Agenda item

(To receive a report by Gary James (Accountable Officer – Lincolnshire East CCG) which provides an update on the planning for Winter Pressures across the Health and Care Economy in Lincolnshire.  Gary James (Accountable Officer – Lincolnshire East CCG) and Ruth Cumbers (Director of Urgent Care – Lincolnshire East CCG) will be in attendance for this item).

The Chairman welcomed to the meeting Gary James, Accountable Officer, Lincolnshire East Clinical Commissioning Group and Ruth Cumbers, Urgent Care Programme Director, Lincolnshire East Clinical Commissioning Group.

The purpose of the report was to update the Committee on planning for Winter Pressures across the Health and Care Economy in Lincolnshire.

It was reported that nationally that there was recognition of an increase in demand on urgent and emergency services across the winter months.  It was however highlighted that generally the system was under pressure all year round.  It was noted that the whole health and social care system was running "hot" with the usual expected easing of pressures during the summer no longer being experienced.  It was noted further that the acute sector escalation beds had remained largely open all year rather than as originally planned just for winter only.  It was reported that the A & E performance across Lincolnshire was below the national standard with Lincoln County and Boston Pilgrim consistently underperforming against the 95% four hour treatment target.

The Committee was advised that the Lincolnshire 2016/17 Winter Plan had been produced by the Urgent Care Team with contributions from partners across the health and care community.  The Plan had then been reviewed by key partner organisations to ensure its robustness.  It was highlighted that there was an expectation from NHS England and the NHS Improvement that a robust system wide plan was in place for each winter.  The A & E Delivery Board also had to have assurance that all commissioner and provider plans evidenced both individual organisation and system wide congruence and resilience.

In summary, the Committee was advised that the plan described how the system was aiming to manage pressures by:-

·         Improvements in acute hospitals concerning bed flow processes; Emergency Department efficiency and to fully implement ambulatory emergency care and SAFER (Senior review: that All patients have discharge date, Flow, Early discharge; Review);

·         That community services and the local authority would be focussing on enhancing capacity and reablement to avoid admissions and speed up complex discharges;

·         That commissioners would be focussing on driving greater throughput at treatment centres; and ensuring that demand management schemes were effective in reducing Emergency Department attendance; and

·         That there would be a collective effort focused on managing complex medically fit patients within a fewer number of days; and that there would be improvement's to support, and divert greater number of the over 75 year of patients outside of the acute hospital.

The Committee noted that Delayed Transfers of Care had shown some improvement; however, there had been a slight increase in the figures for August. 

It was reported that both the Surge Plan and Escalation Plan and the Winter Plan had recently been updated.  It was highlighted that unlike in previous years, there had not been any additional central government funding for winter pressures, as the sums had been included in each CCG's base allocations.  As a result investment in the system had been agreed through the System Resilience Group (now called the A & E Delivery Board) with funding decisions being made upon consensus and evaluation of effectiveness of previous schemes, and in setting the A & E trajectory.

The preventative measures planned as part of the winter response included:-

·         Preventative measure such as flu prevention; campaigns for patients and staff.  Particular reference was made to national advertisements for example the NHS 'Stay Well This Winter Campaign' aimed at patients and service users to manage themselves; and who to contact for advice and support.  The Committee noted that the above said campaign had not yet commenced;

·         Joint working arrangements between health and social care to help prevent admissions and speed up discharges.  The Committee noted that the SAFER bundle would help support people to be discharged from hospital sooner and that their care would be planned, and supported by Adult Social Care.  The system was however very dependent on early consultations and ward management.  This was an area that had highlighted a variance across sites.  Reference was also made to Neighbourhood Teams working in a multi-disciplinary way to provide more joined up care.  This meant that people would be treated and cared for nearer to home where possible; and would only be admitted to hospital when necessary;

·         Ensuring that there was operational readiness, for example bed management staffing.  It was noted that patient flow was reviewed on a daily basis; and that a further ward was being opened at Lincoln County comprising of 21 step-down beds.  The Committee noted further that plans were in place to operate seven day working, as Pharmacy was an area of concern.  It was reported that £1 million had been allocated to support additional nurses at ULHT; as recruitment and retention was a challenge;

·         The delivery of critical and emergency care services;

·         The delivery of out of hours' service;

·         Ensuring joint working with the ambulance service, particular reference was made to the handover of patients from ambulance to acute care; and strengthening links with A & E and primary care; and

·         Ensuring that a strong and robust communication strategy was maintained across the system.

In conclusion, it was reported that the A & E Delivery Board would do its utmost to mitigate impacts within existing resources and that operational arrangements would assist in this matter.

During discussion, the Scrutiny Committee raised the following points:-

·         Clarification was sought concerning the policy regarding integration and the reduction in the number of beds.  The Committee was advised that beds had previously reduced from 1005 to 950; the emphasis was to get the right staffing levels for the number of beds.  It was felt that there would be enough beds, as there had been a reduction over the last two years, as a result of the NHS being able to switch the use of beds.  It was highlighted that there was a focus on seeing patients once instead of multiple assessments; and this was being introduced as part of the integrated working in some wards i.e. the SAFER bundle.  There was however, some inconsistency currently, as the principle had not been implemented in all wards as yet, it was therefore still work in progress.  The methodology had been trialled first, once this had been reviewed and lessons learnt had been looked into, the concept would be rolled out further.  The Committee was also advised that the inconsistent approach was being dealt with and that there was an action for social care and health colleagues to engage early in the process;

·         One member acknowledged that changing the name of the System Resilience Group into the A & E Delivery Board had been a national requirement, but it was understandable that these changes might lead to some confusion;

·         The top of page 36 listed a number of schemes to address some of the challenges within urgent care.  One member enquired as to whether the schemes listed and their funding were as a result of new funding, or whether those listed were as a result of re-allocated funding.  The Committee was advised that there was no additional specific funding for Winter Resilience, as the funding was now included in the overall allocation to each CCG, from which an amount was allocated for Winter Planning;

·         Page 36 paragraphs 2 and 3 relating to bed reduction.  The report highlighted that the United Lincolnshire Hospitals NHS Trust planned to establish a number of existing escalation beds on the Lincoln and Pilgrim sites and to increase the core bed stock.  It was highlighted further that it was proposed to operate a step-up; step-down approach to mitigate need; 

·         Page 37 – Clinical Assessment Service – One member enquired as to whether the service was up and running to its full extent.  The Committee was advised that the system was not quite fully operational, as there had been some technical issues regarding the transference of calls, and as a result Lincolnshire was leading on this matter nationally to establish the pathway software; and licence to be used locally.  One member provided the Committee with information relating to their personal experience of the 111 service; and in conclusion advised that the system needed fine tuning and that staff answering calls needed to have up to date information relating to local service provision.  Others echoed this observation, and advised that some callers knew how to work the system to ensure that an ambulance arrived.  The Committee was reassured that the issues raised would be passed back, to ensure that the directory of service provision was updated.  It was also highlighted that the script used for the 111service was a nationally agreed script;

·         The need to get GP services in front of A & E, to capture patients who did not need A & E services.  The Committee noted that this was currently work in progress, however, it was highlighted that there was no capital available to help with the alterations;

·         The need to recruit more staff.  The Committee was advised that ULHT had had some challenges recruiting nurses; and that there had been an increased reliance on agency staff.  However, there was now an increase in the number of nurses in training.  The Committee noted that Lincolnshire had been successful in securing funding for a pilot scheme from the Nursing Association which was due to commence in January 2017;

·         Pharmacy seven day working – It was reported that seven day working included hospital pharmacies, as this would provide a better overall experience for patients;

·         Operation cancellations due to pressures – It was highlighted that on some occasions, cancellations did happen on the day of an operation; but whenever possible, this would be avoided; and

·         One member enquired as to whether the ambulance service was involved in the Plan.  The Committee was advised that the ambulance service was involved in arrangements and that last year the service was involved as winter navigators which had involved paramedics; and that this had worked very well.  It was highlighted that a new process was to be introduced at Lincoln and Boston was to encourage patients that were able bodied to book themselves in rather than the ambulance driver, this would then free up ambulance drivers time.

The Chairman extended thanks on behalf of the Committee to officers and advised that the Scrutiny Committee would be looking forward to a further update in the New Year.

RESOLVED

That the update concerning the planning for Winter Pressures across Health and Care Economy in Lincolnshire be noted.