greater nottinghamshire urgent care system · demand / diagnostic demand on acute services...

Operational Resilience and Capacity Plan V2: 1st September 2014

GREATER NOTTINGHAMSHIRE URGENT CARE SYSTEM

OPERATIONAL RESILIENCE AND CAPACITY PLAN

Section 1: Narrative on local system configuration, key strengths and challenges


1. Local system configuration

The Greater Nottingham Urgent care system serves a population of circa 600,000. This is a diverse

population with high levels of ethnicity and deprivation in the City of Nottingham area whilst the rural

areas have lower deprivation but higher numbers of older people. The urgent care system

comprises:

CCGs Nottingham City CCG

Nottingham West CCG

Nottingham North and East CCG

Rushcliffe CCG

Erewash CCG

Approximately half the population of Erewash

CCG attending NUH for the secondary care

provision

Acute

Hospital

Nottingham University Hospital Services are provided from 2 hospital sites:

Queens Medical Centre focuses primarily on

emergency and cancer care with the A&E

department and trauma centre. City Hospital (4

miles away) has services primarily focused on

longer term care including oncology,

haematology, heart services & elective

orthopaedics. Services are also provided from

Ropewalk

Community

Services

Health Partnerships

Nottingham CityCare

Partnerships CiC

Lings Bar Community Hospital

Provider services predominantly to the

Nottingham County CCG areas

Provides services predominantly to Nottingham

City CCG area.

Community services for Derbyshire patients are

provided by Derbyshire Community Health

Services Trust.

72 bedded rehabilitation hospital situated in

Gamston. The hospital cares for both men and

women generally aged 60 and above, who

require physical rehabilitation following an

admission to an acute hospital, and as such

plays an important role in enabling patients to

be discharged from NUH after the acute phase

of their illness

Mental

Health

Services

Nottinghamshire Healthcare

NHS Trust

Provider of mental health services to all of

Nottinghamshire.


Ambulance

Service

East Midlands Ambulance

Service

Provides the emergency ambulance service for

the urgent care system. Non emergency

transport is provided by Arriva for both

Nottingham City and Nottinghamshire patients,

and by NSL for Derbyshire residents

NHS 111 Derbyshire Health United

Urgent

Primary Care

Services

NEMS CBS

Primary Care „Walk in Centres‟

Dental Services

Provide the out of hours service for the whole of

Greater Nottinghamshire as well as a range of

other services that support the urgent care

system - for example Primary Care streaming

service at A&E, Community Pathfinder scheme.

The out of hours service in Derbyshire is

provided by Derbyshire Health United.

The Greater Nottinghamshire System is served

by 2 „Walk in‟ facilities. The London Road Walk

in Centre which is operated by Nottingham

CityCare Partnerships CiC and NHS

Nottingham City 8-8 Health Centre which is

operated by NEMS. Both of these facilities see

approximately 80,000 patients per annum.

There is an integrated dental unit provided from

the London Road Walk in Centre location and

an Emergency Dental Service provided from

the 8-8 Health Centre.

Social Care Nottingham City Council

Nottingham County Council

Derbyshire patients are supported by

Derbyshire County Council


2. Performance Context

The 4 hour ED standard was achieved during Q1 and Q2 of 2013/14, having not been achieved for

the previous 8 consecutive quarters. Performance fell below the 95% standard in September 2013

and has remained as such for each subsequent month to date. The 2013/14 performance overall

was 93.3% and performance year to date for 14/15 is 87.5% with monthly period being below 90%

for each month since April.

Total >4Hrs %

YTD 73628 9222 87.47%

Q1 (NB NHSE uses weekly data) 47672 5963 87.49%

Apr full month 15276 1779 88.35%

May full month 16173 1820 88.75%

June full month 16223 2364 85.43%

July full month 16433 2279 86.13%

August MTD 9523 980 89.71%

From April 2014, due to consistent failure to deliver the 4 hour ED standard and concerns regarding

the management of the urgent care system as a health community, all four South Nottinghamshire

CCGs were deemed to be „assured with support‟ for domain one - Are patients receiving clinically

commissioned, high quality services?

At that point the Urgent Care Working Group began meeting on a weekly basis and was chaired by

the Director of Operations and Delivery for the Nottinghamshire and Derbyshire Area Team.

Revised Urgent Care structures, workstreams and governance were agreed in May 2014. These

arrangements have subsequently been superseded by the System Resilience Implementation

Group (SRIG) which was established in early August 2014. Further detail on SRIG is included in

Section 11 of this document.

Demand / Diagnostic

Demand on acute services continues to increase. This potentially driven by the growth in the elderly

population (2.2% increase per annum for the over 65 years and 3.7% increase per annum for the

over 85 years). Hospital admissions in the NUH core catchment areas have increased at an

average of 3.7% in the past 5 years.

Elderly patients with increasing frailty and acuity have the potential to stay longer in hospital.

Although the total number of type 1 attends to NUH ED have not increased significantly, there has

been an increase in the proportion of over 65 years being admitted and an increasing length of stay

from 2012/13 to 2013/14 of 0.5 days - this has resulted in overall occupied bed days going up by

3.7% which equates to 600 bed days per month.


Analysis of the current position shows a relationship between high bed occupancy and breaches of

the A&E standard See table 1 below.

Table 1: Relationship between A&E breaches and bed occupancy

Preliminary root cause analysis of breaches between August 2013 - July 2014 has indicated a 60:40

split between breaches resulting from a lack of flow out of ED and breaches resulting from process

issues within ED

There has been an average number of 470 attendances in ED each day (for period March 2014-

August 2014), indicating an increase of 7% on 2013/14. However ED attendance for 2013 were low

and long-term growth is 2% per annum (from 2011 – 2014). ED attendance growth at NUH was

below the NHS average in both 2012 and 2013.

Non Elective admissions to the NUH have increased by 5% over the last 2 year period. Admissions

via ED have remained largely constant over the last 2 years however there has been an 11%

increase in the number of admission via non ED routes (such as the Acute Medical Receiving Unit –

AMRU)

Mental Health:

ED breaches attributable to patients waiting for an assessment by the Mental Health team account

for approximately 3.5% of all ED breaches. The CCGs commission a Rapid Response Liaison

Psychiatry (RRLP) Service which is based within NUH and additional recurrent resource has been

put into the service from April 2014 to increase the level of support to ED.


Delayed Transfers of Care

Delayed transfers of care at NUH increased to 1278 in May from an average number per month

over the previous 12 months of 1066. However some improvement was seen in June as shown in

the table below.

Supported discharges make up only 7% of total discharges from NUH, with a third of these requiring

primarily health input and two thirds requiring social care. The supported discharge process is

currently overly complex involving several steps and some duplication and re-work which adds to

delays. Action being taken improve this includes:

Improvements to the Social Care datasets to allow for the system to measure all

waits/delays within the system enabling transparency and understanding of the number of

patients at each stage of the health and social care assessment process within hospital. All

medically fit patients (i.e. not just DTOCs) will be measured and shared from September

2014, including for social care waits.

Work has been undertaken to establish clear definitions for medically safe for transfer, this

have been agreed across the system and is used to ensure that wards are able to identify

patients at appropriate stages. The Medically Safe for Transfer definition is: The patient‟s

clinical condition is such that ongoing assessment, rehabilitation and / or recuperation could

continue in a less acute environment away from NUH. This should be confirmed by a senior

clinician and documented within the patient notes.

The process for identifying patients who are likely to require a supported discharge and the

timing of notifying the Care Co-ordination Team (CCT) is being reviewed as a matter of

urgency.

Joint health and social care screening of referrals to the CCT has been extended to cover 11

wards with the highest number of supported discharges on the QMC site


Implementation of the new joint health and social care „Leaving Hospital Policy’ which

aims to reduce the pressures on the acute hospital. This policy will enable citizens to make a

timely discharge from acute care to community care in the form of interim residential

placement if their care package or residential placement of choice is not immediately

available

Flow out of the hospital is expected to improve with greater use of interim home care, Crossroads/Red Cross provision supporting patients at home and more intermediate care support to discharge home with support

Patient waiting for admission to Lings Bar Hospital accounts for the largest proportion of DTOCs

and there is a constant waiting list. The number of patients waiting for Lings Bar Hospital peaked in

early July 2014 at 36 patients waiting; the average number of patients waiting for Lings Bar Hospital

since then has been 18.

In May 2013 a Transfer to Assess model was introduced for patients at City Hospital Nottingham

who were at risk of being admitted into a Care Home. One of the identified assessment settings

was Lings Bar Hospital. The evaluation of the trial has shown this model to be successful in

reducing admissions into long term care, as well as reduced length of stay at NUH and across the

entire pathway (see supporting evidence file). However it has resulted in a change in the case mix

of patients in Lings Bar which has increased the average length of stay.

Actions being taken to reduce waits for Lings Bar Hospital:

Senior Clinical Review of all patients undertaken on a weekly basis (since early July 2014)

The Care Co-ordination Team at NUH referring patients with identified levels of need to community hubs, rather than requesting specific services to ensure patients receive the appropriate care, and wherever possible return home directly with their previous package of care re-started, rather than Lings Bar being considered the default for complex discharges


The new leaving hospital policy being adopted at NUH will be considered for use at Lings Bar Hospital.

Additional therapy and social care staff that were introduced in July when waits were at their highest and will be re-introduced as part of escalation processes.

The additional community beds which are being commissioned will support increased flow through the hospital

All members of the local system recognise that that current performance is not acceptable and the

whole system has committed to doing whatever it takes to improve the system to deliver a

consistently high quality, safe urgent care service to the local population which provides an

excellent patient experience.

The health and social care community hold daily conference calls (Monday – Friday) to manage

performance across the system:

9am call involving operational leads - to identify all patients waiting to transfer to the

community and to advise NUH of community capacity available

12 noon call involving „General Managers / Directors‟ to capture all performance data across

the system and ensure all required actions are being taken across the system to optimise

emergency flows;

5pm „Chief Officer / Chief Executive‟ to address / escalate any outstanding actions / areas of

concern.

The standard metrics captured each day are shown at Appendix 3. From 1 September the daily

information at both the 9.00a.m and lunchtime conference call will also include:

Total number of section 2s – to be used as a proxy for future demand in the system

Total number of waits –care packages / placements / disputes to show current blocks in the system

% of current waits that have a section 5 completed - to identify areas that are not using correct discharge process

% of current waits that are past their section 5 / PDD, and total number of days waiting past Predicted Discharge Date

This data will be at patient level for the early morning operational meeting to enable individual plans

to be put in place, and at an aggregated level for the lunch time discussion to enable system

solutions to be identified.

With the current pressures within the system it is essential that there are safeguards in place to

mitigate against patient harm:

No patient will be moved from the department until a senior clinical review has been

recorded..Compliance with this standard is via the EDIS system used within ED which

records all contacts with a patient noting the time and contact. Performance is monitored

throughout the day and also at the weekly demand and capacity meeting. The Trust is


working to achieve the target that 80% of patients have a senior clinical review within 3

hours.

There is a clear Outlier Policy which identifies patients who must be exempt from being

moved to an outlying ward e.g. patients with high level of confusion or dementia, patients at

high risk of falling, etc. All patients must have had a senior clinical review before moving

wards

Daily Board rounds with the full multi disciplinary team providing a review of care of the

patient, progress check on discharge plans and supervision for junior doctors

A comprehensive Urgent Care Performance Framework monitors 56 separate indicators across

Pre-Acute, Acute and Outflow stages of the Urgent Pathway. (See Appendix 2) This is monitored

on a monthly basis by the System Resilience Group.

3. Understanding the pressures causing performance issues

ECIST have undertaken a number of site visits to NUH, with the most recent being in March 2014.

The report from ECIST following their visit in March 2014 identified key challenges as:

Reported deficit of around 50 beds, due in part to a loss of community capacity.

Workforce challenges in recruiting consultants to the Emergency Department (ED), Acute Medicine and Healthcare for Older People (HCOP).

Difficulties in maintaining cubicle capacity to meet demand within the ED

Lack of steady state over the winter months due to a six week outbreak of noro virus

Difficult commissioning round with a number of initiatives funded at risk e.g. respiratory assessment at the city campus and the Lynn Jarrett unit.

Emergency Department regularly overcrowded with an increase in admissions of over 70 year olds from October 2013 and an associated increase in length of stay.

Until recently a lack of a “common view” of the issues driving the deterioration in performance across the Local Health Community to set a foundation for action.

The further support the work undertaken by the Greater Nottinghamshire system to reach a shared consensus of the issues driving the deterioration in performance and external review of the Emergency pathway has been commissioned from Mckinsey and Company. The primary objective of the work is to create „One version of the Truth‟ on the root causes of poor performance across the health and social care system. This piece of work commence on the 11th August 2014 and will be completed by end of September 2014. The formal „stock-take‟ of the System Resilience Plan scheduled for mid October will fully consider the output of recommendations of the external review as well as the „Breaking the Cycle‟ exercise planned for week commencing 27th September which is being supported by ECIST.


4. Existing plans to improve performance A number of separate plans exist to improve performance.

NUH Action Plan to implement the recommendations from ECIST

Following the report from ECIST which identified a number of recommendations NUH

produced a detailed action plan. This is reviewed on a monthly basis to ensure progress

continues to be made. The ECIST report and most recent action plan are available in the

evidence file that accompanies this plan.

System Recovery Action Plan

Developed by the weekly Urgent Care Working Group to ensure a joint understanding of the

issues causing the poor performance, oversee the development of credible plans to improve

performance and monitor progress against these plans. The UCWG set up two workstreams

to oversee the development of detailed action plans to address the pressures within the

system:

Workstream 1 (Avoiding Admissions) The group is chaired by the Chief Officer of

Nottingham North and East CCG and meets on a fortnightly basis. Current programmes of

work include Improved Access to Primary Care, Expansion of Acute Home Visiting Service,

Expansion of Falls Ambulance, development of new alternatives to admission which can be

complemented by the current clinical navigation service and Improved support to Care Home

Sector to reduce avoidable admissions.

Workstream 2 (Improving flow within the hospital setting, including improved

discharge processes to reduce delays in discharge and reduce re-admissions) of the

Urgent Care Working Group is chaired by the Chief Operating Executive for Health

Partnerships. The group has a work plan which is attached in Appendix 5. Current

programmes of work include planning for the rapid improvement event that is to be held at

NUH on 9 September, and a review of metrics used to report performance across the

system.

These workstreams were supported by the capacity modelling group and the performance and

information group. These action plans, which ensure the minimum standards identified by NHS

England will be met, had been developed by system wide groups and signed off at the Urgent Care

Working Group. Each plan has clear actions, accountable lead, timetable and expected

impact/benefit to be delivered across the system.

Short Term Improvement Plan

The system has developed a short term Improvement plan (see supporting evidence file) which

identifies all the actions that are being taken by the system over the next 3 months (to the end of

October 2014) to improve performance. All actions within the plan are being led by the respective


workstreams of the System Resilience Group. The Improvement plan will be updated and

monitored on a fortnightly basis by the SRIG and reported into each SRG meeting.

Reducing avoidable re-admissions

At any time 300 beds at NUH will be occupied by a patient who has been readmitted to hospital

within 28 days. The total number of readmissions includes those admission deemed as unavoidable

as well as avoidable.

In 2013/14 17,500 patients were readmitted (an average of 48 per day) with 61% of admitted

patients coming through the emergency department. A multi-agency joint audit of re-admissions

occurred during 29 and 30 April 2014. The purpose was to understand the reasons why patients

readmit to NUH and what the contributory factors to readmission are, in order to inform the planning

of interventions across the local health and social care system to reduce 'avoidable' readmissions.

Clinical experts estimated that 32% of the 82 readmitted patients reviewed could have avoided

being readmitted. This gives an opportunity to greatly improve the patient experience as well as

freeing capacity. Further work is to be undertaken looking at the length of stay for these patients

whose admissions could have been avoided to quantify the opportunity to release beds.

During the contracting round for 2014/15 it was agreed that eliminating avoidable hospital

readmissions is a priority given the impact on individual patients and the effect on resource useage.

Therefore, the baseline reduction of £4.3m transacted as per the national guidance has been

reinvested exclusively in Nottingham University Hospitals NHS Trust, as a block value, in response

to actions which reduce the level of avoidable emergency readmissions into the Trust as per the

agreement below:

'The readmissions fund will be returned to the Trust in equal thirds at the end of the first 3 quarters

of the 2014/15 financial year contingent on the following:

An agreed plan to reduce avoidable readmissions being developed by the end of the first quarter which includes phasing of schemes and a trajectory for improvement.

Evidence that schemes are being implemented as planned during the second quarter.

Delivery of the agreed readmission reduction trajectory in quarter 3' The delivery of plans to reduce re-admissions is being overseen by Workstream 1 as well as a

dedicated Readmission Oversight Panel which reports back into the NUH contract.. Both NUH and

CCGs have plans in place to address readmissions including review of community based post

discharge follow-up services, review of information given to patients on discharge so that they are

better informed about self care post discharge and a number of other NUH directorate specific

actions.


QIPP plans

At the beginning of this financial year the health system agreed QIPP schemes and proposals for

the use of MRET and other non recurrent monies which would help to reduce pressures within the

urgent care system and in particular at NUH.

The Health Community commissioned McKinsey and Company to test the robustness of existing

plans and their likely impact during 2014/15. Each QIPP scheme was reviewed and awarded an

aggregate score out of ten reflecting the McKinsey current view of the schemes most likely reduce

NUH activity this year; 46% of overall scheme value was rated 9 or 10/10 for confidence of delivery,

with 88% of the value from non-elective admission schemes rated medium or better, and roughly

half of A&E-attendance related value rated low.

This work concludes that:

The impact of Commissioner QIPP schemes on potential bed reduction is equivalent to 26

beds if fully delivered

Few schemes address the discharge (back-door) process, which is a key driver of

readmissions;

These findings are in line with CCGs‟ QIPP schemes which have been primarily focussed on

reducing avoidable admissions.

5. Key strengths of the urgent care system

Despite the challenges in relation to performance, the Greater Nottingham urgent care system has a

number of strengths:

ECIST identified a number of areas of good practice during their review in March 2014

There is good clinical engagement and enthusiasm to continuously improve the system and

thereby quality of care for patients.

There is a South Nottinghamshire Transformation Programme which is designing the future

model of urgent care so that patients are treated, as far as possible, in a community setting

rather than being admitted into institutional care - whether that be in hospital or permanent

admission into a care home

There are a number of developments within the community setting which will decrease

pressure at NUH - these are detailed in the body of the plan but include focused work with

care homes, extension of the rapid response falls team, changed pathways of care,

increased primary care streaming at A&E

There are clear plans for improvements to the system which are owned by the whole system

The Better Care Fund gives a real opportunity to transform local services so that people are

provided with better integrated care and support. Locally the BCF plans moves towards


integrated care provided 7/7 so that patients receive the right care in the right place at the

right time.

6. Key challenges to the urgent care system

There remain a number of key challenges within the system that need to be addressed if there is to

be a sustainable improvement in performance. Many of these challenges remain similar to those

identified by ECIST. These challenges are captured within the System Resilience Risk Register and

plan to address this challenges are detailed within the plan.

Key Challenge Mitigating Action:

Insufficient Capacity There is insufficient capacity across the system to effectively „double run‟ whilst internal improvements are being embedded to increase flow within NUH, and the development of the full integrated urgent care system outside of hospital is put in place. There are financial pressures within the two Councils; in the County Council this has resulted in reduced social work assessment capacity and will mean a reduction n the provision of intermediate care and reablement services.

Opening of 60 additional beds (of which 24 beds

in respiratory and stroke care are for the expected

seasonal pressures and will be open only during

Q4) within NUH to decrease the number of A&E

breaches due to waits for beds in the main

hospital

Opening of 48 additional beds in the community to reduce delays to discharge due to waits for community hospital and intermediate care beds

Members of the Health and Social care system recognise that the development of additional inpatient capacity does not represent a sustainable solution to future service and demographic pressures. However, the urgent creation of capacity in acute and community settings will provide the economy with the headroom to redesign and improve patient flow, whilst also ensuring that the operational benefits of QIPP, preventing avoidable readmissions and improved rehabilitation can be fully measured and realised.

The plan also provides the community with significant capacity resilience to mitigate periods of peak pressure and the potential impact of care home closures or novo virus outbreaks. The additional capacity it creates also mitigates any potential operational problems experienced during implementation, since the plan is not dependent on any one initiative for compete success.

In this context, the implementation of the system resilience plan for 2014/15 and proposed use of the non recurrent resilience monies for additional bed capacity should be viewed as an enabler to support wider and deeper system transformation within and across existing care pathways. The entire health and social care community is committed to transforming the existing service provision, rather than simply adding to it, and the proposed plan offers the greatest prospects for rapidly improving patient experience whilst also pursuing the strategic transformation agenda. The system is fully committed to removing the additional non recurrent bed capacity safely by the end of March 2015.


Key Challenge Mitigating Actions

Workforce: This plan is dependent on having staff with the right skills in place. There are already hotspots within the urgent care system and opening additional capacity could exacerbate these problems. In line with the national picture there is considerable difficulty in recruiting consultants to the Emergency Department (ED), Acute Medicine and Healthcare for Older People (HCOP. (The detail regarding consultant vacancies is within the main plan).

Additional 15.00 - 22.00 Consultant shift in A&E Increases in other consultant capacity

Continuation of use of long term locums, recruitment etc Overseas recruitment for nursing staff Agreement to work collaboratively across the system in the recruitment of nurses Staff flu vaccinations - all organisations are offering their staff free flu vaccinations aiming to achieve the target of 75% of staff vaccinated. Planning for these campaigns is well advanced with clinics starting in October. Clinics are offered at different locations and times to maximise the uptake. A variety of methods are being used to maximise the uptake from traditional communication methods, senior staff leading by example, heads of departments and matrons being charged with encouraging staff to attend, to more innovative approaches such as awards for achieving the 75% target and special out of hours sessions in town Staffing additional capacity - the NUH project plan for mobilising the additional capacity includes full details on progress on staff recruitment. This plan is monitored weekly. The biggest risk areas have been identified as: Staffing during escalation - organisational escalation plans are clear that at times of pressure staff need to be focused on direct patient care and that non clinical SPAs, training, non essential meetings etc will be cancelled to release staff to provide hands on care. Organisations have systems to call in additional staff if necessary

Bank holiday cover - providers will ensure appropriate levels of staff are on duty over the extended Christmas holiday based on activity trends of previous years. A focus will be to ensure there are appropriate staff in place who can keep the flow of patients through the urgent care system so that as activity ramps up in early January, there is capacity available.



Physical Capacity within ED Difficulties in maintaining cubicle capacity to meet demand within the ED Emergency Department regularly overcrowded with an increase in admissions of over 70 year olds

Capital project agreed by NUH for additional 10 cubicles to be in place by January 2015 Various community based schemes being put in place to enable people to remain at home - for example risk stratification and care planning in primary care, re-focusing of the community pathfinder scheme to hep professionals staff, including those in care homes to source alternatives community services to prevent admission to hospital where it is safe to do so

Schemes to improve the discharge function and further reduce length of stay - some of which are internal to NUH such as using pharmacists to transcribe TTO medications, and improvements to the community capacity More pathways for direct admission to City hospital to reduce overall length of stay, and bed pressures at QMC

Direct access to specialty advice / urgent clinic slots - including reciprocal arrangements for consultants to be able to urgently contact GPs

Continued work to increase specialty response at the front door

Real time information systems to be utilised -for example the re-launch of the bed management system, an app to enable GPs to access consultants for advice, information on policies, make referrals etc



The A&E 4 hour standard is not being met The plan identifies solutions that will be in place to ensure consistent delivery of the 4 hour waiting time standard by the end of October, but all parties are clear that performance needs to begin to show an improvement immediately. Following the Perfect Week exercise in the early summer, it has been agreed that:

Every ward to have one patient in discharge

lounge by 9am and to have 50% of discharges via

discharge lounge.

Patients to be admitted in clinical need and time

order from ED and AMRU; support to be given to

ED, site matrons and ward staff to stream

appropriately

All specialties to respond to referral from ED

within 30 minute; early escalation from ED to site

matron, with delays recorded and discussed at

weekly Trust capacity meeting

Speciality bronze on call to be implemented in

specialities; good practice within the Childrens

Hospital to be shared so that clear SOPs are in

place for the bronze role

Introduce pharmacy led TTO prescribing on the

wards


8. Testing the plan The system has commissioned McKinsey to review the urgent care pathway with a focus on the flow

within NUH and discharge. The System Resilience Implementation Group is receiving a weekly

update on this work from the Mckinsey's team whilst the review is taking place. This work will be

completed by 29th September 2014. This review, along with a re-run of the Perfect Week (now

known as „Breaking the Cycle) which is scheduled for the last week in September which will give

an opportunity to stress test the plan. A formal „stock take‟ involving all members of the SRG will

take place during October to review the plan in light of feedback from the external review and the

„breaking the cycle‟. A further „stock take‟ is scheduled for mid January 2015.

9. Escalation Plans

Each organisations business continuity arrangements have been reviewed to ensure alignment.

Actions identified to manage surge/increasing pressures within the system, and to release additional

capacity include

• Cancelling training

• Transferring consultant SPAs to „shop floor‟ sessions

• Cancelling teaching sessions so that senior clinical staff can be directed to the areas where

the need is greatest

• Clinical staff within corporate departments take up clinical roles within their competency

levels

• Review of patients who are waiting for discharge to see whether either the discharge can be

expedited, or if not if the patient can be transferred from the Queens Campus to the City

Hospital

Discussion at the System Resilience Implementation Group clarified areas where the actions of one

partner could potentially impact elsewhere in the system.

The system wide escalation plan has been reviewed, amended and agreed by the System

Resilience Implementation Group. The Escalation Plan will Implemented from the beginning of

September and tested during the month of September and specifically through the Breaking the

Cycle week. The plan will be amended as required and will be submitted to the System Resilience

Group on October 7th for final sign off. Each organisation will ensure that their on call staff are

made aware of the new plan, signing to say that they have read and understood it. Copies of the

plan will be included in on call materials.

The mid day conference call will identify the level of escalation at which the system is operating, and

the Programme Director will ensure that all actions appropriate for that level of escalation have been

taken. This includes ensuring that when pressures ease there is a formal communication of de-

escalation.


10. Risk Management Framework

The major strategic risks to the delivery of the System Resilience Plan have been identified with

mitigation actions in place. The major strategic risks are considered to be:

Inability to recruit sufficient staff to open the additional bed as outlined in the plan.

Unplanned changes in capacity (e.g Care Home contract suspension or closure)

Actions identified within the plan are not delivered in the required timescale

Actions taken do not have the expected impact

Unprecedented levels of demand on the system

Inability to remove the non recurrent beds by 31/3/2015

Reduced patient quality / patient experience

The system wide risk register is in place (supporting evidence file) and will be maintained by the

Programme Director for Urgent Care being updated as required following each System Resilience

Implementation Group meeting. The risk register will be formally reviewed by SRIG on a monthly

basis prior to the risk register being submitted to the System Resilience Group for consideration.

The major strategic risks will also be reflected on each partner organisations corporate risk registers

as appropriate.

11. System Governance The delivery of this plan will be overseen by the newly formed System Resilience Group. This group, which has already met to sign off this plan will ensure delivery, receiving reports on any exceptions to progress against the plan, plus any risks so that the system leaders can take the necessary remedial action. The South Nottinghamshire system has recruited a full time Programme Director for the Non Elective Pathway who takes up post from 1st September 2014. The role of the Programme Director is to establish and lead the PMO arrangements to drive the delivery of the plan. A System Resilience Implementation Group (SRIG) has been established from 4th August 2014 and will meet on a weekly basis. The SRIG will effectively operate as the PMO and provide a detailed report to each System Resilience Group Meeting. (See Terms of Reference for SRIG). A standard agenda and action tracker will be used to ensure that current performance is scrutinised as well as ensuring that delivery of the plan is tracked and remedial actions taken in a timely manner if required (see supporting evidence file) Once the Greater Nottinghamshire plan is assured it will be published on the website of all the Greater Nottinghamshire CCGs. Further discussions will be held at SRIG as to whether the plans are also published on the website of all partner organisations.


12. Use of Non Recurrent Resilience Funding The Greater Nottingham System has the following non recurrent Resilience Funding available

Nottingham City £2,114,671

Nottingham North & East £890,319

Nottingham West £569,402

Rushcliffe £678,169

Erewash £312,510

Total Resilience Monies £4,565.07

Resilience Monies

The System Resilience Group (on 29th July 2014) has agreed that the majority of the non recurrent resilience funding will be used to fund additional non recurrent bed capacity. Emergency Rate Threshold Monies The total value of ERT benefit associated with the NUH contract is £5.620m. As was agreed

through the contract negotiations, £1.2m of this will fund the notice period on B50 and has been

transacted through contract. An additional £736k sits outside of the contract to fund the agreed

PMO arrangement.

Of the remaining £3.684m:

- CCGs have agreed to fund non-delivery of emergency CCG QIPP at 100%. To simplify the transactional process and provide a level of certainty for the Trust and commissioners, there will be a non-recurrent adjustment made to the ERT baseline to the value of commissioner QIPP as transacted through the activity plan. For clarity, this will be shown separately by commissioner within the activity plan. The total value of this baseline adjustment is £2.151m. Performance will be jointly reviewed on a monthly basis by the QIPP Delivery Group, who will confirm the position in respect of QIPP non-delivery for sign off at CEB.

- A residual pot of £1.533m remains to be invested in schemes which will reduce emergency admissions. The Trust is not expected to have any financial liability over and above this value in implementing schemes. If the Trust can demonstrate implementation of and delivery against schemes which require less investment than the value of the ERT pot, they can retain the non-allocated investment. However, the Trust will be required to demonstrate that the recurrent impact of reduced admissions would be greater than the new costs incurred and that patient outcomes have improved. All proposals for schemes will be signed off by CEB. This value will be repaid to the Trust on a monthly basis as a block amount (1/12th of annual value).

There will be no in-year adjustment to the ERT fund.


13. East Midlands Ambulance Service Plan The Greater Nottinghamshire system approved the EMAS System Resilience Plan on the 26th August 2014. The plan includes

Increased Voluntary Ambulance Service and Private Ambulance Provision by 120 hours per day.

Recruitment to additional paramedics and ECA.

Establishing a Regional Operations Centre within the Nottingham EOC to provide Senior Manager cover 24/7 to take a strategic overview of service delivery.

Increased dispatcher capacity and creation of an additional Urgent Care Desk

greater nottinghamshire urgent care system · demand / diagnostic demand on acute services...

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