The Committee received a joint presentation
from Laura Gibson of George Eliot Hospital (GEH), Helen Lancaster
of the Coventry and Warwickshire Integrated Care Board
(C&WICB), together with County Council officers, Zoe Mayhew and
Denise Cross. This presentation on ‘Ambulance Turnaround,
Winter Plan & Discharge Pathways’ included slides on:
- George Eliot Hospital NHS Trust. A
slide showing data for this hospital trust including bed capacity,
emergency department attendances, average data for admissions,
discharges and ambulance visits.
- Ambulance Handover, showing the
weekly numbers of transfers taking over one hour for the period
March to August 2022.
- National Pathway Definitions. There
are four pathways (0,1,2,3). This slide showed the proportion of
people in each pathway and a definition of the respective discharge
arrangements.
- Hospital Social Care and Reablement.
This provided data for such things as referrals, increasing trends,
reablement visits and the provision of equipment in the home.
- Social Care Domiciliary Care. This
reported the data on referrals and increasing demands, domiciliary
care pathways and typical waiting times for packages of care to
begin.
- Length of stay - graphs showing
hospital stays of over 21 days and the numbers of patients who did
not meet criteria to reside in hospital.
- Pathway issues which identified
contributors to delays.
- Joint actions, a slide which
outlined some of the current initiatives being implemented.
- What does the future look like? A
series of key outcomes to provide a process that was
person-centred, strengths-based, and driven by choice, dignity and
respect.
- Winter plan 2022/23.
- Core objectives and key actions for operational
resilience
- New national board assurance
framework key metrics.
- System wide planning aims. These
sought to ensure there were no delays throughout the care pathway,
maintaining services, ensuring sufficient bed capacity, admission
prevention through use of alternate treatment services, timely
discharge, partnership working and workforce wellbeing.
Debate took place on the following areas:
- Officers were thanked by several
members for the presentation.
- The objectives were welcomed, with
questions on the expected timeline for their completion and
progress made to date. Some work was already underway, but a
detailed timeline could not be provided. The challenges of the
forthcoming winter period were not yet known, and some objectives
may need to be reviewed, but the experience of partnership working
over the last two years and moving care away from acute settings
were key aspects raised.
- The system approach to addressing
delayed discharges was welcomed. A point was made that all NHS
services should have a focus on discharge, with specific reference
to delays due medication provision.
- It was noted that private ambulance
services were used, together with Warwickshire Fire and Rescue
Service ‘hospital to home’ scheme.
- Discussion about the collection of
medical equipment that was no longer required, so that it could be
reused by other people. Officers explained that the recycling of
some smaller items was not feasible either for cost or infection
control reasons. There were periodic campaigns where people could
return equipment to designated sites and the service provider,
Millbrook Healthcare could be contacted to collect equipment
too.
- More information was provided on
‘virtual’ wards. These utilised technology, remote
monitoring and community-based medical services to support people
to be at home rather than in an acute hospital. This solution
wasn’t suitable for all patients, especially not those who
may need emergency or critical care. Where consultants deemed the
patient may benefit, it provided for regular calls and periodic
visits. It had been very successful especially in the south of the
County, with examples being provided of the types of conditions
where patients were able to use this scheme. The scheme was not
reliant on access to wi-fi, instead using a mobile application and
there was a telephone helpline too.
- The presentation had covered a wide
range of services and was patient centred.
- There were many organisations
monitoring the delivery of health services. It was questioned which
one had overall responsibility for joining up services. Reference
was made to the transition to the new Integrated Care System (ICS)
which ‘held the ring’ and its Board included
representatives of all partners.
- A member spoke about the challenges
for GP services and the additional pressures caused by early
hospital discharge. Discussion took place on the involvement of
primary care networks (PCNs) in the new system. The PCNs had a
voice as a collaborative and were engaged.
- The use of technology was explored,
it being questioned if this should be considered by the committee,
for example around the training required. Changes to service
delivery were essential and the use of technology was seen as a key
opportunity in managing some pathways more effectively. The
technology being used by patients was simple and easy to
understand, which it needed to be for those who were unwell.
- Pete Sidgwick responded to the
earlier point about who was in control. It was actually about all
partners working together to make a positive contribution, so that
people were only treated in hospital when they needed such care.
There were honest conversations where things were not working
effectively and also about how best to collaborate. Health and care
services would never achieve everything and constantly had to
adjust to improve and respond to new challenges.
- Reference was made to the closure of
hospitals/wards such as Bramcote Hospital, which provided
rehabilitation services. Such services were now delivered in
community settings requiring therapists to travel. An example was
provided of the positive impact for an individual of such care,
meaning they were still able to live independently afterwards.
- Zoe Mayhew confirmed that the
approach now was ‘home first’ with a number of pathways
designed to provide support at the person’s home. Examples
were reablement, discharge to assess and there were some interim
step-down beds in residential care settings.
- Discussion about the contributors to
discharge delays. Denise Cross explained how the discharge process
now worked. There were daily meetings between practitioners, and
with the family at an early stage to agree the care plan for the
individual. There were better outcomes from getting people home
earlier. For those needing more intensive therapy/support, there
was bedded provision in care settings, with an ethos of helping
people to become more self-sufficient. This approach was working
well, with 72% of those having reablement support not needing
longer-term care afterwards.
- Chis Bain of HWW commented that
discharge was a complex area, and he was pleased to see the complex
and system led response. In terms of the earlier point about who
had overall control, it should be the patient. The NHS was good at
identifying delays, but less so the impact of them for patients,
their families/carers and those with protected characteristics.
This should be examined. A further point was the issue of delays
and links to hospital readmissions. Delays had overtaken poor
communication as the key concern amongst patients. A range of
responses was needed to reduce A&E attendance and admission.
There were roles for other parts of the system, with pharmacy being
referenced particularly. HWW was working on a piece about the
assumptions made by commissioners and providers about the actions
of others. Previously it had been
questioned if the PCNs were engaged in the ICS. From the HWW
perspective, the question was are patients engaged with the PCNs?
This was important to ensure patient views reached all parts of the
ICS.
- Several points were made about the
average data for GEH admissions and discharges, which showed a
higher number for hospital admissions.
Linked to this was the timescales for the arrangement of care
packages. It was questioned how hospital bed capacity was
managed.
- Laura Gibson confirmed that bed
capacity changed daily and was monitored closely. There was some
surge capacity, use of assessment areas and admission avoidance
where clinically appropriate. However, problems did occur due to
hospital flow. Winter planning work included how to reduce the
shortfall of available beds, as it was known that the winter period
posed additional challenges. Helen Lancaster gave clarity on
typical lengths of stay in hospital (8-9 days) and the proportion
who were in hospital for more than 21 days, which was a focus,
particularly for patients who could be cared for in another
setting. It was acknowledged that there was disparity in the
typical admission and discharge data, which was why the surge
capacity was needed.
- Discussion about the core objective
on increasing resilience in the NHS 111 and 999 services, through
increasing numbers of call handlers. Reference was also made to use
of community-based triage services including clinical
practitioners.
- It would be useful to receive data
which shows the correlation between delays in admission or
treatment commencing and the length of the resultant hospital
stay.
- Further reference to the disparity
between average admission and discharge data. A councillor asked
how staff used this data, referring to statistical analysis tools
to enable advance planning, rather than a reliance on responsive
surge activity.
- Helen Lancaster confirmed that all
organisations did use demand/ capacity tools to model service
needs. This included assumptions around such things as growth,
winter planning, flu and Covid rates. It extended beyond emergency
to elective care services. There had been an impact from the
pandemic, but also in responding to delays and demand levels that
were proving difficult for organisations to manage. All health and
social care providers had workforce challenges around staff
recruitment and retention. The councillor viewed that there was a
need for use of real time data rather than historic data and to
monitor trends, to give more accuracy and the time needed to
react.
- The Portfolio Holder, Councillor
Bell was concerned about bed capacity and knew there was resistance
to increasing bed numbers. She assumed that targets on discharge
were being met and patients were being discharged at the correct
time. On admission, she knew that GEH only admitted patients when
this was absolutely essential. She spoke about surge capacity and
the locations where patients were placed. There were increasing
numbers of patients with more complex needs and she sought clarity
and honesty about the actual bed numbers required and asked whether
this was being modelled.
- Laura Gibson confirmed this was
being undertaken to look at additional areas which could be used.
Areas designated for surge capacity were risk assessed and were old
wards that were suitable for patients in the short term. GEH had
invested in new wards for elective procedures and transferred the
previous wards to be used for non-elective care. There had been an
increase in delays, which meant that lengths of stay in hospital
had increased. There were endeavours to reduce these delays, which
in turn should mean there was not a need for additional beds. There
was a need for short term capacity but also for a longer-term
solution that patients were treated in the correct setting. She
spoke more on the daily monitoring to determine whether the surge
capacity was required. Councillor Bell asked for more information
to show that there was sufficient bed capacity at GEH with
effective discharge and she drew comparison to the higher bed
provision in the south of Warwickshire, despite it having a smaller
population.
- The Chair referred to a previous
planning application to provide additional facilities for elderly
person care on the GEH site. An update was sought about this
scheme, which would be provided after the meeting. She then
referred to the need for bedded step-down care provision, quoting
from the data in the presentation, which showed that hospital bed
capacity was being taken by people awaiting a package of care, who
could be located more appropriately. Becky Hale spoke of work to
assess short-term bed capacity requirements across the County for
rehabilitation and assessment of care needs. Reference was also
made to the assessment of capacity requirements for the winter
period. This was separate to the review of community hospital
provision in the south of Warwickshire, which had been considered
by the committee previously.
- The Chair commented that there
should be a patient centred approach. She asked a further question
about reablement. Denise Cross gave an outline of the scheme,
it’s referral process, the assessment of need, the choice and
risk-based approach to returning home or going into short-term
care, in order to plan the customer’s longer-term support
needs. A lot of compliments were received about this service.
- Further discussion took place about
the use of predictive analytics and artificial intelligence. The
Chair viewed that the public sector could be slow to engage with
industry experts to make use of such technology and she asked if
services in Warwickshire did use such experts. She offered to
provide advice, given her business experience. Laura Gibson would
research and respond on this point. Another area discussed was the
use of wearable technology, which could for example monitor falls.
Such technology was used with examples being in maternity, diabetes
and blood pressure services, also in the community and care home
settings. There was a bespoke NHS IT team which engaged with
industry to seek solutions and analytics work was undertaken.
- The NHS was a huge organisation, and
it was questioned if it was sufficiently agile. Reference was made
to the stroke service reconfiguration which had a very good outcome
but took a long time to complete. Officers confirmed the
arrangements being discussed at this meeting needed to be in place
for the winter period. Whilst winter plans were reviewed annually,
there had been a greater focus this year because of the known
challenges. Each organisation would have its own plan with
timescales and there was an overarching plan.
- Assistive technology for dementia
patients was discussed. In the north of Warwickshire, the My Sense
solution was provided via the community home first team. This was
well received and especially helpful for informal carers. An
outline was given of future plans to enhance this service, working
with a range of suppliers. Other aspects raised were the initial
assessments and the benefits of discussing assistive technology
once the patient had returned home. Discharge arrangements could be
complex and there was a need to support patients at each stage. In
some cases, this involved a number of agencies including housing.
The focus was to help people leave the acute hospital and then to
provide tailored support in the community.
Examples were given
of the challenges faced and there was a need for a two-way dialogue
with families needing support. The Chair suggested these points be
discussed further after the meeting.
- A member acknowledged the amount of
good work taking place. There had been some concerns raised at this
meeting which needed to be included in a conversation about the ICS
around the strategic joining-up of services. The work programme did
include for an update on the ICS at the November Committee.
The Chair closed this item, thanking the
speakers and acknowledging the significant amount of work being
undertaken.
Resolved
That the Committee notes the presentation on
Ambulance turnaround, winter plan and discharge pathways.