Agenda item

10:20

At the time the Oxfordshire Winter Plans were presented to the Committee in November 2017, Members asked to review their subsequent effectiveness. The attached report (JHO8) from the Oxfordshire Clinical Commissioning Group (OCCG) includes information on the success of some of the new initiatives, for example flu jabs for Social Care staff, to learn where the system should be investing in the future.

At the time last year’s Oxfordshire Winter Plans were presented to the Committee in November 2017, the Committee asked to review their subsequent effectiveness. Members considered the report JHO8 from the Oxfordshire Clinical Commissioning Group (OCCG) which contained an evaluation of last year’s Plan.

The Chairman welcomed OCCG’s Chief Executive, Lou Patten and Chief Operating Officer, Diane Hedges; Karen Fuller, Deputy Director, Adult Services, Oxfordshire County Council (OCC); and Sam Foster, Chief Nurse, together with Sarah Randall, Deputy Director of Clinical Service, Oxford University Hospitals NHS Foundation Trust (OUH), to the meeting. Stewart Bell, Chief Executive, Oxford Health and Dr Kiren Collison, Clinical Chair, CCG joined the Panel to respond to questions later on in the session.

Diane Hedges introduced the report JHO8 which covered all angles of the urgent care pathway. Although the focus was on how urgent care supported patients, the report also covered the whole range of options for patients, such as the option to call the 111 service which was supported by clinical advice, the Out Of Hours (OoH) service and the Minor Injuries Units (MIU). It also covered examples of interventions made to try to encourage people not to use the urgent care services, such as the pilot use of the SoS bus in Oxford, the use of the OoH service for patients requiring repeat medication and the use of advice from pharmacy services direct from the 111 service so as not to take up GP time. A wide range of approaches were also being used, such as safe havens for people suffering from mental health illnesses. She stated that the GP Access Fund should increase access to these.

Diane Hedges also informed the Committee that, as potentially expected, the 4 hour target for people waiting in Accident & Emergency (A & E) had not been met and the service had been escalated to the highest level. In January/February, when pressures had been felt nationally, operations had been cancelled and Trusts had been requested to re-think their approaches to elective operations. It had been the worst winter in terms of weather nationally with huge numbers of patients waiting to be treated. However, in adversity, alternative solutions had been found to assist in different areas of work, for example, in the approach to home care. Patients had been assessed on an individual basis to enable them to move from their hospital beds more quickly. More care home beds had been bought and the number of community beds had been extended to avoid risk, wastage etc.

Lou Patten also highlighted another example of real success which had been the implementation of much tighter assessment systems in hospital and community hospitals, with less duplication, which had resulted in good use of  community hospital beds. Assessments of Delayed Transfers of Care (DToC) patients who had occupied a hospital bed for 7 – 21 days, were linked to the home circumstances of the patient in the first instance, which had resulted in strong progress in this area. OCC had led this work which had gleaned a better response and had encouraged people to work together.  A working party team was already reviewing this shift in emphasis to the individual as against the bed, and the social and therapeutic impact of this; and was looking at what was learnt, with a view to reorganising the approaches to winter pressures for 2018/19.

Questions asked and responses given were as follows:

When and where were the extra beds planned and where were the evaluations of action taken so that this could be measured against in the future? Sam Foster responded that this would be undertaken in September in order to measure capacity. A Committee member stated that a clear understanding of which funding streams each intervention drew upon would also be required, for example, the Better Care Fund, the OCCG or OCC pots etc. In addition, learning about how effective the additional clinical resources given by the South Central Ambulance Service (SCAS) had been, together with information about whether it had been a one off pot of funding to try a different way of working. Also, how learning would take place from this experience? how were staff feeding into them? were they joint plans? and what roles were available for staff to apply for if they were moving from one position to another? Diane Hedges responded that the extra resourcing had gone into the procurement of urgent 111 services to provide for clinicians. Learning had taken place on which area of clinical service had had the best impact within workforce constraints. The Accident & Emergency Development Board had considered how to best access GP hubs and whether they could increase capital access and clinical advice. She added that it had been a challenge, as it was in every area, to supply sufficient numbers of clinicians.

A member asked how many patients did the plan equate to? Sam Foster responded that collecting and measuring data as a system was quite tricky, but the figure tasked with equated to 44 beds or beds equivalent. Some guidance would be coming in relation to this work. A member commented that whatever method of evaluation was chosen, it would have to have scientific rigour;

The representatives were asked why they were not able to do what they had achieved so successfully in previous years and what challenges did they face in putting it together?  Lou Patten responded that the situation had been very different this year. Significantly more comprehensive reflection had taken place and there had been more emphasis on the empowering of clinicians. The challenges associated with funding streams was that they often came late.

A Committee Member asked where the third - party providers came from and what was the cost of backfilling job vacancies? Diane Hedges responded that the CCG had a good relationship with Age UK. Sam Foster commented also that Age UK had proved to be very helpful in their support for OUH in getting patients back into their own beds at home. The Trust was looking to work with additional agencies. She undertook to let the Committee have the costs involved.

Sam Foster was asked how long non-urgent surgery had been postponed for and when did they plan to catch up? She replied that non - urgent surgery for patients had been cancelled across the Trust at the behest of national NHS. These patients had now been caught up with and there were now no long waits. Diane Hedges stated also that some patient beds had been cancelled due to workforce pressures. Sam Foster referred also to the national shortage of registered nurses, of whom more were leaving than joining the service (the Board papers provided more detail than they had in the past in relation to staffing, also giving more clarity on where the vacancies lay and on recruitment). The focus was on staffing for theatres and emergency departments. The Trust currently had 250 offers out to overseas nurses. There had also been joint recruitment to vacancies within the system which had proved to be successful in accordance with the initial working party. Success had also been achieved with the numbers of temporary workers who had been made permanent. This had also incentivised large numbers to work extra hours in order to keep maximum capacity open. The Working Party had also ensured escalation if it was deemed necessary and it was also working towards paying support workers more money. Its focus was on the optimum safety, as it was aware that temporary staff came with risks. In addition, a significant amount of monitoring of emergency plans was undertaken to ensure that the situation in relation to elective and unplanned operations was in a better fashion than last year.

A member asked if any analysis had been undertaken into what constituted an emergency at A & E; and was there any evidence of a definition/categorisation of presenting which might be included in a business case on how A & E could be developed in the future. Also, was the 4 - hour target realistic nowadays – could it be achieved or should it be scrapped? Sam Foster explained that patients were triaged immediately on entry. If they were brought in by ambulance, then they were triaged as a priority. If they presented with a relatively minor clinical problem, they were placed in GP streaming. The latter service was up and running at the John Radcliffe Hospital and numbers attending had increased. She undertook to bring back to Committee a case mix with information on where they had been treated. The mix of patients did tend to change in the winter with more presenting with influenza and respiratory disease etc. She added that there was a significant amount of focus currently on trying to do things differently in A & E departments and decisions were generally made on the next steps within 30 minutes, thus improving performance statistics to 90%. There had been no further 12 - hour trolley waits in April. The system was not quite there as yet and there was a need to ensure the Winter Plan was part of the Urgent Care improvements. Sarah Randall commented that evidence had seen improvements which had the most impact on those patients with extended stay (7 – 21 days) in hospital. Evidence had proved that the local health economy statistics were at their most satisfactory where hospitals had lower occupancy rates, which were in turn cheaper. The work being undertaken on reducing the 4-hour target and helping extended stay patients to return to their own homes had given the system a head start in comparison with other areas (10 – 20% reduction). This was equivalent to a 44 bed reduction. There was a will to achieve this target but the 4-hour target was very complex and necessitated high impact action being taken as a system - and sometimes required more work to get it organised.

With regard to a comment from a member about the need for patients to obtain care in a home situation, rather than in a care home, Sarah Randall  responded that the question of providing ‘in house’ carers was being looked at in the OCC review. This was currently a large area of learning within Social Care, as well as that of system working with OUH and Age UK on patient outcomes. This was in a bid to take services away from a hospital situation and to centre the service around the patient themselves and what other support they had around them. She added that this would also have a positive impact on the DToC situation. She stated that the policy of Adult Social Care was to support the patient within their own home as much as possible, using facilities such as extra care housing, care support at home and using community support at home. She added that locality bases were working very actively together.

In response to a question about whether a proportion of patients were being regraded from one of requiring an emergency operation, to a non-emergency status, Diane Hedges gave her reassurance that it was not about regrading, but more about giving the correct advice to services. The CCG was looking to only having a reasonable number of people referred to urgent care, via the emergency services, and were asking clinicians to support that approach, by giving their clinical view. Lou Patten stated that there were strong indications in other areas, with similar demographical linkage, that this approach was both workable and cost-effective. Diane Hedges added that a whole range of emergency areas were now using clinicians and GPs, by, for example, increasing the level of GP involvement into the 111 service, GP support to the Out of Hours practices and hubs, and the offer of additional week-end appointments at surgeries. This had often caused a stretch on daytime services, tensions in the system, pressures on OH and on OCC funding. This work had been brought together by GP Federations, the Local Medical Council, OUH and the CCG. Lou Patten added that GPs had to offer a broad range of clinical competencies and it was necessary to comprehensively evaluate where this precious resource was being placed, and how it helped patients in the system.

A member asked if the extra GPs were being brought in from outside or whether they were already in the system. Diane Hedges and Lou Patten responded that the additional resource was often managed by a group of practices together, but it was in the province of the GPs themselves to manage their own resources. They had provided these additional resources either by extra recruitment or by operating leaner practices.

A member asked if a patient’s medical record could be instantly accessed by staff on admittance from another hospital. Stewart Bell responded that currently a number of different systems were in play. An Oxfordshire care summary was in place to view essential information such as patient notes from other systems. Not all were available, but good progress was being made to achieve this, for example, the OoH’s service was able to access GP records.

In response to comments from a member, Diane Hedges endorsed the importance of sustaining primary care. The nature of primary care was changing. Nationally, the introduction of different sorts of skill mix to surgeries in order to maximise GP time was under investigation, such as the introduction of clinical pharmacists to attend to, for example, the multiple medications for older people. Also the numbers attending Minor Injuries Units had reduced during the winter period and there was a need to understand why this was happening and what injuries patients were presenting with in order to make the best use of the service and the maximum use of services already in place.

Lou Patten added that GPs already had a good idea about how they could enhance their capacity and now it was about listening to the GP Federation Alliance, together with Oxford Health, for possible formal collaborative integration of services. In response to a question about why the GP contribution to the Winter Service Plan was not sustainable all the year round, Dr Collison explained that in primary care different levels could approach the problem ie. in the practice itself, at cluster or locality level. At local level there were possibilities, such as the introduction of nursing practitioners to take some of the GP load, or the movement of some of the GP’s paper work into the back office. There was a significant time reduction at cluster level which could be achieved, for example, the looking after older people in a more proactive way. At locality level, urgent access partners were available, together with visiting services. Notwithstanding this, there were many gaps in GP workforce and aspects of the job were being looked at to provide the variety which GPs were looking for, for example, rotation around different areas of the job.

Lou Patten was asked if it would be possible to develop a model which would result in a radical reduction in the numbers of patients attending A & E. For example, some local communities could perhaps pilot schemes to this end. She responded that she sat on the regional A & E Board and agreed that it was about understanding the population, getting into the communities, looking at what voluntary services were available and then assimilating the key factors. This could then be brought to five key priority areas.

At the close of the session, the Chairman thanked all representatives for their attendance and their input and requesting the following:

(a)  keeping evaluation reports and future plans focused and brief, and with the inclusion of some measurable impacts and targets and some indication if where original GP hours came from;

(b)  more information on the plans going forward for GP contribution, including what would be a measurable impact in percentage terms;

(c)  information on whether there was an issue around 7 day working in some localities and where was it not happening? Why was this? And what impact it was having in the areas where it had been introduced;

(d)  more information on whether Oxford City was the best place for the SoS bus and not Banbury? Was this service better suited to the city where there were greater numbers of people, in order to discourage people from going to A & E?

(e)  more information on who the third party providers were in relation to the 111 service and how Age UK assisted in returning patients to their own homes?

(f)   some detail on the additional costs of backfilling staff vacancies with agency staff and whether private providers had been used; and

(g)  more detail on hospital bed closures.