Agenda item

To follow

In attendance for this item were:

Worcestershire Acute Hospitals NHS Trust -

Matthew Hopkins, Chief Executive

Anita Day, Chair

Richard Haynes, Director of Communications and Engagement 

Herefordshire and Worcestershire Integrated Care Board

Mari Gay, Managing Director

Herefordshire and Worcestershire Health and Care NHS Trust 

Susan Harris, Director of Strategy and Partnerships

Worcestershire County Council

Rebecca Wassell, Assistant Director for Commissioning

The Chairman welcomed Anita Day, Chair of Worcestershire Acute Hospitals Trust (the Acute Trust) and introduced her to the Health Overview and Scrutiny Committee (HOSC).

The Acute Trust Chief Executive (CE) introduced the update on improving patient flow through the system, following earlier reports to the HOSC, after which Committee members would have the opportunity of a tour of the new Emergency Department facilities currently being built.

News coverage of queuing ambulances outside hospitals across the country was referred to, and it was recognised the situation in Worcestershire was not good enough.

The Chief Executive informed the HOSC that an unannounced inspection of both of the Trust’s Emergency Departments by the Care Quality Commissioning (CQC) had taken place from the 21 to 23 November. The inspection had included medical wards, other facilities such as the discharge lounge, with further plans to inspect some GP surgeries, social care and ambulance services – to date the CQC did not plan to visit community hospital services.

The CQC Inspection Report was not expected until end of March 2023, however no immediate safety concerns had been escalated to leaders in respect of acute hospital or ambulance services, and initial feedback referenced good practice regarding privacy and dignity, and a positive culture in wards being a significant difference to the previous inspection. Whilst significant pressures remained, the initial feedback and the fact that no immediate safety concerns had been raised, was reassuring and a tribute to staff.

Nonetheless, a number of concerns had been raised which the Trust was working to address including medicine management and the fact that patients were spending too long in the discharge lounge.

The CE made the following additional points regarding the main areas of focus which the Worcestershire system had agreed as specific urgent actions within Urgent and Emergency Care (UEC) to increase speed of recovery and to realise the benefits of significant investment over the previous 12 months:

·         The aim of the new Emergency Department building (which would triple the capacity of Same Day Emergency Care (SDEC)), was the ability to direct patients to facilities designed to meet their needs, for example those requiring immediate medical attention such as blood tests or X-rays, but were not emergencies, and could usually be discharged the same day – this sort of testing facility was currently available but was too small.

·         The first floor of the new ED would be open from 12December with the full new ED opening in May/June 2023.

·         Front door streaming was an area of focus connected to being able to treat non-emergency patients in an appropriate setting – it was important that ambulance crews could take these patients directly to the area designated for Same Day Emergency Care, and GPs could also refer people there, which would relieve pressure.

·         Directing non-emergency patients to alternative facilities was very important since the original ED facility at Worcestershire Royal Hospital was designed to respond to 40-50 patients a day and was now often seeing 120-130 a day.

·         A Discharge Task Force was focusing on every single patient who was ready to go home or move to an alternative setting, with a view to consistently hitting discharge targets on 6-7 days a week, which over the previous 6-8 weeks had been consistently hit no more than 2 days a week.

·         Regarding current pressures on the flow from the ED to wards, whilst the Trust worked to implement the North Bristol Trust Model, it was reassuring that the CQC had not identified any concerns about patient dignity.

·         Ongoing review of demand and capacity across the system for example to review bed occupancy, meant that this was much better than previously.

·         The Managing Director of Herefordshire and Worcestershire Integrated Care Board (ICB) referred to a number of extra initiatives relating to the resources allocated for the winter schemes.

·         The Acute Trust Chair stressed how hard it was for all of those present to see ambulances queuing to hand over patients, and that staff were working incredibly hard in very difficult circumstances. Whilst it was reassuring that the CQC had not identified any immediate safety concerns, the situation remained a concern, which was behind the work set out around the balance of patients arriving at and leaving hospitals -the process needed to be as efficient as possible.

The Chairman invited questions and the following main points were raised:

·         When asked whether the new ED facility would have sufficient staffing across all levels, the HOSC was advised that the number of ED Consultants at the Trust had significantly increased from 8 to 18, which was very positive since a site with two big facilities required 2 rotas of 10 at each.  Nursing numbers had improved but there were currently only 5 acute physicians available to run the two facilities, when ideally 20 were required.  The gaps were being addressed through locum consultants, a new hybrid Consultant/GP role and it was also hoped that the new ED facilities would attract new staff.

·         Several members expressed concern that Minor Injuries Units (MIUs) were underused and raised the problem of how to educate and inform the public as well as GPs about where to go for what treatment. The Health and Care Trust’s Director of Strategy and Partnerships acknowledged the need to have a consistent, simple message. Unfortunately, experience showed that communication campaigns led to greater confusion, therefore the advice was to use NHS111, which although not perfect, was best placed to advise what could be treated where and when and avoid the frustration of someone visiting an MIU which could not meet their needs.

·         Regarding understanding around the role of MIUs, the Acute Trust’s CE advised that learning could be extended to some ambulance crews who were more familiar with Herefordshire or Warwickshire and less so with the types of illnesses which could be treated at MIUs in Worcestershire.

·         A HOSC member asked for an approximate breakdown of factors which delayed a patient being discharged from hospital once medically fit to do so, which was an area the Committee was keen to have better understanding of. The ICB representative explained that performance for those on pathway 1 (going home with support in place) was very good, however delays were more likely for patients requiring decisions around long-term care due to families taking time to choose a residential care home, and care home staff wanting to visit and assess the patients.

·         Delays for patients being discharged to a community hospital could be a week at worst, but for those moving to care homes the delay could be several weeks – it was a very knotty issue.

·         In response to a follow-up question about whether space could be freed up elsewhere within the system to enable medically fit patients to move out of acute care, it was explained that community hospitals had already maximised space, however the importance of early conversations with families to manage expectations was referred to as well as a new, promising approach to commission ‘step down’ beds within particular care homes with wrap-around care, as a temporary measure whilst families made longer terms plans. 

·         HOSC members agreed an alternative ‘step down’ setting would be helpful in relieving pressure since decisions for families around long-term care would always be difficult.

·         The Acute Trust CE referred to factors adding pressure on acute care, for example the increase in the average age of patients being treated and the fact that the health of too many people was deteriorating unnecessarily – the increased preventative emphasis on keeping people well in the community would make a big difference.

·         Regarding the plans for direct GP referral to the new assessment units and Same Day Emergency Care, a HOSC member pointed out that he continued to hear about people struggling to get GP appointments, which could impact the proposed streaming model. The Acute Trust CE acknowledged there would be some patients in this position and that both A&E Departments therefore included a GP from lunchtime to evening. There would also be some patients who could have been advised by a local pharmacist, others who had in fact seen a GP but who sought an instant answer and others who arrived at A&E in a very sick condition – therefore there would be provision for those who needed to be seen, and it was also important to make sure GP appointments were there for people who needed them.

·         The Acute Trust Chair highlighted the fact that Worcestershire performed well regarding numbers of GP appointments, but recognised it was a very real problem for some people from her own experiences of talking to people in A&E, therefore education was important.

·         The Acute Trust and Health and Care Trust representatives acknowledged the additional challenge brought by strike action planned for December but explained that the Trusts were preparing and were experienced in redeploying staff.

·         A Councillor who was not a member of the Committee referred to the statistics in the Agenda report which showed 958 ambulance hospital handover delays above 60 minutes for Worcestershire Royal Hospital in October. The Councillor recounted the recent experiences of her mother and daughter which had involved a 4 hour wait for an ambulance, 11 hours in A&E and an hour to exit the carpark – and stressed the severity of the situation in Worcestershire. The Acute Trust CE acknowledged these situations were not good enough and needed to improve.

·         The possibility of targeted communications to certain localities to direct the public to MIUs had been used in the past and it was known that where MIUs were valued they were very well used, for example in Bromsgrove, therefore it was important to capture this learning.   

·         The Acute Trust had increased the availability of testing and diagnostics to help reduce the length of patient stay in acute beds.

·         A HOSC member praised the value of this discussion in clarifying issues related to patient flow, which the Committee had been concerned about for some time and in particular, the lack of capacity (to meet population demand at WRH) which was totally unacceptable.

·         When asked how councillors could help by advising residents about the appropriate routes for care, the ICB representative said that the message should be that Primary Care (GPs) is open, with NHS111 for out of hours enquiries.

·         When asked whether public awareness about pressures at WRH may be deterring some people from seeking emergency care, the Trust’s CE referred to the graphs included at Appendix 1 including current A&E demand, which did not evidence this.

·         In response to a member’s concern about reports of people being re-admitted to hospital and the possibility that pressures were leading to people being discharged too early, the Acute Trust’s CE reassured HOSC members that re-admission rates were monitored and were slightly up, although in general he believed there were improvements needed in earlier discharge.

·         When asked about the tipping point in terms of pressures on acute care, the Acute Trust CE pointed out that services across the health and social care system had received considerable investment, which was positive. Increased staffing was what would make the biggest difference, as highlighted recently by one of the Trust’s non-executive Directors, Dame Julie Moore, and problems would remain until the staffing situation was resolved. A particular weakness with relevance to patient flow was the lack of consultants with expertise in care of the elderly, of which Worcestershire had 3 and needed 20 and the problem was compounded by the fact that staff, especially those newly qualified staff, chose hospitals where they would be part of a larger team.

·         Acknowledging the significant staffing pressures, a HOSC member referred to the areas of activity and focus outlined and asked if there was a view on when the corner might be turned, and the Trust’s representatives felt that if the new pathways, A&E capacity and discharge scheme were successful, they would make a difference, but pressures would remain until the staffing situation was solved.

·         Comment was invited from the Healthwatch Worcestershire representative present who agreed that the majority of staff were absolutely doing their best. Regarding MIUs he reported that the public was unclear what they could and could not provide and he felt that one source of information/website would be helpful for urgent and emergency care.

·         The Healthwatch representative also pointed out that it would be helpful to have some firm data around availability of GP appointments to help with system planning since although Worcestershire had good GP provision there were problems with people queuing on the phone. It was recognised that everyone was doing their best to improve the situation.

·         The Vice-Chairman asked whether there was anything the HOSC could do to expediate publication of the CQC report however was advised that this was unlikely due to the further visits planned to GPs, social care and the Ambulance Service, plus the normal post-inspection requirement for data and policies – however the Trust was already responding to the areas of concern from the initial feedback.

The Chairman thanked everyone for their contribution to the discussion, and on behalf of the HOSC, requested that a further update on patient flow be scheduled.