Agenda item

Bromley Winter Assurance Plan Update


Report ECHS19039


The Board considered a report which provided an overview of the schemes delivered throughout winter 2018/19 from Bromley CCG and the London Borough of Bromley winter pressures monies fund through the Better Care Fund (BCF). These schemes were identified by the Bromley A&E Delivery Board and were presented for the Board's information. Funding for this year's Winter Resilience Schemes was £646k for Bromley CCG and £1,027k from the London Borough of Bromley and were delivered under budget.


The winter resilience funding was allocated across the health system to ensure there was additional capacity in the system to ensure patients were seen in the appropriate care setting. This included schemes to support patients and clients in secondary, community and primary care. The report looked at the utilisation and impact of the CCG schemes and the London Borough of Bromley schemes, which would inform future planning for Winter 2019/20.


Despite the PRUH A&E four hour performance target worsening this winter, all Type A&E attendances had decreased slightly when compared to the previous years. Both surgical and medical admissions were comparable to the previous year’s winter period. Although it was difficult to ascertain a sole attributable reason for this, as well as the mild weather, the significant added capacity to the system to support people in the community would have contributed to the lower attendances. Positively, there was a notable improvement in the reduction of reported Delayed Transfers of Care (DToC) for winter 2018/19, with an average decrease of 79% versus the previous year. Compared with 2016/17, winter 2018/19 saw an 82% reduction of reported DToC's. This had led to a reduction of 416 (75%) lost hospital bed days compared to the previous year.


The focus on Discharge to Assess Pathway and Community Continuing Healthcare Assessments had increased the number of patients leaving the hospital earlier with temporary packages of care whilst the full assessment was carried out in the community. Over the past two financial quarters, Bromley CCG CHC had consistently met and surpassed the NHS England target of 85% of full Decision Support Tool (DST) assessments in the community.


Although all winter schemes offered were in the majority well utilised and showed positive impact, significant numbers of people still required hospital based care, especially those with complex health and social care situations. Due to the complexity and demographic of patients, further work was required to provide a more integrated response to admission and attendance avoidance. A full review of the Bromley CCG Winter Resilience Schemes had been provided to Board Members. For 2018/19 Bromley CCG had commissioned several Resilience Schemes aiming to provide additional capacity across a range of community services. This had included increased primary care capacity through additional GP appointments, an advanced nurse practitioner home visiting service and a multidisciplinary Bromley @Home Team was piloted to prevent avoidable admissions from the community and facilitate earlier discharges from the hospital. An additional nurse post was implemented for Extra Care Housing units to support proactive and clinical management of patients to reduce LAS call outs. There was also increased capacity commissioned across urgent care centres and a performance matron post within the hospital to support patient flow. Other highlights from the review included there having been an additional 2,260 appointment slots for GP practices and these hub appointments had been 96% utilised, highlighting that it had been a valuable service.


In relation to winter communications, the CCG had funded a flu advertising campaign both in print and digitally to encourage the take up of the flu vaccinations, specifically for over 65s. This work had been extremely beneficial, with the borough having the highest uptake in London. The CCG had also designed an information poster for Care Homes called 'Are you concerned about a resident?'. The poster had listed alternative pathways instead of ringing 999, where appropriate, and had included a direct line to services such as NHS 111 and Rapid Response.


The conclusion of the Local Authority’s review had been that broadly the areas of spend were appropriate and provided much needed capacity to the system during the winter months. The main points of learning included that Intensive Personal Care had been over utilised, whilst Fast Response Personal Care had been underutilised. Fast Response Personal Care had most likely been underutilised due to the increase in utilisation of the Discharge to Access Pathway, to which it was very similar. Dependent on the evaluation of the Discharge to Access Pathway, it may be a better use of spend to focus on Intensive Personal Care to support more intensive need for patients wanting to return home, but needing intensive support once there to manage for a short period of time after discharge.


Recommendations of the review included the need to start to plan as early as possible, preferably in the summer, to allow for staff recruitment to increase the capacity of existing schemes and services. Services needed to be streamlined to avoid confusion when patients were referred, and for further development of an integrated urgent and emergency care system in the community that provided a single point of access to a range of community services. A Board member noted that the learning and recommendations for next winter stated that ‘a more realistic approach’ needed to be taken with regards to staff recruitment. The Urgent Care Lead, Bromley CCG responded that the plan would be built on in advance, considering different ways of working, to get it up and running before the start of the winter period. A Board Member queried if the staff required would be available to be recruited. The Urgent Care Lead, Bromley CCG responded that there were schemes such as banks for nurses and consultants that could be utilised. The Managing Director: Bromley CCG said that staffing was a fundamental problem for the NHS, and noted that it would be more sustainable to get in early, and offer potential staff the commitment of work over the winter period. The Chairman highlighted that retention of staff was the number one concern across London.


A Board Member noted that a table of figures had been provided in the report, listing surgeries uptake of the Advanced Nurse Practitioner (ANP) home visiting scheme, which indicated that the uptake was significantly lower and patchier than expected. The Urgent Care Lead, Bromley CCG responded that this had been followed up, and previously GP clusters had indicated that they liked this service. Some practices had utilised the service, whereas others had been able to manage their capacity issues well. The Clinical Chairman: Bromley CCG advised Board Members that the criteria for Rapid Response referrals had changed, and there needed to be a greater clarity of services with fewer choices. Practices needed to understand the services that were available to them, and use them sensibly as a resource.


A Board Member suggested that the funding allocations for services could be considered, and if a service was not being used to its maximum, a proportion of its funding could be transferred to services that were over utilised. The Urgent Care Lead, Bromley CCG agreed, and said that the flexibility of the services would be looked at. In response to a question from another Board Member, the Urgent Care Lead, Bromley CCG clarified that the £10k included in the 2018/19 spend had been for a deep cleaning service which had been required at a hospital.


In response to a question, the Urgent Care Lead, Bromley CCG advised Board Members that Hunter Consultancy had been working with King’s College University Hospitals NHS Trust to review the discharge process, identify community pathways and improve planning. The Managing Director: Bromley CCG noted that this was funded by NHS Improvement, and not by the CCG.


The Chairman requested that an update on the Bromley Winter Assurance Plan be provided to the meeting of the Health and Wellbeing Board on the 21st November 2019.


RESOLVED that the update be noted.

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