Attachment 9 Report to the Board of Directors 2015/16 Date of meeting 18 Subject Report of Prepared by Seven Day Services Medical Director Ashling Rivá, Project Manager Previously considered by Transformation Board, 17 November 2015 Question(s) addressed in this report Addressing the gaps identified in the BAF on lack of a robust detailed project plan Board Action Required Approval X Discussion Decision Information Executive Summary, purpose and recommendation(s) The purpose of this report is to document progress on seven day service standards and the focus for 2016 and 2017. The Board is asked to consider the information supplied, recognising the challenges the Trust faces with implementation of the 10 clinical standards, and confirm. Of note NHS IQ have not provided any financial assistance or project guidance aside from base line assessment templates.
Strategic Context/Objective(s) and Board Assurance Framework links Strategic aim(s) To be safe To be effective To be caring To be responsive To be well-led Strategic objective(s) 4 X BAF references 4e This paper provides assurance against the Trust objective(s) identified X This paper is to close a gap in control/assurance in relation to the objective(s) Legal/regulatory (relevant legislation and specific reference where appropriate) No legal requirements. However, there is expectation that the ten clinical standards, developed by the NHS England Seven Day Services Forum, will be met by NHS organisations by 2017. Equality Impact/risks: (Equality Delivery System 2 EDS2 Nov 2013) Negative Neutral X Assurance/monitoring DEFINITIONS Information: Update to ensure Board has sufficient knowledge on subject matter and to provide assurance on progress Discussion: seeking Board members views, potentially ahead of final course of action being agreed Decision: when being asked to choose between alternative courses of action Approval: positive resolution, to confirm paper is sufficient to assure the Board in its ongoing monitoring role, or to address a gap in control Page 2 of 12
1.0 Introduction In April 2013 the James Paget University Hospitals led by the Medical Director started work towards improving the provision of services on a seven day basis. At about the same time there was a national drive to improve provision of NHS services seven days a week. This paper provides progress on the work done so far and next steps to continue to work towards the goal of full seven day service provision. The James Paget University Hospital became a National Pilot Site in October 2013 having applied and been selected out of over 70 applicants, forming the Seven Day Services Transformation Improvement Programme (SDSTIP). Originally this group consisted of HealthEast, Great Yarmouth and Waveney s Clinical Commissioning Group and James Paget University Hospitals NHS Foundation Trust, as participants in the NHS Improving Quality. This group met bi-monthly with subgroups reporting progress against the clinical standards listed below. In 2014 the title became that of Early Adopters Delivering NHS Seven Days a Week. The groups original formation was to include all integrated pathways within the patient experience to include Social Work, Mental Health and Out of Hospital pathways pertaining to the 10 Clinical Standards listed below; 1. Patient Experience. 2. Time to first Consultant review. 3. Multi-disciplinary review. 4. Shift handovers. 5. Diagnostics. 6. Intervention/key services. 7. Mental Health. 8. Ongoing Consultant review. 9. Transfer to community, primary care and social. 10. Quality Improvement. Work was commenced on all 10 standards in late 2013. In March 2015 NHS IQ visited the James Paget University Hospitals to assess our progress against the standards. Presentations included; Social Care, Mental Health, Summary Care Records, NHS 111and Out of Hospital Team. Informal feedback on the day was very positive about the work going on at the JPUH with partners but formal feedback from this visit has not been forthcoming despite numerous attempts to obtain this and membership of this group does not seem to be consistent or directional. It is unfortunate that the team did not inform us that we would be required to submit data on four of the standards based on an audit as at the time we had been looking at various ways to collect information electronically.. Page 3 of 12
2.0 Progress In September 2015 Monitor and NHS England outlined priority focus to four of the ten clinical standards. Trusts are expected to deliver these standards by 2016. These are: Standard 2 Time to first Consultant Review Standard 5 - Diagnostics Standard 6 Intervention/Key Services Standard 8 On going consultant review NHS IQ published our compliance on their website as The Trust is fully compliant with one of the four priority clinical standards (6) and we are making progress against the other 3 standards. This is detailed on the table overleaf. The other 6 standards will be expected to be delivered by 2017. At this point we are not aware of the consequences of non-deliverance of these standards within the time frames. It is a requirement for all trusts to deliver these standards in the time frames. Page 4 of 12
Clinical Standard Standard 2 Time to first Consultant Review Standard Result Action for the Trust from this report Inpatients seen by a consultant within 14 hours. Evidence that Patients are seen within 14 hours 90% or more of the time. Trust = 0 out of 10 (as we have currently have no means to measure) Currently the Trust has no IT system to measure or monitor compliance. Different options were looked at with IT but none would be ideal. We are not aware of any other trusts able to capture this electronically either. Manual audits to evidence this are required. Request made to Audit Department to complete audit on specialties identified below; Cardiology, General Medicine, (EADU audit showed 86% compliance), General Surgery, Geriatric, Gynaecology, ITU, Obstetrics, Paediatrics, (Psychiatry N/A), Trauma and Orthopaedics. Standard 5 Diagnostics services and Therapies Diagnostic services available 7 days per week. Trust = 11 out of 14 Compliant; Biochemistry, Chemical Pathology, CT, Haematology, Histopathology, Microbiology, Radiology, Therapeutic lower GI endoscopy, Therapeutic upper GI endoscopy, Ultrasound, X ray. The audits are due to be completed in February 2016 Not compliant. Bronchoscopy (currently twice a week), Echocardiology (previous study evidenced lack of requirement 7 days of the week), MRI lists when required (to clear waiting list - not as routine). Therapies require Investment Bid and staff consultation to introduce shift systems to cover 7 day therapy services. Standard 6 Interventional services Consultant directed interventions are available seven days per week Trust = 9 out of 9 Compliant Page 5 of 12
Standard 8 Ongoing Consultant Review Ongoing Consultant review every 24 hours 7 days of the week Trust = 2 out of 13 Compliant; ITU, EADU Lack of Consultant staff base to support this standard. During weekdays some patients are not always seen by a senior decision maker once every 24 hours. There are 2 consultant ward rounds per week (on average) by a consultant. In between, patients are reviewed by juniors and registrars. Daily discussions with consultant staff however as necessary and consultant staff will review those patients as required During weekends those who require review as a result of their medical conditions are reviewed mostly by Registrars. When necessary the consultant will always review those patients ACTION: Explore gaps in detail. Initiate dialogue with Consultants along with review of job plans to extend service. Full compliance would require additional funding for an enhanced Consultant staff base along with managing on-going recruitment constraints. Page 6 of 12
3.0 Progress to date 3.1 Clinical Standard 1: Ongoing Patients, and where appropriate families and carers, must be actively involved in shared decision making and supported by clear information from health and social care professionals to make fully informed choices about investigations, treatment and ongoing care that reflect what is important to them. This should happen consistently, 7 days a week. A patient representative sits on the SDSTIP Committee. A compliment data collection process on the ward does not define days of the week, this form is to be adapted. PALS supply data regarding complaints regarding processes that caused patient dissatisfaction over 7 days of the week. (previously 5 ) Carer and patient Experience Committee has recently been set up ensuring that Carer and Patient Experience is given a high priority on a day to day basis. 3.2 Clinical Standard 2: Early Adopter Site Priority 2016 All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours from the time of arrival at hospital 7 days of the week. Manual Audit covering 10 specialities. Audit to be completed February 2016 to form baseline, moving forward 3.3 Clinical Standard 3: Priority 2017 All emergency inpatients must be assessed for complex or on-going needs within 14 hours by a multi-professional team, overseen by a competent decision-maker, unless deemed unnecessary by the responsible consultant. An integrated management plan with estimated discharge date and physiological and functional criteria for discharge must be in place along with completed medicines reconciliation within 24 hours. Reviews should be completed using patients existing primary and community care records MDTs should consist of Nursing, Medicine, Pharmacy, Physiotherapy and Occupational Therapy. Currently A plan for; a) Physiotherapy and Occupational Therapy review at the weekend b) Number of patients for discharge seen at the weekend by therapist c) Number of therapy assessments undertaken at the weekend. Page 7 of 12
Therapies regarding 7 Day Services has become a separate sub project - Priority 2016 Business case for Therapists requiring more detail for financial investment. Therapists are however, working on rotas at the weekend within cardiology, respiratory and orthopaedics and identifying number of cases seen at the weekend, the number of assessments undertaken and recording the number of discharges from these assessments. 3.4 Clinical Standard 4: Priority 2017 Handovers must be led by a competent senior decision maker and take place at a designated time and place, with multi-professional participation from the relevant incoming and out-going shifts. Handover processes, including communication and documentation, must be reflected in hospital policy and standardised across seven days of the week. Competent Senior Decision Maker defined as Consultant. Handover Policy now in place. 3.5 Clinical Standard 5: Early Adopter Site Priority 2016 Hospital inpatients must have scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology. Radiology The department has worked incrementally over the last 2 years to increase the amount of services available at the weekend in keeping with the Trust s needs. PACS Staff are now on-call to support IT specifically for the Radiology Department at weekends Ultrasound There is a designated Ultrasound sessions for Obstetric and Gynaecological examinations 09.00 12.00 on a Sunday morning, with additional Radiographer-led general medical and gynaecological lists carried out on Saturdays as required. Radiologists provide a 24/.7 emergency ultrasound service and carryout inpatient ultrasound for urgent general medical cases at the weekend. Plain film The department offers a 24/7 plain film service and will expand it plain film reporting to 7/7 by 1 st April 2016. Page 8 of 12
CT The current on-call system for CT 24/7 requires conversion to a shift system this has been set as a Divisional priority and an Investment Bid. This will include support working but will require some recruitment and training to achieve. MR Weekend lists carried out as required. Radiologist cover There is 7/7 on-site Radiologist cover provided with an 8/8 Nighthawk service for automatic reporting. Radiology Nurses There is a Radiology Nurse on-call rota that provides support to Radiologists and radiographers for interventional work out-of-hours. Administration Weekend working as required and designated sessions for Bank Holidays. Endoscopy There is Gastroenterologist-led on-call service with additional weekend working and further planned extension to departmental working hours for bowel screening service. POCT Funding for 7/7 Ambulatory Bay provision agreed and 24/7 pathology services. Clinical measurements Requirement for 7 day services reviewed and not required at this time. For review 2016/17. 3.6 Clinical Standard 6: Compliant and complete Hospital inpatients must have timely 24 hour access, seven days a week, to consultantdirected interventions that meet the relevant specialty guidelines, either on-site or through formally agreed networked arrangements with clear protocols, such as: Critical care Interventional radiology Interventional endoscopy Emergency general surgery Clinical Standard 7: Priority 2017 Where a mental health need is identified following an acute admission the patient must be assessed by psychiatric liaison within the appropriate timescales 24 hours a day, seven days a week: Within 1 hour for emergency* care needs Within 14 hours for urgent** care needs Page 9 of 12
Winter pressures money had resulted in additional psychiatric liaison but this money was withdrawn April 2015. Resilience funding ceased in April 2015 and this provision is no longer in place 7 days. Funding for mental Health in general has been proposed as part of 2015/16 CQUIN and consideration of whether weekend psychiatric services can be achieved within these monies. 3.7 Clinical Standard 8: Early Adopter Site Priority 2016 All patients on the AMU, SAU, ICU and other high dependency areas must be seen and reviewed by a consultant twice daily, including all acutely ill patients directly transferred, or others who deteriorate. To maximise continuity of care consultants should be working multiple day blocks. Once transferred from the acute area of the hospital to a general ward patients should be reviewed during a consultant-delivered ward round at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient's care pathway. Manual Audit covering 10 specialities. Audit to be completed February 2016 to form baseline, moving forward. 3.8 Clinical Standard 9: Priority 2017 Support services, both in the hospital and in primary, community and mental health settings must be available seven days a week to ensure that the next steps in the patient s care pathway, as determined by the daily consultant-led review, can be taken. Multidisciplinary team including social care staff was working in place over 7 days at the JPUH in 2014/2015 with funding from CCG resilience funds. There is also in place an in and out of hospital team in Lowestoft consisting of multidisciplinary staff who work 24/7. There are plans in place to implement another out if hospital team in Great Yarmouth 24/7. This year resilience funds have not been agreed by the CCG for the continuation of Social Care Staff at the JPUH over the weekend. This may be reviewed and the continuation of this service is being supported by the Urgent Care Board. Page 10 of 12
3.9 Clinical Standard 10: Work ongoing All those involved in the delivery of acute care must participate in the review of patient outcomes to drive care quality improvement. The duties, working hours and supervision of trainees in all healthcare professions must be consistent with the delivery of highquality, safe patient care, seven days a week. A Unified Mortality Review Group has been formed this was a step forward in the direction of looking at mortality, corporately. We are striving to make more progress in achieving the goals laid out in the Unified Mortality Review Group s strategy. The action plans from this meeting are being taken forward. CHALLENGES: As well as financial, challenges integrating 7 day services within directorates are; Culture Staff traditionally working Monday to Friday. Terms and conditions- Consultant contract. Recruitment in hard to recruit to specialities e.g. stroke and care of the elderly especially in relation to Standard 8 On going review by Consultants. IT capacity to deliver on solutions. Challenging the too busy culture when solutions to work to the 10 clinical standards are introduced. For 7 day services to be successful we need all providers to work across 7 days otherwise process to discharge patients will fall down. Therapy discharges at the weekend are inter-dependable with other service and clinician decision to discharge being clearly documented to enable discharge to happen. Financial implications of all of the above. The Seven Day Services Transformation Improvement Project group have not met for several months due to ongoing negotiations with the CCG; they will reconvene early 2016 subject to clarity on the CCGs Commissioning Intentions for 2016/17. NHSIQ stipulate that Trusts should comply with standards 2, 5, 6 and 8 by 2016 however Board should note this will be difficult to achieve without substantial resource and investment. The trust will need to integrate the seven day services into the rest of the transformation programme with a focus on investing to save. The development of seven day services will undoubtedly, apart from improving quality of care and patient experience, reduce cost as flow during the week improves. Page 11 of 12
IN CONCLUSION: There has been some progress in within the JPUH and having been an early adopter we are ahead in comparison with other trusts who are just beginning the journey. Of note is the progress in weekend services with non clinically related services e.g radiology admininstrative staff at the weekends There has been some progress within the wider clinical system. The trust would need to make some investment decisions but these would need to be integrated into the trusts transformation programme. Page 12 of 12