Brighton and Sussex University Hospitals Trust

System Resilience Group

Agenda Item No. 8a

System Resilience Group • Based on the population that flows into BSUH – Princess Royal and Royal

Sussex County sites • Chaired by Brighton and Hove CCG • Comprises:

• Three main CCGs; Brighton and Hove, Horsham & Mid Sussex and High Weald, Lewes, Havens

• NHS England • All main providers including independent and private sector; • Three Local Authorities

• Covers: • Urgent and emergency care – esp 4 hour A&E target • Elective care – esp national target of referral to treatment in 18 weeks • Access to cancer services – national targets

A&E Performance: 95% treated within 4 hours

Graph 1: BSUH A&E 4 hour Performance April 2014 – February 2016 Source: BSUH weekly SitRep

Ambulance Handover Delays - BSUH

Graph 2 - Ambulance handover delays Source: BSUH Daily winter SitRep

Handover Delays - Kent Surrey and Sussex

A&E Performance • Improvement on last year – still well below acceptable levels • PRH generally over 95% but County well below • A number of external reviews into why, CQC etc:

• Not solely due to high numbers presenting at front door • Not solely due to high numbers of delayed discharges • Although both of the above increasing of late • Clinical model and flow through hospital • Peaks in attendance hard to accommodate • Constricted space at County site

• Handover delays a significant clinical risk • Patients waiting in queues under the care of paramedics • SECAMB unable to respond to urgent calls if crews held up • Commissioners supporting immediate handover policy

BSUH System – Urgent Care Stocktake March • The stock-take confirmed the content of the plan is appropriate, however: • There has been a recent increase in Non elective admissions on both PRH and RSCH sites. At PRH this can

be attributed to changes in coding, at RSCH there has been a reported increase in acuity • A&E activity has risen slightly in recent weeks, however it is not at the same level as the national trend • There has been a recent increase in ambulance conveyances to RSCH • BSUH have been on ‘Black’ escalation status more frequently in recent weeks than earlier in winter • There is evidence of some increase in delays, more notably at PRH than RSCH, however there is a need to

record non acute delays accurately • Clearly performance demonstrates that ‘flow’ has not been consistently achieved, therefore a need to

maximise impact and fully embed all plans • There has been an increase in ambulance handover delays, and a corresponding impact on Ambulance

response times • Very good system engagement and support from ECIP has helped to define the following areas of focus in

2016/17.

Recommended Areas of Focus • SECAMB to build on current successful non conveyance pathways • CCGs continue full implementation of proactive care to prevent avoidable

admission, focusing on high intensity users with a multi-disciplinary team approach in primary care. Supported by associated plans for interoperability of care records

• Fully implement BSUH configuration of internal pathways and ambulatory care model

• Fully embed BSUH Right Care Each Place Each Time model across sites to support efficient, safe and timely simple discharges

• SCFT develop Responsive Services model: include community rapid response service, discharge to asses and community short term services providing responsive community based services to reduce unnecessary admission, assess patients at home, develop single point of access and reduce number of standalone teams

• Hospital at Home: develop the clinical vision supported by a robust business model to allow early discharge home to sub acute care at home releasing acute hospital capacity.

• Review the opportunity to reduce non elective admission from care homes

Referral to Treatment within 18 weeks

Cancer Access

Increased waits for treatment • Not due to significant increases in demand for elective care • Urgent care demand impacts on elective activity • Large number of additional patients who had not completed their

treatment added to the waiting list last year - including a substantial cohort of over 52 weeks

• National support programme working with BSUH to resolve operational issues

• Additional capacity in alternative NHS and independent sector being sought, particularly in key specialties such as digestive diseases

• Longer term strategic approach through Sustainability and Transformation Plan (STP) to ensure sufficient elective capacity to meet future demands

Resilience Update for HWBB

Coastal West Sussex System Resilience Group

April 2016

Agenda Item No. 8b

System Resilience Group and Resilience Operational Group

• The System Resilience Group (SRG)- the forum where all the partners across the health and social care system come together to undertake the regular planning of service delivery for urgent, cancer, mental health and elective care in all provider settings

• A working sub group of SRG, the Resilience Operational Group (ROG)

meets weekly to develop plans and manage demand surges across the system enabling cross-organisation working to maintain patient flow

Resilience

The Coastal West Sussex (CWS) SRG seeks to ensure operational resilience by: • Delivering the A&E 4h wait and other emergency metrics • Delayed Transfers of Care kept at a minimum • Delivering speciality compliant 18 week pathways • Delivering safe Infection Control Capacity for C Diff /MRSA/D&V • Deliver timely ambulance handovers • Ambulance conveyance rates

WHSFT A&E 4h Wait and Other Emergency Metrics

A&E attendances rose in October and February 2015 compared to 2014 For the total period Oct – Dec 2015 figures show a 1.51% increase on volumes compared to the same period 2014. Figures have continued to rise January and February with near 11k attendances each month Emergency Admissions via A&E for the same quarter saw a 0.95% rise in 2015 against 2014, January and February have seen a steady fall on December’s volumes

WHSFT has remained above the England Average 4hr Waits since January 2014 , meeting the quarterly 95% compliance target 2015 and also for January and February FY 2015 There was a slight dip in December2015 below compliance target but significant improvement on December 2014

WSHFT A&E 4h Wait and Other Emergency Metrics

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A & E Attendances A & E 4 hour breaches

4-12hr Waits Emergency Admissions via A&E

A & E 4 hour wait % England Average 4hr Waits

4 Hr Compliance Target

Category Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

A & E Attendances 10245 12479 10134 8950 9324 12385 12900 10428 11515 12072 11687 11279 11645 10883 10823 10908 10956

A & E 4 hour breaches 473 707 1363 727 400 304 234 339 291 276 318 587 528 420 686 514 613

A & E 4 hour wait % 95.38% 94.33% 86.55% 91.88% 95.71% 97.55% 98.19% 96.75% 97.47% 97.71% 97.28% 94.80% 95.47% 96.14% 93.66% 95.30% 94.40%

4-12hr Waits 80 153 332 267 97 47 36 40 37 25 42 142 125 89 146 108 128

Emergency Admiss ions via A&E 3538 2846 2988 3536 2916 2767 3557 2772 2921 2973 2855 2899 3165 3003 3293 3196 3104

England Average 4hr Waits 93.77% 93.50% 90.22% 90.40% 92.20% 92.60% 93.30% 94.33% 94.80% 95.00% 94.32% 93.38% 92.32% 91.28% 90.97% 83% 82%

4 Hr Compl iance Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

20152014

WSHFT Delayed Transfers of Care Percentage DTOC (3.5% Compliance)

WHSFT has remained below the Amber national target of 3.5% for most of 2015, only going above this target in April 2015 and Sept 2015

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Percentage DTOC (RAG based on 3.5% compliance and 5.0% for fail)Amber over 2.5 (internal target)Amber over 3.5 (national target)

Delivering WSHFT RTT Total Compliance Against Target

Total RTT compliance has been on a downward trend sine October 2014 but has seen an improvement since August 2015

Delivering Safe Infection Control Capacity for Beds

Closed Due to D&V

Beds closed to D&V have dramatically reduced December 2015 against December 2014

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Number of beds closed due to D&V/norovirus like symptoms

Delivering Safe Infection Control Capacity for C Diff /MRSA

The threshold for MRSA is zero, there have been 0 incidents in 2015 C.Diff has seen a rise in count of incidents October 2015 (7) against 2014 where there were just 2 incidents

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Deliver Timely Ambulance Handovers SECAmb Monthly Handover Delays - St Richards

Hospital recorded incidents from SECAmb data • Sum of Hand Over delays greater than 30mins –Average 48 per month 2015

• January 2016 Sum of Hand Over delays greater than 30mins at St Richards

peaks at 60 representing 2.25% of total Patient Handovers

• Sum of Hand Over delays greater than 60mins peaked in May 2015 with 5 Breaches, 0.29% of Total Patient Handovers

We are showing an increase in handover delays from October 2015 at both sites In response we are initiating a project that has proved successful at BSUH

Deliver Timely Ambulance Handovers SECAmb Monthly Handover Delays - Worthing

Hospital recorded incidents from SECAmb data

• Sum of Hand Over delays greater than 30mins –Average 65 per month 2015

• Sum of Hand Over delays greater than 30 mins at Worthing peaks at 75 May 2015 representing 3.43% of total Patient Handovers

• Sum of Hand Over delays greater than 60mins peaked in January 2016 with 6 Breaches, 0.25% of Total Patient Handovers

Worthing > 30 Minute delays fell December 2015 compared to 2014 as well as the > 60 minute delays

Resilience Schemes 2015/16 ROG and SRG agreed the 2015/16 schemes as follows-

• Community bed capacity- extra capacity for winter • Locum juniors for escalation outliers in the acute trust • Weekend Medical staffing in A&E and Admission wards • Weekend Therapy, pharmacy and phlebotomy in the acute trust • Patient Transport- dedicated vehicles provided at each acute site to support on the day discharges • Integrated Transfer Team to enhance Discharge teams in both acute and community hospitals • Intermediate Care Team West- multi disciplinary team providing up to 6 weeks rehab • 7-day therapy in community beds- physio and OT • Intermediate Care Team packages of care- domiciliary care provided as part of ICT • Rapid Assessment Intervention Team/ Community Transfer Nurses- enhancing the teams during

winter to ensure admission avoidance and patient flow through acute and community beds • Night sitting service- enhanced over winter to maintain people in their own homes and avoid

admission/ improve discharge • Primary Care- additional slots (Christmas/Easter) and extra appointments • SECAmb- capacity in A&E to manage surges in demand and release vehicles to respond to 999 calls • Mental Health- triage coordinator and posts in Crisis Response Team to avoid admission

Risks and performance pressures

• Increasing older population, higher acuity and complexity • Significant workforce issues across all providers, particular pressure in

nursing, GP and carers • Fragility in nursing home and domiciliary care markets

Looking forwards

• Whilst winter is clearly a period of increased pressure, establishing sustainable year-round delivery requires our capacity planning to be on going and robust

• SHREWD will be implemented across CWS providing real time data from

provider systems giving an overview of demand/capacity across the whole system

• This enables responsive and efficient management of peaks in demand.

SHREWD will also contribute to the development of a responsive ORC plan based on actual demand and agreed system triggers that result in effective action being taken nearer to real time

Resilience Update for Health & Wellbeing Board

SASH SRG

Agenda Item No. 8c

System Resilience Groups

• The System Resilience Group (SRG)- the forum where all the partners across the health and social care system come together to undertake the regular planning of service delivery for urgent, cancer, mental health and elective care in all provider settings

• It is a multi-organisational Group with partners across the SASH economy ie from Crawley, Horsham and Mid Sussex and East Surrey.

• The purpose of the SRG is to take the strategic lead on developing transformation plans that will deliver resilience in the health and social care economy.

Resilience Schemes

The SRGs seek to ensure operational resilience by: • Delivering the A&E 4h wait and other emergency metrics • Keeping Delayed Transfers of Care to a minimum • Delivering speciality compliant 18 week pathways • Delivering safe Infection Control Capacity for C Diff /MRSA/D&V • Deliver timely ambulance handovers • Maximising out-of-hospital capacity

SASH System Resilience Schemes 2015/16

SASH SRG have prioritised and the current schemes for the winter are as follows- • Enhanced access for primary care into step up capacity • Pharmacy support to care homes • Additional resource to manage capacity and flow across the acute and community

settings • Additional Patient Transport • Enhanced resource in SASH “front door” team • “Top Up” resource to SCT to support domiciliary care market • Additional social worker resource to support community beds (hospital beds and

transition beds) • Additional resource in SASH to support 7 day working (theatre lists, MRI) • Enhanced daytime/weekend cover of Children’s Assessment Unit • Additional resource within A&E • Consultant resource to review medical outliers • Ambulance handover nurse • Support to enable implementation of SHREWD (System Health Resilience Early

Warning Detection) system

SASH System On going Resilience Enhancing Initiatives

• Completion of Transforming Urgent Care, Crawley programme (Urgent Treatment Centre, increased Clinical Assessment Unit capacity, improved paediatric and mental health services)

• Completion of sub-acute ward in Crawley Hospital • Embedding of Primary Care within the A&E Department to reduce admissions • Consolidation of community teams (admission avoidance, intermediate care,

specialist nursing etc) into a single Responsive Service • Review of specification for community beds to increase capacity available as

“step up” care for primary care and the community • Progression of Integrated Hospital Discharge Team • Roll out of SAFER bundle across all beds (hospital and community) • Continued development of Clinical Hub • Review of long term conditions pathways

Risks and performance pressures

• Increasing older population, higher acuity and complexity • Significant workforce issues across all providers, particular pressure in

nursing, GP and carers • Fragility in nursing home and domiciliary care markets

Looking forwards

• Whilst winter is clearly a period of increased pressure, establishing sustainable year-round delivery requires our capacity planning to be on going and robust

• SHREWD will be implemented across the CCGs providing real time data

from provider systems giving an overview of demand/capacity across the whole system

• This enables responsive and efficient management of peaks in demand.

SHREWD will also contribute to the development of a responsive ORC plan based on actual demand and agreed system triggers that result in effective action being taken nearer to real time

Agenda Item No. 8d

A summary of the Health and Wellbeing Board Winter Pressures Meetings, Winter 2015

1. Introduction

1.1 Between January and March 2016 the Chairman of the Health and Wellbeing Board, acute and community providers and CCG leads met to understand and support action on immediate pressures within the West Sussex Health and Social care system and to consider ongoing and future issues for the System.

1.2 Partners worked together to ensure immediate actions were taken to increase packages of care, to share more effectively data on patients ready for discharge and to coordinate information to the public on where best to access health care.

1.3 The meetings also discussed ongoing concerns being taken forward by those attending the counties three System Resilience Groups based at Brighton and Sussex University Hospital, Sussex and Surrey Hospital and Western Sussex Hospital Trust The main areas raised/addressed were the need for a single trusted assessor, concerns around ambulance and patient transport services, continuing health care packages and recruitment and support for the health and social care workforce and the ability to share data across organisations

2. Evaluation of efficacy of actions undertaken to support the Health and Social care system over the winter season.

2.1 The engagement between Health and Social Care relating to the on-going resilience against system pressure, should not be focussed solely on the “winter” periods, as there is less of a defining point at which the system pressures start and recede compared with past years.

2.2 By maintaining all year round engagement of health and social care in system resilience planning, has the result of improving systems that can be deployed not only in the winter season but equally in summer spikes in pressure in the acute hospitals due to tourism as well as an unforeseen event such as an outbreak such as E.coli.

2.3 An on-going nominated lead within each health and social care organisations responding to system pressures helps to build a formal and informal network and understanding of each other’s issues, which can then be considered when developing services that may have impacts of other organisations.

2.4 Jointly explore possibilities for increasing the interim bed capacity to support reduction in delayed transfers of care.

3. Outstanding Actions

Agenda Item No. 8d

• Review retention of workforce issues, with consideration to plans for addressing recruitment collectively across the system to enable rotation of staff to encourage staying in post.

• Explore the concept of a collective academy approach, to include mentoring and professional coaching for new staff. (To be raised at Coastal Cabinet and shared with northern working group).

• Develop a system-wide agreement on agency staffing protocols with the aim of avoiding ‘job-hopping’ and support continuity of care. Taking into account the differences in workforce between the North and South of the County, with workforce and system interdependences and existing pay rates.

• Explore the issue of delayed transfers of care exacerbation due to inpatients with a community Social Worker having to wait for them to assess them rather than the Hospital Social Worker Team.

• Explore increased flexibility of beds within WSCC capacity (Marjorie Cobby House) within the CQC registration parameters.

4. Identified learning for the future to be taken forward by the system resilience groups.

4.1 Assess the possibility of contracting staff specifically to work in the school holidays (the reverse of term time contracts).

4.2 CABS to support to increase the knowledge and skills for care and nursing staff in collaboration with CCG nurse educators. Consider a flying squad of clinical educators to advice on care of complex cases.

4.3 Skills audit of care and nursing home sector required to allow a focus on providing the learning and development opportunities, supported by community clinical tutors (possibly part of the CCG to support this).

4.4 Review the results of the future planning session held by Coastal West Sussex Board on the 9th Jan and the HWB meeting of the 4th Feb, to advise the system resilience groups.

4.5 Consider the extension of Sussex Community Trust community nurse Bank to take on a role in provision of domiciliary social care.

4.6 Consider setting early triggers to activate multi-disciplinary actions to:-

• Increase capacity in hospital social work teams with community social workers (specifically with those who have inpatients from their caseload awaiting assessment)

• Extend MIU opening times where these close at 17:00. • Extend minor illness clinics at GP surgeries utilising GPs, nurse

practitioners or paramedic practitioners

Agenda Item No. 8d

4.7 WSCC social Care to utilise the “Seasonal Pressure” Sharepoint site, requested by the Director of Adult Services and built to support the February 2015 pressure period, allowing an overview of care package requests and one point for posting information on capacity and restriction on use of providers.

4.8 Strengthen the resilience of the Care Nursing Home and Domiciliary care providers by offering through the WSCC Learning and Development Business Continuity workshops run by WSCC Resilience and Emergencies Team.

5. Preparing for Winter 2016/ Learning and actions for HWB consideration

5.1 Communication • Develop and agree proposals for a county-wide all year-round

communications programme to ensure understanding on access to general and emergency health care for all age groups.

• Build on the existing "Right Care Right Place" campaign run by the NHS England and CCG communications teams but in collaboration with WSCC communications team to build in social care options.

5.2 Develop Escalation protocols • Forward planning for resilience • Agree a shared definition for medically fit for discharge • Trusted assessor model

Prepared by Barry Newell Resilience and Emergencies Advisor

Dr Nike Arowobusoye Director of Public Health