In attendance for this item were:
Worcestershire Clinical Commissioning Groups: Mari Gay, Chief Operating Officer and Lisa Levy, Chief Nurse/Director of Quality
Worcestershire Acute Hospitals NHS Trust: Michelle McKay, Chief Executive and Inese Robotham, Interim chief Operating Officer
Worcestershire County Council: Avril Wilson, Interim Director of Adult Services and Frances Howie, Director of Public Health
West Midlands Ambulance Service: Mark Docherty, Director of Clinical Commissioning & Service Development/Executive Nurse
Worcestershire Health & Care NHS Trust: Sue Harris, Director of Strategy and Partnerships and Melanie Roberts, Deputy Lead for Community Service Delivery Unit
The Chairman set out the context for the update on winter evaluation work, which had been requested in response to the HOSC's concern about the need for significant improvement in the Acute Hospital Trust's performance and capacity.
A presentation on Worcestershire Urgent Care and Patient Flow had been circulated before the meeting (available on the Council's website here ), which focused on the evaluation of winter 2017/18 and preparing for winter 2018/19.
The Chief Executive of Worcestershire Acute Hospitals Trust (WAHT) talked through the presentation, which included health partners' preparation for winter 2017/18, specific winter schemes, outcomes and overall evaluation. Planning had started in May 2017, with governance via the A&E Delivery Board, and based on best practice and analysis of previous winter pressures.
Specific winter schemes had included focus on:
· reducing avoidable hospital attendances
· reducing demand in A&E by enhancing alternative assessment areas within WAHT
· creating sufficient inpatient and community capacity
· focusing on best practice discharge processes and revised discharge to assess processes from hospital to nursing homes
· collaborative work to increase system control with a local 'winter room'
One of the challenges of winter months was the change in patient cohort, which meant more patients with complex discharge circumstances.
Winter evaluation work had been completed by Midlands and Lancashire Commissioning Unit on various aspects of the winter plan, and NHSE had also commissioned a system-wide analysis of the urgent care and patient flow system by a consultancy group (Carnall Ferrar).
Using the evaluation work, planning for winter 2018/19 had already started and was focusing on:
· preventing demand for acute based services – through increased immunisation for the health and social care workforce and older people (against flu, also pneumococcal immunisation for older people), as well as prevention of urinary tract infections and falls
· maximising the new services/contracts across the system –extended hours at the Frailty Assessment Unit, new primary care contract and new neighbourhood teams, plus an Urgent Treatment Centre at the Alexandra Hospital (the Alex)
· matching predicted demand and capacity – utilising demand and capacity tools, building work for redesign of acute beds at Worcestershire Royal Hospital (WRH), also a system-wide urgent care and patient flow system reset
· further enhancing public and stakeholder awareness – around choices for urgent care, focus on maintaining independence in the elderly and building on a one-system communication plan for staff
The challenges for 2018/19 were completion of building works on WRH site within timescales and workforce availability across the system. To mitigate these challenges, bedded capacity across the system was being assessed to provide alternative capacity, and workforce requirements were being identified in order to commence recruitment.
The Committee was shown a schedule for winter planning which would be overseen by the A&E Operational Group, and a submission was due to be sent to NHSE in early September 2018.
Main discussion points
· a member asked about the scale of the problem and challenge with demand on A&E. He referred to 20% of patients leaving with guidance only, which suggested they had not needed to go to A&E in the first place. The CCG and WAHT representatives acknowledged that when more people attended A&E it caused greater discomfort for everyone as there was limited physical capacity in the department. Conversely Worcestershire had one of the lowest levels of 'minors' attendance at Minor Injuries Units in the country. Access to GPs had been extended. The situation was challenging but the CCGs and WHAT, along with NHS111, would continue to communicate the message that A&E was for serious incidents only and to encourage people to access services differently.
· A member asked about work to review hospital bed numbers and the assumptions from previous modelling exercises, since bed numbers appeared to be insufficient. The CCG representative advised that having looked back at bed modelling undertaken some years ago, it appeared the population growth which had been experienced since then, had not been anticipated. There were currently not enough acute hospital beds, but the system had to be realistic and could not therefore be modelled on a best case scenario of bed numbers. More beds had been brought in, although there were other contributing factors.
· Several members expressed concern about whether capacity would meet demand in the long-term - however the CCG representative believed there was a 'fighting chance', with WRH benchmarking well on patient length of stay. As well as pressures during winter, the heat also impacted on demand, however the additional hospital capacity would mean a better chance to improve patient flow.
· Regarding the capacity issues, a member asked whether A&E matrons were used, and whether there should be extended use of beds at the Alex? The WAHT Chief Executive confirmed that both WRH and the Alex had matrons with specific responsibility, and although they were not available 24hrs, each site had triage staff.
· The WMAS representative pointed out that triage was also carried out by ambulance staff, and there was scope for the paramedic role to add greater value. For example if ambulance staff had already x-rayed and diagnosed a patient's broken leg, hospital staff could move on to the treatment stage, without waiting for a further x-ray.
· New system-wide planning tools would enable assumptions to be made across the system, which should give greater understanding of the impact of pressures from demand on particular services, including from projected population growth. The CCGs were concerned about fluctuations in care home numbers, and both the CCGs and WAHT representatives agreed that a sufficient workforce was the biggest challenge.
· Regarding capacity and population growth, a member expressed great concern about Section 106 monies, which (in her role as a District Councillor), she had observed were not being allocated as a contribution to health from developers, for substantial housing plans. Another member reported that he understood NHS England was a statutory consultee for planning applications. The Council's Director of Public Health referred to the health supplementary planning document, and the opportunities to use this as a strategic lead into making informed bids for funding from the development control process. She suggested that clarification from the district council planning authorities about what was being done to maximise health services, would be helpful, which the Committee agreed to request.
· Regarding patient discharge, a member queried whether enough use was being made of community hospitals? The Worcestershire Health and Care Trust reminded the Committee about the new Neighbourhood Teams, which brought specialities together and a different way of working with the community hospitals.
· A member asked about the effectiveness, feedback and plans of the new pilot which had revised the protocol for ambulance borders and conveyances, and also asked how HOSC members could keep informed? HOSC members were reminded that the FoAHSW (Future of Acute Hospital Services in Worcestershire) review had articulated the future of the Alex as a centre of excellence for elective surgery, but also that it would have an A&E, except for children. The cohort involved in the pilot diversions would still go to A&E and did not have symptoms which required the WRH site, such as strokes. The pilot was not at all in conflict with plans, but represented a planned approach, rather than the reactive approach of recent years. It was due to continue to the end of July. Experiences from the first weeks showed approximately 10 patients a day were diverted, ambulance handovers had improved, and patient time in WRH Emergency Department had decreased, with no incidents or complaints. The WMAS representative added that the pilot was something which had been considered for a number of years, and was now possible because a paramedic was present on every ambulance. Ambulances were able to provide treatment, not just transport and WMAS believed that taking patients to the right place was better than the nearest. He reassured the Committee that moving these patients was not unsafe, and believed it was being done for the right reasons – enabling quicker treatment was important not only to the patient but to the system. The pilot was clear on the area involved (DY10 / DY11), and the exclusion criteria. Significantly, for once, Worcester had not been on the list (of hospitals experiencing handover delays) during the first week of the pilot. Whilst this had not been maintained as the system had been impacted by the current hot weather, everyone involved was committed to improvement.
· A member flagged up concerns about diverting patients in winter months in this way, since the roads between Kidderminster/Bromsgrove and Redditch became particularly dangerous.
· The HOSC Chair was aware of positive comments from the public about community hospitals and sought assurance that the pilot would not impact on elective surgery at The Alex? The WAHT representative advised that the numbers involved amounted to around 4 admissions a day (from the 10 diverted), which was small. The FoAHSW model sought to maximise elective surgery through better theatre use.
· It was suggested that language used to describe various services could be confusing for the public, for example the Urgent Care Centre. The CCG representative confirmed that further urgent treatment centres were walk-in facilities. Further thought would be given to effective communication with the public about their options when unwell .
· In response to a member's recent experience of being unable to access health services without being routed via A&E, for a health need which was not of serious nature, it was acknowledged that the new models of care aimed at getting patients to the right place at the right time, still required work
· When asked about conveyances to A&E arising from calls to NHS111, which the committee understood had been far fewer under the previous provider (WMAS), the WAHT representative acknowledged that there had been issues but advised that recent improvements had been made. Ambulance teams were called inappropriately at times, however this was a national issue. The WMAS representative agreed that improvements were needed and it was important to get to grips with such issues before the winter.
· Building plans for WAHT were clarified. The £29.6m business case stemmed from the FoAHSW model, with an additional 81 acute beds coming on stream by 2021, however this had subsequently been brought forward to the start of the programme. Although good news, the advance funding had been piecemeal in fruition because of the processes involved in accessing it. However the new bridge link at WRH to access the ward areas in the Aconbury buildings was due for completion in December 2018, which would improve access to the 50 existing but unmodernised beds (meaning that more acutely ill people could be cared for than at present). By the end of March 2019, there would be two newly modernised wards in Aconbury East providing 46 beds in addition to the existing 50 and subject to full business case approval, by the end of September 2019, an additional 35 newly modernised beds will be available in Aconbury East totalling 81 new beds on top of the existing 50.
· When asked if a magic wand could be waived, how many extra beds would be asked for, the WAHT representative advised that approximately 80 was believed necessary, which was also the figure in the FoAHSW plan. While WAHT would much rather have the additional beds right now, they would also need the staff too. In relation to projected population growth, it was clarified that there was not a linear equation with bed need, and it was important to reflect on significant changes in care and the reaches of technology. For example at one time having a baby would have involved a week's hospital stay and this was now much shorter. The programmes in place were long-term but there would always be an element of guess work.
· It was clarified that the £29.6m was for acute services at the WRH and the Alex as part of the FoAHSW plan, however access to funds needed to go through the Herefordshire and Worcestershire Sustainability and Transformation Partnership (STP) process. All organisations across the STP had agreed that the capital expenditure was a priority.
· A member expressed frustration at hearing the concerns about hospital capacity. He also pointed out the role of the Council's social care function to facilitate people being able to leave acute health care.
· Speaking as a newcomer to the UK, the WAHT representative said that the workforce challenges in terms of recruitment and retention were something she had never seen in her career. The community had nostalgic memories of the NHS, a hook which she felt could be used for recruitment. There was much negativity in the public eye but there must be a way to work collectively. The WMAS representative also pointed out the need for people to use the service more responsively, if it was to be retained. The CCG representative hoped that progress with more integrated systems would help and give more flexibility.
· A member sought clarification on community bed usage under the STP and the Worcestershire Health and Care Trust representative (also the STP Communications and Engagement Lead) advised that optimum usage was planned going forward, with no planned reductions and that community hospitals functioned and benchmarked very well. It was important to structure services around a model for safe, robust care in people's homes - and referring to changes in mental health treatment and closure of institutions, she made the point that the answer was not just beds.
· The Council's Director of Adult Services pointed out that today was not only the 70th anniversary of the NHS, but also of social care. There was huge public esteem for the health system, but actually it would only work if health and social care worked in partnership and also promoted wellbeing.
The Council's Director of Public Health reminded members of the Council's responsibility around health and well-being and the importance of playing its part in prevention, something which she hoped to discuss more through the coming year.
· A member highlighted the benefits of prevention and referred to the previous Supporting People Agenda which 'joined up' the various services.
The Chairman thanked the attendees for the quality of the information provided. The Committee agreed it would be important to request clarification on the issue of health contributions for section 106 monies from the district councils, It would also request further updates on hospital capacity and preparation for winter pressures later in the year. The HOSC would also seek clarification on use of community hospital beds through the STP, moving forward.