Agenda item

This report provides an update for the Community and Wellbeing Scrutiny Committee on Winter Pressures – learnings from winter 2017/18 and sets out a system-wide approach on winter preparedness in Brent for 2018/19.

Rashesh Mehta (Assistant Director for Integrated Urgent Care and Long-Term Conditions, Brent Clinical Commissioning Group (CCG)) introduced the report which provided an update on learnings from winter 2017/18 and set out the plans of Brent CCG, London North West University Healthcare National Health Service (NHS) Trust (LNWUHT) and Brent Council for 2018/19 which had been based on a system-wide approach. The plans for winter 2018/19 had been coordinated by executives from Brent CCG, Brent Council, London Ambulance Service (LAS), NHS 111, Urgent Care Centres & Community Services and Accident and Emergency (A&E) Delivery Boards and had been scrutinised by NHS England (NHSE) and NHS Improvement (NHSI). Furthermore, the A&E Delivery Boards had focused on five key initiatives against the national winter requirements – reducing extended lengths of stay; development of an ambulatory emergency care service; minor patients breaches reduction; improving ambulance handovers; and implementing effective demand management schemes (for details please see paragraph 3.2 of the report (page 30 of the Agenda pack)).

James Walters (Deputy Chief Operating Officer, LNWUHT) added that winter planning for 2018/19 had started earlier than in previous years and assured Members that the Trust had been successful in supporting the Trust’s A&E Department to achieve performance targets – for instance, 90% of patients were seen within the target of four hours and ambulance handover times had been improved. However, since December 2018 various flu strains and cooler weather had led to an increased demand for services – for instance, over 750 patients had been treated and 130 ambulances had arrived at Northwick Park Hospital on Saturday 26 January 2019.  Mr Walters pointed out that a specific focus had been placed on timely discharge of patients as unnecessary delays could increase the risk of healthcare acquired infections. A special Older People’s Short Stay Unit had been launched at Northwick Park Hospital and there had been plans to extend the scope of the Home First Initiative across all discharge pathways and to additional hospital sites. Members heard that stakeholders had taken a collaborative approach towards the simplification of the discharge pathways from hospital to community, reducing the pathways from 17 to four (for details please see paragraph 6.7 of the report (pages 36-37 of the Agenda pack)). In response to the Chair’s request to outline any different practices at Imperial NHS Trust, Clare Hook (Director of Operational Performance, Imperial NHS Trust) said that these were similar to the ones at LNWUHT.

Members welcomed the report and enquired about the performance of A&E Departments at Northwick Park Hospital and St. Mary’s Hospital. Mr Walters said that the longest wait for a bed at Northwick Park Hospital had been eight hours, but the actual journey for patients could have been longer as they may have sought help from NHS 111 or their General Practitioner (GPs) prior to presenting themselves at the A&E Department. He reminded the Committee that the target to assess, treat and discharge patients at Northwick Park A&E Department was four hours. If they had to be admitted to hospital, there was a further target of four hours to access a bed. Mr Walters added that there was a higher demand for A&E services in weekends then during weeks and reported that there had been approximately 35 breaches of the four-hour standard. Dr Frances Bowen (Divisional Director of Medicine and Integrated Care, Imperial NHS Trust) commented that the A&E Department at St. Mary’s Hospital had been very busy throughout January 2019 and despite the fact that performance had improved by 10-12%, patients often had to wait for beds to become available. Furthermore, the Department had to deal with major traumas and a flu crisis which contributed to the pressure experienced by the service.

This led to questions about the lack of improvement of actual waiting times at A&E departments and patients waiting to be admitted on trolleys. Mr Walters explained the second four-hour waiting target referred to the time patients would wait for a bed once a consultant had agreed to admit them to hospital. In the previous year 88% of patients requiring admission had been allocated a bed within four hours of attending an A&E Department, while this year the figure had reached 90% which represented an improvement in real terms as the overall number of patients seen had increased. As a general rule, patients should not wait more than 12 hours on a bed to be admitted to hospital, but if they had been receiving ambulatory care, then they could be given a chair.

Members referred to the development of an ambulatory emergency care service and the way it contributed to mitigating the pressures experienced by the system. Mr Walters said that there arrangements had been made for all acute hospitals to provide ambulatory emergency care at least 12 hours a day, 7 days a week. The service had been opened until 10 pm each night which had allowed for a high number of patients to be seen without putting pressures on beds. Awareness among GPs had been good and they had the ability to refer patients directly, avoiding the need for a visit to an A&E Department. Ms Hook added that ambulatory care was a good facility for patients who had been discharged but had to go back for additional procedures as these could be delivered without the need for a hospital admission. In a similar way, there had been a positive collaboration with specialist and district nurses to deliver community services which provided better care for patients and allowed them to avoid unnecessary visits and admissions.

The Committee discussed the role of GP Access Hubs and community provision in influencing the way residents accessed emergency services. Mr Auladin said that Brent CCG had reviewed GP access across all sites and work had been carried out to ensure that patients could access the Hubs, rather Urgent Care Centres or A&E departments and doctors had been able to access patients’ records electronically. Julie Pal (Chief Executive, Healthwatch Brent) referred to paragraph 5.3 of the report (pages 33-34 of the Agenda pack) and commented that a number of patients were not familiar with the way GP Access Hubs operated and suggested that the creation of a broader communication plan had to considered by all partners. Mr Auladin responded that the Health Partners Forum had been used as a means to communicate with local residents. In addition, the possibility of booking appointments at the Hubs had been promoted in partnership with NHS 111 and Healthwatch had raised awareness by placing leaflets promoting self-help in GP surgeries. In relation to the community aspect, Members heard that the length of stay in stalls had been extended to 48 hours (the length of stay for vulnerable people was 6 weeks).

Mr Walters said that he could not comment on the reason behind flu-related hospital admissions in 2017 as he was not a Public Health Specialist, but he noted that measures had been taken to contain the flu in 2018/19. Staff had been vaccinated; patients in A&E departments had been made aware about the flu jab and infection control, along with other preventative measures, had been operated in hospitals. Nevertheless, it had to be taken into account that hospital-acquired flu could manifest itself in the community if people who had been infected were discharged. Sheik Auladin (Managing Director, Brent CCG) added that Brent CCG had conducted a proactive campaign, promoting the benefits of receiving a flu vaccination, aimed at raising awareness among patients in GP surgeries and GP Access Hubs, which had been complemented by the Adult Social Care Team and the Public Health Team at Brent Council. Particular emphasis had been put on vaccinating older residents and on developing a rapid test to help flu diagnosis. Nevertheless, Dr Bowen explained that the vaccination was effective in approximately 40-50% of the people who had received it. This was due to the fact that as it had been developed using a combination of knowledge of previous flu strains and predictions about potential new strains that could become active in a particular year, and it could not cover all potential viral mutations.

In response to a question about the effectiveness of the cooperation between the Council, Brent CCG and the trusts, Mr Walters pointed out that all stakeholders had a positive working relationship. The fact that commissioners understood the challenges providers faced had enabled the system to stabilise and deliver efficient services that would correspond to the needs of the future. Dr Bowen added that beds had already been open in order to meet operational targets and planning for additional bed capacity both in formal settings and in the community had started. Furthermore, Imperial NHS Trust held monthly Delivery Board meetings in collaboration with the Council to ensure that patients were placed back in the community as soon as possible. Nevertheless, Phil Porter (Strategic Director of Community and Wellbeing, Brent Council) admitted that procedures did not always follow the prescribed plans, but the constructive relationship, which allowed for challenge, between partners allowed issues to be addressed in a timely manner.

Responding to a question about Delayed Transfers of Care (DToCs), Mr Walters said that some of the major causes of delay for both health and social care were waiting for care placements (in particular patient / family choice) and housing and accommodation issues. The LNWUHT had challenged Brent Council on the work that had been done to make it easier for people to be discharged and it had been emphasised that if the pace of discharging patients had not been maintained, this could lead to an increase in the amount of time patients waited for a bed. Mr Porter noted that the Local Authority had worked with health partners to conduct an audit of critical issues. He added that funding had been secured for the recruitment of an additional full-time Housing Discharge Worker and for improving the efficiency of the Hospital Discharge Team which had been processing referrals from multiple hospitals, including some managed by the Imperial NHS Trust. The measures that had been put in place had contributed to a significant improvement of performance which had been outlined in paragraph 7.1 of the report (page 38 of the Agenda pack). Helen Woodland (Operational Director, Adult Social Care, Brent Council) highlighted that Brent Council had worked with its hospital partners to expand the Home First programme which reflected what was best for residents – that they were supported to return home and be cared for in the community rather than in a placement. As part of this, an additional handyman service had been introduced to enable speedier and effective adaptations to people’s homes to support a timely discharge back into their homes. Ms Woodland pointed out that all Social Worker vacancies had been filled, although not all members of staff were on permanent contracts. This was due to the fact that such arrangements would provide greater flexibility if a new service model, compromising of teams consisting of health and social care, occupational health and social work roles, was implemented in April 2019. 

A Co-Opted Member of the Committee referred to paragraph 4.7 of the report (page 32 of the Agenda pack) and enquired about the rationale behind investing in a handyman service but not allocating money to improve the way Adult Social Care and Short Term Assessment, Rehabilitation and Reablement service (STARRS) staff worked together as a ‘virtual’ team. Ms Woodland responded that there was a project that had been jointly commissioned with Brent CCG and the LNWUHT. It would look at barriers to collaborative working and its aim would be to redesign the team in such a way that all stakeholders would work across discharge in a uniform way, but there had been difficulties associated with recruiting and retaining Occupational Therapists as part of the existing Home First model. 

Mr Walters commented that overall Brent had been able to plan winter provision successfully as so far it had avoided the need to open additional beds. He recognised the complexity of the work carried out by the Reablement Team as patients often needed intensive rehabilitation before they could return to the community and lead independent lives.

Mr Auladin said that Brent CCG had commissioned 75,000 additional GP and 25,000 nurse appointments across all 56 practices in Brent. An enhanced service had been delivered to nursing homes by providing them with a single point of access for GPs and pharmacists.  The LNWUHT had addressed the fact that a significant proportion of patients admitted to hospital were aged 70 and over by embedding the frailty pathway into the A&E Department at Northwick Park Hospital. Vulnerable patients were connected to a Consultant Geriatrician and a team dedicated to the type of care they needed. This approach had been developed further by launching the Older People’s Short Stay Unit where an admission to hospital had still been necessary and the Frailty Team worked effectively with partners in the Borough to try and reduce the risks of re-admission.

As far as mitigating risks associated with cold weather was concerned, Mr Walters said that the LNWUHT had put in place a number of policies to ensure the hospital could operate in winter conditions. The Trust had worked in partnership with NHSE, the Local Authority and Brent CCG to design mobilisation and continuity plans which set out how it could support residents in the community in the best possible way. Learning from previous years had indicated that snow made access more difficult and led to an initial dip in the number of visits to A&E departments. This was followed by a higher demand for orthopaedic and pulmonary care as people often fell or developed respiratory diseases. Mr Auladin added that Brent CCG monitored the local acute system on a regular basis and had taken the necessary measures to ensure that it was as well prepared as it could be for the 2018/19 winter pressures.

RESOLVED that the contents of the Winter Pressures – learnings from winter 2017/18 report, be noted.

Councillor Hylton joined the meeting at 6:39 pm

The meeting was adjourned for a comfort break between 7:11 pm and 7:15 pm.