Agenda item

19.1.      The Committee considered a report providing an update on planning across East Sussex to deal with seasonal surges in demand, extreme weather and other issues associated with the winter months.

19.2.      Ashley Scarff, Director of Commissioning Operations – High Weald Lewes Havens CCG; Jessica Britton, Managing Director of East Sussex Better Together CCGs; Mark Angus, Winter Director, Sussex and Surrey CCGs; Andy Cunningham, Head of Care Management (Hospitals), (in attendance from the Adult Social Care Department); Dr Adrian Bull, Chief Executive, East Sussex Healthcare NHS Trust (ESHT) and Joe Chadwick-Bell, Chief Operating Officer, ESHT, provided answers to a number of questions from HOSC.

Maintaining 85% bed capacity over the winter period

19.3.      Mark Angus explained that 85% is recognised nationally as the ideal occupancy rate for beds in an acute hospital. However, it is also recognised that occupancy rates will usually be higher than 85% over winter months due to the fact that, whilst the number of admissions are not necessarily much higher, patients who are admitted tend to be sicker and therefore are admitted for longer periods. He said that the winter resilience plans aim to manage this period of generally higher occupancy safely and effectively within hospitals, whilst also ensuring that the whole healthcare system can respond in a co-ordinated way to individual surges in demand.

Avoiding unnecessary readmissions due to early discharge of patients

19.4.      Mark Angus said that the healthcare system in East Sussex performs relatively well in relation to readmission rates. This is due to a number of checks and balances that are made during the discharge process that ensure patients are only discharged when ready to leave hospital. He confirmed that this process does not change during the winter period. Joe Chadwick-Bell added that figures showed that since introducing same-day ambulatory care at the A&E Departments readmissions rates had not risen. This demonstrated that whilst patients were receiving a shorter period of care than they would if admitted as an emergency inpatient they were not experiencing worse outcomes.

Personal Management Plans for patients with chronic conditions

19.5.      Joe Chadwick-Bell explained that patients with a long term condition generally have a shared care plan agreed between their consultant and GP that clinicians will have access to. The East Sussex Better Together (ESBT) Alliance has amended the care pathways for five long term conditions so that should a patient with one of these conditions be in crisis they are referred to the ESBT Crisis Response Team and managed in the community, where possible.

Readiness of NHS 111 over winter and ability to book appointments

19.6.      Mark Angus said that there is a detailed plan for NHS 111 over the winter based on lessons learned from last year, including ensuring that there is sufficient workforce in place to meet expected demand. Recruitment to 111 has been encouraged by introduction of a national career framework, which clearly defines the career path opportunities for both non-clinical and clinical call-handlers to improve the attractiveness of the role of call-handler and clinical assessors.

19.7.      Mark Angus confirmed that the CCGs were working with 111, the primary care extended access providers, the out of hours GP service (provided by IC24), and the providers of the three Urgent Treatment Centres (UTCs) running in Sussex (including Lewes Victoria Hospital) to put in place the ability to book urgent care appointments via 111 by Christmas. He said that appointments may not be directly bookable as the necessary ICT systems are not yet available, so this would be an interim telephone-based system.

Flu vaccination rates for staff and vulnerable groups

19.8.      Mark Angus confirmed that there was no deadline by which hospital trusts must vaccinate their staff but all were making good progress. Mr Angus said that vaccination rate as at the end of October for Brighton & Sussex University Hospital NHS Trust (BSUH) was 44%; for Maidstone and Tunbridge Wells NHS Trust (MTW) was 45%; and for East Sussex Healthcare NHS Trust (ESHT) was 63%, which was within the top 10 in the country. Dr Adrian Bull confirmed that the vaccination rate at ESHT is now 70%. Mark Angus added that uptake amongst over 65 year olds as of the end of October was around 50%, which is the result of an ongoing programme to vaccinate more vulnerable groups.

Delays in GP practices receiving flu vaccinations

19.9.      Mark Angus confirmed that there is a sufficient supply of vaccines but there were some teething problems with the new ordering system used by GP practices. He said that lessons will be learned for next year, for example, ensuring GP practices are aware of how the ordering system works and encouraging GP practices to share stock. Ashley Scarff added that some GP practices had arranged vaccination clinics correctly at the beginning of October but, regrettably, the vaccine stock did not arrive on time, resulting in the clinics being cancelled at short notice. He confirmed this issue has now been addressed.

Communications plans for urgent care

19.10.   Mark Angus said that the overarching message being communicated is ‘help us help you’ and is primarily aimed at making sure people know about available urgent care services, such as UTCs and extended access GP services. He said that the communications plan would continue to be refined around the principle of promoting these alternatives to A&E, which will become easier as awareness of these services grows in the medium to long term. The success of this communication plan could be measured if an increase in usage of these services is observed at the same time as a drop in A&E attendance. He said that the national campaign to raise awareness of NHS 111 over the autumn led to a 7% increase in usage of the service, which is an example of a successful campaign.

19.11.   He clarified it was not about ‘telling people off’ for using A&E but understanding that, once the elements of urgent care in place, calling 111 would result in receiving a responsive service that can facilitate the patient seeing someone in a timely fashion and that the patient’s care needs will be met either over the phone, or  where possible by referral to appropriate services, rather than attend A&E.

Communications plans for adult social care

19.12.   Andy Cunningham said that East Sussex County Council:

·         provides winter communications to domiciliary care organisations working in the county, in particular around encouraging flu uptake amongst their workforce and elderly vulnerable clients;

·         asks that staff working for domiciliary care organisations and community nurses report any instances where patients either do not have working heating or are not using it; and

·         provide some extra funding to domiciliary care companies to enable their staff to spend more time with elderly patients immediately following their discharge from hospital, for example, ensuring they have put the heating on, made a meal for them and ensured they are settled down safely.

Reasons for high A&E visitation for women aged 19-29

19.13.   Mark Angus explained that initial data analysis of A&E visits indicated women aged 19-29 were a group with higher attendance levels than expected. This was an initial study and further work will be done in the future to understand the reasons for it.

System resilience over the winter

19.14.   Mark Angus explained that the CCGs are working to ensure that there is continuous out of hours cover over Christmas and the New Year. Ashley Scarff added that the CCG is developing system resilience over the winter period by ensuring rotas are in place allowing for sickness cover so that if an out of hours doctor is not available, for example, someone else within the healthcare system can fill their position.

19.15.   Jessica Britton said that the CCGs are as assured as they can be going into the winter period that the healthcare system has sufficient resilience to support local people over the coming months. She added that there has been some success in recruiting more GPs, particularly in the Hastings & Rother area, which has added to the resilience of the service.

Reasons for resilience of ESBT LAEDB

19.16.   Mark Angus confirmed that the winter planning last year by the Local A&E Development Board (LAEDB) for the ESBT area has been shared across the region. The plan was seen as one of the more resilient because it involved activities such as daily executive-level calls across the health and social care system, and weekly face-to-face meetings, allowing for quick learning and adaption of patient discharge plans. It also saw the development of multi-agency discharge events involving senior social care workers and senior nurses going into wards and working through the issues causing DTOC with the teams on the ground. Joe Chadwick-Bell explained that these DTOC reduction plans are carried out throughout the year but are carried out with more regularity during winter.

Delayed Transfer of Care (DTOC)

19.17.   Joe Chadwick-Bell said that DTOC are classified as being due to social care or health reasons, for example, health reasons may include patients waiting to have NHS delivered therapy and rehabilitation in place; whereas the small number of social care delays tend to be due to very complex social care patients who need individual care plans in place before discharge.

19.18.   Joe Chadwick-Bell added that the trust is also reviewing on a weekly basis the top 15 longest staying patients to see whether anything can be done to discharge them sooner. As a result over the last two years the longest length of stay has reduced from around 100 days to 60-70 days, and these patients are mostly still medically unfit to be discharged.

Preparedness of ESHT for winter

19.19.   Joe Chadwick-Bell confirmed that all medical staff rotas for the winter period are filled across ESHT; nursing rotas are in the process of being filled; and all wards at Eastbourne District General Hospital (EDGH) will be opened over the winter period. The Trust is also holding weekly assurance meetings with each of the division heads to ensure robust plans are in place. Ms Chadwick-Bell explained that the trust will ensure that minimum safe staffing levels are maintained across the winter period, for example, by reducing levels of planned activity and putting incentives in place for staff to work on peak days. Nevertheless she anticipated that there are likely to be periods of challenge, particularly between Christmas and New Year.

19.20.   Dr Bull added that recruitment levels are in a better position than two years ago, for example, consultant posts across the A&E Departments are now fully staffed. He said that the overall vacancy rate is less than 10% and turnover is at 11%, both better than comparative trusts. However, recruitment and retention issues remain in some specialities and the trust is working with oversees recruitment consultants to increase recruitment levels further, which has had a positive effect over the past 6 months.

Ward rounds in care homes

19.21.   Ashley Scarff said that Enhanced Care in Care Homes and Nursing Homes is a service commissioned by HWLH CCG involving GPs proactively going into care and nursing homes to assess patients and provide support to staff. This is instead of the traditional system whereby a care home would only have reactive contact with the healthcare system when making a 999 call for an ambulance or an urgent GP visitation for a resident, often leading to a hospital admission. Initial results of the service in its effect on admissions to A&E have been very encouraging and it is being rolled out further to other care and nursing homes.

Mental Health services over winter

19.22.   Mark Angus said that there are an increasing number of patients presenting at A&E with mental health issues, which has a considerable impact on the departments. The Sussex and East Surrey Sustainability and Transformation Partnership (STP) Executive has met to consider whether the winter resilience plans in place are sufficient to manage the increase in people presenting with mental health issues over the winter period, and it was agreed that some additional work needs to be undertaken.

19.23.   Mr Angus said that last year there were some patients who required medical admission to A&E who also needed admitting to an inpatient mental health facility. However, there was insufficient capacity at the Sussex-based inpatient facilities to admit them resulting in a number of out of area placements, sometimes a significant distance away. Work has been undertaken over the past 12 months to develop ways of freeing up beds in these inpatient facilities, which are often at very high occupancy levels due to instances of Delayed Transfer of Care (DTOC). This work includes multi-disciplinary working between health and social care teams, such as regular reviews of individual DTOC by senior staff, and a fortnightly chief executives meeting about inpatient mental health beds in the local system. Dr Bull added that a number of other innovative services have been developed in support of mental health in Sussex, including the street triage teams in Eastbourne and Hastings, which is available seven days a week for adult patients.

19.24.   The Committee RESOLVED to:

1) note the report; and

2) request an update via email on the outcome of the winter planning in April 2019.