Written Ministerial Statement
The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.
Health, Social Services and Public Safety - Work of the Unscheduled Care Task Group
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Published at 11.30 am on Wednesday 19 November 2014
Mr Wells (The Minister of Health, Social Services and Public Safety): On 10 February 2014, my predecessor, Edwin Poots MLA, announced that he had commissioned the Regulation and Quality Improvement Authority (RQIA) to conduct a review of unscheduled care services in the Belfast Trust with a view to the wider regional context. On 1 July 2014 he announced that the RQIA had published its report and that he had accepted its findings and recommendations for transforming the delivery of unscheduled care.
Having considered the findings of the report my predecessor also announced on 1 July that he had decided to establish a regional task group to take forward the RQIA's recommendations, under the leadership of my Department’s Chief Medical Officer, Dr Michael McBride, and Chief Nursing Officer, Charlotte McArdle, who co-chair the task group. The task group’s immediate action was to oversee and coordinate a range of actions to support the reform of urgent and emergency care services and the implementation of the RQIA's recommendations. To achieve this, the whole system will have to work together, including our GPs, Ambulance Service, community care teams and staff in acute hospitals.
My predecessor also said that he wanted to see results, and therefore set the clear aims for the task group of eliminating all avoidable 12-hour emergency department waiting time breaches from this winter onwards and of making significant progress towards achieving the four-hour waiting time standard , over the next 18 months. Elimination of lengthy delays is critical to ensuring high-quality care and to improving patient experience.
The Assembly is aware that the HSC achieved a 44% reduction in the number of 12-hour waiting time breaches during last year. I am pleased to report that in the first six months of 2014/15 this progress has continued with the lowest number of 12-hour waits in five years. That is a considerable achievement, and I pay tribute to all staff in the HSC who worked hard to deliver this significant improvement, but there is still much more to do. Regrettably the Belfast Trust has been the exception to this continued improvement and I have made further comments below on the position in Belfast.
The RQIA’s report contained 17 recommendations. The purpose of my Statement today is to update the Assembly on the progress being made in addressing these recommendations: 10 recommendations have been taken forward by the Task Group and 7 were for the Belfast Trust to address by a dedicated work stream within the Task Group. A report on progress achieved against the recommendations follows below.
Escalation
The task group has established an escalation work stream which has worked closely with the Health and Social Care Board (HSCB) in developing a Regional Unscheduled Care Escalation Plan which will ensure that there is a consistent and robust methodology for monitoring and raising the level of escalation across the region including keeping the ambulance services informed of periods of heightened pressure across HSC Trusts. The work stream is also working with Trusts to review and test each of their escalation plans to provide assurance of the robustness of these plans. This will include an assessment of their ability to respond over the Christmas and New Year period.
Care of frail older people
The task group’s focus is to strengthen the unscheduled care services provided to our frail older population There has been considerable progress including: identifying improvements in the transfer of information between nursing homes and Emergency Departments; developing standards which reduce the number of internal hospital moves older people can be subjected to; and, developing a standard which restricts the discharge of older people from hospital late at night without their or their family’s permission
Recommendation 3 of the RQIA report specifically identified the potential for direct assessment of frail elderly patients to the Belfast City Hospital and I am pleased to report the Belfast Trust has now established Phase 1 of their project ‘BCH Direct’, which will ensure that frail elderly patients can be directly assessed and admitted to the City Hospital site. The number of patients assessed and admitted has been steadily increasing over the last number of weeks and the Trust has received very positive patient and carer feedback about the experience.
Respiratory Services
Recommendation 4 of the RQIA report similarly asked the Belfast Trust to examine the potential for direct access admission for respiratory patients. The Trust is in the process of finalising the arrangements to expand direct access to the Belfast City Hospital under the ‘BCH Direct’ project for those with respiratory illness and has set a target of January 2015 for full implementation.
In addition the task group is working to develop a discharge care bundle for COPD (Respiratory) patients, lead by the Trust’s respiratory nurses, which will ensure a safe effective discharge home and contribute to prevention of hospital admissions.
Patient Flow
Ensuring effective patient flow, both within and across hospitals was a key thematic finding of the RQIA report. There were a total of four recommendations within the report (5, 7, 8, 13) highlighting the importance of getting this right. In response to this the task group established a patient flow work stream that has made substantial progress to date in driving forward improvements. These include: the development of a regional model for unscheduled care that identifies alternatives to ED attendances particularly for older people and those requiring urgent assessment rather than emergency care; an audit tool is being developed to identify any delays in the patient’s journey. This will help Trusts identify gaps and take action to correct delays; a regional approach to multidisciplinary assessment at discharge is also being developed. This will ensure a safe discharge process which minimises the bureaucracy often associated with this process; regional standards for Triage nursing practice and Emergency Nurse Practitioners are being developed, supporting nurses to develop their skills and improving the consistency of approach throughout Northern Ireland; and, a regional audit tool is being developed and tested to monitor the fundamental aspects of nursing care in the Emergency Department. This tool will help quality assure that patients receive the care they need.
The Task Group has also proposed that the HSCB works with Marie Curie (MC) to introduce an extension of the seven day a week Out of Hours Rapid Response Palliative Care Service, currently in place in the North and Southern Local Commissioning Group (LCG) areas, to cover in-hours at weekends and bank holidays and to roll out a similar service to the northern sector of the Western LCG. The pilot is planned to commence on 1st January 2015 and will also involve partnership working with NIAS, who will refer, under agreed protocols, directly to the service, rather than transferring patients to an Emergency Department. The scheme will be evaluated after 12 months, when consideration will be given to full regional roll-out.
Diagnostics and Out of Hospital Care
Recommendation 10 of the RQIA report seeks to maximise alternative models of accessing hospital services outside of the traditional ED route, including an examination of the arrangements for provision of direct access to hospital-based assessment and admission services for appropriate patients. The Northern Ireland Ambulance Service (NIAS) is planning to introduce a clinical support desk to provide callers and responding ambulance staff with clinical advice, utilising decision support software and accessing referral pathways. All emergency vehicles, both ambulances and rapid response vehicles, have been equipped with mobile phones in addition to radio communication system. These are pre-programmed with the contact numbers of receiving hospital departments including: Emergency Departments; Cardiac Cath. Labs; and, potentially stroke teams.
The RQIA’s recommendations 12 and 13 are closely linked and aim to ensure that large numbers of patients do not present to Emergency Departments at any one time, as this can cause significant pressure and have consequences for the patient experience. To address this Trusts are working with NIAS, and other transport providers, at local levels to improve non urgent transport of patients. The HSCB has also developed a Locally Enhanced Service to support general practitioners to commence home visits earlier in the day and bring forward the time of day patients are being referred to hospitals. This includes options for additional clinical (GP) sessions for managing acute demand. These sessions are to help meet the additional demand for acute appointments and home visits during the winter months with the aim of speeding up the triage and assessment of patients who present with an urgent acute problem who may require admission to hospital.
Belfast Trust
The Belfast Trust has started to implement a programme of measures designed to deliver sustained improvements in unscheduled care services. The programme, known as IMPACT, is a three year programme focused on significantly improving patient safety, patient experience and patient outcomes. The programme aims to achieve this by reducing waste, harm and variation in care. While I recognise that some progress has been made, the Trust in recent months has continued to experience, unlike most other Trusts, high levels of patients waiting more than 12 hours in both the RVH and Mater Hospital EDs. In addition the RQIA carried out an unannounced inspection of the RVH ED and Acute Medical Unit (AMU) on 12 to 14 May 2014. The RQIA’s report highlights that although some progress had been made to address its recommendations by May of this year, a concerted effort was still required to ensure recommendations are actioned and implemented in full. Following this inspection, RQIA inspectors provided feedback to the Belfast Trust’s senior management team and some staff. At this meeting RQIA described the interim findings of the inspection, and provided recommendations for immediate consideration, to ensure patient safety.
My Department received the RQIA’s Inspection Report on 30 September 2014 and on 17 October 2014 held an accountability meeting with the Belfast Trust, HSCB and PHA to seek assurances that the Trust was addressing the RQIA’s findings. The RQIA has today published its unannounced inspection report and the Belfast Trust has published its updated Quality Improvement Plan. My officials are considering the assurance provided by the Trust at the meeting on 17 October, supplemented by additional information provided by the Trust, that it has addressed the RQIA’s findings. The information and assurance provided by the Trust will inform a further unannounced inspection by the RQIA before the end of this year.
I am very disappointed that given the assurances that the Belfast Trust made to my predecessor that it would bring about sustained improvement appear to have not been fully realised by the Trust. Therefore when I receive the follow-up unannounced inspection report by the RQIA later this year I expect to see and require significant improvement.
Values and Principles
A key recommendation of the RQIA report was the need for a set of principles to guide the future design of urgent and emergency care in Northern Ireland. I fully support this recommendation and in order to ensure that the focus and drive for improvement and innovation is maintained my Department is developing a Values and Principles Statement that will underpin the development of future policy and service delivery for Emergency and Unscheduled Care. I intend to begin a process of public consultation on the draft Values and Principles Statement in the coming days. This will be an important document and it is right that patients, their families, clinicians and the public should have a say in its development.
My Department is also considering how we might build on the progress achieved by the Task Group. Potentially this could involve a new regional policy framework for unscheduled and emergency care services in Northern Ireland. This will require further detailed work and I will provide a further update to the Assembly on this in the months ahead.
Education, Training and Development
The RQIA’s recommendations focused on how we strengthen the contribution of our staff through education, training and developing. The Chief Nursing Officer and her team have been working with Trusts and our local universities to develop a training program for Advanced Nurse Practitioners. These new and exciting roles in nursing will help strengthen the contribution of a very experienced and skilled group of staff.
Preparations for Winter 2014/15
In addition to the specific responses to the RQIA recommendations the Task Group is also overseeing a range of work to ensure that urgent and emergency care services are prepared in advance of the winter. Each HSC Trust has developed a local implementation plan for the elimination of avoidable breaches of the 12 hour waiting time standard. These plans have been reviewed by the Task Group and my Department has asked that the HSCB monitor implementation of these over this winter.
The Executive has allocated a total of £5m funding to unscheduled care services to help ease winter pressures in the months ahead. To date, some £2.3m of this funding has been allocated to Trusts, including the Ambulance Service, to fully fund or contribute to the costs of a range of measures to improve unscheduled care. The remaining £2.7m of the additional funding will be allocated to Trusts to fund measures to improve patient flow and expand capacity over the winter.
I commend this Statement to the House.
