Issue - meetings

Representative of Stockport NHS Foundation Trust have been invited to the meeting to update the Scrutiny Committee on their continuing efforts to reduce unscheduled admissions.

Ann Barnes (Chief Executive) and James Sumner (Director of Operations), Stockport NHS Foundation Trust, attended the meeting to update the Scrutiny Committee on the Trust’s performance against the 4-hour admission waiting time target.

It was reported that performance at the Trust had improved, but the Emergency Department 4-hour target was not being consistently met. The Trust performance was improving gradually and this was against a background of deteriorating performance nationally.

It was also reported that a change to the process for GP referring patients for admission was shortly to begin that would allow patients to be admitted directly to the department rather than going through the ED. This would affect approximately 25 patients per day, and while not necessarily contributing to the achievement of the admission target, would improve patient experience.

In relation to the recruitment of ED Consultants it was reported that this remained a challenge due to a shortage nationally, but the Trust had recruited additional advanced nurse practioners.

In relation to preparations for winter, partners were working together on a whole system plan that would allow all parts of the economy to remain resilient during increased pressure.

The following comments were made/ issues raised:-

·         The recent decision about Healthier Together and hospital designations, as well as the work around Stockport Together, had removed some uncertainty that may have been a barrier to recruitment. The conversations that had now begun about future service configuration and the opportunities for innovation could be an incentive for recruitment in some cases.

·         During the difficult winter period at the beginning of the year performance against the 4-hour target suffered, although all parts of the economy came together to respond and to ensure patients were safe.

·         The proximity of Mastercall’s new premises to the hospital would assist with managing pressures at the ED as the difficulties in parking at their previous premises had discouraged people using the facility.

The Chair acknowledged the efforts made by partners during the previous winter and recognised that while performance against the Monitor 4-hour admission target had been impacted, the Trust and other partners had taken these steps to ensure patient safety and quality of care.

RESOLVED – (1) That Ann Barnes and James Sumner be thanked for their attendance and presentation.

(2) That the Scrutiny Committee would welcome a further presentation from the Stockport NHS Foundation Trust on their future plans in light of the significant reform programmes taking place locally and across Greater Manchester.

Ann Barnes (Chief Executive) and James Sumner (Director of Operations), Stockport NHS Foundation Trust have been invited to the meeting to provide an update to the Scrutiny Committee on unscheduled admissions to Stepping Hill Hospital.

Details of the previous meeting at which this matter was considered can be found at http://democracy.stockport.gov.uk/ieIssueDetails.aspx?IId=13559&Opt=3

Ann Barnes (Chief Executive) and James Sumner (Director of Operations), Stockport NHS Foundation Trust, attended the meeting to make a presentation to the Scrutiny Committee in relation to the Trust’s performance against the 4-hour Emergency Department (ED) Target and their ongoing efforts to address increased attendances at ED.

Mark Chidgey (Director of Quality & Provider Management), Stockport Clinical Commissioning Group (CCG) and Terry Dafter (Director of Adult Social Care), Stockport Council, also attended the meeting to provide input into the discussion from the perspective of their respective organisations.

The presentation covered the following issues:-

·         In November 2014, the Hospital were continuing to implement the measures set out in the Trust’s Action Plan to address unscheduled care, and performance was fairly consistently above or just below the 95% target.

·         From the second week in December the Hospital experienced unprecedented pressure. This pressure was not related to increased attendances at ED, nor because of significant increases in inappropriate attendances but was due to the increase demand from frail, elderly patients with respiratory conditions. Many of these patients also had complex needs requiring social care support (between 40-50%, up from the usual 20%).

·         The challenge for the hospital and other parts of the economy was to create sufficient capacity to allow for patients to be appropriately discharged. The problems with waiting times encountered by the ED, reported in the national press, were largely a consequence of the lack of ability to discharge to other appropriate care.

·         The hospital responded to the pressure by making provision to accommodate additional medical patients using winter resources and with additional areas, as well as additional staff being used to meet the demand.

·         The Trust ensured daily monitoring was in place to maintain safety and review provision. A conscious choice was made to prioritise the safety of patients over the performance target.

·         The Trust, CCG and the Council collaborated to address discharge challenges to create capacity and ease the pressure on the Hospital and ED.

·         Although the immediate pressure had subsided for the Hospital and for primary care, there remained risk for the remaining months of winter should the weather worsen or in the event of a flu outbreak.

·         Given the nature of the problem, the Trust and partners had coped well with the additional, unprecedented pressure.

Terry Dafter echoed the points made in the presentation, in particular the unprecedented nature of the pressure. He emphasised that the medical needs of the patients, the average age of whom was 90, meant that they could not be deflected from hospital to other services. Adult Social Care Services had also experienced severe pressures as a result of the respiratory illness affecting its service users.

Mark Chidgey stated that the pressures experienced by the Hospital had been reflected across the local health system with significant additional pressure on primary care and GPs. The CCG had worked with the Trust to ensure quality and safety were maintained and that the Trust’s contingency plans had been implemented and were fit for purpose.

Councillors asked questions and made comments on the presentation and issues around ED and the pressures on admission. These included:-

·         Given the national pressures on hospitals and EDs, why was performance at Stepping Hill the worst nationally? In response it was stated that as part of the ongoing work to address unscheduled care, improving discharge had been identified for action under phase 3 of this project. Because this issue had not been systematically addressed prior to this winter Stepping Hill Hospital faired proportionately worse than other hospitals. The Trust nevertheless stood by its approach of prioritising safety over achieving the 4 hour target as this was in the best interests of patient safety.

·         Was consideration given to declaring a major incident as other NHS trusts/ hospitals had done in response to the particular illness/ pressure? In response it was stated that actions taken by the Trust in terms of staffing levels etc.,  ...  view the full minutes text for item 4

Ann Barnes (Chief Executive) and James Sumner (Director of Operations), Stockport NHS Foundation Trust will attend the meeting to provide an update to the Scrutiny Committee on unscheduled admissions to Stepping Hill Hospital.

Details of the previous meeting at which this matter was considered can be found at http://democracy.stockport.gov.uk/ieIssueDetails.aspx?IId=13559&Opt=3

Ann Barnes (Chief Executive) and James Sumner (Chief Operating Officer), Stockport NHS Foundation Trust, attended the meeting to make a presentation to the Scrutiny Committee in relation to the Trusts performance against the 4-hour Emergency Department (ED) Target and their ongoing efforts to address increased attendances at ED.

The presentation covered the following issues:-

·         Recent review of governance had been undertaken, in particular the Trust Board’s Assurance structure.

·         Measures set out in the Action Plan previously considered by the Scrutiny Committee had been completed in most cases, although outstanding actions remained in relation to Information & Technology.

·         Current performance exceeded the 95% target and was in excess of the trajectory target, due to intensive work by the Trust in the preceding two months. The Trust believed there was a clear correlation between the measures being put in place and the improvements, although the Winter period would put increased pressure on the ED.

·         There was a general upward trend in ED admissions at Stepping Hill that reflected a regional and national trend. The deflection arrangements put in place by the Trust had been successful but deflected attenders had been replaced with new ones.

·         The Trust had introduced a range of indicators to monitor the system to be better able to respond to pressures.

·         Recruitment remained a challenge to the implementation of schemes and measures.

Ann Barnes also provided the Scrutiny Committee with an update in relation to the Trust’s transformation agenda, designed in part to reduce costs as a result of financial pressures in the NHS. The update included the following issues:-

·         Working in partnership with other NHS Trusts across the ‘South Sector’ to address common cost challenges.

·         The Trust was committed to a transformative approach to the financial challenges, to do things differently and more efficiently, rather than simply to do less.

·         Although there was a significant challenge, the Trust was broadly on target to meet its financial reduction requirements for the current year, although the increasing target in future years would be more challenging.

Councillors then asked questions / made comments, including:-

·         The improvements made were welcomed, but queries were raised about the consequence of missing the target during the Winter. It was suggested that although it was likely that performance would dip during the Winter period, this was likely to be the case across the South Sector.

·         Work with Mastercall to provide additional primary care support was welcomed.

·         Concerns were expressed that although the Trust had good and innovative ideas to respond to changing demands, it was not always able to implement them in a timely manner. In response it was stated that the Trust was now a more stable and robust organisation and the management team had been restructured to enable it to better implement change, which was moving at a considerable pace now.

·         The Clinical Commissioning Group was also investing in a range of services that should avoid admissions, including work with care homes.

·         While improvements were welcomed, concerns were raised about whether this was likely to increase demand as performance, and waiting times, improved.

·         There was no clear pattern to the increases in the attendances as numbers had reduced in previous years. Further communications could be undertaken to remind the public about seeking treatment from appropriate sources, but also to improve ‘front of house’ services to seek to divert attenders to primary care or pharmacists wherever possible.

RESOLVED – (1) That Ann Barnes and James Sumner be thanked for their attendance and presentation.

(2) That the Chief Executive of Stockport NHS Foundation Trust be invited to report back to the Scrutiny Committee in the New Year on performance in relation to the 4-hour admission target.

(3) That the Chief Executive of Stockport NHS Foundation Trust be requested to circulate the Executive Summary of the Trust’s recent Governance Review to Scrutiny Committee members.

To consider a presentation from the Chief Executive and Director of Operations, Stockport NHS Foundation Trust.

Following on from the presentation made to the Scrutiny Committee in July 2013, this presentation will provide an update to the Committee on the actions taken by the Trust to address performance against the 4 hour target for unplanned admissions.

Details of the previous meeting at which this matter was considered can be found at http://democracy.stockport.gov.uk/ieListDocuments.aspx?CId=153&MId=5322&Ver=4

Ann Barnes (Chief Executive) and James Sumner (Chief Operating Officer), Stockport NHS Foundation Trust, attended the meeting and provided an update on progress with implementing the Trust’s action plan to address performance against the 4-hour target for unplanned hospital admissions. A copy of a briefing report was also submitted (copies of which were circulated).

The update provided background information to the reduction in performance in the previous year that had prompted the involvement of Monitor, the NHS Regulator, and highlighted actions taken by the Trust since the last update made to the Scrutiny Committee in July 2013.

The following issues were highlighted:-

·         Performance against the 95% target had improved and the Trust had achieved the standard for the preceding two months and was currently above the target level for October up to the date of the meeting.

·         The eight point plan agreed with Monitor had been delivered, with the exception of the recruitment of Emergency Department (ED) consultants where repeated attempts had proven unsuccessful. Recruitment of these consultants, as well as middle grade doctors, remained a challenge.

·         New services had been introduced including the Ambulatory Care Unit, a pathfinder project with the North West Ambulance Service, and IV Therapy Pilot, put in place to ensure those who did not need to be admitted were kept out of hospital.

·         The additional Winter Pressures resources would be targeted to those areas of highest need in collaboration with the Clinical Commissioning Group (CCG).

The following comments were made/ issues raised:-

·         Difficulties in recruitment reflected a national trend. Plans were in place to recruit to other posts/levels to support and supplement the expertise already in place. Expanding the number of Nurse Practioners through training of existing staff was being undertaken.

·         The allocation of the £1.5m of extra, non-recurrent A&E monies was to support projects that would realise savings elsewhere in the system. Many of these projects were genuinely innovative. One of the projects was to provide additional support to target repeat attendance caused by or related to alcohol.

·         Addressing dangerous alcohol consumption was complex and required changing ingrained patterns of behaviour. This was not necessarily most appropriately done in a hospital setting.

·         There was an excessive dependence on hospital care in Stockport and this would have to change in the future as it was unsustainable and unaffordable. Greater emphasis on prevention and community delivery was needed. Encouraging the public to use the most appropriate services was continuing.

·         There was a danger of patients becoming lonely and isolated if more care was provided at home. This was being considered as part of the work on health and social care integration and Stockport One.

·         The project with the North West Ambulance Service, to try to ensure only emergencies were brought to hospital, had been very successful so far although further work was needed to verify the data. It was not yet possible to identify how many patients may later have been admitted. The pilot demonstrated the efficacy of the work of the Ambulance Service in deflecting non-emergencies but also highlighted the willingness of the public to call an ambulance for GP-manageable conditions or even for inappropriate issues.

·         Out of hours care was key to the overall approach to reducing hospital admissions and A&E attendances, but patients often felt unsure about the treatment so were not able to make the right choices when they needed assistance. The cost of the alternatives to this service meant that it had to be given the opportunity to succeed.

·         Phase 2 of the work to address unplanned admissions was to try to quantify the number of admissions could have been more appropriately dealt with in other ways, outside of the hospital setting, to ensure the right care was provided.

RESOLVED – (1) That Ann Barnes and James Sumner be thanked for their attendance and presentation.

(2) That the Chief Executive, Stockport NHS Foundation Trust be invited to provide  ...  view the full minutes text for item 4

To consider a presentation from the Chief Executive and Director of Operations, Stockport NHS Foundation Trust.

Following on from the presentation made to the Scrutiny Committee in April 2013, this presentation will provide an update to the Committee on the actions taken by the Trust to address performance against the 4 hour target for unplanned admissions.

Details of the previous meeting at which this matter was considered can be found at http://democracy.stockport.gov.uk/ieIssueDetails.aspx?IId=13559&Opt=3

Ann Barnes (Chief Executive) and James Sumner (Chief Operating Officer), Stockport NHS Foundation Trust, attended the meeting and made a presentation on progress with implementing the Trust’s action plan to address performance against the 4-hour target for unplanned hospital admissions.

The presentation provided background information to the reduction in performance in the previous year that had prompted the involvement of Monitor, the NHS Regulator, and highlighted actions taken by the Trust since the last presentation made to the Scrutiny Committee in April 2013.

Since April, a range of actions had been taken by the Trust and performance had seen a marked improvement. However, in the preceding month there had been a significant increase in demand at the hospital’s Emergency Department (ED) during peak times, which had hampered achieving the target. While this was technically a breach of the target, the waiting times being experienced were only marginally over the 4-hour target as the measures put in place by the Trust meant that patients were no longer experiencing very long waits. The causes of the increased demand were not known, but it was believed to be partly as a result of high temperatures and increasing numbers of people presenting to the ED with minor issues.

There were also particular difficulties being experienced in recruiting Emergency Department Consultants, which was mirrored nationally, and this would continue to present a challenge in implementing the Action Plan. Work was also continuing with partners to address the causes of inappropriate demand and providing alternative treatment options.

It was further reported that the Care Quality Commission had made an unannounced visit in May shortly after the new measures were put in place in the ED and Ambulatory Care Unit. Feedback from the CQC, based in part on patient feedback, had been very positive.

The following comments were made/ issues raised:-

·         Uncertainty around future plans for hospital configurations, including Healthier Together, made EDs that were not major trauma centres less attractive for ED Consultants. A number of other options were being explored to try to address the shortfall in expertise.

·         Managing demand and stopping people going through the ED door was key, although was a significant challenge. Work with other partners to address this was welcomed.

·         Stepping Hill Hospital was fairly unusual in Greater Manchester in not having a GP walk-in facility at the hospital, which tend to work well at taking pressure of EDs. Options for this were being explored.

·         A significant number of attendances were still related to existing medical conditions. The Trust was looking to develop health and social care systems to help overcome this.

·         There was a tension between reducing waiting times and discouraging attendance. Were the target not a consideration, the Trust’s recent measures would be seen as a significant improvement in the service provided.

·         The Trust Board was taking all necessary actions to ensure the four-hour target was met, however it’s primary concern was safety and quality of care.

RESOLVED – (1) That Ann Barnes and James Sumner be thanked for their attendance and presentation.

(2) That the Chief Executive, Stockport NHS Foundation Trust be invited to provide a further update on performance in relation to unplanned admissions to the meeting of the Health Scrutiny Committee on 22 October 2013.

The Chief Executive of the Stockport NHS Foundation Trust will attend the meeting to discuss ongoing efforts to reduce unplanned admissions and reduce A&E waiting times.

The Chief Executive (Ann Barnes) and the Acting Director of Operations & Performance (James Sumner) from Stockport NHS Foundation Trust attended the meeting to update the Scrutiny Committee on efforts to improve performance in relation to the healthcare standard requiring 95% of patients be admitted or treated and discharged within 4 hours of attendance to the Emergency Department of the hospital.

Stepping Hill Hospital had approximately 7,500 patients attend its Emergency Department each month, of which approximately 25% would be admitted. In the year to date attendance had increased by 3.9% and an increase in admissions of 7.6%, peaking during the winter period at 30-40% admissions. This pressure had required additional bed capacity to be found.

A hospital which had two successive quarters of not meeting this standard would trigger intervention by the NHS regulator Monitor. In the case of Stepping Hill Hospital, performance had been below this target for three consecutive quarters and had resulted in Monitor notifying the Trust at the end of January that it was in breach of its Authorisation. Leading up to this and since the notice was issued, the Trust had been having regular meetings with Monitor as part of the delivery of a rectification plan to address both the below target performance and to address more long term pressures on unscheduled care.

The Plan that had been agreed anticipated compliance with the 95% target by September of this year. The Plan was based on the assumption that the winter pressure on admissions would continue, therefore it was hoped that because of the prudence built into the Plan’s assumptions, compliance could be achieved earlier.

The Trust had been subject to a range of external reviews in addition to those by Monitor, all of which had found that the Trust’s Plans were sound and that appropriate progress was being made.

The following comments were made/ issues raised:-

·         In response to questions about failing to fully implement the Plan, it was stated that for each measure contained within it there were a range of contingencies to ensure that compliance would be achieved. The Plan had also been developed to ensure that the measures within it would have a long term impact, be sustainable and that improvements would result from the measures, not simply because of changing levels of demand. The difficulties being experienced by the Trust should be seen in the context of a national trend of worsening performance.

·         The Plan had been developed with the assumption that levels of demand would remain high, and had not factored in any of the other actions being taken by the Trust or the Clinical Commissioning Group to address unplanned admissions, such as the Stockport One project. Members welcomed the focus on reducing demand and prevention rather than reactive care, although it was recognised that it would take time to overcome a public culture of prioritising hospital care.

·         There was no clear pattern to Emergency Department admissions and as such no ‘quick fix’. GPs were provided with feedback as to the distribution of people presenting. The Trust was confident, supported by the opinions of other bodies, that they had correctly identified the causes for reduced performance and the remedy.

·         The difficulty of being seen to ‘turn people away’ to more appropriate care opportunities, such as GPs and pharmacies, was recognised. Careful management and working closely with other providers was important to ensure appropriate care was provided but also that the public were not using this as a bypass to a GP appointment. The Trust’s involvement in community care meant that it was better placed to prevent avoidable escalations for those with existing conditions.

·         In response to questions, it was stated that the three most important practical actions the Trust was taking were: (i) improving discharge from hospital and ensuring a senior doctor take responsibility for moving patients through their care pathway; (ii) increasing in-reach capacity; and (iii) recruiting additional  ...  view the full minutes text for item 1