South Tees System Resilience Group Update – Winter 14/15
1. Purpose
The purpose of this paper is to provide an update to Middlesbrough Health and Wellbeing
Board on the current winter pressures and performance for winter resilience 2014/15
along with the progress being made in relation to 24/7 working following the special
meeting of the Health and Well Being Board in September ’14.
2. Background
A surge in urgent care activity along with associated pressures in the health and social
care system can happen at any time during the year however the risk is heightened
during the winter months.
It is the role and responsibility of the South Tees System Resilience Group (SRG) to
ensure all providers have robust plans in place to respond to such periods of urgent care
surge. The SRG comprises of membership from all key health and social care
stakeholders including commissioner and provider organisations and representatives of
the Voluntary and Community Sector (VCS).
3. Winter Resilience Funding
NHS England undertook to release ‘winter resilience’ monies to SRGs (routed via Clinical
Commissioning Groups) during August and September, targeted at supporting system
responses to anticipated pressures for the coming winter period. This additional resource
was to be focused on key areas to mitigate the impact of winter urgent care surge.
The SRG has subsequently implemented a process whereby schemes have been
reviewed, supported (or rejected) and implemented. A national process has been initiated
via NHS England to monitor allocation of resources and performance for each of the
supported schemes. Details of the supported schemes can be found in appendix 1.
During October 2014 a second tranche of funding was allocated direct to Acute
Foundation Trusts (FTs), locally this was used to increase the number of resilience beds
available within South Tees Hospitals NHS Foundation Trust and support additional GP
capacity within the GP led walk-in centre.
NHS England implemented separate arrangements with Ambulance Trusts, utilising lead
commissioners to target resources at schemes intended to support managing winter
pressures. This approach has been further supplemented locally through the
implementation of local initiatives which include; additional capacity being sourced to
support GP urgent transport services (funded via the CCG) thus creating additional
urgent response capacity, implementation of the Hospital Liaison post (HALO) to facilitate
timely handovers and the implementation of revised arrangements for the management of
patients awaiting handover to A&E in order to free-up paramedic capacity.
4. Winter monitoring and management
On the 4th November 2014 NHS England initiated formal daily situation reporting. This
can be summarised as a daily update highlighting the pressures experienced in the
previous 24 hour period. Daily situation reports are primarily concerned with the position
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reported by FTs and in particular focus on; A&E performance, capacity (including bed
availability, delayed transfers of care, bed occupancy rates, bed closures – specific to
D&V/Norovirus), along with numbers of reported ambulance handover delays and diverts,
and cancelled operations. The report also details each FTs position in terms of the level
of reported escalation (using the North East Escalation Plan ‘NEEP’ rating).
A community services update is also provided; this is primarily concerned with the
availability of community hospital bed capacity but does include community nursing.
The daily situation report is used to provide an indication of pressures within the system
as a whole.
5. Surge and escalation
The North East Escalation Plan (NEEP) is an escalation framework that operates at 6
levels of escalation. NEEP level 1 is an organisations normal operating level. At each
level of escalation agreed actions and communications will be put into place to restore a
normal operating level within the organisation. The NEEP level is an indication of patient
flow and pressures.
The FT (including Community Services), Local Authority and the Out of Hour provider
have NEEP plans in place and report daily escalation levels. North East Ambulance
Service complies with the National escalation framework (REAP) which works on the
same principles as NEEP.
6. Situation reporting
Throughout the winter period the SRG has continued to monitor levels of pressure in and
across the South of Tees system, using organisations NEEP levels as a barometer. From
the initiation of daily situation reporting through to the 5th of January the Local Authority
has consistently reported NEEP level 1. The North East Ambulance Service has reported
REAP level 3 up to the 16th December and level 4 from this point forward. The table
below summarises the reported NEEP levels at South Tees Hospitals NHS Foundation
Trust during the same period.
NEEP level
No. of times each escalation
level was reached
1
2
3
4
18
21
2
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It should be noted that a Trust reporting NEEP level 3 (FT experiencing significant
pressures) and 4 (severe operational disruption including cancellation of elective activity)
would often signify considerable system pressure. Appendix 2 details the regional
position, by way of a comparison, across all Trusts in the North East region.
7. Local pressures
The following table details specific operational pressures reported by the FT, and its
partners, throughout the period.
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Area
Emergency Department
4 hour standard
performance
Escalation bed capacity
Delayed Transfers of
Care (DTOCs)
Cancelled Operations
Bed Occupancy
Ambulance to hospital
handover delays (3rd
November to the 7th
January)
Position statement
The FT achieved its weekly Emergency Department 4
hour performance standard the first week in November
2014 but failed to achieve the standard for the next 8
weeks to 4th January 2015
Escalation beds were opened on a phased approach. 8
beds were opened on 30th December 2014, 13 beds on
2nd January 2015 and 18 beds on 5th January 2015 and
these have remained open
Since the beginning of the reporting period the mean
average DTOCs stand at 44. The lowest number
reported being 30 (22nd December 2014) and the
highest 70 (5th January 2015)
A total of 91 elective operations were reported as
cancelled in the previous 24 hours throughout the
period
Bed occupancy levels average 96.6% throughout the
period. This is above the national optimum
recommended bed occupancy level of 85%
NEAS reported the Trust had a total of 271 ambulance
handover delays at James Cook University Hospital
during this reporting period broken down by the
following timeframes:
 30 to 60 minutes – 181 delays
 60 to 120 minutes – 77 delays
 Over 120 minutes – 13 delays
8. Key Influencing factors
Influenza is currently at a seasonal high however has not reached the levels witnessed in
2010/11, which was the last notable season/period of significant influenza. There are now
signs at a national level that activity has ceased to rise and may have peaked in the
community. However, activity in the North East has continued to rise (North East England
Public Health Report w/e 15th January).
It has also been notable that there has been a reduction (over the previous winter) in
terms of the number of hospital outbreaks of Norovirus and Rotavirus during the reporting
period; historically outbreaks have considerably increased system pressures.
The volumes of emergency activity, in terms of Non Elective Admissions (NEL) and
Accident and Emergency attendances, continue to be a point of significant national
pressure. However, locally commissioners have seen marginal improvements
(reductions) in reported levels of activity, both in terms of admissions and attendances
over previous years. It should however be noted that attendances at the GP walk-in
centres have seen significant growth in recent weeks.
9. Sustained national pressures
The pressures experienced within the South of Tees locality have been experienced both
regionally and nationally, in many cases to a significantly higher degree (in terms of A&E
attendances and growth in admissions). As a direct consequence of this, and in light of
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significant levels of escalation across all providers following the Christmas holiday period
NHS England called for all SRG’s to convene to review current resilience plans and
schemes.
South Tees SRG convened on 6th January 2015 to review existing plans and the impact
they were having. The SRG agreed a set of actions to support a reduction in system
pressures; this plan was submitted to the NHS England Sub Region Team (formerly the
Area Team) on the 7th January 2015. The action plan is currently being implemented and
delivery will be monitored via the SRG.
In addition to these national requirements an extra-ordinary North East CCG Forum was
convened to discuss the sustained pressures across the Region. A set of actions were
agreed to ensure all Acute Trusts provide daily capacity information to NEAS to support
safe ambulance conveyance and an immediate review of all escalation frameworks to
ensure a more standardised approach is taken across the region particularly with regards
to the cancellation of elective activity and the requesting of mutual aid.
10. Specific work undertaken in support of 24/7 working
Following a special meeting of the Health and Well Being Board in September ’14 action
was taken to explore potential opportunities to increase the availability of services on a 7
day or 24/7 basis in support of reducing ‘urgent care’ associated system pressures. The
following initiatives have been progressed or explored;
Social Care
 Additional social worker capacity to provide a seven day service to support discharges,
this includes additional off-site management cover/support. This has been
supplemented to with FT support for administrative input to process any incoming
referrals. This resource is being funded through the SRG monies.
 Provision of equipment to support weekend and ‘out of hours’ discharges through the
continued use and implementation of equipment sub-stores in and across the
community.
 Further exploration of the requirement for a weekend service potentially provided via
Connect staff continues. However, there are currently a limited number of requests, in
part due to reduced levels of discharges over the weekend period. Where a need has
been identified during a weekend period domiciliary care is currently bridging the gap.
Secondary Care
 The FT is working to establish a substantive forum to oversee the delivery of Seven
Day Services within STHFT. The forum reports to the Trust’s Transformation Board
and via this Board to the Trust Board as required. BOD supported the forum as a
vehicle to embed the 10 Clinical Standards as principles for services provided over
seven days. A Clinical Reference Group (CRG) is providing robust definitions within
the standards to recommend to the forum.
 Hospital therapy (physical and occupational) services have been enhanced to provide
7 day working. This ‘front of house’ service is now available 7 days per week from 8am
to 8pm via A&E and from 8am to 5pm via the AAU.
 Additional staffing capacity has been secured (through use of SRG monies) to ensure
7 day medication dispensing is both effective and responsive, meeting patient needs
and preventing delayed discharges.
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System-wide and CCG led initiatives
 Multi-agency input to the ‘care-home’ project, as part of the Better Care Fund
programme of work focused on reducing admissions from care homes to the FT
commenced in January ‘15.
 7 day transport is available to support discharges from the FT, this is available via both
Medical Services (private ambulance) and via traditional ambulance service contracts.
PTS Transport is not a barrier to discharging on weekends.
 The CCG has, in collaboration with the Out of Hours GP provider, piloted extending
the GP out of hour’s service to include a GP based within the Minor Injuries Unit at
Redcar Primary Care Hospital. The GP is available to assess patients, supporting a
reduction in onward referral or transfer to JCUH.
 A multi-agency pilot has been undertaken to trial providing GP capacity within the A&E
department at James Cook University Hospital. Unfortunately due to regional capacity
pressures the service has not been provided on a consistent basis and therefore has
not demonstrated the level of benefit initially anticipated. Alternative options are being
progressed within the SRG to ensure that GP input to A&E can be appropriately
trialled and evaluated.
11. Conclusion
From an SRG perspective the system remains at a heightened level of escalation
however action plans, resilience schemes and commissioning intentions continue to
support this period of surge and escalation.
While the South of Tees Health and Social Care economy has experienced significant
pressure, it should be noted that all partners have worked collaboratively via the SRG to
mitigate the potential risks and to return services to normal operating parameters as
efficiently and effectively as possible. This has been a significant contributing factor to the
South of Tees locality reporting lower levels of NEEP escalation than many other areas
within the Northern region.
The SRG continues to manage and monitor the ability and effectiveness of the system to
respond to pressures during the winter months, including taking action where necessary.
The winter monitoring period is anticipated to continue until at least 31st March 2015.
South Tees CCG
28th January 2015
Appendices
1
Tracker
Appendix 1
22.1.15.xlsx
2
North East and
Cumbria Winter
Brief
Appendix 2
22.1.15.docx
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