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Improving Urgent Care performance through the delivery of the Integrated Care programme

2 Delivering Integrated Care in West Suffolk

Distribution

Organisation/Name Role FrequencyDr Emma Derbyshire, WSCCG GP Clinical Lead Iterative until approvedUrgent Care Network Redesign Iterative until approved

Document Control

Title Delivering integrated care in West Suffolk - Improvement PlanAuthor(s) See team belowFile Ref

Review History

Name of Reviewer Organisation Role Date VersionSandie Robinson WSCCG Head of Planning and Delivery 21.6.13 1.0Dr Ed Garratt WSCCG CCG Chief Operating Officer 02.07.13 1.1 Graeme Jones NHS England Regional Head of Delivery 15.07.13 1.2CCG Executive WSCCG CCG Chief Operating Officer 24.07.13 1.3Dr Ed Garratt WSCCG CCG Chief Operating Officer 29.07.13 1.4Tracy Dowling NHS England Area Team Director of Operations 30.07.13 1.5Dr Ed Garratt WSCCG CCG Chief Operating Officer 09.09.13 1.6Sandie Robinson WSCCG Head of Planning and Delivery 09.09.13 1.6


Table of Contents

Executive Summary 4

Section 1 Introduction 5

1.1 Our Vision1.2 Integrated working1.3 Public Engagement1.4 Performance1.5 Commissioning Intentions for 2014/16

Section 2 Diagnostic 13

2.1 Key Points Arising from Analysis of Recent Urgent Care Activity2.2 Breach Analysis2.3 ECIST Emergency Care Dashboard2.4 ECIST System Diagnostic

Section 3 Recovery Plan 23 3.1 Coordinated programme of action by providers and commissioners

consisting of a series of performance improvement programmes3.2 Plans demonstrate credible and robust trajectories3.3 Plans demonstrate actions for immediate recovery of A&E

performance, winter planning measures and sustainable improvement

3.4 Actions proportionate to degree of risk in achieving recovery and sustained delivery based on historic trust performance

3.5 Plans show prioritised deployment of ECIST teams and other improvement support to the most challenged health economies

3.6 Plans are informed by pre-existing actions agreed by with relevant sector regulators (NTDA, Monitor) for recovery and sustainable delivery of the A&E 4 hour standard

3.7 Plans address the necessary actions on ambulance divert policies, ambulance handover delays and crews ready delays

3.8 Plans consider 7 day working and simplification of urgent care pathways

3.9 Plans demonstrate triangulation between e.g. admission avoidance, Cost Improvement Plans (CIPs), workforce; non-elective admissions; LOS and DTOC

3.10 Plans mention the deployment of contractual levers (fines for breaches) in connection with underperformance

3.11 West Suffolk Foundation Trust Re-admission, Non Elective Threshold Re-Investment

3.12 Key Outcomes

Section 4 Governance and Best Practice 464.1 Urgent Care Boards established around each A&E unit that

regularly meets and has representation of all stakeholders across the health economy

4.2 Plans provide assurance that risks are mitigated and all safeguarding measures are in place which comply with the Francis recommendations


This plan sets out the evidence base for the whole system approach to improving local A&E performance as well as delivery of longer term solutions to demand management and service quality. It is ambitious as it relies on whole system working. Persistent poor performance locally against the A&E target and ambulance turnaround demands a very different approach than in previous years to deliver sustainable solutions for winter 2013/14 and beyond. The importance of sustainability is underlined by the growing elderly population in Suffolk. Almost 1 in 5 (19%) of the current Suffolk population is over the age of 65. By 2020 the number will increase to almost 1 in 4 (24%) with the proportion of over 85’s increasing from 3% to 4%. If everything stays the same in terms of service models and delivery:

• Thecostofemergencyadmissionstohospitalforpeopleover the age of 65 will rise from £79m to £104m over the next 10 years.

• TheSuffolkCountyCouncilservicecostprojectionwillgrow from £89m (2009) to a projected £125m.

• ThereisaprojectedcombinedNHSandSuffolkCountyCouncil increase in spending of £61.5 million.

Supported by the National Emergency Care Intensive Support Team (ECIST), our plan is based upon a detailed diagnostic of the causes of the poor performance. In summary our analysis shows that the majority of breaches of the A&E target are caused by a shortage of beds at West Suffolk Hospital NHS Foundation Trust (WSFT). At a system level, ECIST diagnostic has emphasised that the local health and social care system is too often working in silos, which means that it is vulnerable in times of pressure. At its simplest, the plan is therefore aimed at reducing the shortage of beds by improving integrated working in West Suffolk.

The plan focuses on the three elements of the patient pathway outlined below:

• Prehospital-Wholesystemapproachtopreventing admissions

This work stream has a particular focus on improving:

- The crisis response to urgent care through the development of integrated multi-disciplinary teams with improved access to specialist geriatrician support.

- The planned care response to people who are most at risk in the future through the implementation of risk stratification, integrated neighbourhood teams and care coordination plus self-management. This work stream also focuses on improving support to care homes

Executive Summary

• Withinthehospital-throughA&Eandsupportingflow

This work stream refers to the plan developed by WSFT with ECIST support to:

- Improving performance within the A&E department- Improving access to assessment and short stay- Supporting frail elderly in A&E with in-reach support

for admission avoidance- Improving delivery of the medical model to inpatient

wards- Improving complex discharge

• Dischargeandon-goingcommunitysupport

This work stream focuses on developing ‘pull-based-discharge’ pathways with a particular focus on:

- In reach into the hospital to support discharge planning

- Improving access to community beds - Improving access to a broader community skill set to

manage complex patients including patients receiving IV therapy in the community.

Good progress is already being made on areas within the plan with strong leadership support from all our system partners and a commitment to maintain focus on the key priorities linked to performance recovery within the plan.

Performance has improved with 95% achieved for June - August and therefore a positive position for Quarter 2.It is recognised however that the strong leadership from the whole system must continue if we are to successfully secure the turnaround of performance at pace within West Suffolk and also to deliver on the longer term ambitions of the plan as a whole. Our local Urgent Care Network will be pivotal in securing and driving this forward.

Yours sincerely

Dr Christopher BrowningChairman, West Suffolk Urgent Care Network and West Suffolk CCG


SECTION 1: INTRODUCTION


1.1Our vision

In autumn 2012 the West Suffolk Health and Social Care system and its wider service partners developed a vision that local people:

• Willnothavetonavigatearoundacomplexsystemtofind the right information, care or service that meets their need

• Willhavetheirhealthorcareneedidentifiedearlybefore a crisis occurs

• Willhaveaccesstoarangeoflocalservicesthatfocuson supporting people to self-care and supporting primary prevention

• Willhavetheircarecoordinatedacrossclinicalandservice areas without duplication.

The key principles:

The West Suffolk system has also signed up to the following principles:

• Theserviceuserwillbetheorganisingprinciple• Clinicalorserviceintegrationmattersmost• Localserviceswillbeclinically/practitionerled• Therewillbeastrongprogrammeofpreventionand

community development • Theserviceuserisempoweredtomanagetheirown

condition • Theserviceuserhastheircarecoordinatedbyanamed

key worker • Theserviceuserwillhaveaccesstolocalservices• Localserviceswilldevelopshareddefinedcareoutcomes

with the service user • Localserviceswillshareinformationandtechnology

where this is in the interest of the service user • Serviceswillbeaccessedthroughasinglecontact

number • Theserviceuserneedswillhaveaccesstoservices24/7• Theserviceuserwillnotbeexpectedtorepeat

information about their care or clinical history to services involved in their care.

Supporting these principles is a number of system objectives which are outlined in a Memorandum of Understanding.

The following organisations have formally signed up to the delivery of the vision and joint plan for integrated care:

• WestSuffolkHospitalFoundationTrust(WSFT)• NorfolkandSuffolkMentalHealthFoundationTrust

(NSFT)• SuffolkCommunityHealthcare(SCH/Serco)• EastofEnglandAmbulanceTrust(EEAST)• WestSuffolkClinicalCommissioningGroup(WSCCG)• SuffolkCountyCouncil(SCC)• AgeUKSuffolk• SuffolkFamilyCarers• AssociationofIndependentCareHomeProvider

The long term vision for Integrated Care is outlined diagrammatically overleaf.

1. Community Intervention Service2. Roving ECP3. Mental Health a. Dementia Intensive

Support Service4. Admission Prevention/

Early Intervention5. Home First/Social Care6. Pull based Discharge -

ESD7. Community Beds8. Interface Geriatrician and CGA

Supportive Self Management/Planned Care Urgent Care and Pull Based Discharge

Acute Trust

Locality supported by pathways between:

1. Primary Care2. Community3. Social Care4. Mental Health5. Voluntary Sector

Change to health or social status requiring

intervention

Clinical assessment and decision

on need and urgency

Urgent health/social needs met

Intensive case management

Case Management - frail, elderly and complex needs

General Care and Support

Prevention and Promotion

Integrated Community Neighbourhood Teams, ACS

and mental health/primary care (Locality focussed)

Community Networks

Self Care and Independence

PATHWAY

Care managed according

to need and dependency

CARE COORDINATION


1.2Integrated working

West Suffolk CCG’s ambition is to drive integrated working in its health and social care system. The case for integrated working and its impact on delivery of good care and improved patient outcomes is well documented. What is also known is the challenges of implementing the necessary changes at pace and that a commitment to whole system working involving not only health and social care but also other services that influence the health and wellbeing of communities is critical to success.

The West Suffolk plan outlines our commitment to make the necessary step change in particular in preparation for winter 2013/14 and also to provide the system platform for developments that need to take place in 2014/15. The plan has been informed by the following diagnostic assessments:

• Localmappingofarangeofnationalbestpracticedocumentation from the Royal College of General Practioners) RCGP, The Kings Fund and the NHS Federation Zero Tolerance guidance supporting ambulance handover. The local system has also referred to the range of guidance developed by ECIST on ‘Effective approaches in Urgent and Emergency Care’ 2013

• In2012TricordantLtdundertookadeepdiveintolocalservices and developed a Joint Strategy between Suffolk PCT and Suffolk County Council that identified the priorities for change to support the provision of care for older people and led to the system sign up to delivery of integrated neighbourhood teams.

• InJune2012theWestSuffolkCCGestablishedthe Integrated Care Steering Group which involved membership from health and social care as well as Family Carer organisations and Age UK Suffolk. This group took the work from Tricordant and lessons learnt from the national Long Term Conditions programme led by Sir John Oldham and developed the first system wide plan aimed at managing demand away from the hospital. The plan has been further developed following further system wide workshops:

1 The Kings Fund The case for integrated care 2011. Thistlethwaite P (2011) Integrating health and social care in Torbay: Improving care for Mrs Smith.

2 RCGP Guidance for commissioning integrated Urgent and Emergency Care ‘A whole system approach’ August 2011, The Kings Fund Top Tem Priorities for Commissioners 2013,NHS Confederation Zero Tolerance ‘Making ambulance handover delays a thing of the past’ 2012, NHS Interim management and support ‘Effective approaches in urgent and emergency care’ 2013.

- In August 2012 the CCG invited Professor David Oliver, National Clinical Director of Older People, to Suffolk to meet with system clinical leaders and members of the public to build on the work already underway with the neighbourhood teams and explore approaches to improving access to specialist clinical support and interfaces between the community and acute trust. This informed the development of Interface Geriatrics (IGs) and comprehensive geriatric assessment (CGA).

- In autumn 2012 the system met again at a workshop to bring together the key themes from the evidence base and the August workshop to develop high level principles that defined what good integrated working looked like and what services and user groups would benefit most from an integrated care approach. This was cemented in a whole system Memorandum of Understanding which has created the catalyst for change. The key here is ensuring the integrated care approach is built from the bottom up as well as from the top down.

• InOctober2012,thepoorA&EperformanceatWSFTled the hospital to invite the ECIST to undertake a diagnostic of their internal processes and pathways.

The findings informed the development of the Emergency Care Pathways (ECP) plan at WSFT which

is focused on delivery of five work streams.

Each work stream has a detailed action plan, an assigned clinical and managerial lead and an Executive sponsor and Programme Management Office support. The ECP actions being delivered by WSFT to improve internal processes and practice is incorporated within the system wide Integrated Care plan.

ECIST continue to support WSFT to deliver the plan and all milestones have been achieved to date. The plan has also been discussed with Monitor who confirmed on 19 June that, the Trust was meeting its improvement trajectory and therefore satisfactory progress is being made.

• TheCCGalsocommissionedECISTtoextendthisdiagnostic assessment to the wider system.


The final shape and priorities within the Integrated Care action plan have been informed from these final diagnostics and its implementation is led by the Urgent Care Network which became operational in April 2013 and is supported by the Integrated Care Steering Group.

There are a number of key milestones that are pertinent to the delivery of this plan outlined below:

ShorttermactionplanforrecoveryofA&Eperformance

• SubmissiontoAreaTeam:24May2013.

Medium term action plan (to include plans in preparation for winter 2013/14)

• SystemsignofftorevisedEscalationPolicy:19July2013• CCGsignofftoSystembidsfortransformationfunding

to support delivery of medium term actions including winter: Plan B: 31st July 2013.

Longterm-Thesustainablestrategicplan

• Agreesystemvisionforurgentcare:2October2013.• ApprovalofStrategicPlan:6November2013.


1.3 Public Engagement

The CCG is a clinically led, patient driven organisation. It has been described by NHS England as an exemplar in terms of its public engagement during the CCG authorisation process. The CCG holds annual ‘Patient Revolution’ events, where they hand over the agenda to the public to discuss the issues that matter most to local people.

At the recent Patient Revolution event on 1 May 2013, there was considerable discussion of the urgent care system. Some of the key messages that came out are recorded below - and they emphasise the need for greater integrated working in West Suffolk.

The emergency services are there butthey’renotwellco-ordinated.

Need more integration with community services to keep patients safe and happy at home.

The patient will get 4 x1/2 hour carer time per day which isn’t enough. The patient needs more integrated care and needs to know the services available to them.

Weneedariskstratificationtooltoidentifythese patients and how they can be supported.

A&Econsultantsneedtothinkmore holistically and involve other groups inA&E(e.g.involveAgeUKinA&E).

Paramedics are more involved in domestic and social issues and with patients who can’t access the correct services therefore they just call 999 and are using up vital ambulance resource.

There is a culture of most services saying ‘our department closes at 5pm’ and then the ambulance service can deal with all the problems outside of this time.

Some patients who call their GP surgery and are told it will be 6 hours before the GP can visit the patient. Because it’s not an urgent issues it meansthepatientwillgotoA&Etobeseen.

There is miscommunication between various specialists and GPs and community services. Proactive management of patients is required to work out a treatment plan for these complex patients and to ensure GPs and specialists work together and that all essential services are induced in the treatment plan. If a patients needs are properly met then they won’t call 999 when it’s unnecessary to do so.

Patients are discharged too quickly from hospital without the right services in place. This means the patient will call 999 when they get home as they don’t know what else to do.

Linking health and social care is vital and we need to make more use of the voluntary sector.


1.4Performance

The two charts below show performance to date against the NHS Constitution A&E waiting times’ standard, with the second chart showing performance against the England average.

There is a long-term increase in demand at West Suffolk Hospital FT with A&E attendances up by 7.6% above plan. Conversion rates into admissions have also increased, with thresholds lowered to around 30%.

Performance has improved week on week in the the last month in line with progress against the action plan and also a drop in A&E demand to more expected levels.


1.5 Commissioning Intentions for 2014/16

The CCG recognises that the Commissioning Intentions for the next two years are important as it faces an increasingly challenging financial landscape. The key draft intentions below aim to outline the high level proposals from the CCG and have been informed from discussions held with membership practices at an engagement session on 31 August and feedback from the CCG Patient Revolution event in May. The Commissioning Intentions have been developed through the CCG Clinical work-streams and will continue to be progressed through this route in the next few weeks before final approval by the CCG on the 25 September.

The Integrated Care work stream aims to improve patient’s experience of urgent care, reduce the number of emergency admissions, length of stay in hospital and the number of people who are placed into long term care by:

• Bringingallelementsofthehealthandcaresystemtogether to manage more people away from crises, urgent care support and into planned care interventions including self-management.

• Ensuringthattheprovisionofemergencyandurgentcare has fully integrated 24/7 services and a simple way for patients to access them.

The work stream will be focusing on three particular areas of development over the next two years which include:

• Improvingthedeliveryofemergencyandurgentcarethrough whole system redesign

• Furtherdevelopmentofprimaryandsecondaryprevention of ill health through interventions such as assistive technology and community development programmes that can safely support people at home

• Enhancingthecurrentproviderlandscapethroughjointworking with SCC commissioning colleagues to formally recognise the role of family carers, voluntary and independent organisations as partners of care.

Keypriorityinitiative1:

The CCG will work with the urgent care system and in partnership with Suffolk County Council to develop a new model of Emergency and Urgent Care provision in west Suffolk informed by the key principles arising out of the National Review 2013/14. This will include the review of service specifications for primary care out of hours services, Urgent access number ‘111’ and Community Services (in line with contract end dates).The new model will aim to go live in 2015 and will give consideration to:

• Integrated‘wholesystem’CareCoordination24/7• SinglepointofAccess• Accesstorangeofresponsesincludingspecialisturgent

care support outside an acute hospital 24/7• Sharedinformationacrosscarepathway• TheuseofAssistiveTechnology


The CCG will work with Ipswich and East CCG to implement the stroke specification for hyper acute stroke care locally. The CCG will procure the early supported discharge element of the stroke pathway in 2014.


The CCG will build on the work programme of 2013/14 around supporting frail people at home with a focus on the development of community networks which will include:

• FurtherdevelopmentofthevirtualwardswithaccesstoComprehensive Geriatric Assessment

• Marketdevelopmentthatincludesabroaderrangeofservices to support primary and secondary prevention of ill health and which could be delivered in partnership with local communities

• Implementationoftheself-managementstrategy• Implementationofthefamilycarersstrategy


To improve patient experience and health outcomes by:

1. reducing the length of stay of frail elderly within an acute and community hospital

2. providing alternatives to long term home care placements through:• Furtherdevelopmentofthepullbaseddischarge

pathway across the system.• Exploringthejointcommissioningofepisodes/

packages of care as a forerunner to PbR in community contracting.

• Developalternativeswiththe3rdsectorforlongerterm rehabilitation/reablement.


SECTION 2: DIAGNOSTIC


2. Review of Urgent Care Activity during winter 2012/13

2.1 KeyPointsArisingfromAnalysisofRecentUrgentCare Activity

An analysis of winter activity at West Suffolk Hospital FT between November 2012 and March 2013 has been carried out. The key findings are set out below:

2.1.1 KeyFindingsinRelationtotheEmergencyDepartment

• Thenumberofpatientsbeingconveyedbyambulanceto West Suffolk Hospital during November to March was broadly in line with 2012/13 levels;

• Therewasanoverallincreaseof5.9%inA&Eattendances during the winter period of 2012/13 when compared to 2011/12, with a significant increase (11.7%) in the month of December alone;

• Duringthewintermonths,therewasan9.3%yearon year increase in attendance between 9pm-9am, whilst the number of attendances between 9am-9pm increased by 4.8% year on year;

• Duringthe2012/13winterperiod,theaveragenumberof attendance per hour was 7.5, compared to 7.1 in the previous year. The maximum number of attendances in any one hour was 19 (21 in 2011/12);

• A&EattendancestendedtopeakonaSunday(averaging 170 per day) and around 16% of the weekly total; whilst the number of 4 hour waiting time breaches tended to peak on a Monday (averaging 14) - around 18% of the weekly total.

2.1.2 Recent Urgent Care Delivery

• WestSuffolk’sperformanceagainstthe4hrA&Etargetfor months 7-12 of the last financial year was as follows:

October 2012 91.8% January 2013 91.2%

November 2012 94.6% February 2013 94.4%

December 2012 95.0% March 2013 90.3%

• ForJuly2013,performancestoodat95.7%andAugustat 95.55%.

2.1.3 Further analysis

Further analysis is set out below.

GP Referred Emergency AdmissionsDetail of admissions by day of week

• Fridayisformostpracticesthedaywithhighestnumberof GP referred emergency admissions (via A&E or EAU). This may imply that patients either choose to not seek primary care support until too late or they are concerned about accessing out of hours provision over the weekend.

1

19

9 84

26

0

Sun Mon Tues Wed Thurs Fri Sat

LengthofStayforWeekendAdmissionsDetail of LOS by day of week

• AdmissionsovertheweekendresultinlongestLOS. This may imply the lack of weekend provision relating to specialist decision making and diagnostics

1410

46

10 1013

Sun Mon Tues Wed Thurs Fri Sat


53

Secondary Care Emergency AdmissionsDetail of admissions by age group

85 & Over

75-8447%

61%65-74

55-64

Number of admissions

Costs for unplanned admissions

5 3

7

4

7

5

9

6

9

7

11

11

15

16

18

24

1421

• 47%ofalladmissionsrelatetothe55yearoldandoverage group equating to 61% of the costs.

• Theactionplanputsaparticularfocusontheover65-year old age group.


Secondary Care Emergency AdmissionsAmbulatory Care Sensitive Conditions

The chart below shows the number of admissions by member practice in 11/12 and 12/13 for all Ambulatory Care Sensitive (ACS) conditions per 1,000 list size for patients aged 65 and over and average cost per admission for 12/13 in West Suffolk.

On average the number of emergency admissions for ACS conditions have increased year on year. Cellulitis, respiratory conditions and DVT generate the highest level of cost.

As part of the QOF, QP point process last year the West Suffolk GPs reviewed the 2011/12 data on emergency admissions of patients with ACS conditions, within their practices. The practices then attended external review meetings to further explore the possible reasons for the number of admissions that were still attending secondary care.

They provided a number of overall conclusions and the following suggestions were fed into the CCG’s redesign work plans:

• AFtreatmentpathway-thisisnowinplaceandnationallyrecognizedasgoodpractice;• GPstepupbeds;• FocusonSuffolkCommunityHealthcare’sneighbourhoodteamstoensurerobustcommunityserviceprovision- this is underway and MDTs are in progress;• Useofspecialistnurseclinics;• Improveaccesstourgentinvestigations-directaccesspathwaytox-raynowinplace;• Vitamin‘D’pathway-currentlybeinglaunched;• Nursinghomecare-thisisaprioritywithintheactionplantobelaunchedon1stAugust;• Asthmaadmissions-rolloutofchildren’sasthmapathwayunderwayasdevelopedbyCYPclinicalnetworkandmaterials

have been provided to primary care to help children better manage their condition.


Secondary Care Emergency AdmissionsFalls and fragility fractures

The chart below shows the number of admissions by member practice in 11/12 and 12/13 for the Falls or Fragility Fractures in patients aged 65 and over per 1,000 list size and average cost per admission for 12/13 in West Suffolk.

On average the number of emergency admissions for falls and fragility fractures have fallen year on year.

Falls has been a priority area for the CCG. The pathway work is currently being consolidated across the whole system to embed best practice evidence into every clinical area.


WhenPatientsarearrivingatA&E

The chart below shows the attendance levels across the week and time of day for West Suffolk patients.

There is a direct correlation between the level of A&E attendance and primary care opening hours.

The pre-opening hours rising demand and the demand after 1830hrs indicates an opportunity for primary care to manage this demand out of hospital and is being considered as part of the suite of transformation bids supporting action plan reference IC1.6.


‘111’

The 111 service soft launched in Suffolk on 22 January 2013 and following support from DH and the SHA (now NHS England) proceeded to public launch on 19 February 2013. This was in line with the initial project plan and the project was launch on time and on budget. The contract is co-terminus with the Out Of hours Contract (March 2015) and both will be re-procured in 2014.

Clinical Governance Lead is Dr Billy McKee (I&ES CCG) and his deputy is Dr Simon Arthur (WS CCG) and both are heavily involved in both the Clinical and operational performance of the service. Clinical Governance and call review groups will continue on a monthly basis through the life of the service and dovetail with contract management and Patient Safety and Quality. The Clinical Governance procedures have been detailed in a separate CCG paper, presented to the Clinical Executive.

The service locally has been well received by the Public and by clinicians from our stakeholder community. Performance overall is has been good, but we still face some operational challenges as the Harmoni call centre in Ipswich also delivers 111 services for Lincolnshire and Milton Keynes CCG’s. The service reports on a daily basis (7 days a week) and performance is discussed in detail 3 times a week (and adhoc if necessary) based on performance tolerance and escalation protocols. These daily ‘situation reports’ are shared widely with CCG leads, our stakeholders and the Area Team.

The Activity for the overall service up to July:

Overall(Feb-July)

Total calls received 84,236

Total calls triaged 68,040 (82%)

Calls transferred to a 111 Clinical Advisor 15,956 (19%)

Total ambulance dispatched 6,979 (10%)

Total Conveyed 3,429 (49%)

CallstoOOHbyEast/West East 34,391 (64%) / West 19,236 (36%)

Overall this is in line with estimates of approximately 19,000 a month when the service is in full operation.

The time of call is still heavily focused in the ‘Out Of Hours’ period versus the activity in hours:

Month Feb Mar April May June July

In hours 385 1,486 1,986 1,724 1,578 1,566

OOH 10,983 13,888 13,070 15,086 11,778 10,706

Total 11,368 15,374 15,056 16,810 13,356 12,272

This activity during in hours is expected to increase and the call centre is prepared for this and resourced accordingly.

Calls are triaged by Health Advisors (non-medically trained call handlers) who operate the NHS Pathways Software. The software is risk averse and as such can drive a more urgent disposition for Out of Hours service and the Ambulance service.


2.2 Breach Analysis

Breach analysis takes place on a daily basis and a detailed root cause analysis is undertaken routinely. The main reason for breach activity is access to a medical bed and delays in initial assessment. Psychiatric breaches and delays in specialist opinions have also been a regular occurrence in recent months.

The chart below offers data for breaches since April 2013:

The analysis of breach activity informed the development of the Urgent Care dashboard to fully understand the main reasons for bed capacity and flow issues.

The Urgent Care dashboard is set out at 2.3 on page 21.

2.3Urgent Care Dashboard


KeypointsdrawnfromtheUrgentCaredashboard:

• A&Etimetoclinicaldecisionmaking-inconsistentapproaches by the senior clinicians within A&E on application of early clinical decision making was identified as an issue in the ECIST diagnostic. Developing a standardised approach is a key element of the action plan.

• Weekenddischarges-deliveryofsevendayworkingacross the system is a key factor in achieving consistent levels of discharges across the whole week at WSFT. Key improvement areas within the plan include access to senior clinical assessment and flexibility of care homes and community beds to accept a transfer of care outside Monday to Friday 9 to 5.

• MedicineAverageLOS-lackofsevendayprovisionandlate time of discharge has been identified as an issue impacting on long lengths of stay particularly on the medical wards. Seven day working is a key element of our plan.

• MedianTimeofDischarge-theECISTdiagnostichighlighted a culture of expected dates of discharge, clinical criteria for discharge and daily morning, consultant-led board rounds are not embedded. Improving flow through an effective discharge planning approach is being progressed through our plan.

WSFTbedcapacityplan

WSFT have now developed their bed capacity dashboard that will be updated each day to support the planning of beds and inform early escalation of capacity issues. An example of this is accompanying this update.

2.4 ECIST System Diagnostic

In February 2013 ECIST conducted a system diagnostic, which was presented to the Urgent Care Network’s first meeting in April 2013. In summary the diagnostic made the following conclusions:

Diagnostic headlines from ECIST

Main Headlines Evidence of silo working between health and social careLack of strategyLimited access to information sharingGovernance structures not in place

CCG Need decision makers at UCNNeed to develop strategy for Urgent CareNeed to develop an urgent care dashboard

WSFTInconsistent clinical review model in A&E, no ambulatory care pathways, need frail elderly pathway in A&E supported by admission avoidanceLong Continuing Healthcare process, poor relationship with community servicesInpatient medical wards and discharge - discharge too late in day, gaps in 7 day provision, long length of stay, no standardisation of ward round practice.

Primary Care Lack of clarity on access issues and plans for improvementClarity on sharing of clinical information cross care pathways Community Services Long length of stay in community beds No early supported discharge for strokeNo integration with social care for admission avoidancePoor integration with acute trust to build confidence for discharge to home - heavy reliance on community beds

Social CareMore potential to put greater focus on care homesSocial CareNo input into admission avoidanceNo strategy for 7 day or twilight / night workingLack of home care providersPackages of care - need to leave open

Ambulance ServiceOpportunity to improve handover processes. Requires observational audit and redesign Opportunity to develop admission avoidance vehicle as part of an integrated admission prevention response

OOH/111Critical review needed of existing streaming model from ED to OOHInformation sharing across organisations could be improvedUse of special notes varies by practice

Voluntary SectorSuffolk Family Carers: Need to clarify role within admission prevention pathway on schemes such as respite on prescription. Need to identify permanent funding stream for agreed health related schemes. Good progress on carers passport at WSFTOpportunity to enhance GP liaison work if funding stream can be identified permanently


SECTION 3: RECOVERY PLAN


3.1 Coordinated programme of action by providers and commissioners consisting of a series of performance improvement programmes

The system wide plan was signed off by the West Suffolk Urgent Care Network on 3 July 2013. The plan contains a coordinated programme of action by providers and commissioners consisting of a series of performance improvement milestones.

The plan is divided into short term high impact actions for immediate recovery of A&E performance (See 3.3.1 + Appendix) and longer term high impact changes for sustainable improvement. (See 3.3.2 + Appendix). The primary measure of impact is based upon influence on bed capacity, which is the chief cause of A&E breaches. Each action shows its impact upon bed capacity, risks, mitigations, and timeline for delivery.

The plan also maps across to the findings of the ECIST system diagnostic outlined in section 2.4.

In terms of programme management each project in the plan has an identified SRO, who is the lead owner - and responsible officer for the project. The CCG has recommended a work book methodology to ensure robust programme management. Organisations may use their own methodology providing this provides adequate assurance to partners.

Projects are monitored using the existing governance structures. This includes managing:

• Programmeandprojectplanning• Projectdevelopmenttoimplementation• Performancemanagementofprojectspost

implementation

The Urgent Care Network therefore has a key role in performance management and escalate to the Suffolk System Leadership Partnership when required.We have a CCG wide escalation policy that supports the system to be clear when to escalate if performance issues arise in one organisation or across the system.

Urgent Care Planning Group (every two weeks)

• Reviewsoverallprogressofallprojects• Deepdivereviewofprogressforspecificprojects• Reviewsriskregister(underdevelopment)• Reviewsperformanceofprojectspostimplementation

(monthly reports required for all projects)

Urgent Care Network

• Receivesprogrammemanagementreportsfromsystemplanning group

• Receivesdetailedprogressreviewsonspecificprojects• Agreescorrectiveactionwhennecessary• Reviewsperformanceofprojectsbyexception• ManagesurgentcareperformanceusingtheUrgent

Care Network dashboard


Mar

Mar

Feb

Feb

Jan

Jan

Dec

Dec

Nov

Nov

Oct

Oct

Sep

Sep

Aug

Aug

Jul

Jul

Jun

Jun

May

May

Apr

Apr

100.0%

100.0%

99.0%

99.0%

98.0%

98.0%

97.0%

97.0%

96.0%

96.0%

95.0%

95.0%

94.0%

94.0%

93.0%

93.0%

92.0%

92.0%

91.0%

91.0%

90.0%

90.0%

WSHA&EPerformance (Year to date cumulative)

Source: Unify Sitreps and Daily A&E Reports

WSHA&EPerformance (Monthly actuals)

Source: Unify Sitreps and Daily A&E Reports

2011-12

2011-12

2011-12 Target

2011-12 Target

2012-13

2012-13

13-14 Position

13-14 Position

2012-14 Target

2012-14 Target

“Do Nothing”

“Do Nothing”

Interventions

Interventions

3.2 Plans demonstrate credible and robust trajectories

Our plan demonstrates credible and robust trajectories supported by the high impact actions that we have put in place during the summer and early autumn. The governance and accountability of the Urgent Care Network has been formally signed up to by the whole system with clear performance improvement steps within the delivery of the plan outlined in the trajectory.

The trajectory shows that we will hit 95% year to date cumulative score in October 2013.

The impact of our short term plan for June supported 95.42% performance.


The following schemes will support the delivery of year to date 95% performance by October 2013. The schemes aim to halve the average daily breaches from 12 to 6 breaches a day. The metrics for the schemes are shown in Appendix 1.

July • ReviewcurrentCareHomeLESwithpractices• Aligncarehomehighvolumeuserswithprimarycare

practices and agree case management approach with clinical pharmacists and GPs

• AgreewithSCHtheuseoftheCareCoordinationCentre to be the single point of access for the care home

• Reviewthetrainingneedsofthetargetedhomesandalign the existing training packages to support the home staff

• DevelopmentofDischargechecklistfromacutetosupport the timely transfer of care to the care home

• ImplementationofRiskStratificationtool(viatheQIPPLES)

• ImplementationofMDTs• Mentalhealthcrisesresponse24/7• Seniorearlyclinicalassessment• ReviewandimproveddeliveryofContinuingHealthcare

process • 7daydischarge• Standardisedapproachtodailyward/boardrounds

August• ImplementationoftheSCHCommunityIntervention

Service (CIS) to integrate community health, social care, Enhanced Care Car (already operational) mental health (Dementia Intensive Support Service), pull based discharge from A&E, specialist nurses and enhanced comprehensive geriatric assessment

• Implementationofintegratedtriageandsinglepointofaccess with social care

• Implementationof24/7CareCoordinationCentre• CCGexecutivesignofftransformationfundingtoshare

costs of the EEAST Enhanced Care Car as part of the CIS • LaunchofrevisedSuffolkEscalationPolicy• TransformationfundingproposalstobeagreedbyCCG• Implementationofplannedcareapproach• Developmentofinformationdashboardforcarehomes

to monitor impact of interventions • Systempolicytopullbaseddischarge

September

• Primarycaretodeveloppracticelevelproposals• GPpracticeadmissionpreventionplans• Monitortheperformancequalityofcarehomesin

relation to CQC, Quality Improvement Visits and safeguarding through the Integrated Care work stream

• Shortstayassessmentunit• AmbulatorycareUnit-topvolumeambulatorycare

pathways now diverted from A&E to this unit. Further extension to other pathways

October

• ImplementationofInterfacegeriatrics• ImplementationofAmbulatoryCareSensitive

Conditions pathways

3.3 Plans demonstrate actions for immediate recovery ofA&Eperformance,winterplanningmeasuresandsustainable improvement

The plan is prioritised to show the short term high impact actions that will help to recover the A&E performance. The plan also incorporates the winter planning measures that are in the process of being implemented through the Urgent Care Network’s use of CCG transformation funding. Finally the plan covers longer term high impact actions for sustainable improvement.

Each project is rated out of 5 by impact upon bed capacity, which is the key factor in A&E performance at West Suffolk Hospital NHS Foundation Trust:

5: Major > 5 beds a week

4:Significant 4 beds a week

3: Moderate 3 beds a week

2: Minor 2 beds a week

1: Negligible 0 -1 bed a week


3.3.1 High impact (pre winter) action plan

The key actions within this plan include:

Ref IC1 to 5: Integratedadmissionprevention-24/7provisionofacoordinated response through a single point of access. Range of services to include Enhanced Care Car by EastofEnglandAmbulanceTrust,integratedhealthand social care triage and response (including EOL) incommunityandwithinA&Esupportingpullbaseddischarge,WelcomeHomeservicefromAgeUKSuffolkand provision of comprehensive geriatric assessment.

Diagnostic assessment: silo working, poorly integrated health and social care response to admission prevention, poor interface between community and acute.

• Summary

To support more adults to remain in the community by providing a coordinated, single response urgent care function.

To reduce the number of avoidable admissions into an acute hospital by ensuring organisations work across the 24 hour period providing flexibility in cover and enhanced care provision to support a wider range of urgent care needs. This project aims to centralise the function of admission prevention creating one crises response across the whole system. This is also supported by section 256 funding (appendix 4)

ImpactonA&Epositionlevel4/5 RAG Rating

• Outcomes

The high level metrics associated with admission reduction is part of a broader suite of initiatives aimed at reducing admissions and ambulance journeys (15% reduction of non-elective activity totalling £1,531,031).

These metrics include:

- Reduction in ambulance attendances and conveyances

- Reduction in admission conversion- Improved delivery of an integrated approach to

admission avoidance with less handoffs - Reduction in need for long term care packages- Reduction in long term care placements- Greater complexity of patient care need managed in

the community

• Timeframeandmilestones

- Implementation of weekly review of admission avoidance data - end June 2013- Implementation of integrated triage and single point of access with social care - August 2013- Implementation of the SCH Community Intervention

Service (CIS) to integrate community health, social care, Enhanced Care Car (already operational) mental health (Dementia Intensive Support Service), pull based discharge from A&E, specialist nurses and enhanced comprehensive geriatric assessment - July 2013

- Implementation of 24/7 Care Coordination Centre - August 2013

- CCG executive sign off transformation funding to share costs of the EEAST Enhanced Care Car as part of the CIS - August 2013- Launch of revised Suffolk Escalation Policy -

August 2013- Implementation of Interface geriatrics - October 2013

• Comment

Level of risk reduced on plan as all but one area in on track. Single point of access for health and social care not yet in place (IC1.1) although mitigating actions being taken for review by Network on 2 October.

Ref IC1.6 and 7:Improving primary care access and management offrequentattenderstoA&E

Diagnostic assessment: Lack of clarity on primary care access issues and plans for improvement.

• Summary

To secure an improved level of urgent care access in primary care through the development of GP telephone

triage in primary care and additional urgent care home visiting. All practices to produce action plans for reduction

in A&E activity. All practices offer minor injury service.

ImpactonA&Epositionrating4/5 RAG Rating

• Outcomes

- Patient triaged to right level of response by primary care - 90 minute response to urgent care home visiting request- Timely referral to hospital for assessment- All practices offer minor injury service



- Minor injuries service - implemented - Transformation funding proposals to be agreed by CCG - August 2013- Primary care to develop practice level proposals -

September 2013- Implementation - September 2013- Admission prevention to A&E plans - September 2013

• Comment

Transformation funding agreed by Urgent Care Network to support primary care to develop improved access to same day urgent care.

Ref IC1.8 and 3.2: Improved clinical management of people within care homes

Diagnostic assessment: More potential to put greater focus on care homes.

• Summary

To reduce the number of A&E attendances, emergency admissions and other NHS costs of patients from nursing and residential homes by improving the clinical management of their residents.

To improve the engagement with practices and the neighbourhood teams to support the care home staff in the training and education. To ensure every resident has a care plan including, where appropriate, an advanced care plan, regular holistic needs assessment and medicine reviews. Key to delivery of this initiative will be the proactive planned care support of clinical pharmacists and primary care and the interface of the integrated admission prevention service with the care homes.


• Outcomes

10% reduction of non-elective activity (dementia and EOL) from care homes totalling £237,000).

- Reduction in ambulance attendances and conveyances

- Reduction in admission conversion- Improved preventative care and recognition of

potential for health or social deterioration


- Review current Care Home LES with practices - July 2013

- Align care home high volume users with primary care practices and agree case management approach with clinical pharmacists and GPs - July 2013

- Agree with SCH the use of the Care Coordination Centre to be the single point of access for the care home - July 2013

- Review the training needs of the targeted homes and align the existing training packages to support the home staff - July 2013

- Development of Discharge checklist from acute to support the timely transfer of care to the care home - July 2013

- Implementation of planned care approach - August 2013

- Development of information dashboard for care homes to monitor impact of interventions - August 2013

- Monitor the performance quality of care homes in relation to CQC, Quality Improvement Visits and safeguarding through the Integrated Care work stream - September 2013

- Evaluation of approach - monthly from September

Ref IC1.9 to 13: Management of most vulnerable/highest risk patients with multiple long term conditions: Proactive case findingandNeighbourhoodTeams Diagnostic assessment: Poor integration with acute trust to build confidence for discharge to home - heavy reliance on community beds.

• Summary Development of a model for the delivery of person

centred multiagency integrated care (physical health, social care, mental health, independent and voluntary providers).


• Outcomes

The high level metrics associated with admission reduction is part of a broader suite of initiatives aimed at reducing admissions and ambulance journeys (15% reduction of non-elective activity totalling £418,000)- Reduction in ambulance attendances and

conveyances- Reduction in admission conversion


- Improved delivery of an integrated approach to admission avoidance with less handoffs

- Reduction in need for long term care packages- Reduction in long term care placements


- Development of a joint vision and principles for integrated working across health and social care June 2013

- Launch of integrated teams - including case management. Rolling programme from May 2013

- Implementation of Risk Stratification tool (via the QIPP LES) July 2013

- Workforce development from April 2013- Implementation of MDTs from July 2013- Implementation of Interface Geriatrics - 1 October

2013

Ref IC1.14: Ambulatorycaresensitiveconditions- out of hospital pathway development

• Summary

The development with primary care of key pathways to support the management of key pathways that currently provoke an acute admission or outpatient appointment. The top pathways under review include Deep Vein Thrombosis and Cellulitis.

ImpactofA&Epositionrating3/5 RAG Rating

• Outcomes

- Reduction in secondary care activity- Improved patient outcomes


- Agreement to new pathways - September 2013 - Implementation - October 2013

• Comment

Extension to access for IV therapy provision in community due to commence on 1 October following release of Transformation Funding

Ref IC2.1 to IC2.4:ThroughA&Eandsupportingflowwithin the acute hospital

Diagnostic assessment: Inconsistent clinical review model in A&E, no ambulatory care pathways

• Summary

West Suffolk Foundation trust has a comprehensive action plan developed with the support of the national ECIST covering the following key areas:

- Improving the Emergency department- Improving access to assessment and short stay- Frail elderly (which is covered under Integrated

admission prevention)- Improving management of inpatient medical wards

(and discharge which is covered under Supporting Discharge)

• Outcomes

- Increased numbers and seniority of staff with A&E- Early senior clinical assessment- Reduced admissions for assessment (to move to an

assess to admit model)- Reduction in ambulatory care admissions- Closure of short stay assessment are overnight- Improved transfers of care


- Mental health crises response 24/7 - July 2013- A&E streaming model - June 2013- Senior early clinical assessment - July 2013- Short stay assessment unit - September 2013- CDU - delayed (December 2013)- Ambulatory Care Unit - September 2013- Surgical Assessment unit - June 2013

IC2.1: RAG Rating

Comment

Streaming models of care delivery and delivery of senior assessment in place. Median time to be seen by a clinical decision maker under 60 minutes. CDU due to complete on 16 December and draft operational policy out for consultation. Escalation area in ED now closed.


IC2.2: RAG Rating

Comment

High volume clinical pathways for Ambulatory Care in place. Final Ambulatory Care Unit officially launched 2 September. The morning handover structure is due for review in September with a view to improving and strengthening the process. A new medical model is currently being negotiated and, if agreed, will implement an in-reach medical model and provide appropriate cover for the new Acute Medical Unit and the Wards. Ward F8 has relocated to F7 and only short stay patients are now admitted to this ward as from Monday 2nd September. A staffing model for both F7 and F8 has been agreed. There remains a shortfall within Band 5 recruitment, which is being mitigated with a plan to allocate experienced staff from across the medical wards. Work on the Acute Medical Staffing model is still on-going with input from ECIST. The preferred model was presented to the Finance Director and the Chief Operating Officer and recruitment will commence once the model is agreed. In the interim, these posts will be filled by locums. The initial work to review the existing medical take model was completed on time and the options for an improved model have been presented to the Executive Directors and the preferred model has been identified and presented to the Medical Consultant Teams. Pull based model with early senior assessment in ED/ Assessment Units by a multi-disciplinary elderly care assessment team completed. The following has been delivered:

• Developedpolicyandstandards• Reviewedmodel• Implementedpilot• Auditedpilotandcomparedwithprepilotauditresults• Recommendationsmadebasedonfindings Next steps

Older People Assessment Team (OPAT) report to be shared with the Trust and CCG to seek organisational support to put forward recommendations from audit for sustainable model. Aiming for 1 October full implementation IC2.3: RAG Rating

IC2.4: RAG Rating

Comment

Ward board round standard operating procedure (SOP) agreed by Consultants. Electronic whiteboard training commenced using the SOP. Reducing delays in TTO’s work commenced. Along with radiology pathway work for ultrasound scans under review to reduce waits for inpatients. Plan for roll out of nurse led discharge across medicine well under way.

RefIC3.12&3:Supporting Discharge

Diagnostic assessment: Long continuing healthcare process, poor relationship with community services. Inpatient medical wards and discharge - discharge too late in day, gaps in 7 day provision, long lengths of stay, no standardisation of ward round practice.

• Summary

This suite of projects are aimed at improving the internal processes within West Suffolk Foundation Trust and within the community hospitals to ensure that every patient has access to a daily MDT review, estimated date of discharge and care plan. The project also puts the recommendations from the ECIST guidance paper three ‘Effective Approaches in Urgent and Emergency Care concerning priorities for the discharge of frail older people’ into practice through the development of a whole system pull base discharge model.


• Outcomes

- Improved health outcomes through reduction in length of stay in hospital

- Conversion of long to short stay length of stay- Reduction in delays- Reduction in admission into long term care

placements


- Review and improved delivery of Continuing Healthcare process - July 2013

- 7 day discharge - July 2013- System policy to pull based discharge - August 2013- Realignment of community beds to support planned

care rehabilitation discharge pathways and provision within Bury St Edmunds - June 2013


- Standardised approach to daily ward/board rounds - July 2013

• Comment

Work with the CCG looking at reducing delays within the CHC process continues. Option 4 for the new way of working for the discharge planning team now written as the transitional funding has been agreed.

Ref IC4.3 and 4.5 Enablers

• Publiccommunications The CCG has developed a seasonal communications

plan in partnership with the urgent care system which aims to:- Celebrate the work of organizations- Reinforce messages to the public to help plan for

their health in winter- Reinforce use of other ways to help get help or

alternatives to A&E

• Developmentofcontingency(PlanB)forwinter2013/14. The CCG is currently completing a winter assurance framework checklist based on the 2012/13 template for the system to review at its Urgent Care Network meeting on 2 October

To support delivery of the priorities, the Urgent Care Network has now agreed on those areas which would benefit from transformation funding to support the necessary stepped changes ahead of winter. Each proposal for funding was assessed by the system membership of the Network against a weighted criteria and approved by the CCG Board on the 7 August. All proposals are expected to become fully operational by the 1 October. The Network has also agreed to fund additional winter Plan B beds which will be located within the Bury St Edmunds locality.

3.3.2 Medium term sustainable impact

Ref IC1.10 to 12:Communitydevelopment,Self-management and enhancing support to family carers

• Summary

This project aims to bring key partners of the third sector who currently play a vital role in supporting local people and communities but are poorly integrated within the main care pathway. The key focus is to reach out to the community through these organisations to enhance

social integration of frail elderly in particular recognising this has an impact on resilience against physical and mental health problems.

ImpactonA&Epositionrating4/5 (Health Communities Collaborative demonstrated a 32% reduction in falls in older people).

RAG Rating

• Outcomes

- Improved capacity to support primary and secondary prevention of ill health through better integration with neighbourhood teams

- Reduction in primary care appointments- Improved understanding and appropriate use of local

services by local communities- Reduction in use of urgent care as a result of

improved social integration and social networking.- Reduction in family carer breakdown


- Community development - low level care support packages - Up to March 2014

- Non urgent Community Transport protocols - July 2013- Dementia Friendly Communities - Up to March 2014- Family carer support - Primary care and WSFT - up to

March 2014

Ref IC1.13: Falls and fragility fractures

• Summary

The falls pathway is now operational within West Suffolk so this project is about developing the key elements of embedding the pathway fully, developing primary prevention and proactive case management across the system

The fragility fracture pathway is new and will take a further 12 months to realise the full benefits of fracture reduction.


• Outcomes

- Reduction in falls related admissions- Reduction in fragility fractures



- Ambulance referrals of fallers to care coordination centre - August 2013

- Fracture liaison service - phased roll out. Completion February 2014

- Primary prevention exercise programme - Phased approach up to March 14

- Opportunistic falls screening - primary care January 2014

Ref IC3.3: Early Supported Discharge for stroke

• Summary

This project aims to implement a pull based discharge pathway for acute stroke patients who could manage their rehabilitation programme within their own home.


• Outcomes

- Reduction in acute length of stay for stroke patients- Improved patient outcomes


- Implementation - September 2014

Ref IC3.5: Improve access to IV drugs in the community

• Summary

The Community provider currently provides a service to support patients at home requiring IV infusions. There is some evidence that the current provision could be extended to provide a service to a larger number of patients who currently receive their service as an inpatient. Further work is being undertaken to identify the extent of this potential and the pathway options.


• Outcomes

- Reduction in acute length of stay - Improved patient outcomes


- Implementation - Phased approach from October 2013

3.4 Actions proportionate to degree of risk in achieving recovery and sustained delivery based on historic trust performance

The assessment of impact and risk is outlined in the attached action plan in Appendix 1, which reflects the ECIST system diagnostic recommendations. The granular elements specific to West Suffolk hospital are shown at Appendix 2.

West Suffolk CCG and health and care providers including the voluntary sector are all committed to effectively performance manage the delivery of the Integrated Care Plan for West Suffolk, through the following systems and processes.

Monthly system-wide West Suffolk Urgent Care Network, chaired by Dr Christopher Browning, CCG Clinical Chair and West Suffolk CCG Clinical Executive. An urgent care system-wide dashboard - see 2.3 - supports the system to enable providers to flex capacity and resources, to re-act to spikes in demands across the system. This will ensure that flow is not jeopardised. The Urgent Care Network has a Risk Register, which follows a consistent format. The Risk Register contains each action/objective assessed in terms of achievement, setting out existing mitigations.

CCG Chief Operating Officer has executive responsibility for Integrated Care (including Winter Planning), in support of Dr Browning and the CCG Elected GPs; a monthly information pack is produced on the progress with the delivery plan, for scrutiny and review through the West Suffolk CCG Integrated Care Workstream. The information pack currently shares financial position and acute activity against plan, QIPP delivery, NHS constitution and national targets, local quality premium indicators, contractual targets/standards and CQUIN updates for our acute, East of England Ambulance Services, out of hours, community and mental health providers, to the local health care economy. The second phase due in July 2013 of the information packs will include feedback in relation to quality improvement visits, safeguarding and CQC profiles and will include more qualitative indicators, infection control; serious incidents; complaints; safety thermometer; falls; pressure ulcers and results of any root cause analysis. The information packs will continue to evolve to address making every contact count and further recommendations from the Francis Report. The CCG will work with Healthwatch Suffolk to explore mechanisms to incorporate the patient experience.


Each programme and project of work is underpinned by a stringent risk management process. Every work stream has full risk and issue register which includes records of the risk owner (clinical and non-clinical), risk area, mitigation plan and updates. The risks are efficiently and regularly tracked, monitored, flagged and actioned using the West Suffolk CCG PMO function. An overall PMO risk register highlights all of the key risks and issues and links and highlights interdependent risks. This feeds into the Integrated Care Workstream and the CCG Clinical Executive monthly report.

The CCG convenes a weekly teleconference with all partners to discuss A&E performance and system working. The frequency of these meetings changes to daily as winter approaches and / or performance is compromised.

Urgent care metrics are reported to the CCG executive leads on a daily basis via a dashboard reporting on A&E performance, A&E breach activity, ambulance activity and handover performance (see below). A summary of the week’s activity and performance is presented for scrutiny to the CCG executive meeting every Wednesday.

West Escalation Reportes:

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Fri 19/07/2013 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 24° 13° 0 mm 0 CMThu 18/07/2013 47 68% 93% 100% 100% 94% 98.55% 138 2 96.57% 96.57% 93.24% 31 22% 2 1 13 6 14 21 26° 14° 0 mm 0 CM

Wed 17/07/2013 49 54% 98% 100% 100% 94% 96.65% 179 6 96.47% 96.47% 93.20% 46 26% 1 0 --- --- --- --- 27° 16° 1 mm 0 CMTue 16/07/2013 42 68% 97% 100% 100% 88% 99.38% 162 1 96.46% 96.46% 93.17% 43 27% 0 0 6 0 6 13 26° 15° 0 mm 0 CM

Mon 15/07/2013 43 61% 98% 100% 100% 95% 95.98% 174 7 96.28% 96.28% 93.11% 54 31% 1 1 --- --- --- --- 26° 15° 0 mm 0 CMSun 14/07/2013 49 68% 93% 98% 100% 82% 94.62% 223 12 96.30% 96.30% 93.08% 53 24% 2 1 --- --- --- --- 23° 14° 0 mm 0 CMSat 13/07/2013 49 59% 89% 100% 100% 90% 98.38% 185 3 96.47% 96.47% 93.06% 37 20% 2 0 --- --- --- --- 27° 15° 0 mm 0 CMFri 12/07/2013 48 70% 98% 100% 100% 92% 98.71% 155 2 96.30% 96.30% 93.01% 39 25% 0 0 --- --- --- --- 22° 12° 0 mm 0 CM

Thu 11/07/2013 48 62% 98% 100% 100% 98% 96.27% 161 6 96.10% 96.10% 92.96% 40 25% 2 2 --- --- --- --- 20° 19° 0 mm 0 CMWed 10/07/2013 46 66% 95% 100% 100% 89% 98.14% 161 3 96.09% 96.09% 92.92% 44 27% 0 0 --- --- --- --- 21° 9° 0 mm 0 CMTue 09/07/2013 44 57% 98% 100% 100% 100% 97.70% 174 4 95.88% 95.88% 92.87% 46 26% 1 0 --- --- --- --- 25° 12° 0 mm 0 CM

Mon 08/07/2013 47 71% 95% 100% 100% 89% 98.51% 201 3 95.65% 95.65% 92.82% 50 25% 4 2 11 0 3 4 23° 10° 0 mm 0 CMSun 07/07/2013 47 66% 95% 98% 100% 94% 93.41% 182 12 95.17% 95.17% 92.76% 35 19% 3 0 --- --- --- --- 23° 10° 0 mm 0 CMSat 06/07/2013 49 83% 96% 100% 100% 98% 97.58% 165 4 95.49% 95.49% 92.75% 34 21% 1 1 --- --- --- --- 22° 10° 0 mm 0 CMFri 05/07/2013 38 56% 91% 100% 100% 84% 98.08% 156 3 95.09% 95.09% 92.70% 36 23% 2 1 --- --- --- --- 22° 10° 0 mm 0 CM


Mon 01/07/2013 55 57% 87% 98% 100% 96% 92.43% 185 14 92.43% 92.43% 92.56% 65 35% 1 0 4 0 2 7 19° 11° 0 mm 0 CMSun 30/06/2013 43 85% 100% 100% 100% 95% 98.99% 199 2 95.42% 92.57% 92.57% 46 23% 0 0 --- --- --- --- 24° 13° 0 mm 0 CMSat 29/06/2013 52 73% 93% 98% 98% 87% 92.42% 211 16 95.27% 92.48% 92.48% 52 25% 3 3 --- --- --- --- 21° 12° 0 mm 0 CMFri 28/06/2013 44 67% 98% 100% 100% 98% 100.00% 129 0 95.40% 92.48% 92.48% 39 30% 0 0 --- --- --- --- 20° 11° 3 mm 0 CM


Mon 24/06/2013 43 58% 94% 97% 97% 77% 91.24% 194 17 94.84% 92.20% 92.20% 47 24% 0 0 --- --- --- --- 14° 8° 1 mm 0 CMSun 23/06/2013 53 50% 81% 92% 94% 98% 91.67% 192 16 95.02% 92.22% 92.22% 48 25% 0 0 --- --- --- --- 19° 11° 8 mm 0 CMSat 22/06/2013 46 56% 93% 100% 100% 98% 96.86% 159 5 95.20% 92.23% 92.23% 42 26% 0 0 --- --- --- --- 19° 11° 6 mm 0 CMFri 21/06/2013 54 73% 100% 100% 100% 91% 97.35% 151 4 95.12% 92.17% 92.17% 50 33% 0 0 --- --- --- --- 19° 10° 2 mm 0 CM

Caveats

The weather information comes from www.accuweather.comThe ambulance handovers and button submit percentages are based on unvalidated data and this will not tally with the contractual monthly minimum data set.

Wider System A&E Bed stateAmbulance Discharges


Formal concerns relating to provider performance are raised through existing contractual mechanisms, as well as monthly CEO:CEO meetings.

The CCG has recently refreshed the system wide escalation policy which provides guidance to the health and care system on managing system pressures and risks to performance through the application of escalation triggers which stimulate a system response to high levels of demand or capacity pressures. The CCG oversees and drives the implementation of the policy across the system through the following operating framework:

Suffolk wide urgent care escalation policy 2013/14: Framework for action:

I Each organisation has a recognised capacity, based upon beds, workforce, equipment, etc as appropriate to that organisation, which has been agreed by the system as a whole;

II Each organisation has also agreed a range of additional capacity, real or virtual, which can be accessed during the winter period or indeed any period of heightened pressure of demand or activity;

III Each organisation has agreed a series of trigger levels at which, when capacity is challenged or exhausted, internal or system-wide action has been agreed to be appropriate – this may include use of agreed additional capacity, transfer, diversion or substitution of services, or enhanced triage or cancellation of certain services;

III All the system organisations have agreed to use a common approach, directed by NHS West Suffolk CCG in its current role as system manager, to communicate and jointly manage system pressures so that the entire capacity of the system is brought to bear most efficiently on demand and activity, in the interests of patient safety, quality of outcome and maintenance of access;

IV This approach will be maintained both during normal working hours and out of hours.

In addition West Suffolk Hospital has a PMO function that drives their internal plan. The PMO function is overseen by the Chief Operating Officer and Director of Major Projects. The plan has six workstreams which meet weekly. They are overseen by a steering group chaired by the Chief Operating Officer and attended by Medical Director/Nursing Director/Managerial Work Stream Leads/Clinical Work Stream Leads/Nursing Work Stream Leads/Estates and Strategy leads where appropriate. The steering group maintains overview of progress against agreed milestones, provides constructive challenge, provides support and resolves issues and ensures achieving expected quality/performance outcomes.

A summary of current internal progress provided by the Trust can be found below:

WorkStream1-EmergencydepartmentOverallWorkStream RAG Rating

With the sustained implementation of both Rapid Assessment and Treatment (RAT) and the streaming process, there has been a reduction in A&E related four hour breaches and improvements in ambulance turnaround times for the month to date. Demand has continued to increase.

Staff morale remains positive and this is apparent when entering the department. The repeated staff morale survey for July will be undertaken this week with data available the first week in August. In developing comprehensive staff cover matched to peak demand, ENP shifts have been extended to support the department until midnight and a consultation is underway with A&E consultants about working hours. Work for the new Clinical Decision Unit (CDU) has commenced with the removal of asbestos from the main corridor. This will now continue for the next 16 weeks.

WorkStream2-Assessment&ShortStayOverallWorkStream RAG Rating

Ward F7 has now relocated to G9 leaving F7 available for enabling work to commence in preparation for the new Short Stay Ward. Advertisements for staffing have been on-line and advertised around the Trust over the past week. It is pleasing to see the level of interest in this from our staff. A back-up strategy for staffing F7 is underway and we have recently been successful in attracting 23 more Portuguese Nurses to enable existing staff to be released into these new posts. A further 14 nurses are planned to start work in September. A clinical capacity plan is being prepared for the Board meeting in September 2013, showing how the appropriate levels of staffing will be recruited and deployed during the winter 2013/14.

WorkStream3-InpatientMedicalWards&DischargeOverallWorkStream RAG Rating

Standard operating procedures for daily board ward and ward rounds have been completed. Ward plans are under development to address time of day discharge, weekend discharge and overall length of stay. Internal waits have been identified and the top two are awaiting x-ray diagnostics and specialist referral review. The nurse led discharge pilot is complete and a plan to roll out across medicine is in place.


WorkStream4-Frail&ElderlyOverallWorkStream RAG Rating

A Pilot of Older Peoples Assessment Team (OPAT) completed (ran from 1-19 July). Pilot audit data is currently being reviewed, to be compared to pre pilot audit data to identify both internal and external enablers and barriers to supporting early discharge. Formal evaluation will be shared with the Trust and CCG to seek organisational support to address issues highlighted that delay or prevent early supported discharge.

WorkStream5-ComplexDischargeOverallWorkStream RAG Rating

Our staff has had Involvement in Care Home Review with the CCG and ambulance service SCH commenced a review of Care co-ordinators role along with discharge planning and we commenced 7 day length of stay review. An internal action plan has been written and requires agreements from partner organisations. WorkStream6-CommunicationsOverallWorkStream RAG Rating

3.5 Plans show prioritised deployment of ECIST teams and other improvement support to the most challenged health economies

ECIST have been working with West Suffolk Hospital and the wider health economy since October 2012. Their input through delivery of the diagnostic and support to shape the action plan and priorities within it are outlined within the sections 2.4 and 3.3.

Monitor review West Suffolk Hospital’s performance on a quarterly basis through the compliance framework self-assessment and Board declaration. As well as detailing performance against individual targets in the previous quarter this includes an indication of the Board’s confidence in the ability to deliver targets going forward. The Trust’s relationship team at Monitor also review and challenge the organisation’s performance and strategic plans through the Annual Planning Review.

The CQC continually review the Trust’s performance against a range of indicators and sources of intelligence. These are summarised through the monthly Quality Risk Profile reports and inform the CQC’s inspection programme. The CQC undertook an unannounced visit of the Trust in June 2013 and although the report from this visit is still draft no regulatory action has been identified. As part of this visit and the CQC’s on-going monitoring arrangements “hard” and “soft” quality indicators are reviewed for emergency care performance.

3.6 Plansareinformedbypre-existingactionsagreedbywithrelevantsectorregulators(NTDA,Monitor)forrecoveryandsustainabledeliveryoftheA&E4hourstandard

This plan builds on the feedback from the tripartite team on the submission of the short term plan in May that there was not a vision or narrative plan. Our vision is described in this document and there is a detailed longer term plan which covers risks, barriers, mitigations, contractual levers, trajectories. Our plan is based on a detailed diagnostic assessment and outlines the system priorities for delivery within 2013/14 to bring sustainable change and performance improvement.

The plan also incorporates feedback from NHS England and Monitor on our first draft medium plan following a meeting held on 15 July 2013.

3.7 Plans address the necessary actions on ambulance divertpolicies,ambulancehandoverdelaysandcrewsready delays

Handing over a patient from an ambulance to an emergency department is expected to take no more than 15 minutes. But as the National Audit Office highlighted in its review of ambulance services in June 2011, only around 80 per cent of handovers meet this expectation. Each failure to meet this standard means a delay and poor experience for the patient waiting to be received. It also means a delay in an ambulance crew being available to dispatch to a new emergency call - posing a potential safety risk to the next patient waiting for an ambulance in the community.

West Suffolk CCG and Ipswich and East Suffolk CCGs are the lead commissioners of the ambulance contract across the East of England, and they employ a team to carry out the commissioning and management of the contract. The main mechanism is the regular monthly ambulance consortium meetings consisting of representatives from the 19 CCG’s across the East of England, representatives from the East of England Ambulance Service NHS Trust, the lead commissioning team and a GP representative. All of the contractual levers are used and penalties imposed for non-performance (see 3.10).

In addition a number of sub groups support the consortium by monitoring individual elements of the contract and providing regular reports to all consortium members. For example the quality sub group reports on the quality and CQUIN elements of the contract.


West Suffolk CCG meets with the Ambulance Trust and West Suffolk Hospital on a monthly basis to review ambulance performance at A&E as part of an agreed tripartite approach to managing performance.

The health system in West Suffolk have implemented NHS Confederation’s ‘Zero Tolerance: Making ambulance delays a thing of the past’ recommendations to improve the current delays, as per: IC2.4 of the plan. They are as follows:

Recommendation 1

Patient handover delays are seen as a jointly owned whole-system issue. Leaders from all parts of each local health economy are committed to work as partners to reduce delays in order to improve patient experience, care and safety.

Recommendation 2

WSFT, the EEAST and the WS CCG have each identified specific individuals who have committed to work together - and with social services colleagues and other partners - to explore, understand and address the causes of handover delays in their area and the impact they have on patient experience, safety and costs. Particular efforts are made to involve primary care and Suffolk Community Healthcare. Progress in tackling handover delays are monitored at board level by WSFT and the CCG.

Recommendation 3

The WS CCG actively seeks support for a zero tolerance approach to handover delays in their health economy, in which significant delays of 60 minutes or over are regarded as unacceptable. Associated financial penalties are agreed to reinforce this approach, and are consistently applied.

Recommendation 4

WSFT, the EEAST and the WS CCG now adhere to agreed, explicit and well understood definitions for describing, recording and monitoring handover processes, including key performance indicators start and stop times.

Recommendation 5

WSFT and the EEAST, with the support of the WS CCG, have developed common KPIs to support adherence to the national standard of 15 minutes for both arrival to handover and handover to crew clear targets. These KPIs allow room for some ‘flex’ rather than being absolute 100 per cent targets.

Recommendation 6

WSFT and the EEAST, with the support of the WS CCG, have developed systems that capture data automatically and transparently against agreed definitions, including start and stop times. This data is considered the single source of truth and is accessible by all partners. Data collection and reporting processes include a validation process to ensure data is accurate and agreed by all partners.

Recommendation 7

Partners in West Suffolk work jointly on local process mapping exercises, involving acute, ambulance and commissioning staff at all levels to review current handover and discharge pathways, identify where efficiencies can be made, pinpoint how processes can be streamlined and suggest areas for development.

Recommendation 8

WSFT now model their maximum hourly ambulance attendance capacity in partnership with the EEAST. They review internal mechanisms for managing patient flow across the hospital and examine how this can help to mitigate against significant and lengthy delays as a direct result of multiple attendance surges.

Recommendation 9

WSFT and the East of England ambulance service, with the support of the CCG, have developed common escalation plans and are working to ensure that these function as well out of hours as they do in hours.

3.8 Plansconsider7dayworkingandsimplificationofurgent care pathways

The CCG has commissioned through CQUIN 7 day consultant assessment within 24 hours of all new admissions, access to diagnostic tests and consultant review of patients with a clinical concern.

7 day working is a priority area within the plan relating to admission avoidance and supporting discharge. See plan reference IC1.1, IC1.4 and IC2.4, covering:

- 24/7 crisis response which involves EoL hospice care, admission prevention, social care, and ambulance-enhanced care car;

- Extension of above to bring 7/7 Age UK welcome home service and dementia intensive support;

- 7 day discharge of patients from inpatient beds.


3.9 Plans demonstrate triangulation between e.g.admissionavoidance,CIPs,workforce; non-electiveadmissions;LOSandDTOC

The whole system plan triangulates the elements of the patient pathway as described in the three sections of the plan - pre hospital, through A&E and within the hospital and supporting discharge. The West Suffolk system recognises the interdependencies of all elements of the pathway in securing the very best outcomes for local people. The Urgent Care Network will oversee the impact of this plan on all system metrics and triangulates the information to inform this plan - see 2.3. For example, increased staffing at West Suffolk Hospital should reduce length of stay and delayed transfers of care, but might have an impact upon community bed capacity.The new Urgent Care Network information dashboard is being prepared for 14 August 2013 and will contain information on:

1.A&Ea. Total AE Attendancesb. Total AE Breachesc. Conversion Rated. % Achievede. Emergency patients discharged to nursing

homes(Total)f. Death in usual place of residence (Total)g. Ambulances queuing over 30 / 60 minutesh. A&E time to clinical decision makingi. A&E staff sickness absencej. Weekend dischargek. Medicine average length of stayl. Medium time of dischargem. A&E, DVT, clinic and SAU attendancesn. Patients staying greater than 50 days

2. Ambulance Servicea. Conveyedb. Non Conveyedc. % Conveyed, etc.d. Response times

3. 111a. Calls answeredb. Calls triagedc. Calls transferred to advisor, etc.

4.Out-of-hoursServicea. Total Homeb. Total Basec. GP Advice, etc.

5. All Admissionsa. Total Admissionsb. Total LOS

c. Total Non-Elective admissionsd. Total Readmissions - can further define categoriese. Interface Geriatrics 65+: Total Non-Elective

Admissionsf. Fallsg. Excess Bed daysh. Alcohol related admissionsi. Emergency Admissions from Care Homes (EOL and

dementia)

6. Othera. Frail and Elderlyb. Frequent Fliersc. Social Care Informationd. Outcomes against predictionse. Cancelled Operations(Area Team)

3.10 Plans mention the deployment of contractual levers(finesforbreaches)inconnectionwithunderperformance

Contractual levers are being applied through the exception notices with milestones for delivery and breach consequence of £196k. On failure of a milestone the CCG will also issue a second exception notice to the provider’s CEO and Board and to Monitor, and may retain any monies withheld under the first exception notice. Should the contract expire before milestones are complete (i.e. March) the CCG may retain the withheld sums.

The key milestones include:

1. Implementation of a PMO and Steering Group - April 2013

2. Implementation of the actions within the A&E work stream - End Sept 2013

3. Implementation of action within the Assessment and Short Stay work stream - End Sept 2013

4. Implementation of all actions within the Inpatient and Discharge work stream (specifically moving discharge profile forward by 2-3 hours) - End Sept 2013

5. Implementation of actions within the Frail Elderly work stream - End August 2013

6. Implementation of all the actions within the Complex Discharge work stream - End July 2013

7. Implementation of the actions within the Communications work stream - End June

Psychiatric breaches: 95% of patients referred by acute hospital A&E for a psychiatric assessment should be made within 1 hour of arrival and have a completed assessment and transfer/discharge within 4 hours of arrival. Breach consequence of £120 reduction in payment for each occasion thresholds not achieved.


WSH has the following key performance indicators within the contract, associated with the A&E 4 hour standard, most of which are monitored monthly with the exception of the 4 hour standard which is monitored daily:

Quality Requirement

95% of A & E attendances where the patient was admitted, transferred or discharged within 4 hours of their arrival at an A&E department

All handovers between ambulance and A & E must take place within 15 minutes

Zero tolerance on >12 hour trolley waits in A&E

No deterioration on 2012/13 out-turn in the following areas:

National Quality Premium Measures

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s NHS OF 2.3.ii

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) NHS OF 2.3.i

Emergency admissions for acute conditions that should not usually require hospital admission NHS OF 3a

Emergency admissions for children with lower respiratory tract infections. NHS 3.2

Frequency of monitoring

Informally daily, formally quarterly

Informally weekly, formally monthly

Informally daily, formally monthly

Monthly

Remedial action plan expectations (to be agreed with the provider)

Recovery of the quarter to date performance in the next calendar month

Automatic financial consequences applied and where performance is consistently poor or deteriorating, remedial action plan set to agree recovery in the next calendar month

Automatic financial consequences applied, root cause analysis undertaken and remedial action plan set accordingly

Joint investigation to understand cause followed by a recovery plan if required

Reference number

1

2

3

4


Quality Requirement

A&E indicators (1):

The Provider shall satisfy at least one of the following Patient Impact Indicators:

Patient Impact Indicators: 1. Unplanned re-attendance rate <5%2. Left department without being seen 5%

Time to treatment in department (median) for all patients arriving by ambulance. 50% of patients within 60 minutes

Number of admissions for cellulitis and DVT per head of weighted population

Percentage of Patients presenting at type 1 and 2 (major) A&E sites in certain high risk categories who are reviewed by an emergency medicine consultant before being discharged Threshold for admission via A&E: Locally agreed threshold for overall conversion rates of emergency admissions via A&E, based on best practice (set at 25.75%)

Single longest total time spent by Patients in the A&E department, for admitted and non-admitted Patients not to exceed 6 hours. n.b. exceptions that demonstrate third party prevented achievement will be excluded

Time to initial assessment (A&E Clinical Quality indicators Data definitions): Time from arrival to start of full initial assessment, which includes a brief history, pain an early warning scores (including vital signs), for all Patients arriving by ambulance: not to exceed 25 minutes


Monthly

Monthly

Quarterly

Quarterly audit of compliance

Monthly

Monthly

Monthly


Remedial action plan set to agree recovery in the next calendar month


Remedial action plan set to agree recovery in the next quarter

Remedial action plan set to agree recovery in the next quarter

Remedial action plan set to agree recovery of year to date position in the next calendar month



Reference number

5

6

7

8

9

10

11


East of England Ambulance Service Trust has the following key performance indicators relating to supporting the A&E department:

Suffolk Community Healthcare has the following key performance indicators relating to supporting the A&E department:

Quality Requirement

Following handover to clear between ambulance and A & E, ambulance crew should be ready to accept new calls within 15 minutes.

Local Quality Targets; R2A19GGP Urgent

Quality Requirement

Reduction of 10% in average LOS compared to average LOS in 11/12 across each community hospital and commissioned bed site.

Triage and assessment of referrals from hospital discharge team within 1 Operational Day.

Identification of Service Users with recurrent admissions (>1 admission in a 3 month period) to Ipswich Hospital who have a long term condition and are not known to the community matrons. n.b. this is proving difficult with PCD restrictions.

Response times for acceptance of referral to arrival at the Service User: Emergency /admission prevention referral - 2 hoursUrgent Referral - 4 hoursroutine referral - 72 hours.


Monthly

Monthly


Monthly

Monthly

Monthly

Monthly


Monthly fines based on handovers in excess of 30 minutes is £20 per occurrence and in excess of 60 minutes is £1000 per occurrence.

Subject to GC9.


To be agreed with the provider.

Remedial action plan set to agree recovery in the next calendar month.



Reference number

1

2

Reference number

1

2

3

4


Quality Requirement

Transfer from acute hospital to community based provision from receipt of referral within a timescale not exceeding 48 hours providing the Service User is medically and physically fit for discharge.

The community beds will be available for access across a 24 hour period, 7 days a week.


Monthly

Monthly



Immediate.

Norfolk and Suffolk Foundation Trust has the following key performance indicators relating to supporting the A&E department:

Quality Requirement

95% of patients referred by acute hospital A&E Departments for a psychiatricassessment within 1 hour of arrival in A&E and being medically fit for assessmentHave a completed assessment and transfer/discharge within 4 hours of time of arrival.

No patient stays more than 8hours in an A&E as a result of afailure by Provider to assess and transfer/discharge them as appropriate.

Response to a request for psychiatric assessment for an acute hospital in patient within24 hours.


Monthly

Monthly

Monthly



Root Cause analysis and action plan to resolve.


Reference number

5

6

Reference number

1

2

3


In addition to the use of General Condition 9 within the NHS Standard Contract the CCG will apply the following contractual levers (fines for breaches:

Provider

WSFT

WSFT

WSFT

WSFT

WSFT

WSFT

WSH

EEAST

Direct Consequence

2% of revenue derived from the provision of the locally defined service line in the quarter of the under-achievement.

£200 per patient waiting over 30 minutes. £1,000 per patient waiting over 60 minutes (in total, not aggregated with CB_S7a consequence).

£1,000 per breach.

£1 per breach over threshold.

Non-payment for breach over the threshold calculated at year end. Payment calculated on average cost per breach over threshold (total monthly cost/ number of Patients) = average cost of Patient breach. Average cost x number of breaches above threshold = consequence.



£20 per event where > 30 minutes £100 per event where > 60 minutes (in total, not aggregated with CB_S8a consequence).

Quality Requirement

95% of A&E attendances where the patient was admitted, transferred or discharged within 4 hours of their arrival at an A&E department.

All handovers between ambulance and A & E must take place within 15 minutes.

Zero tolerance on >12 hour trolley waits in A&E.

Time to treatment in department (median) for all patients arriving by ambulance. 50% of patients within 60 minutes.

Threshold for admission via A&E: Locally agreed threshold for overall conversion rates of emergency admissions via A&E, based on best practice (set at 25.75%).

Single longest total time spent by Patients in the A&E department, for admitted and non-admitted Patients not to exceed 6 hours. N.B. exceptions that demonstrate third party prevented achievement will be excluded.

Time to initial assessment (A&E Clinical Quality indicators Data definitions): Time from arrival to start of full initial assessment, which includes a brief history, pain an early warning scores (including vital signs), for all Patients arriving by ambulance: not to exceed 25 minutes.

Following handover between ambulance and A & E, ambulance crew should be ready to accept new calls within 15 minutes.


Provider

NSFT

NSFT

Direct Consequence

£120 reduction in payment foreach occasion threshold notachieved.

If RCA shows more than 8 hour wait as a result of failure by Provider’s services to meet their needs Consequence £1000.

Quality Requirement

95% of patients referred by acute hospital A&E departments for a psychiatric assessment within 1 hour of arrival in A&E and being medically fit for assessment.

Have a completed assessment and transfer/discharge within 4 hours of time of arrival.

No patient stays more than 8hours in an ED as a result of afailure by Provider to assess and transfer/discharge them as appropriate.


Summary £m

£000

3.11 WestSuffolkFoundationTrustRe-admission,NonElectiveThreshold Re-Investment

The following allocation has been agreed with the providers.

Provider

SCH via WSft Federation

SCH

N&SFT

SCH

SCH

SCH

SCH

Scheme

An integrated falls and fracture liaison service

Early Intervention Team

Dementia Intensive Support Service

Community Team Bury

Community Team Haverhill

Community Team Newmarket

Community Team Sudbury

Emergency Threshold

185

90

85

923

503

763

696

3,224

Re- Admission

395

216

327

298

1,236

Total

185

90

85

1,318

719

1,090

994

4,481

Contracted as above

12/13 O-Turn

Over investment

3.24

2.58

0.66

1.24

0.72

0.52

4.48

3.30

1.18

SCH: Suffolk Community HealthcareN&SFT: Norfolk and Suffolk Mental Health Foundation Trust


3.12 KeyOutcomes

The plan aims to realise the following outcomes:

Pre-hospital

Reduction in emergency admissions 15%Reduction in emergency admissions from care homes (EOL and dementia) 10%Reduction in falls related emergency admissions 15%Reduction in alcohol related admissions 7%Reduction in ambulance conveyances 15%

ThroughA&Eandwithinthehospital

Delivery of the A&E 4 hour standard >95%Reduction in ambulatory care emergency admissions 10%

Supporting discharge

Reduction in excess bed days 15%Reduction in delayed transfers of care (acute and community) Reduction in admissions to residential and care homes Reduction in long term care packages

Improved patient outcomes and experience


SECTION 4: GOVERNANCE AND BEST PRACTICE


4.1 UrgentCareBoardsestablishedaroundeachA&Eunitthat regularly meets and has representation of all stakeholders across the health economy

Below are the terms of reference for the West Suffolk Urgent Care Network, chaired by Dr Christopher Browning, CCG Chair. The Network became operational in April 2013 and has secured the representation of executive officers from across the system. The Network reports into the whole system Suffolk Leadership Board chaired by the CCG’s Chief Officer.

Keymilestones

• Finalsignofftosystemactionplan-3July2013;• Agreementofprocessforsubmissionoffunding

requests from system to support delivery of plan over winter 2013/14 - 3 July 2013;

• Finalsignofftosystemgovernancestructure-3July2013;

• Futuremeetings:- 14 August 2013- 4 September 2013- 2 October 2013- 6 November 2013 - 4 December 2013- 8 January 2014- 5 February 2014- 5 March 2014

Purpose

• TheWestSuffolkUrgentCareNetworkwillleadthedevelopment and oversee the delivery of the urgent and emergency care pathway in west Suffolk. The primary focus for the group is to ensure that the local people of west Suffolk have access to high quality care, delivered at the time they need it by professionals with the right skills. The work of the group will be focused on outcomes and quality for patients / customers.

• Theoverallaimofthegroupistoensurethatthereisawhole system approach to pathway review and redesign and facilitating the linked objectives of improved performance and a coherent local service delivery framework. Specifically, its role is to:

• Developandagreeawholesystemintegratedvisionfor urgent and emergency care and drive the necessary stepped changes across the system to deliver this vision for the people of west Suffolk.

Membership

• Representationfromeachorganisationisexpectedatevery meeting and nominated members should be able to make decisions on behalf of their organisation and executive lead.

Commissioners

West Suffolk CCG Urgent Care Executive Lead: Dr Christopher Browning, Chair; Julian Herbert, Chief Officer; Dr Emma Derbyshire, GP Clinical Lead for Integrated Care

Suffolk County Council Executive Lead: Anna McCreadie, Strategic Director of Adult and Community Services

Providers

West Suffolk NHS Foundation Trust Urgent Care Executive Lead: Stephen Graves, Chief Executive Officer

Suffolk Community Healthcare Executive Lead: Sharon Colclough, Managing Director

Harmoni and 111 Executive Lead: Dr Marjorie Gillespie, Interim Regional Clinical Director

East of England Ambulance Service Urgent Care Executive Lead: Andrew Morgan, Chief Executive Officer

Local Medical Council: Dr Godfrey Reynolds, Chair, Suffolk LMC

Suffolk Family Carers: Jacqui Martin, Chief Executive Officer

Age UK Suffolk: Sharron Cozens, Director of Services

Norfolk & Suffolk Mental Health FT Executive Lead: Andrew Hopkins, Chief Executive Officer

Cambridge University Hospitals NHS FT: Debbie Morgan, Director of Commissioning

Public Health Executive Lead: Tessa Lindfield, Director of Public Health, Suffolk County Council

Suffolk Healthwatch: Annie Topping, Chief Executive Officer

Additional members with specific expertise may be co-opted to the Network as required to provide specialist opinion, e.g. paediatric specialists, pharmacy etc.


Frequency of Meetings

Monthly

• ThequorumwillbeChairorViceChairandmembersfrom at least four different organisations.

KeyResponsibilities

• Understandthecurrentpathwayusingawholesystemdiagnostic to specifically identify what is working well and what areas can be improved;

• Toagreealocalvisionforurgentandemergencycare and agree the whole system priorities for implementation;

• Todevelopawholesystemactionplantomapplannedwhole system improvement against agreed and owned milestones for change;

• Todevelopaflexiblewholesystemcapacityplanthatisaligned to demand and surge activity;

• Establishreliableperformancemetricsforthewholesystem;

• Monitorandreviewsystemperformanceagainstagreedbaselines;

• Ensuretheco-ordinationofemergencyandurgentcareprojects and initiatives across all stakeholders.

The Urgent Care Network reports to the bi-monthly Suffolk System Leadership Partnership attended by Chief Executive Officers of providers and commissioners across Suffolk.

AllA&EdepartmentscoveredbytheUrgentCareBoards

The terms of reference previously outlined, include membership from Cambridge University Hospitals NHS Foundation Trust as well as West Suffolk Hospital NHS Foundation Trust.

R&IPsownedanddrivenbyseniorrepresentationofallstakeholdersatUrgentCareBoardlevel,withinvolvementfromlocalgovernment,NTDA,Monitor,ECISTteam,CQC

The Integrated Care plan was signed off by the Urgent Care Network on 3 July 2013, which contains senior representation from all stakeholders, including local government.

The West Suffolk Hospital NHS Foundation Trust action plan developed by ECIST, CQC and Monitor has been incorporated into this plan - see IC2 and Appendix 2.

Monitor review West Suffolk Hospital’s performance on a quarterly basis through the compliance framework self-assessment and Board declaration. As well as detailing performance against individual targets in the previous quarter this includes an indication of the Board’s confidence in the ability to deliver targets going forward. The Trust’s relationship team at Monitor also review and challenge the organisation’s performance and strategic plans through the Annual Planning Review.

The CQC continually review the Trust’s performance against a range of indicators and sources of intelligence. These are summarised through the monthly Quality Risk Profile reports and inform the CQC’s inspection programme. The CQC undertook an unannounced visit of the Trust in June 2013 and although the report from this visit is still draft no regulatory action has been identified. As part of this visit and the CQC’s on-going monitoring arrangements “hard” and “soft” quality indicators are reviewed for emergency care performance.


Mechanismsinplacetoshareknowledge,learningandbestpracticeacrosslocalhealtheconomy,involvingstakeholderssuchasNTDA,MonitorandECIST.

There are the following mechanisms in place to share knowledge, learning and best practice:

• IntegratedCareSteeringGroup-meetsmonthlyandinvolves all local partners in the development of the community elements of this plan. This network has involved Sir John Oldham to develop its strategy and Professor David Oliver, National Clinical Director of Older People, to develop the comprehensive geriatric assessment development work (IC1.3, IC1.5) and the role of Interface Geriatrics. It has also used Tricordant’s review of Joining Up Older People’s Services in Suffolk (2012).

• UrgentCareNetwork-meetsmonthlyandbringstogether Executive level leaders from the local health economy to share knowledge, learning and best practice and oversee delivery of the plan. This network has invited ECIST to share best practice and insight – such as work in Milton Keynes and Chelsea and Westminster.

• TheWestSuffolkCCG/WestSuffolkHospitalClinicalLiaison group meets bi-monthly and brings together lead GPs and hospital consultants who discuss urgent care as a standing item.

• WestSuffolkHospitalNHSFoundationTrusturgentcareplan workstreams are supported and overseen by ECIST and Monitor.

• TheSuffolkSystemLeadershipPartnershipandSuffolkHealth and Wellbeing Board meet bi-monthly and brings together Chief Executive leaders from across the Suffolk health economy which covers three CCGs. Best practice from local health systems are shared.

• TheCCGhoststheNorfolk,SuffolkandCambridgeshireCCG network. This network currently discusses urgent care as a standing item.

• TheCCGattendsNHSEnglandeventsandlearningsetson Urgent Care, where there is an opportunity to learn from best practice across the Midlands and East.


SuffolkHealth& WellbeingBoard

Chair: Councillor Joanna Spicer

Suffolk Commissioners Group

Chair: Anna McCreadie, Strategic Director of

Adult and Community Services Suffolk County

Council

Suffolk Leadership Group

Chair: Julian Herbert, Chief Officer West

Suffolk Clinical Commissioning Group

Stakeholder Management Boards

Task and Finish Groups

Interdependencies

Suffolk Family Carers Partnership Board

Suffolk Family Carers Market Development

Group

Suffolk Stroke Improvement Programme

Suffolk Dementia Programme

Dec

isio

n m

akin

gD

evel

op

men

tal a

nd

del

iver

y

Integrated Care Steering Group (monthly)Chair: Dr Emma Derbyshire, CCG GP

Urgent Care Network* (monthly)Chair: Dr Christopher

Browning, CCG

*Appendix three: Terms of Reference

Clarity and responsibilities for local communications and escalationbetweenproviders,Urgentcarenetworksandthecommissioner

CCG governing bodyChair: Dr Christopher

Browning


4.2 Plans provide assurance that risks are mitigated and all safeguarding measures are in place which comply with the Francis Report recommendations

On the 6th February 2013 Robert Francis QC published his final report of the public inquiry into the Mid Staffordshire NHS Foundation Trust. In a letter to the Secretary of State for Health he notes that there were numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust.

Reasons include;

• Aculturefocusedondoingthesystem’sbusiness-notthat of the patients;

• Standardsandmethodsofmeasuringcompliancewhichdid not focus on the effect of a service on patients;

• Toogreatadegreeoftoleranceofpoorstandardsandof risk to patients;

• Afailureofcommunicationbetweenthemanyagenciesto share their knowledge of concerns;

• Assumptionsthatmonitoring,performancemanagement or intervention was the responsibility of someone else;

• Afailuretotacklechallengestothebuildingupofapositive culture, in nursing in particular but also within the medical profession;

• Afailuretoappreciateuntilrecentlytheriskofdisruptiveloss of corporate memory and focus resulting from repeated, multi-level reorganisation.

Francis report recommendations;

• Fosteracommonculturesharedbyallintheserviceofputting the patient first;

• Developasetoffundamentalstandards,easilyunderstood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated;

• Provideprofessionallyendorsedandevidence-basedmeans of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service;

• Ensureopenness,transparencyandcandourthroughoutthe system about matters of concern;

• Ensurethattherelentlessfocusofthehealthcareregulator is on policing compliance with these standards;

• Makeallthosewhoprovidecareforpatients-individuals and organisations - properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service;

• Provideadegreeofaccountabilityforseniormanagersand leaders to place all with responsibility for protecting

the interests of patients on a level playing field;• Enhancetherecruitment,education,trainingand

support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do;

• Developandshareeverimprovingmeansofmeasuringand understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.

Key actions to deliver the Frances Recommendations

• Monitoringqualitystandardsandpatientsafetyinformation (e.g. incident and serious incident reporting, hospital standardised mortality ratios (HSMR), audit results, safety thermometer (Harm Free Care))

• AnnualQualityAccountsverification• Monitoringstandardsofinfectionpreventionandcontrol• Monitoringpatientexperiencethroughreviewing

complaints and results of surveys / feedback• Patient,staffandrelative/carerfeedbackthroughQuality

Improvement Visits • Monitoringsystemsandtrainingforsafeguarding

children and adults• Developmentandmonitoringofclinicalstandards• Undertakingandoverseeingseriouscasereviews• Ensuringcompliancewithdeprivationofliberty

standards (DOLS) • Undertakingqualityimprovementvisits(QIVs)• Undertakingclinicalinvestigationsandreviews• InformationsharingwiththeLocalAuthorityonadult

safeguarding concerns and the monitoring of quality standards in Residential and Nursing homes

• LiaisonwiththeCQC• DevelopmentofaNursingHomeNetworkwiththe

Local Authority• Developmentofasharedperformancedashboardof

residential and nursing homes to monitor care standards compliance, adult safeguarding referrals and CQC concerns

• Ensuringprovidershaveappropriateclinicalgovernancearrangements

• Therootcauseanalysis(RCA)process

Each commissioned healthcare provider is required contractually to submit information on recognised indicators of the safety, quality and effectiveness of services. This information includes:

• Experienceinformationfrominternalandexternalsurveys and complaints data.

• Incidentandseriousincidentreportingdata,complyingwith national and local reporting timeframes and quality of reporting and analysis


- Infection prevention and control measures, including clinical practice and environmental audit data and numbers of healthcare-associated infections (HCAIs) and outbreaks of infection identified

- Safeguarding of adults and children staff training and reporting of incidents data, evidencing compliance with thresholds of reporting and demonstrating multi-disciplinary working as appropriate

- Information on reports received from external organisations, for example the Care Quality Commission (CQC) with action plans to address areas for improvement identified

All clinical workstreams within the Action Plan are subject to a Safeguarding check. The workstreams have information packs that will include feedback in relation to quality improvement visits, safeguarding and CQC profiles and will include more qualitative indicators, infection control; serious incidents; complaints; safety thermometer; falls; pressure ulcers and results of any root cause analysis. The information packs will continue to evolve to address making every contact count and further recommendations from the Francis Report. The CCG will work with Healthwatch Suffolk to explore mechanisms to incorporate the patient experience.

Provider and commissioner assurance is provided by;

• Qualitywalkabouts/CCG/GoverningBodywalkabouts• Unannouncedandplannedqualityimprovementvisits

(QIVs)• Monthlyclinicalqualityreviewmeetings(toreview

contract elements)• Regularmeetingswithproviderspecialistse.g.infection

prevention and control specialists, clinical governance leads

• SeriousIncidentsrequiringinvestigation(SIRI)reporting

The information from these sources is reviewed to identify any concerns or themes, either related to the event or the service. It is considered in the context of other available data, either previously reported or available within external reports, benchmarking against comparable organisations.

The information is used to determine the level of performance, safety, quality and effectiveness of services. Actions are agreed to address data which falls below locally and nationally agreed standards: progress on these actions is monitored at the contract review meetings with assurance of completion provided over an agreed time period.

Evidence of implementation of actions is checked through the quality improvement visit process.

The West Suffolk Hospital Trust Board and Council of Governors have reflected on the findings of the Francis report and looked to learn from the failings. The following action is being taken:

• Continuingtoreviewnursestaffinglevelsandskillmixat ward level and outpatients. This follows recruitment from Portugal of 23 nurses during 2013 and 14 additional nurses in September 2013. The Trust are developing clinical capacity plan for the Board meeting September 2013, showing how the appropriate levels of staffing will be recruited and deployed during the winter 2013/14

• UpdatingtheTrust’swhistleblowingpolicytoincludethe National Whistle Blowing Helpline and ensuring staff are aware of the policy and list of nominated people who they can contact to discuss any concerns

• Takingaccountoftheoutcomeofthreemajornationalreviews: Mortality (Keogh), Patient Complaints (Clwyd) and Patient Safety (Berwick)

• Continuingtomakeiteasyforstafftoreportincidents.Learning from even largely minor incidents helps us to avoid more serious incidents in the future

• Implementingavaluesbasedapproachtostaffrecruitment which is linked to the Patient First Standards

• Designingalargeeye-catchingposterforallclinicalareas promoting the number to call if any patient their family or carer is not happy with the quality of care being provided

• CompletingtheDenisonOrganisationalCultureSurvey,which has been funded by the Suffolk and Norfolk Dementia Alliance, for acute providers in the two counties. Underlying beliefs, values and assumptions held by staff are known to affect their performance and the quality of patient services. A comparison of the data from the five acute trusts will help WSFT to work with frontline staff to build on identified strengths and address areas requiring improvement.


The CCG has also discussed with the public the implications of the Francis report at its recent ‘Patient Revolution’event in May 2013 - see 1.4. At the event the public audience discussed the question of ‘How can we be sure that what happened in Mid Staffs isn’t happening here?’ Below are some of the quotes from the discussion - the issues of integrated working and information monitoring are addressed through this plan:

An example of safety is the number of procedures a consultant has to carry out to be skilled-ifthereisn’tenoughclinicalworktodo,consultantscanbecomede-skilled.

Worktobedoneonimprovingprevention of care packages in community.

Joinedupworkingiskey–alotofinformationabout,butorganisationsneedtotalktoeachother.

Need to breakdown culture of organisational/budgetary boundaries.

Involve social workers at the earliest opportunities.

WSHmusttalksystematicallytoHealthwatchSuffolk and CCG and other agencies who gather information of patient safety.

WeshouldempowerHealthwatchandcommunities to walk on to a ward and speak to staff.

Staff survey can reveal a lot about the state of an organisation.

Somepeoplearefrightenedofcomplaining-think it will affect their long term care.

NextchallengeinWSHistosavemoney- how can this be done safely?

Patient’sassociategoodcarewithstaffinglevels.

WSHuses39,000hoursofvoluntarytimea year and tries to use volunteers in a complementary way where appropriate.

WSHneedstocommunicatetopatientsthattherearesystemsinplacetopreventMid- Staffs happening.

InMid-Staff,lotsoftrendswherecomingthroughtheLINk,butnobodycollatedall the information.

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