Hertfordshire and West Essex

Integrated Care System

Hertfordshire Health Scrutiny

NHS Refresh & Reset

30th September

Update on the Herts & West Essex ICS

• ICS application approved from 1st May 2020

• Single Executive lead & Joint CCG CEO appointed from 1st June – Dr Jane

Halpin

• Senior Executive team being established – Managing Director for each

CCG

• Revising priorities & work programme in light of covid experience and

developing national priorities

Principles

• Working together with common purpose, to achieve the best possible outcomes in the best

interests of the people of Hertfordshire and West Essex

• Focused on transformation and will simplify systems and cut bureaucracy

• Valuing a ‘place’ based approach to finding local solutions to local problems

• Ensuring that the actions we take and the decisions we make are made as close as possible to

those affected

• Co-producing change with patients, service users, carers and the public

• Managing risks and opportunities together

• Finding the resources – time and money – to agree and implement our plans

Vision & Priorities

Covid Response – Impact on providers

• Acute

– Elective activity/out patients paused

– Some Acute trusts stopped routine referrals (ENHT remained open to all referrals)

– Shift to virtual consultations / what kept going / (cancer pathways)

– All critical urgent work reviewed / all waiting lists reviewed and critically prioritised - trusts working across the ICS to develop risk

stratification at speciality level and ensure consistency

– Referral assessment service has been established at speciality level to ensure services continue to run safely, meet infection prevention

and control processes and see as many patients as possible incl.;

� Advice and guidance

� Virtual appointments where possible (approximately 30% of all appointments)

� Ensuring patients are fully worked up (with all appropriate diagnostics) before appointments

– Staffing reduced across all services

– Introduction of Testing

– All urgent and two week wait referrals were maintained

– From 15th June WHHT accepting all referrals (routine, urgent and cancer) to all specialities

– All specialities have restarted services (ENHT resumed Electives as part of Operation restart from end of June)

– Increased collaboration with Independent Sector Providers

– Development of red/green pathways and A&Es / (hot/cold sites)

– Development of green pathways and comms to ensure patients feel safe to attend appointment where required

• Mental health – Reduction in dementia, IAPT, and most direct contact services

– Crisis interventions were maintained as much as possible, some virtually

– Services were adapted to meet priority demand e.g. MH assessment hub

• Primary care– Routine face to face appointments paused

– All patients “triaged” to maintain safe care (e.g. telephone first)

– Use of new technology to maintain care where possible (e.g. attend anywhere, e-consult, etc)

– Virtual clinics, respiratory hubs established to maintain response to urgent need with increased use of technology

– Services were adapted to meet priority demand e.g. Respiratory hub developments, domiciliary vehicles attached to each

hub for essential home visits

– Direct support to NHS111 to manage triage and queues with additional extended access appointments

• Community– Reduction in rapid response and most direct contact services

– Services were adapted to meet priority demand (and expanded where required e.g. DH2A and POA)

– Virtual clinics and technology developed to maintain priority need

Covid Response – Impact on providers

Covid Response –joint working

The Strategic Coordination Group (SCG) convened to ensure all multi agency partners

across the Local Resilience Forum (LRF) acted collaboratively and as individual

organisations to preserve life and relieve suffering.

It ensures delivery of a safe and coordinated response for the whole County, linking,

where appropriate, to regional or national aspects and providing an agreed situational

awareness of the incident.

The NHS are represented by East and North Herts CCG & Herts Valley CCG at the

SCG and a Health Economy Tactical Coordination Group (HETCG) with health and care

providers across Hertfordshire has been stood up to support this.

Covid Response –joint working System Activity Recovery Group (SARG) overseeing the work of 3 sub groups:

• ICS - Discharge, Care Homes and Winter plan recovery task and finish group with objectives to:

– Share learning & ensure consistency in process where possible

– Review winter plans and consider mutual aid principles in times of surge / second peak

• ICS – Planned Care Recovery Group

– Development of Clinical Prioritisation Tool

– Review of all regional recovery Adapt & Adopt plans (PIFU, Endoscopy, Diagnostics, Theatre efficiencies)

• ICS – Urgent & Emergency Care Group

– SHREWD dashboard

– Think 111 First

• CHC as part of the wider ‘Discharge to Assess’ work stream

– Funding tracker in place to monitor individual placement to ensure assessment and review is undertaken.

– Revised discharge guidance and CHC guidance issued in August 2020

• ICS - Out of hospital capacity meeting chaired and administered by HCC, with objectives to :

– Ensure residential and nursing homes capacity in place for ’discharge to assess’ provision

– Review of home first principles - ‘discharge to assess’ & ‘rapid response’ re; flow out of hospital and admission avoidance

• Swabbing cell

• Testing cell

Covid Response – joint working… cont’d • Local area work with ICPs;

– ICP implementation group meeting weekly, Joint SOP written and agreed for schedule 1 and schedule 2

– ICP level Schedule 1 & 2 assessments commenced 1st September jointly with HCC

• Care Homes

– Multi organisational Care Home cell in place

– Enhanced care in care homes being delivered jointly through MDTs.

– Quality monitoring in place CCG and HCC, homes risk-stratified and additional support put in for at risk homes.

– Training rolled out to supported living and home care providers.

• Other key joint working areas:

– Covid 19 data hub

– VCS support in the community

– Aligned working of staff in community to support vulnerable people

– Community equipment

– Domestic abuse

– Covid Testing

– Homelessness & asylum seekers

– Planning for winter across all services

Key Issues for the next 6 monthsThe next 6 months sees the NHS needing to Recover & Restore services, current focus on:

– Elective care incl.;

• Overnight elective and outpatients / day cases

• MRI/CT and endoscopy procedures

• Outpatient and follow ups (face to face or virtual)

• Prioritisation of high-risk pathways – e.g cancer patients

• System approach to managing waiting lists

• Collaboration between hospitals and GPs - communication with patients where planned care has been

disrupted

• Maintaining new infection control (inc self isolation and testing) requirements

– Primary care incl.;

• Restoring activity to usual levels where clinically appropriate

• Address backlog of child immunisations and cervical screening

• Build on enhanced support to care homes with structured medical reviews

• Utilising ‘risk stratification’ tools.

• Face to face appointments & Enabling ‘virtual clinics’ in secondary care

• Continuing remote triage and video / telephone consultation where appropriate

• Maintaining respiratory hubs

• Potential increased involvement in pharmacy & dentistry direct commissioning

Key issues for next 6 months.– Community services incl.;

• Maintain crisis response services

• Support for recovered Covid patients with ongoing health needs

• Resume home visiting care focussing on vulnerable/shielded patients

• Work collaboratively to embed ‘discharge to assess’ pathways

• Resume ‘continuing health care’ assessments including those with ongoing care needs

– Unplanned Care incl;

• NHS 111 Think First & direct referrals to both primary and secondary care

• Communications campaign (#helpustohelpyou) to reduce avoidable hospital attendances

• Projected A&E attendances & 111 call volumes – to manage increase in demand

• Maximising hear & treat and see & treat with the ambulance service – reducing conveyances

• Utilising NHS Volunteer responders scheme, Red Cross and St Johns Ambulance

– Ensuring all services can recover, manage the on going Covid 19 Pandemic and prepare for local

outbreaks & potential second peak

Key issues for the next 6 months

• Mental Health incl;

– Reducing waiting list for dementia diagnosis service (EMDASS) to pre-covid levels

– Delivery of NHS Long Term Plan requirements incl.;

• Expansion of IAPT (low level support for anxiety and depression)

• Perinatal mental health support

• Support for children and young people

• Physical health checks for both learning disabilities and people with mental ill health

• Employment support

• Managing concern that Covid will lead to a significant increase in demand for mental health services

– Modelling with public health to allow us to develop plans to respond appropriately to any increase in demand

across mental health services

Key issues for next 6 months

• Flu vaccination programme

– Because of Covid 19 the flu vaccine is being offered to additional cohorts:

– Household contacts of those on the NHS Shielded Patient List.

– Children of school Year 7 age in secondary schools (those aged 11 on 31 August 2020) delivered by The

School Age Immunization Service (SAIS)

– Health and social care workers employed through Direct Payment (personal budgets) and/or Personal

Health Budgets, such as Personal Assistants, to deliver domiciliary care to patients and service users

• Target of 75% across all cohorts,

– Practices working together across their Primary Care Networks and in partnership with pharmacists

– Alternative premises where practices are not suitable, staff overtime and equipment and PPE.

• The high risk groups are being prioritised early in the programme, including;

– Care homes and

– NHS and social care staff.

• HCC are supporting with sourcing alternative venues for large scale vaccinations

• Communication teams are working together to ensure consistent messaging

• Councillors help in spreading this message would be appreciated.

Large Scale Strategic/Capital Issues

• PAH re-development – progress since joint scrutiny & next steps timeline

• ENHT £15m Capital Bid (Emergency Department expansion)

• West Herts re-development

– Stage of development

– Importance for progress to deliver new models of care

WHHT’s Outline Business Case will consider a wide range of

options, with a focus on improving emergency care:

• 2017 – our strategic outline case (SOC) considered options to resolve all concerns.

• 2018 – our ‘refreshed’ SOC had a financial limit of £350m (in line with 2017/18 turnover) so

investment in emergency care was prioritised.

• 2019 – West Herts Hospitals NHS Trust named as one of six hospital trusts in Health

Infrastructure Plan - £400m pledged.

• 2020 – feedback from regulators confirmed that an option including more new build at WGH,

including replacing rather than refurbishing the main PMOK clinical block (costing c£590m) could

be included within the OBC option appraisal BUT there is no guarantee at this stage that this

amount of funding is available.

The Trust has recently developed its proposed shortlist of options:

• Our recommended preferred option is to significantly improve emergency and specialist care service, with a

major new clinical facility to be built on land adjacent to the current Watford General Hospital and the main

PMOK block replaced.

• Our plans will also improve planned medical and surgical services at Hemel Hempstead and St Albans City

Hospitals.

• In order to secure funding for this, the shortlist appraisal will need to demonstrate to NHSEI, DHSC and HMT that

this option presents the best overall value for money, is affordable and can be delivered by 2025/26.

• An independent report has concluded that ‘greenfield’ sites would take longer to deliver and carry a higher risk of

overall failure than the Watford General Hospital / Watford Riverwell options.

• We would like as many local people as possible to give us their views on the proposed shortlist and the

recommended preferred option, so are currently conducting a survey to gain feedback from patients, staff and the

public.

In common with other Trusts that have received ‘HIP1’ funding, a key

consideration is the impact of COVID19 on future hospital design:

• Proactively promote staff well-being in building design.

• Importance of emergency / elective separation.

• Flexibility of design to enable green/blue zones.

• Creation of one way routes for patients to avoid cross contamination.

• Significant increase in the proportion of single rooms.

• Clustering beds to facilitate flexibility in zoning.

• Create ability to easily ‘cohort’ clinical areas.

• Ensure space can be easily re-purposed, e.g. standardisation of room sizes/ buffer zones.

• Increased ventilation requirements

WHHT is aiming to deliver improvements as quickly as possible:

• Now that the Trust has appointed a design team, it is examining ways in which the timescale above could be accelerated.

• A range of stakeholder events have been convened (via Zoom) with patients, staff and the public, to inform the development of the

Outline Business Case.

PAHT new hospital update

Top level Programme

Key areas of focusClinical engagement: large numbers of clinicians from across the organisation and in primary and community care designing our new facility

Demand and capacity: detailed analysis has been completed and aligned to system assumptions

Model of care: new integrated ways of working have been developed which will transform the care we deliver to our patients (including learning from Covid-19).

Public engagement: working with patients and the public through a range of workshops and engagement events to design services bespoke for their needs

Innovation: engaging clinicians form across the world to help design services fit for the 21st Century and putting technology at the heart of everything we do

Design: our emerging designs that are net zero carbon with beautiful aesthetics are also planned to be pandemic compliant

Actions and Next steps

Thank youwww.healthierfuture.org.uk