Agenda item

Update on Urgent and Emergency Care Workstream

Report attached. NHS Leads for the Urgent and Emergency Care Workstream will attend and provide the Joint Committee with an update on the above.


Gary Collier, Senior …….. outlined the structure of the Urgent and Emergency Care Network. Gary advised that the Board has complete oversight of the work undertaken and links with all A& E Delivery Boards to make sure that the strategic direction of the Board can be delivered.


Gary also highlighted the role of the Clinical Reference Group which was made up of multiple clinicians who provide advice to make sure that the work carried out is focusing on the right pathways.


The Network also incorporates two other regional groups, the delivery team and operational groups which focus on identifying challenges which will be progressed via task and finish groups such as the ambulance turn around group which is currently looking at trying to improve arrivals and discharges.


A three year strategy had been signed off at the beginning of 2017 which had subsequently focused on the vanguard programme. However, a longer term programme was now needed focusing on a range of areas.


Gary highlighted a range of outcomes achieved as a result of the strategy so far. These included the development of the flight deck which provides an understanding of activity in A & E and ambulance service pressures; the development of mental health training; behavioural analysis as to why patients move around the system the way that they do as part of the Great North Care Record System; the development of the NHS Health Child App which sets out the types of care children might need and provides information on where services are located and which recently won an award; the development of an emergency care programme which looks at patient flows and training for care home staff on when patients need to move into hospital settings.


Gary stated that one of the key advantages of this Network is that it has an understanding of what is happening in primary care and the demands on the system. This has meant that in Newcastle and South Tees they have been able to implement a cardiology and transport service where there is a dedicated transport service.


Gary also highlighted the work to develop a Directory of Services and stated that as part of this work they were looking to see how they could get more voluntary services included in the Directory.


The Joint Committee was also provided with a high level overview of the income and cashable and non- cashable savings achieved by the Network so far. It was noted that not all of the work of the Network was quantifiable for example work around clinical assessment services which created benefits in ensuring that patients were in the right place.


Gary stated that it was considered that the Network had made some really good progress so far and he introduced Bas Sen, Chair of the Clinical Reference Group, who would highlight some of the performance metrics.


Bas stated that he would provide the Joint Committee with information on the work of the Network and how it dovetails with the STP and would also provide an update on performance in relation to this winter.


Bas stated that the Urgent and Emergency Care Network was unique in that it spans the whole region whereas others don’t. In terms of performance this year Bas noted that the Joint Committee would be familiar with the A & E standards and that patients should be seen and treated within four hours of arrival. Bas noted that these standards have not taken into account the increasing volume of attendances year on year. Bas stated that never-the-less Cumbria and the North East was leading the country in terms of performance. Bas referred the Joint Committee to slides setting out attendances and admissions which highlighted that these had flattened and decreased which might raise the question as to why performance had not improved. Bas stated that the key reason for this was that emergency admissions had had gone up by 25 %. Bas indicated that reducing emergency admissions was the key to improved performance.


Bas noted that the Joint Committee would also be familiar with delayed transfers of care which refers to patients who remain in hospital for a variety of reasons although they are medically fit to be discharged. Bas indicated that this winter delayed discharges as a result of issues relating to home care were more of a problem than last year.


Bas also highlighted performance in relation to ambulance handovers and noted that there were a number of delays relating to ……..


Bas also highlighted the NHS 111 system which he considered was a huge success as the number of calls had increased year on year and had gone up by 23 %. However, Bas noted that an issue with the system was that as call handlers were not medically trained they are guided by a medically driven protocol which errs on the side of caution and so they send more people to hospital and send more ambulances.


As a result a second step has been added in to the 111 system, which is clinician involvement and this created a shift in performance of approximately 80% which has since continued.


Bas stated that in terms of how the work of Network dovetails with the STP it is acknowledged that going into the future a radical change in the health system is necessary which may involve many steps.


Bas noted that the Joint Committee might be familiar with the system in the US and United Health and Kaiser Perminente? the way that organisations such as this look at value added steps. This involves analysing patient centred work flows and looking at value added steps and non-value added and taking out the non-value added steps eg the amount of time a patient spends in a waiting room. Bas stated that the aim of the STP was to take out the non-value added. The Network has also carried out this type of work in relation to heart attacks, paediatrics and major trauma. Bas advised that he was involved in developing the major trauma system in this region and the work undertaken had led to a decrease in mortality of between 30% to 50% since 2012. This had been achieved by taking patients to a designated centre so that whilst an accident might occur in Durham the patient would be taken to Newcastle or South Tees where the two hospitals in question were manned 24/7 by highly skilled staff and with high levels of technical equipment in areas such as radiology facilitating the scanning of patients in 3 minutes thereby cutting down on diagnostics in major trauma. Bas stated that this means that patients can be in theatre within 30 minutes which was impossible under the old system. Bas stated that he felt that this approach was the way forward.


The Chair thanked Bas for the information provided and noted that some of the Committee could remember when Kaiser Perminente was considering coming to the UK.


The Chair asked if Ian could also highlight the triage work that the Queen Elizabeth Hospital had been taking forward in relation to emergency care.


Ian advised that he is one of the Co - Chairs of the Urgent and Emergency Care Network and the Halo system which the Chair was referring to had been adopted by most hospitals now. It involved a Hospital Ambulance Liaison Officer who was a member of NEAS becoming part of the team. It had been trialled in hospitals suffering the most challenges and it had subsequently become a vital part of the system and had made a definite difference. Ian advised that the Queen Elizabeth Hospital had been lucky in that this approach had been introduced at the time the hospital had opened its emergency care centre. The work on Halo had emerged as a result of the work of the Urgent and Emergency Care Network.


It was however noted that Newcastle did not have the Halo system and its handover times were the best in the region.


The Chair noted that they had received information that admissions had increased and she queried why this was the case.


Bas explained that this is because the system is not integrated so when a call is made to NHS 111 and a patient advises they have chest pains, even if they are young and have been relatively fit and well up to that point, they have to be taken to the emergency department in a hospital via an ambulance. Bas stated that there is a need for a virtual ward which could give care to a patient at home. However, for  such a model to be in place there would need to be an integrated service where the first point of contact could be someone’s carer who could then have access to a district nurse/OT/social worker / GP or other relevant specialist where needed. Bas stated that if such a system was to be in operation then he believed that this would mean that 50% of patients could stay at home and would not need to be admitted to hospital.


The Chair also noted that information had been provided on the NHS 111 pilot of making referrals direct to local pharmacies and she queried whether this was likely to be rolled out across the region.


Andre advised that he would provide the Joint Committee with information on this project later on in the meeting.


Councillor Robinson noted that the £682,000 funding for winter pressures worked out at 40 pence per head of population and he queried how the NHS had worked out that the population in that area was only worth a spend of 40 pence. Councillor Robinson also advised that he had a stroke approximately six weeks ago and if he had to go to James Cook Hospital rather than the local hospital, where he received excellent care from the staff, he would likely not have survived.


Bas advised that he was not saying that all stroke cases should go to major centres, only complex highly specialised cases need to go to major trauma centres. Bas stated that most hospitals can deal with acute strokes and the work they are doing is not about taking good care away.


Bas advised that the £682,000 was the amount of funding allocated to the Urgent and Emergency Care Network for collective schemes. Alongside this there was also significant funding allocated to NHS providers in the region amounting to millions of pounds.

The Chair asked if the £682,000 funding allocation to the Network had been ringfenced.


Bas explained that the funding had been allocated to the Network and the Network had collectively prioritised what the funding should allocated for and it had been used in a number of ways eg to have NEAS staff in A & E Departments, provide additional IT and storage equipment for paramedics etc.


The Chair asked whether the monies allocated to providers had been allocated on a needs basis and whether this had been ringfenced.


Bas stated that the process for allocating the monies effectively meant that the monies were ring fenced. NHS England had advised that if providers could not provide adequate explanations as to how the monies were to be spent then these monies would be clawed back.


Councillor Schofield noted that many members on the Joint Committee were aware of the health care system adopted in the US and were concerned about going down that path. Councillor Schofield stated that there were millions of people in the US who were disenfranchised from the health care system because they could not afford to be part of it. Councillor Schofield stated that any valued added system developed in the patch must ensure that people are not disenfranchised.


Bas stated that there was no intention of blindly adopting the US system.


Councillor Schofield stated that it was pleasing to hear that the work of the Network would dovetail with the STP and she queried how this would work, would it have to be specifically incorporated or was it something that was built in to the STP.


Bas explained that the Network has some independence as they scrutinise clinical models and the Network would not endorse a model which was not appropriate.


Councillor Schofield queried what would happen if there were ever problems with the NHS 111 system given the high level of calls.


Gary advised that no provider operates in isolation so if there was a significant incident which affected the North East and NHS 111 provision the work would be shared with another NHS 111 provider.


It was queried how the work being progressed would affect payments to different parts of the system. Gary noted that work was often tariff driven which did not always facilitate transformation by the Network. However, work was starting to take place to look more broadly at how they could ensure that finite monies could be shared in different ways amongst providers. Providers are engaged in this work and the NHS is trialling new payment systems in vanguard areas. However, this type of work could not be implemented overnight.


Ian explained that active conversations were taking place with local commissioners who were looking to develop a local payment mechanism.


Ian stated that United Health and Kaiser Perminente had been set up for a very different type of healthcare system and this was why the approach here was different and was being focused on developing an integrated care system. Bas stated that the secret to an integrated care system was that it was not just about services but about integrated finances also.

Councillor Charlton noted that the number of abandoned calls to the NHS 111 system appeared to have increased hugely and she queried the reasons for this.


Gary explained that this was as a result of a significant increase in call volumes which could not have been predicted and which the staffing model had not been geared up for in terms of activity. As a result changes have been made to the staffing model and performance is back on track.


Councillor Charlton queried whether the increased number of abandoned calls had led to additional admissions. Gary stated that he would argue not as the calls to NHS 111 tend to relate to lower risk health issues unlike 999 which deals with more serious health matters. Gary advised that there was some ongoing analysis taking place to see if there was a link to A & E attendances but at this current point in time it was not believed to have had an impact.


Bas indicated that he was not certain that this was the case as he was concerned that people did not always know which number to call in all circumstances. Bas considered that sometimes people were confused as to which number to call. Bas considered that there was a natural tendency in some people not to call 999 and he considered that if calls were not effectively filtered then this might increase admissions.


Councillor Watson noted that handover delays could definitely fall under the category of non – value added. Councillor Watson also noted that this could apply to circumstances which he was aware of when family members had to wait for seven hours to be admitted to a hospital bed only to be seen and then told to go home and circumstances where people wait for six hours to receive medication from the pharmacy. Councillor Watson queried whether these were common occurrances which could be sorted.


Bas indicated that this was a really important point and work was taking place to try and resolve these types of issues but it was important to remember that the Network only started three years ago.


The Chair indicated that it would be helpful for the Joint Committee to have a further update on the progress being made by the Network at a future meeting.


















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