Agenda item

1.1.        The Committee considered a report by the Assistant Chief Executive on the extent of delays in handover of patients from ambulances to hospital emergency departments, how handover is managed, and actions in place to address this issue.

1.2.        East Sussex Healthcare NHS Trust (ESHT), Brighton & Sussex University Hospital NHS Trust (BSUH) and South East Coast Ambulance Service NHS Foundation Trust (SECAmb) provided presentations on their role in the hospital handover process.

1.3.        HOSC asked the witnesses from the three Trusts a number of questions.

Impact on ambulance services

1.4.        HOSC asked when SECAmb would reach a critical point in terms of handover delays.

1.5.        Geraint Davies said that SECAmb was already at a tipping point and there were regularly days where there were ‘planned wipeouts’ ( i.e. no ambulances available to respond to new calls). These occurrences did not necessarily fit a pattern.

1.6.        Tim Fellows, Operational Manager, SECAmb, said that the delays in hospital handover meant that most ambulances were having to travel from one of the three hospitals in Brighton, Eastbourne and Hastings to respond to emergency calls, making response times more lengthy. If hospital handover times could be improved then ambulances could be redistributed strategically across a wider geographic area so that there would always be an ambulance close to most residents. He clarified that patients, in the main, had not been suffering any harm as the response times were still good and the quality of care remained high.

Causes of handover delays

1.7.        Dr Adrian Bull, Chief Executive, ESHT, said that hospital handover was not an issue just for the A&E department, or even the hospital, but the health system as a whole. The delays in hospital handover were a symptom of a wider problem that was also affecting ESHT’s 4 hour and 12 hour A&E waiting time targets.

1.8.        Dr Bull accepted that hospital handover times were unacceptable but made the point that it was dangerous when considering a system–wide issue to focus on just one parameter and try to fix it at all costs. He said that handovers were taking so long because busy staff were attending to patients who need care elsewhere; a patient waiting in an ambulance with paramedics may be safe whilst another patient may arrive at A&E in urgent need of care. Focusing exclusively on handover would have knock-on effects elsewhere. It was a complex interdependent problem with a lot of competing issues that need resolving,

Actions to reduce handover times

1.9.        HOSC asked what actions are being taken to reduce handover times, in particular the recruitment of staff, and what the timescales for these actions having an effect would be.

1.10.      Geraint Davies said that the main issue for SECAmb was for acute trusts to get the appropriate capacity at A&E departments to enable ambulance crews to handover patients in a timely way. He recognised the pressure this put on acute trusts, which was why the ambulance and acute trusts needed to work in partnership to get a realistic system in place. He said that it would be a significant challenge to reduce handover times to the level that they were in April 2013.

1.11.      Dr Bull said that the A&E departments at Eastbourne District General Hospital (EDGH) and Conquest Hospital required greater capacity. The Trust has the funds to provide this capacity, but is unable to recruit sufficient staff at present. Due to the need for continual cover of the department the Trust is forced to rely on agency staff, costing more than if they were able to recruit the five additional permanent staff needed. 

1.12.      Jenny Darwood, General Manager – Urgent Care, ESHT, said that there was a recruitment and retention issue at ESHT. There are vacancies in all medical levels in the Trust, including middle grade and consultant level. The Trust was actively trying to attract staff to work in East Sussex, for example, by offering incentive payments and developing training packages for new staff, including for specialist doctors to work towards becoming consultants. Dr Bull reminded HOSC that escalating pay to attract consultants could have a knock on effect of forcing other NHS organisations to increase their offer to this limited pool of staff; competition for agency staff had already caused their cost to increase significantly.

1.13.      Dr Bull said that there were other ways of improving capacity through the system and ESHT was working to analyse the potential impact of such improvements. For example, the Trust had commissioned an expert team to match surges in demand to the allocation of staff. ESHT was also working with NHS Elect to review the allocation of capacity on both hospital sites to urgent and elective care.

1.14.      Dr Bull said that ESHT is working fully and collaboratively with social services at the discharge end of the process to create capacity; CCGs and primary care at the other end to see if demand for hospital care can be reduced; and with neighbouring hospitals and the ambulance trust when patients enter the system.

1.15.      Dr Bull recognised that in situations like that caused by the delays in hospital handovers that relationships can become fraught between ambulance and hospital staff. He was committed to ensuring that professional courtesy was maintained at all times so that the patient was not caught in the middle.

1.16.      Andrew Stenton, Interim Director of Operations - Unscheduled Care, BSUH, echoed the difficulty of recruiting to some medical roles. As the Royal Sussex County Hospital (RSCH) is a major trauma centre it has 24 hour consultant cover which helps in many ways – but there is a shortage of junior doctors and, in particular, nursing roles which was also a national problem. He said that BSUH had the funding to fill these roles but, like ESHT, was relying on agency and bank staff due to difficulties recruiting permanent staff. The Trust has various strategies, such as recruiting from abroad, to reduce these staffing issues but it was difficult to put a timescale on when they may be resolved because it was a national problem.

1.17.      Dr Steve Holmberg, Medical Director, BSUH, said that there were not enough doctors in training grades to fill the vacancies nationally in some specialities. He agreed that increasing pay offers was not the solution to attracting staff; it was more effective to improve the job offer, for example, by offering career development.

1.18.      Andrew Stenton said that BSUH used escalation protocols to bring in clinical staff from other areas to the A&E department– such as staff on training, or carrying out non-clinical roles on that particular day – to assist in managing peaks. Direct patient care takes priority during times of considerable pressure.

1.19.      Tim Fellows said that a lot of good work was going on in the county, for example, developing specialist assessment pathways at the Conquest Surgical Assessment Unit where ambulance clinicians can admit patients directly. The fractured neck of femur pathway at the Princess Royal Hospital takes pressure off A&E by allowing patients to be admitted directly to the right place quickly. Paramedics are also focused on non-conveyance where appropriate, i.e., avoiding hospital admissions.  The stroke centre at Eastbourne DGH and the major trauma centre at Royal Sussex County Hospital were also effective.

Leadership

1.20.      Given that this issue cuts across several organisations, HOSC queried whether there is one person taking the lead on co-ordinating efforts to reduce hospital handover times.

1.21.      Dr Bull said that he was taking the lead on, and was accountable for, reducing hospital handover times at ESHT, and he was ensuring that the Trust was doing everything it needed to. He also considered that he was responsible for ensuring ESHT worked with partner organisations on the issue.

1.22.      Andrew Stenton clarified that there was no one person responsible for co-ordinating system wide responses to hospital handover delays. There is a statutory group – the System Resilience Group – which brings together all NHS bodies in community, acute, and ambulance services - that looks at this and other issues on a monthly basis. The group is held accountable by the wider NHS for delivery on these areas.

Current waiting times

1.23.       HOSC asked what the current waiting time is at acute hospitals for handover,

1.24.      Geraint Davies said that a deal was being negotiated through the System Resilience Group to set a realistic target of 30 minutes for handover, as the national target of 15 minutes would be too challenging for the system. This would be accompanied by a realistic trajectory to achieve 30 minute handover times. NHS organisations go into escalation procedures when a patient breaches a 45 minute handover time. This is so that organisations can understand what the delay means for the patient and the system as a whole.

1.25.      Geraint Davies said that the only hospital in the Trust’s area performing well was Medway Hospital, which was also the only hospital where handover times had fallen over the past two years. This had been achieved by redesigning the A&E Department and assigning dedicated handover nurses. He said it was an example of good practice but could not necessarily be replicated elsewhere due to individual circumstances; in particular that Medway NHS Trust had put these processes in place because it had been in special measures.   

1.26.      Andrew Stenton said that Princes Royal Hospital in Haywards Heath had shorter handover times than the RSCH due to the different type of care the hospitals provided and the volume of patients that they dealt with; there was a great deal more pressure at RSCH than at the Princes Royal.

1.27.      Jenny Darwood said that the 4 hour window for seeing patients in A&E started when patients arrived in an ambulance so ESHT had no incentive not to take over their care.

National picture

1.28.      HOSC asked whether the 60% increase in handover hours was similar to the national level, and asked how it had impacted on patients.

1.29.      Geraint Davies said that the South East area covered by SECAmb was an outlier in the top quartile and always has been. Some hospitals stood in the top 5 or top 10 nationally for handover delays.

1.30.      Dr Bull said that there had been no data to suggest there was any adverse effect on patient outcomes so far. ESHT has a system for reporting and investigating any incident where harm had occurred to a patient and there were no such incidents where hospital handover delays had been the cause.

1.31.      The Committee RESOLVED to:

1)    request a report in December 2016 on the work led by the System Resilience Group and Urgent Care Network to improve the wider urgent care system and reduce handover delays;

2)    request additional data from SECAmb on:

a.    Comparative hospital handover times nationwide; and

b.    The number of planned wipeouts over recent years and whether there are spikes in demand