To receive a report from Mr Mike Ryan Director of Urgent and Emergency Care, Leicestershire, Leicester City, and Rutland (LLR) System. The report summarise the recommendations and learning from the winter period 2017/18, and outlines the approach to better resilience and patient experience for 2018/19.
The Board received a report and presentation from Mr Mike Ryan Director of Urgent and Emergency Care, Leicestershire, Leicester City, and Rutland (LLR) System. The report summarised the recommendations and learning from the winter period 2017/18, and outlined the approach to better resilience and patient experience for 2018/19.
During the presentation the following comments were noted:-
· Winter pressures traditional saw a drop in A&E performance in December, January and February. This pressure had increased in recent years and was now being experience from October to April. This increase put added pressure across the whole health system.
· There were less patients attending the A&E in the winter compared to other time in the year.
· There was a pattern of increasing number of older patients arriving by ambulances and being admitted to hospital in the winter. The admissions were not due to larger numbers per se but a result of more ‘repeat’ patients being re-admitted. 80% of patients admitted to in-patient wards in UHL were aged 70 years or older, yet this demographic group represented 20% of the population at large.
· There was a decrease in younger non-admitted patients in the winter and whilst the instances of delayed transfer of care did not increase; bed occupancy and length of stay did increase.
· On average performance in the winter is 4.2% lower than the rest of the year but this year had seen a decrease of 6.2%.
· There were 15-16 designated bays for ambulances but in the winter period in was not uncommon for 20-25 ambulances occupy the same designated area.
· There was marked decrease in the 4 hour performance target in December, January and February. It was difficult to balance resources to meet the demand when the various conditions requiring patient to be admitted were not known in advance and could vary as winter progressed.
· The pressures were about establishing continuity all year round knowing that the numbers of respiratory conditions, trips and falls and frailty etc were increasing.
· 14 key stake holders were working with A&E to address the pressures and mitigate the knock-on effects with the health and social care sector.
· The escalation level had been at 3 or 4 for most of the winter period.
· This year had also seen higher number of elective surgery cancelations than in 2016/17 following Department of Health instructions and there had also been exceptional levels of cancellations of urgent and cancer related operations unseen in previous years.
Members of the Board commented that:-
· That whilst much of the presentation made sense to clinicians it was not particularly user friendly or accessible for the public and non-clinicians to understand the issues and enable Board Members to appropriately challenge the issues.
· As slips, trips and falls in the winter period contributed to pressure on resources it was felt that it would be useful to have an holistic approach and have details of other non-clinical initiatives, such as gritting arrangements in the winter, which could contribute to reducing risks of slips, trips and falls. The Board should be taking an overarching view of all the partners initiatives that could be used to reduce hospital admission in the winter.
· There was view that the winter care arrangements were too focused on being reactive with little focus on prevention to stop individuals being admitted to hospital. Gritting highways, pavements, keeping homes warm and dry, ensuing vulnerable people had regular company and were well fed seemed a better way to address the pressures on admissions rather than remodelling capacity to meet the demand during the winter months. It was considered that non-clinical partners on the Board had good examples of successes to reduce demands.
Health representatives on the Board commented that:-
· The issue of the presentation relying heavily on clinical data was accepted and the holistic approach was welcomed and there was a commitment to bring a further non-technical update in September to include a multi-agency approach including the lessons learnt from other partners, such as EMAS and the A&E delivery Board to learn how they predicted demand and the initiatives being used to break down inter agency barriers to improve responses across the health and social care system.
· Admission arising from frailty and multi–morbidity represented approximately two third of hospital admissions and there was potential to develop initiatives within the health and social care sector to reduce these admissions.
· The impact on staff last winter was also difficult to manage as the length of responding to the winter pressures over a longer sustained period of time had been hampered by staff sickness and absences.
· There was a limited emergency bed capacity governed by physical space and staff availability constraints
· It was, however, also possible to close the gap between demand and capacity by opening more wards or converting wards to medical wards in response to demands. A new respiratory ward was also being built at Glenfield.
· There was a need to work more efficiently and the number of stranded patients, those in hospital for over 87 days was coming down but this relied on inter agency collaboration
· The Chief Executive of the City CCG was now Charing the A&E Board and the Frailty and Multi morbidity Task Force a d this had potential to recuse the impact of 20% of the population taking 70% of health capacity.
Following a comment on the impact of the new Emergency Department on winter care it was noted that the patient experience and the physical environment had been totally transformed. However, these improvements did not solve the entire problem as they still need an efficient patient outflow. explain
Members of the Board also commented that :-
· The Board had a role in promoting and supporting interventions that would make difference and produce better outcomes.
· It was widely recognised that staff worked hard under difficult circumstance at time but the prime concern was the health and wellbeing of people in the city, It was important to have good GP hubs there was still a concern that many people admitted into hospitals had high levels of needs but their treatment was affected by the high occupancy rates.
· It would be useful for the Board to have details of the numbers of patients being re-admitted to hospital. If there were patient being discharged medical care but not needing to be in hospital then this may impact on GP services there was a lower ratio of GPs to the population than in European nations.
· Members found the term ‘stranded’ unhelpful as if a patient needed to need to be in hospital that is where they needed to be and should not be seen as ‘stranded’.
That the presentation and report be received and that a further report on the whole system approach to winter preparedness be submitted to the September meeting.