Agenda item

This item is part of the new review into Access to Healthcare in Southwark.

An Urgent & Emergency Care briefing is attached from Lambeth and Southwark Urgent Care Board.  

6.1  The chair invited Dr Patrick Holden, Urgent Care clinical lead for Southwark Clinical Commissioning Group (SCCG) and Andrew Bland, SCCG Chief Officer, to present on the Lambeth & Southwark Urgent Care Network Board paper. Dr Patrick Holden commented that nationally Accident and Emergency care has seen performance deterioration, therefore the Department of Health required the SCCG to produce a plan to improve.

6.2  He explained that there are two main reasons for the increase in pressures on A & E - acuity is going up and Mental Health is going up, including in people not previously known to services. The plan to improve the increase in ‘acuity’ includes enhanced rapid response and home wards, which enable people be discharged. Mental Health is being tackled through the community care plan. Andrew Bland explained that further work is ongoing by the Urgent Care Network Board on Mental Health and they have talked about escalations between providers and provided the Department of Health with iterations of the plan.

6.3  The aim is to get plans up and running well before winter and agree the plan by 1^st September. The SCCG also expect that A & E will receive more money from central government to deal with increased demand over the winter; however the details are not clear yet. A member commented that he had heard that there will be £500 million for the whole country. Andrew Bland responded that traditionally this is received in the middle of winter, but where will it be targeted is the most pertinent question. He added that the performance of King’s College Hospital at Denmark Hill and Guy’s Hospital is very good - but this is partly a result of additional money.

6.4  A member commented that he suspected that the increase in patients experiencing mental health issues was to do with the impact of welfare reform. Andrew Bland emphasized that all partners are seeing a greater number of patients with mental health problems and that the Urgent Care plan is about treatment, but prevention is an important issue, and the SCCG have a longer strategy about mental health.

6.5  Members asked about patient behaviour and how to best direct people to the most appropriate services.  Andrew Bland reported that the SCCG have been putting information in surgeries, however they have discovered that information needs to be targeted otherwise it has not been found to be useful. He reported that the SCCG is working with Healthwatch on this.

6.6  The chair then invited hospital trust representatives to briefly present their papers and take question on access to A & E and Urgent Care. Dr Katherine Henderson, Clinical Lead, Guy’s & St Thomas’ (GST) ; James Hill, Head of Nursing for the Emergency Dept, GST ; Angela Dawe, Director of Community Services, GST ; Ms Briony Sloper Deputy Divisional Manager for Trauma and Emergency Medicine , Kings College Hospital (KCH) presented.

6.7  A member asked if Guy’s Urgent Care service had a performance indicator for access and emergency staff from GST responded they had a four hour target which they achieve easily. They reported that the Urgent Care centre is not overwhelmed.

6.8  Members asked about the proportion of patients who attend an A & E department who could have been treated at GPs, and commented that constituents have reported that they find it difficult to access GP appointments. The emergency staff reported that around 20% are more minor aliments that could be treated out of A & E / Urgent Care, however they explained that it is hard to turn people away as this is a difficult conversation to have with patients presenting at an emergency department. The reasons for attending may be complex and to do with deprivation or the level of medical concern. For example parents may well bring in young children because they are worried and this is particularly true for people who need more support – for example single parents whose first language is not English .With the economic downturn some people , like cleaners,  are justifiably worried that if they lose a shift they will lose their job.

6.9  The KCH representative explained that King’s College Hospital at Denmark Hill has seen an increase in acuity, particularly among older people, which means the number of people being admitted into beds, has increased. People arriving at A & E are sicker people, more likely to be admitted, who stay longer and are harder to get home. She explained that has been an increase in attendance by ambulances. The majority of attendances are from Lambeth and Southwark. She reported that the King’s A & E was built for 900000 but is now seeing much more. A temporary ward block has been added and another one is now being put in place, which is relieving pressure.

6.10  Guy’s and St Thomas’ staff reported that up to 40 % of the patients who turn up at A & E / Urgent Care are not from Lambeth or Southwark, and some are not from London or the UK. A few people who arrive are from Europe and they often come back because many are homeless.

6.11  Emergency staff reiterated that mental health is a key issue - and public health education. Staff reported that it is not just sick people, but also people who have higher social care needs and A & E departments are getting a surge of iller patients later in the day - nobody knows way .Emergency staff emphasized that while there is an issue of people not accessing the right place to receive the most appropriate care there is also the issue of people presenting too late.

6.12  Members asked what the driver is for poor mental health. Emergency staff explained that the national increases in the breach of the 4 hour access target are a symptom of a system under strain. Emergency departments become the default when people can’t access services they need in other places; A & E are trying to manage this, but there is an issue about turning people away. It is not a simple as saying ‘go away’ as there is a need for efficient signposting and also to ensure that other services are very accessible. Sometimes it is better and easier to treat someone. Staff reported that they have a 10'% increase in attendance but a 30 % increase in the need for assessments, which is very significant. Staff reported that people are getting very distressed and there is difficulty in moving people to the right bed.

6.13  Emergency staff were asked what steps are being taken to keep older people out of hospital. Dr Holden, CCG, responded that often the provision of good soft care can keep people at home and that the use of ‘rapid response’ has been very good, but the ‘home ward’ effectiveness has been more limited. The SCCG added that they are launching a home and community care strategy which they think that will make a difference.

6.14  Members asked how patients are dealt with at A & E who might not need an emergency response. Staff explained that patients are met and then people may get streamed to a GP and or an emergency nurse. Members asked about the payment the hospital receive if they do not need emergency care  and emergency staff explained that hospital may get a paid the lower tariff - but none of the emergency tariffs cover the actual cost.

6.15  Members commented that many local walk-in centers have a very low waits and suggested that these were promoted more. There was a discussion about terminology used and services available; for example someone could not go to the Lister Centre for a fracture, but this would be available at Guy’s Urgent Care centre. Members commented that there is confusion about where to access minor and urgent care. 

6.16  Andrew Bland cautioned that a disproportionate focus on minor presentations at A & E would not be justified and emergency staff agreed, commenting that acuity and the level of dependence are the main issues. Emergency staff added that in their view prevention rather than restricting access at the door would be preferable.

6.17  A member commented on the A & E attendances from Europe and asked if anything could be done to mitigate this and emergency staff explained that the central location meant this was inevitable. A member asked has if patients from Europe were a big problem and emergency staff emphasized that the numbers were few.

6.18  Members referred to the report and noted that A & Es seem to particularly struggle in February and July. Emergency staff agreed and said this was virus time and it was also difficult in December, however August was usually slow, but this year there has been no drop in acuity.

RESOLVED

The SCCG will bring their Mental Health Strategy to the committee.

SCCG and Healthwatch will provide an update on their targeted campaigns to increase signposting, access and engagement with the right health services.