Southend University Hospital Foundation NHS Trust Risk Summit

1. Appendix A Southend University Hospital Foundation NHS Trust Risk Summit NHS Southend CCG and NHS Castle Point & Rochford CCG The Commissioners’ Perspective 31st March 2014

2. Content • CCG role • Performance trends across emergency care • Actions taken by the commissioners • Urgent Care Working Group • How has the wider system responded?

3. Context • Southend CCG is lead commissioner for services from SUHFT • Responsibility to ensure we commission high quality, safe services on behalf of our population • There has been inconsistent achievement of the A&E 4 hour standard since March 2012 • This has impacted on the ability to achieve other NHS Constitution standards and further reduced quality

4. A&E 4 Hour Standard since April 2011 Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

5. A&E Attendances Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

6. A&E Attendances – AMU removed Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathway Criteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only

7. A&E Admissions Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathway Criteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only Attendances with Outcome as “Admitted” only

8. Non-Elective Conversion Source: SUS-SEM Via MedeAnalytics, adjusted to remove AMU-pathway A&E Attendances

9. Bed Occupancy 2011-12 Nov-Feb 2013-14 Nov-Mar 2012-13 Nov-Feb Source: NHS England Sitreps, 4 years of collections, 7 day rolling average

10. Delayed Transfers of Care 2012-13 Nov-Feb 2011-12 Nov-Feb 2013-14 Nov-Mar Source: NHS England Sitreps, as a percentage of occupied beds, 4 years of collections, 7 day rolling average

11. Delayed Transfers of Care

12. Friends and Family Test Source: Unify2

13. Ambulance Handover Times Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

14. Ambulance Handover Times – expressed of % of total Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

15. Ambulance Handover Times – over 30mins Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

16. Ambulance Handover Times – over 60mins Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

17. Themes from the Data • A&E standard has been met in only one quarter since Q3 2011/12 • A&E attendance has not increased significantly • A&E conversion rates have increased • DToC are small • Ambulance handovers have remained constant but recently higher number of ambulance waits over 30 and 60 minutes

18. What does this mean for patients? • Leads to a crowded department with patients both waiting to be seen and waiting for beds • Overall poor patient experience and safety • Evidence has shown that patients admitted through a crowded A/E have a 43% increase in mortality at 10 days • Patients admitted after 4-8 hours in A/E stay on average 1.3 days longer in hospital and 2.35 days when this reaches 12 hours • Treatment initiation is often delayed in a crowded department • FINALLY for patients seen and discharged from A/E there is a direct correlation between the length of time waited and a higher chance of dying in the next 7 days

19. Action taken by the CCG since April 2013 • Performance management and contractual action • System co-ordination and winterplanning • Managing demand • Quality visits and external reviews

20. Performance management and contractual action during 2013/14 • Weekly performance meetings COO- COO since July 2013 • Two letters of serious concern to CEO • Required formal root cause analyses and exception reports • Action under the contract • Contract Query – 7th March 2013 • 1st Exception Report – 29th May 2013 • 2nd Exception Report – 27th September 2013 • Closure Notice – 15th November 2013 • Contract Query – 21st January 2014 • 1st Exception Report – 13th March 2014

21. System co-ordination and winter planning • System conference calls – daily since November 2013 • Winter plan developed through two stakeholder half day workshops and full evaluation of demand management schemes • Scenario testing (Exercise Eskimo) to ensure effective escalation and production of escalation guide • Winter money allocated to the hospital (£0.9m out of £1.4m)

22. Managing Demand • Full evaluation of schemes over summer which identified sub-optimal performance in schemes and took corrective measures • Implemented a successful programme to increase GP referrals to the Single Point of Referral • Extended hours for hospital Day Assessment Unit • Increased GP practice MDTs • Implemented strengthened model of GPs supporting care homes • Public education – local campaigns to use NHS 111 and avoid A&E • Commissioned system bed capacity review – due April 2014

23. External reviews and quality visits Emergency Care Intensive Support Team visited twice with recommendations which has formed basis of recovery plans Themes from CCG-led quality visits – unannounced and announced:00hrs: • Potential patient safety risk from delayed offloading of patients from ambulances • Inappropriate attendees in minors • Slow triage of patients in waiting area • Slow transfers from A&E to wards • Inappropriate skill mix and staffing levels for nursing and medical staff in A&E • Lack ofseniordecisionmakers onthe emergency floor • Highuse ofagency medical&nursing staff • A&E department size too small

24. In Summary • Significant problem in meeting A&E 4 hour standard for last 24 months • Demand, discharges and bed capacity has remained constant across the system • Unableto recoverquicklyfrom periods ofsurge prolongingimpact • Main underlying issue is staffing shortages in the A&E department – consultant, middle grade doctors and nursing • Size of the department is a limiting factor • Process management has not been fully embedded with clear leadership • .

25. Further action required for the hospital • To appoint a performance director for emergency care. • To establish a senior consultant rota of permanent clinicians to provide senior leadership in the department. • Revise A&E recovery plan to incorporate KPIs and clear and accountable actions for implementation and delivery. • Implement a medical, nursing and service manager recruitment plan. • To establish minors see and treat. • To establish majors rapid assessment. • To embed process for escalation to specialist teams. • To embed internal and external escalation processes. • To achieve earlier patient discharge. • To ensure 3x daily site visits take place. • To develop a clear plan to deliver the paediatric pathway. • .

26. Further action for the wider system • Urgent Care Working Group meeting fortnightly moving to weekly • Review pathway for minors across system • Implement our frail elderly pathway in line with the integrated pioneer plan • Better management of patients with long term conditions in the community • Implement system-wide A&E recovery plan.