20.1. The Committee considered a report on the plans across East Sussex to deal with seasonal demand surges, extreme weather and other issues associated with the winter months. The Committee then asked the witnesses present a number of questions.
20.2. The Committee asked how much additional funding had been made available for the winter period and whether it was designated for specific areas of spend, for example, improving Delayed Transfer of Care (DTOC) rates
20.3. Mark Stainton explained that local authorities and the NHS both receive separate allocations of winter funding from the Department of Health in recognition that there is a need to increase resources in both social care and health to maintain patient flow. Jessica Britton said that the Local Accident & Emergency Delivery Board (LAEDB) agrees jointly how the funding is allocated. She said she would confirm to the Committee the exact allocation the Clinical Commissioning Groups (CCGs) in East Sussex received for the winter period via email.
20.4. Mark Stainton confirmed that East Sussex County Council (ESCC) had received approximately £2.3m of winter funding to be spent on reducing DTOC. He said that DTOC had now been consistently low in East Sussex for a long period of time, so the money was being directed towards the cohort of patients who are not yet DTOC patients but who, if nothing is done, could become classified as such. These are the patients who are medically optimised to be moved through the Discharge to Assess pathways, so the winter money was being spent on increasing the capacity of the Discharge to Assess pathways via spot purchasing nursing home beds and increasing homecare capacity.
20.5. Joe Chadwick-Bell said that the contract agreement between East Sussex Healthcare NHS Trust (ESHT) and the CCGs included dedicated winter funding of approximately £4-5m. This money has been allocated by the trust to a number of schemes, such as opening additional acute and community beds; recruiting additional therapy staff to assist with the Discharge to Assess pathway; and extending the opening hours of pharmacies on the acute hospital sites to seven days.
20.6. The Committee asked what additional capacity will be available for the Discharge to Assess pathways
20.7. Mark Stainton explained that ESCC is purchasing 10 additional nursing home beds from the independent sector for the duration of the winter period. This will increase the capacity of the Discharge to Assess pathway for people with a range of more complex needs who can be discharged from a hospital bed but need to be assessed in an intermediate bed before being discharged back home or to residential care. He said some of the beds were already opened and the remainder would be opened on 24th December alongside ESHT’s additional acute and community beds.
20.8. Mark Stainton added that for the Home First Discharge to Assess pathway – discharging people directly to their own homes for assessment – the winter money was being spent on broadening the eligibility criteria for patients to receive an assessment at home, allowing more patients to be seen in that way.
20.9. Funding is also being used to enable assessments to be carried out seven-days per week at all acute sites East Sussex patients may have been admitted to, including the hospital sites run by Brighton & Sussex University Hospitals NHS Trust (BSUH) and Maidstone and Tunbridge Wells NHS Trust (MTW).
20.10. The Committee asked whether all additional capacity would become available by opening additional beds rather than converting surgical beds to medical beds
20.11. Joe Chadwick-Bell confirmed that the winter plan involved opening all available acute beds on both hospital sites during the winter, as both hospital sites have a number of beds that are closed during most of the rest of the year. At Eastbourne District General Hospital (EDGH), for example, this included opening a 10-bed ward and increasing the capacity of a 14-bed ward to 28 beds. The community-based beds opened by ESHT comprise additional beds at Bexhill and Rye Hospitals closed during the rest of the year.
20.12. The Committee asked whether there are more falls during winter and whether this affected the number of cancelled elective surgeries
20.13. Joe Chadwick-Bell said incidents of cancellation of elective surgery due to an influx of trauma patients are rare, happening only 2-3 times per year, and would tend to take up consultant operating time rather than beds. Trauma patients would only be taken to the Conquest Hospital in Hastings and not the EDGH – and major trauma cases would go to Royal Sussex County Hospital (RSCH) in Brighton – so increased falls would not affect elective surgery at EDGH. Trauma patients at Conquest are also likely to be patients with orthopaedic trauma, such as fractured hips, rather than internal organ trauma, so elective general surgery would not be affected. Joe Chadwick-Bell added that there does not tend to be many additional falls during winter as people tend to stay inside due to the weather; Easter was the time of year for increased numbers of accidents as it coincides with the improved weather.
20.14. The Committee asked about what happens to planned surgical admissions during the winter period
20.15. Joe Chadwick-Bell explained that there had effectively been a zero-tolerance approach to cancelling elective surgery in place at ESHT for the past three years. This approach is based on the view that patients on the elective list are as important as emergency patients, so elective procedures should not be cancelled to make way for emergencies unless there are very exceptional circumstances.
20.16. All proposed cancellations of elective surgery must be approved by Joe Chadwick-Bell herself, as Chief Operating Officer, with the only exceptions allowed being when either an elective patient would be taking the final Intensive Care Unit (ICU) bed; or where there was a large influx of trauma patients who would need to take precedence in the operating theatres, meaning elective patients would end up waiting unnecessarily in hospital beds for their surgery. Both events happen only two-three times per year and affect only a few patients.
20.17. The Committee asked whether there are sufficient staff to cover the additional beds opening at ESHT during the winter period, and whether agency staff would be required.
20.18. Joe Chadwick-Bell explained that the trust is confident that the additional beds, which will open from 24 December, can be staffed. The trust helps to ensure as many staff are available as possible during the winter period by ensuring leave is spread out throughout the year, staff rotas are finalised eight weeks in advance of the winter period, and staffing levels are monitored on a weekly basis.
20.19. Joe Chadwick-Bell confirmed that the trust will require agency and bank staff to staff the additional wards opened during winter, however, they are also used during day-to-day running of the trust and are used by all NHS trusts in England. The winter beds are staffed by substantive nurses and clinicians in the first instance, with agency and bank staff used where there is not sufficient cover available. Additional wards open during winter are also always led by a substantive member of staff and at least one of them will be on duty in each ward during every shift.
20.20. The Committee asked whether ESCC has sufficient staff in place over the winter period
20.21. Mark Stainton said that staffing remains a challenge, but early planning and dialogue helps to ensure appropriate staffing support can be put in place. Leave arrangements for ESCC employees, such as social workers and care managers, are spread appropriately across the year so that staffing levels over Christmas will not be significantly different to the rest of the year. The Department of Health’s early announcement of the winter pressures money to fund the additional independent sector capacity has allowed time for these organisations to put leave arrangements in place and employ additional staff for a fixed period of time on temporary contracts to meet that anticipated increase in demand.
20.22. The Committee asked about what the key risks were and what mitigating actions were in place
20.23. Joe Chadwick-Bell said that ESHT’s biggest risk is whether it has sufficient beds, but she was confident that the trust had everything in place to mitigate against this risk. Demand for beds is expected to peak during January.
20.24. The trust carries out frequent bed modelling to anticipate bed occupancy levels. The two variables that affect the bed occupancy levels are the number of patients coming into the hospital and the length of stay of those patients. Joe Chadwick-Bell clarified that there did not tend to be many more patients during winter, but those who do get admitted tended to stay longer. The number of patients coming into the hospital is greater than the same time last year, but this was anticipated in the bed modelling. The length of stay of patients, which is monitored at a speciality level, is largely matching what the models predicted but with a couple of variances in elderly care and general medicine.
20.25. Joe Chadwick-Bell said that the mitigations against the increased winter length of stay of patients include:
· the Integrated Discharge Team focussing on reducing the time from when a patient is medically fit to being ready to leave through the Discharge to Assess Pathway;
· the increased use of the ambulatory care unit to manage emergency care patients to prevent them needing to be admitted to a hospital bed, including the opening of a new unit at the Conquest Hospital’s Emergency Department (ED) on 20 December;
· investing £1 million into the trust’s frailty teams, resulting in additional staff being recruited ahead of Christmas;
· holding weekly meetings with the CCGs and ESCC to go through every element of the winter plan, risk assess and identify any mitigations that need to be put in place.
20.26. The Committee asked what additional demand and capacity for mental health care would be during winter across the whole of East Sussex
20.27. Joe Chadwick-Bell explained that in the area of East Sussex covered by ESHT there were examples of joint working between the ESHT and the mental health trust, Sussex Partnership NHS Foundation Trust (SPFT), that had been in place for some time that were beginning to be rolled out elsewhere, for example, a mental health crisis response team that is in attendance at the two hospitals’ EDs 24/7, and emergency lounges at both hospital sites’ mental health units that act as designated places of safety. The emergency lounges are used by patients who have been sectioned by the Police under Section 136 of the Mental Health Act and need to attend a place of safety, or patients who attend ED and are displaying mental health symptoms.
20.28. Jessica Britton offered to provide the Committee with details of how BSUH and SPFT are working together to provide services for residents in the west of the county.
20.29. The Committee asked for confirmation that ambulance response times would not be affected by increased handover times at the hospital sites during winter.
20.30. Jessica Britton said that South East Coast Ambulance NHS Foundation Trust (SECAmb) undertook detailed demand and capacity modelling as part of its winter planning. The LAEDB has confidence that the modelling is accurate and SECAmb’s plans are sufficient to meet the winter demand. Jessica Britton offered to provide more details of SECAmb’s winter plans via email.
20.31. Joe Chadwick-Bell explained that handover delays are caused by patients not being flowed from the EDs to wards elsewhere in the hospitals, causing a lack of available beds in ED and preventing handovers from occurring. She said there were some hospital handover delays at ESHT, but improvements had been made over the past two years and East Sussex is performing very well compared to other areas nationally.
20.32. Joe Chadwick-Bell said that ESHT works very well with SECAmb and is clear it is aiming to meet the national 15-minute target and an absolute maximum of 30 minutes, including ambulance wrap-up time, for the handover of patients from the care of SECAmb’s ambulance crews to the ED staff at ESHT’s two main hospital sites during winter.
20.33. Joe Chadwick-Bell detailed some of the plans in place to achieve the handover time target, including:
· putting in place in the past year a ‘full capacity protocol’ that aims to ensure all patients are moved quicker from ED onto wards and from the wards out into discharge lounges, should the ED department beds all become full;
· providing ESHT staff with access to SECAmb’s ambulance screen, enabling them to see ambulance demand increase and allow them time to plan for additional patients being brought into the EDs;
· allowing ESHT staff to monitor the handover time of all ambulance crews, allowing them to determine whether action needs to be taken to move patients through the hospital quicker; and
· inviting the National Emergency Care Intensive Support Team to visit the ED departments and talk to staff about the importance of handover times and impact on ambulance services if their crews are not released in a timely manner.
20.34. Mark Stainton explained that more alternatives were being developed in the community setting to conveying a patient to a hospital ED via ambulance, where appropriate. This is a better outcome for the patient and frees up ambulance capacity. They included the Crisis Response Team and rapid access to district nursing within 2 hours.
20.35. The Committee asked what the average length of stay was at the acute trusts was and whether it had increased over the last two years
20.36. Joe Chadwick-Bell said that length of stay has been reduced by approximately 2.5 days over the past three years across both hospital sites. This has enabled the hospitals to absorb the additional patient activity. The average national length of stay is four days and is currently 3.7 days at the Conquest Hospital and 3.9 days at Eastbourne District General Hospital (EDGH). Each individual speciality, such as stroke services, had also seen reduction of length of stay. Joe Chadwick-Bell offered to provide further details to the Committee via email.
20.37. The Committee asked whether patients are sent home early during winter.
20.38. Joe Chadwick-Bell explained that the trust aims to make sure each discharge is appropriate and safe. Readmission rates are monitored and show that, although the length of stay of patients has been falling, readmissions have not been increasing. Furthermore, a clinical review of readmissions is carried out every month and the majority of cases of readmission are for unrelated issues to that which they had been treated for and discharged previously, or planned readmissions.
20.39. The Committee asked about plans in place to support staff during the winter period when they are under extra strain
20.40. Joe Chadwick-Bell said that staff wellbeing is key to the trust’s success and is monitored throughout the year. The Trust has a number of wellbeing offers to staff experiencing stress or other signs of poor emotional wellbeing, including a mental health specialist within the occupational health team; speak-up guardians for those who may feel uneasy about escalating an issue via their line manager; stress audits by the Wellbeing Team to investigate why groups of staff may be having concerns about their workspace; and a number of ambassadors who wear badges and who individuals can talk to and be directed to an appropriate service. In addition, if a member of staff needed specialist help then they would be directed to a specialist member of staff.
20.41. The Trust also aims to maintain the general wellbeing of staff, for example, Matrons and Heads of Wards monitor staff welfare, as do senior staff during particularly busy periods such as the first three weeks after Christmas; the wellbeing teams provide staff with snacks, soups and water and enable them to have breaks and check on their welfare; and at the end of shifts there is an end of shift huddle for people to speak about any issues they have to ensure they do not go home worrying.
20.42. Joe Chadwick-Bell agreed that winter was a difficult period of time for staff, but there are no specific additional support services for staff during the period. She said she would speak to the wellbeing team about whether there should be additional support and find out whether staff thought there should be too.
20.43. Mark Stainton said that there was a staff welfare counselling service available to all ESCC staff, which is well promoted. A wellbeing team also studies trends of sickness and absence to identify hotspots early on. There are also mental health first aiders within the ESCC’s operational teams, who are members of staff with special training and who are well known by their colleagues.
20.44. The Committee asked whether staff had been flu vaccinated.
20.45. Joe Chadwick-Bell explained that 70% of staff were vaccinated last year, which was one of the best nationally. At the end of October this year the trust was at 60% and is well on track to exceed last year’s rate. Jessica Britton said there was a similar vaccination programme in place for CCG and local authority staff, as well as vulnerable patients.
20.46. The Committee asked whether there will be any additional evening or weekend GP practice appointments or pharmacy consultations made available over the winter period.
20.47. Jessica Britton confirmed that the GP improved access was now fully available across the county throughout the year. This additional capacity supports the Plan. She added that there was sufficient capacity for people to see a pharmacist when they needed to during weekdays or weekends.
20.48. The Committee asked whether there was any indication how many GPs were able to use video conferencing with patients and whether this reduced hospital admissions
20.49. Jessica Britton said that online consultation facilities with GP Practices had begun to be introduced recently in the Eastbourne and Hastings areas, including as part of the Improved Access appointments at evenings and weekends. They could be used where appropriate, in addition to telephone conversations, as an alternative to face-to-face appointments. Uptake of this service is increasing as it is being rolled out.
20.50. The Committee asked for more detail of the NHS 111 service’s learning from last year.
20.51. Jessica Britton said that it likely related to lessons on improving resilience of the 111 service over the winter period and would provide further detail to the Committee. She added that 111 was key to winter communication plans nationally and locally, which involved taking out adverts in newspapers, bus stops, GP practices and social media campaigns.
20.52. The Committee RESOLVED to:
1) note the report
2) request an email to be circulated providing the following additional information:
· Confirm allocation of winter planning funding to the CCGs
· details of how BSUH and SPFT are working together to provide services for residents in the west of the county.
· SECAmb’s winter plan
· Details of NHS 111 winter plan, including its communication plans to raise awareness of the service.
· Figures for uptake on video consultation and other alternative ways of contacting GPs
· Analysis of the length of stay at ESHT over the past three years.
3) request an email update on the outcome of the winter period.