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11 November 2013
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Claire Griffiths
Deputy Clerk
Chamber and Committee Service
National Assembly for Wales
Dear Claire
Re: Inquiry into Unscheduled care
I am writing further to your invitation for me to attend the PAC on Tuesday 19th November 2013. I am responding in recognition of both my roles – the first as one of the two lead Chief Executives allocated to unscheduled care and also as Chief Executive of Aneurin Bevan Health Board. I hope it will help the Committee if I am able to respond in relation to my experience of both of these.
As far as the WAO report on unscheduled care is concerned, I received this as a fair assessment of demands, expectations and progress in an unscheduled care system that clearly remains under pressure, is not in a static position notably in respect of demand and is trying to ensure actions are taking place across the whole of the unscheduled care system and not just the hospital environment. The national report clearly has to aggregate up experiences, performance and commentary above any individual Health Board, so I am grateful that I have also had the opportunity locally to receive our local report and assessment from the WAO in Aneurin Bevan Health Board.
Delivering improvements and performance in unscheduled care remains the responsibility of individual Health Boards in providing services for their local population from primary care through to specialist hospital treatment, but as would be expected this involves working closely with the Welsh Ambulance Service NHS Trust specifically and local partners and stakeholders.
Claire Griffiths 11 November 2013
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I can advise that in developing our national work programme for unscheduled care during 2013 that we have been able to anticipate most areas highlighted by the WAO within the national work programme for Unscheduled Care which represents key actions facilitated by Chief Executives in support of improvements in emergency system performance. This means we acknowledge the areas for improvement and recommendations set out by the WAO and have set out ourselves to work on these areas to impact on performance and services. In particular we have sought to learn from the specific and exceptional pressures we experienced in the last Winter period and have set out enhanced Winter planning arrangements for the months ahead of us, under the supervision of Welsh Government colleagues.
We are working in a system of increasing demand, driven by demographic changes and average age of admission through A&E rising above 80. The system and demands placed upon it are not static, and the WAO assessment does acknowledge this in setting the context for the report. At appendix 1 I have attached as an example the increase in A&E activity locally in Aneurin Bevan Health Board over the last few years and a trend in ambulance attendances – in particular there has been an increased presentation of patients needing to be seen through our majors flow. This means we are having to adapt very quickly an A&E model that traditionally has focussed on accidents, injuries and traumatic injury (e.g. road traffic accidents) into one having to respond to vulnerable people (mainly older people) and attendances from societal issues such as alcohol. We still need to ensure A&E can deal with the former, but there have to be alternative services and different ways of managing demand for the latter. This requires a different attitude and approach to the way we commission and develop services locally and we are having to review our service provision quite fundamentally from avoidable hospital admissions, better pathways focused on primary care services, different staffing models that respond to recruitment difficulties, alternative emergency care services and better public education of options.
The NHS of course has the major role and responsibility for organising the unscheduled care system – but it is a system that cuts across other areas of provision (e.g. primary care) and other public services (e.g. social services). The WAO report is correct that for us to keep ahead of the increases of demand that are currently impacting on the performance of the system, we need all parts of this system to manage patients in the appropriate environment, with the action of last resort being A&E. As an example, we have developed a primary care approach called “A is for Access” within Aneurin Bevan Health Board which jointly with the Community Health Council and Local Medical Committee, assesses and targets primary care waiting times and have seen progress and improvement on this in a short period of time. We are also fortunate to have good local relations with local government with may examples of joint teams and initiatives in place and have benefitted from a very strong and shared approach to our Winter plans for 2013-14.
Claire Griffiths 11 November 2013
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We will need to ensure that such joint actions across GPs, social services and hospital and community services are driven forward. We need all to be working effectively and together, not just the hospital system.
Targets aside, we need to focus on the patient experience throughout. I think the WAO report validly shows this as an area for improvement and Health Boards in Wales openly report pressures, progress and performance in respect of the current system targets from 4 hour waits to ambulance turnaround. This includes working with the public and patients on the choices they have for alternative and other more appropriate services, particularly where the system even when under the greatest pressure is consistently offering access and turnaround for the majority within the 4 hour target. There is more that we can do nationally and locally on both understanding patient experience and public education and why choices to attend are being made. Reporting more broadly on issues affecting is a normal part of my own Health Board’s public reporting and our reports do try to set out performance, balanced with patient surveys on their experience and measures of staff views. Using all three together allows us to understand better the most effective actions to deliver consistent services. As an example I have attached at Appendix 2 a simple assessment on patient experience we have been using in Aneurin Bevan Health Board that gives a different perspective from performance. We will continue to use these and further experiences we receive from surveys our CHC undertakes, in particular to try to understand patient choices for attendance.
There are significant workforce pressures in A&E Departments and out of hours services. Some of these are driven by shortages and changes occurring around doctors in training and a view of the need to provide better supervision and more specialist training. These issues have been well rehearsed and promoted by doctors themselves in service discussions around Wales, including in great detail and with open information available through the South Wales programme. There are some sites struggling to attract staff at all levels, raising service concerns about sustaining local services safely at all sites. Such safety issues have to be highlighted and cannot be left without action to simply fail. At the same time, there are positive opportunities for unscheduled care workforce in developing advanced nurse practitioner roles as highly experienced roles that discharge traditional doctor roles and can be recruited to more easily. There is a general concern however that some staff - doctors and nursing staff – are starting to choose different NHS careers away from A&E, not least due to the specific workload, patients’ expectations and high pace environment that is being experienced across the whole of the UK. Creating sustainable and safe unscheduled care services will require decisions to be made on specialist centres, that will in future be able to attract and retain senior and experienced clinical staff. Given vacancies across the UK, and similar pressures on services, they have many choices about where to work.
We are liaising with our colleagues in England, Scotland and Northern Ireland and we know that the pressures and challenges are no different for them. This was particularly true of demand and experience over this last Winter.
Claire Griffiths 11 November 2013
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We will be using these links as a matter of routine for further improvement and best practice through the national work programme and the National Collaborative we have established to help us focus on patient flow draws on experienced and advice inside and outside Wales.
I cannot overstate how much time, attention and resources we deploy to such a serious area, in order to provide safe and responsive services for unscheduled care. Despite detailed work on planning, when the system pressures are not static, there can be a significant impact from significant peaks in demand which require us to make local decisions for accommodating patients and bringing our contingency plans into action. As an example, some of the patterns of admission and attendance have changed over these recent years, with increasingly more activity shifting to evenings and overnight against a trend of activity more traditionally in more normal hours. This has been seen in Welsh Ambulance Service activity as well as in the hospital setting.
At the same time, traditional solutions on this not least more beds, does not provide us with a sustainable response. We have shown locally in Aneurin Bevan Health Board and across Wales that by commissioning more beds, without underpinning these with other system changes, the beds simply fill up. By getting our unscheduled care services in balance for the demand placed upon it and the capacity needed, whether in hospital or across pathways in other settings, gives us all the flexibility to get our elective services delivering, our primary care system to manage its own increasing demands and to push forward better community-based integrated services. Whilst we are in the middle of these pressures, staff are often focusing on the immediate operational issues rather than having the time to change the system. Our role on the national programme is to create to flexibility for organisations and staff to pause and focus on options to create a different way of working and delivering unscheduled care activities. Our staff remain the key to resolving this with their own views on actions that will work and make a difference.
For completeness, I have attached a summary of progress and alignment of the national work programme with the WAO report (attached at Appendix 2) which I have used within the Unscheduled Care Programme. This will complement the accountability of individual Health Boards and WAST to deliver local plans and improvements. The national work programme will remain an active and dynamic work programme and I am keen to ensure that we take advantage of all analysis, assessments and experiences that continue to focus on improving care for patients within our unscheduled care services.
I am very happy to respond to these and other areas highlighted by the WAO report during the Committee inquiry.
Claire Griffiths 11 November 2013
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Given the opportunity to respond to the WAO themes, I will be accompanied by Judith Paget, Chief Operating Officer and Deputy Chief Executive, Aneurin Bevan Health Board, to support the session.
Yours sincerely
Dr Andrew Goodall
Prif Weithredwr/ Chief Executive
Enc
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Appendix 1- Year on Year – RGH & NHH A&E Attendances
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Source: Symphony To October the ED attendances are 4789 down on the same period last year, a 4.6% reduction.
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Appendix 1a - ABHB Ambulance Conveyance Volume Projection 2013
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Source: Symphony The ED Ambulance attendances to October are 176 up on the same period last year, a 0.6% increase.
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Appendix 2-ED patient satisfaction scores September/October 2013 |
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Source: ED Department Improved rating for staff attitude, cleanliness & food over previous period. |
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Appendix 3
Wales Audit Office Recommendations and national contribution of USCI Programme
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1. Address the current safety issues within the hospital emergency departments a. Medical and nurse directors to carry out joint urgent reviews to understand safety implications in EDs. Reviews to identify the extent of issues and produce specific action plans.
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The USC programme will support the development of analyses of real time data and target areas affecting patient flow, many of which are under detailed consideration within Local Health Boards. The measurement and Information workstream and the National Collaborative for Patient Flow will provide all Wales support.
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2. Drive delivery of USC vision a. Progress on USC plans to be reported to WG and New National Programme b. New USC programme to ensure that the 10 high impact steps to transform USC are addressed.
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The USC Steering Board will ensure that the overarching work programme addresses the 10 high impact steps and assesses improvement. Detailed programme plans are being worked up and will be based on the development of products. The programme schedule now includes a mechanism for mapping all products to the WAO recommendations as well as the 10 High Impact steps which informed the initial work programme that has informed actions and planning during 2013.
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3. Improve understanding of demand, performance, patient experience and outcomes a. LHBs and WAST to implement the new framework for patient experience to ensure that they ask about USC across the whole system and not just in ED b. USC indicators used by LHBs to include: patient experience and outcomes, primary care access, performance of OOHs, ambulance services and local NHSDW performance, 4 hr and 12 hour waiting time performance, instances of corridor nursing and overnight stays in ED, performance of community- based USC services and measures related to patient flow, including responsiveness of impatient specialist teams c. WG and LHBs to ensure the national Emergency Data Set is completed consistently to understand demand d. LHBs to improve clinical coding e. PHW to provide LHBs and WAST with support to strengthen local demand analysis
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The USC Steering Board recognises the central role of the National Service User Experience Group and its leadership in this area. Patient experience has been identified within the new programme as a cross-cutting theme and all workstreams will be expected to demonstrate how plans and products have built in the patient experience from the outset. This will be tested through separate programme assurance activities and reported to the new Steering Board on a regular basis. In addition, the Measurement and Information Worksteam will work with Welsh Government to agree a revised data set. Work commissioned from Public Health Wales will support local and national analysis. |
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4. Communicate with the public and improve understanding of the need for change a. WG to decide on revisions to Choose Well b. WG to decide strategic direction for NHSDW and the model for 111. 111 to have timeline to implementation in 2015, supporting electronic systems to gather information on casemix and volume, and a communication campaign c. WG to develop national definitions of USC services and facilities, to improve public understanding
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The USC programme includes an Out of Hours Workstream that will work with Welsh Government on the 111 service and promotion of Choose Well as appropriate.
A targeted communications strategy will developed over time.
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5. Addressing critical skills with unscheduled care skills and workforce a. WG to share good practice in the use of Emergency Care Practitioners (ECP) b. LHBs to monitor use of ECPs and include in workforce plans c. WAST to deliver transformation in the skill base of its staff d. Consider and address the root causes of recruitment and retention problems in ED and primary care OOHs services e. LHBs to consider revising staffing models for USC to include paramedics and nurses with extended decision making skills. f. LHBs to consider whether physicians and GPs can be used in EDs to ease recruitment problems g. LHBs to reassess skill base of staff in EDs to ensure competence in addressing the needs of older people
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The USC Programme will link into unscheduled care skills and workforce issues through the Review of the Ambulance Service Programme Plan. The Workforce agenda will be prioritised by NHS Workforce and OD Directors, noting most of this work is being undertaken locally or through collaboration across Health Boards, and the NHS Workforce Education and Development Service, with progress reported to the USC Steering Board. Learning around new models of care and alternative settings will be facilitated by the national programme.
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6. Optimise the capacity for USC that exists within general practice a. LHBs should work with GPs to agree and monitor local standards for access to urgent primary care b. LHBs to encourage general practices to implement access arrangements that reflect good practice c. LHBs to strengthen the support, guidance and information given to GPs to avoid emergency admissions d. LHBs to request that GPs provide them with data on their capacity and demand for seeing patients within the practice.
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The USC Programme is supporting this through the Measurement and Information Workstream which will be developing a range of common metrics. A dedicated Out of Hours Workstream will also be looking to support the service in this area. A clinical reference group is part of the programme structure and has a role to engage GPs in taking this agenda forward.
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7. Unblock issues with flow in the acute hospital and improve integrated working between health and social care a. LHBs to generate more shared ownership of the pressures and patient flow issues by improving links between staff in EDs, Clinical Decision Units and inpatient ward teams b. WG to lead a specific programme of work to support better integration of health and social care to ensure timely discharge of patients.
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The USC Programme has established a National Collaborative for patient flow which is supporting individual LHBs by providing external support, expertise and training as required. The Integrated Care Workstream is examining aspects of integration between Health and Social Care which require support.
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In conclusion, the national USC Programme is working alongside the activities to reconfigure hospital services and other groups which are operating at the national level. It continues to have a role to lead and support actions and interventions which will improve delivery locally and will complement the LHBs and WAST individual responsibilities to improve their unscheduled care system performance.