Southend University Hospital Foundation NHS Trust

Risk Summit

NHS Southend CCG and NHS Castle Point & Rochford CCGThe Commissioners’ Perspective

31st March 2014

Appendix A

Content

• CCG role

• Performance trends across emergency care

• Actions taken by the commissioners

• Urgent Care Working Group

• How has the wider system responded?

Context

• Southend CCG is lead commissioner for services from SUHFT

• Responsibility to ensure we commission high quality, safe services on behalf of our population

• There has been inconsistent achievement of the A&E 4 hour standard since March 2012

• This has impacted on the ability to achieve other NHS Constitution standards and further reduced quality

A&E 4 Hour Standard since April 2011

Quarter 2011-12 2012-13 2013-142013-14

2014-15

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4

Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4

Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

4/3/2

011

5/1/2

011

5/29/2

011

6/26/2

011

7/24/2

011

8/21/2

011

9/18/2

011

10/16/2

011

11/13/2

011

12/11/2

011

1/8/2

012

2/5/2

012

3/4/2

012

4/1/2

012

4/29/2

012

5/27/2

012

6/24/2

012

7/22/2

012

8/19/2

012

9/16/2

012

10/14/2

012

11/11/2

012

12/9/2

012

1/6/2

013

2/3/2

013

3/3/2

013

3/31/2

013

4/28/2

013

5/26/2

013

6/23/2

013

7/21/2

013

8/18/2

013

9/15/2

013

10/13/2

013

11/10/2

013

12/8/2

013

1/5/2

014

2/2/2

014

3/2/2

014

3/30/2

014

4/27/2

014

5/25/2

01475%

80%

85%

90%

95%

100%

4Hr Performance4wk Avg - 4Hr PerformanceStandard (95%)

4Hr P

erfo

rman

ce

A&E Attendances

4/3/2

011

5/1/2

011

5/29/2

011

6/26/2

011

7/24/2

011

8/21/2

011

9/18/2

011

10/16/2

011

11/13/2

011

12/11/2

011

1/8/2

012

2/5/2

012

3/4/2

012

4/1/2

012

4/29/2

012

5/27/2

012

6/24/2

012

7/22/2

012

8/19/2

012

9/16/2

012

10/14/2

012

11/11/2

012

12/9/2

012

1/6/2

013

2/3/2

013

3/3/2

013

3/31/2

013

4/28/2

013

5/26/2

013

6/23/2

013

7/21/2

013

8/18/2

013

9/15/2

013

10/13/2

013

11/10/2

013

12/8/2

013

1/5/2

014

2/2/2

014

3/2/2

014

3/30/2

014

4/27/2

014

5/25/2

01475%

80%

85%

90%

95%

100%

1400

1500

1600

1700

1800

1900

20004Hr Performance 4wk Avg - 4Hr Performance Standard (95%)Volume 4wk Avg - Volume

4Hr P

erfo

rman

ce

Volu

me

of A

&E

Atten

danc

es

Quarter 2011-12 2012-13 2013-142013-14

2014-15

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4

Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4

Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

A&E Attendances – AMU removed

Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathwayCriteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only

4/3/2

011

5/1/2

011

5/29/2

011

6/26/2

011

7/24/2

011

8/21/2

011

9/18/2

011

10/16/2

011

11/13/2

011

12/11/2

011

1/8/2

012

2/5/2

012

3/4/2

012

4/1/2

012

4/29/2

012

5/27/2

012

6/24/2

012

7/22/2

012

8/19/2

012

9/16/2

012

10/14/2

012

11/11/2

012

12/9/2

012

1/6/2

013

2/3/2

013

3/3/2

013

3/31/2

013

4/28/2

013

5/26/2

013

6/23/2

013

7/21/2

013

8/18/2

013

9/15/2

013

10/13/2

013

11/10/2

013

12/8/2

013

1/5/2

014

2/2/2

014

3/2/2

014

3/30/2

014

4/27/2

014

5/25/2

01475%

80%

85%

90%

95%

100%

1300

1400

1500

1600

1700

1800

1900

20004Hr Performance 4wk Avg - 4Hr Performance Standard (95%)Volumes (Adjusted for AMU) Volumes (Adjusted for AMU) - 4wk Avg

4Hr P

erfo

rman

ce

Adju

sted

Aan

dE V

olum

es

Quarter 2011-12 2012-13 2013-142013-14

2014-15

Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4

Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4

A&E Admissions

Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathwayCriteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner onlyAttendances with Outcome as “Admitted” only

4/3/2

011

5/1/2

011

5/29/2

011

6/26/2

011

7/24/2

011

8/21/2

011

9/18/2

011

10/16/2

011

11/13/2

011

12/11/2

011

1/8/2

012

2/5/2

012

3/4/2

012

4/1/2

012

4/29/2

012

5/27/2

012

6/24/2

012

7/22/2

012

8/19/2

012

9/16/2

012

10/14/2

012

11/11/2

012

12/9/2

012

1/6/2

013

2/3/2

013

3/3/2

013

3/31/2

013

4/28/2

013

5/26/2

013

6/23/2

013

7/21/2

013

8/18/2

013

9/15/2

013

10/13/2

013

11/10/2

013

12/8/2

013

1/5/2

014

2/2/2

014

3/2/2

014

3/30/2

014

4/27/2

014

5/25/2

01475%

80%

85%

90%

95%

100%

300

320

340

360

380

400

420

440

460

480

5004Hr Performance 4wk Avg - 4Hr Performance Standard (95%) Admissions Admissions - 4wk Avg

4Hr P

erfo

rman

ce

Num

ber o

f A&

E Ad

mis

sion

s

Quarter 2011-12 2012-13 2013-142013-14

2014-15

Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4

Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4

Non-Elective Conversion

Source: SUS-SEM Via MedeAnalytics, adjusted to remove AMU-pathway A&E Attendances

4/3/2

011

5/1/2

011

5/29/2

011

6/26/2

011

7/24/2

011

8/21/2

011

9/18/2

011

10/16/2

011

11/13/2

011

12/11/2

011

1/8/2

012

2/5/2

012

3/4/2

012

4/1/2

012

4/29/2

012

5/27/2

012

6/24/2

012

7/22/2

012

8/19/2

012

9/16/2

012

10/14/2

012

11/11/2

012

12/9/2

012

1/6/2

013

2/3/2

013

3/3/2

013

3/31/2

013

4/28/2

013

5/26/2

013

6/23/2

013

7/21/2

013

8/18/2

013

9/15/2

013

10/13/2

013

11/10/2

013

12/8/2

013

1/5/2

014

2/2/2

014

3/2/2

014

3/30/2

014

4/27/2

014

5/25/2

01475%

80%

85%

90%

95%

100%

15%

17%

19%

21%

23%

25%

27%

29%

31%

33%

35%4Hr Performance 4wk Avg - 4Hr Performance Standard (95%) Conversion to NEL rateConversion to NEL rate - 4wk Avg

4Hr P

erfo

rman

ce

% o

f A&

E Att

enda

nces

Adm

itted

Quarter 2011-12 2012-13 2013-142013-14

2014-15

Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4

Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4

11/1/2011 12/5/2011 1/12/2012 2/15/2012 11/16/2012 12/20/2012 1/29/2013 11/4/2013 12/6/2013 1/14/2014 2/17/2014 3/21/201480.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%Southend UHFT Rest of Essex National

SitRep Period Start (to next SitRep Period)

Bed Occupancy

Source: NHS England Sitreps, 4 years of collections, 7 day rolling average

2011-12Nov-Feb

2012-13Nov-Feb

2013-14Nov-Mar

Quarter 2011-12 2012-13 2013-142013-14

YTDQ3 Q4 Q3 Q4 Q3 Q4

SUHFT A&E 4hr Performance 96.9% 95.3% 93.8% 89.6% 94.2% 88.7% 92.8%

Number of Weeks below Std.

0 4 6 13 4 10 29

11/1/2011 12/2/2011 1/10/2012 2/10/2012 11/12/2012 12/13/2012 1/21/2013 2/21/2013 11/26/2013 12/31/2013 2/3/2014 3/6/20140.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Southend UHFT Rest of Essex National

Source: NHS England Sitreps, as a percentage of occupied beds, 4 years of collections, 7 day rolling average

2011-12Nov-Feb

2012-13Nov-Feb

2013-14Nov-Mar

Delayed Transfers of Care

Quarter 2011-12 2012-13 2013-142013-14

YTDQ3 Q4 Q3 Q4 Q3 Q4

SUHFT A&E 4hr Performance 96.9% 95.3% 93.8% 89.6% 94.2% 88.7% 92.8%

Number of Weeks below Std.

0 4 6 13 4 10 29

Delayed Transfers of Care

Total Social Health0

2

4

6

8

10

12

2012/13 population weighted Delays per 100,000

Southend England Eastern Region Comparators

Social Health0

5

10

15

20

25

30

35

40

45

Number of Delays

2012-13 Delays2013/14 YTD Delays

Friends and Family Test

Source: Unify2

4/1/2013 5/1/2013 6/1/2013 7/1/2013 8/1/2013 9/1/2013 10/1/2013 11/1/2013 12/1/2013 1/1/2014 2/1/2014 3/1/20140

10

20

30

40

50

60

70

80

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

41 41

60

66

51

70

55

66

51

47

54

23

Eng Score SUHFT Score Eng Response Rate SUHFT Response Rate

F&F

Scor

e

Resp

onse

Rat

e

Ambulance Handover Times

Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest

7/7/2

013

7/21/2

013

8/4/2

013

8/18/2

013

9/1/2

013

9/15/2

013

9/29/2

013

10/13/2

013

10/27/2

013

11/10/2

013

11/24/2

013

12/8/2

013

12/22/2

013

1/5/2

014

1/19/2

014

2/2/2

014

2/16/2

014

3/2/2

014

3/16/2

014

3/30/2

014

4/13/2

014

4/27/2

014

5/11/2

014

5/25/2

014

6/8/2

0140

100

200

300

400

500

600

70%

75%

80%

85%

90%

95%

100%

Under 15mins 15-30mins 30-60mins Over 60mins 4Hr Performance Standard (95%)

Num

ber o

f Am

bula

nce

Han

dove

rs

4Hr P

erfo

rman

ce

Ambulance Handover Times – expressed of % of total

Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest

7/7/2

013

7/21/2

013

8/4/2

013

8/18/2

013

9/1/2

013

9/15/2

013

9/29/2

013

10/13/2

013

10/27/2

013

11/10/2

013

11/24/2

013

12/8/2

013

12/22/2

013

1/5/2

014

1/19/2

014

2/2/2

014

2/16/2

014

3/2/2

014

3/16/2

014

3/30/2

014

4/13/2

014

4/27/2

014

5/11/2

014

5/25/2

014

6/8/2

0140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70%

75%

80%

85%

90%

95%

100%

Under 15mins 15-30mins 30-60mins Over 60mins 4Hr Performance Standard (95%)

Perc

enta

ge o

f Am

bula

nce

Han

dove

rs

4Hr P

erfo

rman

ce

Ambulance Handover Times – over 30mins

Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest

7/7/2

013

7/21/2

013

8/4/2

013

8/18/2

013

9/1/2

013

9/15/2

013

9/29/2

013

10/13/2

013

10/27/2

013

11/10/2

013

11/24/2

013

12/8/2

013

12/22/2

013

1/5/2

014

1/19/2

014

2/2/2

014

2/16/2

014

3/2/2

014

3/16/2

014

3/30/2

014

4/13/2

014

4/27/2

014

5/11/2

014

5/25/2

014

6/8/2

01470%

75%

80%

85%

90%

95%

100%

0%

5%

10%

15%

20%

25%

% over 30mins 4Hr Performance Standard (95%)

4Hr P

erfo

rman

ce

Perc

enta

ge o

f Han

dove

rs

Ambulance Handover Times – over 60mins

Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest

7/7/2

013

7/21/2

013

8/4/2

013

8/18/2

013

9/1/2

013

9/15/2

013

9/29/2

013

10/13/2

013

10/27/2

013

11/10/2

013

11/24/2

013

12/8/2

013

12/22/2

013

1/5/2

014

1/19/2

014

2/2/2

014

2/16/2

014

3/2/2

014

3/16/2

014

3/30/2

014

4/13/2

014

4/27/2

014

5/11/2

014

5/25/2

014

6/8/2

01470%

75%

80%

85%

90%

95%

100%

0%

2%

4%

6%

8%

10%

12%

14%

16%

% over 60mins 4Hr Performance Standard (95%)

4Hr P

erfo

rman

ce

Perc

enta

ge o

f Han

dove

rs

Themes from the Data

• A&E standard has been met in only one quarter since Q3 2011/12

• A&E attendance has not increased significantly

• A&E conversion rates have increased

• DToC are small

• Ambulance handovers have remained constant but recently higher number of ambulance waits over 30 and 60 minutes

What does this mean for patients?

• Leads to a crowded department with patients both waiting to be seen and waiting for beds

• Overall poor patient experience and safety• Evidence has shown that patients admitted through a crowded

A/E have a 43% increase in mortality at 10 days• Patients admitted after 4-8 hours in A/E stay on average 1.3 days

longer in hospital and 2.35 days when this reaches 12 hours• Treatment initiation is often delayed in a crowded department• FINALLY for patients seen and discharged from A/E there is a

direct correlation between the length of time waited and a higher chance of dying in the next 7 days

Action taken by the CCG since April 2013

• Performance management and contractual action

• System co-ordination and winter planning

• Managing demand

• Quality visits and external reviews

Performance management and contractual action during 2013/14

• Weekly performance meetings COO- COO since July 2013

• Two letters of serious concern to CEO

• Required formal root cause analyses and exception reports

• Action under the contract

• Contract Query – 7th March 2013

• 1st Exception Report – 29th May 2013

• 2nd Exception Report – 27th September 2013

• Closure Notice – 15th November 2013

• Contract Query – 21st January 2014

• 1st Exception Report – 13th March 2014

System co-ordination and winter planning

• System conference calls – daily since November 2013

• Winter plan developed through two stakeholder half day workshops and full evaluation of demand management schemes

• Scenario testing (Exercise Eskimo) to ensure effective escalation and production of escalation guide

• Winter money allocated to the hospital (£0.9m out of £1.4m)

Managing Demand

• Full evaluation of schemes over summer which identified sub-optimal performance in schemes and took corrective measures

• Implemented a successful programme to increase GP referrals to the Single Point of Referral

• Extended hours for hospital Day Assessment Unit

• Increased GP practice MDTs

• Implemented strengthened model of GPs supporting care homes

• Public education – local campaigns to use NHS 111 and avoid A&E

• Commissioned system bed capacity review – due April 2014

External reviews and quality visits

Emergency Care Intensive Support Team visited twice with recommendations which has formed basis of recovery plans

Themes from CCG-led quality visits – unannounced and announced:00hrs:• Potential patient safety risk from delayed offloading of patients from ambulances • Inappropriate attendees in minors• Slow triage of patients in waiting area• Slow transfers from A&E to wards• Inappropriate skill mix and staffing levels for nursing and medical staff in A&E• Lack of senior decision makers on the emergency floor• High use of agency medical & nursing staff• A&E department size too small

In Summary

• Significant problem in meeting A&E 4 hour standard for last 24 months

• Demand, discharges and bed capacity has remained constant across the system

• Unable to recover quickly from periods of surge prolonging impact

• Main underlying issue is staffing shortages in the A&E department – consultant, middle grade doctors and nursing

• Size of the department is a limiting factor

• Process management has not been fully embedded with clear leadership

.

Further action required for the hospital• To appoint a performance director for emergency care.• To establish a senior consultant rota of permanent clinicians to provide

senior leadership in the department.• Revise A&E recovery plan to incorporate KPIs and clear and accountable

actions for implementation and delivery.• Implement a medical, nursing and service manager recruitment plan.• To establish minors see and treat.• To establish majors rapid assessment.• To embed process for escalation to specialist teams.• To embed internal and external escalation processes.• To achieve earlier patient discharge.• To ensure 3x daily site visits take place.• To develop a clear plan to deliver the paediatric pathway.

.

Further action for the wider system

• Urgent Care Working Group meeting fortnightly moving to weekly

• Review pathway for minors across system

• Implement our frail elderly pathway in line with the integrated pioneer plan

• Better management of patients with long term conditions in the community

• Implement system-wide A&E recovery plan.