Urgent Care in Primary Care
1. Executive Summary
1.1 This paper is concerned with the way in which our urgent care services are
planned, organised and delivered to meet the needs of local people. It concentrates
on ‘’primary care urgent care’’, those services outside acute hospitals which support
local people when they need urgent care and attention. It outlines proposed models
for the delivery of primary care urgent care across Leicestershire and Rutland. It
describes the national and local drivers for change, the models for delivery of urgent
care in place now and describes the case for change. The paper details the pre-
engagement the PCT has undertaken with public, patients and relevant stakeholders
and describes how these views have been used to inform the proposed options for
the future, upon which we will consult the public.
1.2 The Board is therefore asked to receive this report and approve the options for
change outlined in this paper and to agree the publication of a consultation document
in late February for the public and stakeholders based upon the options outlined.
2. National and local drivers
2.1 The Primary Care Foundation was commissioned by the Department of Health to
undertake a review of urgent care in General Practice. They concluded in their report
Urgent care a practical guide to transforming same-day care in general practice 1 that
urgent care in general practice matters not only to patients but to the NHS as a
whole. They provided evidence that if general practice managed urgent care ‘as early
as possible in the patient’s journey, the workload and costs for the rest of the NHS
will be reduced’. The report outlines both driving principals for good urgent care in
primary care and recommendations designed to deliver improvements in care. These
recommendations have been considered in developing our models of care.
2.2 The Office of the Strategic Health Authorities undertook an Emergency Services
Review and stated in their report Good Practice in Delivering Emergency Care: A
guide for Local Health Communities 2 that ‘safe, high quality, consistent and effective
provision of both in-hours and out of hours primary care is crucial to provide care as
close to the patient’s home as possible’. They supported the view that this was
essential if attendance at Accident and Emergency was to be reduced. In December
2009 a local diagnostic review of the whole emergency care system in Leicestershire
was undertaken by the same National Emergency Care Intensive Support Team who
had produced the report. They recommended improvements to the management of
urgent care in primary care, including improving access to same day care in General
Practice and a review of the aims and access for the range of Urgent Care Centres.
2.3 In response to public surveys, the Department of Health has set a target for GP
practices to open beyond their usual core hours of 8am to 6.30pm and deliver an
Primary Care Foundation 2009
Office of the Strategic Health Authorities July 2009
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increased number of routine appointments in early mornings, evenings or on a
Saturday. In NHS LCR by 31st March 75% of practices will have this in place.
Solutions will then need to be sought to ensure all patients have access to extended
2.4 Locally the PCT has given considerable commitment to developing primary care
in terms of capacity, capability and quality via the development of its Primary Care
Strategy. Following a successful first year of the 5 year strategy where considerable
service improvement has been undertaken, the second year will focus upon
improving urgent care in primary care as described within this document. Our work
with communities and local people over the last 12 months looking at their overall
priorities identified improving access to primary care services as a top priority.
2.5 Models of urgent care presently in place, both in and out of hours, do not deliver
a consistent model of care across the county. Local reviews of both Community
Hospitals and Out of Hours General Practice provision have been recently
undertaken. These recommended a consistent model of care should be developed,
delivered from fewer sites, where demand was sufficient to safeguard the quality and
productivity of services. These principles have driven the decision making when
considering future provision.
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3. What services we have now
3.1 In Leicestershire and Rutland, the following are currently available for people who
need urgent care:
• GPs surgeries – all GPs provide urgent care for illness, and most GP
practices in Leicestershire and Rutland now offer care for minor injuries.
However, this is only during the GPs’ normal opening hours. These hours
nowadays often include extended hours beyond traditional Monday to Friday
day-time periods, and some practices also open on Saturday mornings.
• GP out of hour’s services. All practices are covered by the GP Out of Hours
service when the surgery is closed. It is open from 6.30pm to 8am every
night during the week, and all the time during weekends and bank holidays. If
patients call their GP surgery when it is closed they are given an alternative
telephone number to ring, or transferred directly. They then give their details,
and a doctor or nurse will ring them back with advice, or arrange a face-to-
face consultation in a community hospital or minor injury unit, or sometimes
arrange a home visit. If it is decided at the time of the phone call that an
ambulance is needed, this will be called. (Face to face services are offered at
Loughborough Walk-In Centre, the Urgent Care Centre at Leicester Royal
Infirmary, Hinckley and Bosworth Hospital, Rutland Memorial Hospital and
Feilding Palmer Hospital, Lutterworth.)
• Walk-In Centre. There is a Walk-In Centre in Loughborough which is open 24
hours a day, seven days a week. No appointments are necessary, but the
service also sees people by appointment that have been referred by the out
of hours service.
• Minor Injury and Illness Units. There are minor injury and illness units at the
following community hospitals:
- Market Harborough and District Hospital (9am-9pm)
- Rutland Memorial Hospital, Oakham (9am-9pm)
- Melton Mowbray Hospital (weekends and bank holidays 8.30am-6pm, with
Latham House Practice in Melton Mowbray seeing patients for minor injury
during their normal opening hours)
- Feilding Palmer Hospital, Lutterworth (9am-9pm)
• Urgent Care Centre at Leicester Royal Infirmary (open 24 hours a day, seven
days a week, and available for use by people from Leicestershire and
3.2 In addition to this, people can also get advice from:
• Pharmacists – they can offer advice and treatment for many common
conditions, including ear and eye infections, coughs, colds, diarrhoea and
headaches. They are health experts on the high street, and no appointment
is needed to see them. They provide free advice and if appropriate will
supply medicines to buy. Many supply emergency contraception.
• NHS Direct (0845 46 47). This is a phone service staffed by nurses and
professional advisers, giving confidential healthcare advice and information
24 hours a day.
• The Out of Hours Dental Service (6.30-10pm week days, 7.30am-3pm
weekends, and 7.30am-10pm bank holidays). This provides telephone
advice and access to emergency treatment if required, by appointment.
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3.3 What are the issues with current services?
• A wide variety of models of care both in and out of hours.
• Inconsistent patient pathways which are confusing for both patients and
partners such as A & E teams and ambulance teams.
• Inconsistent provision of routine and urgent care within General practice, for
example. differing core hours, differing capacity.
• Inconsistent provision of minor injury services within practices.
• Lack of linkage between walk-in facilities, General practice and minor injury
facilities and out of hour’s service delivery.
• Inconsistent use of other providers, e.g. pharmacy.
• Many patients accessing Accident and Emergency when a Primary Care
solution would have been more appropriate.
• At present the variety of practice based systems prevents information being
shared across the pathway in an electronic format.
4. What people told us
4.1 The National GP Patient Survey
This survey showed that (for the period April-September 2009) 54% of patients
wanted their GP surgery to open at additional times, and of these, most (53%)
wanted them to open on a Saturday morning, compared to 29% who wanted week
day evenings. In addition, 33% of patients did not know how to contact a GP when
the surgery was closed.
4.2 Feedback from our questionnaire
4.2.1 During December 2009 and January 2010 we invited members of the public to
complete a questionnaire about urgent care. We received 3710 responses.
4.2.2 We asked if people knew where the nearest minor injury unit was. 62% did but
32% did not.
4.2.3 44% of those that replied had used a minor injury service. Of those who had
used a service, the ones most frequently mentioned were:-
Loughborough Walk in Centre
Latham house GP practice
Leicester Royal Infirmary
Market Harborough Hospital
Rutland Memorial hospital
Feilding Palmer Hospital
4.2.4 Only 37% of people had consulted their GP for a minor injury at any time.
4.2.5 When asked what they would use for urgent help for a minor injury or illness
Local GP in the week 2661
Local GP Saturday morning service 1158
Loughborough Walk- in Centre 1095
Other minor injury/illness unit 820
Leicester city urgent care centre (at the LRI) 489
Oadby & Wigston 8-8 centre when it is open 343
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4.2.6 Finally we asked people how easy it was at the moment to understand where to
go for urgent care. 47% said it was very easy or quite easy, and 38% said it was
quite difficult or very difficult.
4.2.7 From this we understand that people want to be able to use their GP service,
and would like to have access to a Saturday morning service. There also need to be
urgent care centres to support this.
4.2.8 It is also clear that a significant number of people do not find it easy to know
where to go for urgent care.
4.3 Feedback from our local GPs
We asked local GPs their views on how urgent care could be delivered in the future,
and this is some of what they said:
• Patients don’t know where they should go for urgent care – this affects how
they use the services currently in place
• Patients also need more, consistent information about how to care for
themselves when injured or ill
• GPs could see some of the patients who currently go to urgent care centres
or Accident and Emergency
• Extended GP practice Saturday opening hours in various localities would help
patients access appropriate services.
4.4 Feedback from our partners
We also asked other partners, in local authorities, in Local Involvement Networks,
and in other NHS Trusts, what they thought. They had the opportunity to complete
the questionnaire, and they also supported in general our plans to simplify and
improve our urgent care services.
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5. The vision for primary urgent care
5.1 Principles driving development of the Primary Care model.
• Patients should receive the right care at the right place, the right time,
delivered by the right Health Care professional.
• General practice already provides the majority of ‘primary urgent care’
during core and extended hours and as such must be central to any
• Patients require clear and consistent models of service delivery to
support them in accessing appropriate levels of care to meet their
• Models of care should be supported by clear and consistent information
on when and how to access services and what they deliver – both via
individual practitioners and county wide campaigns.
• “Urgency” is defined by the patient; however models of care will vary
according to clinical need.
• Services should be locally accessible where appropriate.
• Services should be clinically safe and cost effective both of which are
influenced by the volume of demand.
5.2 What model of care are we proposing and why?
We propose a new model of care in which:
• Local people will be much better informed and less confused about services
• NHS professionals such as EMAS will be better informed about services and
what they offer.
• It will be easy to understand where to go to get urgent care
• Advice, care and opening times will become more consistent.
• Local people will be helped to look after themselves when they feel that this is
the right thing to do
• People with long term care needs and those in care homes will have their
care planned and information shared to prevent unnecessary hospital
• People can access GP practices open beyond usual core hours either at
evenings or weekends.
• People’s primary care needs will be addressed by GP practices or by an
Urgent Care Centre closest to them.
• The acute hospital will be able to concentrate their skills on the more serious
and life threatening situations.
• People will use the ambulance service and Accident and Emergency less for
minor illness and injury
• There are clear links between in hours and out of hours care.
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5.3 The Model of Care
The model has three distinct elements: General Practice Provision, Primary care
Locality level services and county wide Urgent Care Centres.
Figure 1 Model of Care
Primary Care Locality level
Core and Enhanced Services
5.4 General Practice Core and Enhanced Provision
5.4.1 The majority of Primary Care urgent care will be delivered in hours, including
extended opening hours (EOH), via every General Practice across Leicestershire
County and Rutland, of which there are 85. Evidence shows provision of timely
routine care prevents some patients becoming urgent and delivery of general
practice interventions to urgent patients prevents them needing to inappropriately
access services elsewhere e.g. Accident and Emergency.
5.4.2 To facilitate this delivery of same day urgent care, practices will need to:
• ensure patients can contact the practice
• consistently identify and manage patients who believe their
needs are urgent
• ensure there is sufficient capacity to meet demand.
5.4.3 To support this model practices will be encouraged to increase their routine
number of appointments via the adoption of extended hours (75% already deliver
this). It is intended that all patients should have access to extended opening hours.
5.4.4 We also wish to deliver a consistent model of minor injury provision in primary
care. This will be achieved by improving the current minor injury Local Enhanced
Service (LES) to ensure consistent access to this service for patients.
5.4.4 Patients will also be supported in accessing care via other mechanisms where
appropriate, such as self care, support and advice from local pharmacists, support
from community services such as District Nursing Teams and specialist community
nurses to prevent their conditions becoming urgent.
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5.5 General Practice Locality provision
5.5.1 It is proposed a locality level service will be provided by a General Practice or
group of Practices working together, from an accessible General Practice premises
or agreed community-based alternative. These services will be open on a Saturday
morning as a minimum and will deliver care to a population of approximately 40,000
5.5.2 The locality service will deliver urgent care to any Leicestershire and Rutland
patients, not just those registered with a particular practice. This will include those
who walk in and those patients who have contacted the out of hours service, and
following triage require a face to face appointment. It will also offer minor injury
5.5.3 Where there is a lack of extended opening hours offered by practices within a
locality, the locality level service will be encouraged to provide additional routine
appointments as well as urgent care.
5.6 Urgent Care Centre Provision
5.6.1 An Urgent Care Centre will provide urgent care services to patients from across
the whole county who choose to access their services, regardless of where they live
or which GP they are registered with.
5.6.2 An Urgent Care Centre will be open at least between 8.00 a.m. and 8.00 p.m.,
7 days per week including bank holidays and provide both medical and nursing
urgent care services at appropriate times.
5.6.3 It will, during its opening hours be able to deliver urgent and routine care to any
patient who walks in and urgent care to any patient who has contacted the out of
hours service and following triage requires a face to face appointment.
5.6.4 It will be able to treat conditions such as minor ailments, minor injuries, and
emergency contraception as a minimum. They will also provide onward referral and
support to enable patients to self manage, as appropriate.
5.6.5 Urgent care centres will provide the following diagnostics, as a minimum: blood
sugar analysis, D-Dimer, ECG, pulse oximetry, pregnancy testing, level 4+ INR.
5.6.6 Systems should be in place to manage demand and ensure timely access to
services such as telephone advice and clinical triage.
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6. The proposals for achieving change
6.1 Developing our proposals
6.1.1 In putting together our proposals we first put in place the following overall
• Any option cannot be more expensive than the amount we already plan to
spend. Public sector budgets have to be managed very carefully in the
current financial climate.
• Services should not be duplicated if possible and should be cost effective
• Changes should not increase the gap in expenditure across localities.
• Services should be able to manage most of the patients who attend them and
take referrals from the ambulance service and Out of Hours services.
6.1.2 As we developed our proposals, we also considered:
• The demand for services (including use of Accident and Emergency)
• Clinical quality and patient safety
• The size and need of the populations served
• Information about where there are areas of deprivation in Leicestershire and
Rutland as this helps us decide where services are most needed
• Possible locations and opening times of services
• The likely costs of providing the staff and facilities
• The likely availability of GP services out of hours
6.1.3 We would like urgent care services in the future to be more focused on GP
practices or groups of GP practices, building on all the care they already offer,
including minor injury services and longer opening hours. We know from feedback
and surveys that people would like more Saturday morning opening hours for GPs,
so we have developed an option that includes this.
6.1.4 We detail in section 6.2 the issues we considered
• Attendances levels at centres offering urgent care in the county
• Population, need and use of Accident and Emergency (A&E) departments
• Projected demand
• Staffing and the need to maintain staff skills
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6.2 Issues informing the proposals
6.2.1 Attendances by centre per year At the moment, relatively small numbers of
people use the minor injury units in our community hospitals as shown in Table 1.
Table 1 Attendances by centre per year
Centre Minor injury Out of hours Total Weekly
/illness GP service activity activity
Loughborough Walk-in 51042 3503 54545 1049
GP minor injury service 19284 19284 371
Market Harborough 8217 8217 158
Rutland hospital 5053 1995 7048 136
Hinckley &Bosworth 3800 3800 73
Feilding Palmer hospital 910 2279 3189 61
Melton hospital 1486 1486 29
We would still like to have urgent care centres, offering both out of hours services,
and care for minor injuries and illnesses, but we suggest that there should be fewer
centres than we have now. We can then be sure they are both safe, and cost
effective, and offer the same level of care at each one. This will also give us the
opportunity of making more tests available for those who attend urgent care centres,
including breath tests, urine tests, blood tests, ECG (records the activity of the heart),
D Dimer (blood test to diagnose clots).
6.2.2 Population, need and use of Accident and Emergency services The factors
that are likely to influence use of walk in services most are age and socio-economic
Table 2 Use of accident and emergency (A&E) departments for potentially
avoidable minor illness and injury
Locality Potentially avoidable A&E attendances
Blaby and 4467
Hinckley & 3968
Melton, Rutland 3262
Oadby& Wigston 2709
Charnwood South 2271
North West 2206
Charnwood North 906
Table 2 shows that a significant number of people attend A&E departments at acute
hospitals for illnesses and minor injuries that could be managed elsewhere.
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6.2.3 Use of Walk-In services is highest in young adults and local data from LRI
Accident and Emergency department supports this with the highest use being from
the 15-24 year age group.
Estimated Population mid-2007 20 year age groups Leicestershire districts and
whole PCT area.
0-19 20-39 40-59 60-79 80+ Total
Leicestershire 153,000 159,800 182,300 117,300 28,600 641,000
Blaby 22,200 22,700 26,500 17,400 4,100 92,900
Charnwood 39,000 49,200 42,600 27,400 6,600 164,800
Harborough 20,300 17,400 25,200 15,600 3,800 82,300
Hinckley and Bosworth 23,700 25,000 31,100 19,900 4,700 104,400
Melton 11,500 10,900 15,000 9,400 2,400 49,200
Leicestershire 21,700 21,700 26,200 16,800 4,000 90,400
Oadby and Wigston 14,600 12,900 15,600 10,900 2,800 56,800
Rutland UA 10,700 7,500 10,500 7,800 1,900 38,400
Rutland 163,700 167,300 192,800 125,100 30,500 679,400
Table 3 shows that the highest young adult population is in Charnwood, already well-
served by the Loughborough Walk-In Centre, followed by Hinckley and Bosworth,
6.2.4 People from more socio-economically deprived communities also have higher
attendance rates at A&E departments.
Table 4 District Index of Multiple Deprivation scores
LA CODE LA NAME Score
31UH North West Leicestershire 14.73
31UE Hinckley and Bosworth 10.90
31UJ Oadby and Wigston 10.51
31UG Melton 10.43
31UB Blaby 8.41
00FP Rutland 7.49
31UD Harborough 7.08
This table shows that the most socio-economically deprived districts in Leicestershire
are North West Leicestershire and Charnwood, followed by Hinckley and Bosworth.
Harborough is the least deprived district.
6.2.5 Health needs data do not give a clear answer to the model of emergency care
provision. To address issues of access in a rural setting a more dispersed model is
preferred. Extension of GP based services may have some impact on emergency
admissions (access to GP services being a factor that seems to impact on
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emergency admission rates) whereas non-GP minor illness and injury services are
unlikely to impact on this.
6.2.6 The options we propose have been modelled to take into account the likely
changes in activity resulting from any changes to the ways services are delivered.
This modelling has looked at the current use of the centres, the use of A&E, the
impact of the new 8-8 centre in Oadby & Wigston and the likely increase in demand
generated by any new service.
6.2.7 With regard to urgent care centres we need a critical mass of staff for centres
and the staff should include GPs at appropriate times. Nurse led units without
medical support cannot cope with the same range of presentations, and partners
such as Out of Hours GP services and the ambulance service are therefore more
cautious about referring or taking people to these centres and they default to A&E or
centres with GP support.
6.2.8 Some of these changes will be made by alterations to the way services work
now, and can be started by working with GPs. However other changes will alter
which services are offered in which areas, and we want to consult local people,
clinicians and partners to see what they think of these alterations. We have therefore
identified a number of options.
6.2.9 We want to ensure that we make best use of existing services and feel that
there are three centres that are already delivering much of the work of an Urgent
Care Centre. These are the Loughborough Walk in Centre for the north of the county,
the Leicester Urgent Care Centre at the LRI and the new 8 to 8 centre to open in
Oadby & Wigston in March 2010. Based on the health need and economic
assessment, there is no clear case for expansion of other sites into urgent care
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6.4 The options proposed for consultation
We are suggesting three options for the future of urgent care in primary care in
Leicestershire and Rutland. They all use existing centres (the 8 to 8 centre in Oadby
and Wigston opens in March 2010).
6.4.1 Option 1
No change. Three of the existing urgent care centres – the Walk-In Centre at
Loughborough, the urgent care centre at Leicester Royal Infirmary, and the new 8 to
8 centre in Oadby and Wigston, together with the existing minor injury and illness
units in community hospitals, and some minor injury care from GPs in their normal
opening hours, and GP Out of hours services in their current locations.
It could mean continued confusion about where to go for care. It will not develop a
GP centred approach with the benefits of continuity of care and will still have the
issues of some units seeing small numbers of patients.
6.4.2 Option 2
Three of the existing urgent care centres – the Walk-In Centre at Loughborough, the
urgent care centre at Leicester Royal Infirmary, and the new 8 to 8 centre in Oadby
and Wigston - will offer both walk in and GP Out of Hours services. Urgent care will
continue to be provided by GPs in their normal opening hours.
It provides greater consistency at the three centres, but will not provide much
flexibility for the public, and contains fewer local options outside normal GP opening
6.4.3 Option 3 (the preferred option)
Three of the existing urgent care centres – the Walk-In Centre at Loughborough, the
urgent care centre at Leicester Royal Infirmary, and the 8 to 8 centre at Oadby and
Wigston - will offer both walk in and GP Out of Hours services.
Improved urgent care would be provided by GPs during their normal hours, and there
would be new Saturday morning locality GP services in each of the following areas:
• North West Leicestershire
• Blaby and Lutterworth
• Oadby and Wigston
This is our preferred option, because it combines the consistency of larger urgent
care centres with local services on Saturday morning, the request most popular with
local people. The focus on enhancing GP services would provide greater continuity
of care for patients.
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6.4.5 We recognise that some of the options proposed could result in changes in how
the services are delivered which will affect staff currently working within the existing
service. We will be discussing these options with those staff in order to ensure we
have a full understanding of the changes. We recognise that this is a highly skilled
and scarce workforce and we will be focused on retaining those key skilled people
within our health community.
6.4.6 With all our suggested options we will work with patient groups to look at the
existing out of hour’s arrangements for pharmacists and dentists. We have already
extended opening hours for dentists in new dental contracts.
6.4.7 We also considered the planned pilot of a new 111 phone number for the East
Midlands area. People will be able to ring this number if they need urgent health
care, and they will then be directed to the right help for them.
7. How do we achieve the model?
During the consultation period we will develop plans to take forward those changes
and improvements that do not impact on the consultation about options. The areas
this plan will cover are outlined below.
7.1 Communication Strategy
Develop a communication strategy with the aim of making it easier for the public to
know what to do if they need urgent care, and to support self care.
7.2 Improve Access to General Practice
Work with Practices to improve urgent care in primary care, including
• Improved telephone access
• Better matching of capacity to demand
• Longer opening hours
• A consistent model for assessing and treating patients with urgent
• A review of when and how home visits are delivered
7.3 Improve Pharmacy Provision
Work with Pharmacies to improve opening hours and ensure support to patients to
self care. Refocus the medicine usage reviews delivered by pharmacists to those
patients most likely to require urgent care such as those on multiple medications.
7.4 Deliver Consistent Service Specifications
Review service specifications for minor injuries in General Practice and develop a
specification for the General Practice Locality solutions. Review the existing service
specifications for the ‘Urgent Care Centres’ to ensure improved access and
timeliness of provision, in partnership with Leicester City PCT.
7.5 Deliver Improved Pathways of Care
Work with all stakeholders to ensure new pathways of care, including facilitating
EMAS ambulance service using Urgent Care Centres as an alternative to Accident
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7.6 Deliver a Consistent Information Sharing solution
An IT solution is required to support the sharing of patient information between
practices, and wherever the patient chooses to access their urgent care. We will work
with partners to introduce systems that improve care.
8 Our plans for consultation and next steps
8.1 It is proposed that formal consultation will be for 12 weeks, starting in late
February 2010. However, if an election is called, all consultation will be stopped from
the time the election is called until after the election occurs. It will then start again
after the election. Following approval of the agreed option, we will then complete an
action plan to implement the changes.
8.2 Our initial equality impact assessment has identified that there might be an
impact on access for different groups of people. We will now do a full impact
assessment and we will make sure that the equality implications will be considered at
all stages of the consultation process. We will engage with communities and
representatives of the different strands of diversity with the support of our Equality
and Diversity team.
8.3 The work on the urgent care in primary care strategy will form part of the wider
plans for transforming urgent care in Leicester, Leicestershire and Rutland. Building
on the actions identified by the Emergency Care Support team, the work will be
integrated into the wider strategy of the Acute Care Board to enhance and improve
urgent and emergency care.
8.4 The board is asked to receive this report and approve the options, and to approve
that the Chairman and Chief Executive sign off the public consultation document
based on this paper.
Associate Director Unscheduled Care
Associate Director Primary Care Commissioning
Associate Director Communications and Engagement
01 February 2010
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