ealing: improving a&e performance plan€¦ · 4 v12: improving a&e performance the trust...

1 V12: Improving A&E Performance

Ealing: Improving A&E Performance Plan

Background

Performance in A&E departments across the country in recent months and difficulty in reaching the 95% target for all patients attending A&E to be seen

in 4 hours has prompted NHS England to require all Local Area Teams (LATs) to start working on recovery and improvement plans for each local area.

Plans are to be drawn up and signed off locally by the Urgent Care Board by 31st May 2013. NHS England advises that plans to improve current

standards will be divided into three phases:

1. An urgent recovery programme with significant attention given by local and national commissioners and providers to all factors which can help

recover standards (including clear performance management);

2. A medium-term approach to ensure delivery over the next winter period to include care system planning as well as a review of the levers and

incentives in the system;

3. In the longer-term, the implementation of an urgent care strategy in order to deliver safe and sustainable services.

Phase 1 will focus on:

- Delivery of an agreed local plan to sustain the current performance and to ensure capacity and demand is aligned across 2013/14 so that A&E 4

hour target is met in each quarter;

- Preparation for working on a winter plan 2013/14 to sign off by Area Team by November 2013;

- Evidence that best practice is being implemented locally, but local communities encourage to innovate.

1. Introduction

This paper is in response to the guidance outlined above and has been drawn up by the Ealing Clinical Commissioning Group (ECCG) together with all

key partners. A draft of the plan prior to submission to NHSE was shared at the Ealing Executive Management Committee on 29th May and

subsequently approved by the CCG, EHT ICO, and social care partners at the London Borough of Ealing. Initial feedback was received on Friday 8th

June and a further version of the plan is attached. This document is expected to be iterative and reviewed by Ealing Urgent Care Network Board monthly

and at its next meeting on 28th June.


This paper includes details of

1. An agreed local action plan which should be read in conjunction with the London Assurance Checklist;

2. Specific actions to be taken by The Ealing Hospital (EHT ICO) to improve and sustain the A&E 4 hour standard by end of Q1 and beyond;

3. Other steps to be taken;

4. Top 3 Priorities for Ealing;

5. Preparations for Winter Planning 13/14 including Demand/Capacity assurance

6. Ealing Urgent Care Network Board;

7. Local leadership.

8. Proposed Dashboard Metrics for monitoring performance - national and local

2. The Ealing Improvement Plan

Delivery of the A&E 4 hour Operational Standard (May 2013) suggests that recovery and improvement plans should be drawn up, using the various stages of the patient‟s journey through the emergency system as the framework1. The A&E Action Plan attached at Appendix 1 has been collated in collaboration with partners and represents future plans as well as schemes currently in place as part of on going service redesign to improve the patient pathway through urgent care.

As Ealing is not in any of the groups requiring A+E Recovery and Improvement Plans because of poor performance, the focus of this submission is to highlight current performance and identify the programmes of work being undertaken individually and in partnership to ensure the health economy in the Ealing area sustain the required level of performance into the future.

The narrative below outlines the current performance and the major themes of joint working in the health and social care economy. Attached with this plan are comprehensively completed good practise checklists, which have been completed by providers and commissioners. These provide the detail underpinning the existing good work, which is going on in the area to keep performance standards at the required level and sustain these into the future. The completed London Assurance Checklist should be read in conjunction with information in this section.

1 Key to Status column: Green – already in place, Amber – planned or in the planning phase, Red – no plans in place.


3. Sustaining the A&E 4 Hour Standard in Ealing and Dashboard metrics.

NHSE guidance suggests the following development of a dashboard to monitor the overall impact of the programme and manage system resilience.

In addition to the national standards, a suite of local metrics, that are key drivers for Ealing Health Economy have been agreed by the working group,

are noted in appendix 3 and will form the basis of a our local dashboard.

12/13 Performance.

The overall A&E performance in 2012-13 was as follows:

A&E 95% in 4 hours, all types: 96.94%. i.e. the national standard (95%) was met, though the local standard as per the acute contract (98%) was not

met.

A&E 95% in 4 hours, type 1: 93.11%. i.e. the local contractual standard was not met.

A&E activity for the full year was 41,645 attendances, which represented an increase in 1,115 attendances from 2011/12 and UCC attendances were

marginally (439) down on 2011/12.

There was significant variability by week of between 722 and 900 attendances per week with a mean of 801 (appendix 2). Weakly peaks were not

confined to the winter months. However, total attendances in the critical months of December, January and February were higher at an average of

820 per week The worst cases of A&E performance were on and immediately following days of “spikes” on demand.

LAS conveyances for the full year were 19,549, with a flat trend across the whole year and a weekly mean of 376 arrivals, but with higher variability

between 320 and 433 per week.


The Trust reduced black breaches from 53 in 2011/12 to 14 in 2012/13.

Emergency admissions were above plan during the year, and also showed an underlying increase trend of 2%. The ICE QIPP scheme started during

the year.

A non-elective admissions audit was conducted in year. Patient records and reasons for admissions were reviewed jointly by two Trust A&E

Consultants and by a GP specialist in Emergency Care. The audit showed that 19% of all emergency admissions were potentially avoidable given

relevant investments in acute, primary and community care or processes. 6% of all emergency admissions were made for reasons of meeting the 4-

hour target.

This work is now being taken forward as part of the Acute Urgent and Unscheduled Care Pathway QIPP programme.

The Trust took specific steps to address the challenges in 2013-14, including introduction of the Rapid Assessment Team.

The Trust also responded to a formal Contract Query in relation to performance against the 95% Type 1 local standard, and following a Contract

Management Meeting, put forward a turnaround action plan. The plans included in this document are based from this Action Plan.

(Quarter 1 Performance (April – June 2013)

Year to date (to the A&E performance has been as follows: A&E 95% in 4 hours, all types: 97.37% - the 3rd best performer in London) and A&E 95%

in 4 hours, type 1: 93.76%. The cause is that there was a dip in performance in the first two weeks of April in common with the pressures

experienced across London and nationally, although performance has demonstrated consistent improvement since that date and since the start of

May has been above the 95% level, with Ealing now the 2nd best performer in North West London. Appendix 2 shows the performance YTD mapped

against the equivalent period last year.

Quarter 2 Performance


Ealing has identified a number of actions that other health care partners could take to ensure that the significant pressure on emergency care is

mitigated in part by:

1. LAS to have oversight of all ambulances (including private ambulances) to more effectively manage an even flow to each hospital. This has been

raised with CSU;

2. Improved collaborative working across North West London to manage capacity. This has been raised with CSU.

3. Review of access to primary care services, following analysis of frequent attenders by multi-agencies, through the ICP/Frequent Flyers

workstream. ECCG will raise the need to review availability of routine/urgent GP appointments with NHS England Primary Care Contracting

Team;

4. Ealing will consider enhancing GP Out of Hours provision (evening and weekends) when pressure on the department is at its greatest.

5. NHS 111 capacity to be added to the CMS system. This has been raised as a suggestion with CSU and NHS England.

6. Improved provision of rapid response particularly to attend patients‟ homes at the request of LAS. EHT ICO to connect with Ealing LAS to review

Appropriate Care Pathway should improve diversion of patients away from ED to ICE service.

Quarter 3 and Quarter 4 Performance

Expansion of the ambulatory care pathways (resource dependant) will allow a greater number of patients to bypass the ED. Health economy wide

winter planning, coordinated by the CSU and ECCG, will ensure a state of readiness for Winter 2013/14. It is anticipated that this will reduce the

number of patients attending A&E. However, it should be noted that it will take time for these schemes to bed down and therefore demand may not

reduce as expected. This will be considered as part of EHT‟s contingency plan as part of its winter planning.

4. Top Three Priorities for Ealing to Improve and Sustain Performance

The health and social care economy have worked together to implement considerable improvements and identified all the necessary work streams

and initiatives to improve the flow of patients through the urgent care system in the future. However, using the three key stages of the patient

journey, the top three priorities that would reap the most significant benefits for all partners are deemed to be:

Tackling avoidable hospitalization. This priority brings together the effort to reduce A&E attendance from GP referrals, OOH, 111, and nursing home referrals (as well as LAS conveyances). The review of GP referrals is the highest priority in this group.

Home based solutions and not bed based solution. The NEL Audit has provided quantified evidence of the opportunity; reducing admissions by


up to 19% will transform the service. The QIPP is addressing this area. Focus on ICE effectiveness is the highest priority in this group.

Improving patient flow in hospitals. This priority combines both capacity planning and the process of patient flow through from admission to

discharge. The highest priority is implementation of the demand–capacity-modelling work, which must deliver both a bed capacity model and a

clinical staffing requirement model.

These three priorities have been identified on the basis of the magnitude of the impact they each have in tackling demand or addressing capacity.

ECIST

Although EHT has not worked with the ECIS Team, a comparison of the ECIST team recommendations and the schemes adopted at EHT reveals

that EHT are following the best practice recommendations as follows:

RAT in ED: Speciality wards; EDD pilot: criteria led discharge; escalation protocols: real time bed management pilot underway; 1 by 11am

discharges: ambulatory care commencing.

A number of these actions are highlighted in the Improvement Plan at Appendix 1

At this point in time, the CCG, with the Trust have not made a decision on whether to ask for specific help from the ECIST however the use of ECIST

remains “in view” and will be considered as part of the Urgent Care Board. to the problem solving. The use of the ECIST remains “in view”.

5. Other Steps to be Taken

QIPP

The Acute Urgent and Unscheduled Care Pathway QIPP programme will be focussed on 4 work streams (Frail Elderly, ACSC, MH and Alcohol and

Frequent Flyers) with the aim of reducing A&E NEL admissions (excess bed days), especially „frequent flyers‟, reducing readmission and re

attendance rates. These work streams have been prioritised as a result of the NEL Audit reported in January 2013 (copy attached in the Assurance

checklist). The implementation of these work streams is to coincide with the winter planning implementation.

The Urgent and Unscheduled Care Executive Steering agreed on 13 June, an additional multi-agency work stream to consider frequent attenders of

all urgent and emergency care services with the aim of agreeing multi-agency protocol to manage individual patients. However, this will depend on

the agreement of information/data sharing agreements within the current governance rules.


The Programme Board has agreed that the next stage is that the working groups for each of the 4 work streams will meet in June to progress their

detailed work.

To ensure all out of hospital schemes for prevention /reduction of A&E attendances and admissions are all interlinked/triangulated in whole systems

pathway and monitored to ensure this is delivering the reductions in A&E. Some of the key schemes are Intermediate Care Ealing (ICE), Active Case

Management of Nursing Homes, Integrated Care Pilot, and Pulmonary Rehabilitation for COPD patients, and Falls Pathway.

Effective Discharge

ECCG is developing a business case for medium to long-term options to support additional capacity in the community for „step down beds‟ for those

patients who require short term rehabilitation before being discharged home, particularly from hospitals in NWL including Ealing, NWLHT and

Imperial. The Executive at end of June/beginning of July will consider the options available. Currently additional capacity is spot purchased from

Ealing Nursing Homes.

High Dependency Unit

HDU we have implemented hospital at Night to support the critically ill patients not in HDU over night and on the weekends. The Trust is about to commence an Outreach service from July 1st to cover during the week. This will be supported by the ITU Consultant of the week on a daily basis. This will reduce the demand for HDU care within the ITU. HDU is an area of focus the CCG intends to take forward, and will expect to see examined as part of the demand and capacity work to be undertaken by Capita (see below).

Health and Social Care

There is a strong history partnership working between health and social care in Ealing. All initiatives have social care participation in the development

and implementation. For example the Intermediate Care Service was developed jointly and was commissioned and provided as an integrated health

and social care service. Other schemes such as ICP (Integrated Care Pilot), where social care participate in the care planning process through the

MDGs in each Network, Dementia, End of Life, Active Case Management of Nursing Homes, etc. have all had social care participation. There are

also two integrated health and social care Commissioning leads (adults/children) - working collaboratively with Ealing CCG.


There are number of ways in which health and social care services work together in Ealing.

a) MDT or teams including health and social care professionals, such as community mental health teams or child and adolescent mental health

services.

b) Joint commissioning of services by local authorities and CCGs or NHS boards.

c) Pooled budgets across councils and NHS organisations.

d) Strategic partnership such as local safeguarding

e) Structural Integration of organisations such as the creation of care trusts to provide commission health and social care services or establishment

of joint management teams to run councils and NHS bodies.

f) Joint working between health visitors and children‟s social care staff to intervene early with families.

g) Review of research on joint working to support people with neurological conditions.

Peer Review of GP Emergency Referrals

In 2012/13, all 79 practices participated in the GP annual QOF audit and reported on the QOF measures QP004 – QP009. See assurance list of

example of one report from one practice in Ealing. This area will remain a key priority workstream.

Out of Hours

Ealing current contract is up for review in July and will be extended for 9 months, which will include improved local and national standards. The procurement process for new OOH service will commence in due course for 'Go Live' 1st April 2014/15. Review has already commenced and will highlight elements for improvement. The 9-month extension with current provider will include improved local and national standards, for implementation by autumn 13.

Community

Intermediate Care Ealing (ICE) Service is currently reviewing increasing referrals from GPs, UCC and A&Es from other hospitals, such as NWLHT,

Imperial, including review criteria for referrals from other professionals, e.g. TVNs/Community Matrons. Redesigning Pathway for Falls, and Night


Sitting Service will aid the reduction of attenders, specifically „frequent flyers‟ who are also frail elderly. A dedicated ICE Board is established with the

Trust. Improving ICE referrals is a key goal.

Active Case Management of Nursing Homes: Ealing has commissioned an innovative service of primary care providing support to Nursing Homes,

which should reduce frequent attenders and LAS conveyances, and support and maintain people in the community.

Community Nursing Development: EHT ICO is currently planning a „virtual ward‟ in Community Nursing to help support the most high need

patients using the expertise of the Community Matrons to support the new GP Networks which should provide support for next winter.

North West London Sector Health Economy Review of Emergency Activity

Ealing partners have worked together to prepare this Sustainable and Improvement Plan for EHT but note that over the winter period, all trusts within

North West London have been under increasing pressure. With this in mind, the ECCG wishes to explore the possibility of North West London NHIR

CLAHRC co-ordinating a sector-wide review of emergency activity with input from public health and LAS commissioners to understand the reasons

for this increase in activity and identify why some trusts seem to perform better. Findings from this work will of course prove invaluable in informing

plans for Winter 2013/14.

CQUIN

The EHT contract includes the following CQUINs, which are designed to address aspects of the emergency care pathway.

CQUIN Expect Impact

Friends and Family Test Direct feedback from the patient will be used to refine services

Implementation of Coordinate my Care CCGs will have access to outputs of the tools. Communication of patient condition etc. to the GP will enable increased use of community admission avoidance schemes (ICE and other QIPPs e.g. MSK)

Implementation of Admission/Discharge Tool


CQUIN Expect Impact

Dementia – Find, Assess, Investigate and Refer Identifying dementia sufferers, assessing their condition and placing them on an appropriate treatment plan is expected to reduce the levels of unplanned attendances and admissions.

Time to surgery for neck of femur – 24 hours An extremely important service quality improvement CQUIN that will make a big change to outcomes, and contribute to patient flow through improvement.

Emergency admissions to be seen and assessed by relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at hospital

Delayed assessments of patients who have admitted into AMU or other wards has been identified as one of the biggest causes of bed blockages. This CQUIN will address the most troubles specialties - which are in Surgery.

Acute Psychiatric Liaison Service Subject to funding finalisation, the service is expected to provide liaison psychiatry in both A&E and on the wards

GP telephone line This service will allow GPs to obtain telephone advice from ED consultants before making decisions on whether to refer to A&E or to admit. It is expected to make a significant contribution to reducing attendances and admissions

GP Real Time notifications The A&E and inpatient notifications will collectively contribute to better and more timely information to GPs. Whilst the bigger contribution will be to patient care, some impact on attendances and admissions should also result.

Trust Cost Improvement Programmes (CIP).

The Trust has a cost improvement programme aimed at reducing LOS. The Trust aims to closed beds in Ward 7 North, and to introduce an

Accelerated Recovery Technique for certain T&O procedures. The CCG is in the process of reviewing this CIP and all other CIPs (additional

information is required from the Trust). Its aims will be triangulated with the demand and capacity work as commissioned.

The full list of CIPs is in Appendix 4.

Productivity and Efficiency Metrics


The acute contract includes productivity and efficiency metrics sets standards or thresholds that should not be exceeded. If these standards are

exceeded, than a cost penalty will apply. These are designed to incentivise good practice, and together are aimed at improving the overall

performance of the emergency pathway.

30-day re-admissions. A percentage of the cost of the spells will be refunded to commissioners for each re-admission.

Emergency threshold adjustment. The Trust will only be funded for 30% of the costs of emergency inpatient spells, where the level exceeds

the 2008-9-baseline level.

Emergency admissions will be subject to a cap, noting that admissions are happening simply to achieve the A&E 4 hour target.

Details not yet fully agreed.

Safeguarding

During transition in accordance with the 'Safeguarding Vulnerable people in the reformed NHS- Accountability and Assurance Framework' it is important for A&Es to demonstrate a continuing focus on the following specific and general safeguarding areas: The A&E Improvement Plan encapsulates the following:

Specific

The identification of children who are suffering/ or at risk of significant harm

Such children are referred to Children's Social Care - in accordance with Pan London Safeguarding Children Policy and Procedures (

including supplementary procedures)

Notification to Children's Social Care of children who have Child Protection Plans or who have been notified as 'missing children' by the

responsible local Authority

The department has a system in place to ensure that the treating clinicians know and understand who holds Parental Responsibility for the

child/ young person ( relevant to both consent for treatment and safeguarding)

The department has a robust system in place to notify the attendance of a child/ person to their General Practitioner

The Department works with the commissioning organisation to support registration of children/young people, who are not registered with a

GP or linked into universal services ( Health and children not in education or training (NEET)

General


Ensure that staff are suitably skilled and supported (in relation to Safeguarding children - e-g Training and supervision)

The organisation can demonstrate safeguarding leadership is in place (within the department and organisation - Named Nurse and Doctor for Safeguarding Children are in post)

Fully engaged with local accountability and assurance structures ( e.g. - LSCB escalation policy - audit and case reviews)

The organisation & department have in place robust safe recruitment processes (to include permanent, temporary staff and volunteers)

That the organisation/department has measures in place to ensure children and young people are safe in the department in relation to

visiting celebrities and volunteers (Learning from Savile).

6. Preparation for Winter Planning

Ealing has re-established the Urgent Care Network Board (UCNB). In line with the NHSE guidance, Ealing UCNB has taken the lead in the local

health economy for Winter Planning 2013/14, chaired by Rob Larkman, Accountable Officer, BEHH CCGs Federation in North West London. The

operational group, Urgent and Unscheduled Executive Steering Group (UUESG) will co-ordinate and facilitate the delivery of the Winter Plans

reporting to UCNB with all multi-agency partners and professionals. Each month Ealing Urgent Care Network Board (UCNB) will have oversight via a

standing item on Winter Planning 13/14, to monitor the planning and implementation process, in the context of this Improvement Plan. NHSE

representative will also attend to give assurance and have oversight of Ealing‟s Winter Plans.

Key milestones for the Winter Planning process are as follows:

May – Established UCNB – Commenced Winter Planning discussions

June – Commence Winter Planning: Review of 12/13 Experience and High Level Plans for 13/14 Agreed. All agencies high level winter

planning plans requested. To be considered in context of NHSE Initial Briefing Pack for process, timelines and key tasks.

July – NHSE Winter Planning letter and templates released

Aug – Sept: Local Winter Plans drafted and finalised

Oct – NHSE Winter Plans Assurance completed.

Nov – Winter Planning Management and Monitoring Phase

The next meeting will consider lessons learnt from previous winter pressures period (2012/13) from all providers and their current winter plans, which

collectively will inform key priorities for this years‟ winter planning.


Key aims of the 13/14-winter preparation will be as follows:

Review and employ all lessons learnt from 12/13.

Embed schemes that effectively impact on avoiding admissions and facilitating discharges

Improving capacity to actively case find and case manage frequent flyers

Improve our capacity to support step up/step down care

Target support for residential and nursing homes particularly those at end of life.

Improve system communication and coordination with social care, UCC, Community Providers, primary

At this stage, Ealing Hospital already has a winter plan from 12/13 template and will use this again (see Checklist). Key changes for 13/14 will be

using Clayponds as escalation bed capacity and 4 beds for emergency surgery escalation, 6 beds for acute medicine giving total of 30 escalation

beds for winter surge.

Lesson learnt from 12/13 are being reviewed presently, but initial conclusions include:

Winter planning and the formal of review of the winter plan should be complete by October (see above), and before the winter period begins.

Completing the reviews in November is too late to react to material changes and impact December.

Additional funding was used to set up the RAT 24hrs x 7 days per week, and it undoubtedly assisted the situation. However, there is an issue

of timing of funding, with recruitment lead times leading to a fully stable team only established from mid-January onwards.

Escalation processes were seen to be effective. There was good visibility to the current status. Nonetheless, this will be further reviewed.

Demand and Capacity Modelling

ECCG/EHT ICO will jointly commission Demand and Capacity modelling to inform our local health economy winter planning. Capita are being

engaged to perform this work, which will be done as one project across NWLHT and EHT and on behalf of Ealing, Brent and Harrow CCGs. The

CCGs have agreed a set of requirements from this work, which will be satisfied as follows:

What is our baseline activity and how is it split by commissioner, hospital site, point of delivery, specialty and case mix?

How does our baseline clinical performance on agreed metrics compare against other similar NHS organisations? Where and how big are the opportunities to improve?


How well utilised is current capacity?

What estates capacity is required to optimally accommodate baseline demand for services? How does this compare with the current designation of capacity?

How is activity expected to change in the future as a result of external factors such as population, epidemiology, medical advances and recommended clinical practice?

How is activity expected to change as a result of internal/local factors such as commissioning intentions, clinical performance targets, site/service reconfiguration and clinical networks? How might activity flows change as a result?

What estates capacity is required to accommodate future activity for multiple scenarios that incorporate the impact of both external and internal factors? What is the range of capacity requirements based on downside, likely and upside scenarios?

What are the likely implications for financial flows under each scenario?

What capacity is required to achieve performance targets for both elective and emergency care? How do capacity requirements vary in-year?

How does the balance of care shift between acute and non-acute, beds and non-bed services under each scenario? How much additional demand should be expected in primary and community care as a result of changes to acute provision?

How does addressing our immediate operational challenges link to realising a longer-term vision for the health economy?

The agreement with Capita is being finalised presently, and is planned to run for 12 weeks, although it is planned that the acute bed model should be

completed within the first 6 weeks.

EHT are also preparing their internal bed modelling which will be considered at the next UCNB.

7. Local Urgent Care Board

As stated above the Ealing Urgent Care Network Board has now been established and met on the 24th May 2013. The Terms of Reference

(attached) were agreed and were in line with advice provided in Delivery of the A&E 4 hour Operational Standard (May 2013). The UCNB will ratify

the A&E Assurance Checklist and the Sustainability and Improvement Plan at the next meeting on the 28th June 2013. Ealing Local Authority, Ealing

Acute Trust, CCG Chair and UCB Chair signed all these off for submission for end of May.

The Governance Framework for Ealing Urgent Care Board is also linked to the Quality Assurance Framework, across the local health economy,

including regulators such as NTA and Monitor.

The Terms of Reference are in appendix 6.


8. Local Leadership

Leadership for Urgent Care in Ealing lies with the Ealing Clinical Commissioning Group, and Accountable Officer for BEHH Federation of CCGs –

Rob Larkman, chairs UCNB. The clinical lead for Urgent Care is a GP who is also the Deputy Chair of the Governing Body, Raj Chandok. He also

chairs the Urgent and Unscheduled Care Management Steering Group. Members are all Executives from key stakeholder groups (LAS, Local

Authority, WLMHT,111, Out of Hours, UCC, Community providers) along with representation from Ealing and Imperial Acute Trusts.

It is noted that local commissioners have a key role in supporting and ensuring the delivery of high quality emergency services and that

commissioners need to ensure. The ECIST offers advice on what makes a good improvement programme? The following summarises this advice.

The Ealing CCG programme is actively aiming to emulate these attributes.

• Leadership (Clinical and Executive) • Increasing the skill set/OD

• Clear reporting lines/governance • Metrics and measurement • Honesty

• A good understanding of the issues you are trying to fix • Incorporate learning • Prioritising effort • Appropriate resourcing • A good risk analysis with appropriate mitigation

• Communications Strategy; Engagement Strategy • Linking it to patient outcomes/experience and quality

- .


These strands are brought together with the CCG holding an oversight and scrutiny role, supported by the use of performance dashboards (see

Appendix Three) and demand/capacity modelling.

The governance structure is in Appendix 5.

The Urgent Care Board plans to oversee the development of the Ealing Urgent Care Strategy jointly with local partners and will map all existing and

planned services and provide the local vision for improving capacity, patient experience and quality across the system, based on evidence of good

practice.

For and on behalf of Ealing Urgent Care Board:

Mohini Parmar

CCG Chair

Kathryn Magson

Chief Operating Officer (Interim)

19.06.13

Attachment: Capita‟s proposal: North West London Health Economy, Proposal for demand and capacity modelling.


Appendix 1

Ealing A&E Improvement Plan

Legend: Green Status = schemes implemented, Amber status = schemes planned /or in progress, Red status = no current plans.

Status Impact: H = High, M = Medium, L = Low

Stage A: Prior to A&E

Aspect of Care Action Named Lead(s) Delivery Date Status/Impact H/M/L

Strengthening primary and community care for frail elderly patients

Use of community diversion schemes

Strengthening GP Out of Hours services

Use of virtual wards in the community

Support to care homes to avoid emergency referrals

Patient Education

A1. Integrated Care Programme

(ICP): case management and risk

stratification of >75s

This will be managed via the new

DES Risk Stratification scheme

and frequent attenders/GP peer

review of emergency referrals.

CCG

Raj Chandok

In place

H

A2. Redesign Falls Pathway CCG

Raj Chandok

July 2013

H


A3. Implementation of Night Sitting Service This will be managed via the Innovations Fund monitoring

CCG Raj Chandok

September 2013

L m M

A4. End of Life Care:

Co-ordinate My Care (CMC)

A whole systems programme of training and education for staff in primary, community and secondary care as well as relatives

CCG

Vijay Taylor

Soft launch in place,

awaiting final 111

launch. Primary Care

training complete and

Acute Trust

implementation agreed.

M

A5. COPD Pulmonary Rehab. Service: newly implemented service providing assessment and classes in conjunction with NWL Hospital and ICS Managed via 8 KPIs

CCG/EHT ICO

Sally Armstrong/Alex

Fragoyannis,

Marie Buxton(EHT ICO)

In place

H

A6. Community Diabetes Service: multi-disciplinary service which provides education for patients Managed via ICO Contract variation

CCG

Raj Chandok

EHT ICO

Joanna Paul

In place

H

A7. Intermediate Care

Ealing(ICE) Service in place:

CCG Service in place.

Expected impact as yet

H


SPA – Single Point of Access

Rapid Response

Step Up Beds(Magnolia)

Improvement actions:

Increase referrals from GPs, including criteria of GPs having seen patient from 24hrs to 3 days!

Increase pick up from other A&E/UCCs from Imperial/NWLHT

Review criteria for referrals from other professionals – for e.g. TVNs/Community Matrons,

Managed via EHT ICO contract and specifically delivering 2 KPIs. Also planning a CQUIN to manage dementia in community and reduction admission rates for Jubilee Ward(WLMHT and EHT)

Shanker Vijayadeva

EHT ICO

Joanna Paul

not seen.

A8. Extended hours DES

- Primary Care Saturday morning surgeries.

- Also Featherstone Clinic offers 8am to 8 pm appoints, for patient unable to obtain appointments at

NHSE/ECCG 2011

M


their own surgeries (walk-in surgery).

NHSE to monitor usage

A9. Ealing GP OOH Contract Contract Review and procurement underway NHSE leading and monitoring current OOH Contract

NHSE/CCG Summer 2013

H

A10. Community Nursing Development Planning of a „virtual ward‟ underway in Community Nursing to help support the most high need patients using the expertise of the Community Matrons to support the new GP Networks which should provide support for next winter .

EHT ICO Community

Services

Joanna Paul

Winter 2013/14

M

A11. Active Case Management of

Nursing Home patients in place

and procurement of an expanded

service almost complete

NHSE/CCG monitoring including

via frequent attenders

CCG

Shanker Vijayadeva

June 2013

H

A12. Medicines Management CCG: Beryl Bevan January 2013


Medicines management schemes-

reviewing all care home

medications including

antipsychotic prescribing

L

A13. LAS pathway development

The CCG, EHT, UCC and the LAS

have agreed an exclusion pathway

for patients that are brought into

the hospital by the LAS and would

be suitable for the UCC

All stakeholders

Kathryn Magson(CCG)

Chris Blake(EHT ICO)

Peter McKenna(LAS)

Laura

McLoughney(UCC)

2013

L

A14. Frequent Flyers

Behaviour Change Workshop for

frequent users of urgent care

services.

Review of Frequent Attenders

across all providers and plan of

action:

a)Improved working between

primary, secondary and

community(ICE Service)

b) Exacerbation of Chronic

J Downey – CCG PPI

lead

Kathryn Magson(CCG)

Peter McKenna(LAS)

Chris Blake(EHT ICO)

Laura

McLoughney(UCC)

Autumn

H


disease- improved access to

Specialist Nurses and GPs.

Integrated Care Pilot(ICP)

c)Alcohol related(QIPP

workstream)

d) Mental Health(QIPP

workstream)

Rollout arrangements for NHS 111

A15. Ealing 111 launched CCG Shanker Vijayadeva

Soft launch complete M


Stage B: Patient journey through the Hospital system

Aspect of Care Action Lead(s) Delivery Date Status

Prompt booking of patients to reduce ambulance turnaround delays

B1. LAS delays are reviewed on a

daily basis by senior staff. The

introduction of the RAT suite has

helped to reduce the delays in

handover time. New HAS process

will be in place by Sept 13, to

improve joint reporting from LAS

and EHT.(RAT – ECIST best

practice)

Contract Performance target

EHT ICO – CS/BE

Peter McKenna(LAS)

HAS Sept 13 H

B2. Expand ambulatory care

pathways to bypass A&E –

DVT/Cellulitis pathway in place,

others planned in collaboration

with primary care.(ECIST best

practice)

Raj Chandok, CCG

Fiona Wisniacki, EHT

ICO

Autumn 2013 L

Full see-and-treat in place for minors

B3. UCC provided by Care UK at EHT Contract performance

UCC

Laura McLoughney

In place

H

Regular seven-day analysis should be in place for rapid identification and release of bottlenecks

B4. Patients admitted under the

medical teams are transferred to

the AMU and are seen by the on-

call team. These patients are then

EHT monitoring:

MH/SR

In place H


discussed at a daily tracking

meeting which is consultant lead.

Patients are placed under suitable

specialty teams. They then should

be allocated a bed on the relevant

speciality ward with 48 hours.

Surgical patients are assessed in

the ED and are admitted directly to

the relevant speciality ward.(ECIST

best practice)

B5. Process mapping Completed:

Priorities agreed for pathway

redesign:

Elderly Frail

Mental Health/ Alcohol

ACSC.

Frequent Flyers Key outcomes agreed: Reduction in ‘excess bed days’ Reduction in attendance to admission rate Reduction in attenders

Urgent/Unscheduled

Care Pathway Steering

Group

Raj Chandok, CCG

Chris Blake, EHT ICO

Autumn 2013

H

Bed base management B6. Target for reducing outliers

met since mid-April 2013

EHT ICO: CB/PR

April 2013


B7. Bed model, based on LOS and benchmarked against Dr Foster data of neighbouring Trusts, piloted since April. To be formally approved at Exec and will realign specialties towards based on ALoS.

EHT ICO: CB/PR

June 2013 H


Stage C: Discharge and Out of Hospital Care

Aspect of Care Action Lead Delivery Date Status

Designation of expected date of discharge (EDD) on admission

C1. Pilot started September 2012 but stopped when key members of the operational team left. Pilot to recommence 1 June 2013 on 3 wards and will be led by Head of Nursing for Medicine.(ECIST best practice)

EHT ICO: PR/MH/AMC

June 2013

H

C2. Roll out of EDD to all wards and pre-assessment workstream project to increase day cases and efficiency starts 4 June 2013. In additional a pilot for MACP in A&E, Real-time Workstream for EpRO.

EHT ICO:

PR/ML/NN/BE/CR

June 2013

H

Maximisation of morning and weekend discharges

C3. EHT have planned discharge list available from Friday and a Registrar allocated to review patients over the weekend to ensure discharge criteria are met.

EHT ICO: BE In place

H

C4. The 1 by 11am goal has been in place at EHT since October 2012. Focused performance management of this key patient flow target to be implemented.(ECIST best practice)

EHT ICO: PR/ML/MH/AMC

October 12

H

C5. Multidisciplinary Discharge

policy based on criteria led

EHT ICO:MH/ML July


discharge and competency of the

MDT to be ratified for use on all

wards.(ECIST best practice)

M

Full use of discharge lounges C6. Electronic prescribing has already been rolled out to this area and it is able to take stretcher cases. Hours of opening will be reviewed following audit to ensure discharge lounge able to support A&E and wards effectively. Audit due to complete by June 19th 2013.

EHT ICO: JM/ML Review following audit

completion June 2013.

H

Delayed transfers of care minimised continuously

C7. EHT use weekly meetings to discuss all patients with LOS of over 10 days. It is proposed that the meeting reviews patients with LOS between 7 - 10 days to try to speed up discharge.

EHT ICO: MH

In place

M

C8. The EHT discharge team has been located within wards and a training programme has been developed to support nursing staff and MDTs to complete assessments within agreed operational standard time with family and carers present.

EHT ICO: MH In place

M

Flexing of community service capacity to accept discharges

C9. Clayponds Hospital has a „step-down‟ capacity for patients awaiting complex care package arrangements. CCG have agreed to spot purchase

Joanna Paul,EHT ICO

In place

M


beds where needed. Business Case for additional rehab beds(step-down) in community.

Nicola Bradley, CCG

Usha Prema, CCG

Continuing Care C10. Local review of continuing

care includes working with acute

trusts to ensure they have effective

processes in place linked to

hospital discharge, improving the

quality and timeliness of continuing

care assessments

Nicola Bradley, CCG

Continuing Care Team

On-going

L


Appendix 2


Appendix 3

Dashboard for Sustaining the A&E 4-Hour Standard in Ealing

The dashboard described below is provisional, but sets out the CCG‟s intentions for a

dashboard. It recognises that for the system to operate effectively, demand and capacity

must be in balance and be sufficient, whilst at the same time delivering on performance

and quality minimum standards. The dashboard separates those measures that indicate

load on the system, and those that indicate relative success of measures taken to

manage and improve the system. The dashboard also gives consideration to data and

information measurements streams that are readily available and do not requires costly

or time consuming new information streams.

Domain Metric

1. Demand

Demand load

Ambulance conveyances to A&E vs plan

A&E attendances vs plan

UCC attendances vs Plan

Short stay (<2 days admissions) vs plan

Long stay admissions vs plan

Demand management

By Ambulance

CAT A to Admission conversion

In Primary Care

A&E attendances; referred by GPs A&E attendances; referred by GP OOH service

A&E attendances; referred by 111 service Appointment with GP availability

A&E attendances; from Nursing homes

In Hospital

A&E to Admission conversion rate

7 day A&E re-attendances rate

30 day re-admissions rate

2.Capacity

Capacity Utilization

A&E


Domain Metric

A&E: Total time (minutes) - Admitted patients (95th Percentile)

A&E: Total time (minutes) - Non Admitted (95th Percentile) (Site)

Inpatients

Total beddays (emergency admissions)

Open beds

Open escalation beds

Community step up/down

Total beddays (emergency admissions)

Capacity Management

At admission

Patients seen in Ambulatory Care Unit

Time to review patient by consultant

Referrals to ICE

At discharge

15-20 day LOS cohort reduction

Week-end discharges increase

Delayed Transfer of Care (DTOC) reduction

Community step up/down

Achievement of a minimum bed occupancy rate

3.Quality & Outcome

System Performance

A&E 95% 4 hours (all types)

A&E 95% 4 hours (type 1)

A&E 95% 4 hours (Type 1) –“buffer build-up in months 1-7

Ambulance CAT B

Ambulance CAT A

Ambulance hand-over times (<30mins)

Patient Experience

Friends & Family test

Patient Safety

C-Diff. Infections against target

% of eligible staff receiving appropriate Adult / Child Safeguarding training (Levels 1, 2 and 3)


Appendix 4

EHT Cost Improvement Programmes (CIPs)

Index CIP: 362 Supplier Discounts - Procurement

363 Length of stay 365 Nursing ITU 366 Nursing Medicine 367 Nursing Surgery 368 Radiology 370 Pharmacy

371 Nursing Women & Childrens 372 Theatre redesigns 373 Medicines Savings 376 Nursing Theatres 378 Community (AHP) Service Redesign

379 Chiropody Appliances


Appendix 5

New Governance Structure

Diagram 1: The Urgent Care Network governance structure.


Diagram 2: The Urgent Care Network governance set in the context of the overall CCG

governance structure and external bodies.

Quality Framework

2

Ealing CCG QSCRCs / Governing Body

Responsible for the quality of care that

they have commissioned

EHT/ICO CQG Patient Safety

Patient Experience

Clinical Effectiveness

etc.

QSG NHS England, CCG, LA, Healthwatch,

CQC, Monitor, NHS TDA, LETB, PHE

Share information and intelligence

about quality

NWL CSU Quality Reporting, identifying

trends, develop quality

improvement plans, expert

advice etc.

EALING URGENT

CARE NETWORK

BOARD

NHS England

Ealing Hospital NHS Trust (Provider)

Ultimately responsible

Individual

Healthcare

Professionals

Regulators CQC, Monitor,

NHS TDA

Professional

Regulators

Ealing Health & Wellbeing

Boards

Local leadership for

Quality Improvement

NQB

Regulatory Body

Accountability

Membership


Appendix 6

EALING URGENT CARE NETWORK BOARD

TERMS OF REFERENCE

PURPOSE, SCOPE AND FUNCTION

The purpose of the Ealing Urgent Care Network Board is to:

To support and ensure the delivery of high quality urgent and emergency

services, including achievement and sustainability of key national and local

targets.

To provide strategic oversight for the Emergency and Urgent Care System

To support and ensure promotion of integration and close working between all

partners but especially health and social care.

To provide a forum for leading the planning, discussion, implementation and

development of emergency and urgent care services

To be responsible for sign-off all aspects of the Local Recovery and Improvement

Plan(R&IP).

To monitor the delivery of the Local Recovery and Improvement Plan and

attainment of the 4 hour target.

To act as a governing board for the programme of work associated with the QIPP

plans for Urgent and Unscheduled Care.

To use high level data to develop, monitor and review the delivery of agreed

service changes to ensure that they deliver the intended benefits for patients and

the wider health community.

NHSE REQUIREMENTS OF LOCAL URGENT CARE BOARDS:

They review the full range of appropriate data

Best practice is adopted by all concerned

The effectiveness of primary care services is reviewed, including out of hours and admission avoidance schemes

The effectiveness of community services is reviewed, including any walk in centres, minor injury units and how they integrate with secondary care

The effectiveness of ambulance services is reviewed

The effectiveness of NHS 111 is reviewed


There are local plans in place to support the care of the key categories of patient who attend or are admitted frequently

Patients with multiple comorbidities especially those with poorly controlled chronic disease;

o Frail elderly, especially those with MH problems o Sick children; and o High dependency individuals, especially vulnerable adults(homeless, drug

& alcohol related problems, MH problems)

A full range of services is available to acute trusts for those patients in A&E who need services not provided by acute hospitals are in place

Working with local authorities, a review to ensure early discharge is feasible is undertaken

MEMBERSHIP

Core Member Organisation Role Name

BEHH Federation Chief Accountable Officer/Chair

Rob Larkman

BEHH Federation Director of Delivery & Performance

Bernard Quinn

ECCG Clinical Leads Mohini Parmar/Raj Chandok

ECCG Interim Chief Operating Officer

Kathryn Magson

ECCG Chief Operating Officer(until 31/5/13)

Jo Murfitt

EHT ICO Director Christopher Blake

EHT ICO Clinical Lead Dr Fiona Wisniacki, A&E Consultant

EHT ICO Ealing Community Services Director

Jo Paul

London Ambulance Service LAS West London lead Peter McKenna

WLMHT Director Jean George

Imperial NHS Trust Director Steve McManus

Care UK Ealing Urgent Care Centre Senior Director

Laura McLoughney

Ealing Social Services Director David Archibald/Stephen Day (Alan Mountain)

111 Service Director Amanda Mayo

Out of Hours Harmoni Faye Justice

Commissioning Support Unit

tbc tbc

NHSE London Delivery & Head of Assurance, NWL Jo Murfitt


Assurance

CHAIR

The Chief Accountable Officer for BEHH will Chair the Urgent Care Network Board

Meetings

DEPUTY CHAIR

The Network Board will agree and endorse a deputy chair, who be a member of the core

group.

URGENT CARE NETWORK BOARD LEAD/SECRETARIAT

The Urgent Care Network Board will appoint a lead manager to act as the Urgent Care

Network Board Lead/Secretariat who will support the Chair and the Board in the delivery

of its aims and objectives.

a) setting the agenda

b) circulation of papers

c) support and develop the delivery of the work plan

ACCOUNTABILITY

Accountability of the Network Board will be to each stakeholder organisation.

EXPECTATIONS OF CORE MEMBERS

Members should be a designated Executive Director or of senior level with lead

responsibility for emergency and urgent care services for their respective organisations.

Members should designate a deputy in the likely event of being unable to attend a

meeting. The deputy will be expected to remain the same person from within the

respective organisations and will be expected to act in the capacity of the core

member/director lead.

Members will be responsible for ensuring that their own organisation or group is fully

briefed on Network decisions.

FREQUENCY OF MEETINGS


Meetings will be held monthly and will be arranged 12 months in advance.

All communications relating to meetings will be disseminated and papers/reports

circulated in timely manner.

QUORUM

A quorum of 5 members must be present to constitute a valid meeting with a minimum

representation of core member organisations:

Managerial/Clinical: ECCG, EHT ICO, SS, LAS, OOHrs.

The Chair will determine the appropriateness of the represented organisations to make

decisions.

NHSE expect local Urgent Care Boards to ensure

ealing: improving a&e performance plan€¦ · 4 v12: improving a&e performance the trust...

Documents