Urgent care report

Report for Governing Body- September 2016

NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to

live healthier, longer and more independent lives.

NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS

Tel: 0161 426 9900 Fax: 0161 426 5999 Text Relay: 18001 + 0161 426 9900 Website: www.stockportccg.org

Contents ........................................................................................................................................ 1

Introduction ................................................................................................................ 3

Current position ......................................................................................................... 3

Figure 1 Current Urgent Care position illustration ........................................................ 3

Demand ...................................................................................................................... 5

Staffing ....................................................................................................................... 5

Figure 3 Numbers needed / numbers in post / gaps – nursing and medical..... Error! Bookmark not defined. Flow ........................................................................................................................... 6

Urgent Care plans ...................................................................................................... 7

Conclusion ................................................................................................................. 8

Actions for governing body ....................................................................................... 8

Root Cause Analysis (updated March 2016) ................................................................. 9

Urgent care plans 2016/17 ........................................................................................... 10

Winter schemes ............................................................................................................ 13

Current Urgent Care position illustration .................................................................... 14

SRG High Impact Interventions................................................................................... 15

DTOC chart .................................................................................................................. 16

Letter RE: Urgent Care ................................................................................................ 17

Email regarding the Urgent Care Delivery Group ....................................................... 20

System slide ................................................................................................................. 22

Operational Standards Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%Actual 89.11% 97.00% 94.32% 94.79% 92.54% 91.50% 90.07% 77.97% 73.73% 73.50% 72.77% 72.60%

Apr-16 May-16 Jun-16 Jul-16Target 95% 95% 95% 95%

Actual 79.30% 81.60% 85.20% 81.50%

Percentage of A & E attendances where the

Service User was admitted, transferred or

discharged within 4 hours of their arrival at an

A&E department

Introduction This report describes the current System Resilience Group (SRG) view of the Stockport Urgent Care position and details the Winter 2016/17 plan. This report has been written at the request of NHS Stockport CCG Governing Body. The report will be presented jointly by SFT Chief Operating Officer and the Chair of the SRG/Urgent Care Delivery Group.

This paper is written taking into account previous findings from external reviews of the Stockport Urgent Care system, undertaken by the UM review team. The Stockport Root Cause Analysis (RCA) (appendix 1) provides the basis for the previous 90 day plan and for the current urgent care plan (appendix 3), reviewed and signed off at SRG. The previously requested letter to Boards requested at the July 2015 Board to Board meeting of SFT and NHS Stockport CCG is also appended as a measure of the Urgent Care position 12 months ago. Under national direction, the SRG has now been discontinued and reformed as an Urgent Care Delivery Board, and this Board will monitor implementation of the current urgent care plans.

Current position It is well known that the current Stockport urgent care system has struggled to deliver 95% consistently for a long time (Figure 1) and we have seen an increasingly challenged system over the past 12 months.

Figure 1 Current Urgent Care position illustration

In 2016/17 NHS regulators have agreed individual provider trajectories based on improvement from the current performance level as opposed to the national standard of 95%. Delivery of these trajectories is directly linked to receipt of national funding from the Sustainability & Transformation Fund (STF). SFT were asked to produce a deliverable ED trajectory that was signed off by SRG and this is presented in Figure 2. This was discussed at length at an extraordinary August SRG meeting and agreed. SRG agreement was with reservation that the trajectory does not deliver the 95% target, though the SRG agreed that a 95% compliant trajectory for 16/17 would not be assessed as realistic. It is requested that the Governing Body note this trajectory.

FIGURE 2 Stockport Urgent Care Trajectory

Continued review and analysis of the Stockport position has provided a clear indication that at high level there are 3 key root causes to our current position. Addressing these in the short term will significantly mitigate risk across winter, these can be summarised as:

• Staffing - being addressed through rota and ED redesign work, revision of job plans and through work with the GM health and social care partnership to improve overseas recruitment opportunities in Stockport

• Ownership / leadership across the system - a complex issue which needs ongoing work across the system with strong clinical leadership and influence. Plans are in place to start to make changes in this area through a clinical engagement event on 28th September 2016 with relevant leaders across Stockport where the burden and solutions will be discussed.

• Delayed transfers of care (DTOC) - It has been recognised within the urgent care plan that DTOC is a significant issue in Stockport. Whilst these are positive developments as part of the system transformation work, a robust implementation plan for this has not yet been within the view of the SRG and we are seeking clarity around the level of DTOC reduction that is required to manage the urgent care system across the Winter. DTOC is discussed further below.

These high level issues have been discussed as a system in recent meetings with GM and NHSI.

The SRG+ team recognises the requirement of the system to have strong clinical and corporate leadership and the UCDB has been set up with this in mind (appendix 5). This group will have executive representation at all meetings and this will ensure that the urgent care challenge is fully understood across the whole Stockport Urgent Care system, enabling change and improvement to be led from the highest level.

The Urgent Care Challenge

The following offers a summary of rationale for the current performance which is below both the local trajectory and the national standard. This is followed by a summary of the plans illustrated in appendix 3.

Demand Historically demand has been fairly constant, although this year has seen a 4.4% cumulative increase in ED attendances, as of the end of August. An analysis of the factors driving this change show that 2% (6 attendances per day) is a consistent increase driven by the extension of NHS111 in November 2015.

In addition there have been two separate unconnected instances of special cause variation in May (sprains and injuries) and July (weekend activity levels), and together these factors account for the remaining 2% activity increase. Neither has been sustained or repeated. The ED estate and capacity is not designed or sufficient to cope with short term increases in activity as experienced above and these demand surges therefore cause significant challenge.

There have been no changes to primary and pre-hospital care to account for any increase in demand, with continued funding for schemes in primary care to support nursing and residential home visiting, extended access to GP appointments and enhanced access for patients with predictable ill health (Long term conditions) and children. There is also continued investment in the IV therapy service at home. Alternative pathways to admission are also well-used in Stockport, with benchmarking suggesting that Pathfinder is used more widely than elsewhere in GM. The CCG GB received an evaluation report during 15/16 that confirmed these schemes were having a positive impact on admission levels.

There does however remain limited communication between primary and secondary care about patients who may be well known outside of the hospital and who, with the right planning, could be discharged rather than admitted. This should be improved through better use of shared records and through development and expansion of the neighbourhood model of care, which is work that is in train through Stockport Together.

Staffing

Within the Emergency Department at SFT, there have been continued challenges with staffing of both nursing and medical rotas and this has resulted in a predictable challenge in particular in overnight performance of the department. This is well-known and the Trust has plans aimed at addressing some of these issues. GM support with overseas recruitment and potential shared roles across Manchester will strengthen these plans.

Streaming

Significant opportunities have been identified with regards to the streaming of patients, as at present too many patients are unnecessarily streamed as majors when they could be treated and discharged through the ED minors’ or ambulatory pathways through the UCDB.

The Acute Interface workstream of Stockport Together is focused on development and implementation of a front door streaming model which will be introduced on the 17th October 2016 and will enable better flow of acutely ill major patients by streaming acute ambulatory patients away from the main emergency department and into a primary care run unit.

Flow There are also very significant challenges with regards to flow and delayed transfers of care (DTOC) (appendix 6). This position appears to be the product of a combination of factors:-

Challenge Summary Action

Patient Flow Once admitted, patients do not ‘flow’ smoothly through the hospital. Patients often wait in beds for investigations and specialty reviews which could happen upon discharge. This means that patients do not have the regular review needed to identify clinical improvement and plan discharge at an early stage. This means that DTOC patients are identified late in their pathway.

Ownership of SAFER by frontline staff and implementation of plans to address this.

Plans to implement the SAFER project which will enable more regular review and earlier-in-the-day discharges have started but are slow to embed.

Ownership of patients Lack of ownership of the patient across the health and social system with little challenge of those patients who are ‘stuck’

Integrated discharge team development through Intermediate Tier

Integration of discharge processes

Acute, community and hospital service discharge processes are not fully integrated which delays planning for discharge

Integrated discharge team work through intermediate tier

Model of discharge Limited capacity for discharge to assess models

Transfer to assess models in development through intermediate tier work

Packages of Care There are limited capacity for packages of care for those patients who can be cared for in their own home

Expansion of REACH through Winter investment

Residential and Nursing Capacity

There is limited access and capacity for those patients who need to be cared for in residential and nursing beds

Current ongoing discussions to support Stockport residential and nursing home capacity

Out of Area Patients Over a 1/3rd of patients are out of area placement patients

Ongoing discussions to improve processes to repatriate patients to their own localities through integrated discharge team and broader discussions)

There is opportunity to significantly improve shared health and social care ownership of the Stockport’s urgent care challenge through Stockport Together. The current position isolates the ED and acute medical teams as the focus for pressure and scrutiny, whereas ownership and action are required across the health and social care system.

Urgent Care plans There have been weekly meetings of the SRG+ group throughout the past year, with ongoing review of the system, building of relationships and work to acquire a system view of urgent care and agreed responses.

Work has focused on embedding those parts of the 90 day plan that have been identified as having the most impact and on implementation of this year’s plans which are consistent with the 8 high impact interventions of the SRG (appendix 5). There is an assumption as we move to the new UCDG high impact changes, that the previous 8 high impact changes are now embedded. Though work has progressed in most of these areas, further work is required to scope a falls service, implementation of which should contribute to at least 10% reduction in admissions. We will continue to track this through the UCDG.

As a newly formed Urgent Care Working Group we have been assigned 5 new high impacts:

1. Streaming at the front door to ambulatory and primary care within the department

2. NHS111 – increasing the clinical call handler capacity in advance of winter

3. Implement the ambulance response programme (‘see and treat’ and ‘hear and treat’)

4. Implement SAFER to improve and other measures to improve in-hospital flow

5. Implement best practice on hospital discharges to reduce delayed transfers of care (DTOC) including Discharge to Assess and Trusted Assessor

These impacts have been reviewed by the SRG and there is a clear view that implementation will address a number of the continued current challenges, and that our plans should be re-focused and extended appropriately.

As can be seen from our urgent care plans for 2016/17, our Acute Specialist programme is set to deliver changes with respect to impact 1. With regards impact 2 and 3, there is work developing locally and regionally to identify the needs of a clinical hub and to expand see/ hear and treat models that will address these areas.

As referred to above, there is an existing work stream within the hospital targeted at impact 4, but change and outputs to date have been limited.

A combination of work in the Intermediate Tier programme of Stockport Together in developing an integrated discharge team, and work through the current DTOC programme is expected to address impact 5.

The implementation of these pieces of work will be tracked by the Urgent Care Working Group and in Stockport Together where relevant and appropriate.

Conclusion This paper has summarised the current Urgent Care Position in Stockport and highlighted the current issues. It includes appendices which describe the actions and implementation plans which have been developed in response to these issues.

The position as we approach winter is one of continued challenge in achieving the 4 hour ED target. The main issues remain ownership of the urgent care challenges across the system, poor flow through the hospital and limited capacity within social care that would enable prompt discharge from hospital. The lack of an integrated falls service in Stockport also needs to be addressed. Early implementation of the Acute Specialist Interface and Intermediate Tier programmes should ease some pressures on the system as we enter the winter period, though a higher level of across system ownership and leadership is required to fully realise the opportunities of these plans.

Actions for governing body To Note:

• The urgent care trajectory submitted to NHSI in order to achieve the Sustainability Transformation Fund

• That there will be continued challenge in delivery of the ED 4 hour target over this winter period

• The work planned and under implementation to address these challenges

Appendix i

Root Cause Analysis (updated March 2016)

Copy of Copy of Copy of RCA_Respon

System wide RCA Analysis

Root Cause Evidence / Observations SFT Response System response 2016/17 Previous System Response

Ineffective streaming of minors Streaming model in place, run by ENPs…Planned changes at front door with streaming of ambulatory ill patients to primary care assessment in department 8am til midnight

Deflection scheme to OOH provider available.

Surges in minors leads to breaches in majors Minor stream perf = 98% (Apr-Oct 15) & 93% (Nov15 - Jan 16)Continued minor injuries stream but other minors seen in primary care 8am til midnight

Inconsistent use of the RATS model due to variation in staffing and at times of surge.

Expansion of triage capacity to enable triage within specified times

Data: Wait to Triage time is still outside of target (26mins)

MAU model in place MAU in placeData: % admission Movement of AMU to urgent care village foot print

Only “Bronze” Model of MAU in place. Recent pilot of acute medical consultant in ED successful - to be reimplemented in October 2016

CDU is not functioning as a “CDU” due to Medical outliers and demand for beds, resulting in elongated LOS. Acceptance criteria are being reviewed to ensure appropriate use with the introduction of Criteria-led Discharge protocols.Review of Clerking process and protocols in ED and continuity into AMU.

Crisis response model as part of Intermediate Tier Stockport Together Proactive Care model in development, will provide community alternatives and management, other than presenting to ED.

Links to neighbourhood teams and implementation of early discharge with upport Investment in Primary care to increase urgent care capacity /

options is in place and evaluation shows reduction in admissions from care homes and for LTC.

Pathfinder and NWAS clinical hub workNeighborhood model progressing as part of Stockport Together and there will be significant further investment in eg community nursing in 16/17.

Iv therapy service reprocured The IV service has potential for step down patients which is not utilised.

The GP / Paramedic service has high utilisation and this has increased further since the extension of NHS 111.

Mastercall service requires further promotion across the Health Economy.

Junior staff admit more and do more testsDiagnostic “Recipe Book” in place to standardise and minimise the volume and variety of diagnostic tests.

Recipe book implemented in ED

Lack of timely senior review As previous. Consultant in ED

Length of patient journey for admitted patients hasincreased

Escalation policy in place, however operational application needs review. Review of day to day co-ordination between ED/ AMU and Bed Management being undertaken.

Integrated discharge team plans

Matching capacity to demand

Triage Plus model is applied in times of surge to flex assessment capacity.

MAU Model provides initial telephone triage for GP referrals that5 would otherwise arrive without prior knowledge.

Lack of swift handover of clinical care from crews to ED staffNWAS "2 to 1" Policy to release crews from ED when there is a wait to be seen.

Length of stay too longDischarges happen too late in the day Integrated discharge team plansDischarges weighted to Fridays SAFER implementation

Discharge planning not started before admission.Clinical ownership changes and acceptance that these changes will improve the system

Lack of clear pathways to be consistently followedNo daily support from sub-specialty teams to short staywardsPatients wait too long for speciality reviewNo use of referral guidelines (left with the Trust in 2011)Too few ED consultants

Rota does not match capacity and demand Staffing still a problem - both nursing and medical

Capacity does not match demand (hourly, daily and seasonalvariations to be adequately reflected)

Consultant in ED - reimplementation in October 2016

Rota not fit for purposeCapacity does not match demand

Change plans not embedded operationally

Change plans/process not underpinned by OD plan Planned Clinical Engagement

Access to MAU beds Bed capacity review MAU model in place. MAU model in place - change of concept so that MAU is notused as over spill in times of pressure

Breach information is poorInability to track patients through the systemNo real time information to manage bedsDate Quality issues

Pharmacy ward cover for TTOS Winter in reach projectModel funded non-recurrently to great effect. Recurrent funding not currently available.

Pharmacy cover currently not in place

Additional beds and home care capacity has been put in place over the winter to respond to increases in demand.

Escalation policy in placeDaily 11.30 meetings are in place to manage the process for

those identified as delayed transfers of care and a process is agreed to match demand with avialbale capacity.

Integrated discharge team plansCurrent processes remain too dependent on Senior

Management scrutiny and staff need to be empowered to make the necessary decsions.

The economy has agreed a comprehensive escalation policy which is operational. Options have been extended to

include eg boarding policy but the system has not managed to consistently de-escalate at all from red to amber whereas

this should be achieved in a similar time period that de-escalation from black to red has happened.

Medically fit and Section 5s too high / length of stay too high. DTOC work in progress

Work is planned to gain a shared view of DToC process/definition in order that all stakeholders understand where focus needs to be maintained.

Bed Managers / Social Workers / Discharge co-ordinators / CAIRD work together but not to a single set of objectives or within an integrated team focussed on "patient home". Integrated discharge team plans

Work is planned to implement the 8 high impact changes and benchmark our current position. As part of this but also integral to the proactive care model is (one !) integrated discharge team who would work within and across the MCP.

ANP links to inreach and pull - currently at small scale

There are significant difficulties with current provision in the market. All available action through SRG has been considered to gain addtioanl capacity through the payment of premiums to providers. SRG has committed to maintain any additional capacity through the coming weeks. We are actively working to secure new providers within the market in the medium term .

Care capacity remains fragile - work to clarify capacity and demand

The economy operates assess to discharge, the current capacity of 19 beds is insufficient as too many patients are referred into CHC; Either capacity would need to be significantly increased or process isseus addressed.

Capacity is often available in eg intermediate care or care homes but limitations , based on quality & safety, of the number of patients who can be admitted to a home each day limit the flow in and there is no equivalent eg to the acute boarding policy which risk manages this.

We are actively working to secure new providers within the market but this is a medium term objective. SMBC have just announced a £20m in care home estate. The CCG and SMBC have an emerging but not fully articulated integrated commissioning strategy for the care home market and how capacity will be maintained and increased.

There is not an effective "pull" system, starting before admission, back to patients homes through the neighborhood mdel of care.

System not proactive in preventing further escalation

A fragile care home and domiciliary market with providers reducing capacity due to uneconomic prices and impact of minimum wage.

Internal and external escalation

Too many patients admitted ‘inappropriately’

Patients wait too long to be assessed (significantly longer than peers)

Too many patients admitted (especially at busy periods)

Potentially high mix of ambulance attends

Lack of robust bed management system Complete

Ongoing issues with Junior medical cover overnight due toworkload and senior support avilable.

Staff not engaged in the process of change

Medicine BG focus on clinical and non-clinical engagement -regular communications being sent corporately, strongerengagement with consultant body being developed andgreater focus on clinical ownership, rather thanmanagement leadership.

Lack of robust ED IT system Complete

Acute physicians not available at the right time

The size of the consultant workforce precludes consistent "out of hours" coverage.

On-call arrangements for physicians not providing timely access

International Recruitment is being initiated for all "hard to recruit" specialty groups, including ED. Retention packages have been agreed with ED staff where possible.

Problems of accessing beds

The following have been agreed with the Medicine Consultant body to facilitate bed access/ flow:

- Specialty in reach into AMU to take place each afternoon- Better use of the transfer unit i.e. earlier transfers and for a broader cohort of patients ( aim for 1 per ward by 9am)- Early white board rounds before 9 o'clock to take place on each ward- Simple discharges are being moved from AMU to specialty wards and unwell specialty patients are being held in AMU

Patients not seen quickly enough in ED

Time to senior review too long

Lack of timely senior review

Lack of community alternatives for some key areas (IV therapy, NWAS conveyance)

Half of patients on short stay wards are not short stay patients affecting flow

Rota not fit for purpose

Appendix iii

gent care plans 2016/17

Appendix iii

Appendix iii

Appendix iii Winter schemes

Scheme Description Expected Impact

Saffron Ward Keep open existing beds Existing scheme - impact already embedded and evaluated

SFT Action Plan Committed from last year’s plan Existing scheme - impact already embedded and evaluated

Impact of NHS 111 Contractual commitment – continued triage of patients into Mastercall OOH service

Existing scheme - impact already embedded and evaluated

Home Care, Staffing, Night Sitting Additional capacity in REACH 25% Reduced delayed transfers of care

EMI Beds x 3. The Meadows Existing 3 beds Existing scheme - impact already embedded and evaluated

Hydration Service Intravenous fluid therapy service in residential and nursing homes 10% reduction in relevant attendances

Co-location of primary care in Ed- effective streaming

Co-located Primary Care and streaming 8am-midnight of ambulatory ill patients away from the Emergency Department

30% reduction in admissions for relevant cohort

Escalation Capacity (25 beds x 5 mths)

Escalation beds Improved patient flow-

Optimisation of current in hours MAU to be consistent 14 hours service 7 days per week

Full complement of staff 7 days per week with fully operational optimised ambulatory care pathways. Point of care testing to facilitate rapid safe decision making at the ED Front Door

Improved patient flow, reduced admissions 8am until midnight

Appendix iv

Current Urgent Care position illustration Operational Standards Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16

Percentage of A & E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actual 89.11% 97.0% 94.32% 94.79% 92.54% 91.50% 90.07% 77.97% 73.73% 73.50% 72.77% 72.60%

Operational Standards Apr 16 May 16 Jun 16 Jul 16

Percentage of A & E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department

Target 95% 95% 95% 95%

Actual 79.3% 81.6% 85.2% 81.5%

Appendix v

SRG High Impact Interventions High impact changes

1.Early discharge planning

2. Systems to monitor patient flow

3. Multi-disciplinary, multi-agency discharge teams

4. Discharge to assess

5. Seven day services

6. Trusted assessors

7. Focus on choice

8.Enhancing health in care homes

Appendix vi

DTOC chart

Stockport NHS FT

Appendix viii

Letter RE: Urgent Care Dear Gillian and Jane,

RE: Winter Resilience in Stockport, 2015/16

I am writing to you following the request at the Board to Board meeting on the 2nd July, to provide a letter describing the Stockport system position for Winter 2015/16, along with a level of assurance in the system's ability to meet the 95% ED 4 hour target consistently.

1. The SRG self-assurance document, returned to NHSE on 2nd September.

2. Benchmarking of the Stockport DTOC rate compared to

The self-assurance document provides the broader perspectives of the system and is in line with the 8 high impact interventions for urgent care that have been reviewed through the SRG meetings.

The SRG self-assurance process has resulted in an assessment of limited assurance and highlights 3 key risks to delivery:

1. Significant vacancies and use of locum, bank and agency at SFT. 2. Delays within processes, most significantly access to diagnostics. 3. Whole system ownership and escalation with action

Vacancies and Recruitment -

Failure to fill medical and nursing posts with locum cover are a frequent reason for high levels of evening and overnight breaches. As a result there have been too many patients in ED and thus a higher admission rate. The significant reliance on agency and locum staff also comes at a cost premium. The absence of full staffing levels therefore simultaneously adversely impacts performance, capacity and cost.

In addition to impacting current performance, recruitment is the highest risk to delivery of the 90 day plan.

Delays within Processes

The Action Plan has been compared against the Root Cause Analysis and Utilisation Management review to identify gaps in the system, which have been discussed and are recognised by the SRG. It focuses predominantly on the hospital system and the parts of the system that directly impact on flow. The action plan has been agreed by SRG as the right thing to do and is absolutely consistent with the commissioned reviews. There are however a number of risks to full implementation of the plan that have been highlighted to NHSE and Monitor at the recent Tripartite meeting:

• Staffing capacity issues across both nursing and medical within the Trust

• Consistent social care support and management of DTOCs at an agreed level

Appendix viii

• Buy in within the Trust to the new ways of working to ensure full and consistent implementation as the system is challenged through winter. This will rely upon a significant culture change within the Foundation Trust and will require sustained high quality leadership when the system is under stress

The SRG self-assurance process shows that the Action Plan covers the majority of required process improvements, with a smaller number of notable issues that still need to be addressed:

• Managing fluctuations in ambulance demand, in particular around batching of admissions - this should hopefully be improved by the action plan in better streaming of patients out of ED but the SRG is also awaiting an update from NWAS on out of hospital improvements which have apparently addressed this issue in Tameside.

• Pharmacy ward cover for take home prescriptions - this enables earlier discharge of patients and improves flow. This was improved in 14/15 but has now been removed as part of the SFT cost improvement plan.

• Documentation standardisation - this would reduce the need for repeat history taking and would be achieved through an electronic record

• The potential to identify patients’ needs earlier, ideally in the community to reduced

attendance - this cannot be addressed through the action plan but will be addressed in the longer term through the proactive stream of Stockport Together

• Assessment for intermediate care acceptance - the SRG is however implementing the definition of medically fit as 'no longer gaining benefit from hospital admission' and exploring discharge to assess models.

System escalation

One of the learning points from winter 14/15 was the speed and seniority of escalation. Whilst this is now significantly improved with the establishment of the weekly SRG+ group (SRG chair, SFT Director of operations and SMBC Director of Adult Services), performance will also rely heavily on successful implementation of system wide escalation plans and a coordinated timely response to Urgent Care pressures. Significant work is under way to improve and align escalation plans and these will be fully tested and signed off as an economy by the end of October. Further monitoring of escalation will be led through the SRG and weekly SRG+ meetings.

Impact of CIP plans

In addition to the items raised through the SRG self-evaluation process, the CCG has been consistently raising the risks to quality and performance of CIP plans. At present the CCG has not been able to identify a clear process for assessing the impact of CIP plans within SFT. The SRG requested confirmation of schemes and interventions funded in winter 14/15 which are no longer in place. This has now been received and includes:-

• Sd

• Sds

Appendix viii

• Sd

Over and above this SMBC are also consulting on plans for savings to be implemented in 2016/17. Whilst the impact of these schemes will occur after the coming winter, the issue of underlying financial positions and subsequent actions is one which the SRG will continue to highlight as a significant additional risk

Summary

The external feedback from the Tripartite and SRG show that Stockport is an economy which is willing and able to work together to improve. Significant progress has been made as we move towards the coming winter. However, as an SRG and in my role as SRG Chair, it is felt that we should not move beyond limited assurance of sustained achievement of the 95% 4 hour standard until there is more demonstrable evidence that agreed improvements are significantly impacting . This absolutely includes substantive recruitment but for example, there also remain concerns that the Winter escalation beds have remained open throughout the Summer months, leaving limited capacity for escalation of the Urgent Care system in winter 15/16.

I hope that this letter provides a clear SRG perspective on our urgent care system, the improvements achieved and the remaining challenges.

Yours sincerely

Appendix iv

Email regarding the Urgent Care Delivery Group

Dear all,

As you will be aware, the System Resilience Group has now been stepped down and, under national guidance, we have now become an Urgent Care Delivery Group. As an executive member of your organisation, you have been asked to attend. You will be aware that achievement of the 95% 4 hour target for A&E has continued to be a problem for the Stockport system and we will be under considerable GM and national scrutiny as we progress through Winter.

Executive representation is crucial at this challenged time. I appreciate that this may not always be possible for certain organisations and where that is the case, I would ask that there is deputised senior representation. In addition, it is vital that the group have assurance that feedback of the challenges and engagement of relevant plans is appropriately communicated to the executive level. Where attendance is not achieved, I will contact the respective organisations to discuss further.

I am keen that we have clinical representation from key stakeholders: CCG, SFT, Viaduct. Appreciating time challenges, this need not be exec representation as long as there are other exec members in attendance.

This group has been given 5 key areas of focus, around which the agenda will be designed. I would summarise these as follows:

1. Streaming at the front door of A&E

2. 111 Development of a Clinical Hub

3. NWAS expansion of see and treat/hear and treat

4. SAFER implementation

5. Delayed transfers of care

Our role will be to track the progress of implementation of these across Stockport.

Our other role for winter will be tracking of implementation of the Winter Plan.

If you are key to any parts of these plans, please come prepared to discuss and update the group. If other representation is required from your organisation to ensure a full and productive discussion, please can you ensure that these people are in attendance, or that you are briefed and able to speak to any reports/updates.

Appendix iv

Our risk register from SRG will roll over into this group and we will review the SRG ToR at the first meeting and adapt as necessary. We will also continue to review the urgent care dashboard in this meeting.

All of these will be on the agenda for the first meeting. I look forward to seeing you there.

Best wishes,

Dr Catherine Briggs

Chair Urgent Care Delivery Group

NHS Stockport CCG

Appendix x

System slide