Agenda item
Barts Health
To receive:
a. a presentation on managing winter pressures at RYL
b. a verbal update on last year’s review of A&E review recommendations (scrutiny review circulated for information)
Minutes:
The Deputy Group Director, ECAM and Clinical Director, Emergency Departments together with Deputy Director of Operations, ECAM and Acting Hospital Director, Royal London Hospital (Barts Health) and Associate Director of Public Health spoke to the Panel on the matter of Accident and Emergency (A&E) winter pressures. He informed the Panel that:
· Yearly, 300,00 patients were seen by Barts Health and of these, 155,000 per year were treated by Royal London Hospital (RLH) for a range of both minor and urgent conditions.
· The service was delivered through structured facilities designed to deal with a range of severity of conditions.
· Performance targets at Royal London Hospital (RLH) for A&E were set at 95% and performance was presently at 90% of targets.
· The following factors detrimentally affected access of local people to A&E services and were factors which each contributed to poor access to RLH beds
o Bed-base issues – discharges
o Trend towards elderly patients incurring prolonged length of stay
o RLH was the specialist centre for gunshot wound events and received A&E referrals from other areas
o Delayed return of referred patients to their home Health Trusts in each trust area
o Demographic changes indicating a trend towards an increased incidents of elderly trauma (e.g. hip fracture) than seen in previous years
He noted the following measures/initiatives to alleviate prolonged stay in acute beds:
- Statistics showed that, at any one time, 10% of the 700 beds provided at RLH were filled by occupants not actually recovering treatment. He suggested that a role of the CCG should be to try to facilitate movement to short-stay respite care in order to free beds for acute medicine.
- RLH worked with local GPs to deliver the Hot Clinics scheme
Dr Ramadhan noted that notwithstanding these schemes there were still pressures with patient influx into A&E and that other Trust Hospitals experienced the same pressures except that of tertiary care.
In response to the Panel's questions, the following information was provided:
The no impacts of the implementation of the Better Care Fund on the service had yet been observed. However the fund was announced by Government in 2013 and formed part of NHS two-year operational plans and five-year strategic plans. Therefore it would be more appropriate to monitor impacts in the forthcoming year.
One incident of Norovirus had been posted at RLH presently with no further spread.
The information campaign on buses and billboards promoting appropriate use of A&E and other forms of access to healthcare services had had no impact on public behaviour.
It was noted that outcomes of the last A&E review provided indications of the motivators for the patterns of A&E usage observed and, resulting from this, more investigations would be undertaken.
No data on the proportions that unnecessarily attended A&E was available at the meeting. However the Panel was advised that:
- There was no bar to access this service
- Usage was influenced by a number of factors such as opening times of GP surgeries, times of access to ancillary support services e.g. translators
- During the daytime a different stream structure was observed but at night times staffing levels were lower. Therefore during early morning hours there was competition between numbers attending and when these were able to access healthcare.
Concerning what factors would constitute desirable levels of access, the Panel was informed that the staffing model was able to cope with patient ingress but problems were experienced at patient discharge. Therefore it was recommended that the campaign should also incorporate on appropriate departure from A&E and how quickly this can be undertaken appropriately.
Patient expectation and repatriation into local District General Hospitals (DGH) were issues that also needed to be considered. Some repatriations were complicated by the status of the patient (e.g. overseas tourist etc.) and therefore complex negotiations were often required.
Additionally, on a daily basis, 50 beds were occupied by patients who were fit to be moved on to other appropriate types of care. However but no suitable next stage care facilities were available. Faster onward discharges were also affected, in part, by a lack of suitable onward facilities that would have previously been available e.g. nursing homes: there were presently only two in Tower Hamlets. Additionally, in past years, hospitals provided a number of convalescent beds for those in need of nursing care. This form of hospital provision no longer existed.
It was noted that communications with Tower Hamlets Council were good and there were a range of arrangements with the CCG relating to how the care was resourced. However conversations with other DGHs were not always constructive.
Mr Burbige noted that, in his view, residents of the borough incurred detriment because of RLH’s, operational successes and because of its Tertiary Unit facilities. Dr Ramadhan advised that this detriment was offset by the immediacy of the major trauma facilities available to any local residents suffer such a mishap.
Concerning discharges delayed because a consultant authorisation was awaited, the Panel was informed that afternoon patient reviews were now undertaken in all wards and there were also nurse-led patient discharge criteria which addressed this kind of situation.
Concerning the timing of release of winter pressures funding and its effects on levels of resilience in the service, the Panel was informed that by advance planning of how the funding would be used, staffing levels could also be synchronised in advance to meet the need during the periods of high demand. However this model carried a financial risk as it required money to be committed before the funding was released by Government additionally it required management approval before recruitment could be undertaken.
Concerning recommendations arising from the A&E Review relating to employment of local people, into healthcare roles, the Panel was informed that RLH supported the employment of local people into healthcare clinical roles and their progress into professional nursing roles. Members were also informed that roles at Bands 1-3 were aimed at this kind of career progression and talent pools and apprenticeship were other forms of entry into health careers.
Dr Ramadhan invited Panel members to visit A&E at RHL to experience the environment in which acute emergency medicine was delivered.
The Chair thanked Barts Health representatives for their presentation and the invitation extended.
RESOLVED:
The presentation be noted
Supporting documents:
- Barts 150218 Tower Hamlets HSP presentation 150302 final [Read-Only], item 2.1 PDF 331 KB
- Barts AE Report TA 2014 FINAL Draft, item 2.1 PDF 246 KB