Dr Daniel BeckettDr Daniel BeckettConsultant Physician, NHS Forth ValleyConsultant Physician, NHS Forth Valley

IntroductionShort term (3 month) report commissioned by the Emergency Access Delivery Team (EADT) at the Scottish Government in March 2009 into pressures experienced by NHS Scotland over winter 2008/2009

Main findings of the report were initially presented at the National Winter Planning Conference at Airth Castle in June 2009

IntroductionThe main driver for the project was the drop in performance across the organisation against the four hour target (now standard) for emergency access of careIncrease in twelve hour trolley waitsUnfavourable press articles

Novel methods of assessing pressure in the Emergency Department were presented

ED time profilesSite A, Dec 08 Site B, Dec 08

ED time profilesNHS Scotland, Dec 08 NHS Scotland, Jul 09

IntroductionThe Project was commissioned to

Give a clear description of the demands on the system, levels of activity and pressure points over the winter periodAssess the extent to which the system ‘coped’ or showed signs of strain Describe the aspects of winter planning and system response which worked and which didn’tDerive lessons for the future, and explore how recommendations may be implementedIdentify the extent to which additional capacity in primary care can improve the effectiveness of the whole system of unscheduled care.

FindingsMany health boards dealt with similar challenges across the winter months and festive periodsNine recommendations were made giving health boards direction and guidance on meeting these challenges for winter 2009/2010

ChallengesLevel of winter planning highly variable between health boards Timescales for starting the winter planning process varied from April to NovemberAcute sector and primary care preparing separately in many instances

Some Community Health Partnership (CHP) winter planning leads were appointed – worked wellCommunity Mental Health Services

Poor engagement from social work departments

RecommendationOne. Health Boards should ensure that their winter planning starts early and that the process includes Community Health Partnerships and Social Work Departments. There should be a clear relationship between the winter plan and pandemic flu plan.

ChallengesEscalation plans variable across boards

Different triggers (observed activity/predicted activity)Variable buy-in from some stakeholders (for example CHPs)Difficulties with accessing primary care bed base in some boards

Complex referral pathwaysBed ownershipPatient TransportPatient choice

Challenges

RecommendationTwo. Integral to the winter plan should be the escalation plan. This should involve all stakeholders including Community Health Partnerships. This includes the utilisation of beds in Community Hospitals, and protocols for referral should be agreed now, dealing with any challenges regarding perceived bed ownership

Challenges9/14 territorial health boards have developed their own internal predictor of activity.However there is patchy use of System Watch in some boards, and no use in others

Perceived inaccuracyPerceived complexity

System Watch has a proven track record of accurate long, medium and short term prediction of unscheduled activity.

Challenges

RecommendationThree. System Watch should be used systematically for long to medium term predictions of unscheduled activity, and those predictions should be acted upon to create the required capacity, both in terms of beds and to support initiatives to avoid admission. Consideration should also be given to the use of System Watch for planning of elective activity over the winter months.

ChallengesThe greatest number of four hour breaches and 12 hour trolley waits occurred on Monday 5th JanuaryThe majority of boards restarted elective activity on this date, whilst still experiencing high levels of bed occupancy following the festive periodOnly one board utilised System Watch to align elective activity with predicted unscheduled activity over the winter period

ChallengesScotland emergency and elective inpatient admissions

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RecommendationFour. Health boards should undertake more accurate modelling over the festive period to plan elective capacity and optimise the use of bed capacity. This may then enable hospitals to reduce the number of elective admissions on the first Monday in January. Further consideration should be given to front loading the first week in January with minor procedures, and back loading with majors. Also medical elective activity (such as clinics and endoscopy lists) could be back loaded during this week.

ChallengesThe numbers of patients discharged over the festive periods were significantly reduced, largely due to a reduction in discharges from downstream wards. Hospitals then vulnerable at the start of January

Lack of senior medical staffLack of social work inputLack of AHP support

Challenges

Challenges

RecommendationFive. The level of discharges over the holiday period should be improved. This might include:

increased consultant presence with dedicated discharge ward rounds in downstream wards

Discharge early in the day is key to maintaining capacity

utilisation of a rapid response team (or equivalent) of AHPs with access to homecare packages without recourse to social work assessmentre-energising and establishing ownership of the Estimated Date of Discharge policy, plus introducing Nurse Led Discharges (NLDs)

RecommendationSix. Medical directors should ensure that appropriate numbers of consultant medical staff are on site to deal with the predicted activity over the two week festive period

ChallengesFour territorial health boards across Scotland did not hold daily bed meetings over the winter periodIn other boards bed meetings were held once, twice or three times daily. Many boards are using sites as a single bed base, changing the admitting hospital dependent on whole system pressuresClinician attendance at, and input into, bed meetings was generally poor

RecommendationSeven. Daily bed meetings should take place at every site, and should occur twice daily during the winter period. Consultant medical staff should have a greater awareness of bed management issues

ChallengesAll eleven mainland health boards relied on boarding patients as a solution to capacity issues over winter 2008/2009There are few written protocols for boarding patients, and policies (and extent) vary widely

60% of all medical patients on one siteThere is a move towards increasing boarding of patients from Emergency Departments and Acute Medical Units (and also ‘treat and transfer’ policies between sites)

ChallengesBoth boarding of patients and ‘treat and transfer’policies are considered by the Scottish Government to be poor practice. This is especially the case when patients are boarded from Emergency Departments and Acute Medical Units.

RecommendationEight. Boards should work towards eliminating the boarding of patients as a solution to bed capacity problems. Specifically, the boarding of patients from the Admissions Unit and/or Emergency Department should never occur.

ChallengesIt was noted that the elective 18 week referral to treatment target (RTT) and the four hour standard for access of emergency care could be perceived as being competing rather than complementary

Surgical wards kept closed over the festive period despite 4 and 8 hour breaches in the Emergency DepartmentReturn to full elective activity on 5th January despite high levels of bed occupancy and predictions of high levels of unscheduled medical activity

RecommendationNine. If all the above measures have been undertaken, including consultant review and discharge of downstream patients, and all capacity beds filled (including community beds) then the 98% standard for emergency access of care should be achievable

If ongoing difficulties then priority should be given to emergency admissions over routine elective proceduresThe Scottish Government has, for the last 10 years, made it clear that clinical decision making always trumps routine elective targets.

And finallyThanks for listening (again...)Full report available online at www.shiftingthebalance.scot.nhs.uk//initiatives/sbc-initiatives/emergency-access-delivery-programme/winter-planning/

Now over to you...

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