SURGE PLAN (A&E Sustainability Plan) for Wolverhampton Health Economy 2013/14

Transcription

1 SURGE PLAN (A&E Sustainability Plan) for Wolverhampton Health Economy 2013/14 Acute Trust: CCG: Local Authority: Mental Health: Community WiC: OOH provider: Ambulance Svs: CCG Partners: Royal Wolverhampton NHS Trust (New Cross), Type 1 A&E & Type 3 A&E (Phoenix Walk in Centre) Wolverhampton Clinical Commissioning Group (WCCG) Wolverhampton City Council Black Country Partnership Foundation Trust Showell Park Walk in Centre Primecare West Midlands Ambulance Service South East Staffordshire & Seisdon Peninsula Contact Details for further information: Dee Harris, WCCG deeharris@nhs.net or

2 Contents Executive Summary Assurance Report... 4 Governance... 4 Recovery plan content PURPOSE BACKGROUND ANALYSIS OF THE PROBLEM SUMMARY OF THE KEY ISSUES Actions to address the key issues Prior to A&E Within A&E Flow out of hospital GOVERNANCE Communication and ownership Senior/exec level ownership Urgent Care Board (UCB) Mechanisms to share knowledge, learning and best practice Contractual Monitoring and Levers Quality Financial and Clinical Risk Mitigating Financial Risk Mitigating Clinical Risk (service and delivery) Risk Log Emergency Planning/Scenario Testing MONITORING AND RESPONDING TO THE URGENT CARE SYSTEM Workforce Planning TRAJECTORIES A&E 95% trajectory and performance to date A&E ambulance turnaround/handover Crew Clear - Performance Utilising data RCMT 2 x daily reporting Daily communication Collaborative working Use of 70% retained tariff/winter Pressures money SURGE PLANNING Mental health

3 6.2 Community Pressure Ulcers Community Based Schemes admission avoidance Integrated Social Care and Capacity Team Walk in Centre WMAS Frequent Service Users (FSU) Patient communication MEDIUM TO LONG TERM PLANS Urgent Care Strategy Primary Care Strategy CONCLUSION Appendix 1 - RECOVERY AND SUSTAINABILITY PLAN Appendix 2 RWT Analysis of the Problem Appendix 3 Terms of reference for UCB Appendix 4 Mental Health A&E Escalation Process Appendix 5 RWT Diagnostics Appendix 6 Commissioning Stocktake Appendix 7 South East Staffs and Seisdon CCG Appendix 8 Stakeholder sign off

4 Executive Summary Assurance Report In reply to the Area Team response to Gateway ref 00062, Wolverhampton Health Economy has developed the following A&E Recovery and Sustainability Plan 2013/14. This plan has been compiled in partnership with all stakeholder organisations who have committed to working together to ensure capability and capacity to deliver a safe, sustainable & quality service which is responsive to patient demand throughout periods of pressure. Parts of this assurance report may be replicated in the body of the main plan. This plan is owned at a senior level by the relevant executives and clinical leads from all the organisations. This includes executive directors leading on urgent care for all key stakeholders. This plan feeds into, and is supported by, each of the individual stakeholder plans for surge and capacity management. In specific response to the Area Team feedback on version 1 submitted on 28 May 13, Wolverhampton Health Economy have tailored this assurance report in line with the framework by which the CCG were assessed. Feedback from the first iteration indicating level of assurance provided at first submission is highlighted below. Governance ASSURANCE FRAMEWORK Urgent care boards established around each A&E unit that regularly meets and has representation of all stakeholders across the health economy ( Assured) All A&E departments covered by Urgent Care Boards ( Assured) LOCAL HEALTH ECONOMY RESPONSE The local Urgent Care Board (UCB) has a history of working collaboratively over the last 12 months with membership representative of a wide range of stakeholders. The terms of reference have since been revised to include membership from a patient representative and the local mental health organisation. Alongside this the responsibility of the group has been widened to capture the recommendations as set out in the gateway reference The Board meet monthly and have representatives at executive, director and senior manager levels to ensure ownership of this plan and the actions within it. This is paramount to ensuring the health economy work together especially where organisations are dependent upon each other. The UCB formally reports to WCCG Governing Body. Further detail can be found in section 4 with the terms of reference detailed in Appendix 3 The main acute trust, Royal Wolverhampton NHS Trust is the single main provider of acute health care and is coterminous with the local authority, Wolverhampton City Council. Black Country Partnership Mental Health Trust is the main provider of mental health services. The UCB covers the geographical area of Wolverhampton including the main Acute provider. However, due to the geographical nature of the South East Staffs and Seisdon Peninsula CCG and the use of acute services by patients 4

5 living within this catchment area, clinical and managerial representatives from South East Staffs and Seisdon Peninsula are also members of the UCB and play a key role in shaping the service provision. Clarity and responsibility for communication and escalation between providers, urgent care networks and the commissioner ( Assured) Recovery and Improvement Plans owned by senior representatives of all stakeholders at Urgent Care Board level with involvement from local government, NTDA, Monitor, ECIST team, CQC (Partially Assured) Mechanisms in place to share knowledge, learning and best practice across the local health economy, involving stakeholders such as TDA, Monitor, IST (Partially Assured) The main body of the plan covers the communication both internally within organisations and between the wider health economy. The UCB will be using recently developed data dashboards to ensure regular monitoring of activity levels to enable speedy response. This plan has been discussed in detail at the June and July 2013 UCB. This plan is signed off by senior representatives of all stakeholder organisations. RWT worked with the TDA and ECIST have reviewed their action plan and commented favourably. RWT will be inviting ECIST in formally at a later date to review the outcomes of the action plan and offer additional support required Wolverhampton health economy is represented at the Black Country Urgent Care Group where there are opportunities for learning from experience and sharing best practice. The Black Country winter wash up was an opportunity to bring key stakeholders together to share learning from last Winter, whilst the local Winter wash up focussed on the challenges faced specifically here in Wolverhampton. The local Surge group will review the practical challenges experienced at times of pressure and this will be fed into the UCB for consideration when redesigning services. The local health economy will be utilising locally developed dashboards alongside the data analysis relating to causes of pressure that the CCG has commissioned from the CSU. See section 5.3. A monthly performance review is held with the TDA at which the RWT Chief Operating Officer is in attendance. The acute action plan has been shared with the TDA has been approved following consultation with ECIST. RWT welcomes any support from ECIST to support the health economy review and identify any further improvements for the whole health economy. Plans provide assurance that risks are mitigated and all safeguarding measures are in place which comply with the Francis recommendations (Partially Assured) WCCG, as host commissioner, has invested in a quality of care improvement scheme with RWT across the entire organisation including A&E and Urgent Care. This scheme directly addresses a number of the issues highlighted in the Francis Report. For further details around quality please see section 4.5 5

6 Recovery plan content The recovery plan, including timescales, responsibility and expected outcomes can be found in appendix 1. ASSURANCE FRAMEWORK Coordinated programme of action by providers and commissioners consisting of a series of performance improvement programmes (Partially Assured) LOCAL HEALTH ECONOMY RESPONSE The action plan detailed in Appendix 1 is a combination of actions by all stakeholders including RWT, Black Country Partnership Foundation Trust, Wolverhampton Local Authority and community providers, all overseen by the commissioner. The schemes specific to RWT which are aimed specifically at a programme of action which are not funded in addition to the contract and are not dependent on other organisations will be managed by the Trust. All the remaining schemes will be coordinated by the commissioner with clear project plans, start/end dates and are outcome driven. Building on the good performance of the acute trust, trajectories have been set (see section 5.2) Close monitoring by Commissioners and performance management will be key to ensuring the health economy obtain maximum benefit from the investment. Details on what each scheme will deliver and how it improves the system performance can be found in Figure 5 & 6 in Section 5.7. Justification for rolling over schemes from 2012/13 can be found in Appendix 1 Plans demonstrate credible and robust trajectories (not assured) Plans demonstrate actions for immediate recovery of A&E performance, winter planning measures and sustainable improvement (Partially Assured) Trajectories agreed with commissioners can be found in section 5.2 RWT have reached the contractual target of 95% for Type 1&3 combined for Q1 2013/14 as per the NHS Standard Contract and met the annual target for 2012/13, one of the few to do so. The schemes described in Appendix 1 are the result of local discussion and evaluation of investment from Winter Pressure schemes in 2012/13. The strategic attempt of these schemes is to maintain the urgent care system, achieve the average 95% whilst creating some headroom at periods of reduced pressure on services. A number of schemes were not deemed to have had a significant impact on addressing pressure within the A&E department and have therefore not been carried forward. Commissioners and providers have confidence that those schemes carried forward will have an impact, and as such, a number of the schemes will be funded for a full year effect whilst others will be implemented in time for winter pressures. Where schemes from 2012/13 have been carried forward, those with the potential for the biggest impact on pressure have been prioritise for early implementation 6

7 Actions proportionate to the degree of risk in achieving recovery and sustaining delivery base on historic trust performance (not assured) The Acute Trust has a history of strong performance against the target despite increase in activity from both walk in patients and those conveyed by WMAS. Further analysis of the activity can be found is section 3 and Appendix 2 The analysis in appendix 2 has sought to identify areas of weakness/pressure and as such the detailed actions and investments are specifically aimed at maintaining achievement of key performance indicators for 2013/14 The financial risk to all stakeholders has the potential to be significant but the clinical risk to patients is paramount and as such, as a result of the analysis, senior representatives across the health economy have invested in both workforce (clinical and managerial) and 3.072m investment in schemes/projects that the stakeholders are confident will reduce pressure in existing and predicted pressure points. With a number of schemes not commencing until Q3/4, this gives increased assurance that the system has the flexibility during the winter period. See section and for further detail Plans show prioritised deployment of ECIST teams and other improvement support to the most challenged health economies (not assured) Plans are informed by preexisting actions agreed by the relevant sector regulators (NTDA, Monitor) for recovery and sustained delivery of the A&E 4 hour target (Partially Assured) Plans address the necessary actions on ambulance diverts policies, ambulance handover delays and crew ready (not assured) As indicated earlier, ECIST will be invited in as agreed at the UCB. A monthly performance review is held with the TDA at which the RWT Chief Operating Officer is in attendance. The acute action plan has been shared with the TDA has been approved following consultation with ECIST. RWT welcomes any support from ECIST to support the health economy review and identify any further improvements. RWT worked closely with the TDA and have agreed/approved their action plan. TDA shared the RWT plan with the ECIST. RWT are in regular contact with the TDA around all aspects of performance including the action plan. Commissioners have an established process whereby regular data monitoring of the ambulance hand over and crew ready reporting is monitored and fines are issued according to the NHS contract see section 4.4 (contract monitoring) & section 5.2 (Ambulance related activity monitoring). As this process for implementing the fines was down to local determination, commissioners agreed a two month bedding in process to ensure systems and procedures were in place to accurately measure and monitor these targets. During April and May, activity against the targets began to show improvement however since 1 June, when fines were imposed activity against these targets have significantly improved. See section for further information. With regards to ambulance divert policies, Wolverhampton is part of the Black Country ambulance divert scheme see section 6.5 7

8 Plans consider 7 day working and simplification of urgent care pathways (Partially Assured) The Acute provider is committed to fully introducing 7 day consultant working in all key clinical specialities Progress thus far is good and robust action plans are in place for the introducing of 7 day working in those specialties where to date it has not been feasible to fully implement 7 day working. The emergency department has 7 day consultant working well established, with consultant presence in the ED rostered until 11.00pm and beyond when demand requires extended consultant presence. It is planned to introduce a second consultant on site out of hours from Q following successful recruitment of additional consultants. The Acute physicians currently provide consultant presence in AMU 6 days a week, this will move to 7 days in Q4 following recruitment of additional consultants later this year. Within the main medical specialties 7 day consultant working is well embedded in Gastroenterology, Diabetes and Renal. 7 day working was introduced in Respiratory in February 2013 and good progress is now being made with enhancing patient care and supporting patient flow and discharges arrangements. Acute Stroke consultants also provide 7 day consultant working on the Acute Stoke unit, but as yet 7 day working has not been introduced in Care of the Elderly due to consultant numbers. A recruitment plan is in place which targets key individuals who would strengthen the CoE team. Surgical Specialties also have achieved 7 day working, with consultant presence on site at weekends for General Surgery, Orthopaedics, Gynaecology and Cardiology. Paediatrics also provide a 7 day service. In addition to this the acute trust has also strengthened both clinical and non-clinical support services to support this extended way of working. Pharmacy now provides full day opening at weekends and key therapy services also provide routine services 7 days per week. With effect from Autumn 2013 the fully integrated Health and Social Care Patient flow team will also be working 7 days per week to help facilitate patient discharge of 7 days. The acute trust has also recently started to consider how access to appropriate diagnostics could be facilitated over an extended working week. The urgent care strategy for Wolverhampton which is currently being finalised aims to reduce the multiple access points into the Urgent Care System. Supporting this is the access for urgent referrals, predominantly from GPs into the Acute Trust. To streamline and simplify this, the health economy has developed Wolverhampton Urgent Care Triage Access Service (WUCTAS). Following referral to WUCTAS they ( as in WUCTAS) have the ability to streamline referrals 8

9 to other points of access, e.g. community nursing and also other specialist services such as Respiratory Hot Clinics in the community and diagnostics. Part of the on-going development in this financial year is the extension of WUCTAS to include Social and Surgical along with access to urgent outpatient appointments (see WUCTAS v2 scheme detailed in Figure 6, under section 5.7 Plans demonstrate triangulation between e.g. admission avoidance, CIPS, workforce, Non-elective admissions, LOS and DTOC (not assured) None of the CIP plans for RWT plan to reduce workforce or impact on the quality of service provision in emergency care. A number of schemes are in place to reduce LoS across medical specialties and this should facilitate smoother transition of patients through emergency care. The impact of the Integrated Patient Flow team is beginning to take effect with a reduction in the DToC rate which is now running at approximately half the rate seen this time last year. WCCG and RWT working together on a number of community based admission avoidance schemes (see appendix 1) This includes redesigning the traditional A&E front end. For example: Paediatric Hot Clinic and Primary Care alongside A&E. Plans mention contractual agreements associated with R&IPs with timescales for recovery and sustained improvement of the A&E 4 hour standard (not assured) Plans mention the deployment of contractual levers (fines for breaches) in connection with under performance (not assured) General comments Action plan submitted is already self-assesses as amber and red in large number of actions. AT assurance says RAP in place but local system plan says TBC. Not clear how improvement support is in place or used. Current performance is one of the worst in the region and action plan does not give sufficient confidence improvement trajectory will There is a commitment to delivery against this plan which is agreed across the local health economy and will be subject to close performance monitoring to ensure sustained improvement There are already contractual agreements in place, should these be required. The Urgent Care Board does not envisage creating any additional contractual service variations. There are clear penalties for commissioners to enforce against agreed national targets See section 4.4 for further detail. The CCG have a process in place to closely monitor activity against the contract. Reporting formally to internal groups and fining providers accordingly. Current performance is one of the worst in the region [This comment has now been rescinded and has been identified as factually incorrect] Action plans have been substantially revised and concerns addressed. Wolverhampton Health Economy is one of the better performing in the region. Trajectory to achieve 95% was challenging to achieve however the trust have achieved 95% for Q1 13/14 therefore no contractual breaches have occurred Additional winter pressure beds Whilst RWT have access to the same number of winter pressure beds as last year, it is noted that this year we have implemented a number of admission avoidance schemes and RWT are working in partnership with the Social Care on an integrated capacity team (see section 6.3) and with additional resources invested in therapy services in A&E, AMU and 9

10 be achieved. step down, there is confidence in the system that demand for bed capacity this year is manageable. Already we have seen a reduction in the use of step down facilities resulting in increased access to spot purchased beds if suitable. However, RWT plans are dependent on other parts of the health economy ensuring implementation of their surge schemes. The Trust has limited additional capacity it can open due to environmental (physical space) and human constraints. There are plans in place to ensure that additional beds can be opened, however activity increases above prediction or serious infection control outbreaks which affect length of stay could affect bed availability. 10

11 1. PURPOSE The purpose of this report and attached A&E recovery plan is to put into context the issues faced by Wolverhampton Health Economy, and in particular the Acute Trust in respect of activity levels, admission rates and the impact on quality targets in A&E. This plan will be reviewed regularly with the next review being undertaken before 31 August See appendix 1 for further details of schemes. 2. BACKGROUND Wolverhampton Health Economy has experienced unprecedented demand on its urgent care services which is reflective of trends across the country. This demand has steadily grown over recent years resulting in winter pressure wards remaining open throughout the summer of 2012/13. Performance against the 95% quality indicator at RWT has historically been good. RWT has never previously failed to achieve the target in any one year or in a quarter. It achieved the contractual target for the year 12/13. However, they did not achieve the target for quarter 4 in 12/13. Performance in the Type 1 A&E has faced considerable challenge throughout the year and in particular over the final 2 quarters of the year. During this period, type 1 only managed to achieve the 95% standard in 1 month. See figure 1 below Figure 1 performance comparison for Type 1 and Type 1&3 combined Performance is also consistently below that of 11/12. This can in large parts be explained by the increase in attendances that the department has seen. However, the actions taken to date have started to see an improvement in performance with the 2013/14 performance showing an improving trend. Figure 2 A&E performance year on year comparison 100% A&E Performance - Yearly Comparison 98% 96% 94% 92% 90% Target 2011/ / /14 88% 11

12 3. ANALYSIS OF THE PROBLEM To enable targeted interventions, an analysis of the pressure in A&E has been undertaken. Further detail can be found in Appendix 2 In summary, attendances at A&E have increased by 5,000 when compared to the previous year (2012/13 v 2011/12), an increase of over 5%. In addition to this, ambulance conveyances to the Trust have also increased significantly over the same period. There have been in excess of 2,051 more ambulances conveyed to the A&E department when compared to the previous year, an increase of over 5.4%. The % increase into RWT Type 1 A&E is consistently higher than the WMAS average, since October 2012 ambulance conveyances have increased 5.8% into RWT against a 1.1% WMAS average. This equates to an extra 43 ambulances per week into RWT based on this period The increase in ambulance conveyances has a disproportionate impact given that the admission rate for patients arriving via ambulance in Q1 is over 45.7%, compared to standard admission rate via A&E at 18.6%. The pressures in A&E are felt across the Trust as admissions increase, this leads to increased demand for beds following admission that in turn has resulted in fewer beds being available for elective care. There has been a dramatic spike in the number of cancelled operations due to lack of beds. This is despite the Trust having opened in excess of 70 beds across the hospital (New Cross and West Park) 3.1 SUMMARY OF THE KEY ISSUES Increases in ambulance conveyances Increases in A&E attendances Increase in admission rates from A&E department, assumed to be due to increased complexity/co-morbidity of patients Some evidence of increase in attendances/admissions in out of hours periods after 6pm and weekends. In addition to this analysis, recent delays with regards to patients requiring mental health assessment and/or admission have highlighted the further work required to ensure a quality, prompt and responsive service for this patient group is essential to ensure care is not compromised See section 6.1 for further details. Delayed discharges are at present a periodic issue and not a major system problem, although there is some evidence of delays for patients in the Staffordshire regions. Learning has also been taken from both the local and regional winter wash up events where multi agency input has enabled the local health economy to better prepare for the anticipated surges in activity. 12

13 3.2 Actions to address the key issues In order to address the key findings identified in section 3.1, the Urgent Care Board has defined the following three areas of priority Prior to A&E The health economy has embedded successful projects from last year and developed new A&E avoidance schemes to alleviate pressure on increased A&E attendance Within A&E Increases in staff, 24/7 working and increased support to diagnostics and ancillary services to address rising admission and increased complexity of patients presenting. We are piloting additional psychiatric support (mental health assessment) in A&E and are putting additional resource into the crisis response team in-reaching into A&E Flow out of hospital Whilst delayed discharge is not a significant problem, we see spikes of activity and we have invested in additional step down and other intermediate care schemes to sustain performance. This sits alongside the successful work of the integrated discharge team (see section 6.3 for more detail) 4. GOVERNANCE Communication and ownership 4.1 Senior/exec level ownership In Wolverhampton the current Urgent Care Board (UCB) comprises of senior & executive level representatives with membership covering a wide range of clinical expertise, including Acute and Community clinicians, health and social care representatives, CCG executive and clinical leads, Out of Hours provider, West Midlands Ambulance, Mental Health, Public Health and CCG representation from outside of Wolverhampton (South East Staffs and Seisdon Peninsula) where a number of patients use the services of the local Acute Trust. In addition, at a local health economy level, Chief Executive/Chief Officer level representatives from key stakeholder organisations attend the Area Team Urgent Care Board. 4.2 Urgent Care Board (UCB) The recent work of this group has been the development of the city s Urgent Care Strategy which is currently in draft format and will be out for public consultation over the Summer of The work to date has involved analysis of current patterns of activity, finance and activity modelling, review of current provision across the city including Walk in Centres, GP Access in Primary Care, Out of Hours services and A&E activity. The overarching aim is to build an urgent care system that meets the patients needs, provides quality services, value for money and is sustainable. The UCB will be to oversee the implementation of the strategy and ensure the revised system meets all the objectives whilst not compromising on quality. 13

14 The terms of reference for the UCB (See Appendix 3) have been revised to address the recommendations in the Gateway reference In addition to the recommendations, Mental Health Service senior representative to be included in the membership. The Terms of Reference for the UCB have been agreed. In addition to its current remit, the responsibility now includes: Incorporate the sign off/ratification of this A&E Recovery Plan and any future iterations of this plan as and when required. Formally review the A&E recovery plan on a quarterly basis Oversee the implementation and monitoring of progress against the plan. This will also include prioritisation of schemes where required, maintaining a risk log and data monitoring review and approve bids from those funds retained from the 70% excess urgent care funds retained for the use of schemes to reduce pressure on A&E Using a locally developed dashboard, the group will undertake further diagnostics, monitor the changes to service provision/financial investment to ensure it has a positive impact on the wider quality metrics Close monitoring of the 4 hour target, A&E turnaround times and readmission rates. 4.3 Mechanisms to share knowledge, learning and best practice The UCB does not work in isolation. To support the work of the UCB, the local Surge Planning Group, consisting of GP clinicians, Acute Trust, WMAS, Mental Health, Local Authority and Regional Capacity Management Team will be the operational arm, meeting monthly and reporting to the UCB. This will also include membership from South East Staffs and Seisdon Peninsula, a neighbouring CCG outside of the Black Country Cluster. To ensure robust communication, across all Urgent Care networks in the surrounding area, representatives from the UCB are also members of the Black Country Urgent Care Group. This group is representative of all four CCGs and is an opportunity to look at best practice, share learning and develop/implement/monitor the impact of schemes at a Black Country level to achieve economies of scale. Reporting to Health and Wellbeing Board will be by exception on an adhoc basis at times where issues/challenges relating to the urgent care and/or primary care strategy requiring a collaborative solution Figure 3 below shows the interaction between the various organisations and lines of reporting and sharing information across organisational boundaries. 14

15 Figure Contractual Monitoring and Levers The CCG Business & Performance Team and Contracts Team are closely monitoring the activity and data against the operational standard as set out in the contract. If, prior to the Trust failing to meet the operational standard, performance against the operational standard becomes a concern, a Contract Query Notice will be issued via Clause GC9 Contract Management. This will enable early intervention where needed to rectify the issue. See figure 4 below depicting communication flows. In addition to formal contract levers, where concerns are raised with regards to performance against the operational standards/trajectories, the UCB will be responsible for submitting a revised recovery plan, specifically targeting the area of concern, along with a business case for appropriate funding to bring the performance back to agreed standards 15

16 Schedule 4 Quality Standards Operational Standards as defined in the Standard NHS Contract 2013/14 Ref Operational standards Threshold (2013/4) Method of measurement Consequence of breach Monthly or annual application of consequence CB_B5 Percentage of A&E attendances where the patient was admitted, transferred or discharged within 4 hours of their arrival at an A&E department Operating standard of 95% Review of service Quality Performance Report 2% of revenue derived from the provision of the locally defined services line in the quarter of underachievement Quarterly CB_S7a All handovers between ambulance and A & E must take place within 15 minutes Handover >15 minutes Review of monthly Service Quality Performance Report 200 per patient waiting over 30 minutes Monthly CB_S9 Trolley waits in A&E Any trolley wait >12 hours Review of monthly Service Quality Performance Report 1,000 per breach Monthly 16

17 Figure 4 CCG internal monitoring and communication If RWT fail to reach the operating standard, the contractual fines will be applied. 4.5 Quality Continued transparent and open quality monitoring relationship that is underpinned by contract management with levers and penalties imposed when appropriate. Scrutiny is routinely undertaken via the Quality Review process and enables consideration of performance, patient feedback, serious incidents, media interest - or potential for media interest. In addition, quality and risk profiles are closely monitored in conjunction with the regulator and area team as well as quality improvement evolving through investment, development, CQUINs and QIPP programmes. Investment in 7 day working, supernumery nursing cover and improving care outcomes are key priorities for the acute trust. The CCG will support the patient flow from urgent through a pathway to community services including care homes when appropriate. Each step of the way there is quality monitoring undertaken to assure the CCG. 4.6 Financial and Clinical Risk WCCG Risk Over performance against the contract last year (2012/13) for urgent and unplanned care resulted in a decision to contract at outturn for 13/14. It was felt that this would be a prudent step given the pressures faced in the system. If however levels of in year activity exceed this figure, the CCG risks not meeting its financial targets as flexibility within its budgets is limited. RWT Risk Contractually RWT only receives 30% of emergency tariff for all activity over an agreed baseline. Whilst the CCG is committed to reinvesting the 70% threshold monies back into the urgent care system this does pose a financial risk to the Trust as they do not 17

18 automatically receive the full tariff. This means that for the activity over and above baseline levels it is unlikely that costs are covered by the income received. In addition, there is a risk off failure to achieve elective contracts LA Risk The LA already faces a significantly challenging financial position and this means that it may be difficult for them to sufficiently meet the demands placed on their services in support of the urgent care system. For example, this has the potential to impact on timeliness of discharges, in particular if step down beds and other community based care packages are impacted Mitigating Financial Risk Collaborative working and close monitoring of performance by the UCB will ensure early action/intervention if required. The fining regime for providers will result in ring fenced funds being retained by the CCG, reinvested in areas of pressure. Extensions to the physical space in ED will result in fewer corridor delays and subsequent fines for handover delays. The patient flow programme seeks to reable patients to return to their usual place of residence in a timely way resulting in increased bed capacity Mitigating Clinical Risk (service and delivery) If urgent care services are overwhelmed then community and elective activity will be affected. There will be a risk to Referral to Treatment (RTT) or other similar KPIs not achieved and the potential for elective operations to be cancelled. As services are increasingly stretched the risk is that quality may be compromised. The quality schemes in place mitigate against this risk There is a risk of reputational damage for the Wolverhampton Health Economy if there are failures to hit the specified targets. RWT hit the 95% A&E contractual target for 2012/13 and also achieved Q1 13/14. To mitigate against the risk of failure, the UCB will monitor the system regularly whilst also developing the Urgent Care Strategy for the medium to long term sustainability of service provision 4.7 Risk Log The newly configured Urgent Care Board will develop its own risk log which will feed into key stakeholder s risk monitoring systems. This will become part of periodic monitoring and management processes. 4.8 Emergency Planning/Scenario Testing An established rota system is in place across the Black Country to deal with issues that arise out of hours. Sandwell City Hospital holds the rota and their switch board is the central point of contact for Acute Trusts. Providers can contact OOH on call rota by calling (SWB main hospital switchboard number). 18

19 For management of issues in-hours, a senior manager rota is maintained. The health economy contacts the administration team on who will ensure escalation to the senior manager on call to make direct contact with the relevant organisations. To ensure that the health economy is prepared for times of pressure, Wolverhampton Clinical Commissioning Group (WCCG) will be undertaking two scenario testing exercises in relation to emergency responsiveness. These exercises will be run in partnership with the Emergency Planning function commissioned from Public Health. The first of these exercises will cover the WCCG internal processes, and focus on ensuring that all senior managers/execs on call either in or out of hours utilise existing data to analysis the daily position and take appropriate action/intervention. The second of these events will then engage with all key stakeholders - RWT, Black Country Partnership Foundation Trust, Local Authority and WMAS. Data analysis will be undertaken to assess areas of pressure in A&E over the previous 6 12 month period and this will be used to set scenarios pertinent to our local health economy. This will provide the opportunity for the whole health economy to engage in establishing robust processes for managing surge across organisational boundaries. Both of these exercises will take place before 1 Oct 13 to ensure the system is prepared for the expected surge in activity over the Winter period of 2013/14 To support the senior managers/executives on call, both in hours and out of hours, technology is being developed to streamline the recording of information which will not only provide a robust evidence trail to support any root cause analysis but also provide a structured approach to ensuring a smooth transition between in hours and out of hours when issues have arisen. This technology will be in the form of an ios App to run on Apple devices (ipad, iphone) which will be accessible to both commissioners and providers. The app accesses local secure server storage to present a single version of live working documents to all parties. Instantaneous live updates can be added and all activity is recorded for review purposes. This will be piloted in Wolverhampton with the option to roll out across the Black Country in time for winter pressures. To ensure the whole health economy is prepared for emergency situations, the Emergency Planning Officer will be undertaking an exercise during 2013/14 to ensure capability to manage the delivery of health care provision when an emergency has been declared. All senior executives of the CCG undertook training in emergency preparedness. RWT undertook major incident practice earlier this year. 19

20 5 MONITORING AND RESPONDING TO THE URGENT CARE SYSTEM A number of actions are in place to monitor the system and mitigate risk. These are summarised below Action to mitigate risk Workforce Planning Setting trajectories Utilising Data to monitor the system including trajectories and EMS reporting Daily communication Enabling collaboration (surge and UCB) Investment (financially and physical resource) Scenario Testing Debrief when issues arise Response to pressure in the system Contractual levers including financial penalties Increase Bed Capacity Teleconference Responsive on call arrangements (in and out of hours) Exec to Exec problem solving where necessary 5.1 Workforce Planning Ensuring adequate workforce, both numbers and skill mix, is in place to meet demand is crucial. Workforce plans are discussed regularly via the modernisation programme and annual planning basis. 20

21 5.2 TRAJECTORIES A&E 95% trajectory and performance to date Current Performance, agreed delivery dates and trajectory Trust The Royal Wolverhampton NHS Trust 4 week rolling average 2012/ /14 Q1 Q2 Q3 Q4 YTD Q1 2013/14 Q1 2013/14 Q2 2013/ % 97.40% 96.50% 95.20% 94.01% 96.00% Forecast Actual Forecast 95.00% 95.10% 96.00% Q2 2013/14 Actual 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Trajectory - All Types Actual Performance - All Types Standard

22 Trajectory for whole year /14 Week Ending Trajectory - All Types Actual Performance - All Types Type 1 Trajectory Week Ending Trajectory - All Types Actual Performance - All Types Type 1 Trajectory QUARTER 1 QUARTER 3 07/04/ % 95.90% 92.6% 06/10/ % 96.2% 14/04/ % 89.10% 93.1% 13/10/ % 95.8% 21/04/ % 91.80% 93.6% 20/10/ % 96.1% 28/04/ % 95.10% 93.6% 27/10/ % 95.8% 05/05/ % 95.90% 93.6% 03/11/ % 95.4% 12/05/ % 94.60% 93.6% 10/11/ % 95.6% 19/05/ % 92.90% 93.6% 17/11/ % 95.3% 26/05/ % 95.20% 93.6% 24/11/ % 95.4% 02/06/ % 97.10% 93.6% 01/12/ % 95.3% 09/06/ % 97.50% 94.1% 08/12/ % 94.1% 16/06/ % 98.00% 94.1% 15/12/ % 93.7% 23/06/ % 95.00% 94.1% 22/12/ % 95.6% 30/06/ % 98.00% 94.1% 29/12/ % 95.7% QUARTER 2 QUARTER 4 07/07/ % 96.60% 95.7% 05/01/ % 94.7% 14/07/ % 95.80% 94.4% 12/01/ % 94.5% 21/07/ % 95.85% 94.6% 19/01/ % 95.1% 28/07/ % 96.5% 26/01/ % 95.0% 04/08/ % 96.6% 02/02/ % 95.4% 11/08/ % 96.7% 09/02/ % 95.2% 18/08/ % 96.5% 16/02/ % 95.4% 25/08/ % 96.2% 23/02/ % 95.3% 01/09/ % 96.1% 02/03/ % 95.5% 08/09/ % 95.9% 09/03/ % 94.9% 15/09/ % 96.1% 16/03/ % 94.6% 22/09/ % 96.4% 23/03/ % 94.3% 29/09/ % 96.5% 30/03/ % 95.1%

23 5.2.2 A&E ambulance turnaround/handover Month Ending actual performance min Handover mins & >60 mins - performance and trajectory Actual Performance 60min + Total fines Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 22,800 16,800 9,600 April Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 May June July 13 Aug 13 Sept 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb Handover (30-60 mins & >60 mins) April 13 May 13 June 13 July 13 Aug 13 Sept 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 March 14 March 14 Trajectory for >30 min handover actual performance min data source

24 5.2.3 Crew Clear - Performance Crew Clear - Performance Total fines Month Ending Crew clear in mins Crew Clear- 60min + Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep , April May June July 13 Aug 13 Sept 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Crew Clear - Performance 2013/14 Crew clear in mins Crew Clear- 60min + March 14 data source 24

25 Q1 performance for handover times (30 60 min and over 60 min) The data below shows handover breaches at New Cross Emergency Department (ED) for Q1. Time period of handover is recorded from when the ambulance arrives at ED (using either AVL data or geo fencing) to when the PAT release is pressed on the CAD. If no pat release is entered then the crew clear time is used as the handover time. The target for ambulance handovers is 15 minutes. Fines are, handover time minutes 200 and over 60 minutes min Over 60 min Total fines handover handover April ( 20,800) 2 ( 2000) 106 ( 22,800*) May ( 16,800) 0 84 ( 16,800*) June ( 9,600) 0 48 ( 9,600*) Total fines 236 ( 47,200*) 2 ( 2000)* * In the interest of all partners across the local health economy it was agreed fines will be enforced from 1 June 13 onwards as the system remained under pressure. Q1 performance for crew ready The crew ready time is managed robustly by WMAS through the local management team. The data below shows breaches on the time WMAS resources clear and are available for the next call after handing over in ED (as recorded by the PAT release. Target to clear after handover is 15 minutes. Fines are, clear time mins after handover 20 and over 60 minutes min to Over 60 min to Total fines clear clear April ( 660) 0 33 ( 660) May ( 760) 3 ( 300) 41 ( 1060) June ( 500) 0 25 ( 500) Total Fines 96 ( 1,920) 3 ( 300) The following table shows activity relating to PAT release which correctly captures the patients experience month on month. This demonstrates RWT and WMAS commitment to the process and shows positive progress month on month. PAT release for RWT A&E Apr-13 May-13 Jun-13 Jul % 90.00% 90.70% 91.30%

26 5.3 Utilising data The UCB will be utilising a locally developed dashboard which will provide executive/senior managers early indication of areas of pressure and potential breaches on all the quality indicators for A&E along with close monitoring of achievement against the trajectories as set out in section above. Close monitoring of activity, especially in relation to NHS 111 will be key to ensure patient flow is monitored and services adapted where required. Alongside this the separate CSU dashboard and analysis commissioned by CCGs across the Black Country will provide data regarding the cause of pressure. 5.4 RCMT 2 x daily reporting Close monitoring of the Regional Capacity Management Team escalation levels (1-4) will also be routinely undertaken with any of the key stakeholders able to call a teleconference. Consistent level 3 reporting over a 2 day period will trigger a teleconference, initially between RWT and the commissioner to establish the issue presenting issue(s). This will lead to a multi-agency teleconference if it is established that cross organisational involvement can resolve the presenting issue. 5.5 Daily communication In addition to the dashboard, a daily snapshot (circulated at approx. 12:00) of activity over the previous 24hours is circulated by the Acute Trust to executives at RWT, CCG, Local Authority and Mental Health. Reduced performance reported via this daily will trigger a multiorganisational teleconference at 13:00 to ensure awareness and ownership of local escalation issues at executive level. Responsiveness of organisations at the early stages will reduce the risk of breaches. 5.6 Collaborative working Black Country communication and engagement Collaborative working is key especially in areas where it relates to services commissioned on a wider footprint to that of the local health economy and/or where solutions are likely to be beneficial from both a clinical perspective and/or where financial economy of scale can be achieved. The Black Country is focused on the 4 distinct health economies that have their own hospital sites, local authorities, etc. It has been recognised that there are areas where it is helpful to collaborate and pool resources and skills. There is a Black Country Urgent Care Group that is GP led and includes stakeholders from across the Black Country (Acute Hospitals, the two local mental health trusts, West Midlands Ambulance Service, Dudley, Sandwell, Walsall and Wolverhampton local authorities, out of 26

27 hours providers, 111, Regional Capacity Team, as well as commissioners). The group meets on a monthly basis and acts as a forum for: Sharing good Practice from the local health economies and from beyond (Staffordshire s Emergency Care Plans shared July 2013 for example) Co-ordinating the winter wash up Linking local health economy plans and strategies so that other Black Country health economies are aware of actions that may impact on them To be a link to neighbouring health economies i.e. Birmingham and Staffordshire re changes that may impact on the Black Country To share broader activity information To carry out agreed projects that would apply across the Black Country Is in the process of developing a Black Country risk log to focus on areas of common risk Supporting the appropriate use and development of the regional escalation system in a consistent manner across the Black Country. Supporting this group is a Commissioning Manager who also takes a lead on a Black Country basis for WMAS and 111 and who works via Black Country wide groups to feed into Regional work and to be a point of contact and knowledge for local CCGs. Surge Pressure At times of surge there have been Black Country teleconferences. These have been put on hold as local teleconferences in each CCG dealt with local issues. A Black Country wide teleconference would be held in exceptional circumstances if requested by any health economy. West Midlands Ambulance Contract The Commissioning Manager attends the Regional Commissioning Group meeting for the Ambulance contract and feeds information back to the Urgent Care leads in each CCG as well as seeking any comments. On a local basis there is the Black Country Ambulance Commissioning Group that has local CCG s and WMAS staff monitoring the contract, quality indicators and acting as a forum for local ambulance issues. The notes of the meeting are shared at the Black Country Urgent Care Group for information and comment. 111 The Commissioning Manager attends regional meetings as required and also supports the Black Country 111 Clinical Governance Group chaired by a GP that monitors the contract and acts as the Black Country interface with NHS Direct/111. There is also a monthly call review meeting where approximately 5 calls per month are reviewed and any learning points shared. These meetings have been focused on particular themes i.e. Badger, Primecare, long call back times etc. 27

28 On both of these areas the notes are shared across the local CCG s. The Commissioning Manager also attends meetings as required whether local resilience forums or other groups to feedback on urgent care issues or 111/WMAS related issues. Black Country On call The Commissioning Manager facilitates the Black Country on call, organises the rota, and delivers training sessions as required. 5.7 Use of 70% retained tariff/winter Pressures money A number of schemes piloted in Q4 2012/13, which proved to be successful in reducing pressure on A&E services, have been identified for implementation in 2013/14 as part of this recovery and sustainability plan. Additional schemes, some of which have not yet been trialled, will also be implemented in 13/14. Funding for these schemes will be from both the 70% readmissions money ring fenced for reinvestment in urgent care services, and the Winter Pressure monies anticipated from NHS England in Q3 2013/14. Funding stream Total Value 70% readmissions money 1,676,000 Winter Pressure money 1,396,000 Total investment 3,072,000 The UCB are tasked to review the data and activity and, if performance dips from the required standard, the UCB will develop business cases in year and submit to the CCG for the use of the remaining 70% emergency admissions retained tariff to target areas of pressure in the system. Bids for funding will be reviewed by the CCG Business and Performance Team and signed off by the CCG Governing Body. For a full breakdown of these schemes against the likely funding stream, see figure 5 use of 70% emergency admissions & figure 6 use of winter pressures detailed below. The same schemes are also detailed in Appendix 1 where they are broken down in to the following four categories: Schemes to reduce attendance/admission prior to attending A&E Schemes targeting flow within the hospital (Acute Trust actions - non funded Schemes targeting flow within the hospital (Funded from 70% emergency threshold/winter monies) Schemes targeting discharge out of hospital 28

29 Figure 5 schemes to be funded from ring fenced 70% emergency admissions money Name of initiative Cardiology In reach to EAU (carried over from 12/13) Cost 180,000* Dates of operation 7th Jan onwards Short description of initiative Increase availability of additional diagnostic support at weekends to assist with discharge planning Methods of monitoring effectiveness of initiative Achievement of A&E targets. Reduced turnaround delays. Improved response times Data Required/ Benchmark data A&E 4 hour target RWT (quality indicator - past 12 by months) Breeches of the 4 hour target this needs to be added to the CVO to request data as detailed Breech data is only available from RWT Number of patients seen at weekends by the cardiac physiologist Target Reduction in wait times across service from request to diagnostic tests being undertaken and reported at weekends and across week due to knock on effect of increased access Sustained achievement of A&E 4 hour target 95% of patients Lead name/organisatio n Jonathan Odum Medical Director - RWT Additional Support for resolving Step Down Pressures (Carried over from 12/13) 150,000* Q1 & Q4 To enhance the social work capacity within step down facilities to assist with the planning of care for discharges and reducing delayed discharges. Joint development with SW support to reduce the number of step down beds Reduction in length of stay in step down facilities Reduction in number of step down placements Length of step down stays for completed episodes Number of step down placements Less than 30 days by Sept 2013 for Wolverhampton residents awaiting Social Care support (Baseline activity proxy of 44) Less than 40 by Sept 2013 (Baseline activity 58 placements for Wolverhampton residents awaiting Social Care support) Jonathan Odum Medical Director RWT Anthony Ivko Assistant Director for Older People and Personalisation - LA 29

30 Weekend pharmacy cover (Carried over from 12/13) Ambulance nurse triage (carried over from 12/13) Wolverhamp ton GP in a car (Carried over from 12/13) 64,000* Full year 200,000* Full year 300,000* Q1,3 &4 through more appropriate placement and review the strep down process Additional opening hours and pharmacy provision at weekend to ensure all discharges can be completed in a timely manner. Additional nursing support to ensure that ambulance handover can take place as soon as possible on arrival to the A&E department. Prevents delays to ambulance handover. Carried forward from 12/13: Work in collaboration with the Black Country Achievement of A&E targets. Reduced turnaround delays. Improved response times To support the achievement of the ambulance turnaround/hando ver time at RWT A reduction of ambulance dispatches for associated activity (Primary Care/low priority calls). Review the project impact against emergency attendances Additional Saturday afternoon opening from 12/1/13 Number of discharges facilitated by extended opening service Ambulance handover time at RWT by month A&E attendance activity (past 12 months) by WMAS Ambulance conveyance rates to A&E for low priority Increase in number of discharges facilitated by extended service opening Reduction in delayed discharges due to unavailability of drugs etc 100% of clinical handovers to be completed within 30 minutes of recorded time of arrival at A&E. A 1% reduction in low priority conveyance (G2 category) to RWT Jonathan Odum Medical Director RWT Jonathan Odum Medical Director RWT Richard Young Director of Strategy & Solutions - CCG 30

31 Therapy services Rapid Response Plus: (carried over from 12/13) 282,000* Full year Therapy services in reach into A&E for extended hours: Therapy services in reach into EAU: Therapy services support in step down provision Pilot run over winter period results for four months were positive: To increase patient flow Reduce delayed discharges Decrease LOS in step down facilities Current pilot will provide benchmark data Measure LOS in stepdown Monitor DTOC Dependent on baseline, reduce delayed discharges and LOS by 15% (TBC) Richard Young Director of Strategy & Solutions CCG Anthony Ivko Assistant Director for Older People and Personalisation - LA Community Geriatrician (Carried over from 12/13) 150,000* Full year Actively responding to patients admitted from Nursing Homes to facilitate speedy discharge Monitoring the number of contacts and speed of discharge Benchmark is zero as not previously available. Measure number of contacts Speed of discharge Reduce the LOS for patients admitted from Nursing Homes and progressively decrease delays in discharges (base line to be established Jonathan Odum Medical Director RWT Mental health practitioner presence in A&E along with additional clinical staffing in 150,000* (% from recurring funds) This scheme will be funded Q1&Q2 This is to provide additional support at weekends and after 5pm weekdays to reduce the numbers of patients whom could breach whilst waiting for a psychiatric Improved quality through reduction in response times for specific mental health patients (i.e. self-harm): Increase in achievement of A&E attendance activity (past 12 months by month) A&E 4 hour target RWT (quality indicator - past 12 by months) Breeches of the 4 hour target (reasons relating to 10% reduction in breeches relating to specific mental health conditions at A&E Improvement in response times to A&E department for patients requiring Jonathan Odum Medical Director RWT John Campbell Chief Operating Officer - BCPFT 31

32 the RAS team (carried over from 12/13) Senior medic in A&E 24/7 (Carried over from 12/13) from a combinatio n of both 70% emergency threshold and winter pressure money 200,000* Full year assessment. We will be commissioning this service from one of our local mental health Trust providers who already operate an established in-reach service into A&E. this initiative will build additional capacity on this pressured service. Additional senior decision maker in A&E department to ensure appropriate treatment of very ill patients and ensure that the department has senior leadership, not just on call cover out of hours. A&E 4 hour target Reduced breeches at A&E. To support the improvement in decision making in A&E for admissions and discharges and associated measures. specific mental health conditions including selfharm) this needs to be added to the CVO to request data as detailed Breech data is only available from RWT A&E 4 hour target at RWT (quality indicator - past 12 months) 10pm-6am Quality Measure, Time to see a clinician (12 months) 10pm-6am Outcomes data: admitted to hospital bed & discharged from A&E between the hours of 10pm and 6am (by week) Mental Health Assessment 10% improvement in time to first assessment between 10pm and 6pm Jonathan Odum Medical Director RWT 32

33 Figure 6 Schemes to be funded from Winter Pressures Money Name of initiative Additional portering capacity (Carried over from 12/13) Locum Radiologist (Carried over from 12/13) Cost Dates of operation 90,000* Q3 & 4 82,000* Q3 & 4 Short description of initiative The additional costs of portering are due to increased volumes of A&E attendances and resultant admissions with ambulance transfers up to 20% higher than last year. The additional porters will ensure the timely transfer of patients from A&E to wards. To increase the weekend availability of radiologists Methods of monitoring effectiveness of initiative Reduction in delayed discharges Increase in capacity through acceleration of throughput. Achievement of A&E targets. Improved response times Data Required/ Benchmark data Reduction in number of four hour breaches A&E 4 hour target RWT (quality indicator - past 12 by months) Breeches of the 4 hour target this needs to be added to the CVO to request data as detailed Breech data is only available from RWT Number of additional patients seen Types of scans undertaken Target 0 delays in patient transfers within and from New Cross Reduction in waiting times from request for diagnostic test to reporting results across service across week due to knock on effect of increased access. supporting achievement of A&E 4 hour target 95% of patients Lead name/ organisation Jonathan Odum Medical Director RWT Jonathan Odum Medical Director RWT WUCTAS v2 (new scheme) 25,000* Q1, 3&4 Extend current service to include Social, Surgical and urgent outpatient appointments Increased access via WUCTAS Total number of calls and number of diverts away from A&E Minimum of 17% reduction of GP urgent referrals attending A&E Jonathan Odum Medical Director RWT 33

34 Primary Care alongside A&E including support to nursing homes (new scheme) 317,000* Q3 & 4 Learning from GP in A&E scheme in 12/13 has helped frame the model in 13/14. Primary Care function alongside A&E 24/7 incorporating the OOH provision and urgent visits to nursing homes Total number of patients diverted 10% of current A&E activity being diverted through a Primary Care front end Provide a seamless service targeting primary care work presenting to A&E Jonathan Odum Medical Director RWT Richard Young Director of Strategy & Solutions CCG ICCU Capacity 82,000* Q3 & 4 Additional nonemergency transport (Carried over from 12/13) 20,000* Q1 & Q4 Additional nursing staff to support and sustain an additional ICCU bed which is currently not open for 3 months. Increase transport availability from current (non-emergency) transport provider to reduce delayed discharges and increase acute bed capacity. The opening of the additional ICCU care bed that is currently closed. Providing adequate capacity to support activity. Achievement of A&E targets. Reduced turnaround delays. Improved response times ICCU admissions activity from all sources by month ICCU length of stay activity baseline over past 12 months The number of patients transferred to another A&E 4 hour target RWT (quality indicator - past 12 by months) Breeches of the 4 hour target this needs to be added to the CVO to request data as detailed Breech data is only available from RWT 80% bed utilisation of additional bed only Reduction from baseline in the number of patients being transferred to other hospital providers that require ICCU care Reduction in length of wait times for transport in support of sustained achievement of A&E 4 hour target 95% of patients Jonathan Odum Medical Director RWT Richard Young Director of Strategy & Solutions CCG 34

35 Dr First scheme (New Scheme) 80,000* Q3 & 4 Widely published scheme available to redesign/reconfigure appointment systems in GP surgeries (based on10 GP practices signing up to the scheme) Number of practices signing up Number of practices signed up Increased appointment slots Increased access to urgent care slots in primary care Richard Young Director of Strategy & Solutions CCG Paediatric Hot Clinic (new scheme) 225,000* Q3 & 4 Rapid access to both a telephone advice service between GP and Paed consultant with access to a hot clinic for common conditions (upper resp/gastro) Use of the hot clinic Use of telephone access HRG monitoring Reduction in HRG for upper resp/gastro Richard Young Director of Strategy & Solutions CCG Walk-in centre additional capacity (carried over from 12/13) Community Equipment to facilitate discharge 150,000* Q1, 3&4 125,000* Q3,4 To fund the increase in walk-in activity. Additional equipment required to facilitate speedy discharge An increase in activity between the usual opening hours at both walk in centres Reduction in delayed discharges Numbers of urgent discharges facilitated A&E and Showell Park Walk in Centre attendance activity (past 12 months) broken down by month & time of day A&E 4 hour target RWT (quality indicator - past 12 months) broken down by hour/week). Time to see a clinician in the Walk in Centre Number of pieces of equipment loaned to facilitate discharge Reduction of A&E attendances in minor (lower acuity) HRGs with equal and opposite increase in WIC activity Reduce to zero the number of discharges delayed due to availability of equipment Richard Young Director of Strategy & Solutions CCG Richard Young Director of Strategy & Solutions CCG Patient Communication 50,000* Q2, 3 & 4 To enable the health economy to communicate Numbers of publications Numbers of publications Increase public awareness around Richard 35

36 with patients at times of pressure, these funds will purchase radio advertising and patient leaflets for heatwave/cold weather produced and distributed/broadcast produced and distributed/broadcast better use of the urgent care system Young Director of Strategy & Solutions CCG Mental health practitioner presence in A&E along with additional clinical staffing in the RAS team (carried over from 12/13) 150,000* (% from recurring funds) This scheme will be funded from a combinatio n of both 70% emergency threshold and winter pressure money Q3 & Q4 This is to provide additional support at weekends and after 5pm weekdays to reduce the numbers of patients whom could breach whilst waiting for a psychiatric assessment. We will be commissioning this service from one of our local mental health Trust providers who already operate an established in-reach service into A&E. this initiative will build additional capacity on this pressured service. Improved quality through reduction in response times for specific mental health patients (i.e. self-harm): Increase in achievement of A&E 4 hour target Reduced breeches at A&E. A&E attendance activity (past 12 months by month) A&E 4 hour target RWT (quality indicator - past 12 by months) Breeches of the 4 hour target (reasons relating to specific mental health conditions including selfharm) this needs to be added to the CVO to request data as detailed Breech data is only available from RWT 10% reduction in breeches relating to specific mental health conditions at A&E Jonathan Odum Medical Director RWT John Campbell Chief Operating Officer - BCPFT * Denotes indicative estimate awaiting final costings 36

37 6 SURGE PLANNING In addition to the agreement to invest in schemes targeted to reduce pressure on the urgent care system, a number of separate work streams are currently being undertaken. 6.1 Mental health A daily communication process has been established between the Black Country Partnership NHS Foundation Trust, the Royal Wolverhampton NHS Trust and Wolverhampton City Council to ensure mental health A&E attendance is monitored on a twice daily basis to ensue any actual / potential problems are being addressed and resolved pro-actively, with a particular focus upon bed availability at Penn Hospital and potential delays regarding assessments under the Mental Health Act 1983, where this is a requirement. See Appendix 4 An escalation process has been developed which will utilise conference call facilities involving Executive representatives from across Black Country Partnership NHS Foundation Trust, the Royal Wolverhampton NHS Trust, Wolverhampton City Council and the CCG to ensure that if a person has not been admitted at eight hours post decision to admit all relevant parties are engaged to ensure that delays are eradicated and admission occurs as soon as possible. This includes arrangements to be utilised outside normal working hours. The Urgent Care Mental Health sub-group are developing revised mental health care pathway information for all A&E staff to ensure that all staff have access to appropriate information regarding referral processes across Adult Mental Health, CAMHS, Older Adults and Learning Disability Services, within and outside normal working hours. This group is to examine good practice models and clinical guidance (NICE, Royal College of Psychiatry etc) to inform the CCG s commissioning intentions regarding a bespoke Mental Health team for A&E. A proposed service model will be reported to the August 2013 Development and Delivery Group within the CCG. Development was previously funded from winter pressures non recurrent money, but in 2013/14 additional funding will be identified in a mix of both 70% emergency threshold money and winter pressure money anticipated to be available in Q3. In the interim additional financial resource has been committed to provide a Staff Grade Locum Psychiatrist to provide focussed support from within the Mental Health Referral and Assessment Service (RAS). This has been in place from April 13, and the impact upon patient experience and waiting times is currently being evaluated. This is to be extended to include further additional financial resource to increase the capacity of nursing staff within the Referral and Assessment Service to support the assessment and care of people with mental health difficulties within A&E and the urgent care pathway as a whole. Following a recent de-brief (July 2013); a strong emphasis is being placed upon partnership working and improved communication across the health and social care economy to address patient experience across the urgent care pathway for people experiencing mental health difficulties as described above. This work involves the West Midlands Police, but also focusses upon the cross agency working of the Referral and Assessment Service and the Local Authority s 37

38 Intake Team and Emergency Duty Team. A focus is being placed upon the availability of professionals authorised to assess people as part of the provisions of the Mental Health Act This will include review of the current on-call system and training provision. While service re-modelling within mental health is taking place the CCG will continue to closely monitor the impact of additional resources and service delivery via the usual contract monitoring and Clinical Quality Review processes. The local health economy will see a 300k investment (% of recurring funds and non-recurring funds) over 2yrs. 6.2 Community Pressure Ulcers The provision of equipment in the community is a fundamental part of many care packages, it can be particularly important as part of discharge planning, the re-ablement agenda and long term independent living. As a result of health and social care national, regional and local policy initiatives, there has been an increase in provision of all types of Community Loan Equipment (C.L.E) over the past five years. In the services delivered 26,948 pieces of equipment, of which 8498 were classed as medical equipment, which is 31% of all equipment delivered. Within the provision of medical equipment, 3011 pieces related to pressure care (beds, mattresses or cushions). This means that pressure care equipment makes up 35% of all medical equipment and 11% of all equipment delivered. This is an increase in the provision of beds by % and pressure care by % of over 10 years There are a number of key strategic priorities that are contributing factors to the increase in demand and which must be considered in the future design of the service support including Delivery of Ambition 1 - One of NHS Midlands and East's five ambitions to "Eliminate avoidable grade 2, 3 and 4 pressure ulcers by December 2012." Delivery of Safety Express - the Department of Health QIPP Safe Care work stream which includes prevention of pressure ulcers The trajectory of demand this year is replicating last year and so it can be assumed that the same or greater level of equipment, including pressure care equipment will need to be provided Community Based Schemes admission avoidance Rapid Response Plus Rapid response plus was a pilot funded during winter 2012/13 to in reach Therapy Services into the Emergency Department (ED) to prevent hospital admissions and into EAU to facilitate discharges from acute care. Analysis identified that 212 admissions were avoided 38

39 from ED during the first four months of the pilot. Of the people assessed in ED by the Rapid Response Team 77% avoided admission this is a higher percentage than similar services operating in other areas. The analysis identified that 78% of those assessed on EAU were referred on the day of admission and 87% on the same or next day. The CCG has agreed to fund this service for the whole year following the successful pilot to support admissions avoidance and facilitating discharge from acute care. Care Homes Support The CCG is leading work to identify ways the local health and social care economy can support care homes and their residents. The main aim of the work is to reduce the number of ambulance conveyances, A&E attendances and acute admissions. The programme includes a focus on admissions to acute care for patients on end of life pathways. The work will include training care homes to support end of life residents and identifying how to support care homes to enable residents to remain in their care. Another focus of the work is designed to identify clinical support that can be accessed by care homes as an alternative to calling an ambulance. This support will reduce the number of avoidable admissions to acute care from care homes. Falls Service Public Health is leading on implementing community based balance classes for patients who have experienced a first fall. The falls service will be reconfigured to include a triage and signposting provision to identify people who could benefit from these classes. The aim is to prevent a subsequent fall and reduce the requirement for acute care. The falls service will be reviewed to identify other changes that may be required to reduce the number of falls that result in acute admissions. Discussions with the local care homes forum has identified that they felt that if the falls prevention team provided support into care homes this would help prevent falls. A large proportion of admissions from care homes relate to residents who have fallen. This possibility will be considered as part of the larger falls service review. Community Intermediate Care Service The CCG is reviewing the existing community intermediate care service. Initial findings identify that consideration should be given to redesigning the service to become a community rehabilitation service. An admissions avoidance pathway will be developed as part of this work to ensure that the community rehabilitation service can be accessed by the Emergency Department, GPs and other professionals to assist in avoiding admissions to acute care. 39

40 6.3 Integrated Social Care and Capacity Team RWT and Wolverhampton City Council are determined to achieve better joined up working within the Acute Trust environment, therefore measures need to be taken to introduce and facilitate a flexible, dynamic and capable service that improves patient experience. The development of a singular health and social care team within the RWT Acute environment is in line with the Integration of Health and Social Care agenda. The Integrated Health and Social Care team will consist of various roles across health and social care with the focus of patient flow and discharge. Earlier involvement, aligned processes and roles of the integrated team will not only reduce LOS but also provide more time for discussion with the patient, helping to reduce a significant cause of complaints i.e. that of not involving the patient in decisions around their discharge. Closer involvement through sharing teammate s knowledge of the patient will also reduce discrepancies and inaccuracy in the information the patient is given. This collaborative methodology has been evidenced in the pilot models launched to date that effective and closer working reduces LOS, delayed discharges and promotes better discharge destinations. A roll out plan is in force to promote and to develop this methodology and support the flow and discharge arrangements across the Trust. To achieve this form of integrated and collaborative working it has been necessary to provide a supporting infrastructure including a co-located space and IT systems sharing to support these objectives. Co-location and integration of the teams will allow currently long and complex requests for assessments to be replaced with simple updates to existing databases. The allocation of work process will replace simple ownership of specific areas. These changes will save between 1 and 14 days in the discharge process for certain patient types. This co-location is also vital for spontaneous and informal discussions of patients, ward status and trends across the hospital that will create a huge body of patient-centric information allowing for predictive planning. The team will be fully operational as a singular resource across RWT and WCC from autumn However the pilot models and collaborative working to date has reduced Delayed Transfers of Care by on average 25% in comparison to 2012 allowing targeted responses and collaborative planning. LOS reduction has contributed to the wider Trust flow by allowing more patients through the system and responding to surges in activity. 40

41 6.4 Walk in Centre Wolverhampton health economy has two walk in centres. Phoenix Walk in centre is nurse led and will benefit from financial investment, particularly the Community Intermediate Care Team. Showell Park however is currently managed by NHS England. In 2012/13, Showell Park significantly over performed against a baseline contract (Base line minimum 10,000 attendances; Actual end of year outturn approx. 32,000). Discussions are on-going with NHS England on how to support the Walk in Centre provider in providing the key role of facilitating patients avoidance at A&E where appropriate. 6.5 WMAS Black Country Cluster Divert Process WMAS_DivertsDeflec ts PROCESS_v4.docx The WMAS operates a Black Country cluster divert process when the acutes in the Black Country reach certain EMS levels. This process has been agreed to help to maintain an overview of ambulance patient flow to try to spread the workload, should any of the acutes be under pressure. This is managed by the Strategic Operation Cell (SOC) commander based in the WMAS Regional Coordination Centre. WMAS continues to deliver 999 ambulance responses for hear and treat, see and treat and see and convey for patients in the West Midlands region. Work is being undertaken to upgrade paramedic skills to enable further diagnostic skills to treat patients in the right setting first time with Community Paramedic schemes, WMAS has created a hub model for efficiencies and is developing Hospital Ambulance Liaison Officers (HALOs) to better support the acute and community services. WMAS are continuing to develop the Directory of Services (DoS) that supports the identification of alternative services for appropriate patients who call 999, the new 111 number and for utilisation by health care professionals with patients. Work is also underway to identify frequent service users that contact the service more than 10 times per month with the intention of reducing the number of 999 calls as part of this years CQUIN s WMAS are looking to improve HALO coverage by pooling the current hours of the Black Country HALO s. This is hoped to provide wider coverage for up to 16 hrs per day at surge times, 7 days per week. With the hours pool the Acute Trusts A&E departments will receive better availability and access to a HALO within budget. The HALO s will continue to work with the A&E department to maintain excellent working relationships and to further guide with the use of the patient release times and understanding the flow within the departments. It is also believed that with increased knowledge of each department there is greater resilience from the team. The HALO s will also be assisting with the work on frequent service users (FSU) with an MDT approach in an aid to reduce the number of 999 calls and attendances to A&E. As part of the CQuIN the CCG will support this with West Midlands Ambulance Service by targeting patients 41

42 who are high users of services, along with other services such as the police. The main aim is to identify high users and empower and encourage them to better manage their care and reduce the demand they place on these agencies. There is also work on end of life registers (as part of a 2 year project) that is aimed to support peoples end of life care plans avoiding unnecessary trips to A and E and potentially poor care for that individual. In addition to this HALO s will also be supporting the use of the DoS with operational staff and working with the DoS lead to identify any issues raised by operational staff. Also the HALO s will work with the ED Dr s to complete confirm and challenge with the crews to allow learning, should any of the patients be identified as not appropriate for ED; this learning is taking place as a case study for the identified crews. WMAS still strives to improve the hear and treat, see and treat and see and convey rates to ensure that patients are treated in the right setting first time. There is training being undertaken by paramedics on the community paramedic schemes to give them additional diagnostic skills to allow them to complete a more detail assessment of patient and treat or refer to the most appropriate service. The Trust has a Black Country cluster divert process that is managed by the Strategic Operations Cell (SOC) that helps to improve the flow of patients in the Black Country. GP in a car provided by WMAS This utilises a GP led referral car to attend to lower category green 2 calls targeting in particular those patients with chronic co morbidities with a view to managing these patients within the community without the need to transport to an acute site. They have been able to do this due to their experience and skill set in managing this type of patient within primary care with this they would also be able to achieve a shorter on scene time than that of traditional WMAS staff. The service evidenced a reduction in the number of patients attending an acute trust which would lower the demand at the front door, therefore improving the turnaround of ambulances which would then put resourcing back into the system to help manage demand. Falls car - provided by WMAS As above, the rationale was to utilise the appropriately skilled staff to answer 999 calls for a fall. The FALLS3 asset came into operation on 10th December Since then (up to 03/03/2013) the resource has made 413 responses and significantly reduced A&E conveyance of these patients These schemes are being reviewed and undergoing final evaluation when they ended at the end of Quarter /14. There will be a decision following the review of the schemes as to whether they will be recommissioned for winter 2013 /

43 6.6 Frequent Service Users (FSU) Wolverhampton CCG recognises the work WMAS is undertaking to address the pressure FSU have on the urgent care system. To support this, the CCG is working with GPs in Primary Care to target the top 2-8 patients (depending on size of practice population) for each practice. By utilising the Commissioning Support Unit MiCS data system, each practice will identify their key target group and establish multi-disciplinary teams, including the patient, in an attempt to reduce their demand on both WMAS and A&E. 6.7 Patient communication Wolverhampton Health Economy will utilise all national and regional communication opportunities at times of peak pressure including heatwave, cold weather and bank holidays. In addition to national and regional communication, the CCG will utilise social media including Facebook and Twitter. Over 50% of GP practices are signed up to use the text messaging service called MJOG. Whilst not all patients registered at these practices have agreed to receive mobile communication, those that have will be targeted with additional information at times of local, regional or national pressure where applicable. Together with key stakeholders, the CCG will use patient engagement mechanisms to ensure key patient groups are kept up to date and have the ability to make informed comment on service changes Extensive patient engagement is taking place via the Urgent Care Strategy development and the health economy are securing patient representation on the Urgent Care Board 43

44 7 MEDIUM TO LONG TERM PLANS The health economy recognises the challenge that increased demand is having on urgent care services in the city. Whilst this plan covers the short term strategy for managing surges in activity, the local health economy are developing transformational and sustainable medium to long term plans to ensure the urgent care system is affordable whilst ensuring quality. 7.1 Urgent Care Strategy The continued pressures within Urgent and Emergency Care prompted the development of an Urgent and Emergency Care Board, a review of urgent and emergency care in Wolverhampton and a commitment to work with our patients to develop a sustainable way forward. Urgent & Emergency Care is a priority in Wolverhampton and the Urgent & Emergency Care strategy focuses on the services available for people resident within the city and for those who use our services. Patients and healthcare professionals have and will continue to be at the forefront of the developments and their views integral to the final strategy. The strategy intends to improve quality and translates local and national policy into action, outlines the local context, current activity and defines how the vision for urgent and emergency will be delivered through a proactive, robust system that directs patients to the right service in the right place at the right time. The Urgent and Emergency Care Strategic Board will take this work forward and oversee the development and delivery of the strategy. There are urgent elements in almost all care pathways and therefore this strategy is interlinked with all other Strategies being developed for the city such as Primary Care, Planned Care, Long Term Conditions, Mental Health, Health Inequalities and Intermediate Care The strategy seeks to develop a cohesive approach involving our patients and partners in the development of high quality and affordable services for the future. It describes the proposed arrangements for the future urgent and emergency care system in Wolverhampton and for those patients using our services within the city but who are resident in other areas of the country. The short to medium term solutions are being developed alongside the strategy and are currently being implemented. 44

45 7.2 Primary Care Strategy In order to meet the challenges posed by the increasing demand, Wolverhampton CCG recognises the need to develop the capacity, capability and flexibility of primary care providers. Key aims within this are to maximise access to primary care services, address issues of unacceptable variation in clinical quality and facilitate greater responsiveness to the health needs of the Wolverhampton population. This will require a focus on developing approaches to better integrated team working, workforce development and maximising the potential of providers. The CCG has started work on scoping a development path by which these aims can be achieved. This development agenda will have a direct impact on the success of the CCG s Urgent and Emergency Care Strategy. It is not expected that a final strategy will have been fully developed to have a significant impact on this plan for 2013/14. The CCG will, however, use and evaluate the initiatives outlined in this plan to inform our approach to primary care provider development, in addition to other 2013/14 QIPP schemes. 8 CONCLUSION The local health economy recognises the urgency of working in partnership to address the change in patient use of urgent care services. This plan brings together the key stakeholders, who are all cosignatories of the plan and describes how the health economy will work together to address urgent care issues locally in the short term. This recovery plan should also be considered alongside the medium to longer term work of the local health economy (including CCGs outside the geographical boundary) which is currently in the final stages of developing an urgent care strategy and separate Primary Care Strategy. This will incorporate key areas around Primary/Social Care, Ambulatory Care, Primary Care alongside A&E and work around admission avoidance (WMAS Falls car/gp in a car, support to nursing homes and supporting primary care around urgent home visits). This plan does not replace each stakeholder s contractual responsibility to have their own surge plan for addressing peaks in demand throughout the year, not just during the predicted spikes in activity during the winter period, but should also be read in conjunction with them. 45

46 Appendix 1 - RECOVERY AND SUSTAINABILITY PLAN Due to the sustained high activity levels experienced in 2012/13 and the failure to meet the 95% quality target in Q3 & 4 for Type 1 only, and for Q4 for both types of A&E, the health economy have signed off and implemented this recovery & sustainability plan with a aim to achieving the contractual target for Type 1 and Type 3 activity combined. Monitoring of this plan will be undertaken by the UCB 1.1 ACTION PLAN - PRIOR TO A&E The following schemes have been agreed for implementation in 2013/14. Prioritisation of the schemes will be undertaken at the UCB. These schemes are intended to avoid attendance/admissions Prior to A&E (Primary Care Access including multi-disciplinary team) Wolverhampton GP in a car Extension of Primary Care Access - opening hours and additional capacity New scheme or carried over from 2012/13 Carried over from 12/13 Carried over from 12/13 Justification for funding if carried over from 12/13 Or Expected outcomes if scheme is new for 13/14 Significant reduction in pressure on both WMAS and A&E, however, savings not realised due to high running costs Approximate value based on Feb 13 invoice Funded significant increase in capacity during existing opening hours at one walk in centre as opposed to extending opening hours. Further funding to be split between the two sites/providers Time frame for delivery Q1, Q3 & Q4 Q1, Q3 & Q4 Investment 300,000 (no Project Mgr costs) 150,000 (no Project Mgr costs) Ownership and responsibility Richard Young Director of Strategy & Solutions - CCG Richard Young Director of Strategy & Solutions - CCG Dr First Scheme to increase Urgent Care appointments in GP Surgery New Scheme Widely publicised scheme available to redesign/reconfigure appointment systems in GP Surgeries (based on 10 GP practices signing up to the scheme) Q3 Q4 80,000 (no Project Mgr costs) Richard Young Director of Strategy & Solutions - CCG Appendix 1 46

47 WUCTAS v2 extend current service to include Social, Surgical and urgent outpatient appointments New Scheme Phase 1 up and running. Scope to extend and achieve greater economy of scale and provide system management for winter surge plan. Q1, Q3 & Q4 Project Manager time 0.33wte ( 25k) Richard Young Director of Strategy & Solutions - CCG Jonathan Odum Medical Director - RWT PAED Hot Clinic GP Alongside A&E (in/out of hours) including support to Nursing Homes New Scheme New scheme Rapid access to both a telephone advice service between GP and Paed Consultant and Hot Clinic for common conditions (at present upper respiratory) Poor evidence of success with current model. No plans to extend on this basis, however model being revised/reviewed in line with the local urgent care strategy anticipate revised model in Q3/Q4 Clinical input based on 8hrs per day, over 6mths, 2GPs at 100ph Q3 Q4 Q3 Q4 200,000 Project Manager time 0.33wte ( 25k) Clinical input 292,000 Project Manager time 0.33wte ( 25k) Richard Young Director of Strategy & Solutions - CCG Richard Young Director of Strategy & Solutions - CCG Jonathan Odum Medical Director - RWT Patient Communication New Scheme To provide additional communication via radio media and leaflets at time of pressure (Heatwave, cold weather, bank holidays) Q2, 3 & 4 50,000 Richard Young Director of Strategy & Solutions - CCG Appendix 1 47

48 1.2 ACTION PLAN - FLOW WITHIN THE HOSPITAL The following schemes are specific to the Acute Trust and have no financial investment outside of the current contractual agreement. It is the responsibility of RWT to deliver against these actions Work stream Action Expected outcome Update Responsible Timeframe Flow in A&E Department Ensure early first assessment within 1 hr Review of medical staffing rota s to Reduction in A&E breaches for first assessment New Rota s to be introduced in Q2. Increased consultant CD A Morgan June 13 of presentation ensure appropriate Ensure timely triage and senior cover at peak Clinical outcome optimised presence x2 after 6pm prioritisation for review times of patient Establish Clinical Decisions Unit (CDU) Conversion of clinic space in A&E department to accommodate 7 CDU trolleys/beds Reduction in overall breaches in A&E department, especially patient waiting for blood results or social/psychiatric assessments Reduction in patients being seen and assessed in the corridors Improved ambulance handover Reduced financial risk to trust in terms of penalties Paper to closed session Trust Board May 13 - Agreed. CDU in use 12 hrs day with effect from July. CDU will be open 24 hrs with effect from August COO G Nuttall; supported by A&E clinical team Aug 13 Appendix 1 48

49 Increase majors capacity Expansion of A&E department to increase numbers of majors cubicles ( 9) Reduction in patients been seen and assessed in corridors Improves access and availability for earlier clinical review Improved patient experience with regard to privacy and dignity Paper to closed Trust Board May 13 - Agreed Building and design work completed COO G Nuttall, supported by A&E clinical team Nov 13 Ensure appropriate nursing and medical staff to cover developments Increase nursing establishment (over and above existing establishment) to safely staff CDU and new majors cubicles Improved ambulance handover Reduced financial risk with regard to imposition of penalties Improved Staff morale as a result of improved staffing compliment Improved patient experience Reduction in complaints Linked to paper for CDU/ Majors Recruitment of nurses on going, but going well. Completed for CDU Div Matron R Baker supported by Directorate Matron CD ED Dept A Morgan June 13 Revised July 13 for Medical Staff In conjunction with CCG and Social Care case review of high intensity users Increase medical compliment to safely staff CDU and cover majors cubicles Review patients who are high intensity users with relevant clinical teams and support workers Clear treatment pathways for patients who are regular attendees Additional medical posts being recruited, but mainly into existing vacancies Additional action plan for recruitment of middle grade doctors No progress as yet CCG R Young to establish process A&E team A Morgan, J McKiernan and H Flayvell July Appendix 1 49

50 Review flows to pathology for test results. Ensure that system process for blood results is slick and not subject to loss and delay Reduction in breaches for tests not arriving Review of flow system has occurred. Revised telephone escalation system in place for A&E. Requires monitoring Pathology G Danks; A&E D Fitton June Review ambulatory care pathways Review the clinical effectiveness of WUCTAS, with Acute and Primary care involvement Daily review of all patients either via ward of board round twice a day Consistent use of Estimated Discharge dates (EDD) across wards Ensure that Trust has streamlined pathways for ambulatory conditions Establish multidisciplinary group to review referrals into EAU Review job plans to ensure patients are seen /reviewed on a daily basis for senior clinical decision making Review access to diagnostics Ensure there is consistency across medical and surgical wards in the use of EDD s to assist with discharge planning Re-direction of patients from A&E to AME clinic Clear process for management of patient and referral access Reduced length of stay Use of standardised ward round pro-forma More timely discharge Clearer information for patients and relatives about expected discharge date Reduction in length of stay Some pathways already exist in community e.g. COPD CCG have already given notice of their wish to undertake this piece of work as part of urgent care strategy Follows recommendations from Royal College of Physicians Meeting with Consultants in May to implement Audit of ward rounds to be undertaken August. Monitoring of ward LOS commenced Audit in August to review use of EDD MD J Odum, supported by Divisional MD MD J ODum MD J Odum, Supported by Divisional MD MD J ODum with support from Divisional Medical Directors and Matrons On going Commenced On going Audit reports in August June Appendix 1 50

51 Ensure profile of discharges is moved forward Availability of diagnostic test at weekends, in line with 7 day model Ensure there is consistent production of information with regard to hospital activity and consistent use within divisions -: - Re-admissions, Length of Stay by specialty consultant, community access information Ensure TTO s and discharge summaries are completed as part of ward rounds as soon as possible Ensure appropriate patients are transferred to discharge lounge Establish small working group to establish demand and capacity for more routine diagnostics at weekends to assist with diagnosis and discharge planning. Review information that is currently available, how often produced and how frequently used for action or information Reduced delays for TTO s and production of discharge summaries Increased in early morning discharge by 5 patients (varies by day) Establishment of response standards for diagnostic tests Increased availability of diagnostic tests at weekends Reduce length of stay Clear set of information criteria to produce for clinical and management teams to assist with activity planning. Discharge summary action plan, links to contract On-going. Monitoring of discharge lounge shows small improvement. Further work required. Like to require investment (staffing) As recommended in Kings Fund Paper Review of Urgent and Emergency Care Colchester dashboard to be introduced with effect from August Clinical Support units also introducing regional information MD J Odum, supported by Matrons MD and COO J Odum and G Nuttall, with support from divisional management team Head of Information and Divisional Management teams June September Review in June Implementation of dashboard in August Appendix 1 51

52 The following schemes require financial investment in addition to the current contractual agreements Flow within the hospital Ambulance nurse triage New scheme or carried over from 2012/13 Carried over from 12/13 Justification for funding if carried over from 12/13 Or Expected outcomes if scheme is new for 13/14 Time frame for delivery Investment Significant evidence showing increased quality as a result of reduced ambulance turn-around times. Full year 200,000 Ownership and responsibility Jonathan Odum Medical Director - RWT Consultant in A&E 24/7 Carried over from 12/13 Successful however evidence suggests that a middle grade presence 24/7 would be most effective use of resources Full Year 200,000 Jonathan Odum Medical Director - RWT Mental health practitioner presence in A&E Weekend pharmacy cover Carried over from 12/13 Carried over from 12/13 Unable to recruit to post until very end Q4. Extend into Q1 and evaluate. Mainstream if successful Full year 300,000 Possible extension into full year in order to provide increased choice and capacity Full year 64,000 Richard Young Director of Strategy & Solutions - CCG John Campbell Chief Operating Officer - BCPFT Jonathan Odum Medical Director - RWT Cardiology In-reach to EAU Carried over from 12/13 Some evidence that this has avoided emergency admissions Q1, Q3 & Q4 180,000 Jonathan Odum Medical Director - RWT Appendix 1 52

53 Locum Radiologist Carried over from 12/13 Some evidence that it reduced delays Q3 & Q4 only 82,000 Jonathan Odum Medical Director - RWT ICCU Capacity Carried over from 12/13 Some evidence that it reduced delays Q3 & Q4 only 82,000 Jonathan Odum Medical Director - RWT Additional portering capacity Carried over from 12/13 Evidence of reduced burden to ancillary services owing to increased urgent care volumes Q3 & Q4 Only 90,000 Jonathan Odum Medical Director - RWT 1.3 Action Plan - Discharge out of hospital Discharge out of hospital Additional Support for resolving Step Down Pressures (City Council funded project) New scheme or carried over from 2012/13 Carried over from 12/13 Justification for funding if carried over from 12/13 Or Expected outcomes if scheme is new for 13/14 Q4 2012/13 shows significant usage of step down facility minimised delays in discharge. Case management of step down patients has moved to social care. This funding supports the additional provision required to complete this task. The data for step down shows that: Ten patients whose stay exceeded 100 days have been successfully discharged In November a quarter of all step down patients had been resident for more than 60 days by May only 15% Time frame for delivery Q1 & Q4 2013/14 Cost 150,000 Lead Richard Young Director of Strategy & Solutions CCG Anthony Ivko Assistant Director for Older People and Personalisation - LA Appendix 1 53

54 exceeded 60 days The increased support has allowed more step down placements to be authorised at any one time reducing pressure on discharges from acute care The increased support has allowed more people to benefit from step down placements due to a greater throughput reducing pressure on discharges care Additional nonemergency transport Carried over from 12/13 Some evidence that delayed discharges were reduced. Q1 & Q4 20,000 Richard Young Director of Strategy & Solutions CCG Therapy services Rapid Response Plus - Therapy services in reach into A&E for extended hours - Therapy services in reach into EAU - Therapy services support in step down provision Carried over from 12/13 Pilot run over winter period results for four months were positive: Prevented 212 admissions from A&E Assessed 281 people on EAU 244 people seen on EAU within 48 hours of admission 35 people actively worked with while in step down to facilitate discharge and free up capacity in the system Avoided admissions for 77% of all people assessed on A&E other schemes across the country have achieved lower percentage rates Average cost per patient would be (significantly lower than an admission to acute care) Full year 282k Richard Young Director of Strategy & Solutions - CCG Jonathan Odum Medical Director - RWT Appendix 1 54

55 Community Geriatrician - Actively responding to patients admitted from Nursing Homes to facilitate speedy discharge Carried over from 12/13 Geriatrician in place since December Wards contact geriatrician to inform them that a person has been admitted from a nursing home. The patient is then actively worked with by the geriatrician to facilitate a swift return to their nursing home. These patients include those at end of life who would prefer to die in their usual place of residence. Activity data shows a 7% decrease in patient admitted from nursing homes that die in acute care. The community geriatrician is also offering support to nursing homes to provide improved quality of care for residents and prevent avoidable attendances to A&E and avoidable admissions to acute care. Full Year 150k Jonathan Odum Medical Director - RWT New Scheme Richard Young Director of Strategy & Solutions CCG Community Equipment to facilitate discharge Increased use of community equipment for medical reasons requires further investment to support discharge. Q3, 4 125k Anthony Ivko Assistant Director for Older People and Personalisation - LA Appendix 1 55

56 Appendix 2 RWT Analysis of the Problem The graph below shows that in excess of 5,000 extra attendances were seen in the department when compared to the previous year, an increase of over 5%. This has continued in Q1 which has seen attendances rise 2.7% year on year. 10,000 9,500 A&E Attendances - Yearly Comparison 9,000 8,500 8, / / /14 7,500 Ambulance conveyances to the Trust have also increased significantly over the same period. The graph below shows that in excess of 2,051 more ambulances were conveyed to the A&E department when compared to the previous year, an increase of over 5.4% Actual Ambulance Numbers - Yearly Comparison 11/12 12/13 13/14 Interestingly, the % increase into New Cross is consistently higher than the WMAS average, since October 2012 ambulance conveyances have increased 5.8% into New Cross and 1.1% WMAS average. This equates to an extra 43 ambulances per week into New Cross than last year based on this period. Appendix 2 56

57 New Cross = PINK, WMAS = BLUE 20% Percentage growth in Ambulances - Comparison with same period in previous year 15% 10% 5% 0% -5% -10% -15% The increase in ambulance conveyances has a disproportionate impact given that the admission rate for patients arriving via ambulance during Q1 is 45.7%, compared to standard admission rate via A&E at 18.6% % % of Admissions from A&E - Yearly Comparison 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% April May June July August September October November December January February March 2011/ / /14 The pressures in A&E are felt across the Trust as admissions increase, this leads to increased demand for beds following admission that in turn has resulted in fewer beds being available for elective care. There has been a dramatic spike in the number of cancelled operations due to lack of beds as evidenced in the graph below. This is despite the Trust having opened in excess of 70 beds across the hospital (New Cross and West Park) Appendix 2 57

58 Cancelled Operations (No Beds) - Monthly 12/13 vs 11/ / / /14 Summary of key issues Increases in ambulance conveyances Increases in A&E attendances Increase in admission rates from A&E department, assumed to be due to increased complexity/co-morbidity of patients Some evidence of increase in attendances/admissions in out of hours periods after 6pm and weekends. Appendix 2 58

59 Appendix 3 Terms of reference for UCB Wolverhampton Health Economy Urgent Care Board Terms of Reference CONTENTS Section Page 1. PURPOSE SCOPE & FUNCTION 2 2. MEMBERSHIP 2 3. OBJECTIVES 3 4. DUTIES & RESPONSIBILITIES 3 5. REPORTING & ACCOUNTABILITY 4 6. PERFORMANCE MANAGEMENT ARRANGEMENTS 4 7. FREQUENCY OF MEETINGS 5 8. QUORUM 5 Version: V3 Date of Approval: Date of Issue: June 2013 Date of Next Review: Appendix 3 59

60 1.0. PURPOSE, SCOPE & FUNCTION Urgent Care Board 1.1 The purpose of the Urgent Care Board is to: 2.0. MEMBERSHIP Develop the Urgent & Emergency Care Strategy To ensure that the population of Wolverhampton and its catchment area is able to access high quality urgent and/or emergency care Ensure that care is centred around the patients needs Ensure that care is delivered by the appropriate clinical team(s), in the appropriate environment, both in primary and secondary care. 2.1 Membership of the Board: Name Mr Ian Badger Christine Curtis Dr Tim Dukes Dr Stephen Edwards Ms Cheryl Etches Maxine Espley Gwen Nuttall Dr Helen Hibbs Dr Cathy Higgins Mr Derek Hunter Mr Anthony Ivko Dr Suneil Kapadia Louise Landucci Mr Andrew Morgan Dr Julian Morgans Dr Jonathan Odum Title Divisional Medical Director RWT Regional Head of Clinical Practice West Midlands Ambulance Service General Practitioner& Chair Seisdon Peninsula CCG Medical Director Black Country Partnership NHS Foundation Trust Chief Nursing Officer, RWT Director of Planning & Contracting, RWT Chief Operating Officer, RWT Joint Chief Office for Wolverhampton Clinical Commissioning Group Clinical Director Children s Services, RWT Urgent Care Lead, Black Country Cluster Assistant Director Older People and Personalisation Divisional Medical Director, RWT Service Development & Redesign Manger, RWT Clinical Director / Consultant Emergency Services, RWT Clinical Commissioning Group Board Member/Urgent Care Clinical Lead Medical Director, RWT Appendix 3 60

61 Mr Mark Walsh Mr Richard Young Dee Harris Public Health Healthwatch Representative to be confirmed Public Governor, Council of Members RWHT Director of Strategy and Solutions Wolverhampton CCG Commissioning Solutions and Development Manager Urgent Care (CCG) Katy Spence Public Health Consultant Healthwatch to nominate Black Country Partnership Foundation Trust 2.2 Other leads will be asked to attend the meeting as and when required. 2.3 The membership of the Board will be reviewed 6 monthly to ensure that it best reflects the aims and objectives and timescales set out in the Strategy itself. 2.4 The Chair of this Board will be the Medical Director at The Royal Wolverhampton NHS Trust.in their absence, the Vice Chair will be the Director of Planning & Contracting at The Royal Wolverhampton NHS Trust OBJECTIVES 3.1. To ensure that any development of new service models for urgent and emergency care drive quality, safety and productivity whilst enhancing the patient experience As a health economy to develop new models of urgent and emergency care which ensures best use of resources. 3.3 To review models/pathways already in place and look at how these can be enhanced further by collaborative working and integration focused on the patient s journey. 3.4 To provide urgent and emergency care services that ensure patients get the right treatment in the right place, from a suitably skilled workforce as quickly as possible through an integrated single point of access that delivers a seamless pathway To have facilities and services available, accessible and responsive so that patients may receive care within the primary care setting when appropriate (delivering the goal of more care closer to the patient s own home) or in secondary care as appropriate. 3.6 To develop standards, targets and KPI s in line with the objectives defined in the strategy. 3.7 To ensure delivery of the quality indicators for A&E, develop, implement and monitor any remedial action plans Appendix 3 61

62 3.8 Urgent Care Board to oversee the use of ring fenced funding. Specifically the use of funding must be clearly identified to support the urgent care system and acute providers ability to deliver the operational standard DUTIES & RESPONSIBILITIES 4.1 The Board will have the specific responsibility to review current provision of urgent and emergency care and to have a clear focus on responding to local needs and ensuring that quality and safety of care and the patient are at the heart of all developments for urgent and emergency care. 4.2 Duties are: To develop and implement an Urgent & Emergency Care Strategy, which outlines explicit clinical pathways for urgent and emergency care improving the patient experience and ensuring the most appropriate care To direct and monitor the activities of the Work Streams ensuring the work programme achieves its milestones and changes are implemented effectively To oversee the transformational change and programme plans, ensuring delivery and achievement of high quality urgent and emergency care and ensuring engagement of all teams in the re-design process To ensure there are clear, measurable outcomes and benefits of developments that are taken forward Communicate outcomes and outputs across the Organisations involved To monitor the performance of relevant emergency care indicators including quality indicators To liaise with health economies bordering Wolverhampton recognising the interdependencies of these health economies including Dudley, South Staffordshire and Walsall To ensure highest possible quality and value for money is achieved To oversee the quality indicators for A&E and any subsequent remedial action plans to ensure compliance against these targets Have responsibility for recommending the use of ring fenced resources, not already committed by the CCG Responsibility to review appropriate data and act upon this data to ensure quality standards for services for patients are delivered. Appendix 3 62

63 Review the effectiveness of primary and secondary care and other services delivering and managing Urgent and Emergency care Ensure a full range of services are available for those patients in ED who need services not provided by the acute trust Work with local authorities to ensure, when appropriate, early discharge is undertaken Two members from the UCB will attend the Black Country Urgent Care Group 5.0. REPORTING & ACCOUNTABILITY 5.1 The Urgent & Emergency Care Strategy Board (the Board) is accountable to the Trust Management Team (TMT) of The Royal Wolverhampton Hospitals NHS Trust, the CCG Boards of Wolverhampton, Seisdon and South Staffordshire and the Ambulance Service Board. 5.2 The Urgent and Emergency Care Strategy Board will provide a report to the above Boards (see 5.1) on progress of work streams undertaken by the Board, on a quarterly basis. 5.3 Minutes of the Strategy Board and Chairman s report noting actions and updates on actions will be kept as part of the formal record for the Board PERFORMANCE MANAGEMENT ARRANGEMENTS Key monitoring frameworks will be used as part of the formal record for the Board. The Urgent & Emergency Care Strategy Board will monitor and evaluate its performance against the appropriate targets and locally agreed performance metrics relevant to all partner organisations 7.0. FREQUENCY OF MEETINGS The Group will meet on the 2 nd Friday of every month QUORUM 8.1. A quorum will consist of not less than 50% of members of the Committee, as listed in section 2 and must include the chair or the deputy chair and 50% of the members from partner organisations excluding Black Country Cluster Group and Healthwatch. Appendix 3 63

64 Appendix 4 Mental Health A&E Escalation Process A & E Escalation Process On call contact details for MH Services (BCP) and New Cross Hospital (RWT) are as follows: Day Time Evenings/Week-ends Mental Health (BCP) New Cross Hospital (RWT) Day Time Via A&E / Divisional Management Teams Director on call Evenings/Week-ends (after 5.00 pm Mon-Fri) Manager on call (first) Contactable via switchboard Contactable via switchboard Escalation beyond the above will occur if a resolution is not easily achievable and will be in accordance with agreed daily contact to ensure all reasonable action is being taken to transition patients through the A&E department in a timely manner. The patient s experience of A&E should be positive and to the highest standard. Regular contact will take place as follows and will also allow for further communication at the point whereby the decision to admit has been taken and the patient remains in the department at 4 hours and at regular intervals thereafter (following the decision to admit). This will enable a review by stakeholders to ensure all reasonable actions are being taken. Appendix 4 64

65 Daily calls at am and 3.30 pm between JCU/RWT/BCP/Social Care Decision to admit 6 hours later still in department. Contact name: Daytime tel no: Evening/Week-end tel no: Decision to admit 8 hours later still in department Inform area team Contact name: Daytime tel no: Evening/Week-end tel no: Decision to admit 10 hours later still in department Contact name: Daytime tel no: Evening/Week-end tel no: Decision to admit 12 hours later still in department Contact name: Daytime tel no: Evening/Week-end tel no: Post breach review meeting will be held if a patient is not transferred within 12 hours or should Commissioner/Provider wish to review a particular incident or the process for monitoring and escalating care in accordance with the Mental Health Act. Appendix 4 65

66 Diagnostic Appendix 5 RWT Diagnostics RWT Diagnostic Performance Diagnostic and Recovery plan information Can you explain what the specific reasons are for the Trusts' A&E underperformance? Could you please provide details and data on: * What is the change in A&E attendees (in-year and yr-on-yr)? * Actual attendees vs. plan/outturn for 2011/12. * Admissions vs. plan/outturn for 2011/12. * What is change in Non-elective activity (in-year and yr-on-yr)? * Has your A&E conversion rate changed and what is it (in-year and yr-on-yr)? * Are there any bed capacity constraints currently (staffing / Norovirus)? * If the level of acuity has changed -could the Trust evidence this? * Has the Trust had any workforce challenges (A&E staffing)? Increase in A&E attendances, growth in ambulance conveyances far in excess of WMAS average, complexity of patients presenting, ageing population and space constraints within A&E department and bed capacity. The trust has seen an increase of 5% year on year attendances which is on the back of a 3.5% increase the previous year. This equates to an overall increase of almost 9% in 3 years. Performance in 2011/12 was almost 1% higher than the plan. Admissions are 5% over performing against plan. Non-elective activity has grown 2% in year. Conversion rate is 17% for 2012/13, 17.2% for 2011/12 and 15.8% for 2010/11. The organisation has had intermittent closure of beds/wards due to Norovirus throughout the Winter. It is a much improved situation than previous years with minimal bed closures. There have been some challenges to recruit substantively medical staffing in A&E at both consultant and middle grade levels, we have seen a higher reliance on locum staff this winter but the position is now improving although gaps at consultant level due to A&E being a shortage speciality. Staffing levels have increased since the Stafford impact has been seen, see below: ED Nursing 9.45 wte recruited April 2011 Nursing 5.2 wte recruited April 2012 Nursing 1.7 wte Winter 2012 (AOA) ACP s 3wte April 2012 Consultants 4wte April 2012 Junior docs 1.4 wte April 2012 AMU Consultant 1wte Summer 2012 (24/7 working) Nursing 5.3wte 2011 Appendix 5 66

67 Winter External Support Breach Analysis Has there been an impact from the NHS 111 rollout? If so, could you quantify that impact and its effect on your A&E performance? Could the Trust quantify both the number of 8hr and 12hr trolley waits/ breaches that have taken place in-year (2012/13)? Could the Trust outline if there have been any quality & patient safety issues (SUIs) raised in A&E (in-year)? What actions have the Trust taken to minimise and mitigate avoidable harm? The soft launch of 111 occurred on the 19/3/13 as yet it is too early to quantify any impact or not. Ambulance conveyancing continues to be almost 8% above last year, compared to WMAS average of 2.4% (for Q3 & Q4). With an average extra 4 ambulances per day diverted from Staffordshire. There have been 71 8 hour trolley breaches and 0 12 hour breaches. There have been no SUI s as a result of current pressures. We have seen an increase in ambulance delays but have proactively managed flows in conjunction with HALO and increased nursing resource to manage ambulance flows. Do you use 7 day analyses (DH/MA analysis tool)? What are the key features/ Themes that have or are appearing from the breach analysis? Has the IST visited the hospital and if so when? Have you fully implemented the IST recommendations made? If not when will this be completed? What further support is required (TDA/IST)? Has your winter contingency capacity and/or escalation remained open? If so, how many beds? Yes Bed not available, waiting for first assessment, complex clinical need and admission avoidance No N/A None as yet We have 73 winter contingency beds open between New Cross and West Park with access to a further 44 day case/short stay beds on a flexible basis. Whilst it would have been our plan to commence a phased closure of these with effect from 31/3/13 this will not commence in the immediate future and certainly not before A&E performance is restored and sustained. There have also been outliers in surgery beds that have impacted upon elective capacity. Could the Trust quantify the amount of winter monies received in 2012/13? 344,000 - other winter funds have been allocated to Social Care and CCG services. Appendix 5 67

68 Flow Outline how the winter monies were deployed and what impact this had on A&E performance? Additional CHC Training for Nursing and Social Care Teams Ambulance Nurse Triage, ICCU Capacity, Consultant in A&E 24/7, Additional non-emergency Patient Transport Services, GP in A&E. What is the current level of DTOCs (Q4 to date)? Average at 5.3% What is the maximum and minimum number of DTOCs? And what is the average compared to the same period last year? What are the actions you are taking to improve flow through your adult inpatient bed capacity during the period? What actions have you put in place to improve the rate of discharge of simple and complex discharges? How are you working with social care and commissioners to reduce your DTOCs and improve flow? What is the average weekly pattern of discharges by day and against plan for Q4? Minimum 21 maximum 54. Average is 40 compared to 29 last year. 7 day working in a medical specialities, Weekend discharge teams, Strengthened the management of the hospital out of hours, Extended pharmacy opening hours. Rapid assessment team to support frail elderly patients in A&E Introduced a social care and health integrated discharge team (Wolverhampton) Community respiratory clinics CoE consultant support to nursing and residential homes Expanded district nursing and CICT teams Increased the numbers of step-down beds Additional Cardiology in-reach to Acute Medical Unit (AMU) Additional clinical medical support to SAU. Each ward to identify 1 patient for early am discharge by 9.15 Daily review of DTOC s with Wolverhampton Wolverhampton Social Care approve packages of care without assessing patients Routine bank holiday working for social workers Extended working for social workers on COE wards to include weekends and until 8.00pm The discharge pattern is consistent across weekdays with a slight increase towards the weekend. Mon & Tues 17%, Wed & Thurs 18% and Fri at 20%, Saturday and Sunday account for around 10% at weekly discharges, split evenly across both days. Appendix 5 68

69 Recovery Plan Partnership working Do you have an urgent care network? What actions is the network undertaking? What are the arrangements with commissioners in terms of: * Level of mutual support (financial/other) provided by commissioners? * Do you share breach analysis with commissioners? * Are their local health system TCs when required? * What is the current status regarding community bed capacity? * What additional support has been provided by ISTC or other providers i.e. mutual support during Q3 and Q4? Yes - Black Country Urgent Care Group, which is chaired by David Hegarty (Clinical Senate Lead) which provides an overview of operational issues across the Black Country. A local surge resilience group - includes MH, Social Services, WMAS and GP commissioners is also in place across the Wolverhampton Health economy which is currently monitoring activity and implementation of local projects impacting upon surge. An Urgent and Emergency Care Strategy Group looks at whole system, chaired by Medical Director with Clinical and managerial reps from host and other local CCG's. Tele-conference takes place daily to include CCG, Social Care and LAT Community beds at West Park Hospital plus 14 open and 67 step-down beds purchased by commissioner Funded a range or projects from winter funding monies and 2% reserve, GP working in A&E, GP IN A CAR, some of which will be extended into Q1, i.e. the triage nurse in A&E. 7 day breach analysis is shared with commissioners along with referrals to A&E by GP Practice. Teleconferences have been instigated on a daily basis. Recovery Plan Is there a Board agreed Recovery Action Plan in place? (If so please attach with your response) If yes, when was it agreed and could you confirm this has been agreed with commissioners? N/A What date does the Trust expect to be back on track and achieving A&E safely and sustainably? If no RAP is in place, when will one be agreed? Mid April - see trajectory TBC Appendix 5 69

70 Could you briefly provide in the box below details on the current short/medium and longer term actions to address A&E underperformance. In addition, based on the recovery trajectory outlined on the "Trust Summary" tab, could you quantify (where possible) the impact of these actions on A&E performance: Short/ Medium term: Continuation of Q4 winter pressure schemes into Q1 (the LAT originally indicated this but now may back-track given funding pressures Mental Health medical staff to commence in A&E from 28th March 2013 Opening of a CDU to support admission avoidance/create flows Pro-active A&E consultant recruitment Extend A&E Major s area by 10 cubicles (subject to available capital funding) Enhanced staffing levels for ambulance off load area Phased opening of 2 further medical wards (ward 1 from 1/4/13) Roll out of integrated patient flow team to include community hospital wards Long term (sustainable measures): New A&E build (single emergency portal) Appendix 5 70

71 Appendix 6 Commissioning Stocktake Prior to A&E Strengthening Primary and Community Care for frail and elderly patients Use of community diversion schemes Strengthening GP out of Hours services Use of Virtual Wards in the Community Wolverhampton - current position CICT established. Currently working on a proposal for expansion of CICT, OT, elderly support team expansion, roll out of community old age physician scheme. WUCTAS, Hospital at Home and Step Up and Down currently used. CCG to consider establishment of Rapid Access clinic "same day, next day" to try and prevent admission. Elderly Care and Assessment Treatment Unit with the provision of supportive home reablement. Current contract has been extended for a 12 month period to take us to End Sept 14. During this time there will be revisions to the current population based contract to an activity based contract. The CCG are in the process of drafting the LTC strategy, of which one of the core aims of the strategy is the implementation of systematic risk profiling which will inform a multi-disciplinary virtual ward model to be facilitated by the community matron service. This model will ensure that patients are engaged with the development of personalised management plans, which will include which services the patients should contact in an emergency, for example the Respiratory Hot Clinic, Community Matrons etc. Support of Care Homes to avoid emergency referrals Peer review of GP emergency referrals Reducing ambulance conveyance rates Patient education on appropriate us of emergency services Roll out arrangements for NHS 111 The acute Trust and CCG are currently discussing the expansion of the current old age physician support to nursing homes (see above proposal for Frail and Elderly assessment unit). Will be sharing emergency admissions data with all practices for discussion in peer groups as part of Quality Outcomes Framework. Currently at 63.50%. Working with West Midlands Ambulance to establish diversion schemes Engaged in Cluster communications regarding Choose Well. Utilising the GP text messaging service to send out generic messages to patients regarding when/where to go. Sandwell and West Birmingham is the lead commissioner for the Black Country. Wolverhampton are fully engaged in Black Country groups established to ensure robust implementation and monitoring of NHS111 Appendix 6 71

72 Flow within the hospital Prompt booking of patients to reduce ambulance turnaround delays Full see and treat in place for minors On-going support of ambulance handover nurses (A&E/AMU) and the introduction of CDU. Currently in place for peak periods. Acute trust to provide implementation plan including indicative cost for full roll-out. Prompt initial senior clinical assessment within A&E and rapid referral if admission is needed Ensure early first assessment within 1 hour of presentation, ensuring timely triage and prioritisation for review of the patient. To ensure this takes place, a review of the medical staffing rota will ensure appropriate senior cover at peak times Prompt initiation of blood and radiological tests with rapid delivery of test results Review flows to pathology of test results ensuring that the process for blood results is slick and not subject to delay. Plans completed to develop CDU for patients whose results are time sensitive. Prompt access to specialist medical opinion Full use of computer-aided patient tracking and system for progress chasing Regular seven day analysis should be in place for rapid identification and release of bottlenecks Bed base management Daily consultant ward rounds Provision of specific services for patient groups such as those with mental health problems Introduced 7 day work in all medical specialties. Escalation process in place to ensure early medical opinion MSS System already utilised. Acute trust to develop proposal for roll out to AMU for consideration by CCG In place; daily review of DTOC and weekly review of long stay patients Early discharge incentives introduced for medical specialties Daily review of all patients either via ward or board round - ideally twice daily. A review of job plans to ensure patients are seen /reviewed on a daily basis for senior decision making. There are designated teams providing assessment within EDT for people of all ages with mental health and / or substance misuse difficulties (including CAMHS, Older Adults and Adult Services). Outside working hours all this activity is conducted by the Referral and Assessment Service ((RAS), provided by the Black Country Partnership NHS Foundation Trust. These pathways are all currently the subject of review. From March 2013 a Staff Grade Psychiatrist has provided focussed support to the EDT pathway working from within the Referral and Assessment Service to support speedy assessment and treatment/discharge/onward referral. Appendix 6 72

73 Discharge and out of hospital care Designation of expected date of discharge (EDD) on admission Maximisation of morning and weekend discharges Full use of discharge lounges Minimisation of outliers Delayed transfers of care reduced Flexing of community service capacity to accept discharges Trust to undertake review to ensure consistent application. Discharge incentives introduced for medical specialities Discharge lounge in place for appropriate patients Trust has policy in place to minimise. Reviewed on a daily basis. The CCG, Local Authority and acute provider are working together to implement a step down policy to streamline the management of patients placed within step down provision. The aim of this work is to ensure appropriate placements are made and patients are placed within step down provision for the minimum amount of time. This will improve the throughput within step down and ensure additional capacity is available for discharge from hospitals. The CCG funded a pilot scheme to in reach therapy services into A&E to prevent admission to hospital. The success of this pilot is currently being evaluated and decisions concerning continued funding will be made based on the evaluation. Work will also be undertaken within the coming year to evaluate the current intermediate care provision within the city to ensure it meets the needs of the local population and is effective in preventing admission and facilitating discharge. Reviewing of continuing care processes To support the speedy assessment of patients and reduce pressure on Urgent Care systems, the CCG and Acute Trust are currently developing an integrated assessment team. Q4 spend included training for additional staff to undertake the training to increase the number of patients assessed and reduce LOS in Step down beds. Competency sign off of recently trained healthcare professionals required. Appendix 6 73

74 Appendix 7 South East Staffs and Seisdon CCG South East Staffs and Seisdon Clinical Commissioning Group; SES and SP CCG have considerable flow into RWHT. This document summarises the supporting actions to Wolverhampton s A&E recovery plan: Programme of Work Plan Progress Prevention of attendance and turnaround in A&E Reduction in activity from Care homes Strengthening GP OOH s Services Review of CHC assessments process and approvals Dedicated south staffs Hospital Discharge Team Social Care (Currently social care are not allocating a social worker until section 5 received) Working alongside the community health and social care provider (SSOTP) to redesign CIT (Community teams) to be more responsive to urgent cases by building capacity and enhancing skill mix Enhance the training and support available to local care homes to manage their clients in times of crisis including end of life Review in partnership with Wolverhampton CCG Agreed with RWHT that CHC assessments completed by dedicated Hospital Staff will be accepted, following shadowing from south Staffs CHC Assessor To have identified team of workers responsible for all south staffs patients within RWHT fully integrated onsite into the hospitals discharge office and team Referrals for social care to be sent electronically and all sec 2s will be responded to within 24 hours. Consider learning from Accountable Care Partnership (with Good Hope Hospital) to review feasibility of removing Section 2s and 5s. New Model of Community Nursing is currently out to consultation Service Specification / Business case waiting approval to proceed. Dates confirmed for competency review Now completed In discussion with SSOTP to develop the model and identification of team to deliver a robust and sustainable service. Partially completed ( will be established by September 2013) Referrals are now being sent electronically to the team commissioner has a schedule of meetings to ensure change happens and is sustainable to reduce LOS. Linked to dedicated resource onsite from September 13 Appendix 7 74