Urgent Care Services

West Midlands Urgent Care Clinical Pathway Group Urgent Care Services West Midlands Overview Report Report Date: March 2011 Visit Dates: May to November 2010 Images courtesy of The Stroke Association, Sandwell & West Birmingham NHS Trust and NHS Photo Library WMQRS Urgent Care overview report V1 20110405.doc 1

CONTENTS Key Points... 3 Introduction... 5 Health Economy... 8 Primary Care... 11 Ambulance Service... 14 Acute Trust-Wide... 15 Emergency Departments... 17 Acute Medical and Surgical Admissions... 18 Commissioning... 20 Quality Standards and Peer Review Process... 20 Appendix 1 Health Economy Urgent Care Checklist... 22 Appendix 2 Compliance with Quality Standards... 23 Appendix 3 Abbreviations used in this Report... 30 WMQRS Urgent Care overview report V1 20110405.doc 2

URGENT CARE SERVICES WEST MIDLANDS OVERVIEW REPORT KEY POINTS 1 This report summarises the conclusions of the 2010 peer review visits to West Midlands services for urgent care services which reviewed compliance with WMQRS Quality Standards for Urgent Care Services and identified related issues. One hundred and forty nine reviewers, mostly from the West Midlands, took part in the review visits and therefore received development and learning (Continuing Professional Development) from the programme. 2 The overall impression of urgent care services across the West Midlands was that services were working under extreme pressure and, in some cases this was putting an intolerable burden on staff. There was striking variation in the culture and approach to urgent care. Some health economies, or individual services within Trusts, were actively managing the pathway and finding ways to improve patient care. Others were bogged down in coping with the ongoing flow of patients and saw the difficulties they faced as inevitable and insoluble. Most worrying was a small number of examples of unacceptable patient care which staff had come to accept as the norm, because they saw no alternative, and where staff no longer filled in incident forms because they thought that nothing happened as a result. 3 The percentage compliance with the applicable Quality Standards for health economy urgent care Quality Standards (including primary care and acute Trust urgent care services and commissioning Standards) ranged from 54% to 72%. 4 Services should be working to meet all of the applicable Quality Standards. The peer review visits identified some issues which are key to improving the urgent care pathway. Appendix 1 gives a checklist, based on the peer review visit findings, which health economies could use to review their priorities for action. The Steering Group recommends that all health economies regularly review their progress against this checklist. 5 Patient flow through the urgent care pathway was a problem in most health economies. Two Trusts were not experiencing problems to the same extent. Both of these Trusts were commended for the speed and responsiveness of their imaging and pathology services. 6 The patient pathway for people with mental health problems was proving difficult in nearly all health economies. Most Emergency Departments and Acute Medical Admissions Units did not have staff with the expected mental health-related competences. It was also common for there to be delays in response from mental health services, especially outside normal working hours. Mental health crisis teams would respond but not within the expected timescales and so patients experienced long waits, or were admitted, while awaiting an assessment. Mental health liaison teams in acute Trusts often did not cover patients of all ages and all common presentations and the staff providing these services often had a very high workload with little or no cover for absences. Services were often individual dependent rather than being based on sustainable systems and processes 7 Compliance with applicable Quality Standards for the 34 primary care services reviewed (Minor Injuries Units, Urgent Care Centres, Walk-in Centres, and GP led health centres) ranged from 36% to 88%. Some services were excellent but there was considerable variability in the range of services offered at different places. The range of services available also varied at different times of day or depended on who was on duty. NHS Direct achieved 100% compliance with applicable Quality Standards. WMQRS Urgent Care overview report V1 20110405.doc 3

8 GP Out of Hours services were generally well organised and, in some cases, impressive. Staff training, guidelines and protocols and governance arrangements were often being improved in response to recent reports and PCT and SHA assurance processes. 9 A range of issues impacting on the urgent care pathway at a Trust-wide level were evident during the reviews. Responsive imaging, pathology and pharmacy services were crucial to effective patient flow. Some Trusts did not have robust, easily accessible clinical guidelines. Bed management arrangements varied considerably with some Trusts heavily reliant on frequent bed management meetings. There was less evidence of data being used proactively to predict and manage capacity. Some Trusts could not easily evidence that staff had appropriate competences for their roles. There was also variability in the use of extended roles for nursing and therapy staff. 10 There were many examples of good practice in Emergency Departments and acute medical and surgical admissions units. Reviewers were particularly impressed by the services which had achieved rapid review by Senior Decision Makers, good availability of acute medicine clinics and good in-reach by specialty-specific teams. 11 In many Emergency Departments reviewed the problems of patient flow were so severe that patients brought by ambulance were queuing in corridors or waiting in ambulances until they could be seen. Senior medical staffing was an issue in 10 Emergency Departments and nurse staffing levels were low in eight services. The environment in two Emergency Departments was considered unfit for purpose. Appropriate governance arrangements were not in place in some Departments. Availability of physiotherapy and occupational therapy was not clearly defined in the Quality Standards but good availability of these services clearly improved the flow of patients through the Department. 12 Eight acute medicine or surgery units did not have robust arrangements for review by a senior decision-maker within twelve hours of admission even though other services were moving towards rolling ward rounds. This was a particular problem at night and weekends when cover was usually from general medical or surgical consultants. Low nurse staffing levels were identified in 15 services and some issue about nursing competences in 16 services. 13 Acute medicine and surgery units sometimes did not have the same response from imaging and pathology services as Emergency Departments and some did not have good availability of physiotherapy and occupational therapy staff. WMQRS Urgent Care overview report V1 20110405.doc 4

INTRODUCTION 14 This report summarises the findings of the 2010 peer review visits to West Midlands urgent care services. This review programme was sponsored by the West Midlands Urgent Care Pathway Group on behalf of NHS organisations in the West Midlands. These visits reviewed compliance with the WMQRS Quality Standards for Urgent Care Services (2010) and identified related issues. These Quality Standards are based on national guidance on the provision of urgent care services. (Full references are given in the Quality Standards which are available on the WMQRS website: www.wmqi.westmidlands.nhs.uk/wmqrs. 15 The aim of the standards and peer review programme was that: a. Service providers and commissioners will work together to improve service quality. b. Quality review visits will give an independent view of service quality. c. Reviewers will learn from taking part in review visits. d. Good practice will be shared. e. Patients and their families and carers will know more about services they can expect. f. Commissioners will have better service specifications. g. Service providers and commissioners will have better information to give to the Care Quality Commission and Monitor. 16 The reports of the review visits to each health economy are available on the WMQRS website www.wmqi.westmidlands.nhs.uk/wmqrs. The visits identified many examples of good practice. These are listed in the reports of each visit and a good practice sharing event was held on 5 th November 2010. More information on the good practice identified through the visits is available on https://groups.itsservices.org.uk/display/ucsgp/home. A further good practice event for acute surgical teams will be organised in 2011. This Overview Report inevitably dwells on some of the problems with urgent care services in the West Midlands. It must be read with the understanding that NHS organisations in the West Midlands agreed to undertake the peer review visits in order to help improve the quality of clinical services. We are the first region to have such a programme and knowledge of the weaknesses of our services will give us a greater chance of making them better. 17 This report describes the situation at the time of the peer review visits (May to November 2010). Services may have changed and developed since these visits. 18 Visits took place to all health economies across the West Midlands except for South Birmingham (Table 1). The visits looked at the patient pathway from first contact with urgent care through to discharge or transfer to the care of an appropriate specialty-specific team. The primary care reviews covered GP Out of Hours Services, Walkin Centres, Urgent Care Centres, Minor Injuries Units and NHS Direct. The patient pathway continued through the West Midlands Ambulance Service to Emergency Departments and general acute medical and surgical admissions. The Quality Standards and review visits concentrated on the first 24 hours of admission as patients should normally be transferred to an appropriate specialty-specific team during this time. Related Trust-wide and commissioning Quality Standards were also reviewed. 19 The reviews covered a range of primary care services (table 2). Reviewers met staff from each of these services and, in most cases, reviewers also visited the facilities. This was not possible for all Minor Injuries Units in rural areas and compliance with a few Quality Standards at five services was therefore based on the service s selfassessment 1. 1 Each visit report states whether or not services were visited and, where applicable, compliance based on selfassessment is identified in the Appendix. WMQRS Urgent Care overview report V1 20110405.doc 5

Table 1 Urgent Care Reviews 2 Service No. reviews Primary Care 45 Ambulance Service 1 Emergency Department * 20 Acute Medical Admissions 17 Acute Medical & Surgical Admissions (combined units) 2 Acute Surgical Admissions 16 Acute Trust-wide 14 Commissioning** 16 131 *Includes one Emergency Department with a combined Surgical Assessment Unit Table 2 Primary Care Services Reviews Primary Care Services No. reviews GP Out of Hours 8 Urgent Care Centre and GP Out of Hours combined 2 Subtotal 10 Walk-in Centre 13 Urgent Care Centres 5 Minor Injuries Units 16 Subtotal 34 NHS Direct 1 45 20 Primary care reviews covered both NHS and independent providers of services and reviewers included NHS and independent sector staff. Communication with primary care service providers was through the PCT urgent care lead. This communication did not always work well and some providers had very short notice that the review was taking place. This issue is discussed in further in section 75. In addition to the South Birmingham services, one Minor Injuries Unit in Herefordshire was not reviewed because of particular local issues. The GP Out of Hours service for Wolverhampton was not reviewed at the same time as other Wolverhampton health economy services because of an imminent change of provider. 3 21 Table 3 shows the dates on which services were visited. The urgent care reviews took place alongside reviews of critical care, stroke (acute phase) and TIA, and vascular services. Links between services were also considered. 22 Table 4 shows the number of reviewers of different disciplines who took part in the reviews of urgent care services. A total of 161 reviewers were trained and 149 undertook at least one visit and sometimes more than 2 This represents all urgent care services identified by health economies except for: South Birmingham (including University Hospital Birmingham NHS Foundation Trust and primary care services); one Minor Injuries Unit in Herefordshire and the Wolverhampton GP Out of Hours Service. These services could be reviewed at a later date if required. 3 The new provider is PrimeCare whose systems were reviewed in other health economies. The premises used were reviewed as part of the Wolverhampton visit. WMQRS Urgent Care overview report V1 20110405.doc 6

one. Participation in training and review visits is Continuing Professional Development (CPD) for staff and table 4 therefore also shows the CPD benefit that organisations have gained from this review programme. Table 3 Visit dates Health Economy Acute Trust Visit dates 2010 South Warwickshire South Warwickshire NHS Foundation Trust 11 May North Warwickshire George Eliot Hospital NHS Trust 20 May Herefordshire Hereford Hospitals NHS Trust 16 June Worcestershire Worcestershire Acute Hospitals NHS Trust 22 & 23 June South Staffordshire (West) Locality Mid Staffordshire NHS Foundation Trust 30 June North Staffordshire University Hospital of North Staffordshire NHS Trust 7 July South Staffordshire (East) Locality Burton Hospitals NHS Foundation Trust 14 July Coventry and Rugby University Hospitals Coventry & Warwickshire NHS Trust 7 & 8 September Wolverhampton The Royal Wolverhampton Hospitals NHS Trust 22 September Shropshire Shrewsbury & Telford Hospital NHS Trust 28 & 29 September Dudley Dudley Group of Hospitals NHS Foundation Trust 6 October Heart of Birmingham and Sandwell Sandwell & West Birmingham Hospitals NHS Trust 13 & 14 October Walsall Walsall Hospitals NHS Trust 19 October Birmingham East & North and Solihull NHS Direct Heart of England NHS Foundation Trust 16 & 17 November 19 October West Midlands Ambulance Service NHS Trust 9 November Table 4 Urgent Care Specific Reviewers Background No. Trained No. Reviewed Background No. Trained No. Reviewed User/carer 13 11 Acute Medical Admissions Commissioning 8 8 Consultant Nurse 9 10 9 5 Primary Care Acute Surgical Admissions GP Nurse/ Manager 6 9 6 4 Consultant Nurse 1 8 4 5 NHS Direct Acute Trust-wide West Midlands Out of region Ambulance Service WMAS Out of region 1-12 - 0 2 10 4 Mental health liaison Pharmacist Imaging Anaesthetist Business management 4 2 3 3 17 4 2 4 6 15 WMQRS Urgent Care overview report V1 20110405.doc 7

Background No. Trained No. Reviewed Background No. Trained No. Reviewed Emergency Department Health economy-wide Consultant Nurse 29 14 17 9 Governance Executive Lead 12-10 14 161 149 Notes: 1 All except one of the trained reviewers were offered the opportunity to review. 2 The number trained column indicates those who attended urgent care or governance training. Reviewers trained through cancer, renal or critically ill children programmes are not included in this number. Out of region reviewers are trained on the day rather than attending specific training. Executive leads had a briefing telephone call but did not attend a training session. 3 Executive leads and imaging, anaesthetist, allied health professional, business management, governance and commissioning reviewers also contributed to the reviews of critical care, stroke (acute phase) & TIA and vascular services. 23 The remaining sections of this report summarise the findings of the peer review visits and, in particular, identify issues which were common across the region or which may have region-wide implications. For each finding, the number of services to which it was applicable is given in brackets. Similar issues could be categorised differently, depending on the particular local circumstances. For example, a finding that was an immediate risk in two services, a concern in six and suggested for further consideration in four is shown as (IR:2; C:6; FC:4). Some overall findings are based on the conclusions of the Steering Group, most of whom had participated in several reviews. 24 Services should be working to meet all of the applicable Quality Standards. The peer review visits have, however, identified some issues which are key to improving the urgent care pathway. Appendix 1 gives a checklist, based on the peer review visit findings, which health economies could use to review their priorities for action. The Steering Group recommends that all health economies regularly review their progress against this checklist. HEALTH ECONOMY 25 The overall impression of urgent care services across the West Midlands was that services were working under extreme pressure and, in some cases this was putting an intolerable burden on staff. There was striking variation in the culture and approach to urgent care. Some health economies, or individual services within Trusts, were actively managing the pathway and finding ways to improve patient care. Others were bogged down in coping with the ongoing flow of patients and saw the difficulties they faced as inevitable and insoluble. Most worrying was a small number of examples of unacceptable patient care which staff had come to accept as the norm, because they saw no alternative, and where staff no longer filled in incident forms because they thought that nothing happened as a result. Overall Compliance with Quality Standards 26 The percentage compliance with the applicable Quality Standards for health economy urgent care Quality Standards (including primary care and acute Trust urgent care services and commissioning Standards) ranged from 54% to 72% (Figure 1 4 ). The compliance reflects the situation at the time of the peer review visit and the situation may have changed since then (although experience from other review programmes is that some aspects of the quality of care change relatively slowly). Comparisons of percentage compliance should be viewed 4 All graphs of percentage compliance are in visit order. Early visits (especially South Warwickshire and North Warwickshire) had significantly less time to prepare than those services reviewed later in the programme. WMQRS Urgent Care overview report V1 20110405.doc 8

with caution as a different number of services were reviewed in each health economy and because Quality Standards are not of equal importance. Overall risk scores are also being developed for each service. Risk scores and percentage compliance taken together give a more reliable indication of the structure and process aspects of the quality of care for patients accessing urgent care services. Appendix 2 shows the number of services meeting each individual Quality Standard. This allows individual services to compare their compliance with others. Patient Flow 27 Patient flow through the urgent care pathway was a problem in most health economies (IR:1; C:8; FC: 3) 5. South Staffordshire (East) (Burton Hospitals NHS Foundation Trust) and Coventry / Rugby (University Hospitals Coventry and Warwickshire NHS Trust (UHCW)) were not experiencing problems to the same extent. In addition to efficient organisation of the patient pathway, both these Trusts were commended for the speed of response of their imaging and pathology services and for their information systems. 28 There were many reasons for delays in patient flow through the urgent care pathway, as described in the rest of this report. All health economies were actively working to improve patient flow and some were actively seeking external guidance from known experts in this field or from other hospitals that had successfully addressed issues. The extent of health economy-wide understanding of the changes which needed to be made and the expected impact of these changes was much more variable. In general, PCTs faith in admission avoidance was not shared by colleagues in acute Trusts. Clinical staff in acute Trusts were often not aware of the admission avoidance schemes which were operating in their area and one PCT manager thought that they did not need to know. Reviewers identified potential for improving patient flow in nearly all health economies. Only one hospital 6 had significant problems with patient flow despite having implemented many of the expected improvements to the patient pathway. 5 IR: North Warwickshire; C: South Warwickshire, Herefordshire, Worcestershire, Shropshire, North Staffordshire, South Staffordshire (West), Walsall, BEN & Solihull; FC: Wolverhampton, Sandwell & Heart of Birmingham, Dudley. 6 Birmingham Heartlands Hospital WMQRS Urgent Care overview report V1 20110405.doc 9

29 Some health economies had the equivalent of one or two acute wards occupied by patients who were medically fit for discharge. This aspect of the patient pathway was outside the scope of the review visits. It was apparent, however, that different health economies were tackling the issue with varying approaches and varying vigour. Some, for example, North Staffordshire, were giving this issue a great deal of senior management attention whereas others appeared to accept it as a fact of life. Some systems for more complex discharges, for example, those in Birmingham East and North health economy, appeared to be working well. 30 Health economies with significant patient flows from Wales or other regions experienced difficulties with out-ofregion ambulance liaison, admission avoidance and discharges. Care for People with Mental Health Problems 31 Care within the urgent care pathway of people with mental health problems was of significant concern across the region (IR:1; C:12 7 ). At the time of the reviews, the only health economies meeting the expected Quality Standards for the care of people with mental health problems were Herefordshire and a pilot service RAID for Heart of Birmingham residents at City Hospital (Sandwell and West Birmingham NHS Trust (S&WBH)). A speedy response was available at all times of day and night and reviewers commented particularly on the attitude and approach that mental health services felt they had a responsibility to respond quickly to someone in an Emergency Department or Acute Medical Admissions Unit who needed a mental health assessment. Good inhours support was available at Mid Staffordshire NHS Foundation Trust. The Aquarius Service commissioned by Birmingham East and North PCT to support Good Hope and Birmingham Heartlands Hospitals was also commended. This service was proactive in working with wards and departments to identify patients with drug or alcohol-related problems who might benefit from short interventions. 32 Other health economies had a range of problems. National guidance expects that, in Emergency Departments (ED) and units accepting acute medical admissions (AMU), at least one nurse per shift should have competences in the assessment and management of people with mental health problems or dementia. This Quality Standard was met in only five per cent of services. Mental health services were then rarely able to respond within the expected timescales 8 : a. Appropriate initial assessment by a competent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas b. Appropriate initial assessment by a competent child and adolescent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas for young people c. Mental Health Act assessment by a Section 12 approved person within 60 minutes in urban areas and 120 minutes in rural areas d. Mental health in-patient facility able to admit patients within one hour of the decision to admit. 33 Only seven per cent of EDs and AMUs met the relevant Quality Standard (AE / AF-307) on mental health assessment. Most common were delays in response outside normal working hours. Mental health crisis teams would respond but not within the expected timescales and so patients experienced long waits, or were admitted, while awaiting an assessment. One of the worst examples was an answer-phone message which said we will contact you within four hours but, if you haven t heard from us within that timescale, please ring again. Waits for assessments of many hours and sometimes days were reported. Reviewers were concerned that this was inappropriate care for the patients, often caused distress to the patients themselves, their families and other patients, and placed significant pressure on staff within EDs and AMUs. Staff in acute Trusts said that response times were slow because patients were considered to be in a place of safety and so were not a priority for Crisis Team response. 7 All health economies were either a concern or immediate risk except Herefordshire and Heart of Birmingham (City Hospital) 8 QS AE-307 & AF-307: based on Managing Mental Health Needs in the Acute Trust, Academy of Medical Royal Colleges (2008) WMQRS Urgent Care overview report V1 20110405.doc 10

34 Most health economies had better arrangements for access to mental health assessment in normal working hours, but these were far from robust. One had no mental health liaison service with time allocated for their work in the acute Trust 9. Others had services for some age groups (for example, for under 65s or for over 65s) or presentations (for example, a service for people with deliberate self-harm or people with alcohol problems) but not for people of all ages and all common presentations. It was also common for the liaison service to be provided by one or two CPNs, sometimes with very high workloads, and with little or no cover for absences. Some of the most heart-wrenching reviewer quotes were about the care of people with mental health problems including: staff say the way to get a mental health assessment is to take the patient outside the Emergency Department and let them be arrested the mental health services respond quickly to calls from the police. PRIMARY CARE Walk-in Centres, Urgent Care Centres, Minor Injuries Units 35 Primary care services which contributed to the urgent care pathway included Minor Injuries Units, Walk-in Centres, Urgent Care Centres and GP led health centres. Compliance with applicable Quality Standards for the 34 services reviewed ranged from 36% to 88% (Figure 2). Worcestershire and Shropshire MIUs had combined assessments Key to abbreviations for figure 2: Key Health Economy Services 1A South Warwickshire Minor Injuries Unit, Stratford 1B Minor Injuries Unit, Ellen Badger Community Hospital 2 Herefordshire Minor Injuries Unit, Hereford 3 Worcestershire Minor Injuries Units: Bromsgrove, Malvern, Tenbury, Evesham & Kidderminster 4 South Staffordshire (West ) locality Minor Injuries Unit, Cannock 5A North Staffordshire Walk in Centre, Haywood 9 Wolverhampton WMQRS Urgent Care overview report V1 20110405.doc 11

Key Health Economy Services 5B 5C 6A 6B 6C South Staffordshire (East) locality Minor Injuries Unit, Leek Walk in Centre, The Midway Minor Injuries Unit, Lichfield Minor Injuries Unit, Tamworth GP, Burntwood 7 Coventry Walk in Centre, (Assura LLP & CCHS) 8A Wolverhampton GP, Showell Park 8B Walk in Centre, Phoenix Health Centre 9A Shropshire Walk in Centres: Malling Health - Telford and Wrekin 9B 9C Walk in Centre, Malling Health, Shropshire 10 Dudley Walk in Centre, Primecare 11 Walsall Walk in Centre, Phoenix 12A 12B 12C 12D 13A 13B Heart of Birmingham & Sandwell Birmingham East & North and Solihull Minor Injuries Units: Whitchurch, Bridgnorth, Ludlow, Oswestry Urgent Care Centre, Summerfield ( Assura) Walk in Centre, Boots Urgent Care Centre, Greet Walk in Centre Malling Health, Sandwell Walk in Centres, Warren Farm & Washwood Health Solihull: GP Led Walk in Centre 36 Some of the services were excellent, with reviewers commending all aspects of the service at the Walk-in Centre Haywood, Stoke on Trent. The Camp Hill Centre in Nuneaton, although not directly contributing to the urgent care pathway, was also praised for its approach to meeting the primary care needs of a very deprived area. 37 The most striking feature of the reviews of primary care urgent care services was the variability of the services offered both between different services and, within a service, at different times of day or when different staff were available. For example, suturing and imaging often varied in availability depending who was on duty. Commissioners and the providers themselves were usually, but not always, clear about the expected service but patients and staff working in other parts of the health economy s urgent care pathway were often unclear. Some services accepted category C patients brought by ambulance but others did not. Ambulance staff reported that it was often not easy to divert patients to these services because services varied. The variability appeared to relate mainly to staff competences rather than being based on analysis of local needs and must limit the contribution which these services can make to the urgent care pathway. Some services considered that they should not be reviewed because they were not part of the urgent care pathway. They were reviewed because they were listed by NHS Direct as a Walk-in Centre, Urgent Care Centre or Minor Injuries Unit (MIU). This illustrates the lack of clarity about the services offered. In several services, most patients were registered with a GP and were using the Walk-in Centre, MIU or Urgent Care Centre because this was more convenient than seeing their own doctor. 38 The second striking feature was the different activity levels, ranging from 600 to over 40,000 patients per year. Reviewers considered that some of the small services were not seeing sufficient patients to ensure that staff maintained competences for their roles (C:3; FC:2) 10. Reviewers raised issues about some aspect of staff competences or training and development in a further eight services (C: 5; FC: 3) 11. Some services, however, had good competency-based training programmes for nursing staff, and this was identified as good practice in the Lichfield and Tamworth MIUs and in the Greet Urgent Care Centre (Heart of Birmingham tpct). 10 C: SW(2); Shropshire MIUs (Whitchurch); FC: Hereford MIUs, North Staffs (Midway) 11 C: Shropshire MIUs; HoB (Boots); Dudley (Primecare); Walsall WiC; Solihull GP WiC. FC: Shropshire (Malling); South Staffs West (Cannock). WMQRS Urgent Care overview report V1 20110405.doc 12

39 Several services were not working to robust guidelines and protocols (C:6; FC:7) 12 and in some services there was a lack of understanding of the need for documented guidelines. The clarity of clinical guidelines was commended in four services, Haywood (Stoke on Trent), Greet Urgent Care Centre (HoB), Washwood Heath and Warren Farm (BEN). Only sixteen of the services reviewed met the Quality Standard relating to audit of implementation of clinical guidelines. 40 Eleven primary care urgent care services did not have effective links with their local Emergency Department (C: 2; FC 6) 13. Reviewers commented that better working relationships could help to direct patients appropriately and could provide opportunities for staff training and experience, especially in order to ensure that competences were being maintained. For example, rotation of nursing staff between the Phoenix Walk-in Centre, Wolverhampton and the New Cross Hospital Emergency Department was well-established. 41 Links between primary care urgent care services and links the local urgent care network (or equivalent) were also variable. Although this was specifically identified in only two reports (C:1; FC:1) 14, many of the problems being experienced by services may have been helped by better cooperation with other urgent care services. In Worcestershire, however, there was good networking between the Minor Injuries Units, with sharing of guidelines and protocols, and this cooperation was developing in both Herefordshire and Shropshire. 42 NHS Direct achieved 100% compliance with the relevant Quality Standards. Reviewers were impressed with the robustness of all aspects of the service, staff training, guidelines and governance arrangements. Reviewers only comment was that the service may benefit from better links with local health economies. GP Out of Hours Services 43 GP Out of Hours services were generally well organised and, in some cases, impressive. Compliance with Quality Standards ranged from 70% to 94% (figure 3). Staff training, guidelines and protocols and governance arrangements were often being improved in response to recent reports and PCT and SHA assurance processes. Reviewers were concerned about the high use of locum doctors in one service 15. Three services could not show that they were fully compliant with the expected staff training, one of which was because the service had recently taken over from another provider 16. 12 C: Hereford MIUs, South Staffordshire (Burntwood & Cannock), HoB (Summerfield & Boots), Dudley (Primecare); FC: Shropshire (Malling & MIUs), Coventry (Community), North Staffordshire (Midway), Wolverhampton (Showell Park & Phoenix Centre), BEN (Washwood Heath & Warren Farm) 13 C: South Staffordshire (Burntwood & Cannock); FC: Worcestershire MIUs, South Staffordshire (Lichfield & Tamworth), Shropshire MIUs, Wolverhampton (Phoenix), Sandwell (Malling) 14 C: Walsall (WiC); FC: HoB (Boots) 15 Warwickshire (Harmoni) 16 Worcestershire (Harmoni), Dudley (Primecare), Walsall (Waldoc) WMQRS Urgent Care overview report V1 20110405.doc 13

*: Urgent Care and GP Out of Hours Combined 44 Reviewers were particularly impressed by the services provided in Shropshire by ShropDoc. This service managed the local Care Coordination Centre, always had an additional GP with particular expertise in mental health problems who could be called in if required. ShropDoc doctors carried Rapid Response Boxes for palliative care, catheterisation, resuscitation, syringe drivers and controlled drugs and therefore undertook much of the nighttime care that might otherwise have been referred to district nurses or resulted in patients being admitted. Other examples of good practice included the nurse competency-based training programmes run by Harmoni and Primecare, the arrangements for super-numerary induction at Assura services, West Mercia Clinical Guidelines at North Staffordshire s and the effective use of health care support workers by Badger GP Out of Hours Service. 45 It proved difficult to review compliance with QS AA-202 which expects that a) all healthcare professional should have sufficient knowledge of English; b) if non-uk based, should have a risk assessment of their training and experience; and c) should have contracts which require sharing of information about work undertaken for other organisations. Many of the services reviewed said that this was met but were unable to provide evidence of compliance (for example, details of risk assessment process or model contracts). Although six services met QS AA-202, this was usually not based on robust evidence. AMBULANCE SERVICE 46 Many aspects of the services provided by West Midlands Ambulance Service NHS Trust were praised and the Trust met 79% of the applicable Quality Standards. Reviewers noted that the service was going through a time of considerable change. Reviewers were concerned about arrangements for reporting serious incidents and near misses. WMQRS Urgent Care overview report V1 20110405.doc 14

47 The review of West Midlands Ambulance Service (WMAS) was mostly about the internal workings of the service. Issues of links between WMAS and other NHS organisations in the West Midlands were not fully reviewed. ACUTE TRUST-WIDE 48 Compliance with the 13 Acute Trust-wide Quality Standards ranged from 46% to 85% (figure 4). 49 Three hospitals 17 did not have robust arrangements for 24/7 access to endoscopy through a relevant rota or clear arrangements for managing the care of patients. This was classified as an immediate risk in each case and arrangements have now been clarified. 50 Concerns raised about imaging services (C:6; FC:2) 18 included delays in access to imaging, long waiting times for reporting and high workload. There were, however, examples of well-organised imaging support to the urgent care pathway, including Burton Hospitals NHS Foundation Trust and University Hospital of North Staffordshire NHS Trust. Trusts varied in the extent of their use of nurse-requested imaging and at least two Trusts were still operating a system of consultant to consultant referral for out of hours CT scanning. 51 In two Trusts ultrasound was being used outside imaging services without appropriate governance, including oversight of machines and clarity of expected training(c:2) 19. Some visits did not have a specialist imaging reviewer and so this issue may not have been consistently identified and this problem may be more widespread. 52 The Critical Care Overview Report identifies problems with availability of anaesthetic staff for critical care which may impact on the urgent care pathway as well as on critical care services. 17 GEH, WAHT, Burton 18 C: SW, WAHT, Mid Staffs, S&TH, RWHT, Walsall; FC: GEH, Dudley 19 Walsall and Mid Staffs WMQRS Urgent Care overview report V1 20110405.doc 15

53 At a Trust-wide level, seven Trusts had difficulty providing evidence that staff had the competences expected for their roles(c:4; FC: 3) 20. There were three reasons for this. Sometimes, Matrons did not have a clear framework of the competences they expected for different groups of staff. Secondly, Matrons could not always access the training records of their staff easily as these were held centrally, and so they were not able to monitor whether staff had achieved (and maintained) appropriate competences. Thirdly, in some organisations, post-basic training opportunities appeared to be linked primarily to individuals interests rather than ensuring staff had the competences for their role before considering further development. 54 Some Trusts had excellent clinical guidelines that were well organised and easy to access and use. Reviewers were particularly impressed by the West Mercia guidelines and the pocket version in use at University Hospital of North Staffordshire NHS Trust. The lack of easily available, robust guidelines was raised as a concern in seven Trusts and as an issue for further consideration in two. Some organisations did not espouse the need for guidelines, including the need for NICE guidance to be operationalised for local use in a format quickly accessible by junior doctors. The other problem was accessibility, with some Trust intranets being very difficult to navigate, with one Trust filing clinical guidelines alphabetically according to the exact wording of the title. By contrast, the intranet/s at Burton Hospitals, Shrewsbury & Telford Hospitals and University Hospitals Coventry and Warwickshire were easy and intuitive to navigate. Documentation of systems and processes, or document control was of concern in eight Trusts 21, with some policies and procedures being many years out of date. Some Trust systems highlighted review dates although this sometimes just made more obvious the extent of the need for review. Organ donation was a particular problem with only eight Trusts having an up to date policy on organ donation (QS AC-313). 55 Reviewers did not find any examples of bed management arrangements which fully met the expectations of the Quality Standards. Trusts varied considerably and bed management was raised as an issue in seven Trusts (C:2; FC:5) 22. Some Trusts relied heavily on bed management meetings, including four times daily meetings in one Trust. There were fewer examples of Trusts using data proactively to predict and manage capacity. Data were available on problems (for example, patients waiting a long time for admission or delayed discharges but few examples of key stages of the patient pathway being monitored (on an ongoing or sample basis). Imaging and pathology response times were crucial to the urgent care pathway but the expected timescales for these were rarely documented and even less often monitored as part of the urgent care pathway. Priority was often given to Emergency Departments but not always to acute medical and surgical admission units which sometimes resulted in delays. Some bed managers had very good liaison with their PCT/s and social services, for example, in Birmingham East and North, whereas in others these links were less good. 56 The responsiveness of pharmacy services also made a huge difference to the efficiency of the urgent care pathway. Some Trusts, for example, Shropshire, North Staffordshire and HEFT had common TTOs available in the Emergency Department and acute medical and surgical admissions units to avoid delays in discharge. Shropshire s E-script enabled automated production of TTOs and ensured discharge information was completed. The Emergency Department at University Hospital of North Staffordshire had a drug boxes which stayed with the patient. The pharmacy service at Dudley Group of Hospitals NHS Foundation Trust was an example of extremely good practice. Pods were available in ED and the Medical Admissions Unit, TTOs were dispensed by robots very quickly and weekend pharmacy opening hours had been changed to later in the day when most ward rounds had been completed. In general, however, waiting times for dispensing TTOs were variable and rarely monitored as part of the urgent care pathway. Pharmacy opening hours also varied, especially at weekends. 20 S&TH, UHCW, S&WB, Walsall; FC: HH, WAHT, Dudley 21 HH, WAHT, S&TH, UHCW, Mid Staffs, Burton, RWHT, Walsall 22 C: S&TH, Dudley; FC: SW, GEH, RWHT, S&WB, HEFT WMQRS Urgent Care overview report V1 20110405.doc 16

57 Only seven Trusts 23 had policies to ensure that young people aged 16 to 18 were offered the choice of care in an adult or children s setting (QS AE-610). For those admitted to adult care, policies to ensure flexible visiting and care in a side-room were rarely in place. Most Trusts did not have systems for monitoring the number of young people being cared for on adult wards and arrangements for involvement of paediatricians in their care (where appropriate) were not robust. 58 There was also variability in the use of extended roles for nursing and therapy staff although there was good practice in some services, for example, the Emergency Department at City Hospital Birmingham (S&WB) and Acute Medical Admissions Unit at Mid Staffordshire Hospitals. In several Trusts there was the potential to speed up the patient pathway through greater use of extended nursing roles, nurse prescribing, nurse-led protocoldriven pathways and nurse-led discharge. EMERGENCY DEPARTMENTS 59 Emergency Departments experienced many of the problems already described in the health economy and acute Trust-wide sections of this report, especially around patient flow and access to mental health services. These points are not repeated here. Compliance with Quality Standards ranged from 52% to 78% (figure 5). 60 Reviewers saw many examples of good practice and impressive services. In addition to those already mentioned, reviewers were impressed by the well-designed observation units at South Warwickshire NHS Foundation Trust and Birmingham Heartlands Hospital (Heart of England NHS Foundation Trust); the Vital Pac IT system in use at Shrewsbury and Telford Hospital NHS Trust provided a way of recording early warning scores, identifying the appropriate escalation and ensuring high risk patients were monitored and managed efficiently; the mental health risk assessment matrix at George Eliot Hospital NHS Trust and Worcestershire Acute Hospitals NHS Trust; the therapy teams at University Hospitals Coventry and Warwickshire NHS Trust and City Hospital, Birmingham 23 HH, Mid Staffs, Burton, S&TH, UHCW, Walsall, Dudley WMQRS Urgent Care overview report V1 20110405.doc 17

(S&WBH); and the Patient Environment Worker at Sandwell Hospital (S&WBH) who ensured the department was clean and tidy, all stores were organised and equipment needed was immediately available. 61 In many Emergency Departments the problems of patient flow were so severe that patients brought by ambulance were queuing in corridors or waiting in ambulances until they could be seen. 62 Senior medical staffing was an issue in 10 of the 20 EDs reviewed (IR:1; C:7; FC:2) 24. There was a shortage of consultants in two services, of middle grade doctors in one and of both in five services. This was a particular problem as Departments were trying to ensure senior doctor review early in the patient pathway. In some services, there was a tension between the model of care that staff wanted to operate and the staffing levels which could be justified by the number of patients. Services were having significant difficulty recruiting consultant and middle grade doctors and there was some evidence of this problem moving around the region due to recruitment of existing consultants. In two Departments reviewers were concerned that consultants were not fully committed to a model of senior doctor review early in the pathway. 25 63 Nurse staffing levels were low in eight services (IR:1; C:5; FC:2) 26 and in three of these, plus one other, nursing staff did not have all the competences expected for their role 27. 64 The environment within two Emergency Departments was considered unfit for purpose 28. New builds were planned for both but these were some years away from completion. Five departments did not have appropriate facilities for the assessment of patients with mental health problems 29. 65 Ten EDs were not submitting data to TARN and / or CEM audit programmes (AE -701). Other governance issues identified were a lack of audit and / or a lack of multi-disciplinary arrangements for review of morbidity, mortality, incidents and complaints (IR:1; C:1) 30. 66 The Quality Standards were not detailed about physiotherapy and occupational therapy support to the Emergency Department. (This will be changed in Version 2.) It was clear that good availability of these services had a big impact on speeding up the patient pathway and limited availability, such as was seen in two services, lead to delays and / or patients being admitted unnecessarily. ACUTE MEDICAL AND SURGICAL ADMISSIONS 67 Acute medical and surgical admission services experienced many of the problems already described in the health economy and acute Trust-wide sections of this report, especially around patient flow and access to mental health services. These points are not repeated here. Compliance with Quality Standards in Acute Medical Admissions Units ranged from 41% to 82% (figure 6) and in Acute Surgical Admissions Units from (figure 7). 68 As with Emergency Departments, there were several examples of excellent care for patients being admitted with acute medical and surgical problems with services implementing rolling ward rounds, acute medicine clinics and in-reach from other specialties (such as in Birmingham Heartlands Hospital, Royal Wolverhampton Hospitals and UHCW). Some services had excellent support from physiotherapy, occupational therapy and social workers. Other examples of good practice included the band 4 medical coordinator at Sandwell Hospital (S&WBH) who actively managed patient flow through the Emergency Admissions Unit and the organisation of the surgical 24 IR: GEH; C: SW, S&TH x 2, UHCW (Rugby), UHNS, Mid Staffs, S&WB (City); FC: WAHT (WRH), S&WB (S well) 25 South Warwickshire & Good Hope Hospital (HEFT) 26 IR: GEH; C: SW, WAHT (WRH), S&TH (PRH), RWHT, Walsall; FC: S&WB x 2 27 SW, GEH, UHNS, Walsall 28 UHNS, Walsall 29 WAHT (WRH), Burton, S&WB x 2, HEFT (GHH) 30 IR: GEH; C: S&TH (PRH) WMQRS Urgent Care overview report V1 20110405.doc 18

admissions units at Birmingham Heartlands Hospital (Heart of England NHS Foundation Trust), City and Sandwell Hospitals (S&WBH). *: Combined Acute Medical and Surgical Units WMQRS Urgent Care overview report V1 20110405.doc 19

69 Eight services did not have robust arrangements for review by a senior decision-maker within twelve hours of admission (C:8; FC:5) 31 even though other services were moving towards rolling review and a four hour target for senior decision-maker review. This arose for several reasons: a) in a few services consultants were not yet committed to a model of rapid review by a senior decision-maker; b) in others this was achieved during the hours that acute medicine / surgery consultants were available but not at nights, weekends and bank holidays when general physicians and surgeons covered the service; and c) some Trusts did not have a surgeon available for the management of emergency patients without other commitments. 70 Low nurse staffing levels were identified in 15 services (IR:1; C:9; FC:5) 32. Some issue about whether nurses had all the expected competences for their role in 16 services (C:9; FC:7) 33. 71 Several services were starting to run acute medicine / ambulatory clinics, for example, Heartlands, Coventry and Stafford. Reviewers identified that these had potential to avoid admissions when GPs, GP Out of Hours services and Emergency Departments had easy access. They could also reduce length of stay when Acute Medical Units utilised them for post-discharge follow-up. 72 Several surgical assessment units had recently been established and were considered to have the potential significantly to reduce admissions and length of stay. In Sandwell a post-discharge follow-up clinic for acute surgical patients was working well and reducing length of stay. COMMISSIONING 73 Some commissioners had very good understanding of their local urgent care services and were actively monitoring their quality. Quality monitoring of primary care services was more variable than secondary care monitoring with less evidence of the use of appropriate quality indicators. Reviewers recommended that commissioners should re-review compliance with the Quality Standards in two services because of the lack of robust evidence of compliance 34. Clinical Quality Review meetings for secondary care services were normally taking place but were not looked at in detail as part of the reviews. Commissioners at Wolverhampton City PCT were commended for having implemented an ambulatory care local tariff. QUALITY STANDARDS AND PEER REVIEW PROCESS 74 An evaluation of the urgent care standards and peer review programme will be undertaken when all reports have been finalised and distributed. Some findings are, however, already clear: Most of the Quality Standards were relevant and useable for peer review (despite the speed with which they were produced). A small number of Standards need revising based on experience of using them or because national guidance has already changed, especially in the management of trauma. The Steering Group plans to undertake these revisions during 2011 so that an updated set of Quality Standards is available as soon as possible. The National Clinical Quality Indicators for Emergency Departments (DH, 2010) cite the West Midlands Quality Standards and peer review process as an example of good practice and recommend that peer review should be used alongside the indicators. The Society for Acute Medicine has also expressed interest in adopting the West Midlands Quality Standards. 31 C: SW, S&TH x 3 (AMU x2, ASU PRH), Walsall (AMU), HEFT (AMU x 3): FC: WAHT (AH ASU), Mid Staffs (ASU), RWHT (AMU), S&WB (City ASU), HEFT (BHH ASU) 32 IR: Dudley (AMU SSU); C: GEH (AMU), WAHT (WRH AMU), UHCW (CDU), UHNS (frail elderly), Mid Staffs (AMU), RWHT (AMU), Dudley (GP unit), Walsall (ASU), HEFT (Solihull AMU); FC: SW (AMU), Burton (AMU), S&TH (PRH ASU), S&WB (S well EAU), Dudley (ASU) 33 C: SW (AMU), GEH (AMU), UHNS (AMU & ASU), Mid Staffs (AMU), RWHT (AMU), S&WB (S well EAU & City AMU), Walsall (ASU); FC: SW (ASU), S&TH (RSH AMU & ASU), UHCW (AMU), Mid Staffs (ASU), RWHT (ASU), S&WB (City ASU) 34 Summerfield (HoB) and Malling (T&W). For consistency, this recommendation should have been made for Boots (HoB)as well but this was not included in the report. WMQRS Urgent Care overview report V1 20110405.doc 20