Item 8.2 for 4 June 2013 Acute Sector Winter Update

NHS GRAMPIAN

Acute Sector Winter Report 2012 – 2013

Aim

The purpose of this paper is to summarise the acute sector’s experience and response during the 2012-13 winter period.

Strategic Context

The Emergency Care Centre (ECC) became operationally ready in December 2012.

The £110m investment in the ECC supports NHS Grampian’s Healthfit 2020 vision by:

providing a focus for the modernisation of unscheduled care across the North East and North of Scotland

being a significant step in the redevelopment of the Foresterhill campus by bringing together unscheduled care services in one facility

supporting partnership working across agencies i.e. involving NHS Grampian, NHS24 and local authority staff to improve unscheduled care services

Dr Gray’s Hospital is undergoing a refurbishmentprogrammein order to enhance the acutefacilities offered to the population of Moray. This work is due for completion in September 2013.

Discussion

One of the main indicators of quality and organisational responsiveness to winter pressures is performance against the government standard of 98% of patients discharged or transferred from A&E within 4 hours. NHS Grampian’s performance against the standard for 2012/13 was 95%. However, during the winter period of November 2012 – March 2013, this reduced to 94%. Grampian’s position is generally above the Scottish average.

NHS Grampian has a history of performing well against the 4 hour standard and facing the challenges of increasing levels of admissions through its medical admission areas in addition to the traditional front door of A&E. However, performance against the standard has not always been consistent. This apparent inconsistency cannot be explained entirely by seasonal variation or demand. There is extensive work being done by the NHS Grampian Unscheduled Care Network to identify sustainable alternatives to admission for patients. However, for those patients who still access the hospital directly or require admission, it is necessary for the acute sector to develop local capability and capacity to manage patients efficiently and effectively. In order to do this we recognise the need to actively engage staff in the challenge of delivering the standardfor significant and sustainable improvement to be achieved.

There have been two separate multi-disciplinary and multi-agency participative sessions regarding the organisation’s response to winter pressures in 2012-13. The first was held on 30 January by the Clinical Operational Management Team (COMT) and the second was on the 15 February which was the annual seasonal debrief. Both of these sessions were focused on improving unscheduled care servicesand learning from recent experiences.

A key action arising from COMT was to have an agreed data set for reporting on key performance and quality indicators such as the 4 hour standard, numbers of patients transferred to other wards, re-admission rates and length of stay. The data presented at the meeting provided an overall positive picture since the opening of the ECC. However, it is important to recognise that ongoing review and monitoring is required.

Initial data showed that the requirement to move patients reduced in the first two weeks of 2013 compared to previous years. However, over-interpretation is to be avoided until a robust intelligence stream is in place. The provision of robust and consistent data will help provide support actions required in preparation for winter 2013-14.

The actions from the seasonal debrief included the need to move to seven day working for all services including AlliedHealth Professions (AHPs) and support services. Further key factors were: the need to augment our discharge capacity via the introduction of an internal transfer team, the use of the discharge lounge and increasing transport responsiveness.

A significant factor noted at both COMT and the seasonal debrief was the impact of patients remaining in the acute sector when they were no longer receiving or needing acute care provision. A snapshot was taken on 27 January 2013 of patients in ARI who no longer required acute care but were in hospital awaiting care at home, a care home or another NHS environment. Although these patients were not technically delayed discharges, in terms of overall patient experience, it is important that patients are in the accommodation most appropriate for their needs. On 27 January there were 55 patients whose discharge was subject to delay. The combination of these patients’ bed days equated to 933 bed days lost. It is clear,as we prepare for winter 2013-14, that further work is required with social work colleagues and other NHS environments to improve our pre-planning and prediction of demand and capacity requirements.

Throughout the winter period Dr Gray’s experienced pressures on beds due to:

fewer beds being available overall
the number of patients whose discharge was subject to delay.

A reduction in bed numbers hadan impact onthe hospital’s ability to manage within its bed base. “Treat and transfer” has been enacted from Dr Gray’s on 28 occasions since 11 January 2013 with patients actually transferred for capacity reasons on 26 occasions. This was predominantly formedical patients but also included surgical patients. Between 11 January 2013 and 19 May 2013, 49 patients were transferred for capacity reasons and 86 for clinical reasons.

There was also an increase in the number of elective patients postponed for theatre in DrGray’s because of bed capacity issues - 10 patients in 2011-12 and 26 in 2012-13.

Resource implicationsfor winter 2013-14

For winter 2013-14, ARI will need to revisit the use of a winter expansion ward and this will have a cost implication. The cost is yet to be determined but potentially could be supported via the reconfiguration of existing capacity.

Dr Gray’s may need to explore the use of its day case ward to support overnight stays in order to expand for elective capacity when unscheduled activity exceeds capacity. The cost of this is yet to be determined.

The requirement for appropriate and responsive discharge is paramount for non complex patients. The availability of appropriate transport – either through the Scottish Ambulance Service (SAS) or through community/voluntary transport providers is key to this. Therefore the sector must look to improve its discharge planning to ensure adequate notification to the SAS and also support opportunistic discharge via the use of an internally provided transport solution.

The acute sector must enhance its internal transfer team function; this may also have a cost implication for the Facilities Department.

A&E services in both ARI and Dr Gray’s face workforce issues that have the potential to significantly impact on service provision in 2013-14. Recruitment arrangements require to be reviewed to ensure appropriate levels of staffing for GMED and A&E.

Risk

The relevant strategic risk is 851: Delivery strategies are not aligned to meet the future needs of the population.

Conclusions

The opening of the ECC in December 2012 enabled NHS Grampian to deliver patient centred care to the population of Grampian in an efficient and effective manner. Although there was a reduction in the number of patients attending A&E in ARI in 2012-13 this should be seen in the context that it is a 1.8% reduction only on the previous year following a trend of annual increases. However, Dr Gray’s did experience an increase of 13% in their A&E attendance numbers.

There is work still to be completed in order to meet the 4 hour standardconsistently, irrespective of the season.

The acute sector is focused on improving unscheduled care provision to the population of NHS Grampian.

Recommendations

The Board is asked to:

Note the work being undertaken within the acute sector to manage its unscheduled activity.
Support the provision of accurate and consistent intelligence data for all unscheduled quality indicators such as length of stay, readmission rates etc.
Support the strategic direction of the Unscheduled Care Network in order to reduce the number of patients admitted into the acute sector.
Support the development of closer working with social work in order to manage demand across health and social care more effectively.

Executive Lead

Dr Pauline Strachan, Deputy Chief Executive and Chief Operating Officer

Prepared by: Clare Smith

Designation: Divisional General Manager, Acute Sector

Date: 15th May 2013