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The Kingston, Richmond, Surrey Downs Clinical Commissioning Groups and Kingston Hospital Foundation Trust Partnership – Whole Systems Urgent Care Board A&E Sustainability & Improvement Plan 2013/14

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Version Control

Version Date Author Development/Edits

0.1 09.09.2013 Tony May First Draft

0.2 17.09.2013 Tony May Edit – second draft

0.3 18.09.2013 Tony May Edit

0.4 19.09.2013 Tony May Final Draft incorporating agreed amendments

0.5 10.10.2013 Tony May Final Version

Document Approval

Organisational/Board/Individual Group Date

Final Draft before submission to NHS England approved at the Kingston Whole Systems Urgent Care Board meeting on 19/09/2013 with recommended amendments incorporated in this final draft v0.4

19.09.2013

Tripartite approval. 10.10.2013

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Contents 1 Executive Summary ....................................................................................................... 4

2 Introduction .................................................................................................................... 6

3 Background and Context ................................................................................................ 6

4 Performance Overview ................................................................................................... 8

5 Kingston Whole Systems Urgent Care Board ............................................................... 12

5.1 Purpose & Aims .................................................................................................... 12

5.2 Scope ................................................................................................................... 12

5.3 Membership .......................................................................................................... 13

5.4 Performance Management .................................................................................... 13

5.5 Key Tasks and Responsibilities............................................................................. 15

5.6 Programme of Work and Board Structure ............................................................. 15

6 Urgent Care Improvement Plan - Patient Journey through the Emergency System ...... 16

6.1 Prior to Arrival at A&E ........................................................................................... 16

6.2 Journey through the hospital ................................................................................. 18

6.3 Discharge and Out of Hospital care (using the framework set out in delivery of the A&E 4 hour operational standard) .................................................................................... 20

6.4 Winter Planning .................................................................................................... 24

7 Summary Conclusion ................................................................................................... 24

8 Addendum [1] .............................................................................................................. 26

8.1 Emergency Pressure Increase Year on Year at Kingston Hospital ........................ 26

9 Addendum [2] .............................................................................................................. 29

9.1 Kingston Hospital A&E figures by Area/Location and Specialty ............................. 29

10 Addendum [3] ........................................................................................................... 31

10.1 Adult Psychiatric Liaison Service pilot 2013/14 ..................................................... 31

11 Addendum [4] ........................................................................................................... 32

11.1 Kingston Hospital Foundation Trust A&E Action Plan 2013/14 .............................. 32

12 Addendum [5] ........................................................................................................... 35

12.1 Kingston Hospital DTOC Audit .............................................................................. 35

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1 Executive Summary The Partnership, consisting of Kingston, Richmond, Surrey Downs and Kingston Hospital Foundation Trust, recognises the importance of multi-agency planning and coordinated preparation to maintain and improve the quality and performance of urgent care services for local patients. In particular we are committed to a collaborative and managed approach for addressing the additional pressures placed upon A&E during the winter season and other periods of high demand. This plan describes the initiatives and actions in place across all partners, to ensure that preparation is robust and processes are in place that can adapt to pressure surges as and when they arise. This plan also describes the numerous initiatives in progress both within and outside of the hospital environment that as a whole will help to continue to reduce A&E attendances and admissions and achieve the A&E 4 hour target, for example:

Kingston at Home programme that see the integration of the provision of health and social care community services to deliver joined up services that support admission avoidance and early supported discharge.

In Richmond the merger of intermediate Care and Reablement teams

Admission avoidance schemes in Kingston, working with nursing homes

In Surrey Downs, reinforced community nursing team, rapid response services for identified patients and risk stratification

Multi-agency working group to support the implementation and supported training for Co-ordinate my care and End of Life across all health areas

Desmond and Walking Away services for diabetes, via Your Healthcare CIC in Kingston

Rapid and Adult Response teams, especially targeting the care home sector.

Risk stratification/ profiling

Multi-disciplinary Team (MDT) case management of “high” risk individuals.

Community Matrons are in post in all localities

New working group to look at improving primary care access and the interface between A&E and primary care.

NHS 111 pilot service and OoH provision in Kingston & Richmond.

Current review of Walk In service provision in Kingston.

Richmond has Teddington Memorial Hospital Walk in Centre.

Working Group to resolve issues that can affect the timely discharges of patients back home and reduce delayed transfers of care to other services in or outside the hospital.

A crucial element of our joint response will be complementary, integrated contingency arrangements to handle peaks in demand and unforeseen circumstances in conjunction with performance reports on key metrics; these will be used to monitor pressure in the system and identify areas requiring additional support to maintain performance.

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The pressures posed by winter and other periods of high demand can be unpredictable. Whilst the A&E 4 hour standard at Kingston Hospital was maintained there were episodes of challenging performance as a result of a multitude of factors such as:

The tendency towards a more complex/ dependent case mix

Reductions in timely discharge of patients, including delayed discharges and repatriations

Increased demand for emergency care in most specialities Extra demands on services during winter impact upon all parts of the NHS including primary care, ambulance and acute hospital services, such as accident and emergency, critical care, medical inpatient beds and social care. This plan and the preparation of all partners for the approaching 2013/14 winter are developed by the Partnership as shown through the Winter Checklist 2013/14. The finalisation of the plan and the on-going implementation and performance management will be overseen by a newly established Kingston Whole Systems Urgent Care Board. This Board will ensure that health and social care systems are prepared and coordinated to respond to the increased needs and/ or service demands through the winter period and maintaining resilience during other periods. Continuous Improvement The changes proposed are substantial, and safety and quality are of paramount importance. Our approach will be informed by the recent reviews undertaken by Professor Sir Bruce Keogh and Professor Don Berwick. Keogh wrote:-

“We found that, while trusts in the main complied with quality and safety processes, they were slow in learning lessons when things go wrong and embedding that learning in improved ways of doing things. A common finding was that the feedback loop back to staff who reported quality issues was ineffective – they reported an issue, but did not know what action had been taken as a result. Sometimes staff did not feel empowered to take action when they had identified an issue and in a few cases, staff felt uncomfortable raising issues with senior management (which may explain the fact that review teams were frequently approached by staff who wanted to explain their concerns in private).

Professor Don Berwick’s review, “’A Promise to Learn- a Commitment to Act’; Improving the Safety of Patients in England”, also identified the central importance of developing a continuous improvement culture in provider organisations. He wrote:-

“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

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“Unscheduled care services

are services that are

available for the public to

access without prior

arrangement where there is

an urgent actual or

perceived need for

intervention by a health or

social care professional.”

DoH

2 Introduction This plan provides an overview of the initiatives and actions to be planned and progressed, in partnership, by Kingston, Richmond, Surrey Downs and Kingston Hospital Foundation Trust Partnership, hereafter to be referred to as the ‘Partnership’ and the members of which are as follows:

Kingston Clinical Commissioning Group

Royal Kingston Borough Council

Kingston Hospital Foundation Trust

Your Healthcare CIC

Richmond Clinical Commissioning Group

Richmond Borough Council

Hounslow & Richmond Community Healthcare NHS Trust

Surrey Downs Clinical Commissioning Group

NHS England (specialised and primary care commissioning)? These organisations are working together to maintain and improve the performance of the Urgent Care Pathway for patients within the Kingston local health economy. This plan has been prepared in response to generic guidance from NHS England and in conjunction with wider strategic initiatives such as the Better Services Better Value (BSBV) review. The 4 hour Accident and Emergency (A&E) target, which is that 95% of patients must be admitted, transferred or discharged within 4 hours, has been met by Kingston Hospital Foundation Trust over the last few years. We recognise the importance of building a strong collaboration across agencies to continue to both sustain and improve our local health economy performance, building in the process of continuous improvement. The finalisation of this plan and the on-going implementation, continuous improvement and performance management will be overseen by the Partnership via the newly established Kingston Whole Systems Urgent Care Board for Kingston and its associated local health and community social care economy. The Board, chaired by Dr Vince Grippaudo, Kingston CCG’s Clinical Lead for Urgent Care and Governing Board member, will be the primary local forum for urgent care systems development.

3 Background and Context Urgent Care system and its’ various pathways for urgent and unscheduled care are complex, involving numerous professionals, all suitably trained and knowledgeable to

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direct, diagnose and treat people or to help reduce unexpected attendances at A&E and unscheduled hospital admissions. Although some urgent care takes place in a hospital most takes place in the community. When it is not a life threatening emergency people can obtain advice from NHS111 who can navigate them to the appropriate local community or primary care service or if necessary to A&E. Adults and children may be seen in a range of settings such as a Pharmacy, GP Practice (in hours) or a GP Out of Hours service, Walk-in Centre, GP Led Health Centre, Emergency Department/ A&E; Children may be seen in a specific children’s assessment unit or be visited by a District Nurse – see below diagram. Nationally, however, there is immense pressure on the urgent and emergency care systems, notable during both summer and winter months. In some areas of England this has had an impact on the achievement of the operational standard for A&E whereby 95% of patients must be admitted, transferred or discharged within 4 hours. The A&E operational standard is designed to deliver patients’ rights under the NHS Constitution. In ‘Everyone Counts: Planning For Patients 2013/14’ NHS England reinforced the NHS Constitution commitment and as such have requested that those CCGs with hosting responsibilities for A&E departments on their patches produce sustainable plans; this is part of NHS England’s approach to achieving CCG Assurance. Kingston Hospital has provided a good service over the past years, and has managed to meet monthly its 4 hour A&E target with good results in treating people so that the majority are sent home, or discharged to an appropriate community service, thus preventing avoidable hospital admissions. For example, in 2012/13 only circa 15% of patients attending A&E were admitted. However, there is a continuing requirement to sustain this good performance, build resilience and provide continuous improvement, in the face of operational challenges and expected increases in demand for A&E in Kingston Kingston faces some key challenges. The number of both older people and children (in Kingston, Richmond and Surrey Downs) is set to increase, which is likely to have major implications for urgent and social care services as these groups tend to use these services

Re-directed to NHS 111 in Out of Hours

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more frequently, than others. The outcome of Better Services, Better Value (BSBV) will see changes in A&E provision in South West London and if this is implemented will likely make Kingston Hospital A&E busier1. There is also the extra pressure of the current economic situation that dictates that we must do things better with the same amount of equivalent funding in the face of increasing demands. Kingston via the Whole Systems Urgent Care Board is building on the current good work already in place making improvements in urgent care and shaping unscheduled care in the area via innovative redesign in order to meet our challenges and NHS England’s requirements. A key to our plans is building on the evidence that shows that providing an integrated and proactive Urgent Care System, supported by a continuous improvement approach, which works across primary, community, social and secondary care. This will have a positive and significant impact on patients requiring or seeking urgent care and ensure that more are appropriately seen in another care setting to A&E and those that need to be seen in A&E meet the 4 hour target over 2013/14 and beyond.

4 Performance Overview A&E Performance at Kingston Hospital Foundation Trust is good, and was one of the few hospitals in London that continued to achieve the A&E performance standards (95%, 4 hour wait performance target), despite increasing year on year emergency pressures. Key deliverables for Kingston Hospital over 2012/13 were:

Their elective programme was maintained.

The medical, nursing and therapy teams worked well together to ensure the delivery of care on the escalated wards.

The ambulatory pathways were effective in increasing the number of patients in hospital for less than 24 hours and in supporting follow up care on an outpatient basis.

The admission rate from A&E attendances remained low. The medical and nursing teams were effectively supported by the increase in OT support at weekends and in the evenings.

The detailed plans for bank holidays ensured that increase support from clinical support services was available to the clinical teams, thus facilitating effective clinical pathways and discharge.

Daily ward rounds and RAG reviews Monday to Friday enabled effective decision making.

The provision of an additional registrar at weekends to support discharge. However, to ensure good performance continues throughout the rest of the year 2013/14 and beyond the Partnership has developed a Winter Checklist for 2013/14 that will be submitted for approval to the Tripartite Panel consisting of NHS England, Monitor and NHS Trust Development Authority. The Winter Checklist details what needs to be put in place and managed to ensure all initiatives and good practice across the Kingston health economy are achieving the desired performance and outcomes. These will be regularly monitored and reviewed, and improvements supported via the Whole Systems Urgent Care Board.

1 The BSBV projections forecast a possible increase in activity of between 28% and 40%, with

predominately higher acuity patients.

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The below table shows over the past few years the pressure on A&E, the pattern of A&E attendances and Emergency admissions as well as the 4 hour wait performance at Kingston Hospital over time.

The above table highlights four important facts (see Addendum [1]) as follows:

1. Since the introduction of the A&E 4 hour target (2004/05) Kingston Hospital has overall year on year achieved greater than the current 95% target

2. Emergency admissions have fluctuated over the last 10 years

3. A&E attendances have increased year on year

4. The conversion rate of how many A&E attendances resulted in an admission at Kingston Hospital grew from 2001/02, peaking in 2005/06, and thereafter has declined year on year.

The next chart shows average daily percentage of A&E 4 hour target performance at Kingston Hospital from April to end of August 2013/14. The second chart shows the average daily percentage of A&E 4 hour target performance for 2013/14.

Number Yearly total % change Number Yearly total % change

2001/02 * 33 10,466 16,492 53,639 84,522 19.51%

2002/03 52 16,989 16,989 3.01% 85,737 85,737 1.44% 19.82%

2003/04 52 18,209 18,209 7.18% 92,964 92,964 8.43% 19.59%

2004/05 52 20,554 20,554 12.88% 98,072 98,072 5.49% 96.08% 20.96%

2005/06 52 21,008 21,008 2.21% 99,359 99,359 1.31% 97.43% 21.14%

2006/07 52 18,477 18,477 -12.05% 101,353 101,353 2.01% 97.87% 18.23%

2007/08 53 19,014 18,655 0.96% 104,787 102,810 1.44% 97.61% 18.15%

2008/09 52 15,490 15,490 -16.97% 105,769 105,769 2.88% 98.06% 14.65%

2009/10 52 18,817 18,817 21.48% 109,402 109,402 3.43% 98.12% 17.20%

2010/11 52 17,221 17,221 -8.48% 109,237 109,237 -0.15% 98.15% 15.76%

2011/12 52 17,361 17,361 0.81% 112,230 112,230 2.74% 97.06% 15.47%

2012/13 53 17,103 16,780 -3.34% 115,427 113,249 0.91% 96.44% 14.82%

2013/14 * 22 6,831 16,563 -1.29% 47,440 112,541 -0.63% 96.15% 14.72%

* Numbers are extrapolated so annual profile based on historic activity built in. Last data: 01-Sep-13

Source: A&E Weekly Sitreps and Kingston Daily A&E returns.

Financial

Year

% Conversion

Rate

Emergency Admissions A&E AttendancesWeeks

Reported

4-hour w ait

performance

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Although overall Kingston Hospital has met the 4 hour target, nonetheless there are some specific areas and specialties where the hospital has experienced some difficulty in meeting the 4 hour A&E target. These are Majors and Resuscitation in terms of area/ location and their associated specialties: Medical, Surgical, and Orthopaedics due to the complexity of case mix - see the table in Addendum [2]. The largest two reasons for not meeting the A&E target in the aforementioned areas and specialities tends to be either due to bed delays (waiting for a bed to move the patient to) or clinical (the patient needs to remain in A&E for longer due to medical reasons – complexity of their medical condition). The improvements in place to address this are outlined in section 6.2.

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There was an unexpected and therefore unplanned increase in activity, which peaked in December 2012, and this had an impact on the level of escalation that could be provided. The pressure on beds required the opening of Derwent Ward at Kingston Hospital over the winter of 2012/13 as an escalation ward, which had implications for and pressure on staffing to ensure the maintenance of high quality care. The need for escalation beds meant that it was not always possible to place a patient in the most appropriate speciality based ward, despite best efforts by hospital discharge coordinators to identify those patients most suitable for such escalation beds. In addition, it was not always possible to manage medical escalation within the medical unit as well as surgical escalation in the surgical unit at times, and instead patients were transferred to another department in the hospital. There were also some issues from time to time in retaining access for GP admissions due to some variability in the availability of beds on AAU for direct GP admissions. With regards to specialities not associated with Majors and Resuscitation, the Psychiatric specialty stands out as not meeting the 4 hour A&E target. This is something that has been recognised and currently being addressed by mental health commissioners from the three health areas that use Kingston Hospital via the new Adult Psychiatric Liaison Service – see addendum [3]. This service goes live in September 2013. This recognises that many patients who are admitted to Kingston Hospital have either a primary, secondary or tertiary diagnosis of dementia, delirium or depression, whilst others have a UTI diagnosis which often results in dementia type behaviour. There is also recognition that more could be done in the primary community and social care sectors to help reduce A&E attendances and Admissions and this plan details the initiatives in place or being developed that will realise this goal – see section 6 below.

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5 Kingston Whole Systems Urgent Care Board To ensure that the overall A&E target in 2013/14 and improvements to the urgent care system are maintained, our partners across the Kingston Health Economy have formed the Kingston Whole Systems Urgent Care Board. This board reports into the Kingston Whole System Transformation Board. Before looking at the specific services already in place helping to deliver A&E target for 2013/14 as well as noting new initiatives to bring about improvements the next section looks at the purpose and aims of the Whole Systems UCB, its’ scope, who its members are, the performance management in place, its key tasks and responsibilities, and finally the Board structure as well as overview of its’ programme of work.

5.1 Purpose & Aims The purpose and aims of the Whole Systems Urgent Care Board are:

Oversee the development and implementation of a whole system urgent care strategy and plans

Oversee the review and mapping of current service delivery and plans against the good practice checklist to inform future service development and changes to improve effectiveness, sustainability and safety of A&E and unscheduled/ urgent care services

Share leading practice across the whole urgent care system

Identify and oversee a range of specific working groups to effect change and improvement across the whole system and hold them to account, as appropriate

To implement and deliver the decisions of the Epsom Transformation Board and Richmond CCG urgent care work as it relates to Kingston health economy

To also make recommendations for key projects aligned to the strategic priorities

To assure the Board on the feasibility of key projects as part of the business planning and decision making process

To lead multi-disciplinary transformation programmes on the key priorities

To ensure the integrated commissioning and delivery of services is achieved

5.2 Scope The geographical scope of the Whole Systems Urgent Care Board includes the population supported by Kingston Hospital and, where appropriate, the surrounding primary, social, community and mental health services both in and out of hours. The geographical patch encompasses primarily Kingston, Richmond and East Elmbridge, and secondary Wandsworth and Merton. The services in the scope of the Whole Systems Urgent Care Board will be determined by the urgent care strategy and plan. Where any service is included in the urgent care strategy and plan this will be inclusive of all health and social care providers and cover the entire population.

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5.3 Membership The Whole Systems Urgent Care Board will bring together all the members of the Partnership as follows:

1. Kingston Clinical Commissioning Group

2. Royal Kingston Borough Council

3. Kingston Hospital Foundation Trust

4. Your Healthcare CIC

5. Richmond Clinical Commissioning Group

6. Richmond Borough Council

7. Hounslow & Richmond Community Healthcare NHS Trust

8. Surrey Downs Clinical Commissioning Group

9. London Ambulance Service

10. Harmoni for OoH and NHS 111

11. NHS England (specialised and primary care commissioning)

12. Helthwatch, Kingston Upon Thames

Colleagues from other agencies e.g. South West London and St George’s Mental Health Trust and others will be invited to attend the Board when relevant issues are discussed. The Urgent Care Board is chaired by Dr Vince Grippaudo. Membership comprises senior representatives of each of the organisations at Clinical lead, Chief Officer, Director and Senior Manager levels. There is a high level of clinical leadership and engagement on the Board both from within the Trust, Kingston Hospital and from commissioning organisations

5.4 Performance Management The Board will monitor performance across the urgent care system using a dashboard of metrics covering all elements of the system. This dashboard is expected to include the following: PRIOR TO A&E

% Cat ‘A’ ambulance performance (8 minutes) Currently available via UNIFY & NHS England – London Region/ LAS contract monitoring reports. (Split by Red 1 or Red 2)

Ambulance Conveyance rates Available weekly via NHS England – London Region

Ambulance handovers >15 minutes Available from HAS system via CSU and in weekly NHS England – London report.

Primary Care Access measures GP patient survey to assess access to primary care.

GP Out-of-Hours performance Provision and uptake of out-of hours’ service.

111 Service Performance measures

Data available via UNIFY: Calls answered, calls transferred to clinician, call-backs as well as ambulance conveyance numbers.

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HOSPITAL SYSTEM

Friends and Family Test for A&E Available through Nationally-published performance by the HSCIC.

Kingston Hospital 4hr All-type Performance Available daily via hospital systems, weekly through Unify

Kingston Hospital 4hr Type 1 Performance Available daily via hospital systems, weekly through Unify

% patients seen in 4 hours at Type 3 services Data for Minor Injuries Units available monthly via SUS.

A&E Department Attendances Available daily via hospital systems

A&E Admissions conversion rate (total) Available daily via hospital systems

GP Admissions Emergency admissions from GPs available via SUS

Mental Health 4hr breaches Available daily via hospital systems

MIU Attendances (Type 3) Data for Minor Injuries Unit at Queen Mary’s Hospital and Teddington memorial hospital available monthly via SUS.

Kingston Hospital Bed Occupancy Available daily via hospital systems

Non-elective length of stay Available monthly via SUS

Zero Length of Stay Admissions Available monthly via SUS

Readmission rates Available monthly via SUS

Mortality rate. Available via Public Health by disease area. However, may only be available annually.

DISCHARGE & OUT OF HOSPITAL

GP-Led Health Centre Attendances Data should be available from identified centres.

Crisis Response Times Available from Mental Health Trust

Intermediate Care Measure Requirements to be defined around capacity

Community Care measures Requirements to be defined around capacity

Discharges from Kingston Hospital by time of day

Available from KHFT (If currently compiled and published)

Delayed Transfers of Care Available via UNIFY and community providers.

Community bed occupancy Supplied by Community Bed Providers

Care Homes data Number of contacts from Your Healthcare Care Homes support team by identified care home.

Disposition to institutional care Available via SUS

[The dataset above will be reviewed and added to as the project continues, in light of local priorities or by national datasets becoming available.]

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5.5 Key Tasks and Responsibilities The key tasks of the Urgent Care and System Improvement Board will be to ensure that the full range and responsibilities of an Urgent Care Board are fulfilled, with a focus on longer term sustainability, through ensuring:

Leadership capacity and expertise is in place to manage urgent and emergency care issues within the health economy

Ensure urgent care and A&E plans are in line with good practice, delivering service developments and changes that improve the effectiveness, sustainability and safety of A&E and unscheduled care services

Leadership capacity and expertise is in place to undertake data review and analysis as well as to share findings with key stakeholders

Identification and agreement on key priorities to achieve sustained improvement

Resources are in place (senior leadership, external support, commissioned capacity) to accelerate proposed improvements

Effective programmes are in place to deliver sustained improvement, holding partners to account for delivery of each part of an integrated approach via UCB monitoring of performance

Learning from programme delivery, and that performance information is shared across programmes

The impact of successes and challenges in integrated working are considered, and to propose new ways of facilitating integrated care

Relating outcomes of the programme work streams to the BSBV modelling assumptions, engage the BSBV team as appropriate.

5.6 Programme of Work and Board Structure

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6 Urgent Care Improvement Plan - Patient Journey through the Emergency System

The plan provides assurance to NHS England and evidences the strong performance of the South West London regions A&E departments, with Kingston Hospital meeting the 4 hour A&E target in 2012/13. However, to ensure this is sustained and continuous improvements are made to meet increasing demands and challenges, Kingston Whole Systems Urgent Care Board are undertaking the following initiatives and plans as outlined in the following three key stages of the patient pathway through the A&E and urgent care system:

1. The patient journey prior to A&E

2. The patient journey through the hospital

3. The patient journey at point of discharge and out of hospital. The section (6.1) on prior to A&E covers improved provision for the needs of elderly and frail patients; ensuring appropriate care is provided in a community setting for patients with long term conditions (LTC)2; providing sufficient capacity in the Community Ward; improving access to General Practice to divert patients from A&E and ensuring sufficient surge capacity in out of hours and NHS 111 services. The hospital system section (6.2) details the numerous initiatives in place or actions to be delivered in 2013/14 to sustain good practice and address issues to ensure the delivery of the A&E performance standard. Finally, the Discharge and Out of Hospital section (6.2) details how it will improve discharge planning and reduce delayed transfers of care both at Kingston Hospital, as well as in neighbouring community hospitals.

6.1 Prior to Arrival at A&E A range of best practice programmes and plans are in place to support management of demand in both primary and community care to reduce A&E attendances and maintain the good admission rate:

Integration of the provision of health and social care services to deliver joined up services that will enable people to receive treatment and care at home, and prevent their admission into hospital. This will also support peoples being discharged from hospital to home earlier to receive rehabilitation and support.

Kingston at Home (KaH) programme as an example of the above

o A key deliverable is the enhanced packages of care to support the frail and elderly patients within their home

o The programme co-located integrated community care teams in 2013

o KaH will increase the number of people receiving sub-acute care at home whilst remodelling community beds to focus on step up care and step down at home

2 Long term conditions (LTC) are conditions that cannot at present be cured, but can be controlled or

helped by medication and other therapies. Examples include diabetes, asthma, heart failure, progressive neurological diseases, ulcerative colitis and chronic obstructive pulmonary disease (COPD). Of these, many live with a condition that limits their ability to cope with day-to-day activities.

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GP Extended Hours Access Scheme (Direct Enhanced Service) in operation to provide extended opening hours above core contracted hours, and thus provides more appointment slots, for both urgent and routine care. This will encourage patients with an urgent, but not emergency issue, to see their GP or other healthcare professional within the extended hours and not turn up at A&E.

Develop GP appointment systems to facilitate more people being able to contact their GP.

Develop GP appointment systems to allow NHS 111 to book direct GP appointments with the caller/ patient on the line.

In Richmond the merger of Intermediate Care and Reablement teams.

A number of admission avoidance schemes:

o Occupational Therapy (OT) in A&E

o Rapid Response and Acute Nursing services to assess and treat sub-acute ill people at home

o Nursing Advice, Support and Care Management into care homes (residential and nursing homes)

o Alternative Care Pathways with London Ambulance Service (LAS)

o Risk Stratification

o Telehealth

o Care/ Nursing homes support and falls prevention

o Crisis teams/ Mental Health unscheduled care – extended joint KHFT older people/ psychiatric liaison service pilot.

Multi-agency working group to support the implementation and training for ‘Co-ordinate My Care’ (CMC)3 and End of Life Care (EoLC)4 across all health areas, and the development of CMC and EoLC registers to facilitate reduction of unwanted and inappropriate interventions & emergency admissions to hospitals.

Use of Community Diversion schemes, such as

o Chronic Obstructive Pulmonary Disease (COPD) pulmonary rehab service since 2011, plus the COPD local enhanced service (LES)

o Current review of the Community Heart Failure service and Rehab service with a view to implementing a new cardiology service and rehab services

o Community Heart Failure Nursing in place for Surrey Downs CCG

Desmond and Walking Away services via Your Healthcare in Kingston

Rapid and Adult Response teams, especially targeting the care home sector.

KCCG is working with primary care to implement risk stratification/ profiling and MDT case management of “high” risk individuals.

3 Coordinate My Care is a clinical service that coordinates care, giving patients a choice and improved

quality of life. It also provides patients with a secure personalised care plan describing the care they would like which can then be shared with all the experts caring for them both day and night, see http://coordinatemycare.co.uk. 4 These are locality level end of life care registers that provide a means of recording & communicating

key information about people’s wishes and preferences for end of life care.

http://coordinatemycare.co.uk/

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Work on Long Term Conditions (LTC) to ensure uniformity of quality of care across the spectrum of primary and community care services to reduce variation and help the facilitation of reduction in hospital emergency admissions.

Community Ward in Richmond focused on LTC.

Community Matrons are in post in all localities and the model is supported by close community team working across the Rapid Response, IMPACT, District Nursing services.

A working group set up to look at improving primary care access and the interface between A&E and primary care.

Scope potential of a walk in service in Kingston to provide an alternative service for a number of urgent conditions as an alternative to A&E.

Richmond CCG has Teddington Memorial Hospital Walk in Centre and Surrey Downs CCG has the Physician led Community Assessment Unit (CAU) based at Leatherhead Community Hospital, which provides clinical assessment, diagnosis and treatment for a number of ailments for adults over the age of 18 years.

Using NHS 111 as a navigating service to help callers/ patients find an alternative clinically appropriate service to A&E, and thus help manage the flow of patients into A&E.

Putting in place a system at Kingston A&E to allow healthcare professionals after initial assessment to recommend to a patient that could be seen by an alternative primary or community care service outside of A&E to call NHS 111, via a dedicated telephone, to see if they can be treated quicker rather than wait in a busy A&E.

In Surrey Downs CCG:

o They provide a community nursing team, rapid response services for identified patients.

o Healthcare professionals carry out case reviews of frequent fliers and sets appropriate actions to be taken for said patients, as well as looking at ways to minimise these occurrences.

o The CAU is in place, as previously mentioned, and is currently capable of providing patients and primary care professionals with prompt access to medical specialist input and diagnostics while serving as a viable alternative care setting to A&E.

o Developing the idea of a paramedic led service for 2015 with the consultation already underway in 2013.

6.2 Journey through the hospital Kingston Hospital Foundation Trust has a number of initiatives and actions in place to improve the flow within the hospital to support the 4 hour A&E target as follows:

Modelling of winter activity over the past 3 years to enable robust sequencing of the opening of escalation beds.

KHFT has seen an increase in category “A” patient ambulance call outs for seriously ill patients requiring ED attendance. As a result the hospital is developing how best to manage their workload, improving skill mix and looking at ways to reduce such attendances.

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Establishment of a dedicated care of the elderly unit with increased numbers of beds with day ward facilities to ensure that more care of the elderly patients are cared for by care of elderly consultants.

Recruitment of extra nursing staff to support the opening of escalation beds.

Integration of medical and surgical assessment beds on the AAU.

Establishment of the admission on the day lounge for elective surgical patients to maintain the flow of the elective programme.

Commissioning by the CCG of a psychiatric liaison service for elderly patients.

Agreement to support an additional band 5 discharge co-ordinator post and to OT assistants for 6 months to assist with complex discharges and reduce delayed transfers of care.

Sharing of information with partner organisations on DTOC and collectively developing an action plan

Revision of the over 5 day length of stay meeting to ensure the team can focus on those with extended length of stay and requiring input from a care of the elderly physician.

Ambulance hand over targets will be made more stringent over 2013/14 to avoid patients waiting in ambulances before they are admitted to A&E.

KHFT has the following ambulatory pathways in place for: DVT, PE, cellulitis, anaemia, syncope, exacerbation of MS, paracentesis, AF, asthma, chest pain, upper GI bleed, headache, first seizure, and lower respiratory tract. The Trust has a dedicated acute care physician.

KHFT will undertake a review in 2013/14 to asses which ambulatory pathways impact the greatest number of patients and develop these pathways to help increase their volume and activity with support from primary care and community services.

KHFT escalation process allows senior management team to support front line staff provide solutions to remedy/ remove any blockages that have occurred preventing a patient seeing a doctor or being discharged.

KHFT is reviewing the feasibility of providing a second dedicated rapid assessment process/ treatment cubicle located in majors and led by the senior medical team to help improve the number of patients who are handed over by the ambulance team within 30 minutes.

The hospital has 10 trolley/beds which are available from 10 am to 10pm and allow direct admission from GP referrals Monday to Friday. This has been in place for a number of years and has been successful in diverting referrals from A&E. It has now been integrated in the acute assessment unit to provide increased medical and nursing support and timely access to patients. Some clinic patients go directly to the speciality ward, whilst others are admitted to the AAU.

KHFT has undertaken analysis of blockages on AAU and on the wards and has a discharge work stream which has been in place for 18 months, focusing on blockages e.g. delays in transfer to specialist units, transport, TTOs, delays in cardiology investigations etc. This has been successful in supporting the reduction in length of stay.

Providing additional phlebotomy at weekends to enable early blood taking, receipt of results and discharge.

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The effective management of the 20 assessment beds and 30 short stay beds on AAU is critical to the management of flow. This will be supported by the appointment of 2 additional ACPS. This will enable the ACPS to offer direct access to GPS across the extended day Monday to Friday and Saturday am in line with GP opening hours.

Establishment of 7 smaller medical and elderly care wards with capacity on each ward for escalation beds.

Provide additional clinical support services at times of high activity - particularly during the 8 weeks when up to 30 beds may be required.

Maintenance of an even spread of elective activity across the week.

Extended shop floor presence of the ED consultants 7 days per week following the recruitment into the 10 consultant posts to ensure prompt decision making.

Twice daily bed meetings chaired by the advanced site practitioner and attended by a senior manager to ensure effective decision making.

Impact of recent increase in the number of wards and the reduction in the number of beds on each ward, enabling a focus on discharges before midday.

Increase in Occupational Therapy (OT) assistants by 2, and discharge coordinators by 1 to support the OT assessments and completion of health needs assessments.

Actions arising from the Integrated CQUIN and the urgent care board as they relate to orthopaedics. This includes improvements in DTOC

Focus on early morning discharge and improvements in discharge across each day of the week.

To introduce nurse facilitated discharge.

To focus on individual HRGs to reduce length of stay.

Use of repatriation process to ensure that those patients waiting for beds at tertiary centres are transferred within 24 hours.

Re-launch of the weekly complex discharge meeting with a focus on those patients who have been in hospital for more than 10 days.

Provision of a social worker on site for 2 days per week from Surrey social services

Effective management of consultant and junior doctor leave.

6.3 Discharge and Out of Hospital care (using the framework set out in delivery of the A&E 4 hour operational standard)

As delays in discharge planning and delayed transfers of care (DTOCs) impacts on bed management and the ability of hospitals to move patients seamlessly through the system, the Kingston Whole Systems Urgent Care Board has made this a priority for Kingston Hospital Foundation Trust (KHFT) and supporting Community and Social care services. Kingston Hospital is consistently an outlier in terms of DTOCs compared to other LHEs. The proportion of weekly unavailable beds data associated with DTOCs to total of GA beds ranged from 3.52% across core bed position of 333 beds to 6.56% compared to an average across London of 0.96% to 3.09%. However the level of DTOCS at the hospital was consistent with the 2011/12 pattern.

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The four most frequently reported reasons for delayed discharge were, in order of frequency:

Waiting for social services arrangements

Waiting for transfer to another hospital, but no bed available

Delays by the medical team in arranging discharge – e.g. in filling HNA paperwork, doing TTOs or assessing capacity

Delays by the patient’s family – e.g. in viewing or finalising homes The above four reasons altogether constituted over 80% of the total reported reasons for delays in discharge as shown in the pie chart below.

A contributory factor to why there is the level of reported delays in discharge is possible due to the number of community health and social care organisations that the Hospital’s teams have to interface with. In addition, community hospitals are also subject to DTOCs that also impact on the whole system. The following table shows which CCG areas patients who have had a delay in discharge come from.

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A considerable amount of work has already been undertaken and continues – see addendum [5] for a summary of the most recent Kingston Hospital DTOC audit, with the aim to improve discharge planning and reduce delay transfers of care (via the 2013/14 Integrated Commissioning for Quality and Innovation (CQUIN) payment). This work will build on this. A time limited Task and Finish Group has been established, comprising membership from across the local health and social care economies who are members of the Kingston Whole Systems Urgent Care Board. The objective of the Group is to improve discharge planning and reduce delayed transfers of care both at Kingston Hospital, as well as in neighbouring community hospitals, by:

Mapping current discharge and DTOCs work streams

Reviewing current DTOC performance across at Kingston Hospital and its community partners

Mapping the issues from the perspective of the hospital, community health service provider and social services and reach a consensus on the priority areas

Reviewing the patient pathway to understand barriers to effective and timely discharge

Reviewing best practice guidelines and policy on discharge planning and DTOCs

A CQUIN scheme payment

enables Clinical

Commissioning Groups to

reward excellence, by linking

a proportion of healthcare

providers’, like Kingston

Hospital, income to the

achievement of local quality

improvement goals.

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Reviewing tools e.g. patient tracking software which could assist in managing patients and their timely discharge

Producing a report and recommendation for the UCB by September 2013. There are a number of actions agreed to reduce DTOCs at Kingston Hospital as follows:

Mapping the stages of the Health Needs Assessment (HNA), identifying which elements can be influenced by KHFT, and to agree a target for completion as well as to increase the number of discharge coordinators to support this target, if appropriate.

Looking at ways to speed up, align and simplify discharge processes, criteria and administration, supplying effective guidance and access to key information.

Community health and social care providers to educate and provide information to the Hospital teams on the scope and range of CHS with a focus on sending patients home as the best and most appropriate outcome with the right support when required.

Re-introducing the successful Kingston Borough Patient Navigator service (previously run as a pilot), which established Community In-Reach to work with Kingston Hospital’s teams to identify, advise and facilitate discharge with a focus on sending the patient home. This service’s role is not only an educative one but also raises awareness of the range of services available in the community that could support patients.

Your Healthcare district nursing hours will be extended to close the 5.00pm to 7.00pm gap.

Your Healthcare will work with Princess Alice Hospice to provide Clinical Nurse Specialist on-call support between 8.00pm and 8.00 am as additional support for End of Life Care

Utilising the 8 beds at Hobrick House over the winter of 2013/14 to provide additional therapy and nursing input.

Exploring Spot purchase arrangements from independent sector where a bed is the safest option for the individual based on their assessed need when capacity needs to be increased to deal with unexpected activity.

Exploring options to review admissions policy with Neuro Rehabilitation Service and see if they can provide interim services at home to support effective and early discharge to home.

Kingston Hospital to explore feasibility of implementing a Discharge Management Tool.

Kingston Hospital to implement improvements and changes to working practices, taking forward key learning for RBK and internal reviews

To work with Mental Health services to agree actions to reduce DTOCs

Setting up direct reporting mechanisms into the Whole Systems Urgent Care Board, weekly DTOC summaries reported to CCG commissioners, and for a DTOC KPI to be discussed as part of monthly contract performance reviews with our community and social care providers, and KHFT.

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6.4 Winter Planning The NHS England highlights ten key areas or domains that are vital to ensuring all services and winter planning arrangements across local health and social care systems are well coordinated, responsive and resilient:

1. Leadership and Surge Management

2. Primary Care and Out of Hours Services including NHS 111

3. Social Care (including housing and wider Local Government

4. Intermediate Care

5. Mental Health

6. London Ambulance Service (LAS) Interface with Hospital Trust / ED services

7. Infection Control

8. Severe Weather and Business Continuity Planning

9. Staffing

10. Communications Measures are being actively taken to manage risks associated with each of these key areas and to ensure mitigation strategies are included in plans across the whole health economy. An evaluation of the effectiveness of the winter planning process and allocation of additional funding during 2012/13 was undertaken. The CCGs will work with its health and social care partners to ensure that the lessons learnt from winter 2012 are built into the 2013/14 plans to enhance a whole system resilience capability. The overriding objectives for 2013/14 are to maintain safe, high quality services for patients, including the effective management of infection, Emergency Department access, ambulance turnaround times, urgent and other elective treatments and effective DTOCs. The plans for 2013/14 will be an integral part of a long-term local strategy and the commissioning of responsive services that meet patient need. The 2013/14 winter plans aim to assure continuity and successful response of essential services at times of high demand and to enable effective contingencies to be initiated on a planned and managed basis. They will be constructed in the context of the need to ensure sustained performance across the whole system. The Partnership will work together through the Whole Systems Urgent Care Board to ensure the whole health economy understands and addresses the identified pressure points.

7 Summary Conclusion Winter impacts on the full spectrum of health and social care services and each year there are extra demands on services during winter. Meeting the A&E standard during 2012/13 was challenging, but with the implementation of a range of initiatives, was achieved at Kingston Hospital Foundation Trust. The performance at Kingston Hospital is on track to meet the 95% standard. The Trust and local health and social care community will continue to focus all efforts on this throughout the year.

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This plan has presented an overview of the initiatives and actions in progress to maintain and improve the performance and quality of the urgent care pathway for patients. The plan focuses on managing the three phases of a patient’s journey through A&E / urgent care: prior to A&E, the hospital system and discharge and out-of-hospital care and involving all aspects of the health and social care system.

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8 Addendum [1]

8.1 Emergency Pressure Increase Year on Year at Kingston Hospital

Four important facts stand out from the above table. Firstly emergency admissions have fluctuated, increasing in the mid-2000s and again in 2009/10, but over the last three years have more or less returned back in terms of volume of admission to levels found in the early 2000s. Secondly, however, A&E attendances have increased year on year except for 2010/11. The following chart compares in more detail A&E attendances against Emergency admissions rates at Kingston Hospital, and clearly shows that there has been a continuing reduction of A&E attendances converting into emergency admissions, even though the A&E activity has shown an increase since 2001 it seems to have become reasonably stable since 2009.

Number Yearly total % change Number Yearly total % change

2001/02 * 33 10,466 16,492 53,639 84,522 19.51%

2002/03 52 16,989 16,989 3.01% 85,737 85,737 1.44% 19.82%

2003/04 52 18,209 18,209 7.18% 92,964 92,964 8.43% 19.59%

2004/05 52 20,554 20,554 12.88% 98,072 98,072 5.49% 96.08% 20.96%

2005/06 52 21,008 21,008 2.21% 99,359 99,359 1.31% 97.43% 21.14%

2006/07 52 18,477 18,477 -12.05% 101,353 101,353 2.01% 97.87% 18.23%

2007/08 53 19,014 18,655 0.96% 104,787 102,810 1.44% 97.61% 18.15%

2008/09 52 15,490 15,490 -16.97% 105,769 105,769 2.88% 98.06% 14.65%

2009/10 52 18,817 18,817 21.48% 109,402 109,402 3.43% 98.12% 17.20%

2010/11 52 17,221 17,221 -8.48% 109,237 109,237 -0.15% 98.15% 15.76%

2011/12 52 17,361 17,361 0.81% 112,230 112,230 2.74% 97.06% 15.47%

2012/13 53 17,103 16,780 -3.34% 115,427 113,249 0.91% 96.44% 14.82%

2013/14 * 22 6,831 16,563 -1.29% 47,440 112,541 -0.63% 96.15% 14.72%

* Numbers are extrapolated so annual profile based on historic activity built in. Last data: 01-Sep-13

Source: A&E Weekly Sitreps and Kingston Daily A&E returns.

Financial

Year

% Conversion

Rate

Emergency Admissions A&E AttendancesWeeks

Reported

4-hour w ait

performance

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Thirdly, the conversation rate of how many attendances result in an admission at Kingston Hospital grew from 19.5% in 2001/02, peaking at 21.1% in 2005/06, but has subsequently declined to 14.8% in 2012/13. The following chart shows this in more detail. The second chart below maps total A&E attendances against Emergency admission rates at Kingston Hospital.

Using the last 4 full years of data (to avoid any particular outlying events in one year) the following chart shows the outcome of mapping activity over the year (January to December) to show any seasonal variations between each year. As you will see from the below chart A&E seasonality seems particularly stable back to 2009/10, whereas the emergency admissions seem less so.

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Fourthly, since the introduction of the A&E 4 hour target (2004/05) Kingston Hospital has overall year on year achieved greater than the current 95% target. The following chart shows weekly percentage of waits less than 4 hours at Kingston Hospital, showing the peaks, troughs and average normal activity. The second chart, below shows the number of people seen within the 4 hour target at Kingston Hospital. The third chart shows this year’s (2013/14) daily A&E waits under 4 hours at Kingston Hospital (Cumulative position). The fourth chart shows average daily percentage of A&E 4 hour target performance at Kingston Hospital 2013/14.

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Location

Att <4hr % Att <4hr % Att <4hr % Att <4hr % Att <4hr % Att <4hr % Main REU Total Main REU Total

Apr-13 3,306 3,044 92.1% 2,771 2,742 99.0% 339 245 72.3% 2,205 2,179 98.8% 779 778 99.9% 9,400 8,988 95.62% 407 0 407 4.72% 0.00% 4.33%

May-13 3,432 3,155 91.9% 2,804 2,780 99.1% 311 198 63.7% 2,437 2,408 98.8% 813 812 99.9% 9,797 9,353 95.47% 524 0 524 5.83% 0.00% 5.35%

Jun-13 3,269 3,097 94.7% 2,772 2,755 99.4% 295 231 78.3% 2,192 2,167 98.9% 676 674 99.7% 9,204 8,924 96.96% 447 0 447 5.24% 0.00% 4.86%

Jul-13 3,538 3,357 94.9% 3,043 3,013 99.0% 284 223 78.5% 2,267 2,248 99.2% 830 830 100.0% 9,962 9,671 97.08% 400 0 400 4.38% 0.00% 4.02%

Aug-13 3,305 3,061 92.6% 2,833 2,806 99.0% 334 241 72.2% 1,645 1,627 98.9% 663 663 100.0% 8,780 8,398 95.65% 0 0 0 0.00% 0.00% 0.00%

Sep-13 576 511 88.7% 452 441 97.6% 57 35 61.4% 335 329 98.2% 142 142 100.0% 1,562 1,458 93.34% 0 0 0 0.00% 0.00% 0.00%

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

13/14 17,426 16,225 93.1% 14,675 14,537 99.1% 1,620 1,173 72.4% 11,081 10,958 98.9% 3,903 3,899 99.9% 48,705 46,792 96.07% 1,778 0 1,778 3.97% 0.00% 3.65%

Specialty

Att <4hr % Att <4hr % Att <4hr % Att <4hr % Att <4hr % Att <4hr % <4hr % Att <4hr %

Apr-13 873 604 69.2% 389 322 82.8% 214 180 84.1% 88 84 95.5% 126 109 86.5% 375 361 96.27% 7,335 7,328 99.90% 9,400 8,988 95.62%

May-13 841 585 69.6% 419 318 75.9% 244 208 85.2% 82 78 95.1% 149 126 84.6% 425 408 96.00% 7,637 7,630 99.91% 9,797 9,353 95.47%

Jun-13 782 630 80.6% 397 345 86.9% 240 217 90.4% 109 104 95.4% 117 104 88.9% 367 351 95.64% 7,192 7,173 99.74% 9,204 8,924 96.96%

Jul-13 819 664 81.1% 447 389 87.0% 241 207 85.9% 99 92 92.9% 82 73 89.0% 352 338 96.02% 7,922 7,908 99.82% 9,962 9,671 97.08%

Aug-13 842 606 72.0% 410 344 83.9% 237 199 84.0% 113 108 95.6% 72 64 88.9% 267 256 95.88% 6,839 6,821 99.74% 8,780 8,398 95.65%

Sep-13 140 88 62.9% 85 53 62.4% 40 32 80.0% 11 9 81.8% 11 8 72.7% 60 56 93.33% 1,215 1,212 99.75% 1,562 1,458 93.34%

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

13/14 4,297 3,177 73.9% 2,147 1,771 82.5% 1,216 1,043 85.8% 502 475 94.6% 557 484 86.9% 1,846 1,770 95.9% 38,140 38,072 99.8% 48,705 46,792 96.07%

As at 05-Sep Figures in blue are month-to-date.

Psychiatric Paediatrics

LocMajors Minors Resus Children REU

SpecMedical Surgical Orthopaedics Gynaecology A&E / REU Total

Att

Total Sent to GP service % GP service conversion

9 Addendum [2]

9.1 Kingston Hospital A&E figures by Area/Location and Specialty

Delving deeper into the data for 2013/14, the following table shows the type of reason recorded by Kingston Hospital for not meeting the A&E target. The largest two reasons tend to be either bed or clinical followed by delay within A&E within the medical, surgical, orthopaedics and psychiatric specialties (as at 17th July).

2013-2014 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 120 64 32 7 3 8 7 0 241 6.3% 3.3% 1.7% 0.4% 0.2% 0.4% 0.4% 0.0%

Diagnostics 0 0 0 1 0 0 3 0 4 0.0% 0.0% 0.0% 0.1% 0.0% 0.0% 0.2% 0.0%

Specialty 78 76 55 9 44 23 14 0 299 4.1% 4.0% 2.9% 0.5% 2.3% 1.2% 0.7% 0.0%

Transport 1 1 1 0 0 0 10 0 13 0.1% 0.1% 0.1% 0.0% 0.0% 0.0% 0.5% 0.0%

Bed 549 162 57 10 2 11 9 0 800 28.7% 8.5% 3.0% 0.5% 0.1% 0.6% 0.5% 0.0%

Clinical 371 73 28 0 24 34 20 1 551 19.4% 3.8% 1.5% 0.0% 1.3% 1.8% 1.0% 0.1%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 1 0 0 0 0 0 1 0 2 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1% 0.0%

REU 0 0 0 0 0 0 0 3 3 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2%

TOTAL 1,120 376 173 27 73 76 64 4 1,913

Apr-13 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 11 9 6 1 1 1 0 0 29 2.7% 2.2% 1.5% 0.2% 0.2% 0.2% 0.0% 0.0%

Diagnostics 0 0 0 1 0 0 1 0 2 0.0% 0.0% 0.0% 0.2% 0.0% 0.0% 0.2% 0.0%

Specialty 15 9 3 0 9 4 0 0 40 3.6% 2.2% 0.7% 0.0% 2.2% 1.0% 0.0% 0.0%

Transport 0 0 0 0 0 0 1 0 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2% 0.0%

Bed 176 39 20 2 2 1 2 0 242 42.7% 9.5% 4.9% 0.5% 0.5% 0.2% 0.5% 0.0%

Clinical 67 10 5 0 5 8 2 0 97 16.3% 2.4% 1.2% 0.0% 1.2% 1.9% 0.5% 0.0%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

REU 0 0 0 0 0 0 0 1 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2%

TOTAL 269 67 34 4 17 14 6 1 412

May-13 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 14 10 4 0 1 1 0 0 30 3.2% 2.3% 0.9% 0.0% 0.2% 0.2% 0.0% 0.0%

Diagnostics 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Specialty 11 18 12 3 14 3 3 0 64 2.5% 4.1% 2.7% 0.7% 3.2% 0.7% 0.7% 0.0%

Transport 0 1 0 0 0 0 1 0 2 0.0% 0.2% 0.0% 0.0% 0.0% 0.0% 0.2% 0.0%

Bed 156 53 14 1 0 6 0 0 230 35.1% 11.9% 3.2% 0.2% 0.0% 1.4% 0.0% 0.0%

Clinical 75 19 6 0 8 7 2 0 117 16.9% 4.3% 1.4% 0.0% 1.8% 1.6% 0.5% 0.0%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

REU 0 0 0 0 0 0 0 1 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2%

TOTAL 256 101 36 4 23 17 6 1 444

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Jun-13 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 26 14 4 1 1 2 2 0 50 9.3% 5.0% 1.4% 0.4% 0.4% 0.7% 0.7% 0.0%

Diagnostics 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Specialty 9 9 10 2 8 9 3 0 50 3.2% 3.2% 3.6% 0.7% 2.9% 3.2% 1.1% 0.0%

Transport 1 0 1 0 0 0 4 0 6 0.4% 0.0% 0.4% 0.0% 0.0% 0.0% 1.4% 0.0%

Bed 40 15 3 2 0 0 0 0 60 14.3% 5.4% 1.1% 0.7% 0.0% 0.0% 0.0% 0.0%

Clinical 75 14 5 0 4 5 8 1 112 26.8% 5.0% 1.8% 0.0% 1.4% 1.8% 2.9% 0.4%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 1 0 0 0 0 0 0 0 1 0.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

REU 0 0 0 0 0 0 0 1 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4%

TOTAL 152 52 23 5 13 16 17 2 280

Jul-13 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 22 12 11 2 0 3 0 0 50 7.6% 4.1% 3.8% 0.7% 0.0% 1.0% 0.0% 0.0%

Diagnostics 0 0 0 0 0 0 2 0 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.7% 0.0%

Specialty 13 16 12 1 3 2 3 0 50 4.5% 5.5% 4.1% 0.3% 1.0% 0.7% 1.0% 0.0%

Transport 0 0 0 0 0 0 1 0 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% 0.0%

Bed 60 14 6 4 0 1 1 0 86 20.6% 4.8% 2.1% 1.4% 0.0% 0.3% 0.3% 0.0%

Clinical 60 16 5 0 6 8 6 0 101 20.6% 5.5% 1.7% 0.0% 2.1% 2.7% 2.1% 0.0%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 0 0 0 0 0 0 1 0 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% 0.0%

REU 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TOTAL 155 58 34 7 9 14 14 0 291

Aug-13 Medical Surgical Ortho Gynae Psych Paed A&E REU TOTAL Medical Surgical Ortho Gynae Psych Paed A&E REU

Delay w ithin A&E 45 17 6 2 0 0 5 0 75 11.8% 4.5% 1.6% 0.5% 0.0% 0.0% 1.3% 0.0%

Diagnostics 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Specialty 27 20 17 3 7 4 5 0 83 7.1% 5.2% 4.5% 0.8% 1.8% 1.0% 1.3% 0.0%

Transport 0 0 0 0 0 0 2 0 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.0%

Bed 83 20 8 0 0 2 5 0 118 21.7% 5.2% 2.1% 0.0% 0.0% 0.5% 1.3% 0.0%

Clinical 81 9 7 0 1 5 1 0 104 21.2% 2.4% 1.8% 0.0% 0.3% 1.3% 0.3% 0.0%

Unknow n 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Other 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

REU 0 0 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TOTAL 236 66 38 5 8 11 18 0 382

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10 Addendum [3]

10.1 Adult Psychiatric Liaison Service pilot 2013/14 Kingston Hospital will start an Adult Psychiatric Liaison Service pilot in September 2013 for people over 65 who have functional mental health problems. Commissioners have identified that there is a need to deliver a compatible service alongside the Adult service for Older People with dementia, delirium or depression. Consequently mental health commissioners from three health areas who use Kingston Hospital are initiating a pilot to determine the need for Older People Psychiatry Liaison Service at Kingston Hospital. The aim of the pilot is primarily a rapid assessment service in the acute setting of mental health. It aims to provide better services, and reduce avoidable admissions. Co-morbid psychiatric illness imposes heavy costs on the economy; addressing these issues in the acute service will reduce waiting times, increase value for money and provide a better patient experience for service users and carers. This service will also reduce lengths of stay on the wards. This will be a provision which is integrated into the current Adult Service but which will be accountable through performance measures designated solely to the older patient mental health cohort in Kingston Hospital. Kingston Clinical Commissioning Group data shows that many patients who are admitted to Kingston Hospital have either a primary, secondary or tertiary diagnosis of dementia, delirium or depression, whilst others have a UTI diagnosis which often results in dementia type behaviour. A key aim of the service is to be able to quickly diagnose whether individuals with UTI have dementia.

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11 Addendum [4]

11.1 Kingston Hospital Foundation Trust A&E Action Plan 2013/14

Action By whom By when Impact Progress

1. To determine the number of escalation beds required each week during the winter months for all specialities (medicine, surgery, orthopaedics and ICU.

Service improvement/productivity lead for medicine

Aug 2013 To ensure that the Division has a robust well communicated plan of when and where the additional beds will be opened to ensure adequate planning and preparation of the ward areas.

Completed

2. To determine the additional staffing required for the escalation beds and the financial impact of this by ward.

Head of nursing September 2013

This will ensure that we have the necessary staff in place to support the additional beds.

completed

3. To determine the sequence of opening the escalation beds linked to action 2 and communicate this plan to the nursing and medical teams.

Divisional Manager, Head of nursing and speciality lead for medicine

September 2013

Wards are prepared for when they will have additional beds open and the duration they will be operational in each area.

Completed

4. To ensure that there is adequate senior and junior medical cover when escalation beds are open and there is a clear plan of how this will be delivered.

Divisional manager and speciality lead for medicine

Sept 2013 Wards will have the required medical staff to ensure proactive intervention and up to date treatment plans.

On track to be completed by the end of the month

Action By whom By when Impact Progress

5. To ensure that support services are aware of the programme to open additional capacity in existing wards so that additional

Head of nursing and therapies manager

Sept 2013 Appropriate support available for the additional escalation beds

On track to be completed by the end of the month

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workload is managed appropriately, this includes

Therapies Pharmacy Procurement Catering Domestic services Discharge co-ordinator

6. To ensure that the elderly mental health liaison service is implemented and accessed

C Lee Sept 2013 Elderly patients with mental health issues have timely intervention from the appropriate specialist.

This has been commissioned and commences in September 2013.

7. To plan in detail the management of patients in the two weeks prior to Christmas

Head of nursing November 2013

Maximum number of effective and timely discharges before Christmas and provision of business as usual during the holiday period

8. To continue the work of the discharge work stream including: Management of TTOs Booking of transport Planning for each morning discharge Effective RAG boards

Speciality lead for medicine

Ongoing To enable timely effective discharge

9. To produce an escalation policy ( linked with the repatriation process) for patients requiring transfer to another acute hospital and ensure that this is communicated throughout the hospital

Divisional manager for medicine and emergency care

October 2013

Patients transferred to the most appropriate setting for their care within 24 hours.

10. To ensure that each division has a robust plan for the management of leave during expected peaks in activity

Divisional Directors

October 2013

This will ensure that adequate staff are available to manage demand.

11. To review the escalation process for those patients medically fit awaiting care in the

Divisional manager for medicine and emergency care

October 2013

Early intervention to ensure that patients are appropriately placed.

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community

12. To respond to the findings of the DTOC analysis by increasing the number of discharge coordinators and therapy staff.

Therapies manager

October 2013

The increase in discharge coordinators will enable the earlier completion of HNA/DST. The increase in therapy staff will ensure that patients are mobilised earlier and that the changes of being discharged home, rather than to a community bed are optimised.

13. To identify a plan for the in reach of specialities on AAU

Divisional directors

October 2013

Increased number of discharges from AAU and earlier intervention on the correct clinical pathway.

14. To ensure that patients with over 3 weeks length of stay are tracked daily

Therapies manager

Ongoing Optimising care pathway for this cohort of patients

15. Produce plan for the eventuality that all available bed space is occupied

Divisional manager for medicine

October 2013

Clear plan for managers to follow during the day, night and at weekends.

16. Participate fully in the plan produced by the DTOC work group

Chief Operating officer and team

Ongoing Optimisation of timely discharge from hospital.

17. Implement the bed escalation plan

Operational team As required Management of peaks in activity to ensure patient safety

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12 Addendum [5]

12.1 Kingston Hospital DTOC Audit Kingston Hospital undertook an audit of DTOCs across four randomly selected months in 2012/13 which identified the main reasons for DTOCs measured against DH SitRep guidance and criteria. All the patients in the audit had been declared medically fit for discharge based on having completed:

All the treatments required during their acute hospital admission

The required physiotherapy or OT assessments necessary to facilitate discharge.

The audit identified the following reasons for delays:

22% associated with outstanding health needs assessments requiring completion by the hospital team

20% associated with the availability of community health beds provided by community health services providers across the 3 main community health services of Kingston, Richmond and Surrey

27% associated with either awaiting panel funding decision for CHC (continuing healthcare) or assessment by nursing homes.

There were no social care delays recorded or identified as part of the audit.

the kingston, richmond, surrey downs clinical ......challenges and expected increases in demand for...

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