Agenda item

In attendance for this Item were:

 

NHS Herefordshire and Worcestershire Clinical Commissioning Groups

Simon Trickett, Chief Executive

Mari Gay, Managing Director

 

Worcestershire Acute Hospitals NHS Trust

Matthew Hopkins, Chief Executive

Paul Brennan, Chief Operating Officer and Deputy Chief Executive

Jo Newton, Director of Strategy and Planning

Richard Haynes, Director of Communications and Engagement

 

Worcestershire Health and Care NHS Trust

Matthew Hall, Chief Operating Officer

Sue Harris, Director of Strategy and Partnerships

 

Worcestershire County Council

Elaine Carolan, Assistant Director of Adult Services

Kathryn Cobain, Director of Public Health

 

The Chairman referred Health Overview and Scrutiny Committee (HOSC) Members to the presentation included in the Agenda papers. Simon Trickett, Chief Executive (CE) of Herefordshire and Worcestershire Clinical Commissioning Group (CCG) explained that he would lead. The organisations represented believed a collective view of the response to COVID-19 was needed, which it was hoped would prove helpful to the HOSC and would pave the way for further discussions of the evolving situation.

 

Whilst the pandemic had needed an enormous response, this had also created a very different environment and different ways of working. The CCG CE paid tribute to staff as well as service users for their adaptability – and this was echoed by the HOSC Chairman. The presentation provided an overview of the journey to date, how some parts of health and care systems had changed, engagement work, learning and modelling for the future.

 

System governance

The pandemic was declared nationally as a level four major incident, and at that time Worcestershire was only just emerging from another major incident of flooding, which was an unprecedented combination.

 

Locally, the national incident manifested itself as the Local Resilience Forum across West Mercia, with all major health and care organisations involved. Ways of working were quickly established, including daily gold command calls with organisations across the health and care system, with the aim of protecting and developing hospital capacity and to respond and co-ordinate efforts.

 

The integrated care journey in Worcestershire had been a long one, but enormous strides had been made through recent collective working.

 

COVID-19 cases

A graph demonstrated the total number of confirmed cases up to 4 June, which showed the peak period was from the last week of March through to mid April. Since then there had been a steady decline in cases, although the last few days had seen a slight upturn. The pattern of cases followed the anticipated trend in pandemics.

 

A further graph showed the total number of care home cases. It was pointed out that the care home sector involved many different organisations and that unfortunately many people living in homes required acute hospital care. Therefore, a collective response had been important to do everything possible to protect residents, prevent the need for hospital and to work with homes with positive cases of COVID-19.

 

The cumulative number of cases graph showed a significant increase across March and early April, which then slowed down, demonstrating these mitigating efforts. In Worcestershire so far, there had been 386 confirmed cases across 65 care homes, which was a reasonably small proportion out of approximately 200 homes.

 

Worcestershire hospital demand

The graph showed how health and care organisations had tried to manage demand. Initial national modelling from Imperial College in March, based largely on experiences from COVID-19 in Italy had been particularly alarming, since at that time acute hospital capacity was not sufficient to cope if this trend had been followed through, and this is what had driven the Government’s policies on social distancing.

 

Experiences and data from the United Kingdom by the end of March meant that the Italy data could be used as a basis, in conjunction with local information to develop predictions about what might happen. The current number of hospitalised cases in Worcestershire was consistent with the projected ‘good compliance’ projection, therefore this modelling exercise had proved to be very positive in planning capacity. The good compliance of the local population was recognised.

 

Workforce impact

Access to testing had been an important factor behind the fall in cases and had also enabled staff (testing negative) to return to work to sustain services.

 

Primary Care Delivery Model

Primary Care was a good example of an area where services had changed quite dramatically and worked together effectively. Members were aware that GP practices had already been teaming up to form primary care networks, with 11 networks across Worcestershire. Prior to COVID-19, the agenda for working together had been restricted to certain aspects, however the response to the pandemic brought swift agreement to work together more closely to manage support.

 

The graph showed the different hubs (red, amber and blue, depending on patient need and whether there were suspected COVID symptoms). Face to face treatment, particularly where COVID symptoms were suspected (red hubs),

required a whole host of protective measures which were completely impractical for each GP practice to facilitate, therefore there was only one red hub per area.

 

Digital Transformation – Primary Care

Taking the example of GP appointments (from a very low base), by mid-April, every GP practice across Herefordshire and Worcestershire could offer telephone consultations, and increasingly video. Across the two counties 22,035 video consultations took place in Primary Care.

 

Onward Care Team

Discharge from hospital (in order to free up capacity) had been absolutely critical and it was important to understand the context around this. As this need lessened, ensuring exit from hospital to a safe environment was also very important and key players here were the Council and Health and Care Trust.

 

This work was backed up by some significant Government policy changes. Discharge usually involved a huge amount of assessment and balance between continuing healthcare (CHC) and social care. If someone’s prime needs were health related, the NHS paid for care, whereas if needs were social, the Council or the individual paid for care. Early on, the Government decided to suspend CHC assessment and presume that everyone was eligible for CHC; this was still in place and would be watched for national confirmation.

 

The Council was spending several additional million pounds (of Government funds via the CCG) and the CCG was also spending approximately an additional £1m a month, therefore although onward care had been very successful, it had not come without costs, and the way forward financially would be subject to national debate.

 

Next steps

The different phases of the response to COVID-19 nationally were set out, moving from response into restoration (where Worcestershire was now), recovery and reset of services. A wider discussion would be needed around what the public wanted from health services and what was reasonable.

 

Temporary service changes

The HOSC was shown a list of services which had changed temporarily in response to the pandemic. It was very important to understand that these services had changed for one of two reasons; either because it was not possible to keep the service safe (for a range of reasons), or because staff had been redeployed to services considered of higher priority. The temporary service changes reflected these two reasons in equal measure and were:

 

•       Most face-to-face outpatient appointments suspended

•       Community hospital bed usage changed

•       Older adult mental health ward (Athelon Ward) decanted

•       Child development centres moved to virtual

•       Planned respite for adults and children suspended

•       Elective surgery moved to independent sector or cancelled

•       Kidderminster Minor Injuries Unit (MIU) closed overnight, Tenbury & Evesham MIUs temporarily closed

•       Garden Suite (chemo) and Women's Health Unit both moved from the Alexandra Hospital (The Alex) to Kidderminster Treatment Centre

•       Maternity moved to Princess of Wales Community Hospital

•       Screening for breast, bowel and Aortic Aneurysms suspended

•       GP Out of Hours restricted to two sites (WRH and The Alex)

 

(A correction was noted to the presentation slides – GP Out of Hours had been restricted to two sites – Worcester and Redditch, not Kidderminster)

 

Putting patients first

Paul Brennan, Chief Operating Officer (CEO) at Worcestershire Acute Hospitals NHS Trust (The Trust) outlined what services had been maintained during COVID-19.

 

During the peak, on 6 April, there had been 141 COVID patients across the Alexandra and Worcestershire Royal Hospitals and 28 in intensive care, whereas at the start of May this had dropped to approximately 60 COVID patients and approximately 12 in intensive care. Today there were only 27 COVID patients with 2 in intensive care. This showed a dramatic decline however, over the last 2-3 weeks ambulance conveyances and emergency attendance for non-COVID related illnesses had increased significantly, to almost normal levels.

 

In terms of the past 12 weeks, the first priority had been to maintain Urgent and Emergency Care which included emergency medical services and urgent surgery (needed within 24 to 72 hours). This was kept going throughout the pandemic period at Worcestershire Royal and the Alexandra hospitals.

 

For cancer care, nationally the Government ‘purchased’ capacity within the independent sector and within a week of the pandemic starting, there were arrangements in place with BMI Hospital (Droitwich) and Spires (Worcester), which were used predominantly to treat cancer patients or urgent surgery. By the end of last week, 467 operations had been done in the independent sector, as well as 271 endoscopies.

 

Additionally, regarding the cohort of patients who need complex elective care or cancer care for example because of co-morbidities, requiring high dependency care, which could not be done at BMI or Spires hospitals, a ‘super clean’ facility had been opened up at Worcestershire Royal Hospital in the Aconbury Unit.

 

The Trust normally saw 40,000 outpatients, whereas there were only approximately 20,000 outpatient appointments (approximate numbers) in April, of which 10,000 were virtual. Urgent appointments were done by telephone or video.

 

Therefore, urgent patient activity had been maintained but routine work was not taking place. The Trust was now at the point of bringing back more services into use, safely, and looking at how the independent sector could be used more.

 

System approach to engagement

Sue Harris, Director of Strategy and Partnerships for Worcestershire Health and Care NHS Trust pointed out that in terms of engagement, Worcestershire was fortunate to have strong relationships already in place through the Herefordshire and Worcestershire Sustainable Transformation Partnership (STP) which had enabled experiences of the pandemic to be captured very early on. The STP communication and engagement workstream was therefore in place and had been working tirelessly to guide restoration and recovery, including those changes that could require formal consultation.

 

Dialogue had been mobilised with the public, involving Healthwatch and the voluntary sector, although the more traditional means of engagement had not been available, so it had been challenging to capture the experiences of those individuals who lacked access to technology, therefore work on understanding inequalities would be needed in the future. A lot of effort had also gone into getting feedback from staff.

 

Surveys, including one done by Healthwatch had been useful in highlighting concerns, for example, access to Mental Health Services, which had prompted launch of the ‘Now we’re talking’ campaign to bring back awareness of services and self-referrals. Information on how to access urgent dental care had been another need identified through engagement.

 

Feedback from engagement on Children and Young People Services had been both positive and negative; some people felt well supported by friends and family during lockdown, whilst others had concerns about school and education. Another piece of work had focused on patient discharge and community support.

 

Nationally, there had been a real step change about mobilisation of outpatients and use of digital transformation, for example in GP practices, which was also part of the system’s engagement work.

 

The engagement findings were being compiled on the STP website and there was also an engagement portal to try and capture views from individuals.

 

It was really important to note that the Council had been a key partner in this approach and the role of Here2Help in identifying themes and providing feedback had been really valuable.

 

Evaluation

The HOSC was advised about work to evaluate learning from engagement, including over 2250 responses from an ongoing Healthwatch survey, which had been really successful. The quality of data would be very helpful in analysing people’s experiences.

 

Future modelling

Work had been undertaken to develop a set of early warning triggers (for the pandemic), which were now in place and this demonstrated how the pandemic in Worcestershire would be monitored, for example more calls to NHS111 or requests for GP appointments. As explained earlier, COVID-19 cases were now trailing off, although the increase over the past few days from 20 to 30 people in hospital beds, would be watched carefully. Health work on track and trace and antibody testing would also play a part moving forward.

 

Looking to local Members and how they may help, the CCG representative pointed out their valuable links to local communities; it was important to thank people for their compliance during lockdown, encourage it to continue and also to feed back any new guidance for example on wearing face masks, or engagement such as the Healthwatch survey.

 

The Chairman thanked those present for a comprehensive update which he felt demonstrated the control of the situation. He invited questions and the following main points were made:

 

·         The Chairman asked who had produced the data for the Worcestershire hospital demand modelling graph to show projections for good (or bad) compliance. The Director of Public Health believed this was from Public Health England working with NHS England; there were multiple data sources and multiple models in use.

·         A Member suggested the compliance model would be of benefit  nationally, to demonstrate the impact of good compliance.

·         When asked about the impact of COVID-19 in Herefordshire, which was now covered by the same CCG, the CCG CE advised that overall the graphs were very similar, albeit there were some small differences as Herefordshire was a smaller area.

·         A Member asked about modelling and plans in respect of the potential surge in demand. It was explained that although referrals for non-elective surgery such as hip replacements had increased, having been paused for the first two months of COVID-19, referral numbers were nowhere near expected levels.  The CCG was working on a demand and capacity model incorporating current operational restrictions and what could be done to generate extra capacity.

·         Three big independent hospital providers had played a big role in addressing the need, which was expected to continue for the time being. The Member suggested that communicating to the public that the restoration of NHS services would be gradual was vital.  The CCG CE acknowledged the difficulty of planning the detail of restoration and that nationally, communicating this to the public would be important.

·         Referring to a briefing note prepared for Worcestershire County Councillors, the Chairman queried differences in numbers of positive COVID-19 cases per 100,000 of the population across the district areas of Worcestershire. The Director of Public Health advised that the COVID-19 cases per 100,000 measure was intended for use across large populations of millions and could be less reliable when applied to much smaller numbers. However, factors such as an older population and the number of care homes would affect any one particular area.

·         A Member spoke about her extremely positive experiences of online GP systems introduced during COVID-19 and asked whether such new ways of working would be carried forward. In response the CCG CE was confident that a whole range of areas would change now that experiences during COVID-19 had shown that the technology could work and had freed up GP time.

·         Concern was expressed about a potential surge in children’s mental health problems and this was acknowledged as a big concern because of the lack of normal interactions. Child and Adolescent Mental Health Services (CAHMS) had continued throughout the period, according to priority, with face to face care where needed as well as by video and phone. School nursing teams had maintained contact with schools and kept in touch with all known patients. A 24 hour/7 days a week single point of contact had been set up for children, adults and carers to speak to a mental health professional, which was backed up by a 24/7 crisis response. Referrals had gone right down but were starting to increase.

·         A question was asked about Respite Services and the Worcestershire Health and Care Trust Chief Operating Officer explained that a balanced risk approach had been needed to address needs of both adults and children, in negotiation with families and carers. Some families preferred not to use respite services during COVID, but demand was now starting to step up.

·         The Health and Care Trust representative highlighted work by trusts across the Midlands to monitor potential increases in mental health problems during lockdown on all age groups, this included post-traumatic stress disorder, something which had not been necessary before.

·         The HOSC Chairman said that county councillors received regular updates and highlighted to the district council Members of the Committee the comprehensive briefing report prepared for County Councillors on the Council’s response to COVID-19 (4 June 2020 Cabinet Report), which would be circulated to them after the meeting.

·         A Member sought reassurance about the accuracy of testing at the Worcester Sixways drive-in facility, following queries from a resident who had found the DIY test very difficult to do, in particular the back of throat swab. The Director of Public Health said that the Council had highlighted the need for a mixed method facility at the site, which had been the original intention, since it was known that some people found DIY tests uncomfortable. Data from the previous 7 days (from the Department of Health and Social Care) showed 92 void tests from 300 to 500 per day which was a small number, therefore this should provide reassurance, although the Council would continue to keep an eye on the testing facility. The Director of Public Health was happy to provide further information to Cllr Raine after the meeting.

·         Several Members raised further concerns about the disruption to young people’s schooling and exams and potential spikes in anxiety, and the CCG CE suggested children’s mental health should be added to the HOSC work programme for consideration in around six months’ time when the data was clearer. Demand for Mental Health Services would require monitoring and it was possible that the current service model and support provision would need to be reconsidered.

·         The Director of Public Health explained the role of Worcestershire Children First and referred to proactive work with health and public health colleagues to help the return to school. School was good for wellbeing, although the risks needed to be balanced. A sub-group of the Health and Wellbeing Board was also actively involved. The all-age Health and Wellbeing Strategy due to be reviewed and a meeting later that day would look at the impact of COVID-19 and the need for a new and targeted focus on services and investment for children’s mental health.

·         The Vice-Chairman queried whether talk of a second spike was making people anxious unnecessarily and the representatives present acknowledged that there was no national model to predict events after June, however a second spike was common-place with pandemics and the Chief Medical Officer’s view was that it was highly likely. COVID-19 had not gone away and most of the population had not been exposed to it and did not have antibodies. In the absence of a vaccine, the defences available were social distancing, hand washing and PPE, however it was human nature to tire of such measures. Any slight rises in cases would be monitored very carefully and engagement with local communities would continue.

·         Referring to the temporary service changes, the Vice-Chairman asked when it was likely that services would be restored, in particular MRI scans, since such changes would need to be subject to consultation if they were being considered as permanent. The CCG CE agreed that any permanent changes would require consent and explained that such changes were happening nationally and had been less significant in Worcestershire than in other areas. An update was provided, for example plans to reinstate opening hours at Minor Injuries Units. Suspension of screening programmes had been a national decision; however, all screening would be reopened on an individual basis, including breast.

·         The Vice-Chairman asked if the reason for the recent increase in COVID-19 cases was known, and the Acute Trust CE said that there was no known factor at this stage and while assumptions could be made about cross contamination by staff, the Trust was very driven with staff PPE and social distancing and the way in which patients are managed through the hospital had changed. The bump in cases was being carefully monitored.  In response to a follow up question about whether the new cases came from a specific location in Worcestershire, the Director of Public Health undertook to arrange for further analysis.

·         A Member asked whether there was any modelling which could help tackle the much higher levels of COVID-19 being experienced by black, asian and minority ethnic (BAME) groups and the CCG CE agreed this was a huge topic and was subject to a lot of collective work. The Acute Trust had set up a BAME staff group to support staff and the wider community. It was known that health and care services sometimes struggled to link with some communities and this was something which councillors could also help with.

·         The Chairman asked whether there was any further update on the Trust’s £29 million expenditure project and was advised that a full business case had been approved by the Trust’s Board and had been submitted to the Department of Health. Regarding support for digitalisation, the Trust was now considering how to build a strategic outline case, however in general it was expected that capital would be constrained moving forward.

 

On behalf of the HOSC, the Chairman thanked everyone for their time and contribution, and, as had been expressed earlier, he asked for the commitment of all the organisations represented in responding to COVID-19 to be recognised, and thanked all medical staff across the county.