Treatment Room Engagement Paper - May 2011

NHS LANARKSHIRE

REVIEW OF THE TREATMENT ROOM SERVICE.

ENGAGEMENT PAPER

IndexPage

1. Summary3

2. Introduction6

3. Background6

4. Treatment Room Service Definition7

5. Current Service Provision8

6. Key Principles 8

7. Core Treatment Room Service: Current And Proposed9

8. Service Access: Current And Proposed10

9. Treatment Room Capacity11

10. NHS Lanarkshire: Future Service Model Options12

11. Operationalisation Of The Proposed Options14

12. Treatment Room Accommodation16

13. Staffing Resources17

14. Workforce Development18

15. Recommendations18

16. Strengths And Weaknesses19

17. Conclusion20

Tables

1 Service Strengths And Weaknesses Of Each Option13

Appendices

1Sub Group Members21

2Practice Nurse Profile 2007: Treatment Room Data22

3Proposed Core Clinical Interventions24

4Spread Of Treatment Room Services Across Lanarkshire25

5Treatment Room Activity Data28

1. Summary

1.1 This review has been undertaken to look at how a better Treatment Room Service can be provided for patients that is more effective and efficient. The aims of the Treatment Room Service review are to:

Provide a standardised service
Increase the number of patients the service can see, within existing resources.

1.2 Like allpublic sector organisations, NHS Lanarkshire faces significant challenges to ensure the most efficient and effective services are delivered at a time of increasing financial constraint. As a result we need to utilise the additional investment in community nursing already received to ensure that the increased levels of activity planned around areas such as the full implementation of the organisations long-term conditions strategy including the mainstreaming of Keep Well and Anticipatory Care Plans, the implementation of national policy such as Getting it Right For Every Child and HALL 4 as well as the increased demand for treatment rooms services is achieved. Therefore the treatment room review is aimed at increasing clinical capacity enabling more patients to be treated within our current resources given the increased demand for this service.

1.3 In relation to Keep Well, the Scottish Government willinvest £1millionto ensure this programme is mainstreamed within clinical practice and effectively and efficiently delivers against the national targets. A proportion of this will be invested within community nursing to take on the nursing component of this work and will not impact on the current levels of clinical activity within the Treatment Room Service.

1.4 In undertaking the review the Sub Group, appendix one, scoped out the current treatment room service provision and outlined a number of potential service models as detailed in section 10with a view to establishing a consistent approach across Lanarkshire. In doing so it found:

Inequity of service across Lanarkshire
A variety of clinical interventions being undertaken ranging from phlebototomy only to a wide range of interventions including immunisation.
District Nursing input to the service both on a planned and unplanned bases impacting on their ability to care for housebound patients
Inability to proactively manage patient flows resulting in sometimes lengthy waits for patients on the day of access
Increased demand on the service with no additional resourceand often without advanced notice to the service to enable any planned increase in demand to be effectively managed reducing lengthy waits for patients on the day of service access.

1.5 Through the review process it has been identified that some patients may attend the treatment room for phlebotomy and are then asked to attend Keep Well. Whilethe Keep Well health screen is much more than phlebotomy, there is potential to reduce some of the duplication arising within both services freeing up capacity to undertake more treatment room activity to the benefit of patients.

1.6 Given the prevalence of coronary heart disease in Lanarkshire, it is essential that all people living in Lanarkshire between the ages of 40 and 65 years have the opportunity to access this anticipatory care programme. To achieve this it needs to form part of the main stream community nursing service. Those accessing Keep Well are on the whole mobile and able to attend clinics. The treatment room is a locally accessed nursing service providing a range of clinical interventions to patients who are not housebound. Additionally there would also appear to be some overlap with patients accessing both services. It is therefore logical to include Keep Well within the Treatment Room Service.

1.7 In considering the issues the Sub Group propose that:

There is the provision of a universal service across all community health partnershipunits, sharing the total treatment room funding across areas to provide a service in every Locality. The actual number of treatment room sites would be agreed on a unit basis (e.g. could be one site, a few sites, or a peripatetic service provided to practices). An outline of how this would be implemented within each of the units is detailed in section 11.
Allocation of treatment room resource should be rebased on a Unit bases utilising NRAC a nationally agreed formulary for the allocation of health service funding in Scotland.
District Nursing will no longer input to the service freeing up their time to concentrate on housebound patients. Some of the District Nursing hours currently utilised within the Treatment Room Service will be transferred to this service to enable the withdrawal of District Nurses to occur.
Core clinical interventions outlined in appendix three are implemented with a central review mechanism being established to amend these across the organisation on a two-yearly basis;sooner if required.
The health screening element of Keep Well, the coronary heart diseaseanticipatory care programme, is incorporated into the treatment room service increasing access across Lanarkshire. Additional investment will be available to enable this to occur.
The Core Service is made available Monday to Friday 8am to 6pm with the Keep Well component continuing to work in the evenings and Saturday mornings as required. This will be further explored as part of the engagement process.
A system of appointments with some availability for urgent appointments each Monday to Friday are established in all treatment rooms to enable the flow of patients to be proactively managed avoiding some of the peaks and troughs in the workload currently experienced.
Practices inviting patients as part of the General Medical Services (GMS) contract to attend the treatment room for venepuncture must do so in conjunction with the service enabling the flow of patients to be best managed. Patients on a number of disease registers must be identified to avoid the need for multiple attendancespreventing any unnecessary discomfort to patients.
A capacity management tool will implemented and monitored with a view to maximising the number of patients seen by the treatment room service.
LEAN methodology will be implemented to reduce all unnecessary process with a view to standardising practice freeing nursing staff time to see patients. Activity will be capped on a Unit basis. Application of LEAN in Wishaw health Centre has created an additional 122 new appointment slots per week with 50 per week being unused reducing the waiting time for a phlebotomy appointment from 3 weeks to 4 days highlighting the benefit in utilising this approach.
Workforce plan will be reviewed to reflect the service model and core activity being delivered by the service.

1.8 The recommendations outlined in this paper provide a number of benefits including:

Increased treatment room capacity
Increased district nursing capacity
Standardised practice across services
Access to Keep Well for all people between the ages of 40 to 65 years in all localities
Identification and diagnosis of previously undetected coronary heart disease
Reduction in unnecessary visits to the treatment room service via improved co-ordination of disease registers
Increased referral to smoking cessation services.
Achievement of H4 and H8 HEAT targets.

2. Introduction.

2.1 This report provides an overview of treatment room nursing across NHS Lanarkshire with a view to proposing a standardised model across the organisation which meets the needs of the people of Lanarkshire. In doing so the report:

Provides an overview of currenttreatment room nursing provision across the organisation
Outlines potential service models for consideration, within available financesand recommends the way forward.

3. Background.

3.1 A Sub Group has been established to review the treatment room services as part of the CRES Community Nursing Review programme(appendix 1) to look at how a better Treatment Room Service can be provided for patients that is more effective and efficient. The aims of the Treatment Room Service review are to:

Provide a standardised service
Increase the number of patients the service can see, within existing resources.

3.2 Like allpublic sector organisations NHS Lanarkshire faces significant challenges to ensure the most efficient and effective services are delivered at a time of increasing financial constraint. As a result we need to utilise the additional investment in community nursing already received to ensure that the increased levels of activity planned around areas such as the full implementation of the organisations long-term conditions strategy including the mainstreaming of Keep Well and Anticipatory Care Plans, the implementation of national policy such as Getting it Right For Every Child and HALL 4 as well as the increased demand for treatment rooms services is achieved. Therefore the treatment room review is aimed at increasing clinical capacity enabling more patients to be treated within our current resources given the increased demand for this service.

3.3 In relation to Keep Well the Scottish Government will invest £1million to ensure this programme is mainstreamed within clinical practice and effectively and efficiently delivers against the national targets. A proportion of this will be invested within community nursing to undertake the health screening component of this work and will not impact on the current levels of clinical activity within the Treatment Room Service.

3.4In undertaking the review process, variation in the number of treatment rooms, hours of service and type of activity currently undertaken has been identified across NHS Lanarkshire. This ranges from some Localities providing a phlebotomy only service to others providing full treatment room services with dedicated treatment room staff to all practices on a number of sites or on the same site.

3.5In some instances district nurses provide the treatment room service to individual GP practices, while others are redeployed from planned activity to cover expected and unexpected treatment room nursing staff absence. This disrupts services to housebound patients and requires to be addressed as part of the review process enabling the treatment room service to become self sufficient.

3.6The background to these issues is somewhat complex. During the 1980s, treatment rooms were offered as a resource as part of health centre development. In addition, prior to the new General Medical Services (GMS) contract, practices were encouraged to appoint practice nurses, with health boards providing 70-85% of the funding.Not all practices took up this option. Applications were considered based on the overall geographical spread of practice nurses and the provision of treatment rooms to try to ensure equity.

3.7With the introduction of the new GMS contract in 2004, staff costs were incorporated into a GPpractice’sglobal sum payment. In addition boards were advised that resources allocated under section 40 of the Scottish guidance to the contract should not be altered without prior consultation. However this was not a commitment to maintain the status quo indefinitely nor a remit to boards to increase nursing services to practices in response to increased demand. Recent clarification to NHS Boards from the Scottish Government around this issue has identified that this does not form part of the contract. Therefore the service must be managed with due regard for patient need and financial resources available.

3.8In addition,“Investment in Primary Care” funding was established in April 2001. The aim being to encourage innovation in general practice byfacilitating NHS primary care trusts at that time to work with practices and primary care professionals to innovate and improve patient services by supporting local initiatives that contribute to delivery of the NHS plan and Local Delivery Plans (LDPs). Again, not all practices accessed this funding. Those who did established a range of services including treatment room and phlebotomy services.

3.9Given all of the above it is far from clear whether the current provision of treatment room serviceis equitable across NHS Lanarkshire. There is therefore a need to review the service and standardise practice.

4. Treatment Room Service: Definition.

4.1 No national service model or definition currently exists for treatment room services. This is evident by the wide range of service models and clinical interventions utilised across Scotland with some NHS Board having no treatment room service. However, in accessing information about a wide range of similar servicesthey are defined as:

“Nursing services provided within a local clinical settinggenerally Monday to Friday providing a range of agreed core clinical interventions to non housebound patients”

4.2 On the whole this describes the service provided in NHS Lanarkshire and would seem a reasonable definition to utilise in considering the future model.

5. Current Service Provision

5.1Treatment rooms have historically been provided within health centres and GP practices with the service being provided by:

Dedicated treatment room staff
District Nurses with treatment room time built into their schedule and/or utilised to cover unplanned leave of the dedicated treatment room staff.
Practice Nurses providing some of the treatment. However an audit of Practice Nursing in Lanarkshire undertaken in 2007 identified that this was in the minority of practices, furthermore practice nursing involvement in treatment room provision had reduced over the previous 3 years, (Appendix, 2)

5.2 Across Lanarkshire there is no uniformity of service, in relation to the number of treatment roomsprovided in an area, or the range of interventions provided. Therefore the service currently being delivered to the patients is inequitable, Appendix 4.

5.3 District Nurses in a number of areas are being relied upon to run treatment rooms; this has a detrimental impact on the District Nursing services and is not the most effective use of their time,reducingtheir ability to meet the needs of housebound patients. Given their growing focus in Care Management of patients with complex needs, this dependence on the District Nursing service to continue to undertake treatment room activity, often at short notice requires to be discontinued. This will enable District Nurses to provide more care to housebound patients and support the continued implementation of the Long-Term Conditions Strategy and older peoples services strategy enabling more people to be cared for at home.

5.4 The work of treatment rooms has evolved over many years, not least due to the GMS contract which has significantly increased the need for phlebotomy to be undertaken within treatment room, along with many other interventions. At present, there are no clearly defined core clinical interventions across Lanarkshire causing nurses to struggle to cope with rising numbers of patient attendances with no new resources or up-skilling of staff.

6. Key Principles.

6.1 In undertaking the review the sub group identified a set of key principles which should underpin the process and lead to a more equitable treatment room service which meets the needs of local communities. They are:

Standardised opening hours
Core interventions to be provided by the service across Lanarkshire
Each locality to provide a treatment room service at strategically chosen health centres, based on demand, practice populations and population density.
In larger health centres, only one treatment room service should be provided enabling more flexibility around service delivery to be achieved.
As the bulk of activity is phlebotomy, the workforce requires to be further skill mixed, ensuring more appropriate utilisation of registered and unregistered nursing staff skills, increasing overall capacity and providing a more cost effective service.
District nurse practice-based clinics and coverage for planned and unplanned treatment room leave should be discontinued.
LEAN methodology and a capacity planning tool should be implemented to maximise patient contact.
Appointment system facilitates both planned and an agreed level of unplanned care to be provided.

6.2 These principles will enable the effective and efficient delivery of high-quality, patient-centred care.

7. Core Treatment Room Service: Current And Proposed.

7.1 The work of treatment rooms has evolved over many years, not least due to the GMS contract which has significantly increased the need for phlebotomy to be undertaken, along with many other interventions. It is important to note that treatment rooms are not an accident and emergency service and access must be via a referral from general practice or other healthcare professional.

7.2 At present there are no clearly defined core clinical interventions or agreed volume of activity across Lanarkshire’s treatment room services causing the service to struggle to cope with rising numbers of patient attendances with no new resources. This provides an inequitable service to patients. In reviewing the range of interventions provided it is proposed that a single core range of clinical intervention is operated in all treatment rooms enabling appropriate workforce profiles and staff development plans to be established(Appendix 3). This will be reviewed on a minimum of a two yearly basis and the range of interventions amended where appropriate and agreed on a pan Lanarkshire basis. In support of this approach standardised referral, documentation and protocols will be developed and implemented, Monitoring will be via the usual performance management systems.

7.3 In considering the future core interventions for the service the sub-group examined data from all treatment rooms and considered their evidence base. The group also considered the mainstreaming of Keep Well, the anticipatory care programme for Coronary Heart Disease (CHD), a key component of the Long-Term Conditions Strategy. This programme is currently being successfully piloted in some but not all localities but requires to be mainstreamed by April 2012 in line with Scottish Government Policy. It is a proactive screening programme aimed at people between the ages of 45 and 65 years with a view to preventing CHD where possible and maximising the treatment regimes of patients with the disease where required. It consists of a simple blood test, screening assessment and lifestyle advice. Where necessary access to general practice for treatment or lifestyle services such as smoking cessation are actioned. The service operates during the week and on Saturday mornings at a frequency to meet the needs of patients as part of the Keep Well programme.