Proposed Overnight Closure of Prince Philip Hospital’s MIU

Closure of the Minor Injuries Unit (MIU) in Prince Phillip Hospital (PPH) overnight (8pm to 8am), is being proposed for a six-month period by the Carmarthenshire Unscheduled Care Management team, 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.

The Board is asked to approve this proposal, following its approval by the Quality Impact Assessment Panel and Executive Team.

Healthcare Inspectorate Wales (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 3 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 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 e.g. PV bleed in pregnancy which can present in MIU too.

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.

The MIU Clinical Lead has endorsed the proposal outlined in this report, to ensure the service is strengthened in regard to medical cover and improved quality and safety for the department.

Further, the GP cluster leads are cognisant of the proposal and are key stakeholders in the review of the future role and function, to ensure the service model meets the needs of the local resident population.

The proposed short-term option would be to close the MIU overnight between 8pm and 8am for a period of six months. This would enable improved medical staffing over a 12-hour day and not having to cover 24 hours, and would support the Emergency Nurse Practitioners (ENPs) working in the MIU.

An overnight ENP service has been considered; however, the ENPs have expressed significant clinical safety concerns due to the nature of patients that self-present.

A redirection protocol is in place to redirect patients to the nearest ED; however, these patients, if clinically unwell, need to be stabilised first and with the significant waits for ambulance transfer, this could leave the ENP with a patient they do not have the skills to assess and treat.

Following the proposed overnight closure, an oversight group will be instigated to ensure consideration of patients’ health needs, and the views of stakeholders, to ensure that patients access care in the right place, first time.

View the full assessment here.

Statements:

MP Nia Griffith and Lee Waters MS have issued statements on the proposed MIU closure:

MP Nia Griffith said: “I stressed to  Hywel Dda Health Board bosses  our massive concerns at any plans to reduce opening hours of minor injury unit at Prince Philip Hospital. Vital they recognise that Llanelli is the biggest town in west Wales & keep our services here.”

Lee Waters MS said: “Nobody was happy about the A&E being taken away but we were promised round the clock Doctor-led care by a team of GPs and nurses instead. The need for that hasn’t gone away. The NHS exists to meet the needs of the people and Llanelli is one of the highest areas of need in the whole Hywel Dda Health Board area. If the health board are struggling to recruit staff then they need a new plan, not to break the promises they made for 24 hour care at Prince Phillip Hospital”