To consider the temporary winter closures of the Ross-on-Wye and Leominster minor injury units (MIUs), in the context of urgent and emergency care, and to determine any recommendations the committee wishes to make to a responsible NHS body and / or to the executive.

 

The chairperson invited Jade Brooks, acting director of operations of NHS Herefordshire Clinical Commissioning Group (CCG), and Jane Ives, managing director of Wye Valley NHS Trust (WVT), to introduce the item.

 

The key points included:

 

i.           The paper (agenda pages 25-51) detailed the current position on urgent and emergency care in the county and provided information on the temporary closures of the minor injury units (MIUs).

 

ii.         The arrangements adhered to national guidance on urgent and emergency care, with an accident and emergency (A&E) delivery board in place to oversee developments and a programme of transformation, and to ensure that system partners came together to provide a good standard of care for the population.

 

iii.        The NHS planned for surges in demand during the winter period and patient safety was paramount.

 

iv.        This was the third year where a decision had been taken to close the Leominster and Ross-on-Wye MIUs temporarily during the winter period in order to maintain patient safety across Herefordshire and mid-Powys.  The first year was described as an ‘ad hoc’ arrangement, with people uncertain about the opening times.  For the second and third year, proactive and earlier decisions had been taken.

 

v.         The winter pressures were due to the increase in demand and the acuteness of illnesses, particularly in terms of respiratory and cardiovascular diseases, which resulted in longer lengths of stay.  This limited the availability of beds and resulted in congestion in the hospital.

 

vi.        It was reported that, over the last two years, adult emergency demand had increased by 70 admissions per week.  To manage the additional demand, WVT had opened 24 more beds and had improved ways of working but there were still significant pressures during the winter period.

 

vii.       There was a workforce of emergency nurse practitioners, who largely worked autonomously, and could see three to four patients per hour.  It was reported that the demand at the Leominster and Ross-on-Wye MIUs was around one patient per hour and it was not considered that the emergency nurse practitioners were working at full capacity in the MIU settings.  In addition, there was a shortage of nurses generally and emergency nurse practitioners in particular.

 

viii.      A range of measures over the last two years had improved triage times, maintained ambulance turnaround times, and reduced mortality rates.

 

The chairperson welcomed the reduced mortality rates and made the following observations:

 

i.           Illustration A (A&E attendances at Wye Valley NHS Trust April 2017 to November 2019, agenda page 25) showed attendances declining during the winter period.

 

Ms Ives said that there was a difference between attendances and admissions.  Attendances were higher in the summer months, due to minor injuries, but adult admissions were higher in the winter months, as demonstrated by Illustration B (ambulance conveyances to Wye Valley NHS Trust April 2017 to November 2019).

 

ii.         The framing of the attendances in Table 2 (Total attendances at MIUs September 2017 – August 2018, agenda page 30) which incorporated the winter closure period in the calculations was considered unfair.

 

Ms Brooks reported that for 2018/19, making assumptions about the level of activity had the MIUs been open, the rate of attendances was around 1 per hour in both localities; it was noted that this information was not included in the published papers.  She commented on the need to consider access issues, such as the ease to get to an MIU versus attending a local GP surgery or the A&E department.  Another factor was the availability of certain services on any given day, such as x-ray, which meant that patient experience in each setting was different.  It was reported that patient feedback indicated that people valued the MIU in their locality and were more likely to use the unit if they lived less than ten minutes away.   It was emphasised that there was a need to reflect on whole population access to urgent and emergency care.

 

The vice-chairperson made a number of points, including: the paper provided detail about urgent and emergency care but did not answer all of the questions about the temporary closures of the MIUs; the omission of figures from the Ledbury MIU and the Kington MIU made it difficult to draw comparisons; it was suggested that, rather than moving resources to Hereford, better ways of working within communities should be examined; both Leominster and Ross-on-Wye were the largest market towns in the county and had compact residential town centres, therefore the majority of each population could reach the respective MIU within ten minutes; there was a need to understand the increasing demand and a key theme appeared to be frailty, as suggested in Illustration C (age profile of patients in hospital acute beds quarter 1 2019/20, agenda page 26); the potential to enhance urgent and emergency care in the market towns should be looked at in order to take the pressure off the hospital in Hereford; and the paper was lacking in assurance that the temporary closures of the MIUs was the only or best way to address the identified pressures.

 

In response to the points made:

 

o      Ms Brooks reiterated that the temporary closures related to patient safety and enabled the capacity and skills of experienced staff to be utilised most effectively during the winter period.  She added that this was not a decision that had been taken lightly and, in view of three years’ of temporary closures, the health partners would not be sat before the committee with a fourth.  The time was being used to get underneath the reasons for people using the MIUs and the possible alternatives if the system could not sustain minor injury unit activity.

 

The situation in Kington was outlined, where there had been low activity at the MIU and similar injuries being presented to those at the GP practice.  Therefore, a pilot was undertaken whereby the GP practice would see and treat people for minor injuries, whether registered or not.  This had been in place for over a year and it had demonstrated that this function could be delivered differently and the patient experience simplified.  This learning was being considered in the context of other MIUs and the views of the public would be welcomed.   The intention would be to return to the scrutiny committee with a long term solution.

 

o      Ms Ives confirmed that the increases in admissions and utilisation of bedded capacity were predominantly in older age profiles.  The reasons driving demand were multi-faceted, including population demographics, the severity of illnesses as people aged, and the challenges for social care and primary care.

 

The vice-chairperson commented on the need for the Herefordshire system partners to work closely together to ensure that care pathways were working as efficiently as possible, both to minimise admissions and to return people home as quickly as possible.

 

Questions and comments were invited from the attending councillors.  The principal points of the ensuing discussion are summarised below.

 

a.         A ward member considered it regrettable that consultation had not been undertaken prior to the current temporary closures and it was questioned how councillors and the residents of Herefordshire would be engaged going forward.

 

Ms Brooks reiterated that the decision on the temporary closures was undertaken on the basis of patient safety.  In terms of the long term future of the MIUs, there would be consultation and engagement with all partners; this would include those actively involved in urgent and emergency care and also those providing support functions to people at home, such as voluntary and community organisations.  The town councils in the MIU areas were seen as critical stakeholders, as well as the patients in those communities.  Therefore, if change was proposed, the options would be presented to the public and further feedback sought in order to provide assurance and confidence.

 

b.         Further to the question and supplementary question asked under the ‘questions from councillors’ item, a ward member questioned whether the local NHS definition of significant or substantial change could be shared.

 

Ms Brooks said that the CCG had guidelines on engagement and consultation which adhered to NHS guidance.  The CCG would engage and consult on change, with patient safety or procurement decisions being the exceptions.

 

A ward member suggested that there was a need for the council and other stakeholders to be involved in setting this definition to ensure earlier, proactive engagement and consultation.  The chairperson said that this could form the basis of a recommendation in terms of a joint protocol or memorandum of understanding.

 

Ms Brooks commented that it was the usual process for the CCG to bring issues to the scrutiny committee but the pre-election period had slowed the flow of information in this instance.  Although there was no reason why a joint protocol or memorandum of understanding could not be agreed, there could be instances where risks to patient or staff safety would require immediate action.

 

c.         The cabinet member - finance and corporate services questioned why statistics for the Ledbury MIU were not included in the paper; as this prevented the assessment of whether the temporary closures of the other MIUs resulted in more attendances at Ledbury.  It was noted that the performance dashboard information excluded the winter months, so it was not possible to see the changing circumstances and statistics over various aspects of operation during this critical period.  It was commented that it appeared that the redeployment of staff from Leominster and Ross-on-Wye was being used to bolster understaffed provision in Hereford, at the expense of those market towns.

 

Ms Ives reiterated that staffing requirements were different in the winter and resources had to be used flexibly to meet the highest levels of demand and risk.  A key issue was the flow of patients back out into the community.  It was reported that a frustration for nurse practitioners was the feeling of being under-utilised in the MIUs, despite the levels of activity and waiting times elsewhere in the system.

 

d.         The cabinet member - finance and corporate services said that councillors had been told, during the development of the core strategy, that one of the reasons that there were no expansion plans for the hospital was because the asset would be worked harder, and people would move faster through the system and back out into the community.

 

Ms Ives said that: she was not in post then; care close to home was important at the right time, following acute episodes or to prevent people from becoming ill in the first place; demand within the MIUs was limited; the activity information suggested that the temporary closures of the MIUs had a limited impact on A&E performance and attendances; and workforce was the biggest issue, so the resource had been to be used carefully.

 

e.         As a point of clarification arising from point c. above, the chairperson said that she understood that the total attendances at Ledbury MIU during September 2017 – August 2018 to be 2,974.    It was noted that this was higher than Leominster MIU (1,930) and Ross-on-Wye MIU (1,968) and this could be a result of Ledbury being open 24 hours a day, 365 days a year.  The chairperson suggested that it was important to consider both the overlapping and out of hours provision for each locality.

 

f.          A ward member, referring to a recent situation where a resident had been injured following a fall but could not attend the Leominster MIU due to the temporary closure, commented on the challenges for people in the market towns and surrounding areas to access services in Hereford, especially given the distances and travel time involved.  Therefore, it was considered that services should be kept a local as possible within the available resources.

 

g.         The chairperson questioned whether staff in the community hospitals could help to support the MIU function, especially out of hours.

 

Ms Ives said that the staff were busy looking after their patients and ward nurses did not necessarily have the same level of training and experience as emergency nurse practitioners to deal with the range of minor injuries presented.

 

A ward member questioned what else emergency nurse practitioners could be doing to ensure that their time and skills were being utilised in the most effective ways in the market towns, such as providing services within a community hospital or supporting local GPs.

 

Ms Brooks said that the importance of the minor injury function at a local level was recognised and it was not being suggested that this should be shifted to the A&E department.  It was accepted that the temporary closures had left members of the public feeling concerned and confused, and potential solutions would be considered during the year.

 

h.         A committee member recognised the need to provide the appropriate level of medical care at times of greatest need but expressed concern about the apparent underutilisation of staff.  In particular, the statistics were considered problematic, with paragraph 5.5.1 of the paper (agenda page 30) identifying MIU attendances between September 2017 and August 2018 ‘equates to on average… 1.6 per hour’ but it was contended that the average might be 2.5 per hour if the weeks when the MIUs were closed were properly omitted from the calculations.  It was noted that the total attendances at Ledbury MIU figure was likely to be higher because it had not closed during the winter.

 

Ms Ives reiterated that the 2018/19 figures indicated that the rate of attendances was around 1 per hour.  Acknowledging that the committee could not comment on figures it had not been provided with and that the data in the papers was unhelpful, an undertaking was given to provide further information for committee members.

 

i.           A committee member asked for clarification regarding 5.5.10 of the paper (agenda page 31), ‘During temporary closures the attendances to Hereford A&E Department from the HR9 and HR6 postcode remain consistent with usual activity therefore there was no increase when the MIUs were closed’.

 

Ms Ives, referring to feedback from staff, commented that some of the patients being seen in the MIUs had types of injury which might usually be expected to be self-managed, with insect bites given as an example.  It was considered that there was an element that an accessible MIU could drive its own demand.  During the temporary closures, people were likely to find access into other services, such as primary care and pharmacies.

 

j.           The chairperson sought assurance that the review of the long term future of the MIUs, and related consultation and engagement, would take proper account of: the pressures being squeezed around the system; ensuring that the right resources were in the right places; and there would be no disservice to local communities, particularly at a time when some services were being decentralised as a means to enhance community resilience.

 

k.         A ward member felt that there was a siloed approach to urgent and emergency care settings, and that there should be a more fundamental look at the spectrum of local services and how they should be organised in the future.

 

l.           A ward member said that: Ross-on-Wye Town Council had been advised that there was no reopening date for the MIU and there was a concern that this was not a temporary but a permanent closure; confirmation was sought that there would not be a reoccurrence of the temporary closures in the fourth year; despite assurances on consultation and engagement, local people had not been consulted on any of the temporary closures; the situation appeared to be about resources and, if there was not enough money to provide the service, people should just be told that; it was regularly reported that plans were in place to recruit staff but this did not appear to be changing the workforce situation; examples were provided of injuries sustained by local people which, due to the MIU closure, resulted in them travelling to Hereford or Ledbury, or calling other emergency services, so there was displacement occurring in the health service and in other agencies; a survey had indicated that people would travel to Hereford if they could not attend the MIU; and it was essential to keep appropriate services local and serving the community.

 

In responding, Ms Brooks made a number of points, including: it was recognised that the organisation of services was more important than the numbers; consideration was being given to a range of services, including primary care and out of hours provision; winter pressures often continued until Easter but the MIUs would reopen, and as quickly as possible; any proposal for significant change would require an assessment of the options, consideration of the impact on both the population that used the service and the surrounding population that did not, and there would need to be engagement with NHS England and the council; the discussion had been valuable and would inform options for the future; at the present time, the CCG had not taken a decision on the MIUs and a consultation was not formally planned; surveys about the MIUs and consultations on other matters had been undertaken in recent years; this was about patient care but the current levels of activity did not represent good value for money; there were various and ongoing initiatives which had brought nurses and other skilled staff into the county, nevertheless there were national pressures in terms of workforce; it was acknowledged that there was likely to be some displacement but no formal data had been captured about people’s expressed wishes of where they would have gone to if all the facilities had been open; and members were urged to encourage people to engage with consultations to understand both their experiences of urgent and emergency care, and the level of awareness about the services available to them.

 

Ms Ives added that: the potential for displacement was acknowledged but this was not apparent from the data collected; and workforce recruitment and retention was a priority, with turnover reduced from 14% to 10% over the last two years, improved staff survey results, a successful international nurse recruitment campaign, and a decrease in the number of nurse vacancies.

 

m.        The cabinet member - finance and corporate services: questioned whether the natural variations in A&E attendances might obscure the additional numbers of attendees from Leominster and Ross-on-Wye during the MIU closures and it was noted that ambulance conveyances picked up during those months; suggested that further data was needed on this correlation and possible causation; noted that insect bites could be serious, especially for people with suppressed immune systems; and commented on the need for joined up communications in A&E, GP surgeries, MIUs, pharmacies, and other healthcare and community settings, to ensure that people were aware of the appropriate places to go, the facilities available, the opening times, and the capacity to provide care and treatment.

 

Ms Ives acknowledged that insect bites could be serious and emphasised that people had to do the right thing for them.

 

n.         The cabinet member - health and wellbeing commented on the close working between WVT and the council, demonstrated by the significant reduction in delayed transfers of care.

 

The director for adults and communities said that the Herefordshire system was under significant pressure in terms of finding efficiencies, with the NHS responsible for its quality of service and safety of patients, and the local authority responsible for patients who were vulnerable and in need of safeguarding.  Therefore, the system partners had to work together to manage demand more effectively.  It was reported that delayed transfers of care had reduced by around 50% during the last year as a result of service changes, integrated working and further investment.

 

o.         The chairperson, referring to same day primary care, said that people living on the border that chose to register with a GP surgery in Wales did not have similar provision and this inequality needed to be acknowledged.

 

Ms Brooks noted the different regulatory framework and guidance in Wales.  It was reported that such residents, or visitors to the county, could use out of hours primary care services.  It was also reported that regular meetings were held with counterparts in Wales to highlight concerns and look at inequalities caused by differences in service provision.

 

p.         In response to a question, Ms Brooks provided an overview of falls prevention and response services.  The director for adults and communities added that this provision was being reviewed, alongside the proposed investment in assistive technology, in order to manage demand better and upstream support.

 

The chairperson thanked Ms Brooks and Ms Ives for their attendance and input.

 

There was a short adjournment to prepare draft recommendations.  The resolution below was then discussed and agreed by the committee.

 

Resolved: That

 

1.       In view of the recurring temporary closures of the Minor Injury Units in Leominster and Ross-on-Wye, that the Clinical Commissioning Group be recommended to undertake a full options appraisal, with a more relevant set of statistical information (to include the total number of MIUs in the country and how many have closed during winter periods) and an evidence base obtained from healthcare providers and system partners, on future options for the Minor Injury Units to include an appraisal of the future of the community hospitals.

 

2.       That the Clinical Commissioning Group and Herefordshire Council officers develop a joint protocol or memorandum of understanding (to be produced by the end of April), about how the parties will reach a view as to whether or not any changes in the provision of health services constitute ‘substantial development’ or ‘substantial variation’ in relation to the duty on relevant NHS bodies and health service providers to involve and consult the public, including the relevant scrutiny committee(s).

 

3.       That the Clinical Commissioning Group review the approach to consultation and engagement generally where there is a likely to be an impact on communities and service providers.

 

4.       That the Clinical Commissioning Group review opportunities for joined up communications in GP surgeries, pharmacies and other healthcare services to highlight where people need to go to access appropriate healthcare relative to the health conditions they present with.