Agenda item

Pennie Ford (Director of Assurance and Delivery, NHS England South (South East)), Hazel Gleed (Head of Emergency Preparedness, Resilience and Response, NHS England South (South East)), Matthew Capper (Director of Performance and Delivery, NHS Ashford and Canterbury & Coastal CCGs), Corrine Stewart (Assistant Director of Commissioning, NHS Dartford, Gravesham and Swanley CCG), Jacqui West (Health Interface Manager, Kent County Council) and Adam Wickings (Joint Chief Operating Officer, NHS West Kent CCG) were in attendance for this item.

(1)       The Chairman welcomed the guests to the Committee. Ms Ford began by explaining that the previously established Systems Resilience Groups had been replaced with Local Accident and Emergency Delivery Boards (LAEDB) which had a more focused remit on the delivery of urgent and emergency care. She stated that the winter pressures facing Accident and Emergency departments were really challenging and there had not been a reduction in pressure throughout the course of the year. She noted that there was a national A&E Improvement Plan which had made recommendations to be implemented locally including improving flow and discharge processes. She reported that improved discharge was particularly important for older people who began to lose function if they stayed in hospital longer than required. Mr Scott-Clark commented that, in addition to muscle wastage, the longer patients stayed in hospital, it was more likely that they would get a hospital acquired infection.  

(2)       Ms Ford explained that in preparation for winter, each system had been refreshing their escalation plans and changing terminology following a national review of definitions. She reported that all systems had tested their plans including their response to snow and flooding; an increase in pressure was expected over the bank holiday period and into early January. She highlighted the national flu immunisation programme and the importance of Councils in encouraging people to take up the flu vaccination. The peak of the current winter’s flu season was not known; it had been late last winter and at Christmas during the previous winter.  Ms Ford invited each health economy to give an overview of their preparations for winter.

(3)       Mr Capper stated that in East Kent, a whole system meeting was held at the beginning of October to review and refresh response plans, escalation triggers and terminology to ensure they dovetailed together. He noted that the cold weather and flu plan was due to refreshed within the next two weeks. In the run-up to the Christmas holidays, a super discharge week was planned where all agencies would be working together in an enhanced way to create additional capacity in the system; a follow up activity was planned for January. He reported that the implementation of GP triage model at the Kent & Canterbury Hospital, Canterbury last year had reduced the number of admissions; the CCGs with the providers were looking to replicate model as quickly and safely as possible at the William Harvey Hospital, Ashford and the Queen Elizabeth The Queen Mother Hospital, Margate.  He explained that the daily escalation levels were circulated including the information about beds, workforce and A&E performance from the Single Health Resilience Early Warning Database (SHREWD).

(4)       Mr Capper noted that the Out of Hours and 111 services had changed to a new provider which would provide greater efficiencies; the 111 service had recently gone live and would be responsible for providing 80% of the call cover by Christmas as part of the handover with South East Coast Ambulance NHS Foundation Trust (SECAmb). He stated that a community geriatrician resource had been developed to increase flow through acute and community hospitals as part of the Integrated Discharge Team provided by the Kent Community NHS Foundation Trust. He reported that the Discharge to Assess pilot, which carried out health and social care assessments, had been expanded alongside the Home First programme.

(5)       Ms Stewart reported that North Kent had been preparing since spring to align their plans, learn from previous years and implement improvements. She stated that the North Kent CCGs had implemented SHREWD and had developed a monthly operational resilience group as part of LAEDB.  She explained that in Dartford, Gravesham & Swanley, the key priority was to stream patients at the front door of Darent Valley Hospital, Dartford and assess within 15 minutes to understand their needs and direct them to alternative setting if appropriate such as the Minor Injuries Unit or the Ambulatory Ward for patients with COPD and Asthma. She reported that in Swale, the CCG was working with Medway Maritime Hospital to redirect patient from A&E to the primary care unit which had led to a 22 – 33% reduction in A&E attendance and improve discharge, with the implementation of the Safer Care pilot which included an estimated discharge date, to reduce ambulance handover delays.

(6)       Ms Stewart stated that a discharge lounge at Darent Valley Hospital had been created to enable patients fit for discharge to be moved out of beds and create capacity for new patients. The CCGs were also implementing Discharge to Assess initiatives to support frail patients return home such as the Hilton Nursing Project which provided assessments and recovery support in the patient’s home; the project was currently helping to support 10 discharges a week. In Dartford, Gravesham & Swanley, a Care Navigators Pilot had been implemented with health, social care and voluntary services’ support. Projects for frequent A&E attendees and palliative & end of life patients were also planned.

(7)       Mr Wickings noted that West Kent had implemented SHREWD and were in daily discussions with Maidstone and Tunbridge Wells NHS Trust; he reported that there was good working relationship between the CCG and the Trust. He stated that using winter resilience money from the beginning of the year, a number of measures had been implemented including integrated COPD services, Home First service and additional support in nursing homes. He noted that GPs were working in both A&E departments with the service working better in one than the other. He stated that the CCG had assurance that preparations were going well but acknowledged that there may be difficulties in the winter period.

(8)       Ms West explained that Kent County Council were partners of the LAEDBs and used SHREWD as part of its system resilience planning which included non-validated data as it was only validated once a week. She noted that the Hilton Nursing Project had also been implemented at Tunbridge Wells Hospital using CCG funding. She reported that KCC occupational therapists were providing assessments which provided additional equipment to patients post-discharge and helped to reduce their overall care package and improve patient flow. She stated that the central purchasing team were working with families able to identify homes with vacancies. She noted that Integrated Discharge Teams had been implemented on all hospital sites whose teams included KCC staff and the voluntary sector. She also stated that KCC supported Home First service and provided Enablement at Home services.

(9)       The Chairman enquired about the communications plan.  Ms Ford explained that there were a number of national campaigns such as the Stay Well This Winter campaign by NHS England and Public Health which encouraged members of the public to look after themselves during the winter. She reported that there were local communication campaigns which included details about alternative care provision including the use of pharmacists and using 111 as an alternative to A&E. Mr Capper noted that the communications team in East Kent were providing face-to-face information in shopping centres about alternative care provisions. He highlighted the Health Help Now app which provided users with information about their nearest health services in Kent and campaign information. He noted that as part of the national vanguard in Canterbury & Coastal CCG, a waiting list app was being developed. Ms Ford acknowledged that there were different ways to communicate with older and younger people; apps and social media were aimed at younger and working age groups. Members gave suggestions of engaging with older people through established groups such as the Elders’ Forum in Dartford; the Women’s Institute and National Women’s Register in Sevenoaks; and town & parish councils across Kent. Ms Ford resolved to take Members’ comments about improving communication back to the LAEDBs.

(10)     Members of the Committee then proceeded to ask a series of questions and make a number of comments. A Member enquired about winter pressure levels remaining in the summer, engagement with the care home sector and assessments at home.  Ms Ford explained that the late winter pressures last year remained into the summer which had resulted in services already being stretched going into this winter; the cause of this was unknown. She stated that the recommendations in the national A&E Improvement Plan could make a difference once implemented. Ms West stated that engagement with the care home sector; the Central Purchasing Team was speaking daily with the private sector and a Care Home Forum run by KCC and the CCGs had developed strong links with the care home sector. Ms West explained that as part of Discharge to Assess model in East Kent, patients whose needs could be safely met at home, were considered as part of Pathway 1 and were assessed within two hours of arrival at home. She noted that the Discharge to Assess team functioned within set working hours and patients were not discharged outside of these times; a similar system was due to be implemented in North and West Kent.

(11)     In response to a specific question about patient and GP involvement in discharge, Ms Stewart explained that Dartford, Gravesham and Swanley CCG had recently held a four day event to look at improving discharge with health, social care and voluntary sector partners. One of the key outcomes of the event was to improve communication in and outside of hospital; a 30 day review event was planned for December. She noted that Dartford & Gravesham NHS Trust provided each patient with a booklet about the type of care they would be receiving and the estimated date of discharge. She acknowledged the importance of GPs as part of a patient’s care particularly in A&E where doctors were able to see GP records and prescriptions for the patients and the provision of a telephone service which enabled GPs to speak to a senior nurse to explain the specific circumstances of a patient and receive advice about whether to refer them to the ambulatory care unit.

(12)     Mr Inett stated that Healthwatch Kent had carried out Enter & View visits to all A&Es in February 2016. Patients were generally very satisfied with the service; lots of the attendees had turned up A&E as they had been unable to get a GP appointment and did not like using 111 service. He noted that Healthwatch had recently carried out a piece of work about discharge; staff were working very hard to improve discharge processes but there was a tension as there was a lack of placements  in East & West Kent and difficulty in  recruiting carers in North Kent to support discharge. A Member requested a wider discussion about delayed discharge of care to establish what KCC and partners could do to improve to reduce delays.

(13)     A number of questions were asked about muscle wastage, pressure on services from border areas such as Bexley and the involvement of KMPT. Ms Stewart stated that Dartford & Gravesham NHS Trust had implemented the use physiotherapists on wards to help mobilise people and ensure that they remained physically fit; a finding of the recent discharge event organised by Dartford, Gravesham and Swanley CCG was that muscle deterioration began when patients entered assessment wards. Ms Stewart reported that pressure from border areas was a significant issues; a third of the activity from Dartford & Gravesham NHS Trust came from Bexley and the surrounding areas. The CCG was working with colleagues and representatives from Bexley to align the work being carried out. She noted that the London Ambulance Service (LAS) would convey patients to Darent Valley Hospital when services in London are under pressure; the CCG had ambulance liaison meetings with SECAmb and LAS to improve communication and talk through issues. Ms Ford reported that KMPT was a crucial member of each LAEDB. A Member requested further details about SHREWD and Ms Ford undertook to provide this.

(14)     RESOLVED that the report be noted and NHS England be requested to provide an update about the performance of the winter plans to the Committee at its June meeting.