Minutes:
Ian Armitage gave a verbal update;
‘At the urgent treatment centre in Hemel Hempstead we have new patient testing in place and there are just two outstanding, waiting for sign off from the clinical trust as there have to be clinical protocols in place to make sure the equipment is safe to use in another environment. We are also developing multi- disciplinary teams at the urgent treatment centres, so job specifications have been put in place for a pharmacist and it has been agreed that the community navigator team who currently work closely with GPs will be based at the urgent treatment centre. They are considering the potential for an Emergency Care Practitioner car, they have one car at the moment that goes to care homes and helps with preventing people going to hospital by dealing with whatever circumstances they find at the home, and feel that by having one based in the urgent treatment centre there could be potential for offering a similar service to people in their own homes. There has been quite a steep increase in activity since April this year, from hovering around 75 attendances at the UTC per day, by the end of July that had risen to 95 – so quite a considerable increase. If you then look at the comparison with the attendance for the same period at A&E while there was a slight rise and month on month variation, what you do see is the significant difference between the rise in the UTC attendance, so you can draw the conclusion that there is activity that would otherwise of gone to A&E being driven towards the UTC’.
The workforce review: ‘Currently looking at whether we can extend the working hours at the UTC until 12 o’clock, a commitment was given during a public exercise where we said as part of this consultation we will look to see whether we can do this and are currently looking at data around GP availability, the graphs that I am showing tell that there is not a significant increase in clinician time or in clinical staff, we have done a survey of GP’s to see if anyone is expressing an interest in working extra hours. Once we have all the information we have to put together a board paper for November where we will provide an update on those findings and there will be a board decision as to whether or not we actually do move to opening hours of 12 o’clock or whether, in fact, we remain the same. At the moment it doesn’t seem to be the activity that would indicate the need to do that but more importantly, we haven’t had a tremendous feedback from the survey that we have done of the GP’s of people interested, and what we do need to keep in mind at all times is the safety of patients, we don’t want to offer a service which then has to be closed intermittently because we can’t staff that service.
Further developments that are happening around Urgent Care we have NHS 111 and the Out of Hours Service which is linked and the clinical assessment service which again David alluded to earlier which provides a clinician when people phone 111 to take calls. We are looking at incorporating a mental health clinician in there, there is already a pharmacist as part of that team and a few months ago there was a soft launch of NHS 111 online which people might not of heard about as it was a soft launch and the reason for that is they want to iron out all the IT difficulties which might come with the full launch, but what it will offer is people being able to log on to the service and if necessary once they have answered the questions, to speak to clinician. We are also working with the extended access GP workforce, one of the issues we have around delivering Urgent Care Services, whether that be Out of Hours , or in hours at the Urgent Treatment Centres or Extended Access Hours is GP’s and GP’s are central to a lot of these services and what we really need to think carefully about is how we optimise that workforce so that we take account of blended workforce opportunities where nurses and trained emergency nurses or advanced nurse practitioners can take on some of the roles that GP’s currently do, otherwise we just aren’t going to have the workforce to deliver all of the initiatives. A&E attendance we did a deep dive – specifically looking at people who have a low level need when they present to A&E, just to see the scale of the problem was. We found that there were about 24,000 people a year who did not really need to be there or could have been treated at an Urgent Treatment Centre or elsewhere. We are working with locality GP’s and with those that we found in certain areas where there were a higher number of patients from certain practises that were attending under those circumstances and we are looking at ways in which we can divert people away from the front door. Our referral management approach is looking at the ways that GP services can be operated more effectively. GP streaming which might be something you have heard of – it is a project we have tried before, it is where we have a GP located at the front door of A&E so that where people who could be dealt with by a GP instead of having to go through A&E System arrive, there is someone there to treat those conditions. It has not been tremendously successful in the past and we think that was probably because of the space that has been allocated which has restricted what the GP can do during the time that they are there – this time we have included a nurse to support the doctor, a primary care nurse to do the actual streaming as that was another area of doubt where the hospital nurse was erring on the side of safety and then probably not referring as many people through to the GP as they could, and we have a dedicated space now in the hospital. This will start at the end of October/November time. We also have a variety of winter schemes which we started planning in Mid-August and earlier for certain things, so we are now putting things in place ahead of winter just to make sure that we have control for this coming year. GP practises have commissioned their flu programme already and that is in line with the national standard around directed enhanced service. NHS England is commissioning a range of community pharmacies to provide flu vaccinations also and there is a variety of initiatives to reduce A&E attendances, some of which I have mentioned, and others which will improve flow through the system. We often focus on the front door of an acute hospital and we talk about the four hour standard and that is what you hear on the news but there is also the flow through the hospital that actually relieves some of that pressure at the front door and that is another thing that we are working on. We have a mandated aim given to us by NHS England to reduce the length of stay by 25 % and we want to maintain ambulance turnarounds. Ambulance turnarounds actually can impact heavily on an A&E department, especially if you are not turning the ambulances around quickly enough, they can often end up stacking up one behind another which is not good for patient care or for patient safety. West Herts Medical Centre sits in the same building as the Urgent Treatment Centre and as part of the consultation, we agreed that we were going to put plans in place to move the walk in element of the Medical Centre to the Urgent Treatment Centre so the clinical time and the staff time will go with them but it makes sense to have all the walk-ins and booked appointments into an Urgent Treatment Centre in one place and the decision around how we then manage the registered population at West Herts Medical centre without moving the site is one that will be taken in mid- September at a board meeting.
The final side shows the delayed transfer of care and that is where someone who is medically fit for discharge and is classified as requiring a statutory service whether that be a healthcare service or whether it be a social care service, that has been notified to the people that arrange discharge and that person hasn’t then left the hospital within 24 hours of that notice to be discharged. We were quite high, round about 9 or 10% earlier last year and probably towards the end of last year. We are down now to round about 4.5%. It differs between the Acute Trust and the Community Trust but overall the direction of travel is in the right direction.’
Action point: Cllr Guest asked that once the information from the meeting in September became available it was sent to Sharon Burr.
Cllr Birnie said that he appreciated the was a shortage of GPs willing to work the 10 – midnight slot, but asked if there was always a GP available on the 111 service during those times?
Ian replied that yes there would be a GP available but they would not be based at the Urgent Treatment Centre.
Cllr Birnie asked if it would then be possible to give assistance to a person who seriously needed it.
Ian confirmed that there were three ways in which they did that , through the 111 service, the out of hours where you can actually go to a base which they would suggest, which may be Watford General Hospital, if you can’t get there then there is an out of hours GP in a car who will visit you at home and if it is something that can be handled over the phone there will be a clinical advisor attached to 111 who would be a clinical advisor or a clinician who is qualified to give you that advice.
Cllr Birnie then asked about attendances at A&E and whether or not the deep dive that was done as mentioned earlier was time related and is there any significant increase in this time slot that we are talking about.
Ian replied that was not the case, the time periods people were turning up at A&E with low level needs was between 10:30 and 20:30. The GP at front of A&E is employed during those times.
David confirmed that there was a fall off for Urgent Care between 22:00 and 08:00. A very small percentage of people attended during that time.
Cllr Hicks asked if the figures would rise again in the winter, and David replied that they would, but by putting winter schemes in place and schemes that actually help the flow of people out of hospital, they would be looking to reduce any rise in the winter.
Cllr Guest declared that she is a community pharmacist and does provide a flu vaccination service.
Cllr England mentioned the 25% reduction in the average length of stay and asked what was seen as the main way of achieving that and over what timescale?
David explained that they had a meeting today which involved the West Herts Trust and all partners looking at our winter plan and that is the focus of how we build the winter plan, so we have asked if the initiatives in place are actually going to address the flow through the system.
Cllr England said that if they were going to achieve a 25% reduction uniformly across the year, then that is 25% but if you are going to focus that reduction in the winter plan then effectively then during that shorter period you are going to reduce by 50% or more – David explained that they will measure it is to take the average current length of stay, so if the average length of stay is 100 days then they would want to get it down to 75, just as an example. A general improvement is required so there is an expectation that everyone is able to improve their length of stay. They are trying to shrink the inactive time.
Cllr Birnie asked if re-admission figures were affected by people leaving earlier, David said that they had not, but said that it was a good point and he would make a note of it just to make sure that they do not see that, because it would indicate that people are leaving hospital too early.
Cllr England asked whether Urgent Treatment Centre GP availability during that two hour period so the 111 system has GPs working in it – where is the nearest centre to Dacorum where 111 is being provided?
David answered that it is Welwyn Garden City and it is opposite the QE2 hospital in the old ambulance headquarters.
Cllr England said that would it be a solution to base the 111 service at the Urgent Treatment Centre as then you would not have the problem of attracting doctors to work on their own because they would be working with other people and they might find that more attractive.
Cllr Guest asked that this was looked into and if they could come back to us – David said that he thought it was highly unlikely because of the cost and the contracts now in place.
Cllr Taylor asked if the power point presentations could sent to member support.
Action point: David and Ian to forward presentations.