HEALTH OVERVIEW AND SCRUTINY COMMITTEE

22 September 2022

South East Coast Ambulance NHS FT Update

Report from: Emma Williams, Executive Director of Operations

Author: Ray Savage, Strategic Partnerships Manager (SECAmb)

Executive Summary

Handover delays have become a national concern and are recognised as having a direct impact on ambulance response times.

Since updating the HOSC in March 2022, the NHS has continued to be challenged across all sectors, including NHS ambulance services. Ambulance services have continued to be reported in the media for delayed responses to patients in the community and the number of hours being lost due to delays in crews being able to hand their patients over to staff within the emergency departments.

The HOSC has asked for a broader update than that given in March 2022 on ambulance handover delays, and to include an update including neighbouring acute hospitals, i.e., Tunbridge Wells Hospital and the Royal Sussex County Hospital.

Nationally, NHS England (NHSE), in its letter dated 12 August 2022 to Integrated Care System chief executives, set out the key actions and core objectives in preparation for what is anticipated to be a difficult and challenging winter. These key actions and core objectives will require a system response and detailed actions and plans will be captured through the NHSE Board Assurance Framework.

Each acute trust has its individual action plans and developments to reduce ambulance handover delays and poor patient experience as well as manage the risk associated with patient handover delays.

South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is committed to working with acute trust partners in reducing delays to ambulance handover where practical. For each hospital, SECAmb continues to ensure its local management team takes an active role in working with the hospital to reduce and improve processes for handover where practical.

It is recognised that delays to ambulance handover are multifaceted and is now perceived as a ‘system’ problem.

1. National background

1.1. Delays for ambulance crews handing over their patients at hospital emergency departments have been a focus of the media and widely reported during prime-time national news broadcasts as well as in the leading tabloids during the past 18 to 24 months, not only for the poor patient experience and the clinical risk of being held in either the back of an ambulance or queueing in a hospital corridor but also the hours being lost in ambulance availability. The latter is often reported in the context of patients having long waits in the community for an ambulance response.

1.2. These delays are acknowledged as a national problem, affecting all ambulance trusts within the United Kingdom, and are not isolated to any one geographical area.

1.3. As reported to the HOSC in March 2022, the NHS Long Term Plan sets out as one of its priorities a reduction in ambulance handover delays. The aim is to have ‘zero tolerance’ towards any handover delays greater than 60-minutes. It also has a focus on a return to the national standard of all patients being handed over within 15 minutes.

1.4. In response to these significant delays, the NHS Emergency Care Improvement Support Team (ECIST), a clinically led national team who has been providing support to those hospitals that are reporting the highest number of ‘lost hours’ due to handover delays, has sought to achieve improvements in systems and processes by sharing their breadth and depth of experience as ‘best practice’ from other hospitals that have good practices in place for receiving patients from ambulance crews and enabling an efficient handover.

1.5. ECIST brings a focus on the achievement of delivering high-quality care and has been proactive across the southeast in supporting several hospitals within the SECAmb operational area. In Sussex, they have been working with the Royal Sussex County Hospital.

1.6. However, it must be acknowledged that ambulance handover delays are not simply attributable to poor systems and processes within an emergency department but are multifactorial, including the ability of a hospital to effectively discharge patients who no longer require ‘acute’ care but can be supported back in the community.

1.7. At the recent NHS England/Improvement (NHSE/I) webinar ‘Safely Reducing Avoidable Conveyance SDEC Webinar’, Mark Gough – Head of Ambulance Improvement NHSE/I, presented that the continued increase in ‘hours lost’ for ambulance services, per day due to handover delays, had a strong correlation with ambulance response times. He highlighted the national increase from May 2019 when less than 500 hours per day were being lost to the month of May 2022 which saw greater than 3000 hours lost on a daily basis.

1.8. On 12 August 2022, NHS England set out its key and core objective priorities for each Integrated Care System (ICS) in preparation for winter 2022-23. The letter to ICS chief executives sets out 8 key actions and core objectives, of which four are 999 and 111 focused:

· 111 call abandonment

· Mean 999 call answering times

· Category 2 ambulance response times

· Average hours lost to ambulance handover delays per day

1.9. Some of the other key actions/core objectives have a focus on areas such as:

· Timely discharge

· Better support for people at home

· Reducing hospital occupancy

1.10. The letter emphasises that a system approach is required and is accompanied by the ‘Board Assurance Framework’ that sets out a significant number of measurables by which each ICS will have to give account.

1.11. As indicated in point 1.6, the response to ambulance handover delays is multifaceted including improved ‘flow’ through the hospital enabling patients occupying a bed in emergency departments who have been identified as requiring admission to be moved to an appropriate ward/assessment area expeditiously.

2. Sussex position

2.1. During the first 8 months of 2022 (January – August), the total hours lost (Sussex) due to hospital handover delays was 20,389. This compared to the same period for 2021 resulted in 15,523 total hours lost, indicating a 55% increase over 2021.

2.2. The Trust overall lost 54,534 hours for the same period.

2.3. Total hours lost (or turnaround delays) are measured from 30 minutes after a crew’s arrival at the hospital to being ready to respond to the next emergency call. The 30 minutes includes a 15-minute window for the crew to clinically and physically hand their patient over to the department staff, and then a 15 minute ‘wrap up’ to clean the ambulance, stretcher, replace linen and make the ambulance ready for the next response.

2.4. Appendix A highlights the differing delays by hospital for the period 2022 and highlights that some of the greater challenges are at the Royal Sussex County Hospital, where c10% of all handover delays were greater than 60 minutes.

2.5. All hospitals combined totalled c4.2% for this period for greater than 60 minutes. It should be noted that 42.8% of total handovers were also undertaken within 15 minutes (Appendix B).

2.6. The Sussex Urgent and Emergency Care Transformation Programme Board has as a standing agenda item ‘Ambulance Handovers’ and gives each acute trust an opportunity to update on the work/actions that are being taken to support improvements in ambulance turnaround. In addition to these updates, there is regular dialogue between each acute trust’s management and clinical team with SECAmb’s local operational managers.

2.7. The Sussex Urgent and Emergency Care Transformation Board also provides focus for the development of non-ED pathways that support patients to receive the right care in the right place and reduce acute conveyances e.g., Urgent Community Response (UCR), Same Day Emergency Care (SDEC) and Virtual Ward (VW) pathways. The Trust is working with the system to establish these as direct referral pathways to support crews, reducing pressure on conveyance and therefore potential impact on handover delays.

2.8. For 2022, the past 3 months has seen a reduction in the number of ambulance transports which by comparison has not been reflected in the ‘hours lost’ due to handover delay figures. The reduction in ambulance transport is reflective of what could be described as the ‘seasonal norms’ i.e., warmer weather during the summer months reduces the number of patients presenting with respiratory conditions etc., (even though extreme heat can increase activity). The seasonal reduction for the summer months of 2021 was not evident and can be linked to the continuing pandemic with increasing numbers of patients starting to access health services (Appendix C).

2.9. Each hospital emergency department has a ‘handover screen’ which enables hospital staff to see at a glance an inbound crew. In the ambulance the driver will activate the ‘Mobile Data Terminal’ in the cab and, as soon as the destination is selected, the hospital is notified of the pending arrival of that crew. In addition to this, the clinician with the patient will be capturing key details on their electronic Patient Clinical Record’ (via an iPad) and this is transmitted to the destination hospital so that the receiving clinical team can see specifics regarding the incoming patient and the crew assessment of the presenting complaint. This is in addition to the handover screen.

2.10. It must also be recognised that in some hospitals the physical constraints of the estate can be a ‘congesting’ factor e.g., numerous ambulances arriving simultaneously, resulting in some patients being held in a corridor or, at worst, in the ambulance.

2.11. The Trust’s local operational management teams have been working closely with their acute hospital counter parts to support crews at times of pressure and ensure patient safety considerations are prioritised; this includes assessing the impact on patients awaiting a 999-response in the community.

2.12. The Trust is also committed to working with partners, in particular Sussex Community Healthcare NHS Foundation Trust and East Sussex Healthcare NHS Trust, on the continued access to alternative pathways that provide the right support/intervention for patients, either at the point of the 999-call or following crew assessment.

2.13. Not all patients are conveyed and for July 2022, c43% of patients dialling 999 were either telephone triaged (hear and treat) or not conveyed following an ambulance crew assessment (see and treat/refer).

2.14. The Trust will continue to work with all partners in the development and access of ‘pathways’ with the key aim of getting the patient the correct support/intervention through the use of alternatives, whether it be by conveyance to an alternative to an emergency department or by referral to other services for a follow up on the patient.

2.15. East Sussex County Council’s Adult Social Care and Health Department (ASC&H) work together with NHS and wider system partners to support timely discharge from acute and community hospitals. ASC&H have well established integrated management arrangements and teams such as Health and Social Care Connect (HSCC) and the Joint Community Rehabilitation service (JCR) who have not only flexed their criteria during the pandemic to support the discharge of COVID positive patients from hospital but, continue to provide rehabilitation to adults in the community.

2.16. ASC&H also have a dedicated hospital social work team, who work closely with health colleagues, on a daily basis to support patient flow and avoid unnecessary admissions. A key part of this has been undertaking Care Act assessments within the emergency department to prevent admissions but, also working to embed the Discharge to Assess (D2A) and Home First hospital discharge pathways to support people to leave hospital and have their needs assessed in either their own homes or in care home settings.

2.17. East Sussex County Council (ESCC) is a member of the Sussex Health and Care Partnership (SHCP) which is a partnership of health and care organisations working together across Sussex. In 2022/23 the aim is to continue to strengthen this partnership through integrated approaches to planning, commissioning, delivering and transforming services across the shared priorities for health and social care.

3. Maidstone and Tunbridge Wells NHS Trust - Tunbridge Wells Hospital (Pembury)

3.1. The Trust has been working with Maidstone and Tunbridge Wells NHS Trust (MTW) colleagues on improving the process of handover at both of the Trust’s acute hospitals, Maidstone and Tunbridge Wells.

3.2. At the Tunbridge Wells site, ambulance crews arriving will follow one of two ‘Rapid Assessment Point(s)’ (RAP). This is dependent on whether the patient is displaying signs of virus infection e.g., COVID-19. Once in the appropriate part of the department, the ambulance crew will speak with the doctor in charge and undertake a clinical handover. When the patient has been accepted, they are transferred to a hospital bed and the crew pass on the ‘pin’ number to the department receptionist and leave. The receptionist will then enter the ‘pin’ number onto the handover screen, which time stamps the crew handover and stops the handover clock.

3.3. In addition to this, hospital and SECAmb operational managers monitor the inbound ambulances and any that are delayed in waiting to handover. There is good and open communication/dialogue between both trusts and the on-day operational managers when delays are building up.

3.4. When handover delays greater than 60-minutes occur, they are jointly reviewed for shared learning and to explore opportunities to improve the process.

3.5. Dependant on staffing levels in the department, a triage nurse has greeted crews on arrival and supported the streaming of the patient to either the ‘red’ or green’ zones or onto one of the specialist departments, e.g., surgical assessment.

3.6. Another factor that adds to delays in the emergency department is the current number of self-presenting patients. Currently, MTW is experiencing a 15% increase when compared with 2019 (Appendix D).

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4. University Hospitals Sussex NHS Foundation Trust - The Royal Sussex County Hospital

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4.1 The Royal Sussex County Hospital (RSCH) has been undergoing extensive development of its estate over the past years following significant investment into improving patient access and care.

4.2 Its emergency department has regularly been significantly challenged with its current capacity to meet the high numbers of patients either self-presenting or arriving by ambulance.

4.3 At the RSCH, hours lost in 2021 (January to August) were 4,922 and in 2022 for the same period the lost hours were 5,876, presenting a 19% increase. The RSCH also has one of the highest greater than 60minute handover times (Appendix E).

4.4 Systems need to be careful with directly comparing individual hospitals and the actual hours lost due to the differing factors at each hospital, including the number of ambulance transports.

4.5 The average number of ambulance transports (conveyances), as with other acute trusts, has not increased over the past 12 months but, more recently, has reduced at the RSCH (Appendix F).

4.6 The Hospital has established a robust Urgent and Emergency Care (UEC) improvement programme, with of the main focuses being on reducing ambulance waiting and handover times. The programme has now been running for four months and in this time, we have seen improvements across the University Hospitals Sussex group, with Worthing Hospital and the Princess Royal Hospital featuring in the top two sites consistently for regional handover performance on 60 minutes.

4.7 The work at RSCH to support offloading has been focused on the use of ‘fit 2 sit’ capacity and using the ‘majors’ part of the emergency department differently, but as stated above, this continues to be a challenge due to the ‘estate’ of the department.

4.8 Work at St Richards Hospital has commenced on the delivery of reverse queueing and flow into the ‘majors’ department for direct ambulance handover, which has shown early improvements on the 30- and 60-minutes ambulance handover. However, this performance remains variable.

4.9 The root cause of the flow challenges into the emergency department are linked to the inpatient flow and ultimately discharges. The Trust is seeing a record level of Medically Fit for Discharge (MFD) patients across all four of the Trust’s acute hospital sites. To tackle this, there is a programme of work underway to address the length of stay (LOS) of simple discharge patients or those on pathway ‘0’, as well as to support the LOS reduction for those patients waiting on community services to be in place or care in another facility.

4.10 The Trust and SECAmb have been working proactively together during the past 6 months have seen the relationships between the two organisations improve.

5. East Sussex Health Care NHS Trust (ESHT) - Eastbourne District General Hospital / Conquest Hospital

5.1. For the period January to August 2022, the ambulance transports (conveyances) into the Conquest Hospital were 14,933 and 13,130 for EDGH. For the same period in 2021, transports into the Conquest Hospital were 14,920 and 13,682 for EDGH. These figures highlight, that transports into ESHT, overall, have not shown an increase (Appendix G).

5.2. Ambulance handover delays greater than 60 minutes have been higher at the EDGH than at the Conquest (Appendix H).

5.3. Total hours lost due to handover delays at both sites for the period January to August 2021 were 4,417 and for the period January to August 2022 hours lost were 5,433, presenting a 23% increase.

5.4. The Conquest Hospital saw a higher percentage increase in total hours lost with a 32% increase between the comparable period in point 4.3, with the EDGH showing a 12% increase.

5.5. Some of the primary drivers for delays in ambulance handover reflect the national position, where acute hospitals are operating at high levels of bed occupancy, therefore limiting the opportunity to effectively transfer patients who require admission to an acute bed from the emergency department to a ward.

5.6. ESHT is currently operating at c95% bed occupancy with a continued high number of patients who do not meet the criteria to remain or are medically ready for discharge (MRD). Many individuals, who are either responsible for funding their own care or are eligible for local authority funded support, are waiting for ‘assisted packages of care’ or community rehabilitation beds.

5.7. In line with other hospitals, self-presenting patient numbers are high, and this combined with ambulance transports, emphasises the capacity constraints within emergency departments.

5.8. ESHT has on both sites surge and escalation areas that are often full due to the numbers of patients requiring a hospital bed for assessment.

5.9. ESHT has a number of key actions that it has/is taking to improve ambulance handover:

· 15 new nurses starting at the Conquest Hospital during September 2022 to support patient flow.

· Medical staffing gaps will also be resolved during September 2022.

· Ambulance delays are reviewed 4 times a day.

· The introduction and testing of a new internal forecasting tool to identify days when urgent care is likely to struggle to meet demand.

· The re-launch of joint learning events between SECAmb and ESHT where cases, trends and themes are presented and discussed, with a focus on developing/accessing alternative pathways.

o ESHT also independently reviews its own records to identify trends with crews, including days and times as well as conditions most likely to be met with delays to enable root cause analysis.

· Reviewing the administration support to achieve a dedicated person to have oversight of the handover screen with the aim of improving data quality.

5.10. Resolving the staffing issues in the emergency departments will mean that both the EDGH and Conquest Hospital will be able to open their respective Rapid Assessment and triage areas.

5.11. ESHT is focused on improving its patient flow through the following actions:

· Multi Agency Discharge Events (MADE) have been taking place during the year to expedite discharges.

· As the provider of both acute and community services, ESHT has been able to exploit ‘in reach’ from its community teams to support the stroke pathway.

· Additional medical and nursing workforce teams have been sought.

· All delays for discharge are escalated as well as those for mental health assessment.

· Review of all outliers and patients in escalation areas to expedite discharge

· Early ward rounds to identify discharges and expedite discharge dependant diagnostics.

· Liaise with external partners to expedite placements.

· Senior management attendance at ward rounds to support challenges and expedite delays in discharging.

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