Agenda item

To follow

Attending for this Item were:

NHS Herefordshire and Worcestershire Integrated Care Board (HWICB)

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

Worcestershire Acute Hospitals NHS Trust (WAHT)

Paul Brennan, Deputy Chief Executive

West Midlands Ambulance Service University Foundation NHS Trust (WMAS)

Vivek Khashu, Strategy and Engagement Director

Herefordshire and Worcestershire Health and Care NHS Trust (HWHCT)

Rob Cunningham, Associate Director for Integrated Community Services

Worcestershire County Council (the Council)

Mark Fitton, Strategic Director for People

At the 8 July 2022 HOSC, Members had received information on plans to improve patient flow and improve performance on ambulance hospital handover delays.  By way of update, the HOSC learned that the Worcestershire System continued to be in a very challenged position and ambulance delays were of greatest concern nationally.  All partners were committed to the agreed  Improvement Plan, however, delivery of the Plan had stalled, in part due to a spike in COVID-19 cases and workforce issues. 

The Winter Plan, covering Herefordshire and Worcestershire, referred to specific geographical issues when required.  It focused on national core objectives and actions and gave clearer responsibility for the HWICB.

Demand and capacity analysis had shown that before any of the winter schemes or urgent care improvements were implemented, there was a shortfall of 45 acute beds to effectively manage urgent care pressures.  This figure was an improvement on previous years when a shortfall of 80 to 100 beds had been reported.

Several immediate winter schemes were referred to, including additional pharmacy capacity, extra transfer teams to move patients out of the Emergency Department (ED), more discharge co-ordinators and a Matron to oversee long length of stay.  In addition, hours had been extended at Minor Injury Units (MIU) and the 2 hour community response had been well utilised to respond to patients in their own home.  Furthermore, a pilot scheme for virtual wards with a dedicated team and technology was to begin for frail elderly patients.

To improve handover delays, the adoption of the ‘North Bristol Push Model’ had been implemented in September, initially on the Worcestershire Royal site.  The North Bristol Model required a minimum number of transfers of patients in each 24 hour period from the ED to assessment units and from those units to wards.  The transfers required at least the equivalent number of safe and timely discharges.  The Model had delivered some improvements, however further work was required to fully embed the Model before consideration would be given on possible introduction at the Alexandra Hospital.

The HOSC Chairman invited questions and in the ensuing discussion, the following main points were made:

·         WMAS had previously stated the risk level for Worcestershire was 25/25, which had now remained the same for 12 months.  Some areas within the region were in a slightly better position than Worcestershire, but most areas were incredibly challenged

·         At the 8 July HOSC, it was reported that a target for significant improvement had been set for 1 September.  When asked whether this had been achieved, it was stated that it had not been possible to implement and Partners were now working with NHS regional and national teams to reassess the trajectory of improvement

·         Despite the net capacity increase of 29 beds at Worcestershire Royal Hospital since July, there had been little or no impact on handover delays.  The North Bristol Model had been in place for 4 weeks and did initially have a positive impact by moving 36 patients out of the Emergency Department in each 24 hour period, increasing to 54 patients after the first week.  These moves were irrespective of capacity elsewhere and did mean some patients were boarded on wards without a bed.  Despite this, ambulance handover delays remained and some patients were spending significant hours in the back of an ambulance

·         The new Urgent and Emergency Centre, located in the Aconbury Unit of Worcestershire Royal Hospital, was set to open from 14 November.  With other plans, the physical space available would be much larger and there was capacity to increase North Bristol Model numbers greater

·         It was noted that WAHT could not improve the situation in isolation.  The Urgent Community Response had been in operation for around 12 months.  It initially had around 25 referrals each day and now there was routinely around 40 to 45 referrals each day, with some direct from WMAS call handlers or paramedics

·         12 surge beds, across the community hospitals, had been created to ease acute pressures

·         When asked whether the Care Quality Commission (CQC) was content with care taking place in the corridor, it was reported that discussions had taken place.  On occasions when the ED was caring for over 100 patients, there was a need to rebalance the risk across the acute hospital site.  WMAS had also discussed the situation with the CQC and reported that the patient at greatest risk was the one when an ambulance could not get to them in a timely manner.  WMAS and WAHT balanced risk as best they could

·         A national briefing outlined collective core objectives to form part of winter planning.  Locally, key risks to delivery included the impact of COVID-19 and other respiratory challenges, workforce issues and the local market for Care Home placements.  WMAS was also concerned about its falls response

·         A Member was extremely concerned about the very significant challenges that Worcestershire faced and asked why an emergency had not been declared.  In response, WAHT was in receipt of a lot of support from the NHS national team and government was aware that the WAHT was under huge pressure.  By May 2023, physical capacity would be almost double what it was presently and recruitment was not of concern at the moment

·         In response to a query as to whether patients were discharged too early, it was reported that it was generally the opposite and patients were not discharged early enough.  Worcestershire had good performance on long length of stay nationally and the re-admission rate was low

·         At the time of the meeting, there were 98 COVID-19 positive patients across both acute hospitals, with 57 beds dedicated to COVID-19 patients, meaning around half of patients were on wards with other patients.  4 patients were in the Intensive Care Unit, however in those cases COVID-19 was incidental

·         At the time of the meeting, 301 ambulances were on duty across the West Midlands region.  31 were in Worcestershire and 10 of those were at hospitals, with the longest wait being from 05:52am.  Across the region, there were 225 calls outstanding, 27 across Herefordshire and Worcestershire.  In September, the average handover time, over a 24 hour period, was 4 hours although across the region, it was not unusual for up to 20 hours to be experienced

·         When asked how worried the HOSC should be, Members were informed that response times had improved marginally for Category 2 calls, however, there was concern over the Category 3 calls, which included falls.  The HWICB was concerned, however was encouraged with the slight improvement and recognised the challenges ahead

·         The HWICB rated the overall risk as red, with NHS national team discussions taking place weekly.  Once approved, it was agreed to share the Risk Assessment with HOSC Members

·         The HWICB had recently recruited a Director of People, to focus on workforce planning across the system.  Different strategies for recruitment had taken place across the System, including international recruitment.  There was also ongoing work looking at skill sets for various posts and how people could be retained by looking at work/life balance and options to retire and return.  It was suggested that HOSC may wish to look at workforce at a future meeting.  WAHT acknowledged there were consultant recruitment challenges in some areas, such as stroke services and acute medical services, however, the example was given whereby cardiology recruitment was often oversubscribed.  Recruitment to ED Consultants had been of previous concern, however, was now fully complete.  It was reported that retaining staff was often more difficult than the recruitment of staff

·         Staff wellbeing was vital as employees were often the best advocates for recruitment by promoting a positive message within their own professional networks.  It was agreed that information on WAHT wellbeing packages of care would be shared with HOSC Members. 

·         HWHCT reported that they had also introduced different ways of working to retain staff and ensure staff wellbeing.  To combat rising transportation costs, HWHCT was looking at mileage rates paid and exploring whether pool cars or electric vehicles was beneficial

·         The Cabinet Member with Responsibility for Health and Wellbeing appreciated the issues faced, advising that a whole system solution for prevention was now required to assist with admission avoidance

·         In response, HOSC Members were advised that system partners did work collectively and there were very positive cross organisation relations.  The System wanted the same outcomes; however, it should not be overlooked that the population was growing, living longer and with increased acuity and frailty.  Worcestershire benchmarked very well on prehospitalisation activity, including primary care.  There were no concerns in relation to acute clinical care 

·         When asked whether Staff were committed to the North Bristol Model, it was reported that not all staff were fully engaged and there were concerns about rebalancing the risk across the hospital.  On occasions, the North Bristol Model had to be suspended for safety issues and it had been anticipated that on implementing the model, discharges would be earlier in the day.  This had not been the case and whereas 30% of discharges should be before midday, it had only been around 16%, although more recently was around 20%.  In general terms, around 85% of discharges should be before 4.30pm, however most discharges took place between 4pm and 7.30pm.  It was reported that discharges needed to be brought forward by 3 to 4 hours and it was hoped that additional physical space would help

·         Data provided in the Agenda showed that there had been an improvement in significant ambulance handover delays in September, which could not be attributed to any one factor

·         At any one time, around 50 patients were in community hospital beds and could not go home or go to a Care Home.  Delays did occur, mainly when discussions over long term care had to take place as patient choice had to be taken into consideration, especially as decisions were being made on where the patient would possibly live for the rest of their lives

·         In response to a query over conversations with families around discharging patients to their family support network when safe to do so, it was acknowledged that a national communication approach was needed to advise families of their responsibilities

·         For clarity, winter plans were supported by new additional funding from the NHS regional winter pot

·         A Member asked for further information on the role of HOSC in relation to the HWICB

·         A Member was concerned about the length of time from a GP referral to treatment and asked whether there was any link to ED activity.  By the end of March 2023, it was anticipated that no patient would be waiting over 78 weeks for treatment and there was no direct link to length of wait and ED activity, although urology services was of concern

·         HOSC Members asked for their thanks to be passed on to all staff across health and social care organisations.

The HOSC Chairman brought the discussion to a close and thanked everyone for the update.  Questions not asked during the meeting would be sent on to those present.