Agenda item - Royal Sussex County Hospital A&E Pressures

Presentation on current A&E pressures at the Royal Sussex County Hospital and on system approaches to mitigation (verbal).

7.1       The Chair told members that this item arose from a letter to the last HOSC by Cllrs De Oliveira and Burden, expressing concerns about conditions at the Royal Sussex A&E. The committee did explore some of these issues with Dr Findlay, CE of University Hospitals Sussex, at the last meeting, but members were keen to have a dedicated item at the following meeting. Members also agreed that a future item should have a whole health & care system focus, recognising that A&E is not just about the hospital trust.

 

7.2       The item was presented by Claudia Griffith, NHS Sussex Chief Delivery Officer. Ms Griffith was joined by Dr George Findlay, UHSx Chief Executive; Dr Andy Heeps, UHSx Chief Operating Officer and Deputy CEO; Professor Katy Urch, UHSx Chief Medical Officer; Peter Lane, UHSx Hospital Director for the Royal Sussex County Hospital; John Child, Chief Operating Officer, Sussex Partnership NHS Foundation Trust; Steve Hook, BHCC Interim Corporate Director (Health & Adult Social Care), Housing, Care & Wellbeing; and by Chloe Rogers, Sussex Community NHS Foundation Trust, Area Director (Brighton & Hove).

 

7.3       Ms Griffith told the committee that the Royal Sussex County Hospital (RSCH) A&E department faces significant pressures and that the local health and care system works together to meet these challenges. RSCH A&E is a busy department, with 270-300 patients per day. The site is also very constrained, which makes managing these patient numbers complex. There are high levels of attendance from people living locally, from people in deprived communities, and from students and younger people. There are particular challenges in meeting the statutory 4 and 12 hour waiting time targets and in terms of patient experience.

 

7.4       In the long term, there is a plan to re-build the RSCH emergency department., and NHS capital funding is reserved for this. In the short term, system partners are taking a number of measures to mitigate pressures. These include:

 

·         The Urgent Treatment Centre situated next to A&E

·         The use of virtual wards

·         Funding for additional GP appointments

·         Better use of community pharmacy capacity

·         The Brighton walk-in centre

·         Better liaison with and support for care homes

·         Outreach work with the local nighttime economy

·         Additional support for the most vulnerable groups (e.g. homeless and rough sleepers via Arch GP practice)

·         A focus on high intensity (repeat) users, with services supporting those who attend A&E most frequently

·         Additional primary care appointments can be offered to people presenting at A&E

·         A homeless team operates in A&E providing support to homeless and rough sleeping patients.

 

7.5       Chloe Rogers informed members of services that Sussex Community NHS Foundation Trust (SCFT) is involved in. These include:

·         An Emergency Community Response Team (around 200 referrals per month). The team is meeting national 2 hour targets and is able to handle increasingly complex cases

·         SCFT works closely with ambulance services, attending in response to calls in situations where they can offer a better treatment option than an ambulance call-out

·         Virtual wards – these offer an alternative to hospital admission for some patients

·         Admission prevention – there is a team at A&E meeting patients from ambulances and providing care instead of admission where appropriate.

 

7.6       Dr George Findlay informed the committee that UHSx is focused on the 4 hour wait target; there has been improvement, but there is still some way to go. Similarly, waits associated with ambulance handovers have improved, but more work is needed. Although the number of people presenting at A&E has remained fairly stable, we are seeing a higher proportion of people who require hospital admission.

 

7.7       Peter Lane told members that other measures being taken to mitigate A&E pressures include:

·         The use of a continuous flow model to make flow through the RSCH as efficient as possible

·         The introduction of a surgical assessment unit

·         Development of a pharmacy first programme

·         Regular staff huddles to better manage flow

·         A focus on reducing the time it takes for patients in critical care to be transferred to a ward environment.

 

7.8       Ms Griffith outlines some measures being used to streamline discharge processes. These include:

·         Working in partnership with VCS organisations which offer a ‘settle’ service to help patients immediately following discharge

·         A transfer of care hub – a multi-disciplinary team which focuses on discharge arrangements for more complex patients

·         Maximising the use of community bed capacity

·         A team which supports patients once they have returned home.

 

7.9                   John Child told members that:

·         Patients whose discharge from acute mental health beds is delayed due to waiting for supported accommodation, nursing placements and packages of care (patients clinically ready for discharge) is the root cause of people waiting at A&E for admittance to an acute mental health bed.

·         Sussex Partnership NHS Foundation Trust (SPFT) is working with system partners to address this issue: e.g. via the Sussex Mental Health and Housing Programme.

·         There are many more initiatives ongoing, including improving the urgent and emergency mental health care pathway, focusing on admission avoidance through enhanced community services, the Sussex Mental Health Helpline, and remodelling the SPFT crisis and home treatment teams

·         There is no single initiative that will resolve the long standing challenges rather a series of planned improvements across urgent, acute and community mental health services with each having an incremental impact.

·         Whilst the pressures remain there have been improvements- the number of patients assessed as needing hospital admission each month has reduced over the last 18 months, the number of patients waiting and the length of time waiting have also improved since highs in autumn 2023

 

7.10    Steve Hook told the committee that A&E is part of a much larger system, with flow through and out of the hospital a critical factor in managing A&E capacity.

·         There are two hospital social work teams, one focusing on acute beds and the other on step-down beds

·         Around 200 people are supported at any one time

·         The Sussex system is challenged, but there is a major focus on discharge and this is having an impact – currently there are around 20 patients in RSCH who are medically fit for discharge but awaiting a care package; this is down from an average of around 30 at Easter

·         There is a focus on improving pathways into step-down beds and into the Discharge to Assess initiative (where patients receive care assessments once they have returned home)

·         There has been an increase in in-house reablement beds at Craven Vale

·         Adult social care works closely with SCFT to prevent admissions, with around 1500 patients seen in the last year. The team helps divert lots of activity from the RSCH emergency department.

 

7.11    Cllr Evans noted that the Secretary of State for Health had recently described the NHS as ‘broken’. Cllr Evans stated that we know that the problems with A&E locally are being repeated across the country, and, although it is good to hear about effective initiatives, we should not pretend that the system is functioning well. Dr Findlay replied that he challenged the notion that the NHS was broken: there are significant problems across the country and patient experience is often not great, but staff are working very hard and the great majority of patients continue to receive good care. Patient feedback from the RSCH emergency department is over 80% positive.

 

7.12    In response to a question from Cllr Wilkinson on rates of people presenting at RSCH A&E with mental health problems compared to other parts of the country, John Child agreed to provide a written response.

 

7.13    In response to a question from Cllr Wilkinson on the success to date of the Mental Health Urgent & Emergency Care Improvement Plan, Mr Child told members that the situation at RSCH has improved, but significant challenges remain. There are smaller numbers of patients waiting for a mental health bed, but some people are waiting far longer than they should.

 

7.14    Mo Marsh told the committee that care in RSCH A&E is excellent, but that communication between hospital departments and primary care is often poor; that patient experience is often not good, particularly in terms of waiting times; much more work is needed on patient records; and a more holistic approach to care is required. Ms Griffith responded, acknowledging that there can be a disconnect between services. However, this is being addressed via the Integrated Care Team (ITC) programme. Digital patient records are being improved also, although there is still a long way to go.

 

7.15    The Chair noted that she had heard about a number of GP appointments being cancelled. Ms Griffith responded that she was happy to follow up on this outside the meeting.

 

7.16    In response to a question about disruption to the hospital when the Emergency Department is reconfigured, Dr Findlay responded that the Trust is well-used to managing complex building projects on the RSCH site.

 

7.17    In response to a question from Cllr Baghoth on why there are such long waits at RSCH A&E when the numbers of people attending are not unusually high, Dr Findlay responded that there are not more people attending, but their care needs are increasing and they do take longer to treat. However, the main issue is flow through the site rather than demand. The system needs to work together to tackle delays in discharge and to reduce average length of stay.

 

7.18    Geoffrey Bowden noted that the NHS treats around 1.7 million people a day, with an increasingly older population and greater deprivation and with a third less beds than 25 years ago. The NHS is not broken, but staff are doing an amazing job to continue to deliver services despite these challenges.

 

7.19    In response to a query raised by Cllr Evans about hospital staff not always volunteering their job titles, which can be confusing to patients .Dr Findlay responded that all staff should be wearing ID (this is regularly checked), and that staff are encouraged to use their names when talking to patients.

 

7.20    In response to a question from Cllr Hill on the Red Cross homeless support service, Ms Griffith told the committee that the system works with the Red Cross to evaluate people with a homeless/rough sleeping background to ensure they are offered wrap-around care so as to mitigate the risk of an escalation of their health problems.

 

7.21    In answer to a question from Cllr Hill on the processes to recruit surgical consultants, Dr Findlay confirmed that processes have been refreshed and the Royal Colleges are being invited to all panels, although they are not always able to attend, and there is no requirement for them to be involved in recruitment.

 

7.22    The Chair thanked everyone attending for their contributions.