Agenda item

(To receive a report from Gary James (Accountable Officer – Lincolnshire East Clinical Commissioning Group (CCG)) which provides the Committee with an update on urgent care services within Lincolnshire.  Gary James (Accountable Officer – Lincolnshire East CCG) will be in attendance for this item)

A report by Gary James (Accountable Officer – Lincolnshire East Clinical Commissioning Group (CCG)) was considered which provided an update on urgent care services within Lincolnshire.

Gary James (Accountable Officer – Lincolnshire East CCG) and Ruth Cumbers (Urgent Care Programme Director – Lincolnshire East CCG) were in attendance for this item.

At 12.07pm, the Chairman temporarily left the meeting and handed the Chair to the Vice-Chairman, Councillor T M Trollope-Bellew.

The NHS constitution set out that a minimum of 95% of patients attending an A&E department in England must be seen, treated and admitted or discharged in under four hours ("the four hour A&E standard").  The target was originally introduced at 98% in 2004.  More recently all types of departments had seen the number of attendances increase.

The national context was further explained with the impact on winter performance showing an increase in older patients presenting at A&E who then were admitted as an emergency.  These patients were found to wait longer in A&E than other patients due to their complex needs and multiple illnesses which increased the chance of the four hour target being breached.

Local context in relation to A&E attendances and performance in Lincolnshire noted that the four hour A&E standard had been falling since the winter of 2014/15 and that the overall performance delivered at the end of 2015/16 was 86.0% compared with 90.2% in 2014/15.

As part of the 2016/17 planning and contract round, local systems were expected, by NHS England and NHS Improvement, to agree sensible trajectories for the Q4 performance at year end (March 2017).  This regulatory decision reflected the number of systems failing to meet the 95% target across the country.

In Lincolnshire the agreed Q4 position for 2016/17 was 89% and, of the nine systems within the Central Midlands locality, three had a trajectory which delivered 95%.  Regulators were satisfied that 89% represented a sustainable position within the local system despite being 6% below the constitutional standard.  The report provided the figures for each month and confirmed that the agreed trajectory was achieved overall in Q1.

Bed Occupancy rates for hospitals were context dependent and varied between organisations.  In recent years, there had been a national increase in the intensity with which beds were being used (this was measured by bed occupancy).  For the year to date, United Lincolnshire Hospitals NHS Trust bed occupancy rate was 91.7% compared with 92.5%.  However, the number of weekly acute beds open had fallen from 1005 in 2015/16 to a current average of 994 which demonstrated an overall improved position.

In relation to Delayed Transfers of Care (DTOC), Lincolnshire DTOC rates had fallen over the first quarter of 2016/17 with performance in June delivering  3.6% of bed days lost.  The system was on track to achieve the target of 3.2% by the required date of October 2016.

Lincolnshire Community Health Services (LCHS) NHS Trust had experienced significant DTOCs through the first quarter of 2016/17 although these had been historically below 4%.  The main outliers which had influenced the increase were improved reporting by Rehabilitation Services of patients who required onward placements appropriate to their needs and an increased demand upon Older Adult Division where the primary reasons for delay were "awaiting residential or nursing home placement or availability".  The average demand for residential care was 65% of the total DTOC.

Within the Older Adult inpatient areas it was reported that eleven patients were DTOC over 90+ days and four at 60+ days, prime pathology specific to dementia.

There had been a notable increase in the Adult Acute Inpatient area DTOC for ward 12a at Pilgrim Hospital with three patients attributing to 14% of the total increase in May and June.  Within the Connolly Ward at Lincoln County, the male acute ward had consistent DTOC across the period with two patients at 90+ days and three patients at 60+ days with prime delay due to housing.

Over the past 12 months, 154,998 calls had been made to the Lincolnshire 111 service with 37,895 calls made during Q1 2016/17.  63% of calls had resulted in patients being signposted to attend a primary or community care facility and 10% of calls resulting in no recommendation for service provision.

The urgent care recover plan had focussed on two distinct areas:-  a 30 day rolling programme of actions for Pilgrim Hospital; and five priority areas agreed with the Emergency Care Improvement Programme (ECIP).  In February a concordat had been agreed by leaders from each part of the Lincolnshire system and the regional tripartite to demonstrate the overall commitment to the five priorities:-

1.    Emergency Care Flow;

2.    Safer Care Bundle & 'No Waits' process implemented on 5 wards per month (including community);

3.    Therapy Review/Improvement;

4.    Amalgamation of existing discharge portals into a home first/Discharge to Access model (Transitional Care); and

5.    Perfect Week Programme.

Delivery of the trajectory and Recovery and Improvement Action Plan was managed via several multi-agency stakeholder groups.  This included a weekly Urgent Care Delivery Group meeting with ULHT which reported in to their fortnightly Operations Group.  Within LCHS, there was an Operational Delivery Group which delivered internal transformation change.

In addition, the Lincolnshire Urgent Care Working Group met fortnightly to agree four to six week actions to support the recovery of the four hour emergency department standard and also tracked recovery of the overarching Recover and Improvement Plan.

The introduction of A&E Delivery Boards had been made by NHS England, NHS Improvement and the Association of Directors of Adult Social Services (ADASS) which replaced local System Resilience Groups (SRGs) and were designed to focus primarily on A&E.  The Board was mandated to oversee five improvement initiatives:-

1.    Streaming at the front door to ambulatory and primary care;

2.    NHS 111 – increasing clinical call handler capacity in advance of winter;

3.    Ambulances – Dispatch on Disposition and code review pilots;

4.    Improved flow – "must do's" which each Trust should implement to enhance patient flow; and

5.    Discharge – mandating 'discharge to assess' and 'trusted assessor' type models.

In relation to Grantham A&E and the temporary partial closure, a monitoring process had been agreed and implemented.  Early monitoring undertaken by ULHT suggested that:-

·       Daily average attendances at Grantham were in the region of 60 and demonstrated a reduction of 20 attendances per day on average attendance (80) between 1August 2016 and 16 August 2016 which was less than the 25 reduction predicted.  The daily peak of attendances was now being seen earlier in the afternoon which suggested a change in presenting behaviour. There had been no increase in attendance at Lincoln or Pilgrim;

·       Daily average admissions at Grantham were 12 compared to a previous average admission rate of 14.  This suggested a daily reduction of two admissions per day and was less than the six predicted.  There had been no increase in admissions at Lincoln or Pilgrim; and

·       There had been no material change in Out-of-Hours presentations.

Members were invited to ask questions, during which the following points were noted:-

·       It was acknowledged that some patients making up DTOC figures were delayed due to their care package but, on occasion, there was a requirement to adapt their own home to meet their needs and this could take between six and nine months;

·       Patients referred to who were often in a difficult position with a package of care was due to mental health needs and their ability to cope and manage as an individual within their own home required particular attention in relation to housing and social needs.  This was the element which prevented some patients being discharged;

At this point of the proceedings, Mr P Keeling, representative of Healthwatch, declared an interest on the grounds that he was the Chief Executive of The Respite Association.

·       Concern was noted about Nursing Homes across the country deregistering and the news that three homes in Lincolnshire giving notice of their intention to deregister.  It was confirmed that these homes were having difficulty with the recruitment and retention of nurses.  Both the CCG and County Council had undertaken a review of financial packages available to nursing home.  Although this had introduced a significant financial pressure to the CCG it was a pressure which was deemed necessary;

At 12.20pm, the Chairman returned to the meeting and resumed the Chair.

·       A minimum of eight to nine beds were open across all three sites and were referred to as escalation beds, some of which were at full capacity.  These figures were updated daily to reduce the number of open beds.  A plan from ULHT for those escalation beds was also included in those figures.  It was acknowledged that these were in permanent use and that point had been taken back to the Trust;

·       In order to deal with unexpected surges in demand, daily resilience calls which brought all systems together had increased.  There was extra capacity within LCHS which increased the number of clinical assessors in ambulance call taking sessions.  GP practices were engaged also as part of the surge and escalation plan.  Costs incurred would be due to the impact on the pressures of day-to-day working;

·       To ensure that the required number of escalation beds were available at all times, hospitals either stopped or did less planned care over those pressure periods;

·       The nationally agreed targets for the A&E standard, agreed with ULHT, was 89% and, as part of the package, ULHT had received extra financial support from NHS England and NHS Improvement in the region of £47m to help them meet this standard;

·       The winter plans were due on 3 October 2016 and it was suggested that these could be presented to the Committee at its meeting on 26 October 2016;

·       Part of a national project, of which EMAS had control, was to find out if giving ambulances an extra two minutes on targets would give a better outcome for patients.  The results to-date was that this did improve patient outcomes as it gave ambulance staff slightly longer to make decisions about the best care for the patient;

·       Although the Chairmanship of the Urgent Care Board was now Jan Sobieraj, Chief Executive of United Lincolnshire Hospitals NHS Trust (ULHT), the Chairman asked that Gary James (Accountable Officer – Lincolnshire East CCG) attend to present the update as Commissioner of these services.

RESOLVED

1.    That the current position with regard to urgent care in Lincolnshire be noted; and

2.    That a report on Winter Planning for 2016/17 be scheduled on the Work Programme for the Health Scrutiny Committee for Lincolnshire for consideration at its meeting on 26 October 2016.