ITEM 2 Minutes of Luton System Resilience Group Date: Wednesday 25 May 2016 Time: 1:00 3:00pm Venue: Meeting Room 1 First Floor, The Lodge, 4 George St West, Luton, LU1 2BJ Name Initial Title Organisation Nicky Poulain NPo (Chair) & Director of Commissioning & Luton Clinical Commissioning Group Integration Caroline Capell CC Assistant Director of Unplanned Care Luton Clinical Commissioning Group Adrian Cullen AC Commissioning Priorities Manager Luton Clinical Commissioning Group Linda Sharkey LS Service Director Cambridgeshire Community Services Noeleen McLoughlin NM Project Support Manager Urgent Care Luton Clinical Commissioning Group Dr Masoud Amini MA Urgent Care Clinical Lead & GP Luton Clinical Commissioning Group Bernie Naughton BN Director of Management Local Healthcare Solutions (LHS) Colette McKeaveney CM Director Age Concern Luton Lucy Nicholson LN Interim Chief Operating Officer Healthwatch Marion Collict MC Director of Operations & Transformation Luton & Dunstable Hospital Simon King SK Senior Locality Manager EEAST Shahin Parmar SP Commissioning Priorities Manager Luton Clinical Commissioning Group Marilyn George MG Integrated Operations Manager L&D / LBC Carole Gillespie CG Head of Commissioning Development Luton Clinical Commissioning Group Mark Morton MM Commissioning Priorities Manager Luton Clinical Commissioning Group Dr Rafid Aziz RA Lead Medical Director Care UK Eugene Jones EJ Director for Luton Mental Health Wellbeing East London Foundation Trust (ELFT) Services Karen Hall KH Deputising for and on behalf of Julia Mead, SEPT Integrated Services Bedfordshire and Luton Service Lead for Integrated Community Services Vanda McGibbon VM Lead Nurse Hospital @ Home Luton & Dunstable Hospital No Actions 1. Introductions: NPo chaired the meeting and introductions were made. Apologies: Bridget Cameron, Reena Silvester, Nina Pearson, Marie Louise-Smith, Judith Jackson, Rebecca Pheby, Jane Moakes, Maud O Leary, Natasha Bartlett, Mark Morton. 2. Minutes and actions from last meeting Wednesday: The Minutes were reviewed and agreed as an accurate reflection of the meeting. Action 1 - NM to circulate final amended minutes. Actions from 20.01.2016 and 23.03.2016 were then reviewed as follows: Action 6 from 20.01.2016 was noted completed and closed. Action 1, 2, 3, 4 and 5 were noted completed and closed. Action 6 CC informed that this action has been completed and that LCCG are working in conjunction with BCCG and the next scheduled meeting is the 20 May 2016. Action 7 and 8 were noted completed and closed. Action 9 CC informed the group that she is meeting Tanith Ellis from the L&D to discuss this action. CC reminded the group that MM is convening a Paediatrics working group and requires representation from this group. Action 10,11 and 12 were noted completed and closed. Action 2 All please confirm with MM who from your organisation should be involved with this Paediatrics Working Group.
NPo informed the group that L&D have signed their contract and it has been discussed how MRET marginal allocation will be used. NPo clarified SRG could focus on how future schemes could be used. NPo noted that as a system we need to acknowledge what is working well. NPo informed SRG that she will be meeting with David Carter, NHSE and other colleagues soon after today s session will help inform that meeting. 3. Overview of Winter 2015/16 3.1 A&E Mental Health Psychiatric Liaison Workers EJ drew the group s attention to his report advising the A&E Mental Health Psychiatric Liaison workers provide an interface within the L&D and offer an opportunity to signpost and treat patients presenting with mental health issues. EJ clarified that this team of specialists bring the opportunity of diagnosis, treatment and management of patients and improve on patient outcomes. CC requested clarification on the A&E reduction times indicated within the report. MC confirmed that mental health patients often went over the four hour target whilst awaiting an assessment and now this has improved. RA queried if the service accepts referrals from GP s. EJ stated that the service only takes referrals from A&E. NPo asked the group to explore what happens if a 111 outcome is for the Crisis Team, where do they call? RA explained that during home visits he contacts the Crisis Team. SK reminded the group of the workshop he ran involving the Ambulance service, Police and ELFT that are developing pathways to refer mental health patients to the Street Triage. SK noted that this service went live on the 23 May 2016. EJ confirmed that there is a Crisis Resolution and Home Treatment Team (CRHT) who will see patients in crisis within the home and there is a Community Mental Health Team (CMHT) and he will clarify the pathways for accessing these services and forward an update to this group. Action 3 EJ to clarify referral pathways for Community and Crisis Mental Health services. MC informed the group that she met with ELFT clinicians this week. MC highlighted that the Mental Health Community service is available and has now been re-established and is accessible via 111. AA queried the age group range for the service. MG stated that there is no crisis response service for over 65 year olds. EJ explained that ELFT will be developing a children s service this year. MG informed the group L&D do not have access to the ELFT database RIO. MG highlighted the risks and reminded the group of the agreement in place for Luton patients that are known to both ELFT and the L&D. AP confirmed within central Bedfordshire there is a different process however noted that mental health practitioners are slow to respond. MG explained that more specialist placements are required as some mental health patients could be delayed awaiting a placement for three to four weeks. NPo explained that these concerns contradict what the report says. EJ clarified that this is not what the report is about. EJ advised that the RIO concern is a governance issue and he will take this action away. EJ queried what the duplication of work involved. MG advised that all patient data would need to be uploaded on to both RIO and Liquid Logic systems. KH informed the group that the duplication of work is a patient safety issue as it could lead to patients going missing from either system. Action 4 EJ to check out governance regarding L&D having access to RIO. NPo requested clarity with regards to Psychiatry Liaison Teams assessments. MC confirmed that the service that is in place interfaces with the community. NPo queried the speed at which patients are seen for an assessment. MC acknowledged the fact that there is room for improvement however in comparison to what was in place previously this service is having a great impact. MG concurred stating that the service is superb once patient gets past ED. MG noted that bed issues would be more of an issue for these patients. CG queried the interventions in place for frequent attending mental health patients. NPo reminded the group that the service is proactive and would pick up on any of these referrals. EJ noted that the group is not looking at psychiatry in isolation and suggested that the group should have sight of all mental health pathways. ACTION: MA to work with EJ regarding mental health pathways. MA suggested looking at patients not on radar for example mental health first time presentation to OOH. MA queried why referrals from OOH to Psychiatric Liaison service is not possible. EJ advised that he will share pathways for CMHT and CRHT for both in and out of hours with AM. EJ provided assurance that the crisis team will see everyone referred, assess and make judgement. MA informed the group that whilst working within UGPC, Psychiatric Liaison service refused accepting referral from UGPC for two patients, and had to refer back those, who already streamed from A&E to UGPC, back to A&E. MA requested sight of the criteria from ELFT regarding pathways and SPOA. EJ advised that within ELFT s year two development plans a SPOA is included. EJ noted that he doesn t agree that their service is fragmented and will forward a diagram to help this groups understanding of Action 5 EJ/MA to share ELFT Mental Health pathways and criteria. Action 6 - MA to link with Mental Health Clinical lead Dr Anthea Robinson and EJ regarding mental health pathways. Action 7 - EJ to take back to ELFT possibility of referral from UGPC. Action 8 EJ to share flow diagram of ELFT services with SRG. Luton System Resilience Group Meeting Minutes 25.05.2016 - Final Page 2 of 5
how ELFT work. SP informed the group that ELFT have been invited to Cluster meetings and there may be a need to step back. SP explained that on a practical level Practices need to understand who they call in relation to different mental health events. NPo reminded the group that Dr Anthea Robinson is the CCG Clinical Lead for Mental Health. NPo confirmed that ELFT S year two plan includes the development of a Single Point of Access (SPOA). NPo queried how easy it was to navigate through the system and noted the superb services that ELFT are currently providing. CM suggested developing a sanctuary service. EJ agreed that this may be a potential option for the future and advised that ELFT are currently exploring a range of options including those with housing possibilities. 3.2 L&D Initiatives 3.2.1 Hospital at Home MC drew the groups attention to her update report on Hospital at Home (H@H). VM informed the group that the Hospital at Home Team are aligned with the Acute Community Care Team (ACCT) and they are reliant on each other and are in contact on a daily basis promoting admission avoidances and supporting hospital discharge. VM also advised that the H@H Team work closely with District Nursing Teams in the community. LS informed the group that communication between the teams has always been good although it was better when the ACCT Team were based within the hospital. LS queried the reduction in bed days although agreed that the service supports flow and acknowledged that their role in the community supports GP s. LS advised that CCS would not have capacity to complete QDS four times a day. MC asked what organisation is best placed to complete this work clarifying and acknowledged. MC acknowledged that CCS maybe best placed to support the reduction of admissions. MC noted that lots of patients are being discharged requiring infusions and decisions need to be made regarding who is best placed to support these patients. NPo explained that these patients are complex and GP s are not happy to deal with these complexities alone and require consultant support. NPo reminded the group that if patients discharged too early there is the likelihood of them being readmitted so there needs to be a balance. MC reminded the group that the L&D s focus is on the numbers of patients coming in the front door which needs to be managed in a more timely and planned way. MC stated that the numbers of patients medically fit and ready to discharge in where the blockage is. NPo explained the need to understand an average patient s requirements as our system supports payment by results and has not got funds to pay twice to support patient s health needs. MG stated that there are occasions when patients are medically fit and sitting in wards when they then become medical and require more support by the hospital. NPo queried where as a system we are using our resources. AA queried if the H@H T look at readmission rates. VM assured the group that they do and advised that the team support admission avoidance and advise on self-care. MC suggested that the H@H Team should be a commissioned service. NPo noted that current needs suggest that commissioned services should be at the front end of the hospital. CC informed the group that our System Resilience Plan will focus on admission avoidance and queried if EEAST could take patients to other healthcare setting rather than the hospital. SK advised that it is possible however pathways would need to developed. CC asked the group to explore what kind of patients could go to different settings. LS advised that a definitive service could be established and triggers and interventions could then be agreed. MC queried if a patient needs IV s then CCS would need to provide. LS agreed that CCS could support with IV s but if patient has an issue regarding a fall or if there are social issues other interventions and pathways would need to be available. AA stated the need to ensure that the ACCT support tools stay within the hospital as this supports GP colleagues in the community. ACTION NPo requested SRG members to agree a system wide admissions avoidance pathway that includes social care and the ambulance service. SK reminded the group that the ambulance services do not have access to the background knowledge of patients or an awareness of who chronic patients may be. 3.2.2 ED Consultant & 3.2.3 Ambulatory Care MC drew the group s attention to the ED and ACC reports and reminded the group that these schemes maintained the four hour target supporting the ambulance service regarding offloads and management of patients. MC stated that there had been a significant rise in numbers of patients coming to ED. MC explained that patient awareness is increasing about getting a quick service at the L&D and informed the group that the most significant increase noted this Winter was in paediatrics. ACTION 9 All to develop a system wide approach to developing an admissions avoidance pathway to include social care and ambulance service. MC informed the group that the additional funding allowed the L&D have longer consultant cover in ED and the L&D have seen the benefits from having Senior Consultant in A&E and are exploring Luton System Resilience Group Meeting Minutes 25.05.2016 - Final Page 3 of 5
the potential of having this in place 24/7. NPo reminded the group that Urgent Connect is also within the L&D. CC explained that a delay in GP referrals later in the day has the effect of stocking up of ambulances. BN asked the group to explore the peak periods of presentation and queried what the alternatives may be. MC informed the group that during the Junior Dr s strike the L&D looked at an alternative approach to working within ED. MC explained that Dr David Kirby, Senior Consultant worked on the front desk in streaming within the ED and greatly reduced patient admittance, those patients that advised that they could not get a GP appointment he rang their practice and arranged appointments, he admitted patients that needed to be there and streamed as appropriate. MC advised that out of 40 patients that Dr Kirby dealt with, 10 were sent to ED, 10 were sent to UGPC, 10 were discharged at the front door and 10 were sought access to own GP. Discussion took place and CM explained the issues regarding same day appointments which some Practices can offer however some single handed Practices cannot. RA reminded the group of two pilots where GP visiting service took place earlier in the day which helped support admission avoidance. NPo advised that in a previous role GP Acute Visiting was done in East and North Hertfordshire and noted that for the investment it was not worth it. NPo drew the group s attention to a new pilot called Primary Care Home which is running in Luton with CCS, Medics Cluster and Kingsway Cluster at the moment. LS explained that the pilot is a combination of primary and community care which is well positioned to make the changes needed establishing integrated working on a local level to deliver care close to home for prioritised patients that is responsive to local needs, improves health outcomes and offers value for money. LS advised that prioritised patients needing an intervention will be flagged on systems and the CCS team will initiate a visit. LS advised that this model takes away working in silos as an individual or organisation and it also removes barriers and decisions are made with regards who is best placed to deal with the patient at their time of need. MC drew the group s attention to the Ambulatory Care update and explained that regarding the funding that was available the L&D invested this in medical and nursing staff to support beds that were placed within the Ambulatory Care department due to increased winter pressures. Discussion took place regarding referrals to the Ambulatory Care Unit. CC reminded the group that Sally Shaw is the Manager for the GP Liaison and Integrated Discharge Teams based within the hospital and all GP referrals should use the Urgent Connect pathways which will be coordinated through Sally s team who can then refer back to the community. 3.3 EEAST Initiatives 3.3.1 HALO SK informed the group that EEAST are consulting with CCG partners regarding their Operating Model and queried if a presentation could be circulation to SRG members for discussion at a future meeting. NPo asked that the presentation be forwarded and advised that it could be circulated with the minutes. ACTION 10 NM to circulate Operating Model SK referred the group to the HALO update and asked the group to note the table of activity within the report. SK stated that handover to clear delays have greatly improved. MC advised that the L&D use the inbound screen to monitor ambulance arrivals and noted that having the ability to see expected arrivals proves useful however the HALO is unable to prevent ambulance pile up. NPo suggested that demand management & remodelling may prove beneficial to EEAST. SK informed the group that EEAST are intending to move lots more staff into the control room, and out of necessity will continue to fund. 3.3.2 Private Ambulances SK provided the report overview of the PAS which has been a support function to EEAST as 35% of EEAST staff are on training so PAS has supported non-emergency transport. 3.4 Therapy Services AA explained that this scheme helped reduce patient s length of stay, supported partnership working and offered crisis management support. AA informed the group that an audit of their scheme showed that the service has been able to keep numbers of rehabilitation beds to 20, maintain flow and support hospital discharge. NPo noted that the re-enablement teams are working well. MG concurred and advised the group that from 1 st June 2016 re-ablement will be taken in house at the hospital. NPo requested an update to see how this work progresses in the future. ACTION 11 - MG to provide an progress report for re-ablement to come to SRG at a future meeting. NPo requested an update from Age Concern Luton on their activity throughout the Winter. CM explained that year on year patients numbers are increasing. CM advised that when patients are about to be discharged from hospital and plans have been put in place regarding their support within their home and then they become medical this is called stand downs. CM advised that Luton System Resilience Group Meeting Minutes 25.05.2016 - Final Page 4 of 5
stand downs have increased this year which is becoming an issue. CM stated that this year so far 650 patients have been maintained at home for six weeks after discharge. MG agreed that stand downs are also an issue for Social Workers, and late discharges are also a problem. NPo recalled that to take away medication (TTA) and non-emergency transport proved to be an issue in the past. MC informed the group that there is still have a number of patients who don t make discharge times because of this. CM agreed and advised that many patients discharged without care packages was also proving to be an issue. MG reminded the group that the L&D policy states that no patients to be discharged after 9.00pm and there have been occasions that patients are being discharged later than this. ACTION: AC to pick this up outside of this meeting. 4. Planning 2016/17 NPo informed the group that discussions from today s workshop will feed into Luton s System Resilience Plan which will be on the agenda for next months meeting and there needs to be clear priorities which should include prevention, proactive management, GP Access perception versus real. ACTION: CM to track some patient journeys and feedback to CC which may help identify gaps in the system which can inform the SRG System Resilience Plan which can be discussed with this group. ACTION 12 AC to clarify discharge times process. ACTION 13 CM to track some patient journeys and feedback to CC which may identify gaps in the system which can inform the SRG System Resilience Plan. MA queried what the L&D s TTA targets are. MC advised that there is an issue regarding TTA however noted that this delay is not waiting on medication. MC explained that the delay occurs when waiting on clinicians to prescribe. MC informed the group that during the Junior Dr s strike this was addressed and it was recorded that there were no delays in prescribing on that day. KH raised concerns that if medications are not made available at discharge this is also causes a risk for community services. MC advised that the L&D are sited on this and it has been noted as a risk. Discussion took place and NPo suggested that we need to do something as a collective regarding medically fit patients. MC advised that a focus on this would be helpful. NPo suggested that clarity regarding stakeholder groups would be required. CG noted that whole self-management, self-care and understanding needs to be included. NPo explained that Public Health s core contract includes care prevention and self-care and needs to be incorporated. AA suggested educating patients so they understand processes. CC advised that Self Care will be an agenda item at next month s meeting. CC also advised that she is looking at different options regarding system resilience calls and an update will be included within the System Resilience Plan. LS suggested that interventions regarding paediatrics needs to be included. BN requested that consideration of a GP on call rota A named GP on call, who could link to GP Access be included which might mean that a local GP would be on call once or twice a year. ACTION 14 ALL need to discuss medically fit patients. 5. Any other business May Bank Holiday On Call Pack NM informed the group that final updates for the on call pack need to be submitted today as the final pack will be circulated tomorrow Thursday 26 May. Date of Next Meeting: Wednesday 22 June 2016, 1:00-3:00pm Meeting Room 1, The Lodge, Luton. Luton System Resilience Group Meeting Minutes 25.05.2016 - Final Page 5 of 5