Item 10 - Resilience Update
North Lanarkshire Council · 22 March 2023
Back to Health and Social Care Integration Joint Board — 22 March 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 10 SUBJECT: Resilience Response TO: Integration Joint Board Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Kirsty Orr, Head of Planning and Development, NHSL Ross McGuffie ,Chief Officer North HSCP DATE: 7th March 2023 1. PURPOSE OF REPORT 1.1 This paper is coming to the Integration Joint Board: For approval For endorsement To note 1.2 This paper sets out the actions taken to date during the pandemic response. 2. ROUTE TO THE INTEGRATION JOINT BOARD 2.1 This paper has been: Prepared Reviewed Endorsed By the command structure in the Health and Social Care Partnership. 3. RECOMMENDATIONS 3.1 The IJB is asked to: (1) Note that NHS Lanarkshire stood down its Covid Live Incident down in January 2023, though command structures have been adapted to continue to focus on ongoing wider resilience challenges, specifically around service pressures (2) Note that NHS Lanarkshire was able to move from black to red status on 6th March 2023, following a successful ‘firebreak’ as part of Operation Flow 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 NHS Lanarkshire stood down its Live Covid Incident in January 2023, however, the operational pressures emanating from the pandemic recovery have been pronounced, with NHS Lanarkshire in Black status since 27th July 2022. Yes No N/A
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2 5.1.2 Operation Flow was developed to create a ‘firebreak’ to rapidly reduce hospital inpatient capacity, then creating the staff capacity to work on service redesign to bring the system as a whole back into equilibrium. 5.1.3 Following the 9-day firebreak, hospital inpatient capacity reduced by around 15% across Lanarkshire, supporting the system to move from black to red status on 6th March 2023. 5.2 Operation Flow 5.2.1 Operation Flow is the whole system strategic planning approach aimed at supporting a sustained recovery of the entire health and social care system. Language matters and consequently the use of the word FLOW within the context of this work has a clear purpose as outlined below: • Focused – a time limited intervention with exit to a sustainable service model • Lanarkshire– recognising the various geographies and demographics affecting our services across the County • Optimal – focusing on improvement rather than completely fixing the system during the project timescale, including learning from other systems • Whole System – the project must be truly whole system covering the whole patient journey into and out of our health and social services 5.2.2 Flow is underpinned by the Lanarkshire Discharge Without Delay programme. 5.3 Stabilising our system through a Firebreak 5.3.1 It was clear that progressing improvement work across our system would be exceptionally challenging when our 3 acute sites and community services continued to be in escalation and full capacity. Consequently, it was agreed to attempt to stabilise and decompress our system through implementation of a “Firebreak” to allow sustained improvement work to progress at pace. 5.3.2 It was recognised no single specific action could achieve this and the firebreak aimed to coordinate a range of actions, including some that were already underway, to gain the scale of response required. 5.3.3 Following extensive whole-system collaboration and planning, the Firebreak commenced on 23rd February and ran until Friday 3rd March 2023, covering the following coordinated actions: Mobile multi-agency team undertaking daily review of all acute inpatients across the 9 days, with the aim of identifying actions that can be taken to facilitate discharge or transfer to a more appropriate location to reduce the number of additional patients across our Acute Hospitals. Mobile multi-agency team undertaking daily review of all patients in an offsite bed across the 9 days to create flow from our Acute sites. Mobile Multi-agency teams capturing the number of clinically stable patients who are waiting for a diagnostic test by modality to expedite these tests/procedures to facilitate discharge.
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3 Provision of professional to professional clinical decision making support for care home residents prior to conveying to hospital. SAS crews using consultant connect to access support / advice from Emergency Medicine colleagues for patients prior to making a decision to convey to hospital (excluding 999 category patients). Reduced number of access routes to hospital based urgent and emergency care. All potential referrals to Emergency Department, Care of the Elderly and Hospital @ Home from SAS crews via Consultant Connect to determine if there are other alternative care options rather than hospital (excluding 999 category patients). Expanded access to Ambulatory Care during the Firebreak period by increasing hours of operation over the weekend period and redirection of patients referred by NHS 24 on 111 to treatment rooms for wound care, minor burns etc. Increased senior clinical decision maker resource in Hospital @ Home to support more people in the community for the duration of the Firebreak period. Increased capacity within Home Assessment Teams within Wishaw and Cumbernauld areas to support discharge. 5.4 Measuring Impact 5.4.1 At the end of the firebreak on Friday 4th March, hospital occupancy had decreased significantly to 96% in University Hospital Wishaw, 92% in University Hospital Hairmyres and 90% in University Hospital Monklands. 5.4.2 In addition, capacity was further improved by increased pre-noon discharges (up to 25% across the three sites) and increased use of the discharge lounges (up to 17% across Lanarkshire). 5.4.3 Each ward was given a target number of daily discharges, the ‘ward beat’, with Haimryres reaching 88% of its target over the 9 day firebreak and Monklands and Wishaw achieving 92%. This was a very positive outcome given it was the first time running this methodology. 5.4.4 Consequently, ED performance also improved, including over the weekend of the firebreak:
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4 5.4.5 The Flow Navigation Centre supported four key pathways during the firebreak: Hospital at Home – 99 referrals were supported through the firebreak (week before firebreak was 49) Treatment Rooms – 10 patients (9 North, 1 South) were redirected to the Treatment Room Care Home pathway – 10 patients were referred and reviewed by the GP OOH service, with only 1 requiring admission Consultant Connect – 96 NHS24 patients were diverted away from ED by self-care advice or redirection to another service such as Pharmacy, District Nursing or GP Practice. 5.4.6 The Scottish Ambulance service received 1968 emergency calls during the firebreak, with 42% resolved without the need to attend a hospital. Referrals to Hospital at Home also increased markedly, with 16 referrals during the firebreak and use of Consultant Connect was above average throughout. Ambulance turnaround times at the acute sites also decreased, being below average throughout the firebreak. 5.4.7 Overall, the firebreak has been very successful, demonstrating a genuine whole system effort. Feeback from staff involved has also been positive, with staff feeling both listened to and supported and noting that the sites are feeling much safer, e.g. earlier identification of deteriorating patients. 5.4.8 Whole system learning sessions are now being taken forward to identify key learning from the firebreak, including crucially how we create sustainable ways of delivering some of the key aspects of the firebreak activity. The Flow Foundation Bundle is one of those key aspects, setting out a combined set of simple rules for all receiving and inpatient wards to improve flow: Discharge beat for each ward MDT Board Rounds each day Planned Date of Discharge Criteria-Led Discharge Pre-noon discharge and use of the discharge lounge Real-time updating of patient movements on Trakcare Daily site huddles to ensure situational awareness and resolution of flow challenges
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5 5.5 Improvement Actions 5.5.1 Operation Flow aims to use the decompression of the firebreak to then move into rapid and sustained improvement for urgent and unscheduled care as a priority for the Lanarkshire system. 5.5.2 Four layers of improvement activity have been identified across the system as a whole, with activity already underway to implement key aspects: Layer 1 - Supporting at Home – service improvement actions that support people to remain in a community setting e.g. telehealth, community care, pharmacy. Reablement and actions to avoid escalation. Expand the alternative methods of care delivery including expanding the scope of Consultant Connect and Hospital @ Home, enhanced connections with Housing, Third and Voluntary Sectors Layer 2 – Redirection/Triage at Front Door – service improvement actions that direct people to stay away from front doors including FNC e.g. call before you convey, scoping the concentration of staff resource at EDs to support re-direction for the 7 -14-day period (senior medical staff, pharmacy, ENP, SAS etc) Enhancement of ambulatory care models e.g. OPAT, scope further opportunities for Hospital @ Home or to alternative methods of care delivery e.g. Ambulatory Care Layer 3 – Emergency Department Flow – service improvement actions that revise our ED and Front door processes inc. Continuous Flow Model, Assertive Flow management, increased scheduling of minor injuries through 111 / FNC, Review of ED processes, Implementation of REACT model across the 3 sites, Implementation of Continuous Flow Model and Assertive Flow management, Scheduling of minor injuries Layer 4 – Discharging – service improvement actions that enhance Ward Discharge Planning Processes including expanded use of the Discharge Lounge, PDD, am Discharge, Criteria Led Discharge, Discharge to Assess across all localities, Diagnostic Virtual Wards, maximising the use of Home Assessment/Home First and Reablement as an alternative to prescriptive referrals, supporting assessment in the individual’s own home and maximising rehab opportunities and independent living 5.6 Delayed Discharge 5.6.1 One of the key aims of the Firebreak was to utilise multi-agency teams to review all inpatients on a daily basis, with the aim of improving the flow of the 95% of patients who don’t need supported discharge, but also supporting earlier identification of the 5% who will require support. 5.6.2 Consequently, one of the anticipated outcomes of the firebreak was the identification of a significant number of referrals for Social Work/Social Care support, though it is hoped that once the backlog of newly identified patients is cleared, the more proactive identification of patients will help to reduce delays in future. Over the nine-day firebreak, 180 referrals for supported discharge were received in North Lanarkshire, with a further 81 in the three days running up to the start. To put this into context, during peak winter pressures in 2019/20, North Lanarkshire averaged 77 referrals per week for supported discharge, which was the highest rate in Scotland. 5.6.3 However, despite the spike in demand, the recently improved performance in delayed discharge has been maintained. At the start of the firebreak, there were 84 delays in the system, with 40 of these on the acute sites, and at 7th March, this has reduced to 70 delays, with 27 on the acute sites.
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6 5.6.4 There remains a risk of short-term increases in delays due to the very high number of referrals for complex assessment (14 referrals in a single day for complex assessments on one site alone in the middle of the firebreak). While additional Social Work capacity has been identified to support these cases through the assessment process, there is a risk that a number will become delays before complete. 6. CONCLUSIONS 6.1 There has been a tremendous whole system effort to plan Operation Flow and to enact the firebreak at scale and pace. 6.2 The reduction in occupancy levels across all three sites has allowed NHS Lanarkshire to move from black to red status on 6th March 2022, following over 6 months in black status. 6.3 Attention has now moved to make the most of the system decompression to move forwards with the ambitious change programme identified to ensure the positive performance improvements can be sustained and indeed further improved over time. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES This relates to all nine national outcomes. 7.2 ASSOCIATED MEASURE(S) A weekly performance framework has been developed to track progress. 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT Risk IJB 09/21 sets out the impact of Covid on the roll out of the IJB’s Strategic Plan and is currently rated at very high. 7.5 PEOPLE The Strategic Planning Group has increased in frequency to quarterly throughout the pandemic to support engagement with staff, service users and carers and staff roadshows have also recommenced on a quarterly basis. 7.6 INEQUALITY & FAIRER SCOTLAND DUTY Yes No N/A 8. BACKGROUND PAPERS None. 9. APPENDICES
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7 ............................................................................. CHIEF OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Ross McGuffie on telephone number 01698 752 591.