Cambridge and Ely Urgent Care Plan 2013-2014
Cambridge and Ely
Urgent Care Plan
2013-2014
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Cambridge and Ely Urgent Care Plan 2013-2014
1. Summary
a. Plans show prioritised deployment of ECIST teams and
other improvement support to the most challenged
health economies
b. Plans are informed by pre-existing actions agreed by
with relevant sector regulators (NDTA, Monitor) for
recovery and sustainable delivery of the A&E standard.
Cambridge University Hospitals NHS Foundation Trust (CUH) performance against the 95%
4 hour emergency care standard was 94.6% for 2012/13. The standard was achieved from
August to February but not delivered in March (90.1%). From a national perspective
performance has been below 95% since September 2012.
Current emergency admission rate per 1000/weighted population is above the average for
Cambridgeshire as a whole. This increase in emergency demand requiring admission,
particularly the 3.5% increase in the over 85 years cohort during 2012/13 has led to the Trust
being under significant bed pressures for a sustained period, with increasing and regular
instances of Emergency Department (ED) crowding. Cambridgeshire Clinical Commissioning
Group (CCG) figures indicate length of stay is above average for emergency admissions.
Cambridgeshire Association to Commission Health (CATCH) and Cambridgeshire Health
Local Commissioning Groups (CAM Health LCG) commission services for a population of
304,000 of which 44,200 are over 65 and 6,700 are over 85. The older population is rapidly
increasing.
The frail elderly population in the Greater Cambridge area is growing even more quickly than
the national average. In less than ten years (by 2021) it is estimated that the number of frail
elderly people will have increased from 6,000 to 9,000.
The increase in the numbers of over 85 year olds being admitted as an emergency to CUH
has resulted in higher levels of Delayed Transfers of Care (DTOC). This is a major problem
in the Cambridge Health System. The main causes of DTOC during 2012/13 were delayed
assessments and lack of social care resources leading to below optimum care arrangements
being made for people with on-going care needs in the community.
Over the past 12 months CUH and the surrounding urgent care system have had a number
of different reviews undertaken on areas relating to the unplanned care pathway and service
models. Two have been undertaken by the Emergency Care Intensive Support Team
(ECIST); the first looking at the whole systems contribution and impact on unplanned care
and a second that looked more internally at the systems and processes of CUH. The third
report, in October 2012 led by Professor Phelps, was clinically focussed and was a rapid
response review of the frail elderly pathway commissioned by the Clinical Commissioning
Group. CUH have also worked with Monitor to develop Turnaround Plans.
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Cambridge and Ely Urgent Care Plan 2013-2014
Key findings from the reviews were as follows:
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health services
The detailed reports from the visits are available on request. Actions arising from these
reviews have been incorporated in the health and social care system plan. This plan has
been under development since February 2013. We recognise that planning is constant and
we will continue to manage performance across the system and develop our plan to deliver
continuous improvement for our patients and residents.
Our agreed Urgent Care Plan aims to:
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Provide enhanced community and rapid response services to prevent inappropriate
hospital visits and admissions.
Prioritise our focus on the older population as increasing demand from this cohort has
resulted in system pressure
Improve patient flows following admission to hospital to reduce length of stay and
improve outcomes.
Reduce length of stay in hospital by
enhancing community services to ensure
patients are discharged as soon as
possible.
Each strand of our plans will therefore enable
strong performance and high quality patient
care by enhancing capacity. For example:
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Acute community nursing aims to free up
10 acute beds during the winter period,
by avoiding unnecessary admission.
Additional step-up beds in Cambridge
and Ely should free a further 10 acute
beds during the winter months.
The rapid response Acute Geriatric
Intervention Service should avoid 32
admissions per month.
New ways of working at CUH to reduce
variation of care and length of stay aims
to increase capacity by 155 beds.
Increased community rehabilitation and
community rehabilitation beds will
improve the capacity to discharge
patients quickly.
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Cambridge and Ely Urgent Care Plan 2013-2014
2. System Balance
A fundamental principle for the UCB is that the health and social care system must be in
balance. It is critical that organisations do not plan and performance manage in isolation.
This was the reason why in February 2013, health and social care partners agreed to form
the System Planning Group. This is effectively a sub group of the Urgent Care Board, with
the objective of accelerating system planning and performance management.
As a consequence of this approach, we have coordinated our efforts to improve performance
and quality. For example, creating additional capacity at CUH will reduce utilisation providing
space to decant patients and enable the ‘deep cleaning’ of wards in order to reduce CDiff,
which has been a problem. Recruiting and retaining health workers and care workers is an
issue in the Cambridge area. Rather than competing for the same group of staff, joint
overseas recruitment and apprenticeships have been developed. As it is of mutual benefit to
reduce DTOC and LOS to relieve blockages, investment has been agreed to increase
community nursing, community rehabilitation beds and reablement.
These plans and investments have been driven by the joint analysis of the causes of
pressures in our system and joint commitment to their resolution.
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Cambridge and Ely Urgent Care Plan 2013-2014
3. Performance
a. Plans demonstrate credible and robust trajectories
As described in the previous section performance pressures in the Cambridge and Ely
health system have been driven by a 9% increase in over 85’s admissions. Many of our
plans are aimed at avoiding unnecessary admissions for this cohort of patients and the wider
population, whilst increasing community capacity and improving hospital patient flow.
Below are graphs indicating current performance against the four hour target, ED activity
and inpatient activity. Trajectories take account of the projected impact of the plans we have
agreed to meet winter pressures.
CUHFT A&E Attendances and 4 Hr Performance
2200
100.00%
Attendances
96.00%
2000
94.00%
92.00%
1900
90.00%
1800
88.00%
86.00%
1700
84.00%
1600
% Seen Within 4 Hrs
98.00%
2100
82.00%
A&E Attendances
4 Hr Performance
6/2/2013
6/16/2013
5/5/2013
5/19/2013
4/7/2013
Linear (A&E Attendances)
4/21/2013
3/24/2013
3/10/2013
2/24/2013
2/10/2013
1/27/2013
1/13/2013
12/30/2012
12/2/2012
12/16/2012
11/4/2012
11/18/2012
10/7/2012
10/21/2012
9/9/2012
9/23/2012
8/26/2012
8/12/2012
7/29/2012
7/1/2012
7/15/2012
6/3/2012
6/17/2012
5/6/2012
5/20/2012
4/8/2012
80.00%
4/22/2012
1500
Linear (4 Hr Performance)
Graph 1: Weekly CUH A&E attendances and 4 hour performance
CUHFT Admissions Through A&E and A&E Conversion Rate
38.00%
36.00%
700
34.00%
32.00%
650
30.00%
28.00%
600
26.00%
24.00%
550
A&$ Conversion Rate
Admissions Through A&E
750
22.00%
Conversion Rate
Linear (Admissions thru A&E)
6/16/2013
6/2/2013
5/19/2013
5/5/2013
4/7/2013
4/21/2013
3/24/2013
3/10/2013
2/24/2013
2/10/2013
1/27/2013
1/13/2013
12/30/2012
12/2/2012
12/16/2012
11/4/2012
11/18/2012
10/7/2012
10/21/2012
9/23/2012
9/9/2012
8/26/2012
8/12/2012
7/29/2012
7/1/2012
Admissions thru A&E
7/15/2012
6/3/2012
6/17/2012
5/6/2012
5/20/2012
4/8/2012
20.00%
4/22/2012
500
Linear (Conversion Rate)
Graph 2: CUH weekly admissions to A&E conversion rates
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4/7/2013
3/23/2014
3/9/2014
2/23/2014
2/9/2014
1/26/2014
1/12/2014
12/29/2013
12/15/2013
12/1/2013
11/17/2013
11/3/2013
10/20/2013
10/6/2013
9/22/2013
9/8/2013
8/25/2013
8/11/2013
7/28/2013
7/14/2013
6/30/2013
6/16/2013
6/2/2013
5/19/2013
5/5/2013
4/21/2013
Axis Title
Cambridge and Ely Urgent Care Plan 2013-2014
CUHFT A&E Performance - 2013-2014 Trajectory
100.00%
98.00%
96.00%
94.00%
92.00%
90.00%
88.00%
Graph 3: CUH A&E Performance trajectory 2013-2014
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Cambridge and Ely Urgent Care Plan 2013-2014
4. Contractual Levers and financial incentives
a. Plans mention contractual agreements associated with
R&IPs with timescales for recovery and sustained
improvement of the A&E 4 hour standard (applied during
2012/13 when performance below standard – this will be
applied again if required)
b. Plans mention the deployment of contractual levers
(fines for breaches) in connection with
underperformance
For 2013/14 the CCG has agreed a more robust contract escalation strategy. The aim is to
maximise the benefit of contractual levers to improve performance, or where necessary fine
providers for under performance. Funding can then be redirected to address winter
pressures.
Through the terms of our 2013-14 agreed contracts we will transparently and fairly enforce
all mandatory consequences as set out in the 2013/14 NHS Standard Contract. This will be
led by the Local Commissioning Groups’ (LCG) Clinical leads, with the appropriate contract
manager working, through the regular monthly contract management meetings, in
partnership with other CCGs and NHS England.
The CCG has stated its determination to providers that it will ensure our local health and
social care system performs to the best of its ability on all national performance
requirements and therefore contract query notices will be the normal way of initiating
performance recovery and we expect the monthly contract and performance meetings to
routinely manage RAPs including consequences with LCG Clinical Leadership.
The key areas where we will track and monitor performance are;
1. Quality and Safety requirements – there is a comprehensive set of national and local
quality requirements that will be monitored thorough a monthly quality dashboard.
2. NHS Constitution requirements - these are monitored through Trust specific monthly
performance reports.
3. Cambridgeshire & Peterborough CCG local contract requirements – these include
activity and productivity thresholds.
4. Contract Activity and financial performance – these are monitored through Trust specific
monthly activity and finance reports
5. Performance Thresholds and Escalation Process for non-delivery of requirements: the
thresholds that providers have to achieve and the triggers for escalation of performance
issues under the contract are explicit.
An on-going piece of work is to ensure that we have a robust section 256 with
Cambridgeshire County Council where the commissioner is clear what will be delivered as a
result of transferring the funding to them. This has proved challenging to date however
progress is being made. The intention as with last year and the winter monies that the
resource will be targeted at the areas that support admissions avoidance and expediting
people out of hospital when they are no longer requiring acute medical intervention.
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Cambridge and Ely Urgent Care Plan 2013-2014
Quality Assurance & Safeguarding
In light of the 2013 Francis report it is vital that commissioners and providers look out for the
early warning signs associated with poor care. The whole rationale for healthcare is to put
the patient first. Whilst there are qualitative contractual standards that organisations are
monitored on it is often the softer more qualitative aspects that triggers concern. To this end
clinical commissioners via the CCG quality team have embarked on a number of initiatives to
monitor this e.g.
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Quality walkabouts led by a GP and Nurse from the LCG (Planned & Unplanned)
GP present at White Board rounds
Monthly contract meetings with Trusts
Review of complaints/feedback/patient experience information
Information from the above including the national KPis is correlated and triangulated to get a
‘rich’ picture of Providers and its overall patient performance and quality. Any issues arising
are reported to the UCB and actions agreed.
Financial incentives aligned to urgent care plan
The System Plan is supported by two Section 256 agreements. One is between the CCG
and Cambridgeshire County Council to invest in the development and delivery of reablement
services. The funding is specifically for post-discharge and reablement support via the NHS
to increase social care capacity in order to improve patient outcomes and reduce DTOC and
readmission. The second is funding passing from the Area Team to Cambridgeshire County
Council to further support investment in social services. We have agreed in principle to KPI s
and outcomes with the County Council are in the process of finalising to ensure the most
effective use of resources to deliver better outcomes for our residents and patients.
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Cambridge and Ely Urgent Care Plan 2013-2014
5. Governance
Cambridgeshire and Peterborough Clinical Commissioning Group (C&PCCG) became a
statutory organisation from 1st April 2013. We are the third largest CCG responsible for a
registered population of approximately 878,000 with a budget of c£854m. Our local authority
partners are Cambridgeshire County Council and Peterborough City Council. There is
commitment across our providers to work together to ensure that urgent care services
deliver excellent patient experience, efficiency and high quality effectiveness ensuring that
the patient is seen by the most appropriate care provider. We recognise that there is work to
be done to enable us to achieve our jointly agreed outcomes and this plan describes the
infrastructure and processes to ensure we can do this in a constructive and learning
environment.
5.1 Urgent Care Board
Oversight
The Cambridge and Ely system works within the larger CCG
footprint - delivery is devolved to local system level with an
overarching governance arrangement to ensure consistency
of delivery and outcomes for all our patients. Each individual
system has developed bespoke plans for their system and
the planning has utilised local knowledge around gaps in
service provision, previous activity patterns in the acute
settings and advice from national Improvement Support
Teams (where a review has been carried out) to define
work-streams being taken forward in 2013/2014.
There is also a collaborative Urgent Care Network (UCN) which is CCG wide and takes
place quarterly. The Network brings together key individuals from across providers and
commissioning teams throughout the CCG and reviews overall performance on urgent care
pathways, provides guidance on urgent care good practice and shares learning from across
the three urgent care systems. The September 2013 meeting will be focussed on reviewing
implementation plans of winter initiatives and will ensure that each system has appropriate
interventions to manage seasonal surges. The January collaborative UCN will review
impacts of winter interventions and ensure that learning is shared across the local systems.
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Cambridge and Ely Urgent Care Plan 2013-2014
The Cambridge and Ely Urgent Care Board membership
Member
Organisation
Role
Dr Geraldine
Linehan (Chair)
Cambridgeshire and Peterborough
Clinical Commissioning Group (CATCH
Local Commissioning Group)
Cambridgeshire and Peterborough
CCG (Camhealth Local Commissioning
Group)
Cambridgeshire and Peterborough
CCG (CATCH and Camhealth LCGs)
Cambridgeshire and Peterborough
CCG (Camhealth LCG)
Cambridgeshire and Peterborough
CCG (Isle of Ely Local Commissioning
Group)
Cambridgeshire and Peterborough
CCG
East of England Ambulance Trust
East of England Ambulance Trust
Cambridge University Hospitals NHS
Foundation Trust
Cambridge University Hospitals NHS
Foundation Trust
Cambridge University Hospitals NHS
Foundation Trust
Cambridge University Hospitals NHS
Foundation Trust
GP and Chair of
CATCH LCG
Michael Grande
(Vice Chair)
Nigel Smith
Arnold Fertig
John Szekely
Michael Thoseby
John Knott
Phil Lumbard
Fran Cousins
Sandra Myers
Richard Biram
Richard Kendall
Richard O’Driscoll
Ken Fairbairn
Claire Bruin
Cathy Walsh
Jean Pomfrett
Chris Garner
Jackie Galwey
Viveca Kirthisingha
Jez Reeve
Sandie Smith
GP
Local Chief Officer,
Cambridge system
GP and Chair of
Camhealth LCG
GP
Information Manager
Area Manager
Elderly Care Lead
Chief Operating
Officer
Director of
Integration
Consultant
Geriatrician
Emergency
Department
Consultant
Cambridge University Hospitals NHS
Complex Discharge
Foundation Trust
Manager
Cambridgeshire County Council
Head of Contracts
Cambridgeshire County Council
Director Adult Social
Care
Cambridgeshire and Peterborough NHS Psychiatrist
Foundation Trust
Cambridgeshire and Peterborough NHS Chief Operating
Foundation Trust
Officer
Urgent Care Cambridgeshire
Chief Operating
Officer
Cambridgeshire Community Services
Head of Service
Cambridgeshire Community Services
Community
Geriatrician
Cambridge Voluntary Sector
Chief Executive
Cambridgeshire Healthwatch
Chief Executive
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Cambridge and Ely Urgent Care Plan 2013-2014
The diagram below sets out the governance structure in the Cambridge and Ely Health
System. Separate submissions have outlined the how the local UCBs interact with other
CCG programmes of work.
The diagram below shows the governance and escalation structure for the Greater
Cambridge and Ely System.
Governance has been significantly strengthened for 2013/14. The revised arrangements
outlined above are now fully implemented and are supported by weekly operational review
meetings, which can be escalated to daily meetings when indicators indicate pressure is
building in the system.
Cambridge and Ely Health System Governance Structure
Note: escalation can be direct to UCB or Urgent Care Chief Executive Group
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Cambridge and Ely Urgent Care Plan 2013-2014
5.2 Monthly Urgent Care CEO Group (Cambridge Health
System)
CEOs of Cambridge University Hospital NHS Foundation Trust, Cambridgeshire and
Peterborough Clinical Commissioning Group, Cambridgeshire Community Services and
Cambridgeshire County Council meet monthly. This group includes the Strategic Director of
Adult and Children’s Services at Cambridgeshire County Council and the CCG Chief
Operating Officer and Accountable Officer.
The CEO Group takes a strategic overview to ensure plans are in place and performance
management is robust to meet the winter pressures. CEO s also make investment decisions
on behalf of their organisations to ensure resources are aligned with winter pressure
priorities.
Chief Executive
Chief Clinical Officer (Accountable Officer)
Chief Operating Officer
Strategic Director Adult Social Care
Chief Executive
CUHFT
CCG
CCG
Cambridgeshire County Council
Cambridgeshire Community Services
5.3 Monthly Urgent Care Board
The Urgent Care Board comprises senior managers and clinician from all key partners in the
health and social care system. For example, This includes Social Care colleagues, NHS
clinical commissioners and managers, acute trust clinicians and managers, community
service clinicians and managers, mental health clinicians and managers, ambulance,
housing and out of hours GP service.
The UCB is a forum to engage all stakeholders from across the urgent care system in ongoing developments.
A Performance Dashboard has been implemented to manage performance across the
system.
The members review monthly performance metrics to identify any ‘hot spots’ for service
improvement and remedial action. The wide membership and specifically the senior clinical
input offers multifaceted scrutiny to new business cases as ideas are presented and
developed. Progress with the Cambs and Ely Urgent Care Action plan is discussed on a
monthly basis with the UCB members.
5.4 System Planning Group (fortnightly)
This Group was commissioned by the Urgent Care Board. The objective is to support the
aims of the Urgent Care Board by developing and maintaining a health and social care
system plan to ensure the best possible outcomes for patients and service users.
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Cambridge and Ely Urgent Care Plan 2013-2014
This includes the identification of demand and
capacity across the health and social care system
for all periods of the year (including the winter
months) in order to inform and co-ordinate robust
decision making and investment.
Objectives:
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-ordinated approach to system planning
and the development of a system plan which
is owned by all organisations in the
Cambridge and Ely health and social care
system.
A system plan based on robust data which
includes links to outcomes and enables the
UCB to manage progress and take corrective
action when necessary.
Plans which enable organisations to make
well informed investment decisions, for
example by taking into account the impact on
other parts of the system.
Plans which respond to winter pressures and
ensure organisations are well prepared.
Specific system projects have been established to
support winter planning including:
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Demand and Capacity Planning (including predictive modelling) across health and social
care.
Establishment of a combined health and social care purchasing unit for Residential,
Nursing and Domiciliary Care
Integrated approach to planning and procuring intermediate care resources.
The Group comprises Senior Managers and Directors who identify system risks and delivery
pressures and agree specific interventions.
5.5 Single Transition Service Meetings (STS) - fortnightly
Senior Managers and clinicians from CUH, CCG, CCC, CCS along with the Complex
Discharge Transformation Manager meet fortnightly to specifically discuss patient flows and
DTOC issues. They are responsible for developing, implementing and managing
improvement plans for patients in the system who have on-going care needs.
5.6 Continuing Care Pathways Group - fortnightly
This meeting is chaired by the Complex Discharge Transformation manager and is the
programme board which oversees a number of workstreams to improve DTOC. The meeting
is attended by project managers who hold operational roles in the organisations. This is the
forum for project managers to update on progress with implementation and impact.
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Cambridge and Ely Urgent Care Plan 2013-2014
5.7 CUHFT Turnaround Programme
This is a very extensive Programme of work taking place at CUHFT. The programme has 7
major work areas each with an Executive Sponsor and Clinical Lead; Unplanned Care,
Length of Stay, Variation of Care, Theatres, Outpatients, Investigative Sciences, Drugs
Unplanned Care and LoS.
The programme feeds into system wide developments and System Plan.
The Monitor Turnaround Director and team attended Urgent Care Board meetings and
System Planning meetings to help integrate CUH turnaround plans with the system wide
approach. These plans and recommendations form part of the system wide plan for Greater
Cambridge and Ely.
5.8 Weekly Patient Flow - Tactical Planning (these
meetings will be held daily at times of escalation)
This is a key operational group comprising providers and commissioners to agree immediate
actions at a patient level to improve patient flow and address specific pressure in the health
and social care system. This Group can also escalate immediately to involve nominated
senior representatives from key organisations (usually UCB decision making managers and
clinicians).
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Cambridge and Ely Urgent Care Plan 2013-2014
6. Risk Management
The whole essence of managing an
effective urgent care pathway is how
organisations manage risk and mitigate
against the impact of risks occurring.
This is an area that is being
strengthened across the CCG. A
corporate approach to risk management
and ensuring appropriate controls are in
place is being implemented. Each UCB
is developing a Risk Register, which
follows a consistent format and uses the
NPSA scoring around likelihood and
consequence. The Risk Register
contains each action/objective assessed
in terms of achievement, setting out
existing
control
measures
and
identifying any weaknesses in control
measures. We are also in the process
of identifying the assurance of the
controls and actions are identified to
address the risks.
Linking to our governance processes the
Risk Register for each UCB will be
monitored at the relevant UCB
(Controls), and a composite report
provided to the collaborative UCN
(Assurance). There will be regular
reporting from the collaborative UCN to
the Governing Body and risks that are
assessed as significant will be added to the CCG risk register.
At a Cambridge/Ely level as outlined above the UCB has started a local risk log whereby
risks are captured by members evaluated and acted upon. Risks are then reviewed at each
UCB meeting to assess whether their probability and impact have changed. Controls are
monitored The UCB risk log is then correlated with the wider CCG UCN risk log which forms
part of the governing body assurance framework.
6.1 Programme and Performance Management
Each project has an identified SRO, who is the lead owner and responsible officer for the
project. The CCG has recommended a work book methodology to ensure robust programme
management. Organisations may use their own methodology providing this provides
adequate assurance to partners.
Projects are monitored using the existing governance structures. This includes managing:
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Programme and project planning
Project development to implementation
Performance management of projects post implementation
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Cambridge and Ely Urgent Care Plan 2013-2014
Each organisation represented on the UCB is responsible for the delivery of specific projects
which support these aims and objectives, However, it is the responsibility of the UCB to
ensure the approval and delivery of projects against the agreed budget and timelines.
Where the UCB encounters severe and repeated quality or performance issues this would
be escalated to the relevant authority such as,
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Monitor for FT providers
TDA for non FT providers
CQC for Quality Issues
Escalation Policy and Process
The CCG has an established and common escalation policy and associated process which
enables trusts within the CCG catchment to escalate operational issues in order to either
trigger specific actions or raise awareness of the issue/concern amongst
providers/commissioners. This is undertaken via the Director on-call system this includes
ambulance divert policies and handover arrangements. Table 1 describes the escalation
classifications and definitions used.
Status
Green
Amber
Red
Black
Definition
The local health economy capacity is such that the organisation is able to maintain patient
flow and is able to meet anticipated demand within available resources.
The local health economy is starting to show signs of pressure. Focused actions are required
in organisations showing pressure to mitigate further escalation. Enhanced co-ordination will
alert the whole system to take action to return to green status as quickly as possible.
Actions taken in Amber level have failed to return the system to Green and pressure is
worsening. The local heatlh economy is experiencing major pressures compromising patient
flow, further urgent actions are required across the system by all partners.
All actions have failed to contain service pressures and the local health economy is unable to
deliver comprehensive emergency care. There is potential for patient care to be
compromised.
Table 1 Trust Escalation Classifications
Contacts for Director on Call to facilitate escalation
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Cambridge and Ely Urgent Care Plan 2013-2014
Urgent Care Board role in performance management
The Urgent Care Board is responsible for performance management. The UCB provides a
coordinated response to health and social care issues. For example, the Monitor Turnaround
Director joined the Board when working with CUH to improve performance. ECIST are
invited to Board meetings to provide external advice and assessment. Standing business
items include:
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Driving improvement by ensuring the delivery of improvement and recovery plans.
Programme management of task and finish groups.
Progress review and agrees corrective action.
Performance management across the system.
Manages urgent care performance using the Performance Dashboard. This includes
A&E performance and trends.
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Cambridge and Ely Urgent Care Plan 2013-2014
7. Cambridge and Ely Urgent Care Action Plan,
July 2013-2014 - Medium Term Action Plan
a. Coordinated programme of action by providers and
commissioners consisting of a series of performance
improvement programmes
b. Plans demonstrate actions for immediate recovery of A&E
performance winter planning and sustainable improvement
(performance currently meeting the standard)
c. Actions proportionate to degree of risk in achieving recovery
and sustained delivery based on historic performance
d. Plans consider 7 day working and simplification of urgent
care pathways
The Cambridge and Ely System Plan is attached at appendix 1.
All partners have been involved in developing and agreeing the Plan, which began
development in February 2013. Since then the System Planning Group, which includes
senior managers and clinicians from CUH, East of England Ambulance Service, the CCG,
County Council and Cambridgeshire Community Services, has met every two weeks to
develop plans and manage performance.
As outlined in Section 1, the Urgent Care Plan aims to increase capacity and manage
demand across the system throughout the year, and to cope effectively with winter
pressures.
Plans include enhanced community services, 7 day working (for example, expanded
ambulatory care, 7 day out of hours GP cover in the Emergency Department) and increased
bed capacity within the hospital. Additional and flexible intermediate care capacity (for
example, step up and step down beds) will enable the system to respond effectively to
particular pressures. CUHFT are aiming to create additional capacity equivalent to 155 beds.
This will help to reduce utilisation and create more flexibility during winter. The success of
these schemes will ensure that only those with true acute needs are accessing CUHFT and
that the acute delivers on its 4 hour target
The document was developed and is managed by the local Urgent Care Board.
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Cambridge and Ely Urgent Care Plan 2013-2014
8. Winter Contingency Proposals 2013 / 2014
a. Plans demonstrate triangulation between eg. admission
avoidance, CIPs, workforce, non elective admissions, LOS
and DTOC
The System understands that planning is continuous. The document attached (appendix 1)
describes additional resources which the system is planning to implement during Nov 2013 –
Mar 2014. An analysis of last winter and impact of schemes to manage demand has
informed the Plan. The Plan above includes agreed winter initiatives. As described earlier in
this document the plan balances admission avoidance, patient flow and enhanced
community services to address the meet anticipated winter pressure.
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Cambridge and Ely Urgent Care Plan 2013-2014
9. Winter 2012/13 Managing Capacity &
Demand that demonstrate sustainable
performance
a. Plans demonstrate actions for immediate recovery of A&E
performance, winter planning measures and sustainable
improvement
b. Plans demonstrate triangulation between e.g. admissions
avoidance, CIPs, workforce, non elective admissions, LOS
and DTOC
The Cambridge and Ely system recognises that improving patient flow through the urgent
care pathway is an essential way of managing increases in demand. It is vital that this is
coupled with schemes that can quickly react to increased demand and flex capacity
provision across the relevant sectors. .
In 2012/2013 CUHFT and partners from the Urgent Care System ran a programme called
the Perfect January. This incorporated a number of work streams which were funded
through winter monies. A core team of representatives from across organisations in the
system met weekly over winter to review implementation of the schemes and monitor
impacts. A detailed evaluation of activity in the acute setting is available on request - this
compared activity from 2011/2012 to activity in 2012/2013.
The UCB recognises that
planning is continuous
and our plan incorporates
learning from past
experience and from
others. The Urgent Care
System around CUHFT is
currently working to an
action plan which aims to
increase capacity and upskill competency of
community service
provisions, introduce new
services and augment
existing community and
acute pathways to
improve flow between
acute and community
settings.
For example, the current plan includes the following

Introduction of MDT Coordinators. These staff will work with vulnerable patients in the
community. Developing treatment plans for those in the community at risk of admission
to the acute sector and also supporting discharges for patients who are inpatients
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Cambridge and Ely Urgent Care Plan 2013-2014






The community service are implementing a Community Referral Point – a single point of
access to reablement/ICT, inpatient rehab beds, interim beds, district nursing and out of
hours nursing. This can be accessed by both primary care and secondary care
CUHFT are enrolled on the Ambulatory Emergency Care Network and are rapidly
developing pathways to reduce need for inpatient admissions
On-going programme of work around DTOC aims to get the local discharge planning
team working to section 2 notifications, embed a culture of discharge to assess and
increase step down resource by carrying out a review of capacity
CUHFT are commissioning MediHome to deliver virtual beds to facilitate Early Supported
Discharge and reduce LoS in order to increase acute capacity and quality (for example,
by reducing CDiff)
Enhanced community capacity – for example, community nursing, step up, step down
Responsive services, such as the Acute Geriatric Intervention Service to help
The plan described above is focused on sustainable urgent care pathway adaptations;
however, there is recognition that short term increases in service capacity and introduction of
additional roles / provisions are required to meet the demands which will inevitably increase
over winter. Some of the actions in the table below are based on our 2012/13 learning and
are now incorporated in our System Plan (appendix 1). Others are new initiatives at pipeline
stage and will be further developed for consideration by the UCB to support the inevitable
surge in seasonal demand.
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Cambridge and Ely Urgent Care Plan 2013-2014
FOCUS AREA
SCHEME
DESCRIPTION
IMPACT
LEAD& Organisation
Priority rating 1-2
Community Services
AGIS (Acute Geriatric
Intervention Service)
Rapid response inter-disciplinary
approach to urgent care in the
community for the elderly. Vehicle
manned by a paramedic and social
worker/therapist and the clinical
case load of the vehicle is assessed
virtually on a weekly basis by the
community geriatrician. Remit of the
service to provide interventions for
‘frail elderly’ and can be contacted
directly by GP practices. Additional
vehicle from September 2013.
Admission avoidance
 Numbers of falls
responded to
 Number of ‘sick other’
responded to
 Number of referrals by
GPs
Phil Lumbard
EEAST
1
Implemented
Community Services
Acute Community Nursing
Pilot (Medihome)
Pilot provision of acute home
healthcare to frail and elderly
patients needing urgent and active
response in the community.
From September 2013. 10
virtual beds for the CATCH
LCG.
Reduced hospital
admissions.
Increased support to end
of life pathway
Dr Catherine Bennett,
CATCH LCG
1
Agreed (September
2013
implementation)
Community Services
Commission additional
rehab/step up/step-down
beds
24 beds currently commissioned
from CNC. Negotiations for further
capacity with other providers are
taking place to commission an
additional 20-30 beds for step
up/step down purposes from Nov
2013
From November 2013
Nigel Smith, CCG
1
Plan agreed and
monitored weekly
Acute consultant working
in ED 7 days a week
(additional service 08:00-18:00
Saturday and Sunday) The role of
the acute medicine consultant will be
to redirect patients out of the
emergency department to other
available admission avoidance
services at the front door (inc.
ambulatory care, RADAR,
Medihome)
Admission avoided
 Quality standards
 Referral to ambulatory
care
 Referral to RADAR
 Referrals to START
Sandra Myers
CUHFT
1
Modelling based on
previous demand to
maximise impact
Reduce ‘Older People’
hospital attendance and
admission
Front Door
Reduced admission, LoS
and DTOC
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Cambridge and Ely Urgent Care Plan 2013-2014
FOCUS AREA
SCHEME
DESCRIPTION
IMPACT
LEAD& Organisation
Priority rating 1-2
Front Door
Increase throughput into
ambulatory care clinic
Ambulatory care clinic will run 7
days a week and take referrals for
generic ambulatory care conditions
from the GP liaison sisters and the
acute medicine consultant based in
ED
 Numbers accessing
ambulatory care
 Numbers diverted from
GP liaison
 Numbers taken from ED
 Numbers of admission
avoided (by pathway inc
generic pathway)
Sandra Myers
CUHFT
1
Agreed based on
success of ‘Perfect
January’ 2013
Front Door
Increase Liaison Psych
(old age and younger
adults)
Have both old age psychiatry and
liaison psychiatry working at the
front door of ED. Identifying people
with dementia / delirium or mental
health and behavioural problems as
early as possible in their attendance
and either help to discharge direct
from ED or ensure that care plans
are in place to support them during
inpatient admission.
Increased numbers of
patients reviewed by the
liaison services.
 Numbers of
referrals/reviews-both
services.
 Time from review to
discharge for older
peoples service
 younger adults
admissions avoided
Fiona Thompson & Cathy
Walsh
CPFT.
1
Business case
agreed by CCG
Acute Discharge
Increase number of
therapists, TOPAS,
discharge planning,
Medihome staff on
weekends
The hospital will be increasing the
numbers of therapists and discharge
planning staff which work over the
weekends to ensure that
interventions and assessments take
place over the weekend
Reduction in DTOC and
Sue Bursnall, Carl
bed days lost to DTOC.
Hancock, Sandra Myers,
 Number of assessments Richard O’Driscoll
on weekend
 Number of discharges on
weekend
1
Agreed – plans
developed
Acute and community
discharge
Interim Beds
Additional interim beds funded to
support patients awaiting placement
in long term care packages. Aim to
use the additional interim beds for
assessment so these are not taking
place in the acute sector
Admission avoidance and
DTOC reduction

Numbers admitted

DTOC
1
Additional
rehabilitation beds
agreed by CCG and
commissioned
Ken Fairbairn, Cambs
County Council
Further work on –
going with County
Council
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