Urgent and emergency care at Grantham and District Hospital

We want you to tell us what you think about our preferred change proposal to develop:

• A 24/7 Urgent Treatment Centre (UTC) at Grantham and District Hospital

The primary role of an Accident and Emergency (A&E) department is to assess and treat people with major trauma, serious injuries and those in need of emergency treatment.

United Lincolnshire Hospitals NHS Trust (ULHT) currently provides A&E departments at Lincoln County Hospital, Pilgrim Hospital, Boston and Grantham and District Hospital.

The A&E departments at Lincoln County Hospital and Pilgrim Hospital, Boston are consultant-led 24 hour services that provide the full range of accident and emergency care, with support from 24/7 diagnostics and access to critical care.

However, the Grantham and District Hospital A&E department has for some time (since 2007/8) only dealt with a limited range of presenting emergency conditions. This is because of its small size, limited availability of specialist staff and limited range of 24/7 support services to support very ill patients after they leave the A&E department.

This means the majority of patients treated at Grantham and District Hospital A&E department arrive with injuries or illnesses that can be safely treated at an Urgent Treatment Centre (UTC). As the service is supported by a skilled range of doctors, GPs, practitioners and nursing staff, it is able to provide an extensive range of assessment and treatment that meets the needs of the local population.

The service available at Grantham and District Hospital is well understood by the local healthcare system, including the ambulance service. If they assess a patient local to Grantham as having a care need greater than can be dealt with at Grantham and District Hospital, they will take them to the next closest hospital with the right facilities and skills to care for them.

If patients do present at Grantham and District Hospital A&E department with conditions that the hospital is not able to deal with, the skills and experience are there to manage the patient whilst transfer is quickly arranged to a more specialist unit for the appropriate treatment.

Prior to 2016 the A&E department at Grantham and District Hospital was operating 24/7 (dealing with a limited range of presenting emergency conditions).

Since 2016 it has been operating on reduced hours (currently closed between 6.30pm and 8.00am) due to difficulties faced by ULHT in safely staffing its A&E

departments. This change did not impact on the limited range of emergency conditions the service could deal with.

A summary of the current provision at ULHT’s A&E departments is set out below

In addition to the three A&E departments currently provided by ULHT, six Urgent Treatment Centres (UTC) are provided by Lincolnshire Community Health Services NHS Trust (LCHS). These are located at:

Lincoln located with A&E
Boston located with A&E
Louth
Skegness
Gainsborough
Spalding

These urgent care services can treat a wide range of conditions which are not critical or life threatening such as sprains and strains, suspected broken limbs and feverish illness in adults and children. They play a significant role in protecting A&E departments for those patients who really need them.

The Minor Injuries Unit service at Stamford Hospital (which is currently provided by North West Anglia NHS Foundation Trust) is available to people in and around the Stamford area in the south of the county.

This section sets out the challenges and opportunities for urgent and emergency care and what we hope to achieve by making changes.

Challenges

• Nationally there is a shortage of emergency medicine (A&E) doctors, which means greater competition between hospitals for doctors and an over reliance on doctors employed on a temporary basis
• Emergency medicine doctors are very difficult to secure, which in turn can lead to medical staffing vacancies and risk to the quality of patient care. Ultimately this can lead to service and patient safety concerns – as experienced by Grantham and District Hospital A&E department when the opening hours were reduced
• There have been genuine efforts to recruit and retain staff to work in Lincolnshire’s A&E departments but with limited success – the uncertainty over the future of the Grantham and District Hospital A&E has added to the reluctance to join the county’s team
• Independent clinically-led reviews have concluded that in the interests of safety the A&E department at Grantham and District Hospital should not re-open 24/7 unless sufficient staff can be recruited and retained on a long term and sustainable basis
• The A&E service at Grantham and District Hospital has, since 2007/8, only dealt with a limited range of presenting emergency conditions, and services are similar to that of an Urgent Treatment Centre (UTC) yet the description of the service as an A&E is still in place
• Using a description of A&E for this service creates unrealistic expectations and misunderstandings about the level of service that is and can be provided at Grantham and District Hospital

Opportunities

By making changes, we can look to ensure:

• High quality urgent care services are delivered at Grantham and District Hospital on a 24/7 basis in a sustainable way for the long term, by:
  • Making relatively small changes in the scope of safe and high-quality services, ensuring Grantham and District Hospital receives patients in line with its medical capabilities
  • Those few patients with the highest levels of need that cannot be met at Grantham hospital receive care in the most appropriate and safest place for them
  • Improve our ability to attract and retain talented and substantive staff to an effective, high quality, successful and sustainable service
• All patients see the right clinician for their needs, first time, 24/7, and therefore receive the best possible care, including not having to wait unnecessarily
• Patient health and the overall patient experience are improved​​​​​​ ​​​​​​​​​​

There has been ongoing engagement with the public throughout the Lincolnshire Acute Services Review programme, particularly through the ‘Healthy Conversation 2019’ engagement exercise.

Some consistent themes in relation to urgent and emergency care have been shared by the public and stakeholders throughout our engagement to date:

• The need to improve urgent and emergency care services across the entire county to deliver the best possible care for everyone
• Concern that the variety of urgent and emergency care service options across the county, with different names and specifications, was confusing and contributing to inappropriate use of services
• A clear desire that people should only use specialist A&E services when they are appropriate, to protect them for those requiring them
• Specific to Grantham and District Hospital:
  • A wish for 24/7 walk in access
  • Some concerns about increased travel time for local people if an A&E was no longer provided at the hospital
  • Some concern that other services at the hospital would be affected by not having an A&E department

We have consistently taken into account all public and stakeholder feedback throughout our work.

In light of the feedback received in relation to urgent and emergency care we have considered how we can deliver a sustainable 24/7 walk in service at Grantham and District Hospital.​​​​​

Our proposal for change is to establish a 24/7 walk in Urgent Treatment Centre (UTC) at Grantham and District Hospital, in place of the current Accident and Emergency (A&E) department.

The UTC would be provided by a community health care provider, with existing doctors retained as part of the team and consultant (senior doctor) oversight provided to the unit. The multi-disciplinary workforce would have the ability to manage all presentations, including those requiring stabilisation and transfer to an alternative hospital with the right skills and expertise.

It is anticipated this change would affect around 3% of those patients currently attending the Grantham and District Hospital A&E. This is equivalent to 2 patients a day, on average. These are patients who require onward transfer for immediate specialist care.

A key part of our process to evaluate options to tackle the challenges we face was to hold a clinically- led health system stakeholder workshop and four workshops with randomly selected members of the public.

For urgent and emergency care, where only one solution remained following the shortlisting of options, attendees at these workshops were asked whether they agreed or disagreed that the changes proposed would help to improve the current situation and meet the challenges identified.

The table opposite summarises the level of stakeholder and public support for the change proposal.

As we have developed our proposals we have considered the quality and equality impact of the preferred option for urgent and emergency care at Grantham and District Hospital.

Through our equality impact assessment we identified three groups of people, two of which can be defined by protected characteristics, which may be more likely to be impacted, positively or adversely, by this proposal.

These three groups are age, disability and those who are economically disadvantaged.

Our observations from these assessments are set out below. We will continue to review and develop these, including the impact on different groups of people within our population, with independent support, through our public consultation in light of the feedback we receive.

Potential positive impacts

• 24/7 walk in urgent care would return to Grantham and District Hospital through a high quality service delivered in a sustainable way for the long term
• The vast majority of patients (estimated to be around 97%) seen at the Grantham and District Hospital A&E department would continue to be seen and treated at the 24/7 Urgent Treatment Centre (UTC)
• The UTC would provide greater accessibility due to increased opening hours compared to the current A&E arrangements (currently closed between 6.30pm and 8.00am). Access to treatment would further improve for children because the UTC team would broaden to include community and primary care staff (eg. GPs) who are more experienced and familiar with treating children than a traditional, non-paediatric A&E team.
• Patients would spend less time in the UTC compared to an A&E department due to the different model of assessment and management it uses. Specialist follow-up input would be arranged as required
• The UTC would be provided by a community health service provider, which would support better integration with primary care and community services and the provision of care closer to home
• For a small number of patients (estimated to be around 3%, which is equivalent to 2 patients a day on average) currently attending the Grantham and District Hospital A&E who wouldn’t be able to have their care needs met by the UTC, care would be received at an alternative site with the right facilities and expertise to ensure better clinical care outcomes

Potential adverse impacts

• For the small number of patients (estimated to be around 2 a day) with greater needs who wouldn’t be able to have their care needs met by the UTC, treatment would be received at an alternative site with a full A&E service
• These patients would get the specialist input they require at the right time and receive the best possible care. However, it is acknowledged that needing to travel further for this care may be seen as an adverse impact by some people
  • Of those 3% of patients seen at an alternative site with the required specialist (A&E) services, it is estimated that if travelling by car around 60% of them would travel over 45 minutes (the threshold agreed by the local health system for this type of activity). This equates to less than 9 patients a week. It is estimated there will be no increase in the number of patients travelling more than 60 minutes by car
  • However, given the serious nature of the conditions these patients are expected to have, most are likely to travel by ambulance. This is what happens now for those patients requiring a level of emergency care that cannot be met by Grantham and District Hospital A&E
  • Of those attending an alternative site it is estimated around a third would attend Lincoln County Hospital and the remainder would attend hospitals out of the county, with the majority going to Peterborough City Hospital
  • The friends and family of those patients receiving treatment at an alternative hospital which better meets the patients care needs, may have to travel further to see them if they require specialist in- patient care