Gloucestershire Winter Resilience Plan 2017/18

6th March 2018 Presentation to Health Overview and Scrutiny Committee

Deborah Lee – CEO GHFT

Professor Mark Pietroni – Speciality Director for Unscheduled Care GHFT Maria Metherall – Head of Urgent Care

Sharon Nicholson – Director Winter Flow Dave McConalogue – Consultant in Public Health - GCC

Agenda

Recap of the plan

Winter performance

What went well & key learning

Flu

Collaboration

Planning ‘System’ Working

WINTER PLAN 2017/18

Basis for the plan

• Improve 4 hour A&E performance for winter

• Maintain both planned and emergency care within services Acute Trust.

• Maintain safe care and a positive experience for all patients despite increased operational pressures.

• Provide robust staffing by supporting staff to stay well alongside securing required staffing levels.

Gloucestershire requirements

• Ensuring there is enough service capacity to meet the pressures of winter.

• Further Reduce Delayed Transfers of Care (DToC)

• Reducing variation in practice by adopting principles within the good practice guide “ Focusing on Improving patient Flow”.

• Introduction of Primary Care Streaming in A&E Department

• Reforming and redesigning the wider Urgent and Emergency Care system and designation of Urgent Treatment Centres

• Roll out of the Ambulance Response Programme.

NHSE/I planning requirements

Key winter schemes & Approaches

Pilot trauma to GRH, elective to CGH.

Surgical Assessment Unit at GRH, to receive referrals directly from

GP’s and ED.

Weekend social workers and integrated

brokerage.

Primary Care streaming within the emergency

department.

Increase in Domiciliary Care.

GP direct admissions to Acute Care Unit.

Creation of Winter Pressures Ward for

Medically Fit Patients.

Integrated Frailty Model with enhanced Older

Peoples Assessment and Liaison (OPAL).

Additional discharge to assess (D2A) and

community based beds.

Improved system patient flow.

Increase in Care Navigators and Trusted

Assessor Capacity.

Mental Health Acute Response Service.

Key winter schemes & Approaches

Strengthened navigation and coordination in the emergency department.

Extension of Ambulatory & Emergency Care

opening hours.

Revised approach to red/green & SAFER

initiatives.

Rolling out the Ambulance Response

Programme with SWAST.

Winter pressures initiative with Primary

Care.

Emergency Zone professional standards.

Weekly cross-provider Multidisciplinary

Meetings.

Introducing new Escalation Framework.

Ring-fenced beds for emergency department

within Urology and Vascular Services.

Extend Criteria led Discharge.

Extended Therapy & Pharmacy Opening

hours in Acute Trust.

Development of system wide winter flow task

force.

System Headlines National 4-hour performance standard met in November (95.7%), the first time in 4 ½ years.

Winter average of 91% - System moved from CAT 4 to CAT 2 (GHFT 15th out of 137 trusts nationally)

90% of adult social care assessments (hospital team) completed within 2 days (5 days permitted)

Successful Trauma & Orthopaedics service reconfiguration pilot.

No ambulance handover delays above 1 hour despite increased activity.

Increased access to Primary Care appointments.

652 (59%) more weekend discharges in December 2017 than December 2016.

Underpinned by strong collaboration and partnership working.

Reduced Length of Stay >14 days acute hospitals.

Reduced Delayed Transfers of Care (3rd best in the country for January).

10% point improvement in patient experience in ED

• 20% more elective procedures conducted in Jan 2018 than Jan 2017 with fewer beds and theatres.

• A&E breaches attributed to T&O down from 8 per week to 1 per week on average.

T&O service reconfiguration pilot.

• November +8.68% points (2016 – 86.62%, 2017 – 95.3%)

• December +16.84% points (2016 – 73.86, 2017 – 90.7%)

• January +15.01% points(2017 – 74.69%, 2018 – 89.7%)

Significantly improved winter ED performance.

• Winter 16/17 568 handovers >30 minutes and 13 over 1 hour

• Winter 17 /18 127 handovers > 30 minutes and zero over 1 hour

78% reduction in ambulance handover delays.

• December 2016 -6732 occupied bed days.

• December 2017 – 3946 occupied bed days.

41% reduction in bed days for delayed patients.

• December 2016 – 1106 weekend discharges.

• December 2017 – 1758 weekend discharges.

59% increase in weekend discharges supported by improved system weekend working.

Winter Taskforce

+7 day Length Of Stay patient reviews.

Integrated brokerage function incl. evening &

weekends.

Daily adult social care presence at navigation meeting with proactive

and joint decision making.

Increased discharge to assess capacity.

Allocation of respite, discharge to assess and Care Navigator capacity

to Community Hospitals.

Additional beds for patients ‘waiting’ on completion of social

work and therapy assessment.

Improved system – weekend discharge

Simplified single point of clinical access referral

process.

Simplification of referral process in the Trust

when pathways.

Real time allocation to community beds when

in severe escalation.

Senior adult social care presence in the Trust

allocating when in severe escalation.

Winter Taskforce Continued…

Improved access for same day discharge to

community beds.

Daily Navigation meetings and weekly partnership meetings

having positive impact.

Shared learning from Trust to Community

hospitals.

Increase in complex sub-acute patients being

successfully managed by Community hospitals.

2G involvement in partnership and daily navigation meetings.

Staff taking a system wide view to support

flow.

Delayed patient reviews across GRH and in the Community hospitals.

Care homes assessing and taking patients on

the same day over weekends.

Social Worker & Brokerage working

Saturdays and Sundays across site.

Onward Care Team working Saturdays and

Sundays GRH and Sunday CGH.

Cross System Transfer process for cohorting

FLU patients from Trust to Community Hospitals.

Gloucestershire County Council service

New hospital to home supported 292 people (71% needed only short term support)

Brokerage service (CBOP) – Integrated service supporting rapid identification of beds and suitable support.

Adult Social Care – additional weekend social worker capacity in the acute.

Discharge to Assess beds – new accelerated processes developed with acute and community hospitals.

Chapel House beds – 85 admissions, average length of stay 9 days, bed usage at over 80%.

GHFT

Strong ED Performance.

• Focus on achieving 90% 4 hour performance sustained over Winter (Nov – Jan 91.9%)

New ways of working.

• Onward Care Team supporting simple as well as complex discharge.

• Simplified pathways out of hospital.

T&O Pilot – delivered a 20% increase in elective activity and 50% reduction in trauma waiting

59% increase in weekend discharges.

• 1106 (Dec 16) to 1758 (Dec 17).

78% reduction in > 30 minute ambulance handover delays

Significantly closer partnership working with ASC, MH, CBOP & Community Health Services.

GCS services

Exceptional support to the acute at times of extremis.

Accelerated access to community hospital beds.

Community Hospital 26 day Average Length of Stay compared to 22 day median and 23.3 day 95th percentile.

Rapid response have supported 80% (1295) more patients this winter than last to remain in their own homes. (2016/17 Dec-Jan – 1612, 2017/18 Dec-Jan – 2907).

Huge flexibility from IAT (front door team) to respond to need, working with GHFT to deploy where needed.

SWASFT - Activity

111

Care UK’s SW 111 service maintained a strong and consistent clinical service across the winter period

• Our robust clinical staffing position has allowed the Care UK Acute Calls Team and ED Revalidation services to assist in ensuring there has been no significant increase ED and 999 referral rates in Gloucester, against an overall increase in call volumes through the winter period to date

Care UK were able to rapidly deploy a dedicated A&E revalidation line specifically to assist with system challenges within the Gloucester Hospitals Foundation Trust

• This resulted in further ED cases from 111 being re-directed to more appropriate services such an Minor Injury and Illness Units and GP Out of Hours services

WHAT WENT WELL & LEARNING

What went well?

Partnership working & system collaboration.

Greater provider ownership and mutual

respect with less blame.

Rapid Response team has increased capacity

and is delivering significant system

benefit.

Increased number of appointments in

primary care

Hospital at home & care navigator services are growing and having a

positive impact.

Direct bookable GP appointments for

patients presenting at GRH at times of

extremis

Discharge bed model (Chapel House) is

working well with good throughput and low

Length of Stay.

Dedicated GRH clinical validation line (111) at

times of extremis

We are experiencing smoother and quicker transfer to community hospitals for a number

of years.

Real time allocation to community beds during

escalation.

Allocation of Adult Social Care to

community hospitals & Acute hospitals.

GP support within emergency department.

What went well?

Integrated Brokerage – greater co-ordination and clarity re: funding streams.

Greater control within GHFT.

Processes and pathways have been simplified.

IAT – front door proving flexible and providing

support.

Rapid recovery when performance dips.

SWASFT support for diversions at times of

extremis is very helpful.

Strong handover delays plan.

2G involvement in partnership meetings and

daily navigation meetings…. Real time

issues picked up.

Staff are looking across the system to support rather

than being constrained by organisational boundaries.

Lessons Learnt

• Processes underpinning the patient journey.

• Quality of Discharge.

• Rehabilitation.

• Long term planning of social work capacity in community/hospital.

• Flu preparedness across all systems.

• Internal triggers within GHFT.

• Consistent pathways for Community Hospitals & locality ASC access to out of hospital services.

• Further strengthening of escalation actions during periods of extreme pressure.

• Better use of data to predict trends.

Where improvements can be made:

Lessons Learnt cont…

• Over-prescribing needs of patients to return home.

• Changing pathways.

• Flexibility of communications plan.

• Transport , changing the mind-set of patients and staff alike to use family and friends as first transport option.

• Empowering staff to have difficult conversations.

• System understanding of Mental Health assessments.

• Ensuring sufficient mortuary capacity.

• Future of Care Sourcer – re: End Of Life placements.

• MRSA swabbing.

Further Learning

Drivers for change

• Operational challenges: A&E enforcement notice and failing all constitutional standards.

• Patient Experience: significant level of cancelled operations (600 per year) and increasingly long waits for routine assessment and surgery.

• Poor clinical trauma outcomes: high mortality for hip fracture.

• Staff: increasing frustration with inability to deliver good care.

• Loss of opportunity to local NHS through T&O work to other providers.

• Poor training experience for junior medical staff affecting recruitment.

• Reputation: not commensurate with quality of staff and many services.

• Desire to demonstrate proof of concept for hot : cold model.

Headlines so far: 9 weeks in

• 20% more orthopaedic operations undertaken in January 2018 compared to January 2017 despite utilising few beds and theatres.

• A 50% reduction in the number of patients cancelled in the week prior and on the day (90% of cancellations that occurred attributable to unfit patients and only one to lack of beds).

• Trauma cancellations per week down from an average of 8 patients to 3 and (6 of the 9 weeks in the period had ZERO cancellations).

• A 15% reduction in fracture clinic appointments since trauma triage has been introduced – ‘virtual’ clinic.

• The average wait for upper limb trauma surgery (from injury) reduced from an average of 16.2 days to 8.1.

• The number of A&E breaches, attributable to T&O, down from an average of 8 per week to 1 per week.

• Significantly enhanced teaching experience for doctors in training

• Improved job satisfaction amongst staff

FLU UPDATE Dave McConalogue

• Data sources: GP reporting of influenza like illness (ILI); Lab reports; and outbreak reports – much of influenza activity is not reported

• Both influenza A and B circulating: Much higher levels of influenza B than previous season

• Data suggestive that peak of influenza in Jan, but season can be long

• 42 care home outbreaks in Gloucestershire (higher than any other CCG area) – plans for care home staff flu vaccination pilot

Burden of disease in Gloucestershire

GP (In Hours) influenza-like illness consultation rate per 100,000 practice population

Vaccine uptake (as of end of Dec 2017)

• NHS Services: 7500 - 1600 more than 2016/17 (All NHS trusts achieving 70%+ uptake)

• GCC: 1500 (500 in 2016/17)

• National flu vaccination programme (to Dec 2017)

• Improvements across most risk groups

• Introduction of school based programme (reception to year 4)

• Areas identified for renewed focus: pregnant women

Planning for next season

• Planning day for 2018/19 flu season - NHS England, Local Authorities and NHS

• Improving uptake of vaccine in pregnant women – workshop for providers and commissioners

• Care home staff influenza pilot: testing different approaches

• Coordinating GCC and NHS staff influenza programmes – increasing accessibility for staff

Next steps

Continued delivery.

Winter review.

Planning for winter 2018/19 to start in March 2018.

Embed sustainable processes to underpin flow.

Draw learning from pilots to inform future service models.