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The Wandsworth, Merton, Lambeth

and St George’s Healthcare Trust

Partnership – Urgent Care

Improvement Plan 2013/14

Draft v0.9 – 3rd

Phase Submission

South West London

Local Health Economy

Urgent Care Improvement

Plan 2013/14

Version Control

Version Date Author

Development/Edits

0.1 22.05.2013 Kosar Parveen Template prepared with skeletal outline

0.2 29.05.2013 Kosar Parveen, James Olweny, Iain Rickard

Template reviewed by Chief Officer, amendments added, final copy submitted to NHS England as 1st phase edition

0.3 06.06.2013 Kosar Parveen 1st phase edition developed for phase 2 submission. Circulated to all partners for content

0.3 11.06.2013 Kosar Parveen Phase 2 DRAFT submission circulated to all partners for content/comments

0.4

16.06.2013 Lucie Waters Edit

0.5

19.06.2013 Kosar Parveen Amendments Added

0.6

19.06.2013 Graham MacKenzie Chief Officer’s Edit

0.7

25.06.2013 Kosar Parveen Final Amendments Added

0.8

02.09.2013 Kosar Parveen 3rd phase edition developed for submission on 23/9/2013

0.9 23.9.2013 Kosar Parveen Final amendments added for submission to NHS England on 23/9/2013

Document Approval

Organisation/Board/Individual/Group

Date

Wandsworth CCG Management Team – 2nd phase edition circulated to Management Team and partners

05.06.2013

Wandsworth CCG Management Team – 3rd phase edition circulated to Management Team and partners

09.09.2013

All partner Boards agreement and sign-off of final plan 10.09.2013

Wandsworth Clinical Commissioning Group

Operating Plan 2013/14 - DRAFT v0.1

Contents

1. Introduction ............................................................................................................................... 1 2. Background and Context ........................................................................................................... 1 3. Executive Summary ................................................................................................................... 1 4. Patient Journey Through the Emergency System – The 3 Phases Summary ........................ 5 4.1 Prior to arrival at A&E – 6 4.2 Journey through the hospital – 6 4.3 Discharge and out of hospital care (Using the framework set out in Delivery of the

A&E 4 hour operational standard [Gateway 00062]) – 6 5. Urgent Care Board ..................................................................................................................... 7 5.1 Remit of the Board – 7 5.2 Membership – 7 5.3 Key Tasks and Responsibilities – 8 5.4 Performance Management – 8 5.5 Board Structure – 11 5.6 Terms of Reference – 11 6. Urgent Care Improvement Plan ............................................................................................... 11 6.1 Emergency Care Intensive Support Team (ECIST); Local Services Report – 12 7. Performance Overview ............................................................................................................. 13

7.1 Provider Risks & Mitigations – 13 7.2 Current Position; Overview of Performance & Plans for 2013/14 – 14 7.3 Reflections from 2013/13 – 15 7.4 Winter Planning 2013/14 – 16 7.5 Performance Graphs – 17 7.6 Capacity Planning; St George’s Bed Capacity Model – 21 8. Committed Resources for Urgent Care .................................................................................. 25 8.1 Provider Plans to Meet Funding Resource Requirements – 25 8.2 Urgent Care Board and NETA Allocation – 25 8.3 Delivery of Winter Funded Projects – 26 8.4 Winter 2013 and Funding Allocation – 26 8.5 Scoring Criterion – 27 8.6 Scoring Process – 27 8.7 Metrics Agreed for Monitoring of Initiatives – 28 8.8 Proposal Containing All Initiatives – 28 8.9 Summary Table of Proposal – 36 9. QIPP Plans & Associated Reductions in NE Admissions & Attendances – 40 10. Balance Scorecard (Health System Improvement Impact Dashboard with Metrics) ........... 43 11. Board and Partner Sign-Off ..................................................................................................... 44 12. Summary Conclusion ............................................................................................................... 44 13. Appendices ............................................................................................................................... 45

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1. Introduction

This plan presents an overview of the initiatives and actions in progress by the Wandsworth, Merton, Lambeth and St George’s Healthcare Trust Partnership, hereafter to be referred to as the ‘Partnership’ and the members of which are as follows:

Wandsworth Clinical Commissioning Group

St George’s Healthcare NHS Trust

Wandsworth Borough Council

London Ambulance Service

Merton Borough Council

Merton Clinical Commissioning Group

Lambeth Clinical Commissioning Group

NHS England (Specialised and primary care commissioning)

These organisations are working in partnership to maintain and improve the performance

and quality of the urgent care pathway for patients within the South West London region.

2. Background and Context

Nationally there is immense pressure on the urgent and emergency care systems, notable as present during summer months and this is before expected additional winter pressures. In some areas of England this has had an impact on the achievement of the operational standard for A&E which is that 95% of patients must be admitted, transferred or discharged within 4 hours. The A&E operational standard is designed to deliver patients’ rights under the NHS Constitution. In ‘Everyone Counts: Planning For Patients 2013/14’ NHS England reinforced the NHS Constitution commitment and as such have requested that those CCGs with hosting responsibilities for A&E departments on their patches produce sustainable plans; this is part of NHS England’s approach to achieving CCG Assurance.

3. Executive Summary

This plan represents the third draft of the Urgent Care Improvement Plan for the partnership and meets the requirements for 2013/14 winter planning, as due for submission on 23rd September 2013. In summary the main thrusts of the plan are as follows;

1. There is a very comprehensive plan in place as well as a proposed series of initiatives for winter 2013. The initiatives are based on the evaluation exercises carried out based on the experiences during previous winters. However the plan is deemed to be at risk by the partnership based on the following reasons;

2. In the present situation and in the context of very limited availability of dedicated winter funds, as per winter 2012, delivery of the overall plan and sustained performance is regarded as high risk by the partnership.

3. Pressures within the system – bed capacity. Modelling carried out during the Business Planning process for 2013/14 highlighted several bed pressure points where bed shortages are highlighted. In summary this suggests that a shortfall in

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capacity of between 25 – 40 beds is evident and this is over and above current plans.

4. The decision taken by the Department of Health, to focus winter funding on the most challenged communities, means that the rest of the country faces increased demand and higher acuity levels but with significantly reduced resources compared with winter 2012. At St George’s Healthcare Trust, this leaves the Trust to deal with a 14% year on year rise in ED attendances arriving by ambulance, (a higher acuity of patients, which are more likely to require admission) but with £2M less funding compared with winter 2012.

5. Approximately £9M of NETA monies is attributable to St George’s Healthcare Trust based on 2012/13 performance; however there is no agreed process in place for the realization of this funding, from the responsible CCG /NHSE commissioners and access to these funds is therefore at risk at this late stage, given that winter is upon us. Partners have yet to declare their NETA contributions.

6. Wandsworth CCG has identified its share of NETA funds for St George’s Healthcare Trust of £1,224.5M for immediate investment in winter initiatives, as described under section 8 of the plan.

7. Further, additional schemes have also been identified, up to a total value of approximately £9M. It is the intention that these initiatives will be implemented as and when further NETA funds or other resources are identified and made available across partners.

Funding Pressures 2013 Winter Funding The total source of NETA funding made available by Wandsworth CCG is £1,224.5M, which has been allocated as follows;

1. £905K as contributed by Wandsworth CCG, as their NETA contribution.

2. £319.15K allocated to social services initiatives, again as part of the CCGs NETA funding contribution.

Nationally £500M of winter funding has been identified to ensure that A&E departments are able to deliver a well-managed and safe winter Unfortunately, portions of the funds have not been allocated to St George’s Healthcare Trust or to SW London generally, despite the knowledge that it was the additional funding of approximately £9M, provided for the whole of the SW London health economy which delivered a safe urgent care/A&E system during winter 2012. The local share of the £500M needs to be at least at the level of 2012/13, to support the need for additional winter capacity both within the trust, as well as in and around the wider health system as indicated by both the attached ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’ as well as by the significant amount of additional winter funding requested by partners, via initiatives/bids submitted for winter funding consideration. In 2012/13 the Trust and local CCGs received winter pressures funding to the sum of £2.5m (£1.8m from the national fund and £0.7m through Wandsworth PCT). Although this was not confirmed in the 2012/13 financial year until December 2012, this funding was deployed in full and made a significant contribution to performance across the system. Indeed the trust continued a number of these schemes into the first quarter of 2013/14 to address continuing emergency pressures.

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St George’s will also be adversely affected as the result of neighbouring health communities not benefiting from winter funding on the basis of past good performance. Slide number 9, demonstrates that NETA (Non Elective Threshold Adjustment) monies, pertaining to St George’s Healthcare Trust emergency activity, are distributed widely amongst CCGs in SW London and beyond and also in NHS England; it is vital this reinvestment is provided direct to the trust to deal with the risks and bed shortages being faced. Pressures within the system – bed capacity. Modelling carried out during the Business Planning process for 2013/14 highlighted several bed pressure points where bed shortages are highlighted. In summary this suggests that a shortfall in capacity of between 25 – 40 beds is evident and this is over and above current plans, if high levels of activity continue, however given that winter is upon us, there is no reason why this activity should reduce, in fact the reverse is expected. To clarify, detailed planning was carried out in the previous year, which provided a steer in terms of pressure point and for which plans are in place to deal with this. However subsequent activity modelling has shown that the original plans to forecast activity, did not take into account the unexpected activity hike. The latest modelling assumes that 2013/14 winter activity will be higher than summer activity. Although St George’s Healthcare Trust planned capacity well in advance and put initiatives in place to accommodate capacity shortfalls, the very high levels of activity to date are well above plan and could not be forecasted. (The breakdown of actual bed requirements is provided on slide number 6 of the attached PowerPoint presentation ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’). NETA Funding Wandsworth CCG – NETA Contribution NETA monies are defined as the ‘70% Non-Elective Threshold Adjustment (NETA)’. This in essence means that, for emergency activity beyond the 2009 threshold levels, Providers are paid at the rate of 30% and not the full amount for the activity rendered. Briefly the initiatives will be resourced from the £1,224.5.5m of NETA funds provided by Wandsworth CCG. The proposed initiatives are focussed at St George’s Healthcare Trust in the main (£905K) and social services initiatives (£319.15K) and the four specific pathways impacting on winter pressures, as deemed appropriate by the UCB based upon NHS England guidance and evidence in respect of seven day working. The proposal as detailed within Section 8.1 onwards, has been presented with the initiatives broken down into the individual pathways which they represent. The four pathways are as follows: 1. Seven Day Working (SDW) and in-hospital Pathway Initiatives 2. A&E and Front End Pathway Initiatives Clinical Requirements 3. Social Care Funding Requirements to Support Hospital SDW Model 4. Discharges Out of Hospital Pathway Initiatives In addition to the initiatives profiled for this first tranche of investment, the Delivery Group has also received a high number of applications for further initiatives. The intention will be to approve these, as and when further resources are identified from NETA funds or other resources across the UCB partner organisations.

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Activity Overview The Trust’s A&E department and urgent care system are working phenomenally hard to deliver a secure winter for 2013 and to date, have delivered a very strong performance overall. However this is against the background that activity for the year to date has been in excess of projected activity levels as agreed by both Commissioners and Providers, this is despite having used all planning tools and having strong plans in place to predict and manage daily activity levels e.g. Surge Plans. The excessive activity experienced to date, has not dissipated and moving forwards into winter 2013, we expect that there will not be a reduction in activity and quite likely that this will increase. Importantly the issue of excessive activity is greatly exacerbated by the funding shortfall as detailed below. The Delivery Group The Delivery Group is the operational arm of the UCB, as set up by the UCB and undertakes the implementation of all initiatives and workstreams, required to achieve delivery of the strategy for winter 2013 and beyond into the following quarters. The Delivery Group is chaired by Andrew McMylor – Director of Delivery, Wandsworth CCG and support is provided by Kosar Parveen - A&E/Urgent Care Project Manager. The core membership consists of key operational staff from each of the member partners. It is the function of the Delivery Group to ensure;

1. The management and delivery of the funding process, including processes for receipt of bids, evaluation of bids and the application of a scoring criterion.

2. The Delivery Group is responsible for performance monitoring of the final initiatives selected for delivery, as well as for the reporting of regular progress to the UCB.

3. The Delivery Group is responsible for working across all partners and via the Wandsworth CCG, A&E/Urgent Care Project Manager – Kosar Parveen, providing support, coordination of work and partnership working across all partners.

Performance Matrix Table The performance matrix table has been refreshed with the specific metrics to be used to monitor A&E/urgent care system performance, as agreed by the Urgent Care and System Improvement Board.

The on-going implementation, performance management and work in relation to the plan, will be continued to be directed by the Urgent Care and System Improvement Board for St George’s and the local health and social care economy. The Urgent Care and System Improvement Board will ensure that via the Delivery Group, the health economy is prepared and coordinated to respond to the increased winter pressures. The plan has been prepared by the Partnership in response to both the generic guidance issued from NHS England, as well as the specific feedback received in response to both the first submission made on 31st May 2013 as well as the second submission made on 19th June 2013 where the Partnership were required to respond to the four areas.

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This third submission as due on 23rd September 2013 is the culmination of the work and involvement of all partners in both the Urgent Care Board and the Delivery Group. The partnership also welcomes the participation of London Ambulance Service (LAS) as a core member of the Delivery Group, thereby offering both strategic and operational input into the work for winter planning. The established Urgent Care and System Improvement Board for St George’s and the local health and social care economy, chaired by Dr Nicola Jones, Clinical Chair of Wandsworth Clinical Commissioning Group, is directing both the work and allocation of winter funding, to ensure that the local health economy is ready for winter. The Board is the primary local forum for the planning and partnership approach, in relation to the whole urgent care system and the Delivery Group, which is also operational, is the ‘task and finish' group which enacts the operational delivery of the decisions taken by the Board (see section 8.1). Winter safeguarding Arrangements have also been considered within current planning arrangements across the boroughs and there is no change to the usual safeguarding and on-call Director arrangements.

4. Patient Journey Through the Emergency System – The 3 phases and associated

actions to manage attendances

In April 2012, the Trust was awarded exemplar service improvement status by NHS London and NHS Top Leaders. The Service Improvement Programme then commenced in July 2012 and is now being overseen by the NHS Trust Development Authority (NTDA). There have been a number of initiatives commissioned by partner organisations under the Quality, Innovation, Productivity and Prevention (QIPP) Programme, which have been audited and proven to reduce pressure on secondary care in terms of A&E attendances, emergency admissions, outpatient attendances and length of stay.

The QIPP projects include but are not exclusively limited to the Community Ward, Falls

and Bone Health, GP Referral Management, Admissions Avoidance for Harmful and Hazardous Drinkers, the Urgent Care Centre and Self-management programmes for patients with Long Term Conditions. It is anticipated that these projects will reduce A&E attendances, and we will be able to directly attribute a reduction of 6000 A&E attendances, 1000 admissions, 1100 occupied bed days and a potential increase of 500 out-patient appointments to these schemes. The QIPP plans are all three year plans which commenced this in 2012/13 and we expect the full benefits in 2013/14 and 2014/15 onwards.

Both Wandsworth and Merton Social Services Departments are top quartile performers

nationally for Delayed Transfers of Care (DToC). Performance reports for 2012/13 show that for social services only DToC, that Wandsworth Borough Council was ranked 16th and London Borough of Merton was ranked 21st out of the 152 boroughs.

Wandsworth Social Services have the lowest delayed transfer of care rates in London for

non-health related reasons. Even when health related reasons are added, Wandsworth remains in a strong position (fourth within London). There are a number of successful initiatives currently running (provision of step-down, non-acute nursing beds) which have been piloted (24 hour live-in care) which has been audited and proven to have significantly reduced length of stay and re-admissions. Routinely, Social Services successfully expedite transfers of care through integration of staff into the STAR team at St. George’s, the Intermediate Care Bed Based Team and the Community Ward. Additionally, social care staff are involved in the assessment and development of care packages for patients at a very early stage in the discharge planning process.

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4.1 Patient journey PRIOR to A&E – Managing A&E Attendances

A range of best practice programmes are in place to support management of demand:

Self-Management programmes Integrated community care, End of Life Care (avoidance of inappropriate admissions for

this group of patients) and falls prevention, management and bone health for frail and elderly patients

Support for carers Enhanced management of patients with long term conditions in primary and community

settings - including COPD, Diabetes, Heart Failure and Coronary Heart disease, including specialist training for practice nurses to deliver this

Community Ward with input into MDT from Senior Health Consultant, Specialist Nurses, Advanced Nurse Practitioner and Social Care to manage complex cases in community more effectively

Local Enhanced Services to support A&E including enhanced GP access, action plans to reduce A&E attendances and promote joint working with secondary care

Re-configuration of GP Out of Hours community clinics at Brocklebank and Balham Health Centres

Using NHS 111 as an alternative to A&E and Urgent Care and to manage the flow of patients into A&E

4.2 Patient journey THROUGH the hospital – Pathways and Capacity

St George’s Healthcare NHS Trust has a noted programme of process transformation:

Partnership working with London Ambulance Service to avoid handover delays and

understand flows of patients into A&E Improvement project at St. George’s to widen the provision of ambulatory care services Improving flow through the Urgent Care Centre by reviewing triage processes and skill

mix Improving flow through A&E by ensuring robust pathways are in place for patients with

specialist conditions and that regular reviews are carried out by AMU and Specialty Consultants

Managing capacity by reviewing bed availability, discharge planning and flexing bed capacity between urgent and elective patients during business as usual and times of surge

Ensuring provision of services for specific groups of patients, including sick children and patients with mental health, alcohol and substance abuse issues

Acute Coronary Syndrome pathway Heart Failure and Atrial Fibrillation pathways in development Integrated information management systems to facilitate working between health

organisations and with social care 4.3 Discharge and out of hospital care using the framework set out in Delivery of the

A&E 4 hour operational standard (Gateway 00062)

All partners are working collaboratively on effective and efficient discharge arrangements:

Ensuring robust models for discharge planning, including removing bottlenecks in patient flows, ensuring accommodation is available for patients awaiting discharge and that all mechanisms are in place for discharge (Prescriptions, Transport, etc.)

Working to agreed length of stay targets for specialties and minimising delays in transfers of patients to social care.

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Providing step-down capacity in the community settings to facilitate discharges and prevent re-admissions.

5. Urgent Care Board

The Partnership has a fully operational ‘Urgent Care Board’. 5.1 The remit of the Board:

Clinical and senior leadership is maintained across the health and social care system to consider the drivers for and responses to, increases in urgent care demand.

There is a long term commitment to continuous improvement ensuring that high level focus continues as well as an integrated approach across CCGs, health and social care, commissioners and providers, leads to sustained improvement in quality, performance and affordability in the medium to long term.

Through shared analysis and data review, there is a common understanding of the barriers to improved performance and agreement on the priority actions.

There is a clear delivery programme with effective monitoring of the implementation and evaluation of the impact.

Resources to support urgent care performance are identified and managed on a collaborative basis across the health and social care economy, including oversight of the use of the 70% funding retained from the excess urgent care tariff.

Links the work on Urgent Care and integrated approaches to care out-of-hospital to the SW London Strategy Programme ‘Better Services, Better Value’ (BSBV) to ensure that trajectories for urgent care are met.

5.2 Membership

The Urgent Care Board has brought together the members of the Partnership as follows:

1. Wandsworth Clinical Commissioning Group 2. St George’s Healthcare NHS Trust/integrated acute and community (SGH) 3. Wandsworth Borough Council 4. NHS England/London/South Area Team/Primary Care (NHSE) 5. NHS England/London/Specialised Commissioning (NHSESp) 6. Lambeth Clinical Commissioning Group (LCCG) 7. Merton Borough Council 8. Merton Clinical Commissioning Group (MCCG) 9. Royal Marsden NHS Foundation Trust – Community Provider Arm (RMH)

Colleagues from other agencies e.g. South West London and St George’s Mental Health Trust, London Ambulance Service, Lambeth Council, are being invited to attend the Board when relevant to the issues under discussion. Discussion has been held with the Chief Executive of London Ambulance Service as to the best way to service the Board and it has been agreed that senior level representation is made to the Board via an Operations Director and that a local Operations Manager, from the SW London area is represented at the Delivery Group. The Urgent Care Board is chaired by Dr Nicola Jones, the Clinical Chair of Wandsworth CCG. Membership comprises senior representatives from each of the Partner organisations at Clinical lead, Chief Officer or Director level. There is a high level of clinical leadership and engagement on the Board both from both within the Trust and from commissioning organisations.

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5.3 Key Tasks and Responsibilities

The key tasks of the Urgent Care Board are to ensure that the full range and responsibilities of an Urgent Care Board are fulfilled, with a focus on longer term sustainability, through ensuring:

Each of the partner arrangements has strong ‘Risk and Issues Management’ plans in

place and the Board will oversee these plans Leadership capacity and expertise is in place to manage urgent and emergency care

issues within the health economy Leadership capacity and expertise is in place to undertake rapid data review and share

findings with key stakeholders Identification and agreement on key priorities to achieve sustained improvement Resources are in place (senior leadership, external support, commissioned capacity) to

accelerate proposed improvements Effective programmes are in place to deliver sustained improvement, holding partners

to account for delivery of each part of an integrated approach Learning from programme delivery and performance information is shared across

programmes, and a further programme of continuous improvement The impact of successes and challenges in integrated working are considered and to

propose new ways of facilitating integrated care are proposed Relating outcomes of the programme work streams to the BSBV modelling

assumptions, engage the BSBV team as appropriate. 5.4 Performance Management

The Board is monitoring performance across the whole urgent care system using a dashboard of metrics covering all elements of the system. The performance matrix table has been refreshed with the specific metrics, to be used to monitor A&E/urgent care system performance, as agreed by the Urgent Care and System Improvement Board. For the latest copy of the specific metrics to be used to monitor winter performance during the next few months, please refer to the embedded DRAFT document immediately below.

Urgent Care

Performance Dashboard - DRAFT for Phase 3 Submission 17.09.2013.xlsx

The potential performance metrics in their entirety to be measured across the whole of the urgent care system are detailed below. This has been retained as demonstrative of future planning arrangements vis-à-vis metrics covering all elements of the urgent care system.

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Whole System Urgent and Emergency Care Metrics

PRIOR TO A&E

% Cat A ambulance performance (8 minutes) Currently available via UNIFY & NHS England – London Region

Ambulance Conveyance rates Available weekly via NHS England – London Region

LAS usage of ACP resources TBC

Ambulance handovers >15 minutes Available from HAS system via CSU and in weekly NHS England – London report.

Primary Care Access measures 24 & 48 hour access targets. Availability of data TBC as may no longer be routinely measured.

No. of appointments available to be booked by UCC.

GP Out-of-Hours performance Provision and uptake of out-of hours service.

111 Service Performance measures Data available via UNIFY:

Calls answered, calls transferred to clinician, call-backs

HOSPITAL SYSTEM

St. George’s 4hr Type 1 Performance Available daily via CMS

UCC Performance UCC activity available monthly via SUS.

UCC subject to same 4 hour wait target as main ED.

UCC Adult and Paediatric split UCC activity available monthly via SUS and can be analysed by age or patient category.

% patients seen in 4 hours at Type 3 services Data for Minor Injuries Unit at QMH available monthly via SUS.

A&E Department Attendances Available daily via CMS

A&E Admissions (total) Available daily via CMS

GP Admissions Emergency admissions from GPs available via SUS

Mental Health 4hr breaches Available daily via CMS

MIU Attendances (Type 3) Data for Minor Injuries Unit at QMH available monthly via SUS.

St. George’s Bed Occupancy Available daily via CMS

Non-elective length of stay Available monthly via SUS

Zero Length of Stay Admissions Available monthly via SUS

Readmission rates Available monthly via SUS

Elective Cancellations

Available monthly via SUS

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Mortality rate. Available via Public Health by disease area. However, may only be available annually.

DISCHARGE & OUT OF HOSPITAL

GP-Led Health Centre Attendances Data should be available from identified centres.

Crisis Response Times Available from Mental Health Trust

Intermediate Care Measure Requirements to be defined around capacity but will be refined further

Community Care measures Available by ‘day of week’ and readily available

Discharges from St. George’s by time of day Available from St. George’s (If currently compiled and published)

Delayed Transfers of Care Available via UNIFY

Community bed occupancy Could be supplied by Community Bed Providers

Care Homes data Requirements to be defined around capacity

Disposition to institutional care Available via SUS

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5.5 Board Structure

5.6 Terms of Reference This was agreed during the initial meetings of the Urgent Care and System Improvement Board. 6. Urgent Care Improvement Plan

The plan provides assurance to NHS England and evidences the strong performance of the South West London regions A&E departments. The Urgent Care Improvement Plan details the three key stages of the patient pathway through the A&E and urgent care system and focusses upon improvements which can be made at each stage of the journey detailed as follows. 1. The patient journey prior to A&E 2. The patient journey through the hospital 3. The patient journey at point of discharge and out of hospital. The section on prior to A&E covers improved provision for the needs of elderly and frail patients; ensuring appropriate care is provided in a community setting for patients with long term conditions; providing sufficient capacity in the Community Ward; improving access to General Practice to divert patients from A&E and ensuring sufficient surge capacity in out of hours and NHS 111 services. The hospital system section considers improved joint working between St. George’s and London Ambulance Service to improve the patient handover process and better understand patient flows into A&E; Provision of a range of ambulatory care services to appropriate patients to reduce A&E attendances and emergency admissions; Improving efficiency of patient flows through the Urgent Care Centre and away from A&E and ensuring there is sufficient skill mix in the Urgent Care Centre to provide for as many

Urgent Care Board

NHS England

Wandsworth CCG Senior User

Merton CCG Senior User

Lambeth CCG Senior User

St. George’s Healthcare NHS Trust & Community Services Wandsworth

Senior Supplier

Sutton & Merton Community Services Senior Supplier

London Borough of Merton Senior Supplier

London Borough of Wandsworth Senior Supplier

London Ambulance Service Senior Supplier

? Commissioning Support Unit Executive

CCG & CSU Performance Teams Project / Delivery Assurance

Winter planning Scorecards Winter conference calls

Project Manager Wandsworth CCG

Delivery Group

Operational Members

Team Members

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groups of patients as possible; Improving patient flows through A&E by establishing pathways for patients with complex conditions; Ensuring there is sufficient senior medical cover in A&E to make treatment decisions and prevent admissions where possible; Ensuring that there is sufficient bed capacity and discharge planning in place to accommodate elective and non-elective patients during business as usual and the winter period and that there is provision for specific groups of patients with complex needs, including children, those with mental health issues and alcohol and substance misusers. Finally, the Discharge and Out of Hospital section details how bed management processes can be improved to allow the Trust to predict bed usage, balance elective and emergency admissions and ensure that all patients are accommodated in the appropriate parts of the hospital; Discharge planning is examined to ensure that any bottlenecks are reduced as much as possible and that resources such as transport and packages of care are provided for patients leaving hospital; Delays in transfers of care are as minimised through discharge planning soon after admission and liaison with Social Services and other providers; Sufficient medical cover is provided on specialty wards and that there is support from Community Services Wandsworth to minimise avoidable and admissions and delayed transfers of care.

6.1 Emergency Care Intensive Support Team (ECIST) – Local Services Report

St George’s Healthcare Trust invited the Emergency Care Intensive Support Team (ECIST) to visit the premises in September; although the final report is not due until 23rd September, the initial high level feedback is as follows:

1. Emergency Department (ED) and Acute Medical Unit (AMU) are functioning well, there are some areas for improvement, but they are not the main problem with respect to patient flow.

2. Real time information for bed management decisions is urgently required. 3. A focus is required on both discharges and internal waits. 4. Seven day working is required, particularly within specialty wards. 5. A Surgical Admissions Unit (SAU) is required; this is planned for 2014/15 as it requires

capital build. 6. More robust pathways are required for the management of frailty. 7. Further opportunities for community integration need to be reviewed. For greater detail regarding mitigation plans in place, please refer to slide 11 of the attached ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’.

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7. Performance Overview 7.1 Provider Risks and Mitigations

Risks There are significant risks for patients, vulnerable groups and frail/elderly patients during winter 2013. This also impacts on the wider health economy if winter 2013 is not funded adequately; further this will also impact on general performance metrics which are subsequently reported to NHS England and Department of Health (DoH). These include:

1. Compromising patient safety by operating beyond recommended levels of bed occupancy and throughput.

2. Significant numbers of medical and surgical outliers throughout the winter. 3. Patients with specialist needs not accessing the most appropriate beds. 4. Delays in accepting inter-hospital transfers for acute tertiary services such as cardiac

surgery and neurosurgery. 5. Prolonged use of escalation areas only appropriate for inpatient care as a last resort

e.g. endoscopy, Neuro Day Unit. 6. Reliance on temporary staffing to cover additional activity. 7. There is evidence to suggest that acute services are operating at the limits of safe early

discharge, e.g. readmission rates, compliance with heart failure pathway. Significant cancellations of elective surgery may also impact upon delivery of the 18 week RTT standard target. This subsequently requires the unplanned outsourcing of elective activity to the private sector, to maintain RTT performance which is not ideal in quality terms and thus adds further financial pressure to the organisation. The financial value of the NETA funds to St George’s Healthcare Trust based on current plans is £9.22M. The 30% marginal rate does not cover the financial costs of having to open escalation areas, utilise private sector capacity as well as the loss of elective income built into current budgets. For greater detail regarding risks, please refer to slide 10 of the attached ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’. Mitigation Plans Mitigation Plans are based on both new and daily capacity/activity management plans as well as the Emergency Care Intensive Support Team (ECIST) report as due in September. Initial high level feedback from the ECIST Team is as detailed below and the team are returning to assist with implementation plans:

1. Emergency Department (ED) and Acute Medical Unit (AMU) are functioning well, there are some areas for improvement, but they are not the main problem with respect to patient flow.

2. Real time information for bed management decisions is urgently required. 3. A focus is required on both discharges and internal waits. 4. Seven day working is required, particularly within specialty wards. 5. A Surgical Admissions Unit (SAU) is required; this is planned for 2014/15 as it requires

capital build. 6. More robust pathways are required for the management of frailty. 7. Further opportunities for community integration need to be reviewed.

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Surge Management Plans are proactively used on a daily basis to improve patient flow and

LoS, to manage daily capacity as well as spikes in daily activity.

For greater detail regarding mitigation plans in place, please refer to slide 11 of the

attached ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’.

7.2 Current Position – Overview of Performance & Plans for 2013/14

St Georges achieved the 95% target for ‘All Type’ performance for Quarter 1 with a performance rate of 95.55%. However, the Trust had a challenging quarter 2 due to increased activity and delivered July ‘All Type’ performance at a rate of 94.5%. The Trust saw an increase in A&E attendances, ambulance conveyances and admissions due to the heat wave during July. There was also an increase in the admission of frail and elderly patients, which led to a lower than usual number of discharges. The Trust took action by opening escalation beds, reviewing elective surgery and cancelling operations where appropriate. More recently the trust though experiencing high activity hikes have strong plans in place and as a result are maintaining the A&E standard. The CSU are monitoring issues and the actions being taken by the Trust in the SEL bi weekly A&E Performance conference call. The A&E department has recently undergone a full scale refurbishment and modernisation, and was officially opened by Dame Ruth Carnall, Chief Executive of NHS London in January 2013. This improved a number of areas including:

The children's emergency department which has been expanded to include a new

space for a combined walk-in and minor Paediatric injuries service A new Paediatric majors area where children with more serious injuries are treated A new Paediatric Assessment Unit, which is a short stay area for children who need

short stay observation or are awaiting investigations, but do not need to be admitted The Clinical Decision Unit (CDU) has been expanded creating more capacity, and has

been kitted out with improved facilities which mean a better patient experience. The CDU is for those who require planned investigation and treatment for a period of no more than 24-36 hours

Additional space for the Urgent Care Centre (UCC) which provides treatment for minor illnesses and injuries like strains, bites, burns, infected wounds or chest infections

A new reception, waiting room and triage area

St George’s is working on plans to increase inpatient bed capacity at the Tooting site to ensure they are able to respond to peaks in demand for emergency admissions. A winter ward will be opened for the winter period in 2013, and an additional 15 extra inpatient beds are also due to be opened in December 2013. This is to ensure there are sufficient inpatient beds available for patients being admitted through A&E, whilst the trust continues to deliver elective work. Furthermore six extra general critical care beds are due to open in the last quarter of the 2013/14 financial year. Significant demand and capacity planning, at a specialty level, has been undertaken by St George’s and will be a key input to the Urgent Care and System Improvement Board. The Urgent Care Board will ensure that consideration of 2012/13 bed base, learning from 2012/13 and projections for 2013/14 are inputs to early Board meetings, to inform winter planning. The local actions and initiatives by Wandsworth CCG, St George’s Healthcare Trust and partner agencies across the urgent care pathway, both within and outside the hospital environment are summarised in Appendix 1 attached to this report.

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The main areas of action are profiled against the three stages of the urgent care pathway in Section 4 from p5 onwards.

7.3 Reflections from 2012/13

In recent years, numbers of patients attending A&E at St Georges has risen from 100,522 in 2007/08 to 120,836 in 2011/12 – a 20% increase in activity over a 5 year period. However, attendances in A&E started to reduce from July 2012 when the Tooting Walk-In Centre (TWIC) closed, and the Urgent Care Centre then opened in October 2012. Attendances have remained lower each month from July 2012 onwards and are lower than the numbers of attendances experienced from April 2012 to June 2012. Between 2011/12 and 2012/13 St George’s saw a drop of approximately 15,500 attendances, comparing the A&E with TWIC attendances to A&E with UCC attendances. Implementing the UCC has enabled the trust to better manage the flows of patients attending A&E at any one time, and to give patients the most appropriate care for their clinical condition. Additionally St George’s and CCGs have been working together to ensure that patients for whom A&E may not be the most appropriate care setting are redirected back to Primary Care. Whilst the attendance numbers have been reducing, there has been a shift in the type of case mix presenting from a lower proportion of the “minors” type and a higher proportion of patients with a higher acuity, which require emergency admission. Partner organisations were involved in developing the local 2012/13 winter plans as well as health system surge planning arrangements, in partnership with all key stakeholders within the wider health and social care community. The 2012/13 winter planning process built on winter plans from previous years and took into account the lessons learnt from 2011/12. Planning assumptions for potential winter demand at St George’s Healthcare Trust were considered using the latest position on underlying demand for activity and potential growth from 2011/12 baseline for emergency admissions. Bed capacity, incorporating both acute and community service, levels of occupancy and average lengths of stay were also factored into the modelling. There was no indication from the historical analysis of the infection data that the levels of Norovirus in the health community would be any different from the previous year. The attendance levels and admissions at the Trust for most of the winter 2012/13 were within expected levels, but there were days where levels spiked above plan, impacting on performance. The pattern of attendances across the week remained a mirror image of the previous year, with Monday showing as the day of the week which consistently has the most attendances. The Trust was below the 95% for type 1 in November, December, February and this can be correlated to the increased levels of acuity, resulting in longer lengths of stay, delays in transferring care, including repatriations to other hospitals and intermittent loss of beds due to Norovirus outbreaks. Another contributory factor was the potential need for more inpatient beds at the Tooting site for emergency admissions. Whilst the volume of available beds within the Trust was at a lower level than in previous years, additional beds were opened to cope with pressures. Performance in Q4 was assisted by additional winter funding to support the Trusts remedial plans to improve patient flow and recover performance during periods of peak demand. Performance was monitored and managed through weekly conferences calls against emergency and urgent care standards including A&E wait times and ambulance handover. The 2012/13 year-end achievement against the A&E 4 hour standard was 95.3% for type 1 and 96.0% for all types.

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7.4 Winter Planning 2013/14

The Department of Health highlights eight key areas that are vital to ensuring all services and winter planning arrangements across local health and social care systems are well coordinated, responsive and resilient:

1. Ambulance handover times 2. Operational readiness 3. Out of hours arrangements 4. NHS/Social Care joint arrangements to prevent/avoid admissions and facilitate early

discharge 5. Links between the London Ambulance Service, Primary Care, CCG’s and NHS Trusts 6. Critical care services 7. Preventative measures 8. Communications

Measures are being actively taken to manage risks associated with each of these key areas and to ensure mitigation strategies are included in plans across the whole health economy. An evaluation of the effectiveness of the winter planning process and allocation of additional funding during 2012/13 has been carried out. CCGs have collaborated with health and social care partners, to ensure that lessons learnt from winter 2012 are built into plans for winter 2013/14 to ensure whole system resilience. The overriding objectives for 2013/14 are to maintain safe, high quality services for patients, including the effective management of infection, Emergency Department access, ambulance turnaround times, urgent and other elective treatments. The plans for 2013/14 are not simply designed to last just a few months, but will be an integral part of long-term local strategy for the management of winter and beyond. Winter pressure management is provided by the South London Commissioning Support Unit on behalf of the CCGs in South London. The main information flows / communication channels in use to manage risks and issues are as follows:

Daily reporting of performance against the 4 hour target. Daily reporting of capacity pressures via CMS. The CMS system provides a score

reflecting the severity of pressures on bed and A&E capacity. Increasing scores trigger increasing levels of escalation and management.

Weekly exception reports produced by Trusts not meeting 95% target for a particular week. These reports detail the nature and magnitude of pressures and actions proposed to address them.

2 x weekly conference calls. One between acute trusts, CCGs, CSU, NHS England, LAS and others to summarise weekly performance and agree actions to address any issues identified. Second conference call between CSUs and NHS England.

Feedback provided from weekly conference call to CCG Exec / Management Teams.

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7.5 Performance Graphs

LAS Arrivals at St. George's The graph above breaks down ambulance arrivals at St. George's A&E department by type and hourly, over a typical week and compares 2012/13 activity with 2011/12. Summary Overall, the numbers of ‘peak’ incidents are lower in 2012/13 than in 2011/12. The reduction in arrivals is most noticeable during normal working hours, when alternatives to A&E are most often available. There has been little change in out of hour’s activity performance. One key workstream for the Urgent Care Board to consider is whether improved out of hours provision could reduce the number of arrivals by ambulance further and ease pressure on the system. Category A & C calls from NHS 111 since its launch have also been included. As expected, there are more arrivals of this type during out of hours. However, the total numbers are small and therefore unlikely to have put significant pressure on the A&E/Urgent Care System.

Acuity of Patients in A&E The graph on the following page shows number of A&E attendances for Wandsworth residents and the percentage of these that are Minors and Majors between April 2012 and April 2013

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Summary There has been a reduction in A&E attendances from July 2012, at which point the Urgent Care Centre opened and appropriate patients were diverted from the UCC to their local GP or other services. July 2012 also saw a switch in proportions of minor and major patients. St George’s is experiencing a lower proportion of minors and a higher proportion of attendances from patients with a higher acuity, who still require emergency admission.

Emergency Spells at St. George's The graph on the following page shows the increase in emergency spells at St. George's. This represents Wandsworth resident patients admitted via the Emergency Department. Summary This demonstrates an increase in patients attending the Emergency Department requiring admission and also a decrease in emergency short stay activity, a proxy for increased complexity of patients admitted.

4,000

9,000

14,000

19,000

24,000

29,000

40.00%

42.00%

44.00%

46.00%

48.00%

50.00%

52.00%

54.00%

56.00%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13

Monthly A&E attendances, and percentage of A&E attendances that are majors and minors

No. of A&E attendances monthly

% Minors

% Majors

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There are complex factors driving these changes but key drivers are considered to be demographic changes, the fact people are living with chronic long term conditions, and life style choices which have an adverse impact on health. The fact that St Georges is a Major Trauma Centre and is one of the eight Hyper Acute Stroke Units in London means that they are more likely to receive higher number of patients requiring emergency treatment.

Reasons for 4 Hour Breaches at St. George's The pie chart on the following page highlights the main reasons given for patients breaching the 4 hour wait target at St. George's during Winter 2012/13 Summary This data is taken from 4 exception reports submitted by St. George's when the 95% target was not met. 52% of breaches were due to bed management within the Trust, with a further 26% of patients delayed waiting for assessment in the Emergency Department or by Specialty teams.

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

2008-09 2009-10 2010-11 2011-12 2012-13

Emergency spells at St George's

Emergency

Emergency short stay

Other non elective

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Correlation of A&E Attendances and the 4 Hour Target Performance The graph below shows attendance numbers and performance against the four hour target in 2011/12 and 2012/13. Summary Comparing the two winter periods, total attendances were down in 2012/12 compared to 2011/12. However, performance against the 4 hour target was also down. This supports the suggestion that the acuity of patients is greater, when read alongside the graph showing attendances and percentages of patients seen in minors and majors.

10%

24%

28%

13%

4%

1%

0% 13%

4% 1%

2%

0% 1% Reasons for 4 Hour Breaches at St. George's

Clinical Bed management - femaleBed management - male Waiting for specialist opinion (Acute trust)Waiting for specialist opinion (Mental Health trust) Waiting for diagnosticsPrimary care assessment / streaming A&E assessment /A&E Referral

92.0%93.0%94.0%95.0%96.0%97.0%98.0%99.0%

01,0002,0003,0004,0005,0006,0007,0008,000

Ap

r 2

01

1

May

20

11

Jun

20

11

Jul 2

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QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 QTR 4

2011/12 2012/13

% S

ee

n in

4 h

ou

rs

Att

en

dan

ces

Correlation of A&E Attendances & 4 Hour Target Performance

Total AE Attendance Count 4 Hour Target

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Outcomes for Patients Discharged from A&E The graph on the following page outlines the outcomes / destinations of patients upon discharge from A&E over the past 5 years. Summary Data quality has improved significantly since 2009/10 with far fewer outcomes recorded as ‘not known’. Over the past 5 years, numbers of patients admitted have remained stable. Fewer patients are discharged with ""no follow up required"", indicating an increase in acuity. Referrals to other outpatient clinics have become increasingly common since the beginning of 2010/11.

7.6 Capacity Planning – St George’s Bed Capacity Summary Highlights

St. George’s has carried out an analysis of capacity with operational managers and clinical

leads using an operational bed modelling tool called PROMPT. This was developed by a

Professor of Operational Research and uses recent trust activity patterns and length of stay

distributions to simulate future bed configurations to optimise efficiency, and plan capacity.

St George’s Healthcare Trust utilises the PROMPT Tool (Patient Resource Operational

Management Planning) to plan bed capacity for the forthcoming year.

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The notable items based on activity to date are outlined within slide number 6 of the attached

PowerPoint presentation ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’).

Modelling carried out during the Business Planning process for 2013/14 highlighted several bed

pressure points where bed shortages are highlighted. In summary this suggests that a

shortfall in capacity of between 25 – 40 beds is evident and this is over and above

current plans, if high levels of activity continue, however given that winter is upon us, there is

no reason why this activity should reduce, in fact the reverse is expected. Although St

George’s Healthcare Trust planned capacity well in advance and put initiatives in place to

accommodate capacity shortfalls, the very high levels of activity to date are well above plan and

could not be forecasted.

(The breakdown of actual bed requirements is provided on slide number 6 of the attached

PowerPoint presentation ‘Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14’).

St George’s Healthcare Trust – Overview of Bed Capacity Monitoring Tool St George’s Healthcare NHS Trust employs a bed capacity monitoring tool, which allows the

user to model demand and capacity across three different levels. Following discussion with

NHS England about the Finnamore toolkit, as recommended for use by NHS England, it has

been agreed that their toolkit does not offer any further benefits to the model currently in use by

St George’s Healthcare NHS Trust. To clarify, the Finnamore toolkit is helpful to those Trusts

who have not hitherto adopted an analytical approach to modeling demand and capacity but for

those Trusts already using more sophisticated models it does not offer any additional benefits.

The mathematical sophistication of the conversion of demand into required capacity for the

annual modeling, the coverage of the whole trust and thus the Trust’s main pressure points

means that the Trust’s current approach offers wider and more accurate bed capacity modeling

tool than the suggested model.

NHS England has visited St George’s Healthcare NHS Trust and has examined the modeling

tools in use. As a brief overview, St George’s Healthcare NHS Trust carries out demand and

capacity modeling at three levels:

7.6.1 Daily Predictions of Demand.

This is carried out for non-elective medical, surgical and paediatric admissions and is based

on rolling averages. Elective admissions are known and pre-planned on a daily basis and

are monitored for the management of daily bed capacity. Staffing is planned on a daily

basis and according to the pattern of demand.

7.6.2 Capacity modeling for the forthcoming year.

For bed, theatre and ITU, the trust uses a model called PROMPT that takes predicted

demand and seasonal variations (which within the Trust is significant for acute medicine

and paediatrics but much less so for surgery) and simulates, using operational research

techniques, the outlier and cancellation rates for different bed pools, occupancy rates and

length of stay (LoS). The model also takes into account the skewed distribution of LoS,

given that any capacity calculation that uses averages will significantly underestimate bed

requirements. We work closely with the clinical teams on the operational rules for the use of

the different bed pools. This allows the Trust to define the optimal bed requirements for

each specialty through the course of the year. The accuracy of the outputs is of course

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dependent on both activity and LoS behaving as simulated within the model, but sensitivity

is also built in.

7.6.3 Strategic capacity planning.

This is about thinking ahead by 3/5 years and takes into account activity projections,

commissioning intentions, possible reconfigurations and thus informs longer term

developments. This again is a model based on operational research techniques, and is

separate from the PROMPT model used for in year modeling.

High Level Capacity Plans for 2013/14

Plan Milestone Deadline

Beds Open 23 acute medicine beds on Caesar Hawkins Ward

for winter 2013

Oct 13

Focus on LoS in acute medicine (RCP4), senior health,

surgery & neurosurgery (RCP3)

Mar 14

Relocate and expand surgical admissions lounge to

release 6 surgical beds

Dec 13

Plan for medium to long term capacity expansion in

neuroscience

Sep 13

Redevelopment of the existing SAL /(Gray/Vernon) into

new bed capacity - 15 beds with en suite facilities;

Medicine in winter, surgery in summer

Nov 13

Critical

Care

Plan for 5 additional beds for winter 2013 Dec 13

Complete business case for definitive expansion of GICU

in 14/15

Jun13

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Theatre Capacity

A target of 85% utilisation of theatres has been set by St George’s, based upon what seems to

be achievable in terms of peer performance. Most specialties currently achieve between 75-

85% in Main Theatres, and between 65% to 80% in Day Surgery Theatres. The main elements

of the plans to improve theatre utilisation are as follows;

Any growth in activity from 2012/13 to 2013/14 is to be absorbed by improved utilisation,

this principle was also agreed by divisions at the capacity planning meeting held in January

2013.

Individual services are creating individual action plans to increase theatre utilisation as well

as targeting the main areas of lost time.

In the Day Surgery Unit (DSU), utilisation is being targeted to drive more work through as

day cases and as a result to ease pressure on beds and inpatient theatres. The whole

DSU pathway has been mapped and there are several projects ongoing which should see

an improvement in theatre utilisation.

St George’s will continue to use off site elective theatre provision during 2013/14 as

required – with Bariatrics, Gynaecology and Cardiac Surgery activity continuing to be off

site with Neurosurgery and ENT cases planned to go off site in 2013/14 as per the plan

agreed for theatres by EMT in February2013. The estimated bed impact of off-site theatre

provision is 10 beds.

Agreed to review the cost effectiveness of outsourcing different types of activity and/or

moving to 3 session days as well as weekend working.

Continue planning for theatre expansion in 2014 including the new hybrid theatre as well as

use of the 5th floor.

Critical Care Capacity

Critical care bed capacity is also a significant pressure point. Currently there are 49 adult

critical care beds split as follows:

18 General ICU

17 Cardiothoracic ICU

14 Neuro ICU

Occupancy is currently high at 85%-90% (excluding booked beds and cleaning time). Certain

beds were opened during 2012/13 to alleviate some of the pressure as follows;

One extra bed on General Intensive Care opened Oct 2012

2 beds plus recovery on Ben Weir opened Nov 2012

4 beds on Holdsworth ward opened Feb 2013

As a result an extra five beds will also be required by winter 2013/14, the estimate includes the

helipad impact and assumes that the beds opened on Holdsworth ward remain critical care.

Decanting options to facilitate build in the shortest possible time are currently being clarified.

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General Capacity Planning Principles and Assumptions

St George’s will continue to ring fence beds on a divisional basis in 2013/14

The divisional ring fence will only be overridden on the grounds of patient safety

Outlier charging will remain in place.

The bed allocations to each division will remain as they currently stand.

All directorates need to put in place service improvement plans for reducing length of

stay (LoS).

No extra on site theatre capacity will be available to any specialty until it has achieved

the 85% utilisation of current theatre capacity.

It has been agreed that both Medicine and Critical Care need to plan for recruitment to

cater for additional beds, commencing immediately

It is also acknowledged that Critical Care and inpatient bed expansion planned in

2013/14 will impact on the 2013/14 capital programme and the programme has

therefore been revised accordingly.

8. Committed Resources for Urgent Care – The 70% Non-Elective Threshold Adjustment (NETA) Guidance states that the Urgent Care and System Improvement Board will be directing resources to support initiatives that further improve the performance and sustainability of urgent care services. The Board will consider the specifics at the first meeting but the finance remit is likely to include the following:

A commitment from all Board members (health and social care) to review all current spend on urgent care pathways, to consider if there is optimal integration and value for money from current spend

A process for collation of current and proposed new spend across commissioners and providers, split into common resource ‘buckets’ for benchmarking purposes

Consideration of potential new money for priority areas as identified by the Board, through application of the NETA monies

A process for management of spend (re-allocation of current, distribution of new) once the Board has agreed priorities.

8.1 Provider Plans to Meet Funding Resource Requirements 8.2 Urgent Care Board and NETA/Winter Funding Allocation The Urgent Care Board held meetings from July 2013 onwards and agreed in consultation with partners, the areas of the urgent care system, at which winter/NETA resources are to be targeted, based on the evidence base as provided by the performance data; both current and also taken from winter 2012. The UCB is still awaiting clarification in respect of the NETA element available from each local partner.

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In the interim, Wandsworth CCG has provided funds of £1,224.5M attributable to NETA for utilisation by the UCB for winter pressures in the run up to and during winter 2013. This decision is based on partners collectively agreeing, that this will be directed at the A&E department and the hospital more generally, where it faces winter pressures. The summary table below provides an outline of the individual NETA amounts which are to be expected from each organisation, as contribution for winter planning. For clarity the amounts indicated also include an element for specialised commissioning.

No CCG Threshold £M

1 Wandsworth CCG 1.6

2 Sutton CCG 1.6

3 Croydon CCG 1.5

4 Surrey Downs CCG 1.3

5 Kingston CCG 1.0

6 Lambeth CCG 0.8

7 Merton CCG 0.4

8 Richmond CCG 0.3

Sub Total 8.5

Remaining 53 CCGs 1.1

TOTAL 9.6

8.3 Delivery of Winter Funded Projects The Urgent Care Delivery Group is the medium through which winter and NETA funding is being allocated and distributed under the guidance and leadership of the UCB. There is a formal process in place, which requires that partners must submit initiatives to secure winter funding, via the business case funding template and process as outlined by the Chairperson of the Delivery Group during meetings held with partners. Once submitted, the initiatives will be considered against a criterion for the allocation of funds and those initiatives deemed to meet the criterion as outlined, will be submitted to the UCB for consideration and a judgement reached for awarding monies. The submission to the UCB will take the form of a single proposal, containing within it the different strands of the areas at which winter funding is to be targeted. 8.4 Winter 2013 and Funding Allocation The current funding available for winter 2013 is £1,224.5.M. As this is the only source of funding available to the UCB, as solely provided by Wandsworth CCG (partner CCGs and NHS England have yet to declare whether their NETA contributions are forthcoming), the initiatives which have been selected as a result, have been chosen based on the strict criteria, that they are the initiatives which most closely meet the DoH and UCB stated objectives, which is to ensure that the hospital has sufficient resources to maintain the A&E 4 hour target at 95% and to avoid escalation during winter. Within the proposal the initiatives are presented under each of the three pathways, as the three pathways represent the separate funding streams which will make up the overall model of provision within the initial £1,224.5M, for example; pre-hospital pathway, seven day working/in-hospital pathway, and discharges/out of hospital pathway.

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8.5 Scoring Criterion The Delivery Group discussed and agreed a criterion for the judging of initiatives, based on the planning guidance from NHS England for the development of the Urgent Care Improvement Plans and the allocation of winter monies. The criterion was made explicit within the business case template for the submission of initiatives, as was the granularity of the detail sought, against which initiatives would be judged. Guidance states that Urgent Care Boards (UCBs) will consider those initiatives which clearly demonstrate support of the A&E 4 hour target and maintenance of this at a 95% rate and further, that winter monies are targeted at A&E departments across the three pathways, specifically at the following areas;

1. Seven day working across the health economy 2. Discharges/DTOC (Delayed Transfer of Care) 3. London Ambulance Service pathways 4. Length of Stay 5. Costs versus the number of patients benefitting 6. Does the bid service the whole of the patch or is it particular to one specific area,

thereby reducing the overall number of patients benefitting? 7. Does the bid generally target frequent fliers, attendance rates and admissions

avoidance? 8. Levels of acuity of those patients targeted?

8.6 Scoring Process The initiatives were then judged against the above criteria and a scoring matrix used to summarise the initiatives, denoting an ‘X’ where the bid met the specific criteria under consideration. The A&E/Urgent Care Project Manager and the Director of Delivery carried out the initial process, prior to presentation to the wider partners of the Delivery Group for their agreement. The scoring matrix and a draft proposal was then shared with partners via the Delivery Group in a formal meeting and to ensure transparency of both process and judgements reached; partners were asked explicitly whether they agreed to both the criterion applied, method of selection and as a result the final initiatives chosen. All partners present were in agreement and no challenges were raised in relation to the scoring matrix, initiatives process or the final initiatives selected. The initiatives which met the criteria were then forwarded as a single proposal, with the initiatives presented under the key headings of for example, seven day working, discharges etc. for consideration by the UCB.

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8.7 Metrics Agreed for Monitoring of Initiatives The Delivery Group discussed and agreed an approach to the performance management of the successful initiatives, based on a template that would yield measureable clinical and operational outcomes, in an easy to collect and user friendly format. A template has been agreed for development which will measure the following four key areas;

1. Clinical outcomes e.g. 95% target maintained, discharges increased 2. Operational e.g. AMU Consultant secured and role to commence on XX date 3. Benefits e.g. a generic Mental Health Co-ordinator role secured to deal with all mental

health discharges, thus avoiding delays 4. Milestones e.g. milestones specific to the bid in question e.g. four step-down beds

identified and a criterion for access in use 8.8 Proposal Containing Initiatives – Overview For ease of reading, the proposal has been presented with the initiatives broken down into the individual pathways which they represent. The four pathways are as follows:

1. Seven Day Working (SDW) and in-hospital Pathway Initiatives 2. A&E and Front End Pathway Initiatives Clinical Requirements 3. Social Care Funding Requirements to Support Hospital SDW Model 4. Discharges Out of Hospital Pathway Initiatives

The narrative below provides detailed information in relation to the initiatives, as provided by the submitting organisations; a table has also been included as a ‘Summary Table of the Proposal’, which presents the initiatives containing the summary of the service to be provided, core outcomes as delivery and the costs of the initiatives.

8.8.1 Seven Day Working (SDW) and in-hospital Pathway Initiatives Evidence for Seven Day Working (SDW)

The proposal has been based around the DoH, NHS England and UCB declared directives in respect of a focus on seven day working and as a result, a focus on the four pathways required for seven day working.

‘Delivering a Seven Day Health Service’ - Quality Framework, NHS England. The London

Health Programme - Case for Change in Emergency Services.’

Evidence based on and taken from;

• Dr Foster 2011 Good Hospital Guide

• Royal College of Surgeons’ report on High Risk General Surgical Patients

• Academy of Medical Royal College report – Seven Day Consultant Present Care

• Analysis of 14.2m NHS admissions in 2009/10

The NHS is at present carrying out research in respect of the seven day model of care and in

particular, the Adult Emergency Standards seeks to examine the impact of acute medical teams providing cover 7 days per week. Currently there is a lower level of clinical input within emergency care generally, during weekends and as a result, there are potentially fewer discharges and slower flows throughout the hospital impacting on the A&E 4 hour target and thus leading to breaches.

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‘Evidence shows that the limited availability of some hospital services at weekends can have a detrimental impact on outcomes for patients, including raising the risk of mortality.’ 1

‘A large, multicentre study draws attention to an increase in weekend mortality for emergency

admissions: Patients should expect the same standard of emergency care, whatever day of the week they are admitted. This study identified an excess in mortality for those patients admitted at a weekend compared with the weekday that may reflect differences in quality of care.’2

Impacts/Benefits of the bid; The recommended model aims to increase clinical input during weekends, as the expertise of

the acute medical consultant team has anecdotally shown that admissions and discharges occur more frequently and in a timely manner thus easing patient flows throughout the hospital.

To ensure the operational delivery of this model, clinical support services are required as

follows; junior doctors, nursing staff, discharge coordinators and therapy support staff. The extra support required within therapy services is detailed below under ‘Therapy Services’ specifically.

Extra Consultant Support to AMU – Costs; £200K for 6 months In line with the Adult Emergency Standards (AES) the recommendation is that acute medical

teams provide consultant cover 7 days per week, at present cover is provided from Monday

until Saturday morning.

The London Review indicated that there is huge variability and inadequate involvement of

consultants, in the management of acutely ill patients and consequently there is as a result, a

significantly increased risk of dying, if admitted during a weekend compared with weekend

admissions, concluding that this is directly related to the reduced level of senior clinical cover.

To avoid A&E breaches, system blockages and escalation areas being used, the following is

required; an additional 4 consultants as part of the AMU team. Initially locums would be

employed during the winter period whilst substantively recruiting to the posts (which would take

6-8 months).

Impacts/Benefits of the bid;

1. Consistency of medical input

2. Lower admissions and increased use of the ambulatory care model (seeing and treating

more patients via the Acute Assessment Area (AAA), where patients are seen, treated

and discharged (where appropriate) within a 12 hour time frame thus preventing an

admission to hospital.

3. Increased discharges from the acute medical unit – evidence indicates that acute

medical physicians treat more patients in the ambulatory care setting rather than

admitting them.

4. In-reach into ED to pull medical patients through to the Acute Medical Unit; the

expertise in the acute medical team is to see and treat acutely ill patients in an acute

setting and where appropriate, discharge early with follow up support. (Follow up

support is provided via the Admission Avoidance clinics and Early Discharge clinics

within the AMU, which operate daily from Monday to Friday)

1 http://www.england.nhs.uk/ourwork/qual-clin-lead/7ds/

2 http://www.improvement.nhs.uk/7DayServices/SevenDayWorkingEvidenceandResearch/tabid/220/Default.aspx

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5. This will provide the ability to start an admissions avoidance clinic on Saturdays and

Sundays to further reduce admissions and the risk of bottlenecks and therefore

breaches from Monday onwards.

Two Additional Junior Doctor’s AMU – Costs; Weekend Daytime Cover £40K for 6

months

With the increased attendances in ED during out of hours and thus the increased medical admissions out of hours, the weekends have already proven to be busier than previous summers. With two additional junior doctor’s, the medical team can ensure that all medical patients on the specialist wards, are reviewed at the weekends by a doctor, following a treatment plan agreed by the specialist consultant.


1. Patients are treated timely and discharged at weekends wherever possible 2. This will in turn support the flow of patients and capacity from A&E to acute medicine

and onwards throughout the hospital. 3. Patients will be reviewed during weekends by a doctor

Therapy Services – Costs; £270K for 6 months

The project seeks to establish a 7 day therapies service at St. George’s Healthcare Trust, as

part of the seven day model of working.

A weekend therapy service enables patients to begin their treatments promptly, receive

continued rehabilitation during the weekend, and increase the number of weekend discharges.

This increases patient flow through the hospital and removes the blockages which frequently

occur during the beginning of the week, due to weekend pressures. Seven day therapy

services have been shown to improve continuity of care, reduce length of stay, increase patient

satisfaction and meet NICE quality standards across a number of specialties.


The winter pressures pilot 2012/13 targeted and delivered the following benefits across all adult

inpatient services;

Admissions avoidance in ED and CDU.

Assessment of all new patients without delay.

Assessment/treatment of patients who could potentially be discharged on Saturday,

Sunday or Monday if seen by a therapist during the weekend.

Treatment of patients who would benefit from early intervention, preventing loss of

function and potentially facilitating earlier discharge.

During the 12 week period, a total 3107 additional therapy hours were provided, delivering

additional treatment for 1941 patients, which resulted in 299 weekend discharges (89.7% of

patients discharged from therapy).

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Patients who are not currently seen at the weekend are currently:

Patients admitted at weekends.

Patients whose condition will remain stable during the weekend.

Patients who are on elective operating lists on Fridays and weekends.

Service specifics

The data from the two pilot projects indicates that a targeted expanded weekend service in

therapy, would allow improvements to be made in the following key areas:

Admissions avoidance.

Reducing time from referral to assessment by the required therapist.

Starting rehabilitation promptly thereby potentially improving long term outcomes.

Increasing the number of therapy contacts provided which is associated with improved

clinical outcomes.

Achieving earlier discharge to enable reduced length of stay.

Improved patient experience.

Patient Transport – Costs; £200K for 6 months

The request is for additional estates and facilities resources which based on previous winters are required to support St George’s Healthcare Trust to meet the 95% A & E target.

Additional vehicles and staff are required to meet the increased demand for patient transport

during winter. The requests for transport, surge from early afternoon onwards and peak at 4pm and as the acuity requirements for this service are much higher in winter, this therefore requires a greater availability of stretchers.

Impacts/Benefits of the bid; The bid includes providing the following extra capacity to meet demand:

2 stretcher vehicles to support the increased requests at 4pm on weekdays.

Inter hospitals transfers are booked at 4pm when beds are confirmed at host hospitals across most specialities, hence the requirement for the extra vehicles at 4pm.

Extra stretcher vehicles to work from A&E at night to discharge patients and free up bed space within A&E.

1 extra stretcher vehicle on Saturday and Sunday to support 7 day working and increased discharges and transfers at weekends.

Meeting changing demands in the winter season with increased requests out of hours and at weekends.

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8.8.2 A&E and Front End Pathway Initiatives – Clinical Requirements SpR in Surgery (Specialist Surgical Registrar) – Costs; £150K for 6 months At night time (22.00hrs to 08.00hrs) medical services are supported by a medical SpR and

junior doctors with on call consultant support (called in if required). To ensure full cover and to

avoid delayed discharges, an extra SpR is required during the night shift to provide cover

during the busy winter period.

The two previous winters have proven to be very busy, especially during the night.


1. With additional senior medical support, the medical team will be able to provide a safer service and where appropriate treat patient’s ambulatory.

2. It will also provide more senior medical support to the specialist medical wards at night. Transfer Nurse – Costs; £45K for 6 months To avoid delays in those patients requiring transfers onto wards/other areas; current practice means that patient transfers are rarely completed within a single bed move and often require multiple transfers to other wards/units. This is because the final destination is not always available, due to patients in the required beds themselves, awaiting onward movement or discharge. Impacts/Benefits of the bid;

1. Reduced number of moves between beds. 2. Beds are available faster, thus avoiding delays. 3. There is a single point of contact to arrange and coordinate transfers, thus reducing

processes. 8.8.3 Social Care Funding Requirements to Support Hospital SDW Model

The reader should note that some of the social care initiatives as detailed below although

Wandsworth Adult Social Services specific, do provide a service to all patients presenting at St George’s Healthcare Trust regardless of the area of residence’. Evidence for social care funding

The initiatives are based on the evidence of success from previous winters and have demonstrated the provision of a seamless service aligned to A&E and specifically winter pressures vis-à-vis A&E. The initiatives deliver the maximum possible benefit to the widest cohort of patients, as they offer a service across the whole patch and to all patients attending A&E both for attendances and admissions without discrimination.

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24 hour Live in Care – Costs; £146K for 6months

The scheme will operate a 7 day intake and is targeted at frequent flyers presenting both to A&E, acute inpatient beds and those at risk or awaiting a permanent residential and nursing home admission. This scheme will primarily target frail older people who wish to remain living at home but who have frequently present to A&E departments and are as a result often admitted to hospital.

The scheme will provide intensive reablement support in the client’s home but also enable

health and social services to evaluate the client in their own home; in order to determine the best way to meet on-going health and social care needs to avoid frequent A&E presentations as well as admissions. As outlined by the DoH, it is frail and elderly patients who are frequently presenting at A&E due to a lack of support during OOHs and weekends. Impacts/Benefits of the bid;

1. Reduced attendances and admissions amongst frail and elderly patients. 2. This increases the availability of acute beds as patients are no longer requiring acute

admissions. 3. This provides intensive reablement to those at risk of falls.

Weekend Social Worker – Costs; £15K for 6months

A new social work post, to provide weekend social services cover for all Wandsworth residents arriving in A&E (not just St George’s Healthcare Trust A&E department) during weekends, who require a new package of care in order to be discharged or who require step down beds, live in care or the usage of rehabilitation flats. This service would be provided by way of a mobile social worker based within the Wandsworth Emergency Duty Team and would be the central point of access for all A&E Departments from 9am to 5 pm Saturday and Sunday.

Currently there are no referrals made to social services between 5pm on Friday and 9am on

Monday. Wandsworth Social Services have the lowest DToC in London (2012/13), therefore there is likely to be an impact on LoS as opposed to DToC.

The provision of a weekend Social Worker would also act as a gatekeeper to the following

resources; step down beds, live in care, rehabilitation flats, as well as providing general access to reablement facilities. This would allow for A&E diversion and general hospital discharges during very busy weekends during winter. There would be agreed procedures in place; clearly setting out that no person is to be admitted to any step down bed without the agreement of social services.


1. Provides weekend social services cover for all Wandsworth residents arriving in A&E (not just St George’s Healthcare Trust A&E department) during weekends.

2. A mobile social worker would be based within the Wandsworth Emergency Duty Team and would be the central point of access for all A&E Departments from 9am to 5 pm Saturday and Sunday.

3. There is likely to be an impact on LoS given provision of a Social Worker during weekends, thereby reducing bottlenecks caused during weekends and into the early part of the week.

4. This would allow for A&E diversion and general hospital discharges to occur during busy weekends.

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Additional 4 Step Down Beds – Costs; £81K for 6months

This includes cover for on call assessments (Nurses from the provider will be on standby to ensure 7 day admissions take place).

Wandsworth Adult Social Services Department currently purchases 4 step down beds in a

Nursing Home, which provides an alternative to clients remaining in hospital whilst on going discharge arrangements are made. Additional beds are required to meet the increased winter volume and to minimise DToC and LoS (which has a direct impact on A&E). Step down beds were a significant factor contributing to the 2012/13 DToC performance (the best in London). This capacity has been a mainstay in the winter pressure offer for the last 3 winters and has been responsible in the main, for the lowest number of DToCs in London and further it has had a direct impact on readmissions brought about by failed discharges.

Clients will not be required to wait in hospital whilst the necessary on-going arrangements are

made for them, further these assessments and subsequent support planning can be carried out in a non-acute setting.


1. This will meet the increased winter volume and also minimise DToC and LoS (which has a direct impact on A&E).

2. Step down beds were a significant factor contributing to the 2012/13 DToC performance (best in London).

3. Clients will not be required to wait in hospital whilst the necessary on-going arrangements are made for them.

4. The assessments and subsequent support planning can be carried out in a non-acute setting.

Weekend Homecare provision to facilitate timely discharge from A&E, during the

weekend – Costs; £22K for 6months Addressing A&E pressures and achieving the 95% target requires integrated health and social

care pathways. The project will provide weekend homecare cover for any patient presenting to A&E or requiring discharge during the weekend (9am to 5pm) not previously known to social services.

Current homecare provider contracts place a requirement on Providers to assess within 48

hours of referral; however there is no requirement for Providers to commence provision within this timeframe. Specifically, commissioned provision for homecare support over the weekend period is required to facilitate seven day discharges; this will therefore directly support the hospitals’ seven day working model. The project will commence in early October 2013 and end in March 2014.

Clients presenting to A&E or requiring discharge during the weekend, who are in need of home

care support, will be able to return home in a safe and timely manner. Referrals will be taken between 9am to 5pm Saturday and Sunday. Homecare service will be provided between 7am and 10pm.

The service will have a role in scoping and developing direct referrals from A&E to the START

team.

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1. Will provide weekend homecare cover for any patient, presenting to A&E or requiring discharge during the weekend (9am to 5pm) not previously known to social services.

2. Directly support the hospitals’ seven day working model and prevents patients from remaining stuck within the system due to services not commencing.

3. This will minimise delays caused as a result.

Mental Health Support Worker for OOHs and Weekends – Costs; £15K for 6months

The Mental Health Support Worker will provide cover across all three boroughs and will be based in St George’s Hospital Healthcare Trust. The Support worker will deal with delays in respect of mental health issues, for example for those patients awaiting assessment. Anecdotal evidence from the Trust suggests that mental health issues are a significant contributor to delayed discharges within the acute setting.


1. The support will provide cover across the borough for all patients with mental health needs.

2. Patients presenting with mental health issues, due to the length of time required to complete assessments, will no longer be stuck in the system, thereby causing delays and breaches.

3. An audit from the local Trust demonstrated that mental health presentations, although few are a significant contributor to lengthy delays.

8.4.4 Discharges – Out of Hospital Pathway Initiatives Evidence for discharges and out of hospital pathway Rehabilitation providing an intermediate level of care – Costs; £40.5K for 6months

This project will increase the rapid clinical discharge of patients unwilling, unsuitable or ineligible for institutional care, who no longer require an acute level of clinical care but still require an intermediate level of care prior to discharge back to their own home. This will increase the community step down offer through the provision of a rehabilitation flat within an existing established sheltered housing scheme. Strong links will be made with ICT/ START and Community Wards to enable people to safely rehabilitate, in order to return home or ‘try out’ sheltered living, as an alternative to permanent admission to residential care. Importantly the provision of more intense support post discharge will prevent readmissions and further A&E attendances. The overall aim is to reduce the number of people prone to falling and frequently attending A&E, to return to a place of safety where the risks of falls are more adequately managed. Provision of this offer will increase capacity in both acute and non-acute settings, as those with outstanding rehabilitation goals will normally require a non-acute bed for this intervention to be provided; this flat will offer an alternative to non-acute admission.

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Winter 2013 Funding Allocation based on Wandsworth CCGs NETA Contribution £1,224.5M The UCB has in its approach to the allocation of funding used as a template, the same areas to which winter monies were allocated during winter 2012, as the evidence is that these projects yielded the desired results. Given this, the remainder of the initiatives as detailed below total £1,224.5. This sum takes into account all patients presenting and admitted to St George’s Healthcare Trust, for the South West London health economy.

8.9 Summary Table of Proposal The summary table below represents the initiatives which meet the criterion for the initial sum released which is £1,224.5M, as provided by Wandsworth CCG as its NETA contribution. The individual initiatives are presented with an overview of the main service to be provided as well as the key outcomes; greater detail is provided earlier within this proposal.

A&E/Urgent Care Area of Funding 2013/14 (for 6 months)

Seven Day Working and In-Hospital Pathway

4 extra Consultants in AMU team – To avoid A&E breaches, system blockages and escalation areas being utilised, an additional 4 consultants are required as part of the AMU team. Initially, locums would be hired during the winter period whilst substantive posts are recruited (this will take 6-8 months). This will deliver;

1. Consistency of medical input. 2. Lower admissions and increased use of the ambulatory care model

(seeing and treating more patient through the Acute Assessment Area (AAA) – where patients are seen, treated and discharged (where appropriate) within a 12 hour time frame thus preventing an admission to hospital).

3. Increased discharges from the acute medical unit – evidence indicates that acute medical physicians treat more patients in the ambulatory care setting rather than admit.

4. In-reach into ED to pull medical patients through to the Acute Medical Unit – the expertise in the acute medical team is to see and treat acutely ill patients in an acute setting and where appropriate discharge early with follow up support. (Follow-up support provided via the Admission Avoidance clinics and Early Discharge clinics within the AMU- these run daily Monday to Friday).

5. Will provide the ability to start an admission avoidance clinic on Saturdays and Sundays to further reduce admissions.

£200K

Two Additional Junior Doctors in AMU team – With the increased

attendances in ED out of hours and thus the increased medical admissions

out of hours, the weekends have already proven to be busier than previous

summers. With two additional junior doctor’s, the medical team can ensure

that all medical patients on the specialist wards, are reviewed at the

weekends by a doctor, following a treatment plan agreed by the specialist

consultant. This will deliver;

1. Patients are treated timely and discharged at weekends wherever possible.

£40K

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2. This will in turn support the flow of patients and capacity from A&E to acute medicine and onwards throughout the hospital.

3. Patients to be reviewed during weekends by a doctor

Therapy Services – A weekend therapy service enables patients to begin their treatments promptly, receive continued rehabilitation during the weekend and increase the number of weekend discharges. This increases patient flow through the hospital and removes blockages which frequently occur during the beginning of the week, due to weekend pressures. The Therapy Services winter pressures pilot 2012/13, targeted and delivered improvements across all adult inpatient services. This will deliver;

1. Admission avoidance in ED and CDU. 2. Assessment of all new patients without delay. 3. Assessment/treatment of patients who could potentially be

discharged on Saturday, Sunday or Monday if seen by a therapist over the weekend.

4. Treatment of patients who would benefit from early intervention, preventing loss of function and potentially facilitating earlier discharge.

£270K

Patient Transport – The request is for additional estates and facilities resources which based on previous winters are required to support the Trust to meet the 95% A&E target. This will deliver.

1. 2 stretcher vehicles to support the increased requests at 4pm on weekdays.

2. Extra stretcher vehicles to within A&E at night to discharge patients and free up bed space.

3. 1 extra stretcher vehicle during weekends, to support 7 day working, increased discharges and transfers at weekends.

£200K

A&E Front End Pathway

SpR in Surgery (Specialist Surgical Registrar) – At night time (22.00hrs to 08.00hrs) medical services are supported by a medical SpR and junior doctors with on call consultant support (called in if required). To ensure full cover and to avoid delayed discharges, an extra SpR is required on the night shift during the busy winter period. With additional senior medical support, the medical team will be able to deliver;

1. A safer service and where appropriate treat patient’s ambulatory. 2. This will provide more senior medical support to the specialist

medical wards at night.

£150K

Transfer Nurse – To avoid delays in those patients requiring transfers onto wards/other areas; current practice means that patient transfers are rarely completed within a single bed move and often require multiple transfers to other wards/units, as the final destination is not always available. This is due to patients in the required beds also awaiting onward movement or discharge. This will deliver;

1. Reduced number of moves between beds. 2. Beds are available faster, thus avoiding delays 3. There is a single point of contact to arrange and coordinate

transfers, thus reducing the number of processes.

£45K

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Social Care Funding Requirements to Support Hospital SDW Model

24 hour Live in Care – The scheme will operate a 7 day intake service and is targeted at frequent flyers presenting to A&E, acute inpatient beds and those at risk or awaiting a permanent residential and nursing home admission. This scheme will primarily target frail older people who frequently present to A&E and are as a result often admitted to hospital. The scheme will provide intensive reablement support in the client’s home but also enable health and social services to evaluate the client in their own home in order to determine the best way to meet their on-going health and social care needs to avoid frequent A&E presentation as well as admissions. As outlined by the DoH it is frail and elderly patients who are frequently presenting at A&E due to a lack of support during OOHs and weekends. This will deliver; 1. Reduced attendances and admissions amongst frail and elderly patients. 2. Increases the availability of acute beds as patients are no longer

requiring acute beds. 3. Provides intensive reablement to those at risk of falls.

£146K

Weekend Social Worker – A new Social Worker (SW) post, to provide weekend social services cover for all Wandsworth residents arriving in A&E (not just St George’s) during weekends, who require a new package of care in order to be discharged or who require step down beds, live in care or the usage of rehabilitation flats. This service would be provided by way of a mobile SW based in the Wandsworth Emergency Duty Team and would be the central point of access for all A&E Departments from 9am to 5 pm during weekends. The service will deliver; 1. The SW would act as a gatekeeper to the following resources; step down beds, live in care, rehabilitation flats as well as providing general access to reablement facilities. 2. This would allow for A&E diversion and general hospital discharges during busy weekends.

£15K

Additional 4 Step Down Beds – This includes cover for on call assessments (Nurses from the provider being on standby to ensure 7 day admissions). Additional beds are required to meet the increased winter volume and minimise DToC and LoS (which has a direct impact on A&E). Step down beds were a significant factor contributing to the 2012/13 DToC performance (best in London). This capacity has been a mainstay in the winter pressure offer for the last 3 winters – responsible in the main for the lowest number of DToCs in London and further it has had a direct impact on readmissions brought about by failed discharges. Clients will not be required to wait in hospital whilst the necessary on-going arrangements are made for them, as these can be carried out in a non-acute setting. This will deliver;

1. Will meet the increased winter volume and minimise DToC and LoS (which has a direct impact on A&E).

2. Step down beds were a significant factor contributing to the 2012/13 DToC performance (best in London).

3. Clients will not be required to wait in hospital whilst the necessary on-going arrangements are made for them.

4. The assessments and subsequent support planning can be carried out in a non-acute setting.

£81K

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Weekend Homecare provision to facilitate timely discharge from A&E, during the weekend – Current homecare provider contracts place a requirement on Providers to assess within 48 hours of referral; however there is no requirement for Providers to commence provision within this timeframe. Specifically, commissioned provision for homecare support over the weekend period is required to facilitate seven day discharges; this will therefore directly support the hospitals’ seven day working model. Clients presenting to A&E or requiring discharge during the weekend and who are in need of home care support will be able to return home in a safe and timely manner. This will deliver;

1. This will provide weekend homecare cover for any patient, presenting to A&E or requiring discharge during the weekend (9am to 5pm) not previously known to social services.

2. Directly support the hospitals’ SDW model and prevent patients from remaining stuck within the system waiting for services to start.

3. Will minimise delays caused as a result.

£22K

Mental Health Support Worker for OOHs and Weekends – The Mental Health Support Worker will provide cover across all three boroughs and will be based in St George’s Hospital Trust. The Support worker will deal with delays in respect of mental health issues, for example for those patients awaiting assessment. Specifically the support will provide cover across the whole borough for all patients with mental health needs. This will deliver; 1. Patients presenting with mental health issues due to the length of time required to complete assessments, will no longer be stuck in the system, thereby causing delays and A&E target breaches. 2. An audit from the local Trust demonstrated that mental health presentations, although few are a significant contributor to lengthy delays.

£15K

Supporting Discharges; Out of Hospital Pathway

Rehabilitation providing an intermediate level of care – This project will increase the rapid clinical discharge of patients who no longer require an acute level of clinical care but still require an intermediate level of care prior to discharge back to their own home. The aim is to reduce the number of people prone to falling and frequently attending A&E, to return to a place of safety where the risks of falls are more adequately managed. This will deliver; 1. An increase in capacity in both acute and non-acute settings, as those with outstanding rehabilitation goals would normally require a non-acute bed for this intervention to be provided; this will offer an alternative to non-acute admission.

£40.5K

Total

£1,224.5.5M

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9. QiPP Plans and Associated Reductions in NE Admissions and Attendances The QIPP schemes below are aimed at improving services within the community, shifting non-clinically appropriate activity away from A&E to reduce

non-appropriate attendances and admissions to ensure the continued achievement of the A&E 4 hour target and the effective management of the

urgent care systems.

Wandsworth CCG QIPP Plans

WCCG

CATEGORY PROJECT PROJECT DESCRIPTION

Out of Hospital Community Ward

Via the application of a risk stratification tool, both high risk and high need patients are identified

and supported to manage their Long Term Conditions. In doing this both emergency attendance

and admissions are reduced.

Impact - Emergency attendance and admissions are reduced. Patients are treated closer

to home and are enabled to stay at home for longer. Earlier discharge is made possible

via the supported discharge mechanism.

Out of Hospital GP Referrals

This programme seeks to increase the quality of GP referrals into secondary care and promote

the full use of community based services. It is supported through education and the training of

clinicians, peer review and practice based software which presents, national and local guidance,

care pathways, referral templates and formalised peer reviews with trained practice leads.

Impact – Reduced inappropriate GP referrals and the increased quality of referrals.

Out of Hospital Falls and Bone Health Programme

This programme seeks to identify patients at risk of poor bone health as well as promoting good

bone health in those patients at risk, by using tools such as education, exercise and prescription

of medicines for bone health. Further support is provided for patients at risk of falling and those

who have already experienced falls though exercise, balance classes and medication reviews.

Impact – A greater number of patients receiving bone health medication as well as an

increase in those patients identified as being at risk. As a result emergency attendance

and admissions avoided and a better quality of life for those who have previously

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WCCG


experienced falls or are afraid of falling.

Out of Hospital Admissions avoidance for harmful &

hazardous drinkers

A range of secondary and primary care services to help harmful and hazardous drinkers manage

their health better, this includes offering brief interventions, education for reducing the impact of

alcohol on pre-existing Long Term Conditions and assisting hazardous drinkers engage with

health care services.

Impact - Emergency attendance and admissions are avoided in those with alcohol issues.

This reduces the numbers who present in A&E and who are then also admitted due to the

observation time period required. In turn this has the impact of reduced bed stays for

alcohol dependent patients.

Out of Hospital Urgent Care Centre

The establishment of an Urgent Care Centre (UCC) at the front of St George’s A&E department

will triage and divert those patients who do not clinically require to be treated within A&E. These

patients will for example be referred back to their GP (if registered with a GP), or be triaged

through to the UCC to be seen by the GPs within the UCC or referred onward to A&E for more

specialist care. All patients not treated within A&E will be treated at lower tariff rates. A patient

navigator will also redirect patients back into primary care by booking GP appointments and if

necessary, registering patients with a GP. Impact – emergency attendances avoided for non-

clinically appropriate patients, an encouragement/increase in patients registered with a

GPs practice.

Out of Hospital Long Term Conditions

As part of the Out of Hospital Strategy there are a range of rehabilitation and exercise schemes

under the ‘Expert Patient Programme – Self Management’ being put in place which contribute to

patients managing their Long Term Conditions better and to help them to remain mobile and

healthier for longer. Impact – emergency attendance and admissions are avoided due to

better health and mobility.

Secondary

Care

LAS Alternative Care Pathways

Through the use of agreed pathways, patients are conveyed to more appropriate clinical

pathways of care rather than immediately through A&E.

Impact – Emergency attendance & admissions are avoided through the redirection of

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WCCG


patients to more clinically appropriate pathways.

Mental Health Dementia

Through the development of a new Dementia pathway, patients will be diagnosed earlier and

both they and their carers provided with support to ensure better management of their health as

well as the learning of essential life skills to maintain independence and mobility.

Impact – Improved quality of care for patient and carers, reduced emergency admissions

in the early stages of the disease and a delay in the need for care home placements.

Merton CCG QIPP Plans Merton CCG has developed QIPP schemes across a number of key areas, including; urgent care, planned care and long term conditions. The focus

is to seek to impact on both A&E attendances and admission rates by providing alternative services and referral points within the community. A brief

description of some of these schemes is provided within the table immediately below.

Other initiatives that will complement the QIPP schemes outlined below include the availability of a walk in centre and extended primary care access.

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10. Balance Scorecard

The Urgent Care System Improvement Board (UCSIB) has already agreed both a wider and a more focussed performance management tool, based on a whole system urgent and emergency care metrics as detailed in Section 5.4 – Performance Management.

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11. Board and Partner Sign Off The Board will be agreeing a sign off process at the October 2013 meeting of the UCSIB

and in the meantime, all comments and feedback received from NHS England will be incorporated into the final copy of the plan.

12. Summary Conclusion

St George’s Healthcare Trust St George’s proactively planned capacity for 2013/14 and implemented initiatives to accommodate capacity shortfalls; however activity to date is way above expected levels and has remained so for the year to date without cessation. Subsequently the lead into winter is already extremely pressurised and without the additional winter funding based on last year’s levels, it is highly unlikely that a successful winter will be delivered. Revised analysis shows that there is a shortfall of 25 - 40 beds for the forthcoming winter, over and above plan if current activity patterns persist, which given that winter is imminent is highly likely. Following the analysis carried out by the ECIST team visit, to mitigate risks for winter 2013/14, the Trust has identified clear actions as follows:

1. Delivering new beds 2. Deployment of the currently agreed NETA monies (£1,224.5M from Wandsworth

CCG) 3. Review of daily bed management 4. Discharge processes and internal waits 5. Seven day working where possible – through NETA and/or service redesign 6. Opportunities for managing patients elsewhere; led by Community Division 7. Management of frailty - review of pathways 8. Further admission prevention where possible via ambulatory emergency care

Overall Summary of Plan It cannot be guaranteed that despite undertaking these measures that the Trust will be able to fully mitigate the risks that winter poses and thus actually deliver a well-managed winter, unless additional funding is released. The work of the UCB and all winter planning arrangements are well under way via the Delivery Group and the series of meetings and actions undertaken by the Delivery Group. The first tranche of monies have been allocated to the most important elements of winter funding, as directed by the UCSIB, based on the NETA contribution as forwarded by Wandsworth CCG. It is hoped that as partners clarify their NETA contributions, that further initiatives can also be released into the system to ensure a safe and sustainable winter. The UCB has agreed an interim performance matrix table and a wider matrix for use to manage the performance of the urgent care system more widely. St George’s Healthcare Trust’s Bed Capacity Modelling tool has been agreed for use by NHS England based on the reasons cited earlier.

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London Ambulance Service (LAS) have been engaged both strategically and operationally and are represented at both the UCB as well as the Delivery Group. Winter safeguarding arrangements have been confirmed across the boroughs and there is no change to the current safeguarding or the on-call Director arrangements.

13. Appendices

1. Excel Checklist 2. Briefing – St George’s Healthcare NHS Trust Capacity for 2013/14 3. Harmoni/111 Service documents re winter planning

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