Agenda Item No:
10
Date
11th November 2015
Executive Business Meeting
Paper Title:
Decision
Urgent Care Plan 2015
Discussion
Information
Follow up from last meeting
Report author:
Jo Burlingham, Associate
Resilience.
Director,
Operations and
Purpose of the paper:
1. To note Version 1.6 of the Operational Resilience and
Urgent Care Plan as part of the annual assurance
business cycle. Conflicts
involved:
of
Interest None
Recommendations
to None the Board / Committee
1.0
Introduction
The commissioning of Urgent Care services is overseen by the System Resilience
Group (SRG) which facilitates collaborative working across the system to improve
the quality and experience of services through effective coordination of the health
and social care system.
The SRG has outlined principles in relation to the commissioning of these services in
the Operational Resilience and Urgent Care Plan. The Governing Body is asked to
note Version 1.6 of this plan that was approved by the SRG in October 2015. A short
summary of each section of the plan is detailed below.
2.0 Eight High Impact Interventions
New guidance issued from NHS England in April 2015 highlights the requirement for
Operation and Resilience Plans to incorporate the eight high impact interventions
that will deliver improvements in urgent care. This guidance has been reviewed by
the SRG and detailed assurance has been given to NHS England to outline how
each intervention is being addressed. This section outlines the information required.
3.0 Q3 Performance Analysis
1 In line with the Keith Willett’s Urgent and Emergency Care Review, the CCG
undertook an analysis of system data and identified that when a number of factors
occurred on a particular day that the local acute trust they were less likely to meet
the national requirement of patients attending an A&E department needing to be
discharged, transferred or admitted within 4 hours at least 95% of the time.
Following the analysis, the SRG has identified the following actions:

Further analysis to assess impact of prevention of admission schemes,
specifically:
o Rapid response element of integrated community teams
o Newly commissioned respiratory service
o Newly commissioned frailty vehicles

To monitor key metrics across the system to gauge status of the system and to
provide early identification of system pressures including:
o System wide dashboard
o Monthly position for SRG
o Daily position to support operations and patient flow
o Early warning triggers from breach analysis
o Mede Analytics data warehouse and interrogation
The progress of these actions will be monitored through the SRG.
3.0 Urgent Care Plan on a Page
The Urgent Care Plan on a Page was developed through the SRG to address the
key issues highlighted in the analysis of system pressure and to identify the
workstreams required to respond to the urgent care needs of the population of
Hertfordshire. It takes into account the Better Care Fund plans to pool ENHCCG and
Hertfordshire County Council (HCC) funding of approximately £120m to be spent on
care for older people. The CCG and HCC have agreed to jointly commission all out
of hospital community based services for older people, with a focus on prevention of
ill health and improvements in health, reduction in hospital admissions, effective reablement, and reductions in delayed transfers of care.
The first iteration of the plan on a page is outlined in Version 1.6 of the Operational
Resilience and Urgent Care Plan and sets out the key workstreams to deliver
operational resilience across the urgent care system in three categories: PreHospital, Hospital and Post-Hospital. Six areas have been prioritised to focus on the
development of alternative pathways in the first phase of transformation redesign.
These are:
 UTI
 Pneumonia
 Dehydration
 End of Life
 Dementia
 Falls/ Frailty
4.0 Strategic Priorities
2 The key workstreams overseen by the SRG are outlined in the Urgent Care Plan on
a Page. Further detail on priority workstreams are included in this section of the
Operational Resilience and Urgent Care Plan to provide the context of the system
we are working in. These include:








111/ Out of Hours GP Services And Acute In Hours Visiting Service (AIHVS)
Procurement
NHS England Vanguard – New Models of Care Programme
Integrated Care Programme Board
Integrated Community Teams
Falls Strategy
Primary Care Workstreams
Seven Day Working
Additional Enablement and Escalation Bed Capacity
These workstreams are continuing to develop and are key to delivering the
Operational Resilience and Urgent Care Plan.
5.0 Winter Resilience
A key component of managing winter pressures includes the flexibility to commission
additional short term health and social care capacity. This acknowledges that despite
robust escalation plans, winter places on the system additional surges in demand
and pressures on capacity. This section of the plan details a review of the additional
resource that was put in place to support winter 2014/15 and outlines the Winter
Resilience Schemes approved to support this winter (2015/16).
6.0 Winter Communications and Marketing Campaign
For 2015/16, NHS England, the NHS Trust Development Agency, Monitor, Public
Health England (PHE), and the Department of Health are joining up their winter
campaigns. This will bring together PHE’s flu vaccination campaign, the ‘Catch it, kill
it, bin it’ message and “Keep Warm, Keep Well”, with NHS England’s ‘Feeling under
the weather’ campaign and materials to promote NHS 111 in a combined strategy.
ENHCCG are using the nationally consistent messaging to guide patients and the
public this winter.
7.0 Day-to-Day Operational Resilience
In recognition of the need to provide a system wide response to improve
performance in urgent care, a Whole Systems Co-ordination Centre (WSCC) has
been developed at ENHT to provide an oversight of urgent care operations within the
East and North Herts CCG area. The centre enables professionals to monitor
demand and activity in real time and co-ordinate the flow of patients through the
system.
8.0 Escalation, Surge and Capacity Planning
3 Key to the WSCC is the system wide escalation plan. This plan articulates the
specific response required and how surge responses will be co-ordinated between
organisations to ensure our system is sufficiently robust to coordinate Level 1 and 2
Incidents at a provider and System Resilience Group Level.
9.0 Assurance, Risk and Mitigation
Recent communication from NHSE has required assurance from ENHCCG on our
ability to deliver this plan and our preparedness for the winter period, specifically:







Winter Readiness: ensuring primary care opening and provision over the
Christmas and New Year period and into the first few weeks of January.
Out of Hours and 111 contingency services in place in advance of winter.
SRG assurance
Ambulance High Impact Actions
Mental Health Crisis Response
Qualitative assessment summarising the key actions that are being taken
ahead of winter
Capacity and planning templates
This has been provided through a number of returns. The qualitative assessment
summarising the key actions that are being taken ahead of winter by the SRG are
summarised in Section 9.0 of the plan.
10.0 Conclusion
This Plan has identified key areas of work to improve the quality of urgent care
services commissioned and provided for our patients. It is aligned with the strategic
priorities and vision for east and north Hertfordshire and identifies a number of
workstreams prioritised for implementation in 2015/16.
The Governing Body is asked to note this plan as part of the annual assurance
business cycle.
Jo Burlingham
Associate Director of Operations and Resilience
11th November 2015
4 East & North Hertfordshire
Operational Resilience and Urgent Care Plan
November 2015
V1.6
1
Version
Number
01
First Draft
1.1
1.2
1.3
1.3
1.3
1.3
1.3
1.3
Purpose/Change
Second Draft – feedback from SRG
Third Draft – Updated Tracker and 8 High Impact
Interventions (Appendix 1 and 2)
Section 2.0
 Further analysis of system data inserted and
agreed actions from SRG to formulate daily SRG
Dashboard
 RTT updated to reflect latest position
 Cancer – updated to reflect NHSE requirement
for SRG to maintain oversight
 Stroke – latest position updated.
Section 3.0
6 key priorities for pathway redesign added.
Section 5.4
Approved Winter Resilience Schemes 2015/16
Section 8.0
Escalation, Surge and Capacity Planning update
Section 9.0
Assurance, Risk and Mitigation update
Author
Jo
May 2015
Burlingham
(JB)/ Phil
Lumbard
JB
June 2015
JB
August
2015
Gerry Moir September
(GM)/JB
2015
JB
JB
JB/PL
JB
JB
Appendices
 Terms of Reference System Resilience Group
(SRG) added
 Eight High Impact Interventions – September
2015 Submission added
 Retrospective analysis of performance April 2013
to March 2015 added
 System Wide Performance Dashboard Example
added
 7 Day Services Systemwide Implementation Plan
added
 Approved Winter Resilience Schemes 2015/16
added
 Integrated Escalation Framework added


SRG Action Tracker – Updated September 2015
added
SRG Assurance submitted September 2015
added
2
Date
September
2015
September
2015
September
2015
September
2015
September
2015

1.4
Ambulance High Impact Assurance submitted
September 2015 added
 Mental Health Assurance submitted September
2015 added
 Winter Readiness assurance adde
 Risk, Controls Assurance Database
Section 6.0
Winter Communications and Marketing Campaign
added JB
October
2015
1.5
JB
Appendices
Appendix 2, Eight High Impact Interventions
removed
Appendix 3, Retrospective analysis of performance
April 2013 - March 2015 removed.
Appendix 4 – System wide performance dashboard
exampled removed
Appendix 5 – 7 day services system-wide
implementation plan removed
Appendix 7, Integrated escalation framework
removed
Appendix 8, SRG action tracker removed
Appendix 9, SRG assurance submitted Sept 2015
removed
Appendix 10, Ambulance high impact assurance
submitted Sept 2015 removed
Appendix 11, Mental health assurance submitted
Sept 2015 removed
Appendix 6, Approved winter resilience schemes
2015/16 renamed appendix 2
Appendix 12 – Capacity Planning Template renamed
appendix 3
Appendix 13, Risk, controls assurance database
renamed appendix 4
November
2015
1.6
JB
Section 9.0
Inserted a table summarising the Qualitative
assessment action plan for the SRG and the actions
that are being taken ahead of winter.
November
2015
1.6
Appendices
Appendix 13 removed following discussion at SRG
JB
November
2015
3
1.0 Introduction
East and North Hertfordshire Clinical Commissioning Group (ENHCCG) operates at
the heart of a complex system of health service provision for the 600,000 patients in
east and north of Hertfordshire. Working with GPs from our 60 practices we
commission healthcare on behalf of our patients within an allocation for 2015/16 of
£672.681m.
The CCG has set out 9 ambitions to improve the quality of care commissioned and
provided for our patients. Urgent care services are a key component to support the
delivery of these ambitions and commissioning of these services are overseen by the
ENHCCG System Resilience Group (SRG).
The SRG facilitates collaborative working across the system to improve the quality
and experience of services for the population of east and north Hertfordshire through
effective coordination of the health and social care system. In January 2015
ENHCCG revised the format and membership of the SRG to provide clear business
4
and executive meetings to ensure the group was able to discharge its functions
effectively. Revised Terms of Reference for the groups are outlined in Appendix 1.
The revised format provides renewed focus to lead and deliver improvements to
patient flow across the urgent care system and works closely with the Integrated
Care Programme Board (ICPB) which is commissioned by ENHCCG to be
responsible for the development and implementation of a whole system partnership
approach to delivering integrated care for the population.
1.1 Urgent Care Principles
Aligned with the strategic priorities and vision for east and north Hertfordshire the
SRG has outlined the following principles relating to the commissioning of urgent
care services:

System wide commitment from all partners

Seamless care built around the patient's clinical needs rather than around
existing services

High quality, simple to use services, available when the patient needs them,
seven days a week

Supporting people to take responsibility for their own health and to receive the
right care and advice in the right place, first time

Providing urgent care services outside of hospital that respond quickly so that
people no longer choose to queue in emergency departments

Providing services to ensure people with serious or life-threatening conditions get
treatment in places with the right facilities and expertise to help them survive and
recover well

Supporting Parity of Esteem to ensure that people experiencing a mental health
crisis get as good a response from an emergency service as people with physical
health conditions

Ensuring all services meet the NHS Constitution standards and Mandate
commitments and the 9 CCG ambitions
These principles are pivotal to developing commissioning strategies that will deliver
sustainable solutions for urgent care and form a key part of the Operational
Resilience and Urgent Care Plan.
5
1.2 Eight High impact Interventions
New guidance issued from NHS England in April 2015 highlights the requirement for
Operational Resilience Plans to incorporate the following eight high impact
interventions:

No patient should have to attend A&E as a walk in because they have been
unable to secure an urgent appointment with a GP. This means having robust
services from GP surgeries in hours, in conjunction with comprehensive out of
hours services.

Calls to the ambulance 999 service and NHS 111 should undergo clinical triage
before an ambulance or A&E disposition is made. A common clinical advice hub
between NHS111, ambulance services and out-of-hours GPs should be
considered.

The local Directory of Services supporting NHS 111 and ambulance services
should be complete, accurate and continuously updated so that a wider range of
agreed dispositions can be made.

SRGs should ensure that the use of See and Treat in local ambulance services is
maximised. This will require better access to clinical decision support and
responsive community services.

Around 20-30% of ambulance calls are due to falls in the elderly, many of which
occur in care homes. Each care home should have arrangements with primary
care, pharmacy and falls services for prevention and response training, to
support management falls without conveyance to hospital where appropriate

Rapid Assessment and Treat should be in place, to support patients in A&E and
Assessment Units to receive safer and more appropriate care as they are
reviewed by senior doctors early on.

Consultant led morning ward rounds should take place 7 days a week so that
discharges at the weekend are at least 80% of the weekday rate and at least
35% of discharges are achieved by midday throughout the week. This will
support patient flow throughout the week and prevent A&E performance
deteriorating on Monday as a result of insufficient discharges over the weekend.

Many hospital beds are occupied by patients who could be safely cared for in
other settings or could be discharged. SRGs will need to ensure that sufficient
discharge management and alternative capacity such as discharge-to-assess
models are in place to reduce the DTOC rate to 2.5%. This will form a stretch
target beyond the 3.5% standard set in the planning guidance.
6
This guidance has been reviewed by the SRG and assurance has been given to
NHS England to outline how each intervention is being addressed. This work has
informed the development of the Urgent Care “Plan on a Page” which was initially
developed following an in-depth analysis of the systems performance and urgent
care metrics throughout Quarter 3.
In line with the Keith Willett Urgent and Emergency Care Review which highlighted
that surges in demand exacerbate problems in a system already under strain, the
analysis identified that when a number of factors occurred on a particular day that
the local acute trust they were less likely to meet the national requirement of patients
attending an A&E department needing to be discharged, transferred or admitted
within 4 hours at least 95% of the time. This is discussed in more detail below.
2.0 Local System Pressures & Analysis
There is a national requirement that patients attending an A&E department need to
be discharged, transferred or admitted within 4 hours at least 95% of the time. A
contract query notice was issued to ENHT by the CCG in November and
subsequently a Remedial Action Plan (RAP) was agreed to cover A&E performance
against the 4 hour target. The RAP sets out a recovery trajectory for the standard to
be achieved. ENHT achieved 92.3% for 2014/15, evidencing performance
improvements during February and March and delivered 94.5% for the month of
March 2015. The Trust has exceeded the required 95% performance for April and
the focus is now to sustain this performance.
Although the trust achieved the required performance target in April they did not
meet the target in May 2015. Despite an improvement in June with the trust
achieving 95.13% the target has not been met subsequently. Following the
recommendations from the Royal College review of ED, ECIST and a utilisation
management company have been commissioned to undertake a further review of the
ED department. The findings from this review will be incorporated into a revised RAP
to support the required improvements.
Analysis of urgent care metrics for Q3 has shown that volume of attendances at the
Trust is not in itself a major cause of high numbers of patients breaching the A&E 4
hour Operational standard. In June and July attendances were the highest that they
have been in 2014/15, but the target was achieved in both these months. Further
analysis has shown that on days where a number of the following factors occur there
has been a resultant major impact on the ability of the Trust to meet its 4 hour
operational standard:






Ambulance conveyances – higher numbers and patterns of arrival outside
expected times
Ambulance conveyances – more higher priority calls (R1s and R2s)
Higher than expected numbers of 85+ years as these patients have a higher
conversion rate
Higher than expected proportion of majors patients in A&E
Low numbers of emergency discharges both on the day and the preceding day.
Staffing pressures
7
Further to the Q3 analysis, work has been undertaken to retrospectively review the
information from April 2013 to March 2015 to provide useful benchmark information
and more depth to the statistical analysis. This has confirmed that the Q3 analysis
was broadly indicative of the findings across 2013/14 and 2014/15. Admissions were
higher in 2014/15 than in 2013/14 whilst attendance levels have remained
consistent. It is acknowledged that volume of attendances is not in itself a major
reason for breaches.
In 2014/15 highest attendance volumes were seen in June and July but the 4 hour
operational standard was achieved. The reasons identified for the trusts failure to
meet the required 4 hour operational standard in Q3 were therefore equally as valid
across 2013/14 and 2014/15.
The highest contributing factors remain as:






Ambulance conveyances – pattern of arrival outside of expected times
Ambulance Conveyances – more higher priority calls (R1s and R2s)
Higher than expected number of 85+ year olds (conversion rate for this age group
is between 70-80%)
Higher majors to minors split
Low numbers of emergency discharges from the previous day
Staffing issues
Following the in-depth analysis, the SRG has identified a number of key actions and
next steps:

Further analysis of HRG codes to assess impact of prevention of admission
schemes, specifically:
o Rapid response element of integrated community teams
o Newly commissioned respiratory service
o Newly commissioned frailty vehicles

To monitor key metrics across the system to gauge status of the system and to
provide early identification of system pressures including:
o System wide dashboard
o Monthly position for SRG
o Daily position to support operations and patient flow
o Early warning triggers from breach analysis
o Mede Analytics data warehouse and interrogation
The progress of these actions will be monitored through the SRG.
2.1 Referral to Treatment (RTT)
The NHS constitution states that patients have a right to start treatment within a
maximum of 18 weeks from referral, unless they choose to wait longer or it is
clinically appropriate to do so. Operational Resilience Plans need to take into
account capacity planning and profiling across routine elective care to ensure that
RTT waiting time targets are met, despite any pressures that emergency and urgent
8
care demand places on the system. The admitted and non-admitted standards were
abolished from June 2015, and only the 92% incomplete target remains. At CCG
level, the number of patients waiting over 18 weeks has been below the required 8%
consistently throughout 2015/16.
RTT performance against the 92% incomplete standard at ENHT has also been met
consistently throughout 2015/16. To support the delivery of a sustainable 18 week
model, ENHCCG has put aside significant non-recurrent investment in 2015/16 to
address the ENHT backlog position and determine the levels of elective and
outpatient activity required to deliver a sustainable RTT model going forward. The
CCG has jointly modelled levels of activity needed to meet the required backlog
levels. Initial assumptions have been reviewed and agreed as still valid by the trust
and the CCG. The trust has been requested to submit a detailed plan of progress
against the levels of planned activity as the CCG are concerned that the number of
patients waiting over 18 weeks has been increasing, most notably in those waiting
18-40 weeks.
Following continued poor performance at PAH in relation to RTT incompletes and 52
week waits, a contract performance notice has been issued by West Essex CCG.
ENHCCG is working closely with West Essex SRG to support improvements. PAH
are due to resume national reporting in November with October data. Once the trust
has formally submitted the RTT position, the CCG will then have clarity on the actual
numbers of patients who have been waiting over 52 weeks for treatment and can
monitor them to ensure that they are treated at the earliest opportunity, and that
clinical harm reviews are undertaken.
2.2 Stroke
All major stroke targets at CCG level including 4 hours direct to a stroke unit and
patients spending 90% of time on the stroke unit failed for May 2015. This is
indicative of poor performance throughout 2015/16 at both ENHT and PAH. Stroke
meetings between the CCG and ENHT and PAH have been established and action
plans are in place but there has been no significant improvement in performance.
The two key stroke targets, the proportion of patients who access the stroke ward
within 4 hours and the proportion of patients who spend 90% or more of their time on
the stroke unit have consistently been below the national thresholds which raises
concerns given the ongoing discussions around the locations of Hyper Acute Stroke
Units (HASUs).
ENHT has revised their action plan on a number of occasions but has failed to
achieve the required improvements in performance. The CCG was expecting a
significant improvement in early January 2015 following the extension of the stroke
nurse specialist service however this was not realised and consequently a contract
performance notice in line with the 2015/16 contract has been issued to the trust in
July. A RAP has been submitted to focus on 10 key actions required to deliver the
improvements required. This RAP has recently been updated and progress will be
monitored at the Contract Review Meetings
9
Strategically ENHCCG are working with West Essex CCG, Princess Alexandra
Hospital (PAH) and ENHT to accommodate Hertfordshire stroke patients who would
normally go to PAH, to be treated at ENHT following the decision to decommission
Hyper Acute Stroke Services at PAH.
2.3 Cancer
Following the tripartite letter of 14th July 2015 (Improving and Sustaining Cancer
Performance), the remit of the SRG has been expanded to cover the 62 day
standard given the need to drive better and sustained performance. Cancer is now
tabled as a standing item on the agenda to facilitate improvements in pathways and
performance at a system level.
Despite continued good performance against the cancer waiting times standards at
PAH, ENHT have found the 62 day standard challenging.
3.0 Urgent Care Plan on a Page
The Urgent Care Plan on a Page was developed through the SRG to address the
key issues highlighted in the analysis of system pressure (section 2.0) and to identify
the workstreams required to respond to the urgent care needs of the population of
Hertfordshire. It takes into account the Better Care Fund plans to pool CCG and
Hertfordshire County Council (HCC) funding of approximately £120m to be spent on
care for older people. The CCG and HCC have agreed to jointly commission all out
of hospital community based services for older people, with a focus on prevention of
ill health and improvements in health, reduction in hospital admissions, effective reablement, and reductions in delayed transfers of care.
The first iteration of the plan is outlined below and sets out the key workstreams to
deliver operational resilience across the urgent care system in three categories: PreHospital, Hospital and Post-Hospital. 6 areas have been prioritised to focus on the
development of alternative pathways in the first phase of transformation redesign.
These are:






UTI
Pneumonia
Dehydration
End of Life
Dementia
Falls/ Frailty
10
Urgent Care Strategy Principles 15/16








System wide commitment from all partners
Seamless care built around the patient's clinical needs rather than around existing services
High quality, simple to use services and available when the patient needs them, seven days a week
Supporting people to take responsibility for their own health and to receive the right care and advice in the right place, first time
Providing urgent care services outside of hospital that respond quickly so that people no longer choose to queue in emergency departments
Providing services to ensure people with serious or life-threatening conditions get treatment in places with the right facilities and expertise to help them survive and recover well
Supporting Parity of Esteem to ensure that people experiencing a mental health crisis get as good a response from an emergency service as people with physical health conditions
Ensuring all services meet all NHS Constitution standards and Mandate commitments and the 9 CCG ambitions
Pre-Hospital
Hospital
Post-Hospital
•

Clinical hub and use of Alternative Pathways

Managing demand and flow through the system

Ambulatory Care Pathways and protocols for top 10
conditions

Safe, efficient and timely clinical discharge


Implement clinical pathways for:
o
Frailty
o
Falls
o
Respiratory conditions
o
Sepsis
o
Rehydration
Improved use of Intermediate care pathways including D2A,
Home from Hospital, HomeFirst, ESD and CHC pathways

Work with providers to deliver appropriate 7 day and extended
day services to support and improve patient flow

Implement community bed review recommendations and care
home premium in partnership with HCC & HCPA

Develop and commission new forms of homecare to support
people in their home and facilitate safe and rapid transfer from
acute care, e.g. enablement homecare, rapid-access model
•
•
•
•




Develop and implement Primary Care Strategy to
improve access, capacity and sustainability including:
•
Improved access to GP services including
extended hours
•
Improved use of pharmacies
•
Improved access to emergency dental
services
Review and streamline urgent care pathways to ensure
24/7 access
Develop the use of alternative care pathways for prehospital across the urgent care system
Improved use of NHS 111 clinical pathways including
expert clinical triage and direct booking
Working with public health to develop prevention and
self-management strategies aligned to CCG and locality
plans
Reduce locality variation and improve patient outcomes
Self-care, prevention and improved management of
long-term conditions including support to children and
young families and care homes to reduce reliance on
ED
Continue to improve integrated care closer to home
through Vanguard Home Care programme, Support at
Home and roll out of Home First or similar models
across all the CCG Localities
Improved access to diagnostics, tele-health,
telemedicine and tele-care
Improved use of Map of Medicine and End of Life
pathways

Implement programmes to reduce:
o
0-1 day lengths of stays
o
Frequents attenders
o
Readmissions

Further development of Interface Geriatrician model

Stroke/ Dementia /CHC pathways

Explore opportunities for Chest Pain Assessment Unit

Paediatric Streaming and pathway development

Consistent achievement of key performance standards
Transformation programmes, reconfiguration plans and procurement
•
•
•
•
•
•
•
•

Lister & New QEII Final Phase of consolidation and pathway changes
Urgent and Emergency Care System coordination
Locality Empowerment and Primary Care Ambitions
Neighbouring system changes – West Essex/PAH and Royal Free/Chase Farm
Stroke including HASU configuration
Sustainable workforce with appropriate capacity & capability
11
Whole Systems coordination Centre to understand and respond to surges in demand
Improving information sharing systems to facilitate system wide case management
Continue to implement and deliver Better Care Fund plans including Provider led Integration Programme and the three main
work streams of 1)Improving access and assessment, 2)Transferring Care and 3) Integrating Care in the Community
Outcomes








Improving life expectancy at 65
Improving disability free life expectancy at 65
Reducing hospital episodes for people with Long Term
Conditions
Improving the quality of care for people at the end of life
Reducing emergency admissions for people over 75
More people living independently
Increased survival rates from cancer
Improving emotional and mental wellbeing of children
4.0 Strategic Priorities
The key workstreams overseen by the SRG are outlined in the Urgent Care Plan on
a Page above. Further detail is provided on some of the other priority workstreams
below which support the delivery of the plan.
4.1 111/ Out of Hours GP Services And Acute In Hours Visiting Service (AIHVS)
Procurement
The existing contract with our provider has been extended until September 2016 to
allow for a full open procurement with market and locality engagement. ENHCCG
has also piloted an Acute In Hours Home Visiting Service since 2012 with Herts
Urgent Care (HUC). This service has been evaluated and is now included in the
main contract which has been converted from an Alternative Provider Medical
Services (APMS) contract to a NHS Standard contract tailored for NHS 111 in line
with national guidance.
The procurement will work closely with the local Integrated Care Programme Board
which is a provider collaborative initiative across East and North Hertfordshire to
deliver integrated care services for our patients. The CCG is taking the opportunity to
create a new model of delivery, and will look to utilise market and patient
engagement to help shape the model of delivery. The CCG Governing Body has
agreed to re-define the clinical model for these services in light of changes to
unscheduled and Primary care which will incorporate a market engagement
exercise.
4.2 NHS England Vanguard – New Models of Care Programme
ENHCCG has been selected to be one of the first 29 ‘vanguard’ geographies that will
take the national lead on transforming care for patients in towns, cities and counties
across England.
The New Models of Care programme of work focuses on Care Homes and is a
significant issue for east and north Hertfordshire. There are 62 care homes in east
and north Hertfordshire, with 3200 beds, and up to 3000 residents at any one time.
In 2013/14 there were 2794 A&E attendances from patients living in care homes.
Additionally, there were 1744 admissions to hospital from Care Homes in east and
north Hertfordshire at a cost of £5.764m pounds. Of these admissions, 454 had a
zero day length of stay. The system has acknowledged that it needs to do more to
redress the balance and do more to improve the experiences of our patients in care
homes. Developing support to care homes and their patients will have a significant
impact on the effective functioning of the local Health and Social Care system.
The tripartite partnership consisting of ENCCG, Hertfordshire County Council, and
the Hertfordshire Care Providers Association (an organisation representing and
supporting care providers in Hertfordshire, who also manage significant care home
training budgets on behalf of the local authority) will focus on the following projects:
12






Complex Care premium
Enhanced Primary Care Support to Care Homes
Supporting the development and roll out of Interface Geriatrician pathways
Pharmacy support and access to clinical records
Development of specific care pathways – NICE guidelines “Reducing hospital
admissions from nursing homes for older people”
End of life pathways

CQUIN to support for GP ward rounds and tissue viability
The key focus of this programme will be to:

Reduce admissions from care homes into acute hospitals by 15% by March
2016, which would result in a reduction of 261 admissions per annum and an
estimated financial saving of £ 686, 176.

Reduce A&E attendances by 20%, or 559, by March 2016 with an estimated
financial saving of £83, 820.

Reduce delays attributable to care homes by 25% by March 2016, resulting in a
reduction in lost bed days of 300 days per annum.
4.3 Integrated Care Programme Board
The Integrated Care Programme Board is commissioned by ENHCCG and is the
vehicle for the delivering the integrating care vision and work streams for east and
north Hertfordshire.
These include:

Improving access– to simplify how services are delivered through an
improvement in the coordination and quality of access and assessment leading to
the delivery of the appropriate care.

Ensuring seamless transitions of care – to improve the quality and minimise the
numbers of care transfers between providers through a focus on processes within
and between providers combined with transformed coordination of admission,
discharges and choice of provider.

Integrating care in the community - to improve the number of people having care
closer to home through a focus on transforming the approach to proactive care
planning in integrated teams alongside a streamlining of the number and
complexity of care pathways available to our communities and workforce.
13
4.4 Integrated Community Teams
The CCG has stated its ambition to secure integrated care services through a single
accountability model. Following review and evaluation of the integrated community
team pilots in Lower Lea Valley and North Herts Localities, the CCG Governing Body
has agreed in principle to progress the roll out this type of model across the
remaining localities within the CCG.
The model will need to deliver the key core elements of the two existing pilots,
specifically:

Focus on reducing non-elective admissions, and associated reduction in acute
costs, delivering a return on the extra investment in community capacity.

Rapid response within 60 minutes with social care, community health and mental
health capacity with a clear focus on admission avoidance.

Multi-disciplinary team approach to supporting patients via a 'virtual ward' with
complex health, mental health and social care needs, with clear risk stratification.

Full engagement of primary care within the service delivery model

Appropriate 'Virtual bed' capacity for supported discharge, including support to
care homes to facilitate timely discharge of residents back to homes.

An agreed way of working with care homes on supporting complex patients both
with rapid response and through the virtual ward approach
The delivery of this model is based on effective working across all community, social
care and primary care providers. The CCG is therefore engaging with localities to
understand how an integrated community team model could be developed to meet
the specific population's needs of each Locality. It is acknowledged that the service
delivery model will differ based on the nature of the patient population, proximity to
major acute sites, and the configuration of primary care services.
The roll out of integrated community teams across the East and North Hertfordshire
will require additional investment, and providers have been made aware that a 'coproduced' business case from localities and the relevant providers (coordinated
through the Integrated Care Programme Board (ICPB)), outlining the impact of the
proposed model and the estimated return on investment through admission
avoidance is required before implementation can proceed.
Securing Vanguard (p12.) allows us to move quickly and at a greater scale, with
some significant extra capacity in place for winter. The delivery of this model will
need to be based on effective working across all community, social care and primary
care providers. The ICPB provide the mechanism for providers to work together
collaboratively to deliver effective integrated working.
14
4.5 Falls Strategy
Falls and fall-related injuries are a common and serious problem for older people in
Hertfordshire. People aged 65 and older have the highest risk of falling, with 50% of
people over 80 falling at least once a year. Falls are potentially preventable and
accounting for over 4 million hospital bed days each year in England. Around 2030% of ambulance calls are due to falls in the elderly.
In collaboration with Herts Valley Clinical Commissioning Group (HVCCG), ENCCG
and Hertfordshire County Council (HCC), the CCG has agreed a Falls Strategy for
Hertfordshire to reduce the number of emergency admissions related to falls,
increase the number of older people staying stable, reduce the chances of a ‘first fall’
being injurious, ensure effective treatment of injurious falls and maximise well-being
for multi-fallers helping them to return to independence.
Five key delivery work streams have been agreed:

Communications and public awareness - Development of the “Healthy in Herts”
website, which includes signposting, support services and screening tools,
alongside a pan-Hertfordshire publicity campaign.

Screening tools - Making falls every one’s business. A two tiered approach to
universal screening tools for professional and non-professionals.

Community provision of falls prevention classes - A new Hertfordshire Falls
Exercise Pathway has been explored. It will offer an exercise continuum for
classes that can be accessed without referral and at the right level.

High-intensity support - The jointly funded Enablement service will be reconfigured to reflect the need to provide robust support to the most at-risk fallers.
It is vital that there are effective links made with existing services, community
therapy services and the enablement service

Rapid Response - to respond to 999 requests for falls. By providing a
multifactorial response and the provision of expert care the expectation is to
increase falls care provided in appropriate settings and thereby reduce
admissions to acute providers.
4.6 Primary Care
The CCG invested £8,280,549 in 2014/15 to provide a range of enhanced services,
e.g. over 75s health checks, admission avoidance schemes, Long Term Condition
management, over and above core services to improve primary care services for our
population.
The Governing Body has subsequently undertaken a review of this funding approach
to consider consolidating the different funding streams, transition to a recurrent
funding model and a progressive shift towards greater ‘outcomes based’
remuneration. Further work is being undertaken to:
15






Ensure current funding streams represent the most efficient use of resource
Understand which streams should be consolidated
Review the recurrent status of funding
Ensure the balance between ‘outcome based’ and ‘input focused’ remuneration is
optimum in terms of securing the best outcomes for patients
Review the requirement of general practice to achieve the optimum skill mix to
deliver services beyond core and the requirement to design schemes within any
future period of recurrent funding
Review the profit element of services commissioned over and above GMS
To ensure the CCG investment in primary care delivers the greatest health and
wellbeing outcomes for its patients it is important that funding for services is directly
aligned to the CCG’s strategic and primary care ambitions and the outcomes that the
CCG is required to achieve. A Primary Care Scorecard is being developed to monitor
this achievement and will include information that will focus on clinical outcomes.
The score card will also include all of the CCG’s performance standards which cover
many of the same clinical areas but are often measured in a different way from the
Quality Outcomes Framework (QOF) or the additional enhanced schemes. Services
commissioned from primary care beyond ‘core’ should be aligned to these areas and
a remuneration model is proposed to support the necessary improvement in
outcomes. This is a complex area of development and needs to be implemented
carefully to ensure that the benefits are fully realised and there are no unintended
consequences. It is fully recognised that Primary Care is fundamental to managing
resilience in the system.
4.7 Seven Day Working
The SRG has agreed the 5 priority clinical standards to focus on this year as a health
economy. Each provider organisation has undertaken a baseline assessment to
identify what can be delivered against the standards and a system wide
implementation plan is being agreed.
The standards agreed for implementation in 2015/16 are:





Time to First Consultant Review
Shift Handovers
Intervention/Key Services
Mental Health
Transfer to community, primary and social care
A system wide steering group has been established to manage the implementation
of these standards and the ongoing monitoring through system wide metrics. Metrics
will reflect the high level outcomes from the Keith Willett’s Emergency Care Review,
e.g. Length Of Stay, patients admitted at weekend, re-admissions at the weekend,
number of discharges at the weekends and mortality of patients admitted over the
weekend and will be reported quarterly through the CCG Integrated Performance
and Quality Report and the SRG. All providers have agreed to Service Delivery and
Improvement Plans within their contracts to deliver these requirements.
16
4.8 Additional Enablement and Escalation Bed Capacity
To support the workstreams identified in the post hospital section of the Urgent Care
Plan on a Page, (p10.) the joint Intermediate Care Board has commissioned a review
of all community beds. The CCG and county council funding that pays for
intermediate care, short stay and enablement beds has been pooled into the Better
Care Fund from April 2015/16. This offers an opportunity to accelerate previous joint
work to improve community bed provision, and achieve a fully integrated model with
no distinction between ‘health’ and ‘social-care’ beds.
5.0 Winter Resilience
A key component of managing winter pressures includes the flexibility to commission
additional short term health and social care capacity. This acknowledges that despite
robust escalation plans, winter places on the system additional surges in demand
and pressures on capacity. This can be multifactorial and includes infectious disease
outbreaks .e.g. noro virus or reduced capacity against the backdrop of strategic
changes.
Planning for Winter 2014/15 began in May 2014. 42 bids were received from a
variety of stakeholders to support winter pressures. All bids were assessed against
the following principles and criteria:
5.1 Principles


The winter bid offers escalation capacity that is above core contract provision and
supports resilience at times of system surge.
The winter bid ensures that patient safety and quality are maintained or
improved.
5.2 Criteria




Primary care options deflecting Emergency Department (ED) attendance and
admission (where clinically appropriate).
Providing a cohort of escalation beds to support pressures e.g. times of demand
surge or noro-virus outbreaks etc.
Supports seven day service development.
Supports delivery of targets, Handover times, ED performance & Delayed
Transfers of Care (DTOC).
Schemes were assessed against prioritisation criteria by the Urgent Care
Programme Board (now incorporated into the SRG). Recommendations were then
made to the Governing Body. Further due diligence was undertaken to test value for
money. Schemes outlined totalling £5.2 million were approved to support winter
resilience. Some schemes took longer than expected to mobilise due to lack of
available workforce and some were withdrawn by providers as they were unable to
recruit. Schemes that were competing for the same workforce in core services were
deprioritised to ensure the safety of core services. This left a total of 4 schemes for
17
primary care and a total of 23 schemes split across community and acute providers
to support resilience throughout winter.
5.3 Analysis of outcomes
A number of key performance indicators (KPIs) were agreed for each scheme. In
March 2015 schemes that had been operating throughout winter were evaluated
against the agreed KPIs to understand the service received from the investment, the
impact on system pressures and any improved patient outcomes as a result of the
schemes.
All schemes were extended until the end of April as per the NHS England
requirement to provide Easter Resilience. In addition the following successful
schemes were approved for continued funding in 2015/16:

Age UK was commissioned to provide a Hospital Discharge Support Service from
the Lister and QEII hospital for 50 patients a month and consistently delivered
over and above this on a monthly basis. 2251 transfers were undertaken to
support timely discharge from hospital and Emergency Discharge, an average of
98 per week. Continued full year funding was approved and will be incorporated
into the current contracts with Age UK. £120k funding was allocated to support
the three way funded contracts with Health and Community Services (HCS) part
of HCC and Better Care Fund funding streams for 2015/16.

A Hospital Ambulance Liaison Officer (HALO) was commissioned to be based at
the Lister hospital throughout winter to support East of England Ambulance
Service Trust (EEAST) and East and North Herts Trust (ENHT) to improve both
arrival to handover and handover to clear times in line with agreed Remedial
Action Plans. The metric agreed was to deliver a 20% reduction in handover
delays. Whilst the Trust did not achieve the targets in December and January,
there was a significant reduction in February to 145, succeeding the target of 236
the lowest level of handovers in 14/15. 3 Whole Time Equivalent EEAST HALOs
were funded which will deliver a 12 hour service 10am-10pm 7 days a week at a
cost of £205k per annum. The CCG expects to receive £150k allocation from
NHS England and will invest £55k per annum to support this initiative.

Hertfordshire Community NHS Trust (HCT) and HCS were jointly funded to
provide a scheme to extend the Non Weight Bearing (NWB) pathway to increase
bed capacity. For the additional capacity commissioned over 7 months, 27
patients were admitted to these dedicated NWB beds with an average length of
stay of 43 days. Patients on the pathway were discharged home or to
Intermediate Care (ICT) units for further rehabilitation. Maintaining these patients
in core bed based services would have resulted in 809 days additional acute or
ICT blocked bed days. It is estimated that this scheme produced a cost saving of
£159k. As a result of these successes 6 additional non-weight bearing beds will
continue to be commissioned at an estimated cost of £310k for 2015/16.
18

7 day therapies was funded with Hertfordshire Community Trusts at a full year
cost of £418k. Community Discharge Hub and additional Clinical Navigator
resource at the Lister hospital was also funded for one year non-recurrently at an
estimated cost of £153k. This decision was based on the evaluation of
performance throughout winter which demonstrated improved lengths of stay
(LOS) in all community hospitals to less than 19 days with no adverse impact on
bed occupancy figures (reduced from 92% in April to 86% in Jan). Delayed
Transfers of Care (DTOC) also reduced with 86 days in January attributable to 16
patients. The schemes to support senior management input into Multi-Disciplinary
Teams (MDTs) and the provision of 7 day therapy resulted in increased numbers
of discharges at the weekend (82 compared to 4 same period last year).

Out of Hours support for Section 136 and Criteria – Cognitive Aptitude Test (CCAT) schemes were approved for Hertfordshire Partnerships Foundation Trust
from the Mental Health growth set aside in the financial plan and supported by
winter resilience funding. Evaluation of the schemes showed that the Out of
Hours support for S136 was well utilised. A target of 6 was agreed and KPI
monitoring showed consistent achievement of this. C-CAT referrals also
consistently achieved their required target level of referrals per month.

The Thames Ambulance Crew at the Lister Hospital to improve ambulance
offload time and safety within the Emergency Department (ED) during periods of
crowding and additional bed capacity at Pine Lodge to improve patient flow were
approved for continued funding. Evaluation demonstrated that the Thames
Ambulance Crew led to improvements in reducing 60 minute delays despite a
significant increase in ambulance activity. Compliance rates measured against
the 15 minute standard for time to triage for patients arriving by ambulance
improved from 9 to 7 minutes with this initiative. Pine Lodge step down beds were
fully occupied all winter and added valuable bed capacity into the system at times
of pressure. This use of Discharge to Assess principles has significantly
contributed towards the improved DToC performance at ENHT from 3.17% in
February 2014 to 2.78% in February 2015 (National Target 3.2%). The schemes
were funded one year non-recurrently at a cost of £357k for Pine Lodge beds and
£356k for Thames Ambulance Crew.
The cost of all schemes will be charged to winter resilience and total £2.1m leaving
£3.2m of winter resilience funding uncommitted for winter 2015/16.
5.4 Winter Resilience Schemes 2015/16
In July 2015 all providers were invited to apply for the remaining winter resilience
funding. All schemes were required to support the implementation of the eight high
impact interventions to provide system wide resilience and meet the following
requirements:
•
•
To provide additional capacity to reduce out of hours demand.
To provide additional capacity to provide resilience over the winter period.
19
•
•
•
•
•
•
•
To support increased clinical triage to ensure patients access the right services
and enhance the use of alternative care pathways.
To encourage collaboration between providers.
To provide value for money.
To deliver the greatest health and wellbeing outcomes for patients with urgent
care needs.
To prevent duplication of schemes funded by other mechanisms.
To have agreed Key Performance Indicators (KPIs) that demonstrate patient and
system outcomes.
To have agreed communication strategies which are added to the Directory of
Service to support 111 dispositions.
Localities were offered the opportunity to apply for funding of up to £2.50 per patient
per locality to provide the following four schemes:
•
•
•
•
Scheme 1: Additional Capacity in hours
Scheme 2: Additional Capacity out of hours
Scheme 3: Care Home Daily Ward Rounds
Scheme 4: Repeat Prescription Scheme
A total of 16 locality schemes were approved at a total cost of £1,453,740.
Successful schemes will be expected to comply with the KPIs outlined in the original
framework approved by the Governing Body. Performance monitoring against the
KPIs’ will be supported by the Locality Managers and reported and discussed
regularly by localities. They will also be reported to the Executive Team and the
Governing Body, as part of the wider winter resilience reporting.
All other providers were invited to apply for the remaining £1.7m Winter Resilience
Funds. A total of 9 applications were submitted from 8 organisations detailing 23
separate schemes. Proposed schemes total £2,596,803. Applications were
considered in the context of priority-setting to support robust decision-making that
ensures our population has access to the highest quality health care and the best
patient experience within available resources.
14 schemes from other providers were approved to support winter resilience at a
cost of £1,562, 136 (Appendix 2). The total cost of all schemes approved is £3,015,
876 leaving a small amount of contingency to support other schemes as pressures
dictate throughout winter. In addition, spend associated with approved schemes will
be closely monitored to ensure any underspend from schemes that have been
unable to mobilise the intended capacity is utilised to support other schemes.
20
6.0 Winter Communications and Marketing Campaign
For 2015/16, NHS England, the NHS Trust Development Agency, Monitor, Public
Health England (PHE), and the Department of Health are joining up their winter
campaigns. This will bring together PHE’s flu vaccination campaign, the ‘Catch it, kill
it, bin it’ message and “Keep Warm, Keep Well”, with NHS England’s ‘Feeling under
the weather’ campaign and materials to promote NHS 111 in a combined strategy.
This focused behaviour change programme will be developed through a single
campaign approach, covering a variety of media including television, radio, outdoor
and social media, as well as materials for local teams to use.
To ensure that this campaign is as effective as possible, all organisations have been
asked to use nationally consistent messaging to guide patients and the public. This
should make best use of resources and avoid duplication.
East and North Hertfordshire CCG’s approach to winter communications builds on
the existing good relationships between the health and social care communications
leads in the county. We are adopting the same ‘joined up’ approach to our local
winter communications campaign, working across our communications channels and
networks to reach as many vulnerable groups of residents as possible.
7.0 Day-to-Day Operational Resilience
In recognition of the need to provide a system wide response from both the CCG and
providers to improve performance in urgent care, a Whole Systems Co-ordination
Centre (WSCC) has been developed at ENHT. Key partners involved in the
development of the WSCC are the CCG, ENHT, EEAST, HCT, Herts Urgent Care,
HCS, Herts County Council and HPFT. It is in the first phase of its development and
it is providing an oversight of urgent care operations within the East and North Herts
CCG area. The centre enables professionals to monitor demand and activity in real
time and co-ordinate the flow of patients through the system.
All system partners are required to provide information and support, to the operation
of the centre. The aim is that the WSCC will receive and collate information in realtime, however initially it will function on information feeds from each of the
stakeholders at regular set intervals throughout each day. At the point at which this
information is available in real time it will enable the system to identify and act on
surges in demand or other related system pressures. These actions will be informed
on the information available at that specific point in time allowing early escalation of
actions.
The WSCC provides improved coordination and escalation management within
ENHT and enhances communications across the system. The amount of information
coming into the WSCC will enable reporting on trends and/ or changes in demand
and forecasting across the system with recommendations for appropriate actions
and escalation procedures. It is anticipated that the WSCC will provide a positive
influence on performance standards and patient flow which will then enhance the
patient experience.
21
8.0 Escalation, Surge and Capacity Planning
Key to the WSCC is the system wide escalation plan. All systems, led by CCGs as
system leaders, are expected to have a system wide escalation, surge and capacity
plans in place. These plans articulate the specific response required about how
surge responses will be co-ordinated between organisations regardless of wider
modernisation and reconfiguration plans and ensures our system is sufficiently
robust to coordinate Level 1 and 2 Incidents at a provider and System Resilience
Group Level.
The Hertfordshire integrated escalation plan has been agreed and split into four
stages which reflect the status of all organisations in terms of bed availability, level of
emergency demand and status. Actions at each level are to be completed before
moving onto the next level. The plan outlines trigger levels for the different alert
states and the actions required by all partners to manage and respond as required.
The earliest stages of escalation involve using existing local capacity flexibly to
achieve system balance. The escalation levels are designed to encourage early
action at the first triggers of escalation to prevent and reverse escalation to/ from a
higher status; therefore escalation to the higher alert status of red and black are
considered to be required only in very exceptional situations. Only when all
measures had been exhausted, will organisations move on to later stages of
escalation which involve accessing capacity beyond locality boundaries. The
integrated framework provides a consistent and co-ordinated approach to the
management of pressures across the system.
All organisations have signed up to the Hertfordshire Integrated escalation plan and
have a responsibility to:









Work as a system in the equitable share of risk in times of pressure.
Ensure the 8 High Impact Interventions, SAFER care bundle and NHSE
Winter Resilience letter expectations are embedded and delivered
Have a consistent escalation, surge and capacity plan, with Board sign off for
Winter 2015, including timely mobilisation, a coordination of early action in
order to prevent further deterioration of the situation
Manage the escalation and de-escalation processes at the local level
Ensure agreed actions relate to the organisation that has heightened
escalation and the response of all the provider and CCG organisations
surrounding it.
Agree a clear list of criteria about how the status of the health economy will be
determined, based on the status of its provider organisations and other
relevant factors
Detail the responsibilities of each provider organisation, the linkages between
providers, how local providers in red or black status will be managed and the
command and control procedures that will be put in place
Include how GPs will respond to capacity surges within the local area.
Have a full understanding of system discharge positions, to include all delays
as well as DTOCs.
22





Have robust contingency staff plans for peak times including weekends and
Bank Holidays whish are regularly reviewed via the SRG
Ensure all NHS funded organisations have mechanisms in place to ensure
timely and fit for purpose information for the management of the escalation
and de-escalation process.
Use executive led whole system teleconferences to manage pressure and to
predict future pressures within local system economies. The teleconference
will focus on both current and predictive mitigation.
Ensure that staff are trained in their role in surge and capacity plans and that
this is tested via exercise
Ensure that an appropriate out-of-hours on-call system is in place.
9.0 Assurance, Risk and Mitigation
Recent communication from NHSE has required assurance from ENHCCG on our
ability to deliver this plan and our preparedness for the winter period, specifically:







Winter Readiness: ensuring primary care opening and provision over the
Christmas and New Year period and into the first few weeks of January.
Out of Hours and 111 contingency services in place in advance of winter.
SRG assurance
Ambulance High Impact Actions
Mental Health Crisis Response
Qualitative assessment summarising the key actions that are being taken
ahead of winter
Capacity and planning templates
This has been provided through a number of returns to NHSE. The qualitative
assessment identifies the key risks facing the system and summarises the key
actions that are being taken ahead of winter by the SRG. These are identified in the
table below:
23
Table 1: Qualitative assessment summarising the key actions that are being taken ahead of winter
Pressure
System
Capacity
Risk


Throughput

Medical and Nursing staffing are
the biggest workforce challenge
across the system including
Primary Care.
Existing providers and newly
commissioned
alternative
schemes are recruiting from the
same pool of staff which poses a
risk to delivery.
Although the trust achieved the
required performance target in
April they did not meet the target
in May 2015. Despite an
improvement in June with the
trust achieving 95.13% the target
has not been met subsequently.
SRG Action







Joint system wide review of staffing levels led by Directors of Nursing across the system.
Proposed solutions - joint recruitment, rotational appointments and using existing staff,
development of integrated models.
International Recruitment campaign at ENHT
Regular SRG agenda item - Identified on RCAD
Following the recommendations from the Royal College review of ED, ECIST and a
utilisation management company have been commissioned to undertake a further review
of the ED department.
The trust have submitted a standard working plan which the CCG do not feel
appropriately addresses the issues around the 4 hour performance and a CPN will be
issued to formally request the development an A&E remedial action plan in line with
general condition clause 9 under the ENHT contract.
CPN outlines requirement for RAP to include input from the TDA conversations, Royal
College
of
Emergency
Medicine
review
and
the
ECIST
review.
24
System
Capacity

Capacity Challenges for Home 
Care Packages - both demand
and complexity/dependency




System

Governance
Ambulance conveyances
-pattern of arrival
-more higher priority calls (R2s)
- recruitment - highest vacancies
across the consortium






Actions agreed to consider using community and social care OTs to reduce the waiting
list.
Regular social care commissioners and providers meetings to discuss challenges.
Social Care commissioners to attend SRG regularly
Consider Integrated enablement service , Housing Association Flexi Care, Community
Sector Discharge Services, HertsHelp @ Home & Herts Healthy Homes, Flexible use of
Health Care Assistants to provide some homecare, Use of day services facilities,
Independent Living Service, Equipment Service, Reviewing caseloads to release capacity.
All proposed solutions will be mapped to escalation framework. Currently working up
mobilisation plans for implementation
Consortium wide action plan being signed off to incorporate 9 high impact interventions for
EEAST
Local plan also agreed to support locally specific issues
Requirement to improve See and Treat in local ambulance services
Both plans will be monitored through contract review to ensure delivery of interventions
and required targets.
Oversight of delivery will be monitored through SRG.
CCG supporting with recruitment initiatives, e.g. class 2 certification for new starters
25
10.0 Conclusion
This Plan has identified key areas of work to improve the quality of urgent care
commissioned and provided for our patients. It is aligned with the strategic priorities
and vision for east and north Hertfordshire and identifies a number of workstreams
prioritised for implementation in 2015/16.
The strengthened format of the SRG will provide the system leadership to drive
these workstreams forward and deliver the required improvements to patient flow
across the urgent care system. Key actions will be operationally driven through the
business meeting and strategic oversight and performance will be monitored through
the executive function. A tracker of current actions identified through the most recent
SRG Meetings is maintained and supports the operational delivery of this plan.
With commitment from all partners the SRG will develop commissioning strategies
that will deliver sustainable solutions to urgent care challenges and form a key part
of the Operational Resilience Plan.
26
Appendices
Appendix 1 - Terms of Reference System Resilience Group (SRG) Business Meeting
Terms of Reference System Resilience Group (SRG) Business Meeting
Membership of the Business SRG Meeting
NAME
Sharn Elton
Jo Burlingham
Chris Badger
Phil Lumbard
Gerry Moir
Contract Manager as required
Michele Plummer
GP Governing Body
Representation
ORGANISATION
EN CCG
TITLE
Director of Operations, CCG
AD for Operations
AD for Health Integration
Unplanned Care Manager
Assistant Director Performance
Head of Contract Management
PA to Sharn Elton
ENH TRUST
Alison Pirfo
John Watson
Jon Baker
Divisional Director for ED
Director of Operations
Deputy Medical Director
East of England
Ambulance Service
Trust (EEAST)
Darren Meads
Reena Sylvester
Manager
HUC/OOH
Ross Brand
Deputy Chief Executive
Health & Community
Services
Heidi Hall
Arnold Sami
Alison Gilbert
Area Manager, Health and
Community
HCT, HCS and HPFT
Hertfordshire
Partnership University
NHS Foundation Trust
HPFT
Phil Byrne
Jess Lievesley
Hertfordshire
Community Services
HCS
Richard Moore
Georgie Brown
General Manager
NHS England
NHS England
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MEMBERSHIP OF THE EXECUTIVE SRG MEETING
NAME
ORGANISATION
EN CCCG
Beverley Flowers
Nabeil Shukur
Sharn Elton
Russell Hall
Vishen Ramkisson
TITLE
Chief Executive
Governing Body GP
Director of Operations
Governing Body GP
NHS 111 Clinical Lead, EN
CCG
ENH TRUST
Nick Carver
John Watson
Jon Baker
Chief Operating Officer
Director of Operations
Deputy Medical Director
East of England Ambulance
Service Trust (EEAST)
Dave Fountain
HPFT
Tom Cahill
Phil Byrne
Chief Executive
Director of Community
Services
Managing Director, Older
People
Jess Lievesley
Health and Community
Services (HCS)
Iain McBeath
Director of Health and
Community Services
Hertfordshire Community
NHS Trust HCT
David Law
Julie Hoare
Chief Executive
Director of Operations
HUC / OOH
Dave Archer
Chief Executive
NHS England
Dominic Cox
Director of Commissioning
Operation (South)
Purpose
 To improve the quality and experience of services for the population of East and North
Hertfordshire who access non elective care, through effective coordination of major
agencies that constitute the health and social care system
 To deliver the work programme as set by the Chief Executive member of the SRG that
deliver improvements to patient flow in the urgent care system
 To ensure that the work programmes align with the strategic priorities and vision for East
and North Hertfordshire
 To develop commissioning strategies that will deliver sustainable solutions to urgent care
challenges.
 Prioritise and promote integrated models and ways of working across health and social
care in East and North Hertfordshire
 To be responsible for the development and delivery of the Integrated Urgent Care
System Plan
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Aim of the Network
 To work across the local & border economies to provide the high quality, safe and
accessible urgent care services for patients when they require them
 To be responsible for urgent care improvement throughout the local community, including
work to improve patient flow and in particular facilitate timely and effective discharges
 To remove any obstacles to integrated working caused by organisational boundaries
 To develop local protocols and standard operating procedures as appropriate
 To ensure that the escalation plan in place for urgent care is realistic and achievable and
includes key performance thresholds and indicators
 To resolve system wide managerial issues
 To work across boundaries to improve patient experience and clinical outcomes
 To support dissemination of good practice across the local system
 To ensure each organisation is held to account for meeting its responsibilities
 To be responsible for reviewing and developing care pathways and demand
management interventions
 To review and further develop escalation and surge processes across the system
 To give consideration to workforce implications and workforce development requirements
resulting from priorities and service redesigns
 To maintain an oversight of RTT performance, the potential risk to delivery posed by
urgent care system performance and need for mitigating actions
Key Performance Information (Dashboard)
The network will need to agree what “Good Looks Like” & the clearly defined metrics/ KPIs
supporting this. For example:











Emergency department, acute assessment, ambulatory care and emergency admission
activity data
Ambulance response and turnaround times
Primary Care Access (including OOHs)
Total time in A&E and Clinical Quality Indicators (CQIs)
Delayed Transfer of Care rates in Acute and Community Trusts
Number of, and total capacity implication, of acute patients delayed in being discharged
from ED/Acute Assessments Units due to responsiveness/availability of community
support
Readmission rates
Frequent attenders
Bed occupancy across providers
Capacity plans
Untoward incidents
Accountability
To the East & North Hertfordshire System Resilience Group.
Meeting Frequency
 The network will meet monthly on the 2nd Friday of each month prior to the System
Resilience Group Routine Operational Management
 Daily Teleconference Calls will be held to maintain oversight of the system
 Weekly System Calls to review previous weeks performance and discuss pressures for
the upcoming weekend.
 Monthly Whole System Co-ordination Steering Group meeting as a sub group of the
SRG.
Sharn Elton
Director of Operations
September 2015
29
Appendix 2 - Approved Winter Resilience Schemes 2015/16
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31
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