1)    111 and Out of Hours Primary Care

2)    Ambulance Handovers

3)    Admission Avoidance

4)    Same Day Emergency Care + Emergency Department

5)    Hospital Discharge

Dr Dafydd Jones (GP) & Jo Turl (Director of commissioning for NHS Devon) delivered a presentation on Integrated Urgent Care, 111, and Out of Hours General Practise, and highlighted the following points to the Committee-

1.    The Integrated Urgent Care Services (IUCS) currently provided by Devon Doctors were underperforming however, there were both short-term and long-term plans in place to resolve many issues;

2.    The 111 service suffered from a low call answering capacity due to unplanned absence, insufficient weekend establishment, high attrition rates and recruitment difficulties;

3.    The 111 service was however, effective at signposting and triaging to reduce unnecessary demand on 999 and the Emergency Department;

4.    There were contingency plans to enable national flexibility when regional call handlers reached capacity. This was now being used on a planned basis due to demand pressures;

5.    Plymouth had a comprehensive procurement plan in place for a long-term solution: From 1 October 2022, ‘Practise Plus Urgent Care Group’ (PPU) would be taking over the contract from Devon Doctors, bringing greater national capacity, flexibility, experience, and a rating of ‘outstanding’ for 111 call handling. 

The Committee welcomed the various measures enacted to improve Integrated Urgent Care Services. In response to questions raised by the committee, it was reported that-

1.    Devon Doctors were in ‘special measures’, with demand outstripping capacity however, the new provider (PPU) had enhanced capacity and flexibility in times of peak demand;

2.    Workforce and staffing issues were an ongoing national issue that did not solely impact on Plymouth;

3.    Temporary creative solutions were currently in place to bolster staffing including; flexible hours, incentive schemes, and the return of retired staff.

The Committee agreed it would prove beneficial to invite Dr Dafydd Jones & Jo Turl back once PPU had taken over from Devon Doctors in October 2022.

David Harper (County Commander SW Devon- SWAST), James Glanville (Head of Urgent and Emergency Care- NHS Devon), James Wenman (Associate director for Urgent Care), & Jo Beer (Chief operating officer- Derriford Hospital) gave a presentation to the Committee on ‘Ambulance Handovers’, and highlighted the following key points-

a)    Ambulance demand had reached unprecedented levels last summer, with over 400+ incidents per day, compared to 335 per day in April 2022, and 333 per day in May 2022. This had now returned to more expected levels;

b)    There were now significant delays in ambulance response times for category 1 and 2 calls, which correlated with increased hospital handover times. These handovers now regularly exceeded 3hrs and caused a significant reduction in the amount of patients seen by the ambulance service each day;

c)    Increased activity was not seen as a major factor driving increased response times in SW Devon, with 65% of patients managed without admittance to the ED.

Following questions from the Committee, it was reported that-

a)    There were specialist teams investigating patient safety incidents where unnecessary harm may have been caused by handover/ response delays.

The committee requested this data be brought to the next meeting;

b)    While there was currently a single point of entry to University Hospitals Plymouth (UHP), there were alternatives being considered, as well as admissions avoidance strategies and alternative pathways;

c)    A business case was being prepared for a new Urgent Treatment Centre (UTC) on the NW quadrant of Derriford Hospital. A funding bid was being launched to secure the capital necessary;

d)    Ambulance attendance at care homes had reduced but there was ongoing work being done to enable staff to assist residents without the need for an ambulance response;

e)    While SWAST had seen a reduction in patient demand in recent months, this could likely be the result of people attending on-foot themselves, due to delayed ambulance response times.

The Committee requested that further information regarding the 111 service and trialling of hospital admissions systems be provided outside the meeting.

Jo Beer (Chief Operating Officer- Derriford Hospital), Ian Lightly (Head of Integrated Community Services- Livewell SW), and Sarah Pearce (Head of Adult Frailty and Specialist Services- Livewell Southwest) delivered a presentation on ‘Admission Avoidance’ to the committee, and highlighted the following key measures in place to reduce unnecessary ED attendance-

1)    There had been an increased demand at Minor Injuries and Urgent Treatment Centres in last few months (Kingsbridge Tavistock & Cumberland). Despite reduced opening hours due to staffing issues, patient through-flow had been maintained;

2)    Staff were being trained in a ‘Practitioner model’ to allow them to treat minor injuries/illnesses at a variety of locations; 

3)    The 111 service provided a ‘Directory of Services’ to correctly signpost and triage patients;

4)    The open access Mental Health 1^st Response Service provided by Livewell SW had seen increased demand;

5)    The multi-professional Community Crisis Response Team had recently increased their hours to 8am-8pm to offer patients home alternatives to hospital admission;

6)    Same-day emergency care pathways which had closed during the pandemic had been reopened, achieving targets of 40%. New targets of 50% of patients to be treated through the same-day pathway had been set.

In response to questions from the Committee, it was stated that-

a)    A new electronic record system (Nerve Centre) had been introduced in ED to enable the tracking and analysis of attendance statistics;

b)    Negative press coverage of the challenges in accessing health resources such as the 111 service, GPs, and ambulances had undermined the ‘Choose-well’ campaign and led to many patients bypassing triaging to attend ED directly;

c)    The construction of the West End Health Hub presented an unprecedented opportunity to succinctly integrate primary care, community services, and the voluntary sector;

d)    Plymouth would need additional resources in the long-term to deal with the backlog in elective care. Plymouth was part of the national ‘New Hospitals Programme’, and there were plans in progress to construct a Planned Care Centre on the NW quadrant at Derriford;

e)    The new ED build would start this year.

The Committee praised the admissions avoidance measures in place to reduce unnecessary ED attendance, and long-term plans to increase capacity.

The Committee reaffirmed their support for the West End Health Hub.

Jo Beer (Chief Operating Officer- Derriford Hospital) delivered a presentation to the Committee on ‘Same Day Emergency Care and ED’, and highlighted the following key points-

1)    Plymouth stood in the top 10 challenged trusts for ambulance performances, and top 5 for ambulance handover delays. This deterioration started in March 2021;

2)    There had been a reduction in ambulance arrivals at ED, but an increase in walk-ins;

3)    The primary issues preventing ED offloading patients from ambulances were space, flow, and staff problems;

4)    The resumption of ‘same day emergency care pathways’ which had been closed during peak-pandemic, had since resulted in a gradual and continued improvement;

5)    Ensuring coordinated and timely patient discharges was essential to the smooth-running and flow of ED. Complex discharges presented a significant challenge, currently falling below the lunch-time daily target of 30%. Daily discharge targets for 5pm were being met;

6)    A bespoke discharge lounge had been created with 17-20 chairs. Patients awaiting discharge could also be placed in ward corridors to free up bed space;

7)    Staff sickness and unplanned absences presented a significant challenge. At the date of this committee meeting there were approximately 120 patients in Derriford with Covid-19, and 400 staff on sick-leave with Covid-19;

8)    Derriford routinely operates at 104% capacity, with ED regularly receiving more patients than its staff/ design capacity;

9)    Plymouth had substantially reduced its lost-bed days due to discharge delays however, support was being given to Cornwall to do the same.

In response to questions from the Committee, it was stated that-

a)    Ongoing work was being done to improve Pharmacy delays in patient discharges;

b)    The District Nursing Service was available through GP referral, which helped reduce ED attendance;

c)    It was too early to specify when services would return to a previous standard. Many measures were currently in place to alleviate pressures, but long-term solutions would take time;

d)    UHP would look at the possibility of fast-tracking international staff applications however, it often proved difficult to validate/ transfer international qualifications. A health Skills Partnership had been created to assist recruitment and retention issues.

The Committee thanked staff for the presentation and recognised the ongoing challenges, and improvements being made.