1. Mel Pickup, Chief Executive Warrington & Halton Hospitals NHS FT Andy Davies, Accountable Officer Warrington Clinical Commissioning Group Achieving the NHS Constitutional Standard for Waiting Times in Accident and Emergency

2. Context The service model for the provision of Urgent and Emergency care has remained largely unchanged for decades. It comprises of Primary and Community, Secondary and Tertiary care systems working predominantly in silos. It is calculated that over the next 5 years in Warrington due to demographic changes, demand for these services as they are currently provided by secondary care will increase by 23%. Our existing services do no have the capacity to meet that demand whilst achieving 4 hour A+E access target nor do Commissioners have sufficient funding to resource provision as its currently configured. Something has to be done!

3. The NHS constitutional right of 95% of patients attending A and E being seen, treated, discharged or admitted within 4 hours is not being met in Warrington. Performance for financial year ending 2015 was 90.5%. Problem Statement

4. Over the next 6 months to improve baseline performance by 5% against the year to date 4 hour A&E standard for patients attending Warrington Hospitals Accident and Emergency Department (92%) Baseline performance will improve to be at least 95% by the end of June 2015 Objective

6. Maximum Impact 9 Strategic Priorities 1.Care Home support project 2.Extend and further integrate the discharge teams 3.Set up hear and treat and Acute Visiting Service with the local ambulance provider 4.Increase primary care capacity both in and out of hours 6.Expand the assessment areas within the hospital 7.Re-designate a surgical ward to medical beds to reflect the change in patient mix 8.Establish a patient flow team to be lead by the Chief Nurse 9.Run ‘perfect week exercises’ with health and social care partner 5.Establish a fast flow intermediate care facility on the hospital site CCG (SRG)Trust (operational Group)

7. Implementation Plan In Hospital Changes Operational Group The change triumverate COO, MD, DNS Clarity on roles and responsibilities Expansion of the clinical assessement model and creation of capacity phase 1 February phase 2 August (MD) Reconfiguration of bed base Integrated discharge teams and patient flow – commenced February (DNS) ‘Perfect Week’ – January and April (All) Out of Hospital Changes System Resilience Group Care Home support – Warrington health Plus Hear and Treat and Acute Visiting Service North West Ambulance Service Increased Primary Care capacity in and out of hours Warrington Local Authority and Bridgewater Community FT Surgical bedsMedical (COO) Temporary establishment of intermediate care beds May

8. Positive Measures ED attends Performance against 4 hour standard Emergency discharges Ratio of Emergency admissions to discharges Delayed transfers of care Medical outliers Balancing Measures Emergency admission total Emergency admission direct Emergency admission via ED Attendance to admission ratio

9. Learning Clinicians drive the changes that stick Stronger together – the sum of the parts Strong system leadership is required It’s easier to start things than to finish them The tools and techniques worked

10. Intermediate Care Beds AED Performance

11. Causal Problems Causal ProblemSolution OptionsFeasibilityAffordabilityAcceptabilityImpact likelihood Total Score Duplicates work ongoing Staffing Pressures 1.Employ consultants 2.Change shift patterns 3.GP in department 4.Social worker in department 14551455 34343434 51455145 43244324 13 12 14 18 Yes No Discharge Delays1.Home of choice policy to manage expectations 2.Enhance integrated discharge teams 3.Extend community options 4.Increase intermediate care capacity 5.Provide transitional beds 6.Enhanced ward rounds with weekend review 7.Implement patient flow team 5 3 3 2 54 55 3 3 2 54 5 5 5 3 2 53 45 5 3 2 53 4 4 5 4 5 53 44 5 4 5 53 4 3 5 5 5 34 53 5 5 5 34 5 17 18 15 14 18 14 18 Yes Enhances Enhances No Yes Enhances No Pathways1.Implement ambulatory emergency care pathways 2.Develop a single Frailty Pathway 4 34 3 4 34 3 5 45 4 5 55 5 18 15 No Enhances

12. Causal Problems (continued) Causal ProblemSolution OptionsFeasibilityAffordabilityAcceptabilityImpact likelihood Total Score Duplicates work ongoing Bed issues (Environment) 1.Redesignate surgical beds to medical 2.Increase capacity of assessment space 2 42 4 4 34 3 2 42 4 5 55 5 13 16 No No Demand1.Increase capacity in primary care 2.Increase capacity of GP Out of Hours 3.Promote use of other services 4.Implement hear and treat with ambulance services 5.Set up acute visiting service 6.Set up Care home support team prioritising highest referring care homes 7.Redesign primary care front end for Emergency department 2 5 5 5 3 3 32 5 5 5 3 3 3 3 4 5 4 3 2 3 3 4 5 4 3 2 3 5 5 3 4 5 5 55 5 3 4 5 5 5 5 4 4 4 4 5 55 4 4 4 4 5 5 15 18 17 17 15 15 16 No Enhances Yes No No Yes No Equipment1.Implement a single health and social care record 2.Improve access to diagnostics and point of care testing 2 3 2 3 2 22 2 3 43 4 5 35 3 12 12 Yes Enhances