ITEM 13 The Lanarkshire Winter Plan 2023-24 Debrief
North Lanarkshire Council · 22 May 2024
Back to IJB Performance, Finance and Audit Committee — 22 May 2024 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: 13 SUBJECT: The Lanarkshire Winter Plan 2023/24 - Debrief TO: IJB Performance, Finance, Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer NL HSCP Author(s) of Report Craig Cunningham Head of Commissioning and Performance DATE: 22 May 2023 1. PURPOSE OF REPORT This paper is coming to the IJB PFA for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☐ Endorsed By: ☐ Stacey Anderson, Services Support Project Manager on behalf of Craig Cunningham, Head of Commissioning and Performance 3. RECOMMENDATIONS The IJB PFA is asked to approve the following recommendation(s): - [recs] (1) Note the content of the winter 2023/ 2024 debrief. (2) Note the actions for inclusion in Winter Plan 2024/ 2025. (3) Seek a copy of the winter plan 2024/ 2025 in December 2024.
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2 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Winter 2022/23 was one of the most challenging in the history of the NHS, where NHS Lanarkshire was operating under significant pressure and had been through aa sustained period of ‘Black Status’ and accordingly, required a significant improvement plan. Through 2023/24 NHS Lanarkshire invested in a whole system redesign through Operation Flow 1 - Stabilise, 2 - Redesign for winter 2023/24 and worked towards 3 - Reform for early 2024. 5.2 This work, which relied heavily on North and South Lanarkshire HSCPs involvement in a ‘Whole Lanarkshire’ approach, enabled the system to come out of ‘Black Status’ and to gain confidence that the system could improve. The improvement programme of Operation Flow strengthened the whole system approach with focused investment and matrix working with a Task and Finish Transformation programme which was aligned with prioritised investment. 5.3 Significant system change takes time, and the resilient leadership and cultural shift required was a key factor in the success achieved. It was also recognised that there is still significant work to be done in these elements in order to achieve and sustain the key end points required. 5.4 As such, winter 2023/24 was significantly better than the previous winter with robust planning and escalation approaches developed and embedded. These supported a greater system resilience with the front door performance ranking moving up significantly when benchmarked with peers – of note in December NHS Lanarkshire had a very positive position going into Christmas. 5.6 The system learning in 2023/24 cannot be underestimated and the key actions to reduce demand, expedite timely discharges and support people to remain well at home - taking into account the key elements and learning from the winter of 2023/24 - will be built into future plans. 6. Summary of Key Issues 6.1 National Feedback 6.1.1 In previous years, NHS Boards – alongside IJB partners - were asked to complete a template to provide a commentary on each of the key parts of the Yes ☐ No ☒ N/A ☐
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3 system, outlining those areas that worked well, those that could have been improved and areas for future learning for subsequent winter planning. Whilst such a template has not been issued, there has been a request asking for any key learning points. The points highlighted below are the main issues arising from the winter debrief session held in March 2024 and associated learning. A number of the action points have been noted as ‘full year’ issues which will be supporting flow as part of the Operation Flow 3 work. 6.2 Multi-agency approach to planning 6.2.1 As well as the ‘Whole Lanarkshire’ approach which has been adopted in previous years, there was a greater emphasis on utilisation of the wider Local Resilience Partnership (LRP) in the preparation of the report. In particular, undertaking a ‘winter breach’ exercise with scenario planning associated with a significant flooding event and how to manage same. The event, hosted in South Lanarkshire Council HQ, included all members of the LRP and provided for good learning. Beyond that, the winter plan was prepared in conjunction with the Health Board, two IJBs and two Councils thereby again offering the ‘whole Lanarkshire’ shared approach to support wider system pressures across the winter period. 6.2.2 The plan also took account of areas covered in the national preparing for winter event at which key officers were well represented. 6.2.3 Action for 2024/25 – continued maximisation of LRP in shared planning. 6.3 Operation Flow 6.3.1 A conscious decision was taken to focus efforts on maximising ‘flow’ as opposed to establishing additional ‘surge’ beds this winter. This worked well in so far as it reduced ‘safari’ ward rounds, reduced the numbers of patients ‘stuck’ in surge beds out with the normal flow systems – for both NHS and Social Work staff, and in turn, meant a lower number of Delayed Discharges across the system than in previous years. 6.3.2 The increased presence of Senior Clinical Decision Makers in the Flow Navigation Centre (FNC) to provide a ‘Call before you Convey’ pathway for Scottish Ambulance Service (SAS) teams and associated ‘Consultant Connect’ for Primary and Community Care services also facilitated reduced hospital attendance and, where necessary, supported direction to the right service at the right time, first time. 6.3.3 There continued to be promotion of greater awareness of respective roles across acute, community and social care such that as far as possible, people were cared for in the most appropriate setting. This has also been assisted by greater numbers of community/social care staff participating in the daily calls and ward based MDTs to identify people who could be discharged safely. 6.3.4 The concept of ‘discharge to assess’ has also been promoted strongly and there is further scope to extend this practice over the coming year in preparation for next winter. Similarly, the ‘Pathway 4’ team has also
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4 contributed to many patients on a palliative care journey being able to be discharged from hospital and managed safely in their own homes in accordance with their wishes. 6.3.5 Work continues in the enactment of both acute and community flow foundation bundles and, in particular, setting realistic Planned Date of Discharge (PDD) dates and seeking to honour same and reducing late cancellation of planned discharges. 6.3.6 The daily multi agency calls, along with the establishment of site / sector based Flow Oversight Boards (FOBs) to provide weekly reports to Core Executive Flow Oversight Board (EFOB) and Core FOB meetings have also assisted in early identification of any issues and respective action planning. 6.3.7 Actions for 2024/25 will be developed and delivered though the reform and transform programme and will include: a) Optimisation of Unscheduled Care by: 1. reducing LOS and hospital occupancy achieved with improved ward efficiency 2. implementation of flow foundation bundles, 3. creation of digital front door through eTriage 4. increased redirection from our system access points, 5. increased scheduling of minors, 6. expansion of FNC+ Plus to facilitate speciality direct admission, 7. creation of frailty front door a) Reduction in core physical beds with increased virtual capacity and wearables co-ordinated/monitored through FNC+ Plus and b) Enhanced interface between primary, community and acute services to maximise appropriate access and pathways along with escalation and de- escalation of care. c) Continued development of Operation Flow programme and governance structures to co-ordinate, monitor, support and scrutinise development and implementation. 6.3.8 It is helpful to note the work associated with the creation of the FNC + model in more detail. Management of unscheduled care demand is a key element to reducing hospital occupancy and thereby improving unscheduled care performance and management of established staffing levels. The essential role that our FNC has undertaken to date in managing urgent and unscheduled care across our system is recognised, however there are significant opportunities to upscale the existing model. A Vision Session, involving some 70 senior clinical and managerial leaders across the whole
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5 system was held in March 2024 to ensure a consensus on the development of FNC+ Plus through 2024. 6.3.9 FNC+ Plus aligns to the principles of a NHS Lanarkshire Operational Command Centre. This is a key component in managing demand across the system and is underpinned by a consistent Senior Clinical Decision Maker (SCDM) presence 24/7 in the FNC. The key areas of focus for FNC+ Plus are to: • Manage GP demand • Manage Home Care demand • Maximise ED redirection • Co-ordination and monitoring of increased virtual capacity • Maximise redirection and non-conveyance from SAS, NHS 24/111 • Facilitate rapid/support discharge 6.3.10 The planning assumptions that the additionally that FNC+ Plus will provide includes: co-ordination of acute and community Outpatient Anti-biotic Treatment (OPAT) capacity; connection to locality response to support escalation or escalation of care; co-ordination and monitoring of new virtual bed capacity (including wearables); facilitating direct admission booking to reduce lengthy waits in Emergency Departments (ED) and support direction of patients; creating GP hub capability to develop pathways for access to diagnostics; and redirection from ED/Minor Injuries through new pathways to treatment rooms and scheduling to minors where appropriate. Given that managing demand is key to improving Unscheduled Care performance, there is a commitment to delivering the first phase of FNC+ Plus by Quarter 2 (July 2024). 6.4 Maximising Use of Staff 6.4.1 There was a greater understanding of staff pressures such that there was a more proactive approach to aligning staff to service need – including multi- sectorial cross working to support system-wide flow. This also saw a reduction in the negative impact felt when there are too many staff off across the main public holiday periods at Christmas and New Year. 6.4.2 Of specific note was the additional social work staff in and around the hospitals over the peak public holiday period and weekends through January to ensure as many patients as possible were able to be discharged without delay. 6.4.3 Also, as described in 3.8 below, staff were also transferred from the vaccination service during the peak winter period to support acute hospital sites.
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6 6.4.4 Action for 24/25 – continue to ensure effective planning of staff annual leave/Public Holiday leave. 6.5 Joint Working with other groups 6.5.1 Scottish Ambulance Service (SAS) - Continued to strengthen and develop increased joint working between SAS and NHSL in relation to maximising shared pathways – as described at 3.4.2 above, and better utilisation of advanced skills. These ‘advanced skills’ were available in ED as well as the Primary Care Out of Hours (PCOOH) service on a rotational basis. This also saw maximising use of Hospital Ambulance Liaison Officers (HALOs) across the period as well as the regular participation of SAS on the daily calls. 6.5.2 Community Pharmacies - Greater alignment between community pharmacy and hospital pharmacy aided speedier discharge. This was a really good example of effective joint working and will be built upon for next winter. 6.5.3 Actions for 2024/25 – seek to maximise working with other staff groups to expand available resources to manage peak demand. 6.6 Support from GPs at Public Holidays and Weekends in January 6.6.1 Local GPs again provided services at key Public Holidays and Saturdays through January. Across the period this winter, this resulted in 2,882 patients being managed via their own GP as opposed to potentially being seen in PCOOH or ED. 6.6.2 Specifically, in relation to the NHSL PCOOH service, they were able to re- direct 183 patients to their own GP on the two public holidays and a further 480 patients on the Saturdays through January. In turn, this assisted in PCOOH being able to manage the increased demand on the service at that time thereby negating the need to transfer patient overflow to ED as may have been required had the additional support not been available. 6.6.3 Whilst the scheme continues to be successful, it is still possible to increase wider awareness of this such that more patients know they can access their own GP when required to seek urgent care. 6.6.4 Action for 2024/25 – Plan to continue to offer service with wider comms of availability. 6.7 Vaccination Programme 6.7.1 Public vaccination uptake was generally in keeping with national averages and above average for those in the poorest SIMD areas. There however continues to be a need for greater uptake of NHS staff vaccination, this despite a number of developments from the previous year to improve accessibility for NHS staff. This will require further review in the coming year to seek to maximise uptake.
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7 6.7.2 Council owned accommodation that had previously been available to support the vaccination programme is no longer available as it has been re-purposed back to its original use. Since the turn of the year, there has been a reduction in uptake of other vaccines due to the vaccination centres not being as locally accessible as previously. This will require to be addressed prior to winter 2024/25. A number of the vaccination staff also transferred temporarily to other posts – predominantly in the three acute hospitals, to provide additional support to ward/other staff from mid-December through to March to assist in the management of winter pressures. 6.7.3 Action for 2024/25: a) Develop plans to maximise increased staff uptake of vaccinations b) Identify alternative accommodation with a view to maintaining at least national average uptake c) Continue to work with acute colleagues to facilitate staff transfer from vaccinations to provide additional support to hospital sites. 6.8 Infection Prevention and Control (IPC) 6.8.1 Whilst there was not a significant direct issue of high Covid prevalence, there were significant pressures from other winter pathogens e.g. a peak in flu in Jan (although less than last year) but also high levels of respiratory syncytial virus (RSV), mycoplasma and especially norovirus. In a few areas, there continued to be some legacy practice which resulted in a higher level of Covid lateral flow testing being undertaken than necessary which affected flow. This appeared to be due to an over sensitive approach being taken with Covid despite other respiratory infections also being prevalent at this time of year. 6.8.2 This involved asymptomatic patients being tested ‘just in case’, albeit not being isolated whilst awaiting test results. In turn, other respiratory conditions which would previously have been subject to ‘point of care’ testing were going un-noticed. 6.8.3 IPC colleagues raised this with respective acute hospital management teams to take corrective action. 6.8.4 It was also evidenced that visitors were responsible for bringing infection into the sites and there needs to continue to be an emphasis around education in this regard next winter. 6.8.5 Actions for 2024/25: a) Encouragement of ‘point of care’ testing as the default approach for respiratory infections. b) Communications campaigns focused on educating visitors not to attend if having any symptoms, e.g. respiratory infections.
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8 6.9 Use of Data 6.9.1 Using real time data assists significantly in relation to flow management. This has shown improvement across the winter period albeit there is still some further work required to ensure timeous entry to patient management systems. In turn, this would help inform the understanding of likely pressure points to support the agreement of appropriate mitigating actions. 6.9.2 Action for 2024/25 – Continue to increase real time data entry to support awareness of system pressures and potential mitigation of same. 6.10 Communications 6.10.1 There was a regular flow of public messaging across the winter period – heightened at times of greatest pressure. This covered all main aspects of the winter plan from preparing for winter, encouraging uptake of vaccinations and utilising Winter Health Hub to assist in reducing attendances to ED. 6.10.2 Beyond that, the communications plan saw specific work with local pharmacies, NHS 24 and the creation of bespoke videos to be used when EDs were particularly busy with a view to assisting to provide alternative care destinations. 6.10.3 Action for 2024/25 – Prepare winter communications programme to address all respective areas. 6.11 HSCP Performance 6.11.1 Delayed discharge performance is always a key metric focused on during winter and it has not been uncommon to see the number of delays sitting at over 100, with peaks of around 130, during peak winter pressures in recent years. 6.11.2 Through the work of Operation Flow and the major developments set out within the IJB’s Strategic Commissioning Plan such as the roll out of Home Assessment Teams, performance throughout winter 2023/24 has been much more stable. In previous years, North Lanarkshire sat in the top 3-4 partnerships in terms of rate of delay, but the partnership has sat consistently below the Scottish average throughout the winter and other peak pressure periods such as the Easter fortnight. 6.11.3 This is well demonstrated by the Delayed Discharge bed days recorded over the last 12 months:
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9 Figure 1: On-site bed days delayed Figure 2: Off-site bed days delayed
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10 Figure 3 - ***Management data*** - Referrals, discharges and end of week delay position Figure 4 – national comparison – rate of delay 7. IMPLICATIONS 7.1 Employee Implications As workforce supply challenges persist across health and social care, this has led to increased competition for recruitment and retention at local, regional and national level. This poses an ongoing risk and emphasises the need to develop new and transformational roles in response to growing demand across health and social care to ensure there will be a sustainable supply of workforce to meet future health requirements of an ageing population in Lanarkshire, and across Scotland.
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11 7.2 Financial Implications The winter plan was delivered within the anticipated budget levels. It should be noted that the scope for use of reserves or other sources of funding will be reduced in 2024/25. 7.3 Climate Change, Sustainability and Environmental Implications There is no climate change, sustainability, and environmental implications within this report. 7.4 Other Implications 7.4.1 The Winter Plan highlighted the significant risks which were likely to be encountered and the need for the respective mitigations which were put in place. Respective risks have been downgraded as the winter period has passed. 7.4.2 The learning points and actions arising from the winter 2023/24 debrief will form part of the winter plan for 2024/25. In so doing, the various measures currently used for measuring wider system performance will continue to be utilised and refined if required. 7.5 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.6 ASSOCIATED MEASURE(S) 7.7 FINANCIAL This paper has been reviewed by Finance:
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12 7.8 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.9 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.10 INEQUALITIES & FAIRER SCOTLAND DUTY Yes ☐ No ☐ N/A ☒
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13 EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. BACKGROUND PAPERS N/A 9. APPENDICES Please include a glossary of terms if not already included. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Craig Cunningham, Head of Commissioning and Performance Ext:3704 (Phone: 01698 453704) Email: craig.cunningham@southlanarkshire.gov.uk Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☐ N/A ☒
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14 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed