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Herts and West Essex STP

Urgent and Emergency Care Strategy v0.2

APPENDIX A

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Document Control

Document Information

Document Name Urgent and Emergency Care StategyAuthor(s) Charles Allan & Keith BringloeDocument Owner STP PMOFile name Herts west Essex STP UEC StrategyFile path S:\STP PMO\workstreams\U&E\Strategy

Document History

Version Status Changes Date0.1 Draft First draft 23/07/180.2 Draft Second Draft – input from ENHCCG 28/09/18

Document Approvals

Role Name Signature DateUEC SRO Beverley FlowersUEC Director Lead Sharn EltonUEC Clinical Lead Andrew MorrisSTP Director Lead Charles Allan

Background:

This document sets out the draft short and medium term strategy for Urgent and

Emergency Care (UEC) in Herts & west Essex (HWE) STP. The strategy reflects the

latest national UEC deliverables and system wide outcome measures published by

NHS England (NHSE) in June 2018. It also seeks to reflect the development of a

population Health Model (PHM) and the future establishment of an Integrated Care

System (ICS) for Herts & west Essex as well as the Integrated Care Alliance (ICA)

model for the STP.

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The document sets out both the immediate strategy for achieving the required

national performance standards within the mandated timeframes as well as the

medium term transformational vision for Urgent Care across Herts & west Essex. It

reflects the current work of STP Work Streams and takes account of the need to

reduce variation and inequality and to improve outcomes and service quality across

the system.

Strategic Goals:

The STP, through the governance of a single A&E Delivery Board, will review UEC

capacity across the HWE footprint in order to design a system that is fit to meet

future demand and complexity within our population. This will ensure:

People receive the Right Care, at the Right Time, in the Right Place.

People with urgent but non-life threatening physical, mental health or social

needs will receive responsive, effective and personalised services outside of

hospital, delivered in or as close to their homes as possible.

People with more serious or life threatening emergency physical or mental health

needs will be treated in centres with the very best expertise, delivering safe, high

quality services in order to optimise patient outcomes and enable as many people

as possible to safely return to their own homes.

Context:

The strategy for achieving these goals is for HWE STP to develop a single strategic

plan across the STP, to include a single winter plan and escalation process, and to

deliver an integrated urgent care system that treats people at the right place, in the

right setting, at the right time and at the right quality.

This means ensuring that A&E is not the first port of call but is used for the sickest

patients requiring emergency care only whilst offering simple accessible alternatives

that can respond to patients with an urgent care need in a timely manner.

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A successful UEC strategy would mean that people receive integrated urgent care

services that meet national mandated standards as set out in the NHSE Urgent and

Emergency Care Delivery Plan 2018. This includes the requirement for patients

attending Emergency Departments being seen, treated and admitted or discharged

in under 4 hours and achieving the targets set out in the national Ambulance

Response Programme.

It will also mean a reduction in avoidable A&E attendances, empowering our

population to choose well and access alternative urgent care services where

appropriate as well as a reduction in avoidable admissions to hospital with patients

being supported at, or close to home wherever possible.

Patients with a length of stay in an acute hospital of 7 days (stranded) and 21 days

(super-stranded) will also reduce as we support patients to return home in a timely

manner following a hospital admission.

Successful implementation of the strategy will improve patient outcomes and patient

experience from greater integrated working and information sharing between

organisations.

Implementation:

Following discussions at the NHSE annual assurance meeting a single STP wide

A&E delivery board has been established to strengthen strategic leadership and

governance arrangements to support improvements in local delivery.

The national models of care review of urgent care Vanguards concluded that A&E

local delivery boards often look at process and not outcome measures and had

benefited from coming together to identify differences in outcomes at population level

through benchmarking and triangulating information. The outcome measures

identified fall into three domains; clinical pathway, patient and staff experiences.

The single delivery board will focus on monitoring and securing consistency of care

across the STP footprint by:

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Developing one STP urgent care strategy which will include one winter plan

that reflects the recent national guidance around stranded and super stranded

patients i.e. ‘Reducing Long stays in hospital’.

Developing a consistent approach to the delivery of the system wide outcome

measures for urgent and emergency care.

Committing to and delivering the mandated NHSE Urgent and Emergency

Care Delivery plan 2018/19. This is a key requirement and will be the

minimum baseline for delivery.

Measuring progress against the desirable attributes of a well-functioning

urgent and emergency care system (see appendix 1).

Assessing effectiveness and quality improvement over time.

Spreading learning and best practice through the principle of doing things

once across the STP.

This single leadership group will work collectively to prioritise joint issues including

access to urgent care and community pathways. The board would be supported by

the maintenance of the Strategic Resilience Group structure at CCG level that would

retain responsibility for local implementation as outlined in the structure chart below,

working with key STP work streams including frailty and Out of Hospital Care.

The STP has delegated authority to Beverley Flowers, Accountable Officer, East and

North Hertfordshire Clinical Commissioning Group as the Senior Responsible Officer

and Sharn Elton as the responsible director to lead the urgent care system across

the STP.

Herts and west Essex A&E Delivery Board

East & North Herts SRG Herts Valleys SRG West Essex SRG

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The STP A&E delivery board will be attended by representatives from each

constituent organisation across the STP, who will, be nominated to act on behalf of

their respective Chief Executive/ Accountable Officer and have delegated authority

and autonomy to act on behalf of their organisation.

Representatives will be expected to attend the STP A&E delivery board which will be

held monthly. Terms of reference will be drafted outlining the expectations of the

membership including clarity on the level of engagement required in order to deliver

the urgent and emergency care agenda across the STP.

Outcomes:

In the immediate term HWE STP will need to ensure delivery of nationally mandated

UEC standards in order to develop the integrated approach required for the future.

The attributes of a successful UEC System are:

Consistent, high quality outcomes for patients, including low mortality rates.

Care delivered in the most appropriate, and cost effective setting in the first

instance, avoiding unnecessary hospital attendance or admission.

Good system flow, to facilitate timely admission and discharge when required.

Good support for self – care and advanced care planning.

Positive experience for patients, relatives and carers contacting the system.

Staff who feel supported and are able to deliver the very best care.

These attributes will need to be rigorously applied to ensure that HWE meets the

significant demographic challenges that face it over the next five years.

Increasing demand

• Our whole population will grow by 150,000 by 2024

• Over 65s will increase by 12% by 2025• People with multiple long term conditions, severe

mental illness and dementia represent 11% of our population but 33% of our spending

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The UEC strategy will also need to dovetail with other work streams to deliver the

transformation from the left pyramid to the right hand pyramid below; ensuring

capacity and capability are shifted to support the transformation.

The following pyramid outlines the key focus for the HWE UEC strategy:

A&E, Non Elective Admission

GP, Ambulance Service, 111, OOH, Crisis Intervention, UTC, Rapid Response

GP, Ambulance Service, 111, OOH

Services for patients include:

Community Pharmacy, Health walks, smoking cessation, social prescribing, early mental health support

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Future UEC Models:

The diagrams below illustrate a potential future model for an Urgent and Emergency

Care system for Herts and west Essex and a potential model for Acute Hospital Care

in the future.

The new STP A&E Delivery Board will develop a range of models that will take into

account the agreed population health model and detailed modelling undertaken by

recent reviews e.g. Carnall Farrar and Newton Europe. These models will be

supported by agreed clinical pathways and the models will be tested with

patient/service user, carer and staff stakeholders.

POTENTIAL FUTURE URGENT AND EMERGENCY SYSTEM MODEL

Patient

Voluntary Sector

Prevention / Self Care

111 Single point of Access

EEAST

Hear, see and treat

Convey

Federation Hubs: MDT Support

supporting same day access and

clinical advice 24/7

Primary Care

Community Based Services including: Pharmacy Dental Services District Nursing MH Crisis Response ICT Ambulatory Care Units

e.g. paeds, frail elderly Physical & MH complex

and routine care MDTs Disease specific

services e.g. COPD, LD, Complex children

Care Home Support

111 Single Point of Access and Single Point of Discharge will come from one combined resource in the future

A&E Streaming (for 1st contact

patients)

Primary Care Linked to Federation Hubs

A&E DepartmentMajorsMinorsResusPaeds

Assessment Units

Ambulatory Care

Specialty Wards

Repatriation from other hospitals

Home

Transfer to other

hospitals

Home (No support

required)

Discharge to Assess at Home (Supported by

CRT, ICT & HICT)

Medical Rehab –Community

Hospital

Bedded Discharge to

Assess:Step down beds

to facilitate assessment in a

non-acute environment includes CHC assessment

Community MDT: NCC,

Acute/Community and Voluntary Sector

Home +/-Discharge to

Assess

Care Home Nursing & Residential

Sing

le P

oint

of A

cces

s and

Disc

harg

e

POTENTIAL FUTURE ACUTE HOSPITAL CARE MODELPrimary Care

Primary care and Out of hours services potentially co-located with A&E

PC team supporting A&E avoidance Direct access to ACC/ Assessment units Access to GP practice appointment scheduling

Specialty Wards

Daily consultant review of all patients 100% SAFER bundle in use and delivering full benefits Assertive management of over 75 patients including a frailty model

incorporating GP in-reach Multi -skilled staff with clear roles and responsibilities Patients in the best place to meet their needs e.g. no outlilers or

delayed transfers of care. Ring fenced beds for elective patients Seven day working the norm Full use of electronic capabilities to records and share information

and request diagnoses and appointments

A&E Department

24/7 consultant cover MDT Frailty Hub col-located MDT admission avoidance MH hospital liaison / crisis response respond

within 2 hours (including CAMHS), bedded within 4 hours or discharged with community support

Early specialty assessment Innovative roles./ multi-skilled fit for purpose Senior led rapid assessment (15 mins) Rapid access to diagnostics Rapid ambulance handover

Emergency Medical and Surgical Ambulatory Care Units

Direct GP and EEAST access Open 14 hours 7/7 Defined Pathways

A&E Front Door Patient Streaming

Streaming by a senior decision maker

GP redirection

Medical and Surgical/Specialist Assessment Units

Co-located assessment area (hub/floor) and patients moved in 30 mins from A&E

Direct GP and EEAST access to all units Dedicated consultant led teams supported by sub

specialties Rapid senior review Rapid access to diagnostics 24/7 access to all admission areas 24 hr max stay in assessment units

Key Discharge Activities and Standards

Discharge planning and action prioritised to optimise flow e.g. discharge plan, including EDD, within 24 hours of admission, discharge by 10am the norm.

Normal place of residence as default discharge destination

All patients whose acute care is complete to leave hospital the next day with appropriate support

Assess long term care needs at home GP led re-ab;ement beds in the community Trusted assessment to support timely discharge

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Winter Planning 2018/19:

The Winter Plan for HWE STP is in the final stages of development and will support

the wider strategy. The plan will support the delivery of the NHSE operating

guidance to deliver 90% performance against the four-hour operational target over

winter with trusts expected to achieve 95% performance in March 2019. Our plan will

also commit to ensuring that the number of patients on an incomplete elective

pathway will be no higher in March 2019 than in March 2018.

In addition to the mandated actions outlined in the UEC Delivery Plan, the following

system actions are being taken to ensure resilience over winter 2018/19:

STP Wide Surge, Escalation and Capacity Plan including early warning systems

are in place across the system through established daily and weekly system

teleconferences and agreed escalation protocols to monitor illness patterns in the

local community and weather changes that may affect specific patient cohorts.

Reducing bed occupancy and the number of long-stay patients in hospital to

support patient flow eliminate unsafe corridor care and increase the number of

patients receiving the appropriate level of care in their own homes.

Triaging patients into other pathways including primary care streaming for minor

illnesses and injuries and managing up to 50% of acute medical referrals via non-

admitted care pathways.

Reducing ambulance handover delays to ensure that no handover to an acute

hospital exceed 30 minutes.

Ensuring 100% staff flu vaccination uptake across all providers, including social

workers, staff in care homes, nursing homes and hospices.

Increasing access to Primary care through the provision of extended access

services in the evenings and weekends.

An STP wide communications plan to ensure good public awareness of what

services are available over the peak periods, particularly at the weekend and

during holidays.

Ensuring mental health services support demand on emergency departments

(ED) by increasing capacity in community mental health crisis services, as well as

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alternatives that can provide a more suitable service. This includes 24/7 liaison

psychiatry and ensuring sufficient capacity in core community and acute mental

health services.

In addition to the above actions individual providers will also be agreeing internal

operational actions to maximise resource and provide resilience across the entire

STP throughout the winter period. These actions will be discussed regularly in the

local CCG SRG’s and monitored through the single A&E Delivery Board.

Strategy Review:

The HWE STP UEC Strategy will be reviewed by the HWE A&E Delivery Board

annually as part of a regular review process so that any changes locally or from

national policy can be incorporated into a revised strategy document.

Communications Plan:

A designated communications plan will accompany the strategy to ensure wide

engagement with Urgent and Emergency Care, across the system, including

clinicians, staff, patients/service users and their carers.

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APPENDIX 1

Guide to reducing long hospital stays

Appendix 1 - Guide_to_reducing_long_hospital_stays_FINAL_v2.pdf

APPENDIX 2

UEC Assurance Deliverables

Appendix 2 - UEC Assurance deliverables.pptx