Response to the consultation document: (SOME FORMATTING LOST DURING SCANNING)

Proposals for a Safe and Sustainable Urgent Care Network in the South Eastern Trust.
(Including a proposal to change the Emergency Department at the Downe Hospital)

This response is the consensus view of a representative group of GPs from the majority of practices in the Downpatrick/Crossgar/Killyleagh/Newcastle/Dundrum/ Ardglass area.

We are responding to the contents of the consultation document but also wish to raise our concerns about the following issues:

1. the process by which this document was developed and disseminated to local GPs;

2. the discussions that have taken place between the Trust, local GPs and others around Emergency Services;

3. how we as the main local providers of primary care services ensure that there is a safe sustainable urgent and emergency care service for the local population, most of whom are registered as patients with our practices.


The GPs of this area agree with the desire to provide a safe sustainable service for our patients and are disappointed that we were overlooked in the discussions leading to the development of the various options presented in this consultation document.

We have experience of providing many years of primary care to our communities and many of us as individuals have participated in providing out of hours care to the same communities. The recent co-location of OOR and A&E departments has allowed us to see how such services can work together and also to see how busy A&E can become and the complexity of cases it deals with. We therefore have specific insights as to what is feasible in terms of safety and sustain ability for future developments in these services.

The Trust maintains that there is a workforce problem concerning medical staff to deliver existing services making them unsustainable but there is no evidence that the ‘preferred option’ will not move cause a potential workforce problem in Primary Care again making these developments in OOR in this area unsustainable. Some of us feel that this is not of particular concern to the Trust. There are no examples of how such a system is operating safely elsewhere in the NHS.

Given the scale and the implications of the proposed changes it seems scarcely believable that these proposals have been brought forward for consultation with a short time scale during the holiday period. Many of these issues may well have been discussed by the Project Team but were not discussed with local GPs before suggesting that they should lead and implement the proposed service.

The document was developed by a project group that did not have any representation from local GPs. We cannot understand how the Trust would presume (or be fully able) to develop options that we (the local GPs) will be expected to support, implement, give future leadership to and hold clinical responsibility for without having had the opportunity to participate in the development process.

1. Many GPs were unaware of the publication of the document until the first hastily convened informal meeting at the Downe Hospital.

2. As a result of our exclusion from the development process we feel that all possible options have not been considered and that the necessary support and context for the preferred option (Option 4) has not been thought through omitting to consider important operational aspects such as the need for an extended Medical Assessment Unit/the need for processes to be put place for palliative care/the need for a system of ensuring timely confirmation of death.

3. The preferred option (Option 4) seems to rely on the inclusion of a number or team of GPswSI in Emergency Care in the Urgent Care Department. Although this is not explicit from the document as written there is detailed reference to the role of GPswSI and there is an appendix from the Royal Colleges detailing such a role – yet there is no specific mention of the use of such doctors in the preferred option. Our concern is that currently there is NOT a single such GPwSI trained/accredited in this area. To our knowledge no local GPs have been approached to discuss whether there is an interest in development of such a service and no mention of the training, recruitment or maintenance of such a service is made in the proposal.

4. The Urgent Care Project Group did not contain membership from NIAS (although the Project Team did) yet our informal discussions with NIAS colleagues indicate that they do not feel fully involved in the development of the preferred option and how they will be expected to implement it. We would need to be assured that the Project Team NIAS representatives gave sufficient feedback to NIAS colleagues as in the preferred option there is no description of the role of the NIAS. We would ask is there a new role for NIAS and who is discussing this option formally with NIAS?

5. Comments were made at the informal discussion in Downe Hospital that cover would be provided by the F2 doctors in the hospital but this is not detailed in the document. If it is the case then those of us who are currently involved in training F2 doctors would not consider that many of these doctors have sufficient A&E or OORs experience to replace an experienced GP while he or she is out on home visits. We feel this situation would be unsafe if there was a serious case presenting at the Emergency Centre. The detail is missing from the document as to how effective cover would be provided in these situations and by whom.

Overall we consider that there is a lack of clarity in the document about particular issues of importance (such as the use of GPswSI) and does not address adequately or at all other specific issues such as: cover for GPs on home visits; access to protocols re bypass of A&E; the lack of clinical pathways for cases and scenarios presenting in the A&E Urgent Care Centre; lack of plans for training and detail re level of training for GPs manning the service (GPwSI or not); no detail re ‘direct access’ to consultants without detail of what this means; there is no consideration of extra demand for Medical Assessment; there is no detail re timing and personnel involved re operation ofNIPACS at night.

On the basis of the above we consider that the Preferred Option as it is described in the consultation document as ‘Option 4’ is unsafe and unsustainable. It does not meet the standards and the requirements as laid out by the Trust in the introduction and title of the consultation document and in the appendices and supporting documents from the Royal Colleges. It does not satisfy our concerns as local GPs that safety and quality of care were the primary motivators for change.

Detailed response to specific points in the document.
We would like to make the following more detailed comments in response to the consultation document.

Section 3.1.3 page 15: The description of services at Downe Hospital ED Department is disingenuous in its statistics using averages to portray an almost empty department (9 patients per night with 2 admissions). Experienced providers of the A&E service know that attendance and workload is concentrated on certain times and nights of the week.

The analysis should have given information on these busy times as these are the likeliest to provide a challenge to the ‘preferred option’ (Option 4).

Section 2.1.3 Page 9 and following: There is a description and rationale given for the development and delivery of a GPwSI in Emergency and Unscheduled Care service which is described as being ‘relevant to the Trust’s proposal’ . No further clarification as to what this means is given. There is no reference to such a service in operation elsewhere in the Trust or any Trust in N. Ireland. There is no mention of the service in the options and none in the preferred option. The document does not highlight the fact that there is NOT one such GPwSI in this area nor are any proposals included re the development of training/accreditation necessary for such a service. Indeed no further mention is made of training development or accreditation of the doctors who will be expected to implement the proposed service.

Section 2.1 page 19: The description of services includes mention ofNIPACS which describes the reading of X -rays remotely at UHD but does not reference any evidence that this system which we presume operates currently during the day has been assessed as safe and has yet been extended to a night time operation. We have no details as to how the GP on call can participate in such a system nor whether it has been used in this way before nor what the timescales for reading and reporting are nor who exactly would be reading the X-Rays in the middle of the night. The proposed system is not mentioned again in the various other options (was it not considered?) until it returns in the Preferred Option (4.4 page 24). where reference is made to what the acronym NIPACS stands for then a two line description of this technology and a reference to ‘quick reporting and diagnosis’ .

Whether this is the professional description of the service or a lay accessible version there is no detail as to what ‘quick’ actually means.( eg 1-4 hours?)

Section 4.3.4 page 23: In Option 4 there is reference to a ‘consultant presence onsite Monday to Friday and available on call outside ‘these hours” (no detail of the ‘hours’ is given but are we to presume this means at least 9am-6pm or is an extended consultant presence implied?) This section states ‘a GP would be adequately supported…’ no further explanation is given so we are not sure what this means.
Nor is it clear what is referred to by ‘cover arrangements would be in place…’

This section states ‘GPs would have direct access to Consultants for support’ – no indication is given as to what ‘direct access’ means nor the times when this would be available.

These points are repeated word for word in Preferred Option (Section 4.4 page 24) without any further clarification or detail.

Section 4.4 page 24: In the 2nd paragraph in reference is made to ‘clear protocols would be in place n respect of the provision of support from the acute medical wards’ – if this means the F2 doctors are we to presume they will have experience of A&E or OORs. We feel this element may make recruitment of F2s to willingly come to Downpatrick difficult and put strain on the current training system at this level. No other medical F2s in Northern Ireland will have to cover Emergency Centres.

Page 24: In ‘the benefits of the ‘preferred option’ we are informed that the ED Consultants ‘believe this would result in the provision of a safer and more effective model of care… ‘ – No evidence is given for this belief.

Also here ‘the Trust considers that this would be a sustainable service’ – again no evidence is given for this ‘consideration’.

Reference is also made here to ‘This will have minimal impact on acute medicine in comparison to some of the other options’ but no mention of acute medicine is made in the other options!

Also ‘it may impact on the workload of the doctors on site’ is included as a benefit without explanation as to what this means or how it is beneficial.

In this section ‘Concerns’ about the option include:-

There ‘could be some impact on NIAS’ – no detail or clarification is given as to what this might mean whether to the local NIAS service or as to what NIAS considers arc: the safety implications of the options. Are we to take it that NIAS are expected to respond to this Consultation like any other organization even though they are and integral part of the proposed new structure and systems (indeed just like the local GPs). This short phrase is included as a concern without elaboration indicates to us a disregard for the safet )[ implied in an effective Ambulance Service and is one of the most important concerns we have.

• ‘The model has not been tried elsewhere in NI’ – we would ask ‘Have any parts eg the NIPACS; the lack/presence of GPswSI; the cover for palliative care been tried elsewhere?’ If they have could we please have the results of any evaluation?

• ‘May have operational implications for the acute medical team…’ Again what does this mean? Have the medical consultants defined these implications -can they tell us why Ibis is a contrn when impact on the workload is considered a benefit (see above)?

• There is a ‘Potential for future recruitment issues among GPs’ – does this mean to work in the proposed new system or generally in this area? Why were local GPs not asked for an opinion on this before? Who on the project team had the expertise or experience to make this comment.?

• In the final part of the section ‘it should be noted that-‘

‘. a patient mapping exercise has been undertaken that indicates that ‘this system’ (no indication of what is meant by ‘this system’) is safe and will allow the vast majority of ‘appropriate’ ( no indication of what is meant by ‘appropriate’)patients to be managed on the Downe site.

… .the GP will I have access to the Observation Ward (this is the first mention of an observation ward (what is it? who mans it? who is suitable to be kept there? Have protocols been developed with/without GP input?) I

Conclusion. I I Once again ,~t: would like to state our desire to see safe sustainable health services for our patients bl~t the proposals in the consultation document including the Preferred Option fall ~ort of this requirement.

In answer to the three questions asked in the consultation document:

1. Do you agree with the proposed vision for urgent care in the Downe Hospital?
On the basis of our analysis of the consultation document we the undersigned GPs do not agree.

2. How do you Ithink this proposal could be further improved?

We suggest that the project team should develop further options with the participation of the people they expect to lead and implement the service the local GPs and those who will be using the service – local patients.

Have you any other model, supported by evidence, that could deliver a safe and sustainable model of urgent care in the Downe Hospital?
Because we have not been part of the discussions leading to the development of these proposals we have not had the opportunity to discuss and develop such a model nor examine the evidence – we would suggest that there is a complete lack of evidence fro the Preferred Option- at least there is none presented in the consultation document.

Dr. Anne-Marie Hamey
Dr. Alee Greer
Dr. Jane Creaney
Dr. Margot Deeny
Dr. Nigel Hart
Dr. Paddy Moore
Dr. Lloyd Gilpin
Dr. Finbar MeGrady
Dr. Ciara MeCartan
Dr. Ultan MeGill
Dr Malachy Murphy