Agenda item

Jan Ledward gave a presentation on both the Urgent Care Centre at the Royal Preston Hospital site and the mobilisation of the Integrated Urgent Care Services at Chorley and Preston Hospitals.

It was reported that the Greater Preston and Chorley and South Ribble Clinical Commissioning Groups (CCGs) along with Lancashire Teaching Hospitals Trust had submitted a joint bid in August 2015, to the National Urgent and Emergency Care Fund (NUECF) for some capital in order to redevelop the Royal Preston Hospital's Emergency Department and Urgent Care Centre as the current facilities were unsatisfactory and unable to accommodate the amount of activity going through the departments.

A joint bid was also submitted for primary care capital through the Estates Technology and Transformation Fund (ETTF) as the development work would also consist of a primary care front-end to the overall A&E department. As this was considered to be a unique submission, NHS England's Project Assessment Unit (PAU) had reported that there was no formal route to release the monies to the CCGs. It was hoped that this particular issue would be resolved when the CCGs met with NHS England during the week commencing 27 February 2017.

With regard to the NUECF, the Committee was informed that the funding 'envelope' for the North had reduced to £12m and that £3m would be ring-fenced for each region within the North. However, in January 2017, NHS England had advised that due to timing issues, they were unable to administer the NUECF funding as they felt the new facilities would not have been completed by the end of the current financial year. The funding was then withdrawn and all CCGs were required to submit another bid in the next financial year (2017/18).

Members of the Committee were invited to comment and raise questions on the Urgent Care Centre at the Royal Preston Hospital site and a summary of the discussion is set out below:

·  Concerns were expressed in relation to the bid for funding through the NUECF had been deferred to the next financial year in conjunction with recruitment issues faced by the Trust and the current working environment. It was reported that there was no guarantee the funding would be agreed for the 2017/18 year.

·  A question was asked in relation to the purpose of the proposed primary care front-end. It was confirmed that the facility would provide a range of services not only to identify and intervene those presenting at the Emergency /Urgent Care Centre departments who had a primary care need but to also support the overall A&E department in treating and discharging patients.

·  It was suggested that NHS England be invited to attend a future meeting of the Committee.

An update on the mobilisation of the Integrated Urgent Care Services at Chorley and Preston Hospitals was then provided.

It was reported that there were four elements to the contract awarded to GTD Healthcare. Phase one commenced on 23 November 2016 and saw the roll out of a GP out of hours service; Deep Vein Thrombosis (DVT) service across both Preston and Chorley Hospital sites; and a Pathway Alternative to Transfer Service (PATS) to support the North West Ambulance Service and reducing the number of transfers to hospital. Phase two was the mobilisation of the 24/7 Integrated Urgent Care Centres co-located with Emergency Departments at Chorley and Preston Hospitals which commenced on 18 January 2017.

With regard to phase one, it was reported that whilst performance had not been met in all areas, data from January 2017 demonstrated that improvements were being made and the CCGs were working with GTD Healthcare to continue to improve performance. The Integrated Urgent Care Centres had positively contributed to the waiting times against the four hour standard with an average of 77% in December 2016 increasing to an average of 86% since services started in January 2017.

It was reported that at the Preston site, since January 2017, an average of between 50 and 60% of patients were deflected away from the Emergency Department. The Chorley site had seen between 60 and 70% deflection which freed up A&E staff in treating those who required emergency care.

The Committee was informed that since the re-opening of the Chorley Hospital Emergency Department, Wigan, Wrightington and Leigh Hospitals had seen an almost 50% reduction in the number of daily attendances and admissions from all PR post codes from the Chorley area.

Members of the Committee were invited to comment and raise questions on the mobilisation of the Integrated Urgent Care Services at Chorley and Preston Hospitals and a summary of the discussion is set out below:

·  A question was asked regarding the reduction in the ambulance 'shuttle' service between Chorley and Preston Hospital sites. Members were informed that when the A&E department at Chorley Hospital closed, additional ambulances were procured. However, they weren't just for patients to be transferred from Chorley Hospital to Preston Hospital. The additional ambulances also addressed the need to transfer patients from the Medical Assessment Unit at Preston, when it closed to Chorley Hospital. These additional ambulances had been reviewed since April 2016 and had reduced over time as and when services had replaced what had been reduced. The CCGs continued to monitor the additional ambulances. It was their view that since the A&E department had re-opened there was sufficient capacity for the existing ambulance service to commit to any transfers needed. The CCGs were continuing to work with the Trust in re-instating the Medical Assessment Unit at Preston Hospital.

·  Concern was expressed that GP out of hours shifts were not being filled at the Chorley site and therefore transferred over to Preston Hospital. It was reported that some shifts had not been covered due to unfortunate events. It was acknowledged that some shifts were not covered as some agency staff hadn't turned in to work. The Committee was reassured that GTD Healthcare had reviewed staffing levels at both sites to ensure sufficient cover was provided. It was noted that the service was a combined service across both sites which enabled GTD Healthcare to move staff between sites in accordance with demand without affecting appropriate levels of cover for either site.

·  On effective triage services and the continuity of staff providing the service, it was reported that the CCGs were working with the Trust's clinicians to ensure that the pathways put in place were appropriate and reviewed and that contingencies were in place in respect of any absences. Whilst recognising that there were teething problems to be addressed, the CCGs were satisfied with the provider. It was also reported that GTD Healthcare had been successful in recruiting GPs and nurses to the service and reducing their reliance on agency staff.

·  In response to questions on bed blocking and patients waiting on trolleys it was acknowledged that the whole system was under significant pressure and represented a daily challenge in managing the flow. However, ensuring that patients moved through the system effectively had been the focus of the CCGs attention throughout the winter.

·  One member asked about the affect the closure of the A&E department at Chorley had on Lancaster Infirmary and whether there was any detail about the number of people from the PR post codes utilising Lancaster Infirmary. The Committee was informed that whilst they did not have the full facts with them, they were aware that only a very small number of people from the PR post codes had travelled to Lancaster.

·  A query was raised as to whether any work had been carried out to alleviate confusion over when to use emergency services. It was reported that work had been carried out with the CCGs Patient Voice Committee to look into existing information that's available to the public as well as updating the directories that the 111 service use to help them identify the correct pathways to services in the area. In addition to this, relevant websites, information leaflets and posters were continually revised to ensure that they were up to date.

Prof. Mark Pugh and Suzanne Hargreaves gave a presentation detailing the progress and impact on activity and performance on the revised Chorley Hospital Emergency Department and Urgent Care Centre provision.

It was reported that a 12 hour Emergency Department was mobilised on 18 January 2017 as planned. Whilst it was a 12 hour service, there was a requirement to open and staff the department until 10pm each evening. The department was staffed by a mixture of Consultant, middle and junior grade doctors, nurse practitioners and nursing staff.

The Committee recalled that the Trust temporarily closed the department back in April 2016, on the grounds of patient safety as there were insufficient numbers of doctors available to manage both Preston and Chorley Emergency Departments despite recruitment efforts. It was reported that both sites required 14 middle grade positions. The position back in April 2016 was that there were effectively five doctors to manage the two sites. However, the current position was that there had been some improvement with staffing with additional permanent members of staff. Whilst there were now effectively 8.8 doctors available across both sites, the Trust was still dependent on locum s to fill gaps in the rotas.

The Committee was informed that the workforce remained vulnerable. In January alone, it was reported that there were 45 cancelled locum shifts with less than 24 hours' notice. It was noted that as locums were not on permanent contracts they could give short notice of cancellations of shifts. Consultants and middle grade doctors were therefore undertaking additional sessions to cover the Chorley site which had now placed a risk on the Preston site. Gaps were also emerging within the junior doctor rota and that by May 2017, it was envisaged the gap would increase to 10 junior doctors out of the 21 required. Representations had been made to Health Education North Wes to work with the Trust on this issue. However, the Trust was informed that there were gaps across the country in recruiting junior doctors.

The Committee noted that the Urgent Care Centre only dealt with those patients who self-presented, whereas the ambulance cases would go straight through to the Emergency Department and therefore bypass the triage system. With regard to the Preston site it was reported that approximately 50% of people self-presenting had their needs met by the Urgent Care Centre. Whereas at the Chorley site, the Trust was seeing more people having their needs being met by the Urgent Care Centre by comparison.

The Committee also noted that ambulance arrivals equated to around 100 per day across both sites. However, figures showed that whilst that figure remained constant, there was an increase in the number of people being conveyed by ambulance to the Chorley site which confirmed that NWAS (North West Ambulance Service) was conveying people appropriately to the respective sites.

The Committee was informed that the main cause of delays at the front of hospitals was not solely as a result of the overwhelming numbers of attendances at A&E departments but as a result of the overall health and social care system. As a result, the four hour non-admit performance figures since April 2016 had declined. In addition to this it was estimated that around 10% of the Trust's operating bed base was occupied by people who were fit for discharge but were unable to move to a suitable venue for their ongoing care needs such as waiting to be admitted to anther hospital; for community care; for social care package/assessment, for equipment or waiting for residential/nursing home beds.

It was reported that the way in which the Trust managed increase in delays and reduction in discharges was to increase the number of beds available by escalating into areas such as assessment units and day case areas. In such instances the Trust was reliant on agency/locum staff to support. However, this then affected routine and elective (planned) surgery.

The Committee was informed that the Trust was working on a number of initiatives to improve this situation, including the development of the Local Delivery Plan – 'Our Health, Our Care' and the Sustainability and Transformation Plan (STP); participating in the NHS Improvement's Action on A&E programme and gathering intelligence from patients.

Recruitment of medical staff remained an on-going risk not just to the Trust but nationally. It was reported that national agency spend on locums for the previous year was £3bn with £600m of that spent on A&E doctors alone. Capacity within the Trust was stretched. However, assurance was conveyed that the most vulnerable of patients would receive absolute priority.

In summarising, work was ongoing across the health economy to improve patient flow and alleviate A&E pressures. The Trust was committed to better inform the Health Scrutiny Committee of its challenges and plans and that lessons had been taken forward as part of the 'Our Health, Our Care' Local Delivery Plan and the Sustainability and Transformation Plan (STP) for Lancashire and South Cumbria.

Members of the Committee were invited to comment and raise questions and a summary of the discussion is set out below:

·  A question was asked in relation to GTD Healthcare's lack of kitemark status approved through the Care Quality Commission and the affect this had on the North West Ambulance Service to convey patients to the Urgent Care Centre at Chorley hospital after 8pm. It was reported that prior to GTD Healthcare taking on this service, this was not an issue for the Trust. However, it had been confirmed at 8am on the morning of this meeting that Chorley had received its kitemark status therefore resolving this issue.

·  In response to a question on the financial impact of employing locums, it was confirmed that this was causing a financial risk and was an issue that the Trust's Board were aware of. It was noted that the Trust selected their locums very carefully.

·  One member queried the figures in relation to the number of patients deflected from Urgent Care Centre provision back to the Emergency Department at both sites and whether there was a connection between Chorley's limited opening hours by comparison to Preston's 24 hour provision and patients being moved on to the Preston site from Chorley when its Emergency Department was closed. The Committee was informed that the difference in performance figures was down to the 'case mix' and usage from the surrounding areas of the two sites which therefore reflected in the figures provided.

·  Concern was expressed over the national figures for increased A&E attendances and whether NHS England had evaluated the reasons for the marked increase. It was reported that people below the age of 29 predominantly used A&E departments irrespective of what their need was. The Trust was also seeing a big increase in the over 85 population being brought by ambulance. The Committee noted that there were campaigns on A&E usage such as the 'Choose Well' campaign.

·  A question was asked on whether the co-location of Emergency Departments and Urgent Care Centres was the solution to reducing A&E attendances or whether education was the solution to the matter. The Committee was informed that the Royal College of Medicine had researched models throughout the country on this issue and arrived at the conclusion that providers had to give people what they wanted rather than what they needed and advocated models where full provision was offered at the front door through a single point of access. It was confirmed that this model would be used for the 'Our Care, Our Health' Local Delivery Plan.

·  In response to concerns around recruitment, it was reported that the Trust was working with Health Education North West. The Trust currently had around 300 medical students in training at both sites. Concerns were also expressed in relation to Brexit and the uncertainty of long term contracts and career development paths for those professionals currently employed in the NHS from abroad.

The Chair thanked officers and members for their contribution.

Resolved: That;

  i.  The updates provided on the revised Chorley Hospital Emergency Department and Urgent Care Centre provision be noted;

  ii.  NHS England be invited to attend a future meeting of the Health Scrutiny Committee to report on the Royal Preston Hospital Urgent Care Centre Bid.