Attachment 8 Report to the Board of Directors 2016/17 Date of meeting 30 September 2016 Subject Report of Prepared by Purpose of report Previously considered by (Committee/Date) Local A&E Delivery Board Chief Operating Officer / Chief Executive Sue Watkinson, Chief Operating Officer This report identifies and outlines the progress of the newly developed A&E Local Delivery Board. N/A Board Action Required Approval Discussion Decision Information Executive Summary and recommendation(s) This report is developed to provide the Board of Directors with the information and the actions being taken to improve A&E performance within the acute Trust.
Strategic Context/Objective(s) and Board Assurance Framework links Strategic aim(s) To be safe To be effective To be caring To be responsive To be well-led Strategic objective(s) 1. Delivery of this year s Quality priorities 2. CQC compliance/improvement 3. Financial control/performance requirements 4. Workforce strategy General - no specific link to a current year s objective BAF reference(s) This paper provides assurance against the Trust objective(s) identified This paper is to close a gap in control/assurance in relation to the objective(s) Legal/regulatory (The relevant regulatory or legislation requirement with specific reference where appropriate) Equality Impact/risks (Equality Delivery System 2 EDS2 Nov 2013) To comply with Monitor s Regulatory Framework. Impact Positive Negative Neutral Assurance process and frequency of monitoring Through the A&E Local Delivery Board which links into the James Paget Finance and Performance Committee. DEFINITIONS Information: Update to ensure Board has sufficient knowledge on subject matter and to provide assurance on progress Discussion: Seeking Board members views, potentially ahead of final course of action being agreed Decision: When being asked to choose between alternative courses of action Approval: Positive resolution, to confirm paper is sufficient to assure the Board in its ongoing monitoring role, or to address a gap in control 300916 A&E Local Delivery Board Page 2 of 5 Sue Watkinson, Chief Operating Officer 21092016 REP/BOD/SW3009/01
1. Introduction 1.1 This paper sets out the National Directive for each local health and social care community to develop a A&E Local Delivery Board which is Chaired by the Acute Trust Chief Executive. 1.2 The following organisations are represented at the Great Yarmouth and Waveney A&E Local Delivery Board; James Paget University Hospitals NHS Foundation Trust Great Yarmouth and Waveney Clinical Commissioning Group East Coast Community Health East of England Ambulance Service Trust Norfolk Social Care Suffolk Social Care Norfolk & Suffolk NHS Foundation Trust IC24 Out of hours GP providers 2. Remit of the A&E Delivery Board Core Responsibility Leading A&E recovery Developing plans for winter resilience and ensuring effective system wide surge and escalation processes exist Supporting whole-system planning (including with local authorities) and ownership of the discharge process Participating in the planning and operations for local ambulance services Participating in the planning and operations of NHS 111 services including oversight of local DOS development Agreeing deployment of any winter monies Agreeing how money used via sanctions and incentives is deployed for maximum benefit of the system Working within the STP footprints (& UEC Networks) deliver the UEC Strategy locally with specific focus to be given to 1. Expanded access to primary care 2. Creating an out of hospital hub combining NHS 111 and OOH services 3. Delivering on the 4 key UEC hospital standards Supporting Vanguard and New Care Models (where applicable) to ensure good outcomes and supporting spread. Leadership of the Better Care Fund (BCF) will continue to be at local CCG / LA level but the A&E Delivery Boards will have an important role in helping to implement action plans, particularly in the case of Better Care Fund (BCF) Delayed Transfer of care (DTOC) plans where they could help align the discharge elements of A&E plans and DTOC plans. 300916 A&E Local Delivery Board Page 3 of 5 Sue Watkinson, Chief Operating Officer 21092016 REP/BOD/SW3009/01
3. Leadership and Governance 3.1 A review of current arrangements for System Resilience Groups (SRGs) has identified the need for local leadership structures to focus specifically on A&E and to be attended at the Executive level by member organisations. Therefore, SRGs should be transformed into Local A&E Delivery Boards. 3.2 Below is a summary of what we are asking local systems to do. Scope 3.3 The focus of Local A&E Delivery Boards is to be entirely on Urgent and Emergency Care. Initially this will all be about recovery of the 4 hour target but A&E Delivery Boards should also be working with STP groupings on the longer term delivery of the Urgent and Emergency Care review. Geography 3.4 Localities will be asked to review their geographies. Ideally they should be based around local emergency care systems but with an eye to the future. So if two neighbouring A&E departments already have a lot of inter-dependency and may in future be working even more closely together in some form, then the geography may best extend to both. Groups should nest within existing STP boundaries and could be co-terminous with smaller STP geographies. Many will find that the existing SRG boundaries remain appropriate and we would not want to see unnecessary disruption or change for changes sake. Local Delivery Boards may span one or more local authority and should be determined by what makes most sense within the local area. Leadership and accountability 3.5 It is important that every statutory body (including local authorities) has a seat on the A&E Delivery Board and is represented at executive level with the authority to commit to decisions on behalf of their organisations. We would like each group to work with our joint NHSI/E regional team to appoint a named leader to Chair the group. The local governance arrangements need to empower the lead to represent the board externally and to ensure that decisions can be made that bind each of the organisations represented by the group. 3.6 There needs to be a mutual holding to account for systems to work effectively. This arrangement will not be dissimilar to the arrangements that STP groupings have successfully put in place. However, it is crucial that there is support and confidence in whichever person is chosen as chair. 3.7 Joint NHSI/E regional teams will form a regional delivery board and will appoint a Trust CE, a CCG AO and a Local Authority executive to the regional Board along with clinical advisors. There will be a smaller national Board supported by an expert reference group. 300916 A&E Local Delivery Board Page 4 of 5 Sue Watkinson, Chief Operating Officer 21092016 REP/BOD/SW3009/01
4. Baseline Action Plan 4.1 There are 5 key areas for action 1. Streaming at the front door to ambulatory and primary care This will reduce waits and improve flow through emergency departments by allowing staff in the main department to focus on patients with more complex conditions. 2. NHS 111 Increasing the number of calls transferred for clinical advice This will decrease call transfers to ambulance services and reduce A&E attendances. 3. Ambulances DoD and code review pilots; Health Education England (HEE) increasing workforce This will help the system move towards the best model to enhance patient outcomes by ensuring all those who contact the ambulance service receive an appropriate and timely clinician and transport response. The aim is for a decrease in conveyance and an increase in hear and treat and see and treat to divert patients away from the ED. 4. Improved flow must do s that each Trust should implement to enhance patient flow This will reduce inpatient bed occupancy, reduce length of stay, and implementation of the SAFER bundle will facilitate clinicians working collaboratively in the best interests of patients. (SAFER bundle is a systematic process of supporting patient flow whilst in hospital through clearly defined goals in relation to discharge assessments) 5. Discharge mandating Discharge to Assess and trusted assessor type models All systems moving to a Discharge to Assess model will greatly reduce delays in discharging and points to home as the first port of call if clinically appropriate. This will require close working with local authorities on social care to ensure successful implementation for the whole health and care system. 4.2 Appendix 1 contains the Baseline Action Plan which was submitted to NHS Improvement and NHS England along with the Terms of Reference for the A&E Local Delivery Board. The baseline action plan assessment has been ratified and agreed at the A&E Local Delivery Board as an accurate reflection of where the local health and social care community is currently in relation to the 5 key areas. 5. Next steps 5.1 The 2 sub-groups which feed in to the A&E Local Delivery Board are due to meet prior to the next meeting to work through and deliver the 5 key actions outlined in the baseline action plan. 300916 A&E Local Delivery Board Page 5 of 5 Sue Watkinson, Chief Operating Officer 21092016 REP/BOD/SW3009/01
Baseline Survey (September 2016) Trust: Ambulance Trust: NHS 111 Provider: James Paget University Hospital NHS Foundation Trust EEAS Great Yarmouth And Waveney NHS 111 (IC24) Great Yarmouth & Waveney Local A&E Board B RAG Description Scheme already in place/alternative in place Actions in place and on track for initiative to be implemented within rapid implementation guidance timeframes In plans, but risks associated with delivery No evidence of existing implementation or in system plans Initiative 1. Streaming at A&E 1.1 1.2 1.3 1.4 1.6 Statement of good practice B RAG Commentary All major specialties have a consultant immediately available on the telephone Fully compliant, processes and systems embedded in practice to provide advice & streaming for ED & primary care There is a primary care stream available ( if activity levels justify it ) with the Streaming pathways currently being piloted in collaboration with capacity to meet the true patient demand external partners. Streaming from A&E to primary care out of hours on Saturday, Sundays and bank holidays from 1 October 2016. Patients presenting with mental health illness are assessed, managed, discharged or admitted within the ED standard There is an ambulatory emergency care service available for 12 hours per day, 7 days per week which manages at least 25% of the emergency take There is an acute frailty service available 12 hours per day, 7 days per week which treats all eligible patients Agreed clinical pathways with external providers (MH services and ambulance). Referral and onward management protocols agreed. Plans for 24/7 resilence, still being progressed Pathways fully implemented and embedded in practice Strategy document approved and implementation commenced for acute frailty services Page: 1 of 5
Baseline Survey (September 2016) B RAG Initiative 2. NHS 111 calls transferred to clinicians 1.8 2.0 Description Scheme already in place/alternative in place Actions in place and on track for initiative to be implemented within rapid implementation guidance timeframes In plans, but risks associated with delivery No evidence of existing implementation or in system plans Statement of good practice B RAG Commentary Community and intermediate care services respond to requests for patient support within 2 hours Given there is a requirement to increase from 22% to an national interim threshold of 30% (or higher) of calls transferred to a clinical advisor by 31st March 2017, the A&E Delivery Board has plans in place to meet this requirement Agreed processes for indentification and referral of patients for community care services. Are part of Trust admission avoidance strategy utilising out of hospital teams. Response within 2hrs as per agreed standards. Provision/capacity of external support services inadequate to consistantly prevent avoidable admissions for social reasons. Plans for the commissioning of a Clinical Advice Hub continues. Presentation by IC24 to the Clinical Executive Committee undertaken 1st September. The Delivery Board has yet to meet and discuss new national standard. 2.1 Clinical expertise availability is planned according to demand Already put in place by 111 Provider The A&E Delivery Board has a lead starting to integrate the NHS 111 service and local Out of Hospital Provision, particularly OOH The Delivery Board has yet to meet. However the CCG has a clinical and management lead for NHS111. 111 and Out of Hours services within GYW are delivered by the same provider and already integrated. 2.6 2.7 2.8 The A&E DoS service type is ranked as low as possible, apart from other A&Etype services and services not commissioned within the CCG There are alternative services which can accept NHS Pathways outcomes for conditions that can be managed oustide A&E E.g. limb injuries, bites, stings, plaster cast problems, suspected DVT, falls The A&E Delivery Board knows demographics of the area, including if there is a greater demand for OOH services are generated from the elderly Integrated 111 and OOHs Provider aware of these demographics and information can be shared with A&E Delivery Board. Page: 2 of 5
Baseline Survey (September 2016) B RAG Description Scheme already in place/alternative in place Actions in place and on track for initiative to be implemented within rapid implementation guidance timeframes In plans, but risks associated with delivery No evidence of existing implementation or in system plans Initiative 3. Ambulance Response Programme (DoD and coding pilots) 3.1 & 3.2 3.2 3.2 & 3.4 3.4 3.4 & 3.5 Statement of good practice B RAG Commentary There is an ambulance trust executive lead on the A&E Delivery Board able to deliver the required service changes There are working definitions of Hear and Treat and See and Treat agreed across the local health economy and a baseline workforce profile to deliver an increase in these dispositions There are alternative services which can accept ambulance dispositions or referrals and these mapped across localities The A&E Delivery Board has established local mechanisms for increasing clinical input into green ambulance dispositions particularly at times of peak demand The A&E Delivery Board has agreed workforce and service plans in place to deliver an increase in Hear and Treat and See and Treat Yes, this is Teresa Church, Senior Locality Manager for Waveney. Yes, this is on a regional basis, managered by the 3 control rooms across the region. Recruitment is in progress to increase the number of clinicians able to undertake this function. Yes, there is room for improvement but pathways including falls, mental health admission, abdominal aortic aneurysm are set up locally. There are pathways in place for patients requiring PPCI and stroke intervention. Not currently. Not currently, although this is a regionally based service and in progress. Page: 3 of 5
Baseline Survey (September 2016) B RAG Description Scheme already in place/alternative in place Actions in place and on track for initiative to be implemented within rapid implementation guidance timeframes In plans, but risks associated with delivery No evidence of existing implementation or in system plans Initiative 4. Improved Patient Flow 4.1 4.1 4.2 4.3 4.4 Statement of good practice B RAG Commentary SAFER patient flow bundle implemented on assessment and medical wards as a bare minimum, to improve patient flow What percentage of the base wards on each acute site has SAFER in place? The use of the red and green day approach has been considered A baseline assessment of the effective use of EDDs and Clinical Criteria for Discharge has been carried out Ward round checklists are in use in all wards in the acute hospital/s Partial implementation through local alternative approaches incorporating methodology of "Plan for Every Patient" bed management system, Trust wide. Expansion of current implementation plans being completed. Alternative approaches are in place on all Trust wards but not robustly implemented in all areas. Plans being drafted for ensuring full compliance in all areas. Fully imbedded alternative approach utilising "Visual Hosital" patient status system. Baseline assessment completed and recommendations given. Implementation of strategy agreed. Processes for asigning EDD's and delivery of criteria led discharges in progress. Development of wardround checklists based around "SHOP" (sick, home, other patients) model for structuring ward rounds currently being undertaken. "SHOP" model pilots in place on two wards. Clincally Approved Plan's (CAP's) for all patients in place from admission. Page: 4 of 5
Baseline Survey (September 2016) B RAG Description Scheme already in place/alternative in place Actions in place and on track for initiative to be implemented within rapid implementation guidance timeframes In plans, but risks associated with delivery No evidence of existing implementation or in system plans Initiative 5. Improved Discharge 5.1 5.2 5.4 5.3 5.6 5.6 5.6 Statement of good practice B RAG Commentary A home first: discharge to assess pathway is in operation across all appropriate hospital wards Trusted assessor arrangements are in place with social care and independent care sector providers At least 90% of continuing healthcare screenings and assessments are conducted outside of acute settings A standard operating procedure for supporting patients choice at discharge is in use, which reflects the new national guidance Systems are in place to review the reasons for any inpatient stay that exceeds six days There is a responsible director in the trust who will monitor the DToC situation daily and report regularly to the board on this specific issue Related to the above, there is a named senior individual in every CCG and SSD who will be the single point of contact for the nominated trust exec. Discharge to Assess model in place for patients with dementia Trusted Asssessor model's not currently agreed. Discussions onging with external providers and CCG for potential of developing said model's within locality. Currently following CCG pathways that require assessments to occur as inpatients rather than within community setting. Exceptions being "Discharge to Assess" beds in local residential homes for patients with dementia. Direction of Choice ' has been embedded within the Complex Discharge Policy. Systems are in place utilising "Plan for Every Patient" (at ward level) and "Plan for Every Delay" (Complex Discharge team) methodologies. Next step: to determine assurance that processes are universally embedded at ward level and actions occurring to ensure resilience. Yes, the Chief Operating Officer Named individuals within CCG. A&E Delivery Board will request senior named lead from SSD. Page: 5 of 5