Struggling Wye Valley NHS Trust to take a lead on "transforming" urgent care in the county

The focus of the transformation  takes urgent care services “closer to home”.

Talks over the future for urgent and emergency care in the county have been underway since September, including an assessment of views from the public on the way services could be developed.

David Farnsworth, CCG executive lead nurse, said: “The engagement we’ve done so far showed us very clearly what patients want from urgent care. This includes clearer information about the help available, feeling confident they can get help when it’s needed, that it will be relevant to their individual circumstances and knowing that it will be safe and efficient. Older patients particularly want to be as independent as possible but able to get support if it’s needed.

“We have listened to this feedback and have decided to change the way we buy (commission) urgent care services. Our new approach is to focus on the outcomes people across Herefordshire have told us are most important so that providers have the freedom to integrate and be innovative in how they achieve these outcomes for patients.

This  approach is relatively new in the NHS but is gaining momentum in a number of areas.

With consideration as to how the range of organisations currently providing urgent health care in the county can work together,  WVT  has been invited to present proposals on the future pathway of urgent care - and how they would take on the role of lead provider.  

Richard Beeken, WVT chief executive, said that, despite its special measures status, the trust was “up to the challenge” with work on a “detailed plan” already underway.

“This involves a number of changes to the way we operate and gives us the opportunity to shape services and align our plans to meet the requirements of our commissioners, which includes the CCG.

 “Of course, we can’t do this in isolation, and we shall be working closely with our commissioners, patients and a range of other parties to break down traditional barriers and develop innovative approaches and partnerships to meet the challenges before us,” he said.

If the trust’s proposals are assessed as meeting the CCGs requirements they could be implemented by autumn next year.

Along with A&E, urgent care includes GP out-of-hours services, minor injuries treatment, NHS 111, some mental health support, the county’s Walk-In Centre and Accident and Emergency.

WVT already provides A&E and a range of urgent care services in Herefordshire, including Minor Injuries Units at Leominster and Ross-on-Wye.

The CCG reached the view that there was no other provider with the necessary experience and range of expertise that could potentially deliver the benefits sought.

Commissioning that focuses on patient outcomes is referred to nationally as Outcomes Based Commissioning and has been used in other areas for service redesign.

This approach is in keeping with the NHS England Five Year Forward View which sets out the need to break down the boundaries between family doctors and hospitals through the development of new models of care and to redesign and integrate urgent and emergency care services. Our approach will take forward this work in Herefordshire.

Earlier this week, the Hereford Times revealed that, each week day, Hereford County Hospital faces having to discharge between 40-50 patients staying overnight or longer to cope with current admissions.

But WVT has been told by the NHS that extra beds may not be answer with alternatives found through new measures to manage patient flow.

Figures in a system resilience plan for the county’s health services  show the hospital now taking between 35-55 emergency admissions each day.

Around 23 per cent of these patients are discharged the same day, leaving between 30-45 non-elective overnight admissions.

A further 40-60 day case elective patients can be expected each week day and between 7 -11 elective patients overnight.

This means  that from its total bed base of 208, the hospital has to discharge between 40-50 patients who have been in hospital overnight or longer.

The plan breaks the discharge options down to between 7-11 elective patients and 33-40 non electives.

At weekends, when admissions are less, there is a need to discharge between 25-35 non elective patients who have been admitted for at least one night.

On current assessment non-elective patients stay an average 6 days and elective patients 2 days.

With bed occupancy targeted at 95 per cent this gives an overnight requirement of between 220 to 240 beds dependent on the month of year - well above the actual operating  bedded state of the hospital and contributing to its difficulty in managing to the 95% 4 hour target in A&E.

The interpretation doesn’t currently include additional overnight elective patients transferred to the private sector  because the hospital does not have the physical capacity to deal with them without further  compromising urgent care capacity.

This is around  50 patients a month or, roughly, a further 6-8 elective beds each weekday.

Current bed occupancy at the hospital is 95 per cent and well above the national performance expectation of  around 85 per cent.

Advice Wye Valley NHS Trust (WVT) has received through the NHS emergency care intensive support programme suggests extra beds may not be the answer in the medium-term.

That advice cited a significant number of operational changes to patent flow management that could cut the average length of stay.

This, however, came before the upsurge in A&E attendances which, in part, has  increased admissions as a result.

As previously reported, A&E is already working at well above the average 125 attendances a day it was designed for.

Operationally, the trust is only managing to deal with the required bed numbers using capacity set aside for Day Case surgical patients, and the Clinical Assessment Unit, which is should not really be used for patients requiring overnight admission.

This increases the costs for the trust in having to staff areas in addition to normal capacity overnight, and is seen as potentially compromises the quality of patient care.

For the past year, the county’s health community has emphasised alternatives to admission and how much more can be done to deliver those alternatives.

There is an acceptance that continual “fire-fighting” over patient numbers and pressure on moving patients through the system has become the norm rather than ensuring that systems are working effectively.

Against this background, the plan identifies priorities that include additional bedded capacity, better access to “clinically appropriate” care, improved “anticipatory” care, and earlier identification of patients able to be discharged in the day.

The resilience plan concedes that current health services across the county are complicated for patients, with too many entry points that direct patients to services more acute than their needs require.

Patients are often being returned into a more acute environment within the community rather than enabling them to return to their home with help and support.

A&E attendances have seen a year on year growth of 1,640 (3.6%) from 2012/13 to  2013/14. The majority of the increase since 2012/13 1,368 (83.4%) are over 65’s.

Activity at the Minor Injuries Units (MIUs) has reduced by more than the increased attendances at A&E.

Overall, MIU activity has been reducing significantly since October 2012 representing a 38 per cent reduction year on year.

The closure of MIUs in January this year is recognised as having an impact although the trend tips towards significant reduction..

A&E has also seen an increase GP and other provider’ referrals while the number of ambulance arrivals is up by 6 per cent from 2012/13 to 2013/14.

Delayed discharges have seen a five per cent growth.

Analysis has shown a significant decrease in Prime care Out of Hours (OOH) activity year on year due to the introduction of the NHS111 service, which came on line last year.

Prime care, however, is still recorded in the plan as taking atround 2,500 (OOH) contacts a month.

The Hereford GP Walk in Centre (WIC) saw a drop in activity over 2013/14.

However, initial statistics for 2014/15 show a significant increase in such activity to a reported average of around 100 patients a day.

In terms of patient flow to A&E, WIC has reported an increase of 32 per cent year on year with an average of 30 patients per month in 13/14.

March saw a significant increase to 49 patients referred into A&E from the Walk in Centre.

During the last 4 months, the NHS111 data has shown an increasing trend towards ambulance, A&E and

other services, confirming other data showing a rise in emergency activity.

The virtual wards implemented as a pilot across the 8 Hereford GP practices in October last year have supported early discharge for 174 patients, and kept around 135 from being short stay admissions.

A RAAC (Rapid Access to Assessment and Care) scheme  started in January this year had taken 51 patients out of WVT by June and another 32 supported through earlier discharge.

Taurus Healthcare is currently running three GP extended hours “hubs” in Hereford, Ross-on-Wye and Leominster open  open 8am-8pm Sat and Sun and 6.30pm-8pm Monday to  Friday.

The Hereford System Resilience Plan was assured by NHS England in October this year triggering the release of £1.1 million to support targeted improvement in the county’s urgent care.

The related Herefordshire System Resilience Group  has prioritised new investment in various multi-agency partnership schemes agreed as being most beneficial to demand management, diversion and more efficient patient flow through the county’s health and social care pathways.

This funding, however, is non-recurrent.

Additional funding has also  been recently allocated from central resilience funds and plans for this are currently being worked on.

Specifically these are additional system resilience monies worth £2.6 million as direct support to Wye Valley NHS Trust (WVT), and targeted resilience funding of around £92,000 to improve crisis care and early intervention in psychosis, which will extend liaison psychiatry to the community hospitals.

WVT has developed an internal action plan of its own to improve urgent care services with the support of two HNS bodies the Emergency Care Intensive Support Team and the Ambulatory Emergency Care National Network.