1. Review of North East Essex Minor Injury Units and Walk in Centre Dr Hasan Chowhan GP & CCG Clinical lead

2. Requirement from Board Members
The Board is recommended to approve Approach 3 – The Establishment of a Minor Injury Service
HMC

3. Drivers for Review
Continued challenging system performance
Duplication and Confusion in accessing urgent care often resulting in poor patient pathways and experience
Sustainability
Contract Expiry dates (March 2018)
> Walk in Centre (Care UK)
> Minor Injury Units (Anglian Community Enterprise)
HMC

4. If I need urgent treatment – what do I do?
Patient View - Accessing Urgent Care
If I need urgent treatment – what do I do?
How will I get there and back?
Which service will get me seen the quickest?
General Practice
Walk in Centre
Minor Injury unit
NHS 111
Pharmacy
GP Out of Hours
Accident & Emergency
999
What service do I access?
Which service is open?
HMC
Could I help myself?
Will I need an appointment
Will I be seen at a convenient time?

5. Current Patient Pathway Example
Ankle injury (Difficulty weight bearing), lives in Colchester
30 mins
General Practice
111
General Practice
2 hours
X-ray
Walk in Centre
HMC
Up to 4 hours*
Accident & Emergency
*As per National A&E Standard

6. Primary Care Transformation
Care around the Person
Self-care /
Self-Management
Primary Care Transformation
Access to GP 7 days per week
Helping people look after themselves
Care Navigation
GP Triage
Care Closer to Home
Helping people to look after themselves
Single Gateway to access community care
Proactive Care Planning
Care Co-ordination
HMC
Urgent care
Helping people look after themselves
Helping people access the right advice or treatment in the right place, first time
Consistent and high quality care 7 days a week
Ensuring people are treated by staff with the right expertise to meet patient needs

7. Governance process to date
Meeting and Date
Outcome
27th September 2016
CCG Board
Support for draft Urgent Care Strategy
Noted progress of high level appraisals of proposed approaches
24th November 2016
Final System Wide Urgent Care Strategy approved
Approval of proposed approaches
Approval to proceed to public engagement
31st January 2017
Update on Engagement to date
Approval to continue with Engagement process
28th March 2017
Update on progress of review and next steps
25th April 2017
CCG Board Development
Presentation on appraisal of approaches
2nd May 2017
Transformation & Delivery Committee
Recommendation to Board on preferred approach
11th May 2017
Operational Executive Committee
30th May 2017
Update on Progress of review
27th June 2017
Decision to be made on preferred approach
HMC

8. NEE System Urgent Care Strategy 2016-2019 (approved November 2016)
Helping people to look after themselves
Helping people access the right advice or treatment in the right place, first time
Consistent and high quality care 7 days a week
Ensuring people are treated by staff with the right expertise to meet patient needs
HMC

9. Our Potential Approaches
No Change to Current Services
To close the current Walk in Centres and Minor Injury Units
The establishment of a Minor Injury Service Only
Another approach suggested by our public or stakeholders
HMC

10. Approach One – Current Provision
ED Streamer
7am-10pm
WIC
24 hours
9am-5pm
MIU
9am-9pm
WIC
Average 144 Patients a day
47% of NEE urgent care activity
Clacton
MIU
Average Patients 79 a day
25% of NEE urgent care activity
Harwich MIU
Average 20 Patients a day
6% of NEE urgent care activity
A&E Minors
Average Patients 67 day
22% of NEE urgent care activity
24 hours
9am-5pm
9am-12pm Mon-Fri
9am-5pm Mon-Fri
10am-4pm Sat/Sun
HMC
MIU
= Minor Injury Units
WIC
= Walk in Centre
= CHUFT X-ray service

11. 68% of NEE urgent care activity
Approach Two – to close the current walk in centre and Minor injury units
A&E Minors
Average Patients 210 a day
68% of NEE urgent care activity
ED Streamer
24 hours
HMC
Large areas of Rural Deprivation
Significant older population on the coast
Housing Developments
= CHUFT X-ray service

12. What are the benefits of a Minor Injury Service?
Enhanced range of injuries treated
Utilising existing buildings to maintain a local presence
Able to treat non-ambulatory patients
Increased ambulance conveyances to service instead of A&E
Greater Integration with GP Practices (hubs)
Bookable appointments using IUCS as single point of access
Potential for rotational posts across UC services, maintaining high skill set
HMC

13. Approach Three (Yr. 5) A Minor Injury Service A&E Minors Harwich MIS
Colchester
MIS
Average 77 Patients a day
23% of NEE urgent care activity
Clacton
Average Patients 51 a day
15% of NEE urgent care activity
Harwich MIS
Average 14 Patients a day
4% of NEE urgent care activity
A&E Minors
Average Patients a 61 day
18% of NEE urgent care activity
MIS
Remember it’s the 5 year population growth included in the activity.
Note:
MIS locations are represented on map but not drawn to scale
MIS
= Minor Injury Service
MIS
= Minor Injury Service integrated with Primary Care
= CHUFT X-ray service

14. Based on the clinical model the recommendation is approach 3
HMC

15. Simon Morgan Head of Communications and Public Engagement

16. Public Engagement Engagement took place 4 Jan – 1 Mar 2017
Attended 26 support groups meetings, held 12 public meetings across north east Essex
We’ve been in contact with around 2,300 people
Captured feedback through online questionnaire (paper copies available)
Various materials produced
Independent report produced analysing key themes. SM

17. Promoting the engagement
Social media campaign
Press advertising at a reduced rate in the local media
Regular updated s to our voluntary groups
Newsletter updates
Press releases and media interviews
Briefing local MPs
Good support from HOSC and some local councillors. SM

18. Public engagement feedback themesSM

19. Elizabeth Amodio Head of Urgent Care

20. Staff Capacity
A perception that future changes would place additional burden on GP’s, A&E and other services with associated longer wait times
Approach 3
An enhanced minor injury service delivered by staff with the right expertise, would reduce the need for you to attend A&E
Increased support for people to self-care - to reduce unnecessary burden on urgent care services and GP practices
Helping people to access the right service, first time will minimise the time waiting for treatment. EA

21. Location
People prefer to be treated locally, without the need for hospital treatment. Longer journeys could place additional burden on patients and families
Approach 3
The minor injury service would be delivered locally, aiming to be more integrated with GP Surgeries in the future
An enhanced minor injury service available in the community would aim to reduce the need for you to have to travel to hospital.
Recognises the local needs of the population EA

22. Access
Closure of current services would impede access, with the greatest impact on those most in need.
Approach 3
Recognises areas of deprivation and older age, offering a solution to retain services locally.
Recognises the temporary residents and holiday maker population and provides access to urgent care services in our coastal areas.
Greater focus on supporting people to self-care.
Developments in primary care aims to improve access to your GP practice through introduction of extended hours (practices to offer access from 8am to 8pm, 7 days a week by March 2019) supported by consistent triage, care navigation and sign posting. EA

23. Quality of Service
Walk-in Centres were perceived to provide a distinct service for patients whose needs fall between that of general Practice and A&E. People are concerned about the quality of alternative services e.g. NHS 111.
Approach 3
Evidence suggests that walk in centres cater mostly for patients who did not require clinical input and could have self-cared were they better supported to do so, this approach would promote greater use of pharmacies and patient education.
People with a minor illness will have greater continuity of care through improved access to their GP Practice.
The approach recognises the need for a local minor injury service , able to treat a wider range of injuries. This capability reduces the need for the ambulance service to convey patients to A&E for fractures and minor injury, supporting the Ambulance service to meet their response times in attending more serious conditions
The new Integrated Urgent Care Service (111 and Out of Hours GP) aims to increase the clinical advice to support patients EA

24. Changes in Service Provision
A minority of people reported that any change would not affect them, however these patients mostly lived out of the area or stated that they rarely used A&E.
Funding
Approach 3 aims to improve the quality of care and experience for patients through ensuring people can access the right service for their need, first time.
Approach 3 aims to deliver greater financial stability through reducing the number of people attending A&E with a minor injury and improving self-care. EA

25. Approach 4 The public provided the following additional suggestions:
To develop a combination of approaches 1 & 3 with walk in centres in more locations
Approach 3 aims to deliver a minor Injury service integrating with primary care in the future to provide local access for all minor urgent care needs.
Approach 3 supports the driver to reduce duplication in provision of services and pathways
To provide a cost effective, centralised service
Approach 3 would seek to maximise the utilisation of existing estates while there is no better alternative
Analysis of local need suggests that a centralised service could reduce access to care across the locality EA

26. The Financial Case Approach 1
Increase potential of £1.85m cost pressure over 5 years
Assumes no void estates costs
Injury £1.1m
Illness
£0.84m
Approach 2
Increase potential of £7.55m cost pressure over 5 years
Includes Void Estate costs in year one
Injury
£9.71m
Illness
-£2.16m EA
Approach 3
Saving potential of £0.23m over 5 years
Assumes no void estates cost as will utilise existing buildings
Injury
£2.77m
Illness
-£3.00m

27. Recommendation
Based on the public engagement and financial appraisal, the recommendation is approach 3
EA then handover to HMC

28. Current Patient Pathway Example
Ankle injury (Difficulty weight bearing), lives in Colchester
30 mins
General Practice
111
General Practice
2 hours
X-ray
Walk in Centre
HMC
Up to 4 hours*
Accident & Emergency
*As per National A&E Standard

29. Integrated Urgent Care Service (111)
Future Patient Pathway Example
Ankle injury (Difficulty weight bearing), living in Colchester
Integrated Urgent Care Service (111)
15 mins
Direct Booking in line with the LDR
General Practice
Minor Injury service
*Up to 4 hours
HMC
*Type 3 service with national 4 hour standard applied however local measure will expect high % of patients seen and treated within 2 hours

30. What about minor illness?
HMC

31. Self-care/Self-Management
Our aim is to equip as many people as we can with the skills and knowledge to support themselves both in terms of treating minor injury and ailments and how to manage their long term conditions.
This will include:
Development of a self-care strategy led by our community provider with system wide commitment and accountability from all local stakeholders. This will include:
Staff training– ensuring that patients receive the same support and message regardless of the service they access e.g. Good Lives approach
Communication – linking communication teams to support a consistent self-care message
Working with Local Pharmacy Committee, including:
Training for Pharmacists on safety netting to support self-care
Introduction of Care Navigators within primary care
HMC

32. Primary Care Impact
The table below demonstrates the potential increased impact to GPs of minor illness transferring back into primary care from WICs, MIU and A&E, as assumed in Approaches 2&3*:
GP (Number of appointments required per day)
GP Out of Hours (Number of appointments required per day)
Total appointments required per day
Colchester 29 14 43
Tendring 16 6 22
For Colchester GPs this equates to an average 2 patients per day per practice
For Tendring GPs this equates to an average 1 patient per day per practice
HMC
*The T3 Impact to GPs has been assumed based on 47% of minor illness attendances occurring in hours and 27% of out of hours attendances. Also includes 10% of Minor Injury Activity as part of Enhanced Service

33. Transformation Timeline
Maximising Benefits of an integrated system
Model hub & spokes forming
Buildings to support hubs under development
Note: The Local Digital Roadmap (LDR) will begin to shape how information is shared to support greater integration across the system
Care Navigators and extended hours will support the shift in activity for minor illness into primary care
Year 17/18
Year 18/19
Year 19/20
Year 20/21
Year 21/22
Project
Qrt 1
Qrt 2
Qrt 3
Qrt 4
Urgent Care Review
July-18
IUCS
Apr-18
Extended Hours
Care Navigators
Sep-17
GP Hub & Spoke
Jul-17
ED Streamer
Oct-17
Self-Care/Pharmacy
HMC
Completion of Minor Ailments Safety netting training for Pharmacists March 18 which will support shift to self-care

34. Mapped to NHSE Delivery Plan
Benefits of Approach 3
Mapped to NHSE Delivery Plan
Improvement in Patient & Staff experience
Reduction in minor attendance at A&E which will improve Quality of care and experience for patients
Offers alternative conveyance for ambulance and supports Ambulance turnarounds
Enhanced Clinical Quality
Access to on-site x-ray
Electronic access to patient records, diagnostics and prescribing
Increase in patient safety and satisfaction
Improvements in the way people access urgent care services
Clear access route – through 111, GP, Ambulance and walk in
Care delivered in a more convenient setting/closer to home
Financial Savings
Approach 3 delivers longer term financial savings through reduction in A&E attendances
HMC

35. How will Approach 3 impact on the Drivers for change?
Continued challenging system performance
Duplication and Confusion in accessing urgent care
Sustainability
Contract Expiry dates (March 2018)
> Walk in Centre (Care UK)
> Minor Injury Units (Anglian Community Enterprise)
Approach 3 aims to reduce duplication while retaining a local presence
Approach 3 aims to ensure people access the right care first time, reducing the need to attend A&E for a minor condition
Approach 3 aims to deliver an integrated model, able to maximise and share the workforce and skills across the system
HMC
Opportunity to align contracts with the Integrated Urgent Care Service for larger scale benefits

36. Based on the Strategic fit, the recommendation is approach 3
HMC

37. Next steps Dependent on approved approach
Public Communication
28th June 2017 – 11th July 2017
Post Board Decision
Decision from June Board communicated to public and stakeholders as outlined in section 5
TDC
4th July 2017
Approaches 1 & 3
Proposed Service specification(s)
OEC
6th July 2017
Options Appraisal to approve Sourcing route
Proposed Service Specifications
Waiver to extend current contracts to align with revised milestones
Approach to succession planning
Approach 2
Approach to exit planning
CCG Board
25th July 2017
Approaches 1 & 3
Further Quality Impact Assessment on preferred Approach
HMC

38. Requirement from Board Members
The Operational Executive Committee and Transformation & Delivery Committee are recommending that the Board approve Approach 3 – The Establishment of a Minor Injury Service
HMC