buckinghamshire integrated care system. winter …...buckinghamshire integrated care system. winter...

Buckinghamshire

Integrated Care System.

Winter Planning and

readiness

Gary Passaway:

Prepared by System wide Buckinghamshire A&E delivery Group

September 2018

Key Objectives and Introduction

2 Your community, Your care : Developing Buckinghamshire together

Objectives: To ensure that the Buckinghamshire 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 quality 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 Introduction:

This is the overview of where the Bucks system is with winter planning 18/19. The

‘plan for the plan’ and some key milestones are incorporated to demonstrate how

the system aims to sufficiently progress work streams and to achieve plans to help

support the delivery of the objectives identified above. Delivering this plan will be

the work of all partners in the Bucks ICS and the process for this plan is to be

agreed and signed off at the Buckinghamshire ICS A&E Delivery Board / UEC

Improvement Board.

System Focus


The Buckinghamshire ICS will focus specifically on:

•Reducing the number of long stay patients in hospital

•Continuing the development of the GP (primary care) streaming process at the

ED front door

•The comprehensive uptake of the healthcare worker flu vaccination

• A full and comprehensive roll out and establishment of the Improved Access to

General Practice (IAGP)

•Concentrated and aligned working between all system partners including; Health,

Social Care, Mental health, Ambulance Trusts, voluntary services etc.

•Supporting the delivery of elective and emergency care

•Delivering on actions agreed at the Bucks ICS urgent care summit (slide 10)

•Developing and establishing a system wide dashboard that will report and

monitor key system measures and performance which are aligned to our system

priorities, such as LoS, DToC, bed occupancy, 4 hour standard etc.)

System approach


System plan

• Developed by system partners & overseen by ICS A&E Delivery Board / UEC Improvement

Board– proactively formulated, agreed and updated at the A&E delivery Group (all system

partner input)

• Comprehensive plan linked to 7 UEC pillars in Urgent and Emergency Care (UEC) Delivery

Plan

• Informed by lessons learnt from last winter & multi-agency events to test system resilience

including the Bucks ICS winter planning event and whole system table top exercise 24/09/18

• Informed by national guidance from NHS England; including long stay and flu priorities

• Partner organisations’ detailed winter resilience plans inform our system plan

Winter Operating Model

NHSE National & Regional Support

• Winter planning guidance, promotion of best practice & communication

• Coordination, monitoring and reporting

Local Winter Team

• Named responsible directors for Hospitals & system support from community, social care &

CCGs. Operational input through the A&E delivery group. System agreement to appoint a

Winter Director

Local Escalation Plans

• Buckinghamshire system escalation framework with OPEL action cards to support Surge &

Escalation

• Demand and Capacity modelling. Bucks will have a system understanding of what our demand

and capacity gaps are.

• Hospitals and community providers have Clinical Escalation Plans to ensure safety maintained

when system under pressure

Pre Hospital


NHS 111

“Talk before you walk” (for non-medical emergencies).

Integrated Urgent Care (IUC): Capability to adjust ‘live’ capacity for pressured services – meaning

we can flex the system as pressures mount

Directory of Service (DoS) – sense check refresh and update to ensure that DoS directs callers to

the most appropriate local clinical setting

NHS 111 Online

Reducing pressure on 111 and OOHs as 111 Online directs patients to alternate services, or

automatically books them a clinician call-back where appropriate

Ambulance

Ambulance Response Programme (ARP) is now fully established- improved Bucks performance

CAT 3 & 4 channel shift of activity to ED alternatives is being progressed

Telephone advice – Implementation of a Hear and Treat and See and Treat models

Improved support for calls referred by paramedics to GPs - GP Triage

Continue to increase uptake of GP triage

GP Access

Improved Access to General Practice - evening and weekend appointments

Out of Hours GPs

Staffing models applied to cope with predicted demand

UTC – Wycombe General Hospital

Designated Wave one site and Open 24/7, 365 days a year..

Pre Hospital


Community Care Coordination Team

Health & social care single point of referral for re-ablement – work to integrate Rapid Response

Intermediate Care (RRIC) and Bucks re-ablement

Community Assessment and Treatment Service (CATS) Thame & Marlow

Focus on greater utilisation to enable more patients to receive local assessment, diagnostics &

treatments meaning people to remain cared for at home

Multidisciplinary Day Assessment Service (MuDAS) Wycombe

CATs works in tandem with, and enhances the service currently provided by MuDAS

Urgent & Emergency Care (UEC) Transformation Funds

Schemes to support South Central Ambulance Service (SCAS) improve non-conveyance of

ambulances with expansion of the Berkshire West pilot falls service across Oxfordshire and

Buckinghamshire, where a paramedic and Senior Occupational Therapist are available in a car to

visit patients who have fallen, assess them and then make links with rapid response community

services to support the patient at home.

In Hospital


Hospitals • Full workforce plan with additional medical & nursing cover at peak times

• Ambulatory care review undertaken to maximise utilization of the service for medical patients outside

of the ED. Currently 23% with objective to move to 35%

• Pilot across 5 medical wards to be undertaken and support board rounds, EDDs following NHSI work

• Work underway to reduce longer LOS patients by 25% - currently 133 patients (a reduction from 161)

• Tender completed for performance analytics provision to support demand and capacity planning

• Care-Fully Acute Transformation Programme underway

• Capital build for Emergency Observation Unit (EOU)

• Discharge Coordinator pilot across medical wards

• Plan to improve utilisation of Wycombe site

• Ambulatory Emergency Care in place 7/7 until 10pm at Stoke Mandeville Hospital

• Established GP streaming 7/7 service in place with plans to further explore extending to Peads

patients.

• New acute medical model launched 5th December

• Focus on improving patient flow & management of bed occupancy levels

• On-site social care, CHC & community support

• Red cross support to help long stay patients supported discharge home

Urgent & Emergency Care (UEC) Transformation Funds

Long stay reduction project to support the earlier discharge of patients, including MDT team focus on

stranded patients (MADE) and voluntary sector support for patients returning home and being re-settled.

Psychiatric Liaison support on site 24/7

NEL Demand Management – Priority Areas

8 Your community, Your care : Developing Buckinghamshire Together

Avoidable Attendances to ED

Avoidable Admissions to

Hospital Supported Discharge

Care Homes (Airedale)

Alternative care

pathways including

the Use of CATS & MUDAS

Management of EOL

patients

Ambulance Conveyances

CAT 3 & 4 SAFER / Internal

Professional Standards

Maximisation of ACSC

Delirium Pathway

Orthopaedic pathways

Respiratory Pathways

Reduction XSBD &

Discharge to Assess

Red Cross Project

High Intensity

Users

Various work streams to support demand

management and particularly Frimley facing.

Post Hospital


Hospital to Home

Implement earlier discharge planning

Buckinghamshire County Council to lead a system D2A (Home first) Business As Usual model

proposal to ensure opportunities within the Better Care Fund (BCF) are maximised.

Reduce Delayed Transfers of Care

Reduce delays by focus on medically fit & “stranded” or long stay patients across all providers,

acute & community hospitals. Now incorporated to include a weekly Escalation Call with CNO. COO,

Director ASC, CCG – a review of the Top10 longest stay patients across the Trust

Improve Support for self-funders

Independent family support & brokerage

Working to Improve Continuing Healthcare (CHC) responsiveness

Enhance Health & Care Services in Care Homes

• Airedale project rolled out to more than 31 care homes providing remote access clinical support

24/7

• Quality & Care Team (QICT) support

Secure Voluntary Sector support for example:

• Home from Hospital – the Red Cross. This will also include NHSI and system part funded

scheme to support long stay patients being returned home

• Support for Carers – Carers Bucks & the Carers Hub

• Stroke Association

10 Your community, Your care : Developing Buckinghamshire Together

Timeline of actions from Urgent Care Summit

Action Owner Delivery Date

Implementation of full discharge to assess model

BCC October 2018

Implementation of consultant connect

BHT September 2018

Diagnostic access for GPs

CCG October 2018

Review of GP heralded patients

GP Fed September 2018

Review brokerage programme

BHT September 2018

Care home networking event for independent sector care providers

BCC October 2018

Real time data analysis through ALAMAC CCG October 2018

Implementation of system wide priorities including clinical pathways

ALL October 2018

Care home framework

BCC October 2018


Summary of factors affecting performance

The A&E department Patient flow

Long stay patients

Discharges Bed occupancy

Flu Resilience Workforce Admissions

Key factors

Who’s occupying the beds

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

System analysis and forecasting


Forecasting: Key focus on being able to forecast the number of discharges required and admissions

expected. The admission/discharge trigger which can help in planning how capacity can be met.

E.G. on average in August the trigger value was -10 per day (i.e. on average each day there were 10 more

admissions than discharges). -4 or less is regarded as the target to aim, otherwise the adverse position can

lead to use of escalation beds and paralysis of flow.


The issues Review of our data has identified that:

• Over all there has been growth in ED attendances, although type 1

attendances have decreased. This year compared to last year - there

are currently 27 more attendances per day and we expect this to

continue through Winter. There has also been an increase in

attendances at the UTC (was MIIU last year).

• It is forecasted that our admissions will increase over the winter period

• Last year our discharges decreased over winter. Review of data and

forecasting has identified that this year we should achieve more

discharges per day than last year but it will still be lower than the

number of admissions creating issues with flow

• We are moving in to the Winter period with a higher number of outliers

and escalation beds currently in use in the Acute Hospital

• We are moving into the Winter period with more Transfer of Care Waits

than we did last year. This is particularly the case in the Frimley system

• The number of patients waiting for a community bed is higher this year

than last


Key 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

Asthma


Following on from the learning of our colleagues in Berkshire, as part of our children's urgent care

action group - a targeted "asthma education session" is being delivered to 3 schools in

Buckinghamshire. Additionally this is being taken to our adults with learning disability and autism

event " access all areas" on Thursday 13th Sept.

This project incorporates school nurses, school matron/ staff, and our local trust paediatric

respiratory nurses speaking directly to young people about how to best manage their asthma this

winter.

There is also supporting information to take home to parents.


Flu update • Cold weather increases the risk of flu and other diseases.

• Groups such as older people, very young people, and people

with serious medical conditions are particularly vulnerable to the

effects of the cold weather.

• At the same time, there is also a risk of health and care staff

shortages due to flu, travel disruption and caring responsibilities.

• In the 2017 to 2018 flu season moderate to high levels of

influenza activity were observed in the UK with a consistent

pattern of outbreaks in care homes noted. Peak admissions rates

of influenza to hospital and ICU were higher than seen in the

previous 6 seasons.

• For the 2018-19 year an adjuvanted (strengthened) vaccination

is being offered to those over 65 to improve immune response in

this vulnerable group


Flu update Flu marketing is part of the wider “Stay Well This Winter” campaign. Key messages

include

Promote vaccination amongst key target groups (those aged 65 and over, pregnant women,

children, those with long term health conditions and carers)

Improve awareness of the nasal spray among parents of 2–3 year olds and those in school

years Reception to Year 5

The staff facing campaign “Protect yourself”. Protect your patients. Have a flu vaccination”

is based on the following elements;

Flu Vaccination of Healthcare Workers in Primary Care, Trusts & CCGs (Target of 75%

uptake)

Bucks County Council offer vaccination for all their internal staff and those working in its

commissioned services (e.g. Carers in Nursing Homes)

Activity is overseen by a Multi-agency flu group & fortnightly teleconferences

Outbreak response for care homes

CCGs have an agreed pro-active procedure for when a localised outbreak of influenza has

been identified and which meets national guidance and criteria. This involves working

collaboratively with Public Health England and primary care teams.


Flu uptake among school children

• BCC is offering a free flu jab for all staff through community pharmacies paid for by each Business Unit. • Local winter planning funds have been used to offer free Flu jabs for all frontline health & social care

staff, which includes, Social care staff , Care , Residential home staff and Domiciliary care staff • NHS England, have commissioned additional flu services for frontline staff again for 2018/19. GPs and

Pharmacies are commissioned to deliver this for carers and hospice workers (Staff will need to take their photo ID to the providers to receive their free flu jab)

The school based immunisation programme was extended to include year 4 for the 2017/18 season and uptake in all age groups is above national averages For 2018/19 the vaccination programme is being extended to include Year 5 children too (i.e. those aged 8 by 31st August 2018)


Communication strategy Working together as an

ICS to deliver joined-up

communication across

Bucks

Buckinghamshire County Council NHS Buckinghamshire CCG

Buckinghamshire Healthcare NHS Trust South Central Ambulance Service NHS FT

FedBucks Oxford Health NHS Foundation Trust

Buckinghamshire Local Pharmaceutical Committee


Comms

PREVENTION

COMMUNICATIONS OBJECTIVES

• Increase the number of people accessing NHS 111

• Increase the % of people who get the flu vaccination

• Increase % of parents/carers with young children seeking advice from a pharmacist and Health Help Now for minor ailments.

• Promotion of digital advice and triaging app ‘ask NHS’

PREPARE


• Promote ‘HELP US TO HELP YOU’ to build reciprocal understanding with public and NHS on how to stay well and best to access health and social care services.

• Ensure key media and stakeholders are informed and briefed of the campaign so that they can share and support it.

RESILIENCE


• All partners to use owned channels to share consistent messaging.

• Ensure people know how and where to access support.

• Provide important and immediate messaging to support safety and infection control

• Help to reduce unnecessary pressure on services.

Aim:

Change public behaviour to help PREVENT pressures on our health and social care system during the winter period.

Aim:

Build awareness of the work that the system is implementing to be PREPARED for the winter period.

Aim: Ensure health and social care partners work together to give consistent and timely messaging to residents during times of system pressure and/or bad weather.


Comms – Help us to Help you

Health and social care services across the county have carefully planned

for winter

To ensure we treat people in greatest need as a priority we all can help:

• Please get a flu vaccination - We have offered more flu vaccinations than ever

• Make use of services like NHS111 either by telephone or on line

• Make use of digital self care support services such as www.healthhelpnow.nhs.uk and

download the new free App for Buckinghamshire ‘Ask NHS’ for health information and

advice.

• Pharmacies are great resources, staffed by healthcare professionals

• Get the medicines you need from the pharmacy before bad weather or holidays

• Please keep an eye out for elderly or infirm friends or neighbours

Remember to save A&E for serious and life-threatening conditions - But if it

is a genuine emergency, don’t delay – dial 999

http://www.healthhelpnow.nhs.uk/


Campaigns


Communications

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