Agenda item

13:20

 

In light of the recent focus in the press on Accident & Emergency waiting times and winter resilience, a report has been requested from Health representatives on the system’s preparedness for increased activity during the winter period, particularly in the context of the Delayed Transfers of Care (DTOC) figures and the impact of ward closures at the John Radcliffe Hospital (JHO9).

 

The Chief Operating Officer of the OCCG, Diane Hedges, will attend the Committee meeting to provide an update on the Winter Plan including the urgent performance and communications activity to support the plan.

Prior to consideration of this item, the Committee heard addresses given by Sarah Lasenby and Larry Sanders.

 

Sarah Lasenby expressed her general concern about winter care, believing that the present NHS systems were denying patients their health requirements. She made the following specific comments:

 

-       Earlier this year Accident & Emergency had found itself so stretched it had introduced GP triage in hospitals. In her view, beds had been taken away before the outcomes of the changes had been evaluated in the knowledge that there were staff resourcing problems;

-       In her view the ambulatory units were working very well and it was a good scheme. Innovation was good but not when patients were being put into side corridors on trolleys because there were no beds for them; and

-       She expressed her concern regarding the proposed transfer of services from the Horton Hospital to Witney.

 

Larry Sanders commented that he respected the work that was going on into innovations in the NHS, the outcomes of which held many interesting ideas. However, reading between the lines he believed it could not work and crises could happen. This was due to the lack of Government funding and the worsening of the manpower situation with shortages of social care workers and GPs. He believed that it was the responsibility of elected members and various professionals working in the services to speak out; the latter having a dual responsibility to patients and the public, as they were the people who knew the most. He made reference to the bed shortages in the UK being the second worst ratio in its European group. He also stated that in his view the lack of future sustainability of the Health system in Oxfordshire was based on constant reductions of beds which amounted to 300 lost. Moreover, it was his view that there had been no attempt to measure the problem of unplanned admissions or re-admissions, due to premature discharges. He made a plea therefore for people to speak out about their concerns, particularly those who had inside knowledge; and to look at the issues affecting the issues that arise, an example of this being unplanned admissions.

 

The Chairman welcomed the following representatives to the meeting:

 

-       Diane Hedges – OCCG

-       Dominic Hardisty – Oxford Health

-       Richard McDonald and Dr John Black – South Central Ambulance Service

-       Benedict Leigh – Adult Social Care, OCC

 

The above representatives commented on the issues important to their organisation prior to questioning from the Committee, with reference to report JHO9.

 

Diane Hedges stated that there was a need to be realistic, the simple opening of more beds being not straightforward. She pointed out the following:

 

·         that the John Radcliffe Hospital was also a specialist centre which meant that demand was even higher than elsewhere. Thus, diversion to Southampton or London hospitals to service specialist demand would be required;

·         significant workforce issues and the ensuing patient safety issues meant that beds could not be opened even though it was desired. She added that there was a need to break the cycle by sending home the medically fit;

·         the means by which the level of increased need could be met was a complication question. People were living longer with more complex health issues; and

·         the OCCG’s level of confidence in this Plan was cautious – it would like to see the formation of better ways of managing winter pressures, for example with more in-depth risk assessments in relation to bed closures.

 

Benedict Leigh echoed the concerns expressed in relation to the rise in demand for social care, recognising that workforce challenge was a particular problem particularly around domiciliary care. Adult Social Care was undertaking the following measures to give support;

 

·         working jointly with the OCCG to fund flu jabs for all workers in a bid to sustain the workforce over the winter months;

·         working across the whole system and alongside the OCCG on measures to support workforce recruitment. This was a challenge within Oxfordshire which was a wealthy county with low unemployment;

·         working closely with a network of providers to tackle recruitment within Social Care to sustain the other more fragile providers. Also working with other healthcare providers to provide sustainability over the winter period. He added that more than 90% of providers were ‘good’ or ‘outstanding’; and

·         purchasing more beds and  more home care to manage people’s care through the system.

 

Dominic Hardisty listed the following measures being taken by Oxford Health to prevent pressure on acute care:

 

·         the running of MIU’s which could demonstrate that A & E activity could be avoided;

·         the running of EMU/RACU in Witney and Abingdon, the latter was a frailty assessment unit where older people could be seen by gerontologists – both of which could have scope for expansion;

·         Oxford Health runs Out of Hours services, working closely with the South Central Ambulance Service on 111 services. 111 had been quite fragile last winter, but since then Oxford Health had undertaken some robust work to add resilience, putting the services in a far better position to cope;

·         the proposed changes around stroke care had put resources closer to people in the communities; and

·         piloting a rehabilitation service at home to test community service provision. This had helped to respond to out of hospital care inquiries.

 

Richard McDonald spoke of the SCAS transformation. Their core value in innovation was a new way of working to respond to the different expectations of the population. Innovations introduced were:

 

·         as part of the 111 service and as part of a collaboration with Oxford Health, Buckinghamshire and Berkshire, clinicians had joined together to be at the end of a telephone to provide advice;

·         stroke patients now had a first - time ambulance rather than a rapid response vehicle;

·         patients were triaged in a better way in order that the right response be sent to move them to the right place to give the right care;

·         the service would be changing the staff rostas/skill mix/vehicle mix for the winter; and

·         trying to deal with patients closer in the communities. With regard to patients living in rural areas, the service was endeavouring to work out the correct response needs to enable patients to be treated at the correct venue. SCAS had been the top performing service during the changeover period.

 

Dr John Black, Medical Director, SCAS, stated that there would be more integration on care with colleagues in other Trusts For example SCAS was working very closely with OUH sharing best practice in emergency care, reducing delays and ensuring that patients were treated and admitted appropriately to the correct clinician. This was an opportunity for further co-ordinated care at scale and an opportunity to run the service as efficiently as possible by getting decisions from partners quickly so that there were no inappropriate admissions.

 

Questions from the Committee were as follows:

 

-        A member expressed concern that beds had been permanently closed and there would be further closure of beds in the future, in light of DTOC delays in community hospitals.  She asked for reassurance that this tripartite, parallel approach model would also work in the community. Diane Hedges responded that in the past with DTOC, other beds were opened and the equivalent beds were opened in the community supported by clinicians and social workers. This was part of the ambulatory approach. She expressed her disappointment at the DTOC outcomes, emphasising the need to be looking at managing a high volume of patients going through the system. There had been a significant increase in the numbers of patients who were seeking treatment and the Health system had been trying a number of pilots recently in a bid to manage this. Dr Black confirmed the significant increase in demand over the last year with up to 8% requiring surgery. His view was that the wider system was working better together to access the services in community hospitals, ambulatory services and social care. There was a determination that patients would be supported at home, as this was what patients desired the most;

 

-       A member declared himself a supporter of the 111 services to assist with winter pressures. There was nothing in the communication plan that directed people to this service, asking why this was. Dr Black agreed that there was a need to value the 111 service, and it was hoped that as people became used to using it there would be more activity;

 

-       In respect of a question about whether the flu jab was a new initiative, Benedict Leigh stated that carers had always received flu jabs; but the free service for the social care workforce was a new initiative, partly because there was a need to support their resilience;

 

-       A member asked if there was anything significant in place for patients with mental health illness during the winter, given that acute beds were fully stretched, and given the restraints on Health with the Act and the rigorous assessment process. Dominic Hardisty responded that there was significant underfunding of patients with mental health problems. He made reference to the 60-90 minute assessment facility if a person presented at the A & E department at the John Radcliffe Hospital. A new tele – psychiatry assessment was also available which was dependent on a person’s needs. The outcomes of this was that the patient was either sent home or sent to a community hospital where the patient was cared for by staff trained in mental health. In some circumstances, a patient may need to go to a specialist mental health ward. He added that the occurrence of a mental health problem did not tend to be seasonal, although, in the same way as physically ill patients, some may suffer loneliness at Christmas.

 

-       Pressure on wards was different for different age-groups, there being a major shortage of children and young people’s beds in the south region. NHS England had closed admissions due to acuity of patients. Beds in neighbouring counties were required.

 

-       There was no choice but to admit adults of working age. In nine out of ten circumstances people were admitted within three days, or obtained an out of area bed. Over the past year performance had improved and managers had reduced the spend on out of area beds by 50%. Furthermore, there were few beds for older people with complex mental health/physical health needs. NHS services for older people was good but was not quite there yet for people who presented with challenging behaviour and who required specialist dementia care homes. Dr Black added that ambulance staff were permitted access to the patient records for people who presented with a mental health crisis;

 

-       In response to a question about whether there were alternative services open to patients in the teenage unit at the Warneford or at Abingdon, given the workforce pressures mentioned in the report, Benedict Leigh described three main mitigations which had been put in place: 200 hours per week community reablement given by nursing staff; commissioning of additional interim beds in reablement; and more effective support for reablement ie. in funding for occupational therapy and physiotherapy support. He added that intervention in HART would help patients more quickly.

 

-       A Committee member stated that she had been told by constituents that there was a high call volume for the 111 service and given a message to ring back later. She asked how the staff situation was, particularly at week-ends. Richard McDonald responded that the Trust was in the process of recruiting for local staff, but there was a contingency arrangement with Milton Keynes when busy. If this was busy then the Trust used the national contingency to switch to another provider. A busy message was often in place if it was found necessary, but staff would still answer if they were free;

 

-       In response to a question about what resilience was in place if there was a severe outbreak of flu, Diane Hedges stated that this could be a significant problem and there were a range of choices in place for such a situation. The OUH had taken a full capacity policy which extended a bed on each ward to stretch staff to nurse/treat more numbers. Buckinghamshire and Berkshire hospitals were able to open wards but Oxfordshire did not have the same facilities due to workforce issues. The OCCG had tried to identify when the busy times would be and in this situation would purchase additional capacity for primary care. Additional home visits would be made by nurse practitioners in primary care on the days they would be required;

 

-       In response to a question about whether the SoS bus would be rolled out elsewhere from Oxford, and if so, would adequate measures be put in place to direct extra clinicians to the Horton Hospital, Richard McDonald stated that this had been trialled in Oxford but it had only treated 8 patients during the past week. It had been restricted to Oxford due to the high population concentration and number demand. However, three clinicians to 8 patients was not deemed to be the best use of resources. Moreover there was not the appropriate level of activity in Banbury or Bicester for this ambulance service. Diane Hedges added that a national emergency care improvement team had observed that there was a need to be much tighter in matching staff to the anticipated patient footfall. The Team had also stated that it would expect to see more consultants on the ground. It had also implemented primary care streaming in order to increase capacity and to ease the pressure on consultants.

 

At the conclusion of the question and answer session, the Committee considered what action could be taken. Dr Cohen advised that the Committee had been appraised of a clear set of new interventions and new ideas and it would be helpful to know in the Spring which had proved to be most effective.

 

The Committee AGREED to thank all representatives for attending. Members welcomed the system-wide approach on reporting in respect of beds, including acute and community. The representatives were requested to:

 

(a)  return and present an evaluation of the innovations once the winter was over and which were the most effective;

(b)  give a presentation on plans for next year; and

(c)  request Diane Hedges to check the number of beds currently available compared to the same period last year;

(d)  request Diane Hedges to look at staff sickness levels overall and to report back.