Agenda item

Karen Fuller (Director for Adult Social Care, Oxfordshire County Council) has been invited to present a report on pressures within the Oxfordshire Health and Care System.

PLEASE NOTE: This item will encompass key pressures affecting all of Oxfordshire’s health and care system partners in general, as well as some insights into the preparations being made for the pressures of the ensuing Winter season.

The Committee is invited to consider the report, raise any questions and AGREE any recommendations arising it may wish to make.

Karen Fuller, Director of Adult Social Care, introduced the system pressures update, along with Lily O’Connor, Oxfordshire Urgent Emergency Care Director.

They were joined by:

• Cllr Kate Gregory, Cabinet Member for Public Health & Inequalities;
• Ansaf Azhar, Director of Public Health and Communities;
• Veronica Barry, Executive Director of Healthwatch Oxfordshire;
• Dan Leveson, BOB ICB Director of Places and Communities; 
• Anne Carlile, BOB ICB Head of Urgent Emergency Care Programme; 
• Jenna Gilkes, BOB ICB Urgent Emergency Care Programme Manager;
• Sally Steele, Head of Hospitals;
• Felicity Taylor-Drewe, OUH Chief Operating Officer; 
• Louise Johnson, OUH Deputy Director Urgent Emergency Care; 
• Emma Leaver, Interim Chief Operating Officer for Community Health Services, Dentistry & Primary Care;
• Sue Butt, Oxford Health NHSFT Transformation Director;
• Kirsten Willis-Drewett, South Central Ambulance Service (SCAS) Assistant Director of Operations.

The Director of Adult Social Care emphasised the early discussion of system pressures and noted strong organisational collaboration. She cited many representatives as evidence of effective urgent and emergency care efforts. The Oxfordshire Urgent Emergency Care Director stated that despite challenges, Oxfordshire performed well compared to neighbouring counties during the previous winter. She identified gaps in care pathways and highlighted initiatives to reduce duplication, improve continuity, and enhance access to same-day emergency services. Successes in Banbury and Oxford City were noted, particularly in managing patients at home to improve outcomes.

The Committee inquired about improving outcomes, redesignating minor injuries units, public engagement strategies, and primary patient outcomes. The Oxfordshire Urgent Emergency Care Director clarified that the redesignation was mainly for reporting and might not occur, with services remaining unchanged. Simplifying information for the public was emphasised to guide them based on their symptoms. Key patient outcomes included better quality of life, reduced morbidity and mortality, and continuity of care, especially in deprived areas. The Director of Adult Social Care added that understanding urgent care options was crucial for timely and appropriate patient care.

The Executive Director of Healthwatch Oxfordshire requested details on recent developments and service functions, referring to the Healthwatch report. The Urgent Emergency Care Director explained that a detailed list of services, opening times, and functions had been compiled, with plans to provide comprehensive information to the public via the Oxfordshire Live Well website and Google searches.

Members discussed the 111 service, noting delays and initial contact with non-clinical staff. The Urgent Emergency Care Director and SCAS Assistant Director of Operations described the 111 service as integrated and effective, directing patients through care pathways using a directory of services. Non-clinical staff triaged calls, escalating them to clinicians, if necessary, with the ambulance service responding if a clinical response was needed within 30 minutes.

The SCAS Assistant Director of Operations explained that ambulance delays were managed through a triage system categorising calls from life-threatening to less urgent. Patients with worsening conditions were re-triaged to higher priorities. The Oxfordshire Urgent Emergency Care Director noted that delays were caused by inappropriate calls, multiple ambulances arriving simultaneously, and ensuring safe handover. Efforts were made to free up ambulances quickly for critical cases.

Members inquired about Oxfordshire's ambulance service performance compared to other UK regions. The SCAS Assistant Director of Operations reported South Central Ambulance Service ranked second or third nationally, with improvements in handover delays at Oxford University Hospitals showing strong performance.

The Interim Chief Operating Officer for Community Health Services stated urgent community response teams consisted of specialist practitioners providing immediate care. To manage increasing workloads, they aimed to reduce service duplication and improve capacity within specific areas, ensuring appropriate clinical response and managing expectations.

The Committee asked which services were most impacted by workforce and funding limits. The Oxfordshire Urgent Emergency Care Director explained that the issue was not just staff numbers but also skills, which take years to develop. Despite more funding, workforce availability remained challenging. Efforts are ongoing to reduce inefficiencies and ensure appropriate treatment settings to avoid unnecessary hospital admissions, aiming to align resources with demand and improve services. When asked if teams were available countywide, the Director confirmed they were, ensuring consistency and avoiding postcode disparities while addressing health inequalities in deprived areas.

Ansaf Azhar, Director of Public Health, arrived at this stage.

The Committee inquired about fiscal constraints affecting neighbourhood teams' deployment across the county and their impact on reducing hospital costs. The Oxfordshire Urgent Emergency Care Director explained that these teams bridged the gap between hospital discharge and primary care for high-risk patients, focusing on Banbury and Oxford City due to limited funding. Weekly multidisciplinary team reviews aimed to manage high-risk patients elsewhere. The BOB ICB Director emphasised that developing neighbourhood teams was part of a 10-year plan to identify populations benefiting from a multidisciplinary approach to improve access to services and support independent living at home, ultimately reducing hospital costs.

Members asked about addressing the mental health crisis and pathways for children and youth. The Oxfordshire Urgent Emergency Care Director noted Oxford Health's 24/7 crisis response, which reduced waiting times using successful models like Fleetwood's integrated neighbourhood teams for early intervention, starting in Blackbird Leys and expanding to Abingdon. Collaboration with schools and voluntary groups aimed to offer comprehensive support. Emma Leaver stressed managing patient and family expectations and ensuring proper clinical responses to lessen CAMHS's burden through early community interventions.

The Committee asked if redirecting patients from emergency departments to appropriate settings required more resources or better pathways. The Oxfordshire Urgent Emergency Care Director noted that South Central Ambulance Service (SCAS) effectively assessed patients at home while they waited for an ambulance, reducing hospital visits and admissions. Due to resource constraints, this service was available only at certain times, with plans to expand it. Collaboration between SCAS and other partners was key to their success, and SCAS performed well nationally in patient diversion efforts.

Concerns have been raised regarding Thames Valley Police frequently encountering individuals experiencing mental health crises, with crisis teams advising the public to contact the police. The Director of Adult Social Care acknowledged this issue but clarified that such advice was not standard practice. County Council and Oxford Health staff operated around the clock to manage acute mental health crises, coordinating Mental Health Act assessments as necessary. Kirsten noted a shift in policing practices, categorising mental health issues under healthcare, with the ambulance service responsible for acute situations and the police providing support only when there was a risk of harm to first responders.

Members inquired about the persistent rise in emergency department admissions despite initiatives aimed at reducing them. The Oxfordshire Urgent Emergency Care Director explained that some individuals relied on emergency departments as their primary healthcare due to difficulties accessing other services. Frequent emergency department attendees often overlap with regular GP practice visitors. Education and appropriate service responses are essential to addressing this issue. Projects targeting high-intensity users and individuals prone to falls are ongoing, yet visits following falls continue to increase. This situation underscores the need for improved public education and consistent service availability.

The Committee discussed the emergency department waiting times, asking about solutions involving staff or better assessment, and patient transfers. The OUH Deputy Director of Urgent Emergency Care explained that increased patient numbers required efficiency improvements, not more staff, due to skill and funding limits. Efforts included streamlining pathways, directing patients to appropriate care outside the ED, early senior doctor assessments, and quick specialist transfers to avoid delays.

The Committee sought information on smooth hospital discharge processes and clinical measures discussed with patients. The OUH Deputy Director of Urgent Emergency Care explained that daily discussions about discharge dates occurred with patients and were updated based on their progress. Before discharge, an assessment confirmed the patient no longer required hospital care and their early warning scores were within normal ranges for safe home management, possibly with additional services like acute hospital at home.

Members asked if there were plans to expand visiting services, virtual wards, and engagement outside traditional healthcare settings. The Oxfordshire Urgent Emergency Care Director stated they were reviewing visiting services in one area of Oxfordshire to identify duplication and unmet health needs. This involved collaboration with residents to understand their perspectives and requirements.

Members inquired about coproduction involvement in urgent and emergency care. The Oxfordshire Urgent Emergency Care Director clarified that coproduction had been extensively integrated, especially in developing integrated neighbourhood teams. This collaboration included working with local councils and community groups to address specific needs of different areas. Projects in Barton and Banbury highlighted significant input from local residents, shaping services to meet each area's unique requirements.

Further inquiries were made regarding optimising digital technology and data to alleviate pressures on urgent and emergency care services. The Director explained that they had invested in personnel for data optimisation. Comprehensive data collected by GP practices, encompassing emergency admissions, reasons for admissions, age demographics, and more, were updated monthly. Collaboration with the Public Health Director’s team aimed to focus on areas of deprivation and identify unmet health needs, developing a model to interpret primary care data more effectively.

The Committee AGREED to issue the following recommendations subject to minor amendments to the wording offline:

1. To increase engagement with the public to provide reassurances as to any specific outcome measures around Urgent and Emergency Care Services, including successful/unsuccessful outcomes and whole system working more broadly. It is recommended that there is communication to help people receive the urgent care they need.

2. To ensure that there is sufficient planning, support, and resourcing for supporting patients experiencing a mental health crisis. It is recommended that the whole system focuses on the reduction of inappropriate and costly mental health inpatient settings, with a view to improving alternative community-based settings and local crisis responses.

3. To ensure that you continue to engage in coproduction as part of the development of Urgent Emergency Care Services, including around the Integrated Improvement Programme. 

4. To ensure that determinations of medically fit-to-discharge include consideration with the patient and their carer of specific national frameworks such as the meaning of the patient’s National Early Warning Score (NEWS).

5. For there to be sufficient investment in the Neighbourhood model and Multi-Disciplinary Teams, and for evidence to be provided as to whether there is sufficient or insufficient investment. It is recommended that there is a whole system mapping exercise that includes Town and parish councils with local knowledge of community projects and stakeholders (who can also contribute at a neighbourhood level to support reduction of risks and a whole population approach).