Agenda item

Purpose of the item: to inform the Committee of the impact of Urgent and Emergency Care surge on the Surrey Heartlands system during 2023/24, including reference to the previous winter pressures; and to describe the whole system measures being put in place to promote resilience throughout the upcoming winter period.

Witnesses:

Mark Nuti – Cabinet Member for Adults and Health (In person)

Ben Hill, Director – ICS Urgent Care and System Resilience will lead (In person)

Katy Neal, Associate Director – Ambulance Commissioning Surrey Heartlands ICS (attended remotely)

Radcliffe Lisk, Clinical Director UEC (attended remotely)

Jo Hunter, Director – ICS Planned Care (attended remotely)

Lorna Hart, Director of ICS Development. Email (In person)

Andrew Erskine, Deputy Chief Operating Officer SaBP (attended remotely)

Jackie Raven, Associate Director - ICS Urgent Care (attended remotely)

Rachael Graham, Director of Non Acute and Primary Care Contracts (attended remotely)

Key points raised in the discussion:

1.    The Chair asked about the Surrey Heartlands Integrated Care Board’s [ICB] 5 objectives and wanted to know about the investment in I.T. in terms of putting standardised systems in place to improve the delivery of the objectives by joining up processes and performance. In particular, the changes of how things are managed concerning the year-to-year measurement of performance, changes, and improvements. The Director of ICS Urgent Care and System Resilience provided an update on the roll-out of the new electronic patient records in two of the acute hospitals and an upgrade on their third hospital which was rolled-out last year. This will support Surrey Heartlands in its ability to record patient records electronically as opposed to using paper with clinical audits and closer performance monitoring. The Surrey Care Record would also allow for the sharing of records with providers at point of access. The Director of Non Acute and Primary Care Contracts explained that cloud-based telephony is a significant tool offering a voice-redirection option, allowing for multiple lines to be open to better manage demand. Data sharing agreements between both Federations and practices provide confidence with not having the associated risks with distance prescribing or consulting. A Member asked if cloud-based telephony had now been rolled-out across the county. The Director of Non Acute and Primary Care Contracts confirmed it had been rolled-out across the Surrey Heartlands portion of the county.

2.    A Member referred to the high level of complaints received from residents on the length of time for a call-back response. The Member questioned that as General Practitioners (GPs) are under strain, was securing more appointments realistic given recruitment issues to various roles as well as the recovery of dental activity, and how did Surrey Heartlands foresee managing more appointments for residents and patients. The Director of Non Acute and Primary Care Contracts explained that the aim is to be channel-agnostic, making services available however access to care is required. The additional roles reimbursement scheme introduced seventeen new roles with sixty-four thousand appointments from October to March managed. Surrey Heartlands was an early adopter of the Pharmacy, Optometry and Dentistry [POD] commissions, having taken it on from July 2022 and they continue to learn about the challenges faced with their dental contracts as there is an access issues for dental services. 

3.    A Member recognised there is some great technology but there are many people that cannot make use of it and there does not seem to be an education programme for the community. The Member suggested that it would be helpful to understand what kind of education programme existed for people that do not necessarily need to see a doctor and could visit a pharmacist or physiotherapist and wanted to know if digitally excluded people and those that do not see social media adverts have been considered. The Director of Non Acute and Primary Care Contracts referred to the channel-agnostic engagement work undertaken in Surrey Heartlands and with Surrey Healthwatch. Working with a preventative stance for and within communities is included in the delivery of care.

4.    A Member asked about power cuts and in particular the use of 111 and 999 and were Surrey Heartlands satisfied people can call these numbers during a power cut with the newer fibre connections and was there was a plan to protect Surrey residents against such risks. The Director of Non Acute and Primary Care Contracts suggested more vulnerable residents in such scenarios could approach their telephone or mobile telephone operator to request priority access for use of those lines in the event of periods of huge demand. Each practice has a business continuity plan in place in the event of power outages. A fuller response could be provided at a later time. The Director of ICS Urgent Care and System Resilience explained that as an Integrated Care Board [ICB] under the Civil Contingency Act they are a level one responder with several incident plans in place and would work closely with Surrey County Council to look at the vulnerable people in the community and in the event of a power outage there would be a response.

5.    A Member asked why the number of people arriving atAccident and Emergency appear to have doubled with congested emergency departments and what measures had been taken to encourage people to use 111 or another service to avoid going to Accident and Emergency when they may not need to be there. The Director of ICS Urgent Care and System Resilience explained that while there has been a slight reduction regarding ambulance conveyances, patients need to be there as the admission rate is high. The key element is the ability to get flow through their hospitals and several aspects are needed in order to do that. He is confident that the right processes are in place throughout their emergency departments but the ability to function due to demand and then flow-through means they encounter periods of surge and overcrowding.

6.    A Member asked for a clearer understanding on what type of issues all of the additional people that have presented at Accident and Emergency had. The Director of ICS Urgent Care and System Resilience explained there has been a 30% rise in people living with multiple co-morbidities in our communities. In the latter years of life there was an additional demand on health services throughout the NHS. Those people that self-present without going through the routes of 111 first, add to this. Surrey Heartlands are attempting to tackle that by proactively encouraging the use of 111. The Associate Director of Ambulance Commissioning for Surrey Heartlands ICS explained that work being undertaken with the Southeast Coast Ambulance Service (SECAmb) showed that the prevalence of co-morbidities and poly pharmacies are increasing significantly, which increases complexities concerning patient requirements. The 111 service is being actively promoted and directories of services are used across Surrey Heartlands to help divert people away from emergency departments.

7.    A Member asked about the expansion of Surrey and Borders Partnerships [SaBP] safe waiting places and what the ambitions were to open other crisis houses of the challenges encountered in improving and expanding these safe waiting places. The Deputy Chief Operating Officer for SaBP explained they had obtained some funding enabling them to look at the health-based places of safety provision and safe waiting spaces. If a person is detained under an emergency power of section.136 of The Mental Health Act they require a mental health act assessment. The assessment must be safe and appropriate, and it could be challenging to get the environment right. Surrey Police, the SECAmb and Surrey and Borders Partnership are part of an ongoing group looking at all 136 pathways, linking in to the ‘Right Care Right Person’ initiative which explains the interface between people requiring support and the police. With regards to the crisis house, a service was opened in partnership with SaBP less than a year ago, and the contract will be continued with the existing provider.

8.    A Member asked about the high numbers of people under section.136 and whether they could expand on why these numbers are increasing. The Deputy Chief Operating Officer at SaBP explained that comparisons undertaken with the police display broadly consistent numbers with other southeast police services. They had seen an increased level of acuity in recent months with people detained under section.136 without a history of previous mental health conditions who were not formally known to SaBP.

9.    The Vice Chair asked about Covid-19 vaccinations with an awareness of more people contracting Covid-19. When do they expect to get the data to evidence the more recent uptake of the latest vaccinations. What are the persistent barriers, are there new barriers and how are they managing this. The Director of ICS Development and SRO mass vaccination in Surrey Heartlands explained there is 100% uptake in their primary care networks with more community pharmacists now providing Covid vaccinations. Surrey Heartlands is third in the region for uptake for Covid vaccinations with 2.7 million vaccines administered to date. In the current campaign, sixty-seven thousand to date and thirty-five to forty thousand a week is projected between now and the end of October 2023. By the end of October 2023, they expected to achieve about 60% with an expectation for an increase to this figure. In January 2024 they expect to pick up harder to reach cohorts and target areas of low uptake. Mapping and street level reviews are undertaken to utilise pop-ups within those areas. Community Champions and campaigns are used to educate people that are hesitant in taking up the vaccine.

10.The Vice Chair asked about Covid-19 vaccinations and the ‘flu, and whether the need to make two separate journeys to take them could be looked at, avoiding the need for people to travel at different times to take them both. There was also a myth that the vaccinations are not appropriate within the black and minority ethnic community and suggests stronger messaging might be needed around the education to these groups and their communities. The Director of ICS Development and SRO mass vaccination in Surrey Heartlands responded that in terms of co-administration, it has been supported this year from the national team but timings for both the ‘flu and covid vaccines are different. People in care homes would get their vaccines at the same time but ‘flu vaccines are often provided at the general practitioner practice and covid vaccination providers haven’t been aligned enough yet. They are awaiting a national vaccination strategy which is being launched imminently and will help in future years to get vaccinations aligned appropriately. Some people in the Black and Minority Ethnic and Gypsy, Roma and Traveller populations are not GP registered, and the outreach programme will focus on that street-level uptake.

11.The Chair asked how performance was characterised for the Integrated Care System as a whole in handling last year’s winter pressures and whether there are any specific lessons learned from that period that have been applied to the plan. The Chair also asked how they are now working with Adult Social Care to ensure that everything is joined up this year. The Director of ICS Urgent Care and System Resilience explained that pre-and post-Christmas last year was particularly challenging, with much learnt throughout the pandemic. Key risks and issues are now looked at for the day rather than performance numbers. A single point of access lead for the entire system is in place, making it easier for all providers to raise any concerns in that direction. An increase to seven days a week from five is expected with the introduction of the new data platform to enhance their ability to see live information and a constant overview of system pressures which includes improvements at modelling what the impacts of winter could be.

12.The Chair asked about the huge impacts on elective surgery and elective services due to the loss of bed capacity during the strikes and what specific actions are now being taken to address the backlog due to Covid. The Director of ICS Urgent Care and System Resilience explained there was a robust plan in place to manage industrial action at provider and system levels. Efforts to reschedule appointments or operations cancelled as a result would always be made. Planning is undertaken to ensure the right medical cover is in place in all of their organisations working closely with providers to understand the impacts. The Director of ICS Planned Care explained that if they are able to mitigate the impacts prior to the industrial action they do. After the event additional activity is activated allowing patients to be seen as quickly as possible. The focus is on reducing the numbers of people awaiting care regardless of industrial action.

13.The Vice Chair asked about virtual wards and how Surrey Heartlands expect to deliver 400 beds, an increase of 180 beds, and asked what timeframe they expected to be able to do that. The Clinical Director of UEC clarified that this is a two-year programme and they have deferred the growth so they can optimise the technology. They expect to achieve this target by March 2024 with digital technology allowing more patients to be on the virtual ward. Support has been secured for people of digital exclusion so they can be supported with the technology.

14.The Chair asked about the Streaming and Dispatch service. One of the big issues is paediatric care and in particular how well that is focussed due to the surge and low vaccination rates amongst children and young people. There are a large proportion of Children and Young People who have not had the MMR due to vaccine fears in recent years. What are the details of how that is done in relation to the risks that might be encountered. The Director of ICS Urgent Care and System Resilience explained that the streaming and redirection tool is more targeted for those self-presenting over the age of eighteen years old. A further update could be provided concerning the additional questions. They aim to support families by using several different technologies. The key observation is that they see a high demand of children arriving at Accident and Emergency with a particular demand attending East Surrey Hospital. The Director of ICS Development and SRO mass vaccination in Surrey Heartlands explained that the national immunisation strategy is expected to launch imminently being delivered over the Integrated Care Boards from April 2024. The data is expected to enable expansion to build intelligent maps highlighting where better focus is required. Improvements are needed with the MMR vaccine. The Director of Non Acute and Primary Care Contracts explained that a specific response regarding paediatric need would be the Acute Respiratory Infection Hubs [ARI] delivered by primary care. People can use the cloud-based telephony option to be directed into a clinical hub. The Director of ICS Urgent Care and System Resilience explained that a Task and Finish group is in place attended by all acute providers. Primary care and community paediatric services will look at demand and put in a specific plan around paediatrics for winter.

15.A Member asked about legacy cases regarding patients awaiting treatments for over 104 weeks and asked about those patients who have not chosen to do so. What plans are in place to treat them by a set timeframe and when do they estimate they will have been treated in 2023/24 to help address the backlog. What efforts have been considered to reduce the patient wait times, have the impacts on minority ethnic groups been considered, and what measures are in place to ensure they are not further impacted by ongoing delays to patient wait times. The Director of ICS Planned Care explained that the aim is to get to know the patients who are waiting to be seen over sixty-five weeks by the end of next March 2024. There are some patients waiting within the seventy-eight-week cohort. There is no one awaiting outstanding treatment over 104 weeks in Royal Surrey which is the case with Ashford and St. Peters. Surrey and Sussex hospitals [SaSH] have some people awaiting treatment over that time with the majority by choice. They do not expect any additional patients waiting over 104 weeks by the end of October. There was no clear evidence of minority groups being marginalised in terms of the recovery but some of the data is subjective, which does not make it possible to pick up data where a certain community group may or may not attend for a certain appointment.

RECOMMENDATIONS

The Select Committee recommends to NHS Surrey Heartlands, that:

1.            There is more NHS guidance in plain English to help people avoid unnecessary attendance at emergency departments (EDs) and hospital admittance by accessing other clinical services.

2.            Both Surrey Heartlands and Frimley ICBs continue their campaigns, including email, SMS reminders and targeted engagement, for this winter’s flu and Covid-19 vaccination programmes to ensure that all those eligible are made aware of the vaccination and increase uptake of the vaccines.

3.            Commissioners make sure that there is primary care capacity, including out-of-hours provision to meet paediatric health needs in winter 2023/24.

4.            Improvements are made in areas of low uptake for immunisations, and in particular are targeted at those in hard-to-reach communities.