UNSCHEDULED CARE PEMBROKESHIRE

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UNSCHEDULED CARE PEMBROKESHIRE

• THE CLINICAL MODEL

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UCP-BETWEEN THE COMMUNITY AND THE HOSPITAL
Unscheduled Care
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URGENT CARE PEMBROKESHIRE

• A single service
• Multiple providers
• Covers all unscheduled medical and social care
  needs

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PRINCIPLES

• Shortest time to definitive treatment
• Hand-overs minimised or eliminated
• Clinicians empowered to make treatment/admission/d
  ischarge decisions

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GUIDING PRINCIPLES

• Most care will be provided on the basis of agreed
  care plans based on presenting complaint or known
  diagnosis
• Single record for the whole of the service
• Multi-professional
• Same for all components of the service

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PARTNERS

• Hywel Dda NHS Trust
• Pembrokeshire LHB
• Pembrokeshire LA
• Welsh Ambulance Service Trust (WAST)

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COMPONENTS OF SERVICE

• WITHYBUSH URGENT CARE CENTRE
• An Emergency Department (ED)
• An Adult Clinical Decision Unit (ACDU)
• A Paediatric Clinical Decision Unit (PCDU)
• A Primary and Community Care Service (PCCS)
• On site care
• Base for home visits
• A Care Co-ordination Service (CCS)

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EMERGENCY DEPARTMENT (ED)

• Patients requiring immediate stabilisation and
  assessment (resuscitation)
• Most patients with injuries who may need
  admission to hospital (trolley area)

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CLINICAL DECISION UNITS (A.C.D.U.) (P.C.D.U.)

• Most adult patients self-presenting who need
  assessment re in-patient admission
• Most patients referred from Primary Care
• Some patients referred from the ED
• Some patients referred after telephoning the CCS
  and/or WAST

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PRIMARY COMMUNITY CARE SERVICE (P.C.C.S.)

• Most patients not likely to require in-patient
  admission or extensive investigation who
  self-present
• Patients as above identified by telephonic CCS
• Some patients from WAST

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CARE CO-ORDINATION SERVICE (CCS)

• Face to face assessment to differentiate patients
  into particular streams of service
• Similar function for telephone contact certain
  patients from WAST
• Care traffic control pulling patient through
  system
• Organising support for patients accessing
  services outside of WEUCC and to support
  discharge

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SIZE OF THE SERVICE

• Current ED has 33,000 visits/year
• 20,000 see and treat
• 8,000 assess and admit
• 5,000 assess and discharge
• 500 true emergencies
• Current OOH service has 10,000 visits/year
  call-handling and support functions
• Direct admissions via GP 5000/year

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SCOPE OF THE SERVICE

• All patients differentiated either by telephone
  or at the front door and sent to either
• Emergency Department critically ill, life or
  limb threat, trauma not suitable for PCCS
• ACDU further assessment or treatment needed to
  determine need for in-patient admission
• PCCS in-patient admission not likely needed

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PROJECTIONS FOR UCP

• Primary and Community Care Service
• 30,000 attendances home visits
• ACDU
• 16-18,000 visits ? 9-12,000 admissions
• Emergency Department
• 2-4,000 visits ?front-door assessment for
  ACDU

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WHAT DO WE KNOW THAT WORKS ?

• GPs, Nurse practitioners and ED doctors (staff
  grade level) in PCCS
• ED specialists (Staff Grade and Cons.) in ED
• ED and/or Specialists Staff Grade and Consultants
  supported by others for ACDU
• Being assessed by a senior clinical person early

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COMPETENCIES FOR E.D.

• Resuscitation skills (trauma and cardiac arrest)
• Stabilisation skills
• Managing time-dependent emergencies
• Co-ordinating teams (trauma)

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COMPETENCIES FOR ACDU

• Identifying appropriate patients
• Initiating Care pathway for particular patient
• Decisions about admission or discharge

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COMPETENCIES FOR PCCS

• Recognition of common pathology patterns and
  action required
• Time and resource appropriate treatment
• Generalist skills

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HOW MANY DOCTORS ??

• For the PCCS
• 7-8 WTE GPs
• 3-5 WTE Staff Grades (Emergency Medicine) or
• Another combination of both
• If ANPs or ENPs used could reduce the number of
  doctors

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HOW MANY DOCTORS ??

• For ACDU
• 2 WTE Consultants (EM or specialty or combo)
• 4-5 WTE Staff Grades (EM or specialty or combo)
• 7 WTE F2 doctors (full time in ACDU or rotate
  in from other areas)
• ED
• 24/7 cover from competent EM doctor

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WHEN ARE DOCTORS NEEDED ?

• ED 24/7, demand unpredictable
• ACDU 70-80 of work 1000-2200
• PCCS Much of work OOH and weekends but some
  throughout day and very very little at night

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HOW CAN WE DO THIS ?

• Doctors work exclusively in one area as much as
  possible
• Resuscitation skills needed all the time
• When doctors must be available to more than one
  area, must be at low demand times for all areas
  (nights)
• Retain flexibility (minimum 2 doctors)

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DOCTORS NEEDED FOR UCP (?)

• 4 WTE Consultants or Assoc. Specialists
• 8 WTE GPs
• 9-10 WTE Registrars or Staff Grades
• 8 WTE trainee doctors (F2)

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OPTIONS FOR STAFFING

• All Doctors working for UCP exclusively and
  rotating through the various parts of UCP
• Combination of doctors working exclusively for
  UCP and others (primarily ACDU) rotating in from
  existing specialities

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SUMMARY

• UCP fundamentally changes how care is delivered
• Single service for health and social care
• Equitable access and triage of clients
• Senior doctors as point of first contact
• Use of care pathways and pulling patients
  through the system
• Equitable outcomes

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SUMMARY

• The size and scope of the service is beginning to
  emerge and needs final agreement
• The requirements for doctors (both number and
  competencies) is beginning to emerge and needs
  agreement
• Operational policies and implementation will be
  required in all areas very soon and depend on
  these decisions