2018/19 Oxfordshire System Winter Plan

Prepared by Systemwide Winter Planning Group Approved by Integrated System Delivery Board

August 2018

1

Aim of the System Winter Plan Winter period is 1 November 2018 to 31 March 2018

2

To ensure the Oxfordshire health and care system: – is Resilient throughout the winter period - providing

safe, effective and sustainable care for the local population

– has sufficient Capacity available to meet likely demands over winter

– is able to deliver Care for Patients/clients in the most appropriate setting

– ensures Safe and Effective transfer of patients/clients within the system

– Is able to Achieve national and local access targets and trajectories across the system

Home First Ethos

3

• Prolonged bed rest in older people can lead to substantial loss of muscle strength and physical activity. 10 days in a hospital bed (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80.

• Patients’ time is the most important currency in health and social care #Red2Green #Last1000days #endPJparalysis • ‘No Wasting of Patient’s Time’ – Unnecessary Waiting + Sleep Deprivation = Deconditioning Our overarching aim is to prevent deconditioning and enable independence for older people in hospital.

Oxfordshire’s Winter Plan On a page

The Issues

The Risks Demand risks • Significant increase in flu • Significant adverse weather event • Significant supply chain issue Capacity Risk • Major provider failure • Major staff shortages • Significant business continuity issue

A shared business continuity approach to managing risks

The Actions • Organisational winter plans • Shared agreement • An investment portfolio • Projects to make the difference • An integrated winter team to

deliver and manage across the system

The Team • A winter director coordinating a

single team (OCC / OUHFT / OHFT / SCAS / OCCG ) managing flow and performance across the health and social care system

• Seconded in staff, responsibility, and authority

• Operating seven days a week, 8 to 8 • The winter director accountable to

chief executives and works with COOs across the system to build trust and deliver outcomes

The Outcome

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THE ISSUES What is the size of the winter gap and what is driving this?

The A&E department Patient flow

Long stay patients

Discharges Bed occupancy

Flu Resilience Workforce Admissions

Key factors

Who’s occupying the beds

The A&E department, demand and

discharges improved in 2017/18

In hospital metrics deteriorated

in 2017/18

Rising occupancy reduces performance, with accelerating effects above 92%

1/3rd of the growth in emergency admissions came from flu in winter 17/18

Long stay patients can decrease performance by reducing bed flexibility

NHS Improvement Economic Review Oxford: summary of factors affecting performance

7

362

177

258

173

429

329 344 397

308

387

523 506

702

918

764 811 822

647

777

441 416

590

735 731

557

418

Capacity and Demand Gap Bed Days

Bed day gap (CF)

The Gap Over Winter

THE RISKS What are the key risks the winter planning group were concerned about?

Demand risks

• Significant increase in flu

• Significant adverse weather event

• Significant supply chain issue

Capacity Risk

• Major provider failure

• Major staff shortages

• Significant business continuity issue

9

Key Risks

Business Continuity (Plan B)

• Agreement to bring together BC leads across organisations to plan responses to risks

• The winter director will lead this in conjunction with the winter planning group.

• Shared responsibility and shared plans

THE ACTIONS What have we done so far

Learning from Winter 2017/18

• Building on work already started in 2017/18 we aim to further strengthen our Home First approach

• There are further opportunities to improve flow out of hospital through a person-centred approach focussed on people’s strengths and capital. Using the learning from the Age UK work in short stay wards and Red Cross Pilot in ED.

• We can continue to make significant improvements from and high quality and consistent MDT approaches and our approach to long stay patients (e.g. OCC-OH work in community hospitals and OUH-OCC work around stranded patients)

• System focus on long stay patient approach

Partner organisations have created detailed winter plans focused on their areas of work.

OUHFT, OHFT,OCC,SCAS are embedded in this slide

13

Organisational Winter Planning

Winter Plan 2018/19

Adult Social Care

Key Summary Information

Description

This document details Oxfordshire County Council’s approach to supporting health and social care over the winter of 2018/2019. The document records the key areas of focus and the planned changes to be made. These changes are aimed at ensuring people receive the right care, in the right place, at the right time, at a time of increased demand and system pressure.

Date 24th July 2018

Author Craig Williams, Rachel Pirie, Victoria Baran, Steve Thomas

Sponsor Kate Terroni, Director, Adult Social Care

Senior Responsible Officer: Benedict Leigh, Deputy Director, Commissioning Karen Fuller, Deputy Director, Operations

Version No 1.8 Final Draft

Title Winter Plan 2018/19 (Update June 2018)

Status For approval

History Presentation to Finance & Performance Committee 13th June; Trust Management Executive 28th June.

Board Lead(s) Ms Sara Randall, Acting Director of Clinical Services

Key purpose Strategy Assurance Policy Performance

SCAS Winter Plans

Demand and Capacity Management

Using Planning and Forecasting software we are able to accurately predict the

demand for the winter period and then match this demand with staff hours. This

includes reducing the annual leave capacity over the two week Christmas period as

well as increasing OT and bank staff capacity as well as out private ambulance

cover. This has been effective of previous years and maintained a higher out put of

staff hours

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Start date End Date Lead

1 Staged Increase of community beds from 142-150 Carol Duncombe

1.1 Didcot increase by 4 beds 17/08/2018 Carol Duncombe

1.2 Abbey increase by 4 beds 01/09/2018 Carol Duncombe

1.3

Bicester will be back to beds by 16/8 due to painting work; then 8 additonal bed will incrementally be available by

September bringing total to 132 16/08/2018 Carol Duncombe

1.4 Winter escalation beds at Didcot (+1); wallingford (+4); Linfoot (+2); Wenrisc (+2-4) bringing the total to 143 30/10/2018 Carol Duncombe

1.5 Increase SRU bed capacity from 16 to 20 depending on staffing in line with our core buisness- total bed stock 147 30/10/2018 Carol Duncombe

1.6 City staffing remains tenuous- options paper to be reviewed including considertations for virtual beds to plug the gap 30/09/2018 Carol Duncombe

2 Frailty Pathway- Bronze and Silver Lucia Winrow

2.1

Scheduled: business as usual, staffing and annual leave, training,

17/09/2018 Lucia Winrow

2.2

Two Hour Response: mapping out staff with frailty module training so they can be redeployed to pick up pateints form

SCAS in 1 or 2 hour window. Clincal criteria with SCAS, comms to teams and sticker in patients homes. 18/09/2018 Lucia Winrow

3 COPD Lucia Winrow

3.1 proactive care plans 31/08/2018 Lucia Winrow

3.2 responding to scas within 2 hours 31/08/2018 Lucia Winrow

3.3 home oxygen reveiws suspended for some patients 31/08/2018 Lucia Winrow

3.4 PGDs for nebulaisers and steriod. Patient packs with drugs 17/09/2018 Lucia Winrow

3.5 pulmonary rehab for housebound when they discharged 17/09/2018 Lucia Winrow

3.6 staff top tips for other services 13/08/2018 Lucia Winrow

3.7 identify patients (550 per year) that have less than 48 hour stay 13/08/2018 Lucia Winrow

3.8 identify patient with LOS that over 10 days (67 patients) and reduce this by 1 day per patient 13/08/2018 Lucia Winrow

4 Care Home Support Lucia Winrow

4.1 identify five top care home that have most admissions and then undertake targeted work to reduce this 10/08/2018 Lucia Winrow

4.2 visiting weekly on the targeted care home 05/10/2018 Lucia Winrow

4.3 advanced care plans in place for patient 05/10/2018 Lucia Winrow

5 Hospital at Home (PML, OH and OUH) Chris Hewitt

5.1 Identify geographical areas each provider will be covering: north, city, south 13/08/2018 Chris Hewitt

5.2 Review of medical oversight for H@H; this will be funded by OH but can be presented as part of winter planning 13/08/2018 Robbie Dedi

5.3 Improve efficiences and capabilities to support the frailty pathway Gold working together with EMU's 17/09/2018 Jeane Fay

5.4 Roll out outreach programme and virtual ward to support the unscheduled care pathway 12/11/2018 Chris Hewitt

6 Rehab at Home Sandra Allen

6.1Develop criteria for suitable patients: no medical input; singlehanded care; no night care; suitable for discharge to assess;

requiring psychological support to reestablish indepdendence: testing indepedence concept at home 13/08/2018 Sandra Allen

6.2 Develop Rehab Assistant Competences for HCA's aligned with EMU and CTS 13/08/2018 Sandra Allen

6.3 Communications to stakeholders 30/09/2018 Sandra Allen

6.4 Learning from pilot in witney to re-establish Wallingford and roll out to other sites 31/10/2018 Sandra Allen

6.5 Discharge summary for 'Trial at Home' 31/08/2018 Sandra Allen

6.6 Video promoting new service 31/12/2018 Sandra Allen

7 Frailty Pathway Gold (To be confirmed) Robbie Dedi

7.1 Procurement considerations for Healthcare at Home Robbie Dedi

7.2 Consideration of agency ANP's to work with existing staffing Robbie Dedi

OH System Wide Initiatives Aug-18 Sep-18 Oct-18

Organisational Winter Planning

Primary Care (via OCCG) • Improve the uptake of flu vaccination, particularly in

children, and subject to vaccination availability undertake 75% of vaccination by 1 November 2018

• Practices will proactively manage their appointments to manage demand in the most effective way by using an increased proportion of same day urgent compared to routine appointments.

• Practices will be asked to plan additional measures to ensure patients have sufficient repeat medications to last them over the bank holiday periods

• We will work to increase the number of pharmacies providing the NUMSAS service and improve patient awareness of its existence.

Shared agreement

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• Collective responsibility for delivery across the system

• There is system agreement on the target to create the required bed equivalent capacity to support the Oxfordshire system for winter 18/19

• We have system assurance on the bed equivalency impact included within the plan and there is system commitment to close this gap.

• Through the system winter group a number of out of hospital initiatives have been developed and agreed which will provide further capacity.

Winter Investment

• In line with NHSE /I Operating Plan guidance there is the expectation that funding is included within baseline.

• The majority of the 18 specific projects delivering change are in organisations baseline funding

• An additional £700k has been identified to further support winter within OCC/CCG Pooled Budget.

• The approved projects are in this slide. They are funded on the basis of actual spend from November 2018 only, and is subject to the control of the winter team.

Project Cost

SOS Bus 25,191

Primary Care Visiting Service 40,640

PTS Support to ED and discharge 92,000

Home Care flow 100,000

Age UK Discharge Support* 60,000

Home First expansion 200,000

Mental Health Safe Haven** 30,000

Additional Beds *** 150,000

697,831

* plus £80k of STP funding for a total of £140k **covers 2 months, first call on savings against procurement to deliver for the rest of the winter period *** this is the mid case cost over already committed funding, a best case scenario on procurement could deliver a £391k saving. Actual costs known 11/18

Making the difference

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1,200 OH Frailty Oxford and Witney Silver and bronzeadditional community hospital capacity 134-150 bedsHospital at Home (PML & OH & OUH)falls response 50% reduction in conveyance (based on Berks west)OCC initiatives10% reduction in NEL from Horton A&E proposedprimary care visiting serviceintegrated respiratory teamImpact of maintaining stranded /DTOC performance 18/19Ortho-paedicsNeuro wardPTS supportAge UKHome firstEfficiency in short stay (hub) bed daysExtra hub bed days

Operational impact of OUH winter plan schemes

John Radcliffe Horton Total

NEL beds forecast to be occupied 13 August 2018 (low point) 472 108 580

Capacity increase Capacity increaseDemand

reduction

Demand

reductionCapacity increase Capacity increase

John Radcliffe

(beddays)

Horton

(beddays)

Total

(beddays)

Extra hub bed

days

Efficiency in

short stay (hub)

bed days

Home first Age UK PTS support Neuro ward

100% 80% 60% 100% 100% 40%

07-Oct-18 243 119 362 0 121.0 35 0 0 0

14-Oct-18 91 86 177 0 124.3 35 0 0 0

21-Oct-18 178 79 258 0 123.3 35 0 0 0

28-Oct-18 101 71 173 0 104.0 35 0 0 0

04-Nov-18 297 132 429 0 148.2 35 0 0 0

11-Nov-18 190 138 329 0 146.2 35 0 0 0

18-Nov-18 206 138 344 0 127.2 35 0 0 0

25-Nov-18 260 137 397 0 124.1 35 0 0 0

02-Dec-18 243 65 308 0 128.0 35 0 0 0

09-Dec-18 262 125 387 0 158.5 35 0 0 0

16-Dec-18 366 157 523 0 168.2 35 0 0 0

23-Dec-18 426 80 506 0 96.0 35 0 0 0

30-Dec-18 551 151 702 175 64.7 35 0 0 0

06-Jan-19 747 172 918 270 98.2 35 0 0 126

13-Jan-19 678 86 764 140 111.7 35 0 0 126

20-Jan-19 672 139 811 150 107.4 35 0 0 126

27-Jan-19 690 132 822 122 155.9 35 0 0 126

03-Feb-19 549 98 647 0 123.0 35 0 0 126

10-Feb-19 678 98 777 89 133.7 35 0 0 126

17-Feb-19 342 99 441 42 94.5 35 0 0 126

24-Feb-19 297 119 416 0 82.0 35 0 0 126

03-Mar-19 480 111 590 0 75.1 35 0 0 70

10-Mar-19 609 126 735 70 127.3 35 0 0 70

17-Mar-19 631 100 731 74 109.4 35 0 0 70

24-Mar-19 451 106 557 0 102.6 35 0 0 70

31-Mar-19 327 91 418 0 116.0 35 0 0 70

Total Bed days 10,566 2,954 13,520 1,132 3,071 910 0 0 1,358

Note: units expressed in Beddays (except right-hand column)Need to confirm whether new and non-OUH figures in are expressed in bed numbers or bed days

The schemes where this still needs confirmation are shown in red

Provisionally, I have multiplied the original figures by 7 (days a week) by formula, pending confirmation

Confidence of deliverability

Incremental NEL demand vs August 2018

(+ = more beddays required)Winter schemes

OUH initiatives

Brodie Ian (RTH) OUH:

In original template these

schemes were expressed in

bed numbers; now converted

into bed days by x 7.

Brodie Ian (RTH) OUH:

These target figures are now

expressed in bed days (x 7)

Brodie Ian (RTH) OUH:

Includes extra hub beds

Brodie Ian (RTH) OUH:

Includes extra hub beds

Windows User:

20% throughput increase on 123

baseline plus extra hub beds

A system team

• A winter director coordinating a single team managing flow and performance across the health and social care system

• Operating seven days a week, 8 to 8 • The winter director accountable to chief

executives and works with COOs across the system to build trust and deliver outcomes

• The integrated team acts for the system not for the individual constituent organisations

• The integrated team take responsibility for delivery • Members of the team work exclusively to deliver

performance across the whole system • The team needs to be largely self-sufficient and over

time will share team responsibilities across organisational and (where appropriate) practitioner boundaries.

• The team will have deployable resources to manage flow which will be delivered from winter plan investment and prioritisation of business as usual

Provides an integrated approach to planning, daily escalation and delivery of urgent care flow on behalf of the system to achieve performance of • 4 hour trajectory and no 12 hour

trolley waits • No ambulance handovers over 30m • Super-stranded reduction trajectory

(inc. current level 2 escalation) • Better Care Fund DTOC trajectory

and local target to achieve 3.5% • Delivers the winter plan • Supports the development of a

longer-term approach to integration planning, escalation and delivery of urgent care beyond winter.

• Manages system risk • Reports daily and longer-term

learning • Shares good news stories and

improves practice.

Developing the team

• The winter director job has been advertised.

• There remains detailed work to be done on the PID and mandate for the team.

• In particular around the scope of control of the team and the team members from each organisation.

• This work will be done via a joint workshop of COOs/winter planning group/winter team development group workshop.

Communications Plan

• The communication teams from OCCG, OHFT, OUHFT and OCC are working together to support the production and delivery of the Oxfordshire’s Winter Communications plan.

• The plan aims to support Oxfordshire’s System Winter Plan objectives and to ensure that people are aware of and take action to keep well and help avoid an admission this winter.

• Activities tie together national initiatives, including the NHS England ‘Help us, Help you’ campaign, which includes information on self-care and sign posting and the national seasonal flu campaign, with a focus on encouraging targeted groups to ensure they have their flu immunisation.

• A proactive approach to media is being developed and media partnerships explored to maximise positive coverage; this will be supported by a team of ‘spokespeople’ from across the system including the Winter Director.

The actions

• Organisational winter plans

• Shared agreement

• An investment portfolio

• Projects to make the difference

• An integrated winter team to deliver and manage across the system

• A clear communications plan

THE OUTCOME What have we done so far

23

362

177

258

173

429

329 344 397

308

387

523 506

702

918

764 811 822

647

777

441 416

590

735 731

557

418

Capacity and Demand Gap Bed Days

Bed day gap (CF)

The Gap Over Winter

24

362

177

258

173

429

329 344 397

308

387

523 506

702

918

764 811 822

647

777

441 416

590

735 731

557

418

-206

-395

-313

-378

-244

-342 -307

-252

-402 -359

-233 -184

-133

-204 -242

-207 -217 -243

-213

-469 -440

-209 -187 -176

-277

-428

Capacity and Demand Gap Bed Days

Bed day gap (CF)

Bed day gap after schemes

The Gap Over Winter

25

362

177

258

173

429

329 344 397

308

387

523 506

702

918

764 811 822

647

777

441 416

590

735 731

557

418

-206

-395

-313

-378

-244

-342 -307

-252

-402 -359

-233 -184

-133

-204 -242

-207 -217 -243

-213

-469 -440

-209 -187 -176

-277

-428

-135

-323

-241

-311

-136

-235 -204

-149

-287 -237

-109 -74

-28 0

-35 0 0

-32 0

-263 -236

-39 -6 0

-100

-249

Capacity and Demand Gap Bed Days

Bed day gap (CF)

Bed day gap after schemes

Bed day gap after risk adjusted schemes

The Gap Over Winter

THE WHOLE PLAN And questions

Oxfordshire’s Winter Plan On a page

The Issues

The Risks Demand risks • Significant increase in flu • Significant adverse weather event • Significant supply chain issue Capacity Risk • Major provider failure • Major staff shortages • Significant business continuity issue

A shared business continuity approach to managing risks

The Actions • Organisational winter plans • Shared agreement • An investment portfolio • Projects to make the difference • An integrated winter team to

deliver and manage across the system

The Team • A winter director coordinating a

single team (OCC / OUHFT / OHFT / SCAS / OCCG ) managing flow and performance across the health and social care system

• Seconded in staff, responsibility, and authority

• Operating seven days a week, 8 to 8 • The winter director accountable to

chief executives and works with COOs across the system to build trust and deliver outcomes

The Outcome

-600

-400

-200

0

200

400

600

800

1,000

-600

-400

-200

0

200

400

600

800

1,000