Warrington and Halton Primary Care and

Warrington and Halton Hospitals

Working Together

Tuesday 10th July 2018

AGENDA

7pm Introductions/Welcome/Scene Setting: Dr Andrew Davies, Chief Officer Prof Simon Constable, Deputy Chief Executive and Executive Medical Director

7:05

7:10

7:25

7:35

7:45

7:55

2018/19 Contract Agreement – what does it mean? David Cooper/Andrea McGee

Shared Care Agreement between Primary and Secondary Care (interface arrangements) Dr Sangeetha Steevart/Dr Alex Crowe

Paediatric Surgery at WHH– Dr James Melling, Consultant Surgeon

NEW Gynae Assessment Unit – Dr Hulikere Satish, Clinical Director Women’s and Children’s Health

NEW Frailty Assessment Unit – Dr Liz Iles, Clinical Director Specialist Medicine

Wrap up and Q&A – Dr Andrew Davies and Dr Alex Crowe

8pm Final Comments & CloseDr Andrew DaviesProf. Simon Constable

2018/19 Contract Agreement – What Does It Mean?

David Cooper, Director of Finance CCGAndrea McGee, Director of Finance Trust

Shared Care Agreement between Primary and Secondary Care (interface arrangements)

Dr Sangeetha Steevart CCG/Dr Alex Crowe Trust

Shared care protocol Interface arrangements

Dr.S.Steevart

Urgent care/Primary care clinical lead

Warrington CCG

•Based on 5YFV document

• Improve communication

•Reduce workload

•Define responsibilities

Shared care protocol

• 59Y Old male, referred to RACPC clinic

• Had ECG normal /abnormal stress ECHO-arranged CT coronary angio

• Pt calls sec for results-sec faxes results to GP and tells Patient to contact GP for results

• Results shows ASD and valvular disease

Scenario 1

• 61Y Old male ,fall from ladder, seen in A&E ,done CT TAP and discharged

• Sees GP after 6 weeks with back pain ,GP looks at CT TAP results –which shows cyst in pancreas and suggesting MRI

• No letter to GP /MRI not organised either

Scenario 2

• 36 y old lady presented to A&E with back pain

• Was assessed and discharged with advice to see GP to request MRI for possible cauda equina

• GP examines does not need further investigation and had to convince patient no need for MRI –Patient complains

Scenario 3

• 64 Y old female with recurrent UTI .admitted with urosepsis and discharged to Com IV team

• No discharge letter ,2 days later microbiologist calls GP around 5 pmto say urine culture grows VRE and requests what antibiotics the patient is on

Scenario 4

Service Developments at WHH

Paediatric General Surgeryat Warrington and Halton Hospitals

Mr James MellingConsultant Surgeon

Consultant general and colorectal surgeon

Lead for paediatric surgery

Started at WHH April 2017

Surgical training in Merseyside

Post CCT fellowship at Alder Hey 2016-17

• General paediatric surgery clinic (>12 months)– Inguinal hernia and hydrocoele– Umbilical and epigastric hernia– Foreskin problems including phimosis and BXO– Maldescended testes– Laparoscopic cholecystectomy– Lumps and bumps (excluding face, joints, breast and

moles)– Ingrown toe-nails

• Current OPD waiting times = ~4 weeks• Current operation waiting times = <4 weeks

Services at WHH

Services at WHH

• Specialist paediatric surgery clinic

– Miss Jo Minford (once/month)

– More complex surgery

– Associated comorbidities

– <12 months

• Specialist paediatric urology clinic

– Miss Harriet Corbet (once/month)

9962

406

216

1003

119

250

697

960

n outpatients (TOTAL 13613)

Alder Hey COCH East Cheshire

Mid Cheshire Southport and Ormskirk St Helens and Knowsley

Warrington and Halton WUHT

3877

125

18 76560 140

158

n elective surgical admissions including day-case (TOTAL 4459)

Alder Hey COCH East Cheshire Mid Cheshire

Southport and Ormskirk St Helens and Knowsley Warrington and Halton WUHT

WUTH

WUTH

Cases operated on at Alder Hey 2016-2017

Warrington CCG Halton CCG

Circumcision 11 8

Preputioplasty 7 5

Ingrowing toenail 2 1

Orchidopexy 25 19

Umbilical hernia 4 1

Hydrocoele 11 6

Total 60 40

NEW Gynaecology Assessment Unit

Providing high quality care and Improving patient experience

Dr Hulikere Satish, Clinical Director

Women’s and Children’s Health

Pre GAU

• Acute Gynae would be seen on ward C20

• If no capacity on C20 would be accepted but had to go to ED

• Pressure on ED and ability of junior staff to attend ED

• Inappropriate for the majority of Gynae cases to go to ED

• Early pregnancy complications being seen in a none specialist area

Effects

• Constant pressure on the ward• In addition early pregnancy losses are being

treated in inappropriate places • Emergency Department pressure and delays• Poor experience for the patient • Staff morale is being affected due to their

inability to manage the patients in this specialty• CQC

Making it happen

• Women’s Health Improvement board

• Plan

• Steps for implementation

• Business case and SOP

• Team

• Beds

• Execs approval

Benefits

• Improved patient experience

• No admissions to the Maternity unit, surgical assessment unit (SAU) or A/E.

• Direct referrals from GP’s

• Improvement of the 4 hours A/E target.

• Improve performance targets

• Sustain elective activity

• More efficient way of working

• Less cancellations

• Medical staff effectiveness

GAU - Launched 18th June 2018

• Ability to accept referral and send directly to GAU

• Junior staff / senior nursing staff assigned to cover GAU specifically

• Reduce demand on ED

• Improve patient Journey and experience

• Specialist acute care

Focused Care Pathways

• Outpatient Medical Management for Miscarriage and Ectopic Pregnancy

• Outpatient Management of Hyperemesis and excessive Vomiting

• Rapid Access to Ultrasound for Early Pregnancy complications

• Rapid Assessment and Streamlined Referral for Outpatient Specialist Clinics as required – RAPAC, Hysteroscopy, GOPD

Initial success, Patient experience and Emails

• Just wanted to say a huge well done and thank you to all today on the first successful day of GAU14 patients seen today Well done everyone, this will make so much of a positive difference to the patients experience of gynaecology Kind regards Tracey

• Hi All , Just to let you know we have seen 117 patients through GAU in the first 12 days , it is working extremely well. We have had really positive feedback from the women and I am hoping that ED are noticing a difference .Keep up the great work ! Vicky

• Hi All, This is really lovely to hear Vicky, think of the difference you have all made to those patients experience, truly brilliant! Best wishes, Dec

• Well done all - it's going great Kind regards, Kimberley Salmon-Jamieson,Chief Nurse

Next steps - PERFORMANCE

• 6 KEY PERFORMANCE INDICATORS

• CLINICAL AUDIT

NICE QUALITY STANDARD # 69

KPIs TO BE MONITORED AND REPORTED MONTHLY FROM 31.7.18

CLINICAL AUDIT WILL BE PRESENTED AND REPORTED 20TH NOVEMBER

NEW Frailty Assessment Unit

Dr Liz Iles, Clinical Director Specialist Medicine

WHH Frailty Strategy“Living Well with Frailty”(2017 – 2020)

Elizabeth IlesClinical Director for Specialist Medicine

Amanda ThomasFrailty Nurse Consultant

Mark Leigh Transformation Deliver Manager

The Frailty Vision - Living Well with Frailty

The hospital recognises that the hustle and bustle of a busy A&E department is not the best place to care for frail older people. Following a fall, a “funny do” or a minor illness, navigating the complexity of the acute care system can be frightening, isolating and disorientating, …not just for the older person but for their relatives and carers as well.

It is our vision that we identify frail older people, distinguishing them from acutely ill, fit and well older people, and we will match their care to their needs.

At Warrington and Halton Hospitals Trust we believe that all people living with frailty will have a say; they will be consulted and collaborated with during their assessments and care planning, in order that they remain safe and comfortable within their place of residence. Frail older people and their carers will be empowered to self-care; to retain their independence for longer, and to seek help early in their journey should they require it.

A System Wide Approach

Phase Title Description Launch Date

Phase 1a Phased Opening Phased internal opening of FAU to test the model to

ensure robust pathways , and resolve teething problems

prior to extending FAU offer to Primary Care. FAU will

open two  days per week; Monday and Friday, 9am-

5pm. Internal referrals from A&E only. 

Apr-18

Phase 1b FAU launch to

selected GP

practices

Launch of the FAU pathway for selected GP Practices to

test primary care access model, prior to launch to all

agreed primary care practitioners. Monday - Friday,

09am-5pm. Substantive staffing model. Referrals

accepted from A&E and selected GP’s only.

Aug-18

Phase

1c

FAU Launch

extended to

Primary Care .

Launch of the FAU pathway for Primary Care referrals ;

Monday - Friday, 09am-5pm. Substantive staffing

model. Referrals accepted from A&E and all agreed

Primary Care sources.

Sep-18

Phase 2 Ward Referrals

Trust wide

Appropriate inpatients who have not received a frailty

assessment or Comprehensive Geriatric Assessment

(CGA) , will be identified on the wards.  Frailty MDT

management principles for assessment and care and

support planning will become standard across the Trust.

Jan-19

Phase 3 Primary Care

Outreach

Collaborative working with community health  and local

authority partners to develop and improve frailty care

pathways; enhanced care home services, community

dementia registers and care plans  and multi-disciplinary

care plan review for frail older people in primary care.  

Jun-19

Helping frail patients manage their conditions through appropriate services at the appropriate time.

Secondary care drive to support primary care and social care partners to manage patients in the community and closer to home.

Supported by the Warrington Together programme – as part of the wider UEC Work Stream.

Phase 1a: Frailty Assessment Unit is a BCF funded pilot to provide a proof of concept.

Phase 1: Frailty Assessment UnitA New Way Home

Quick access to a specialist multi-disciplinary team (MDT)

Referrals from urgent care and primary care“Home First” philosophyClinical Frailty Score (CFS) screening –

Rockwood Care & Support Plan (CSP) incorporating

community servicesGold standard Comprehensive Geriatric

Assessment (CGA)Timely diagnosticsPurpose built assessment areaFollow up service to support patients after

discharge

Phase 1a: Frailty Assessment UnitReferral Pathway

Frailty Assessment UnitThe FAU Pilot

Launched on Wednesday 30th May and concluded on Friday 06th July.

The pilot was run over 12 day sessions – Monday & Friday; 09:00am - 17:00pm.

Total number of patients referred to FAU – 35 patients via UEC

Total number of patients discharged home on the day - 31 (88.5%)

Average LoS for this cohort of patients – 10 days Total number of bed days saved – 310 bed days

saved

Frailty Assessment UnitPatient Feedback

During the FAU pilot phase the unit has received an array of positive verbal feedback from patients and staff surrounding:

the environment, positive/ supportive staffing, a quick turn aroundand the patient centric holistic

approach.

Wrap up and Q&A

Dr Andrew Davies and Dr Alex Crowe