Local A&E Delivery Board Chair Development Day

Local A&E Delivery Board Chair Development Day Leicester Racecourse Wednesday, 2 nd November 2016 www.england.nhs.uk

Local A&E Delivery Boards National & Regional Priorities Dale Bywater Executive Regional Managing Director, NHS Improvement (Midlands & East) Dr Paul Watson Regional Director, NHS England (Midlands & East) www.england.nhs.uk

National A&E Performance (to Aug 2016) www.england.nhs.uk 3

Best & Worst Nationally www.england.nhs.uk 4

Regional A&E Performance Summary Regional 2016/17 ED position continues to be significantly challenged against the 4 hr 95% NHS constitutional standard. Current YTD (Apr-16 to Aug-16) is 87.13% (NHST + FT Acute + Community only) 5.9% points below the 15/16 year to date level. National year to date is at 89.5%. During Aug-16 segment 3 and 4 performance has fallen the most on last year, despite lower increases in attendances than in segments 1 and 2. 10 Midlands & East Trusts (Acute + Community) are currently achieving the standard YTD, of these only 4 Acutes are achieving the standard:- Luton & Dunstable FT, Birmingham s Children s FT, South Warwickshire FT and Dudley Group FT. Aug-16 performance (Acute + Community) was 87.7%, the highest monthly position achieved during 2016/17, however this is 5.9% points below the same period last year. www.england.nhs.uk 5

% 4hr Performance Mean Temperature C Regional A&E 4 hr Performance (All Type) from Apr-12 Longer term analysis: Midlands & East region has consistently tracked below the national position since 2012; we are currently the worst performing region. 100% 60 95% 50 90% 40 85% 80% Mild winter but temp. in Mar-13 well below avg. M&E region has not achieved 95% since Aug-13 400 winter resilience funding announced Additional 300 winter resilience funding announced M&E YTD performance up to Aug-16 is 5.9% points lower than previous year 30 20 75% 10 70% 0 www.england.nhs.uk M&E National Standard Mean Temperature 6

Regional A&E 4 hr Performance (All Type) July-15 to Aug 2016 Regional 16/17 ED position continues to significantly challenged against the 4 hr 95% NHS constitutional standard Current Year-to-Date (to Aug-16) is 87.1%; 5.9% below the 15/16 YTD level Proportion of patients admitted, transferred or discharged within four hours of arrival in all types of A&E Aug 2015 Aug-16 Change 93.59% 87.67% - 5.92 % Year to date (YTD) performance 93.04% 87.13% - 5.91 % Number of providers (with Type 1) missing www.england.nhs.uk the standard in 2016 34 out of 45 (90%) 7

ED Performance overview A&E Performance - latest 3 months (Sorted Worst to Best) Mar-May % Jun-Aug Change % Most Improved Latest 3 months vs 3 months previous NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST 76.4% 71.0% -5.4% COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST 8.3% THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST 75.0% 73.2% -1.8% THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST 7.6% MID ESSEX HOSPITAL SERVICES NHS TRUST 77.3% 78.1% 0.8% NORTHAMPTON GENERAL HOSPITAL NHS TRUST 6.5% UNITED LINCOLNSHIRE HOSPITALS NHS TRUST 81.5% 79.2% -2.3% PETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST 5.3% UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 79.5% 79.2% -0.3% NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 5.2% HINCHINGBROOKE HEALTH CARE NHS TRUST 81.4% 80.0% -1.4% BURTON HOSPITALS NHS FOUNDATION TRUST 4.6% UNIVERSITY HOSPITALS OF NORTH MIDLANDS NHS TRUST 77.8% 81.0% 3.1% BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 4.5% PETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST 76.9% 82.2% 5.3% KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST 4.3% CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 86.3% 83.0% -3.2% WEST HERTFORDSHIRE HOSPITALS NHS TRUST 4.2% EAST AND NORTH HERTFORDSHIRE NHS TRUST 80.4% 83.8% 3.4% GEORGE ELIOT HOSPITAL NHS TRUST 4.2% WEST HERTFORDSHIRE HOSPITALS NHS TRUST 79.6% 83.8% 4.2% EAST AND NORTH HERTFORDSHIRE NHS TRUST 3.4% SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 82.5% 83.9% 1.4% HEART OF ENGLAND NHS FOUNDATION TRUST 3.3% BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 79.8% 84.3% 4.5% UNIVERSITY HOSPITALS OF NORTH MIDLANDS NHS TRUST 3.1% UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 81.9% 84.5% 2.6% SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST 2.7% UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 85.0% 84.5% -0.5% UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 2.6% WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 83.0% 84.7% 1.6% BIRMINGHAM CHILDREN'S HOSPITAL NHS FOUNDATION TRUST 2.0% COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST 77.0% 85.3% 8.3% WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 1.6% CHESTERFIELD ROYAL HOSPITAL NHS FOUNDATION TRUST 87.8% 85.6% -2.2% SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 1.4% WEST SUFFOLK NHS FOUNDATION TRUST 88.9% 85.9% -3.0% MILTON KEYNES UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 1.2% SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 85.5% 86.4% 0.9% SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 0.9% WYE VALLEY NHS TRUST 88.2% 87.3% -1.0% MID ESSEX HOSPITAL SERVICES NHS TRUST 0.8% WALSALL HEALTHCARE NHS TRUST 88.7% 87.3% -1.4% SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 0.6% KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST 83.5% 87.8% 4.3% DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST 0.5% DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST 88.2% 88.7% 0.5% LUTON AND DUNSTABLE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 0.4% THE ROYAL WOLVERHAMPTON NHS TRUST 89.4% 89.5% 0.1% THE DUDLEY GROUP NHS FOUNDATION TRUST 0.3% NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 84.6% 89.7% 5.2% THE ROYAL WOLVERHAMPTON NHS TRUST 0.1% SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST 90.9% 89.9% -1.0% UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST -0.3% HEART OF ENGLAND NHS FOUNDATION TRUST 86.6% 89.9% 3.3% UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST -0.5% BURTON HOSPITALS NHS FOUNDATION TRUST 85.4% 90.0% 4.6% WYE VALLEY NHS TRUST -1.0% JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 94.1% 90.8% -3.4% SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST -1.0% BEDFORD HOSPITAL NHS TRUST 93.2% 90.9% -2.3% HINCHINGBROOKE HEALTH CARE NHS TRUST -1.4% IPSWICH HOSPITAL NHS TRUST 94.8% 92.2% -2.6% WALSALL HEALTHCARE NHS TRUST -1.4% THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST 84.9% 92.4% 7.6% THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST -1.8% NORTHAMPTON GENERAL HOSPITAL NHS TRUST 86.2% 92.7% 6.5% CHESTERFIELD ROYAL HOSPITAL NHS FOUNDATION TRUST -2.2% GEORGE ELIOT HOSPITAL NHS TRUST 88.8% 93.1% 4.2% BEDFORD HOSPITAL NHS TRUST -2.3% MILTON KEYNES UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 92.8% 94.0% 1.2% UNITED LINCOLNSHIRE HOSPITALS NHS TRUST -2.3% SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST 92.1% 94.8% 2.7% IPSWICH HOSPITAL NHS TRUST -2.6% SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 95.4% 96.0% 0.6% WEST SUFFOLK NHS FOUNDATION TRUST -3.0% THE DUDLEY www.england.nhs.uk GROUP NHS FOUNDATION TRUST 96.0% 96.3% 0.3% CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST -3.2% BIRMINGHAM CHILDREN'S HOSPITAL NHS FOUNDATION TRUST 95.0% 97.0% 2.0% JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST -3.4% LUTON AND DUNSTABLE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 98.6% 99.1% 0.4% NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST -5.4% Change

Top 20 contributors to Regional Performance (Jun to Aug-16) A&E Performance - 3 Months (June, July & August 2016) RAG < 95% Number of Attendances Number Breaches 3 Month Performance Provider 1,666,124 185,342 88.9% If Trust Delivered Std Regional Increase NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST 49,392 14,329 71.0% 0.71% UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 58,988 12,282 79.2% 0.56% UNIVERSITY HOSPITALS OF NORTH MIDLANDS NHS TRUST 61,355 11,684 81.0% 0.52% UNITED LINCOLNSHIRE HOSPITALS NHS TRUST 41,759 8,696 79.2% 0.40% THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST 25,881 6,934 73.2% 0.34% WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 48945 7499 84.7% 0.30% UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 47,358 7,342 84.5% 0.30% CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 37,973 6,439 83.0% 0.27% EAST AND NORTH HERTFORDSHIRE NHS TRUST 39,979 6,472 83.8% 0.27% MID ESSEX HOSPITAL SERVICES NHS TRUST 24,688 5,412 78.1% 0.25% SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 36,768 5,918 83.9% 0.24% WEST HERTFORDSHIRE HOSPITALS NHS TRUST 36,099 5,839 83.8% 0.24% BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 33,584 5,273 84.3% 0.22% PETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST 27,200 4,842 82.2% 0.21% HEART OF ENGLAND NHS FOUNDATION TRUST 67,544 6,817 89.9% 0.21% UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 29,034 4,501 84.5% 0.18% DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST 46,509 5,247 88.7% 0.18% SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST 56,317 5,698 89.9% 0.17% THE ROYAL WOLVERHAMPTON NHS TRUST 46,460 4,893 89.5% 0.15% WALSALL HEALTHCARE NHS TRUST 29,982 3,795 87.3% 0.14% www.england.nhs.uk 9

ED Attendances & Emergency Admissions (Provider Sector Data) At regional level ED attendances continue to show year on year growth (currently +5.56% year to date 2016/17 vs 2015/16. Emergency admissions (all types) also show growth of 6.43%. A&E attendances against plan (note new data added to report) show a year to date variance of 2.95% above plan. Similarly, non-elective admissions are year to date 3.21% above plan. Note that the variances against plan are SUS data rather than published Sitrep figures. A&E Attendances Non Electives 10.00% Actual growth Planned growth 6.00% Actual growth Planned growth 8.00% 5.00% 4.00% 6.00% 3.00% 4.00% 2.00% 2.00% 1.00% 0.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.00% -1.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar -2.00% -2.00% -4.00% -3.00% www.england.nhs.uk 10

A&E Attendances (Provider Sector Data) August 12 month rolling average increase of 4.9%. Midlands and East and London Regions have seen the highest % increases in attendances. On average there has been a 2.8% rise year-on-year since 2013. This year there has been an above average increase from winter onwards. It s been an exceptional increase this year. Although not quite as high as winter it still remains higher than average. April attendances were lower due to the 4 days of industrial action that reduced A&E demand (but still slightly above the long term average). Long term increases higher in the 65 and above age groups. Source Sitrep, Midlands and East data, all A&E types. www.england.nhs.uk 11

Growth in admissions via A&E (Provider Sector Data) Midlands and East have seen the largest 12 month growth of any region, but all regions bar North have seen increases. 6.2% 12 monthly rolling increase in Midlands and East. A higher increase over 12 months in admissions compared to attendances within Midlands and East. Source Sitrep, All Regions, All types. www.england.nhs.uk 12

Correlation between performance, attendances & admissions There is a slight correlation between performance and attendances but it is not strong. There is a stronger correlation between performance and admissions. Source Sitrep, Midlands and East, all www.england.nhs.uk types. 13

Delayed transfers of care: National Overview www.england.nhs.uk 14

Delayed transfers of care: Provider & Local Authority www.england.nhs.uk 15

Ambulance Performance (Aug-16) www.england.nhs.uk 16

A&E Improvement: The National Plan To return to delivery of the 95% A&E standard nationally by March 2017 National requirements for every system Regional teams with your support and expertise will adapt them for local circumstances to maximise sustained improvements Preventing people coming to A&E when they don t need to Internal flow Dealing with discharge issues www.england.nhs.uk 17

Regional A&E Delivery Board Regional A&E Delivery Board Joint SROs NHS Improvement Executive Regional Managing Director Dale Bywater NHS England Regional Director Dr Paul Watson Programme Leads NHS Improvement Nick Hardwick NHS England Tracey Cogan ECIP Pete Gordon Programme Sponsors Acute CEO Programme Sponsor: Glen Burley CCG AO Programme Sponsor: John Wardell Local Authority Programme Sponsor: Rob Tinlin & John Sinnott Ambulance Service Programme Sponsor: Anthony Marsh Programme Clinical Lead Sponsor: Dr Hassan Paraiso Programme 111 Lead Sponsor: David Archer Core Activities Monitoring of regional performance Assurance of local delivery plans & oversight of local implementation progress Coordination of regional improvement support Programme Oversight NHS Improvement RCOO Mark Cubbon NHS England RODD Graeme Jones NHS England Medical Director Dr David Levy Local A&E Delivery Boards Implementation of programme initiatives & activities Delivering performance improvement www.england.nhs.uk Urgent & Emergency Care Regional Delivery Board Oversight of UEC Network wide initiatives & activities 18

Regional A&E Improvement Plan 1. Regional Red to Green Days ECIP programme launched. 2. Regional UEC Network PMO has been expanded to support implementation of the A&E Improvement Plan; group has met as whole "A&E Support Team" including NHS Improvement, NHS England, UEC / A&E PMO. 3. Critical Friend (Glen Burley, Regional CEO Sponsor) as part of his sponsor role Glen has visited a number of Trusts across the patch acting as a critical friend to key risk Trusts. 4. NHS Improvement led Clinical Network Event for MDs and Clinical Directors up and running. The first meeting took place 21 September; more events to be planned and will be driven by the 3 Regional ED Clinical leads. 5. A series of three ED Practitioner Events focusing on front door, flow and discharge in October. These were facilitated by ECIP and involved a number of our high performing Trusts. 6. A number of joint ECIP, NHS England and NHS Improvement events planned focusing on DTOC and Discharge to Assess to take place. www.england.nhs.uk 19

Regional A&E Improvement Plan (2) ECIP support to segment 4 Trusts The following segment 4 trusts are receiving ECIP support: Colchester Hospital University NHS Foundation Trust Mid Essex Hospital Services NHS Trust Norfolk & Norwich University Hospitals NHS Foundation Trust Nottingham University Hospitals NHS Trust Peterborough & Stamford Hospitals NHS Foundation Trust The Princess Alexandra Hospital NHS Trust University Hospitals of Leicester NHS Trust University Hospitals of North Midlands NHS Trust West Hertfordshire Hospitals NHS Trust Worcestershire Acute Hospitals NHS Trust Regional A&E Delivery Board meets 3 November to review list and consider adding a number of other Trusts to this list. www.england.nhs.uk 20

Actions for Local A&E Delivery Boards Priorities for making it happen: 1. Local A&E Delivery Boards are expected to implement the five mandated improvement initiatives by March 2017. 2. All providers must develop an adequately resourced and dedicated team experienced in improvement methodologies, to support delivery of the priorities in their A&E improvement plans by December 2016. 3. Systems must formally assess their capacity and capability to deliver and sustain change using a recognised evaluation tool by October 2016. 4. Identify an executive lead within partner organisations responsible for ensuring robust interrogation and action in response to intelligence by August 2016. www.england.nhs.uk 21

Local A&E Delivery Board Improvement Plans: October Submissions Local Improvement Plans: submitted and jointly reviewed locally by NHS England and NHS Improvement teams. 5 Mandated Initiatives: Rapid implementation guidance used to assess plan elements to provide single BRAG-rating. Winter Plans: assessed against core principles; assurance sought that it is flexible to meet surges in demand and has incorporated lessons from previous years. Recovery Plans: assessed against ability to meet standards; assurance sought that plans are robust and deliverable. www.england.nhs.uk 22

Segment Improvement Plans: October Submission Summary Blue: Scheme already in place/alternative in place Trust BTUHFT 3 BHT 1 BCHT 2 BHFT 3 CUHFT 2 CRHFT 2 CHUFT 4 DHFT 3 ENHT 4 GEHT 2 HEFT 4 HHCT 2 IHT 1 JPUHFT 2 KGHFT 3 LDUHFT 1 MEHT 4 MKUHFT 3 NNUHFT 4 NGHT 3 NUHT 4 PSHFT 4 SWBHT 2 SFHFT 2 SaTH 3 SWFT 1 SUHFT 3 DGFT 1 PAHT 4 QEHKLFT 3 RWT 3 ULHT 3 UHBFT 2 UHCWT 3 UHLT 4 UHNMT 4 WHT 4 WHHT 4 WSFT 2 WAHT 4 WVT 4 Streaming at A&E www.england.nhs.uk Green: Actions in place NHS 111 calls to clinicians Ambulance Response Programme Amber: In plans, but risks associated with delivery Improved flow Improved discharge processes Red: No evidence of existing implementation or in system plans NHSE/NHSI Winter Plan Confidence of Assessment Recovery

Improvement Plans: Regional Priorities A small number of region wide initiatives have been identified that will support the pace of recovery and improve the patient experience: ECIP Red to Green Days to support flow; General Practices ensuring that patients who require urgent conveyance, attend hospital early enough to avoid a default admission (i.e. GP urgent transfers arriving before 14:00 hrs); Focusing on stranded patients i.e. patients with a LOS over 7 days. www.england.nhs.uk 24

Winter Planning The Preparation for Winter 16/17 letter asked local A&E delivery boards to focus on: Bank holiday period service availability (across both the acute sector and additional CCG commissioned services), and out of hospital urgent care. This should also include plans for how availability of services will be communicated to patients to ensure care is accessed at the most appropriate place. Ensuring there is sufficient primary care access to meet projected levels of demand throughout the holiday period, supported by additional GP appointment capacity in the first week in January. Reducing delayed transfers of care, and lowering acute bed occupancy to 85% from 19 December to 16 January. Confirmation of sufficient discharge support throughout the holiday period, from Local Authorities. www.england.nhs.uk 25

Winter Planning (2) 1. A UNIFY collection will open from Friday 4 November covering: Out of Hours, Primary Care, 111, Community and Social Care (submission deadline: 18 November). Local A&E Delivery Board chairs should sign-off submission. Addressing gaps in primary care should be the priority. Any gaps will need to be addressed and DCOs/DIDs will be following up. 2. The new Operational Pressures Escalation Framework has been published (copy in packs). www.england.nhs.uk 26

Forward Look DTOC A national DTOC high risk list has been agreed, focusing on seven systems in the Midlands and East. These systems will be asked for plans to demonstrate rapid improvement in the next two months. A central team is being set up to support improvement on DTOC in these systems. Primary Care in ED Trusts identified through the October submission of plans as lacking primary care streaming services in ED, will be required to prioritise primary care access, out of hours and front door streaming ahead of Christmas. Not Assured Improvement Plans Where a delivery board has a plan rated as red on assurance, narrative will be required to share with the national board, setting out risks to delivery and plans for rapid improvement. www.england.nhs.uk 27

Format of the day 1. Learn more about the national and regional priorities for the A&E Improvement Plan and how to implement them. 2. Opportunity to network within and outside of your geographical area. 3. Understand the benefits of the ECIP Red to Green approach and regional initiative. 4. Learn lessons on commissioning and implementing an Integrated Urgent Care Service. 5. Hear about the success achieved in other parts of the country regarding Discharge Planning and the role of the Independent Care Sector. 6. Hear from and meet speakers who have made improvement happen. www.england.nhs.uk 28

ECIP: The Emergency Care Improvement Programme Red to Green Days Pete Gordon Emergency Care Improvement Programme Regional Lead www.england.nhs.uk 29

The National A&E Improvement Plan Glen Burley CEO, South Warwickshire NHS Foundation Trust Acute Chief Executive Sponsor to the Regional A&E Delivery Board www.england.nhs.uk 30

The National A&E Plan Glen Burley, provider CEO sponsor The essentials of good practice in urgent and emergency care are well established, as described in, Safer, Faster, Better: good practice in delivering urgent and emergency care Important to right size solutions and to review Important to implement from the ground up

Evidence Christmas Junior Doctors Strike Not just about demand Planning Focus Incentives Senior decision making doctors

Implement ambulatory emergency care (AEC) Nov 16 AEC services must be provided over extended hours where possible, 7 days a week. Extended hours should be locally determined and may take time to implement. A funded plan is a minimum expectation. AEC areas must not be used for inpatients as part of escalation plans, as this is entirely counterproductive. There should be direct access to AEC from primary care and emergency departments (ED) following a telephone discussion with a senior clinician. ED direct access is the initial priority. Trusts that do not have existing services should consider enrolling with the AEC Network.

Implement frailty pathways Sep 16 A feature of high performing health and social care systems is a well-developed, evidence based pathway for frail older people Trusts must have arrangements in place to identify people with frailty syndromes and provide comprehensive geriatric assessment within 24hrs of admission All trusts should develop consultant led, multidisciplinary frailty teams working at the front of the pathway (in ED and acute medical units). Best practice is a seven day service

Primary care steam in ED Larger urban EDs should consider developing primary care streams for minor illnesses and/or chronic conditions during peak demand periods. The service should be integrated with the A&E, under its direct management. Patients assessed on arrival and streamed to the service. The service may be staffed by established local GPs or other competent healthcare professionals. Patients should not be redirected away from the service without treatment or advice Non-registered patients should be helped to register with a practice close to their home. The service should not include GPs where general practice has staffing shortages.

Implement the SAFER bundle Nov 16 SAFER bundle significantly improves flow. As a minimum all trusts must implement on assessment and medical wards The red and green day approach compliments SAFER and should be considered for all inpatient wards Every patient in every bed should be reviewed every day by a senior clinician (normally a consultant) on a board or ward round to ensure care plan is progressing, cover 7 days as soon as possible Twice daily consultant ward/board rounds must be mandatory on assessments units All patients must have a written care plan with clinical criteria for discharge and an EDD. Care plan must be determined and signed off by the consultant within 14 hours of a patient s admission The use of ward round check lists is essential to patient safety and should be mandatory

Focus on simple discharge Nov 16 Current disproportionate focus on the management of complex discharges and DTOCs. Essential that there is a relentless focus on non-complex discharge processes (multiple short delays for the many consume more bed days than long delays for the few) All hospitals must establish a systematic process to review the reasons for any inpatient stay >6 days Use stranded patient metric to assess the effectiveness of a hospital s improvement programme.

Implement Internal Professional Standards Aug 16 All departments work together to agree response standards. These should be measureable, auditable and transparent for clarity on what to expect when making referrals or requesting tests and procedures May be derived from Royal College guidance or local agreement e.g. Medical specialties in a hospital agree to attend A&E to assess a patient for admission within 30 minutes of a request A&E agrees to make referrals to specialties within 150 minutes of a patient s arrival at hospital All routine diagnostic tests are completed and reported within 24- hours. Should be bottom up, once established they should be monitored so that obstacles to their achievement cab be tackled.

Priorities for local health and social care communities Implement Discharge to Assess so that frail older patients are discharged from hospital immediately they cease to benefit from acute care Health and social care assessments of care needs are carried out in patients normal places of residence ( home ) rather than in acute hospitals. Setting up D2A requires time and the use of effective improvement techniques to ensure sustainable implementation. Taking time to foster collaboration and to test small changes is important to avoid flawed implementation.

Patient no longer has care needs that can only be met in an acute hospital Pathway 1 Pathway 2 Pathway 3 Patients needs can be safely met at home Unable to return home - Patient requires further rehabilitation/reablement Unable to return home - Patient has very complex care needs and may need continuing care Reablement Service Up to 6 weeks CERT Up to 6 weeks Community Hospital Up to 4 weeks Temporary Residential Home Up to 4 weeks Nursing Home Up to 6 weeks EXPLICIT CHANGE OF FUNDING Self Fund/ Self Care LA funded home care Pathway 1 Self Fund/ Self Care at Home CHC Funded care LA Funded care Self Fund Residential care LA funded Residential care Self Funded care

Whole System Point Prevalence Audit January 2015 Acute 214 6 5 25 24 20 4 14 6 Acute 24/7 care Commmuity 33 7 12 12 0 39 Reablement CERT CERT 1 41 9 The patient could be transferred to a community hospital (requires rehabilitation in a 24/7 care or specialist rehabiliation equipment) Pathway 2 D2A P2 17 1 Pathway 3 Patient could be transferred to a POC D2A P3 11 4 Discharge to Home Reablememe nt 63 9 Community Hospital (rehabilitations and pallative) Patient to be transferred to Nursing Home Awaiting transfer to other Acute hospital

Patients eligible for D2A Pathways 2 & 3 = 445 Unsuccessful Referrals 124 patients Length of Stay (acute) : Accepted Referrals 321 patients Length of Stay : Pathway 2 (85 patients) Pathway 3 (236 patients) Pathway 2 = 45.9 days Pathway 3 = 56.8 days Acute = 18.6 days D2A bed = 29.1 days Total = 47.7 days Acute = 31.0 days D2A bed = 38.3 days Total = 69.3 days Discharge destination : Home 64 Nursing/Residential home 27 RIP 28 Other - 5 Post Discharge Care LA funded care 42% - average 461/week CHC Funded care 44% - average 977/week LA Funded (4) 321/week CHC Funded (1) 850 LA Funded (39) 476/week CHC Funded (41) 980/week Est LA saving 266k LA Funded (17) 262/week CHC Funded (6) 843 Discharge destination: Home 83 Nursing/Residential home 135 Readmitted - 36 RIP 50 Other - 17 Post Discharge Care SWFT provider saving 231k LA funded care 32.5% - average 457/week CHC Funded care 24% - average 864/week LA Funded (71) 503/week CHC Funded (58) 866/week Est CHC saving 820k

Priorities for primary care General practices should have processes in place to respond to and prioritise requests for urgent home visits, usually through early telephone assessment and a duty doctor rota. Commissioners of ambulance services must ensure that ambulance services respond rapidly to general practice requests relating to patients who need urgent conveyance to hospital (aim before 2pm arrival)

Improvement Teams Aug 16 Effective leadership is an essential for complicated programmes Directors of nursing, medical directors and operations directors should work together to support clinicians and managers implement the plan Systems must assess their capacity and capability to deliver and sustain change using a recognised evaluation tool

Lessons learned from implementing an Integrated Urgent Care Service Rachael Ellis 111 Lead Commissioner for the West Midlands 111 Service NHS Sandwell & West Birmingham CCG rachael.ellis4@nhs.net www.england.nhs.uk

Regional and Local Delivery Model NHS 111 Front End Access and Out of Hours Services 16 of the 22 West Midlands CCGs have procured an Integrated Urgent Care Model (incorporating NHS 111 and OOHs services) with a regional Clinical Hub. 8 of the 22 CCGs have procured GP led OOH services under 5 procurement lot groupings other CCGs are undergoing contract variation processes to tie into the Alliance Agreement and the Core NHS 111/OoH Specifications. Collaboration, mutual contingency, and integration with local services is required across the region working under an alliance agreement. Balances regional economies of scale with local specifications Focuses on providing a more seamless experience for patients and improved clinical outcomes 47

West Midlands integrated urgent care providers 111 Out of Hours Contract Variations Integrated Urgent Care services Integrated NHS 111 Access & Clinical Hub (WM 16 CCGs) Care UK (IUCP) Staffordshire 111 Access Vocare Birmingham South Central OOH Badger (IUCP) Worcestershire OOH Care UK (IUCP) Sandwell & West Birmingham OOH Primecare (IUCP) Herefordshire OOH Primecare (IUCP) Warwickshire OOH Care UK (IUCP) Rugby OOH C&WPT Solihull OOH Birmingham Cross City OOH Walsall OOH Wolverhampton OOH Badger (IUCP) Badger and Primecare (IUCP) Primecare (IUCP) Vocare Coventry OOH C&WPT (IUCP) Dudley OOH Malling Health Shropshire + Telford & Wrekin OOH Shropdoc Staffordshire OOH Vocare Binding Alliance Agreement

Service Development Timeframe Implementation Phase (August - November 2016) Go-Live & Embedding of Service (Nov 2016 - April 2017) Business as usual and Development (Apr 2017 Apr 2020) Optional 2 year extension (Apr 2020 Apr 2022) 49

Alliance Agreement Commissioners intend that the Alliance Agreement will provide an agile and flexible approach to deliver innovative, effective, safe and sustainable solutions, delivering excellent patient experience and quality outcomes which embraces new technology, the latest learning and developments and supporting the integration of key services across the system. The collaborative element of this delivery will entail shared objectives, metrics, data and learning across organisations. This will be recognised under this Alliance Agreement, which all providers of the integrated urgent care service in the region will be required to enter into. 50

Strategic Development % Reduced duplication Consistent processes Shared data Shared KPIs Opportunity to extend to ED Improved patient outcomes Seamless patient experience Interoperability Alliance working in practice Shared staff Use of premises Opportunity to extend to 999 Introduction of direct booking Shared learnings Mutual aid and resilience Service innovation Opportunity to extend to community providers 51

Organisation(s) involved An innovative approach to contracting is being implemented, which will bind all providers in the region to work together in delivering truly integrated services. The Alliance Agreement binds all suppliers in the West Midlands to cooperate, collaborate and strive to integrate services. Not all organisations in this slide have signed up to this yet but is used to highlight the ambition 52

Clinical Hub Case type being sent to Hub Medication Enquiry Repeat Prescription Health Information Pharmacist Complex Case Under 5 Over 75 Emergency Contraception Minor Illness Accidental Poisoning Dental Case NHS Pathways Clinician Dental Nurse Clinical Hub Mental Health Nurse GP Advanced Nurse Practitioner HCP Case Sandwell Speak to GP Mental Health Case ED Validation Green Ambulance Validation

Clinical Hub Outcomes OOH Base Visit Appt. 999 Despatch Self Care OOH Home Visit Prescription Referral In hours GP Clinical Hub Dental Appt. Referral Safeguarding Referral WIC / MIU Referral Pharmacy / Optician Referral ED Note: Development is required to achieve direct and electronic referrals for some outcomes

This is service development and not contract management Strong leadership and support for CCGs Contract Variation are complex and difficult to manage Consequences of the size and scale of change Procuring integrated urgent care is complex Set realistic timelines and allow for slippage Collaborating Commissioning essential and in advance National and Local needs better collaboration (about commissioning standards, technical requirements, assurance processes, KPIs) 55 Communication challenges Nobody has all the answers Patient engagement SME are essential Shortfall in technical solutions Technical involvement Succession planning CCG joined vision Contract length critical This is hard and complex Lessons Learned Planning Learning needs to be shared It is a limited and specialist market Diverse providers need managing Robust Governance and Structures for procurement programme and within CCGs This is not a commissioner and provider divide this is working together for the benefit of patients Data is critical for understanding need, specification need to be clear and comprehensive Need multiple experts i.e. finance, contracts, HR, technical, telephony, procurement, legal, Estates, Clinical, patient, comms, data and reporting, quality i.e. safeguarding, information governance.

www.england.nhs.uk Question Time

LUNCH Please sit at your local area table and be ready to restart at 13:45 Central Midlands & North Midlands www.england.nhs.uk West Midlands & East 57

Lessons learned from local system improvement: Colchester Nick Hulme Chief Executive, Ipswich Hospital NHS Trust and Colchester Hospital University NHS Foundation Trust www.england.nhs.uk

A&E Delivery Board Chairs Development Day Spreading Best Practice in Emergency Care The Ipswich Hospital Journey Nick Hulme Chief Executive Ipswich Hospital Our Passion, Your Care.

Summary of performance at Ipswich hospital NHS Trust Year Population nos (000s) No. Medical wards Emergency growth % Emergency medicine LOS ED 4hr Performance 2010 343 13 5.39% 6.37 97.5% 2011 351 12-2.25% 6.49 96.6% 2012 352 12-2.67% 6.34 95.9% 2013 352 12 7.43% 6.29 94.8% 2014 354 12 9.51% 5.67 96.9% 2015 355 13 11.43% 5.44 95.4% Our Passion, Your Care.

Emergency Care Growth (%) Axis Title The Ipswich Hospital NHS Trust Emergency Care- Our Journey Chart Title 11.43% 9.51% 7.43% 6.37% 6.49% 6.34% 6.29% 6.38% (YTD) 5.39% 5.67% 5.44% 5.22% (YTD) -2.25% -2.67% 7 Day Working on Short Stay Ward Introduction of Discharge Coordinators Red To Green 2010 2011 2012 2013 2014 2015 2016 Growth Series1 (%) 5.39% -2.25% -2.67% 7.43% 9.51% 11.43% 6.38%

t Nick Hulme Chief Executive The Colchester story so far.. 17 th May 2016 appointed as CEO to CHUFT No systems or people and an over-regulated culture Time Travel

Where to start? the only question managers were able to ask Red to Green significant improvement Got our hospital back Is it sustainable? Myth busting

External Partners it s all about the hospital SRG : 95% - relax less than 95% - blame the hospital Exposes the myths

What has gone wrong? Really tough since Too easy to slip back to the easy but familiar Worried about the implications of success Failure brings resource

What next? Changes? Didn t push for changes to be implemented Didn t Change the People or Change the People Billy s got the answer.

Any Questions? Nick Hulme Chief Executive, Ipswich Hospital NHS Trust and Colchester Hospital University NHS Foundation Trust www.england.nhs.uk 67

Discharge Planning & the role of the Independent Care Sector Lisa Christensen ECIP Social Care Lead Rachel Fox NHS England (Midlands & East), Independent Care Sector Lead www.england.nhs.uk

Independent Care Sector? Residential & Nursing Homes (18,000, numbers falling.) Domiciliary Providers Housing Supported living Housing Adaptations Learning Disability Dementia care services Respite care Voluntary sector Hospices www.england.nhs.uk

Care Home Department of Health Policy - quality and safety Clinical Commissioning Groups Contract management - quality and safety Local Authority Contract management - quality and safety Care Quality Commission Regulation - quality and safety NHS England Quality Surveillance Groups - quality and safety www.england.nhs.uk 70

Issues Frail older people We don t understand social care (Keith Willett) Perception of ICS as profit-making/ negative rather than key partner Geriatric assessment/care plan drivers means patient arrives in care home sector too early; medics/family as influencers Hospital systems and process, at worst duplication sometimes triplication, TTO s/transport/team structures Contracting process, supply and demand leading to increasing costs / difficulties in handbacks to ICS Lack of data admissions from care homes www.england.nhs.uk

National Focus Out of Hospital Programme www.england.nhs.uk 72

Out of Hospital: Independent Care Sector Programme National team to support health and care sectors to reduce DToC and reduce unnecessary admission -> A&E delivery Ultimately improve outcomes for people receiving care in care homes AND in own home Funding for enhanced support; regional lead, ECIP and focus on provider forum engagement in each LA www.england.nhs.uk

www.england.nhs.uk 74

Vanguard (Care Home) Sites Connecting Care (West Yorks) Gateshead Care Home Project East and North Herts CCG Nottingham City CCG Sutton Homes of Care Airedale and Partners (Lancs) Outcome: Enhanced Health in Care Homes (EHCH) Framework But also Urgent and Emergency Care Vanguards (recognition of ICS impact) www.england.nhs.uk

New Care Models: Vanguards www.england.nhs.uk 76

A&E Delivery Board Focus Improving discharge process can only be delivered in conjunction with ICS www.england.nhs.uk 77

A&E Mandated Initiatives & ICS Streaming: transfer to community within 2 hours of referral with aim of support at home NHS 111: Care homes using service to best effect rather than resorting to ED/999, development of clinical hub, tagging of callers from care homes Ambulance: Care homes to have arrangement to support falls management without conveyance to hospital Flow GP Home visits: urgent primary care assessment of frail adults and rapid transfer to hospital when required; alignment of GP input into care home plus community nursing Discharge to assess and use of trusted assessor modelfocus on assessment taking place outside of hospital www.england.nhs.uk

8 High Impact Changes Change 1: Early Discharge Planning Change 2: Systems to Monitor Patient Flow Change 3: Multi-Disciplinary/Multi-Agency Discharge Teams, including the voluntary and community sector Change 4: Home First/Discharge to Access Change 5: Seven-Day Service Change 6: Trusted Assessors Change 7: Focus on Choice Change 8: Enhancing Health in Care Homes www.england.nhs.uk 79

Not all doom & gloom Focus on discharge means having to focus on ICS Tools available Quick Guide: Discharge 2 Assess Evidence of work going on with ICS including voluntary sector at CCG level & engagement with A&E Boards eg. Lincs Recognition of quality assurance demands at national level work ongoing with CQC Opportunity to learn from CQC outstanding reports Cost benefit analyses and data becoming available Asset based approach within social care personalisation agenda www.england.nhs.uk 80

New opportunities/approaches Workforce crossing organisational barriers; new nursing roles; in-reach into care homes e.g. dementia services Development of Frailty/Dementia services Models of domiciliary care (away from task/time model) LA/NHS provision of domiciliary care e.g. Notts NHS Trust acting as Lead provider e.g. Devon Cares for central brokerage, referring packages of care to providers, overseeing compliance, governance and quality and financial functions Outcome-based provision e.g. Somerset Care, multiprovision based on individual needs (plus own training company) Help to Live at Home joint commissioning on outcomes (Leics) www.england.nhs.uk 81

Understanding, not breaking, the system www.england.nhs.uk 82

Any Questions? Lisa Christensen ECIP Social Care Lead Rachel Fox NHS England (Midlands & East), Independent Care Sector Lead www.england.nhs.uk 83

Lessons learned from Discharge Planning: Tower Hamlets Brian Turnbull Interim Service Manager (Community & Hospital Integrated Care), Tower Hamlets Council Sandra Moore Deputy Director of Performance and Quality, Tower Hamlets CCG Fiona Davies Clinical & Project Lead, Bart s Health NHS Trust Patricia Oguta Interim Team Manager Hospital Social Work Team www.england.nhs.uk

Discharge to Assess in Tower Hamlets 2016 Breaking paradigms, creating ambition, raising the bar Brian Turnbull Interim Service Manager Community and Hospital Integrated Services, London Borough of Tower Hamlets Sandra Moore - Deputy Director of Performance and Quality, Tower Hamlets CCG Fiona Davies Clinical & Project Lead, Bart s Health NHS Trust Patricia Oguta - Interim Team Manager Hospital Social Work Team

Our mission To implement an integrated discharge to assess model (D2A) for older people in Tower Hamlets so that they are discharged from hospital as soon as they are medically stable, rather than staying on the ward waiting for further social and functional assessments to take place.

What we did CCG funded 6 month pilot Model conceived by all partners as Home Support Pathway Intensive planning involving numerous stakeholders Run in partnership with other schemes aimed at reducing LoS 15 patients on pathway at any one time 28 days maximum stay Step-down beds in local extra care sheltered housing facility Involvement of Age UK East London Reablement services provided majority of care packages

Where we wanted to be Positive patient experience Discharge same day as referral Less CHC assessments in hospital Data showing reduced length of stay on HCOE wards (by 1 day) Prevention of deconditioning or hospital syndrome 95% of older people achieving preferred discharge destination Reduced readmissions on pathway and 28 days post HSP

Where we got to 67 patients discharged on D2A 70.1% from care for the elderly wards Most patients wanted to return home (including after being in a step-down bed) 9 patients went to extra care sheltered flats At least 50% of the patients discharged with HSP would have otherwise gone to MEH (in-patient rehabilitation beds)

Outcomes Hints for people 45 Admission rate control group 48% (n=29) vs D2A 15.8% (n=63) Bed days if admitted within 28 days post discharge 346 days (Control Group) vs 50 days (D2A) Medical Wards (excluding AAU) - Readmission Rate 40 35 30 25 20 15 Ward 14E Ward 14F MEH beds HSP 10 5 0 1 2 3 4 5 6 7 8 9 10 11

Patient story 72-year old Bengali woman In hospital for 5 months for revision of an infected hip joint, not engaging with therapists on ward, CHC checklist completed HCOE consultant reviewed and referred for D2A Physiotherapist and social worker met on ward Discharged home - 2 carers 4 x day, hospital bed, continence issues HSP physio, nurse & RSW visited next day; full assessment including medication management, patient not using hospital bed OT visited 2 days post discharge - hospital bed not needed 6 days later - walking around flat, goals set to practice this 8 days post discharge, Social worker resolved issues raised re carers and reduced package to 1 carer 3 x week

What our patients/families said Honestly I could not fault it. I live on my own and was dreading going home although I have a very caring sister but she can t be expected to do everything especially at night. My rehab support was marvellous it was better than I ever thought. A lovely place. (extra care sheltered flat). It was really nice care. I came home and had support there too. I don t need the carers now so I stopped them but I was delighted with all of them. I have the DN still and she is wonderful too. I was very pleased with the service. The carers are extremely helpful and nice to talk to. They are sensitive doing personal care. I had been in hospital 4-5 weeks and was very pleased to get out.

What were the challenges LOS on pathway - often over 28 days (n=11) Operationalising the model, e.g. staffing Uncertainty about future funding Transfers to extra care sheltered flats lots of learning from this Integration with other schemes aimed at reducing the LoS of patients Evaluation of the test and learn model

Where we are now and where we want to be New scheme will have two dedicated Social Workers who will work as part of the MDT, increasing the capacity of incoming referrals Increased patient flow from the Royal London Hospital due to increased capacity in the scheme Evidence needed to demonstrate the level of success achieved for the patient e.g. CHC checklist/bespoke assessment at start and end The care will be provided by the Reablement Team and will support the goals set by the Therapists

Where we are now and where we want to be The full social care assessment process will usually start two weeks post discharge to fully address the change in needs KPI's to cover readmission rates (review at 28 and 90 days post discharge) and the reduction in on-going support costs at the end of the patient s time on the scheme Future challenges are to roll out this scheme as Business as Usual over the following two years and end most ward based assessments

The CCG perspective What are we as a system working in partnership going to do about winter? How can we as a system working in partnership improve flow?

What we did know Lots of older people waiting in hospital for assessment Hospital is alien and confusing to many older people Judgements are made about how a person will manage when they return home based on perceptions about the person after the effects of a stay in hospital The pilot had been a success in identifying home pathway rather than the need for a step down facility 10 days in hospital leads to the equivalent of 10yrs ageing in the muscles of people over 80 (Gill et al 2004, Kortebein, Symans, Ferrando et al 2008))

What we are doing Following the success of the D2A pilot invested using OR funding to continue the model with some tweaks Partnership approach person at the centre Developed set of KPIs, information reporting requirements Robust evaluation? BAU

What do we expect? Improved recovery as people are assessed in their own home in a familiar environment Improved experience for patients and their families Improved hospital flow Reduction in delayed discharges, LOS Reduction in CHC Savings in the long-term

Thank you

Any Questions? Brian Turnbull Interim Service Manager (Community & Hospital Integrated Care), Tower Hamlets Council Sandra Moore Deputy Director of Performance and Quality, Tower Hamlets CCG Fiona Davies Clinical & Project Lead, Bart s Health NHS Trust Patricia Oguta Interim Team Manager Hospital Social Work Team www.england.nhs.uk

www.england.nhs.uk Group Discussion

Delivering Improved Performance in A&E for patients in our local areas Facilitated Discussion (30 minutes): Please cover the following topics in your discussions: i. Progress on implementing the 5 mandated improvement initiatives ii. iii. Delivering Red to Green. Identifying the key challenges and risks to delivery, including cross system and geography working iv. What s working well, including Vanguard examples v. Identifying support needs Feedback (5 minutes): Each group will feedback 2 most pressing key challenges 2 ideas on what could make a difference www.england.nhs.uk