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Quality of Care
Patient Flow
Maternity
General Information
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59
QUALITY OF CARE
The CCG is committed to improving the quality of care for our patients and therefore assessing,
measuring and benchmarking quality is a key focus. We continue to strengthen, refresh and adapt
our quality assurance processes, including learning from others.
We recognise that quality is everyones business and our quality assurance processes is a
partnership with Providers and other commissioners
QUALITY Governance
The quality framework describes our approach to monitoring and assuring quality in all our
commissioned services. The process describes a structured approach to the steps taken in
response to increasing risk and reducing assurance. However, where a significant event or serious
failing is identified a Risk Summit should be called immediately.
The three domains of quality: patient safety, clinical effectiveness and patient experience are
monitored through routine internal contractual processes and quality governance structures and
external sources such as CQC, Monitor, peer reviews, national surveys etc. Providers are required
to have their own quality monitoring processes in place and through the duty of candour and the
contractual relationship with commissioners they have to provide information and assurance to
commissioners and engage in system wide approaches to improving quality.
Stage 1) Routine Quality Assurance Monitoring
Routine Monitoring includes, but not limited to, the following quality metrics:
Patient Safety Indicators include: monitoring of Health Care associated Infections, safeguarding
vulnerable children and adults, patient safety incidents, never events, complaints, mortality rates,
and workforce numbers, skills and training.
Clinical Effectiveness Indicators include: The implementation of the National Institute of Clinical
Excellence guidance, delivery of Commissioning for Quality and Innovation (CQUINS), key
performance indicator monitoring, learning from audit and peer reviews.
Patient Experience Indicators include: Patient reported outcomes measures, Friends and Family
test, patient survey results, respecting privacy and dignity, eliminating mixed sex accommodation
monitoring, complaints monitoring, CQC inspection results, access to services, patient advisory and
liaison service, health watch etc.
Stage 2) Routine Quality Assurance Meetings
Commissioners and providers are involved in a number of meetings where quality is the key priority
and focus of those meetings. We operate a Clinical Quality Board as part of contract governance
arrangements with CHFT this gives opportunities for quality monitoring to take place and assurance
to be gained. This Board is attended by the CCG Quality Committee Chairs (GPs), the CCG Head
of Quality and Director of Nursing and Medical Director from CHFT, this meeting take place bi
monthly. This meeting has an agreed workplan, and has the opportunity to review indicators
described in this paper as well as areas of concern.
Other meetings include focussed meetings around specific areas such as Infection, Prevention and
Control, Safeguarding Board and local contract groups.
Adapted from NHSE guidance on Quality Assurance
3
Risk Summits
Where there are quality concerns identified or the level of assurance is insufficient a Local Quality
Review meeting is held with commissioners, regulators and other agencies i.e. Health watch to
share intelligence and determine if the proposed actions by the provider give the appropriate level of
assurance.
Where assurance is not gained then a Single Item Quality Surveillance Group meeting will be called
involving the commissioners, regulators and the provider to enable the provider to present their
actions to address the quality concerns in a timely manner. This stage will be followed by a rapid
review visit or a risk summit if there are significant risks that the provider is unable to deal with
effectively.
NB The escalation to a rapid response review or risk summit could be instigated at any point in
the process if patient safety concerns require urgent action
CCG Quality Governance arrangements
Each CCG has a Quality Committee, chaired by a GP Governing Body member, included in its
membership is a CCG Lay member. They meet monthly, have and agreed work plan. Agendas
focus on the three domains of Quality, Patient experience, Patient Safety and Clinical effectiveness.
The focus of the Committees is both Quality Assurance and Quality improvement.
The Governing Bodies receive bi monthly reports including Quality and Safety.
Penny Woodhead
Head of Quality
Calderdale and Greater Huddersfield CCGs
Targeted Quality
Assurance Visits
No
Single Item QSG Triggers
Yes
Maintain Enhanced
surveillance for a
minimum 3 months
Yes
No
Single Item QSG
/ or staff
a single, material event
Increasing assurance /
Reducing Risk
RRR/Risk Summit
No
7
Yes
Version 12
Final Version
December 2015
1.0
Purpose
The Surge and Escalation plan describes the agreed local processes for ensuring a
co-ordinated and planned response to circumstances where pressure in one or more
parts of the system is impacting on the systems ability to ensure services are safe
and of high quality. This plan has been developed through the Calderdale and
Greater Huddersfield System Resilience Group (SRG) structure by the following
organisations, all of whom have made a commitment to use the processes to
support the system:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Calderdale CCG
Greater Huddersfield CCG
Calderdale & Huddersfield NHS Foun0dation Trust
Calderdale Council
Kirklees Council
Locala CIC
Spire Hospital Elland
BMI Hospital, Huddersfield
Local Care Direct
Yorkshire Ambulance Service
South West Yorkshire Partnership Foundation Trust
Community Pharmacy West Yorkshire
Voluntary Action Calderdale
NHS England
2.0
Objectives
Page 2
Page 3
Community Services
Limited capacity in Intermediate Care beds and other community beds
Community beds/home(s) closed due to infection or CQC measures
Staff sickness impacting on patient care
Social care
Limited or no capacity in Elderly Mentally Ill (EMI) beds
Limited or no capacity in Home Care Services
Limited or no capacity in Transitional beds
Beds closed due to infection or CQC safeguarding issues
Limited capacity or sickness in social care teams and Gateway to Care /
Re-ablement to support flow out of hospital
Ambulance Services
Demand or reduced capacity impacting on the delivery of services
Demand for ambulances reduces capacity for hospital transfers and A&E returns
WYUC
111 - high demand and abandonment rates cause pressure in A&E and Primary
Care
Primary Care
Demand affecting General Practice access patients access hospital or other
services which could have been avoided
Business continuity issues in individual practice mean that the practice is
struggling to meet demand
Staff sickness impacting on patient care
Using these scenarios, we have worked through our local SRG structures to identify
potential actions which can be used to try to mitigate risk as it occurs and ensure
that services remain safe and are delivering high quality care.
Page 4
The majority of this date is available to NHS England through the UNIFY2 SitRep
submitted by Acute Trusts daily.
2. Bronze Level - Service/Business Continuity
We have agreed with partners the need to refresh their internal Service/Business
Continuity Plans in line with best practice. Whilst there are contractual
requirements around the need for Continuity Plans to be in place, we have
agreed that partners will ensure their plans are; strengthened, fit for purpose and
aligned to this Surge & Escalation Plan. This approach has included the
strengthening of plans in local GP practices.
As part of their approach to business as usual, at a Bronze (Operational)
level, organisations will use their own Continuity Plans to ensure their services
are operationally resilient. Using their internal command and control structures
they will maximise operations to enable them to manage periods of pressures
due to capacity/demand. Organisations are expected to use data to enable them
to predict usual patterns of demand and capacity due to seasonal trends and
mitigate predictable risk wherever possible, and to learn lessons from previous
years.
Page 5
It is expected that organisations will take a pragmatic approach and ensure that
the call is initiated as quickly as possible, before it has reached a critical state.
However, it is recognised that there may be instances where a critical state may
develop which could not have been predicted.
Using their own triggers as a guide, any organisation can request a Silver
Command telecom using the CCGs On-Call structures 24/7. The CCGs On-Call
Manager should be contacted via CHFT Switchboard (01484 342000). The way
in which calls will be initiated will differ dependent upon whether a call is needed
in or out of hours:
Page 6
The CCGs On-Call Manager will contact the Sliver Command members by
using a pre-populated email. These individuals are detailed in the Silver
Command Contact List (Appendix B). Each organisation will be
Seek clarification from the organisation(s) triggering the call about the
current situation
Confirm what actions need to be taken including communication out
Agree the support required from other organisations
Agree next steps and whether another call is needed
Agree of any issues or messages which may require escalation to Executive
leaders in partner organisations
Consider de-escalation arrangements.
Silver Command will expect assurance from individual organisations that they
have exhausted all the actions set out within their individual Service Continuity
Plans and that organisation(s) have worked pragmatically and maturely together
in order to deliver all possible mitigating actions. In addition, it will have the
ability to agree courses of action which are outside those normally available to
individual organisations. This would take the form of:
Also included within this document for reference are; triggers associated with
weather and triggers associated with the delivery of critical care (Appendices D
& E). This will enable organisations to understand how scenarios associated
with limited critical care capacity in other trusts or bad weather locally or
nationally may affect the actions that need to be taken.
Page 7
Locally
NHS England
Based on the daily information supplied to NHS England (set out in 1.0 above),
NHS England will need to be informed where there is a combination of; higher
than normal ambulance handover delays, high bed occupancy levels or bed
closures, a large number of short notice operations cancelled, sustained failure
of the Emergency Care Standard or higher than normal delayed transfers of
care. For the purposes of this plan these will be regarded as circumstances
where an organisation(s) in the system moves to REAP levels 5 (Purple), or 6
(Black).
The EPRR Framework1 also identifies the following situations which should be
escalated to NHS England (Yorkshire and the Humber):
Page 8
3. Silver - an organisation(s)
reach their system trigger
and ask for a Silver
Command to be called
(REAP levels 4,5,6)
Page 9
Level
Trigger
Normal - Bronze
Level 1
Page 10
Level
Trigger
Concern - Bronze
Level 2
Page 11
Level
Trigger
Level 3
Page 12
Level
Trigger
Level 4
Critical - Silver
Potential Service
Failure - Silver
Level 6
Level 5
Page 13
(To be initiated through a call to the CCG Manager On-Call via CHFT switchboard
Organisation
Silver Command
Telephone Number
Calderdale CCG
Greater
Huddersfield CCG
CHFT
Calderdale Council
Kirklees Council
Locala
SWYPFT
YAS
NHS England
Spire
BMI
Third Sector
Page 14
Dial in details:
Date and Time:
1. Attendance and apologies
2. Issues/summary to date
3. Actions being taken and their progress
4. Challenges that are ongoing
5. Assistance needed from other services/organisations
6. Membership for next meeting
7. Agenda items for next meeting
8. Actions before for next meeting including communications and escalation
9. Date, time, location of next telecom if needed
Page 15
Cold weather
Heatwave
Level 0
Long-term planning
Long-term planning
Level 1
Heatwave Action
All year
All year
1 November to 31 March
Level 2
1 June 15 September
Page 16
Summary
Trigger
Normal
Concern
Low bed alert (LBA) activated - less than 4 beds available for 24 hours
across one or more network
Moderate All beds open in Unique Transfer Group (UTG see appendix A) but
Pressure none available for 48 hours and all level 1 delayed transfers
discharged out of units
Severe
All beds across 3 WY networks open but none available for 24 hours
Pressure and patients ventilated out of units
Critical
Potential
Service
Failure
All beds across 3 WY networks open but none available for 48 hours
Major incident involving large number of casualties requiring intensive
care
100% additional capacity achieved but level 5 triggers remain for 24
hours
Regional or national pressure
Page 17
25
Project
Ward orientation
Regular information round
Hello my Name Is campaign
How can I help - supporting staff to work in an enabling culture
Reducing noise at night
Outpatients: A similar approach was taken in order to develop the plan for outpatients, the 5
themes identified for improvement were:
1. Waiting: Start/finish times of clinic, waiting rooms
2. Access: Signage / direction / patient check-in
3. Communication: Patient letters, Hello my name is..
4. Patient Focus: Staff on stage, sharing the short film standing in someone elses shoes
5. Next Steps: What happens next, supporting patients with information about tests and investigations
Accident and Emergency: Improvement priorities have been identified by the departments with
the following priorities:
1. Waiting times:
- Extending the Emergency Nurse Practitioner service to support a quicker process through the minor
injury stream
- Introduced electronic waiting room screens to provide accurate patient information for patients on
number of patients in the department, waiting times for assessment and waiting times to be seen by
a clinician.
2. Staff engagement:
- Bi-monthly patient experience meetings
- Opportunity for complainants to attend and tell their story in person
- You said we did work
26
Details of mortality rates for each site over at least a 3 year period to help assess if there are any
trends.
2.50%
Crude Mortality
Rates by
Site
CRH
HRI
2.00%
1.50%
1.00%
0.50%
0.00%
Crude mortality rates for CRH and HRI individually are plotted monthly for the past three years. In
this case the data is presented as a %mortality, although it is also possible to express the data as
deaths per 1000 bed days, for example. The trends, however, are seen equally using any of these
methods.
As can easily be seen, there is a consistent difference, with crude mortality higher at HRI. It should
be borne in mind that the service configuration currently split between the hospital sites has HRI as
the acute surgical, trauma and oncology base.
Mortality rates are subject to a marked seasonal variation, which is very visible. In common with the
rest of England and Wales, there was a higher winter mortality peak in 14-15 than in previous years.
There has been a lot of national academic debate as to the causes, one of which may be the less
effective influenza vaccine that year.
This past winter has not seen as sustained a peak in mortality, although a late national surge in
influenza reports may affect this.
27
CRH
HRI
50
40
30
20
10
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
In isolation, this is a difficult statistic to interpret, as there is no ideal figure. On the one hand a
high figure might indicate a tendency to discharge too early or poor discharge planning or
community support. On the other hand it might equally indicate good end of life care with
appropriate discharge to home or hospice care at the end of life. Again the HRI oncology service is
likely to result in a higher figure.
Clarification of the reasons why there has been a deterioration in the mortality rates (HSMR) since
2011/12 (which were within the expected/acceptable range).
Standardised mortality ratios (HSMR and SHMI) at CHFT have been the subject of intense analysis for
many years, dating back to our participation in the Safer Patients Initiative in 2006-7. The data has
varied, but it is true that there has been a deterioration in both of these measures since 2011-12.
Our responses to this have been outlined in detail previously, but include a programme of mortality
case review, based on diagnoses that appear to have higher than expected SMRs, groups of patients
of special interest, and latterly working towards 100% coverage of inpatient deaths. We have
undertaken wholesale coding reviews, commissioned external reviews of specific services, and
sought expert advice from Professor Mohammed Mohammed of Bradford University. Despite this,
we have not been able to identify any consistent reason why the HSMR and SHMI at CHFT are both
28
higher than expected. It should be noted that SHMI is rebased so that the average is consistently
100, it is therefore possible that the Trusts position relative to other organisations has deteriorated
due to a failure to improve at the same pace as other organisations rather than an absolute increase
in mortality rates.
Meantime there is an increasing body of academic evidence that there is a poor correlation if any,
between SMRs and other measures of care quality and measurements of avoidable death. The most
recent and highest profile study is that of Professor Black and his team at the London School of
Hygiene and Tropical Medicine, the PRISM2 study (Hogan et al BMJ 2015;351:h3239). In their paper,
the authors conclude: hospital-wide SMRs do not provide a useful indication of the proportion of
avoidable deaths in a trust.
Increasingly, therefore, attention in the NHS is turning to the assessment of avoidability and
opportunities for learning from death through standardised mortality case record review, and CHFT
is participating in work of the Yorkshire and Humber Improvement Academy that has achieved
national recognition.
We continue to focus on care quality through our Care of the Acutely Ill Patient plan, which, along
with other work picks up themes that emerge from out mortality review work.
The proposals contained within the current Consultation will facilitate the delivery of Consultant led
care, 7 days a week, focussing the sickest patients and the Doctors to care for them on a single site,
reducing delays in care and the need to transfer patients between sites, and therefore improving the
quality of in hospital care. Furthermore the delivery of care closer to home will result in fewer
patients being admitted into hospital for end of life care. These actions may impact positively on
reducing the SHMI.
Alex Hamilton
11/4/16
29
30
31
All emergency admissions must be seen and have a thorough clinical assessment
by a suitable consultant as soon as possible but at the latest within 14 hours of
arrival at hospital.
Hospital inpatients must have timely 24 hour access, seven days a week, to
consultant-directed interventions such as critical care, Interventional radiology,
interventional endoscopy, emergency general surgery.
All patients on the AMU, SAU, ICU and other high dependency areas must be
seen and reviewed by a consultant twice daily, including all acutely ill patients
directly transferred, or others who deteriorate. To maximise continuity of care
consultants should be working multiple day blocks.
We are working to improve the transfer of information during shift handover against
using Nerve centre as an electronic hand over tool.
The Trust is currently preparing to implement an electronic patient record, which will
aid a number of quality initiatives, reduce errors, and improve the availability of
32
information across the health care economy, the preparation of this system is
ongoing and is planned to be implemented on the 8th October 2016.
There is ongoing improvement work in the following areas
Clinical documentation
Patient Falls
WHO checklists
33
We have data to show that surgical outcomes improved after acute surgical services
were centralised at HRI a few years ago, reducing mortality associated with
gastrointestinal perforation and obstruction from approximately 12% to 6%. Across
the wider NHS we know that outcomes for Acute Myocardial Infarction (heart
attack), with modern interventions, have significantly improved with centralised
specialist care in our local case, in Leeds.
The same dramatic result has been achieved with acute stroke care in London by
centralising care in a few hyperacute stroke centres, not in every local hospital as
used to be the case. A reduction in mortality up to 3 months after the stroke of 25%
was seen. There is no reason to think that these potentially improved outcomes
from concentration of specialist care are limited to these specific conditions.
There is good data across the NHS to show that acutely ill patients who, as a result of
bed pressures are admitted to wards who usually manage patients under other
specialities (outliers) have poorer outcomes. Moving to a redesigned system in the
future of dedicated emergency and planned provision will help to minimise this and
have a positive impact on outcomes of care.
The Trust is experiencing significant difficulties in recruiting and retaining Senior
Doctors and has significant vacancies both in Emergency Medicine and our medical
specialities. As these services are largely duplicated on both of our current acute
hospitals these jobs require onerous on-call rotas and are therefore unpopular when
compared to positions available in surrounding trusts. Furthermore we are unable to
develop specialist rotas which would be both more popular and potentially deliver
safer care. The centralisation of acute services along with the provision of modern
facilities would substantially improve our ability to recruit and retain staff. It should
be noted that a number of Consultant staff have left the organisation over the last
year citing workforce pressures and the current models of care as contributory
factors in their decision.
Another feature of our hospital mortality work is the sad observation that frail
people or people at the end of their life are sometimes admitted to hospital when
there might have been other ways of caring for them and supporting their family.
The development of non-hospital services, with care closer to home will help avoid
unnecessary hospital admission and help to support care at home. Most people, if
asked, state an advance preference to die at home. We cannot avoid death; but we
can design services that can help people to receive support in their final days in the
right setting.
Alex Hamilton
Associate Medical Director
17/03/2016
34
Activity data for the last three years for A&E is as follows. Note 15-16 is not a full year yet.
Hospital
CRH
CRH
CRH
CRH
HRI
HRI
HRI
HRI
Year Fiscal
2015-16
2014-15
2013-14
2012-13
2015-16
2014-15
2013-14
2012-13
Cases
68,048
72,530
71,475
72,048
66,199
69,775
67,776
69,089
All data is full years except 2015-16 which is April 2015 to February 2016
35
36
PATIENT FLOW
37
FnYr 13-14
FnYr 14-15
FnYr 15-16
Grand Total
CRH to HRI
1,156
1,091
951
3,198
HRI to CRH
Grand total
1,113
2,269
1,008
2,099
921
1,872
3,042
CRH Total
HRI
Transferred to/Admitted to
ADMITTED TO HUDDERSFIELD
TRANSFER TO HUDDERSFIELD
A/E
ADMITTED TO CALDERDALE
TRANSFER TO CALDERDALE A/E
HRI Total
Grand Total
Financial Year
FnYr 13FnYr 14FnYr 1514
15
16
564
570
472
8
572
504
16
520
1,092
7
577
499
21
520
1,097
18
490
930
42
972
1,462
The data shows an increase of 430 patient moves from HRI A/E to CRH.
Reasons are:
Paediatric medical admissions are all now at CRH. This has increased admissions by 250.
180 adults transferring to CRH for specialist assessment in areas such as stroke,
cardiology and gynaecology.
Dr Ashwin Verma has reviewed the data on hospital ward to hospital ward transfers
(roughly 1,000 in each direction each year). Ashwin has advised there is really little
meaningful themes from data. The reasons we transfer patients include:
Transfers from CRH to Surgical Assessment Unit or Surgical wards will be because of GI
bleeds and Surgical condition found/developed.
38
MATERNITY
39
Number of Home
Births
73
101
84
126
118
141
Total Number of
Births
5104
5630
5746
6031
5966
5950
Rate
1.4%
1.8%
1.5%
2.1%
2.0%
2.4%
Home
Freestanding midwife led birth centre
Midwife led birth centre on the same site as the medically led Obstetric Unit
Obstetric Unit
Home birth is offered as standard option to all women who are at low risk of complication.
Our Consultant Midwife works with women who are at high risk of complication but choose
homebirth and their named community midwives to ensure women make an informed choice
about place of birth.
40
Our home birth service is delivered by the on call community midwifery team and is available
24/7. Womens satisfaction with the service is generally high. A community based home birth
champion team was established in October 2014. The team currently has 3.2wte midwives.
As the number of women choosing home birth increases, the home birth team numbers will
increase.
Actions the home birth team are doing to increase homebirth rates include:
This work is being led by the Matron for Community Midwifery Services
Audit
Between October 2014 and July 2015, 135 women expressed a wish to birth at home. 58
women achieved this (43%). Reasons for women not achieving home birth are provided in
Table 2; all are appropriate. Despite extensive searching, it was not possible to obtain
national data against which to benchmark this data. The plan is to rerun the audit Q4 20152016
Table 2: Planned homebirth outcomes
Outcome
n=
49
9
20
Reasons
45
41
n=
22
3
6
5
5
1
1
2
5
Meconium liquor
APH
Malposition
Pain relief
Maternal choice
Increased maternal risk factors
Increased fetal risk factors
4
3
2
1
1
1
1
Not recorded
Malposition
2
1
2
4
3
1
1
TOTAL
135
References
National Institute for Health and Clinical Excellence. 2014. Intrapartum care: care of healthy
women and their babies during childbirth [online]. [Accessed: 15.08.15]. Available from:
http://www.nice.org.uk/guidance/cg190/chapter/1-recommendations#/place-of-birth
Office for National Statistics. 2014. Characteristics of Birth-England-and-Wales [online].
[Accessed: 15.08.15]. Available from: http://www.ons.gov.uk/ons/rel/vsob1/characteristics-ofbirth-2--england-and-wales/2013/sb-characteristics-of-birth-2.html
42
GENERAL INFORMATION
2.
Details of the information that has been used to support the assumptions on
the expected reductions in demand in the numbers of admissions to hospital
(bed capacity).
3.
4.
Details of the plans for expanding the intensive care/high dependency units
on the CRH site to include details of current and expected demand on the
CRH site.
44
Question 1 - More information on the modelling work/analysis that was undertaken that shows
the impact on the flow of patients (into Urgent Care and the Emergency Centre) on each site
based on CRH being the unplanned site and the same analysis based on HRI being the
unplanned site.
Page 131 of the Five Year Strategic Plan for Calderdale and Huddersfield Foundation Trust provides
the output of the modelling of patient flows to the urgent care centres (UCC) and the Emergency Care
Centre (ECC) on each site (this is shown for both CRH being the unplanned site and HRI being the
unplanned site).
The key planning assumptions that were used to develop this are described below.
All modelling has used forecast activity for 2015/16 (as at month 6) as the baseline. Year 1 of the
model is 2016/17.
Demographic growth has then been modelled across the years as below:
It has been assumed the planned care site will not have an Emergency Care Centre but will have
an Urgent Care Centre.
It has been assumed that all ambulance journeys will be diverted to the nearest Emergency Care
Centre based on travel time.
45
The Clinical Director for Emergency Services agreed a list of treatment codes to identify patients
who were suitable for management in an urgent care centre (UCC). These are:
Adults with minor injuries and / or minor illnesses
Children over the age of 5 years with minor injuries
The categories of minor injuries and minor illnesses are highlighted below. All A&E diagnosis fields
that matched the below criteria were used for modelling purposes.
Walk in patients who met the UCC criteria are assumed to be treated at the site they present at.
Walk ins who do not meet the UCC criteria are assumed to firstly attend the current site at which
they are treated, but then are moved to the future unplanned care site (if they need to be moved)
and hence they would appear as 2 attendances in the modelling work. In other words, these
people attend the UCC and then attend the ECC.
Minor injuries
Bites/stings
Burns and scalds
Contusion/abrasion
Diagnosis not classifiable
Dislocation/fracture/joint injury/amputation
Electric shock
Facio-maxillary conditions
Foreign body
Head injury
Laceration
Muscle/tendon injury
Nerve injury
Sprain/ligament injury
Minor illnesses
Allergy (including anaphylaxis)
Dermatological conditions
ENT conditions
Infectious disease
Local infection
Ophthalmological conditions
Psychiatric conditions
Social problem (includes chronic alcoholism and
homelessness)
Soft tissue inflammation
46
The urgent care centres will absorb some of the activity that would otherwise go to the Emergency
Care Centre.
Patient travel times were calculated using MapInfo and the postcode field within the FY15/16 data.
Based on travel times, the nearest Emergency Care Provider was determined for those patients
who were seen at the future planned care site and arrived by an ambulance.
If this is another Trust, the inpatient stay related to this ECC attendance will also be assumed to
have moved to the new provider.
Walk ins who do not meet the UCC criteria or are admitted are assumed to firstly attend the
current site at which they are treated, but then are moved to the future unplanned site (if they
need to be moved) and hence they would appear as 2 attendances in the modelling work.
47
Divert rules
The principles applied to diverting patients to another provider (if they require treatment at an
Emergency Department) are outlined below.
Scenario
Arrival mode at
ED
Principle applied
Ambulance
Walk in/Other*
Ambulance
Walk in/Other*
N/A
Spell moved to planned care site (assumed that all elective transfers
stay within the organisation)
48
The providers included in the travel time analysis are shown below. The impact of activity shifts to
these other providers is included in the Five Year Strategic Plan for Calderdale and Huddersfield
Foundation on page 134.
Nearest Provider
Royal Blackburn Hospital
Fairfield General Hospital
Leeds General Infirmary
Trafford General Hospital
Bradford Royal Infirmary
Pontefract General Infirmary
Pinderfields General Hospital
St James's University Hospital
Manchester Royal Infirmary
North Manchester
The Royal Oldham Hospital
49
Question 2 - Details of the information that has been used to support the assumptions on
the expected reductions in demand in the numbers of admissions to hospital (bed capacity).
This is based on nationally benchmarked information that shows current rates of non-elective
admission for some conditions (e.g. heart failure, angina, gastroenteritis, pneumonia, respiratory
conditions and cellulitis) is above national average.
The development of Care Closer to Home and delivery of new models of care will reduce the
need for hospital non-elective admissions.
These assumptions are described on pages 107 110 of the Pre-Consultation Business Case.
The bed model includes the assumed 6% reduction in non-elective admissions per annum (from
2017/18 onwards). This reduction in admissions has been converted into an associated reduction
in beds over the 5 year period.
The full bed modelling impact (that takes into account the impact of a number of factors such as
demographic growth, reduction in length of stay as well as reduction in non elective admissions)
is shown on page 126 of the Trusts Five Year Strategic Plan. A summary of this is shown on the
next slide.
50
1,200
Number of beds
1,000
800
600
400
200
-
51
Question 3 - Details of the breakdown of the assumptions used to support the modelling
work that has been undertaken on the predicted emergency centre/urgent care activity for
: CRH as the unplanned site and HRI as the unplanned site (This may get covered under
bullet point 1).
52
Question 4 - Details of the plans for expanding the intensive care/high dependency units
on the CRH site to include details of current and expected demand on the CRH site.
8 Intensive care beds are located at HRI and 5 intensive care beds at CRH.
The plan proposes an expansion of critical care beds to provide a total capacity of
18 critical care beds with all the beds provided on the unplanned / emergency site
at CRH.
Occupancy of intensive care beds during 15/16 at HRI was 82% and at CRH it was
65% (this is midnight occupancy).
53
54
55
m
52.8
1.2
9.6
63.6
291.2
354.8
The funding for this capital investment would be required at 354.8m through loan funding from the
Independent Trust Financing Facility (ITFF).
56
The revenue costs across the planning period will require external funding support as follows:
m
115.0
9.1
124.1
Of the above, the 9.1m revenue reconfiguration costs are expected to be funded by Commissioners
/ NHS England.
In totality the cash support required would be:
m
354.8
124.1
478.9
It should be noted that of the 478.9m total funding requirement, 9.1m would come from
Commissioners / NHS England and the balance; 469.9m would require Treasury support through
the ITFF.
Capital funding
The following details are extracted from Table 72: Capital expenditure for CRH as the site for
unplanned care option, section 8.3.1.6.3, page 181 of the 5 Year Strategic Plan document.
The capital expenditure is broken down as follows:
m
63.6
15.5
275.7
354.8
Acre Mill
CRH and all other site costs
Total New build / Upgrade (Reconfiguration)
57
PFI
Facts
Signed in 1998 original term 60 years, break clause 30, 40, 50
Agreement can only be terminated by mutual agreement of all parties and approval of the
lenders - NHS cannot exit the contract unilaterally.
Annual revenue cost 22m, two components:
11m - domestics, catering, porters and security these would be ongoing costs for
the Trust regardless of the PFI, i.e. even if we employed the staff ourselves. The
contract permits regular benchmarking/market testing of these ancillary costs to
ensure we can demonstrate value for money. The provisions for this within the
contract were reviewed by DWF Lawyers in September 2014.
11m - mortgage and capital financing costs (if the site was not financed by PFI the
Trust would still incur estate financing costs as per the rates that apply to NHS
owned estate).
Review of contract
Over the years the contract has been reviewed by accounting and legal teams from:
Deloittes
KPMG
Monitor
These have all confirmed the Trust cannot exit the contract unilaterally
It is not in the interests of the financial lenders to agree to early termination despite the
break clauses.
Summary
We have a responsibility to ensure we deliver the best value for money out of the PFI,
within the conditions of the signed contract equally. If CRH was not part of a PFI
arrangement, significant costs would still be needed by the NHS to pay for patient services
and finance what would then be NHS owned estate.
58
TRAVEL
59
60
The table overleaf shows the current status and the anticipated benefits in terms of
journey time savings associated with the following phases:
Whilst the table focuses on journey time benefits of the interventions because that it was
has been asked from this paper, it is important to note that there are other benefits that
the Fund seeks realise. Good local and regional transport links underpin the
development of business and the creation of new jobs. By helping create around 18,000
new jobs over the next 10 years, unlocking potential development land and increasing
economic output by 1bn per year, the Fund will be key to increasing economic
prosperity and sustainability of the West Yorkshire region as a whole.
As important as journey time savings is journey time reliability. Analysis of journey times
between Halifax and Huddersfield has shown that they can be between 60% and 70%
longer in the am and pm peaks than they are in the middle of the day with high levels of
variability. The interventions proposed or being worked up in the phases will seek to
reduce the variability and the difference between peak and off peak travel times. Clearly
the levels of traffic present in the both the morning and evening peaks means that
journey times will not be the same as the off-peak, but the key point to note is that they
will be substantially more reliable..
61
Phase
Elland Bypass to Free
School Lane
(Calderdale Lead)
2
3
Schemes Description
Jubilee Road to Dudwell
Lane- Widening to form two
lanes inbound and outbound
on Salterhebble Hill
Capacity improvements at
Dudwell Lane and Dry Clough
Lane junctions
Major junction improvements
at the A629 / A6026 Calder &
Hebble junction
Improvements to the strategic
accessibility and public realm
within Halifax Town Centre to
deliver regeneration and growth
aspirations, including unlocking
land for development;
Status
A successful case
has been made for
funding to be
allocated for the
schemes and their
implementation is
being progressed
A successful case
has been made for
funding to be
allocated for the
schemes
Schemes to be
developed
62
2021
2031
NB
SB
Average
0800-0900
03:51
00:49
02:20
1000-1600
01:40
00:39
01:10
1700-1800
03:47
01:50
02:48
0800-0900
03:29
01:43
02:36
1000-1600
01:52
00:52
01:22
1700-1800
04:45
02:12
03:29
2031
NB
SB
Average
AM
03:51
00:49
02:20
IP
01:40
00:39
01:10
PM
03:47
01:50
02:48
AM
03:29
01:43
02:36
IP
01:52
00:52
01:22
PM
04:45
02:12
03:29
63
64