Operational Resilience and Capacity Planning 2014/15

Operational Resilience and Capacity Planning 2014/15

Date: October 2014

Draft:0.4 for review by NHSE

1.0 INTRODUCTION

This resilience plan summarises the current progress in establishing whole system, on-going capacity planning for the York and Scarborough localities in order to achieve operational and system resilience.

This plan supports and aligns with the operational delivery ofthe constituent CCGs’ and providers’ Five Year Strategic Plans and the requirement to deliver all patient rights included in the NHS Constitution.

It has been prepared by the key stakeholders included in the System Resilience Group (SRG) and has been agreed and approved for submission to the national tripartite body including NHS England, NHS TDA, Monitor and Adaas.

The SRG members are outlined below and represent all the key stakeholder organisations who have committed to work together to achieve system resilience. These include:

NHS Vale of York CCG

NHS Scarborough and Ryedale CCG

NHS East of Riding CCG

York Teaching Hospitals Foundation Trust

Yorkshire Ambulance Service

The SRG is supported by unplanned and planned care working groups which include representatives from the following stakeholder organisations:

City of York Council

North Yorkshire County Council

East of Riding County Council

Leeds & Yorkshire Partnership Foundation Trust

NHS England Direct Commissioners

Voluntary and Third Sector Partners

Healthwatch and patients/ public representatives

2.0 SYSTEM RESILIENCE OBJECTIVES

The SRG will work together to plan and deliver more integrated services across the health and social care system to increase resilience in the system and deliver smooth patient flow across primary care, community and acute hospital settings.

The operational resilience and capacity planning process considers how resilience can be assured throughout the year based on robust analysis and review of the current service delivery and performance position, a joint approach across all commissioners and providers locally, and with consideration of the impact that planned care has on unplanned care, and vice versa.

When considering this plan the following core objectives for resilience are central:

Delivery of safe, effective and prompt care
Delivery of overarching system sustainability
Minimising emergency department attendances
Minimising hospital admissions
Minimising inpatient bed days and avoiding delayed discharges (LOS)
Optimising system flow

3.0 SYSTEM CONTEXT

The Operational Resilience and Capacity Planning Guidance (13th June 2014) provides a detailed and specific framework for SRGs to undertake whole system planning for unplanned (urgent and emergency) and planned care.

This resilience plan identifies the key drivers for current performance and issues in the system and identifies a range of proposals from across health and social care partners to deliver additional capacity in order to better manage more patients outside of hospital and increase the flow of patients through hospital and back home.

Principles of good practice have been clearly identified throughout both the unplanned and planned care system and the plan also reflects on which schemes from the winter planning pressures money schemes in 2013/14 had the greatest benefits and impact on outcomes, and have (or can be) funded as a priority in 2014/15.

Voluntary and third sectorstakeholder proposals for contributing towards the resilience plan have or are currently being considered, and this builds upon the now well established partnership working in place between the CCGs and this sector, facilitated by Healthwatch and embedded within the Urgent Care Working Group.

Links to theBetter Care Fundare clear throughout the resilience plan with a number of schemes being programmed managed through the BCF contributing towards avoiding admissions, and now considered to be integral to integrated working and service development. The refreshed BCF plans due for submission in September 2014 will be closely linked to the resilience plan and SRG.

4.0 SYSTEMS RESILIENCE GROUP

4.1 Establishment and Governance

The existing Collaborative Improvement Board (CIB) will take on the SRG function. The Urgent Care Working Group (UCWG) will form one of the working groups supporting the SRG [the unplanned care working group], alongside a newly established planned care working group.Organisational leads from each local stakeholder organisation will be represented on these working groups in order ensure all resilience plans are aligned with local organisational plans and improvement initiatives.

4.2 Terms of Reference & Process Map

The terms of reference for the SRG and the process map summarising the partnership working and alignment of partners and plans are attached as Annex 1

4.3 Partnership working

All members of the SRG represent all parts of the local health community and have agreed to the TORs for the SRG and its constituent working groups. They all attend each group in order to align themselves to one framework and one resilience plan, supporting eachother and each element of the system.

The SRG has now reviewed all Surge & Escalation Plansand confirmed alignment and fitness for purpose for use from September 2014. Scorecards are currently being developed to support utilisation of the plans by all stakeholder organisations.

The unplanned care and planned care working groups of the SRG have worked to finalise the schemes and Action Plans which they believe will have an impact on improving resilience across the whole system. These are captured in the finalised Operational Resilience Planning template which is submitted to NHSE on 18th September 2014.

4.4Programme Management

Responsibility for operational delivery of each scheme contributing to the resilience plan is currently beingagreed and the processes for monitoring and reporting delivery to the working groups and in turn the SRG will be clarified.

The existing programme management system Covalent is available via VoY CCG as required to support SRG programme management, reporting and monitoring of SRG Plans.

A SRG Scorecard/Dashboardfor both planned care and unplanned care will be developed which effectively captures all the metrics required for monitoring and reporting of KPIs, benefits and outcomes across the system for delivery of the resilience plan, including escalation plans for winter 2014/15. For unplanned care there is a clear aim will be to have a predictive modelling which clearly identifies pressures on the system and gives early warning. Additionally this should havefunctionality to model and apply specific changes to the Urgent Care System to understand and map the outcomes. This modelling will therefore add a proactive element and the capability to estimate the risk to service provision.

Any SRG scorecards will align to NHSE tracking tools and assurance requirements. The tracker tool has yet to be released for implementation.

4.5 Monitoring and Communication

There are named executive leads for each member organisation of the SRG and working groups, including Chairs for all groups. These leads can escalate issues within their own organisations and share information and intelligence across the member organisations. Similarly communication across the various programme delivery groups who may be co-ordinating delivery of plans (e.g. Better Care Fund Joint Delivery Group) will also be aligned with the SRG.

5.0 LESSONS LEARNED FROM WINTER PLANNING 2013/14

The UCWG undertook a full review of the impact of 13/14 winter pressures schemes. The outcomes and performance review was undertaken in March 2014 and several schemes appeared to have clear benefits to improved flow and helped to achieve the 4-Hour Target. Most of these schemes have been identified to have a positive impact and, as such, have been incorporated into the 2014/15 resilience plan. The projects are summarised below:

Single Point of Access (Effective Referral Management)–This SPA has been developed with YAS NHS111 and is intended to be funded for at least 6 months during which and evaluation process will look at the impact. The SPA linked Community Services and is a single point of access for health and social care professionals.
Emergency Care Practitioners: An additional three ECP’s were employed to augment the regular ambulance crews. These roles have helped to reduce conveyance rates to A&E and have improved the quality of care for some patients in the urgent care scenario.
End of Life Care and Hospice@Home: This programme provided additional weekend and evening support to individuals on an EOLC Pathway. It helped to provide a better optionthan admission to hospital and increased the opportunity of patients to die in their Place of Choice.
Rapid Access and Treatment Service –The joint hospital and social care team increased their hours of support until 8pm. The impact has been to allow for quicker therapy assessments and packages of care to prevent unnecessary admissions to health and/or social care beds.
Frailty Unit and Social Worker Support: A social worker worked along sided the frailty unit with links to the RATS scheme to facilitate a safer discharge component of the patients’ admission cycle
Emergency Department Staffing– This scheme provided additional Registrars and senior Nurses to work in ED. It included a clinical educator role to provide specific training for staff to aid their work.
Elderly Care – Slow v Quick Pathway – Discharge nurses – Patients to have adequate social care on discharge.
Delayed Transfer of Care – This is an area of significant work that was principally reactive during the winter period and led to an RPIW event that identified several areas of enquiry. The delays in the system have identified the need for increased step-down beds locally.The integrated hospital/community team were provided with additional funding to support individuals outside of the hospital setting.
Additional Community Beds- Additional beds for step-up and step-down were purchased. These provided an additional 1000 bed days to help improve flow and discharge in the system. This project will go forward to support a similar scheme in 2014/15.
Homeless Support Worker – This was funding for a support worker and two beds in ARCLight for the three busiest evenings of the week within the Emergency Department. It received excellent staff and patient feedback and resulted in small numbers of avoided admissions.
Care Homes Support Project – It has used protocols for Nursing and Residential Homes to support vulnerable patients to prevent admission and also to facilitate earlier discharge. It is a scheme that was initially funded with winter pressures money and will be taken forward under the Better care Funding structure.
Equipment Provision – This scheme provided additional equipment to improve discharge flow. It included beds, mattresses and hoists.
Care Home Working Group – This membership group includes all providers and stakeholders in the Care Home Sector. It provided a link to the UCWG and the winter plans for the Care Homes in the locality.
Frequent attenders – YAS identified high users of the emergency services and worked with them to identify alternative options.
Age UK – Funds were allocated for additional discharge support for elderly patients into their homes in a timely way and additionally when other provided transport was not available. This scheme added value and facilitated discharges. It will be considered for longer term funding in the current year.

5.2 Modelling

There is a clear need for predictive modelling and scenario planning in order to be able to both plan proactively for year-long resilience, and identify the mitigation plans required to minimise impact in the system. Any modelling and trend analysis undertaken in 2014/15 would inform future years’ resilience planning and risk mitigation. This has therefore been identified as a key development from September 2014. The identification of current baselines will be critical in order to understand the impact of proposed schemes in the resilience plan, and allow the SRG to monitor the use and impact of non-recurrent resilience funding on a monthly basis. Likewise sharing of live data with providers that supports planning and dashboard development will need agreement through the SRG and its working groups.

6.0 ANALYSIS OF CURRENT RESILIENCE AND DEMAND & CAPACITY

York Teaching Hospitals Foundation Trust has recently been subject to two ECIST reviews to report on the current urgent care and Referral to treatment (RTT) pathways and position. These have provided a detailed analysis and set of recommendations for improvements which are now being addressed through the SRGs and their working groups.

6.1 ECIST Urgent Care

The ECIST reports on all elements of the Urgent care System and made recommendations to improve the System performance whilst maintaining safety and quality. It recognised that the Hospital had embarked on an Improvement Plan. The main recommendations provide the basis of service improvement. The YTHFT Team have accepted the report and are planning to work with the UCWG to establish a plan of agreed actions. Several of the adjustments to the system are already addressed in the UGWG plans following the winter schemes. Annex 2 outlines the summary Action Plan in response to ECIST recommendations.

In order to improve the discharge processes, YTHFT will have to left-shift discharge to an earlier point in the day. The workforce capacity is confronted in ED, particularly with a reduced complement of senior decision. This problem is compounded by a national challenge to Emergency Department recruitment. Mental Health provision is inadequate and erodes 4-hour performance and patient experience. Community nursing and the integration of social care is variable across the local system and it is compounded by having different Local Authorities andhistorical service provision that needs to be aligned to the current service provision. It is recommended that this is reviewed and addressed. Complex discharge services are not helped by variable community hospital referral criteria and operation. ECIST have offered to provide a review of this area as it appears to offer opportunities for improvements. The report advises attention to a frail elderly pathway as an integrated service. ECIST recommended a‘Discharge to Assess’ model which supports earlier discharge with the aim of reducing rapid decompensation of patients whilst in-patients.

The report discusses a specific area for improvements in the application of best practice when treating children in ED. The treatment of the under-fives is an area of attention in the current plans. Ambulatory care was highlighted and it was recognised in the report that the Trust are in the process of dealing with this.

Discharge planning has a prominence in the report with recognition that the Length of Stay profiles are not ideal. The activities promoted in the report are use of discharge toolkits, such as the ‘SAFER’ bundle, daily senior review and the use of take home medications to be provided by midday and that this is used as a KPI. Discharges are adversely affected re-ablement waits and a higher volume of contact episodes in the district nursing team versus the current block contract. Work on a single point of contact is underway

Finally, ECIST recommends that the three CCGs a single standard output driven specification for the Urgent Care System, principally agreed through the UCWG structure. There has been progress on this, although the new SRG structure has provided for an Unplanned Care subgroup each for Scarborough General Hospital and York Trust.

6.2 ECIST IMASnon-elective careRTT

This report by the Intensive Support Team addressed the RTT management and performance processes, policies and the planning for recovery and capacity at York Teaching Hospital Foundation Trust. It also reviewed some of the cancer pathways. The report highlighted a consistent delivery of all three RTT standards over the preceding 12 months. The backlog remains a problem for the Trust and focus has been on the 36 week cohort. The sustainability of the backlog has not been achieved and some of the outpatient waits have affected the pathway management. The report advocated high level oversight and consistency at speciality level and the need to resolve contractual issues. The vision is to achieve sustainability of waiting list sizes with contingency built in. The IST were impressed with the hospital CPD system and considered whether Board reports should include RTT indicators. This issue could be addressed by the proposed Planned Care Dashboard which, via the SRG, could use a cross-economy influence to improve the flow. Annex 3 includes the IMAS Recovery Plan for reference.