Annual Members’ Meeting
3rd September 2012
Welcome
Bruce Laurie
Chairman
1
Annual Members’ Meeting 2012
Governors’ update
Harry Dale
Lead Governor
2
Work of the Council of Governors
• 4 formal Council of Governor meetings held and 1 joint meeting
with the Trust Board
• 12 meetings of the Council of Governors working groups
• Appraisals and appointment of Non-Executive Directors considered
• Approval of the appointment of the Chief Executive
• Governor drive for improvements to responding to complaints and
listening to our patients
• Continue to be the ‘eyes and ears’ of the Trust and feed back
concerns to management which are incorporated into the Trust’s
Patient Experience action plan
• Championing improved patient experience, and involvement in
patient safety walkabouts
3
Changes to constituencies
• Governors approved changes to the constitution in order
to make constituencies more representative of our local
communities by splitting the current Wiltshire
Constituency into three separate areas:
• Northern Wiltshire (2 seats)
• Central Wiltshire (2 seats)
• Southern Wiltshire (1 seat)
• Elections in October/November to elect governors to
these new seats and to Swindon (1 seat) and
Gloucestershire and BANES (1 seat)
4
Changes to the Council of Governors
• Clive Bassett (Appointed governor – Prospect House),
replaced Andy Cresswell (Thames Valley Chamber of
Commerce)
• Dr Jon Elliman (Appointed governor, The Academy) replaced
Lesley Donovan (Academy)
• Cllr Jemima Milton (Appointed governor – Wiltshire Council)
replaced Carole Soden (Wiltshire Council)
End of Terms:
• Kevin Parry (public governor- Swindon) replaced Katherine
Usmar
5
Membership update
Membership by Constituency
217 156
Staff Members
1473
Swindon
Wiltshire
2870
7222
Oxfordshire and West
Berkshire
Gloucestershire and
BANES
6
Developing membership
• Targeting existing forums to spread the word about
membership (parish councils, health forums)
• Focus on increasing youth membership, involvement
in the Trust’s “School’s day”
• Plans to visiting community sites to raise awareness
of membership for patients and staff
7
Upcoming dates/events
• Elections in November for seats in Swindon, Gloucestershire
and BANES, Northern Wiltshire, Central Wiltshire, Southern
Wiltshire and Staff constituencies
• Council of Governors 8 October 2012 at 5.00pm GWH,
Academy
• Council of Governors 29 November 2012 at 4.30pm GWH
Academy
• Look out for events taking place to celebrate 10 year
anniversary of the Great Western Hospital
8
Annual Members’ Meeting 2012
The Year in Review
Nerissa Vaughan
Chief Executive
The environment we’re working in
A period of uncertainty and change
•
Health and Social Care Act 2012 made into law after considerable debate
•
The shift in responsibility for commissioning has begun – moving from
Primary Care Trusts (PCTs) to GPs (via Clinical Commissioning
Groups – CCGs).
•
PCTs and Strategic Health Authority (SHAs) due to be abolished in March
2013
•
National Commissioning Board established
•
Local Involvement Networks to be abolished and replaced with
Health Watch organisations
•
Local Health and Wellbeing Boards bringing together health, social care,
local authority, and CCGs to work in a more joined up way
•
A range of other bodies set up as part of the new structure of the NHS
-2
-4
2014/15
2013/14
2012/13
2011/12
2010/11
2009/10
2008/09
2007/08
2006/07
2005/06
2004/05
2003/04
2002/03
2001/02
2000/01
1999/00
1998/99
1997/98
1996/97
1995/96
1994/95
1993/94
1992/93
1991/92
1990/91
1989/90
1988/89
1987/88
1986/87
1985/86
1984/85
1983/84
1982/83
1981/82
1980/81
1979/80
1978/79
1977/78
1976/77
1975/76
The NHS is facing “zero growth” in NHS spending
compared to an historic average of 3.2% a year
% Annual change in real term NHS Expenditure and planned
expenditure 1974/75 to 2014/15
12
10
8
6
4
2
0
A challenging but successful year
2011-2012
•
Merger with WCHS – most significant change in past year
•
The first year spent aligning services, getting to know people and
understand what works and what we could do better together
•
Work started on delivering the benefits of an integrated organisation:

Improving patient flow across the Trust – GWH and community
staff, Social Services and GPs

Productive Ward being rolled out across the Trust

Developing a new Ambulatory Care service

Appointment of Interim Chief Nurse, Hilary Walker, to lead work on
raising profile of nursing
A challenging but successful year
2011-2012 - continued
Very good performance across over 200 key indicators
•
Just two cases of MRSA across the Trust (out of 1.3m pt contacts)
•
19 cases of Clostridium difficile (C.diff) – 50 fewer than the threshold
•
Just one case of Grade 4 pressure ulcer at GWH, 10 fewer than last year
•
23 cases of Grade 3 and 4 in community – well below 40 threshold
•
GWH became a designated Trauma Unit in April 2012
•
Improvements in PEAT scores – especially Princess Anne Wing at the
Royal United Hospital in Bath
A challenging but successful year
2011-2012 - continued
•
In the top three Trusts in the South West in the latest independent staff
survey results (and in top 20% nationally for staff satisfaction) CQC Staff
Survey
•
9/10 patients rate their care as good or excellent
•
From over 1.4m patient contacts last year we received 444 formal
complaints – which is 0.03% of the patients we cared for
•
Compared with the previous year when we were responsible solely for the
GWH, we had 242 complaints representing 0.04% of patients we cared
for
•
Increased the number of parking spaces for patients at visitors at the GWH
by 10%. After some teething problems the new pay on exit system now
means the car park reaches capacity on far fewer occasions than before
Areas for improvement
Endoscopy
•
National growth in demand in all Endoscopy units being experienced
nationally
•
PCT Performance notice to improve Endoscopy six week waiting times by
October
•
GWH now on track to deliver against the trajectory
•
All fast track and urgent patients treated within appropriate timescales.
Improvements also taking place to provide capacity for this growth and
improve the estate to provide more single sex accommodation
Areas for improvement
Clinical correspondence – clinic letters to be typed and sent to GPs within
two working days
•
A challenging target which the Trust has continued to focus on improving the
speed with which letters are sent to GPs
•
Over the course of the year there has been gradual improvements
Delayed Transfers of Care
•
Over the course of the year there’s been a rise in the number of patients
who are medically fit to be discharged but who remain in hospital
•
Big challenge for health and social care as it relies on both social care and
the NHS playing its part
•
Working together with Local Authorities to tackle this problem to free up
beds
Extra scrutiny
•
Nine unannounced inspections from the Care Quality Commission in 12
months across the Trust – five at GWH and four in the community.
•
Concerns raised:
•

Hydration document on wards

Consistency of safety checks in theatres

Use of Extra Bed Spaces (EBS) on the wards
Following sustained focus, as the Trust we’ve now been given the all clear and
are compliant with every area the CQC measure.

Hydration documentation is much improved (and acting as an example to
other Trusts)

Consistent implementation of the World Health Organisation (WHO) Safer
Surgical Checklist and Team Briefing in theatres has improved processes

By the end of September the final few Extra Bed Spaces will be removed
which is good news for patients and good news for staff

We expect many more inspections over the next 12 months
The year ahead (1)
A new strategy
•
An ageing population, rising costs, increasing competition, reductions in funding,
new technology and drugs and rising expectations mean we can’t stand still.
•
Work has begun on developing a new five year strategy for the Trust – designed to
put us in the best position to meet future challenges
•
Six workstreams are looking at where we need to get to, to provide patients
with the best services not just now but in the future:
•

Maternity

Patient Flow

New Technology

Long Term Conditions

Community Hospitals & Neighbourhood Teams

Marketing
We want to be the Trust that delivers the best for our patients and commissioners.
The year ahead (2)
Pay and Reward
•
Regional Pay, Terms and Conditions Consortium established to look at
options around how we can meet the financial and operational challenges
in the future
•
20 Trusts involved
•
70% of our income is spent on pay – this year pay pressure has added an
extra £1.7m on our pay bill and this pressure grows each year
•
We’ve already looked at a whole range of other areas where we can
reduce cost and we need to seriously look at what we do with pay and
reward
•
The aim is to avoid some of the more difficult decisions we may have to
make in the future if we don’t deliver savings i.e. redundancies
•
No decisions on what this means in practice for staff have been made –
work at this stage is simply looking at the options
•
Final decision rests with the Trust Board here
Financial overview
Maria Moore
Director of Finance and Performance
Financial headlines for 2011/12
• Income
• Surplus
• Financial risk rating
• Payment of suppliers
£290.5m
£536k
3
88% within 30 days
• KPMG External Auditors opinion
– Unqualified Opinion on the Trust’s Financial Statements
– Limited assurance opinion on Trust’s Quality Accounts (the best you can have)
Income £290.5m
Other income
£22.9m
Education & Research
£7.5m
Other PCT & Trusts
£30.3m
NHS
Swindon
£112.6m
NHS Wiltshire
£117.2m
Patients Treated
Community Services
Elective
35,082 patients
34,043
£65.6m
£39.9m
£1,179 per patient
£1,173
803,545 community patients
46,507 minor injury patients
7,445 inpatients
Emergency
£73.4m
Other Clinical
Services
A&E Attendances
£7.8m 70,731 patients
35,804 patients
Outpatients
£38.6m
309,343 patients
400,570
£119per
£96
perpatient
patient
How we spent the money
Services from other Trusts
and NHS bodies
£16.3m
Clinical insurance
£5.7m
All other expenses
£14.7m
Supplies/services for clinical &
general requirements £25m
Other services inc Facilities
Management £18m
Pay £172.1m
Drugs £17.8m
Building & Estates
£20.3m
Approximately £794,000 spent each day to provide Trust services
24
What a typical treatment costs the NHS
£203
First outpatient appointment
£4,559
Emergency hernia
£109
Follow-up outpatient appointment
£7,097
Major hip operation
£1,236
Birth by normal delivery
£5,138
25
Capital Expenditure £4.1m
Cath Lab
£407k
Plant,
Equipment &
Machinery
£733k
Car Parking at
GWH
£410k
Buildings
£209k
Birthing Centre
£94k
IT & Clinical
Systems
£1469k
Medical Equipment
Replacement
£784k
Speech and Language Therapy
Service in Wiltshire
Jennifer Lewin
Head of Speech and Language Therapy
What is communication ?
Universal
Why are Pictures Powerful?
Specialist
Speech and Language Therapy Services in Wiltshire
Provided to:Children
Adults
ALD population
in Wiltshire with the exclusion of adults in the south
(SFT.) and in Swindon.
Looked After Children’s
Nursing team
Safeguarding
Nursing team
Continuing
Care
School nurses
Speech and Language
Therapy
Learning Disabilities
Nursing Service
Health visitors
Community
Medical
Team
Paediatric Diabetes
Nursing Team
Healthcare Training team
Range of cases
•
•
•
•
•
•
•
•
•
•
•
Complex feeding issues in babies
ASD diagnostic team
Acquired communication impairment
Specific language Impairment
Phonological disorders
AAC from high tech-low tech
Progressive neurological conditions
Voice disorders
Fluency
CVA
Oral cancer
Service Aims
• Focussed on community model
• The best care close to home
• Engaging with families who find it hard to
access traditional models of healthcare
• Working with others
• Focus on early intervention
• Flexible workforce to meet needs
Adults
Provided in :
• Local community hospitals
• Residential and nursing homes
• Client’s homes
Provision :
• Specialist assessment, diagnosis and advice
• Group intervention
• 7.2 wte SLT/SLTAs supporting the Adult Service
Referrals are received from :
• 52 Nursing and Residential Care Homes
•
GP surgeries
• 11 Neighbourhood Teams
• 3 community hospitals
• 1 stroke unit
• 1 hospice
• Consultants from surrounding Acute Hospitals
Children
The children’s speech and language therapy service in
Wiltshire went out to tender in 2009
New service commenced May 2010, 3 yr contract with
option of extending to 5yrs
Jointly commissioned by Wiltshire Council and NHS
Wiltshire
Children
•
•
•
•
•
•
•
340 Early Years settings
240 schools
14 clinics
4 District Specialist Centres.
3600 current caseload
150-200 referrals a month
23 wte SLT/As supporting the
children’s service
• 150 requests for statutory
assessment per annum
Newly commissioned model of service delivery
ensures:
• Early identification of need by all professionals
• Single point of entry.
• All referrals are be triaged.
• Signposting to other services, the SLT website and
advice line.
• Choice of location and time.
• Children will be assessed by a specialist Speech and
Language Therapist within 13 weeks.
• Programmes of care delivered by the TAC to develop
communication rich environments.
• The service is flexible to meet the needs of the
population of Wiltshire.
Choice Making
Visual Timetables
• Transition times
• To let children know
what is expected
TEACCH
• Structured teaching
• Change activities to
maintain interest
• Reward at the end
• Focus on adult agenda
and timescale
Sentences
• “Thank you for helping me with my talking.
I’m a lot happier now and have lots of fun
playing with friends and talking to everyone.
Mummy and Daddy keep smiling at all the
new words I say.”
• Parents writing for their child
• “Jack… came for a course of speech therapy,
although he was reluctant to get involved at
the time we have continued to do the
worksheets. His speech is now 100%
improved.”
• School
• “I just wanted to say that the information you
gave us last night was really helpful – so good
to be given it rather than have to find it out! I
hope there will be more training opportunities
like this for SENCOs and other school staff
too.”
• SENCO
• “Meeting other people makes me feel less
isolated. I didn’t want to attend, but thank you
for including me”
Natter Matters: Parkinsons group
Collaborative Practice
Key to successful outcomes
• Parents/families
• Paediatricians/specialist health services
• Teachers/SENCos
• Early Years settings
• HVs/School nurses
• Specialist SEN services
• Team around the Child TAC
• Clients/carers
• Multidisciplinary team around the adult – Physio, OT, District
Nurse, Dietitian
Partnership
Quality
Community
The New Ambulatory Care
Service at GWH
Ijaz Ahmed
Charlotte Cannon
Amanda Pegden
Sharif Ullah
Introduction
•
•
•
•
Why we needed a new way of working
What is ‘Ambulatory Care’?
Directory of Ambulatory Emergency Care
Implementing the service
Why we needed Ambulatory care?
•
•
•
•
Problems with the traditional way of working
Increasing demand for emergency admissions
Investment in the NHS slowing
Delays and inefficiencies caused by high bed
occupancy
• Patients looked after by incorrect specialties also
contributing to delayed discharges
Definition of Ambulatory Care
• Clinical care including diagnosis, observation,treatment and
rehabilitation,
“not provided within the traditional hospital bed base or within
the traditional outpatient service, and that can be provided
across the primary/secondary care interface”
Ambulatory Care Sensitive Conditions (ACSCs)
• Care of a condition perceived as urgent
• Requires prompt clinical assessment, undertaken by a
competent clinical decision maker.
• Require prompt access to diagnostic support
What did we want to achieve with the
6-month pilot?
•
•
•
•
•
•
•
•
Reduction in length of stay
Reduction in hospital admissions
Reduction in number of ward moves
Reduce medical outliers
Single sex accommodation for all
Faster time to senior medical review
Improvement in the ED service
Provide rapid diagnostics to patients on the Acute Medical
Unit and Ambulatory Care unit
• Improve the patient experience
Impact on patient flow
Peak admissions late in the afternoon
Which type of patients make up this bulge?
 Segmentation of patients by
Length Of Stay
 0-1 day LOS
 Short stay 48-72 hours
 General Internal medicine
> 2days
 20-25% of patients with zero
LOS also took up beds (same
% of 1 day LOS)
Institute for Innovation and Improvement
Institute for Innovation and Improvement
• Identified extent of pre-existing ambulatory
care services
• 49 emergency conditions (including surgical)
with the potential for ambulatory care
– Aimed as a guide for Trusts to enable service
development
– Learning from each other
Financial implications
• Total cost of Inpatient care to NHS England
2009/10 …~ £20.5 billion
• Emergency admissions (60%) 12.2 billion
• ACSCs (11.6%) cost ~ £1.42 billion
• This is equivalent to £1739 /ACSCs admission
• An Average cost of £170,590 for ACSCs per
General practice.
Suitable Conditions
Condition
Acute Admissions From
Care Home
Target %
Condition
Target %
30
Gastroenteritis
60
Acute headache
30
Lower resp tract inf
30
Anaemia
60
Oesophageal stenosis
60
Asthma
Cellulitis
10
60
Painless jaundice
PE
30
60
30
Pleural effusions
60
10
Pneumothorax
10
Chest pain
Community acquired
pneumonia
Congestive cardiac failure
COPD
30
10
Diabetes
DVT
60
>90
Falls
First seizure
60
60
Seizure in known
Stroke
Supraventricular
tachycardias
And others
TIA
too..
Upper gastro haem
UTI
60
10
30
60
10
30
Why offer ambulatory care?
•
•
•
•
•
•
•
•
Safe
Better experience for the patient
Reduce admission rates
Take pressure off the inpatient bed status
Reduce risk of health care-acquired infections
Reduce overall length of stay
Maintain high level of clinical activity
More ‘efficient’ service
How did we do it?
Old AAU Service
• 26-bedded AAU
• Ambulatory Care provided from the seating area
with 3 Consulting Rooms
– Not formal
– Dependent on availability of CRs for assessment
– Overflow into CR impacted on service
• 59% of 0-2 day LOS patients were transferred
– Increasing their LOS, often out-lied so delayed PTWR
even further
– Increased number of ward transfers
Redesigned Service – 6/12 pilot
• AAU moved to 33 bedded Linnet AMU
• AAU became a combined ACU and Observation
Ward, based adjacent to ED
• Opening Hours 10am-7pm Monday-Friday
– Aim to discharge all patients by 7pm
– Last referral must arrive by 6pm
• Consultant led service
• Improved diagnostics
• Early discharge decisions
Redesigned Service
• Designated clinical area
– Waiting area – chairs
– 11 bed spaces (2 monitored)
– 3 Consulting Rooms
– Cardiac Physiology bay with Echo and ETT
– ward TNI
– Doctor’s office
Redesigned service
• Staff
• 4 FTE Acute Physicians – cover Mon-Fri from 10am to
7.45pm with no other clinical commitments
• 1 Band 6 nurse (10am – 6pm)
• 1 Band 3 auxiliary
• F2 and Physicians Assistant
• SHO level doctor/Clinical Fellow
• Secretarial staff
• Ward Clerk
• Cardiac Physiology – until 18:00
• SPA (formerly EDAT) support
• Excellent radiology support for diagnostics
Making it work
• Rapid access to investigations
– X Rays/Ultrasound/Echocardiography/ETT
CT brain/CTPA
• Use of existing clinical pathways
• Modified clerking proforma
Making it Work
• New electronic take list accessible in all clinical
areas
• AMU Band 6 takes GP calls and decides if
patient is suitable for Ambulatory Care
• Development of an ED “pull” system – 12pm
board round/notes review
Making it work
Cultural change
 Embedding a new pattern of behaviour
 Keeping momentum going (much harder getting
people home than admitting)
 Proactive not reactive
 Changing the mindset among clinicians to avoid
unnecessary overnight stay, asking “what do I
need to do to get/keep this patient home?”
Number of patients with an ambulatory care HRG and diagnosis by month
and group
Nov-11 Dec-11
General Medicine
Jan-12 Feb-12 Mar-12
577
716
698
681
698
General Surgery
73
71
69
72
75
Obs and Gynae
22
29
27
23
24
T&O
19
21
17
19
30
Urology
22
27
18
30
26
713
863
829
825
853
Grand Total
Number of admissions to Ambulatory Care
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
% of all patients
admitted to
Acute Med
Obs Grand Total subsequent ward
200 157
357
14.0%
233 233
466
8.4%
261 234
495
9.3%
243 203
446
8.3%
262 241
503
9.1%
General Medicine Ambulatory Care Admissions by month
800
700
Number Admissions
600
500
400
300
200
100
0
8.9 % reduction in the number of Emergency
admissions
Overall emergency admissions with a medical specailty
01/11/2010 - 11/03/2012
400
350
Number of admissions
300
250
200
150
100
50
0
1
3
5
7
9
11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71
Week
AAU -Amb Care Opening
Admissions
Average LoS in days for General Medicine Amb Care Conditions
5.0
4.5
4.0
3.5
LoS in days
2010-11
3.0
2011-12
2.5
2012-13
2.0
1.5
1.0
0.5
0.0
Apr
May
Jun
Jul
Aug
Sep
Oct
Month
Nov
Dec
Jan
Feb
Mar
Number of Medical ambulatory care conditions admitted and number going to AAU - ambulatory care under an Acute Med Cons
Nov-11 to July-12 only (Mon-Fri 10-6)
Condition
Target %
Number
admitted
outside of
% going to amb amb care
care
opening
Of these,
number going
Adms by to AAU - amb
condition care
% going to AAU-Amb Care when
admitted in opening hours
Acute Admissions from Care Homes
30
3
1
33.3%
2
100.0%
Acute headache
30
179
51
28.5%
95
60.7%
Anaemia
60
53
25
47.2%
23
83.3%
Asthma
10
110
24
21.8%
66
54.5%
Chest pain
30
1279
312
24.4%
738
57.7%
Community acquired pneumonia
10
619
46
7.4%
405
21.5%
COPD
10
392
35
8.9%
232
21.9%
Lower resp tract inf
30
240
32
13.3%
142
32.7%
Oesophageal stenosis
60
20
4
20.0%
16
100.0%
PE
60
80
20
25.0%
49
64.5%
Pleural effusions
60
49
13
26.5%
21
46.4%
Pneumothorax
10
23
3
13.0%
16
42.9%
Seizure in known
60
6
1
16.7%
5
100.0%
Stroke
10
270
10
3.7%
169
9.9%
Supraventricular tachycardias
30
416
77
18.5%
236
42.8%
Upper gastro haem
10
78
4
5.1%
49
13.8%
Number of Medical ambulatory care conditions admitted and number going to AAU - ambulatory care under an Acute
Med Cons
Nov-11 to July-12 only
Target
Diabetes
60
DSH
Total
admit
ted
ACU
%ACU
OOH
% ACU in
hours
11
2
18.2%
5
33.3%
60
634
48
7.6%
518
41.4%
DVT
>90
32
14
43.8%
15
82.4%
Falls
60
394
31
7.9%
260
22.8%
First seizure
60
243
28
11.5%
161
34.1%
Gastroenteritis
60
54
4
7.4%
38
25.0%
Hypoglycaemia
60
49
1
2.0%
34
6.7%
Lower gastro haem
60
9
1
11.1%
6
33.3%
PEG associated problems
90
1
0
0
0
Cellulitis
60
134
38
28.4%
67
56.7%
Congestive cardiac failure
30
230
19
8.3%
127
18.4%
Painless obstructive jaundice
30
48
0
0.0%
39
0.0%
TIA
60
123
19
15.4%
85
50.0%
UTI
30
272
16
5.9%
186
18.6%
Other benefits we have seen so far…
KPI
ED Attendances
Nov 2010 - Feb 2011
21366
Nov 2011 - Feb 2012
22585
performance
↑5.7%
Attendances with a ambulatory
care condition
2483
2667
↑7.4%
Ambulance handover within 20
minutes
92.60%
94.10%
↑1.5%
4 hour breaches within ED
associated with medical bed
availability
36.20%
31%
↓5.2%
Medically expedited patients being
seen within the ED
average of 31 per week
average of 27 per week
↓14.8%
Mixed sex accommodation
98
4
↓95.9%
3 or more moves between different
wards as an inpatient
average of 40
average of 8.5
↓78.8%
Discharged from a non medical
ward (Outlier)
average of 44.7 per week
average of 44.7 per week
Equal
Number of days with bays or wards
closed due to infection reasons
17
55
↑323%
Escalation ward open
45
27
↓40%
Future plans
• Full cover for Fridays (limited at present)
• Extending to weekend ACU cover
• Follow up clinic in Ambulatory care area
Your questions
Bruce Laurie
Chairman