must be in place. Pathways therefore need to be responsive to meet whole system demand throughout the year and in times of most activity e.g. winter months. Figure 48 shows whole system pathways with the aim where appropriate of self-care at the end point of a professional intervention. Ambulatory care pathways (See Appendix F) for most common long term condition have been developed to help support people to improve management of their care and over time reduce the need to attend hospital services. The integrated metrics will continually review the pathways at each level and set out actions to mitigate any negative trends. Integrated UECPB Strategy: Version 12 Page 45 of 113

6.1. Whole System Pathway Figure 48 shows whole systems pathway for frail elderly adults and children. For further breakdown of service in each level for each client group please see Figure 49 and Figure 50. Figure 48: Whole System Pathway KEY: S.C: SOCIAL CARE M.H: MENTAL HEALTH CHS: CROYDON HEALTH SERVICES (COMMUNITY) DAAT: DRUG AND ALCOHOL TREATMENT IB: INTERMEDIATE BEDS Integrated UECPB Strategy: Version 12 Page 46 of 113

6.2. Elderly Frail Pathway Figure 49: Elderly Frail Pathway KEY: S.C: SOCIAL CARE M.H: MENTAL HEALTH CHS: CROYDON HEALTH SERVICES (COMMUNITY) DAAT: DRUG AND ALCOHOL TREATMENT IB: INTERMEDIATE BEDS Integrated UECPB Strategy: Version 12 Page 47 of 113

6.3. Children s Pathway Figure 50: Children s Pathway KEY: S.C: SOCIAL CARE M.H: MENTAL HEALTH CHS: CROYDON HEALTH SERVICES (COMMUNITY) DAAT: DRUG AND ALCOHOL TREATMENT IB: INTERMEDIATE BEDS Integrated UECPB Strategy: Version 12 Page 48 of 113

6.4. Whole System Service Provision Figure 51: Whole System Service Provision Integrated UECPB Strategy: Version 12 Page 49 of 113

6.5. Improving Quality Quality is at the heart of everything we do; by adopting the pathways approach we will ensure that our residents are seen at the right time, right place by the right person, first time. Seamless integrated pathways will ensure that we can deliver consistently high quality. The Integrated Quality and Performance Metric indicators will ensure that we meet consistently national and local standards. The Pathways Board will ensure that actions take place across the whole system to reverse negative trends. Integrated U&EC Strategy: Version 12 Page 50 of 113

Service Opening Hours and Improving Quality Figure 52: Level 5 Improving Quality Figure 53: Level 4 Improving Quality Figure 54: Level 3 Improving Quality Integrated U&EC Strategy: Version 12 Page 51 of 113

Figure 55: Level 2 Improving Quality Integrated U&EC Strategy: Version 12 Page 52 of 113

Figure 56: Level 1 Improving Quality Integrated U&EC Strategy: Version 12 Page 53 of 113

7. Appendices 7.1. Appendix A1: Urgent and Emergency Care Pathways Board Governance Structure Chaired by the Assistant Clinical Chair, membership will include senior commissioner and provider representatives across the health and social care system, relevant to the specific areas of responsibility, and other partners as appropriate. Members will need to have seniority within their organisations, in order to be able to take necessary decisions. Clinical representation is vital to the success of the UECPB and regular senior clinical presence is required at each UECPB meeting. Integrated U&EC Strategy: Version 12 Page 54 of 113

7.2. Appendix A2: Urgent and Emergency Care Pathways Board Governance Membership Representation from the following organisations will form the core membership to the Board and will be accountable for delivery of the outputs: Standing Accountable Members Chair/Assistant Chair, Croydon - CCG Director of Commissioning Croydon CCG Deputy Chief Executive / Chief Operating Officer CHS Primary Care Development Lead-CCG Senior Representative - Local Authority Senior Representative - SLaM Ambulance Operations Manager LAS Community Pharmacy Advisor CCG Operations Lead Harmoni - NHS 111 Operations Manager - Virgin Care (UCC and OOH ) Senior Representative Edridge Road Primary Care Contracts Manager, NHS England Senior Commissioning Manager, CSU Local Pharmaceutical Committee Local Medical Committee Integrated U&EC Strategy: Version 12 Page 55 of 113

Representation from the following organisations will form regular membership to the UECPB to advise from their area of expertise and offer views of groups they represent: Regularly Invited Members Urgent Care Commissioner, Croydon - CCG Senior Commissioning Manager, CSU Clinical Governance Manager, CSU ED Consultant, CHS Paediatrics lead, CHS Clinical Governance Lead NHS 111 Clinical Lead, Virgin Care Clinical Lead, Edridge Road Community Health Centre Local Pharmaceutical Committee Local Medical Committee Voluntary sector representation Patient and Public Involvement Leads Other organisational representatives may be co-opted onto the Board at such times as the EUCB decide, given prevailing work streams and operational and strategic needs. Integrated U&EC Strategy: Version 12 Page 56 of 113

Membership of the Executive Committee Representation from the following organisations will form the core membership to the Executive Committee; this Committee will meet as Part Two of the UECPB as indicated as required. (Terms of Reference in separate document) Executive Team CHS CEO CCG CO LAS SEN. DIR. SLAM SEN. DIR. 111 SEN. DIR. V.C SEN. DIR. EDRIDGE ROAD SEN. DIR. LBC EX. DIR. LMC Integrated U&EC Strategy: Version 12 Page 57 of 113

7.3. Appendix B1: NHS London Adult Emergency Care Commissioning Standards No. Commissioning Standards 1 All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital. 2 A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours (for complex needs patients see 23 and 24). 3 All patients admitted acutely to be continually assessed using a standardised early warning system (EWS). Consultant involvement is required for patients who reach trigger criteria. Consultant involvement for patients considered high risk should be within one hour. 4 When on-take, a consultant and their team are to be completely freed from any other clinical duties or elective commitments. 5 In order to meet the demands for consultant delivered care, senior decision making and leadership on the acute medical/ surgical unit. To cover extended day working, seven days a week 6 All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients, directly transferred, or others who deteriorate. 7 All hospitals admitting medical and surgical emergencies to have access to all key diagnostic services in a timely manner 24 hours a day, seven days a week to support clinical decision making: Critical imaging and reporting within 1 hour Urgent imaging and reporting within 12 hours All non-urgent within 24 hours 8 All hospitals admitting medical and surgical emergencies to have access to interventional radiology 24 hours a day, seven days a week: Critical patients 1 hour Non-critical patients 12 hours 9 Rotas to be constructed to maximise continuity of care for all patients in an acute medical and surgical environment. A single consultant should retain responsibility for a single patient on the acute medical/ surgical unit. Subsequent transfer or discharge must be based on clinical need 10 A unitary document to be in place, issued at the point of entry, which is used by all healthcare professionals and all specialties throughout the emergency pathway. 11 Patients admitted for unscheduled care to be nursed and managed in an acute medical/ surgical unit, or critical care environment. 12 All admitted patients to have discharge planning and an estimated discharge date as part of their management plan as soon as possible and no later than 24 hours post-admission. Integrated U&EC Strategy: Version 12 Page 58 of 113

No. Commissioning Standards There should be a policy in place to access social services seven days per week. Patients should be discharged to their named GP. 13 All hospitals admitting emergency general surgery patients to have access to a fully staffed emergency theatre immediately available and a consultant on site within 30 minutes at any time of the day or night. 14 All patients admitted as emergencies are discussed with the responsible consultant if immediate surgery is being considered. For each surgical patient, a consultant takes an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or speciality surgeons. This decision is recorded in the notes and available for audit. 15 All patients considered as high risk to have their operation carried out under the direct supervision of a consultant surgeon and consultant anaesthetist; early referral for anaesthetic assessment is made to optimise peri-operative care. High risk is defined as where the risk of mortality is greater than 10%. 16 All patients undergoing emergency surgery to be discussed with consultant anaesthetist. Where the severity assessment score is ASA3 and above, anaesthesia should be provided by a consultant anaesthetist. 17 The majority of emergency general surgery to be done on planned emergency lists on the day that the surgery was originally planned. The date, time and decision maker should be documented clearly in the patient s notes and any delays to emergency surgery and the reasons why recorded. Any operations that are carried out at night should meet NCEPOD classifications and be under the direct supervision of a consultant surgeon. 18 All referrals to intensive care to be made from a consultant to a consultant. (Consultant involvement in referrals) 19 A structured process to be in place for the medical handover of patients twice a day. These arrangements to also be in place for the handover of patients at each change of responsible consultant/medical team. Changes in treatment plans should be communicated to nursing and therapy staff as soon as possible if they are not involved in the handover discussions. 20 Consultant-led communication and Information to be provided to patients and to include the provision of patient information leaflets. 21 Patient experience data is captured, recorded and routinely analysed and acted on. Review of data is a permanent item on board agenda and findings are disseminated. 22 All acute medical and surgical units to have provision for ambulatory emergency care. 23 Prompt screening of all complex needs inpatients to take place by a multi professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy. 24 Single call access for mental health referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes. Integrated U&EC Strategy: Version 12 Page 59 of 113

No. Commissioning Standards 25 Hospitals admitting emergency patients to have access to comprehensive 24 hour endoscopy services that has a formal consultant rota 24 hours a day, seven days a week. 26 All hospitals dealing with complex acute medicine to have onsite access to levels 2 and 3 critical care (i.e. intensive care units with full ventilatory support). All acute medical units to have access to a monitored and nursed facility. 27 Training to be delivered in a supportive environment with appropriate, graded consultant supervision Table 7: NHS London Adult Emergency Care Commissioning Standards Integrated U&EC Strategy: Version 12 Page 60 of 113

7.4. Appendix B2: London Urgent Care Operational Standards Governance No Standard 1 Each urgent care service is to have a formal written policy for providing urgent care. This policy is to adhere to the urgent care clinical quality standards. This policy is to be ratified by the service s provider board and reviewed annually. 2 All urgent care services are to be within an urgent and emergency care network with integrated governance structures. All urgent care services to participate in national and local audit, including the use of the Urgent and Emergency Care Clinical Audit Tool Kit to review individual clinician consultations. Core Service 3 During the hours that they are open all urgent care services to be staffed by multidisciplinary teams, including: at least one registered medical practitioner (either a registered GP or doctor with appropriate competencies for primary and emergency care), and at least one other registered healthcare practitioner. 4 An escalation protocol is to be in place to ensure that seriously ill/high risk patients presenting to the urgent care service are seen immediately on arrival by a registered healthcare practitioner. 5 All patients are to be seen and receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival at the urgent care service. 6 Within 90 minutes of the time of arrival at the urgent care service 95 per cent all patients are to have a clinical decision made that they will be treated in the urgent care service and discharged, or arrangements made to transfer them to another service. 7 At least 95 per cent of patients who present at an urgent care service to be seen, treated if appropriate, and discharged in under 3 hours of the time of arrival at the urgent care service. 8 During all hours that the urgent care service is open it is to provide guidance and support on how to register with a local GP. 9 The service is to have a clear pathway in place for patients who arrive outside of opening hours to ensure safe care is delivered elsewhere. 10 Access to minimum key diagnostics during hours the urgent care service is open, with real time access to images and results: - Plain film x-ray: immediate on-site access with formal report received by the urgent care service within 24 hours of examination - Blood testing: immediate on-site access with formal report received by urgent care service within one hour of the sample being taken Clinical staff to have the competencies to assess the need for, and order, diagnostics and imaging, and interpret the results. [It is suggested that a cost-benefit analysis be undertaken by each service prior to implementation]. 11 Appropriate equipment to be available onsite: - a full resuscitation trolley - an automated external defibrillator - oxygen - suction and - emergency drugs All urgent care service to be equipped with a range of medications necessary for immediate treatment. 12 Urgent care services to have appropriate waiting rooms, treatment rooms and equipment according to the workload and patient s needs. Integrated U&EC Strategy: Version 12 Page 61 of 113

13 All patients to have an episode of care summary communicated to the patient s GP practice by 08.00 on the next working day. For children the episode of care to be communicated to their health visitor or school nurse, where known and appropriate, no later than 08.00 on the second working day. Staff competencies 14 All registered healthcare practitioners working in urgent care services to have a minimum level of competence in caring for adults, and children and young people (where the service accepts children), including: (a) Basic life support; (b) Recognition of serious illness and injury; (c) Pain assessment; (d) Identification of vulnerable patients At anytime the service is open at least one registered healthcare practitioner is to be trained and competent in immediate life support and paediatric immediate life support, where the service accepts children. 15 All registered healthcare practitioners working in urgent care services to have direct access to urgent referrals to specialist on-call services when necessary, and the right to refer those patients who they see within their scope of practice. Supporting services 16 Urgent care services to have arrangements in place for staff to access support and advice from experienced doctors (ST4 and above or equivalent) in both adult and paediatric emergency medicine or other specialties without necessarily requiring patients to be transferred to an emergency department or other service. 17 Single call access for mental health referrals to be available during hours the urgent care service is open, with a maximum response time of 30 minutes. Patient experience: 18 Patient experience data to be captured, recorded and routinely analysed and acted on. Data is to be regularly reviewed by the board of the urgent care provider and findings are to be disseminated to all staff and patients. 19 All patients to be supported to understand their diagnosis, relevant treatment options, ongoing care and support by an appropriate clinician. 20 Where appropriate, patients to be provided with health and wellbeing advice and sign-posting to local community services where they can self-refer (for example, smoking cessation services and sexual health, alcohol and drug services). Training 21 Urgent care services to provide appropriate supervision for training purposes including both: - Educational supervision - Clinical supervision 22 All healthcare practitioners to receive training in the principles of safeguarding children, vulnerable and older adults and identification and management of child protection issues. All registered medical practitioners working independently to have a minimum of safeguarding training level 3. Table 8: London Urgent Care Operational Standards Integrated U&EC Strategy: Version 12 Page 62 of 113

7.5. Appendix B3: Emergency Department Clinical Quality Indicators No Indicator 1 Ambulatory care To reduce avoidable hospital admissions by improving the provision of ambulatory care. Recognise that not all A&E departments are able to fully clinically code attendances for these two specific. 2 Unplanned re-attendance rate Unplanned re-attendance at A&E within 7 days of original attendance (including if referred back by another health care professional). 3 Total time in the A&E department The median, 95th percentile and longest total time spent by patients in the A&E department, for admitted and non-admitted patients. 4 Left without being seen (LWBS) rate The percentage of people who leave the A&E department without being seen. (>5% is a problem, <3% is a problem) 5 Service experience Narrative description of what has been done to assess the experience of patients using A&E services and their carers, what the results were, and what has been done to improve services in light of the results. (Survey using NHS Surveys) 6 Time to initial assessment Time from arrival to start of full initial assessment, which includes a pain score and early warning score, for all patients arriving by ambulance 7 Time to treatment Time from arrival to see a decision making clinician (someone who can define the management plan and discharge the patient) 8 Consultant sign-off The percentage of patients presenting at type 1 and 2 (major) A&E departments in certain high-risk patient groups (adults with non-traumatic chest pain, febrile children less than 1 year old and patients making an unscheduled return visit with the same condition within 72 hours of discharge) who are reviewed by an emergency medicine consultant before being discharged Table 9: Emergency Department Clinical Quality Indicators Integrated U&EC Strategy: Version 12 Page 63 of 113

7.6. Appendix B4: National Quality Requirements OOH One Performance reporting to PCT monthly Two Report OOH consultations to patient s own GP practice by 08:00 next working day Three Four Five Regular exchange of up-to-date information about patients with predefined needs e.g. Palliative care Clinical audit of all who provide clinical service (RCGP OOHs Clinical Audit Toolkit) (Urgent & Emergency Care Audit Toolkit 2011) Regular audit of patients experience of the service Six Complaints procedure Seven Capacity and contingency planning Eight Telephone answering requirements (Within 60s including a recorded message) Nine Telephone Clinical Assessment (30s, 20min, 60min) Ten Face-to-face Clinical Assessment (walk-ins) Eleven Patients must be treated by clinician best equipped to meet their particular needs Twelve Face-to-face consultations (Emergency 1hr / Urgent 2hrs / Routine 6hrs) Thirteen Providing services for people with language difficulties, impaired hearing or impaired sight Table 10: National Quality Requirements OOH Integrated U&EC Strategy: Version 12 Page 64 of 113

7.7. Appendix B5: Social Care Performance Indicators - Hospital Discharge 1.1 The Community Care (Delayed Discharges etc.) Act 2003 confirmed the responsibilities of NHS Trusts and Local Authority Adult Social Services Departments in relation to the identification, prevention and management of people whose discharge from hospital may be delayed due to health or social care factors. Croydon Adult Social Services, which is part of the Department of Adult Services, Health and Housing (DASHH), has long established policies and procedures in place both at CUH and with out of borough hospitals to prevent or minimise the number of Delayed Transfers of Care (DToC), and in recent years has achieved a consistently good level of performance as evidenced by the national key performance indictor. The local authority s responsibilities in relation to hospital discharges of people who may be in need of social care services are undertaken by teams of social workers and care managers. At CUH this is the Adult Care Team (ACT) whilst the START service responds to the needs of Croydon residents in out-ofborough hospitals. 1.2 The 2003 legislation required local health and social care economies to establish local arrangements. It also established that hospital trusts which do not have an agreement in place can apply financial penalties to the relevant Adult Social Services Department where it has been agreed that the organisation is responsible for the failure to meet the statutory deadlines to ensure that social care support arrangements are in place to enable discharge. When a delay occurs because of a failure on the part of Adult Social Services to meet that deadline a coded delay is agreed and formally recorded. Once a section 5.3 notice (Community Care (Delayed Discharges etc) Act 2003) has been issued Adult Social Services has 24 hours (national standard) to complete all social care discharge arrangements. In CUH it has been agreed that this period of notice is extended to 48 hours before a social care coded delay is recorded. NHS providers and adult social service departments are expected to reach agreement about which delays are recordable, the reason for the delay and whether each one is a health or social care delay. In CUH the Head of Hospital Avoidance and Adult Care Team Manager are responsible for reaching agreement on recordable delays at CUH. 1.3 The performance of all NHS providers and Adult Social Services Departments are published (as Delayed Transfer of Care data) by DH on a quarterly basis, with this being a national performance indicator for the NHS and Local Authorities. This data includes all delays of Croydon residents regardless of which hospital they were discharged from. 1.4 Whilst there are no specific quality hospital discharge KPI s related to social care, the Local Authority is required to undertake and report on nationally determined surveys of service users and carers experience of and satisfaction with social care services as part of the annual statutory returns for the Adult Social Care Outcomes Framework. Integrated U&EC Strategy: Version 12 Page 65 of 113

7.8. Appendix B6: Quality and Performance Metric Clinical Quality Indicators Target ACTIVITY 111 111 in hours / out of hours Numbers and Percentage of where diverted to LAS Number of category A incidents Number of category C1 incidents Number of category C2 incidents Number of category C3 / C4 incidents London Ambulance Service dispersals to Walk-in s excluding ED CHS Type 1 Performance All Type Performance Attendances (split UCC and ED) Re-attendance Rates ED Admission and Non-Admission Attendances AMU beds turnover AMU av LOS Admissions avoided - AMU clinic Admissions avoided - ACE Admissions avoided - ACP Discharges by 1pm (non-elective admissions only - shown as a Percentage of all non-elective admissions Numbers of Medical Outliers Numbers of Surgical Outliers CUH: Daily hospital inpatient admission and discharge profile 28 day readmissions rates Integrated E&UC Strategy: Version 12 Page 66 of 113

SLAM Numbers of Older people attendances and admission rates Numbers of Adults attendances and admission rates Out of Hours Out of Hours Activity by face to face, home visit or telephone advice Edridge Road Overall Activity Walk-Ins Overall Activity for Purley, Parkway, Virgin and ED Overall Activity by hours of the day (Croydon Registered) Overall Activity by hours of the day (Croydon Registered and non-croydon residents) Overall Activity by Days of the week (Croydon Registered) Overall Activity by Days of the week (Croydon Registered and non-croydon residents) Primary Care and Pharmacy Same Day Slots Activity Pharmacy Minor Ailments Activity PERFORMANCE AND QUALITY 111 LAS Category A percentage reached in 8 minutes Ambulance Handover within 15 minutes CHS A&E 4 Hours Waits 95% Target - All Types 95 CHS Breaches by Weekday CHS A&E Attendances vs. Breaches by Arrival Hour CUH (CHS): weekly 4 hr. emergency access performance by week, by patient flow groups CUH (CHS): ED LoS distribution by patient flow group UCC Time Spent in UCC Handover and Streamed Adult Patients (>=16) 95th Percentile 20 Time Spent in UCC Handover and Streamed Paediatric Patients (>=16) 95th Percentile 15 Integrated E&UC Strategy: Version 12 Page 67 of 113

UCC to CHS handover London Borough of Croydon Number of Domiciliary Care Packages Delayed Transfer of Care PATIENT EXPERIENCE Emergency and Urgent Care Complaints 111 Number of SIs/Complaints LAS Number of SIs/Complaints Primary Care GP Practices Number of SIs/Complaints CHS Number of SIs/Complaints Virgin Care Number of SIs/Complaints Edridge Road Number of SIs/Complaints SLAM - Number of SIs/Complaints LBC - Number of SIs/Complaints Emergency and Urgent Care Patient Satisfaction Levels 111 Patient Satisfaction LAS Patient Satisfaction Primary Care GP Practices Patient Satisfaction CHS Patient Satisfaction Virgin Care Patient Satisfaction Edridge Road Patient Satisfaction SLAM - Patient Satisfaction LBC - Patient Satisfaction WORKFORCE 111 - Recruitment on Target / Vacancy Rates LAS - Recruitment on Target / Vacancy Rates Primary Care GP Practices - Recruitment on Target / Vacancy Rates CHS - Recruitment on Target / Vacancy Rates Virgin Care - Recruitment on Target / Vacancy Rates Edridge Road - Recruitment on Target / Vacancy Rates Integrated E&UC Strategy: Version 12 Page 68 of 113

SLAM - Recruitment on Target / Vacancy Rates LBC - Recruitment on Target / Vacancy Rates Figure 57: Quality and Performance Metric Integrated E&UC Strategy: Version 12 Page 69 of 113

7.9. Appendix C: Map of Top 6 ED s by attendances Figure 58: Map of Top 6 ED s by attendances Integrated UECPB Strategy: Version 12 Page 70 of 113

7.10. Appendix D: Map of UCC s, MIU s and Walk in Centre Figure 59: Map of UCC s, MIU s and Walk in Centre Integrated UECPB Strategy: Version 12 Page 71 of 113

7.11. Appendix E: Ambulatory Care Pathways Ambulatory Care Pathways allow patients who are safe to go home to be managed promptly as outpatients, without the need for admission to hospital. Patients presenting to CHS with the following conditions should be managed whenever possible using the Ambulatory Care Pathways. Figure 60: Ambulatory Care Pathways Integrated UECPB Strategy: Version 12 Page 72 of 113

7.12. Appendix F1: Virgin Care Urgent Care Centre Alternative Care Pathway Service description: Croydon Urgent Care Centre, located at the front of the Emergency Department at Croydon Health Services (CUH) is a GP-led urgent care centre that provides treatment for patients with minor illness and minor injuries. The care is delivered by General Practitioners, Nurse Practitioners, Emergency Care Practitioners, Staff Grade doctors and Nurses. X-ray facilities are available on-site. Virgin Care Urgent Care Centre Categories of patients accepted Ankle injury Bites and stings Burns and scalds Digit injury No deformity, able to weight bear with assistance of one person. Animal or insect. No systemic reaction. Less than 3% in adults, less than 1% in paediatrics; no facial burns; no inhalation injury. No open injuries; no infection; no diabetic problems. Earache Elbow injury Eye conditions Lower back pain Must be non-displaced & have good distal pulse. No penetrating injury or peri-orbital cellulitis. No 'red flags', under 65 years of age. Minor allergic reactions Minor head injury Rib injury Skin complaints (incl. rashes) Sore throat Upper respiratory tract infection (URTI) Urinary tract infection (UTI) Vomiting Wounds and lacerations Wrist injuries GCS 15/15; no intoxicating substances; no current anti-coagulant therapy. No history of loss of consciousness. If no primary survey problems, must be due to trauma/injury, not non-traumatic presentation. Patient must be apyrexial; no non-blanching rashes; incl. impetigo, minor cellulitis and wound infections. Patient must be able to swallow; no drooling; no indications of quinsy; no trismus. Uncomplicated infections; flu-like symptoms; the latest version of the flu algorithm should be used in the assessment of these patients. Uncomplicated infections in female patients aged 12yrs and over only. With less than 4 hours history. Minor injuries only, scalp & facial wounds; excluding triangle of the face. No gross deformity, good distal perfusion. Integrated UECPB Strategy: Version 12 Page 73 of 113

Virgin Care Urgent Care Centre Other Gastrointestinal problems Head injuries Musculo-skeletal Injuries Wounds & lacerations Diarrhoea, vomiting, constipation. Minor injuries only, scalp & facial wounds; excluding triangle of the face. Injuries: Low impact, bony and non-injuries, bony injuries, i.e. sprains, strains, tendonitis, fractures, whiplash (without c-spine bony tenderness). Non-injuries: conditions of recent onset only. Grazes, lacerations requiring suturing. Dental problems RTC victims Minor injuries. Table 11: Virgin Care Urgent Care Centre Alternative Care Pathway Integrated UECPB Strategy: Version 12 Page 74 of 113

7.13. Appendix F2: Purley War Memorial Hospital Urgent Care Centre Pathway Service description: Purley War Hospital Urgent Care Centre is a nurse-led health centre that provides treatment for patients with minor ailments and minor injuries. The care is delivered by nurse practitioners and support nurses. X-ray facilities are available on-site Purley War Memorial Hospital Urgent Care Centre Categories of patients accepted Ankle injury Bites and stings Burns and scalds Digit injury No deformity, able to weight bear with assistance of one person. Animal or insect, no systemic reaction. Burns must not be full thickness and must cover less than 5% TBSA in adults and less than 3% TBSA in paediatrics. Minor facial burns but no neck or genitalia or inhalation injury. No open injuries. Infections will be seen even if patient is diabetic. Earache Elbow injury Eye conditions Lower back pain Must be non-displaced & have good distal pulse. No penetrating injury or peri-orbital cellulitis. No 'red flags'. Minor allergic reactions Minor head injury Rib injury Skin complaints (incl. rashes) Sore throat Upper respiratory tract infection (URTI) Urinary tract infection (UTI) Vomiting Wounds and Lacerations No history of loss of consciousness, GCS 15/15; no intoxicating substances; no current anti-coagulant therapy. If no primary survey problems, must be due to trauma/injury, not non-traumatic presentation. Patient must be apyrexial; no non-blanching rashes. Impetigo, minor cellulitis and wound infections will be seen. Patient must be able to swallow; no drooling; no indications of quinsy; no trismus. Uncomplicated infections; flu-like symptoms; the latest version of the flu algorithm should be used in the assessment of these patients. Uncomplicated infections in female patients aged 12yrs and over only. With less than 4 hours history. Minor injuries only, scalp & facial wounds; Superficial grazes, lacerations requiring suturing apart from lacerations that cross the vermillion border of the lip or lacerations to the eyelids or those that obviously require plastics intervention or general anaesthetic or sedation as in very young children. Burns or scalds see above excludes hands and feet. Integrated UECPB Strategy: Version 12 Page 75 of 113

Purley War Memorial Hospital Urgent Care Centre Wrist injuries No gross deformity, good distal perfusion. Other Gastrointestinal problems Head injuries Diarrhoea, vomiting. No constipation. Minor injuries only, scalp & facial wounds see wounds and lacerations above. Musculo-skeletal injuries Injuries: low impact, non-displaced bony or non-bony injuries, i.e. sprains, strains, tendonitis, fractures, whiplash (without c-spine bony tenderness). Non-injuries: conditions of recent onset only Table 12: Purley Wat Memorial Hospital Urgent Care Centre Pathway Integrated UECPB Strategy: Version 12 Page 76 of 113

7.14. Appendix F3: Parkway Emergency Minor Treatment Centre Care Pathway Service description: New Addington Emergency Minor Treatment Centre is a nurse-led unit that provides treatment for patients with minor ailments and minor injuries. The care is delivered by doctors, nurse practitioners and support nurses. X-ray facilities are not available on-site. New Addington Parkway Emergency Minor Treatment Centre Categories of patients accepted Ankle injury Bites and stings Burns Digit injury Elbow injury Eye conditions Minor head injury Rib injury Wounds Wrist injuries No deformity, able to weight bear with assistance of one person. Animal or insect with no associated anaphylaxis. Burns must not be full thickness and must cover less than 5% TBSA in adults and less than 3% TBSA in paediatrics Minor facial burns but no neck or genitalia or inhalation injury. No open injuries. Infections will be seen even if patient is diabetic. Must be non-displaced & have good distal pulse. No penetrating injury or peri-orbital cellulitis. GCS 15, no LOC; no intoxicating substances; no current anti-coagulant therapy. If no primary survey problems, must be due to trauma /injury, not non-traumatic presentation. Minor injuries only, scalp & facial wounds; excluding hands, feet & triangle of the face. No gross deformity, good distal perfusion. Other Gastrointestinal problems Head injuries Musculo-skeletal injuries Wounds & lacerations Non-traumatic neck pain Diarrhoea, vomiting. No constipation. Minor injuries only, scalp & facial wounds; excluding triangle of the face. Injuries: Low impact, non-displaced bony or non- bony injuries, i.e. sprains, strains, tendonitis, whiplash (without c-spine bony tenderness). Non-injuries: conditions of recent onset only. Superficial grazes, lacerations requiring suturing apart from lacerations that obviously require plastics intervention or general anaesthetic or sedation as in very young children. Burns or scalds see above. Adults only. Distal limb injuries i.e. elbows to fingers, below to toes Table 13: Parkway Emergency Minor Treatment Centre Care Pathway Integrated UECPB Strategy: Version 12 Page 77 of 113

7.15. Appendix F4: Edridge Rd Community Health Centre Care Pathway Service Description: Eldridge Rd Community Health Centre is a GP-led health centre provides treatment for patients with minor ailments and minor injuries. The care is delivered by doctors, nurse practitioners and support nurses. X-ray facilities are not yet available on-site. Edridge Rd Community Health Centre Categories of patients accepted Ankle injury Bites and stings Burns and scalds Digit injury No deformity, able to weight bear with assistance of one person. Animal or insect. No systemic reaction. Less than 3% in adults, less than 1% in paediatrics; no facial burns; no inhalation injury. No open injuries; no infection; no diabetic problems. Earache Elbow injury Eye conditions Lower back pain Must be non-displaced & have good distal pulse. No penetrating injury or peri-orbital cellulitis. No 'red flags', under 65 years of age. Minor allergic reactions Minor head injury Rib injury Skin complaints (incl. rashes) Sore throat Upper respiratory tract infection (URTI) Urinary tract infection (UTI) Vomiting Wounds and lacerations Wrist injuries GCS 15/15; no intoxicating substances; no current anti-coagulant therapy. No history of loss of consciousness. If no primary survey problems, must be due to trauma/injury, not nontraumatic presentation. Patient must be apyrexial; no non-blanching rashes; incl. impetigo, minor cellulitis and wound infections. Patient must be able to swallow; no drooling; no indications of quinsy; no trismus. Uncomplicated infections; flu-like symptoms; the latest version of the flu algorithm should be used in the assessment of these patients. Uncomplicated infections in female patients aged 12yrs and over only. With less than 4 hours history. Minor injuries only, scalp & facial wounds; excluding triangle of the face No gross deformity, good distal perfusion. Other Gastrointestinal problems Head injuries Musculoskeletal and distal limb (i.e. elbows to fingers, below to toes) injuries Diarrhoea and constipation but heamodynamically stable. Minor injuries only, scalp & facial wounds; excluding triangle of the face. Injuries: low impact, non-displaced bony or non-bony injuries, i.e. sprains, strains, tendonitis, fractures, whiplash (without c-spine bony tenderness). Non-injuries: conditions of recent onset only. Integrated UECPB Strategy: Version 12 Page 78 of 113

Edridge Rd Community Health Centre Wounds & lacerations Non-traumatic neck pain Superficial grazes, minor lacerations requiring glueing, superficial burns or scalds <2% body surface area (excl. face, neck or genitalia). Adults only. Family planning or sexual health complaints Includes emergency contraception. Table 14: Edridge Road Community Health Centre Care Pathway Integrated UECPB Strategy: Version 12 Page 79 of 113

7.16. Appendix G: GP Map Figure 61: GP Map Integrated UECPB Strategy: Version 12 Page 80 of 113

7.17. Appendix H: Map of Croydon Pharmacies Note: This map does not show Fieldway Pharmacy and Fairview Figure 62: Map of Croydon Pharmacies Source Ordnance Survey, November 2010 Integrated UECPB Strategy: Version 12 Page 81 of 113

7.18. Appendix H1: Pharmacy First - Ailments included in the scheme: Categories of patients accepted Acne Athlete s foot Back pain Cold sores Conjunctivitis Constipation Contact dermatitis Coughs & colds Cystitis Diarrhoea Earache Ear wax Fever Haemorrhoids (piles) Head lice Headache Indigestion Insect bites/stings Mouth ulcers Nappy rash Scabies Sprains & strains Teething Threadworm Toothache Thrush Sore throat Warts & verrucas Hayfever & allergies Table 15: Pharmacy First Ailments included in the scheme Integrated UECPB Strategy: Version 12 Page 82 of 113

7.19. Appendix I: Draft Urgent and Emergency Care Action Plan CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Strategy & Governance Strategy & Governance Reconstitution of UCN to form a EUCB (RS1-R1) EUCB 01/06/2013 Strategy & Governance Agreement of Whole Systems Action Plan EUCB 16/09/2013 Strategy & Governance Development of integrated Quality and Performance Metric incorporating London Standards / CQI Standards/ Social Care Standards EUCB 23/10/2013 Strategy & Governance Review of Quality and Performance Metric at Monthly EUCB EUCB 16/09/2013 Strategy & Governance Recommendation of Urgent and Emergency Care Strategy to Governing Bodies EUCB 24/09/2013 Strategy & Governance Public Health Analysis and projections of total walk in activity based on demographic changes and deprivation EUCB 28/08/2013 Strategy & Governance Development of Demand & Capacity Plan inc Q3 & Q4 Whole System Plans EUCB 23/09/2013 Strategy & Governance Development of Draft Recovery & Improvement Plan for the public EUCB 02/09/2013 Strategy & Governance Strategy & Governance Agree key quality and outcome measures for urgent and emergency care (RS1-R5) Further development of the Urgent & Emergency Strategy. To ensure joint ownership from the UCB and presented on 15th May 2013 (RS1-R3) EUCB 31/05/2013 CCG 15/05/2013 Integrated UECPB Strategy: Version 12 Page 83 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Strategy & Governance Further development of the Urgent & Emergency Strategy. Following the Prof Bell workshop and agreement of EUCB Action Plan (RS1-R4) CCG 16/09/2013 Strategy & Governance Finalise Urgent and Emergency Care Strategy for GB/Boards CCG 23/09/2013 Strategy & Governance Review of Emergency Flow Workshop Mapping workshop to be held before the end of June including senior stakeholders and clinicians facilitated by Professor Bell and team (RS1-R6) CCG / CHS 30/06/2013 Strategy & Governance To complete Draft Public Recovery and Improvement Plan CCG 02/09/2013 Strategy & Governance To complete Final Recovery and Improvement Plan CCG TBC Strategy & Governance To complete draft Demand and Capacity Plan EUCB 25/07/2013 Strategy & Governance To RAG Winter Checklist EUCB 16/09/2013 Strategy & Governance To RAG Demand and Capacity Checklist EUCB 16/09/2013 Strategy & Governance To finalise Demand an Capacity Plan to include Q3&Q4 EUCB 23/09/2013 Integrated UECPB Strategy: Version 12 Page 84 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Improving Self-Care Improving Self-Care Improving Self-Care Improving Self-Care Signposting Up-to-date urgent care signposting to guide Patients to appropriate forms of urgent care by Community Pharmacy. For patients living with Long Term Conditions, the use of enhanced Case Management with the MDT in the community in order to achieve improved targeting of use of services. Social Care to appoint 8 social work staff including one team manager to be deployed to support MDT case management teams CCG 01/07/2013 CHS 01/10/2013 LBC 01/10/2013 Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Development of Integrated Pathway for the frail elderly - discussion at Strategic Transformation Board (RS1-R7) Development of Integrated Pathway for the frail elderly - agreement on Business Case (RS1-R8) Development of Integrated Pathway for the frail elderly - Exploration of outcomes based commissioning utilising the COBIC approach (RS1-R9) Assessment of skill base in Primary Care for delivery of Urgent Care requirements for paediatric patients Scope of assessment process to be decided by UEPB and assessment undertaken. (RS1-R10) CHS 08/05/2013 CHS 30/06/2013 CCG 30/06/2013 CCG 31/07/2013 Integrated UECPB Strategy: Version 12 Page 85 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Assessment of overall primary care capacity from 15.00 to 20.00 hrs to meet the needs of UC patients Review across networks as part of Primary and Community Care Strategy development and review of Purley and New Addington UCC provision. (RS1-R11) Set up peer review process and framework for GP emergency referrals for follow up actions, benchmark existing process and ensure improvement framework overseen by GP Networks and UEPB Review to be commissioned by UEPB (RS1-R12) Frail Elderly - Ensure national standards are applied as a minimum to the care of this patient group Assessment process against national standards to ensure parity with requirements (RS1-14) CCG 31/07/2013 CCG 30/09/2013 CHS 30/09/2013 Improving System Access When Patients Realise Something Is Wrong Paediatric Care - Check for requirement for additional actions to improve paediatric care across the system from primary into secondary provision. Review of paediatric care undertaken to ensure best possible provision ahead of winter 2013/14 (RS1-15) CHS CCG 30/09/2013 Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Medicines management Increase uptake of Repeat dispensing, MURS and NMS to minimize inappropriate medication requests by patients to A&E and WIC as part of urgent care. Improved focus on dementia care and access to ICT to early identify people already using services CCG 18/10/2013 LB / CHS / CCG 01/12/2013 Improving System Access Enhancement of Ambulatory Care CHS 01/06/2013 Integrated UECPB Strategy: Version 12 Page 86 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Improving System Access When Patients Realise Something Is Wrong Review of LAS ACP s and addition of increasing number of ACP s to Community Services e.g. Rapid Response Review of existing ACP s and increase % standards to disposal at other sites Primary Care / Edridge Road / Purley and Parkway LAS 31/10/2013 LAS 01/09/2013 Improving System Access When Patients Realise Something Is Wrong Review of using exclusion criteria at Virgin UCC LAS CHS 01/10/2013 Improving System Access When Patients Realise Something Is Wrong Review of Primary Care Home Visiting Times and evaluation if home visit can be earlier CCG 01/11/2013 Improving System Access When Patients Realise Something Is Wrong Review of Primary Care Same Day slots availability and Opening Hours See 2.05 CCG 01/10/2013 Improving System Access When Patients Realise Something Is Wrong Review of use of Pharmacy Ailments Service CCG 01/10/2013 Improving System Access When Patients Realise Something Is Wrong Falls prevention - See Falls prevention PID. Basic equipment upgrades underway Re-enforcement of therapy plans CHS 01/07/2013 Integrated UECPB Strategy: Version 12 Page 87 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Improving System Access When Patients Realise Something Is Wrong Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Dementia - Dementia nurse specialist has been appointed and Trust education and training in place. Dementia Zone (ED) in place Workforce: Skill mix Delivery of training to support 2-tier working Workforce: The LAS has started a review of rosters far all operational staff, which has a 3 month time line and will be completed in Jan 2014 for implementation around March April 2014 Efficiencies: Recruitment of additional staff within the Clinical Hub to the new role which is targeted to deliver hear and treat Efficiencies: New response model to be implemented when workforce and modernisation programme is completed. Staff Engagement: Engagement exercise and communications strategy delivered: Completion of a series of staff engagement events including delivery of a comprehensive information pack to staff CHS 01/07/2013 LAS 05/08/2013 LAS 01/04/2014 LAS 31/12/2013 LAS 01/04/2014 LAS 20/06/2013 Improving Care and Patient in ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Mental health patients - Assessment processes in A&E to be risk stratified and responsiveness of service to be more aligned to need Success criteria for above to be drawn up and agreed (RS1) Local Pharmaceutical Service Contacts Review Eldridge RD Pharmacy linked to the WIC and Mayday Pharmacy close to Croydon University Hospital are under review CHS / SLAM 31/10/2013 CCG 31/10/2013 Integrated UECPB Strategy: Version 12 Page 88 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital "ACE" service enhancement using Comprehensive Geriatric Assessment CHS 01/08/2013 Enhancement of the COPD admissions avoidance scheme CHS 01/08/2013 Review and implement changes in administrative processes to record handover CHS 01/08/2013 Improving Care And Patient In ED / Hospital Allocate staffing rota to confirm 'click-off' in areas outside of RATT, i.e. paediatrics and the Resuscitation Unit. CHS 01/07/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Extension of RATT coverage CHS 01/07/2013 Review of staffing in RATT to ensure continuous flow CHS 01/08/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Data accuracy for ambulance handover is impaired by availability and use of CAD in all receiving locations Maximise the potential for Urgent Care to manage ambulance arrivalsthrough use of exclusion criteria To improve the efficientcy of handover by clarifying the policy between LAS+CHS To improve the efficiency of handover by redesign the majors process to minimise delays, using learning from the RATT implementation. LAS 10/09/2013 CHS/LAS/CCG 01/10/2013 LAS/CHS CHS 30/06/2013 Improving Care And Patient In ED / Hospital ED IT system does requires complete overhaul to enable visual shop floor management CHS 26/08/2013 Integrated UECPB Strategy: Version 12 Page 89 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Bed Meetings to include predictive model and key quality information CHS 01/06/2013 Implementation of predictors of demand on beds CHS 01/07/2013 Implementation of 24/7 site team CHS 01/08/2013 Adult Emergency Care Standards (AECS) Standards CHS 01/10/2013 Monitoring and expediting of patients 'fit' for discharge CHS 01/07/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Developing a full capacity protocol - Current escalation response does not contain and deescalate pressure quickly. ED can be compromised with regard to flow and safety but the hospital does not change tempo and respond accordingly. Develop internal professional standards - to define the expectations of how specialties will support one another to enable safe and timely decision making and flow CHS 23/09/2013 CHS 01/07/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Recruitment campaign for band 5 ED nursing staff. CHS Complete Recruitment campaign for band 6/7 ED nursing staff. CHS 01/09/2013 Development programme for band 5/6 nursing staff in ED to aid development and recruitment CHS 01/09/2013 Improving Care And Patient International recruitment campaign CHS 01/07/2013 Integrated UECPB Strategy: Version 12 Page 90 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE In ED / Hospital Improving Care And Patient In ED / Hospital Develop a workforce strategy - Recruitment, retention and development of clinical staff in ED has caused a reliance on bank and agency doctors / nurses of variable quality CHS 01/07/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Capacity Requirements for AMU/Short Stay CHS 01/06/2013 Reallocation of ward beds for Short Stay CHS 01/08/2013 Improving Care And Patient In ED / Hospital Staffing requirements AMU to ensure coverage for Non-Invasive Ventilation (NIV) and Ambulatory Care. 'Safe staffing' review to be undertaken. CHS 01/08/2013 Improving Care And Patient In ED / Hospital Winter - surge capacity CHS 01/07/2013 Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital There is a lack of intelligent performance data by specialty and site level to inform decision making / performance management. There is a lack of intelligent performance data by specialty and site level to inform decision making / performance management. Board rounds - Project Initiation Document completed Implementation plan complete - coveringgood ward based practice such as EDD, clinical criteria for discharge, daily / twice daily senior review, managing delays and escalation There is a significant component of Ambulatory Emergency Care already in place in CUH, however a formal programme of development for ambulatory emergency care which covers both ED and AMU. This should have a focus on the same day management of frail elderly. There are c50 ambulatory sensitive conditions which have the potential to be managed on a CHS 01/10/2013 CHS 01/08/2013 CHS 31/07/2013 CHS 31/05/2013 Integrated UECPB Strategy: Version 12 Page 91 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE same day type basis. Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital Improving Care And Patient In ED / Hospital There is a significant component of Ambulatory Emergency Care already in place in CUH, however a formal programme of development for ambulatory emergency care which covers both ED and AMU. This should have a focus on the same day management of frail elderly. There are c50 ambulatory sensitive conditions which have the potential to be managed on a same day type basis. The plans for ED represent a once in a generation opportunity to provide a clinical environment which will support the clinicians in providing first class care. Networking with EDs who have rebuilt there environments would support the development learning wise. Review of ED Psychiatric Liaison and adult mental health liaison and Drugs and Alcohol onward signposting and service availability CHS 03/06/2013 CHS 21/10/2013 CCG 21/10/2013 Improving Care And Patient In ED / Hospital Review ECIST 90 day action plan against trajectories and further develop against the focussed work arising from the risk summit. (RS1) CHS CCG 31/05/2013 Integrated UECPB Strategy: Version 12 Page 92 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital Establish a Rapid Response Service in the community and care homes within a two hour timeframe. Acute Pharmacy Croydon University Hospital Medicines discharge work steam review CHS 01/10/2013 CCG 18/10/2013 Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital Support for Continuing Care Assessment CHS 01/10/2013 Reduction of monitoring timescale from > 10 days LOS to >7 days LOS CHS 01/08/2013 Develop case for Discharge Coordinators CHS 01/08/2013 EDD setting and Board Rounds through use of pilot areas, extending throughout Hospital CHS 01/08/2013 Appropriate Flow For Patients Leaving Hospital Appropriate Flow For Patients Leaving Hospital To review the discharge policy and procedures to review how can be more integrated with whole systems Roll-out of 'Pharmacy Promise' across all wards. Ensuring that prescriptions completed the day before discharge are available on morning of discharge CHS 01/11/2013 CHS 01/08/2013 Appropriate Flow For Patients Leaving Hospital Implement one-stop dispensing across all wards CHS 01/08/2013 Appropriate Flow For Patients Leaving Hospital Service to be profiled on DOS in NHSP new release and a LOP developed to enable referrals through to service when appropriate 111 27/10/2013 Integrated UECPB Strategy: Version 12 Page 93 of 113

CATEGORY ACTION LEAD ORG or BOARD TIMESCALE At every opportunity 111 needs to be involved in processes out of hospital eg advising EVERY patient who attends ED/ is discharged from hospital / Has TTas needs encouragement to call 111 if their condition deteriorates Frequent flyers need special patient notes on 111 system to support 111 in managing these patients rather than sending them in Improving Care Clarifying Options When Returning To The Community Improving Care Clarifying Options When Returning To The Community Improving Care Clarifying Options When Returning To The Community Develop the Single Point of Assessment service such that access to social and community care services are enhanced through appropriate sign-posting and will enable a clinical face to face assessment within 2 hours. The CCG will procure 12 Intermediate Care Beds which will be able to support step up / step down community based facilities supported by the community teams, thus preventing or reducing an acute hospital admission. CHS 01/10/2013 CCG 01/10/2013 Improving Care Clarifying Options When Returning To The Community Use of blister and pre-labelled packs CHS 01/08/2013 Integrated UECPB Strategy: Version 12 Page 94 of 113

7.20. Appendix J: GP and Pharmacy Opening Hours PLEASE NOTE: Within this section (Appendix J) data relating to GP Opening hours and GP Same Day slots is still being verified and further data collected to complete the same day slot analysis. Mayday Nacscode Practice Mon Open Mon Close Tues Open Tues Close Wed Open Wed Close H83009 NORBURY HC 08:30 19:00 08:30 19:00 08:30 19:00 H83042 LEANDER ROAD 08:30 18:30 08:30 18:30 08:30 18:30 H83051 THORNTON ROAD 08:00 18:30 08:00 20:00 08:00 20:00 H83625 BROUGHTON CORNER 09:00 18:30 09:00 20:00 09:00 20:00 H83017 BRIGSTOCK MP 08:00 20:00 08:00 20:00 08:00 18:30 H83020 EVERSLEY MC 08:30 18:30 08:30 18:30 08:30 18:30 H83608 BRIGSTOCK 08:00 18:30 08:00 20:00 08:00 18:30 H83021 LINDEN LODGE (LONDON ROAD) 08:30 20:00 08:30 18:30 08:30 18:30 H83011 NORTH CROYDON 08:00 18:30 08:00 18:30 08:00 18:30 H83624 FAIRVIEW MC 08:00 20:00 08:00 18:30 08:00 14:30 H83634 VALLEY PARK SURGERY 08:30 18:30 08:30 18:30 08:30 13:30 Nacscode Practice Thurs Open Thurs Close2 Fri Open Fri Close Sat Open Sat Close H83009 NORBURY HC 08:30 19:00 08:30 19:00 H83042 LEANDER ROAD 08:30 18:30 08:30 18:30 H83051 THORNTON ROAD 08:00 20:00 08:00 18:30 09:00 11:00 H83625 BROUGHTON CORNER 09:00 18:30 09:00 18:30 H83017 BRIGSTOCK MP 08:00 20:00 08:00 18:30 09:00 12:00 H83020 EVERSLEY MC 08:30 18:30 08:30 18:30 H83608 BRIGSTOCK 08:00 18:30 08:00 18:30 09:00 12:00 H83021 LINDEN LODGE (LONDON ROAD) 08:30 18:30 08:00 18:30 H83011 NORTH CROYDON 08:00 19:30 08:00 19:30 H83624 FAIRVIEW MC 08:00 18:30 08:00 18:30 H83634 VALLEY PARK SURGERY 08:30 13:30 08:30 13:30 Table 16: Mayday GP Opening Hours Integrated UECPB Strategy: Version 12 Page 95 of 113

GP Same Day Slots Nacscode Practice Mon Tue Wed Thu Fri Sat H83009 NORBURY HC 70 60 60 60 60 H83042 LEANDER ROAD H83051 THORNTON ROAD AM: 27 PM: 15 AM: 27 PM: 16 AM: 27 PM: 17 AM: 27 PM: 18 AM: 27 PM: 19 12 H83625 BROUGHTON CORNER 27 27 27 27 27 H83017 BRIGSTOCK MP H83020 EVERSLEY MC H83608 BRIGSTOCK H83021 LINDEN LODGE (LONDON ROAD) H83011 NORTH CROYDON 25 13 14 10 16 H83624 FAIRVIEW MC H83634 VALLEY PARK SURGERY 5 5 5 5 5 Table 17: Mayday GP Same Day Slots Integrated UECPB Strategy: Version 12 Page 96 of 113

Pharmacy Mon Tue Wed Thu Fri Sat Sun Bank Holiday SUPERDRUG PHARMACY 1491-1493 LONDON ROAD, SW16 3LU SAINSBURY S PHARMACY 2 TRAFALGAR WAY, CR0 4XT PYRAMID PHARMACY 1351 LONDON ROAD, SW16 4BE PARADE PHARMACY 299A THORNTON ROAD, CR0 3EW MAYDAY COMMUNITY PHARMACY 514 LONDON ROAD, CR7 7HQ DAY LEWIS PHARMACY 1102 LONDON ROAD, SW16 4DT DAY LEWIS PHARMACY 2 PETERWOOD WAY, CR0 4UQ DAY LEWIS PHARMACY 506 LONDON ROAD, CR7 7HQ CRANSTON LTD 951 LONDON ROAD, CR7 6JE BOOTS VALLEY PLAZA RETAIL PARK, CR0 4YJ BRIGSTOCK PHARMACY 141 BRIGSTOCK ROAD, CR7 7JN BIDS CHEMIST 1495 LONDON ROAD, SW16 4AE ALPHAMED LTD 324-340 BENSHAM LANE, CR7 7EQ 09:00-18:00 09:00-18:00 09:00-18:00 09:00-18:00 09:00-18:00 09:00-18:00 Closed Closed 07:00-23:00 07:00-23:00 07:00-23:00 07:00-23:00 07:00-23:00 07:00-22:00 10:00-16:00 Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-18:00 Closed Closed 09:00-13:00 14:00-18:30 09:00-13:00 14:00-19:00 09:00-13:00 14:00-19:00 09:00-13:00 14:00-19:00 09:00-13:00 14:00-18:30 09:00-13:00 Closed Closed 09:00-22:00 09:00-22:00 09:00-22:00 09:00-22:00 09:00-22:00 09:00-22:00 09:00-22:00 Closed 09:00-13:00 14:00-18:30 09:00-13:00 14:00-18:30 09:00-13:00 14:00-18:30 09:00-13:00 14:00-18:30 09:00-13:00 14:00-18:30 09:00-13:00 Closed Closed 09:00-17:00 09:00-17:00 09:00-17:00 09:00-17:00 09:00-17:00 Closed Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-13:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 Closed Closed Closed 09:00-23:59 09:00-23:59 09:00-23:59 09:00-23:59 09:00-23:59 09:00-23:59 11:00-17:00 Closed 09:00-18:00 09:00-18:00 09:00-18:00 09:00-18:00 09:00-18:00 09:00-12:00 Closed Closed 09:00-17:30 09:00-17:30 09:00-17:30 09:00-17:30 09:00-17:30 09:00-13:00 Closed Closed 08:30-17:00 08:30-17:00 08:30-17:00 08:30-17:00 08:30-17:00 Closed Closed Closed Table 18: Mayday Pharmacy Opening Hours Integrated UECPB Strategy: Version 12 Page 97 of 113

Thornton Heath Nacscode Practice Mon Open Mon Close Tues Open Tues Close Wed Open Wed Close H83037 AUCKLAND SURGERY 08:00 18:30 08:00 18:30 07:15 13:00 H83010 SOUTH NORWOOD HILL MC 08:00 18:30 08:00 18:30 / 20:00 08:00 18:30 / 20:00 H83005 UPPER NORWOOD GRP PRAC 08:30 18:30 08:30 18:30 08:30 18:30 H83041 SOUTH NORWOOD MC 08:30 18:30 08:30 20:00 08:30 14:00 H83609 MERSHAM MC 08:00 18:30 / 20:00 08:00 18:30 08:00 18:30 H83622 SOUTH NORWOOD MP 09:00 19:00 09:00 19:00 09:00 14:00 H83053 PARCHMORE MC 08:00 18:30 08:00 18:30 08:00 18:30 H83022 THORNTON HEATH HC 08:30 18:30 08:30 18:30 08:30 18:30 Nacscode Practice Thurs Open Thurs Close Fri Open Fri Close Sat Open Sat Close H83037 AUCKLAND SURGERY 08:00 18:30 08:00 18:30 08:30 10:15 H83010 SOUTH NORWOOD HILL MC 08:00 18:30 / 20:00 08:00 18:30 H83005 UPPER NORWOOD GRP PRAC 08:30 18:30 08:30 18:30 09:00 11:00 H83041 SOUTH NORWOOD MC 08:30 18.30 08:30 18:30 H83609 MERSHAM MC 08:00 18:30 08:00 18:30 H83622 SOUTH NORWOOD MP 09:00 18:00 09:00 18:00 H83053 PARCHMORE MC 08:00 18:30 08:00 18:30 H83022 THORNTON HEATH HC 08:30 18:30 08:30 18:30 08:30 12:00 Table 19: Thornton Heath GP Opening Hours Integrated UECPB Strategy: Version 12 Page 98 of 113

GP Same Day Slots Table 20: Thornton Heath GP Same Day Slots Pharmacy Mon Tue Wed Thu Fri Sat Sun Bank Holiday SUPERDRUG PHARMACY 1-2 COTFORD PARADE, CR7 7JG SAINSBURY PHARMACY 66 WESTOW STREET, SE19 3RW SAINSBURY PHARMACY 122 WHITEHORSE LANE, SE25 6XB THOMPSONS CHEMIST 86-88 BEULAH ROAD, CR7 8JF THORNTON HEATH PHARMACY 27 HIGH STREET, CR7 8RU WILKES CHEMIST 105 PARCHMORE ROAD, CR7 8LZ LLOYDS PHARMACY 130 CHURCH ROAD, SE19 2NT KLUB PHARMACY LTD 10 CROWN POINT PARADE, SE19 3NG 08:30-19:00 08:30-19:00 08:30-19:00 08:30-19:00 08:30-19:00 08:30-19:00 10:00-16:00 Closed 07:00-23:00 07:00-23:00 07:00-23:00 07:00-23:00 07:00-23:00 07:00-22:00 11:00-17:00 Closed 08:00-21:00 08:00-21:00 08:00-21:00 08:00-21:00 08:00-21:00 07:30-20:00 10:00-17:00 Closed 08:30-18:30 08:30-18:30 08:30-18:30 08:30-13:00 08:30-18:30 08:30-13:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-13:00 Closed Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-13:00 Closed Closed 08:30-19:00 08:30-19:00 08:30-19:00 08:30-19:00 08:30-19:00 09:00-12:00 Closed Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-14:30 Closed Closed DAY LEWIS PHARMACY 283 SOUTH NORWOOD HILL, SE25 6DP DAY LEWIS PHARMACY 3 HIGH STREET, SE25 6EP 09:00-13:00 14:00-18:00 Table 21: Thornton Heath Pharmacy Opening Hours 09:00-13:00 14:00-18:00 09:00-13:00 14:00-18:00 09:00-13:00 14:00-18:00 09:00-13:00 14:00-18:00 09:00-13:00 Closed Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-16:30 Closed Closed Integrated UECPB Strategy: Version 12 Page 99 of 113

Woodside / Shirley Nacscode Practice Mon Open Mon Close Tues Open Tues Close Wed Open Wed Close H83033 ASHBURTON PARK 08:00 19:30 08:00 18:30 08:00 13:00 H83029 HARTLAND WAY 08:00 18:30 08:00 18:30 08:00 18:30 H83035 SOUTH WAY 08:00 19:00 08:00 20:00 08:00 19:00 H83025 WOODSIDE 08:00 18:30 08:00 18:30 07:30 20:00 H83030 SPRING PARK 08:30 18:30 08:30 13:00 08:30 20:30 H83008 THE ADDISCOMBE 08:00 17:00 08:00 13:00 08:00 19:00 H83039 STOVELL HOUSE 08:30 20:00 08:30 18:30 08:30 18:30 H83626 WOODSIDE 08:30 18:30 08:30 18:30 08:30 20:00 H83001 PORTLAND 08:00 20:00 08:00 20:00 07:30 18:30 H83043 SHIRLEY MEDICAL CENTRE 08:00 18:30 08:00 18:30 08:00 20:00 Nacscode Practice Thurs Open Thurs Close Fri Open Fri Close Sat Open Sat Close H83033 ASHBURTON PARK 08:00 19:00 08:00 18:30 H83029 HARTLAND WAY 08:00 18:30 08:00 18:30 H83035 SOUTH WAY 08:00 15:30 08:00 19:00 H83025 WOODSIDE 08:00 18:30 08:00 18:30 H83030 SPRING PARK 08:30 18:30 08:30 18:30 H83008 THE ADDISCOMBE 08:00 17:00 08:00 17:00 H83039 STOVELL HOUSE 08:30 18:30 08:30 18:30 H83626 WOODSIDE 08:00 18:30 08:00 18:30 H83001 PORTLAND 08:00 18:30 08:00 18:30 09:00 11:00 H83043 SHIRLEY MEDICAL CENTRE 08:00 13:00 08:00 18:30 Table 22: Woodside / Shirley GP Opening Hours Integrated UECPB Strategy: Version 12 Page 100 of 113

GP Same Day Slots Table 23: Woodside and Shirley Same Day Slots Integrated UECPB Strategy: Version 12 Page 101 of 113

Pharmacy Mon Tue Wed Thu Fri Sat Sun Bank Holiday TESCO STORES LIMITED 32 BRIGSTOCK ROAD, CR7 8RX MC COIG PHARMACY 143 WICKHAM ROAD, CR0 8TE MONA PHARMACY 246 WICKHAM ROAD, CR0 8BJ LLOYDS PHARAMACY 156 PORTLAND ROAD, SE25 4PT LARCHWOOD PHARMACY 215 LOWER ADDISCOMBE ROAD, CR0 6RB GREENCHEM 20 BYWOOD AVENUE, CR0 7RA GREENCHEM 15 BROOM ROAD, CR0 8NG FISHERS ENMORE PHARMACY 1 ENMORE ROAD, SE25 5NT BOOTS 257 LOWER ADDISCOMBE ROAD, CR0 6RD ADDISCOMBE PHARMACY 302 LOWER ADDISCOMBE ROAD, CR0 7AE SHIRLEY PHARMACY 175 SHIRLEY ROAD, CR0 8SS 08:00-21:00 08:00-21:00 08:00-21:00 08:00-21:00 08:00-21:00 08:00-21:00 10:00-16:00 Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-13:00 Closed Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-13:00 Closed Closed 08:00-22:30 08:00-22:30 08:00-22:30 08:00-22:30 08:00-22:30 08:00-22:30 09:30-22:30 Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-18:00 Closed Closed 09:00-13:00 14:00-18:30 09:00-13:00 14:00-19:00 09:00-13:00 14:00-18:30 09:00-13:00 14:00-19:00 09:00-13:00 09:00-13:00 14:00-18:30 09:00-13:00 09:00-13:00 14:00-19:00 09:00-13:00 14:00-18:30 09:00-13:00 14:00-19:00 09:00-17:00 Closed Closed 09:00-13:00 14:00-19:00 Closed Closed 08:00-22:00 08:00-22:00 08:00-22:00 08:00-22:00 08:00-22:00 08:00-18:00 11:00-13:00 Closed 09:00-17:30 09:00-17:30 09:00-17:30 09:00-17:30 09:00-17:30 09:00-17:30 Closed Closed 09:00-18:00 09:00-18:00 09:00-17:30 09:00-18:00 09:00-18:00 09:00-13:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-17:00 Closed Closed Table 24: Woodside / Shirley Pharmacy Opening Hours Integrated UECPB Strategy: Version 12 Page 102 of 113

New Addington / Selsdon Nacscode Practice Mon Open Mon Close Tues Open Tues Close Wed Open Wed Close H83028 PARKWAY 08:00 20:00 08:00 20:00 08:00 20:00 H83049 HEADLEY DRIVE 08:00 18:30 08:00 20:00 08:00 13:30 H83004 FARLEY ROAD 08:00 18:30 08:00 20:00 08:00 20:00 H83027 PARKWAY 08:00 20:00 08:00 20:00 08:00 20:00 H83014 QUEENHILL 08:00 18:30 08:00 18:30 08:00 20:00 H83046 FIELDWAY 08:30 20:00 08:30 18:30 08:30 18:30 H83018 SELSDON PARK 08:00 20:00 08:00 18:00 08:00 20:00 H83006 PARKWAY 08:00 20:00 08:00 20:00 08:00 20:00 Nacscode Practice Thurs Open Thurs Close Fri Open Fri Close Sat Open Sat Close H83028 PARKWAY 08:00 18:30 08:00 18:30 09:00 12:00 H83049 HEADLEY DRIVE 08:00 18:30 08:00 18:30 09:00 12:00 H83004 FARLEY ROAD 08:00 18:30 08:00 18:30 08:30 11:30 H83027 PARKWAY 08:00 18:30 08:00 18:30 09:00 12:00 H83014 QUEENHILL 08:00 20:00 08:00 18:30 H83046 FIELDWAY 08:30 19:30 08:30 18:30 H83018 SELSDON PARK 08:00 18:00 08:00 18:00 H83006 PARKWAY 08:00 18:30 08:00 18:30 09:00 12:00 Table 25: New Addington / Selsdon GP Opening Hours Integrated UECPB Strategy: Version 12 Page 103 of 113

GP Same Day Slots Table 26: New Addington and Selsdon GP Same Day Slots Pharmacy Mon Tue Wed Thu Fri Sat Sun Bank Holiday BOOTS 1 CENTRAL PARADE, CR0 0JB LLOYDS PHARMACY 123 ADDINGTON ROAD, CR2 8LH LLOYDS PHARMACY 97 ADDINGTON ROAD, CR2 8LG HARRIS CHEMIST LTD 3 CROSSWAYS PARADE, CR2 8JJ GOLDMANTLE PHARMACY 2 FORESTDALE CENTRE, CR0 9AS FIELDWAY PHARMACY 3 WAYSIDE, CR0 9DX DOUGANS CHEMIST 114 HEADLEY DRIVE, CR0 0QF 08:00-20:00 08:00-20:00 08:00-20:00 08:00-20:00 09:00-20:00 09:00-17:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-13:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-13:00 Closed Closed 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-19:00 09:00-17:30 Closed Closed 09:00-19:30 09:00-19:30 09:00-19:30 09:00-19:30 09:00-19:30 09:00-18:00 09:00-15:00 Closed 08:30-20:00 08:30-18:30 08:30-18:30 08:30-19:30 08:30-18:30 10:00-14:00 Closed Closed 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-18:30 09:00-13:00 Closed Closed DAY LEWIS PHARMACY 150 ADDINGTON ROAD, CR2 8LB AUMEX PHARMACY 43-44 CENTRAL PARADE, CR0 0JD 09:00-12:00 13:00-18:00 Table 27: New Addington / Selsdon Pharmacy Opening Hours 09:00-12:00 13:00-18:00 09:00-12:00 13:00-18:00 09:00-12:00 13:00-18:00 09:00-12:00 13:00-18:00 09:00-12:00 13:00-17:30 Closed Closed 08:00-19:00 08:00-19:00 08:00-19:00 08:00-19:00 08:00-19:00 09:00-17:30 Closed Closed Integrated UECPB Strategy: Version 12 Page 104 of 113

Purley Nacscode Practice Mon Open Mon Close Tues Open Tues Close Wed Open Wed Close H83620 COULSDON 09:00 17:30 09:00 17:30 09:00 10:00 H83013 OLD COULSDON 07:00 19:30 07:00 19:30 07:00 19:30 H83052 BRAMLEY AVENUE 08:30 18:30 08:30 19:30 08:30 13:30 H83024 THE WOODCOTE GROUP 08:00 18:00 08:00 20:00 08:00 20:00 H83616 PURLEY 08:00 19:30 08:00 18:30 07:30 18:30 H83015 PARKSIDE GROUP 07:30 19:30 07:30 19:30 09:30 18.00 H83016 KESTON HOUSE 08:00 18:30 07:00 18:30 07:00 18:30 H83048 DOWNLAND 08:30 19:30 08:30 19:30 08:30 14:00 H83050 THE MOORINGS 08:00 18:30 08:00 18:30 08:00 19:30 Nacscode Practice Thurs Open Thurs Close Fri Open Fri Close Sat Open Sat Close H83620 COULSDON 09:00 17:30 09:00 17:30 H83013 OLD COULSDON 07:00 19:30 07:00 19:30 H83052 BRAMLEY AVENUE 08:30 18:30 08:30 18:30 H83024 THE WOODCOTE GROUP 08:00 20:00 08:00 18:00 09:00 11:30 H83616 PURLEY 08:00 18:30 08:00 18:30 H83015 PARKSIDE GROUP 07:30 18:00 07:30 18.00 H83016 KESTON HOUSE 07:00 18:30 08:00 20:00 H83048 DOWNLAND 08:30 19:00 08:30 19:00 H83050 THE MOORINGS 08:00 19:30 08:00 18:30 Table 28: Purley GP Opening Hours Integrated UECPB Strategy: Version 12 Page 105 of 113

GP Same Day Slots Table 29: Purley GP Same Day Slots Integrated UECPB Strategy: Version 12 Page 106 of 113