Plan for overnight closure of hospital injuries unit expected to spark strong opposition

Martin Shipton

Plans to close a Minor Injuries Unit overnight at a west Wales hospital are likely to be strongly opposed by local people, we have been told.

Hywel Dda University Health Board will discuss on Thursday September 26 a proposal to shut the unit at Prince Philip Hospital in Llanelli from 8pm to 8am every day for a period of six months.

Anger

A local political source said: “People are going to be very angry about this, seeing it as a further downgrading of the hospital. There was uproar some years ago when a decision was taken to close its A&E department. People are now expected to go to A&E in Morriston Hospital, Swansea, a 25-minute drive away, or Carmarthen, which can take an hour to get to.

“It’s unsurprising that some people who really need to be seen at A&E choose to go to the minor injuries unit at Prince Philip.”

The health board issued a statement saying the plan to have a temporary reduction in hours was due to “increasing operational and staffing pressures”. It was intended “to ensure the safety of patients presenting at the unit”.

The board’s statement said: “The temporary change will not affect the Acute Medical Assessment Unit and very unwell medical patients will still be taken to Prince Philip Hospital, 24-hours a day, for assessment and treatment as they are now.

“The proposal would mean that adults and children with a minor injury would also still be able to attend the Minor Injury Unit at the hospital between 8am and 8pm every day.

“The proposal to adjust the opening hours of the MIU is being presented due to patient safety concerns, raised both by Healthcare Inspectorate Wales seeking assurances following an inspection in June of last year, and from staff working at the unit. This is due to the frequent inability to find suitably qualified doctors to cover the GP-led service, particularly in evening and overnight sessions.

“This has led to the service being led instead by Emergency Nurse Practitioners who, whilst extremely skilled at dealing with minor injuries, are not able to provide suitable care to patients who require a GP.

“Additionally, some patients attending the unit have more complex needs than can be managed by a GP, as they are considered major. This means they need to be stabilised and transferred onwards.

“The urgent need to address this problem has been endorsed by medical staff at the hospital with growing concerns about the safety of the service and the patients it treats.

“If the proposal is endorsed, the health board will run an information and engagement campaign in the community. This will both inform people about what care and treatment is provided from the Minor Injury Unit, and what the temporary opening hours are, and seek to consider what the future of the service could look like.”

Further information is contained in a report from senior managers to the September 26 health board meeting, where it is an agenda item.

Clinical concerns

The report says the temporary reduction in hours is being proposed “due to a significant and continued lack of medical cover, leading to clinical concerns in relation to patient safety and concerns about the impact of the current service model on staff welfare. This position has been reinforced by recommendations following a Healthcare Inspectorate Wales (HIW) Inspection visit and further correspondence from HIW requesting reassurance on a number of patient safety issues.

“HIW made an unannounced inspection visit to the Minor Injuries Unit (MIU) in Prince Philip Hospital (PPH) in June 2023. An action plan in response to the HIW recommendations following this visit was developed. Since this review, work has continued to review the current 24/7 model for the MIU in PPH, reflecting a number of key factors, including increasing challenges to maintaining the medical staffing within the MIU, along with recent recommendations from the HIW inspection which required an urgent review of the service to address patient and clinical safety recommendations.

“In March 2024, HIW received a letter from staff, which had previously been sent to the Nursing and Midwifery Council (NMC) in June 2023, expressing concerns regarding the clinical safety of the unit. HIW wrote to the health board requesting assurance on the matters raised.

“In response to the review, the Carmarthenshire Unscheduled Care Management team has commenced consideration of both short-term options to ensure the appropriate use of the unit and medium-term with respect to its operating model (and options moving forward). However, this report focuses on the short-term options, and a separate report will be developed via an oversight group on potential longer-term options, which will include a period of engagement to consider any longer-term options with patients and stakeholders.

“The current position is exacerbated by the deteriorating ability to find suitably qualified doctors to cover the rota, meaning that on numerous occasions the MIU has become an Emergency Nurse Practitioner (ENP) led unit only. This lack of cover is exemplified that in the five-month period between February 2024 and July 2024, there were 42 uncovered slots, with only three of them pertaining to a morning (am) slot (23 were overnight slots and 16 were pm slots, which include cover after 8pm).

“The impact of this on the workforce is high levels of stress, anxiety and the inability to do the job they are employed to do, plus increased risk to those patients presenting to the MIU without a suitably qualified doctor in MIU.

“The effect of the current model is demonstrating itself in a number of ways. Over the last six months, the average sickness level has been 22%. This is not a short-term phenomenon; since the beginning of 2023, the average figure has been 17%. A significant proportion (up to 50%) of this is attributable to stress-related conditions. Whilst the vast majority of patients have had a positive experience – currently at 86.1% for June 2024 (as captured via the patient experience team), there were a significant number who felt that their experience was poor or very poor (currently at 3.2% for June 2024 but has been as high as 12.5% for August 2023).

Waiting times

It continued: “The criticism often centred on waiting times, but a number did cite that a doctor was not available to treat them, that they were held overnight whilst waiting for a bed or that it was indicated that having been referred to the MIU, that they should have attended other facilities due to the nature of their presentation.

“There was also evidence that patients were self presenting with ‘majors’, such as head injuries, severe bleeding, abdominal pain and stomas. A number of formal concerns have also been raised regarding the MIU and have generally centred on the lack of availability of doctors, having been referred/self-presentation inappropriately (for problems that the MIU is not designed for). In May 2024, further correspondence from HIW was received, requesting assurance on a number of patient safety issues following further concerns raised by staff.

“The current use of the MIU shows that for the period from April 2021 until the end of April 2024, nearly 25% of attendances would be classified as ‘majors’ (conditions which are not a Minor Injury and thus are beyond the scope of what should be presenting at an MIU). These ‘major’ conditions are wide-ranging and include Stroke, Myocardial Infarction, fractured femurs, and surgical conditions, such as appendicitis or bowel obstruction. Likewise, unwell children with conditions such as acute/surgical abdomen, and women with pregnancy complications, some of which can be straightforward but often need urgent management and further investigations in Glangwili [the district hospital in Carmarthen] eg PV bleed in pregnancy which can present in MIU too.

“If overnight figures are considered (8pm – 8am), in the last 3-year period there were 18,059 overnight attendees, of which 5,762 were ‘majors’, equating to 32% of overnight activity (as compared to 25% of daytime activity). Mental Health patients often stay in MIU for extended periods of time, especially if after assessment they need an inpatient bed and there is no capacity. The Mental Health team are reviewing their model of care and are proposing that all Mental Health patients are assessed in Carmarthen.”