Agenda item

(indicative timing: 10:05am – 11am)

Attending for this Item were:

West Midlands Ambulance Service University NHS Foundation Trust (WMAS)

Vivek Khashu, Strategy and Engagement Director

Worcestershire Acute Hospitals NHS Trust (WAHT)

Robin Snead, Deputy Chief Operating Officer

NHS Herefordshire and Worcestershire Clinical Commissioning Group (HWCCG)

Mari Gay, Managing Director and Lead Executive for Quality and Performance

Herefordshire and Worcestershire Health and Care NHS Trust (HWHCT)

Rob Cunningham, Associate Director Integrated Community Services

Worcestershire County Council (the Council)

Paula Furnival, Strategic Director of People

Rebecca Wassell, Assistant Director of Commissioning

Adrian Hardman, Cabinet Member with Responsibility for Adult Social Care

The HOSC Chairman introduced the Item by reminding Members that in October 2021, the HOSC was alerted by WMAS to significant ambulance hospital handover delays at both WAHT sites.  The HOSC agreed to investigate and evidence was gathered at a single session in November 2021 from all the system partners present.

The resulting Scrutiny Task Group Report had been checked by contributors for factual accuracy and the feedback received indicated that the Report was a true reflection of the discussion.

The Chairman outlined that the purpose of the meeting was not to re-open the scrutiny, rather consider the recommendations and discuss any progress made.

Representatives were invited to make any opening remarks, which included:

·         Organisations had welcomed the focussed Scrutiny Task Group discussion and Report

·         Benefits were being seen from enhanced Discharge planning across both acute hospital sites, with the Alexandra Hospital (the Alexandra) now achieving 30% of discharges before 12 noon.  Worcestershire Royal Hospital (the Royal) was below 30%

·         The Alexandra had best practice in relation to patient flow and good performance in 7 day and 21 day length of stay

·         System partners had put extra physical capacity into the Royal with the aim to improve performance 

·         WMAS reported that significant issues remained, despite conveying fewer patients to the acute hospitals.  Exceptional delays were too regular and every month over 800 handovers were in excess of one hour across both sites.  It was noted however, that the Alexandra handover time was strong, being one of the best in the region.  Issues remained at the Royal with ambulances largely waiting outside with patients on board.

Members were invited to ask questions on progress made against the Scrutiny Report recommendations.  During the discussion, the following points were made:

·         When asked whether the target of 30% of discharges before 12 noon was good enough, it was clarified that the figure was a national target and the Alexandra was achieving it

·         Same day emergency care was performing fairly well, especially at the Alexandra, although both emergency departments (EDs) were congested

·         Conversion rate from ED to admittance was broadly in line with national figures, around 29%

·         WMAS performance in the number of patients conveyed to hospital was the best in the Country with less than half the calls received requiring an ED attendance.  This was attributed to all ambulances having a Paramedic on board, something which other Trusts may not offer

·         A Patient Tracker system had been introduced, which had benefited the whole system as all partners were able to see the potential next steps of a patient journey, with organisations being able to better plan onward pathways

·         Around 110 patients were discharged each day, of which approximately 15% were complex and 85% simple discharges.  The biggest delay was the time between a Doctor reporting a patient was medically fit for discharge and the patient leaving the hospital.  Work was continuing to improve this

·         Delays with Pharmacy were a particular issue at weekends when the number of Pharmacists reduced and cover was generally less available.  Several alternative arrangements were in place, including stock on Wards, access to Community Pharmacists and out of hours services

·         Lack of suitable Transport was not affecting discharge delays and the Provider was working well

·         WMAS provided the NHS111 service and performance had dramatically improved.  Around 90 to 95% of calls were answered within 60 seconds, compared to 10 to 15% in November 2021 and only 5% of calls were abandoned.  A Member suggested that the algorithm for the NHS111 system was risk-averse, to be informed that it was not for WMAS to determine or change national NHS Pathways.  NHS111 and 999 calls were fully integrated with WMAS call handlers able to answer either type of call

·         In July 2021, WMAS had introduced a Clinical Validation Team, working 24 hours a day 7 days a week, to monitor and respond to incoming calls.  Activity in ‘Hear and Treat’, where an ambulance was not despatched, had increased with 18 to 20% of calls now being closed at this point.  An additional 90 clinicians had been recruited, however, there were particular issues with GP recruitment

·         Both EDs in Worcestershire had a GP and Advanced Nurse Practitioner to assist with walk-in patients and they were engaged with daily system calls to ensure consistent messages

·         It was agreed that the System Service Improvement Plan could be shared with the HOSC and updates provided on a monthly basis

·         The Council had introduced an Intermediate Care Team in September 2021 on a trial basis, however, it had been agreed to make the Team permanent and there was a contractual agreement in place.  Furthermore, the Reablement Service had been expanded.  The HOSC learned that greater levels of collaboration had been in place since September

·         Workforce continued to be of concern across the health and social care sector and access to Staff at all levels was of national concern.  In Worcestershire, a particular concern was recruitment and retention in Primary Care

·         Health and Social Care rates of pay was a major factor related to staffing retention issues, especially as other sectors were able to uplift salary.  COVID-19 grants received were utilised well, however it only masked the staffing issue

·         A pilot project to provide 24 hour care after a hospital discharge was due to commence and Domiciliary Care was to be commissioned by the Council on a new basis, covering 10 zones across the County.  With ‘Home First’ advocated, more care out of hospital would have to be considered.  It was hoped that moving to an Integrated Care System would help with overall demand and capacity planning

·         In relation to COVID-19 activity within the acute hospitals, it was reported that at the time of the meeting, there were 100 COVID-19 positive inpatients, with numbers stable and at similar levels over recent months.  A system of Virtual Wards was in place to monitor patients at home to reduce inpatient numbers, however, further beds were also ringfenced

·         Staff absence due to COVID-19 had reached 50% in January 2022 and cases within the community remained high thus affecting services.  Partners were pleased that the decision for mandated COVID-19 vaccination for NHS and Social Care Staff had been reversed

·         There was an ongoing campaign to signpost residents to alternative services other than ED, however, a recent Healthwatch Report reported that residents found it convenient to know that ED was open around the clock.  The number of walk-in patients was around two-thirds and growing both in number and complexity, compared to one third of ambulance attendances.  Clinicians would always see patients in clinical priority regardless of method of arrival

·         It was clarified that an Ambulance crew would determine where a patient was conveyed and the decision was a clinical one rather than patient choice

·         Discharge plans were commenced as quickly as an Ambulance crew had carried out their assessment.  This would then be shared and Onward Care Teams would be able to determine the level of assessment required in order to successfully discharge a patient

·         A 30 bed Clinical Assessment Unit at the Royal was open and the physical layout of the hospital had changed to accommodate this

·         A Member referred to the Fire Authority offer of assistance to help with moving patients during the Winter, to be informed that discussion had taken place, but no agreement had been made.  It was understood that the offer had subsequently been withdrawn, a point which would be clarified outside of the meeting

·         Members heard that there was a population expectation for instant access to information and support.  It was reported that national messages on what the NHS could offer was required

·         In relation to the night-time economy, the HOSC was informed that it was a Public Health priority to reduce alcohol consumption.  Clinicians had noticed an increase in home drinking, resulting in ED attendance and there was also an increase in hostility levels.  In cases of substance misuse or mental health, a patient may require closer monitoring before an assessment could be undertaken, therefore taking up more staff time.  In addition, WMAS crews were now wearing stab vests and had body worn cameras to protect themselves.  Crews had seen a rise in drug, alcohol and mental health attendances, resulting in an increase in Control Room capacity for mental health.

The Managing Director of Healthwatch Worcestershire was invited to comment on the discussion, remarking that a recent survey suggested that although the acute hospitals were rapidly discharging patients to home, patients were still very poorly.  The survey also highlighted that the number of walk-in patients was higher, but patients were waiting longer to attend ED and therefore they were presenting with more complex issues.  There was no evidence to suggest that GP access was an issue, however, the variation in service across the Minor Injury Units was of concern           

The Chairman thanked everyone for a very useful discussion and feedback.  It was agreed to invite representatives to the May 2022 HOSC to receive a further update on progress made against recommendations.  The Chairman also stated that the Task Group Report would be discussed by the Overview and Scrutiny Performance Board before being considered by Cabinet.