The Scrutiny Support Officer presented a report the purpose of which was to introduce a number of senior representatives of local public bodies to receive an update on how the health and social care economy was preparing for the 2013/2014 winter.
The demand on health services had been particularly high during the winter of 2012/2013 which became a very high profile matter in the local media. The Panel had been subsequently keen to consider the topic in more detail at a meeting held on 19 March 2013 the discussion from which resulted in a final report as shown at Appendix 1 of the report submitted.
In order to assist deliberations at the meeting a series of questions as outlined in the report submitted had previously been circulated to all concerned.
A report of the Middlesbrough Health and Wellbeing Board had previously been circulated which outlined the activity taking place in relation to urgent care and winter pressures and provided a response to the questions outlined.
Following introductions the Chair invited the Assistant Chief Constable to address the Panel and give the Police perspective on the pressures during last winter and subsequent months.
From the outset the Assistant Chief Constable indicated that it was unfortunate that a representative from the North East Ambulance Service NHS Foundation Trust (NEAS) had not been in a position to attend the meeting as it was acknowledged that they were a very important part of the matters being discussed at the meeting.
The Panel was advised of experiences whereby operational Police Officers had taken injured and /or ill persons to A and E at JCUH not necessarily all crime related and as a result of incidents in the community.
The significant problems during the winter months 2012/2103 were acknowledged however an example was given of an incident which had occurred on 3 June 2013 and of subsequent deliberations between the Police and NEAS. No ambulance had been immediately available as they had all been despatched to emergencies and 10 were in the emergency queue at JCUH. An ambulance arrived 1hour 40 minutes after the original incident. It was pointed out that such circumstances were currently not uncommon and that the situation had been acute over the 2012/2013 Christmas and New Year period. It was pointed out that between April to 22 July 2013 there had been approximately 25/30 interactions with NEAS for ambulances or support.
Although it was considered that the difficulties were a system of more structured problems being experienced at a national level the Assistant Chief Constable confirmed that there had been subsequent positive discussion with health colleagues on winter and current summer pressures. The Panel was advised that there tended to be an incident every three days where an ambulance was not immediately available in certain circumstances. It was confirmed that the Police had an Action Plan in order to provide guidance to Police Officers of options to pursue in different situations which included the use of walk in or drop in health centres where appropriate.
In general terms it was considered that the situation had improved. Specific reference was made to an officers conference hosted by NEAS in February 2013 which covered issues such as the pressures on A and E, referrals, Out of Hours service, self referrals and the new 111 system.
Following examples given by Members whereby cases had been reclassified impacting on the timing of the despatch of an ambulance the Panel emphasised the importance of communication with patients and for the public to have reassurance in the service. The Panel suggested that representatives of NEAS be invited to attend a future meeting in order for them to provide information on their perspective of current pressures regarding emergency access to JCUH and seek reassurances and clarification with regard to the number and operation of ambulances for Teesside. In response to a comment from health representatives that the issues were closely linked the Panel reiterated the need in the first instance to seek reassurances and for a meeting with NEAS and the Police to take place prior to any further round table discussion with all concerned.
The Panel's attention was drawn to the written response received to the Panel's questions. Additional graphical information was also circulated at the meeting which following analysis of activity at JCUH showed a reduction (1 full day) in pressures associated with bed capacity following improvements and a multi-discipline approach involving the South Tees Hospitals NHS Foundation Trust (STHFT), South Tees Clinical Commissioning Group (CCG) and the Council's Social Care. Partner agencies had been working together by means of the South Tees CCG Urgent Care Workstream to implement system changes that had supported such a reduction although it was evident that there had been a significant degree of seasonal effect (less frail elderly with respiratory conditions) impacting on the numbers of non-elective admissions and ultimately bed capacity within the hospital at that time.
The South Tees CCG had formulated a dedicated Urgent Care Workstream to review issues within Tees and plan for any surge in activity. The terms of reference for the Workstream were outlined in Appendix 1 of the report submitted.
One of the key issues being addressed by means of the Urgent Care Workstream was that of delayed discharges or transfers of care. Such work had been progressed in partnership with key partners, the STHFT, the Local Authority and the CCG.
Graphical information highlighted the most significant reasons for delays to discharge as being delays awaiting assessment and delays in transferring patients to appropriate non-acute health or social care accommodation.
In response to clarification sought from Members as to whether or not the Urgent Care Workstream had the resources to make decisions it was confirmed that their recommendations would be taken to the Urgent Care Board for approval.
The STHFT at JCUH were currently undertaking a series of training sessions with all wards to promote discharge planning and to implement an updated and streamlined process for identifying patients who required referral for additional support on discharge from social care. In addition, the CCG were supporting the Acute Trust in preparing and implementing rapid process improvement workshops in relation to discharge planning with the aim of supporting earlier discharge and also promote optimal safety for patients.
The Panel was advised that Rapid Response Teams, providing nursing and therapy had been introduced in addition to the Council's already well established social care Rapid Response service to deliver additional support to patients, enabling them to remain within their own homes or to facilitate discharge from hospital.
The CCG in conjunction with JCUH Community Services had recently implemented a method of identifying and supporting those people who might be at high risk of an unplanned admission in the future. The service was to be known as 'The Integrated Community Care Team', co-located on a cluster basis such teams would co-ordinate and case manage the care of patients at risk of admission in conjunction with the wider health economy. All patients accepted for management by the team would have an individual Care Plan developed by the GP and the Community Matron.
Methods of additional support offered to individuals at highest risk of admission varied but a proven model implemented in many parts of the country was that of a 'Virtual Ward' aimed essentially to prevent unplanned admissions by adopting the systems of a hospital ward to provide multidisciplinary case management in the community.
It was noted that the CCG in collaboration with JCUH would also scope and progress Nurse Led triage and discharge within the A & E department, ultimately allowing consultants to dedicate their resource to major accident and emergencies opposed to minor ailments.
It was acknowledged that NEAS colleagues took a key role as members within the work stream which had allowed work to progress in conjunction with their plans as the main provider of urgent care transport across the locality.
In terms of the 'Out of Hours' provider, Northern Doctors Urgent Care, the CCG Clinical Lead, Dr Milner, was collaborating with the NDUC Medical Director to review pathways and ensure robust criterion for those patients requiring admission to hospital.
In response to recent national guidance both South Tees, and Hartlepool and Stockton CCGs had undertaken a review of existing locality based urgent care groups to assess compliance with such guidance. In order to comply with the guidance it had been agreed to establish an Urgent Care Board to replace the Teeswide Integrated Urgent Care Network.
The Area Team of NHS England had requested recovery plans from a number of commissioning organisations that had failed to adhere to meeting the 95% four hour target for A & E Departments. South Tees CCG and JCUH had delivered the annual target however in recognition of the pressures experienced at critical points throughout the year the CCG had produced and submitted to the Area Team as shown in Appendices 2 and 3, robust sustainability plans to ensure that they were adhering/could continue to adhere to the key national target.
As part of the responsibility of Urgent Care Boards they would seek assurance regarding the robustness of the collective integrated plans in order to prepare and manage through the winter period. It was confirmed that the Tees locality would develop winter plans encompassing and recognising:-
Primary Care - Access, Out of Hours medical provision, Impact of 111, developments within community services to offer alternative pathways of care,
Secondary Care - Operational bed management, Acute capacity, Critical Care, Diagnostic services, Ambulance handover times, Staffing of all disciplines.
Discharge Services - Utilisation of discharge lounges, Reduced delays of transfer, Discharge profiling across specialities, Community and Social Care support, Reablement.
It was reported that the average length of stay at JCUH had fallen over recent months as a result of system changes and seasonal effect. The full impact of system changes was not expected to be witnessed until October/November 2013 in preparation for the winter.
System changes that had been put in place were reiterated and included:
STHFT working with all ward teams on discharge processes - a full service improvement programme was currently being progressed.
STHFT, LA and the CCG had worked collectively to improve administrative and handover processes between agencies.
Ward based case managers on post for the last nine months, evidence was beginning to emerge regarding the impact of such posts.
In terms of planned work the Panel was advised that it included:-
Rapid process improvement workshop undertaken in July to address internal system blockages with follow up actions identified for 30, 60 and 90 days.
Workshop looking at system design for care of the frail elderly (July).
Development of winter plan for 2013/2014 with a specific focus on avoiding a build-up of delayed discharges over the Christmas and New Year period.
It was noted that discussions were taking place with colleagues in the Local Authority and the STHFT to agree preventative measures.
The Panel in seeking assurances of improvements, the local health representatives stated that improvements in performance were expected but indicated that ambulance capacity was still an issue.
In terms of the Trust the Panel was advised of £6 million investment on recruitment of additional staff and increased bed capacity, 50 additional beds expected to open 1 October 2013 which during the summer, half would be used for surgical patients and half for increased non-elected programme urgent patient. Such beds would be used in winter for extra capacity. Following Members' questions an assurance was given that the Clinical Director Accident and Emergency and the Chief of Service had both been involved and had given personal commitment to the Service Improvement Workshop.
From the GP's perspective, GPs had met with consultants on three recent occasions which was considered to be a positive move. As part of such discussions suggestions for improvement included the possibility of adopting a more flexible model for GPs seeing patients earlier in the day doing earlier tests with the aim of getting patients home if appropriate and also encouraging other ways of working such as next day outpatient appointments rather than A & E admissions if considered appropriate.
Reference was made to the RADAR programme part of the Virtual Ward scheme which monitored patients and provided earlier interventions when necessary.
A view was expressed that there was a need for more prompt, experienced, senior GP decision making in primary and secondary care both in hours and as part of the Out of Hours service.
The Panel was advised of a recent publication of the House of Commons Select Committee which emphasised the importance of integration with primary care, paramedics and GPs. The pilot was one of many actions and had only run for five out of six months and had to be evaluated in terms of the data; if it was the correct model; further work was required with the Ambulance service; if it was cost effective; if a viable option; and contractual arrangements. Following a Members' question it was confirmed that the option of using your own GP was being examined as part of enhancing such a scheme.
The Panel was keen to seek assurances around the question if the South Tees health and social care economy was a 'poorly performing care system'. In response, the local health representatives indicated that whilst performance had dipped during the winter 2012/2013 performance had since improved and continued to deliver the emergency key performance indicators which had been acknowledged by NHS England, Durham, Darlington and Tees. In response to clarification sought by Members on evidence to show such improvements the Panel was advised of the availability of relevant reports which were submitted to the Trust Board and published on the website. Reference was made to the ongoing commissioning process and in particular to the Integrated Management and Proactive Care of the Vulnerable and Elderly Programme (IMProVE).
The Panel was keen to seek assurances about preparation for winter pressures including the steps to improve the take up of flu vaccinations. An assurance was given from the Council's Director of Public Health that ways of increasing the take up of flu vaccination was currently being examined and that the commissioning of the Immunisation Programme was the responsibility of NHS England. It was suggested that a letter be forwarded to the Chief Executive to encourage the take up by staff of the flu vaccination.
Members were reminded of the initiatives being pursued including increased bed capacity, better communication, more social work input, better discharge process, improved links with GPs , continued work with Out of Hours service and NEAS, examining alternative systems and if best practice shown at Sheffield could be replicated in Middlesbrough. The local health representatives indicated that they would be better prepared as the initiatives and actions being pursued went beyond that undertaken for 2012/2013.
In commenting on the arrangements for discharge specific reference was made to the increased team for Middlesbrough, and Redcar and Cleveland of 19 qualified social workers. An indication was given of ongoing work reviewing current processes which included the provision of more accurate information for Planned Management allowing quicker progress to be made.
Reference was also made to the establishment of a Discharge Steering Group to ensure that they were in a better position to respond to winter pressures. From a series of 23 workshops to be completed by September 2013 it was noted that significant improvements had already been seen following eight workshops. Significant work was progressing to ensure that the correct facilities/processes were in place to deal with the prevailing circumstances of 2013 which were not necessarily the same as in 2000.
Members commented on the options including discussions with other agencies/private sector providers on such schemes as step down beds for their patients when it was considered not appropriate for them to return home but not necessarily be in an acute setting. It was acknowledged that detailed information could not be given at this stage as it was currently the subject of a procurement process.
Whilst it was acknowledged that there were some issues relating to JCUH as a major trauma centre an assurance was given that there were processes in place which would be utilised to deal with any major incident and that coping with winter pressures was more of a concern hence the significant work being undertaken.
The Chair referred to the Winter Pressures Final Report which had recently been considered by the Executive when further clarification had been sought on a couple of areas. The Overview and Scrutiny Board at its meeting held on 23 July 2013 had agreed to a special meeting of the Board to which Members of the Health Scrutiny Panel and the Social Care and Adult Services Scrutiny Panel would be invited to attend to discuss the matters raised.
RECOMMENDED as follows:-
1. That all representatives be thanked for their attendance and contribution to the deliberations.
2. That representatives of NEAS and Cleveland Police be invited to attend a future meeting of the Panel to discuss emergency access to JCUH.
3. That on behalf of the Panel, the Chair and Vice-Chair write to the Chief Executive regarding the immunisation programme and seeking assurances on the steps being taken to encourage and improve the staff take up of the flu vaccination.
4. That at a future meeting of the Panel further information be sought on the current Out of Hours service.