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Buckinghamshire Health & Social Care

Operational Resilience & Capacity Plan 2014/15

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Operational Resilience & Capacity Plan



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DOCUMENT CONTROL

Title Buckinghamshire Health & Social Care Operational Resilience and Capacity Plan

Author Bernadette Devine Urgent Care Commissioning Lead

Owner Robert Majilton

Approval Routes

Buckinghamshire Urgent Care Working Group (Systems Resilience Group) V4.3 Resubmission Systems Resilience Task & Finish Group Internal approval by organisations in line with their internal governance processes

DOCUMENT HISTORY

Version Date Comment

V1.0 16.07.14 Internal draft

V1.2 28.07.14 Internal Draft

V2.0 01.08.14 Draft For Provider Input - Circulated

V3.0 06.08.14 Final Submitted to Area Team

V3.1 07.08.2014 BHT amends (SC)

V4.0 20 08 2014 Internal draft following NHSE feedback (Ian Cave)

V4.1 22.08.14 Internal Draft BD

V4.2 26.08.14 Internal Draft Updates from KH

V4.3 27.08.14 RM In Put BD FINAL Submission

V4.4 15 09 2014 Submission to NHSE

V5.1 18 09 2014 Resubmission incorporating feedback from NHSE



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CONTENTS

Executive Summary ..............................................................................................................

Section 1 Overview ...............................................................................................................

1.0 Executive Summary

1.1 Introduction

1.2 Context and Overview

1.3 System Risks

1.3c Mitigating actions

1.3b Risk management

1.4 Urgent care national and local

1.5 Performance Intelligence and System Resilience Plans 2014/15

1.6 Urgent care current performance

Sustaining Resilience in Urgent Care (criteria 1 - 13)

Sustaining Resilience in Elective Care (criteria 1 - 13)

2.0 BHT Acute Site Partner

2.1 Winter 2013/14

2.2a ECIST

2.2b Care Quality Commission (CQC)

2.3 RUC Work Programme Plans & Impact

3.0 SCAS & Resilience Planning for Buckinghamshire

4.0 System Resilience Planning 2014/15

4.1 National Timeline

4.2 ORCP Assurance Process

4.3 Continued Governance & Oversight

4.4 High Risk Reporting Requirements

4.5 SRG Task & Finish Group

4.6 Daily Resilience Calls

4.7 Patient Centred Service

4.8 Ambulatory Care Pathways

5.0 Stakeholder Engagement and Empowerment

5.1 System Winter Communications and Engagement

6.0 Primary Care: Planning and Whole System Capability

6.1 Flu Planning

7.0 Mental Health Services

8.0 Evidence Based and Research Reviews

8.1 Winter Review and Lessons Learned

8.2 Resilience Bids 2014/15

8.3 Whole System Review: SRG Task & Finish Process

9.0 Winter Bids

9.1 SRG ORCP Template Collation



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Appendices

Appendix I – 2013/2014 – Winter Schemes

Appendix II – Gap Analysis

Appendix III- 2014/15 Winter Schemes Prioritisation Framework & Bid Template

Appendix IV – SRG Templates

Appendix V - NHS England – Meeting the Standards for Urgent Care: A minimum

standards checklist.



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Performance Overview

1.0 Executive Summary Buckinghamshire Operational Resilience & Capacity Plan (ORCP) has a vision for

unscheduled care to ensure that people receive good access to high quality services

according to their clinical needs, and that these services are delivered coherently and at best

value for money. The overarching aim is to commission an integrated urgent care system

that seeks to reduce demand for hospital based services by commissioning responsive,

accessible and integrated services outside of hospital that offer choice, meet local need and

are value for money and produce a sustainable and measureable return on investment.

Our vision for the future is one of increasingly integrated services that meet patient needs,

delivers better outcomes and makes efficient use of available resources. A greater

proportion will be provided outside hospital settings – whether for acute, community, mental

health or other needs. Patients will be active participants in maintaining their own health as

well as exercising choice in relation to care. Where it is appropriate for care to be based in

hospitals, this will be delivered to higher standards and in line with agreed pathways.

This document sets out the plans of health and social care partners to support the

unscheduled care patient pathway and is informed by national frameworks of both

description and delivery of service provision1.

1 Transforming urgent and emergency care services in England Phase 1 Report



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1.1 Introduction This plan has been developed in response to the Operational Resilience and Capacity

Planning guidance for 2014-15 published on 13 June 2014 and prepared by NHS England,

the NHS Trust Development Authority, Monitor and the Association of Directors of Adult

Social Services. It describes the Buckinghamshire health and social care approach to

operational resilience and capacity planning for 2014-15. The work described in this plan will

set the ground work for longer term outputs from the National Urgent and Emergency Care

Review.

The plan will be subject to further development during August and posted on the websites of

the Buckinghamshire (CCGs) in September 2014. The plan will be refreshed in October prior

to winter 2014-15.

This ORCP complements both the Whole Systems Resilience Escalation Framework for

Berkshire & Buckinghamshire 20142, and the Major Incident Plan. The former describes how

to manage surges in demand and lack of capacity on a daily basis within existing resources.

The latter describes how to respond to extraordinary events. The ORCP describes how

additional resources will be utilised to improve patient flow and reduce delays.

1.2 Context and Overview

The Buckinghamshire health and social care economy is comprised of the following key

organisations:

Aylesbury Vale CCG, with a population of 200,000

Chiltern CCG with a population of 320,000

Buckinghamshire County Council

Buckinghamshire Healthcare NHS Trust

Oxford Health NHS Foundation Trust

Bucks Urgent Care

South Central Ambulance Service NHS Foundation Trust

Heatherwood and Wexham Park Hospital NHS Foundation Trust

Buckinghamshire Healthcare is co-terminous with Buckinghamshire County Council,

covering a population of over 500,000. This affords excellent partnership and joint planning

2 Whole Systems Resilience Escalation Framework for Berkshire & Buckinghamshire v 2.0 March

2014.



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opportunities and provides sufficient critical mass for our specialist services. As expected

from this geographical co-terminosity, our main commissioners are Aylesbury Vale and

Chiltern Clinical commissioning Groups, which account for over 86% of our local income.

This is set out in the diagram below:

Figure 1: Clinical Commissioning Groups



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Fig 2 Population Heat map and Acute Care Settings AVCCG Settings

Local intelligence and analysis demonstrates that population growth and demographics will

be a major factor in understanding the future baseline demand levels and service provision

required. Over 17% of Buckinghamshire’s population is over 65 with the proportion predicted

to increase to 21% by 2022. It is this section of the community who are major users of health

services with 40% of people over 65 years reporting a limiting long-term illness.

Within Buckinghamshire, there are two main areas of deprivation, Aylesbury and High

Wycombe, accounting for 2.5% of the local population living in the most disadvantaged 30%

of the population as a whole. Such populations have high levels of morbidity and in

Buckinghamshire, cardiovascular disease, cancer, diabetes and COPD are long term

conditions of high prevalence locally.

The health impact and disease burden is as follows:

Circulatory Disease 35%

Cancers 28%



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Respiratory Disease 14%

The local health economy is facing a significant financial challenge. To address this the local

health and social care community have been working together to outline a strategy to reduce

the reliance on acute care through increasing the range and availability of services in

community/primary care and develop more integrated services across health and social

care. This is explicit in the commissioning intentions for both Chiltern and Aylesbury Vale

CCGs. BHT has sought to ensure its strategy is aligned to that of its commissioners.

In order to deliver their commissioning intentions the two CCGs will work together to jointly

commission through matrix working. Five Programme Boards have been established to

implement change across the area and support the QIPP agenda. These intentions are

reflected in our strategy to further develop our integrated services, provide more

comprehensive out of hospital alternatives and develop a more planned approach to

managing those with long-term conditions3.

1.3a System Risks

The Urgent Care pathway and the Planned Care pathway are both central to the system

resilience delivery 2014/15 and are acknowledged as part of the overall strategic risk for

BHT.

Key risks for 2014-15 include:

BHT expanded bed capacity not being in place until January 2015

Social care

Primary care capacity

Lead in time for recruitment of new staff.

There is a financial risk of slippage. This is low risk as it involves specific funding for teams,

risk of higher agency costs if recruitment slips. But there are opportunities from slippage on

other schemes to mitigate this if it occurs.

1.3b Risk management

Management of resilience risks are an integral part of the existing risk management

processes for urgent care which form part of the CCGs corporate risk management

framework. Urgent Care risk registers are reviewed by SRG / UCWG monthly. High risks are

escalated to CCGs Executive Teams and Governing Bodies.

3 BHT Integrated Business Plan 2014/15 – 2018/19 V1.0



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There are twice daily resilience teleconferences which are part of the system escalation

framework and organisations have business continuity plans (BCP) in place. The BHT BCP

has recently been recognised by the Thames Valley NHSE Emergency Planning lead as

being of a high standard.

Operationally many key performance indicators for monitoring resilience are already in place

and reviewed by the BHT Reforming Urgent Care (RUC) Programme Board every two

weeks and by SRG / UCWG each month. These will be supplemented by additional

measures for new services funded over winter. Every week the System Resilience

Programme Manager employed by the CCG will meet with the Urgent Care Programme

Manager from BHT and other key Providers to review these KPIs during the weekly SRG

sub group meetings. This will facilitate early issues identification and early escalation.

This will create the ability to utilise funding from slippage to effectively respond to events as

they unfold on the ground e.g. by implementing bids which have been kept in reserve.

1.3c Mitigating actions

Actions to mitigate key risks included:

a) BHT expanded bed capacity not being in place until January 2015

Mitigation:

BHT reconfiguring existing bed use to reduce safari ward rounds and so improve

Estimated Date of Discharge (EDD) planning and reduce length of stay (LOS) so

reducing the bed capacity required.

Implementation of ambulatory care

Flexible use of escalation beds

Predictive modelling of demand to inform staff rotas so that there is adequate staff

capacity

b) Social care : Quantification of the impact of same day and 7-day s256 initiatives

Mitigation:

Utilise BCF mechanisms to implement changes

Working in partnership with Bucks CC through Adult Joint Executive Team meetings

to maximise use of s256 funding.

These schemes will be in place during Q3 so SRG can assess impact early



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c) Primary care capacity

Mitigation:

Use of Over 75s funding (£1m AVCCG + £1.6m Chiltern) e.g. Care Home Matron;

Vulnerable Older Persons Peripatetic Nursing; Primary Care Early Intervention team.

Piloting and evaluating “Doctor first” approach to GP triage

Implementing an acute visiting service in Chiltern and exploring extending this.

d) Lead in time for recruitment of new staff.

Mitigation:

Using a range of existing staff more flexibly

Funding Psychiatric In-Reach Liaison Service (PIRLS) to older people wards to

reduce LOS and increase capacity in A&E to reduce 4hr breaches.

Funding 7/7 support services; phlebotomy and a team of pharmacists to cover A&E

CDU seven days a week 7am-8pm and at weekends.

Funding increased radiology resource to increase the urgent care capacity.

1.4 Urgent Care National and Local

Urgent care describes medical conditions which do not require hospital admission and can

be managed without a trip to an emergency department. Instead the patient could be treated

using local community services or out-of-hospital facilities. This is distinct from 999 life

threatening emergencies and those major traumas that must be dealt with in Accident &

Emergency Departments, and regional centers such as the specialised stroke unit and

cardiology unit.

Over recent years, NHSE and stakeholder partners have been developing Urgent Care

pathways to provide the best care in the most appropriate care setting. A variety of facilities

and pathways have been developed, including Walk in Centers, Minor Injury and Illness

Units and Urgent Care facilities. The initial provision and development was to reduce

pressure on A&E as understood in the formal definition of such facilities (Tier 1-3). However,

A&E has continued to see a sustained growth in both demand and activity and locally, has

struggled to reach the 95% performance target levels on a consistent basis in the first

quarter of 2014/15.



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Nationally the directive is now to call any facility and pathway that does not require advanced

clinical life support and trauma input a Urgent Care Centre, this, it is hoped will reduce any

confusion in communication that the public may be have in relation as to where to go for the

best and most appropriate level of care. In turn, this will reduce the pressure in Emergency

Departments and will ensure patients get the best care possible in the best place for both

their immediate needs and longer term health outcomes.

The development of Urgent Care Networks will also facilitate the development of

comprehensive urgent care pathways, including that of Ambulatory Emergency Care, which

has the potential to develop Cardiology, Respiratory, Neurology, Rheumatology pathways

along with medical HOT clinics.

Locally across Buckinghamshire there are a suite of Urgent care provision centers, including

a minor illnesses and injuries unit at High Wycombe. MuDAS is a service also based at High

Wycombe which provides direct GP access for elderly patient assessment which is widely

recognised as an excellent contribution to patient experience and outcomes, along with

admission avoidance.

The current challenge with MuDAS is increasing its use and there are plans to expand the

service to the Stoke Mandeville site to spread the learning and incorporate MuDAS at the

front door provision of Stoke Mandeville hospital. Currently patients that arrive at Stoke

Mandeville Hospital are transported to the High Wycombe site, and both the challenge and

opportunity of the current provision is being picked up as resilience bid initiatives.

1.5 Performance Intelligence and System Resilience Plans 2014/15

Buckinghamshire’s plans to develop a system-wide dashboard will enable the system to see

it performance in a targeted way, enabling better use of resources going forwards. Along

with plans to standardize the reporting templates, including that used on the daily resilience

call. This will allow clear views of current performance and will result in faster decision

making.

Linking performance and activity to clinical outcomes will support future commissioning

decisions which reflect the development of the new system-wide pathways, such as frail

elderly care, which further reflects the population health and social care needs of

Buckinghamshire.

1.6 Urgent Care Current Performance



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A&E 4 Hour target

The Buckinghamshire urgent and emergency care system performed relatively well during

2013/14 achieving 94.9% overall for the year (compared to the target of 95%). However

Quarter 1 of 2014/15 has been a challenge to consistently hit the 95%.

A number of local acute providers are also struggling to consistently deliver the 4 hour

standard.

1.6.1

Urgent Care Information



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The Urgent Care Working Group has been reviewing the Management Information pack and

this is being co-ordinated through Central Southern CSU and provider information teams to

develop a richer source of information (part of developing the Urgent Care dashboard) from

which to drive actions to improve performance across the urgent care system and support

monitoring impact of resilience plans. Some initial analysis of available commissioner

information is provided below while that work continues.

The examples below are surrounding A&E.

The data is largely comparing April and May 2013 with the equivalent in 2014.

Accident and Emergency

Who attends A&E?

Table 1 – A&E attendances by age group and arrival method

1.6.2



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The largest groups are over 75 (who largely arrive by ambulance) and 0 – 4 (who arrive by

another means).

How do they get there?

Table 2 – Source of Referral for A&E attendances

1.6.3



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Table 2 shows that of the 3 top categories general increases of 3 – 5% have been seen in

self referrals and emergency services with a 3 – 10% increase in GP referrals.

When do they get there?

Table 3 – A&E attendances by Age and day of week

1.6.4



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This chart shows the largest groups of attendances are Over 75 and 0 – 4. For over 75 the

busiest days are Monday and Friday and the busiest day (Friday is 19% higher than

Sunday). For 0 – 4 the busiest day is Sunday which is 18% higher than Wednesday.

TABLE 4 – Hour of arrival by age group

1.6.5



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The table above shows a heat map of hour of arrival by age group showing the spread of

attendances.

What happens to them?

Table 5 – Discharge Destination

1.6.6



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The majority are discharged either with our without follow up from their GP with the next

largest group being admitted.

1.6.7



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Figure 11: Our emergency activity by division and specialty – 2013/14

Figure 12: Our elective activity by division and specialty – 2013/14

Elective Care Graph 1 Reduction Trajectory 18 Weeks / Plastic Surgery

Integrated Medicine

39%

Specialist Services

41%

Surgery & Critical Care

20%

Emergency Admissions by Division

General Medicine

22%

Paediatrics20%

Obstetrics14%

General Surgery

8%

Cardiology8%

Trauma & Orthopaedics

6%

Midwife Episode

6%

Stroke Medicine

3%

Urology2%

Respiratory Medicine

2%

Other9%

Emergency Admissions by Specialty

Integrated

Medicine

27%

Specialist

Services

25%

Surgery &

Critical

Care

48%

Elective & Daycase Admissions by Division Gastroenterol

ogy

18%

Ophthalmology

10%

Trauma & Orthopaedics

10%

Clinical Oncology

9%

Clinical Haematology

7%

General Surgery

7%

Plastic Surgery

6%

Urology5%

Gynaecology4%

Other24%

Elective & Daycase Admissions by Specialty



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1.6.8 Graph 2 Reduction Trajectory 18 Weeks / Trauma & Orthopaedics

Sustaining Resilience in Urgent Care



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1 Enabling better and more accurate capacity modelling and scenario planning across the system

SCAS already use historical information to model and predict the staff capacity required on a

daily basis across the eastern node area, and the number of patients who will be conveyed

to hospital. Commissioners are working with SCAS to identify whether this data can be used

to assist BHT and HWWP to proactively plan for admissions.

BHT A&E department also use historical data to predict daily A&E attendances and plan

staff capacity so they have sufficient staff to manage the majority of patients who are

discharged from A&E.

UCWG have already undertaken modelling of urgent care flow across the pre-hospital

system comparing activity and flow on bank holiday Monday with a normal Monday to

identify bottlenecks in the pathway. This demonstrated the ability of providers to reduce

variation in demand for A&E

1.6.9.



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BHT have followed best practice to implement a Rapid Access Team (RAT known locally as

IAT) at the front door and segmentation of patients requiring more than 4 hours for treatment

into CDU, AMU and SAU. But this has not been sufficient to improve patient flow through the

entire hospital. As a result Capita has undertaken bed modelling within BHT and highlighted

SMH is 20 medical beds short which is preventing patients being admitted to a specialty

ward and gaining fast access to the relevant clinicians. The resilience plan, supported by a

bid against strategic capital (pending), consolidates escalation capacity within the main

Stoke Mandeville Hospital site, by providing 20 bed capacity.

SCAS recognise periods of high activity (using our predicative capability) and are proposing

to deploy system capacity vehicles to mitigate the possibility of patient risk, as part of bids for

resilience funding

Central Southern CSU has Simul8 software

http://www.simul8.com/products/guidedtours/index.htm?j=10 which we are exploring for use

in capacity modelling. It can be used to compare the effectiveness of existing BHT systems

(A&E; CDU; AMU; SAU) with IMAS experience and recommendations

http://www.simul8.com/products/guidedtours/index.htm?j=10



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http://www.nhsimas.nhs.uk/fileadmin/Files/IST/Unscheduled_Care_Pathways_meeting_dem

and_and_delivering_quality.pdf

The Thames Valley Area Team is identifying potential capacity modelling tools to be adopted

across Thames Valley, and Buckinghamshire CCGs are keen to participate fully in the use of

any tools adopted.

The CCG led Long Term Conditions programme are implementing initiatives to reduce

variation in demand for urgent care. These include rollout of Adastra electronic template for

Advanced Care Plans, which are shared with other urgent care providers. This will be

incentivised by the Admissions Avoidance DES and improve the quality of patents

experience by increasing the number of people who die in their preferred place. It will also

reduce admissions to hospital in the last 72 hours of life.

2 Working with NHS 111 providers to identify the service that is best able to meet

patients’ urgent care needs

Within the ORCP NHS 111 provision is central to current delivery of patient pathways and

vital for future resilience and capacity planning. NHS 111 is a non-emergency number for

accessing local health services. The service acts as a single point of access for urgent care,

providing triage and assessment for callers to ensure they access the best care by

simplifying access to urgent care and emergency care where necessary.

NHS 111 pathways and Directory of Service development (DOS) are part of a continual

process of national development for local delivery and in Buckinghamshire, NHS 111 have

developed a recover plan to ensure resilience and performance monitoring and service

delivery.

Buckinghamshire CCGs directly commissions the Central Southern Commissioning Support

Unit (CSCSU) to maintain, expand and update the Directory of Services (DoS) supporting

NHS 111. The NHS 111 team performs multiple functions, including Forward-planning and

transformative management and the operational maintenance of the DOS Including:

http://www.nhsimas.nhs.uk/fileadmin/Files/IST/Unscheduled_Care_Pathways_meeting_demand_and_delivering_quality.pdf

http://www.nhsimas.nhs.uk/fileadmin/Files/IST/Unscheduled_Care_Pathways_meeting_demand_and_delivering_quality.pdf



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3 Taking part in the Thames Valley dental Out of Hours Review, ensuring that

improvements to community services directly enhance the ability of NHS 111 to refer

effectively into urgent dental care.

4 Reviewing access criteria for walk-in services (Walk-in-Clinics, Minor Illness/Injury Units,

Urgent Care Centres etc), to signpost away from Emergency Departments and into local

community services that provide efficiencies for the health economy as well as a better

pathway for the caller

5 In-depth analysis of call-data from the NHS 111 provider leading to improvements to

NHS 111 referrals, from minor service entry edits for clarity, to re-prioritisation of services

and re-modelling of how the patient can receive the care they require in the best

timeframe

6 Plans to expand DoS capabilities,

7 Having mobile device access for community health professionals to be able to look up

services anywhere at any time

8 DoS rollout to healthcare colleagues in practice settings for information on 3rd sector,

charity and other support networks where they overlap health and social care. In a single

package, the system can support NHS 111 Pathways in the call centre and also health

colleagues across the economy.

9 Ensuring Protected Learning Time cover is seamless when callers are re-directed from

111 to the covering organisation; that Bank Holiday extended opening times for

pharmacies are always accurate so a patient is never incorrectly signposted; changing

details when service demographics change.

10 Clinical leads are always consulted by DoS management upon a change to an entry, be

it the introduction of a new service or pathway, or due to an upgrade to the Pathways

triage tool meaning DoS must be edited. This process is proven to be robust and has

been in-place since go-live.

3 Additional Capacity for Primary Care

Primary care provision and capability is central to the overall delivery of the resilience and

capacity planning currently underway in Buckinghamshire. Patients interface with primary

care 95% of the time in all health profiles, and as such primary care becomes increasingly

central to health and social care delivery.

Practices across Buckinghamshire are facing high urgent care needs demands and a

number of schemes are underway, supported by the current resilience bids submitted.



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Seven day working and greater access to multiple primary care sites and care /social needs

provision will also provide patients with responsive and flexible care which will also prevent

patients going to A&E as a default position, thereby reducing A&E minor attendances.

Research has shown that busy and clogged A&E departments place patients at greater risk.

As part of planning for 2014/2015, the system has looked back on winter 2013/2014, and

has reflected that it was mild overall with minimal disruptive weather, and few cases of noro

virus outbreak. This will also facilitate a more targeting approach to seasonal surge and

resilience planning across the winter months of 2014/15.

It is anticipated that primary care will play a pivotal role in delivering our vision to meet

people’s needs in the community wherever possible and the CCGs will look to facilitate this

through the development and implementation of a Primary Care Strategy, including well

developed primary care co-commissioning arrangements with NHS England which will

enable us to improve quality in primary care and to employ new contracting mechanisms as

appropriate.

Improving Access to Primary Care initiatives:

“Doctor first” type telephone triage has been piloted in Chiltern CCG and has been found to

improve patient access and GP capacity. The CCG is engaged with five more Practices to

extend this further during 2014-15.

In AVCCG two Practices are exploring the use of “Web GP”. This will be evaluated as part of

increasing Primary Care resilience.

Further use of technology to improve capacity and resilience in primary care is being

explored. The following approaches are being considered by practices to improve capacity.

e-mail e.g. patients e-mail questions to GPs via secure e-mail

Texts for appointment reminders and possibly for sharing test results

Online viewing of patient records by patients (including results)

Online repeat prescription requests

Online appointment booking



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Over 75s funding and Admissions avoidance DES (£1m AVCCG + £1.6m Chiltern)

4 Improve services to provide more responsive and patient-centred delivery seven

days a week & 6 Seven Day working arrangements

Actions taken within Buckinghamshire Whole System:

A seven day working gap analysis was undertaken with BHT to review provision, gaps to

inform the internal BHT Reforming Urgent Care Board, (Se Appendix II).

Funding extending Psychiatric In-Reach Liaison Service (PIRLS) to older people wards to

reduce LOS and increase capacity in A&E to reduce 4hr breaches. KPI: Time of referral

request to being seen.

Funding 7/7 support services; phlebotomy and a team of pharmacists to cover A&E CDU

seven days a week 7am-8pm and 7-8 at weekends.

Funding increased radiology resource to increase the urgent care capacity.

Recruited for 7/7 social care staff at SMH to increase weekend discharge.

Investing in additional ACHT cover out of hours.

Implemented ambulance referral to ACHT, MuDAS and Falls service.

Utilising Red Cross services following discharge to reduce readmissions.

ASC are developing 7 day capacity for social care due to begin in September

5 SRGs should serve to link Better Care Fund (BCF) principles in with the wider

planning agenda

Rolling out 2 hours crisis response to provide carers at home to prevent admissions. This is

jointly supported by ACHT and BCC commissioned Buckinghamshire Care staff.



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Buckinghamshire has aspirations to create a large BCF that covers the commissioning of all

out of hospital services for older people (up to £100m). An Outline Business Case has been

approved and further work will be undertaken to develop the model and align existing

services to it in the interim. For example the development of 7 day services for social care,

funded from s256 monies will be in line with the model described in the OBC

6- See Point 4 7 Expand, adapt and improve established pathways for highest intensity users within

emergency departments.

Within BHT and Heatherwood & Wexham Park Hospitals, work has been undertaken to

review and streamline pathways. At BHT the Reforming Urgent Care Programme Board

(RUC) has clearly defined work streams to look at identified pathways and the patients

therein, to ensure patient needs are met. The frail elderly pathway has also been reviewed

as a whole system improvement process by the August Urgent Care Working Group, see

page 24, whereby gaps and recommendations have been identified.

The frail elderly, due to their complexity require multi-disciplinary input and continued

assessment across multiple agencies and in all settings of care, including their own home,

and by the whole system mapping exercise, the system know better understands the need

beyond bed based care and location specific provision. The requirement for better social

care involvement is understood and is a focus of current work stream developments.

The mental health pathway has also been a focus of reform, and locally, services are in

place in the Accident & Emergency setting to ensure patients receive assessment and care

early on in their presentation. The PIRLS service and the extension of the PRILS service via

current winter funding bids 2014/15, will continue to support mental health crisis patients

who present to the acute sector.

The minors pathway is clearly established in all acute trust sites with the MIIU based at High

Wycombe providing further access for the treatment of minor injuries and illnesses, ensuring

robust streaming of care pathways and increasing access by 24/7 provision.



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AVCCG has returned the table below to the Area team as part of a recent audit request to

underpin local system resilience, and has undertaken a system-wide Frail Elderly Pathway

review as part of the local Urgent Care Working Group and SRG work programme.

Table AVCCG Area Team Return Local Resilience Best Practice

Diagram Frail Elderly Flow Diagram Worked up by AVCCG & CCCG August 2014



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8 Have Consultant-led rapid assessment and treatment systems (or similar models)

within emergency departments and acute medical units during hours of peak demand

The PIRLS service has been commissioned to provide rapid assessment within the ED

service. As of the 18th August the service will be present within the department from 07:30-

21:00 7 days per week. The service is seeking to enhance its activity and output via winter

bids submission and hopes to be able to provide at 24/7 service. Nationally there is a

shortage of inpatient mental health beds and this does impact on the A&E department and 4

hour times as patients experience delays in accessing care in the appropriate setting. This

is borne out by local resilience call information.

BHT have:

Extended the physician of the day (POD) provision at weekends. The Trust now have

a second Physician of the Day present on site on Saturdays and Sundays. This

ensures that patients have access to senior decisions makers.

POD hours have also been extended to later in the evening (20.00) 7 days per week.

This accelerates response times for access to a senior decision maker early into the

evening.

Invested in ED nursing and medical workforce alongside on-going workforce

redesign and development.

Redesigned the pathway in ED to enable rapid assessment of arrivals and early

redirection to appropriate services.

Reconfigured the bed base to open an Acute Medical Unit and Surgical Assessment

Unit and developed short stay ward pathways including specialist in-reach.

Introduced a multi-disciplinary and multi-agency review team across A&E and Acute

Medicine to review frail older people on arrival at hospital to support discharge

decision making.

Increased ACHT transfer of care lead presence on the Acute site and this is now the

case 7 days a week.



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Introduced Geriatric Liaison Services and multi-agency review teams to offer early

specialist assessment and planning.

Appointed more senior consultants to provide a 7 day a week service and

Community geriatrician to develop an emphasis on admission avoidance/discharge

to assess.

Introduced multi agency groups at practice level to support patients to access care in

advance of a crisis and support prevention.

9 All parts of the system should work towards ensuring patients’ medicines are optimised prior to discharge BHT as the acute provider have undertaken the following actions to improve patient

medicine optimisation:

There are clinical pharmacists at ward level who reconcile patient medicines on

admission and discharge and throughout the patient’s stay, to optimise medicines for

patients and support patient outcomes - Reconciliation includes medication

interaction of newly prescribed medicines

Urgent Care Pathway focus incudes oversight and intervention via the pharmacists

on the wards who are close to the very sick and or deteriorating patients

TTOs are prepared in timely manner. In 2014 satellite pharmacy has been introduced

in cardiology, acute medicine and surgery. This reduces dispensing time, which at

ward level =is 20-30 minutes turnaround time and in main pharmacy it would be 90

minutes.

2014 electronic discharge summaries are being developed and this will include

medicines as part of the summary with a copy for the patient and an email copy to

the GP, this begins in November/December as a pilot.

10 Processes to minimise delayed discharge and good practice on discharge BHT continues with its RUC programmes chaired by the COO to ensure delivery of the

determined change programme. The RUC’s five work streams are looking at the internal flow

system of BHT and redesigning flows, pathways, roles and settings of care as part of its



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portfolio to begin to free up the internal flow. The front door aspects of BHT are also

dependent to an extent on the backdoor discharge flow being available and the RUC also

focuses on the entire pathway.

New models include, Discharge to Assess / Assess to Admit, and the integration of Health

and Social Care Funds, providing an opportunity to link up the system for the best outcomes

for patients, carers, and families.

Which simplified, illustrates the expectation and outcome of right care right place right

patient ethos, alongside three sections of pathway:

A) flow prior to hospital admission,

B) flow through hospital admission

C) discharge and discharge / community interfaces.

• Current actions and progress includes:

• Recruiting for 7/7 social care staff at SMH to increase weekend discharges

• Investing in additional ACHT cover out of hours

• Funding additional spot purchase of beds

• Implementing discharge to assess models of care

• Funding increased BHT Rehabilitation and Reablement Service

• Funding extra step down community rehab bed capacity for Bucks patients in

Wexham Park A&E and PACE service

• Funding a vulnerable care home nurse facing WPH

• Fund a Carer's Hub from 11.00-18.00 Mon-Fri at SMH

• Implemented ambulance referral to ACHT, MuDAS and Falls service

Within BHT current actions include:

• Daily Operational (site management) meeting attended by multi-disciplinary teams

to enable identification and owner of the actions needed to ensure the most efficient

use of bed capacity within BHT whilst ensuring that patients are placed appropriately

according to their clinical needs. Attended by ward sisters at 08:30 daily to identify



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patients ready for discharge and any issues that need addressing to enable

progression along the discharge pathway.

• Daily Facilitated meetings Monday – Friday- These involve a multidisciplinary,

including ASC, review of patients daily on wards to gather intelligence of systematic

delays and an action plan to resolve. Going forward these are further enhanced by

the consultant based on the ward to support and lead discharge planning

• Daily Integrated Discharge meetings (IDM) with Adult Social Care to identify

patient needs and agree actions in order that patients are transferred safely and

timely to appropriate care settings for their needs. The forum is a platform for raising

awareness of patient’s individual needs and where a whole system approach works

for the patient and their carers needs to minimise constraints and resolve issues

using a collaborative approach. Delayed discharges are identified and plans agreed

to progress discharge.

• Daily teleconference call with CHC to discuss patients who meet Continuing

Healthcare eligibility and agree the Lead responsible for co-ordinating care.

Information is fed into Daily IDM.

• Daily teleconference call with Herts to discuss patients who are eligible for

Hertfordshire social care support. Information is fed into the daily IDM

• Teleconference call with Hertfordshire CHC as needed to discuss patients who

meet Continuing Healthcare eligibility and agree the Lead responsible for co-

ordinating care. Information is fed into Daily IDM.

• Call with other OOA authorities as needed to discuss patients who meet CHC/ASC

eligibility and agree the lead responsible for co-ordinating care. Information is fed into

Daily IDM.

• Escalation pathways for OOA are in place and utilised as required.

11 Plans should aim to deliver a considerable reduction in permanent admissions of

older people to residential and nursing care homes



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Bucks has a low rate of hospital admissions from Care Homes compared to many other

areas which are cited as good practice e.g. Bath & NE Somerset and Derbyshire. This

position has been achieved following HIEC work in AVCCG and Milton Keynes in 2012 and

taken forward through a local enhanced service which ensures residents of care homes

receive weekly access to GPs in the Care Homes to provide long term conditions

management, medicines optimisation and advanced care planning.

This service is supported by a community geriatrician who has been appointed in the last

year by BHT. She is able to bridge secondary and community care and target her input to

those care homes with high NHS use which have not benefited fully from the GP LES. This

NHS work is in partnership with the local authority Care in Quality Team (QiCT), which work

closely with Bucks care homes to ensure they achieve the required standards expected by

CQC.

In 2013/14 BHT led on a winter bid scheme for spot purchasing of beds. The extra capacity

was seen as providing useful system capacity and has been repeated for 2014/15 as a

winter bid led by both CCGs.

There is also a Medicines Management Pharmacist supporting QiCT and reviewing

medication in care homes. This complementary and co-ordinated approach enables care

homes in apparently high use of NHS services to receive input which assists them in being

as efficiently organised as possible and for their residents to benefit from optimisation of their

medical conditions. The CCGs regularly evaluate which care homes are having high SCAS;

A&E and admissions, and reprioritise these services to support where there is greatest need.

In the south of the county we plan to fund a vulnerable care home nurse facing WPH

In AVCCG one locality is also piloting a Care Home Matron approach to identify added value

to the existing services.

In addition the CCG’s are investing under the Over 75 Fund in Primary care capacity to

support older people where they reside.

12 SRG plans should utilise patient risk stratification tools with an aim of gaining a

better understanding of the needs of the 2-5% percent of highest risk patients



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Buckinghamshire resilience planning incorporates the Unplanned admissions DES and

locally, 100% of GP practices have signed up to deliver, participate in and work through

MAGs to ensure best practice for patients for their care needs.

This includes the use of the ACG clinical risk stratification tool, and completion of the Bucks

Coordinated Care Record which is supported via the Adastra platform. This care record

enables out of hours care providers to access patient level data which in turn provides

immediate access to clinical information on which to make well informed decisions. Again,

supporting unplanned admission avoidance, keeping the patient close to their home and

relatives and ensuring the right health and social care input is given first time right place.

Having successfully implemented practice-based risk stratification and multi-agency care

planning (MAGs) for high risk patients, our GPs are well placed to take on the role of

Accountable clinician for patients who may be at risk of admission; co-ordinating care

provided by a range of professionals to enable patients to remain in the community and are

starting to do so through the Admissions Avoidance Directly Enhanced Service and other

arrangements being put in place to support the care of the over 75s and high risk patients.

The interface between general practice, community services and social care is likely to

change, as new integrated models emerge.

The SUS+ Urgent Care View online system provides primary care with information about

their patients who are starting to use.

13 Use of Real-time System-wide Data

SCAS ED Interface: SCAS ED IM&T interface allows real time review of current A&E

department activity and waiting times. Alongside this, SCAS also has a whole system

overview due to the geographical basis of the SCAS footprint. This allows contemporaneous

overview of both ambulance pick and arrival activity and also sight of the ambulance

handover times and clear times.

To implement a ‘live’ EPR system in ophthalmology which supports the merging of clinical

management systems with patient pathway tracking, providing real time scheduling.



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TVEA maintain information about capacity across Thames Valley and this will be extended

by use of CMS for all areas.

Sustaining Resilience in Elective Care

Context

Pressure within referral to treatment pathways at BHT began to build in the summer of 2013,

particularly in the specialities of T&O and plastics. Initial action was taken to secure

additional external capacity which came on-line later that summer.

However the backlog continued to grow, along with overall waiting list numbers throughout

the rest of the year, with a number of other surgical pathways including some diagnostics

starting to show significant backlogs. Senior leadership at the Trust sought support of the

Intensive Support Team (IST) in November and immediate validation and reanalysis of all

referral to treatment pathways was undertaken.

Detailed backlog recovery trajectories were produced for all breaching RTT pathways

showing clearance rates by week running from December 2013 to the end of September.

One example, orthopaedics had a backlog of 680 patients which is due to be reduced to 66

cases by the end of August. Similarly average waiting times are being lowered in all

supporting diagnostic specialities, for example radiology MRI is reducing by half the number

of patients currently being booked in at over 4 weeks.

Delivery of consistent 18-week RTT performance

In line with the ‘Driver Tree’ from the national elective care guidance, the system will work

together to assure delivery of consistent 18-week performance through the following steps:

Maintain capacity and demand balance – The Trust completed capacity plans in

July for all specialities, with the support of IMAS. Output of this work was then

shared across the system, including executives at the Trust and local CCGs.

Additional external capacity has been sourced from three independent providers

which have been used initially to help in reducing the backlog. This external capacity

will also be used in the medium term to address the system capacity gap in

Orthopaedics.

Pathway Management – The Initial work on capacity has identified a clear ongoing

gap in orthopaedics and key pressure areas on diagnostic pathways. The



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orthopaedic pressure requires the development of a sustainable new pathway to right

size capacity to demand. The commissioner and provider are working together to

develop a plan to support the delivery of sustainable orthopaedic services (including

pain services and imaging within this). A first design workshop is being held in

August to agree the patient outcome measures expected and possible options for

how to deliver these. The Trust is leading, under the chairmanship of the Chief

Operating Officer and Medical Director, a ‘Reforming Elective Care’ programme to

transform planned care pathways with the aim of improving the quality of care for

patients and maintaining sustainable access times for the first time in several years.

The core work streams of this programme are:

Quality in Outpatients

Theatre productivity

Rapid diagnostics

Data quality

Whole pathway capacity and transformation

Tracking and validation – Weekly tracking information is available across the

system from Bucks Healthcare Trust. It shows the patient tracking lists (PTL) for all

stages of the pathway IP, OP and diagnostic. The commissioner makes weekly

outpatient referral information available to GP practices. The system is able to see

the stage of treatment summary for first appointment, follow up appointment,

diagnostic admission and admission combined along with the target levels. The

ambition for the system will be to add the referral information to this to complete a full

picture. The Trust and the Commissioner have agreed to a process in which weekly

data packs reflect real time information at the point of submission. Patient Tracking

Lists are cleansed and signed off prior to submission to the Commissioner. In

addition, a forecast is included that shows:

Numbers of patients breaching without a date;

Estimated backlog at the end of month vs plan; and

Forecast booking profile for the following month to give assessment of breach profile.

External activity and capacity are also factored into the forecast.

Regular cleansing and validation of data is necessary as uncleansed data may reflect bits of

dirty data: patients treated who haven’t yet been removed, or patients who have joined the



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list as data errors and need correcting, or patients who have been treated by external

capacity and not yet removed.

Performance management – All waiting time information and backlog trajectories

are published on a weekly basis and made available across the system. The Trust

meets internally on a weekly basis through an ‘access and performance

management group’ to review this information and delivery progress. The

commissioner meets informally with the Trust on a two weekly basis and formally on

a monthly basis with clinical leaders from both organisations to review performance.

Leadership and focus – Both commissioner and Trust provider boards receive a

monthly performance report of elective pathway performance. Each CCG has a GP

clinical lead for elective care who meets regularly with clinical colleagues at the

provider trust. The Trust has asked the IST to review operational reports and

working arrangements of their internal performance group.

1 Review and revise patient access policy, and supporting operating procedures

The Trust's Access Policy was significantly revised in January 2014 and signed off by the

Trust executive in April 2014.

Alongside this a revised set of Standard Operating Procedures has been published. The

implementation of these operating procedures is clearly visible to the commissioner in the

weekly information set. For example the information set shows by speciality the admitted

‘clock stop’ patient numbers including total activity, breaches and previous week

comparison. The commissioner has revised all policies on procedures of limited clinical

value and put these updates into the local contract schedules. SRG will review the Access

Policy against national rules and guidance in September.

2 Develop and implement a Referral to Treatment (RTT) training programme for all

appropriate staff

The Trust is implementing training for over 150 administrative staff by the end of August

2014 against the revised standards. This is followed by full competency assessment, a



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training programme for new starters, and an onward monitoring and SOP adherence

programme. There is also development of an e-learning module to ensure all clinical and

booking staff are aware of the rules around RTT, and embed a forward monitoring

programme and module for all new starters upon induction. Assurance will be provided by

monitoring numbers of clinical teams completing the training package.

3 Carry out an annual analysis of capacity and demand for elective services at sub

specialty level, keeping under regular review and updating when necessary

With IMAS support, an annual programme of capacity and demand management was

completed in July 2014 for the majority of core specialties. The outputs from this were

shared with members of the executive and colleagues from CCGs. The outputs from this will

feed into capacity and operating plans for 2015/16, and a programme of annual refresh is

timetabled.

Further work is required to do a deeper review of key pressured specialties (orthopaedics)

and to pick up key pressure areas on diagnostic pathways. Further IST support is proposed

to further complete this work. The aim is to complete this by the end of September.

4 Build upon any capacity mapping that is currently already underway, and use the

outputs from mapping exercises as an annex to resilience and capacity plans. This

will avoid duplication and integrate capacity mapping into 'business as usual'

arrangements

The capacity and demand planning piece completed in (3) above will be used as an annex to

operational resilience and capacity plans.

5 Ensure that all specialties understand the elective pathways for common referral

reason/treatment plans, and have an expected RTT ‘timeline’ for each

All specialty areas have identified 'timed pathways' for all stages of treatment: these are

identified and monitored through the Trust's Access and Performance Group.



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6 ‘Right size’ outpatient, diagnostic and admitted waiting lists, in line with demand

profile and pathway timelines

The sub-specialty capacity gaps demonstrated in the work above (3), are proposed to be

managed through a transformational cross organisational programme board; 'Reforming

Elective Care'. This is a system wide service improvement forum to track key pathway

changes from referral, through outpatients, diagnostics, theatres and discharge. This group

will track the capacity gaps identified through the IMAS supported analysis completed and

ensure a programme of work to cost effectively 'right size' the gaps.

All specialty areas that had identified gaps in their capacity plans are the subject of individual

action plans to ensure that the appropriate staffing, facility and pathway efficiency measures

are in place to meet the future demands for 14/15 and onwards. These are being completed

across the healthcare system and are accompanied by appropriate contracting and cross

organisational pathway improvement discussions.

The major area of focus for the system is a network wide review of MSK, including pain,

orthopaedics and rheumatology (including imaging). This will be a joint provider and

commissioner led review with recommendations around the future make up of regional MSK

services to ensure appropriate pathways, capacity, cost effectiveness and outcomes.

This will be accompanied by a specific provider led programme looking at internal

orthopaedic culture, ways of working and processes, building on work scoped through a

series of learning events at other providers in the UK and abroad. This will focus on

removing all waste from the MSK provider pathway, focusing especially on outpatients

/diagnostics, and theatres.

7 With immediate effect, review local application of RTT rules against the national

guidance, paying particular attention to new clock starts and patient pauses

As part of the Reforming Elective Care board, there is a specific data quality work stream

that completes the following:

Ensuring all staff appropriately trained in RTT rules and data validation.

Completing an audit programme - 'validating the validation'.



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Establishing clinical sign off of timed pathways and agreed clock stop 'rules'.

Use of system reporting to flag areas of concern and deviations from agreed

standards.

Review of RTT outcome form - design and clinician accuracy.

8 Pay attention to RTT data quality. Carry out an urgent ‘one off’ validation if

necessary and instigate a programme of regular audits

Strengthen the internal data validation team, moving towards a 'semi-permanent' team (6

months) with both a specific training and audit programme. Complete full PTL validation as a

first priority as a one off exercise and then establish targeted rolling programme

9 Put in place clear and robust performance management arrangements, founded on

use of an accurate RTT patient tracker list (PTL) and use this is discussion across the

local system

The Trust runs a weekly Access and Performance Management Group (APMG) that is

accountable for reviewing all Trust PTLs and timed pathways. This group is accountable to

the COO / Deputy CEO and monitors any deviation from agreed pathways.

The operational reports and working arrangements for the group are currently being

reviewed by the IST.

A summary position of the overall system compliance is monitored through the Right Care

Steering Group.

10 Ensure that supporting KPIs are well established (size of waiting list, clearance

time, weekly activity to meet demand, RoTT rate etc) and are actively monitored

All supporting KPIs are reported at a sub-specialty level through APMG.

IST are providing active support in reviewing these and also making recommendations as to

how these should be reflected in subsequent board reporting.



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11 Demonstrate how good practice in referral management is being followed

All referrals into the organisation are visible and managed to strict standards (reported

through APMG) of time taken to upload onto the system, make visible and appointments

being booked.

In addition the Trust has undertaken 3 audits in the last 6 months of referrals from

intermediate services to ensure correct clock information is available to the Trust when the

referral is received (MSK and gynaecology). Onward audits are programmed for these areas

for November 2014 to check ongoing compliance and implementation of suggested

improvements.

12 Demonstrate that patients receiving NHS funded elective care are made aware of

and are supported to exercise choice of provider

Choice of provider embedded at the point of referral.

13 Provide assurance during Q2 2014/15 at Board level on implementation of the

above

BHT - sign off by board in Q2

CCG - assurance through the Right Care Group up then to board

Innovation

Remove diagnostic delays for vascular imaging

Pilot through the use of additional ultra-sonographer support a one stop imaging service for

all new and follow up vascular appointments. KPI: reduction in diagnostic referrals (Target:

Reduce by 75% by 01/02/15) and removal of unnecessary follow ups (Target: Reduce by

15% by 01/02/15).



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Reduce orthopaedic follow up appointments (elective) and fracture clinic

appointments, increasing new appointments in a cost effective way

Establishment of virtual clinic model: use of technology to screen and remotely manage both

elective and acute orthopaedic referrals - free up consultant time for elective new work. KPI:

New appointment times for orthopaedics (Target: 4 week maximum wait by 28/2/15)

Reduce follow up appointments

Digitalisation programme to facilitate the establishment across all relevant specialties of non-

face to face contacts where possible. KPI: Reduction follow up appointments (Target: 0.2

ratio change 31/3/15)

Robust PTL and RTT tracking of all patients in a 'live' EPR – pilot

To use a bespoke IT solution in ophthalmology (largest elective specialty) to merge the

clinical management system with patient pathway tracking, removing RTT paper forms and

providing real time scheduling. KPI: RTT performance (Target: Specialty specific compliance

2% + above baseline)

A range of further innovations are being progressed across the system to support changes

to the current treatment pathways with the aim of improving quality and increasing efficiency.

Some examples would be:

Introduction of an advice and guidance email service by the provider Trust to support

GPs and offer a choice in not necessarily moving straight to making a referral.

The establishment of a virtual clinic model through the use of technology to screen

and remotely manage both elective and acute orthopaedic referrals.

To implement a ‘live’ EPR system in ophthalmology which supports the merging of

clinical management systems with patient pathway tracking, providing real time

scheduling.

App development and use “service finder”

Synergistic cross professional posts

2.0 BHT Acute Site Partner

Urgent Care Pathway

Within Buckinghamshire there are three acute hospital trusts, BHT, Heatherwood and

Wexham Park and Milton Keynes. The acute pathway for BHT is provided across two sites,



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Stoke Mandeville and High Wycombe, with the former dealing with Type 1 A&E flow and the

latter taking acute stroke and cardiac flows and the non- elective provision. There are some

patient flows into Heatherwood and Wexham Park, along with some to Oxfordshire and

Bedfordshire due to the logistical nature of population based care provision by CCGs. At the

BHT site, there are urgent care pathways for A& E, acute medical and surgical patients –

(CDU, AMU, and SAU ) allowing patients to be seen and treated in a safe environment.

2.1 Winter2013/14

Over winter 2013/14 and continuing into this financial year, 2014, BHT has struggled to meet

its AE 95% performance target. This figure is closely monitored by the local CCG and is

taken as a system indicator – along with the other acute trusts in Buckinghamshire – as a

sense check for system pressure and patient experience. The visibility of reporting enables

the system to work together with the acute trusts, BHT in this instance to look at capacity

and demand, flow, innovation and ambulatory care pathway development. BHT has

submitted 17 briefings to the Trust Development Authority (TDA) in which they have reported

15 occasions of not meeting the 4hr wait and 2 where they have achieved the target.

2.2a ECIST

BHT have worked with ECIST to review its Emergency flow and ECIST have revisited the

Trust to review its progress twice over the past 12 months. The most recent ECIST visit was

March 2014 and recommendations included:

Develop a new clinical model for the front door ED/CDU/AMU/SSU and ambulatory

care including frailty pathways that is deliverable with your current workforce

Undertake a review of workforce and develop a deliverable workforce plan in the light

of the constraints in employing the medical workforce originally desired

Develop ambulatory care as a process rather than individual pathways – this can be

done quickly and from experience elsewhere has a significant impact on flow

Work with commissioners and social care to develop a robust intermediate tier of

services with a single point of access that ensures more patients go home to be

assessed rather than waiting in hospital to have assessments completed. Link to

work streams overseen by the Urgent Care Working Group

Make greater use of MUDAS on the Wycombe site



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ECIST diagnostic also identified…

• Workforce constraints are confounding new pathways

• Ambulatory care required further development

• Intermediate tier services in the community are not rapidly pulling medically fit

patients out of hospital

• Managerial processes to manage patient flow are complex and reactive and could be

streamlined and more proactive

• Alternatives to hospital are not being fully utilised

Deeper investigation of the urgent care pathway illustrated that peak flow times that put any

extra demand in the system, noted as between 7pm and 2 am began to tip the system flow

balance into the negative, causing further back log into the ED department itself.

2.2b Care Quality Commission (CQC)

In June 2014 the Care Quality Commission published the Chief Inspector of Hospitals report

on BHT. This made recommendations for improvement in the following areas:

1. Reduce mortality

2. Reduce harm

3. Improve patient experience

4. Goals for organisational safety culture

5. Goals for Improvement Methodology

Lessons learnt from these sources in addition to local analytics of activity and finance across

the system and lessons learnt from last winter, are fundamental drivers underpinning

development of the 2014-15 ORCP plan

2.3 RUC Work Programme Plans & Impact

Within BHT the Reforming Urgent Care board has a clear work programme, clinically led and

locally delivered. Initiatives include:

• Expansion of the Frail Elderly assessment services: Ensuring fewer frail elderly patients

are admitted to an Acute bed following an attendance to A&E for a fall

Introduction of Ambulatory Care Services : Implement new AEC to reduce the length

of time that patients are waiting in A&E and to improve the number that are admitted

to a ward or discharged within 4 hours of arrival at A&E



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Review and redesign of our Acute Medical Model and ward based working: To

ensure that patients are admitted to a speciality ward with fat access to the relevant

clinicians and reducing the number of moves some patients experience

Surgical reviews within 2 hours of arrival: To aid patient flow and reduce the length of

time that patients are waiting for a surgical review

Discharge to assess: To reduce the LOS of patients requiring care in their usual

place of residence.

BHT will be delivering the Perfect Week as outlined in the ECIST recommendations.

A project team, led by Clinicians and with CCG involvement has been formed with

the aim to set up the Perfect Week in October 2014.

There has been an expansion of the POD role to facilitate patient assessment,

discharge and flow. The Acute Care Hub Model was scoped as part of the RUC last

year and as a result the AMU and short stay model was implemented

3.0 SCAS & Resilience Planning for Buckinghamshire

SCAS is the provider of both emergency 999 and 111 dispositions cross Buckinghamshire

and is central to the whole systems resilience plan. SCAS is also part of the major incident

response for Buckinghamshire and has robust internal business continuity plans. Links to the

local council(s) for logistical operational planning and incident management, such as large

public gatherings also fall under this arena.

Emergency Preparedness, Resilience and Response (EPRR), Business continuity and

Daily Resilience

To comply with the requirements of a category 2 responder (Civil Contingency Act 2004) and

the NHS Standard Contract section 30, Aylesbury Vale CCG and Chiltern CCG have a Major

Incident Framework 2014, Incident Response Plan 2014, Business Continuity Plans 2014

and CCG escalation Framework 2014 in place. This is supported by the 24/7 on call director

arrangements. All the on call directors have been trained to the required Skills for Justice

National Occupational Standards.

As part of the national 2013/14 Emergency Preparedness, Resilience and Response

(EPRR) assurance process Aylesbury Vale CCG and Chiltern CCG provided assurance to

NHS England and the CCGs Governing Body that they were fully compliant with the NHS

core standards for Emergency Preparedness, Resilience and Response 2013. This was



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completed in March 2014. These EPRR core standards are the minimum standards which

NHS organisations and providers of NHS funded care must meet in order to ensure that they

have appropriate plans in place for responding to a wide range of incidents such as flooding,

extreme weather, surge in demand and incidents effecting business continuity.

As part of the annual EPRR assurance process for 2013/14 Buckinghamshire Healthcare

NHS Trust was required to assess itself against the NHS core standards for EPRR. In the

main BHT was compliant and developed an improvement plan for outstanding actions. BHT

has a Resilience Committee chaired by the Accountable Emergency Officer. The Resilience

Committee has clear roles and responsibilities with designated working groups to complete

the action plan. The Resilience Committee has been cited as an example of good practice

by NHS England Thames Valley.

The new assurance framework was published in July 2014 and Aylesbury Vale CCG and

Chiltern CCG are in the process of repeating the self-assessment. This will be undertaken

before winter. The CCG is currently reviewing the 2014/15 submission from BHT.

All organisations have robust business continuity plans in place which detail individual

service line responses to service interruption, including management of services during

inclement weather. Currently, the overarching CSU plan is currently expected by the

National Business Continuity team.

Daily Whole System Resilience.

Buckinghamshire and Berkshire CCGs Escalation Framework 2014 was updated after the

Buckinghamshire whole systems winter exercise 2013 and the updated NHS England

Thames Valley Framework 2014. The framework sets out the procedures to manage day to

day variations in demand across health and social care systems as well as the procedures

for managing significant surges in demand. The purpose is to ensure that all partners, health

and social care have a mechanism to access additional capacity in the right part of the

system when demand peaks. The CCG has responsibility, working with partners, to manage

resilience within the system. On a daily basis Thames Valley Emergency Access coordinates

the system supported by the CCG which provides in hours operational manager and 24/7

coverage at Director level as required.

4.0 System Resilience Planning 2014/15



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The ORCP and vision is to ensure robust resilience and capacity planning going forwards

into 2015. Nationally this has been driven by the recognition of the pressure A&E’s continue

to be under and in a local context it offers a system-wide approach to cross-provider

planning and joined up care. This in turn benefits patients, carers and families, and also

allows for better staff planning and provision.

Completing the national template has provided a system-wide opportunity to undertake a

gap analysis around services currently in place, and this has begun to highlight what needs

to be developed next.

Within the resilience portfolio, the ORCP also includes working relationships with the Bucks

County Council and the Thames Valley Area Team for areas such as flu planning and

Primary Care capacity.

The ORCP is currently in the process of setting local service provision within the national

strategic direction by:

Reviewing the terms of reference of the Urgent Care Working Group to take into

account local delivery of system resilience across urgent and planned care

Setting up an operational System Resilience Task & Finish Group to develop the

plan. The ongoing requirement for this group is being reviewed as it has been

considered a useful operational forum.

Acknowledging and utilising opportunities for provider cross-working and co-

terminus service and personnel / staff funding.

Planning based on business intelligence to produce evidence based outcomes of

care which benefits patients by intelligent dashboard development.

Supporting an overall system performance within the UCWG/ SRG and by linking to

internal provider programmes to broker service development interfaces.

Coordinating and planning with provider partner stakeholders to ensure system-wide

cohesion, performance and service delivery.

4.1 National Timeline



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As a High Risk system, Buckinghamshire will receive support and input into the resilience

and capacity planning feedback and will work with NHSE and the TDA to ensure recovery

and service improvement plans are put in place. The subsequent plans will be signed off by

the SRG and internal stakeholder boards, with the final plans being signed off by all partner

organisations and published on CCG websites during September. Plans will be revisited in

October, and it is noted that the public visibility of the plans will require communication

strategies to be put in place.

Risk assessment processes have been put in place as part of general controls assurance for

Buckinghamshire and the SRG has oversight and ownership of the plans. Risk areas are

noted as primary care and pace of change within social care requirements.

4.2 ORCP Assurance Process The process for system resilience plan sign off for Buckinghamshire will follow the national

timetable and the internal agreed oversight procedure defined in the CCG’s Urgent Care

Working Group /SRG Terms of Reference.4

The Executive Board will be sighted on the contents of the capacity and resilience plan, and

the SRG will be the oversight, scrutiny, and decision making body, supported by the SRG

Task and Finish Group. External review and ratification will be undertaken in line with the

Area Teams (NHSE) process which is as follows:

a. Elective ECIST Workshop: 05.08.14

b. Collective Assurance of ORCP Plans 07.08.14

4 TOR awaited from the Area Team.



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c. Area Team, and TDA attendance at the September SRG 16.09.14

The on-going developmental assurance and oversight within the template has been iterative

in nature and this has ensured whole system input and agreement. The template itself has

been fully reviewed and correlated with the Winter Bids allocations 2014/15 to deliver cross

provider pathway working, inter provider operability and innovation.

The System Resilience Group discussed the initial bids from organisations for the available

funding at the meeting on 29th July. The group prioritised those bids which would add

greatest value to the system resilience and agreed the initial submission to NHSE. The

meeting also included confirmation from all organisations that their submissions which

formed the plan had been approved by their Chief Executive and Finances by the Director of

Finance. On the 9th September the revised plan was approved by SRG for submission to

NHSE for the assurance meeting on the 16th September. The SRG included Director level

representatives who were able to agree this system wide approach on behalf of their

organisations. Once the plan has been agreed by NHSE the plan will be taken to

organisations Boards.

The system maturity is reflected in the overall decision making process and progress as

detailed in the return. The exercise itself has been transparent and focused on on-going

resilience rather than short term fixes. Financial governance and guidance is awaited from

the Area Team as Buckinghamshire has been determined as a High Risk system, and as

such, monies have not been released to local finance officers. SCAS national allocation is

being hosted by one nominated CCG – West Berkshire, and this allocation utilisation is still

in discussion.

4.3 Continued Governance & Oversight

The delivery mechanism is governed monthly by the System Resilience Group (SRG) and

the Urgent Care Working Group (UCWG). These meet on alternate months. SRG

membership includes Director level representatives from NHS and Bucks County Council

commissioners, Health Watch and all urgent care Provider stakeholders. While the UCWG

has a smaller membership including CCGs, Bucks CC, SCAS, BHT, HWWP and focuses on

specific topics for more in depth analysis. Both groups routinely review activity, performance,



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service improvement project delivery including from the BHT Reforming Urgent Care

programme (RUC) and the urgent care risk register and agree system wide actions to

mitigate risks. These metrics will be supplemented by additional KPIs to ensure the ORCP is

effectively governed. These groups report to the Urgent Care Joint Executive Team (UC

JET), which consists of health and social care commissioners only, and review finances and

performance of individual providers against their contracts. This joint approach is adopted

across Buckinghamshire and also delivers efficient and integrated working across both

CCGs for several other programmes of work including elective care (Right Care Group), long

term conditions (Medicines Management JET), children (Children’s JET) and services jointly

commissioned with Bucks CC (Adult JET). JETs report to individual CCG Executive teams

and through these to individual CCG Governing Bodies.



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4.4 High Risk Reporting Requirements

As a high risk system (influenced by the RTT 18 week target) TDA and Area team oversight

and scrutiny will form part of the governance and reporting requirements.

The SRG will be supported by a programme approach ensuring that delivery is both efficient

and effective and remains focused on the desired outcomes, this will be a joint role with

supporting the Reforming Urgent Care programme at BHT improvement alignment of

programme reporting and delivery and reducing duplication in the system. This PMO

approach brings a number of benefits to the system around the area of Resilience and

capacity planning, which is both the business development driver

:

Provides a rapid response approach to projects and work streams

Encourages a culture of empowerment and ownership by providing fit for purpose

support where needed

Aligns with the organisational development plan in developing and up skilling staff

Provides specific support to the ORCP and RUC

This approach was used successfully during the Better Healthcare in Buckinghamshire

programme.

The daily monitoring of demand and capacity by the winter pressure team also ensures

relevant information especially during rising pressures to both the duty manager and the on-

call executive. This is through a series of updates outlining any key issues, action taken or

required. This is especially pertinent during times of rising pressures in preparation for the

weekend should demand exceed capacity and commissioner support be required.

4.5 SRG Task & Finish Group



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The SRG Task & finish Group held weekly meetings commencing the week of the 25th June

2014, which described the process initially and oversaw the return process of both the

resilience bids and the provider stakeholder templates, This was also in conjunction with the

Urgent Care Working group.

On 15th July the Urgent care Working Group agreed the process setting the following

timeline;

SRG T&F weekly meetings

Resilience Bid process deadline 22nd July

SRG T&F Template oversight and gap analysis meeting: 22nd July

UCWG sign off process 29th July

The meeting continues to run supporting the operational delivery of the wider Urgent Care

Working Group / Systems Resilience group.

4.6 Daily Resilience Calls

The daily resilience call also underpins system real-time analysis and immediate opportunity

to make decisions and broker partner stakeholder actions. The ORCP has provided have

instigated a more robust presence on the call to support providers to understand and

manage bottlenecks and capacity surge; escalating within organisations and between

organisations where appropriate to facilitate improved provider intra-operability. Within all of

the above and particularly as part of the daily resilience call process, the ORCP process will

be part of the Buckinghamshire Escalation Framework, allowing timely responses to

emerging service surges or risks. Involvement of commissioners in the daily system

resilience teleconferences when the system is under pressure, is key to ensuring escalation

occurs based on the objective criteria within the Thames Valley escalation framework. The

framework includes the requirement for Providers to not declare black status until they have

discussed all options with the CCG duty director on call and agreed that this is the only

option. When the system is at red escalation or higher, there is an afternoon follow up call to

ensure actions decided in the morning have been completed and to decide next steps. This

provides commissioners with the opportunity to deescalate quickly when circumstances have

improved.

The Escalation Framework

This follows the NHS England alert levels, comprising 4 distinct alert levels.



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Table 2: Definition of Escalation Statuses

GREEN Level 1: patient flow management - The Local Health and Social

Care System capacity is such that organisations are able to

maintain patient flow and are able to meet anticipated demand

within available resources. Commissioned levels of service will be

decided locally.

AMBER Level 2: mitigation of escalation – The Local Health and Social

Care System starting to show signs of pressure. Focused actions

are required in organisations showing pressure to mitigate further

escalation. Enhanced co-ordination will alert the whole system to

take action to return to green status as quickly as possible.

RED Level 3: whole system compromised – Actions taken in Level 2

have failed to return the system to Level 1 and pressure is

worsening. The Local Health and Social Care System is

experiencing major pressures compromising patient flow, Further

urgent actions are required across the system by all partners.

BLACK Level 4: severe pressure and failure of actions – All actions

have failed to contain service pressures and the local Health and

Social Care system is unable to deliver comprehensive

emergency care. There is potential for patient care to be

compromised and a serious untoward incident is reported by the

system. Decisive action must be taken to recover capacity.

4.7 Patient Centred Services

With the patient at the heart of all service planning and delivery both for health and episodes

of care need, understanding our resilience and current capacity allows for proactive

forecasting and planning. Getting it right first time in terms of care requirement, level of

intervention and care provision is key to the Urgent Care work stream within the overall

ORCP.

The demographics of Buckinghamshire includes a recognition of the significant impact of an

ageing population as part of its growth in demand.

4.8 Ambulatory Care Pathways

Ambulatory care pathways will be supported by the Unplanned Admissions DES and the

development of MAGS which identify, stratify and assess patient need to ensure their clinical



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and social needs to not escalate and result in an unplanned and unnecessary admission.

This will be dependent upon the cohesion of the ORCP along with 7/7 working.

This approach will also support patients to received timely intervention, prevention and care

closer to their own homes, preventing condition deterioration and promoting admission

avoidance. Supporting vulnerable patients within their own local home and or / care

environments is accepted as both best practice and best for patient outcomes. This does

require close joint working with social care services as patients often have multiple health

co-morbidities along with complex social care requirements.

As part of the overall development of Unplanned Care a number of supportive programmes

of work have been and continue to be underway across all partner stakeholders

underpinning the planning and delivery of the ORCP. Within the ORCP planning process,

three key flows are identified as follows, and planning and bid review and allocation

undertaken accordingly. They are:

Admission Avoidance – Prior to Admission Assessment Services

ED Front Door and in Hospital Flow

Supported Discharge

See fig 1.0

Which may be understood as a non-linear whole system of health and social care provision

which maximises patient experiences and outcomes along with ensuring best value for

Ed front Door & In Hospital

Flow

Supported Discharge

Pre-Hospital

Community



Version 5.1 18 09 2014 IC 57

money and return on an investment that includes health outcomes, staff performance and

asset utilization.

5.0 Stakeholder Engagement and Empowerment

Across the Buckinghamshire system, patient engagement, involvement and empowerment is

seen as central to delivery of service provision. Patient behaviour, footfall and health and

social care access is recognised as key to new pathway redesign, new ways of working and

as such, produces a strong Compaq between services and outcomes. Engaging patients,

carers, their families and friends is understood to build a capability that will help whole

system sustainability and balance.

Using the communication strategy to sign post patients to the most appropriate care setting

during the winter months will help Buckinghamshire deliver the right care in the right place

at the right level of intervention. Using an effective communication for the winter, which has

been put forward as a winter bid, Buckinghamshire will communicate using new methods of

technology, including an via an app for phones, which hosts a “service finder”. Further, by

using intelligence to target HRGs by practice. Flu planning is also central to patient and

public engagement, and again this unifies aspects of both winter bids and system resilience

planning.

The allocation of funding for the carer’s hub based at Stoke Mandeville Hospital will enable

carers of in patients to visit a “one stop shop” to get advice, support and sign posting to

support themselves and the person the care for. Carers and their position are statutorily

recognised, however, it is envisaged that the carers hub will also provide invaluable informal

support, and its success has been demonstrated elsewhere. Plans to expand the carers hub

to include the High Wycombe site have been discussed and will form part of the ongoing

capacity & resilience programme to ensure equality of access to such support on both BHT

sites. For High Wycombe this will be important due to the presence of the cardiac and

stroke pathways for Buckinghamshire.

5.1 System Winter Communications and Engagement:

Over the Winter months there will be an integrated communication and engagement winter

pressures campaign designed to reduce inappropriate A&E attendances from Bucks

residents whilst providing an instant online signposting and self-care information

source. The campaign will utilise both traditional and modern communication channels and



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materials, including media, social medial, leaflets and posters. There has been much liaison

with communication staff in neighbouring CCG areas, to identify their needs as well as those

of Bucks, so that we can achieve joined up messaging around the CCG borders and avoid

confusion of patients in those areas e.g. South Bucks/East Berkshire

Communications though all relevant channels are designed to:-

• Clearly signpost Bucks residents to appropriate health services for their needs

• Provide health instant self-care/health advice

• Encourage appropriate use of NHS 111, pharmacies and MIIU services

• Encourage appropriate use of health services by parents of under-fives

• Encourage earlier take up of pharmacy services by the elderly

• Promote uptake of flu vaccination

• Provide reassurance and increase confidence in resilience of services

Action Description Audience Implementation

System Confidence Letters to local MPs, HASC and other key influencing stakeholders to share resilience plans Media release, website and newsletter content outlining actions being taken to increase resilience and to launch campaigns Reminder public messaging around key dates – holiday pharmacy opening times

Key influencing stakeholders Staff in health and social care organisations, General public

1st October2014 October As required

Flu Vaccination Working jointly with PH and NSHE – to amplify campaign through all channels

Vulnerable target groups as per PH plan

September/October

Treat Yourself Better Roll out of Pharmacy Voice campaign in Bucks

People of working age.

September through to end Feb.

Talk Before You Walk All Better Now – campaign targeting parents of under-fives – using social media, shopping centre road shows materials widely distributed.

Parents of Under-Fives – specifically fever / bronchiolitis prevention

October through to end Feb

The Earlier The Better Campaign to encourage frail elderly and their carers to seek pharmacy help

Elderly and carers End October through to end Feb

Health Help Now Self-care portal to go live with promotional campaign

All general public November launch.

Just Because Campaign to provide appropriate services information

Students December pre-Christmas and January after Christmas.



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6.0 Primary Care: Planning and Whole System Capability

6.1 Flu Planning

The ORCP includes input locally on flu planning mechanisms for 2014/15. This will include

both flu vaccination and prevention and NHS Pandemic flu resilience preparation. The

former will focus on both at risk groups and staff groups via individual providers. Pregnant

women will also be able to access flu vaccine at their booking antenatal appointments led by

BHT. The communications strategy will include both the general public, patients and hard to

reach groups. Taking advantage of pharmacy capability and capacity the 2014/15 ORCP

will utilise pharmacists to administer the flu vaccine At Risk category patients, again

providing innovation and better health outcomes for the local population5.

7.0 Mental Health Services Mental health provision remains a priority for both local CCG pathway development and also

as part of overall resilience and capacity planning for winter planning 2014/15. In up to 5% of

visits made to emergency departments, the patient has a primary diagnosis of mental ill

health problem. The interface between BHFT and RBH has improved in recent years and

there is better joint working between these two organisations. SCAS have a CQUIN in their

contract to incentivise improved management of patients with a mental health need.

The PIRLS service in BHT is also an example of mental health patient pathway

improvement, providing early assessment for patients who present at A&E. A previously

mentioned in section 8 – Rapid Assessment in Accident & Emergency Departments – PIRLS

is also seeking to expand its service both in terms of access service provision and as in-

patient ward in-reach to improve the experience and outcomes of mental health patients.

8.0 Evidence Base and Research Review

As part of overall resilience planning, AVCCG requested local public health leads to identify

evidence-based interventions for reducing demand for urgent care in Bucks. The meta

analysis report produced summarised the evidence from the published literature on the topic

of urgent care, broken down into the areas of:

1

www.gov.uk/government/organisations/public-health-england/series/immunisation 2

www.gov.uk/government/organisations/public-health-england/series/immunisation-againstinfectious-disease-the-green-book 3

www.gov.uk/government/publications/public-health-commissioning-in-the-nhs-2014-to-2015



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Section A: What do we know about why Urgent and Emergency Care demand has

increased generally?

Section B: What does the evidence say about effective interventions for reducing

demand?

Section C: What are the findings from other places?

Section D: Urgent and emergency care: a prescription for the future (Recommendations

from the Think-Tanks).6

A summary of the analysis is as follows:

Reasons for increased demand:

A recent King’s Fund reporti found that age is the strongest driver for the use of hospital

emergency beds with very young children and older people being at risk of higher

admissions.

Social deprivation and higher levels of morbidity are strongly correlated with higher rates

of admissions

Geographic location – those who live nearer an A&E are more likely to access it

whereas rural communities have lower hospital usage

There is also longstanding evidence of “supply induced demand” suggesting that health

care is more closely correlated with supply rather than need.

Evidence of effective interventions:

Despite considerable efforts by the health community and numerous examples of

innovative programmes across England, emergency admissions have continued to riseii.

6 Dr Shakiba Habibula Public Health team, Buckinghamshire County Council; 11.07.14, ref also to the

RAND StudyPurdy. S Avoiding hospital Admissions. What does the evidence say? [Internet. London: The King’s Fund;2010.



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There is very little evidence on what can be put into place to reduce non- elective

admissions. The evidence that exists demonstrates that it is very hard to reduce non-

elective admissions but reducing length of stay is easier.

Reducing non-elective admissions is extremely challenging. The challenge is

demonstrated clearly in a recent study by the King’s Fund, which showed that the best

performing areas in the country for reducing length of stay for over 65s (some by as

much as 23%), were unable to reduce their rates of admission at all between 2006 and

2010 (Imison, 2012).

The Nuffield Trust has recently considered (June 2013) thirty different service models,

finding it hard to uncover those which were successful in reducing emergency

admissions – something that a recent review by the Kings Fund and others have also

notediii iv

There is some consensus in both the published and the unpublished literature that

senior decision making at the earliest possible stage will reduce attendance at A&E

conversion to admission. This also seems true of reducing length of stay in elderly

patients – it is vital to get them on the right care plan, as defined by a senior clinician, as

soon as possible.

Evidence so far from numerous studies have not been able to demonstrate a reduction

in A & E admissions or attendances due to generic case management of high risk

patients, in fact, the evaluation of the recent English integrated care pilots found a

significant increase in emergency admissions (Roland et al, 2012) and these were most

marked in case management sites.

(See Appendix IV).

8.1 2013/14 Winter Review and Lessons Learned

In January 2014 the Bucks Urgent Care Working Group (UCWG) undertook a “hot debrief” to

identify lessons learnt that would assist in planning for 2014-15. This involved stakeholders



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from Health and Social Care commissioners and Providers including BHT, HWWP, SCAS,

Bucs CC and Oxford Health.

Key learning points were:

• There are reduced discharges at week-ends due to lack of ASC staff to organise care

packages

• Spot purchasing is useful in transferring people out of hospital

• HALO in A&E reduces handover delays

• Patients requiring admission are arriving late in the day

• Variation between demand for admission and discharges leading to acute capacity

problems and 100% bed capacity, which exacerbates efforts to reduce LOS

These have informed these plans for 2014-15.

In 2013/14, the schemes were mainly targeted at the acute flow sector as that was

highlighted as the greatest performance risk area. Going forwards, 2014/15 will see a

system-wide approach with clearly determined KPIs and performance monitoring.

2013/14 performance data review illustrates the necessity to establish a known baseline,

whilst setting aspirational improvement measures for 2014/15, during the winter months and

through “steady sate” behaviours throughout the financial year.

In terms of staff post implementations, lessons learned also include the need to understand

the lead in time for posts to become “live” from bid allocation stage to on site working, this

has to be taken in to account for new posts requested in 2014/15. Some staff groups are a

scare resource nationally, and so as part of whole systems thinking new ways of working,

professional accountability and resourceful job planning with extended roles into areas such

as nurse led discharge have to be part of the forward ORCP.



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8.2 Resilience Bids 2014/15

The Resilience bids process for 2014/15 has been undertaken as part of the overall

Resilience and Capacity Planning process as stipulated by NHSE and Monitor7, with a

funding potential of £2.7 million.

The aim of the planning guidance is to ensure resilient plans that support delivery across

Buckinghamshire and stakeholder providers in times of surge demand, such as winter. The

process itself has provided the opportunity for a gap analysis which has allowed

Buckinghamshire health and social care providers to see where “steady state” operational

planning is not yet providing fully assured capability and, and such poses a risk to increased

seasonal surge demand.

Using the funds to support seasonal surge predicted demand in winter 2014/15 the SRG

reviewed 27 bids in total. The SRG took the decision to allocate funds across the provider

stakeholder organisations based on system capacity and resilience requirements going

forwards.

A summary of current funding proposals are included in Appendix III, key elements include:

Remodelling of pathways and service provision

Supporting ECIST recommendations

Ambulatory Care Development

7

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/320224/Operational_resilience_and_capacity_planning_for_2014-15.pdf



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Discharge to Access

Bed capacity

Admissions Avoidance

Ambulance Capacity & Turnaround

Extension to Mental Health In-reach

Carers Hub Development

Communications Support

South Bucks Flows Around Heatherwood & Wexham park

This will ensure that the rising demand for services is managed across a broader portfolio of

provision and intervention which will ensure return on investment, best value for money and

improved patient outcomes. Underpinning this will be the management of the Urgent care

pathway in a broader framework which will reduce A&E demand and see an increase in

services being provided differently at a variety of stratified care needs locations.

The resilience plan and bid allocation has been taken with due consideration from all partner

stakeholders via the SRG and has taken into account system-wide challenges. The SRG

have also attempted to look longer term within this planning process whilst accepting winter

non-recurrent funding is time limited. A fully transparent process has been undertaken and

some challenging choices made within the financial envelope available. The SRG group has

made financial allocation decision based on the best fit and best system return in line with

the strategic direction of travel.

The ORCP resilience bid submission for 2014/15 clearly describes a portfolio of provision

ranging from staff, to transport, to increased clinical and social care capacity, alongside

innovation. These bids must be seen in the wider context of other investments such as

through the Section 256 in Social Care Services with a health benefit and in Primary Care

through the Unplanned Admissions DES and Over 75 fund. A financial summary is included

below:

Within the resilience bids for 2014/15, and as a prerequisite from NHSE and Monitor to

release the funding to local CCGs, Buckinghamshire bids all have pre-determined KPIs

which detail per scheme their predicted outcome. This will be monitored weekly and

published monthly on a public facing website having been locally agreed and signed off

through the SRG and the accountable officer. Buckinghamshire as a High Risk system will



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now also work with closely with all parties, including the TDA and NHSE to ensure delivery

across the provider network.

8.3 Whole System Review: SRG Task & Finish Process

The bids and the KPIs have been agreed through the SRG process and represent whole

systems resilience thinking. The SRG Task and Finish meeting held on 22nd July reviewed

all SRG plans to date and undertook a matrix mapping exercise of the bid requirements per

provider. This provided a gap analysis of what areas require development for ORCP going

forwards.

A key component of managing winter pressures includes the flexibility to commission

additional short-term health and social care capacity, such as spot purchasing beds, and

light building alterations to facilitate timely discharge. This acknowledges that despite robust

escalation plans, winter places on the system additional surges in demand and pressures on

capacity. This can be multifactorial and includes infectious disease outbreaks .e.g. noro-

virus or reduced capacity as part of planned strategic changes.

For winter 2014/2015, the CCGs have the ability to fund additional capacity across primary,

secondary, community health and social care with an investment of £2.7 million across both

AVCCG and CCCG locally. A cost-benefits analysis is currently underway of all schemes to

inform what the priorities should be to support the system in winter 2014/2015.

There has been some success using the Winter Monies during 2013/14, however the system

is still not achieving all key performance measures, and further improvement is needed. We

have reflected upon the lessons learnt from last winter.

Key themes have emerged which have been shared at the Thames Valley Area Team:

1. The outcomes to be delivered must be determined at the outset with clarity on the

Whole System impact. System wide improvement to drive use of resources.

2. Each project scope, interfaces, interdependencies should be clearly determined.



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3. Clear KPI’s and milestones to be set with all interested parties and actively used to

ensure the project is delivering each month.

4. Risks to delivery should be identified early such as hard to recruit staff or complex IT

requirements.

5. Need to establish an overarching programme approach with proportionate individual

project reporting. Reporting mechanisms to be agreed for each organisation and

across organisations.

6. Minimum performance standards should be used to indicate where a scheme is failing

and should be halted.

7. Value for money criteria should agreed at the outset.

8. Evaluation methodology of each scheme needs to be built into original proposal.

Alongside this work sits escalation planning which forms an integral part of system resilience

and winter planning within the Local Health & Social Care Community, throughout all

community and hospital care settings. The integrated framework will aim to provide a

consistent and co-ordinated approach to the management of pressures across the CCGs

acute and emergency care systems.

The 2013/2014 escalation plan review commenced at the end of March and includes key

pieces of work being taken forward: These themes have been shared with the SRG and

have been incorporated into the planning, allocation and oversight of the 2014/15 resilience

bids.

9.0 Winter Bids 2013/14

During 2013/2014 all bids were assessed against the following principles and criteria and

these will be utilised again during 2014/2015: (See table 2.0).



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The winter bid offers escalation capacity that is above core contract provision and

supports resilience at times of system surge.

The winter bid ensures that patient safety and quality are maintained or improved.

Primary care options deflecting ED attendance and admission (where clinically

appropriate)

Providing a cohort of escalation beds to support extremis pressures e.g. times of

demand surge or noro-virus outbreaks etc

Supports 7/7 working

Supports delivery of targets, Handover times, ED & DToCs

Alongside a further set of questions which focus on whole system fit:

Table 2.0

9.1 SRG ORCP Template Collation



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The resilience and capacity planning templates for 2014/15 have provided a methodology of

capturing the necessary outputs required, noting provider inter-dependencies and providing

clear areas for investment during both “steady state” and seasonal surge .Resilience bid

templates were provided to stakeholder partners to ensure the returns were of sufficient

detail and quality to secure allocated funding. This included the 13 must do’s as set out by

national expectations, which will provide the benchmark for the gap analysis within a

systematic framework.

A local template was agreed alongside that of the national two part template to elicit the KPI

and escalation functionality that would be required going forward in 2014/15,this was shared

with CCCG, which saw the introduction of signed off and web published capacity and

resilience plans, along with clear KPI monitored and measured deliverability.

Each bid was assessed against an agreed criteria which also underpins the ORCP 2014/15.

The 7 key items selected reflected the systems levers upon which resilience and capacity

depend and were highlighted as key from the “Lessons Learned” exercise of 2013/14.

Stakeholder providers were given a guidance document setting out the key principles to

consider when selecting bids to submit.

The final resilience bid allocation in Buckinghamshire was undertaken by the Urgent Care

Working Group on 29th July. The overall bids are summarised in Table 3 along with their

financial request / allocation. They include ACCG and CCCG submissions.

The KPIs determined per bid will form the basis of the resilience and capacity performance

measurement and monitoring expectations for 2014/15, for both system capability and

delivery and against individual bids per provider.

The opportunity provided by the 2014/15 process is one whereby interoperability between

providers has been identified and agreed upon in advance which clearly encourages system

resilience, responsiveness and keeps the patient at the centre of the frame of delivery;

where each KPI signifies patient experience and clinical at its heart.

The resilience and capacity templates will be reviewed during august 2014 by the Area

Team, and feedback will further inform the implementation of the season surge investment

process in September 2014. This will be managed by the System Resilience Group going

forwards.



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Appendix I Winter Pressure Schemes Review 2013/14 The following table presents a key based review of the 2013/14 Winter Pressure Schemes. The bids were put in place following a successful bid application process to NHSE in 2013. The table illustrates the pathway of implementation and impact , for example primary care, secondary care, community care and follows the patient pathway flow of: a) Prior to arrival at A&E, b) Flow Within hospital and c) Discharge / Out of Hospital Care The review demonstrates a balanced bid allocation investment across all areas of the patient pathway. The table is a snap shot view, and more data in terms of scheme evaluation is available on request. Winter Pressure Schemes Review 2013/14 Table Key

Key:1

Lessons Learned Positive & Improvement Opportunities



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ECIST

Data Status

Non Applicable

Primary Care

Community

Secondary Care

Additional Capacity

7/7 Working

Delivery of Targets

* Prior To Arrival at A&E

** Flow Within Hospital

** Discharge / Out of Hospital Care

**Table to be added



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Appendix II: 7 Day Working Gap Analysis: BHT

Patient Experience

Time to First Consultant review

MDT Review

Shift handovers

Diagnostics Interventions key services

Mental Health

Ongoing review

Transfer to community, Primary / Social care

Quality Improvement

Medicine

Radiology

Pharmacy

Pathology

Therapy

Key: RAG Colour Value Statement Response

No

Needs More Evaluation

N/A response

In Place

No Evaluation in Response



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Appendix III: 2014/15 Winter Bids

Number Scheme Title Scheme Description Impact Forecast Scheme Allocation Organisation

6 A1:Enhancement of Psychiatric In-Reach Liaison

Service (PIRLS)

PIRLS Rapid Specialist Mental Health Assessment for BHT Older Ward Based

patients (not currently covered by PIRLS)

1. Time of referral Request to being seen = 1 hr 2. Assessed patients will have

documented psychiatric needs care plan and risk assessment.

3. Professional level assessment [qualifications] per practitioner.

£59,000 OH

7 A3: Enhancement of

Psychiatric In-Reach Liaison

Service (PIRLS) based at Stoke

Mandeville Hospital

Increased PIRLS Band 6 [per shift] A&E located.

1. Time of referral Request to being seen = 1 hr 2. Assessed patients will have

documented psychiatric needs care plan and risk assessment.

3. Professional level assessment [qualifications] per practitioner.

£96,000 OH

8 E5: Modelling bed

capacity

Revenue support to additional bed capacity

This bid was internally prioritised by BHT, post the SRG (29 July 2014) and

therefore needs confirming by SRG. The use of resilience funding is supported by a separate bid by BHT for £2m strategic

capital from the Trust Development Authority

Support additional capacity, consolidates escalation beds.

£400,000 BHT



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1

A2: Enhancement of Multi-Disciplinary Assessment (MuDAS)

MuDAS Co-morbid Mental Health patient, mental health assessment and sign posting, reducing avoidable admissions, home support and dementia assessment. CPN based in MuDAS during opening hours.

1. Immediate mental health assessment & sign posting. 2. Assessed patients will have documented psychiatric needs care plan and risk assessment. 3. Professional level assessment [qualifications] per practitioner.

£45,000 OH

3

E15: Ambulatory Emergency Care Service

To set up an ambulatory emergency care service (Monday to Friday 09:00 – 17:00). To provide co-ordination of the medical take and triage into ambulatory emergency care through the appointment of Acute Care Co-ordinators. (ACC).

Manage 10% of medical take through AEC. Through the appointment of the ACC’s: Improved co-ordination of the medical take. Early senior review of patients by registrar as they are freed to do so.

£361,000 BHT

4 E13: Admission Avoidance MuDAS SMH

To strengthen the frailty pathway by providing an on-site MuDAS at Stoke dedicated to supporting the ‘front door’ (A&E, CDU and AMU) supported by an enhanced REACT therapy team.

1. Ratio of frail elderly patients attending A&E to those admitted 2. An increase in the proportion of frail elderly zero to one day length of stay patients

£151,000 BHT

5 H1: Communication and Engagement Campaign to promote appropriate use of health services in Buckinghamshire

Talk Before You Walk

Health Help Now.

£66,600 CSU/AVCCG & CCCG



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Number Scheme Title Scheme Description Impact Forecast Scheme Allocation

Organisation

9 7 Day working

support services

Development of 7 day working and

support services

E8: Phlebotomy Support:

Progress through the patient pathway

for urgent admissions. Urgent blood

samples require adequate staffing

levels 7 days a week.

E12: Pharmacy Support:

A team of pharmacists to cover A&E

CDU seven days a week 7am-8pm

and 7-8 at weekends. Key role is to

prevent primary admissions within the

ED MDT, intervene on medicines

related patient care issues, prevent

deterioration due to omission of

medicines.

E16: Radiology – resource to increase

the urgent care capacity:

Enable ongoing efficient response to

radiology requests from A&E and

urgent care pathway to ensure a timely

and efficient Radiology service.

1. Pathology reporting turnaround time.

1. Medicines Reconciliation Targets.

2. Admission Rates

3. Omitted doses in A&E

1. Waiting times in MRI

2. Reported backlog to manageable levels, and

have all reports reported by the agreed

departmental standards.

£200,000 BHT



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10 E9: Rehabilitation and Reablement Service

Early discharge from Acute and Community beds. Increased rehabilitation, nutrition and mental health support in community settings.

1. No of referrals to community from ED + Out of Hours. 2. Length of hospital stay. 3. MUST score for diabetic patients. 4. Mental health assessments and support.

£116,000 BHT

11 G2: Extra step down rehab packages supporting transfer of Care Wexham Park Hospital A/E

To support extra demand for step down community rehab beds for Bucks patients from A/E transfer of care Wexham Park

1.Number of patients assessed

2.Reduce conversion rate from A/E to admission

Increase in patient number discharged from A/E to community services

£143,000 CCCG

12 G3: Vulnerable Care home Nurse Facing WPH

1.No of care home admissions

2.Number of referrals to community services with reasons for referral.

3. No change in the number of discharges back to care homes based on 2013.14 baseline.

£50,000 CCCG



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13 B2: System & Capacity Vehicle

Increased capacity. 1. Conveyance time % within 1 hour improves

£114,760 SCAS

14 B5: HALO ED/SCAS Interface Performance & Handover Support

1. Handover times 2. Clear up times

£90,600 Funded through the national ambulance allocation to SCAS

SCAS



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15 B3: System Community Demand Practitioner

Support for Very High Intensity Users (VHIU)

1. Number of VHIUs calling SCAS each month 2. Number of hours at scene with VHIUs pm 3. Number of conveyances to A&E from VHIUs pm

£42,428 SCAS

16 E6: Patient Transport

Focussed on responding to and managing the urgent care assessment and treatment needs of the frail elderly people. The aim is to be able to transport people to MuDAS and home providing multidisciplinary assessment that prevents attendance to and admission via A&E.

1. Number of patient attending MuDAS 2. Referral to transfer time. 3. Number of potential admissions avoided.

£120,000 BHT

17 E7: ACHT Extension

Managing the urgent care needs of house-bound and frail patients. Provide support to patients in their place of residence to prevent out-of-hours attendance and admission via A&E.

1. Number of patient contacts. 2. Referral of response waiting time. 3. Percentage of urgent admission avoidance referrals visited. 4. Reduced travel time and cost.

£84,000 BHT



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18 G1: Transfer of Care Wexham Park Hospital A/E

This project is approached as an ‘Invest to Save ‘ as it has the capacity to shift patients along the admission avoidance care pathway from A/E to community. Provisional data from PACE (East Berks commissioned services at Wexham Park A/E) for Bucks patients provides intelligence that is considered as a baseline in support of this proposal.

The service aim is to provide all Bucks GP registered patients with a single point of access providing a comprehensive multi-disciplinary assessment for consideration of appropriate community health and social care teams including access to step down rehab beds 7 days a week.

1.Number of patients assessed

2.Reduce conversion rate from A/E to admission

Increase in patient number discharged from A/E to community services

£102,000 CCCG



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19 C1: Carers Hub Operate a Carer's Hub from 11.00-18.00 Mon-Fri at SMH. Hub will support carers’ health and wellbeing providing face-to-face support. Link the carers to Carers Bucks Adult Support Team. It will help health staff to facilitate timely discharge and improve re-ablement outcomes.

1. Readmission rates for individual/family they support.

£19,000 AVCCG

20 E11: Surgery- Ambulatory Care Model

Increased emergency surgical capacity and flow. Service aims to eliminate delays for surgical assessment. Open up the day surgery over the weekends, providing same day bed capacity.

1. Surgical breaches In the emergency department. 2. Time taken to theatre. 3. Discharges before 11am 4. Use of ambulatory capacity at weekends.

£200,000 BHT

21 G4: Additional step down rehab beds supporting transfer of care Wexham park Hospital A&E

To support extra demand for step down community rehab beds for Bucks patients from A/E transfer of care Wexham Park Hospital

£103,000 CCCG



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22 H3: Spot Purchase Beds

This is targeted at strengthening the frailty pathway and to support patient flow by providing a non hospital environment for reablement of patients requiring ongoing in-patient care but not within an acute setting.

1. Clinical KPIs 2. Care plan in place and delivery monitored and

documented by the care home staff 3. Record the number of patients seen by GP

within 24hrs of admission to the care home 4. Time of completion of assessments - MUST,

Waterlow, moving & Handling Record of any adverse events.

No. of pressure ulcers developed and category of same No. of falls including level of harm resulting from the fall Weekly activity report of use of the beds by bed (for BHT patients only) -.Daily bed occupancy -. by bed date of admission, EDD set, EDD achieved, -.LOS and outcome-discharge destination .-Total number of patients in beds

£150,000 AV & CCCG

23 H2 Programme Manager 1. A&E standard achievement £60,000 AVCCG/BHT



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1 E1: Op Res: Virtual Orthopaedics Clinics

To implement a virtual model of clinic management in orthopaedics, concentrating on remote management of clinic referrals and virtual management of electives to improve surgical capacity.

Number of face to face follow up appointments and capacity.

£64,500 BHT

3 E3: Vascular Diagnosis

Proposes system to condense multiple vascular clinics into fewer sessions and ultra-sonographer expertise to complete imaging at first appointment. remove significant numbers of follow up appointments and reduce RTT Pathways by 6-8 weeks. Require additional; sonographer and ultrasound machines for vascular dept. Supports resilience plan and reduces activity in secondary care services.

1. Number of patients imaged in 1 stop clinic 2. RTT Non-urgent vascular pathway reduction.

£52,340 BHT

4 E4: Elective Pathways Minimum Standards

To map further requirements needed to deliver the minimum standards of organisational resilience for elective care. Focuses on the RTT competency and training packages. An annual programme for further capacity and demand planning work for increasing the breadth of sub-specialities. Requires programme management support for a system wide transformational board in elective pathways. Provider specific support for a complete review of MSK service provision and internal efficiencies. Hope to increase the breadth of data quality monitoring and validation support.

1. RTT and data accuracy. 2. Completion of capacity and demand modelling. 3.KPI's of reforming Elective Care board. 4. Reduction in recommended configuration of MSK pathway.

£216,160 BHT



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Appendix IV ECIST Recommendations and Actions Taken

1 Capacity modelling

Additional ward of 20 wards required on the Stoke Mandeville Hospital site

2 Admission Avoidance

Implementing Ambulatory Care and Frail Elderly Models in A&E

3 7 Day Working

Expand support services and ward based medical model Extending weekend surgery capacity to support Trauma

4 Community Discharge

Investing in additional therapy and ACHT cover out of hours Implementing discharge to assess models of care Spot Purchasing of Community Beds Discharge to Assess MuDAS Falls Service



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Appendix V Public Health Analysis Table 1: Factors identified as contributing to increased demand for both ED & 999 services

Identified reasons for increased demand

Ageing population

Fastest growth in Emergency Department attendance reported in patients over the age of 65

(proportions >65 attending EDs varied between 12‐21%

Older cohorts (i.e. >85 years) are 4 times as likely to present to ED and 8 times more likely to be transported as younger adult age groups

Underlying factors behind older age ED/999 use:

Long term medical conditions increase with age (e.g. accounting for >80 % of ED visits by older people)

Fallers twice as likely to be older

Self‐care: functional impairment coupled with a lack of support

Nursing residential care populations ‐ evidence of greater use than

older people in own homes

Factors that promote access to primary medical care are associated with reduced ED utilisation

Male gender, Lower socioeconomic status

Loneliness and lack of family support

Fragmentation of family units and government policies encouraging older people to stay in the home associated with increased use of emergency services

Changes in organisation of primary care services, reduced access to primary care

Linked to issues such as: change to out of hours GP contract (UK); reduction in GP numbers (Australia); payments for consultations; unsuccessful attempts to access care (USA)

Access to a primary care provider reduced utilisation of ED services

Health promotion and health awareness

Increased awareness of need for early medical intervention for certain conditions (e.g. stroke) due to health programmes/ media campaigns.

Convenience



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Convenience of ‘one stop’ shop with full range of specialists/diagnostics identified in several international studies.

Deprivation

Lower socioeconomic status associated with increased use of emergency number services

Table 2: Factors identified as reasons for accessing Urgent and Emergency Care

Identified reasons for decisions to call 999

Patient perception of severity of the condition/perceived medical necessity

Bystanders likely to dial 999, whereas patients and their relatives prefer to access primary care.

Paramedic recommendation, Perceived shorter waiting time in ED

Perceived shorter time to treatment/quicker access

Perceived competence of ambulance service to ‘deal with anything’

Perception of limitation of primary care based urgent care to deal with issue

Influences of previous urgent care experiences in decision making, i.e. negative experiences of primary care based services

Interpersonal factors and the assessment of risk in decision making

Advised by someone else ‐ the most frequent reason for presenting to the ED was ‘being advised to attend by someone else’. The ‘adviser’ was more likely to be a health professional (doctor or nurse or NHS Direct) than to be ‘friends or family’.

Perceptions of seriousness ‐ different factors categorised including need to see specialist, thought they had a fracture, or wanted to see a doctor as soon as possible

Positive experience of ED in past

Identified reasons why patients decide to not access primary care

Perceived severity of their condition, delay for appointment likely, services unavailable out of hours

Referral to ED likely



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i Imison, C., Poteliakhoff, E. and Thompson, J. (2012) Older People and Emergency Bed Use. The King’s Fund ii What does the evidence say on how to reduce non-elective admissions, readmissions and length of stay? Authors: Anna Middlemiss, Wakefield Council and Greg Fell, Bradford Council. July 2013 iii Bardsley, M, Steventon, A, Smith.J and Dixon, J (2013) Evaluating Integrated and Community Based Care: How do we know what works? Nuffield Trust www.nuffieldtrust.org.uk/publications iv What does the evidence say on how to reduce non-elective admissions, readmissions and length of stay? Authors: Anna Middlemiss, Wakefield Council and Greg Fell, Bradford Council. July 2013



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Glossary

ACHT = Adult Community Healthcare Team

BHT = Buckinghamshire Healthcare Trust

CCG = Clinical Commission Group

COO = Chief Operating Officer

CSCSU= Central South Central Support Unit

DoS = Directory of Services

ECIST = Emergency Care Intensive Support team

EPRR = Emergency Preparedness Resilience & Response

JET = Joint Executive Teams

KPI = Key Performance Indicator

MAGS= Multi Agency Groups

MuDAS = Multi-Disciplinary Assessment Service

ORCP = Operational Planning and Capacity Resilience

PIRLS = Psychiatric In Reach Liaison Service

PMO = Project management Office

POD= Physician of the Day

PTL = Patient targeted Lists

RAT= Rapid Access Team

RUC= Reforming Urgent Care

SCAS= South Central Ambulance Service

SRG= Systems Resilience group

TVEA= Thames valley Area Team

UCWG= Urgent care Working Group

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