Agenda item

Report CSD22088

The Senior Commissioning Manager – Urgent & Emergency Care, SEL CCG (Bromley) (“Senior Commissioning Manager”) provided an update on the One Bromley review of winter 2021-22, including recommendations for the Urgent and Emergency Care Transformation workstreams and winter 2022-23 planning. A summary of the review of winter 2021/22 and planning for next winter 2022/23 was presented and is attached at Appendix A.

The Senior Commissioning Manager advised that during winter 2021/22, the system had been under considerable pressure, managing a fourth wave of COVID-19 alongside the usual seasonal pressures having a significant impact on the workforce as well as demand for services. The whole system had continued to run at full capacity for the whole of the winter period. The Better Care Fund (BCF) winter funding provided to the London Borough of Bromley (LBB) £1,069,000 and SEL CCG (Bromley) £669,000 was used to support the system to respond to winter demands across the five key pillars of the 2021/22 Winter Plan. These were:

1.  Increasing system capacity

2.   Data sharing and escalation

3.  Single Point of Access and discharge arrangements

4.  Admissions avoidance 

5.  Communication and engagement

Members were advised that 75% (£808,520) of the Local Authority budget was used to fund additional workforce capacity and Extra Care Housing step down flats all year round, whilst 25% of this budget was utilised to provide:

-  additional therapy and brokerage capacity;

-  7-day working and social admission avoidance resource;

-  mitigate increased financial impact due to the need to undertake increased number of post discharge assessments within 4-weeks national discharge arrangements; and,

-  project management to respond and manage the seasonal pressures.

In response to a question, the Senior Commissioning Manager advised that the Extra Care Housing step down flats were included as they were funded through the BCF winter schemes, however they were provided all year round. The LBB Assistant Director for Integrated Commissioning confirmed that it was normal practice for the funding to be spent in this way.

The SEL CCG (Bromley) funds were allocated in line with what worked and learning from previous years. This included:

-  increasing primary care capacity through additional primary care access hubs appointment slot for Bromley patients;

-  utilising additional NHS England/Improvement funding to set up GP Virtual Assessment Hubs (VAHs) to support with 111 demand and COVID-19 calls – this reduced inappropriate referrals to the urgent treatment centres with, on average, 8.5 patients per day redirected into their own practice or GP Hub appointments, rather than having to attend an urgent treatment centre;

-  additional capacity in admission avoidance teams including Rapid Response (RR) and Rapid Access Therapies Team (RATT);

-  additional palliative care support in care homes;

-  additional clinical capacity across primary care, GP out of hours service and urgent treatment centres during the festive period; and,

-  allocation to support a winter communications and engagement campaigns aimed at both the public and the workforce.

Members noted that proactive public engagement would be key to the success of the scheme and enquired about the allocated spend on winter communications and engagement. The Senior Commissioning Manager advised that more funding had been allocated to winter communications during 2021/22 than ever before, and similar was planned this year. A patient leaflet had been sent to residents to provide information on the health and social care services available and how they could be accessed. A winter branding campaign had also been developed across partners, and a directory of services was produced to help hospital staff identify patients for referral into the community. The Senior Commissioning Manager confirmed that the recommendations related to 2022/23 and agreed that a revised version of the report, including the allocated spend on communications and engagement, could be circulated to Members following the meeting.

The One Bromley Winter Review Workshop had been held on 10^th May 2022, and was attended by the majority of One Bromley partners, including colleagues from King’s College Hospital – Princess Royal University Hospital (PRUH); London Ambulance Service (LAS); London Borough of Bromley – Adult Social Care; SEL CCG – Bromley; Oxleas NHS Foundation Trust; Bromley Healthcare; Bromley GP Alliance; Bromley Third Sector Enterprise; Greenbrook Healthcare and the High Intensity User Service. The workshop focussed on three main themes:

1.  Demand and capacity planning

2  Unpredicted issues and actions to mitigate future pressures

3.  Recommendations for summer and next winter planning

From the workshop, system partners had formulated an initial set of recommendations. These were categorised into Urgent and Emergency Care (UEC) system transformation recommendations and winter planning recommendations, and had been taken to the Bromley A&E Delivery Board in June 2022. Within the UEC system transformation recommendations there were three workstreams – capacity and recruitment; hospital discharge / community wrap around services; and UTC / Emergency Department attendance and admissions. In terms of recommendations for winter planning 2022/23, the five key pillars from 2021/22 had been refined further to focus on:

1.  Increasing system capacity

2.  Meeting seasonal demands

3.  Data and escalation

The Senior Commissioning Manager highlighted that the key point taken from last year was early agreement of the scheme, and discussions were underway with partners at the One Bromley A&E Delivery Board regarding the scheme spend. A draft would be presented at the meeting in August, and would be fully signed-off by September 2022 – the final draft would then be presented to the relevant governance bodies. It was noted that a winter intelligence hub had been launched the previous year, which would be further developed to include a winter dashboard and daily intelligence on demand and capacity. If there were surges in the system, they intended to improve the early identification of pressures and actions to mitigate this.

In response to a question from the Chairman, the Place Based Director (Bromley) – SEL CCG (“Place Based Director”) confirmed that the winter pressures had not abated in recent months, as would usually be expected, and both GPs and the A+E Department had continued to experience pressures. To help address this, they had looked to increase capacity, such as locating a GP in the outpatient departments over the Easter period. Data was being shared to enable flexibility in terms of how the increase in the number of patients was managed. In addition to the winter schemes, there were a number of strategic discussions around expanding the virtual ward approach, and work in the community, to reduce the reliance on hospitals. Part of this would also be dependent on how the Primary Care Networks responded to the ‘enhancing access to General Practice’ initiative. It was highlighted that communication with residents was essential and there was also a need for engagement in terms of self-management, where appropriate.

A Member asked for clarification in relation to the proposed scheme ‘front door admission avoidance – social care element’ and the impact tracking statement that the ‘posts recruited to 0 social admissions throughout the period’. The Senior Commissioning Manager said that this related to a Social Care Manager being located within the Emergency Department to assist with admissions avoidance and facilitate discharge where possible. The LBB Assistant Director for Integrated Commissioning advised that this post had been recruited to part time, rather than full time, over the winter period – for the coming winter something similar would be provided through Bromley Well, with signposting and advice provided on alternatives to entering the hospital.

A Member noted that ensuring a high uptake of the flu vaccination in the community could help towards mitigating winter pressures and asked what plans were in place. The Place Based Director highlighted that the uptake of the flu vaccination in the borough was particularly good – for several years Bromley had recorded the highest uptake across London for the 65+ cohort, and was also one of the top boroughs for uptake by the under 65 at risk cohort. The importance of the flu vaccination was recognised – it was noted that there were some alarming reports in the media regarding an earlier, and more severe, outbreak of flu in Australia during the winter period. They were therefore keen to ensure that practices were prepared to vaccinate care home residents as early as possible this year. Bromley Healthcare and the Bromley GP Alliance also supported practices in the delivery of flu vaccinations to housebound patients. The Place Based Director advised that GP practices would also be asked to deliver COVID-19 vaccinations alongside flu vaccinations, and it was hoped that the mass vaccination centre, which would move from the Civic Centre to The Glades, would do the same. As part of the COVID-19 vaccination programme they would be stepping up previous sites, such as the Orpington Health and Wellbeing Centre. This year, all practices had been asked to place their orders of the flu vaccination earlier, as in previous years there had been delays in receiving the vaccines.

In response to questions, the Senior Commissioning Manager said that, as mentioned, traditionally there was a dip in activity during summer, and a rise in winter – however this summer activity had stayed in line with last winter, which had put the whole system under pressure. It was noted that there were differences in activity, including more focus on respiratory issues, and therefore the planning of the flu and COVID-19 vaccination programmes would be key. The Place Based Director advised that COVID-19 was more than a respiratory illness and a specialist COVID-19 services had been established. With regards to the cost of living crisis, no analysis had been undertaken to see if this was impacting the increased activity. The Place Based Director advised that last winter an increase in flu cases had been anticipated, and there had been an increase in childhood infections of bronchiolitis, which had been included in the modelling for the upcoming winter period. It was noted that it would not be possible to measure the impact of the cost of living crisis on discharges from hospital. The Place Based Director highlighted that this was a system responsibility, and not entirely a health issue – a careful assessment of a patients’ home environment was undertaken before discharge from hospital and follow up calls made. They would continue to monitor what was happening across the system, and how the needs of the population were changing, and would collectively do their best to mitigate and manage changes.

A Member noted that residents had raised issues about being unable to get timely GP appointments and enquired if there was any information on demand and average waiting times. The Place Based Director said that the number of GP appointments had increased significantly over the last couple of years, compared to pre-pandemic levels, due to additional virtual appointments. It was noted that face to face appointments were also back to pre-pandemic levels, however some residents were still finding it difficult to get an appointment with their GP. Work was underway with GPs in Bromley to improve their telephony systems, and ensure that those patients wanting to have a face to face appointment were able to do so. The Chairman requested that an update on GP Access be provided to the next meeting of the Health Scrutiny Sub-Committee.

The Chairman thanked the Senior Commissioning Manager and Place Based Director for their update to the Sub-Committee.

RESOLVED that the Committee noted:

i.)  the actions and activity undertaken by the One Bromley System Partnership during 2021/22 winter to mitigate system pressures against the five pillars of the One Bromley Winter Plan; and,

ii.)  the outcome of the Winter Review Workshop in May 2022 that identified:

-  recommendations for system resilience / improvement and recovery throughout the summer; and,

-  recommendations for 2022/23 winter’s planning.