Agenda item

Susan Acott (Chief Executive, Dartford and Gravesham NHS Trust), Patricia Davies (Accountable Officer, NHS Dartford, Gravesham and Swanley CCG and NHS Swale CCG), Dr Fiona Armstrong (Clinical Chair, NHS Swale CCG and Clinical Representative for NHS Dartford, Gravesham and Swanley CCG), Dr Philip Barnes (Medical Director, Medway NHS Foundation Trust), Mark Morgan (Interim Director of Operations, Medway NHS Foundation Trust) and Elliot Howard-Jones (Director of Operations and Delivery, NHS England Kent & Medway)were in attendance for this item.

(1)       The Chairman welcomed the guests of the Committee and asked them to introduce the item. Ms Davies began by explaining that an additional £10 million winter funding had been made available in North Kent: Darent Valley Hospital (£4 million) and Medway Maritime Hospital (£6 million). Both hospitals had introduced a system governance structure to utilise the funding with clinicians designing and developing the winter plans.

(2)       Darent Valley Hospital had a challenging winter with wet but mild weather. The Dartford and Gravesham NHS Trust had developed good clinical relationships with the community team, mental health team and ambulance service to ensure the whole system worked well. The Integrated Discharge Team (IDT) was introduced as part of the winter funding in September to reduce inappropriate admission to hospital. The IDT were working with patients who initially required diagnostics and treatment in an acute setting but were  quickly discharged to receive further care and support in the community. The IDT leadership team was hosted by Darent Valley Hospital; the CQC noted that the IDT was an area of excellence in their inspection report.

(3)       The winter funds had also been used to develop telehealth and formulate the Better Care Fund application. Telehealth and telemedicine had been utilised in care homes enabling consultants to remotely monitor patients. The Better Care Fund application was proposing to expand the integrated discharge team and integrated primary care team. As part of the proposed collaborative model for primary care, district nurses would be moving back into GP practices. Changes in community services had moved district nurses out of surgeries; this had caused dissatisfaction amongst nurses who were not working with the same cohort of patients and did not have direct support and back up of specific GPs. Demand for primary care was  phenomenal with a large proportion of GPs coming up for retirement. An integrated primary care team would generate a different type of workforce and utilise skills to provide care outside of hospital.

(4)       Ms Acott noted that the IDT was created to respond to patients with more complex needs, such as dementia, who are not best served by coming into hospital.  There had been an increasing number of patients presenting with dementia; half of all medically stable patients in the hospital had dementia. The introduction of telemedicine had supported home care; it had enabled patients with dementia who would have been previously admitted to hospital, when their nursing or residential home could not cope, to stay in a familiar environment and give confidence to nursing staff to support them.

(5)       Mr Howard-Jones added that the current emergency system has been working at or near capacity for a large amount of time; redesign was required in response to the Keogh Urgent and Emergency Care Review. CCGs were redesigning services with their local populations and Urgent Care Groups were working to create system coherence with health and social care services. One of the key roles of the Urgent Care Groups was to monitor performance; these groups were looking more widely at the quality of care and management of acuity, rather than focusing on the 95% target of patients seen within four hours. Emergency management had been significant due to flooding; the response has been exceptional. The Sheppey Bridge incident was cited as another good example with the ambulance service, Darent Valley Hospital and Medway Maritime Hospital providing an excellent response.

(6)       Members of the Committee then proceeded to ask a series of questions and make a number of comments. A Member shared his personal experiences of visits to a Minor Injury Unit (MIU) and A&E. He expressed concerns about the difficulty in getting a GP appointment resulting in unnecessary A&E attendances; limited services available at a MIU and a lack of connectivity between MIU and A&E with regards to triage.

(7)       The Member also referred to a piece of work being carried out by Healthwatch Kent about A&E attendances. Mr Inett was asked to comment, he reported that a joint ‘Enter and View’ exercise was recently carried out by Healthwatch Kent and Healthwatch Bexley at Darent Valley Hospital’s A&E department. Healthwatch found that patients were quite satisfied with the care and patient experience at the A&E department. Healthwatch Bexley were currently writing the report, once published, Healthwatch was planning a return visit as the department was quite quiet during the first visit. The report could be brought to HOSC at a later stage.

(8)       Further, Healthwatch England recently published the results of a survey; 1 in 5 people who attend A&E know that it is not the most appropriate place for their care needs. Culturally, A&E had become the point of least resistance for immediate care. GPs, CCGs and NHS England had developed an urgent care pathway agreement to offer emergency GP appointments; GPs were being asked to sign up to this. Healthwatch Kent had found that people did not access the Faversham MIU as they are not aware of what services it provided and did not understand the difference between treating illness and injury.

(9)       Clarification was sought regarding the increase in A&E attendance. Ms Davies explained that there had been demographic growth since the 1960s; however A&E attendance had significantly increased nationally in the last 10 – 12 years. A&E attendance at both Trusts has been fairly flat over the last two – three years. The Trusts were now looking to the future; NHS Dartford, Gravesham and Swanley CCG were anticipating additional pressure on their services as there had been a change of activity in South London with the London Ambulance Service diverting to Darent Valley Hospital. There was also projected demographic growth in Gravesham with the Ebbsfleet development over the next five years. NHS Swale CCG was looking to tackle health inequalities now, such as clinical obesity in 33% of children, to mitigate the impact on acute providers in the future. Both CCGs are working with the King’s Fund to model future acute bed capacity.

(10)     One of the Members enquired if the Sheppey Bridge incident affected Medway’s A&E performance. Dr Barnes explained that A&E performance was better during the immediate period following the Sheppey Bridge incident. Accidents, minor and major injuries were included within the 95% target of patients being seen within four hours. Medway dealt well with accidents and minor injuries. It has been difficult to deal with major incidents due to increased ambulance conveyances and bed occupancy.

(11)     A Member questioned why the changes to A&E had not happened before. Ms Davies explained that the reorganisation of the NHS from Primary Care Trusts to Clinical Commissioning Groups has enabled lead clinicians to design services and make decisions; bureaucracy had previously prevented clinicians getting involved. The winter funds had enabled clinicians to make key changes to improve A&E performance.

(12)     The issue of inappropriate A&E attendance was raised. Ms Davies explained that the King’s Fund had looked at the type of patients who attend A&E and admissions in NHS Swale CCG and NHS Dartford, Gravesham and Swanley CCG. Their research found that 20 – 25% of patient could have been better looked after in the community.

(13)     A timeline for the Medway Emergency Village was requested. Dr Barnes explained that the Medway Emergency Village should be completed by Christmas this year. It was a very ambitious change programme. In the interim, the hospital was using existing ward stock to achieve different ways of working.

(14)     A question about the major incident planning and practices was asked. Mr Morgan explained that emergency practices were tested regularly in all hospitals. From next year, emergency planning and testing would  be built into the contracts with the CCGs which would  be set out in the essential services plans. The Sheppey Bridge incident was a major incident test in real life. Medway NHS Foundation Trust had a formal committee for emergency planning which employed emergency planning officers who ensured key services take forward emergency plans and programme tests. Mr Howard-Jones added that in Kent there was a local health resilience conference which meets on a two-monthly basis to test resilience and review emergency plans. After a major incident, a formal debrief was held to evaluate and review the emergency plans.  It is chaired by Mr Howard-Jones and the Director for Public Health at Kent County Council.

(15)     A series of questions were asked about signposting to the most appropriate service. Mr Morgan explained that many patients did not know where they should go for urgent and emergency care. At the proposed urgent care centre in Medway, patients would be seen by a primary care clinician who would be able to signpost the patient to the most appropriate place for care. The urgent care centre would also be able book GP appointments and register patients for GP surgeries. Evidence had shown that if people were turned away, they would return at a later point. Dr Armstrong highlighted examples of signposting being piloted in North Kent such as the Health Now app. CCGs were  working with NHS England, who commission primary care, to free up GPs  to enable them to carry out greater numbers of same-day appointments. The future of the walk-in centre in Swale was being reviewed and would be consulted on; at present it enabled unregistered patients to directly access primary care. Ms Davies accepted that more education, training and signposting was required; walk-in centres and minor injury units needed to be more clearly defined to avoid confusion. A suggestion was made for the CCGs to advertise on borough and district websites.

(16)     Questions were asked about GP retirement and recruitment and the use of decision-making tools. Ms Davies acknowledged that there was an issue with GP retirement: 33% of GPs in Swale and 20% of GPs in Dartford are due to retire in five years. An educational research hub was being developed in North Kent to attract new GPs. With regards to decision-making, Ms Davies explained that the guests represented different organisations, which had different governance structures. Decisions were taken through a board of directors who had access to decision-making tools. When joint boards were convened, prioritising tools were  used to help with commissioning intentions.

(17)     Mr Inett enquired about the urgent care delivery group. Ms Davies explained that the group was convened by the CCGs within each health economy boundary. The patient representatives on the delivery groups were mainly from the voluntary sector. Ms Davies stated that she would be happy to involve Healthwatch in future meetings of the delivery group.

(18)     A Member made a comment about the use of acronyms in the NHS reports. The Scrutiny Research Officer was asked to update the letter sent to the NHS to include a note about the use of acronyms.

(19)     RESOLVED that:

(a)    the guests be thanked for their attendance and be requested to  take on board the comments made by Members during the meeting and  a report be presented by the representatives to the Committee in nine months’ time.

(b)    a meeting be arranged between with Healthwatch Kent and Members of the Committee to consider how the work of Healthwatch Kent, in areas such as urgent and emergency care, could  support the work of the Committee.