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Operational Resilience and Capacity Plan V2: 1st September 2014
GREATER NOTTINGHAMSHIRE URGENT CARE SYSTEM
OPERATIONAL RESILIENCE AND CAPACITY PLAN
Section 1: Narrative on local system configuration, key strengths and challenges
Operational Resilience and Capacity Plan V2: 1st September 2014
1. Local system configuration
The Greater Nottingham Urgent care system serves a population of circa 600,000. This is a diverse
population with high levels of ethnicity and deprivation in the City of Nottingham area whilst the rural
areas have lower deprivation but higher numbers of older people. The urgent care system
comprises:
CCGs Nottingham City CCG
Nottingham West CCG
Nottingham North and East CCG
Rushcliffe CCG
Erewash CCG
Approximately half the population of Erewash
CCG attending NUH for the secondary care
provision
Acute
Hospital
Nottingham University Hospital Services are provided from 2 hospital sites:
Queens Medical Centre focuses primarily on
emergency and cancer care with the A&E
department and trauma centre. City Hospital (4
miles away) has services primarily focused on
longer term care including oncology,
haematology, heart services & elective
orthopaedics. Services are also provided from
Ropewalk
Community
Services
Health Partnerships
Nottingham CityCare
Partnerships CiC
Lings Bar Community Hospital
Provider services predominantly to the
Nottingham County CCG areas
Provides services predominantly to Nottingham
City CCG area.
Community services for Derbyshire patients are
provided by Derbyshire Community Health
Services Trust.
72 bedded rehabilitation hospital situated in
Gamston. The hospital cares for both men and
women generally aged 60 and above, who
require physical rehabilitation following an
admission to an acute hospital, and as such
plays an important role in enabling patients to
be discharged from NUH after the acute phase
of their illness
Mental
Health
Services
Nottinghamshire Healthcare
NHS Trust
Provider of mental health services to all of
Nottinghamshire.
Operational Resilience and Capacity Plan V2: 1st September 2014
Ambulance
Service
East Midlands Ambulance
Service
Provides the emergency ambulance service for
the urgent care system. Non emergency
transport is provided by Arriva for both
Nottingham City and Nottinghamshire patients,
and by NSL for Derbyshire residents
NHS 111 Derbyshire Health United
Urgent
Primary Care
Services
NEMS CBS
Primary Care „Walk in Centres‟
Dental Services
Provide the out of hours service for the whole of
Greater Nottinghamshire as well as a range of
other services that support the urgent care
system - for example Primary Care streaming
service at A&E, Community Pathfinder scheme.
The out of hours service in Derbyshire is
provided by Derbyshire Health United.
The Greater Nottinghamshire System is served
by 2 „Walk in‟ facilities. The London Road Walk
in Centre which is operated by Nottingham
CityCare Partnerships CiC and NHS
Nottingham City 8-8 Health Centre which is
operated by NEMS. Both of these facilities see
approximately 80,000 patients per annum.
There is an integrated dental unit provided from
the London Road Walk in Centre location and
an Emergency Dental Service provided from
the 8-8 Health Centre.
Social Care Nottingham City Council
Nottingham County Council
Derbyshire patients are supported by
Derbyshire County Council
Operational Resilience and Capacity Plan V2: 1st September 2014
2. Performance Context
The 4 hour ED standard was achieved during Q1 and Q2 of 2013/14, having not been achieved for
the previous 8 consecutive quarters. Performance fell below the 95% standard in September 2013
and has remained as such for each subsequent month to date. The 2013/14 performance overall
was 93.3% and performance year to date for 14/15 is 87.5% with monthly period being below 90%
for each month since April.
Total >4Hrs %
YTD 73628 9222 87.47%
Q1 (NB NHSE uses weekly data) 47672 5963 87.49%
Apr full month 15276 1779 88.35%
May full month 16173 1820 88.75%
June full month 16223 2364 85.43%
July full month 16433 2279 86.13%
August MTD 9523 980 89.71%
From April 2014, due to consistent failure to deliver the 4 hour ED standard and concerns regarding
the management of the urgent care system as a health community, all four South Nottinghamshire
CCGs were deemed to be „assured with support‟ for domain one - Are patients receiving clinically
commissioned, high quality services?
At that point the Urgent Care Working Group began meeting on a weekly basis and was chaired by
the Director of Operations and Delivery for the Nottinghamshire and Derbyshire Area Team.
Revised Urgent Care structures, workstreams and governance were agreed in May 2014. These
arrangements have subsequently been superseded by the System Resilience Implementation
Group (SRIG) which was established in early August 2014. Further detail on SRIG is included in
Section 11 of this document.
Demand / Diagnostic
Demand on acute services continues to increase. This potentially driven by the growth in the elderly
population (2.2% increase per annum for the over 65 years and 3.7% increase per annum for the
over 85 years). Hospital admissions in the NUH core catchment areas have increased at an
average of 3.7% in the past 5 years.
Elderly patients with increasing frailty and acuity have the potential to stay longer in hospital.
Although the total number of type 1 attends to NUH ED have not increased significantly, there has
been an increase in the proportion of over 65 years being admitted and an increasing length of stay
from 2012/13 to 2013/14 of 0.5 days - this has resulted in overall occupied bed days going up by
3.7% which equates to 600 bed days per month.
Operational Resilience and Capacity Plan V2: 1st September 2014
Analysis of the current position shows a relationship between high bed occupancy and breaches of
the A&E standard See table 1 below.
Table 1: Relationship between A&E breaches and bed occupancy
Preliminary root cause analysis of breaches between August 2013 - July 2014 has indicated a 60:40
split between breaches resulting from a lack of flow out of ED and breaches resulting from process
issues within ED
There has been an average number of 470 attendances in ED each day (for period March 2014-
August 2014), indicating an increase of 7% on 2013/14. However ED attendance for 2013 were low
and long-term growth is 2% per annum (from 2011 – 2014). ED attendance growth at NUH was
below the NHS average in both 2012 and 2013.
Non Elective admissions to the NUH have increased by 5% over the last 2 year period. Admissions
via ED have remained largely constant over the last 2 years however there has been an 11%
increase in the number of admission via non ED routes (such as the Acute Medical Receiving Unit –
AMRU)
Mental Health:
ED breaches attributable to patients waiting for an assessment by the Mental Health team account
for approximately 3.5% of all ED breaches. The CCGs commission a Rapid Response Liaison
Psychiatry (RRLP) Service which is based within NUH and additional recurrent resource has been
put into the service from April 2014 to increase the level of support to ED.
Operational Resilience and Capacity Plan V2: 1st September 2014
Delayed Transfers of Care
Delayed transfers of care at NUH increased to 1278 in May from an average number per month
over the previous 12 months of 1066. However some improvement was seen in June as shown in
the table below.
Supported discharges make up only 7% of total discharges from NUH, with a third of these requiring
primarily health input and two thirds requiring social care. The supported discharge process is
currently overly complex involving several steps and some duplication and re-work which adds to
delays. Action being taken improve this includes:
Improvements to the Social Care datasets to allow for the system to measure all
waits/delays within the system enabling transparency and understanding of the number of
patients at each stage of the health and social care assessment process within hospital. All
medically fit patients (i.e. not just DTOCs) will be measured and shared from September
2014, including for social care waits.
Work has been undertaken to establish clear definitions for medically safe for transfer, this
have been agreed across the system and is used to ensure that wards are able to identify
patients at appropriate stages. The Medically Safe for Transfer definition is: The patient‟s
clinical condition is such that ongoing assessment, rehabilitation and / or recuperation could
continue in a less acute environment away from NUH. This should be confirmed by a senior
clinician and documented within the patient notes.
The process for identifying patients who are likely to require a supported discharge and the
timing of notifying the Care Co-ordination Team (CCT) is being reviewed as a matter of
urgency.
Joint health and social care screening of referrals to the CCT has been extended to cover 11
wards with the highest number of supported discharges on the QMC site
Operational Resilience and Capacity Plan V2: 1st September 2014
Implementation of the new joint health and social care „Leaving Hospital Policy’ which
aims to reduce the pressures on the acute hospital. This policy will enable citizens to make a
timely discharge from acute care to community care in the form of interim residential
placement if their care package or residential placement of choice is not immediately
available
Flow out of the hospital is expected to improve with greater use of interim home care, Crossroads/Red Cross provision supporting patients at home and more intermediate care support to discharge home with support
Patient waiting for admission to Lings Bar Hospital accounts for the largest proportion of DTOCs
and there is a constant waiting list. The number of patients waiting for Lings Bar Hospital peaked in
early July 2014 at 36 patients waiting; the average number of patients waiting for Lings Bar Hospital
since then has been 18.
In May 2013 a Transfer to Assess model was introduced for patients at City Hospital Nottingham
who were at risk of being admitted into a Care Home. One of the identified assessment settings
was Lings Bar Hospital. The evaluation of the trial has shown this model to be successful in
reducing admissions into long term care, as well as reduced length of stay at NUH and across the
entire pathway (see supporting evidence file). However it has resulted in a change in the case mix
of patients in Lings Bar which has increased the average length of stay.
Actions being taken to reduce waits for Lings Bar Hospital:
Senior Clinical Review of all patients undertaken on a weekly basis (since early July 2014)
The Care Co-ordination Team at NUH referring patients with identified levels of need to community hubs, rather than requesting specific services to ensure patients receive the appropriate care, and wherever possible return home directly with their previous package of care re-started, rather than Lings Bar being considered the default for complex discharges
Operational Resilience and Capacity Plan V2: 1st September 2014
The new leaving hospital policy being adopted at NUH will be considered for use at Lings Bar Hospital.
Additional therapy and social care staff that were introduced in July when waits were at their highest and will be re-introduced as part of escalation processes.
The additional community beds which are being commissioned will support increased flow through the hospital
All members of the local system recognise that that current performance is not acceptable and the
whole system has committed to doing whatever it takes to improve the system to deliver a
consistently high quality, safe urgent care service to the local population which provides an
excellent patient experience.
The health and social care community hold daily conference calls (Monday – Friday) to manage
performance across the system:
9am call involving operational leads - to identify all patients waiting to transfer to the
community and to advise NUH of community capacity available
12 noon call involving „General Managers / Directors‟ to capture all performance data across
the system and ensure all required actions are being taken across the system to optimise
emergency flows;
5pm „Chief Officer / Chief Executive‟ to address / escalate any outstanding actions / areas of
concern.
The standard metrics captured each day are shown at Appendix 3. From 1 September the daily
information at both the 9.00a.m and lunchtime conference call will also include:
Total number of section 2s – to be used as a proxy for future demand in the system
Total number of waits –care packages / placements / disputes to show current blocks in the system
% of current waits that have a section 5 completed - to identify areas that are not using correct discharge process
% of current waits that are past their section 5 / PDD, and total number of days waiting past Predicted Discharge Date
This data will be at patient level for the early morning operational meeting to enable individual plans
to be put in place, and at an aggregated level for the lunch time discussion to enable system
solutions to be identified.
With the current pressures within the system it is essential that there are safeguards in place to
mitigate against patient harm:
No patient will be moved from the department until a senior clinical review has been
recorded..Compliance with this standard is via the EDIS system used within ED which
records all contacts with a patient noting the time and contact. Performance is monitored
throughout the day and also at the weekly demand and capacity meeting. The Trust is
Operational Resilience and Capacity Plan V2: 1st September 2014
working to achieve the target that 80% of patients have a senior clinical review within 3
hours.
There is a clear Outlier Policy which identifies patients who must be exempt from being
moved to an outlying ward e.g. patients with high level of confusion or dementia, patients at
high risk of falling, etc. All patients must have had a senior clinical review before moving
wards
Daily Board rounds with the full multi disciplinary team providing a review of care of the
patient, progress check on discharge plans and supervision for junior doctors
A comprehensive Urgent Care Performance Framework monitors 56 separate indicators across
Pre-Acute, Acute and Outflow stages of the Urgent Pathway. (See Appendix 2) This is monitored
on a monthly basis by the System Resilience Group.
3. Understanding the pressures causing performance issues
ECIST have undertaken a number of site visits to NUH, with the most recent being in March 2014.
The report from ECIST following their visit in March 2014 identified key challenges as:
Reported deficit of around 50 beds, due in part to a loss of community capacity.
Workforce challenges in recruiting consultants to the Emergency Department (ED), Acute Medicine and Healthcare for Older People (HCOP).
Difficulties in maintaining cubicle capacity to meet demand within the ED
Lack of steady state over the winter months due to a six week outbreak of noro virus
Difficult commissioning round with a number of initiatives funded at risk e.g. respiratory assessment at the city campus and the Lynn Jarrett unit.
Emergency Department regularly overcrowded with an increase in admissions of over 70 year olds from October 2013 and an associated increase in length of stay.
Until recently a lack of a “common view” of the issues driving the deterioration in performance across the Local Health Community to set a foundation for action.
The further support the work undertaken by the Greater Nottinghamshire system to reach a shared consensus of the issues driving the deterioration in performance and external review of the Emergency pathway has been commissioned from Mckinsey and Company. The primary objective of the work is to create „One version of the Truth‟ on the root causes of poor performance across the health and social care system. This piece of work commence on the 11th August 2014 and will be completed by end of September 2014. The formal „stock-take‟ of the System Resilience Plan scheduled for mid October will fully consider the output of recommendations of the external review as well as the „Breaking the Cycle‟ exercise planned for week commencing 27th September which is being supported by ECIST.
Operational Resilience and Capacity Plan V2: 1st September 2014
4. Existing plans to improve performance A number of separate plans exist to improve performance.
NUH Action Plan to implement the recommendations from ECIST
Following the report from ECIST which identified a number of recommendations NUH
produced a detailed action plan. This is reviewed on a monthly basis to ensure progress
continues to be made. The ECIST report and most recent action plan are available in the
evidence file that accompanies this plan.
System Recovery Action Plan
Developed by the weekly Urgent Care Working Group to ensure a joint understanding of the
issues causing the poor performance, oversee the development of credible plans to improve
performance and monitor progress against these plans. The UCWG set up two workstreams
to oversee the development of detailed action plans to address the pressures within the
system:
Workstream 1 (Avoiding Admissions) The group is chaired by the Chief Officer of
Nottingham North and East CCG and meets on a fortnightly basis. Current programmes of
work include Improved Access to Primary Care, Expansion of Acute Home Visiting Service,
Expansion of Falls Ambulance, development of new alternatives to admission which can be
complemented by the current clinical navigation service and Improved support to Care Home
Sector to reduce avoidable admissions.
Workstream 2 (Improving flow within the hospital setting, including improved
discharge processes to reduce delays in discharge and reduce re-admissions) of the
Urgent Care Working Group is chaired by the Chief Operating Executive for Health
Partnerships. The group has a work plan which is attached in Appendix 5. Current
programmes of work include planning for the rapid improvement event that is to be held at
NUH on 9 September, and a review of metrics used to report performance across the
system.
These workstreams were supported by the capacity modelling group and the performance and
information group. These action plans, which ensure the minimum standards identified by NHS
England will be met, had been developed by system wide groups and signed off at the Urgent Care
Working Group. Each plan has clear actions, accountable lead, timetable and expected
impact/benefit to be delivered across the system.
Short Term Improvement Plan
The system has developed a short term Improvement plan (see supporting evidence file) which
identifies all the actions that are being taken by the system over the next 3 months (to the end of
October 2014) to improve performance. All actions within the plan are being led by the respective
Operational Resilience and Capacity Plan V2: 1st September 2014
workstreams of the System Resilience Group. The Improvement plan will be updated and
monitored on a fortnightly basis by the SRIG and reported into each SRG meeting.
Reducing avoidable re-admissions
At any time 300 beds at NUH will be occupied by a patient who has been readmitted to hospital
within 28 days. The total number of readmissions includes those admission deemed as unavoidable
as well as avoidable.
In 2013/14 17,500 patients were readmitted (an average of 48 per day) with 61% of admitted
patients coming through the emergency department. A multi-agency joint audit of re-admissions
occurred during 29 and 30 April 2014. The purpose was to understand the reasons why patients
readmit to NUH and what the contributory factors to readmission are, in order to inform the planning
of interventions across the local health and social care system to reduce 'avoidable' readmissions.
Clinical experts estimated that 32% of the 82 readmitted patients reviewed could have avoided
being readmitted. This gives an opportunity to greatly improve the patient experience as well as
freeing capacity. Further work is to be undertaken looking at the length of stay for these patients
whose admissions could have been avoided to quantify the opportunity to release beds.
During the contracting round for 2014/15 it was agreed that eliminating avoidable hospital
readmissions is a priority given the impact on individual patients and the effect on resource useage.
Therefore, the baseline reduction of £4.3m transacted as per the national guidance has been
reinvested exclusively in Nottingham University Hospitals NHS Trust, as a block value, in response
to actions which reduce the level of avoidable emergency readmissions into the Trust as per the
agreement below:
'The readmissions fund will be returned to the Trust in equal thirds at the end of the first 3 quarters
of the 2014/15 financial year contingent on the following:
An agreed plan to reduce avoidable readmissions being developed by the end of the first quarter which includes phasing of schemes and a trajectory for improvement.
Evidence that schemes are being implemented as planned during the second quarter.
Delivery of the agreed readmission reduction trajectory in quarter 3' The delivery of plans to reduce re-admissions is being overseen by Workstream 1 as well as a
dedicated Readmission Oversight Panel which reports back into the NUH contract.. Both NUH and
CCGs have plans in place to address readmissions including review of community based post
discharge follow-up services, review of information given to patients on discharge so that they are
better informed about self care post discharge and a number of other NUH directorate specific
actions.
Operational Resilience and Capacity Plan V2: 1st September 2014
QIPP plans
At the beginning of this financial year the health system agreed QIPP schemes and proposals for
the use of MRET and other non recurrent monies which would help to reduce pressures within the
urgent care system and in particular at NUH.
The Health Community commissioned McKinsey and Company to test the robustness of existing
plans and their likely impact during 2014/15. Each QIPP scheme was reviewed and awarded an
aggregate score out of ten reflecting the McKinsey current view of the schemes most likely reduce
NUH activity this year; 46% of overall scheme value was rated 9 or 10/10 for confidence of delivery,
with 88% of the value from non-elective admission schemes rated medium or better, and roughly
half of A&E-attendance related value rated low.
This work concludes that:
The impact of Commissioner QIPP schemes on potential bed reduction is equivalent to 26
beds if fully delivered
Few schemes address the discharge (back-door) process, which is a key driver of
readmissions;
These findings are in line with CCGs‟ QIPP schemes which have been primarily focussed on
reducing avoidable admissions.
5. Key strengths of the urgent care system
Despite the challenges in relation to performance, the Greater Nottingham urgent care system has a
number of strengths:
ECIST identified a number of areas of good practice during their review in March 2014
There is good clinical engagement and enthusiasm to continuously improve the system and
thereby quality of care for patients.
There is a South Nottinghamshire Transformation Programme which is designing the future
model of urgent care so that patients are treated, as far as possible, in a community setting
rather than being admitted into institutional care - whether that be in hospital or permanent
admission into a care home
There are a number of developments within the community setting which will decrease
pressure at NUH - these are detailed in the body of the plan but include focused work with
care homes, extension of the rapid response falls team, changed pathways of care,
increased primary care streaming at A&E
There are clear plans for improvements to the system which are owned by the whole system
The Better Care Fund gives a real opportunity to transform local services so that people are
provided with better integrated care and support. Locally the BCF plans moves towards
Operational Resilience and Capacity Plan V2: 1st September 2014
integrated care provided 7/7 so that patients receive the right care in the right place at the
right time.
6. Key challenges to the urgent care system
There remain a number of key challenges within the system that need to be addressed if there is to
be a sustainable improvement in performance. Many of these challenges remain similar to those
identified by ECIST. These challenges are captured within the System Resilience Risk Register and
plan to address this challenges are detailed within the plan.
Key Challenge Mitigating Action:
Insufficient Capacity There is insufficient capacity across the system to effectively „double run‟ whilst internal improvements are being embedded to increase flow within NUH, and the development of the full integrated urgent care system outside of hospital is put in place. There are financial pressures within the two Councils; in the County Council this has resulted in reduced social work assessment capacity and will mean a reduction n the provision of intermediate care and reablement services.
Opening of 60 additional beds (of which 24 beds
in respiratory and stroke care are for the expected
seasonal pressures and will be open only during
Q4) within NUH to decrease the number of A&E
breaches due to waits for beds in the main
hospital
Opening of 48 additional beds in the community to reduce delays to discharge due to waits for community hospital and intermediate care beds
Members of the Health and Social care system recognise that the development of additional inpatient capacity does not represent a sustainable solution to future service and demographic pressures. However, the urgent creation of capacity in acute and community settings will provide the economy with the headroom to redesign and improve patient flow, whilst also ensuring that the operational benefits of QIPP, preventing avoidable readmissions and improved rehabilitation can be fully measured and realised.
The plan also provides the community with significant capacity resilience to mitigate periods of peak pressure and the potential impact of care home closures or novo virus outbreaks. The additional capacity it creates also mitigates any potential operational problems experienced during implementation, since the plan is not dependent on any one initiative for compete success.
In this context, the implementation of the system resilience plan for 2014/15 and proposed use of the non recurrent resilience monies for additional bed capacity should be viewed as an enabler to support wider and deeper system transformation within and across existing care pathways. The entire health and social care community is committed to transforming the existing service provision, rather than simply adding to it, and the proposed plan offers the greatest prospects for rapidly improving patient experience whilst also pursuing the strategic transformation agenda. The system is fully committed to removing the additional non recurrent bed capacity safely by the end of March 2015.
Operational Resilience and Capacity Plan V2: 1st September 2014
Key Challenge Mitigating Actions
Workforce: This plan is dependent on having staff with the right skills in place. There are already hotspots within the urgent care system and opening additional capacity could exacerbate these problems. In line with the national picture there is considerable difficulty in recruiting consultants to the Emergency Department (ED), Acute Medicine and Healthcare for Older People (HCOP. (The detail regarding consultant vacancies is within the main plan).
Additional 15.00 - 22.00 Consultant shift in A&E Increases in other consultant capacity
Continuation of use of long term locums, recruitment etc Overseas recruitment for nursing staff Agreement to work collaboratively across the system in the recruitment of nurses Staff flu vaccinations - all organisations are offering their staff free flu vaccinations aiming to achieve the target of 75% of staff vaccinated. Planning for these campaigns is well advanced with clinics starting in October. Clinics are offered at different locations and times to maximise the uptake. A variety of methods are being used to maximise the uptake from traditional communication methods, senior staff leading by example, heads of departments and matrons being charged with encouraging staff to attend, to more innovative approaches such as awards for achieving the 75% target and special out of hours sessions in town Staffing additional capacity - the NUH project plan for mobilising the additional capacity includes full details on progress on staff recruitment. This plan is monitored weekly. The biggest risk areas have been identified as: Staffing during escalation - organisational escalation plans are clear that at times of pressure staff need to be focused on direct patient care and that non clinical SPAs, training, non essential meetings etc will be cancelled to release staff to provide hands on care. Organisations have systems to call in additional staff if necessary
Bank holiday cover - providers will ensure appropriate levels of staff are on duty over the extended Christmas holiday based on activity trends of previous years. A focus will be to ensure there are appropriate staff in place who can keep the flow of patients through the urgent care system so that as activity ramps up in early January, there is capacity available.
Operational Resilience and Capacity Plan V2: 1st September 2014
Key Challenge Mitigating Action:
Physical Capacity within ED Difficulties in maintaining cubicle capacity to meet demand within the ED Emergency Department regularly overcrowded with an increase in admissions of over 70 year olds
Capital project agreed by NUH for additional 10 cubicles to be in place by January 2015 Various community based schemes being put in place to enable people to remain at home - for example risk stratification and care planning in primary care, re-focusing of the community pathfinder scheme to hep professionals staff, including those in care homes to source alternatives community services to prevent admission to hospital where it is safe to do so
Schemes to improve the discharge function and further reduce length of stay - some of which are internal to NUH such as using pharmacists to transcribe TTO medications, and improvements to the community capacity More pathways for direct admission to City hospital to reduce overall length of stay, and bed pressures at QMC
Direct access to specialty advice / urgent clinic slots - including reciprocal arrangements for consultants to be able to urgently contact GPs
Continued work to increase specialty response at the front door
Real time information systems to be utilised -for example the re-launch of the bed management system, an app to enable GPs to access consultants for advice, information on policies, make referrals etc
Operational Resilience and Capacity Plan V2: 1st September 2014
Key Challenge Mitigating Action:
The A&E 4 hour standard is not being met The plan identifies solutions that will be in place to ensure consistent delivery of the 4 hour waiting time standard by the end of October, but all parties are clear that performance needs to begin to show an improvement immediately. Following the Perfect Week exercise in the early summer, it has been agreed that:
Every ward to have one patient in discharge
lounge by 9am and to have 50% of discharges via
discharge lounge.
Patients to be admitted in clinical need and time
order from ED and AMRU; support to be given to
ED, site matrons and ward staff to stream
appropriately
All specialties to respond to referral from ED
within 30 minute; early escalation from ED to site
matron, with delays recorded and discussed at
weekly Trust capacity meeting
Speciality bronze on call to be implemented in
specialities; good practice within the Childrens
Hospital to be shared so that clear SOPs are in
place for the bronze role
Introduce pharmacy led TTO prescribing on the
wards
Operational Resilience and Capacity Plan V2: 1st September 2014
8. Testing the plan The system has commissioned McKinsey to review the urgent care pathway with a focus on the flow
within NUH and discharge. The System Resilience Implementation Group is receiving a weekly
update on this work from the Mckinsey's team whilst the review is taking place. This work will be
completed by 29th September 2014. This review, along with a re-run of the Perfect Week (now
known as „Breaking the Cycle) which is scheduled for the last week in September which will give
an opportunity to stress test the plan. A formal „stock take‟ involving all members of the SRG will
take place during October to review the plan in light of feedback from the external review and the
„breaking the cycle‟. A further „stock take‟ is scheduled for mid January 2015.
9. Escalation Plans
Each organisations business continuity arrangements have been reviewed to ensure alignment.
Actions identified to manage surge/increasing pressures within the system, and to release additional
capacity include
• Cancelling training
• Transferring consultant SPAs to „shop floor‟ sessions
• Cancelling teaching sessions so that senior clinical staff can be directed to the areas where
the need is greatest
• Clinical staff within corporate departments take up clinical roles within their competency
levels
• Review of patients who are waiting for discharge to see whether either the discharge can be
expedited, or if not if the patient can be transferred from the Queens Campus to the City
Hospital
Discussion at the System Resilience Implementation Group clarified areas where the actions of one
partner could potentially impact elsewhere in the system.
The system wide escalation plan has been reviewed, amended and agreed by the System
Resilience Implementation Group. The Escalation Plan will Implemented from the beginning of
September and tested during the month of September and specifically through the Breaking the
Cycle week. The plan will be amended as required and will be submitted to the System Resilience
Group on October 7th for final sign off. Each organisation will ensure that their on call staff are
made aware of the new plan, signing to say that they have read and understood it. Copies of the
plan will be included in on call materials.
The mid day conference call will identify the level of escalation at which the system is operating, and
the Programme Director will ensure that all actions appropriate for that level of escalation have been
taken. This includes ensuring that when pressures ease there is a formal communication of de-
escalation.
Operational Resilience and Capacity Plan V2: 1st September 2014
10. Risk Management Framework
The major strategic risks to the delivery of the System Resilience Plan have been identified with
mitigation actions in place. The major strategic risks are considered to be:
Inability to recruit sufficient staff to open the additional bed as outlined in the plan.
Unplanned changes in capacity (e.g Care Home contract suspension or closure)
Actions identified within the plan are not delivered in the required timescale
Actions taken do not have the expected impact
Unprecedented levels of demand on the system
Inability to remove the non recurrent beds by 31/3/2015
Reduced patient quality / patient experience
The system wide risk register is in place (supporting evidence file) and will be maintained by the
Programme Director for Urgent Care being updated as required following each System Resilience
Implementation Group meeting. The risk register will be formally reviewed by SRIG on a monthly
basis prior to the risk register being submitted to the System Resilience Group for consideration.
The major strategic risks will also be reflected on each partner organisations corporate risk registers
as appropriate.
11. System Governance The delivery of this plan will be overseen by the newly formed System Resilience Group. This group, which has already met to sign off this plan will ensure delivery, receiving reports on any exceptions to progress against the plan, plus any risks so that the system leaders can take the necessary remedial action. The South Nottinghamshire system has recruited a full time Programme Director for the Non Elective Pathway who takes up post from 1st September 2014. The role of the Programme Director is to establish and lead the PMO arrangements to drive the delivery of the plan. A System Resilience Implementation Group (SRIG) has been established from 4th August 2014 and will meet on a weekly basis. The SRIG will effectively operate as the PMO and provide a detailed report to each System Resilience Group Meeting. (See Terms of Reference for SRIG). A standard agenda and action tracker will be used to ensure that current performance is scrutinised as well as ensuring that delivery of the plan is tracked and remedial actions taken in a timely manner if required (see supporting evidence file) Once the Greater Nottinghamshire plan is assured it will be published on the website of all the Greater Nottinghamshire CCGs. Further discussions will be held at SRIG as to whether the plans are also published on the website of all partner organisations.
Operational Resilience and Capacity Plan V2: 1st September 2014
12. Use of Non Recurrent Resilience Funding The Greater Nottingham System has the following non recurrent Resilience Funding available
Nottingham City £2,114,671
Nottingham North & East £890,319
Nottingham West £569,402
Rushcliffe £678,169
Erewash £312,510
Total Resilience Monies £4,565.07
Resilience Monies
The System Resilience Group (on 29th July 2014) has agreed that the majority of the non recurrent resilience funding will be used to fund additional non recurrent bed capacity. Emergency Rate Threshold Monies The total value of ERT benefit associated with the NUH contract is £5.620m. As was agreed
through the contract negotiations, £1.2m of this will fund the notice period on B50 and has been
transacted through contract. An additional £736k sits outside of the contract to fund the agreed
PMO arrangement.
Of the remaining £3.684m:
- CCGs have agreed to fund non-delivery of emergency CCG QIPP at 100%. To simplify the transactional process and provide a level of certainty for the Trust and commissioners, there will be a non-recurrent adjustment made to the ERT baseline to the value of commissioner QIPP as transacted through the activity plan. For clarity, this will be shown separately by commissioner within the activity plan. The total value of this baseline adjustment is £2.151m. Performance will be jointly reviewed on a monthly basis by the QIPP Delivery Group, who will confirm the position in respect of QIPP non-delivery for sign off at CEB.
- A residual pot of £1.533m remains to be invested in schemes which will reduce emergency admissions. The Trust is not expected to have any financial liability over and above this value in implementing schemes. If the Trust can demonstrate implementation of and delivery against schemes which require less investment than the value of the ERT pot, they can retain the non-allocated investment. However, the Trust will be required to demonstrate that the recurrent impact of reduced admissions would be greater than the new costs incurred and that patient outcomes have improved. All proposals for schemes will be signed off by CEB. This value will be repaid to the Trust on a monthly basis as a block amount (1/12th of annual value).
There will be no in-year adjustment to the ERT fund.
Operational Resilience and Capacity Plan V2: 1st September 2014
13. East Midlands Ambulance Service Plan The Greater Nottinghamshire system approved the EMAS System Resilience Plan on the 26th August 2014. The plan includes
Increased Voluntary Ambulance Service and Private Ambulance Provision by 120 hours per day.
Recruitment to additional paramedics and ECA.
Establishing a Regional Operations Centre within the Nottingham EOC to provide Senior Manager cover 24/7 to take a strategic overview of service delivery.
Increased dispatcher capacity and creation of an additional Urgent Care Desk
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