Agenda item

13.1.    The Committee considered a report providing an update on the work being undertaken to reduce Hospital Handover times between South East Coast Ambulance NHS Foundation Trust’s (SECAmb) ambulances and the Emergency Departments (ED) of the three hospital trusts that provide services to East Sussex residents.

13.2.    The Committee asked why performance at the Royal Sussex County Hospital (RSCH) was an outlier compared to other hospital trusts, particularly given conveyances to the hospital had not increased recently, and asked whether enough was being done to improve the service when compared to the number of actions being taken elsewhere.

13.3.    Harvey McEnroe, Managing Director for University Hospitals Sussex NHS Foundation Trust (UHS), said UHS accepts that the RSCH continues to be an outlier in its handover performance, despite improvements in other hospitals owned by UHS. There are three reasons for this:

1.    the challenges with the estate restricting the flow of patients through the ED, made worse by COVID-19 infection prevention measures restricting how the corridors are managed;

2.    the increasing acuity of patients presenting at the ED via ambulance makes it more complicated to manage them, having a knock-on effect to admissions, despite the Urgent Treatment Centre (UTC) and Same Day Emergency Care (SDEC) streaming off lower acuity capacity; and

3.    the flow of admissions through and out of the hospital, including delays in discharging patients, has a knock on effect on the flow of patients from ambulances into the ED. The hospitals improvement programme is aiming to improve the flow of patients within the hospital, but there is a wider system issue with the number of Medically Fit for Discharge (MFD) patients waiting for discharge, which has not improved as much as other UHS-run hospitals.

13.4.    There is an additional issue of the fatigue of staff following an extremely difficult winter and summer and the lingering effects of COVID-19. This limits the extent to which staff can respond to changes in the ED. He clarified they are being helped as much as possible through the process. 

13.5.    Harvey McEnroe explained that the Trust is developing an Urgent and Emergency Care Improvement Plan for RSCH that will set out plans to improve patient flow. The top priority for UHS is to eradicate the 60-minute handover delays and then prioritise 30-minute handovers. The relationship between the ED Team and SECAmb has dramatically improved over the past 6-8 months, in part driven by the implementation of Fit 2 Sit and the Full Capacity Protocol (which moves people out of ED to prioritise the ambulance crews), and by replacing the culture of seeing the ambulance queue as an extension of the ED and treating them as a priority. Ray Savage confirmed SECAmb is working incredibly hard with UHS to expedite handovers at the RSCH, including embedding a member of staff in the department during busy periods to assist ED teams. He added that handovers are a system wide issue and often delays in the ED are caused by the delays in the discharge of MFD patients. Ray Savage assured the Committee the ambulance trust would continue to work with UHS in the coming months, during what is expected to be a very challenging winter, to reduce if not eliminate 60-minute handover times and then focus on over 30-minute handovers.

13.6.    The Committee asked for further details on the number of MFD patients waiting for discharge.

13.7.    Mark Stainton, Director of Adult Social Care and Health, said that ambulance delays are a manifestation of a system under pressure, but are not a new problem and will not be solved overnight. All organisations present at the meeting will have staffing challenges to some extent and for the East Sussex County Council (ESCC) Adult Social Care Department (ASC) it is care workers in the independent sector. The current challenge around discharge of MFD is around the availability of beds in care homes and other alternatives to residential care in the community. Whilst under pressure, there is less challenge in the non-residential care sector, as ESCC took steps to increase the volume of home care workers, including the successful overseas recruitment of over 100 home care workers from two Eastern European countries and the Far East.

13.8.    Mark Stainton added that there is a need to prevent people going to hospital in the first place through admissions avoidance and prevention, and providing alternative pathways for SECAmb to ambulance conveyance, such as the rapid response community nursing service, joint community rehabilitation service, and access to GP appointments within 24 hours. There is an expected announcement of further financial support from the new Secretary of State over the winter period to support discharges.

13.9.    However, funding is only part of the issue and getting people into the roles and working effectively is not something that can be achieved overnight. In addition to overseas recruitment, some of the initiatives to address the recruitment challenges include offering apprenticeships; schemes supported by the Department of Work and Pensions to provide the long-term unemployed on Universal Credit with trial employment whilst protecting their benefits for a period of a month; and working with veterans associations to offer positions to ex-military personnel seeking an alternative career.

13.10.  The Committee asked what could be done to improve patient flows within hospitals.

13.11.  Richard Milner, Chief of Staff at East Sussex Healthcare NHS Trust (ESHT), said the Rapid Assessment and Triage areas would be reopened (through resolving staffing issues) in Eastbourne District General Hospital (EDGH) in October and Conquest Hospital in early November. The purpose of them is to rapidly assess lower acuity patients in a separate area to free up the flow through the wider ED. Mark Stainton added that ASC staff are present in the EDs and gateway wards at ESHT and their role is, where possible, to help avoid admissions into an inpatient bed. This is achieved through the use of block-purchased home care hours, enabling the patient to receive rapid support at home.

13.12.  Harvey McEnroe said UHS has a robust model of alternative support for patients who fit the criteria of admission avoidance, including the Fit 2 Sit area where patients with more moderate acuity are streamed to within the ED, creating capacity for ambulance flow into the majors area. There is also the Stream Away pathway for patients who arrive and are assessed but are not deemed to need ED treatment. He said around 8 patients a day at RSCH, 3 in Princess Royal Hospital and 6-7 in Worthing and Chichester Hospitals attend who would not have needed to come to ED if there was something in the community to help them. UHS is continuing to work with SECAmb to develop these alternative pathways.

13.13.  Katherine Holmes, General Manager for Emergency Care at Maidstone and Tunbridge Wells NHS Trust (MTW), said that in Tunbridge Wells Hospital there is a 14-bed Rapid Assessment and Treatment (RAT) area where ambulance attendances to the department are managed, avoiding the usual triage process. COVID-19 measures can make dealing with patients in a timely manner more challenging in this space, however. There is a community team in the ED that treats patients where appropriate, and a frailty department that can take direct ambulance admissions. The ED also allows SECAmb to take appropriate patients directly to the Same Day Emergency Care (SDEC) area to prevent them waiting in the ED. The Trust also works with SECAmb to analyse the cause of any 60-minute wait time breaches and takes into consideration any learning from it.

13.14.  The Committee asked what the effect will be on discharge rates of patients from the new social care reforms, including the cost cap, increased eligibility rate and the assurance framework.

13.15.  Mark Stainton said a report to ESCC’s Cabinet on 29th September will set out the impact of the social care reforms due to come into effect in October 2023 on ESCC, both in terms of cost to cover the cap and the number of staff needed to undertake social care and financial assessments of the around 3,000 additional people likely to be eligible for subsidised care support. ESCC is in a reasonable position compared to other councils in England and the Council, in anticipation of this additional demand, has begun a comprehensive programme of preparation. This includes developing software that enables people to self-service their care accounts, with remote support from ESCC, and beginning the recruitment of the additional roles needed to create 3,000 additional care accounts. Mark Stainton said ASC already has a well-established internal quality assurance framework and welcomes the national assurance framework, from April 2023, as it will provide external validation of the work of the Department – as is already the case for the NHS and Children’s Services Departments.

13.16.  The Committee asked when each Trust might return to the 15-minute handover target.

13.17.  Richard Milner said that there is no firm timeline for achieving this target. The purpose of developing the changes in handover practices is to build a model that is designed to reduce handover times and to monitor their impact to ensure they are the right actions and improve if not. After that point, a timeline may be developed. 

13.18.  Katherine Holmes said the mindset of zero tolerance to over 60-minute delays is already embedded, as at MTW all over-60 minute handovers are discussed and investigated with SECAmb.

13.19.  Harvey McEnroe confirmed that the Urgent and Emergency Improvement Plan will include internal trajectories for the eradication of 60 and 30-minute handovers. All 60-minute delays are treated as a serious incident and reviewed accordingly. 

13.20.  The Committee asked why Conquest Hospital appeared to have longer handover delays than Eastbourne District General Hospital (EDGH).

13.21.  Richard Milner said that most efforts are focussed on over 60-minute delays, which are greater in EDGH due to the type of patients seen at that ED. Due to the specialisation of the two hospital sites, more elderly and complex patients are taken to EDGH, whereas Conquest Hospital receives less complex patients and is able to treat a larger number of them in the Fit 2 Sit areas. Rhiannon Darling, Operating Unit Manager, SECAmb, said that the streaming of patients means patients who have experienced trauma are more likely to go to Conquest, and these patients are unwell but relatively non-complex.  The patients taken to the EDGH, on the other hand, do not have such a clear medical pathway and on arrival the correct pathway to stream them to is not as simple or obvious as it is for someone with a traumatic injury. This means that it takes more time to diagnose and move the patient to either the SDEC or the Acute Medical Unit (AMU). Based on data from last week, the handover times were roughly the same, but Conquest has had quite a few more patients than EDGH.

13.22.  Ray Savage explained that SECAmb’s conveyances to hospital have generally reduced over the past two months due to new, non-conveyance pathways that are available to paramedics following assessment of a patient. Around half of patients who call 999 are treated on these non-conveyance pathways. The pathways include patients being given advice and support, or an intervention by the ambulance crew and left safely at home, or the ambulance crews call Health and Social Care Connect (HSCC) and refer the patient to community-based teams such as the urgent community response teams. The upcoming virtual wards will also mean ambulance crews can contact the clinical team who are responsible for the patient to speak to them about an alternative to conveyance. Paramedic practitioners also sit within the ambulance hubs and can speak to paramedic crews about the best course of action for a patient. Ray Savage explained that the capacity of these other services, or the time of day the intervention takes place, means that sometimes conveyance is the only option available.

13.23.  The Committee asked to what extent hospital trusts are speaking with each other about sharing good practice to solve the problems at UHS.

13.24.  Harvey McEnroe confirmed that UHS is eager to take system learning from other hospital trusts both directly and in collaboration with commissioners and SECAmb. The Trust is also seeking to implement national guidance with assistance from the Urgent Care Improvement scheme, with members of the national team due to attend to support the ED team shortly. He added that a lot of the good practice would need to be implemented elsewhere in the hospital, as patient flow through wards and the patient discharge process are often the causes of delays in moving patients through ED.

13.25.  Jessica Britton added that there is a comprehensive whole-system programme from NHS Sussex to manage hospital admissions over the winter period and its outcome will be reported to HOSC in the new year.

13.26.  The Committee RESOLVED to:

1)         Note the report;

2)         Request that UHS circulates via email its Urgent and Emergency Care Improvement Plan for the RSCH; and

3)         Request a further report on hospital handover performance, including evidence of how trusts have worked together to make a difference, for the 29 June 2023 meeting, following the end of the winter period.