Agenda item

12.1.     The Committee considered an update on a number of issues relating to urgent care in East Sussex.

12.2.     The Committee asked whether the Clinical Assessment Service has a target for its clinical call back time 

12.3.     Simon Clarke, Head of Operations Integrated Urgent Care (IUC) at South East Coast Ambulance NHS Foundation Trust (SECAmb), said that in 46% of cases where someone calls NHS 111, they will receive a call back from the Clinical Assessment Service (CAS). This call will be from a healthcare professional from the CAS multi-disciplinary team that includes dental nurses, mental health professionals, midwives, general nurses, GPs, Advanced Nurse Practitioners, paramedic practitioners and paediatric nurses. Depending on the acuity of the patient’s symptoms, NHS Pathways will drop them in to a call back queue at the CAS and an appropriate clinician will call them back depending on their skill set. The target call-back times are 20 minutes, 1 hour, 2 hours, 6 hours, 12 hours and 24 hours. The system is generally risk averse and will often set a quicker call back than may be necessary.

12.4.     Simon Clarke explained that just under 40% of patients have been receiving their call back within the set time frame, which was the result of demand far outstripping planned activity. The Trust is mitigating this issue by prioritising call backs for patients with shorter wait times, as they are perceived as higher risk. A Patient Safety team, which is not part of the CAS, will also provide patients who are close to or beyond their waiting time with a welfare call to check whether anything has changed and if their symptoms have gotten worse. Simon Clarke added that this team will not close any of these cases but may recommend to a CAS operator that they are closed. There is also a Clinical Navigator reviewing the call queue on a 24/7 basis to see if any high acuity patients have not been called, or who may need an upgraded call time based on their symptoms.

12.5.     The Committee asked what the pathway is for a patient who calls NHS 111 and is booked into a GP appointment.

12.6.     Simon Clarke explained that patients who ring 111 are triaged by a health advisor using the national NHS Pathways system.  Following a series of questions, NHS Pathways will present the health advisor with a number of services from the Directory of Services (DOS) to refer the patient to. Simon Clarke said that 27% of all patients who call 111 are now being directly booked into an appointment, either by a health advisor or a CAS clinician, to a variety of services including GP practices, Urgent Treatment Centres (UTCs), Emergency Departments (EDs), Walk-in Centres, and GP Primary Care Hubs. GP Extended Access appointments and better access to mental health support and services will also be added to the DOS soon.  

12.7.     Simon Clarke said that the DOS may include the option for a call back from the patient’s own GP practice, even if that practice had told the patient there were no appointments. The Head of Operations explained this was because there are unique slots reserved in GP practices for 111 to book, with all GP practices in East Sussex signed up to the service. Maggie Keating, Urgent and Emergency Care Programme Director at East Sussex Clinical Commissioning Group (CCG), confirmed that GP Practices are committed to provide in-hours appoints to NHS 111 at a rate of 1 per 500 patients on their patient list per day due to COVID-19, however, this will shortly revert to 1 per 3,000 patients per day. Once booked into a GP practice, the patient will appear in that practice’s call back list and be prioritised for a call back based on the information provided by 111.

12.8.     The Committee asked how long on average calls take to be answered by NHS 111.

12.9.     Simon Clarke said the average speed to answer calls has unfortunately gotten longer over the course of the year. This is due to COVID-19 increasing the volume of people contacting the service whilst also reducing workforce capacity through increasing the number of call handlers going off sick. The service should be answering 95% of calls within 60 seconds, however, that is currently varying from day to day between one minute and up to six minutes. The 111 service run by SECAmb, however, is generally performing better than the national average, for example, 78% of calls in July were answered compared to 76% nationally, and 76% in August compared to 70% nationally. Call abandonment rates are also lower than the national average, albeit still in need of improvement.

12.10.   Simon Clarke explained that patients calling 111 are played a national ‘busy message’ in recognition of the demand on the service. This message recommends that patients should go online if they are able to, as the NHS 111 online site has the same functionality as the telephone service, for example, direct referrals to the CAS, EDs, UTCs and 999. 

12.11.   The Head of Operations said SECAmb is working hard to improve performance and has increased the number of health advisors by 25% over the amount the Trust is funded to provide, with further recruitment ongoing. NHS England (NHSE) now recognises that the volume of calls NHS 111 is dealing with nationally far outstrips the predicted volume and the funding envelope provided to deliver the service. NHSE is now speaking with CCGs about how they, as commissioners, can help bridge the funding gap.

12.12.   The Committee asked whether the CCG has plans for extra funding to meet the expanding demand for the 111 service.

12.13.   Jessica Britton, Managing Director at East Sussex CCG, said there is review and discussion both nationally and locally about ensuring the right investment funding into urgent care to ensure it is delivered effectively. Future updates to the Committee on urgent care will be able to provide more details on funding plans.

12.14.   The Committee asked when the digital 111 booking system will be available for patients to book online without calling.

12.15.   Simon Clarke said that much of the same functionality of the NHS 111 call service is available online, especially since August 2021 when ED validation was introduced. ED validation means that if certain questions are answered via 111 online, a patient will be advised to attend ED or will be given the option for a call back from a CAS clinician. It was estimated that this would result in an additional 35 calls per day from the CAS to patients using this ED validation service, however, there have been closer to 60-70. He clarified that this ED validation service was introduced as part of the Think 111 First initiative that expects providers to offer digital services that have parity with telephony services to encourage people to use the digital service rather than just call.

12.16.   The Committee asked for confirmation the CAS would not take paramedic practitioners away from frontline ambulance work.

12.17.   Simon Clarke confirmed that SECAmb does not actively move paramedics from frontline service to the 111-CAS. There are, however, some paramedics currently in the CAS who have been placed on alternative duties, meaning they cannot be on the frontline; and some may do shifts at the CAS to give them a better understanding of the wider service and expand their skill portfolio by practicing diagnosing illnesses over the phone.

12.18.   The Committee asked about what will happen to the service if there is a flu epidemic.

12.19.   Simon Clarke said that if there was a flu epidemic there are specific 111 protocols that can be used, such as enabling other 111 services in the country to take calls, and adding messages on how to self-medicate flu symptoms that are automatically played when someone calls  111.

12.20.   The Committee asked whether 111 can book patients directly into hospital wards.

12.21.   Simon Clarke said that 111 can book patients directly into the front door of the UTC or ED at Conquest or EDGH already, but plans are underway to enable direct booking into same day ambulatory care services at the ED, meaning patients will be able to circumnavigate the ED front door.

12.22.   Matthew Webb, Associate Director of Strategic Partnerships and System Engagement at SECAmb, added that SECAmb is working with commissioners and system partners to identify further areas within the healthcare system where direct access through 111 may improve the patient journey and provide a more coordinated use of the available resources. SECAmb is also reviewing the UTC referral pathway to ensure that the UTC is being used effectively to reduce pressure on the wider system.

12.23.   The Committee asked what 111 does when all available appointment slots are fully booked.

12.24.   Simon Clarke said that services listed on the DOS can turn themselves off if they are too busy, for example, an ED can remove itself if there was a sudden surge in demand and 111 would refer patients to other nearby services.

12.25.   Matthew Webb added that SECAmb is also rapidly increasing the resources it puts into its new urgent care hubs. These are ambulance stations with one located in each of SECAmb’s 10 operating units that are staffed by paramedic practitioners. They are able to offer directions to frontline crews if they are struggling to find where to take a patient if nearby services are full.

12.26.   The Committee asked whether there were mixed messages about whether patients should be accessing the NHS, and how the NHS can improve awareness of NHS 111 and what it now offers to patients. 

12.27.   Jessica Britton said that there is increasing demand for NHS services both nationally and locally that is causing pressure on the service.  She reminded the Committee, however, that it is important people know the NHS is open for business and that they should access its services if they need to. Whilst the NHS locally raises awareness about its services and how to access them, including on social media, the CCG is always grateful for feedback or advice from HOSC members about how to improve communications regarding how local people should access services and advice.

12.28.   The Committee asked how the healthcare needs of patients not registered with a GP and living in Eastbourne town centre will be catered for now the Eastbourne Station Health Centre is closed, such as those who are either homeless or in emergency accommodation.

12.29.   Jessica Britton explained that the majority of patients at the Eastbourne Station Health Centre patient list had transferred to the Victoria Medical Centre and can use the branch surgery in the town centre either remotely or face to face.  The CCG is continuing to evaluate the transfer of the patient list to ensure that the provision put in place is responding to the needs of those patients, including for homeless and rough sleepers. In terms of accessing healthcare via alternative routes to the Eastbourne Walk-in Centre, patients are recommended to ring 111 where they can either receive a clinical assessment via the CAS or a booked appointment at the most clinically appropriate service to meet their needs. The service for our homeless population had been implemented as planned. The Executive Managing Director said the CCG had not seen a significant change in the pattern of service use since the closure of the WIC.

12.30.   The Committee asked whether all patients at the Eastbourne Station Health Centre who wanted to transfer to GP practices other than the Victoria Medical Centre were able to

12.31.   Jessica Britton said she could provide the Committee with exact figures but, in summary, the majority of patients elected to transfer to the Victoria Medical Centre and that those who did not were given assistance by the CCG’s Primary Care Team to register with another practice within their catchment area. 

12.32.   The Committee asked for more details of the new Homeless and Rough Sleeper Service (HRSS) in Eastbourne and what provision there was to increase its capacity.

12.33.   Jessica Britton said the HRSS is running out of two locations in the town centre used by the homeless and rough sleeper community to ensure it is co-located with other services used by that cohort. A mobile health bus is also being introduced that people can drop in to.  Jessica Britton explained the HRSS has increased the available provision to homeless and rough sleepers compared with what was previously available both in the town centre and more widely within Eastbourne.

12.34.   The Committee asked how patients were accessing the Hastings Station Plaza Primary Care Led Hub since COVID-19, particularly vulnerable patients who may not be able to get GP appointments.

12.35.   Jessica Britton said Hastings Station Plaza has been running as a Primary Care Led Hub (PCLH) since 2019. The PCLH is a nurse-led hub open seven days per week that supports a range of needs locally. The CCG is currently reviewing whether the PCLH provides the level of service necessary to meet the needs of the vulnerable groups it is set up to support and this will be reported to HOSC in the future. The Managing Director said there have not been any changes to the service since COVID-19, other than the changes necessary to make it COVID-compliant, and whilst not aware of access concerns to the PCLH, she would investigate any specific concerns relating to any access issues to the PCLH, or to GP practices more widely.

12.36.   The Committee asked about the performance of the UTC at the Eastbourne District General Hospital (EDGH)

12.37.   Joe Chadwick-Bell, Chief Executive of East Sussex Healthcare NHS Trust (ESHT), said that the Trust has been experiencing significant pressures in recent weeks. The Trust has been trying to ensure more patients presenting with primary care needs are sent to the UTC, however, the Trust has been struggling to get enough primary care workforce to meet demand. It plans to rectify this through the development of an extended workforce model.

12.38.   The Committee asked why ESHT was experiencing such high demand in its ED

12.39.   Joe Chadwick-Bell said the wards are currently at 99% bed occupancy levels. The Length of Stay of patients is now slightly lower than two years ago, however, a number of staff are off sick or on leave, and there are difficulties moving patients who are medically ready for discharge into community settings due to the availability of home care and care home places. The Trust is attempting to reduce bed occupancy by prioritising discharging those patients who do not need community health or social care and therefore can be safely moved on when medically fit for discharge; and by increasing the amount of patients who receive same day care in the ED and so do not require a bed.

12.40.   The Committee asked how the temporary closure of a service is communicated internally, for example, the temporary closure of Crowborough Minor Injuries Unit.

12.41.   Jessica Britton confirmed it was the responsibility of both the commissioners and the service providers to ensure external communications, such as websites, are accurate. Jessica Britton said the temporary closure of the Crowborough Minor Injuries Unit has been communicated internally and externally as part of a communications plan, however, the CCG would review this. The Managing Director confirmed that the CCG does check such information is accurate.

12.42.   The Committee RESOLVED to:

1)    note the report;

2)    request further details via email on the number of GP appointments available for 111 to book;

3)    request a future report on urgent care in East Sussex in six months’ time, including on internal communication of service changes, and plans for additional funding for 111 and other urgent care services; and

4)    request confirmation via email the specific number of patients who wanted to be registered with an alternative GP practice to the Victoria Medical Centre.