Agenda item

Report of the Chief Operating Officer, UHCW

 

The Board considered a briefing note of the Scrutiny Co-ordinator and a verbal report and presentation of the Chief Operating Officer, UHCW, which provided an update on the current position of Urgent and Emergency Care (UEC) at UHCW.  The briefing note also provided an update on virtual ward capacity and progress and an update on elective care and the impact of continuing industrial action.

 

The national target for 4-hour performance within the Emergency Department was 76%.  Year to date, UHCW was performing at 72% in comparison with this.

 

The Improving Lives Programme was a priority for UHCW and integral to achieving an improved 4-hour performance and improved patient experience.  It was a partnership programme, across Coventry Care Collaborative, which was about fundamentally changing the way we support people in Coventry with urgent need.  It sets out to prevent avoidable hospital attendances and admissions, reduce hospital length of stay and ensure patient discharge as soon as medically fit. 

 

A number of trials had already evidenced improvement and throughout January the improvements would be rolled out across all hospital wards so that the benefits could be realised for all patients across all specialities.  This would be sponsored by senior leaders further evidencing the commitment of UHCW to achieve improvements for urgent and emergency care pathways. 

 

In addition, a ‘discharge pull’ model of care would go live, ‘pulling’ patients into community provision as soon as medically fit, as part of the One Coventry Integrated Team model.

 

However, it was recognised that despite the ongoing improvement work that Improving Lives was delivering, there would be challenges with patient discharges to packages of care over the winter period. 

 

There were several supportive strategies in place to aid the discharge process with the aim to reduce length of stay, including:

 

·  Regular escalation meetings.

·  Confirm and challenge weekly with all clinical groups for patients with long length of stay (LLOS) >14 days.

·  Discharge before 12pm and before 5pm weekly meetings to focus on driving early discharges.

·  Quarterly Multi Agency Discharge Event (MADE) meetings.

 

Ambulance handover performance remained a priority in order to ensure patients were handed over to the Emergency Department within 15 minutes and waited no longer than 30 minutes, thereby releasing paramedic crews to respond to outstanding calls.

 

In the year to date, 40% of patients had been handed over within 15 minutes compared to a West Midlands average of 36%.  In addition, 80% of patients had been handed over within 30 minutes compared to a West Midlands average of 73%.  During the same time period, 7% of patients waiting in excess of 60 minutes for handover compared to a West Midlands average of 12%.

To support ongoing improvement, in ED there was daily focus and review of ambulance handover times. A regular ‘huddle’ in ED was in place, in conjunction with the HALO, to review daily performance and respond accordingly. This was proving beneficial and would continue over the winter period. 

 

In addition, Same Day Emergency Care (SDEC) continued to be operational providing an option to avoid hospital admission for those who were suitable. Over the winter period opening times would be 08:00 – 22:00, 7 days per week. Medical SDEC currently treated, on average, 55 – 60 patients per day.  The Medical SDEC model was Consultant led and supported by a multi-disciplinary workforce mainly comprising of senior clinical fellows and ACP’s. Work was continuing to improve efficiencies and develop the offer, including bookable slots for patients who presented out of hours or during surges of activity. This was aimed to be piloted in December 2023. This service routinely accepted more than 100 patients conveyed directly by WMAS each month. 

 

Frailty SDEC was in place and would continue over the winter in order to ensure patients avoid admission where possible. The opening hours were 08:00 – 20:00, 5 days per week.  The Frailty SDEC model was Consultant led and supported by a multi-disciplinary workforce comprising of ACP’s, Pharmacists, REACT and a Social Worker.  Work was continuing to develop and increase throughput through this service.  This included a bespoke telephone number for paramedics to call to discuss suitability of direct conveyance and a push model instead of pull model into the service.

 

To be more resilient, the Emergency Medicine Group had been working through several transformation projects to provide efficiencies in the system thus building capacity and resilience. Examples of this included:

 

·  Direct Access Pathway ward moves to collocate Acute Medicine services in one location.

·  Review of Directory of Services to ensure patients are appropriately directed.

·  Continuation of the co-located UTC to see, treat and discharge low acuity patients, this includes booking patients into appointment slots from ED overnight.

 

UHCW host a 40 bed capacity Hospital@Home virtual ward programme offering patients with acute illness a safe alternative to bedded care. The Hospital@Home service, led by a medical consultant, supported patients with frailty, heart failure, acute respiratory illness, infection and general medicine conditions. Hospital@Home had the capabilities to offer digital support in the home as well as administration of IV medications and medical monitoring.

 

The Trust continued to work hard to transform Elective Care and was focused on reducing the number of patients on waiting lists, specifically 78, 65 and 52 weeks.

 

Industrial Action had been a factor in hampering the ability to reach zero, as pathology and radiology delays were the most impacted services as a result of industrial action. 

 

UHCW was ahead of trajectory to meet the 65 week target by March 2024.  A range of short, medium and long term actions were in place to ensure the trajectory was maintained including:

 

·  Insourcing

·  Outsourcing

·  ISP use

·  Mutual Aid

·  PIDMAS

·  Robust validation

·  Consultant triaging of referrals via RAS platforms

·  Additional sessions

·  HVLC pathways

 

UCHW’s DM01/Diagnostic performance had also seen a rapid improvement over the last 6 months with further improvement expected.  Low waiting times for diagnostics would aid the ability to achieve the 65 week performance by March

 

Industrial action had an impact on radiology and pathology turnaround times, which in turn delayed pathways across the services, in particular for routine patients.  There were over 1,700 MRI’s to be reported and 3 week delay for skin pathology results. Mutual aid had been enacted for pathology across the system and outsourcing capacity had been secured.

 

Councillor K Caan, Cabinet Member for Public Health and Wellbeing, thanked officers for the report, highlighting the effectiveness of the Improving Lives Programme, whilst recognising the multiple challenges at UHCW, stressing the benefits of the presence of GP’s on site in A&E and recognising that each patient would provided with support, care and treated with dignity.

 

Members of the Scrutiny Board, having considered the content of the report and presentation, asked questions and received information from the Chief Operating Officer, UHCW, on the following matters:

 

·  The y axis on the 65+ Week Waiters slide represented patient numbers.

·  There had been a significant improvement in elective and emergency department wait times since the opening of the Coventry Urgent Treatment Centre.  Training and education for staff had been undertaken to ensure patient care was consistent across the board.  Telehealth was being investigated so patients would not need to travel between sites.

·  The national target for 65+ week waiters as of March 2024 was zero and this was UHCW’s plan.  South Warwickshire and George Elliot hospitals were currently ahead of the trend however, their profile and complexity was not so complex as that of UHCW.

·  Additional theatre staff had been employed through Medinet, to allow theatre sessions at weekends, which helped with elective care capacity.

·  Patients were being seen locally by specialist teams (not employed by UHCW) in gynaecology and dermatology.

·  An acute bed in UHCW cost approximately £250 per day.  More specialised areas would incur a greater cost.

·  UHCW worked with a number of partnership colleagues in order to improve waiting times.

·  Whilst clinical judgment was used to determine wait times, UHCW worked closely with Netcall in order to keep patients advised of wait times.  Netcall routinely contacted patients every 3 months via text.  Those patients who did not have access to digital platforms were contacted via letter and telephone calls.

·  Patients had been reached out to on a national level via the Digital Mutual Aid System.  If a patient had been on the wait list for more than 40 weeks, they could request to have their care transferred to another hospital.  7000 patients fell into this category, 400 of which had asked to explore the system.

·  UHCW were addressing the challenges of patient wait times.  An additional health care professional was available in A&E 24/7, 7 days a week to support patients in the waiting rooms and respiratory hubs and GP’s with specialist interests were being used to reduce pressures on A&E.

·  When hospital beds were at 92% capacity, patient flow was good however, at 98% (current), flow was slower and ambulance wait times longer.

·  There was an inequity of access to private medicine across the population and ENT was UHCW’s most challenged area.  A community clinic had recently opened in Cheylesmore, providing ENT outpatient treatments and additional capacity.

·  UHCW were undertaking research in the ENT space and hoping to raise ENT’s profile.

·  Weekend hospital discharges was an area for improvement as only half the number of patients were discharged over weekends than during the week, with risk being the main factor. Other factors included old equipment in pathology; replacement equipment would result in quicker turn around times and pharmacy turn around times.  The recent purchase of 2 pharmacy dispensary robots had quickened the dispensary process.

·  To provide a full weekend discharge service, would be resource intensive and financially challenging.

·  Emergency re-admissions were where patients were re-admitted to hospital within 28 days.  If patient discharge was planned from admission, then it was more likely to be successful.

·  Planning for early discharge for patients was important so that stay was not delayed and beds blocked.

·  Each patient was challenged every day regarding length of stay however, there was a cohort of patients ie. Homeless, complex mental or behaviour needs, who tended to get stuck in hospital.  These patients required focus to unblock difficult issues.

·  Criteria led discharge was being implemented.  This was led by consultants for groups of patients with specific objectives to meet in order to be discharged by nursing staff.

·  A lot of activity was taking place around recruitment and retention including the culture of the organisation and making UHCW an attractive employer. And there had been notable success in midwifery and nursing.  UHCW worked in partnership with Coventry University, Warwick Medical School and the Community Diagnostic Centre as feeders.

·  Emergency medicine consultants and teams worked a 24/7 rota.  Staff working over the weekend in A&E were of the same number and medical skill as those working weekdays.

·  Ward based patients were more likely to become stuck in hospital over the weekend due to lower numbers of consultants and the element of risk.

·  Frailty SDEC was same day emergency care and was within A&E but downstairs in the medical assessment unit.  It provided an outpatient setting for patients with frail medical needs and those that did not require to be admitted.

·  The biggest impact on the workforce had been the pandemic.

 

The Chair thanked the Chief Operating Officer, UHCW, for the report and presentation on A&E waiting times, advising each patient was different, individual and would be treated with dignity. 

 

Members requested the following information:

 

• Emergency re-admission data
• Circulate of presentation slides

 

RESOLVED that the Health and Social Care Scrutiny Board (5):

 

·  Notes the work being done with projects ongoing and planned to take place at UHCW to improve the quality of care for our patients, together with the ongoing challenges faced.