A more efficient way of responding out of hours
Out of Hours Urgent Care is care in the community that needs a response before the next routine care service is available, for example, a GP or District Nurse. It is not 999 emergency care.
These are the services providing out of hours urgent care just now:
- The Primary Care Emergency Service (PCES). This is GP and nursing care when your own GP is closed (6pm to 8am during the week, 24 hours at weekends and public holidays). This service is for Fife and Kinross. It provides advice, appointments and visits people at home.
You can access it through NHS 24. A local dispatch team in Glenrothes co-ordinates where people should be seen and who will visit or call to give advice.
The quickest appointment anyone would be offered for an out of hours GP appointment is one hour.
- Minor injury services are delivered in the out of hours periods, that is, evening, overnight and weekends.
- Evening, night and weekend District Nursing.
Like all other parts of Scotland, our services are under constant pressure. This is also having an impact on out of hours’ urgent care. The current system is experiencing the following:
- A national shortage of GPs and nurses available to work evenings, holidays and weekends. This means we struggle to cover the service and ensure that it is safe for patients.
- Clinical and professional skills being spread across four centres. This is not the best use of professional resources and reduces team working.
- The challenge of ensuring a safe level of staff available for the public.
Our priority is to provide the people of Fife with a safe and effective out-of-hours service that best meets their needs. It is simply no longer possible to do that without changing the way we currently provide services.
Why we need to change
These are some of the challenges we are facing for urgent care:
These are some of the challenges we are facing for urgent care:
- It’s getting much harder, nationally, to recruit GPs and nurses for urgent care. We’re finding it difficult to make sure we have enough staff to provide a clinically safe service. In all areas of Fife we’re short of GPs and Nurses.
- Our staff are based in one place all the time. This means they’re not able to move between centres to meet patients’ needs, even though some centres are busier than others.
- People who come for an appointment overnight who then need to see a specialist have to be moved to an acute hospital, sometimes by ambulance.
- Doctors and Nurses recommend that children, who can become very unwell quickly, are seen in a centre with direct access to specialist support. Overnight PCES centres are currently at Glenrothes, Dunfermline and St Andrews, not beside children’s services, which are based at Victoria Hospital.
- We have just enough home visits available at the moment. We know we will need more as the number of very old people increases.
- With a lot of different services providing urgent care, we are not as joined up as we could be and this makes how we work more complicated and less efficient.
Lisa Cooper, Lead Nurse in the Out of Hours Service talks about what the proposed changes to the Out of Hours service across Fife could mean for patients and staff as part of the Joining Up Care consultation.
How we currently provide out of hours services
The diagram below (Figure 5) shows the service arrangements. PCES works from:
- Queen Margaret, Glenrothes, Victoria and St Andrews Community Hospitals in the evenings, at weekends and on public holidays
- Queen Margaret, Glenrothes and;
- St Andrews Community Hospitals through the night.
Minor injuries services are delivered from:
- Queen Margaret and Victoria Hospital
24 hours a day, seven days a week
- St Andrews Hospital 8am-6pm then
6pm-midnight by appointment through NHS 24 (111)
- Adamson Hospital, Monday to Friday from 8am-6pm
The District Nursing Service provides appointments during the evening, and weekends and an on-call service overnight.
How do people use the current service?
The way people use minor injuries services has not changed much over the years.
Figure 6 below illustrates how people used PCES in 2016/17. PCES also provided over 7,000 advice calls.
Use of Minor Injury Services from midnight to 8am is very low. In 2016/17, an average of eight people across Fife used the service each night. At Queen Margaret Hospital, there were three or fewer patients on 77% of nights and 21% of nights at Victoria Hospital.
Calls to the Evening and Night District Nursing Service went up by 40% between 2010/11 and 2016/17. This is because we’re treating more people at home. District Nurses provide support at home for people with complex illnesses and for people who are terminally ill.
How can we change?
We’ve considered a wide range of options and focused on those which we think:
- Offer the best possible clinical care.
- Are possible in terms of the available workforce and will attract people to work in the service.
- Are possible in terms of the money we have available.
- Bring the different services together.
We’re proposing two new options, alongside the current model. These two new options take account of the clinical safety, transport and workforce problems we have with the current system.
- Option 1 (staying the same).
- Option 2 – two centres (Dunfermline and Kirkcaldy), with only Kirkcaldy open overnight.
- Option 3 – two centres (Dunfermline and Kirkcaldy), both open overnight.
The Joined Up Care Consultation Summary document has full details for each Option. Please read this in full before completing the questionnaire.
The urgent care centres described in options 2 and 3 are both within a one-hour drive for everyone in Fife. When we surveyed people in September 2017 and asked them how they got to their GP out of hours appointment or minor injuries centre 94% of people drove or were driven.
Arrangements are already in place with NHS Tayside and Forth Valley for people living nearer these centres. To ensure people have equal access to urgent care we will develop a procedure to support people who have difficulties getting to an appointment. This will be in line with other areas of Scotland.
Options 2 and 3 both have the following:
- Urgent Care Centres that would deliver the full range of urgent clinical care locally. They will be based at a safe venue that the public can access, which makes the best use of available staffing.
- An Urgent Care Dispatch that staff from a number of health and social urgent care services (including clinical staff) would work together from to coordinate services according to need. It would direct how services work in the out-of-hours period to make best use of our workforce and skills according to need. This team would not consult with patients there.
How do we know this approach could work?
Here’s *John’s story which is based on a real patient experience:
* not his real name
Directing people to large centres removes the risk of lack of staff and provides access to greater range of support. Also provides more back up for staff members.