It was agreed that Items 6a and 6b would be considered together as they related to the same topic.
· Dr Charlotte Canniff – Clinical Chair, Surrey Heartlands CCG
· Helen Coe – Director of Recovery and Transformation, Surrey Heartlands ICS
· Jo Hunter – Deputy Director of Recovery and Transformation, Surrey Heartlands ICS
· Nick Markwick – Co-Chair, Surrey Coalition of Disabled People
· Nikki Mallender – Director of Primary Care, Surrey Heartlands CCG
· Dr Pramit Patel – Primary Care Network Lead, Surrey Heartlands CCG
· Kate Scribbins – Chief Executive, Healthwatch Surrey
· Fiona Slevin-Brown – Executive Lead for Urgent and Emergency Care, Frimley CCG
· Simon White – Executive Director of Adult Social Care, Surrey County Council
· Patrick Wolter – Chief Executive Officer, Mary Frances Trust
· Paul Young – Portfolio Lead for Health and Social Care Integration, Surrey Heartlands ICS & Surrey County Council
Key points raised during the discussion:
1. The Director of Recovery and Transformation introduced the report and explained to the Select Committee that Frimley and Surrey Heartlands Integrated Care Systems (ICSs) were working closely together to recover services and deal with the significant pressure the health service was currently under.
2. A Member started by thanking health and care staff for all of their hard work throughout the Covid-19 pandemic. They then asked what mental health support was being offered to members of staff, as well as support relating to abuse they might receive from the public. In response, the Director of Recovery and Transformation explained that a self-help website had been made available to all staff, alongside crisis support and the delivery of approximately 1,500 wellbeing workshops. Regarding abuse, conflict resolution and customer care training was on offer to all staff. They went on to say that exhaustion and burnout, anxiety about returning to the office, and the management of Long Covid were all issues of concern that had been raised by staff. Personal risk assessments had been conducted for all members of staff, and a zero tolerance policy was in the process of being developed.
3. Responding to a question on what measures were in place to deal with potential staff absences and the pressures that these could place on the health system, the Director of Recovery and Transformation explained that a system-wide call was currently held each weekday at 9am at which operational issues were discussed, and this would take place seven days a week from 1 November. Mutual aid was offered to all hospitals, staff were reduced in some areas to deal with pressures elsewhere, and they had access to agency and bank personnel to help with absences when needed. The whole system had been working hard to support one another.
4. Referencing Paragraph 33 of the Surrey Heartlands report, a Member asked about the specific measures being put in place to deal with possible greater demand on Intensive Therapy Units over the winter months. In response, the Director of Recovery and Transformation said that a review had been undertaken on what was done in first two phases of the Covid-19 pandemic and that this had highlighted, both regionally and nationally, the need for investment in critical care services. Plans were currently being formulated for 2022/23 and the number of beds that could be staffed had been almost doubled through the training of staff to support critical care patients. They went on to explain that modelling was being done on a weekly basis and it was expected that peak demand would come towards the end of October. The current focus was on training staff, but there was a possibility that staff might have to be stepped down from other services, such as elective surgery, to deal with the increased demand. However, this would not be done unless absolutely necessary.
5. A Member asked whether there was an adequate supply of flu vaccines and Covid-19 booster jabs and was told by the Executive Lead for Urgent and Emergency Care that there had been a slight delay in these being delivered but that there now were sufficient supplies available.
6. In response to a question about what was being done to discharge people from hospital, the Executive Lead for Urgent and Emergency Care explained that all health and social care partners worked closely together to ensure patients were discharged in a safe and timely manner, and to stop people being admitted to hospital in the first place where this was avoidable. The Executive Director of Adult Social Care added that both the NHS and social care were under extreme pressure and that there were difficulties in recruiting staff. Regarding Discharge to Assess, they informed Members that this was scheduled to come to an end in March 2022 and that they were planning for what would come next, as it would not be desirable to go back to the status quo. Any change to a new model would need to be resourced, but indications from the Treasury were that extra funds for this would not be made available from central government. The Executive Director of Adult Social Care went on to say that, both now and in the future, it was important to ensure that when patients were discharged from hospitals, the destination was still their home, even if this required them to be provided with a period of bedded rehabilitative care. However, this was not just a social care issue, as it also required input from, and close working with, NHS community services.
7. The Select Committee heard from the Chief Executive of Healthwatch Surrey, who spoke about the Discharge to Assess model and the important role played by carers. They went on to explain that recent work undertaken by Healthwatch Surrey revealed that, although there were examples of positive experiences, some patients were being discharged to their homes in a worse condition than when they were first admitted to hospital, and that there were problems with the information provided to carers and the ways in which hospitals were communicating with them. A Member suggested that hospitals could design standardised communications that they could provide to the next of kin of those being discharged into care to ensure they were aware of their care needs and questions they should be aware of.
8. A Member asked about diagnostic wait times and the support being given to those patients whose elective surgery had been delayed and was told by the Deputy Director of Recovery and Transformation that, at the start of 2021, there were nearly 2,500 patients in Surrey Heartlands waiting over 52 weeks for treatment, but that this number had now been reduced to approximately 600. There were a number of programmes in place to review patients’ conditions and ensure they had not deteriorated, and surgery could be brought forward if it was felt this was needed. The Deputy Director of Recovery and Transformation went on to tell the Select Committee about the “waiting well” schemes, which involved partners from across integrated care working together to ensure patients were remaining fit and healthy. This involved the use of remote monitoring systems, which produced physiological measurements to ensure patients’ conditions were not deteriorating during their wait.
9. The Select Committee heard from the Clinical Chair of Surrey Heartlands CCG, who explained that Surrey Heartland was one of the top 10 ICSs in the country in terms of its recovery. Primary care was facing challenges in three main areas: demand, capacity, and models of care and access. Despite these challenges, primary care capacity had increased, and circa 40,000 more appointments were now being delivered per month, with 63% of these taking place in person. The Clinical Chair went on to explain that primary care was facing long-term issues relating to recruitment and retention, GPs nearing or at retirement age, and a workforce demoralised by the pressures of the Covid-19 pandemic. It was important for conversations to be had about the development of a mixed model of access to ensure patients’ needs were met. There was not a one-size-fits-all approach that would work across Surrey, but instead engagement and consultation needed to take place with patients. Data collected by Surrey Heartlands showed that the majority of patients had found digital access helpful but that they were confused about how to access GPs and the benefits of triaging. It was important to make sure patients were able to meet with the right person for their needs, and this was not always a GP.
10. The Director of Primary Care informed the Select Committee that the number of face-to-face primary care appointments taking place in Surrey Heartlands had returned to roughly pre-pandemic levels, and that the uptake of digital appointments was the highest across the whole of south-east England, with 2.1 million contacts taking place through remote channels. On the subject of patient satisfaction with GPs, this figure stood at 86% in Surrey Heartlands, against a national backdrop of 83%. The Director of Primary Care also explained that, prior to the pandemic, the number of annual health checks for those with learning disabilities and autism was 40%, whereas during year of pandemic this had risen to 70%.
11. The Primary Care Network Lead added that although there was the need to celebrate those achievements made by primary care during the pandemic, there were also gaps that required filling by working together. Key areas of focus going forward would be: planning additional capacity through winter, continuing to recover services, narrowing health inequalities across the system, developing Surrey Heartlands’ zero tolerance approach, and ensuring patients were engaged and involved in the co-designing of the new way of working and accessing primary care. They also spoke about the importance of enabling and accelerating the implementation of the Health and Wellbeing Strategy to help empower and support people and level up services across Surrey.
12. Responding to a question about accessing mental health support at GP surgeries, the Clinical Chair spoke about the General Practice Integrated Mental Health Service (GPIMHS), which brought mental health services into primary care settings and had been hugely successful in the areas of Surrey to which it had been rolled out. However, they explained that, due to workforce and resourcing issues exacerbated by the pandemic, it had not yet been possible to roll out the services across the whole of Surrey, leaving some GP surgeries reliant on identifying themselves those patients that required mental health support and, where it was an issue that they could not manage alone, referring on to other services for extra help. Work was taking place to improve mental health services through the Mental Health Improvement Plan, which would have actions for everyone across the health system.
13. A Member asked what was being done to ensure people were more easily able to access primary care services by telephone rather than remote channels, and to ensure face-to-face appointments were available for vulnerable groups. In response, the Clinical Chair said that the purpose of the triage was to identify those patients that might be vulnerable and for their preferred type of appointment to be offered. However, those preferring to be seen face-to-face might have to wait longer, and it might not always be in their best interest to be seen in this way – particularly with regards to putting themselves at risk of being infected with Covid-19. The Director of Primary Care added that one of Surrey Heartlands’ biggest areas of focus was around modernising the telephony system. They explained that government support would be given to achieve this.
14. In response to a Member’s queries about what was being done to make sure the continued prevalence of Covid-19 and the future rollout of vaccinations would not continue to affect primary care, and whether full-time vaccinators were being recruited, the Clinical Chair explained that Surrey Heartlands had at its disposal a large non-clinical workforce that had been trained up as vaccinators over the course of the pandemic and could lead vaccination sites going forward. The vaccination programme had also expanded into community pharmacies, resulting in a lot more choice. However, there were still pressures being put on primary care staff who were volunteering at vaccination hubs. The Primary Care Network Lead added that in Surrey Heartlands there were GP collaboratives working at scale across multiple sites, such as the Woodhatch vaccination hub in Reigate.
15. The Co-Chair of the Surrey Coalition of Disabled People asked what was being done to ensure more people were able to use texting to access services and communicate with clinicians. In response, the Clinical Chair explained that this was used a lot in primary care and that there was now the ability to make this a two-way method of communicating with patients. The Co-Chair of the Surrey Coalition of Disabled People asked for this to be replicated elsewhere in the health system.
16. A Member referred to the 2021 GP Patient Survey and asked what plans were in place to improve those surgeries that had been rated poorly. The Director of Primary Care explained that visits were taking place in each of the 104 practices in Surrey to ensure that best practice was being shared across the system, and that approximately 25 of these visits had already taken place.
17. Responding to a question about handover delays at hospitals, the Deputy Director of Recovery and Transformation told the Select Committee that processes were in place to minimise these wherever possible. They explained that the pandemic had sped up a lot of the transformation work taking place in healthcare and that triaging at the A&E front door was now more advanced. Members were told about the use of SDEC (same day emergency care), acute emergency admissions areas and the diverting of patients who were not critically ill but could be cared for in different locations and at a slightly slower pace. The Deputy Director of Recovery and Transformation went on to explain that all patients were triaged based on their clinical presentation, even if they arrived at A&E in an ambulance, and that work was being done to redirect and support patients at home with advice and guidance. Patients were being directed to other areas of care that were right for their needs, including pharmacies and GP surgeries, as well as 111, which could now book patients directly into A&E. Handover delays were likely to continue to be an issue over winter due to the workforce pressures being faced by ambulance services, but Surrey Heartlands were committed to working closely with them and continuing to take their feedback on changes that could be made.
18. A Member asked about what could be done to signpost patients to pharmacists. In response, the Deputy Director of Recovery and Transformation spoke about the importance of getting support nationally to help change public perception and help people to understand that pharmacies were a trusted local resource that could be used as a first port of call. The Clinical Chair added that the Community Pharmacist Consultation Service (CPCS) was about to be launched in Surrey Heartlands, and that this would help to triage patients to community pharmacies. It would also be possible for GPs to receive feedback on the outcome of consultations. Following a further question from a Member about ensuring pharmacies had the facilities needed to deal with an increase in patients, the Clinical Chair explained that CPCS was a national programme for community pharmacies and that those that had signed up would be provided with additional resource.
The Select Committee recommends that Frimley and Surrey Heartlands:
1. Work closely with Surrey County Council’s Public Health team to create and deliver a communications campaign that highlights to residents the importance in following ‘Hands. Face. Space’ and social distancing to help reduce the pressures being put on hospitals over the winter months
2. Work with residents and Members to co-design standardised communications that hospitals can provide to the next of kin of those being discharged into care, and for these to clearly detail their care needs and questions they need to be aware of
3. Explore ways in which they can highlight to patients the right services for their needs to ensure they do not attend A&E when their condition does not require them to