Winter Pressures in NHS Scotland 2008-2009
Report for the Emergency Access Delivery Team,
Scottish Government
Dr Daniel Be...
2
CONTENTS
CONTENTS..........................................................................................................
3
FIGURES
FIGURE 1. MEAN TEMPERATURE ANOMALY WINTER 2008-2009................................................................
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Winter Pressures Report Executive Summary
Feedback from NHS Health Boards
BACKGROUND
1. In March 2009 the Scottish Gover...
5
in all emergency admissions across the NHS in Scotland in December 2008, followed
by a 1.8% increase in January 2009 (Fi...
6
Figure 9, main report (p31), shows the System Watch prediction for winter 2008-2009.
Activity started to increase early ...
7
Staffing
19. Three major staffing challenges over winter were highlighted:
 Potential problem with non-clinical staff r...
8
 Daily bed meetings should take place at every site, and should occur twice
daily during the winter period. Consultant ...
9
Introduction
1. The National Emergency Access Delivery Team (EADT) works closely with
Scottish Government Health Directo...
10
Methods
Qualitative data
5. All 14 territorial Health Boards across NHS Scotland were visited, plus the
relevant Specia...
11
A&E Data Mart
Established in July 2007, this dataset is an aggregate of monthly patient level returns
for all attendanc...
12
The Scottish Government monitors monthly performance against this Standard
based on daily data. Most NHS Health Boards ...
13
and may be associated with increased mortality and length of stay (Prof D.
Bell, personal communication, March 2009).
6...
14
 Improve response times to all emergency incidents on island NHS
Health Boards to 50% within 8 minutes in 2009/2010.
T...
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Figure 1. Mean temperature anomaly winter 2008-2009
Figure 2: Winter comparison of mean temperatures for Scotland 2006-...
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Figure 3: Days of air frost anomaly winter 2008-2009
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Analysis of qualitative data
Likert Scale analysis
11. Each interviewee was asked to answer five simple questions, with...
18
The mean scores in each category are detailed in Table 1 below.
Table 1. Mean scores given on Likert questions by Clini...
19
Department’s approval a stand-alone winter plan, are now less necessary because
capacity planning is firmly embedded in...
20
21. In NHS Greater Glasgow and Clyde co-location of NHS24 with the GP out of
hours hub, out of hours mental health serv...
21
NHS24 call-handlers handled some of the non-999 SAS activity, and General
Practitioners assisted by triaging some of th...
22
31. Once demand for NHS24 clinicians outstrips capacity then calls are handled
via call-back, whereby the call-handler ...
23
37. Every Health Board increased GP out of hours services, for both clinical and
non-clinical staff, over the festive p...
24
referrals to speciality. Several Emergency Departments have attempted to facilitate
this process by opening Clinical De...
25
Figure 5.
A&E attendances per day vs proportion admitted - Dec 2008- Jan 2009 - Full
staffing
0.00
0.05
0.10
0.15
0.20
...
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49. In the west of Scotland, there were a small number of exceptional days. On 2
December there was an unpredicted over...
27
Emergency Department Time Profiles
51. In addition to the percentage of four hour breaches, analysis of the Emergency
D...
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Figure 8.
Emergency Department time profile Dec 2008
Poor performance
0
5
10
15
20
25
30
35
40
45
50
0.00 0.50 1.00 1.5...
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This is a year-long problem, not specific to winter, but may be exacerbated by the
increased volume of patients during ...
30
Bureau) embedded within the MAU and offered to the GP at the point of referral.
However NHS Greater Glasgow and Clyde f...
31
beds, and the actual number required was 148; a difference of only 6%. NHS Forth
Valley also used System Watch, alongsi...
32
on pressures within the whole system. If this has not been adequately planned in
advance with the Scottish Ambulance Se...
33
73. There was a lack of knowledge, particularly amongst clinicians, regarding the
specific local triggers for escalatio...
34
Health Boards where day-time bed occupancy in the acute sites was often reported to
be approaching 100%, whilst in the ...
35
Figure 10.
Bed Occupancy levels for core and non-core sites
Apr 2008-Mar 2009
70%
72%
74%
76%
78%
80%
82%
84%
86%
Apr-0...
36
with the 4 hour Standard for access of emergency care, with emergency and elective
patients vying for a finite number o...
37
practice at times of pressure boarders should be identified by junior medical staff,
nursing staff or bed managers at a...
38
In general Health Boards reported that Estimated Date of Discharge was variably
employed across the organisation. Some ...
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Figure 11.
Delayed discharges - Scotland - Jan 2006-Apr 2009
0
200
400
600
800
1000
1200
1400
1600
Jan
06
Apr
06
Jul
06...
40
Lanarkshire employed extra consultant physician sessions over the festive
period and during the winter weekends, to ens...
41
PTS by utilising their mental health ambulance, with joint funding between SAS and
the acute division.
100. The Scottis...
42
causes significant stress and distress to patients and their families. Additionally, the
feeling persists amongst socia...
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  1. 1. Winter Pressures in NHS Scotland 2008-2009 Report for the Emergency Access Delivery Team, Scottish Government Dr Daniel Beckett
  2. 2. 2 CONTENTS CONTENTS...................................................................................................................................2 FIGURES.......................................................................................................................................3 TABLES.........................................................................................................................................3 WINTER PRESSURES REPORT EXECUTIVE SUMMARY................................................4 INTRODUCTION..........................................................................................................................9 METHODS...................................................................................................................................10 ASSESSMENT OF PRESSURE.............................................................................................11 ANALYSIS OF QUALITATIVE DATA....................................................................................17 THE WINTER PLANNINGPROCESS........................................................................................................................................18 NHS24....................................................................................................................................................................................19 SCOTTISH AMBULANCE SERVICE........................................................................................................................................20 OUT OF HOURS GENERAL PRACTITIONER SERVICES........................................................................................................21 HOSPITAL ADMISSIONS.........................................................................................................................................................23 CAPACITY AND DEMAND WITHIN SECONDARY CARE.......................................................................................................30 HOSPITAL DISCHARGES ........................................................................................................................................................37 ANALYSIS OF QUANTITATIVE DATA.................................................................................42 LONG TERMTRENDS.............................................................................................................................................................42 WINTER 2008-2009...............................................................................................................................................................43 THE 4 HOUR STANDARD FOR ACCESS TO EMERGENCY CARE.........................................................................................48 PATIENT CHARACTERISTICS.................................................................................................................................................50 SPECIAL HEALTH BOARD DATA..........................................................................................................................................52 GP OUT OF HOURS SERVICES ...............................................................................................................................................55 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS .............................................56 SUMMARY..............................................................................................................................................................................56 CONCLUSIONS........................................................................................................................................................................58 RECOMMENDATIONS.............................................................................................................................................................59 APPENDIX 1: QUESTIONNAIRE...........................................................................................60 APPENDIX 2: LIST OF INTERVIEWEES..............................................................................64 APPENDIX 3: EXAMPLES OF GOOD PRACTICE.............................................................68 APPENDIX 4: FESTIVE MONIES...........................................................................................76
  3. 3. 3 FIGURES FIGURE 1. MEAN TEMPERATURE ANOMALY WINTER 2008-2009................................................................. 15 FIGURE 2. WINTER COMPARISON OF MEAN TEMPERATURES FOR SCOTLAND 2006-2007 & 2008-2009.............15 FIGURE 3. DAYS OF AIR FROST ANOMALY WINTER 2008-2009....................................................................16 FIGURE 4. A&E ATTENDANCES PER DAY VS PROPORTION ADMITTED - DEC 2008-JAN 2009-REDUCED STAFFING 24 FIGURE 5. A&E ATTENDANCES PER DAY VS PROPORTION ADMITTED - DEC 2008-JAN 2009-FULL STAFFING.......25 FIGURE 6. EMERGENCY DEPARTMENT ATTENDANCES AND ADMISSIONS NHS GG&C WINTER 2008-2009 .........26 FIGURE 7. EMERGENCY DEPARTMENT TIME PROFILE DEC 2008 – GOOD PERFORMANCE.................................27 FIGURE 8. EMERGENCY DEPARTMENT TIME PROFILE DEC 2008 – POOR PERFORMANCE.................................28 FIGURE 9. BEDS OCCUPIED BY PATIENTS ADMITTED AS EMERGENCIES (WEEKLY AVERAGE) .............................31 FIGURE 10. BED OCCUPANCY LEVELS FOR CORE AND NON-CORE SITES – APR 2008-MAR 2009 ......................35 FIGURE 11. DELAYED DISCHARGES - SCOTLAND - JAN 2006-APR 2009.......................................................39 FIGURE 12. FIRST A&E OUTPATIENT ATTENDANCES, SCOTLAND, 1998/99 – 2008/09 ...................................42 FIGURE 13. EMERGENCY DEPARTMENT ADMISSIONS VS ALL EMERGENCY ADMISSIONS FEB 2008-JAN 2009 ......43 FIGURE 14. ATTENDANCES, ADMISSIONS & TRANSFERS FROM CORE EDS WINTER 2008-2009........................44 FIGURE 15. SCOTLAND EMERGENCY & ELECTIVE INPATIENT ADMISSIONS WINTER 2008-2009 .........................45 FIGURE 16. SCOTLAND EMERGENCY & ELECTIVE INPATIENT ADMISSIONS INC. DAYCASES WINTER 2008-2009 ...46 FIGURE 17 ADMISSION/DISCHARGE PROFILE WITH 4 HOUR BREACHES FROM CORE SITES DEC 2008-JAN 2009...47 FIGURE 18. NUMBER OF INPATIENT DISCHARGES PER WK DEC 2008-JAN 2009 .............................................48 FIGURE 19. PERCENTAGE OF A&E ATTENDANCES MEETING 4 HOUR STANDARD, JULY 2007 TO APRIL 2009......48 FIGURE 20. REASONS FOR 4 HOUR BREACHES, DEC 2008-JAN 2009..........................................................49 FIGURE 21. NUMBER OF 12 HOUR BREACHES, JUNE 07 TO APRIL 09 ..........................................................49 FIGURE 22. EMERGENCY ADMISSIONS PER AGE GROUP, FEBRUARY 08-FEBRUARY 09 ...................................50 FIGURE 23. EMERGENCY ADMISSIONS WINTER 2008-2009 SPLIT BY RESPIRATORY/NON-RESP DIAGNOSIS .........51 FIGURE 24. EMERGENCY ADMISSIONS WINTER 2006-2007 SPLIT BY RESPIRATORY/NON-RESP DIAGNOSIS .........51 FIGURE 25. SCOTLAND LEVEL MONTHLY EMERGENCY ADMISSIONS FOR ALL DIAGNOSES FEB 08-JAN 09............52 FIGURE 26. NHS24 CALL DEMAND WINTERS 2006-2007 & 2008-2009 AND SUMMER 2008...........................53 FIGURE 27. NHS24 WINTER 08/09 TOTAL CALL DEMAND...........................................................................53 FIGURE 28 SAS CATEGORY A INCIDENTS BY WEEK, MAINLAND SCOTLAND...................................................54 FIGURE 29. SAS CATEGORY A PERFORMANCE MAINLAND BY SUBDIVISION, DEC 06/JAN 07/DEC 08/JAN 09......54 FIGURE 30. GP OUT OF HOURS ACTIVITY ................................................................................................55 FIGURE 31. GP OUT OF HOURS PERFORMANCE FOR 1 HOUR HOME VISITS ....................................................56 TABLES TABLE 1. MEAN SCORES GIVEN ON LIKERT QUESTIONS BY CLINICIANS, MANAGEMENT AND GPOOH STAFF…. ...18 TABLE 2. NHS SCOTLAND EMERGENCY AND ELECTIVE ADMISSIONS DEC 2008 AND JAN 2009 COMPARED WITH THE FIVE YEAR MONTHLY MEAN ...................................................................................................... 45
  4. 4. 4 Winter Pressures Report Executive Summary Feedback from NHS Health Boards BACKGROUND 1. In March 2009 the Scottish Government Emergency Access Delivery Team commissioned a report to review the pressures experienced, and response by NHS Scotland during winter 2008-2009. 2. There has been a significant improvement in the 4 hour emergency access waiting times, increasing from 87% in June 2006 to delivery of the current 98% 4 hour HEAT Standard. However, there was a drop in performance in 11 out of the 14 territorial Health Boards against the 4 hour Standard in December 2008 and January 2009. Overall performance for NHS Scotland during these months dipped below 98% (96.7% and 96.5% respectively). Additionally, there was media interest in how well the NHS had handled winter in parts of Scotland, particularly the central belt, with articles about long trolley waits, and hospitals not coping with adverse weather conditions. Recent figures (March 2009) show performance improved to 97.7% with 140,000 attendances (compared with 128,084 in December). 3. The review was undertaken by Dr Daniel Beckett, Acting Consultant in Acute Medicine at the Royal Infirmary of Edinburgh, with support from NSS Information Services Department (ISD) and Scottish Government Analytical Services Directorate (ASD). Each NHS Health Board in Scotland was visited, plus the relevant Special Health Boards, to obtain a wide range of professional and staff perceptions about their local experience of winter using semi-structured one-to-one interviews. Quantitative data and information was provided by ISD and ASD. 4. The report focused upon December and January as these were the months with the poorest performance against the 4 hour Standard. Comparison was made with previous winter performances, particularly 2006-2007 (as 2007-2008 was widely considered to have been atypical) KEY FINDINGS 5. The key findings from the qualitative and quantitative aspects of this report are summarised below. Hospital Admissions 6. There was a perception amongst Health Boards that winter 2008-2009 had been ‘busier than previous years’ in terms of total numbers of admissions and that the peak had commenced earlier. Health Boards commented that the age profile of patients admitted over winter appeared to be older, with more patients suffering from respiratory disease resulting in greater lengths of stay. Data from the SMR01 dataset confirmed that, compared with the five year monthly mean, there was a 7.9% increase
  5. 5. 5 in all emergency admissions across the NHS in Scotland in December 2008, followed by a 1.8% increase in January 2009 (Figure 16, main report (p46)). Furthermore, there was an 11% increase in the number of patients admitted to hospital with respiratory illness over December and January compared with winter 2006-2007. However in practice this equates to only 2 extra respiratory patients per day across NHS Scotland. There was no evidence for a disproportionate increase in admission of elderly patients or greater length of stay. Hospital Discharges 7. Low levels of hospital discharges, particularly over the festive period, were highlighted as a cause for concern by most NHS Health Boards over winter 2008- 2009. 8. Figure 18, main report (p48), shows admission/discharge profiles across NHS Scotland (from core sites) plus number of four hour breaches. There is a consistent admission/discharge profile in December, with peaks of admissions at the start of the week, mirrored by a peak of discharges towards the end of the week. Admissions outnumbered discharges every weekend (and on Mondays) with a surge of discharges on Christmas Eve. This was followed by the 11 day holiday period, and for nine of these 11 days, admissions outnumbered discharges. The net effect was that hospitals had high levels of bed occupancy when the elective programme restarted at full capacity on 5 January, resulting in a spike in four hour breaches. The system attempted to return to the previous admission/discharge profile over the following week, but had not recovered by the following Monday, 12 January, and further four hour breaches were noted. 9. Reasons highlighted for this reduction in discharges over the festive period included:  lack of consultant staff in downstream wards;  lack of discharge infrastructure over the festive period (e.g. Patient Transport Services, Allied Health Professionals and social work); and  perceived lack of coordination of decision making in the system over the festive period. 10. Tools for discharge planning, such as Estimated Date of Discharge (EDD), and Nurse Led Discharge (NLD) were used patchily, and in some Health Boards not at all. 11. Health Boards reported almost universal improvement in numbers of delayed discharges, with NHS Scotland achieving zero delayed discharges over 6 weeks by April 2008 and 2009 (although this was not achieved in every month). A small number of Health Boards continued to be challenged by significant numbers of delayed discharges over 6 weeks. Capacity and Demand Planning 12. Nine of the 14 territorial Health Boards have developed an internal tool to predict unscheduled activity, and these were largely found to be accurate. Two Health Boards employed tools to predict discharges based on previous discharge patterns. Despite Health Boards being encouraged to use System Watch, there was little use for medium to long term predictions of activity despite its proven accuracy.
  6. 6. 6 Figure 9, main report (p31), shows the System Watch prediction for winter 2008-2009. Activity started to increase early (2 November), but then short term prediction followed well after 2-3 weeks. 13. Eight out of 11 mainland Health Boards opened additional capacity beds in their acute sites this winter. Many Health Boards had difficulties accessing the full complement of community beds, despite the acute site being near, or over-capacity. These difficulties included:  lack of Patient Transport Services;  complex referral pathways; and  patient choice. Escalation Plans 14. There was variation between Health Boards in the effectiveness of local escalation plans. Most Health Boards had a bed management escalation plan, but the triggers for escalation varied between predicted activity, actual observed activity, or simply perception of activity. There were reports of managers and clinicians (including primary care) becoming desensitised to red alert. Conversely there were reports of middle management being reluctant to escalate, or senior managers refusing to escalate to red alert. 15. CHP involvement in escalation plans was variable, with one example of an escalation plan being developed by CHP senior management without clear involvement of CHP middle managers, who were not fully sighted on this and were unable to respond when necessary. Elective Activity 16. Eight of the 14 territorial Health Boards continued with elective work until Christmas Eve and between Christmas and New Year, whereas six Health Boards ran a ‘cancer and urgent only’ service over the festive period. The decrease in elective admissions on 29 December (60% of a ‘normal’ Monday) is shown on Figure 16, main report (p46). 17. The perception in several Health Board areas was that the introduction of the 18 week Referral to Treatment Target, and the disbanding of the Unscheduled Care Collaborative, de-prioritised the 4 hour Standard. Examples of this included:  surgical wards (with staff available) remaining closed over the festive period despite eight hour, or greater, trolley waits in the Emergency Department; and  waiting list initiatives on 5 January despite clear predictions of high levels of unscheduled medical activity. 18. Seven Health Boards did not cancel any elective procedures due to lack of beds, five cancelled a small number (<15 each) and two cancelled significantly more.
  7. 7. 7 Staffing 19. Three major staffing challenges over winter were highlighted:  Potential problem with non-clinical staff retention in out of hours GP services because staff employed under Agenda for Change were not paid extra for working unsociable hours over the festive period.  Implementation of Modernising Medical Careers (MMC) and nationalised medical recruitment has led to a number of medical posts, particularly within acute specialities, remaining unfilled.  Many sites did not have sufficient consultants in the hospital to deal with the predicted activity over the two week festive period and to facilitate quicker discharges in down stream wards.  There was a perception of lack of social work availability due to significant amounts of annual leave being taken over the festive period. Boarding Patients (outliers) 20. Each of Scotland’s 11 mainland Health Boards use boarding of patients outside their own speciality beds as a solution to capacity issues. Over winter 2008- 2009 in some sites up to 60% of all medical patients were boarders, occupying more than 10% of the total bed complement. There has been a recent move to board patients from the Admission Unit (and in exceptional circumstances the Emergency Department) before initial consultant review. This should be considered a clinical governance issue. Recommendations These recommendations should be considered alongside the many examples of good practice detailed in Appendix 3 to this report.  Health Boards should ensure that their winter planning starts early and that the process includes Community Health Partnerships and Social Work Departments. There should be a clear relationship between the winter plan and pandemic ‘flu plan.  Integral to the winter plan should be the escalation plan. This should involve all stakeholders including Community Health Partnerships. This includes the utilisation of beds in Community Hospitals, and protocols for referral and transfer should be agreed to resolve issues relating to perceived bed ownership.  System Watch should be used systematically for long to medium term predictions of unscheduled activity, and predictions acted upon to create the necessary capacity, in terms of beds and to support initiatives to reduce admissions. Consideration should also be given to the use of System Watch for planning of elective activity over the winter months.
  8. 8. 8  Daily bed meetings should take place at every site, and should occur twice daily during the winter period. Consultant medical staff should have greater awareness of bed management issues, including escalation plans for sites.  Health Boards should undertake more accurate modelling over the festive period to plan elective capacity and optimise the use of bed capacity, including maximising the bed capacity in community hospitals. This may then enable hospitals to reduce the number of elective admissions on the first Monday in January. Further consideration should be given to front loading the first week in January with minor procedures, and back loading with majors. Also medical elective activity (such as clinics and endoscopy lists) could be back loaded during this week.  Medical Directors should ensure that appropriate numbers of consultant medical staff are on site to deal with the predicted activity over the two week festive period.  Health Boards should aim to eliminate boarding of patients as a solution to bed capacity problems. Specifically, the boarding of patients from the Acute Medical Unit and/or Emergency Department should not occur (this includes ‘treat and transfer’ policies, with the exception of tertiary care referrals).  The level of discharges over the holiday period should be improved. This might include: o increased consultant presence with dedicated discharge ward rounds in downstream wards; o utilisation of a rapid response team (or equivalent) of AHPs with access to homecare packages without recourse to social work assessment; and o re-energising and establishing ownership of the Estimated Date of Discharge policy, plus introducing Nurse Led Discharges (NLDs). o Patients should be discharged early in the day, as this is key to maintaining capacity. Planning of discharge ward rounds should take this into account.  If all the above measures have been undertaken, including consultant review and discharge of downstream patients, and all capacity beds filled (including community beds) then the 98% standard for emergency access of care should be achievable. Health Boards should note that if there are ongoing difficulties then priority should be given to emergency admissions over routine elective procedures. The Scottish Government has, for the last 10 years, made it clear that clinical decision making always trumps routine elective targets.
  9. 9. 9 Introduction 1. The National Emergency Access Delivery Team (EADT) works closely with Scottish Government Health Directorates to provide direction and support to NHS Health Boards to:  deliver local improvement trajectories for reducing rates of attendances at the Emergency Department (HEAT target T10);  monitor Health Boards’ performance in relation to the maximum 4 hour wait; and  improve whole systems winter planning. 2. In March 2009 the EADT commissioned a short term review of pressures experienced and response by NHS Scotland over winter 2008-2009. The main driver for this was the dip in performance against the 4 hour Standard for emergency access in December 2008 and January 2009 in some parts of Scotland. Additionally, there had been unfavourable media interest regarding NHS handling of winter pressures, particularly in the central belt, with articles about extended trolley waits, and hospitals unable to cope with the adverse weather 3. The purpose of this review was to: - provide a description of unscheduled care systems in Scotland over winter, including levels of activity and pressure points from November 2008 – March 2009 (this being defined as the ‘winter period’); - assess the extent to which the system ‘coped’ or showed signs of strain; - describe the winter planning response, including what worked and what didn’t; - derive lessons for the future, and explore how recommendations may be implemented; and - identify the extent to which community/primary care can improve the effectiveness of the whole system of unscheduled care. 4. The review was carried out by Dr Daniel Beckett, Acting Consultant in Acute Medicine at the Royal Infirmary of Edinburgh, with support from NSS Information Services Department and the Scottish Government Analytical Services Directorate. Each NHS Health Board in Scotland was visited, plus the relevant Special Health Boards, to obtain the perceptions of staff using semi-structured one-to-one interviews. Quantitative data and information was provided by ISD and ASD. The Key Learning Points and examples of good practice will be shared with the Service, both at the National Winter Planning Conference (June 2009) and through distribution of this report, in order to inform planning for winter 2009-2010.
  10. 10. 10 Methods Qualitative data 5. All 14 territorial Health Boards across NHS Scotland were visited, plus the relevant Special Health Boards. Seventy interviews, using a semi-structured questionnaire, were undertaken over a 10 week period. All interviews were digitally recorded and transcribed by the author. All data was anonymised following transcription. A minimum of two people from each Health Board were interviewed. These included:  Hospital management, including Chief Executives, Directors of Operations, General Managers and Senior Bed Managers;  Secondary care clinical staff, with the focus on clinical leads for Emergency Medicine and Acute Medicine;  Clinical and management staff from GP out of hours services;  Social work representation; and  Mental health representation. The Special Health Boards visited were:  Scottish Ambulance Service;  NHS24;  Health Protection Scotland (HPS); and  NHS Education for Scotland (NES). The questionnaire can be found in Appendix 1 to this report, and the list of interviewees in Appendix 2. Quantitative data 6. Information Services Division (ISD) is Scotland's national organisation for health information and statistics (www. isdscotland.org). It collects, analyses and publishes information on health and health care services in Scotland from a wide range of datasets. All datasets adhere to National Data Standards and data collected according to rigorous classifications and rules to ensure they are of consistently high quality. 7. A number of these datasets have been used to support the qualitative findings in this report. These include: ISD(S)1 - Hospital Activity Statistics The ISD(S)1 scheme provides routine quarterly aggregate information for monitoring activity in hospitals, health centres and clinics in NHS Scotland. Information collected (on monthly returns) relates to hospital beds, inpatients, outpatients, day cases, day patients, haemodialysis patients, ward attendees, patients seen by AHP's (Allied Health Professionals) and other technical department staff and cancellations.
  11. 11. 11 A&E Data Mart Established in July 2007, this dataset is an aggregate of monthly patient level returns for all attendances submitted by 33 main/major Accident and Emergency departments (core sites) across Scotland. Data included in this report is for new and unplanned attendances at A&E. This data is still being developed. SMR01 - General Acute Inpatient / Day Case Record Contains patient based data on all inpatient and day case episodes in general and acute wards. Delayed Discharges Published quarterly, this comprises a census of NHS hospital in-patients who are "ready for discharge", but whose discharge has been delayed. The data included in this report is released for management information purposes only and should be treated as restricted information until public release of related data on ISD's website. In addition, the following organisations also provided data:  ADASTRA: This is the main IT system used to capture information on attendances at Primary Care Out of Hours centres.  NHS24 provided information on call dispositions and callbacks, plus performance against Key Performance Indicators (KPIs).  The Scottish Ambulance Service provided data on activity levels plus performance against KPIs. Assessment of pressure 8. Assessing pressures in complex healthcare systems can be difficult, and different perspectives are often required as there is no single measure. Monitoring performance against national targets or standards, and recognised clinical outcomes can give an indication of where pressure exists in the system. In addition there are a number of proxy measures, such as the extent of boarding patients, or cancellation of elective activity, which add useful information. The following targets, standards and measures were used to gain an overall picture of the pressures experienced within each NHS Health Board: 1. 4 hour Target/Standard for access of emergency care This Target specified that from end 2007, no patient will wait more than four hours from arrival to admission, discharge or transfer for emergency treatment. Importantly, the 4 hour Target in Scotland differed from that in England in that it specifically include trolleyed areas in assessment units. This Target was redefined as a HEAT Standard from April 2009 and is widely believed to be a good barometer of ’whole system performance’ in relation to unscheduled care.
  12. 12. 12 The Scottish Government monitors monthly performance against this Standard based on daily data. Most NHS Health Boards use the nationally procured EDIS information system to collect the data, while the remaining Health Boards have had their systems’ compliance tested to allow amalgamation and national analysis of data. The mandatory dataset includes patient ID, hospital code, new or return patient, time/date of arrival and discharge, discharge destination, patient flow group and reason for four hour breach. Often erroneously considered to be purely an Emergency Department Standard, lack of compliance with the 4 hour Standard implies whole system pressure. Simply relying on performance against the 4 hour Standard to assess pressure, however, may be flawed. Variations in delivering the 4 hour Standard may reflect differing admission protocols rather than true differences in performance. If a large proportion of admissions to hospital bypass the Emergency Department (for example direct ward admissions), comparisons with sites that operate a common front door policy may not be valid. This is particularly the case if primary care referrals to hospital are admitted directly to an area of the hospital that is considered, correctly or otherwise, not to be subject to the 4 hour Standard. 2. 12 hour trolley waits Twelve hour trolley waits in the Emergency Department have significantly decreased since the introduction of the 4 hour Standard for access of emergency care. However, they still occur. There should be no 12 hour trolley waits. 3. Bed occupancy The optimum bed occupancy rate is considered to be 82-85% by the UK Government1. Hospital bed occupancy rates are measured at midnight and may not reflect activity during the day when bed occupancy may be significantly higher. 4. Cancellation of elective activity The numbers of operations that are cancelled or postponed for non-clinical reasons are submitted to the Scottish Government. However, different protocols exist between NHS Health Boards on volume of elective activity undertaken over the winter and festive period, and therefore the number of cancellations may not reflect comparable pressures across Health Boards. 5. Number of boarding patients Boarding patients outside their speciality wards occurs at times of hospital overcrowding, which is associated with increased mortality2. Boarding is widely acknowledged to increase in response to increased system pressures, 1 http://www. publications. parliament. uk/pa/cm200708/cmhansrd/cm080506/debtext/80506 -0002. html (Accessed 19 April 2009) 2 Spivrulis, P.C., Da Silva, J.A., Jacobs, I.G. et al. (2006). The association between hospital overcrowding and mortality amongst patients admitted via Western Australian emergency departments. Med J Aust, 184(5); 208-212.
  13. 13. 13 and may be associated with increased mortality and length of stay (Prof D. Bell, personal communication, March 2009). 6. Key Performance Indicators for NHS24 NHS24 has three service delivery Key Performance Indicators (KPIs) as follows:  KPI 1. Call handlers to answer 90% of calls from patients within 30 seconds  KPI 2. To commence 90% of GP priority calls within 20 minutes  KPI 3. To commence 90% of GP routine calls within 60 minutes The latter two of these KPIs are retrospective and based on real time performance. This allows NHS24 to measure accuracy of call routing, appropriateness of call reason, correct propitiation and clinical outcome. The percentage of calls handled via the call-back mechanism is also recorded, as is the proportion of calls that are passed to out of hours partners as pre- prioritised calls. There are also clinical KPIs:  All serious and urgent calls must be answered immediately  Priority 1, 2 and 3 calls must be dealt with in 1, 2 and 3 hours respectively Priority 1 and 2 calls are reported internally. Priority 3 calls are monitored internally but are not reported and do not form part of the external reporting suite. 7. Key Performance Indicators for GP Out of Hours Services The service delivery KPIs for GP out of hours services include the percentage of calls attended to within the one, two or four hour time limit as determined by NHS24. However differences of opinion exist regarding clinical appropriateness of the timeframes advised by NHS24, and also different IT systems are used throughout NHS Scotland (for example Taycare and ADASTRA). These data are not centrally collated and are reported only for local, internal Health Board review. 8. Key Performance Indicators for the Scottish Ambulance Service The primary service delivery KPI for the Scottish Ambulance Service is the HEAT Standard (previous HEAT Target A3): 'Sustain response times to category A calls (life threatening emergency incidents) at 75% within 8 minutes in mainland Health Boards from March 2009.' Other KPIs not currently integral to the HEAT target structure include:  Improve response times to Category B calls (serious but not life threatening) to 95% within target times by 2009/2010; and
  14. 14. 14  Improve response times to all emergency incidents on island NHS Health Boards to 50% within 8 minutes in 2009/2010. The key performance indicators for the Patient Transport Service are punctuality for appointment and punctuality for pick up of priority patients. Regarding the Emergency Medical Dispatch Centre (EMDC), the primary KPI is that 95% of all 999 calls directed to the Scottish Ambulance Service should be picked up within 10 seconds. Meteorological data 9. The Meteorological Office was asked to produce a report comparing winter 2008-2009 with the Long Term Average (LTA) and with winter 2006-2007, as this was used as the comparator winter for hospital activity data. 10. The anomaly maps for temperature indicate that winter 2008-2009 experienced near average temperatures across Scotland (see Figure 1). However, when considering individual months, December had a below average temperature (see Figure 2). Air frost levels were variable when compared with the LTA (see Figure 3). Some central areas and coastal fringes in the east and north- west had a below average number of frost days; however, across the rest of Scotland the number of frost days was greater than average. Key Learning Point 1: The mean temperature over winter 2008-2009 was in keeping with the Long Term Average, with December being a little colder than expected.
  15. 15. 15 Figure 1. Mean temperature anomaly winter 2008-2009 Figure 2: Winter comparison of mean temperatures for Scotland 2006-2007 and 2008-2009 -2.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Nov Dec Jan Feb Temperature°C WINTER 06/07 WINTER 08/09 LTA 1971-00
  16. 16. 16 Figure 3: Days of air frost anomaly winter 2008-2009
  17. 17. 17 Analysis of qualitative data Likert Scale analysis 11. Each interviewee was asked to answer five simple questions, with their answers being recorded in the form of a Likert scale. The questions were as follows: Question 1 The local health system coped well with winter pressures this year 1 2 3 4 5 6 7 Disagree Neutral Agree Question 2 Areas of increased demand were accurately predicted 1 2 3 4 5 6 7 Disagree Neutral Agree Question 3 The Board’s winter plan prepared the local health system for the increased pressure 1 2 3 4 5 6 7 Disagree Neutral Agree Question 4 If there were times that the system struggled to cope, was this due to factors within the NHS Health Board (primary/secondary care) or external agencies (e. g. NHS24/local authority services/Scottish Ambulance Service)? 1 2 3 4 5 6 7 External Combination Internal Question 5 If there were times that the system struggled to cope was this due to predictable or unpredictable factors, or a combination? 1 2 3 4 5 6 7 Predictable Combination Unpredictable Interviewees were broadly grouped into one of three categories:  hospital management;  secondary care clinicians; and  representatives of GP out of hours services (both clinical and non-clinical).
  18. 18. 18 The mean scores in each category are detailed in Table 1 below. Table 1. Mean scores given on Likert questions by Clinicians, Management and GPOOH staff. Question 1 Question 2 Question 3 Question 4 Question 5 Clinicians (total) 4. 6 5. 0 4. 5 3. 9 3. 4 Clinicians (A&E) 3. 9 4. 9 4. 1 4. 0 2. 8 Management 5. 3 5. 5 5. 3 4. 3 3. 7 GPOOH 5. 7 4. 7 5. 0 3. 4 4. 4 12. The number of participants was too small to allow meaningful statistical analysis of the responses. However, clinicians based in Emergency Departments typically disagreed with the statement that ‘The local health system coped well with winter pressures this year’. In contrast, representatives from the General Practice out of hours services tended to agreed with this statement. 13. Emergency Department clinicians felt that the pressures experienced over the winter were largely predictable, contrasting with GP out of hours representatives who felt these were marginally unpredictable. Perhaps the difference in opinions relates to the fact that predictors of activity in secondary care have become commonplace, driven by the unscheduled care collaborative. However, with the exception of NHS24’s modelling tool derived from Simul8, there are no formalised predictors used by out of hours GP services in Scotland. Key Learning Point 2: Many of the pressures experienced across NHS Scotland over winter are the same pressures experienced at other times of peak activity throughout the year, and therefore are predictable. Key Learning Point 3: Areas that Health Boards considered to be good practice, or to have had a positive effect in managing pressures over winter 2008-2009, are highlighted in the text with the Health Board emboldened. A more complete list, with contact details for the relevant people, is found in Appendix 3. The winter planning process 14. The majority of Health Boards stressed that the concept of winter planning was becoming an outdated one, and that the emphasis should be on all year round capacity management in order to accurately predict demand, and detail contingencies to cope with these pressures. This general approach has been supported by the Scottish Government Health Directorates since 2003, when the Director of Performance Management and Finance wrote to all Health Boards stating: “In light of the previous 3 years of effective winter planning and performance and the statement made in the 2002 Winter Report, that: “…in 2003/04 the Department will move away from requiring a specific “winter” plan, leaving local systems to absorb these plans within the broader capacity issues …(but) we must not lose sight of the dangers that winter presents” The department will not require you to submit a separate winter plan this year, since the previous arrangements, under which Health Boards submitted for the
  19. 19. 19 Department’s approval a stand-alone winter plan, are now less necessary because capacity planning is firmly embedded in Health Boards’ normal planning cycles. Generating an additional plan would prove a low value additional burden that would create artificial boundaries in the local planning system and inhibit the seamless year round capacity planning required. ” 15. Almost all Health Boards felt that planning for the two holiday periods had been extremely robust, and had largely delivered to expectations. Many suggested that the focus of planning should be the start of January, when elective activity recommences and bed occupancy is very high. 16. Most Health Boards strived to develop whole system winter plans, involving the local CHPs (Community Health Partnerships) plus other partnership agencies such as NHS24 and the Scottish Ambulance Service in the planning process. Several Health Boards appointed CHP winter planning leads, which was generally felt to have improved the whole systems approach. However, it was felt by the majority of Health Boards that there was a lack of engagement with the local social work department, signified by their non-attendance at winter planning meetings. 17. Examples exist of Health Boards developing winter plans in a sectored manner, with the acute sector and primary care preparing separately. At times of peak pressure this manifested as poor partnership working, as different sectors failed to understand the demands on the whole system. Lack of predefined cross-sectoral roles and responsibilities led to some areas of the service being under severe strain whilst others had excess capacity, for example high acute hospital bed occupancy, whilst local community hospital bed occupancy remained below 70% (see Figure 10, p35). 18. Timescales for starting the winter planning varied between Health Boards from April to November. Some interviewees felt that the development of the winter plan was little more than a paper exercise, and that the plan and contingencies outlined were not utilised or relied upon on at times of pressure. Some interviewees at middle management level would welcome a return to the previous system of winter plans being submitted to the Scottish Government Delivery Directorate for centralised scrutiny, rather than simply confirming that preparations for winter had been developed. NHS24 19. The NHS24 winter plan included a well defined and rehearsed escalation policy, in partnership with out of hours services and all the territorial Health Boards. For the three weeks over the festive period NHS24 staff rotas were suspended to allow matching of capacity to predicted activity. On days of peak predicted activity, NHS24 was staffed to maximum capacity. 20. The NHS24 modelling tool (derived from Simul8) was utilised to predict activity and was largely perceived to be accurate, with the exception of the weekend of 13/14 December and the two four-day holiday periods. It included HPS data and data from ‘flu spotter practices, and also factored in previous NHS24 activity. Predictions were disseminated to out of hours services as a guide to predicted activity.
  20. 20. 20 21. In NHS Greater Glasgow and Clyde co-location of NHS24 with the GP out of hours hub, out of hours mental health service, and Scottish Ambulance Service at Caledonia House in Cardonald was universally acclaimed to improve partnership working. Examples of this include:  On Hogmanay, NHS24 call handlers, who had extra capacity, were able to assist SAS call handlers with non-999 calls, and General Practitioners working for the out of hours service were triaging 999 calls.  Following IT system failure of the out of hours system, General Practitioners were able to sit with NHS24 call-handlers and continue to take pre-prioritised calls until the IT system came back online 12 hours later. NHS24 plan to co-locate their call centre with the SAS East EMDC. On Christmas Eve, Health Protection Scotland informed NHS24 of increased ‘flu spotter rates in the community (specifically in Glasgow, Edinburgh and Aberdeen). The GP out of hours services was advised that they could issue anti-viral therapy. This led to a phone conference between the medical director of NHS24 and the directors of the out of hours GP services. The outcome was that NHS24 did not change its telephone advice to patients and did not mention antivirals. Consequently:  Four Health Boards accessed pandemic ‘flu supplies of oseltamivir (Tamiflu), but prescribed very small amounts  Nine Health Boards made the decision that attempting to access and prescribe oseltamivir would put the out of hours system under enormous pressure, and so made a positive decision not to access stocks.  One Health Board was unaware of the email. The lack of consistency of response from NHS24 and HPS in relation to the same information resulted in local partners taking different courses of action, which caused unnecessary confusion. Scottish Ambulance Service 22. Each Scottish Ambulance Service division contributes to the overarching Scottish Ambulance Service Capacity Management Plan, which is also used for winter planning, and the Scottish Ambulance Service also contributes to territorial Health Boards’ winter plans. 23. Pressures on the Scottish Ambulance Service over the winter are related to increased demand, and adverse weather conditions such as icy roads which can significantly impair Category A response times. A further pressure highlighted at interview was the increasing need for secondary transfer, as some Health Boards increasingly adopt a policy of utilising several sites as a single bed base in order to cope with capacity issues. 24. SAS noted increased activity as early as 3 December, with SAS managers undertaking clinical roles. Activity peaked over Hogmanay and 2 January where, despite all call centres being staffed to maximal levels, on occasion call answering rates were reduced to 15% within the first 30 seconds. Note that co-location of the EMDC with NHS24 and the out of hours centre in Glasgow was advantageous as
  21. 21. 21 NHS24 call-handlers handled some of the non-999 SAS activity, and General Practitioners assisted by triaging some of the SAS calls. 25. Throughout December and January there continued to be significant challenges with meeting the KPI for Category A and Category B calls, due to physical lack of room in the East EMDC. During 2009-2010 the East EMDC will quadruple capacity when it co-locates with NHS24 at South Queensferry. 26. The Scottish Ambulance Service achieved delivery of the HEAT A3 target in March 2009, reaching 77.4% of category A calls within 8 minutes on the Scottish mainland. This target has now become a HEAT standard. To achieve this, some SAS divisions were in escalation mode for the entirety of March, employed significant overtime, and sanctioned the use of extra vehicles, particularly in rural areas with longer response times. Patient Transport Service Please refer to Hospital Discharges (p37). Out of hours General Practitioner Services 27. Feedback from the out of hours GP services across Scotland was largely positive, with the vast majority ascribing to the view that the difficulties in ‘coping’ by NHS Scotland over winter 2008-2009 were largely in the acute sector. 28. Winter plans, particularly for the two four day holiday periods, were felt to be robust. One Health Board, as part of their contingency plan, requested that primary care increase capacity in the three days between the holiday periods (29-31 December). This was felt to significantly reduce the pressures subsequently experienced by the out of hours service. 29. NHS24 issued modelling tool data to each Health Board to allow extrapolation and prediction of out of hours GP activity. Few Health Boards found this data helpful, with predictions of activity differing from actual activity by over 50% on occasions. The majority of Health Boards, although not using a formalised predictor of activity, used their own historic data in order to anticipate demand and plan capacity, and found this generally more reliable. There were some examples where activity peaked earlier in winter than expected (for example due to viral respiratory illness over the weekend of 13/14 December) and an increase in capacity for the corresponding weekend next year is planned by some Health Boards. 30. Some Health Boards (predominantly NHS Lothian and NHS Greater Glasgow and Clyde) handle a proportion of not immediate and life-threatening/not serious and urgent calls for NHS24, as pre-prioritised, or untriaged calls, at weekends. Over the two four day holiday periods this is extended to include all out of hours hubs. These calls are dealt with by General Practitioners without the NHS24 algorithm. Many Health Boards employed extra doctors over the Christmas and New Year holidays specifically to increase pre-prioritised call capacity. On two occasions during December weekends (due to IT failure and an unpredicted peak in activity) hubs were asked at exceptionally short notice to provide extra pre-prioritised call capacity, and had to bring in extra staff, or ask staff to work extended hours.
  22. 22. 22 31. Once demand for NHS24 clinicians outstrips capacity then calls are handled via call-back, whereby the call-handler decides the triage category of the call and the patient is called back within an allotted time span. This places extra pressures on NHS24 and the out of hours GP service, as it shifts a significant proportion of the workload into the evening, when staff modelling is not matched to this demand. 32. There is an increasing move towards co-location of Emergency Departments and out of hours General Practitioner services to improve patient flow. In 21 out of 28 core hospitals (excluding paediatric hospitals), the two services are co-located. NHS Highland has moved to a fully integrated Emergency Department/GP out of hours service at Raigmore Hospital, with patients being triaged into either service on arrival. Across several NHS Health Boards there are issues with perceived patient ownership by Emergency Departments and GP out of hours services limiting partnership working. However, this winter other Health Boards saw >10% of self-referrals to the Emergency Department being referred to, and dealt with, by the GP out of hours service. In some Health Boards these patients are counted as attendances at both the Emergency Department and the out of hours service, which is inappropriate and inflates the attendance figures. This will be a focus of ongoing work with the Scottish Government HEAT T10 target. 33. There are two models of patient appointments employed by GP out of hours services. Most Health Boards operate a traditional appointments system, where patients are issued an appointment time at the nearest Primary Care Emergency Centre, depending on their NHS24 triage category (i.e. 1 hour, 2 hour or 4 hours). Health Boards operating this policy find this is the most efficient mechanism of controlling surges in demand. NHS Greater Glasgow and Clyde run a ‘no appointments’ system, whereby patients are asked to attend their nearest Primary Care Emergency Centre as soon as possible. The service feels that this eliminates a layer of clinical risk, where there is no delay in seeing patients, and also that patients are less likely to self-present to the Emergency Department whilst waiting for their appointment time. In order to manage surges in demand, a robust escalation policy is in place whereby if the waiting time to see a clinician exceeds one hour, then back up clinicians are called in from home. 34. The impact on in-hours primary care of having easily accessible out of hours primary care is unknown. 35. The Key Performance Indicators (KPIs) for GP out of hours services include percentage of home visits achieved within the 1 hour, 2 hour and 4 hour timeframes triaged by NHS24. However it is the perception of some clinicians that the referral algorithm employed by NHS24 is excessively risk averse, and that many home visits triaged for 60 minutes are inappropriate. Preliminary findings from an audit undertaken by Lothian Unscheduled Care Service along with NHS24 found that only 25% of requests for a 1 hour home visit could be validated, with a proportion being re- triaged as simple home care advice. Further work is currently being undertaken to examine this issue further. 36. Health Boards have differing practices for dealing with KPIs. In some Health Boards it is accepted practice that if a clinician makes telephone contact with a patient within the initial allotted timeframe (e. g. 1 hour), and re-triages him or her to a less urgent category (e. g. within 4 hours), then the 1 hour KPI is classed as having been met if the patient is seen within 4 hours.
  23. 23. 23 37. Every Health Board increased GP out of hours services, for both clinical and non-clinical staff, over the festive period to a level they considered to be sufficient to cope with the increase in activity. A minority of Health Boards had difficulty in filling the clinical sessions, and some Health Boards cancelled non-clinical staff annual leave over this period. Several Health Boards noted that with the advent of the European Working Time Directive maximum 48 hour working week in August 2009, it will be difficult to fill clinical sessions for four day holidays in future. 38. Finally, almost all Health Boards flagged up Agenda for Change as posing significant challenges for the provision of out of hours services over the festive period. Non-clinical staff are already paid the unsocial hours enhancement in their salary and this may affect their willingness to work over the festive period. Hospital admissions Emergency Medicine 39. Patterns of access for hospital admission vary, with many sites continuing to operate a traditional single front door policy, where all admissions to hospital, including General Practitioner referrals to specialities, are admitted via the Emergency Department. Sites then differ with regard to whether GP referrals are left for specialists to assess in the department, or whether the Emergency Department initiates assessment. 40. Some of the teaching hospitals have adopted a direct admission policy, whereby if a patient presenting to the Emergency Department is deemed to require inpatient assessment, the patient can be transferred to the Acute Medical Unit without traditional referral. Data from NHS Greater Glasgow and Clyde suggests that this does not increase the proportion of patients admitted (of patients presenting with chest pain). 41. Other sites operate a model where General Practitioner referrals are admitted directly to the Acute Medical Unit, bypassing the Emergency Department. Many specialities (particularly haematology/oncology) continue to admit a proportion of patients direct to the speciality ward. 42. NHS Lanarkshire has established an Emergency Response Centre, a single point of contact for primary care to refer patients into secondary care across the entire health board. 43. Emergency Departments across NHS Scotland differs between Health Boards. Some units operate predominantly as a triage and resuscitation unit, booking downstream beds for patients on their arrival in the department, and providing minimal access to diagnostic services. At one site, to improve flow, patients are moved out of the Emergency Department to the Acute Medical Unit after 2 hours, regardless of whether or not a bed is available (in these circumstances they become a ‘corridor wait’). Furthermore, if no beds are available in the Admissions Unit, GP referrals to medicine are also treated as corridor waits but are not subject to the 4 hour Standard, which is not in line with the Scottish Government definition. Other Departments will instigate, and often complete, the diagnostic process, including GP
  24. 24. 24 referrals to speciality. Several Emergency Departments have attempted to facilitate this process by opening Clinical Decision Units (CDUs). 44. Of the rural and island Health Boards, NHS Highland runs a fully integrated Emergency Department and GP out of hours service at two sites, where patients are triaged into either service on arrival. NHS Western Isles and NHS Shetland Emergency Departments are staffed primarily by Emergency Nurse Practitioners (ENP), with support from ward based medical staff, and NHS Orkney Emergency Department functions only as a minor injuries unit, with all GP referrals and emergency ambulance patients being admitted directly to the general ward. NHS Borders operates an ENP and GP led Emergency Department, with a Consultant in Emergency Medicine. Finally, NHS Dumfries and Galloway employ two consultants in Emergency Medicine, and will appoint three salaried General Practitioners in the department, working towards integration with GP out of hours. 45. Many Health Boards felt that if the Emergency Department comes under sustained activity pressure, then the default position is to admit a larger proportion of patients, easing congestion in the department, but increasing pressure on inpatient beds. However, data from this winter does not support this concept. Figures 4 and 5 demonstrate the number of attendances to the Emergency Department and proportion of patients admitted over December 2008/January 2009. Figure 4 is from a busy Emergency Department with significant medical staffing challenges, and here there is no impact of attendances on admission rates. Figure 5, from a busy Emergency Department with a full complement of medical staff, suggests that the proportion of patients admitted falls significantly with increasing attendance rate (r = - 0. 4, p<0. 0001). Figure 4. A&E attendances per day vs proportion admitted - Dec 2008- Jan 2009 - Reduced staffing 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 100 120 140 160 180 200 220 240 260 280 300 Source: A&E Data Mart, extracted May 2009
  25. 25. 25 Figure 5. A&E attendances per day vs proportion admitted - Dec 2008- Jan 2009 - Full staffing 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 200 220 240 260 280 300 320 340 360 380 Attendances Proportionadmitted Source: A&E Data Mart, extracted May 2009 Key Learning Point 4: There is no evidence to support the belief that as Emergency Departments become busier, the proportion of patients admitted increases. Indeed, in well staffed departments the converse may be true. 46. Many Accident and Emergency Departments attempted to increase staffing levels over the winter and festive period. Some Health Boards did not allow nursing staff to take annual leave over the two four-day holidays. Additional junior medical staff were employed by some departments over the festive period, but significant issues with recruiting locum staff were again reported. NHS Lanarkshire employed additional consultant sessions over the winter weekends, and this policy is to be continued indefinitely. 47. As winter initiatives, NHS Lanarkshire and NHS Greater Glasgow and Clyde employed General Practitioners in the Emergency Department, with the aim of seeing patients suitable for primary care. These pilots were well received, with some GPs able to contribute to the overall activity in the department when there was less primary care activity, and more experienced GPs facilitating two-way learning. Other Health Boards are increasingly employing extended role nursing staff functioning as independent clinicians, with one example being MINTS (Major, Minor Illness and Injury Nurse Treatment Service) nurses in NHS Lanarkshire. 48. Many Health Boards (though not all) felt that winter was busier in terms of admissions, particularly over December. Also many clinicians referred to the fact that patients requiring hospital admission appeared to be more elderly and frail, with respiratory illness, a combination frequently associated with an increased length of stay.
  26. 26. 26 49. In the west of Scotland, there were a small number of exceptional days. On 2 December there was an unpredicted overnight freeze. Although the local authorities managed to grit roads, pavements were not gritted, and this resulted in the phenomenon known as ‘slippy Tuesday’. Emergency Department attendances in NHS Greater Glasgow and Clyde were 20% above the highest number ever previously recorded, and 55% above the normal activity. Although this did not translate into an increase in overall admissions of a similar magnitude (see Figure 6), surgical admissions were 75% above the average, and well above predictions for the day. This put extreme pressure on theatre services at a time when the elective programme was running at maximum capacity. Figure 6. Emergency Department attendances and admissions NHS Greater Glasgow and Clyde winter 2008-2009 0 200 400 600 800 1000 1200 1400 1600 1800 2000 01/11/2008 08/11/2008 15/11/2008 22/11/2008 29/11/2008 06/12/2008 13/12/2008 20/12/2008 27/12/2008 03/01/2009 10/01/2009 17/01/2009 24/01/2009 31/01/2009 Total A&E attendances Admissions to same hospital Other ( not admitted) Transfers (admissions to other hospital) Source: A&E Data Mart, extracted May 2009 50. NHS Greater Glasgow and Clyde opened Clinical DecisionUnits (CDUs) at Glasgow Royal Infirmary and the Southern General Hospital as winter initiatives, with patients being jointly managed by Acute and Emergency Medicine. In their experience these units functioned as an effective buffer against the 4 hour Standard, and were invaluable for times when surge management was necessary, such as on 2 December. Data from the Southern General Hospital showed that the CDU:  reduced the number of patients breaching the 4 hour Standard (now 98% for flow 2 and 3 patients and 99% for minor injuries);  reduced the length of stay for particular patient groups (for example chest pain); and  discharged 87% of patients without recourse to admission to a ward bed. Originally undertaken as a winter initiative, the CDU has been adopted on a recurring basis by the board, opening from Monday to Thursday.
  27. 27. 27 Emergency Department Time Profiles 51. In addition to the percentage of four hour breaches, analysis of the Emergency Department admission/discharge time profile can yield information regarding stability of the whole system. In a stable system deigned to assess, treat and admit or discharge patients timeously, the time profile should reflect a skewed distribution, with the majority of patients admitted or discharged within three hours. 52. Figure 7 is a four hour time profile from an Emergency Department of a well performing site during December 2008, and as can be seen, the distribution is skewed to the left. However in a department with a significant exit block, the peak of admissions/discharges would be shifted significantly to the right. This can be seen in Figure 8, which is an Emergency Department time profile from a poorly performing site over December 2008. Note that the peak time for patients to be moved out of the department (admitted to hospital or discharged) was 3 hours 55 minutes. Figure 7. Emergency Department time profile Dec 2008 Good performance 0 5 10 15 20 25 30 35 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Waiting Time (Hours) No.ofAttendances Source: A&E Data Mart, extracted May 2009
  28. 28. 28 Figure 8. Emergency Department time profile Dec 2008 Poor performance 0 5 10 15 20 25 30 35 40 45 50 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Waiting Time (Hours) No.ofAttendances Source: A&E Data Mart, extracted May 2009 Staffing Issues 53. Staffing levels in Emergency Departments across Scotland vary widely, with consultant cover being a particular issue for certain Health Boards with split site working. The past year, and particularly winter, has seen increasing challenges for Emergency Medicine (and other acute specialities including acute medicine, acute surgery, paediatrics and obstetrics and gynaecology) in terms of filling rota slots. There have been two main reasons for this. If speciality trainees drop out of rotation then, because recruitment is now nationally driven and occurs annually, there can be a delay of many months before the post is refilled. Secondly, many trainees on General Practitioner Vocational Training Schemes (GPVTS) are taking maternity leave (approximately 75% of medical graduates are now female). As trainees are changing placements every four months, this has meant that departments have been left with very short notice regarding staffing deficiencies. One district general hospital was given only four months notice that 3 out of 4 GPVTS trainees (37% of the total of Emergency Medicine junior staff) would not be undertaking their placements in December. 54. These staff shortages are compounded by the fact that Emergency Departments (and other specialities) find it difficult to employ locum staff, as doctors previously willing to undertake FTSTA posts have moved further afield, or entered GP training. Large central belt teaching hospitals are able to employ clinical assistants on an ad hoc basis, but this is rarely feasible outside Edinburgh and Glasgow. Several Health Boards have now amalgamated the funding available for FTSTA posts and established new consultant posts in Emergency Medicine and/or Acute Medicine. 55. Health Boards highlighted the perception that junior medical staff working in Emergency Medicine are increasingly more risk averse, and this can impact on attendance/admission ratios, particularly in sites with limited consultant presence.
  29. 29. 29 This is a year-long problem, not specific to winter, but may be exacerbated by the increased volume of patients during this season. 56. These points were discussed with NHS Education for Scotland (NES). It was felt that Health Boards had been slow to adapt and restructure their workforce in accordance with the long-predicted fall in junior medical staff, resulting from implementation of the European Working Time Directive (EWTD). With regards to recruiting middle grade staff, the running of two recruitment rounds per year in specialities struggling to fill posts would be unlikely to improve matters, as the problem is a lack of applicants. 57. Furthermore, the difficulty in recruiting short or long term locums is thought to be largely a result of recent changes in immigration and employment laws, and is unlikely to change. However, more formal appointments for Training Programme Directors of GPVTS schemes are currently being made, increasing the likelihood of future employers being notified well in advance should a trainee intend to take maternity leave. 58. Finally the issue of junior doctors being perceived as less experienced, and therefore potentially more risk averse, was raised, and it was agreed that in the United Kingdom there had been challenges in implementing the EWTD and a resultant shortening in training. NES is focused on rethinking significant areas of training, increasing its intensity, and making service experience more telling. 59. There were also significant staffing issues with unfilled slots in junior doctor rotas in acute medicine, particularly outside Glasgow and Edinburgh. One Health Board also had critical issues with nursing staff shortage in the Acute Medical Unit over the festive period, despite suspending all annual leave, with off-duty nursing staff asked to remain ‘on-call’ at home. 60. There was little change to consultant physician working patterns over the winter with some exceptions:  NHS Lanarkshire increased to a two tier system of consultant receiving at one site (0900-1600, 1600-2300) and noticed a significant increase in the number of discharges and improvement in patient flow. This is now a permanent arrangement. Additionally, extra consultant physician sessions were employed over winter weekends and the festive period to discharge patients from downstream wards, with the aim that each patient was reviewed every 24 hours.  NHS Greater Glasgow and Clyde doubled the number of on-call consultant physicians at some sites at times of peak predicted activity.  NHS Lothian consultant physicians on-call worked until midnight during weekends of high activity. Alternatives to admission 61. There were many acute medicine driven initiatives offering alternatives to hospital admission this winter. NHS Tayside developed an assessment room for ambulatory care and rapid assessment. Approximately 20% of GP referrals for admission were triaged into this service, saving 200 admissions per month. NHS Lothian successfully piloted a Mon-Fri daily rapid access medical clinic (via the Bed
  30. 30. 30 Bureau) embedded within the MAU and offered to the GP at the point of referral. However NHS Greater Glasgow and Clyde found uptake of a similar clinic was disappointing, when offered as a stand-alone service. NHS Shetland consultant physicians offered an outreach service to care homes on the islands over the festive period, guaranteeing a review within 24 hours within the care home, as an admission avoidance initiative. Originally funded by EADT festive monies, this is still ongoing, funded by the Health Board. 62. NHS Lanarkshire has introduced the Emergency Access Programme Health Board, which is looking to redesign access to emergency care using a whole systems model. There are six streams, including:  primary care in hours;  primary care out of hours;  emergency care redesign;  inpatient capacity management;  information and performance management; and  emergency response centre for NHS Lanarkshire. The six work streams are underpinned by the Acute Access Action Group (AAAG) which consists of senior clinicians and managers from primary and secondary care. This group met weekly over the winter period to discuss four hour breaches and significant issues relating to access to emergency care. Capacity and demand within secondary care Predictors of activity 63. Nine out of Scotland’s 14 territorial NHS Health Boards have an internally developed tool for predicting unscheduled activity. The majority of these Health Boards also predict elective activity, although in every case the unscheduled activity predictor is considered to be more accurate, largely due to poor IT interface with surgical services. The predictors were largely developed during the Unscheduled Care Collaborative, are based on the previous six weeks’ activity and are used to accurately predict between two and 14 days in advance. One Health Boards’ predictor was found to consistently under-predict as it was based solely on data from winter 2007-2008, widely acknowledged to have been a quieter year. 64. The ISD predictor tool, System Watch, was used patchily throughout the NHS over winter, with most Health Boards preferring to rely on the internal predictor. A minority of Health Boards inputted System Watch into their own predictor tool. Reasons for lack of uptake of System Watch include:  perceived inaccuracy, particularly for smaller Health Boards;  broad definition of medical admissions (e. g. including neurology) leading to over-prediction;  perceived complexity; and  lack of awareness of its existence. 65. NHS Lothian used System Watch four months in advance to predict the number of capacity beds that would be required in January. The prediction was 140
  31. 31. 31 beds, and the actual number required was 148; a difference of only 6%. NHS Forth Valley also used System Watch, alongside its own predictor tool, in order to model elective activity, maximising elective activity at times of predicted low unscheduled activity, and running minimal elective activity (plus out-sourcing to external agencies) during the first three weeks of January when unscheduled activity was predicted to be high. There were no breaches of the 18 week RTT target. 66. Figure 9 demonstrates the System Watch prediction for August 2008-August 2009. It demonstrates activity beginning to increase at the start of November (earlier than predicted) but the short term prediction improves in accuracy after 2-3 weeks. Key Learning Point 5: System Watch has a proven track record of accurate long, medium and short term prediction of unscheduled demand. All Health Boards should use System Watch routinely to predict activity, in line with current Government recommendations. Figure 9. Source: System Watch, accessed 9 June 2009 Bed meetings 67. Four Health Boards across Scotland do not hold daily bed meetings in their main hospital, even over the winter period (despite unscheduled care recommendations). Of the remaining 10 Health Boards, all sites had bed meetings at least once daily, with the vast majority holding them twice daily (and some three times daily over the winter period). Increasingly Health Boards are using their sites as a single bed base, alternating the admitting hospital and transferring patients depending
  32. 32. 32 on pressures within the whole system. If this has not been adequately planned in advance with the Scottish Ambulance Service, it potentially results in pressure on Patient Transport Services and delays to patient transfer. 68. The importance ascribed to bed meetings varies across the country. At one large teaching hospital site, which does not utilise a predictor and does not employ bed managers, bed meetings are described as entirely reactive with no forward planning and no ownership of patient flow. NHS Greater Glasgow and Clyde, however, monitors real time bed occupancy, whilst the bed management team at NHS Lothian assesses the actual empty bed base every morning and then looks at predicted admissions/discharges against actual admissions/discharges every two hours to determine bed status. 69. NHS Greater Glasgow and Clyde proactively employed an extra bed manager over the busy winter months, at the Western Infirmary. Furthermore, an additional bed manager was situated at the Victoria Infirmary twice weekly. Although this initiative was felt to have worked well, improving dynamic capacity management, interviewees felt that in retrospect the staff could have been employed four weeks earlier, in December, allowing a period of acclimatisation before the busy period. 70. NHS Lanarkshire has implemented a twice daily conference call between all three acute sites, during which the bed occupancy and escalation status of each site is discussed, and thus the escalation status of the Health Board is determined. The escalation status is then relayed to other stakeholders including primary care via email or text message. At times of peak activity over the winter this conference call included representatives from the out of hours GP service. Key Learning Point 6: Daily bed meetings are necessary at every site. Twice daily bed meetings are necessary at core sites over the winter period. Escalation plans 71. Each NHS Health Board has an escalation plan, but there is variation in the degree to which they are implemented. The three island Health Boards’ escalation plans are based simply on bed occupancy, and when this reaches maximal level (including all contingency beds) and there are no patients suitable for discharge, then elective activity is postponed. Following this, patients are transferred off the island, to NHS Grampian (NHS Orkney/NHS Shetland) or NHS Highland/NHS Greater Glasgow and Clyde (NHS Western Isles). These escalation plans were not required to be actioned this winter. 72. Nine of the 11 mainland Health Boards in NHS Scotland have a bed management escalation plan. However significant flaws were highlighted in several of these plans; for example one Health Board defined red alert as >100% bed occupancy, yet key areas of the hospital (for example CCU) would as a matter of normality always keep one empty bed, thus removing the ability to escalate to red alert. Another Health Board described misuse of the escalation policy, with district general hospitals closing and transferring admissions to the local teaching hospital, whilst retaining empty beds. Others described fear amongst hospital management to escalate beyond green and only executives on call having the ability to escalate to red alert.
  33. 33. 33 73. There was a lack of knowledge, particularly amongst clinicians, regarding the specific local triggers for escalation. There was also a feeling in some hospital sites that if the escalation plan were adhered to, then the escalation status would be red most of the time. Many interviewees commented that both internal and external stakeholders, particularly primary care, had become desensitised to the local hospital site escalating to status red, and hence little or no action was taken. 74. Community Health Partnership (CHP) involvement in escalation plans was variable between NHS Health Boards. In one Health Board an escalation plan was developed by CHP senior management, however CHP middle managers were not fully sighted on this and so were unable to respond when necessary. Capacity Beds 75. Eight of the 11 mainland Health Boards (and two of the three island Health Boards) opened additional bed capacity in the main sites over winter 2008-2009. Only three acute sites opened previously closed wards, which were considered to be ‘winter wards’. Other responses adopted by acute sites included:  opening wards normally closed at the weekend (predominantly ENT);  opening closed surgical wards over the festive period;  overnight utilisation of day-case unit beds;  endoscopy unit beds;  day hospital beds; and  ad-hoc beds placed where possible in wards – for example in dayrooms. The latter four of these are associated with an increase in clinical risk. Some specific sites experienced bed reductions, for example:  23 beds closed in October at an acute elderly medicine site as a consequence of the Vale of Leven report; and  closure of some Community Hospitals and centralisation of services to improve patient care, however with reduced capacity on the acute site. 76. Concerns were raised about medical staff no longer having sufficient awareness of bed management. Indeed the perception of one senior clinician at a large teaching hospital was of the local system having ‘no pressure on beds over the winter. . . as elective activity is significantly scaled down. . . and therefore there are limitless beds to decant (board) into’. In reality this site did not postpone elective cases despite trolley waits in the Emergency Department, and medical wards were asked to accommodate extra capacity beds in non-clinical areas. Key Learning Point 7: Consultant medical staff should have greater awareness of bed management issues. This includes Health Board and site escalation status and triggers. 77. The majority of the mainland Health Boards highlighted the under-use of bed capacity in Community Hospitals. This was a particular problem for larger, rural
  34. 34. 34 Health Boards where day-time bed occupancy in the acute sites was often reported to be approaching 100%, whilst in the affiliated Community Hospitals was as low as 65%. There were several factors identified as limiting factors in flow from the acute sector to community beds: Availability of Patient Transport Services:  highlighted as a particular problem in transporting patients from the Emergency Department, when by definition only limited notice could be given to the Scottish Ambulance Service (though numerically the numbers of transfers from Emergency Departments and Acute Medicine Units is far smaller than from downstream wards). Complex referral processes and pathways:  need for patients to be accepted for transfer to the community bed base by either General Practitioners or Medicine for the Elderly Consultants;  subsequent delays in review, or the referral process itself was rate limiting (for example the need for written referrals);  differing practices for accepting patients for transfer (e.g. one community hospital would accept only one admission per day, regardless of bed occupancy); and  some community hospitals will not routinely accept admissions out of hours, and are reliant on the out of hours service when they do. Patient choice:  Large rural Health Boards may have community hospitals in sparsely populated areas many miles, and several hours travel, from the acute site. These sites tend to be under-utilised, predominantly due to patient choice. 78. Figure 10 illustrates bed occupancy at both core and non-core sites. Core sites are the 33 major hospitals within the Health Board that submit Emergency Department data to ISD. Non-core sites represent community hospitals, or hospitals with small Emergency Departments/Minor Injury Units only. Note that the graphed daytime bed occupancy of all Health Boards is less than the >100% at core sites during the winter which was reported by some. Reasons for this discrepancy include:  bed occupancy being measured at midnight;  no electives at weekends;  zero length stays; and  day-case patients being seen in inpatient facilities.
  35. 35. 35 Figure 10. Bed Occupancy levels for core and non-core sites Apr 2008-Mar 2009 70% 72% 74% 76% 78% 80% 82% 84% 86% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 % Bed Occupancy at core sites % Bed Occupancy at non-core sites Source: ISD(S)1 Hospital Activity Statistics Key Learning Point 8: Bed capacity in community hospitals was significantly under- utilised this winter. Elective procedures 79. Differing policies on elective activity over the festive period were evident. Over the two week holiday period (22 December – 4 January), six Health Boards planned in advance to reduce elective activity to a ‘cancers and urgent only’ service, whereas eight Health Boards continued with a full elective programme until Christmas Eve, and then resumed it for the three days between holiday periods (one Health Board at 80% of capacity). 80. NHS Lanarkshire and NHS Highland front-loaded the week beginning 5 January with minor elective surgery to reduce surgical bed utilisation. For winter 2009-2010 NHS Lanarkshire is planning to back-load medical elective activity (such as clinics and endoscopy lists) for the first two weeks of January. NHS Borders continued to run a ‘cancers and urgent only’ service from 20 December - 12 January without triggering any 18 week RTT breaches. Finally NHS Forth Valley used System Watch to model its elective activity programme (see Predictors of Activity, p.30). 81. NHS Scotland is committed to delivering ‘a whole journey waiting time target of 18 weeks from general practitioner referral to treatment. . . by 2011’3. Health Boards pointed out that implementation of this target could potentially be seen as conflicting 3 NHS Improvement Plan : Putting people at the heart of public services. DOH, June 2004
  36. 36. 36 with the 4 hour Standard for access of emergency care, with emergency and elective patients vying for a finite number of beds. Interviewees from a significant minority of Health Boards stated that since the disbanding of the Unscheduled Care Collaborative and the reclassification of the 4 hour HEAT Target to a Standard of care, there had been a noticeable reduction in focus on emergency care, manifested by systems prioritising planned elective care in the following situations:  closure of surgical wards over the festive period (as elective activity was significantly reduced) and refusal to reopen them to accept medical patients, despite four and eight hour breaches in the Emergency Department;  Health Boards planning waiting list initiatives on 5 and 12 January despite predictions of very high unscheduled medical activity and high bed occupancy;  a Chief Executive refusing to sanction the postponement of non-urgent elective procedures despite the presence of excess trolley waits in the Emergency Department; and  the perception that there is 2% ‘room for manoeuvre’ within the 4 hour Standard, but that the 18 week RTT target is absolute. Key Learning Point 9: In some Health Boards there was a reluctance to postpone elective procedures even when pressures in emergency care were rising. Cancelled elective procedures 82. Over the winter period, all the island Health Boards and four of the mainland Health Boards did not cancel elective work due to lack of hospital beds. Five Health Boards cancelled activity in very small numbers (less than 15 cases each) and two Health Boards cancelled significantly more.  In one Health Board there was an increase in emergency orthopaedic admissions in early December, resulting in postponement of some elective surgery. This then put pressure on the 18 week RTT target over the winter period, resulting in waiting list initiatives in early January.  A second Health Board had a significant norovirus outbreak in late January/February, closing beds, which led to the cancellation of a number of electives. Boarding patients 83. All 11 mainland Health Boards relied on a policy of boarding patients this winter. The largest patient group boarded were medical patients, though a minority of Health Boards also boarded surgical, orthopaedic and medicine of the elderly patients at different stages. 84. Few Health Boards have written protocols for boarding patients. Most aim to board stable patients with an established discharge date from the downstream wards. However the reluctance of wards to nominate patients for boarding was noted. Indeed one interviewee commented that it was not unusual for wards to fail to identify a single patient to board overnight, yet have a significant number of discharges before midday the following day. Failure to do this leads to an increase in boarding of patients from assessment wards or the Emergency Department. Although most sites stated that boarders were identified during daylight hours by consultant staff, in
  37. 37. 37 practice at times of pressure boarders should be identified by junior medical staff, nursing staff or bed managers at any time, and from any area of the hospital. A minority of Health Boards utilised ‘treat and transfer’ policies. For similar reasons, patients from the Acute Medical Unit (and rarely the Emergency Department) were transferred in preference to stable ward patients, and not infrequently they were transferred to boarding beds in the receiving hospital. 85. Both boarding of patients and ‘treat and transfer’ policies are considered by the Scottish Government to be poor practice. This is especially the case when patients are boarded from Emergency Departments and Acute Medical Units. As part of the review, systems were asked how they would cope if the Scottish Government challenged the NHS in Scotland to eradicate or minimise the boarding of patients. 86. Many Health Boards struggled with this concept, highlighting that hospitals cannot run at >95% bed occupancy and accommodate seasonal variation in speciality admissions without boarding. However five Health Boards provided data that demonstrated a reduction in boarding, with NHS Greater Glasgow and Clyde having reduced boarding by over 70% since 2007, primarily by focusing on proactive discharge planning. Most Health Boards stated that their bed configuration was historical and not related to current patient need. NHS Highland significantly reduced boarding by reconfiguring 12 beds from surgery/obstetrics to medicine. 87. The method of recording boarding patient numbers varies between Health Boards. One Health Board only records boarders from Monday to Thursday. Data was in fact only available from selected sites from some Health Boards, and the format differed, meaning that comparison between Health Boards was not possible. Nonetheless, in a Health Board with a self-acknowledged problem with boarding patients, in January 2009 an unacceptably high proportion (up to 60%) of medical patients on one site were subject to boarding, accruing 5290 total boarded bed days for the month for the board, a total of 2.7 boarded days per bed in January. In contrast, NHS Highland recorded only 0.3 boarded days per bed in January. Key Learning Point 10: All mainland Health Boards rely on a policy of boarding patients at times of increasing system pressure. The degree of boarding between Health Boards differs greatly, and some Health Boards have reduced boarding significantly. There has been an increasing move to board patients from Acute Medical Units, or Emergency Departments, before consultant review. Boarding must be reviewed and minimised. Hospital discharges Discharge planning 88. Different discharge planning models are in use across Health Boards in Scotland:  seven Health Boards primarily use Estimated Date of Discharge (EDD);  two Health Boards primarily use Traffic Lights;  two Health Boards use a hybrid model of Traffic Lights and EDD;  one Health Board uses EDD aligned with Jonah’s theory of constraints; and  two Health Boards have no discharge planning protocols.
  38. 38. 38 In general Health Boards reported that Estimated Date of Discharge was variably employed across the organisation. Some reported that all patients were assigned an EDD on admission, but that discharge planning deteriorated once the patient was transferred to an inpatient ward. However other Health Boards reported the opposite experience, where there was little or no discharge planning in the AMU, but a greater appreciation of the role of EDD on the wards, particularly in elderly medicine and surgery. Many Health Boards commented there was no ownership of the EDD, with consultant medical staff having little or no interest. 89. Regardless of which system was employed, there were significant doubts about accuracy of predictions. Managers commented on large numbers of patients with a ‘red’ traffic light being discharged at short notice, particularly from medical wards. Despite a general appreciation that morning discharges improve patient flow, and initiatives such as ‘two before ten’ being lauded as good ideas, this continues to be an issue for almost all Health Boards, with the median time of discharge at some sites being 6pm. Reasons highlighted included reluctance to use discharge lounges, risk averse junior medical staff awaiting consultant ratification of discharge, and delays in pharmacy supplying discharge medication. Key Learning Point 11: Discharging patients early in the day is key to maintaining capacity. 90. NHS Lothian and NHS Grampian include the EDD as an integral part of the hospital bed management system and each patient must have an EDD within 24 hours of admission. However this data is not used as part of bed management predictions, being considered too unreliable. NHS Dumfries and Galloway re-piloted EDD with charge nurse and consultant ownership on a single medical ward as part of a rapid improvement event, and saw a significant improvement in length of stay. Delayed discharges 91. NHS Scotland met the Scottish Government target of zero delayed discharges (>6 weeks in hospital after being declared medically fit) on the census date in April 2008 and April 2009, but not on other months (Figure 11). The target for zero delayed discharges in short stay beds was also met. The majority of Health Boards noted significant improvement in numbers of patients in delay. However large numbers of patients delayed <6 weeks continued to present significant challenges to a small number of Health Boards. 92. It was noted that although the zero target was met on the census dates, there were significant numbers of patients in the system over 6 weeks that were coded 71X (exercising statutory right of choice where an interim placement is not reasonable or possible) or 9 (complex discharges).
  39. 39. 39 Figure 11. Delayed discharges - Scotland - Jan 2006-Apr 2009 0 200 400 600 800 1000 1200 1400 1600 Jan 06 Apr 06 Jul 06 Oct 06 Jan 07 Apr 07 Jul 07 Oct 07 Jan 08 Apr 08 Jul 08 Oct 08 Jan 09 Apr 09 Census month Noofpatients > 6 weeks < 6 weeks Source: Delayed discharge census 93. Some Health Boards’ experience was of patients’ assessment of need being delayed until the six week target was threatened, thus allowing resource concentration on patients nearing the six week trigger. This was not the experience of any of the local authority representatives interviewed. 94. The rural and island Health Boards felt they had a particular problem of patient choice of care home. In low density populations, care homes are few in number and generally widely spread. Patients, perhaps not unreasonably, are not keen to live in homes many miles from (or indeed on separate islands from) their families. Furthermore, at the time of writing, there are currently no available care home beds in two of the three island Health Boards. Physical lack of carers was identified as a significant problem particularly for, but not limited to, the rural and island Health Boards. Festive period discharges 95. Over the festive period, hospital discharges fell significantly across all Health Boards. This largely represents a fall in discharges from downstream wards, rather than from Acute Medical Units. Several reasons were highlighted:  A marked drive to discharge patients in the days immediately preceding Christmas. Patients remaining in hospital over Christmas are those who are not medically fit for discharge.  A common observation was the lack of social work availability over the festive period. Most Health Boards could restart care packages if a patient was admitted and discharged over the festive period (as the carers had not been re-allocated), but it proved very difficult to restart care packages over the festive period if patients had been admitted days earlier. Health Boards were generally unable to order new home care packages over the festive period.  Over the festive period, there was a reduced consultant presence on the downstream wards and in some cases patients did not have a medical review for four days. Some Health Boards attempted to minimise this problem. NHS
  40. 40. 40 Lanarkshire employed extra consultant physician sessions over the festive period and during the winter weekends, to ensure every patient in a downstream ward could be seen daily to identify potential discharges. There remains a historical reticence amongst some medical staff to discharge patients under the care of a different consultant.  Allied Health Professional support over the festive period varied across NHS Scotland. Many Health Boards were limited to on-call physiotherapy only. NHS Greater Glasgow and Clyde’s IRIS (Interdisciplinary Response and Intervention Service) and DART (Discharge and Rehabilitation Team) were available for six out of the eight festive days but reported that demand for their early supported discharge services was very low. The reasons for this were unclear, but may have been related to staff being unaware of their availability during the festive period. NHS Greater Glasgow and Clyde also piloted a winter initiative of the Emergency Department being able to restart homecare packages, as often they were cancelled before a decision was made to admit the patient to hospital. This was not felt to have been successful, as patients were often admitted too late to restart packages the same day. NHS Ayrshire and Arran rapid response team ran over the festive period, funded by festive monies from EADT.  The lack of diagnostics was not felt to be a significant rate limiting step, with most radiology departments running a weekend, or extended weekend, service over the festive period. NHS Fife ensured that investigations to support discharge, such as echocardiography and exercise tolerance testing, were timetabled at least every 48 hours over the festive period; however this is still longer than the average. Patient Transport Service 96. The capacity of Patient Transport Services, particularly after 1700 in the evening and at weekends, was noted as being a significant barrier to discharge by almost every Health Board interviewed. The majority of PTS resources are targeted to match the operational requirements of non emergency outpatient models. As such, availability of PTS ambulances was perceived to be a particular problem in some Emergency Departments (and to a lesser extent, Acute Medical Units). 97. One Emergency Department kept a log of calls to the regional Patient Transport Service that remained unanswered after 120 minutes. The lack of a PTS ambulance was the underlying reason for 3 out of the 5 12 hour trolley waits in one Health Board over winter 2008-2009. Other Health Boards dealt with this issue by admitting the patient to wait for PTS. 98. Capacity and availability of Patient Transport Services was also a major rate limiting step in the transfer of patients from acute sites to community hospitals, particularly for rural or semi-rural Health Boards with the majority of bed capacity in primary care. 99. Several Health Boards funded increased capacity in PTS as an integral part of their winter plans. Other Health Boards purchased their own vehicles. In addition to this, at least four Health Boards employed private ambulance companies to transfer patients to peripheral hospitals. NHS Highland developed evening and weekend
  41. 41. 41 PTS by utilising their mental health ambulance, with joint funding between SAS and the acute division. 100. The Scottish Ambulance Service is acutely aware of the above issues and has highlighted the development of PTS as a key focus for 2009. It was suggested that some Health Boards may have developed a degree of automatic over-reliance on PTS when alternate transport modalities may be just as appropriate. 101. Recent data from patient satisfaction surveys has shown that a significant number of patients (>80%) who travel to hospital in a PTS vehicle for planned care regularly utilise private and public transport for non health related journeys. NHS Highland has a contract with the regional council taxi company, employing taxi drivers who undertake school runs (and thus have Disclosure Scotland clearance). Social work 102. A lack of availability of social work for patient assessment or homecare provision was identified by Health Boards as a common issue, not just over the festive period but also in the lead up to Christmas and the New Year. A small number of Health Boards were informed by their corresponding social work departments that if complex discharges were not highlighted by mid-December then the discharge would not be supported until after the New Year. 103. Many social work employees take leave over the festive period, although measures have been taken by some Councils to prevent excess annual leave being taken at this time. Even when services have been provided during the festive period (for example increased availability of homecare managers and rapid response teams) then engagement has been minimal, suggesting a need for improved advance communication. 104. Nurses from the acute sector in NHS Greater Glasgow and Clyde can order homecare up to four times daily, seven days per week via a telephone hotline, without recourse to either occupational therapy or social work assessment. Nursing staff have found this significantly facilitates rapid discharge, with patients then being re- assessed in their home environment and the homecare package adjusted as necessary. 105. However, initial evidence has suggested that nursing staff are over-ordering, and this has led to some capacity issues in the community and delays in re- assessment. As a result of this a focused programme of nurse education is being introduced. Homecare ordering was also extended to 7 days per week over the winter for the non-acute sector (with patients being assessed in the normal manner) although demand for this was minimal. 106. Also in NHS Greater Glasgow and Clyde, a pilot of joint equipment stores (which are already in existence in other Health Boards) under the name ‘EquipU’ was undertaken. Equipment could be ordered from the EquipU website by hospital occupational therapists or nursing staff, and could be ready within 24 hours for urgent discharges. 107. Finally, social work reported the increasing issue of patients being discharged, primarily from the acute sector, without their care packages being restarted. This
  42. 42. 42 causes significant stress and distress to patients and their families. Additionally, the feeling persists amongst social work staff that the NHS is an increasingly risk averse organisation, and that there are under-utilised opportunities for patients to be discharged to wait at home for a package of care (in cases when they will be receiving it for the first time). Analysis of quantitative data Long term trends 108. To understand the data presented on activity levels in NHS Scotland over winter 2008-2009, it is important to contextualise them with activity over a number of years. However it is difficult to use long-term trends as direct comparators, as there has been a significant shift in the model of service delivery in recent years. Data demonstrates that Emergency Department attendances in Scotland have been increasing year on year since 2004-2005, rising by about 50,000 per annum in these 3 years (Figure 12). Figure 12. 109. The data for the above chart has been taken from ISD(S) 1 data to show historical trends. ISD Scotland were asked to develop a secure A&E Data Mart to serve as a repository for A&E data submissions, which was implemented in July 2007; from this time several NHS Health Boards have asked that this data source be used to complete the ISD(S)1 return. 110. A number of reasons have been suggested to underlie this increase in Emergency Department attendances:  public expectation;  perceived accessibility of the Emergency Department;

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