Agenda item

To receive an update from the Executive Director for Health, Wellbeing & Adults and representatives from the Croydon University Hospital NHS Trust and the Croydon Clinical Commissioning Group on their preparations to manage service demand this winter.

The Sub-Committee had invited representatives from the Clinical Commissioning Group (CCG) and the Croydon Health Service (CHS) along with representation from the Adult Social Care team from the Council to the meeting to provide an update on their preparations for the winter period. The following people were in attendance for this item:-

·         Andrew Eyre – Accountable Officer for the CCG

·         Stephen Warren – Director of Commissioning for the CCG

·         Matthew Kershaw – Chief Executive for CHS

·         Paul Richards - Head of Adult Mental Health Substance Misuse for Croydon Council

During the introduction to the report it was emphasised that plan for winter had very much focused on whole system working with a view to keeping people well and out of Accident & Emergency (A&E) where possible. The plan had been developed jointly by the CCG, CHS and the Social Care team at the Council. A key challenge to the delivery of the plan was the need to manage an increasing demand for services and as such it focused on the following areas:

·         Strengthen Governance arrangements.

·         Developing and delivering out of hospital initiatives.

·         Working to improve capacity within services through the improved maintenance of patient flow.

·         The launch of the new A&E facility at Croydon University Hospital.

Work to date on the plan included:-

·         The recommissioning of urgent care services through the provision of three GP hubs, including the GP Extended Access Hub to provide additional appointments.

·         Continued work on patient education to direct away from A&E towards more appropriate services such as GPs and pharmacists.

·         The Winter Communications Plan included a Flu Campaign which raised awareness of the Flu Vaccination programme, with a particular focus on vulnerable groups and frontline NHS staff.

·         The new Emergency Department opened on 2 December 2019 and was already delivering benefits such as improved ambulance handover times and improved escalation capacity and flexibility within the service.

·         Mental Health Initiatives included multi-agency discharge events focussed on reducing the length of stay in the Emergency Department, with additional beds for mental health patients commissioned with the East London Foundation Trust.

Key challenges to the delivery of the plan were:

·         The recruitment and retention of the staff, which remained a problem across London, particularly in paediatric care. However there had been an improvement since September with a reduction in the number of unfilled shifts in the Emergency Department.

·         Patient discharge continued to be an issue, with work underway to improve discharge processes including enhancing the discharge team through the recruitment of a single manager working across the health service and social care service to improve the focus on discharge.

·         There was a continued focus on long stay patients, with ‘stranded’ patients remaining a significant challenge. There were also a significant amount of patients from other boroughs which increased the complexity when discharging

·         The Council had been given funding of £1.4m to assist with winter pressures including the delayed transfer of care, market stabilisations and LIFE demand.

·         There was further opportunity to develop the GP Huddles which arranged for practices to meet with partners to discuss the care provision for those patients with complex needs.

Following the introduction of the item, the Sub-Committee were given the opportunity to question the representatives. The first question related to demand management and the savings made through educating patients to self-care where possible rather than using urgent services.  In response it was confirmed that A&E attendance was stabilising through work with the GP Hubs, but it was difficult to quantify the number of potential patients choosing to self-care. Intervention at an early stage provided a number of benefits including allowing people to remain well and independent. It also allowed the service to focus urgent care upon those who required it the most.

It was noted that demand management was difficult to predict and as such it was questioned how the risk of misdiagnosis was managed. It was advised that there was always the risk of misdiagnosis, but GPs would always refer patients to specialist services if they were not able to make a diagnosis themselves.

In response to a question about prescriptions and an increased expectation for savings to be delivered through patients paying for some medicines that would have previously been prescribed, it was highlighted that GPs had the clinical freedom to prescribe as needed.

It was noted that during spells of cold weather there was often a spike in the number of injuries relating to falls and as such it was questioned whether the health service was in position to cope with demand. It was advised that the spike in injuries was normally manageable, but there was an important differential between those people who were generally well suffering a fall and those with wider health issues. Work was being undertaken through community nurses and GPs to raise awareness of the need to take extra care.

It was questioned what could be done to improve the take up of the Flu Vaccination Programme, to which it was advised that a lot of the work to raise awareness would be carried out through GPs surgeries and other community based services. Other areas that could be targeted included care homes and the vaccination of frontline NHS staff, which was optional, but strongly recommended. It was noted that there was a need to shift the public perception on vaccinations which could often be negative.

In response to a question about bed occupancy rates, it was noted that it was currently at a high level, with some days approaching 100% capacity, which increased the challenge of ensuring flow through the system. There was an aim to reduce bed occupancy to below 90% to ensure there was greater flexibility within the system.

In regard to more vulnerable, elderly patients, it was questioned where they could be discharged to and how this was monitored. It was advised that discharge rates were monitored on a daily basis, with a list of patients who needed additional support being overseen by the integrated discharge team. There were a number of reasons that caused a delay in discharging a patient including the availability of care home places and the need for home adaptations to be installed.

As there was increasing pressure to improve discharge rates, it was questioned whether this had led to an increase in readmissions. It was confirmed that readmissions tended to fluctuate, particularly at this time of year. There were instances when people were discharged too early, but this was monitored and would be picked up if there was a significant issue.

As it was noted that the Winter Communications Plan was targeted at the South West London area rather than a local, Croydon level, it was questioned how any such communication would help patients negotiate through health service pathways locally. It was advised that the campaign had been designed to address the needs of each borough. It was agreed that further detail on the Winter Communication Plan would be shared with the Sub-Committee outside of the meetings.

From the perspective of the Croydon University Hospital it was noted that a strength of the Emergency Department was that it was well known and easy to access. As such it was important to direct people when first attending, with the first point of contact being a Screening Nurse to guide patients to the most appropriate service for their needs.

At a previous meeting of the Sub-Committee it had been noted that it could often be difficult for the street homeless to access services, as such it was questioned what support was available. It was highlighted that there was a big campaign underway to reassert that the homeless had a right to register with GPs, with the provision of a card to confirm this. It was also stated that entry into the health service for homeless people should be no different to others patients, but it was acknowledged that there could be additional difficulties around discharge when the patient did not have a home.

In response to concerns about the available capacity within the Emergency Department to meet demand and how much flex was available, it was confirmed that the service was currently using about half its flex capacity, but there was also an additional flex ward that could be deployed as needed. It was also highlighted that extended hours for GP Hubs were in operation with extra capacity available, with patients referred to the Hubs from their existing practices.

As it had been noted that additional capacity for mental health patients had been commissioned with the East London Foundation Trust, it was questioned how long the additional capacity was available and what support was being provided for relatives wanting to visit patients. It was confirmed that the additional capacity would be in place until the end of March 2019 to manage the current demand and provide the opportunity to reduce occupancy levels. It was also confirmed that there was support in place to ensure relatives were able to travel to visit patients.

In response to a question about why the length of bed stay was so long, it was confirmed that at present the numbers were high, but the department had the capacity to manage 70 patients for over 21 days, if the number of patients rose above this it would become more challenging to manage demand. It was highlighted that the average length of stay for non-elective surgery was under five days. 

It was noted that at present a lower than expected number of patients were going through GP Huddles and as such it was questioned whether this was due to patients having to go through their GPs for referral.  It was advised that Huddles were something the CCG would like promote further as they had been shown to be effective. There now needed to be an expansion of scope to encourage other healthcare professionals to refer patients who were eligible.

As it was noted that there was 10,000 additional minutes available for appointments with GPs in the borough, it was questioned how this had been allocated. In response it was confirmed that the additional capacity was being provided at the GP Hubs.

In response to a question about the Red Bag Scheme it was confirmed that it had been based upon a similar scheme operated in Sutton and was targeted at care homes and would deliver savings through improving the preparation of people when being admitted to hospital. 

It was questioned what would happen if the Emergency Department was at 100% capacity and a major incident occurred. It was advised that should this occur, then there was a mechanism in place to increase patient discharge.

In response to a question about the waiting times in the Emergency Department it was advised that this would depend on the level of care needed, with urgent care performance being good. For minor injuries, most patients were seen within four hours and discharged the same day.

Regarding ambulance conveyancing at the new Emergency Department it was confirmed that this was sometimes higher than it should be, but this could be down to ambulance staff wanting to test the new service.

It was confirmed that facilities for mental health patients had been improved within the Emergency Department with separate rooms for adults and children.

The Chairman thanked the representatives for attending the meeting and answering the questions of the Sub-Committee.

Conclusions

Following the discussion of this item, the Sub-Committee reached the following conclusions:

1.    The Sub Committee were concerned to note that the Emergency Department was operating at near 100% of its capacity, when there had not been any flu outbreaks or bad weather and as such questioned how prepared they were to meet any increase in demand?

2.    The Sub-Committee were also concerned about the guidance provided to GPs on prescription costs and discretionary prescribing, as it was felt that this may lead to some patients not getting the medicine they required.

3.    The Sub-Committee were concerned that the Winter Communication Plan had been developed on a South West London level and as such questioned whether it would be more effective on a local Croydon level.

4.    The Sub-Committee welcomed the approach of using a multi-service discharge team and agreed that it would like to receive further information about this approach.

5.    The Sub-Committee agreed that it would be important to have a follow-up report on Winter Preparedness in March to find out whether it had been effectively managed.

Recommendations

1.    That the GPs Collaborative be invited to a future meeting to provide further information on discretionary prescribing.

2.    That representatives from the interagency Discharge Team be invited to a future meeting to provide further information on their work.

3.    That the representative from the CCG, CHS and the Social Care team be invited back to the meeting of the Sub-Committee in March to provide an update on the delivery of their Winter Plans.