Agenda item

Review of Urgent and Emergency Care in Gloucestershire

In response to ongoing issues impacting on Urgent and Emergency Care Systems in Gloucestershire, (raised at county scrutiny committee meetings held in July and at a workshop event in September), the members of the Gloucestershire Health Overview and Scrutiny Committee (HOSC) and the Adult Care and Communities Scrutiny Committee (ASCC), to consider a single item agenda on the delivery of urgent and emergency care in the county. 


The meeting will be held in the Council Chamber at Gloucestershire County Council, Shire Hall, Westgate Street, Gloucester GL1 2TG.


Cllr Andrew Gravells to invite a representative from each of the following participant organisations to give a brief (5 minute) verbal overview on the environmental issues affecting the performance of the organisation in the delivery of urgent and emergency care in Gloucestershire.


  1. Gloucestershire County Council
  2. NHS Gloucestershire Integrated Care Board
  3. NHS Gloucestershire Hospitals Foundation Trust
  4. NHS Gloucestershire Health and Care Foundation Trust
  5. NHS Gloucestershire Primary Care
  6. NHS 111 Service
  7. South-West Ambulance Service Foundation Trust
  8. Police and Crime Commissioner/Gloucestershire Constabulary
  9. Newton Europe - members to also receive a presentation on the conclusions and findings of diagnostic work undertaken by consultants, Newton Europe, in partnership with Gloucestershire County Council and NHS Gloucestershire. Please see attached report and slideshow presentation.


In response to ongoing issues impacting on Urgent and Emergency Care Systems in Gloucestershire, (raised at county scrutiny committee meetings held in July and at a workshop event held in September), the members of the Gloucestershire Health Overview and Scrutiny Committee (HOSC) and the Adult Care and Communities Scrutiny Committee (ASCC), received an update on the delivery of urgent and emergency care in the county.


Included in the update was a presentation on the conclusions and findings of diagnostic work undertaken by consultants, Newton Europe, in partnership with the NHS Gloucestershire Integrated Care Board and Gloucestershire County Council.


Cllr Andrew Gravells invited representatives from each of the following organisations to give a brief overview of current challenges and issues impacting on performance.


1. NHS Gloucestershire Integrated Care Board

2. NHS Gloucestershire Hospitals Foundation Trust

3. NHS Gloucestershire Health and Care Foundation Trust

4. Gloucestershire County Council

5. NHS Gloucestershire Primary Care

6. NHS 111 Service

7. South-West Ambulance Service Foundation Trust

8. Police and Crime Commissioner/Gloucestershire Constabulary


Newton Europe


Stuart Appleby and Sam Newton from Newton Europe opened the discussion with a detailed presentation on their work commissioning by NHS Gloucestershire/Gloucestershire County Council.


It was reported that performance across the urgent and emergency health and care system in Gloucestershire had been significantly challenged during the Winter of 2021/22, particularly impacting on older and frail people who make up the majority of the people categorised as Delayed Discharges, also known as those with No Criteria to Reside (NCTR) in hospital beds. Over the winter months, there had been a significant increase in NCTR levels. Details of the No Criteria to Reside (NCTR) performance data reported at the meeting are attached to the minutes.


Members were informed that each person experiencing delayed discharges were at risk of experiencing a detriment to their overall experience and care. The cumulative effect of the volume of NCTR impacting on the county was subsequently impacting on the ability to provide responsive high-quality health and care services to the people of Gloucestershire. In response, health and social care organisations had agreed to come together to review the challenges to the system and to work together to consider a radical transformation to the current approach.


The proposal was to commission external help involving a two-step process. The first stage had been to commission support from the Local Government Association (LGA) who had offered a support package at no cost linked to their wider supporting role from the Better Care Fund. The second stage, was to commission a large-scale consultancy intervention to work across all the health and care partners of the Gloucestershire integrated care system to reform urgent and emergency care, reform system flow and ultimately improve care outcomes and experiences for people in the county requiring care.


Newton Europe commenced its work in July 2022, with the aim of developing an integrated approach to the delivery of urgent and emergency care services and improving system flow based on the needs of the person and carer. The work to encompass physical health, mental health and social care needs following an urgent or emergency care experience.


Engaging with a wide range of patients, hospital staff and carers, the initial findings of the diagnostic work identified a wide range of improvement opportunities for the Gloucestershire system, ultimately requiring significant transformation to the way services are currently operating.


Members were informed that to deliver transformation at scale, the Gloucestershire system would need to commit to a number of principles to ensure the changes can be delivered and, going forward, sustained. These included: -


Ø  Shared ownership of the challenge, with clear accountabilities

Ø  Jointly agreed priorities and plan of action

Ø  Commitment to a long-term programme of change

Ø  Effective governance and integrated decision making

Ø  Learning culture without blame


Having completed the detailed diagnostic work, Newton explained that the focus would now shift to a 12-18 month ‘Design and Implementation Phase’, during which it was generally accepted that given a large percentage of transformations of this scale fail, to deliver the transformation programme successfully, the next steps would be to ensure rigorous planning, but also sufficient capacity to deliver the change. T


The programme components going forward to include: -


      Detailed process redesign

      Identify the targets and aspirations

      Understand the key levers to change

      Coaching and upskilling, where required

      Rigorous trial and iteration approach

      Creation of success measures

      Cementing new roles and processes

      On the ground engagement planning

      Creating long term tools and succeed measures

      Effective and aligned leadership

      Programme governance and management


In view of Gloucestershire’s strong track record of delivering successful programmes at scale, as evidenced through improvements delivered across a number of other clinical and transformation programmes, it was reported that, from working collectively using a system programme, it was hoped to achieve the following outcomes and benefits: -


      Ability to deliver large scale, pathway-based transformation effectively

      Improved pathways and service user outcomes consistent with a focus on promoting independence

      Reduced costs and improved financial sustainability

      Clarity of vision

      Delivery of key strategies

      Alignment with whole system, rather than siloe perspectives – including health partners, council and provider markets

      Greater staff engagement and learning and development facilitating wider value


In summary, Newton stated that the high-level findings of the diagnostic work presented significant efficiency opportunities from which the Gloucestershire Health and Care System could anticipate making improvements to the outcomes and experiences of the local population.


Members noted the findings of the Newton diagnostic work and advised that the outcomes would be used to inform the transformation programme over the next 18 months. Delivery of the programme would be reliant on the joint working of all partners.


Responding to the information, some members remained unconvinced by the proposals and questioned the data being reported, particularly in relation to ambulance response times and delays. Deborah Lee from the NHS Gloucestershire Hospitals Foundation Trust informed members that the current position was improving but was still not at a level or a quality of care that was acceptable to patients or that the Trust was comfortable with. It was agreed progress was being made but still had a long way to go.


One member, whilst expressing her concerns, believed the care and dedication of staff at Gloucestershire hospitals remained high. Questioning the time taken up by patients visiting hospital accident and emergency departments, the councillor enquired if they might be better treated at local surgeries and suggested investing more effort in better communications.


A full and in-depth discussion ensued, involving several points of concern and questioning. The majority of members expressed ongoing concerns about ambulance delays and the impact of such on the whole health and care system. The concerns were acknowledged, with SWAST, (South West Ambulance Service Foundation Trust), representatives reassuring members that firm action was being taken to address the issues and that every effort was being made to ensure the safeguarding of patients.


Mary Hutton, Chair of the NHS Gloucestershire ICB, (Integrated Care Board), referred to the challenges of an aging population and said there were a number of opportunities from which NHS Gloucestershire could address current issues, particularly when working in partnership with the NHS Health and Care Foundation Trust to provide more care at home.


When asked whether the health and care system had sufficient resources, it was suggested that the system was being impacted on more from a lack of people/staff than from a lack of funding. Recruitment and retention of staff was a key area of investment and focus. It was agreed now was an opportunity to look at things differently, including the use of resources. The value and importance of the contributions made by the voluntary sector was acknowledged.


Drawing on the value of caring for people in their own homes, one member questioned the work being done to ensure the quality of care in people’s homes and the need for suitable accommodation provision following discharge from hospital. Another member referred to links between the work to make improvements to people’s homes and local strategic plans and asked if they were combined. Sarah Scott, Executive Director for Adult Social Care, Wellbeing and Communities at Gloucestershire County Council, confirmed that significant work was being invested in adapting housing provision across the county, including work with the 6 district councils. It was suggested that a progress report on housing care and repair work might be useful at future meetings of ASCC and HOSC, and this was agreed. Action by - Executive Director for Adult Social Care, Wellbeing and Communities


Seeking regular updates on all aspects of work required by the transformation programme, several members disclosed how they remained apprehensive about the pace of work anticipated in comparison to the need to make improvement and deliver sustainable outcomes.


After a short break, representatives from each of the following organisations were invited to give a short overview on current issues affecting the performance of their organisation.  


NHS Gloucestershire Integrated Care Board


Ellen Rule from NHS Gloucestershire presented a slide show presentation on the performance of the One Gloucestershire Integrated Care System (ICS). The slide-show is attached to the minutes.


Mary Hutton, Chief Executive of the ICB emphasised the importance of working with wider partners on the newly formed Integrated Care Partnership system and the value of the work of the voluntary sector.


NHS Gloucestershire Hospitals Foundation Trust


Deborah Lee Chief Executive of the NHS Gloucestershire Hospitals Foundation Trust (GHNHSFT) referred to the impact current challenges to the system were having on the quality of care being provided. The balance in wanting to provide the best quality of care in contrast to recruiting specialist and experienced staff, and more importantly, retaining staff, was a key focus for the Trust.


In spite of the challenges, good progress was being made in elective recovery, with a reduced backlog down to 1100. Progress, in comparison to progress being made in other areas of the Southwest region, was very high.   


Gloucestershire Health and Care NHS Foundation Trust


David Noyes, Chief Operating Officer for the Gloucestershire Health and Care NHS Foundation Trust, welcomed the work being undertaken by Newton and expressed his disappointment that a significant amount of the work planned by the Trust had needed to be halted due to the Covid-19 pandemic. Work with Gloucestershire Police and SWAST was being developed and extensive focus to provide care in people’s homes, including work via the Home First Scheme, would hopefully help relieve the pressure on urgent and emergency care. Recruitment remained a huge area of concern with a significant number of challenges.


Gloucestershire County Council


Sarah Scott, Executive Director for Adult Social Care, Wellbeing and Communities at Gloucestershire County Council, referred to the size and scale of the transformation programme and to the challenge of insufficient home care in Gloucestershire. Acknowledging the impact this was having on the health and care system, the Executive Director said that this was no different to the challenges being experienced in other regions and that it was important to make the best use of the capacity and resources available.


Updates on the Cost of Care Exercise and anticipating further government announcements on the huge transformations expected in Adult Social Care, the Executive Director informed members that further updates would be provided to both committees as part of the scrutiny committee information reporting process. 


NHS 111 Out of Hours Service


Kevin Brown, Director of Integrated Urgent Care for the Practice Plus Group gave a detailed overview of the work of the Practice Plus Group.


Key points reported to the meeting included: -


Practice Plus Group is an independent provider of Healthcare services to the NHS, providing a range of services, including Private Hospitals, Ophthalmology, Musco-skeletal services, Health in Justice and Integrated Urgent Care. NHS 111 services are contracted by the NHS via a competitive tender process commissioned on behalf of the NHS Gloucestershire Integrated Care Board.


Gloucestershire’s NHS 111 and Out of Hours services are provided by the Practice Plus Group, the largest provider of NHS 111 in England. NHS 111 call handling is by accredited Health Advisors operating from the NHS 111 contact centre in North Bristol. The contact centre in Bristol oversees a network of call centres located in Plymouth, Exeter, Bristol, Dorking, Worcester, London and Ipswich. Each site provides resilience through a network arrangement of next available Health Advisor.


From the initial contact, patients are supported with advice which may be direct from the Health Advisor or via a Clinical Advisor in the NHS 111 services, or through an alternative pathway selected through the Directory of Services (DOS). The DOS is a directory of clinical services and allows for selection of an appropriate service for the patient’s presenting complaint to NHS 111, and can include direct booking of an arrival time at an Emergency Department. An emergency ambulance can be arranged, where appropriate.


In December 2021, the Care Quality Commission (CQC) undertook an announced inspection of NHS 111 services at Bristol 111, where the majority of Gloucestershire NHS 111 calls are answered. The CQC published a report on the service in March 2022. The service was rated as ‘Outstanding’ for the second consecutive inspection, the first NHS 111 site to receive this accolade.


The CQC report reported the following findings: -


      The service continued to operate comprehensive and well-embedded systems that proactively kept people safe from discrimination and maltreatment when using the service.


      People who used the services were at the centre of safeguarding systems and were protected from discrimination. Innovation was actively encouraged which achieved sustained improvements in safety and continual reduction in harm.


      The provider continued with their well-established, proactive approach to safeguarding processes. This included a 24-hour a day safeguarding hub. Two safeguarding leads were available within the call centre to support the team with coaching. In addition, regular newsletters which highlighted important topics were sent to the team. There was also a central ‘Safe Chat’ digital system, which allowed staff to raise any safeguarding concerns, questions or suggestions confidentially


      The service had a proactive safety record from which to make improvements as quickly as possible where things could have gone better. Examples on where the service had used outcomes of significant incident investigations as a trigger for auditing clinical areas to further improve their processes, including patient safety, could be provided on request.


      The provider continued to keep clinicians up to date with current evidence-based best practice. Staff had the necessary skills, knowledge and experience to carry out their roles. Staff worked well together and in collaboration with other organisations to deliver effective care and treatment.


      The service’s audit programme for health and clinical advisors remained comprehensive. The management team were in the process of introducing NHS Pathways Gold Standard auditing, where calls were audited, self-audited and feedback given to the health advisor and clinician immediately ensuring responsive and effective learning.


      Examples of where the use of technology improved patient outcomes, increased efficiency and reduced the impact on the local healthcare system could be provided.


      The provider’s patient surveys for November 2021 had been exemplary and showed the majority of patients overall had a good or very good experience when using the service.


      The service sees complaints and concerns as an opportunity to make improvement. Any concerns raised are treated seriously and responded to appropriately to improve the quality of service provided.


      The entire team continues to demonstrate a culture of high-quality sustainable care. The provider ensured there were experienced staff  who were clear on their roles and responsibilities. The provider’s governance processes were comprehensive, and included producing  proactive risk assessments that enabled them to respond to patient risks quickly. This ensured they received appropriate care and teams reviewed patients risk and the effectiveness and appropriateness of care and performance across the service live 24 hours a day, 7 days a week.


      The service continues to display a culture of learning, continuous improvement and innovation and this includes:


Ø  Trialing the Pathways Clinical Consultation Support Tool (PaCCs). This is a patient assessment and clinical consultation tool designed as an alternative offered nationally to NHS Pathways (a triage software used throughout 111 services). PaCCs gave clinicians who used the software, more autonomy. The trial showed a positive impact of a reduction in referrals to 999 and Emergency Departments. This supported the other areas of the local healthcare economy.


Ø  Trialing GoodSAM® (a video or image sharing technology via a one-way video call). This allows clinicians to see the patient and support them to identify concerns quickly. Clinicians are very positive about the use of this tool, as it allows them to make a more accurate diagnosis.


Ø  The service has developed its own remote green button, accessible to health advisors working remotely from home. The service allows advisors to easily access clinical support where a patient required cardiopulmonary resuscitation (CPR).


Mr Brown informed members that the organisation intended to work closely with system partners to tackle the capacity pressures on urgent and emergency care in the health and social care system in Gloucestershire. Gloucestershire, like all systems across England, operated under significant pressures. The Practice Plus Group recognises its role in supporting the pressures relating to emergency department, 999 and other areas of healthcare.


Key areas where the Practice Plus Group provides additional and ongoing support included:


      Additional clinical validation of NHS 111 cases where an urgent ambulance (Category 3 or Category 4) ambulance are the determined dispositions of a health advisor assessment.


      Additional clinical validation of NHS 111 cases where an emergency department attendance is identified and to explore further if alternative care pathways could be more appropriate.


      In the early stages of the pandemic, NHS 111 was advertised as the first port of call, which led to very substantial rises in demand and this continued to be marketed as where to go first for ‘urgent’ care.


      Access to general practice is more difficult. It was suggested that this is where NHS 111 was able to support the wider system and continues to do so.


      The Practice Plus Group operates in a national context of General Practitioner and other Healthcare professional shortages, and where the work exceeds the operating capacity to meet that demand.


In 2021, 1.9 million calls were made to NHS 111 in Gloucestershire. At the time of the meeting, comparisons between 2018 and 2021 indicated a rise of 39% in calls to NHS 111 in Gloucestershire. The advent of NHS 111 online had seen growth year on year also and is becoming an increasingly used service.


Patient calls that are triaged through the national NHS Pathways tool, mandated for NHS 111 providers, have seen an increase year on year of cases requiring both ED and 999 referrals.


In 2021, 64% of the volume of cases that had an ambulance C3 or C4 outcome were validated for alternative pathways. 70% of these were found to have alternative pathways (downgraded). Of emergency department cases, 63% were validated and 57% were found alterative pathways (downgraded).


This was against a NHS England key performance indicator of 50%. Mr Brown stated that he was working closely with the Gloucestershire ICB to achieve the highest levels of validation possible to share with the clinical resource available to us.


The Practice Plus Group was recognised by the European Contact Centre and Customer Service Awards 2020 for its response during the COVID Crisis for its care to patients and to its staff and further recognised by the UK Contact Centre and Customer Service Awards 2022 for Innovation and Change.


Southwest Ambulance Service Foundation Trust


SWASFT has the responsibility for the provision of ambulance services across an area of 10,000 square miles, comprising 20% of mainland England. The Trust covers the counties of Cornwall and the Isles of Scilly, Devon, Dorset, Somerset, Wiltshire, Gloucestershire and BNSSG (Bristol, North Somerset and South Gloucestershire).


The Trust serves a total population of over 5.5 million and is estimated to receive an influx of over 23 million visitors each year. The operational area is predominantly rural but also includes large urban centres including Bristol, Plymouth, Exeter, Bath, Swindon, Gloucester, Bournemouth and Poole.


Handover delays remain the single biggest challenge. A hospital emergency department should accept the transfer of a patient into their care from an ambulance within the national performance standard time of 15 minutes. If not, a handover delay occurs and the patient’s care remains with the ambulance service until the hospital accepts the handover of care. This means that SWAST clinicians are held at hospitals, often for long periods of time and unable to attend other calls.


To ensure ambulance clinicians are able to get back out on the road as quickly as possible to respond to other 999 calls in the community, SWAST continue to work very closely with hospitals to release crews as soon as possible.


Handover delays reflect blockages in the flow of patients through the health and social care system.


SWASFT is working with our system partners across the seven Integrated Care Systems in the South West, particularly those most challenged with handover delays, to deliver sustainable improvements for patients.


Providers continue to strive to do more to manage services better, whilst stressing the need for more beds in hospitals and care homes, and more social care support to help those patients that need assistance when they return to living in their own homes.


It was reported that in October 2022, SWASFT lost 41,320 hours to hospital handover delays. Equivalent to 3,756 double-crewed ambulance shifts. In October 2022, Gloucestershire lost 2,663 hours to hospital handover delays. Equivalent to 242 double-crewed ambulance shifts.


Year on year, SWASFT has recorded one of the lowest conveyance rates in England. The Trust has led the way nationally in managing patients without the need for conveyance to an Emergency Department. In October 2022, SWASFT received 82,757 incidents across the South West.


·         Supported by clinicians in our Emergency Operations Centres, 25.65% of patients were treated over the phone or referred to other more suitable NHS services.


·         Where an ambulance was required to carry out a face-to-face assessment, highly skilled ambulance clinicians managed 33.59% of patients on-scene.


·         The Trust has access to a range of non-Emergency Department hospital pathway (e.g. Same Day Emergency Care) with 3.18% of patients being conveyed to these alternative destinations.


·         Only 37.58% of patients were conveyed to an Emergency Department, a figure which has reduced year-on-year. In October 2022, SWASFT received 8,543 incidents in Gloucestershire.


·         Supported by clinicians in Emergency Operations Centres, 21.82% of patients were treated over the phone or referred to other more suitable NHS services.


·         Where an ambulance is required to carry out a face-to-face assessment, highly skilled ambulance clinicians manage 36.61% of patients on-scene.


·         The Trust has access to a range of non- Emergency Department hospital pathway (e.g. Same Day Emergency Care) with 2.72% of patients being conveyed to these alternative destinations.


·         Only 38.85% of patients were conveyed to an Emergency Department, a figure which has reduced year-on-year.


Managing Hospital Handover Delays 


·         The Trust has a comprehensive executive led hospital handover plan, managed by a dedicated improvement team. The plan is positively reviewed by the Association of Ambulance Chief Executives and has the following aims:

Ø  Reduce SWASFT to hospital handover times

Ø  Maintain patient safety

Ø  Ensure health and safety of Trust staff

Ø  Promote effective joint working

Ø  Specific actions include:

·         The Trust is engaged with each hospital across the region and with each ICS at local handover improvement groups. Considerable joint working continues to occur to address the challenge.

·         SWASFT has put significantly more double-crewed ambulances on the road. Back in 2019-20, there were around 37,000 ambulance conveyance hours available on the road in the region, per week. This has been increased to between 47,000 – 48,000 hours per week. The aim is to reach 50,000 hours.

·         SWASFT has sought to agree a Joint Handover Escalation Plan with each hospital. The plan provides a structured approach to escalating handover delays with four levels, and pre-agreed actions for each organisation.

·         SWASFT has 40 paramedics dedicated to the role of Hospital Ambulance Liaison Officer (HALO) located at the most challenged Emergency Departments, to provide local leadership. The officers assist with prioritising the handover of patients waiting to be transferred into hospital care.

·         An established process has been put in place to divert ambulances from hospitals where a system agrees an Emergency Department has to close to new arrivals.

·         There is also a process to request Emergency Departments to immediately release ambulances to free them up to attend Category 1 incidents.

·         SWASFT has focused on a range of actions to improve patient safety during extended delays, including being the first ambulance trust in the UK to work with Tissue Viability Leads at each hospital to implement pressure redistribution mattresses.


·         SWASFT has also have improved clinical guidance to ambulance clinicians, including the administration of medicines during handover delays.

·         Another initiative has been to up-skill frontline clinicians to provide effective care over prolonged periods of time via a series of awareness events.


Police and Crime Commissioner/Gloucestershire Constabulary


Chris Nelson, Police and Crime Commissioner and Becky Beard, Assistant Chief Executive for the Office of the Police and Crime Commissioner gave a detailed overview of the challenges experience by Gloucestershire Police in supporting SWASFT and in responding to issues and incidents at Gloucestershire Hospitals.


Detective Superintendent Steve Bean - Head of Public Protection and Crime Command for Gloucestershire Constabulary and Chief Inspector Sarah Simmons from the Force Control Room and Mental health and Suicide Prevention Lead contributed to the discussion.


It was suggested that representatives from each organisation attend/join hospital forum meetings to share views and ideas on how best to respond to some of the challenges presented to them, and the suggestion was supported.




Cllr Andrew Gravells thanked all representatives in attendance at the meeting for their contributions. He referred to the meeting as a unique opportunity for everyone to express their views and ideas and stated that this would not be a one–off event. Enquiring when the outcomes of the next stage of the Nelson consultation work would be, Cllr Gravells informed members that the outcomes of the work would be presented to the HOSC in the New Year.

Supporting documents: