1. Southend University Hospital Foundation NHS Trust Risk Summit NHS Southend CCG and NHS Castle Point & Rochford CCG The Commissioners’ Perspective 31 st March 2014 Appendix A

2. Content CCG role Performance trends across emergency care Actions taken by the commissioners Urgent Care Working Group How has the wider system responded?

3. Context Southend CCG is lead commissioner for services from SUHFT Responsibility to ensure we commission high quality, safe services on behalf of our population There has been inconsistent achievement of the A&E 4 hour standard since March 2012 This has impacted on the ability to achieve other NHS Constitution standards and further reduced quality

4. A&E 4 Hour Standard since April 2011 Quarter2011-122012-132013-14 2014- 15 Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1 SUHFT A&E 4hr Performance (%) 97.096.396.995.394.895.293.889.691.096.594.287.992.493.4 Number of Weeks below Std. 0004436131234 314 Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

5. A&E Attendances Quarter2011-122012-132013-14 2014- 15 Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1 SUHFT A&E 4hr Performance (%) 97.096.396.995.394.895.293.889.691.096.594.287.992.493.4 Number of Weeks below Std. 0004436131234 314 Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report

6. A&E Attendances – AMU removed Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathway Criteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only Quarter2011-122012-132013-14 2014- 15 Q1 Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 SUHFT A&E 4hr Performance (%) 97.096.396.995.394.895.293.889.691.096.594.287.992.493.4 Number of Weeks below Std. 0004436131234 314

7. A&E Admissions Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathway Criteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only Attendances with Outcome as “Admitted” only Quarter2011-122012-132013-14 2014- 15 Q1 Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 SUHFT A&E 4hr Performance (%) 97.096.396.995.394.895.293.889.691.096.594.287.992.493.4 Number of Weeks below Std. 0004436131234 314

8. Non-Elective Conversion Source: SUS-SEM Via MedeAnalytics, adjusted to remove AMU-pathway A&E Attendances Quarter2011-122012-132013-14 2014- 15 Q1 Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 SUHFT A&E 4hr Performance (%) 97.096.396.995.394.895.293.889.691.096.594.287.992.493.4 Number of Weeks below Std. 0004436131234 314

9. Bed Occupancy Source: NHS England Sitreps, 4 years of collections, 7 day rolling average 2011-12 Nov-Feb 2012-13 Nov-Feb 2013-14 Nov-Mar Quarter2011-122012-132013-14 YTD Q3Q4Q3Q4Q3Q4 SUHFT A&E 4hr Performance 96.9%95.3%93.8%89.6%94.2%88.7%92.8% Number of Weeks below Std. 0461341029

10. Source: NHS England Sitreps, as a percentage of occupied beds, 4 years of collections, 7 day rolling average 2011-12 Nov-Feb 2012-13 Nov-Feb 2013-14 Nov-Mar Delayed Transfers of Care Quarter2011-122012-132013-14 YTD Q3Q4Q3Q4Q3Q4 SUHFT A&E 4hr Performance 96.9%95.3%93.8%89.6%94.2%88.7%92.8% Number of Weeks below Std. 0461341029

11. Delayed Transfers of Care

12. Friends and Family Test Source: Unify2

13. Ambulance Handover Times Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

14. Ambulance Handover Times – expressed of % of total Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

15. Ambulance Handover Times – over 30mins Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

16. Ambulance Handover Times – over 60mins Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’) Period: July to latest

17. Themes from the Data A&E standard has been met in only one quarter since Q3 2011/12 A&E attendance has not increased significantly A&E conversion rates have increased DToC are small Ambulance handovers have remained constant but recently higher number of ambulance waits over 30 and 60 minutes

18. What does this mean for patients? Leads to a crowded department with patients both waiting to be seen and waiting for beds Overall poor patient experience and safety Evidence has shown that patients admitted through a crowded A/E have a 43% increase in mortality at 10 days Patients admitted after 4-8 hours in A/E stay on average 1.3 days longer in hospital and 2.35 days when this reaches 12 hours Treatment initiation is often delayed in a crowded department FINALLY for patients seen and discharged from A/E there is a direct correlation between the length of time waited and a higher chance of dying in the next 7 days

19. Action taken by the CCG since April 2013 Performance management and contractual action System co-ordination and winter planning Managing demand Quality visits and external reviews

20. Performance management and contractual action during 2013/14 Weekly performance meetings COO- COO since July 2013 Two letters of serious concern to CEO Required formal root cause analyses and exception reports Action under the contract Contract Query – 7 th March 2013 1st Exception Report – 29 th May 2013 2 nd Exception Report – 27 th September 2013 Closure Notice – 15 th November 2013 Contract Query – 21 st January 2014 1 st Exception Report – 13 th March 2014

21. System co-ordination and winter planning System conference calls – daily since November 2013 Winter plan developed through two stakeholder half day workshops and full evaluation of demand management schemes Scenario testing (Exercise Eskimo) to ensure effective escalation and production of escalation guide Winter money allocated to the hospital (£0.9m out of £1.4m)

22. Managing Demand Full evaluation of schemes over summer which identified sub-optimal performance in schemes and took corrective measures Implemented a successful programme to increase GP referrals to the Single Point of Referral Extended hours for hospital Day Assessment Unit Increased GP practice MDTs Implemented strengthened model of GPs supporting care homes Public education – local campaigns to use NHS 111 and avoid A&E Commissioned system bed capacity review – due April 2014

23. External reviews and quality visits Emergency Care Intensive Support Team visited twice with recommendations which has formed basis of recovery plans Themes from CCG-led quality visits – unannounced and announced:00hrs: Potential patient safety risk from delayed offloading of patients from ambulances Inappropriate attendees in minors Slow triage of patients in waiting area Slow transfers from A&E to wards Inappropriate skill mix and staffing levels for nursing and medical staff in A&E Lack of senior decision makers on the emergency floor High use of agency medical & nursing staff A&E department size too small

24. In Summary Significant problem in meeting A&E 4 hour standard for last 24 months Demand, discharges and bed capacity has remained constant across the system Unable to recover quickly from periods of surge prolonging impact Main underlying issue is staffing shortages in the A&E department – consultant, middle grade doctors and nursing Size of the department is a limiting factor Process management has not been fully embedded with clear leadership.

25. Further action required for the hospital To appoint a performance director for emergency care. To establish a senior consultant rota of permanent clinicians to provide senior leadership in the department. Revise A&E recovery plan to incorporate KPIs and clear and accountable actions for implementation and delivery. Implement a medical, nursing and service manager recruitment plan. To establish minors see and treat. To establish majors rapid assessment. To embed process for escalation to specialist teams. To embed internal and external escalation processes. To achieve earlier patient discharge. To ensure 3x daily site visits take place. To develop a clear plan to deliver the paediatric pathway..

26. Further action for the wider system Urgent Care Working Group meeting fortnightly moving to weekly Review pathway for minors across system Implement our frail elderly pathway in line with the integrated pioneer plan Better management of patients with long term conditions in the community Implement system-wide A&E recovery plan.