Agenda item

Attending for this Item and representing the Herefordshire and Worcestershire Integrated Care System (HWICS) was:

NHS Herefordshire and Worcestershire Integrated Care Board (HWICB)

Mari Gay, Managing Director

Worcestershire Acute Hospitals NHS Trust (WAHT)

Dr Jules Walton, Deputy Chief Medical Officer

West Midlands Ambulance Service (WMAS)

Vivek Khashu, Director of Strategy and Engagement

Herefordshire and Worcestershire Health and Care NHS Trust (HWHCT)

Matthew Hall, Chief Operating Officer

Worcestershire County Council (the Council)

Mark Fitton, Strategic Director for People

Rebecca Wassell, Assistant Director for Commissioning

HOSC Members were reminded that on 1 July 2022, the Herefordshire and Worcestershire Integrated Care System (HWICS) was established, resulting in health, social care and voluntary organisations working together to integrate services for the benefit of residents within Herefordshire and Worcestershire.  An Integrated Care Board (ICB) had also been established, with a new Chairman appointed.  Further integration plans from central Government were expected in time.

Turning attention to the Agenda, it was explained that since the last Report on 9 May 2022, delays in ambulance hospital handovers had not improved and had deteriorated, with the month of June 2022 recording over 1,000 ambulances waiting over 60 minutes to be handed over to Acute Hospital staff.  The number of ambulances attending the hospital had not significantly increased, however, the number of walk-in patients had increased, with staff seeing more acute cases.  Admissions were stable, yet the number of in-patients with COVID-19 had increased and there was increased staff sickness.

Extra capacity was now available at Worcestershire Royal Hospital (the Royal), through a 29 bed Acute Medical Unit (AMU).  This allowed patients to be referred by their GP to be admitted directly to the AMU and had opened on 4 July.  Alongside this, the existing Medical Assessment Unit had been repurposed providing the Royal with over 35 extra spaces overall.  ‘Plan, Do, Study, Act’ continued to be in place and targets were being monitored as the system was aware of the quality risk.  A target of significant improvement in 5 weeks had been set, alongside the aspiration of 7 day working.  There continued to be a need to improve flow at the Royal and the Alexandra Hospital in Redditch (the Alex) had assisted with the Royal flow.

Members were invited to ask questions and in the discussion, key points included:

·         The Chairman expressed his disappointment about the lack of improvement made on the Worcestershire Royal site

·         Clarification was given that for the month of June 2022, across the 2 acute hospitals, 1,300 ambulances had waited over 60 minutes to handover patients - 975 at the Royal and 325 at the Alex.  To date in July, on average 30 ambulances each day had been waiting over 60 minutes, totalling 229 at the Royal to 8 July

·         WMAS reported that the service had escalated the risk of handover delays and delayed responses to the highest level (25/25).  A score of 25 was defined as ‘likelihood certain, risk catastrophic’.  The service was seeing examples of severe harm, including death, on a near daily basis.  Ambulance response times to Category 1 (999 calls) had deteriorated due to the ongoing situation, however, the sickest patients continued to be prioritised.  Many residents were waiting an unacceptable amount of time for an ambulance and it was evident that harm was happening every day

·         All 29 beds were currently occupied in the newly opened AMU, with the expectation that length of stay would be less than 24 hours, ideally 12 hours

·         Around 15-20% of discharges were complex discharges, meaning around 50 patients across all sites had no criteria to reside on a daily basis.  Regionally, Worcestershire benchmarked very well against length of stay

·         Monday to Friday discharge numbers amounted to around 100-120 from the Royal and 60-70 from the Alex.  Neither site had many discharges at the weekend which was an issue and impacted on Mondays and Tuesday’s which were also causing a concern

·         Only around 38 (of the 100-120) discharges from the Royal were classed as Golden Discharges (i.e. before 10am).  Problems with pre-planning were cited as a reason and discharges were often still late in the day

·         The Committee remained very concerned that the situation was not improving despite ongoing attempts to resolve issues.  In response, it was reported that hospital staff often had to work hard with families to discharge under Pathway 1 (discharge to home), the lack of 7 day working was a constant challenge and the process required improvement

·         Asked why 7 day working was such a challenge, it was attributed to a physical lack of workforce, however, the Health System would support 7 day working, 24 hours each day, if processes improved.  Everyone acknowledged that the situation would not be resolved quickly

·         The Report stated that progress in discharging medically fit patients by 10am was being held up by the late booking of patient transport.  The process was under review to determine whether any improvement could be made.  Around 5% of patients, who were medically fit for discharge, had their discharge delayed, however, it was not uncommon to see discharges late in the evening.  Delays due to pharmacy continued to be present at weekends due to staffing issues

·         Discharge Pathways were explained as followed:

o   Pathway 0 – Home with no support

o   Pathway 1 – Home with reablement

o   Pathway 2 – Community Hospital for additional support (around 70 patients a week across the 7 Community Hospitals with length of stay around 22 days, followed by home with support)

o   Pathway 3 – Usually a Care Home, however, HWICS had introduced intensive assessment and recovery in a Community Hospital initially

·         HWHCT had seen an increase in patients being discharged and more frequently up to 2 days earlier than previously.  The Trust planned to admit around 55 patients each week and was currently running at 70 patients.  Typically, all community hospital beds were filled and if there was a waiting list, this was usually less than 48 hours

·         The working relationship between the Council and HWHCT was very good, with Pathway 1 discharges usually occurring within 24 hours

·         When asked about best practice in other acute trusts, it was reported that there were several professional networks and clinicians had visited other areas to learn from different practice.  There had been lots of shared learning, alongside Peer Reviews and support from NHS Improvement.  Representatives were confident that the System was well sighted on the urgent care service however acknowledged that there was a marked difference between the performance of Royal and the Alex despite there being the same processes in place from the same Acute Trust.  WAHT had linked to another Hospital Trust in order to improve performance

·         In response to the suggestion that residents were concerned, HOSC learned that there were many excellent areas within the System and there had never been an issue on the quality of care received in the Emergency Department

·         When asked which Acute Trusts in the Region performed well, Members were advised Walsall’s performance was consistently better than WAHT, with the example that the number of ambulances waiting over 60 minutes to handover patients for July to date (8 July), Worcestershire Royal was at 229 and Walsall was 4.  However, this wasn’t the picture across the Region.  As WMAS worked with several Trusts around the region, examples of good practice were shared

·         In response to a question as to why the Alex performance was better than the Royal on discharges, it was explained that an Incident Room had been set up on 1 May at the Royal with new processes introduced.  This saw a good increase in the early weeks and learning quickly spread across both sites.  Process and procedures were the same across the sites, however, these required embedding

·         The number of inpatients with COVID-19 was rising, however around 60% of COVID positive patients were in hospital for another reason.  Infection control had not changed

·         If Staff tested positive for COVID-19, they were unable to work for 5 days if asymptomatic and had a negative Lateral Flow Test, and around 2 weeks if symptomatic, this was the same approach as WMAS, who reported that at the time of the meeting, 170 Staff (out of 750) were off work with COVID-19, with 6 off with Long Term symptoms.  Cover for staff absences would consist of a mixture of agency and locum staff and a huge amount of goodwill from Staff who were already operating in very difficult circumstances

·         Residential Care and Nursing Homes were also being impacted, with a 23% Regional reduction in Residential Care Home settings, with Worcestershire seeing a drop of 13.6% of Homes taking residents

·         A new bed management system had been in place since 4 July, which was a revised patient flow system with updated processes in place

·         The Report referred to an Ambulance Border Change in July 2021.  It was clarified that this was not geographical, rather instances of Stroke patients, for example, being conveyed to the most appropriate setting

·         When asked whether an independent review of the current situation had been carried out, Members were told that numerous experts had shared their views, all concluding that the Plan was right and the System had to focus on recovery and delivery of the Plan

·         Assurance was given to HOSC that all Action Plans in place were as a result of recommendations from external reviews and additional resources had been provided to all partners

·         A HOSC Member questioned whether there was merit in providing a consistent service and opening times across all the Minor Injury Units in order that residents could be assured of utilising those services and diverting themselves from A&E.  It was reported that the MIUs were different sizes, in varying locations and separate teams, however, NHS111 and 999 call handlers were able to triage calls and book appropriate slots if required.  Walk in patients were still able to use the MIUs and most of their activity was still from walk in patients.  Residents were advised that the website was updated with current services and opening times across the County.  There was no definition of a Minor Injury, however it was suggested that if a situation was not life threatening, a call to NHS111 would ensure the right outcome for that individual

·         A review would be carried out to assess whether increasing diagnostic provision within the MIUs would reduce pressure within the ED, especially on weekends.  It was suggested that MIUs were undertaking about 50% of potential activity, however the challenge would be whether appropriate Staff would be available

·         ED Streaming was a mechanism of re-directing patients from ED to some other healthcare provider as a way of bypassing the ED, however, this required an experienced clinician and the knowledge that the patient would flow through the alternative system rather than create more bottleneck

·         Additional resource had been secured to facilitate patient discharge however, the test was whether extra staff would make a difference

·         When asked what was needed to make significant improvements, Members were told that extra capacity was key, that streaming at ED would help and early in the day discharges would increase patient flow.  All partners were currently performing at the highest level and workforce was a constant challenge for the whole system

·         Public communication around access to healthcare would continue and a review had been undertaken, the results of which would be shared with HOSC after the meeting

·         The Cabinet Member with Responsibility for Health and Well being was invited to comment and expressed deep concern with the continued poor performance reported, asking what were the solutions to make the major improvements needed and when the System would return to HOSC with a Plan showing outputs and outcomes.  In response, the Committee was advised that extra capacity was needed (both clinicians and for transformation), streaming at the ED, earlier in the day discharge and pathways to the highest level

·         Members were informed that a target had been set to deliver improvement by 1 September 2022, which was extremely challenging.  It was agreed to report the Plan, showing outcomes, to the 19 September 2022 HOSC

·         During the meeting and across the region, 337 ambulances were active and deployed, however, only 35 were available and none were available in Worcestershire.  An increase to 350-390 ambulances would likely occur between 5pm and 7pm.  Across the region, the longest wait at any hospital was coincidently at the Royal having arrived at 7am

·         Pre pandemic, during an average shift, an ambulance crew could expect to see 6 to 8 patients, now it was around 2 to 3 patients each shift.  The deterioration in ambulance response times was as a direct result of hospital handover delays.  In April 2021, Category 1 calls target was missed by 1 minute, with targets for Category 2 and 3 being achieved.  This was no longer the case.

The Managing Director of Healthwatch Worcestershire was invited to comment on the discussion and made the following points:

·         Healthwatch was of the same opinion as WMAS that everyday everyone was at risk of harm and suggested that HOSC may wish to request harm review data in future reports

·         Although there were many negative comments, nothing should detract from the hard work that Staff were putting into patient care

·         In 2017/18, Healthwatch had questioned whether the health structure within the County met the needs of the patient and urged the System to undertake a structural review.

In response, it was reported that the ICS would evaluate the System in time, but the focus would be best practice for patients and patient flow.  The different Pathways were benchmarking well and HOSC was reminded that system integration was around services to people.  Furthermore, structural change was not always the right solution, however systems, such as integration of IT Services for example, was an area which could be strengthened.

The HOSC Chairman thanked everyone for the update and requested a further update at the 19 September 2022 HOSC. 

The meeting was adjourned from 11.45am to 11.50am.