Enhancing Unscheduled Care Services in North Wales: A Rapid Review

1. Rapid Review of Hospital Element of Unscheduled Care Services in North WalesDr Rob AtenstaedtConsultant in Public Health MedicinePublic Health Director for Conwy & DenbighshireSiobhan JonesSpecialty Registrar

2. Background Need for review driven by: • NW reviews including Llandudno Hospital Review & • difficulties in sustaining surgical on call rota across 3 hospital sites. Part of NW Clinical Strategy. Included 2 other 90 day reviews: • Primary/ Community Care • Mental Health

3. Key Question to emerge How should the hospital element of Unscheduled Care be delivered across NW?

4. Process (1) • 90 day research methodology • 3 x 30 day ‘cycles’ • Expert/stakeholder events held after each 30 day cycle - 2 weeks in-between cycles for feedback • 1st 30 days for gathering/considering evidence – huge amount PH work done in this cycle!

5. Process (2) Weekly meetings core project team; • Chief Exec – DLHB Project Lead • Planning • Clinical Directors/ Leads • PH • Welsh Ambulance Service Separate teleconferences to direct PH work

6. Public Health input • Dr Rob Atenstaedt, Consultant (Lead) • Siobhan Jones, StR (Deputy Lead) • Claire Jones, HIAT (data) • Dinah Roberts, LKMS (Lit Search) • Mary Webb, HSCQ (Lit Review) • Margaret Webber, HIAT (Drivetime) • Andrew Jones, RPHD (QA)

7. Objectives of PH Input Due short timescale, pragmatic review by all-Wales team: • Examine burden of accidents & emergencies in NW • Determine what elements high quality hospital USC service should provide • Examine need for hospital element of USC services in NW, in particular no. A&Es • Review current hospital element of USC service provided in NW including hospital activity data

8. Progress with PH Input Series of NPHS reports produced including: • Population Profile of NW • Overview of epidemiology of conditions needing A&E management in NW • Drivetime analysis • Lit review on best practice in USC Services • Profile of current USC services in NW • Data report on hospital USC activity across NW (Joint PH/NW NHS Trust Report)

9. Location Current NW UC Services

11. Key Messages from the literature

12. Profile of A&E attenders from research 1 in 1000 with major trauma 1 in 100 with life threatening illness or injury, of which 75% major illness, 15% trauma, 3% drug over-dose 1 in 4 whose condition does not need facilities of major A&E dept 9 in 10 who attend without first consulting a GP 1 in 6/7 admitted as inpatient 1 in 4/5 is child 1 in 700 dies in A&E dept

13. Elements of high quality hospital USC service – review of evidence High quality USC service: • 24 hr access - radiology, CT, Utrasound, MRI, anaesthetics, general surgery, A&E medicine, neurosurgery and orthopaedic surgery, ICU • Senior Dr presence in ED 24/7 to assess those requiring surgery • Observation wards/CDU’s ↓ length of stay and safety net for inappropriate discharge

14. Elements of high quality hospital USC service – review of evidence • 25% attending ED children –level 3 critical care vital • Trauma teams • EM consultant for 18 hrs/ day • Nurse practitioners ↓ waiting times. Pt satisfaction/ level care = middle grade doctors • Paucity of lit on cost effectiveness

15. Need for Hospital Element of USC Service in North Wales • Trend has been for demand for USC to increase • Little predictive evidence on future demand • Min catchment pop 450,000 for acute hospital/ hospital network (RCS) • Pop 300,000 more realistic for geographically isolated areas (RCS) • EDs in small hospitals with < 40,000 attendances per yr, if < 10km apart, should be merged (CEM) • For distances of 10-20km emergency services should be sustained (CEM)

16. Need for Hospital Element of USC Service Evidence indicated that: • Merging EDs did not always produce expected cost savings • Further work required on economics and cost effectiveness • For life threatening conditions e.g. stroke, head injury and acute coronary syndromes delays in tx lead to adverse outcomes. • The ‘golden hour’ effect for major conditions only available for:

18. Drivetime analysis Drivetime analysis found: • Having 3 A&Es in NW, or 2 A&Es at Bangor/Wrexham or Bangor/Glan Clwyd produces similar proportions residents who travel to nearest A&E < 1 hr (98%) • Having 3 A&Es in NW produces least travel time – 81% of residents < 30 mins • Having only 1 A&E at Glan Clwyd produces lowest proportion residents reaching nearest A&E within 30 mins (51.5%) • Public transport travel times calculated by WAG

20. Unscheduled Care Activity Data • First time data from all 3 hospital trust extracted and compared over 5 years • Looked at A&E attendance, transfers, emergency admissions • Patterns of A&E attendance & emergency admissions notably similar across hospital sites

23. Next Steps RR informed wider project which has: • come up with set of aims/ vision for service • drawn up non-financial option appraisal criteria • Defined set of core services • scored no. models of care • identified further work including: - undertaking financial & economic appraisal - undertaking Equality Impact Assessment - exploring concept of comms hub - agreeing process for next stage, including approach to engagement needed

24. Reflections • Very tight timescales of 90-day research methodology when PH input needed mainly in first 30 days • Delays in receiving data from partners • National PH model worked well and promptly