Agenda item

Following the high level of demand on NHS A&E units across the country and its effect on performance, the Board requested a response from each of the county’s acute hospital trusts regarding their performance against the winter pressures.

 

Declarations of interest:

 

None

 

Witnesses:

 

Daniel Elkeles, Chief Executive, Epsom & St Helier University Hospitals NHS Trust

Caroline Landon, Chief Operating Officer, Epsom & St Helier University Hospitals NHS Trust

Jim Davey, Director of Service Development, Surrey & Sussex Healthcare NHS Trust

Giles Mahoney, Director of Strategy & Partnerships, Royal Surrey County Hospital NHS Foundation Trust

Dr Jonathan Robin, Divisional Director for Acute Medicine & Emergency Services, Ashford & St Peter’s Hospitals NHS Foundation Trust

Karen Thorburn, Director of System Redesign, North West Surrey CCG.

Kate Scribbens, Chief Executive, Healthwatch Surrey.

 

Key points raised during the discussion:

 

1.    The Chairman began by informing Members and witnesses that two additional documents had been prepared by officers; a comparison of 2015/16 and 2016/17 Quarter 3 (October-December) A&E data by Trust and a tabular comparison of Trust responses to the letter sent by the Chairman in January 2017.  These documents are attached to these minutes at annex 1. The Chairman invited each Trust to speak of their performance over the winter period.  A response from Frimley Health is attached at annex 2.

 

Ashford & St Peter’s Hospitals NHS Foundation Trust

 

2.    The Director of System Redesign at North West Surrey CCG explained that she was the Chair of the Local A&E Delivery Board (LAEDB) and that its purpose was to work with all system partners in order to own their performance and hold partners to account to deliver the 4-hour standard and a resilient system.  It was explained that North West Surrey system partners, including Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH), had analysed performance from the previous two winters and developed a planning and preparation process with a prepared escalation procedure.  Alongside a live data system, desktop planning exercises were used to test resilience and support early discharge.

 

3.    Members were informed that the data presented in the Q3 document for ASPH was not accurate as it was data for St Peter’s Hospital only and not the combined data for the Trust.  The Director of System Redesign informed the Board that the Trust’s Q3 4-hour standard result was 90.7%, an improvement on the previous years’ result despite increased demand and attendance.

 

4.    The Board was informed that ASPH saw an additional 9 ambulance attendances per day over the Christmas period compared to 2015/16.  The LAEDB was currently preparing for the anticipated surges of demand experienced over the Easter period.  Members noted that the CCG had invested in additional GP cover and a weekend X-ray service at community hospitals.  The witness also explained that patient flow had been sustained through additional funding to provide Adult Social Care packages via Alpenbest to support discharges over the Christmas period.

 

5.    The Director of Acute Medicine explained that the Trust had declared Opel 3, signifying major pressures which were compromising patient flow, twice since January 2017 however the system response to this escalation on both occasions had demonstrated sound resilience. 

 

6.    Members enquired whether the 4-hour standard was for a patient to be triaged or for patients to see a doctor.  The Director of Acute Medicine explained that the 4-hour standard was from the point of booking into the A&E system until being seen by a doctor.  It was explained that the aim was to get patients to see a doctor within one hour of arrival.  Furthermore, Members were informed that most instances where the 4-hour standard was surpassed, this was not patients waiting to see a doctor, but instead, patients waiting for a bed due to the lack of availability. 

 

7.    Members suggested that the co-location of GPs on site could reduce the number of attendances to A&E.  The Director of Acute Medicine explained that this had been considered, however it was difficult to find suitably qualified GPs who, due to demand could commit to such a scheme.  Members were informed that local GPs were supportive of the concept but were reluctant to participate as they were already at full capacity within their own practices. The witness went on to explain that locum doctors had been considered however the Trust was of the view that this was an expensive option and did not represent value for money.  Furthermore, he explained that the Trust had set up an urgent care centre where highly skilled care professionals were able to see people and advise them according to their symptoms.

 

8.    The witness suggested that increased out of hours GP provision could potentially reduce the number of attendances at A&E departments but this would not guarantee a decrease in the number of admissions.  The Director of System Redesign explained that North West Surrey CCG had a high number of walk-in centres who see up to 200 patients a day with a low rate of patients seen requiring referral to the acute.  In North West Surrey, there were 10 GP practices that were currently offering an extended hours service under a national contract thus providing improved access to appointments.  This was in addition to the development of the Bedser hub in Woking, providing proactive and reactive care to the over 65s in partnership with the Trust, Primary Care, Surrey and Borders, Virgin Care, Adult Social Care and the voluntary sector.  Members acknowledged that work was aligned across the Surrey Heartlands STP footprint to develop and deliver services and improve patient flow.

 

9.    Members enquired about the process following an ambulance arriving at A&E.  The partners explained that upon arrival, the patient would be booked in, triaged and seen by an A&E doctor for an investigation.  The doctor would then refer the patient to the relevant teams who would decide whether it was necessary to admit the patient.  The witnesses explained that when ambulances arrive and beds are not available, this leads to queues of patients waiting on trolleys until beds become available. 

 

Royal Surrey County Hospital NHS Foundation Trust

 

10.  The Director of Strategy & Partnerships at the Royal Surrey County Hospital NHS Foundation Trust (RSCH) explained that the Trust’s performance against the 4-hour standard was disappointing, however it was the view of the system that this was due to a lack of preparedness than in previous years.  The Trust was confident that it would learn from its 2016/17 performance and with the implementation of some reactive measures, the dip in performance would be improved for 2017/18.

 

11.  Members were informed that the current results for Q4 were looking strong following the implementation of some reactive responses.  Members acknowledged that RSCH had invested approximately £1.4million in order to increase GP provision at weekends and to increase capacity by 18 additional beds until the end of March 2017.  Patient flow had been managed by some physical moves within the hospital, and the earlier opening time of the discharge lounge now allowed for beds to be freed up earlier in the day, thus improving patient flow. 

 

12.  The witness explained that a streaming nurse had been strategically positioned to ensure patient flow was managed and to avoid ambulance stacking.  This, combined with 18 additional beds had made a significant improvement to bed availability.

 

13.  Members were informed that the Trust was looking to invest heavily in the A&E department by the end of the calendar year, as well as investing into the community system to support out of hospital care.

 

14.  The witness explained that the Trust was looking to work with neighbouring partners and that they had been to visit Epsom & St Helier Hospitals to understand more about their Epsom Health & Care model in order to learn from their best practises.   

 

Surrey and Sussex Healthcare NHS Trust

 

15.  The Director of Service Development began by informing the Board that the Trust was currently testing their resilience plan for the second time this winter.  The plan was tested at regular intervals to address blockages within the system and shortages as well as assessing quality, performance and outcomes.

 

16.  The witness explained that Surrey and Sussex Healthcare NHS Trust (SASH) had implemented GP cover from 10am until 8pm seven days a week, and the Trust was of the view that this had made a significant difference to patients.  Members acknowledged that GPs were able to assess patients as well as educate them regarding the alternatives to A&E which they felt was important in order to divert unnecessary attendances.

 

17.  The Board was informed that the Trust had set up a Frailty Unit with six trolleys for patients over the age of 76 which was accessible by GP referral, saving the elderly population needing to go through the A&E system.  In addition, there was an Ambulatory Care Unit with a larger therapy offer, providing same-day turnaround care and addressing social and health issues.

 

18.  The Director of Service Development explained that the Trust’s year to date performance to the 4-hour standard was at 94%.  The Trust welcomed the announcement of additional government funding into adult social care, given the high level of packages of care required which would reduce the delays of discharge.

 

19.  Members enquired about the length of wait experienced by the ambulances upon arrival at the hospital.  The witness explained that, on average, the Trust would receive 300 attendances a day, 100 of which would be ambulance arrivals.  The Director of Service Development indicated that no more than one ambulance per day had to wait for more than an hour.  The witness explained that fines were imposed on Trusts for delayed ambulance intake, so it was in their best interests to manage them, and they had turnaround nurses in place to support the patient flow process.

 

20.  Members noted that the Trust had pharmacists on wards in order to improve the dispensation process and reduce delays to people upon discharge.  The witness explained that they also had a Boots the Chemist on site in order to speed up the process upon discharge.  The witness explained that every pharmacist has a formulary list of all the drugs stocked at the site and that it was rare for a patient to be prescribed something that was not on the formulary.

 

21.  The witness explained that the Trust conducted a patient satisfaction survey and there was a feedback section on their website, and that they were committed to responding to all comments, positive or negative.  The partner informed the Board that as part of a recent audit, one of the key questions asked was “why did you come to A&E?” and the most common response was “lack of GP availability”.

 

22.  The Director of Service Development explained that the East Surrey Hospital site had seen an increase of attendance at A&E due to the ongoing redevelopment of the Royal Sussex County Hospital in Brighton.  GPs had also been referring patients to East Surrey Hospital for elective surgery and the hospital was currently in dialogue with colleagues in Brighton in order to manage these additional pressures. 

 

Epsom & St Helier University Hospitals NHS Trust

 

23.  The Chief Executive of Epsom & St Helier University Hospitals NHS Trust (ESTH) explained that the Trust was currently performing ahead of the 4-hour standard target at 95.15% year to date.  The Board was informed that last year, having missed target for five months in a row, the Trust redesigned the care pathway by applying business thinking to hospital practises. 

 

24.  The Board acknowledged that the Trust had set up an integrated care model, Epsom Health & Care, which involved 20 GP practises in Epsom, along with Central Surrey Health as community provider and this council, with a view to providing alternatives to hospital care.  The model focused on reducing inpatient stay and had so far reduced length of stays by a day.

 

25.  The Chief Executive of ESTH informed the Board that out of 1000 patients, only 11 experienced delayed discharge and this was usually down to the arrangements surrounding continuing care packages.

 

26.  The Board was informed that as part of planning for the anticipated surge of demand over the upcoming Easter Bank Holiday weekend, the Trust were looking to run the Bank Holiday Monday as if it was a normal working day with a view of analysing how this staffing concept could benefit the Trust going forward.

 

27.  The Chief Executive of ESTH explained that whilst it had previously been difficult to recruit and retain workforce, it was hoped that the positive results delivered by the Trust would allow for a successful upcoming recruitment drive to attract more candidates for vacant consultant roles.

 

28.  The Board noted that the focus of the redesign of the patient flow had enabled a view to be taken in the middle of the day regarding bed availability, allowing for actions to be taken to improve this the same day.

 

29.  The Chief Executive of ESTH explained that multi-disciplinary team meetings were held on wards every day to discuss every patients current care programme and their next steps were noted on a whiteboard.  Whilst this could be seen to be a laborious administrative task, it allowed for attention to detail to be given to every patient and for informed decisions to be made regarding their ongoing care needs. 

 

30.  Members were informed that the Medically Fit for Discharge ward was for patients for whom the hospital had done all they could do, and their ongoing rehabilitation was dependant on receiving continued care out of hospital.  The Chief Executive explained that prior to the creation of this ward, patients at this stage of care were dotted around the hospital dependant on where beds were available, leading to an un-coordinated view on how to appropriately manage the discharge of these complex patients.  The Chief Executive of ESTH explained that the Medically Fit for Discharge ward had made a positive impact on reducing length of patient stays and it had been particularly successful at their St Helier site, where the ward was run by GPs and managed by a therapist. 

 

31.  The Board was informed that ESTH had a block contract with commissioners rather than a Payment by Results (PbR) contract.  This allowed shared control to address nuances and discrepancies and the Chief Executive considered this to be an important element of the ESTH system.

 

Rachael I Lake left the meeting at 11:50am

 

32.  The Chief Executive of ESTH explained that the Trust had a lot of buildings which were not seen to be fit for purpose.  The Trust was of the view that the Epsom Health & Care model would enable better availability and accessibility to all care services by locating services of key partners on the Epsom site, creating a modern, purpose-built campus of care services.

 

33.  Members enquired how useful the NHS111 service was in order to divert minor injuries away from emergency departments.  The Chief Executive of ESTH explained that NHS111 had two different providers covering the Trust.  It was noted that the London provider was better connected to other services and was GP led, allowing for more relevant decisions to be made.

 

34.  Members were informed that North West Surrey CCG was the lead commissioner for the NHS111 procurement and the mandate was to work towards integrated services, with a clinical hub and integrated out of hours provision.

 

Tim Hall left the meeting at 12:05pm

 

35.  The Chief Executive of Healthwatch Surrey commented that some residents were unaware of alternatives to attending A&E and vulnerable groups had low awareness of the NHS111 service.  It was suggested that educating residents via communications campaigns could have a positive impact in increasing awareness and reducing pressures on emergency departments unnecessarily.

 

 

Recommendations

 

That the Chairman follow up the item with Frimley Park and Kingston Hospital and report back to the Board;

That health scrutiny take a future item on the role of the whole system in reducing winter pressures, exploring both:

• The role of GPs, walk-in centres and other initiatives in reducing attendances;
• The role of partners and initiatives to improve timely discharge and create bed capacity across acute services;

 

That the acute trusts provide a short briefing detailing how they have worked with the ambulance trust to reduce down-time;

That representatives from the acute trusts are invited to attend in autumn 2017, in order to outline how shared learning from 2016/17 has informed planning for 2017/18.

 

The Chairman thanked the Board, his Vice-Chairman, officers and witnesses for their support over the council term.  A Member of the Board offered thanks to the Chairman for the work he had undertaken on behalf of the Board over the past four years.