Council of Members 17 May 2017
Minutes of last meeting: March 2017
Update on Council of Members Deputy Chair Malcolm Hines, Chief Financial Officer
Update on NHS Constitutional standards Andrew Bland, Chief Officer
Accident and emergency A&E waits all types (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission April May June July Aug Sep Oct Nov Dec Jan Feb Mar GSTT 91.9 89.4 89.8 90.8 89.0 88.9 85.6 84.3 88.3 88.7 88.6 86.9 KCH 83.5 85.1 83.8 83.5 88.2 82.5 81.1 81.0 75.8 78.5 81.7 82.2 KCH 86.1 85.6 82.2 82.8 87.4 82.1 81.1 80.8 76.2 79.7 81.5 80.0 (DH) Latest data reflects continued local pressure on the 4 hour target into 2016/17, in line with national pressures. Recovery plans had been agreed with both local acute providers, and are subject to constant review, noting that a number of key actions relating to estates at KCH and GSTT have been subject to delay which have negatively impacted on capacity and patient flow. 5
Accident and emergency Whilst performance against the 4 hour standard has begun to improve at both GSTT and KCH, it is significantly below the national 95% target. KCH - KCH met its agreed performance trajectory in February, and was marginally below trajectory in March. March under-performance was driven by unplanned bed closures (related to infection control, and the decant of wards to allow for emergency estates modifications and staff training) as well as significant staffing issues related to the booking of agency staff through NHS Professionals. GSTT – Performance has begun to improve following peaks in attendances in March. GSTT continues to be affected by on-going estates works which will not be fully completed until 2018, but with a number of key milestones due to be met in the coming months. GSTT has also been affected by staffing issues, particularly regarding GP availability in the UCC and the loss of registrars. Additional Consultants are being recruited, and focus is on the on-going delivery of the ED recovery plan Wider System – DTOCs and MFFDs continue to be low following an intensive piece of work in December, with KCH seeing some of their lowest levels for many months. An increase was noted at GSTT, but this may reflect the Trust’s ‘Helping Patients Home’ week which focussed on discharge pathways and caused an increase in reporting. Work is on-going with the Trust to ensure that best practice pathways are in place, and that discharge notifications are issued at the earliest possible stage to reduce delays. 6
King’s College Hospital Recovery Plan (1) Overview and drivers for under-delivery of 4 hour standard The national standard of patients being assessed, treated and discharged has not been consistently met at KCH since 2013/14. This, and subsequent slides, give details of the underlying causes for under-delivery, the improvement trajectory, and corrective actions being undertaken. Key drivers of under-delivery: Capacity – beds and bed management - Trust operating with fewer beds than had been planned. Although now built, Charles Polky ward at DH has been unable to be substantively staffed, and planned site moves to Orpington and PRUH have not been able to progress due to bed pressures on these sites. Very high levels of bed occupancy (98% plus) at both DH and PRUH Discharge – Reduction of delayed discharges has been a key focus, with levels halving since Christmas. However, there is an imbalance between time to discharge between local and non-local boroughs, with focus on embedding Discharge to Assess and Trusted Assessor protocols to reduce external delays. Repatriations consistently occupy around 28 beds at any one time, with delays for non local Trusts a particular challenge, and accounting for two thirds of delays. 7
King’s College Hospital Recovery Plan (2) Key drivers of under-delivery (Cont.): Staffing - Staffing has been a significant challenge, including overall staffing levels and sickness rates in ED, filling GP rotas for UTC, overall nursing levels and the numbers of experienced nursing staff available resulting in the enforced requirement to maintain safe staffing of the existing bed base. Overnight Delivery - Challenging out of hours performance - staffing and capacity constraints; ED ‘exit block’ leading to the regular displacement of Majors into Minors and the relocation of staff to majors. Performance management oversight strengthened to optimise Minors performance and preserve disaggregated flows. Best Practice Pathways - Inability to implement ambulatory care and frailty pathway improvements due to overall pressures and capacity constraints. Staffing issues have prevented the systematic application of RATing to rapidly offload ambulances. Urgent Care Centre (now renamed Urgent Treatment Centre) – High levels of non-admitted breaches due to sub-optimal pathway. UTC due to open during 2016/17, but now delayed until June 2017 due to estates issues. Specialty Response - Length of wait for specialty response continues to be an issue, with 1 hour standard only met 50% of the time. There is a need to systematically apply and enforce inter professional standards, alongside further work to understand barriers to compliance. 8
2017/18 overall improvement trajectory 100.00% KCH Aggregate Trajectory Actual/Forecast (month end position) Target 95.00% 2017/18 Trajectory 90.00% 85.00% 80.00% Improved Additional Discharge to Additional Dedicated System Flow - beds Access/Trusted 75.00% Beds (DH) UCC (DH) Occupancy Accessor (PRUH/Orp) >92% 70.00% Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 April Delivery vs Trajectory Trust’s compliance has been steadily improving since February March/early April performance affected by unplanned loss of up to 38 beds due to Infection Control. Recovery mid April. April aggregate of 85% versus end of April milestone of 86.29%. Encouraging evidence of improvement at both sites, with both delivering frequent above trajectory compliance but not yet fully stable. 9
Recovery Plan: Planned actions to improve ED performance (1) The following key actions are planned to improve performance against the 4 hour standard at Denmark Hill: Additional beds and bed management - 23 beds on Charles Polky ward due to open in July 2017. This will faciliate improved flow from ED and AMU reducing volumes of patients waiting for beds in ED. DH will also move to a centralised bed management model to provide clearer oversight and ownership. Streamline medical referral pathway - granting direct admission rights for medical patients to ED to reduce waits for specialist opinion and have clearer pathway to AMU Establishment of dedicated assessment areas for medical and surgical referrals – Providing rapid intensive support for those patients at highest risk of admission which will improve flow from ED, embed ambulatory pathways and reduce emergency admissions and length of stay Implementation of frailty pathway - establishment of Frailty Assessment unit, including in- reach to ED to support better management of complex patients and support reduced admissions and LOS 10
Recovery Plan: Planned actions to improve ED performance (2) Management of minors stream and physical separation of UTC - It is recognised that stronger management of the minors stream needs to be in place in order to keep minors breaches to a minimum. Senior oversight now in place 7 days per week. In addition, UTC is currently delivered as part of main ED footprint, which causes significant physical capacity constraints. From June the UTC will move into a dedicated space and operate 24/7 to reduce risk of overnight breaches. Ring-fencing of Rapid Assessment and Treatment Space (RAT) – Ring fencing 2 ED cubicles to allow for Majors and Ambulance arrivals to be rapidly assessed by a senior decision maker. Will reduce decision making time and improve flow Discharge to Assess and Trusted Assessor - Work undertaken across SE London to reduce volume of patients staying in hospital whilst assessments are undertaken, with patients instead supported at home, in intermediate care or in residential homes. Trusted Assessor protocols will allow for assessments to be undertaken by ‘trusted’ health and care professionals to reduce discharge planning delays. Expected to significantly reduce levels of delayed discharges and better support ability of patients to regain independence post hospital admission 11
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