Operational resilience planning template for non-elective care 2014/15

Operational resilience planning template for non-elective care 2014/15 Lead CCG: Lead acute trust: Nottingham Clinical Commissioning Group Nottingham University Hospitals NHS Trust Central Resilience Funding Marginal Tariff savings to reinvest Other funding available locally Total non-elective care support funding for 2014/15 Section 1: Narrative on local system configuration, key strengths and key challenges Please see attached document for the Greater Nottinghamshire narrative for section one of the operational resilience and capacity plan. Section 2: Minimum plan requirements. Please note that development of a sufficient plan to deliver all of these elements is a pre-requisite to qualify for any central resilience funding in 2014/15. More detail on these plan Text in blue italics is provided as examples only and should be overtyped Ref Minimum Plan Requirements Summary of plan to achieve requirement KPIs Target Outcomes Timeframe for Completion Lead Accountable Officer Estimated Costs in 2014/15 1a 1b 1c Enabling better and more accurate capacity modelling and scenario planning across the system Analysis of the current performance has indicated that 70% of the A&E breaches are due to bed availability, and that the majority of delays to discharge are due to waits for beds in the community. Therefore the capacity model has ensured that there is an increase in community beds to support a transfer to assess model whilst also increasing beds within NUH. Ensure sufficient flexibility in capacity and contingent meet surges in demand Detailed capacity modelling has been undertaken looking across the total capacity requirements within the system - secondary, community and social care. The system has agreed that for this year, as it goes through a period of recovery and transition to a more community based model of urgent care, it is prudent to plan for 'over capacity'. Therefore the UCWG has agreed that the following additional beds should be commissioned. 71 additional bed in NUH (of which 24 are specifically to respond to the seasonal pressures seen in respiratory medicine and stroke) and 37 equivalent beds (48 actual) beds in the community (See supporting evidence file reference X ) This additional capacity is higher than the requirements identified in original bed modelling by NUH which forecast a requirement for 75 additional beds to ensure there is headroom to safeguard delivery of key targets and standards. The additional capacity is seen as a stepping stone The current additional bed capacity does not take As per 1a. Plus account of the impact of Commissioner and NUH by speciality. QIPP and the plans in place to reduce avoidable Reduction Trajectory readmission which have been incentivised via the (by Scheme) contract mechanism. Work undertaken by McKinsey and Company identifies that full delivery of Commissioner QIPP 'stretch' targets could achieve a reduction of 26 beds (achieved during Q3 and Q4) and a reduction of 15 beds achieved through work to reduce avoidable admissions. The impact of the Readmission Reduction Programme and Commissioner QIPP delivery provide additional flexibility and contingency. Established mechanism are in place for monitoring the delivery of Commissioner QIPP (via QIPP Delivery Group) and Readmissions (via the Readmissions Oversight Panel) which both report into the Contract Executive Board of the NUH contract. Information from QDG and ROP Use of emergency 'Community supported beds' - in June the partners of the urgent care system identified potential capacity problems in a forthcoming weekend, and by working together managed to have available a further 11 beds within 24 hours. This was largely achieved by the community providers identifying additional staff and input into residential care homes. This model can be used during the coming winter when community capacity constraints are forecast in advance 1. Number of beds / places in the community setting 2. Number of additional beds opened at NUH 3. Number of delayed discharges due to wait for community bed / placements 4. % bed occupancy in NUH and Community Beds 5. Number of Overnight discharges by speciality 6. Number of admissions by speciality 7. Number of 0-1 day length of stay. A further meeting to agree the suite of KPIs to monitor impact of additional bed capacity will take place week 1 - August 2014. 1. Readmission Rate 2. Performance against Readmission 3. CCG QIPP Delivery 4. NUH QIPP Delivery (by Scheme) 1. Reduction in delayed transfers of care 2. Improved flow through the hospital enabling medical non elective LoS to be 5 days or less 3. Achievement of 4 hour ED standard 4. Less discharges between 2200 and 0600 hours 5. Reduction in avoidable readmissions 6. Improved Patient experience As per 1a Plus 1. Reduction in avoidable readmission 2. Activity level aligns with Plan 3. Reduced financial risk across system Base Capacity Plan - Completed. Approved 25th July 2014. Bi-monthly refresh of plan based on actual activity and performance beginning October 2014. Detailed delivery and Implementation plans for additional capacity to be completed by Monday 18th August. Weekly system wide Implementation monitoring meetings will be commenced from Monday 4th August, coordinated by CCG with lead for Urgent Care. NUH ops team are meeting next week with lead from McKinseys w/c 28/7/14 to understand further where the reduction in beds will be delivered through QUIPP i.e. site and speciality. Revised QIPP Delivery Group arrangements from week commencing 4th August (following completion of Mckinsey work). Weekly Implementation meetings from 4th August 2014. Formal 'stock take' agreed for mid October to refresh capacity plan % utilisation of emergency supported bed. As per 1a Criteria for use of this capacity to be determined by end of August 2014 Oliver Newbould, Chief Officer Nottingham West CCG. Oliver.Newbould@Nottinghamwest.nhs.uk. (Chair of Capacity and Demand Group) Programme Director, Non Elective Care (TBC) Oliver Newbould, Chief Officer Nottingham West CCG. Oliver.Newbould@Nottinghamwest.nhs.uk. Programme Director, Non Elective Care (TBC) Dawn.Smith Chief Officer, Nottingham City CCG. Dawn.Smith@Nottinghamcity.nhs uk 4.78M

1d Agree Elective Activity plan which enables RTT performance to be maintained Agree phasing of elective work. The elective 1. RTT for admitted and non admitted pathways (by speciality) workload has been profiled to release capacity for 2. Number of cancelled operations non elective work from Christmas to the end of 3. Number of 'Outliers' March 2015. QMC: To December 23rd full elective operating utilising an expected maximum of 69 beds. 23rd December to 11th January 2015 reduce elective activity by 50%, elective activity contained within maximum of 35 beds to support the emergency take at QMC campus. 12th January to 23rd January 2015 increase electives activity to 70% contained in 50 beds with 19 beds available for the emergency pathway. 26th January to 31st March 2015 increase elective activity to 85% within 56 beds with 13 beds available for Q4 within surgery for the emergency pathway. City Hospital Campus: To December 23rd full elective operating utilising an expected maximum of 184 beds. 23rd December to 11th January 2015 reduce elective activity by 20% elective activity contained within 149 beds. releasing 35 beds to emergency pathway. 12th January to 23rd January 2015 increase elective activity to 85%, 159 beds and 25 beds available for emergency pathway. 26th January full elective programme to resume at City This reduction in elective activity still enables RTT Cancellations for non clinical reasons Elective reduction plan to be are minimised over the winter period agreed by SRG 29th July 2014. To be monitored by the weekly Implementation meeting. Dawn.Smith Chief Officer, Nottingham City CCG. Dawn.Smith@Nottinghamcity.nhs uk 2a Working with NHS 111 providers to identify the service that is best able to meet patients urgent care needs. According to the weekly national situation reports, emergency dispositions in Nottinghamshire from calls triaged by the NHS 111 service have been lower than the national average in every week. In week ending 6th July the national average was 19.6% emergency dispositions, within Nottinghamshire the figure was 16.7%. If Nottinghamshire had achieved the national average this would have equated to a further 95 ambulances being dispatched and a further 12 people being referred to ED Processes are in place with the NHS 111 provider 1. % of answered calls going to ambulance 2. % of answered calls going to (Derbyshire Health United) and other providers in ED 3. Patient Satisfaction the local health community to try and ensure appropriate dispositions from calls to the NHS 111 service. The contract with East Midlands Ambulance Service includes a CQUIN to help ensure close working between the ambulance service and NHS 111. Internally, Derbyshire Health United are working to an improvement plan to further reduce ED dispositions through additional training and support for call centre staff. Reduction in avoidable ED attendances. Reduction in ambulance responses to non life threatening calls. Standard achievement of 8% of Dawn.Smith Chief Officer, Nottingham City CCG. calls going to ambulance and 5% Dawn.Smith@Nottinghamcity.nhs uk. Stewart of answered calls going to ED from Newman, Urgent Care Lead, Nottingham City CCG. 1st September 2014 Stewart.Newman@Nottinghamcity.nhs.uk 2b 2b Improve access to Urgent Dental Treatment and management of patients with Urgent Mental Health needs. Through the call review process, issues have been identified around access to urgent dental services and the management of patients with an urgent mental health need. DENTAL: Dental holding profiles have been created to try and minimise the number of occasions when patients are directed to ED because no other service is available. Access for NHS 111 to dentists with a contractual requirement to provide urgent care slots has been secured. The Local Area Team have developed a proposal to enhance access to specialist dental assessments. MENTAL HEALTH: Funding has been secured to enhance capacity in the community mental health crisis team to enable them to provide further assessment of calls that the NHS 111 assessment has determined should be referred to ED and ambulance services. 1. No of ED attendances for Urgent Dental Treatment 2. Availability of Urgent Dental slots with Dentists 1. Number of transfers to Crisis Team from NHS 111 2. Number of people attending A&E for mental health assessment Reduced ED attendance for Urgent Dental Treatment Reduced ED attendance for patients requiring urgent Mental Health assessment Business Case being considered by Nottinghamshire Derbyshire Area Team 21 August 2014 Service expected to commence September 2014 Julie Theaker, Primary Care Contract Manager, Area Team julie.theaker@nhs.net Stewart Newman, Urgent Care Lead, Nottingham City CCG. Stewart.Newman@Nottinghamcity.nhs.uk

Additional capacity for primary care. Delivery of Challenge Fund Programme (See The local Area Team co-ordinated the Evidence File reference X) submission of a successful bid to the Prime Ministers Challenge Fund. The Greater Nottinghamshire CCGs have received x of non recurrent funding. A range of innovative approaches of service offers will be developed and 3a tested during 14/15 and, following evaluation, will be extended as part of the Better Care Fund (BCF) plans in 15/16. Together the initiatives will enable easier access to General Practice for patients with an urgent 1. No of GP appointments 2. No of Nurse appointments 3. No of extended hours 1. Improved access to urgent appointments 2. Improved patient satisfaction 3. Reduction in ED attendances 4. Minimised health impact of Influenza 5. Reduction in number of minor ailments being treated in ED As per Challenge Fund Implementation Plan. Maria Principe, Director of Primary Care and Service Integration. Maria.Principe@Nottinghamcity.nhs.Uk Fiona Callaghan, Assistant Director of Commissioning, Nottingham North and East CCG Fiona.Callaghan@nottinghamnortheastccg.nhs.uk. Helen Griffiths, Deputy Chief Officer Rushcliffe CCG Helen.Griffiths@rushcliffeccg.nhs.uk Tracey Lindley, Head of Strategy and Development, Nottingham West CCG Tracey.Lindley@nottinghamwestccg.nhs.uk 3b Annual Flu Vaccination Campaign. As CCGs, as part of their role of quality assurance in previous years Practices are well and improvement are supporting Practices to prepared for the delivery of the increase uptake of the vaccination programme. annual flu vaccination campaign. In Work will particularly focus on those Practices line with the national position uptake where uptake was rated as red in 2013/14 or in the over 65 year old population has where performance is 10-20% below target level previously been high; this year across two or more indicators at November 2014 attention will be given to maintaining this but also encouraging higher uptake in the other target groups - children aged between 2 and 4 years, pregnant women, patients within the clinically defined risk groups, carers and residents in care homes. Uptake of vaccination by target group Health impact of influenza minimised August - CCGs check practices have arrangements in hand for vaccination of care home residents, and are contacting all target populations. September - Clinics begin to be held by practices November - uptake reporting by practices; Area Team support / performance manage practices in conjunction with CCGs where uptake is below acceptable level Jane Careless, Screening and Immunisation Coordinator, Nottinghamshire and Derbyshire Area Team. Jane.careless1@nhs.net 3c Home Visiting Service. A home visiting service has been in place in Nottingham City since November 2013. An interim evaluation reports a trend of reducing GP admissions for a significant minority of GP practices who use the service. Expand Home Visiting Service: This service is now being rolled out to provide a service to Practices neighbouring the original catchment area. 1. No of visits by practice 2. No of admissions 1. Reduced calls to EMAS from Care following visit 3. Patient satisfaction Homes 2. Reduced non elective admissions 3. Increased patient satisfaction TBC Maria Principe, Director of Primary Care and Service Integration. Maria.Principe@Nottinghamcity.nhs.Uk Seven day working arrangements in Social Care Both the City and County Adult Social Services Departments provide 7 day services. Care services are commissioned from a range of independent sector providers all of whom operate 7 day services. New packages of care can be started at weekends once the discharge plans and OT or social work assessment have been completed. 3d Primary Care streaming service. A Service has been provided by NEMS within A&E since 2011/12. Activity in the primary care stream increased from the previous year s out turn by: 32.9% in 2011/12 10.7% in 2012/13 63.6% in 2013/14 In 2013/14, 89% of the patients streamed to primary care had their episodes of care completed by the service. A further 6.5% were admitted to secondary care and 4.4% were referred back to ED in order to have their episode of care completed. Investment has been agreed to create sufficient capacity to ensure that NEMS are able to provide the Primary Care Sorter role during all hours (10.00-24.00) when the primary care stream is operating and manage the increase in workload that this will generate 1. No of patients being managed by the primary care stream 2. % if admissions from the primary care stream 3. % of patients returned to ED by the primary care service 1. Patients seen in appropriate setting for their clinical needs 2. Reduced number of patients within A&E dept 3. 4 hour standard met for minor patients in A&E 4. Improved patient satisfaction Commencement of enhanced streaming service (constrained by availability of existing staff) - August. Recruitment of additional staff - August / September Fully staffed service launched - October Stewart Newman, Urgent Care Lead, Nottingham City CCG. Stewart.Newman@Nottinghamcity.nhs.uk

4 7 day working. All parties recognise that 7 day working is critical to enable the urgent care system to work effectively NUH: NUH offer a consultant led service 7 dayweek 1. 4 hour ED standard 2. No of for a number of services with on site discharges at the weekends 3. Average Length of stay presence of consultant across all acute 4. Improved Patient Outcomes HSMR / SHMI 5. Reduction in DTOC emergency specialities. The Trust are 6. Reduction in LOS participating in an East Midlands wide 7 day service baseline assessment conducted by ATOS. This will provide a useful starting point in establishing gaps in compliance with the 10 Clinical Standards for 7 day services. The results of this work are due in October 2014. NUH will Community also seek to work services: closely Key with services its partners to support across 1. 4 hour ED standard 2. No of discharge will be in place seven days a week such discharges at the weekends 3. as the SPA and Welcome Home service in Reduction in DTOC 4. Reduction Erewash, urgent care and re-ablement services in in LOS the City and home based intermediate care services in the County Mental Health: The key services that interface 1. 4 hour ED standard 2. No of with acute services - rapid liaison service, crisis discharges at the weekends 3. team etc -are all available 7 days a week Reduction in DTOC 4. Reduction in LOS Social Care: Both the City and County Adult Social Services Departments provide 7 day services - for example rapid response/ bridging services, intermediate care and reablement services. Care services are commissioned from a range of independent sector providers all of whom operate 7 day services. New packages of care can be started at weekends once the discharge plans and OT or social work assessment have been completed. Where discharges are planned in advance, packages of care can be started at weekends. The County Council have awarded new home care contracts which detail the requirement for 24/7 accessibility and referrals. In the City a crisis co-ordination team has already been commissioned to support discharge over 7 days. Simple discharges can be arranged by ward staff over the weekend including re-starting care A full review of the Non Elective Pathway has been commissioned from Mckinsey and Company which will commence on 11th August and conclude at the end of September. This will identify any further system improvements which could further strengthen the Resilience Plan and any lessons including any in relation to 7 day working will be considered and actions plans put in place as required 1. 4 hour ED standard 2. No of discharges at the weekends 3. Reduction in DTOC 4. Reduction in LOS 1. Improved patient experience. 2. Consistent monthly achievement of the 4 hour ED target. 1. Improved patient experience. 2. Consistent monthly achievement of the 4 hour ED target. 1. Improved patient experience. 2. Consistent monthly achievement of the 4 hour ED target. 1. Improved patient experience. 2. Consistent monthly achievement of the 4 hour ED target. Name: Zara Jones zara.jones@nuh.nhs.uk Job Title: Paul.Smeeton, Managing Director, County health Partnerships paul.smeeton@nottshc.nhs.uk Lyn Bacon, Chief Executive, CityCare Lyn.Bacon@nottinghamcitycare.nhs.uk Caroline Baria, Service Director, Nottinghamshire County Council Caroline.Baria@nottscc.gov.uk Helen Jones. Director of Adult Social Care, Nottingham City Council. Helen.Jones@nottinghamcity.gov.uk Programme Director: Non Elective Care 5 SRGs should serve to link Better Care Fund (BCF) principles in with the wider planning agenda The BCF is recognised as an opportunity to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability. The BCF plans and this operational resilience plan complement each other as the system moves towards integrated care provided 7/7 so that patients receive the right care in the right place at the right time. Specific aspects of this plan which are mirrored in the BCF plans are: - development of transfer to assess models - move towards 7 day working - integrated community care co-ordination team - plans to reduce re-admission to hospital 1. Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population. 2.Proportion of older people (65 andover) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services. 3. Avoidable emergency admissions (composite measure) 4. Patient / service user experience. 5. Delayed transfers of care 1. Reduced hand offs between services 2. Improved patient experience. 3. Reduced non elective admission and more care provided at home. 4. Reduced long term admissions into care homes. 5. More integrated care Maria Principe, Director of Primary Care and Service Integration. Maria.Principe@Nottinghamcity.nhs.Uk Fiona Callaghan, Assistant Director of Commissioning, Nottingham North and East CCG Fiona.Callaghan@nottinghamnortheastccg.nhs.uk.

6 Expand, adapt and improve established pathways for highest intensity users within emergency departments. MENTAL HEALTH: Rapid Response Liaison Psychiatry has been inplace at NUH since 2012. The service model includes a specific team for older adults, increasing links between acute and mental health services to facilitate discharge and reduce length of stay. MENTAL HEALTH: Street Triage was introduced in April 2014. The aim of the service is to provide advice and guidance to police officers to enable them to make appropriate decisions. The objectives are that people are placed in the most appropriate care, will experience better outcomes and a reduction in the use of section 136 detentions, also ensuring people are not taken to hospital unless completely necessary. The initial data for the 2 months the service has been operating in City and County is positive. A high % of referrals have required no further action 104/222. In 2013/14 the average number of S135 detentions per month was 86.5, in April and May 2014 the average was 63, a reduction of 27%. 1. Number of Breaches of the A&E 4 hour standard caused by waits for a mental health assessment. 2. Reduced delays to assessment and treatment by mental health professional 1. No of patients brought into A&E inappropriately. 2. Reduced no of delays to discharge for patients with a complex mental health / social situation. 3. Number of ED breaches attributed to delays in Mental Health assessment. MENTAL HEALTH: Enhanced Community Provision / Expansion of Crisis Response Home 1. No of patients brought into A&E inappropriately. 2. Reduced no of delays to discharge for patients with a complex mental Treatment Service. As part of wider Service health / social situation. 3. transformation plans, there are plans to enhance Number of ED breaches attributed to delays in Mental Health assessment. the community services for adults and older adults. The impact of this should be evident in Q4. 2014/15 1. Reduced A&E breaches 2. Reduced waits in A&E 3. Improved patient experience 1. Reduced A&E attendances 2. Reduced waits in A&E 3. Improved patient experience 1. Reduction in admission to Mental Health in-patient facilities. 2. Improved Patient Experience. RRLP Service in place. Evaluation Lucy Davidson, Assistant Director of of RRLP to be completed by (date) Commissioning, Mental Health. Lucy.Davidson@Nottinghamcity.nhs.uk In Place. Evaluation of Street Lucy Davidson, Assistant Director of Triage will take place (date). Commissioning, Mental Health. Performance and Quality data will Lucy.Davidson@Nottinghamcity.nhs.uk be reviewed within Implementation Group to review impact. Enhanced Community Provision / Lucy Davidson, Assistant Director of Expansion of Crisis Response Commissioning, Mental Health. Home Treatment planned from Q4 Lucy.Davidson@Nottinghamcity.nhs.uk 2014/15* Requires public consultation and sign off by JOSC and all CCG Governing Bodies MENTAL HEALTH; A Complex Patient Pathway panel takes places on a weekly basis where organisations, including social care, meet to develop packages of care for patients who require discharge whose needs require enhanced partnership working to facilitate discharge. Work is progressing with key stakeholders across Nottinghamshire to submit a Declaration Statement and a Crisis Concordat Action Plan. Nottinghamshire Police have agreed to lead this work with the Police and Crime Commissioner and a steering group of key stakeholders is being established. Nottinghamshire Healthcare Trust have prepared a paper regarding their position and actions required. Commissioners are attending a national briefing event at Leeds on the 17.7.14 which will help confirm next steps required. A paper outlining progress and actions is to be presented at the October Health and Well 1. Action plan in place with implementation according to plan 1. Improved multi agency working 2. Improved patient experience 3. Reduced A&E attendances Lucy Davidson, Assistant Director of Commissioning, Mental Health. Lucy.Davidson@Nottinghamcity.nhs.uk Lucy Davidson, Assistant Director of Commissioning, Mental Health. Lucy.Davidson@Nottinghamcity.nhs.uk

FALLS: The Falls Rapid Response Service provided 1. Number of people with 'green' falls transported to hospital by EMAS is to be introduced across the whole of 2. Number of people with repeated falls Greater Nottingham. The Falls Rapid Response Team will provide a response service for 999 calls with Green-coded falls. The Falls Rapid Response Team are a dedicated integrated mobile team made up of a Paramedic (EMAS) and an Assistant Practitioner (Nottingham CityCare Partnership), using a specialised non-conveyance vehicle carrying a range of lifting and handling equipment. This will enable an immediate response and clinical assessment (by the Paramedic) following a fall as well as an assessment (by the Assistant Practitioner) for the support required to maintain the person safely at home if clinically appropriate to do so. As the team has a non-conveyance vehicle, the team will focus on maximising see & treat, the use of local falls pathways and other community-based health and social care services. The service has been operating in Nottingham City where on average 65% of falls patients were treated at home. Non-conveyance of green falls patients has increased from a 50% baseline (2012/13) before the introduction of the service PATIENTS WITH A KNOWN RESPIRATORY CONDITION Re-launch of the pathway for patients with a known respiratory condition to be taken directly to the respiratory assessment unit at the City Hospital campus, rather than being admitted through A&E. The aim is for at least 80% of patients to be admitted via this pathway. The key action required is for effective communication with EMAS crews so that they understand and OUT OF HOURS SERVICE FOR PATIENTS WITH RETENTION OF URINE A new pathway is being put in place to complement the existing service provided by community nurses, so that patients with retention of urine can be treated out of hours in the community rather than attending A&E with a probable DERBY APP A group of clinicians and managers visited the Royal Derby Hospitals to look at the app that they have developed to improve communication between primary and secondary care clinicians. The app allows GPs direct access to speciality advice on alternative management plans for a patient and access to urgent clinic slots, thereby decreasing the levels of emergency hospital admissions. Derby saw a significant drop in admissions following the introduction of the app. It was agreed that this would be a useful tool in Nottinghamshire, and would reduce emergency admissions but probably not to the level seen in ACUTE MEDICAL RECEIVING UNIT (AMRU) The unit provides a dedicated ambulatory care area to assess, treat and discharge all appropriate patients within 12 hours. New pathways are to be put in place so that GPs can book slots in AMRU, and clinicians in AMRU can book appointments/follow up in Primary Care so that they have confidence to discharge a patient without a full hospital admission as they are certain of the level of follow up care that will be provided. The new pathways will be supported by new transfer of care documentation that will follow a patient on their journey thereby improving continuity of care between primary and 1. Number of patients with a known respiratory condition attending A&E 1. Reduced number of patients in A&E 2. Reduced waits for patients 3. Improved continuity of care 1. Number of patients attending A&E requiring catheter care 2. Reduced hospital admissions for catheter care 1. Number of patients referred to urgent clinic slots 2. Number of calls for specialty advice 3. Number of A&E attendances 4. Number of non elective admissions 1. Number of direct bookings into AMRU 2. Number of reciprocal bookings in GP appointments 3. Number of A&E attendances 4. Number of non elective admissions 1. Provide specialised early First Vehicle to start in August. assessment for elderly falls patients. Second one to come on line in 2. Increase 'See and Treat' rates and October ED avoidance. 3. Reduce number of green falls transported to A&E thereby reducing demand on A&E and acute beds. (Increase ambulance nonconveyance rate). 4. Reduce number of acute admissions for falls. 5. Increase number of falls patients treated a home, supported by referral to and use of care pathways and community services (Increase ambulance 'see and treat' rates). 6. Reduce number of repeat falls. 7. Reduce admissions to residential care as a result of falls. 8. Reduce hip fracture rates per 000 population over 65. 1. Reduced number of patients in A&E 2. Reduced waits for patients Agree communication strategy with EMAS - end of August Re-launch pathway - September New pathway launched - October 1. Reduced number of patients in Phased implementation from A&E September 2. Reduced waits for patients 3. Improved continuity of care 4. Improved communication between primary and secondary care 1. Reduced number of patients in A&E 2. Reduced waits for patients 3. Improved continuity of care 4.Improved communication between primary and secondary care Launch in pilot Practices in Nottingham North and East CCG - August Formal review of pilot - September Roll out - October Maria Principe, Director of Primary Care and Service Integration. Maria.Principe@Nottinghamcity.nhs.Uk Nikki Pownell, Deputy Director of Operations, Nottingham University Hospital Nikki.pownell@nuh.nhs.uk Jackie Butterworth, Community Programme Lead jackie.butterwoth@nuh.nhs.uk Jackie Butterworth, Community Programme Lead jackie.butterwoth@nuh.nhs.uk Jackie Butterworth, Community Programme Lead jackie.butterwoth@nuh.nhs.uk

RENAL COLIC 1. Number of patients attending A&E with renal colic Planning is beginning for a new pathway for renal 2. Reduced hospital admissions for renal colic colic whereby GPs will be able to have direct access pathway rather than a patient being seen in A&E and then admitted for tests 1. Reduced number of patients in A&E 2. Reduced waits for patients Plan in place including demand Jackie Butterworth, Community Programme Lead and capacity modelling by October jackie.butterwoth@nuh.nhs.uk CHILDREN ATTENDING A&E WITH A PRMARY CARE CONDITION ED paediatric consultants have been commissioned to develop pathways for conditions that could benefit from alternative pathway management in Primary Care (GP, PN, HV, WIC, NEMS). The conditions identified as appropriate are: - Head injury - Abdominal pain - Vomiting and Diarrhoea - Diabetes - Breathing difficulties (asthma/ wheezing) - Fever - Seizures / Epilepsy REDUCING RE-ADMISSIONS The three highest volume service areas by number of readmissions are General Medicine, Clinical Oncology and General Surgery. Baseline position has been calculated for each speciality with plans to improve performance: General Medicine: Routine delivery of readmission reviews in assessment wards; continue to refine urgent clinics and their use (particularly concerning patients with a short readmit length of stay). Clinical Oncology: Extended role for Specialist Oncology Nurses to offer appropriate advice to those patients where possible to minimise need for hospital based assessment and admission, use a call back telephone clinic to contact all patients who have sought advice from the triage calls in the preceding 24 hours to ensure resolution of symptoms or escalate as necessary, and run a telephone review clinic for all patients in week 1 of their chemotherapy to make an early assessment of complications related to treatment and encourage appropriate self-management or arrange day case assessment. General Surgery: Redesign of surgical clinical pathways including the adoption of an ambulatory care model as part of the creation of a surgical decision making unit (contingent on the 1. Number of children attending A&E with conditions that could be treated in primary care 1. Number of re-admissions by specialty and reason 2. Reduced non elective admissions 3. Patient experience PATIENTS RESIDENT IN CARE HOMES: Detailed 1. Number of A&E attendances for people resident in Care Homes analysis by EMAS has indicated the most common 2.Number of people in Care Homes with care plans reasons for ambulance call outs and conveyance rates for patients resident in Care Homes. It is clear that that some of the ambulance calls and conveyances could be avoided with different pathways. Actions being taken are: Over 75s 5 per head CCG developments will support care homes. All new residents will get a personalised care plan, and new enhanced service for avoiding unplanned admissions should ensure that most of existing residents also have a care plan in place. A working group has been set up to lead this work. They identified that Care homes need a predictable and reliable response when one of their residents becomes unwell; the current default is to contact GP and failing that the ambulance service. A focus of the work is to ensure all care homes understand all the options Revised Enhanced Services are in place to 1.Number of A&E attendances for people resident in Care Homes standardise response of GPs new specifications 2. Number of people in Care Homes with care plan focussing on proactive care and ongoing support. Community matrons/advanced nurse practitioners and targeted therapy services all supporting homes with most admissions 1. Reduced number of children attending A&E 1. Reduced re-admissions 2. Improved patient experience 1. Reduced hospital admissions for people resident in care homes 2. Improved continuity of care 1. Reduced hospital admissions for people resident in care homes 2. Improved continuity of care Deborah Hooton, Head of joint commissioning for children and families deborah.hooton@nottinghamcity.nhs.uk Medicine: August - regular reviews Mark.Boulton, Community Programme underway; October - review mark.boulton@nuh.nhs.uk outcomes Oncology: End of September - Team established and pathway and protocols agreed.; November 2014 - Monthly reporting of key performance indicators in place Surgery - End of October 2014 Plans refined; End of December 2014 Pathway modelled; January 2015 Pathway changes being enacted. Sam Walters, COO, NottinghamNorth and East CCG sam.walters@nottinghamnortheastccg.nhs.uk

The Community Pathfinder and Home Intervention Team provided by NEMS is being re-focused to work with EMAS, Emergency Department and care homes to provide a rapid response clinical discussion for Emergency Department clinicians, EMAS crews, acute admissions areas and care home staff to assist in sourcing community alternatives to a secondary care referral or admission where it is safe to do so. The service will:.offer a telephone contact number for care homes, EMAS crews and secondary care clinicians Agree a care plan for the patient with the service that has contacted the Community Pathfinder and Home Intervention Service and ensure that this care plan is implemented Where a home visit from the Community Pathfinder and Home Intervention Service is necessary this should commence within 2 hours of the decision being made Pass cases to the most appropriate community service for ongoing care and treatment Arrange transport for patients where appropriate Examples of the sorts of intervention to be provided include post-fall assessments (but not pick-ups), minor injury and illness advice for conditions such as UTIs or for chest infections, or 1.Number of calls to the service admissions from Care Homes 2. Number of 3. Number of visits to care homes 1. Reduced 999 calls from Care Homes 2. Reduced admissions from Care Homes Alison McWilliam, General Manager, NEMS AlisonMc@nems.nhs.uk 8 Have consultant-led rapid assessment and treatment systems (or similar models) within emergency departments and acute medical units during hours of peak demand Despite continued attempts at recruiting medical staff there are: 4 vacant A&E Consultant posts 6 vacant Consultant posts in acute medicine 4 vacant consultant posts in HCOP Gaps in on call rotas are covered by locums and initiative payments where possible. All areas are out to recruitment but attracting the right calibre of candidates suitable for substantive recruitment has been difficult. Risk assessment has been completed and is recorded as a 20 risk on the NUH directorate risk register. Despite these difficulties it is recognised that raid assessment and treatment systems will help unblock the system. Therefore: - Consultant cover has in A&E been increased for a proportion of the day/ evening with the additional 3-10pm shift which will help to address the problems tha have been experienced with the changes profile of activity -A HCOP consultant is based in ED on trial basis (Monday am) - Specialties now being provided with information on their queues on the assessment units 3 times a day after bed meetings and have to update on actions 1.4 hour access standard A&E 2.Care Quality Indicators (time to treat, time to review) 1. Improved patient experience. 2. Consistent monthly achievement of the 4 hour ED target. 1. Rolling adverts for acute Robert Heywood, Director of Operations, NUH. physicians has resulted in increase Robert.Heywood@nuh.nhs.uk of 8.25 PA from August 2014. 2. Joint posts out to advert between Rheumatology endocrinology and infectious diseases will gain 14 PA for acute medicine by October 2014. 3. Process has commenced to identify acute medicine PA within existing job plans of stroke physicians. 4. Advert for ED Consultant out July 2014. 5. Advert for HCOP consultant - Locum due to commence August 2014. 9 All parts of the system should work towards ensuring patients medicines are optimised prior to discharge Additional Pharmacist Recruitment:NUH are 1. Number of TTOs written up the day prior to discharge 2. Number of recruiting 9 additional pharmacists to work on the delayed discharges due to waits for TTOs. 3. Number of re-admissions due wards. These posts will improved the timeliness to medication issues. and accuracy of TTO transcriptions to support patient timely discharge; this was trialled during the recent Perfect Week exercise and evaluated positively at ward level. In addition the ward based pharmacists will participate in ward rounds and undertake medication reviews. They will advise patients and their carers on how to take the medications, etc 1. Reduced delays to discharge due to waits for medication. 2. Reduced medication errors. Pharmacist Interviews scheduled Robert Heywood, Director of Operations, NUH. for July 2014. Start date for Robert.Heywood@nuh.nhs.uk Appointed Pharmacists September 2014. Unfilled posts to be covered by use of Locum appointments

10 Processes to minimise delayed discharge and good practice on discharge The bed management system, Horizon, is being re-launched. This will enable effective bed management as well as enabling the Care Coordination Team to be able to see all patients who are medically fit for discharge. 1. Number of delays to discharge. 2. Number of pre noon discharges 3. Number of delays due to choice of home 4. Number of discharges using discharge lounge 1. Reduced length of stay. 2. Reduced admissions from hospital into permanent care Operational Lead for Horizon takes Robert Heywood, Director of Operations, NUH. up post - 21 July Robert.Heywood@nuh.nhs.uk Rapid improvement into permanent care All patients have a Planned Discharge Date; once medically fit the standard for the discharge to be completed is: Simple discharge - 2 hours Complex discharge - 24 hours A Rapid Improvement event at NUH on 9 September will focus on discharge including use of the discharge lounge to free beds as early in the day as possible 1. Number of simple discharges discharged within 2 hours. 2. Number of Complex discharges discharged within 24 hours 1. Reduced length of stay. 2. Reduced admissions from hospital into permanent care Robert Heywood, Director of Operations, NUH. Robert.Heywood@nuh.nhs.uk Rapid Improvement Event planned Robert Heywood, Director of Operations, NUH. for 9th September Robert.Heywood@nuh.nhs.uk Consultant led board rounds in place daily (registrar led in some specialities at weekends) 1. Number of delayed transfers of care 1. Reduced delayed transfers of care Robert Heywood, Director of Operations, NUH. Robert.Heywood@nuh.nhs.uk Transfer to assess model being implemented across the area. Current Care ordination Team to be developed into a single integrated care coordination team to expedite discharge, and putting local packages of care/care placement in place Leaving Hospital (Home of choice) policy developed, including a formal process for eviction; will be presented to HWB in the City in August and to the County Board in September. 1. Number of delayed transfers of care whist patients wait for community packages or placements 1. Reduced delayed transfers of care whist patients wait for community packages or placements Agreement on model for CCT - mid August Staff consulted and new model explained - September SOPs developed; trialled at Perfect Week 2 - end of September Revised CCT launched - October 1. Number of delayed transfers of care whilst people wait for their home of 1. Reduced delayed transfer of care Home of Choice policy presented choice whilst patients wait for their home of to HWB IN August/September. choice SOPs developed Fiona Callaghan, Assistant Director of Commissioning fiona.callaghan@nottinghamnortheastccg.nhs.uk Caroline Baria, Service Director, Nottinghamshire County Council Caroline.Baria@nottscc.gov.uk Helen Jones. Director of Adult Social Care, Nottingham City Council. Helen.Jones@nottinghamcity.gov.uk Communications process to be developed to support the internal implementation process and to make the public aware that staying in hospital once medically fit is not an option. 1. Number of complaints regarding the home of choice policy 1. Public acceptance of home of 2.Number of delayed transfers of care whilst people wait for their home of choice policy choice 2. Reduced delayed transfer of care whilst patients wait for their home of choice Communications regarding policy put in place. Staff training Policy launched Caroline Baria, Service Director, Nottinghamshire County Council Caroline.Baria@nottscc.gov.uk Helen Jones. Director of Adult Social Care, Nottingham City Council. Helen.Jones@nottinghamcity.gov.uk 11 Plans should aim to deliver a considerable reduction in permanent admissions of older people to residential and nursing care homes Nottinghamshire County Council have a Living at Home Programme which is focussed on reducing the numbers of people placed in long term residential and nursing care. Wherever possible, services are provided by health and by social care which help people to remain at home and which support people to regain and retain their confidence and their independence following a hospital stay. Intermediate care and reablement services are commissioned by the CCGs and the local authorities to enable people to return home to recover following illness or trauma. 1. Number of permanent admissions to a care home. 2. Number of people remaining at home 91 days after discharge into a reablement scheme 3. Number of DTOC for patients waiting for a care home placement 1. Reduced admissions into permanent care Caroline Baria, Service Director, Nottinghamshire County Council Caroline.Baria@nottscc.gov.uk Helen Jones. Director of Adult Social Care, Nottingham City Council. Helen.Jones@nottinghamcity.gov.uk The transfer to assess model which is being introduced places emphasis on ensuring that no patients are admitted into long term residential care directly from hospital.

12 Cross system patient risk stratification systems are in place, and being used effectively All Practices have signed up to the avoiding unplanned admissions enhanced service. EHealthscope is being used by practices to identify their at risk population based on the Devon Risk tool to stratify patient population. As a minimum this is undertaken on a quarterly basis by all practices and the patients identified as a result of this process will be discussed during the monthly MDT meetings to assess which require active case management. 1. Number of unplanned admissions from the identified high risk group. 2. Number of delays to discharge for patients who are being actively case managed. 3. Attendance at MDT meetings and number of patients reviewed each month 1. Reduced avoidable admissions 2. Reduced delayed transfers of care 3. Improved patient and carer satisfaction Practice's ex-directory or bypass telephone number given to A&E clinicians, ambulance staff and care homes, as well as the hours it is available - end of July. All patients identified as high risk via the Devon tool to have care plans in place by end of June Monthly MDT meetings - ongoing Maria Principe, Director of Primary Care and Service Integration. Maria.Principe@Nottinghamcity.nhs.Uk Fiona Callaghan, Assistant Director of Commissioning, Nottingham North and East CCG Fiona.Callaghan@nottinghamnortheastccg.nhs.uk. Helen Griffiths, Deputy Chief Officer Rushcliffe CCG Helen.Griffiths@rushcliffeccg.nhs.uk Tracey Lindley, Head of Strategy and Development, Nottingham West CCG Tracey.Lindley@nottinghamwestccg.nhs.uk The Devon tool does not identify 'frailty. A national frailty tool has been developed which has been shown to predict mortality and emergency admissions. Greater Nottinghamshire will be a pilot site for use of this tool from September 1. Patient and carer experience 2. Hospital admissions for the over 75 year group 1. Reduced hospital admissions 2. Improved patient experience Pilot use of tol begins - September Sam Walters, COO, Nottingham North andeast CCG sam.walters@nottinghamnortheastcch.nhs.uk 13 The use of real time system-wide data NUH are re-launching the bed management system, Horizon, and reviewing current escalations within the Trust 1. Capacity information available 7/7 1. Real time capacity information enables efficient bed management Robert Heywood, Director of Operations, NUH. Robert.Heywood@nuh.nhs.uk Real time information is available to silver control 1. Capacity information available 7/7 1. Effective bed management within NUH showing situational report across 2. Reduced delays to discharge both campuses, with EDIS view of ED and acute medicine and speciality receiving unit at City Hospital. 'Horizon Boards' in the operations room are customised to show number of Outliers, discharges planned today and within the next 24/48 hours, use of discharge Lounge, bed requests in assessment areas, medically fit patients and patient who are deemed suitable outliers. System wide management information The Urgent Care Working Group has agreed to use the TDA Monitoring Framework. Part of the commissioned work from Mckinsey and Company will be to develop a performance management framework to support urgent care pathway. This will be available for consideration at the October SRG No of times information was not available to support daily conference calls and weekly Implementation Group 1. Regular timely information available for monitoring and management of the urgent care system Robert Heywood, Director of Operations, NUH. Robert.Heywood@nuh.nhs.uk Draft performance framework Programme Director: Non Elective Care from McKinsey and Company - end of September Proposed performance framework discussed at SRG - October Escalation Plan The system wide escalation policy, which includes de-escalation procedures, has been reviewed. A further exercise is to be undertaken by the weekly Implementation Group to review the triggers and test whether in recent weeks when the system has been under pressure all actions detailed in the Plan have been actioned. The contact list for each organisation has been updated and shared. 1. Triggers for escalation and actions reviewed 1. Well understood escalation plan in Review completed by end of place and used by all system partners August; plan adopted by SRG at the September meeting CONTINUATION OF DAILY CONFERENCE CALLS: A daily conference call (Monday to Friday) at 9.00am identifies available capacity across the system, plus the number of patients waiting for discharge. A further call takes place at 12 noon with senior representative of the health and social care system. 1. All key organisations represented at appropriate level 1. Whole system management of the urgent care pressures Total costs of all minimum requirement schemes: Programme Director: Non Elective Care Programme Director: Non Elective Care Sum of cells above Section 3: Local Plans for Innovation. Plans over and above the minimum requirements to meet local patient needs. If there is any funding gap between the total emergency care support funding and the total costs of the Ref Local Requirements Summary of plan to achieve requirement KPIs Target Outcomes Lead Accountable Officer Estimated Costs in 2014/15 13