Agenda item

Urgent and Emergency Care Services


David Harper (SWAST) delivered an update on the South and West Devon County Ambulance Service to the Committee, and highlighted the following points-


a)    In July, SWAST saw an increase in ambulance activity, peaking at over 400 incidents per day. Since then, ambulance activity had reduced much closer to expected levels, with 2022-2023 data demonstrating close to pre-pandemic trends;


b)    There had been a particular increase in December 2022, with incidents rising to approximately 380 per day, placing significant pressure on the system. This had likely been due to a combination of Covid, Flu, and Strep-A infections;


c)    Even during peak activity, SWAST had been successful in limiting the number of patients conveyed to ED, to around 34% of all patients seen. This had been achieved through placing emphasis on clinical hubs and a ‘see and treat’ strategy, and had thus prevented excess pressure on ED and hospital services;


d)    Through January 2023, the ambulance service had seen a large reduction in demand, likely due to the reduction in Covid and Flu cases, combined with media coverage of NHS pressures, as well as industrial actions;


e)    SWAST had seen a large increase in frontline vehicle service hours. In 2019-2020, approximately 37,000 vehicle hours had been used, however this was now approximately 48,000 hours. While SWAST was funded for 5,400 hours per week, performance data showed they were often providing more;


f)     There was a noticeable correlation between hospital handover delays, and ambulance repose times. There had been a significant improvement in ambulance response times since the reduction in demand, and handover delays;


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


g)    When an ambulance arrived at the hospital forecourt, hospital staff then assumed responsibility for that patient. However, there was a collaborative responsibility between the ambulance crew and hospital staff while the patient remained waiting in the ambulance;


h)    A new system of rapid assessment and triage had been established, where every patient arriving at ED by ambulance was triaged in the hospital face to face within 30 minutes, before ongoing treatment was organised;


i)     There had recently been a power outage to the sever network at Derriford Hospital, which had compromised the hospitals ability to use the IT network to order clinical services. This had caused significant disruption, and taken considerable time to recover;


j)      There had been a significant increase in ambulance crew on-scene times, with crews trying to manage patients at home, without the need to convey patients to ED;


The Committee praised the hard work and dedication of ambulance crews, and agreed to note the report.


Jo Turl (NHS Devon) delivered a presentation to the Committee on the ‘111 and Out of Hours GP service’, and highlighted the following points-


a)    The 111 and Out of Hours GP service had recently changed to a new provider, PPG. While the winter period had been very challenging and hard to predict or prepare for, there had been strong collaboration across the services, and signs of service improvement;


b)    Call answering and abandonment rates had improved greatly from this time last year despite a very challenging December period however, there remained significant challenges recruiting frontline staff;


c)    While 111 call answering performance had greatly improved, there remained ongoing challenges providing face-face appointments, due to staffing pressures;


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


d)    The service was rated by national targets such as call answering time, and abandonment rate, which did not always reflect the quality or effectiveness of the service provided. Through the improvement programme, patient experience data was now being collected to provide a more holistic evaluation of the service;


e)    Through the improvement plan, NHS Devon were exploring options to digitally transfer patients who called 999 to the 111 service, where appropriate, to prevent patients experiencing additional delays by having to hang up, and call 111 themselves.


The Committee thanked Jo Turl, and agreed to note the report.


Jo Beer (UHP), Ian Lightley (Livewell SW), and Sarah Pearce (Livewell SW) delivered a presentation to the Committee on ‘Admissions Avoidance’, and highlighted the following points-


a)    There had not been a significant increase in attendances at Minor Injuries Units (MIU) or Urgent Treatment Centres (UTC) recently however, there had been a considerable effort to upskill staff, as well as the appointment of a primary care clinical lead for UTC. There were opportunities to consider moving some UTC capacity closer to Derriford hospital, where walk-in activity was high, and could me managed through a UTC to free up space within the Emergency Department (ED);


b)    Community Care teams across the city such as the Community Crisis Response Team (CCRT) and Urgent Care Nursing Service (UCNS), helped reduce emergency admissions by providing early intervention and patient management within the community. Plymouth’s CCRT met the newly introduced national standards, providing an 8am-8pm multi-professional service, assessing patients within 2 hours of referral;


c)    Having identified a significant demand for ambulance and ED resources related to patients falling at home, these teams had demonstrated significant success at preventing admissions to hospital. From 20 February 2023, a dedicated 24hr ‘fallers response service’ would be provided;


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


d)    The ongoing integration of locality services was designed to bring a greater ‘wrap around care’, focussing on prevention. The majority of primary care networks were now signed up to ‘Aging Well’, focussing on a frailty prevention strategy;


e)    Workforce and recruitment remained one of the largest challenges however, long-term workforce plans were being developed, and progressing;


f)     Livewell SW provided a 24hr Mental Health Response service through a multi-professional team, delivering telephone and face-face crisis response. Towards the end of the year, there had been a significant increase in call volume, leading to a reduction in calls answered. However, this had since recovered, and the call abandonment rate after 60 seconds was within the national 5% target. After each call, the crisis was either resolved, or referred to additional partner services for further support;


g)    UTCs and MIU services had seen significant improvements since last year, where services were forced to close on a regular basis due to staffing issues. Work in recruitment and training had ensured closure rates had dropped from around 25% a year ago, to under 1% today;


h)    A directory of services had been introduced for medical professionals to signpost patients to the most appropriate service, and ongoing work was being undertaken to ensure ease of access and awareness;


i)     Frequent users of ED were being reviewed to assess measures to prevent frequent admittance, and NHS Devon had commissioned Immedicare, providing care homes with quick access to clinical advice, as an alternative to hospital admission. This had shown positive results across the country, with potential to reduce admissions by up to 50%. 48 care homes were currently undertaking the trial in Plymouth;


The Committee thanked Jo Beer, Ian Lightley, and Sarah Pearce for the report, and agreed to-


1.    Receive an update on progress at a future meeting;

2.    Note the report.


Jo Beer (UPH) delivered a presentation to the Committee regarding ‘Same-day Emergency Care’, and highlighted the following points-


a)    Demand in ED had steadied since the last Covid peak however, ED had experienced an increased sickness of patients presenting at walk-in, primarily due to ambulance delays. Since improvements to ambulance capacity and performance, the number and severity of ‘walk in’ patients had now reduced;


b)    The standard dictated that all patients should be assessed within 15 minutes of arriving at ED. This was more consistently met for people arriving in Ambulances, than ‘walk-ins’ however performance metrics were on an improving trajectory. The introduction of a Rapid Assessment and Treatment area within ED was hoped to further reduce waiting times;


c)    It was widely recognised that ED delays were detrimental and distressing to patients, their families, and staff. In December, the longest wait for a bed following ED admittance, was 19 hours. The mean time for discharge from hospital was 6 hours. This resulted in delays at ED due to lack of ward capacity to move patients onwards. There were ongoing improvement projects to improve discharge rates across the hospital. At the time of this meeting, there were no patients waiting over an hour for ambulance handovers;


d)    The hospital had recently experienced nursing and ambulance strikes, further adding to pressures;


e)    The number of patients arriving at ED with mental health related illnesses had increased recently, and thus required improvement;


f)     The Acute Assessment Unit was designed for patients who did not require admission, but required examination or tests, before returning home with support and a treatment plan. Recruitment was currently underway to expand this services hours of operation, to free up capacity within the hospital. UHP was within the top 50 trusts for same day emergency care, and had aspirations to improve further;


In response to questions from the Committee, it was reported that –


g)    It was sometimes necessary to ‘fast-track’ patients at ED who arrived after others, due to greater clinical need and/or involvement of other emergency services. While this was often seen as unfair, it was sometimes necessary for safety, and to reduce disruption to the department;


h)    There had been significant improvements to Plymouth and Devon’s discharge delays from hospital however, these trends were not present for Cornwall, leading to reduced hospital capacity;


i)     ED staffing was a great challenge, and although significant improvements towards education, recruitment and sustainability had been made, the ED regularly operated over designed capacity.


j)     Derriford no longer had a Clinical Decision Unit (CDU) within the ED, as it been replaced by the HALO space, to assess those unloaded from ambulances. This space would soon be used for the new Urgent and Emergency Care Centre. A business case for a UTC on the derriford site had been developed, and land purchased, following recommendation from the national team. Funding was now being sourced.


The Committee thanked Jo Beer for the update, and agreed to note the report.


James Glanville (NHS Devon), Ian Lightley (Livewell SW), Gary Walbridge (Head of ASC and Retained Functions, PCC) delivered a presentation to the committee on ‘Hospital Discharges’, and highlighted the following points-


a)    Pre pandemic, Plymouth experienced good hospital discharge times however, due to Covid pressures, discharges now regularly involved considerable delays. Plymouth struggled to discharge more patients than were admitted per day, and had installed a target of 5% no right to reside within the acute trust;


b)    It was important to tackle discharges holistically and as a collective, incorporating the community care services, PCC, and the voluntary sector;


c)    On the morning of this meeting, Plymouth had experienced 22 discharge delays, Devon had experienced 8, and Cornwall had 47. These figures showed significant progress, meeting the 5% target however, there was still considerable work to do to reduce Cornwall’s discharge delays;


In response to question from the Committee, it was reported that-


d)    ‘Winter Pressures’ monies had been guaranteed for another two years at similar levels, with possibility to increase year on year. There were already plans being developed to ensure capacity net winter. The Care Hotel had been utilised to provide additional capacity this year, and plans were ongoing between Livewell and PCC to reduce need for this through expanding services such as the ‘Home First service’, ‘Hospital to Home’ and the ‘Short Term Care Centre’;


e)    A review of all discharge services was being undertaken post-pandemic, to evaluate their performance ahead of expected high demand next year;


f)     There were a number of training and recruitment initiatives underway for GPs across the South West to address staffing and retention challenges however, this was a long-term strategy, and was unlikely to lead to a rapid workforce solution;


g)    Due to demand, capacity and resourcing pressures, the health service across the board had been driven to innovation and change. New ways of working had been developed, and practices were unlikely to return to pre pandemic systems and public perceptions.


The Committee thanked James Glanville, Ian Lightley and Gary Walbridge for the update, and agreed


1)    To Recommend that Healthwatch be recommissioned to repeat their patient experience survey of ED following the numerous improvement strategies and works detailed at this meeting;


2)    to note the report.


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