RCCG/GB/17/144 Urgent & Emergency Care Strategy Update 1. Introduction The purpose of this paper is to provide assurance on the effective delivery to date of our urgent and emergency care strategy within the Greater Nottingham footprint of the Sustainability and Transformation Plan 2016-21. 2. Context and Background 2.1 National context The Next steps on the NHS Five Year Forward View (5YFV) was published on the 31 st March 2017. Urgent and Emergency Care (UEC) is one of the main national service improvement priorities. The key deliverables for 2017/18 are that 1. In or before September 2017 over 90% emergency patients are treated, admitted or transferred within 4 hours 2. The majority of Trusts meet the 95% standard in March 2018 3. The NHS overall returns to the 95% within the course of 2018. In April 2017 the Urgent and Emergency Care Delivery plan was published, which articulated in more detail the seven UEC priorities which will deliver transformation of Urgent and Emergency Care and ensure delivery of the mandated national target. The seven UEC priorities for 17/18 described on page 9, build upon the nationally mandated improvement initiatives from 16/17 contained in the Rapid Implementation Guidance for local systems and ECIP (Emergency Care Improvement Programme) system specific recommendations for Greater Nottingham. 2.2 Context of the UEC 5YFV Delivery Plan We remain fully committed to the delivery of the four hour target, however; Patients have a lifestyle view of what is urgent rather than a clinical view and services need to reflect this Too many people are going to A&E rather than more appropriate alternatives and therefore we are not using our expert resources to deal with our sickest patients Capacity is stretched and we need to ensure that patient flow is optimised The system is too complicated and fragmented leading to patients not getting the best care and large variations in performance across the country Our strategy enables us to change this so that: The system is intuitive and helps people make the right decision There are alternatives offered to A&E that provide timely clinical access for urgent close to people s homes 1 P a g e
RCCG/GB/17/144 We focus our skilled resources in hospitals on the sickest patients and those with serious or life-threatening needs We reduce the pressure on our hard-working staff enabling them to provide higher quality care 2.3 Local context Locally the national plans translate into how we simplify and improve urgent and emergency care. We aim to support citizens to access the most appropriate advice or service for their urgent care needs, minimising disruption for citizens and their families. For those with more serious needs, we aim to provide a service that can respond rapidly to meet those needs, whether in a community or acute hospital setting, ensuring that patients receive the best possible care and return home as soon as they are well enough. This will result in: More people able to self-treat as a result of improved quality of information and support available to people with urgent care needs Fewer people arriving at hospital as a result of improved access to urgent care in settings other than A&E, e.g., in general practice or pharmacy Timely and safe care for those needing hospital based urgent and emergency care as a result of swifter access to a senior clinician on arrival at A&E People who are admitted to hospital able to return home sooner as a result of more effective processes for discharging patients 3. Summary of progress against mandated improvement initiatives in 2016/17 3.1 Assess to admit The executive lead for this work stream is Dawn Smith, Chief Officer for Nottingham City CCG. 3.1.1 Primary Care Streaming The Emergency Department at QMC implemented a Primary Care Streaming Model aligned to the Luton and Dunstable model on April 3rd 2017. Using the Luton model protocol, ambulatory adult patients are streamed on arrival at the Emergency Department (ED) between the hours of 8am and midnight, 7 days a week by an ED nurse, and directed to either the Nottingham Emergency Medical Service (NEMS) primary care service or into ED. Where appropriate, NEMS will also treat patients arriving by Ambulance. The aim is for NEMS to see, treat and discharge 20% of all ED attends. Currently weekly volumes are fluctuating between 18-19%, which equates to 550-650 patients each week directed away from the ED. Capital works, 400k funded through a successful bid against the 100 million A&E capital funding, outlined in the spring Budget, start in July 2017 to improve the environment for the GP streaming service. 2 P a g e
PLAN-Point3 PLAN-Point1 PLAN-Point2 RCCG/GB/17/144 3.1.2 Integrated Urgent Care/Clinical hub Since April 2016, NEMs and Derbyshire Health United (DHU) have been working jointly to deliver the mandated delivery actions for Integrated Urgent Care. From February 2017, they have delivered a 24/7 clinical hub function that has re-assessed appropriate patients, in particular, low priority ambulance calls (green 2) and ED calls. This has resulted in a reduction of onward referrals to ED by 80% and 78% for ambulance dispatches. This has resulted in a reduction in ED attendances of 25% of 111 calls previously sent to ED at QMC. The NEMS GP out of hours primary care service has a key role in the delivery of the clinical hub as they provide an effective model of clinical telephone advice linked to 111 to ensure patients are not unnecessarily attending and an appointment booking system to ensure that those who need to be seen are in a timely manner. Overall, our position has improved from 30% of patients assessed by a clinician following a 111 call to 56.2%. The clinical hub function also includes access to the mental health crisis team, pharmacist and dental nurse expertise. The team have also delivered against the other mandated actions resulting in providers having the correct information to support treatment, an appropriate clinical governance structure implemented, a review of capacity and demand and a direct booking policy to the Urgent Care Centre and OOHs where appropriate. This has resulted in 10% of patients in hours accessing services through a directly booked appointment. 3.1.3 Improving ambulance turnaround. An ambulance handover improvement group was convened in 2016 due to the poor performance against the 15 minute handover target at Queens Medical Centre (QMC). This group included a CCG, EMAS and NUH representatives. A review of the current performance data was undertaken and an action plan developed to reduce handover delays. This approach was commended by the national ECIP (Emergency Care Improvement Programme) ambulance advisor and replicated in other regions. The action plan focussed on developing a dedicated handover space to enable EMAS crews to quickly hand over the patient. A key focus was the number of handover delays over 60 minutes as this has the greatest impact on patient care and experience. Focus in 2017 moves into increasing the number of below 15 minute handover delays. A trajectory was developed to monitor performance. Data from March 2017 shows a significant improvement in performance from November 2016 (see below). EMAS Handovers - <15Min Time Bracket Forecast 3200 2600 2000 1400 800 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 3 PJul-17 a g e Sep-17 PLAN-Point1 PLAN-Point2 PLAN-Point3 <15Min HistoricData ActualActivity (Sep16 ->) DoNothing Forecast PlansImplemented Forecast
PLAN-Point1 PLAN-Point2 PLAN-Point3 RCCG/GB/17/144 EMAS Handovers - 60Min+ Time Bracket Forecast 320 240 160 80 0 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 PLAN-Point1 PLAN-Point2 PLAN-Point3 60Mins+ HistoricData ActualActivity (Sep16 ->) DoNothing Forecast PlansImplemented Forecast 4. Today s work today The executive lead for this work stream is Caroline Shaw, Chief Operating Officer at NUH. Work over the last year has concentrated primarily on the consistency of NUH processes and a number of initiatives have been taken forward and embedded within the acute Trust. These include: 4.1 Roll out and embedding of the SAFER approach across all adult wards. The SAFER patient flow bundle is a practical tool to reduce delays for patients in adult inpatient wards (excluding maternity). The SAFER bundle blends five elements of best practice. It s important to implement all five elements together to achieve cumulative benefits. It works particularly well when it is used in conjunction with the Red to Green Days approach (see below). When followed consistently, length of stay reduces and patient flow and safety improves. S - Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal recovery and assuming no unnecessary waiting. F - Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure the first patient arrives on the ward by 10am. E Early discharge. 33% of patients will be discharged from base inpatient wards before midday. 4 P a g e
w/e 24-Jul w/e 07-Aug w/e 21-Aug w/e 04-Sep w/e 18-Sep w/e 02-Oct w/e 16-Oct w/e 30-Oct w/e 13-Nov w/e 27-Nov w/e 11-Dec w/e 25-Dec w/e 08-Jan w/e 22-Jan w/e 05-Feb w/e 19-Feb w/e 05-Mar w/e 19-Mar w/e 02-Apr w/e 16-Apr w/e 30-Apr w/e 14-May w/e 24-Jul w/e 07-Aug w/e 21-Aug w/e 04-Sep w/e 18-Sep w/e 02-Oct w/e 16-Oct w/e 30-Oct w/e 13-Nov w/e 27-Nov w/e 11-Dec w/e 25-Dec w/e 08-Jan w/e 22-Jan w/e 05-Feb w/e 19-Feb w/e 05-Mar w/e 19-Mar w/e 02-Apr w/e 16-Apr w/e 30-Apr w/e 14-May RCCG/GB/17/144 R Review. A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (>7 days also known as stranded patients ) with a clear home first mind set. Metrics are shared weekly with the CCG to enable close monitoring of the performance, examples are shown below Pre-noon discharge 40% 35% 30% 25% 20% Target Pre-Noon Discharges Flow from assessment wards by 12pm 40% 35% 30% 25% 20% 4.2 Red to Green This is a visual management system to assist in the identification of wasted time in a patients journey. The aim is to identify and therefore reduce the number of internal and external delays for patients in an inpatient ward. Red to green has been introduced across all the inpatient bedded care in the Greater Nottingham system. A red day is when a patient receives little or no value adding care and a green day is when a patient receives value adding care that forwards their progress towards discharge. Across NUH 65 wards are using the red to green principles and recording delays, the information is live on Nervecentre (NUH IT system) and is visible to all staff across NUH. The electronic system enables tracking of all internal and external delays and allows for rapid escalation of delays. Outcome metrics on the combined impact of SAFER and red to green implementation are still in development. ECIP recommend tracking the Stranded patient metric for emergency patients (patients with a greater than 6 day length of stay) which is thought to be a more 5 P a g e
20-Jan 27-Jan 03-Feb 10-Feb 17-Feb 24-Feb 03-Mar 10-Mar 17-Mar 24-Mar 31-Mar 07-Apr 14-Apr 21-Apr 28-Apr 05-May 12-May 19-May RCCG/GB/17/144 sophisticated measure than pure length of stay. It is too early to establish a correlation between red to green and stranded patient metric as so many other factors influence hospital stay. NUH Stranded Patients (>6 Days) 900 850 800 750 700 650 600 550 500 55% 50% 45% 40% 35% 30% 25% 20% BedsOcc by Str.Pts % BedsOcc by Str.Pts 4.3 Emergency Department ECIP have been working within the ED department since April 2017, an improvement team of ED experienced clinicians undertook a series of high level observations from which they developed a number of recommendations. These recommendations have been taken up by the ED team who have developed a 90 day improvement plan for the department with implementation support from ECIP. The actions being progressed are detailed in the presentation given to the June A& E board contained in Appendix 2. ECIP also reviewed the overnight performance dip in the 4 hour target and noted that the wait to be seen and the decision to admit times regularly increased overnight leading to delays in processing patients through the pathways out of ED. They highlighted the reliance on locum doctors overnight which correlated with longer waits. As a result there has been an increase in the substantive junior doctor cover overnight since May 22 nd and the ED consultant rots are being reviewed and revised to move the consultant workforce to 24/7 full shift working, similar to the working practice within critical care areas. This is a significant workforce change and involves additional recruitment of substantive consultants and is aimed to be in place by November 2017. To support in the interim there is a move to use locum medical cover during day time hours and increase substantively appointed staff working out of hours. 4.4 Non-admitted performance One of the key improvement areas that is contained within the recovery action plan between NUH and the CCGS is the delivery of 4 hour performance in patients who are discharged directly from the ED and do not require an inpatient admission. These patients equate to 75% of all the ED attends and delivery of 98% 4 hour performance across the non-admitted cohort of patients significantly improves overall 4 hour achievement. The non-admitted performance has been positively affected by the GP streaming at the front door, 98.5% of the patients seen by the NEMS ED service are seen within 4 hours. It also significantly 6 P a g e
w/e 25-Sep w/e 02-Oct w/e 09-Oct w/e 16-Oct w/e 23-Oct w/e 30-Oct w/e 06-Nov w/e 13-Nov w/e 20-Nov w/e 27-Nov w/e 04-Dec w/e 11-Dec w/e 18-Dec w/e 25-Dec w/e 01-Jan w/e 08-Jan w/e 15-Jan w/e 22-Jan w/e 29-Jan w/e 05-Feb w/e 12-Feb w/e 19-Feb w/e 26-Feb w/e 05-Mar w/e 12-Mar w/e 19-Mar w/e 26-Mar w/e 02-Apr w/e 09-Apr w/e 16-Apr w/e 23-Apr w/e 30-Apr w/e 07-May w/e 14-May w/e 21-May RCCG/GB/17/144 reduces the volume of non-admitted patients being seen in ED, minimising overcrowding and allowing ED staff to reduce waits. Improvement in the non-admitted performance has been one of the key factors on the days in June where there has been improvement from the 90% non-admitted achievement in May reported below. A+E Non-Admitted Performance 100% 95% 90% 85% 80% 75% Minors Performance Minors Target NonAdm Performance NonAdm Target 5. Home first/transfer to assess The executive lead for this work stream is Vicky Bailey, Chief Officer of Rushcliffe and Nottingham West CCGs. Overarching purpose; to promote and implement Home First Mantra and implement Discharge to Assess (D2A) and trusted assessor models to improve patient experience and flow across the system. This will deliver an increase in supported discharges and free up bed capacity in the acute hospital setting. The enhanced community support ward (B48) has been was launched 20 March 2017 and continues to be in place. Weekly PDSA cycles have taken place informing the development of a Standard Operating Procedure (SOP) to be implemented across NUH June-July 2017. A shared purpose has been agreed that No person is assessed for long-term care within an acute Trust The team are developing one training package that supports a big bang implementation for; driving the Home First mantra and agreeing system wide language to support the shared vision of D2A, training and support for roll out of 5Q (West Norfolk model) and the three pathways (see picture). In addition, the group are developing one electronic discharge plan (etoc) that follows the citizen wherever they are within the system. Additional home care capacity to support pathway will in place for 1 October 2017 The model for community bed capacity to be agreed with A&E Delivery Board in July and will be procured and in place by 1 October 2017. 7 P a g e
RCCG/GB/17/144 6. Effective Leadership The executive lead for this work stream is Peter Homa, Chief Executive of NUH. This has 3 key elements: 6.1 NHS National Leadership Centre NHS England has supported 9 A & E boards nationally to receive specific support from the National Leadership Centre. Greater Nottingham is one of the 9 national and one of 3 in the Midlands and East who have benefitted from the input of Debbie Sorkin and colleagues from the Kings Fund who are experienced facilitators in organisational development for individuals, teams and systems. The team has been working closely with and supporting staff in the Emergency department, initial feedback shared at the A& E board in June is that this is starting to have a positive impact in the department. The team are also starting to work with colleagues involved in the Home first work stream who are involved in a significant transformational work. 8 P a g e
RCCG/GB/17/144 6.2 A&E Board Development Time-outs Two Change leaders events have been arranged by Paula Ward, Organisational Development lead from NUH. The first event focused on a change and capability assessment based on the NHS Sustainability Model which has been designed for specific improvement initiatives and the A&E programme of work contains the component parts of an active improvement initiative and also has a degree of complexity in that it exists across organisational boundaries. The framework provided a diagnostic tool that helped identify strengths and weaknesses and predicted the likelihood of sustainability for change. The assessment outputs have then informed a strategic and tactical action plan to improve system effectiveness for change for the A&E programme of work. A second session is planned for July to further progress this. 6.3 Daily executive-led review in ED A daily executive-led review now takes place in the ED every Monday to Friday morning at 9am with the Chief Operating Officer, Medical Director and Chief Nurse. The main purpose is to provide visible senior leadership and support to ED. The executives meet with the ED senior leadership team managing the department on the day and the divisional leadership team for medicine to identify any issues from the night shift or anticipated during the day which can be resolved and dealt with immediately to improve patient safety, flow through the ED and hospital and delivery of the target. For example, early identification of staffing gaps across the pathways and delivery of plans to mitigate and escalation of any speciality waits in ED. 7. Next Steps 2017/18 A gap analysis has been performed against the 17/18 national seven urgent and emergency care priorities; a milestone tracker has been developed with accompanying action plan for monthly submission to NHSI and NHSE. Improvement work plans have been agreed and are monitored weekly through the urgent care Programme Management Office. The reported June 2017 position for Greater Nottingham for the 7 priorities described below can be seen in Appendix 1. Summary of the seven priorities to deliver transformation Assess to Admit work stream 1) Digital 111 - Throughout 2017 we will be testing innovative new models of service that enable patients to enter their symptoms online and receive advice online or a call back. 2) NHS 111 - We will continue to develop the response patients receive when they call 111 building on the work done by the Greater Nottingham Vanguard and the delivery of integrated urgent care and 24/7 clinical hub. By the end of 2017/18 the percentage of calls receiving clinical advice will exceed 50%. 3) GP Access - By March 2019 patients and the public will have access to evening and weekend appointments with general practice. 4) Urgent Treatment Centres - Standardise access to Urgent Treatment Centres through booked appointments via NHS 111. These facilities will have an increasingly 9 P a g e
RCCG/GB/17/144 standardised offer - open 12 hours a day and staffed by clinicians, with access to simple diagnostics. 5) Ambulance Response Programme - The ambulance service will offer a more equitable and clinically focused response that meets patient needs in an appropriate time frame with the fastest response for the sickest patients. Today s Work Today work stream 6) Hospitals - In our emergency department we will continue to develop new approaches prioritising the needs of the sickest patients. Work will be progressed on the NUH frailty model of care so that our frail and elderly patients will get specialist assessments at the start of their care and those patients who could be better treated elsewhere, will be streamed away from Emergency Departments building on the work already taking place with primary care streaming at the front door of ED. Home First work stream 7) Hospital to Home - We will speed up the assessment process and ensure that patients are sent home as soon as possible and if home is not the best place for their immediate care, they will be transferred promptly to the most appropriate care setting for their needs. This has been one of the key strategic ambitions of the STP and the Greater Nottingham A& E board. 8. Programme Infrastructure Governance and Oversight Performance against the 4 hour target and delivery of the mandated delivery plan continues to be monitored and governed through the monthly local A & E delivery board chaired by Dr Peter Homa, Chief Executive of NUH. Regulatory oversight is provided through fortnightly escalation meetings with NHSI and NHSE with system leaders chaired by Dale Bywater, Executive Regional Managing Director of NHSI. Delivery of the improvement priorities are through the 4 executive sponsored work streams which report to the local A & E board which in turn reports to the Midlands and East regional A & E board through a Delivery Milestone Tracker report. 9. Recommendations The Governing Body is asked to: Consider and comment on progress to date in delivering the Urgent and Emergency Care priorities Note the areas identified as priorities for 2017/18 and the actions in place to ensure delivery Nikki Pownall Programme Director Urgent Care July 2017 10 P a g e