Scrutiny

Meeting papers

Health and Care Overview and Scrutiny Committee

Tuesday 3 November 2015 at 10.00 am

Cabinet Suite - Shire Hall, Gloucester

Health and Care Overview and Scrutiny Committee

Tuesday 3 November 2015 at 10.00 am

Cabinet Suite - Shire Hall, Gloucester

AGENDA

STANDING ITEMS

1 Apologies for absence Andrea Clarke 2 Declarations of Interest Andrea Clarke

Please see note (a) at the end of the agenda. 3 Minutes of the previous meeting (Pages 3 - 10) Andrea Clarke

SCRUTINY ITEMS

4 CQC Inspection Report of G loucestershire Care Services NHS Trust Amanda Eddington The CQC reports are available online at this link CQC Inspection http://www.cqc.org.uk/provider/R1J . Printed copies of the reports were sent Manager to committee members on 22 September 2015 and are therefore not South West reproduced in this agenda pack. Hospitals Directorate 5 Out of Hours Service - 6 month review (Pages 11 - 20) Emma Williams Head of The South Western Ambulance Service NHS Foundation Trust (SWAST) Operations commenced the delivery of the Gloucestershire GP out-of-hours (OOH) (Urgent Care) service on 1 April 2015. The committee to receive a six month progress SWAST report.

6 Performance Spotlight on South Western Ambulance Service NHS Neil le Chevalier Foundation Trust (Pages 21 - 58) Director of Operations This item is comprised of 9 reports: - SWAST Performance Commentary (pages 21-26) Monthly Activity Performance Report (pages 27-32) Red 1 and Red 2 75 th Percentile (pages 33-34)

Date Published: 26 October 2015

Red1 Gloucestershire Hits and Misses (Map A3) (pages 35-36) NHS111 Call Dispositions (A3) (pages 37-38) Quality Indicators (pages 39-48) Hospital Handover (pages 49-50) Dispatch on Disposition (pages 51-54) Gloucestershire Community First Responders (pages 55-58)

INFORMATION ITEMS

7 Gloucestershire Clinical Commissioning Group Chair/Accountable Mary Hutton Officer Report (Pages 59 - 92) 8 Director of Public Health Report (Pages 93 - 94) Sarah Scott

9 Director of Adult Services Report (Pages 95 - 104) Margaret Willcox OBE 10 Healthwatch Gloucestershire - Podiatry Task Group Claire Feehily Chair, This report is available at this link Healthwatch http://www.healthwatchgloucestershire.co.uk/Information/HWG_Task_Grou Gloucestershire p_Reports/Podiatry_Task_Group.aspx .

Membership – Cllr Phil Awford, Cllr Iain Dobie (Chairman), Cllr Joe Harris, Cllr Tony Hicks, Cllr Stephen Lydon, Cllr Paul McMahon, Cllr Brian Robinson, Cllr Klara Sudbury and Cllr Roger Wilson (Vice-Chairman)

Co -opted Members - Cllr Flo Clucas (Cheltenham Borough Council), Cllr Doina Cornell (Stroud District Council), Cllr Janet Day (Tewkesbury Borough Council), Cllr Jan Lugg (Gloucester City Council), Cllr Helen Molyneux (Forest of Dean District Council) and Cllr Jim Parsons (Cotswold District Council)

(a) DECLARATIONS OF INTEREST – Please declare any disclosable pecuniary interests or personal interests that you may have relating to specific matters which may be discussed at this meeting, by signing the form that will be available in the Council Chamber. Completing this list is acceptable as a declaration, but does not, of course, prevent members from declaring an interest orally in relation to individual agenda items. The list will be available for public inspection.

Members requiring advice or clarification about whether to make a declaration of interest are invited to contact the Monitoring Officer (Jane Burns Tel: 01452 328472 /fax: 01452 425149 e-mail: [email protected] ) prior to the start of the meeting.

(b) INSPECTION OF PAPERS AND GENERAL QUERIES - If you wish to inspect minutes or reports relating to any item on this agenda or have any other general queries about the meeting, please contact: Andrea Clarke, Senior Democratic Services Adviser
:01452 324203/e-mail: [email protected]

(c) GENERAL ARRANGEMENTS 1 Please note that substitution arrangements are in place for Scrutiny (see p81 of the Constitution). 2. Please note that photography, filming and audio recording of Council meetings is permitted subject to the Local Government Access to Information provisions. Please contact Democratic Services (tel 01452 425230) to make the necessary arrangements ahead of the meeting. If you are a member of the public and do not wish to be photographed or filmed please inform the Democratic Services Officer on duty at the meeting.

EVACUATION PROCEDURE - in the event of the fire alarms sounding during the meeting please leave as directed in a calm and orderly manner and go to the assembly point. Please remain there and await further instructions.

This page is intentionally left blank Agenda Annex

Health and Care Overview and Scrutiny Committee (HCOSC) Guidelines

Ø The primary aim of HCOSC is to strengthen the voice of the people of Gloucestershire towards ensuring their needs and experiences are considered as an integral part of the commissioning of health and care services.

Ø The HCOSC is empowered to review and scrutinise any matter relating to the planning, provision and operation of the health and care service in its area

Ø HCOSC has a strategic role in taking an overview of how well integration of health, public health and social care is working in Gloucestershire - and in making recommendations about how such integration could be improved.

Ø HCOSC has a legitimate interest in proactively seeking information about the performance of local health and care services and in challenging the information supplied by commissioners and service providers, for example by drawing on different sources of intelligence.

Ø HCOSC is a key part of the accountability of the whole health and care system, and needs the continuous involvement of all parts of that system.

(Drawn from the Committee’s Terms of Reference and Article 8 of the Constitution)

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Page 10 Agenda Item 5

Health and Care Overview and Scrutiny Committee Meeting

3 November 2015

Title: Gloucestershire GP Out-of-Hours Service six-month review

Prepared by: Emma Williams, Head of Operations (Urgent Care Services) Nick Evans, Gloucestershire OOH Service Manager

Presented by: Emma Williams, Head of Operations (Urgent Care Services)

Main aim: To provide an overview of the first six months of the Gloucestershire GP OOH service delivered by South Western Ambulance Service NHS Foundation Trust

Contents

Introduction ...... 2 Review of service ...... 2 1. Organisational structure and support ...... 2 2. Staff resourcing ...... 3 3. Quality ...... 6 4. Performance ...... 6 5. Patient Experience ...... 7 6. External pressures ...... 8 Summary ...... 9

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Introduction The South Western Ambulance Service Foundation Trust (SWASFT) commenced the delivery of the Gloucestershire GP out-of-hours (OOH) service on the 1 April 2015. The service specification ensures three levels/types of response for the resident and visiting population of Gloucestershire:  Primary Care Centre (PCC) – these are located within hospitals, adjacent to either an Emergency Department (ED) (at Gloucester Royal Hospital and Cheltenham General Hospital) or Minor Injury & Illness Units (MIIU) (in Cirencester, Dilke, Moreton and Stroud). The PCCs are run by GPs and Advanced Nurse Practitioners (ANPs) and primarily see patients who have booked appointments, and also those who may have walked in or been referred from the ED or MIIU.  Clinical hub – calls from NHS 111 and other sources are received, triaged and assessed by clinicians with patients either being given self-care advice, being directed to suitable community services, or booked for a home visit or PCC appointment.  Mobile home visiting service – patients who are unable to make their way to a PCC and who need to be seen by a clinician (primarily a GP) will receive a home visit.

This paper will provide an overview of the first six months of service delivery, focusing on developments and improvements made, external pressures and looking ahead to work which will continue to build on that delivered thus far.

Review of service

1. Organisational structure and support During the preparation and implementation phase of the service, existing managers from within the urgent care services in SWASFT worked with all key stakeholders to successfully launch the service. In addition, a number of key staff were transferred across from Gloucestershire Care Services, the previous provider of the OOH service, and following inductions they have undergone further training to facilitate their roles.

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Following review and in conjunction with feedback from staff and external parties, it was identified that it was essential to strengthen the local management structure. As a result of this, two key roles were recruited to – that of service lead based full-time in Gloucester and in addition, more recently, a lead nurse to support the allied health professional workforce in the same manner as that provided by the GP-lead.

From the start of the procurement exercise to the current day, SWASFT has worked closely with Gloucester Doctors (GDoc) who represent the local GP community across the Gloucestershire County. As a key partner in the delivery of this service, GDoc have also supported and advised on strategies to enhance GP recruitment/resourcing, as well as provided a forum to engage in discussions to improve the quality of the service through joint working. As the future delivery of urgent care services is through collaboration this continued relationship is key to its success.

In addition, the relationship between SWASFT and Gloucestershire Clinical Commissioning Group (CCG) is a strong one. Whilst this is inherently a commissioner-provider relationship, through a culture of honesty and openness together there have been both challenging and supporting discussions which not only hold SWASFT to account for the service delivery, but also provide a forum for discussing wider health economy issues which directly impact on the OOH service.

2. Staff resourcing As described in the introduction, there are three main areas of focus for service delivery within the OOH service. Inherently these require a combination of clinical and non-clinical staff, each of which have individual complications with regards to achieving the required staffing levels across the week

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 Non-clinical staff. These are primarily found within the hub dispatch and support functions as well as reception staff in each PCC. A recruitment programme has successfully been completed which has resulted in a good level of cover in all these roles.

 Hub clinicians. Whilst these roles have been identified as suitable for Nurses and Paramedics, particularly at busy times (e.g. weekends), there has been a need for additional capacity to assist in the management of the queue of patients awaiting telephone triage. As this is a dynamic volume of calls and can vary significantly and within short timescales, SWASFT have invested in the development of remote triage – a process by which GPs with suitable computer systems are able to log on from home for a small number of hours to assist in this activity. Currently there is also consideration of the potential to use other allied health professionals within the clinical hub, specifically at peak times and in relation to particular call types which will enhance service provision – an example of this is using a pharmacist on a weekend to manage pharmaceutical queries.

 PCC clinicians. Clinical cover for the six PCCs has been planned to be covered by a combination of GPs and ANPs. To date, SWASFT have found that the overall availability of ANPs across the county (and beyond) to be very challenged and therefore due to this national shortage, recruitment to these roles has fallen behind expectations. Consequently significant attempts are made to fill these gaps through the recruitment of additional GPs although this comes with a supplementary cost. Whilst recruitment of ANPs is difficult, a number of strategies are being used with an increasing level of success – on a monthly basis the overall pool of staff is increasing.

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GPs are fundamental to the delivery of the service and through the use of an online shift booking system, once registered; they are able to book onto shifts which suit them. Inherently, the vast majority of GPs are not directly employed by SWASFT but rather undertake shifts on a sessional basis paid at an hourly rate. In a similar way to the ANPs, having got past the first few weeks of delivery, GP cover proved increasingly difficult to deliver and achieve 100% cover. Feedback collated by GDoc on behalf of SWASFT indicated that whilst there was more that could be done by the service to encourage engagement, there were issues which related more to the national GP position. Again, in a similar way to the work to recruit ANPs, considerable effort has been put into strengthening the support for the GPs, incentivising shifts where possible, reviewing activity and engaging with local GP forums.

 Mobile clinicians. The majority of home visits are undertaken by GPs, however the use of Specialist Paramedics (formally known as Emergency Care Practitioners) to deliver this care is an area SWASFT is developing. Through the development of a model whereby these staff would rotate through both the OOH and the 999 service, SWASFT are able to offer a unique opportunity which is expected to improve the outcomes for recruitment activity, and also enhance the clinical competence of staff across both service lines.

Generally the cover of mobile resources has been good, and at times when staffing of the PCCs has been difficult, through the flexible use of the clinical staff on the vehicles, and depending on demand, these staff can be moved to support service delivery within the PCCs – seeing patients in the centres as well as being dispatched to home visits as required.

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3. Quality Together with the requirement to deliver a service which is stable from a performance aspect, SWASFT continue to undertake a programme of activities to support improvements in the quality of the service. From a GP aspect, the GP lead reviews clinical delivery, and has delivered specific reports relating to particular areas of care both for individuals and at the service level. Within the ANP workforce, the appointment of the lead Nurse will support their practice, through audit, coaching and learning activities. For the hub clinical staff, a number of staff have been identified to undertake audit and coaching training to enable localised support and development of their colleagues. In addition, on a monthly basis, a development afternoon is run by the GP lead – at these events, case reviews are undertaken and teachings related to specific OOH-related issues are provided; these sessions are open to all.

There have been occasions where a PCC may have had to close/not open depending on the staffing levels; in particular this situation arises most commonly at the peripheral PCCs – at North Cotswold Community Hospital and Dilke Memorial Hospital. A snap-shot review was undertaken to assess the impact of a closure at the peripheral sites to appreciate the potential impact on patients who would otherwise have attended this site. During the two week period in April, 983 patients attended appointments at peripheral PCCs, and 18 closures were seen in total. The postcodes from where all the patients originated were reviewed in consideration to the PCC attended, and it was identified that only 15 patients had to undertake an extended journey (greater than 30mins) during this period as a result of the closures.

4. Performance The service is measured against both nationally and locally agreed quality requirements:  National quality requirements (NQRs) are the primary measures and include timescale measures for both home visiting and PCC appointments depending on the urgency of the need of the patient

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 Local indicators include additional timescale based measures specifically targeted at types of patient group (e.g. palliative cases or healthcare professional cases) as well as additional measures such as feedback collation, complaint resolution and safe-guarding compliance

The performance against the four main NQRs between 1 April 2015 and 30 September 2015 can be found in Appendix 1. As can be seen by the data provided, and despite consistent effort to achieve the standards required the results have been mixed, with better achievement for those cases deemed to be less urgent (for both PCC appointments and home visits). The trust continues to make steady progress progress in all areas of performance and consideration to issues regarding data cleansing and exclusion criteria is ongoing, for example in the cases of patients who are booked in within the last 15mins of the end of the window of measurement. The performance seen in both PCC appointment and home visit cases is directly related to staffing levels – and issues related to this are highlighted above.

5. Patient Experience Below is a copy of the patient safety reporting dashboard for the Gloucestershire GP OOH service.

Source of Feedback May May July Aug 2015 2015 2015 2015 2015 2015 Sept 2015 April April June

Serious Incidents 1 0 0 0 0 1

Moderate Incidents 0 0 0 0 0 0

Adverse Incidents 15 7 14 11 9 10

HCP Feedback 2 13 1 0 10 0

Compliments 0 0 1 2 0 1

Complaints 8 6 6 3 6 3

Violence Related Injuries (to staff) 0 0 0 0 0 0

Never Events 0 0 0 0 0 0

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Key themes coming out of these incidents and complaints include:  Delays in response (time to home visit or ring-back) the to both patients and other healthcare professionals  When reviewing and addressing complaints, the Trust uses the 6Cs model as recommended by Compassion in practice – this identifies each complaint under the area of impact: Care, Compassion, Competence, Communication, Courage and Commitment  The Trust has rolled out the Friends and Family Test (FFT) and obtain responses via the standard patient survey as well as through the an online form, telephone call and via text message  Each month 1% of patients who contact the service are asked to complete a survey – in August & September 47 responses were obtained

All staff complete annual safe-guarding training in recognition of safe-guarding issues for adults and children .

6. External pressures The delivery of the GP OOH service is not done in isolation, and whilst SWASFT recognise that it is an integral part of the Gloucestershire healthcare economy, inherently this means delivering a service which is also under the influence of additional external activities and priorities. Examples of these include:  The relationship between the NHS 111 service and the GP OOH service, and the process by which calls are passed from one to the other  Partnership working with other providers including Gloucestershire Care Services: o District Nursing Service – providing home visiting and dispatch support outside of standard operating hours o Cirencester Hospital – providing urgent ward visits during the out-of-hours periods  Working in collaboration with the Gloucestershire Hospitals NHS Foundation Trust to support their delivery in the Emergency Departments through the support of care for patients presenting with primary care problems.

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 There is currently additional GP service provision being commissioned on behalf of the Prime Minister’s Challenge Fund. Whilst this may directly impact on the availability of GPs to undertake OOH service shifts, it also means that patients will have additional access to GPs outside standard hours and this may also support some of the OOH service demand.

Summary SWASFT are fully committed to the delivery of the GP OOH contract in Gloucestershire and will continue to work with commissioners and partners/stakeholders to do so in such a way that a sustainable high quality service can be accessed by all. Whilst much has been done to implement improvements to date, there are still areas requiring further focus, particularly as the service heads towards its first winter.

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Appendix 1: National Quality Requirements April to Sept ember 2015

The target for achievement for the NQRs listed below is 95%.

August April 2015 May 2015 June 2015 July 2015 Sept 2015 2015 Presenting at PCC: Urgent consultations 87.74% 83.73% 90.76% 87.50% 82.27% 86.04% commencing within 2hrs of completion of (186/212 (175/209 (108/119 (126/144 (297/361 (487/566

Page 20 definitive clinical assessment cases) cases) cases) cases) cases) cases) Presenting at PCC: Less urgent 95.95% 96.36% 97.04% 97.58% 94.67% 96.01% consultations commencing within 6hrs of (3202/3337 (3465/3596 (2362/2434 (1896/1943 (1900/2007 (1516/1579 completion of definitive clinical cases) cases) cases) cases) cases) cases) assessment Home visits: Urgent consultations 79.77% 86.43% 89.44% 85.78% 84.65% 90.05% commencing within 2hrs of completion of (209/262 (242/280 (161/180 (181/211 (193/228 (172/191 definitive clinical assessment cases) cases) cases) cases) cases) cases) Home visits: Urgent consultations 90.57% 92.95% 93.83 93.82% 90.00% 90.46% commencing within 2hrs of completion of (432/477 (527/567 (380/405 (334/356 (441/490 (332/367 definitive clinical assessment cases) cases) cases) calls) cases)

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Agenda Item 6

Health and Care Overview and Scrutiny Committee Meeting

3 November 2015

Title: Performance report

Presented by: Neil Le Chevalier, Director of Operations

Main aim: To update HCOSC members on activity and performance in Gloucestershire

Recommendations: To note the contents of the report

1. Definitions

1.1 The Red1 category refers to those patients who are suffering an immediately life- threatening emergency; cardiac arrest, respiratory arrest, choking. The standard for these calls is to arrive on scene within eight minutes, 75% of the time.

1.2 The Red2 category refers to those patients who are suffering a potentially life- threatening emergency; heart attack, severe breathing problems, serious bleeding. The standard for these calls is to arrive on scene within eight minutes, 75% of the time.

1.3 The Red19T standard requires the attendance of a vehicle that is suitable to convey the patient, to arrive on scene within 19 minutes, 95% of the time.

2. Trust performance

2.1 A summary of the Trust’s performance , including details of performance across the North Division, can be found in the attached performance report.

2.2 To date (1 April – 30 September 2015), the Trust has been required to manage 390,755 incidents across the South West.

2.3 The Trust is pleased to report performance above the national target levels for Red1 from 1 April – 30 September 2015. The Trust is working hard to ensure delivery of the Red1 target for the year to date . Red2 and Red19 performance has fallen short of the required level but this is largely connected with the national trial, dispatch on

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disposition, however, the trial has enabled the Trust to provide a more appropriate response and therefore better patient care. More patients have been given advice over the telephone – hear and treat – without the need for an ambulance response. Please see separate report on dispatch on disposition paper.

2.4 The Trust is the best performing English ambulance trust for 999 calls resolved over the telephone. From 1 April – 30 September 2015, 12.1% of calls were resolved over the telephone, with the national average being 9.6%.

2.5 The Trust continues to be the best performing English ambulance trust for the percentage of patients cared for through alternative healthcare pathways – avoiding unnecessary admissions to hospital emergency departments. From 1 April – 31 August 2015, 52.7% of patients were not transported to an emergency department – the national average being 37.3%. Please see separate report on national Ambulance Quality Indicators.

2.6 The Trust continues to closely monitor the number of handover delays and the associated time lost. Winter pressures are fast approaching and likely to have a huge impact on hospitals and subsequently the emergency departments. Please see the hospital handover report for more detail about handover delays in Gloucestershire. (Please note that information has also been included for Southmead Hospital in North Bristol, the nearest major trauma centre for Gloucestershire patients.)

3. Performance in Gloucestershire

3.1 To date (1 April – 30 September 2015), the Trust has been required to manage 40,417 incidents across Gloucestershire. This is a 4.3% increase on the same period the previous year (1 April – 30 September 2014).

3.2 Of these incidents, 1,010 (or 2.49%) were classed as Red1 calls. We attended these Red1 calls in 8 minutes 65.74% of the time. (The target is 75%.)

3.3 Of these incidents, a further 16,051 (or 39.71%) were classed as Red 2 calls. We attended these Red2 calls in 8 minutes 63.57% of the time. (The target is 75%.)

3.4 For more details and a breakdown by district council area, please see the separate performance and activity report.

3.5 Whilst we continue to see improvements in our performance across the South West, we are still finding it a challenge to meet response times in our more rural areas, especially parts of Gloucestershire. The attached document ‘Red1 and Red2 75 th Percentile’ shows how long it takes for an ambulance resource to arrive at Red1 and Red2 calls 75% of the time. Also attached are two map s showing ‘hits and misses’ in Gloucestershire for August and September 2015. These maps illustrate the low number of calls and how the wide geographical spread of incidents in rural areas means that journey times can exceed the eight minute target. A call to a patient in a

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rural part of Gloucestershire can result in a two-hour round trip. It is also important to note that an ambulance resource remains on scene for an average of two hours, thus temporarily reducing the resources available on the road during the time a patient is being treated.

4. Patient experience

4.1 From 1 April – 30 September 2015 the Trust (all service lines) received 1,163 compliments from members of the public, compared to only 733 complaints.

Month Complaints Compliments April 130 164 May 118 172 June 117 207 July 144 220 August 120 212 September 104 188

4.2 From 1 April – 30 September 2015 in Gloucestershire (all service lines) 100 compliments were received from members of the public, compared to only 81 complaints.

Month Complaints Compliments April 17 13 May 14 15 June 13 23 July 16 19 August 8 12 September 13 18

4.3 An example of the type of compliments received by the Trust can be found below – the ambulance staff were from Staverton and Tewkesbury stations.

“I am an elderly gent who is disabled and lives alone. Tonight one of the veins in my leg decided to burst. I have had this happen before so knew what to do. But after trying very hard for nearly an hour I couldn't stop the flow so had to call an ambulance. This arrived very quickly and I met two Paramedics. They were so kind to me and put me at ease immediately. I could not have asked for better service. I have had to have ambulances before which I might add have always been wonderful. But these two went one step further I felt to put me at ease. The treatment was excellent and they even made sure I ate something before they left as I am a diabetic and hadn't eaten since lunchtime. Many complain about the NHS but I have only praise. In fact I would not be here today if not for the prompt actions of Paramedics and the Staff 19 years ago. So all my thoughts go out to you all and my very heartfelt thanks for all you have done for me. ”

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5. Control rooms (clinical hubs) update

5.1 Over the last year the Trust has undertaken an extensive procurement process to obtain a computer aided dispatch (CAD) system that best meets our needs – MIS has been selected as the preferred supplier with the C3 Nexus product.

5.2 The CAD system is used for the efficient control of our 999 fleet and feeds the ambulance arrival screens in the hospital emergency departments.

5.3 The first stage of this project will see the 999 control rooms (clinical hubs) in Exeter and South Gloucestershire using the same single CAD system. This will allow for a single way of working and the ability to task any available resource across the whole SWASFT area.

5.4 This involves an upgrade to the current system in the clinical hub in Exeter – due to take place at the end of November – and a new CAD for the South Gloucestershire clinical hub – due to take place in early 2016.

5.5 The second stage of the project will see the clinical hub in South Gloucestershire move to new premises. The new location is in a neighbouring business park to the current clinical hub, therefore remaining in South Gloucestershire.

5.6 The new premises will provide room for expansion and improved facilities for staff.

6. NHS 111 update - North

6.1 The Trust has been concerned about the appropriateness of the referrals from NHS 111 in the north division of SWASFT (Bristol, North Somerset, South Gloucestershire, Wiltshire, Gloucestershire and Bath). Issues are identified through feedback from ambulance crews and patient outcomes.

6.2 The Trust regularly meets with Care UK where these issues are raised.

6.3 There is an acceptance that the fundamental issue is the number of clinicians available in the Care UK control room; if more clinicians are available there would be fewer clinically inappropriate referrals to 999.

6.4 By the end of November 2015 the number of clinicians at Care UK will have improved significantly due to recruitment, and since 21 August 2015 a validation clinical advisor has been in post at Care UK to support call-handling of Green ambulance dispatch priorities. This initiative has reduced the number of Green NHS 111 ambulance dispatches.

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6.5 The Trust continues to monitor the situation and feedback to Care UK. Mandy Wegg, Care UK National 111 Clinical Lead, visited Exeter NHs 111 clinical hub in September, followed by a visit to the 999 clinical hub in South Gloucestershire where the impact could be demonstrated first-hand.

6.6 Following these visits, clinicians and floor-walkers provided by SWASFT, worked within the Care UK environment over a weekend at the beginning of October. Initial feedback from this was positive and the Trust is reviewing and evaluating the outcomes from this activity.

6.7 While the Trust was able to facilitate a one-off weekend, it is unlikely to be a sustainable option due to the need for our clinicians to be available in our own NHS 111 and 999 clinical hubs. However, Care UK is keen to establish a permanent effective solution themselves within their own resource capabilities. Please see the separate national NHS 111 report.

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Monthly activity and performance report

The following pages provide information about activity and performance for response to incidents by South Western Ambulance Service NHS Foundation Trust (SWASFT) for the financial year-to-date for 2015-16.

Page 27 Year-to-date activity and performance information for the financial year 2015-16 is also provided for the unitary authorities in Gloucestershire.

Information is provided to the end of September 2015 and was the latest available for submission with the agenda.

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South Western Ambulance Service NHS Foundation Trust

Trust-wide activity/performance 2015-16 year-to-date (1 April – 30 September 2015)

Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents within Performance within Performance within Performance Month with a with a with a Target Target Target Response Response Response April 1,322 1,045 79.05% 23,167 15,824 68.30% 24,452 22,661 92.68% May 1,416 1,067 75.35% 25,072 16,637 66.36% 26,435 24,272 91.82% June 1,357 1,022 75.31% 24,186 15,938 65.90% 25,466 23,204 91.12% July 1,444 1,087 75.28% 25,224 16,828 66.71% 26,552 24,090 90.73% August 1,490 1,135 76.17% 26,123 18,025 69.00% 27,152 24,900 91.71%

Page 28 September 1,334 1,001 75.04% 24,333 16,571 68.10% 25,573 23,391 91.47% YTD Total 8,363 6,357 76.01% 148,105 99,823 67.40% 155,630 142,518 91.57%

Gloucestershire activity/performance 2015-16 year-to-date (1 April – 30 September 2015)

Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 172 125 72.67% 2,591 1,679 64.80% 2,763 2,492 90.19% May 183 127 69.40% 2,792 1,740 62.32% 2,975 2,672 89.82% June 154 100 64.94% 2,534 1,654 65.27% 2,686 2,413 89.84% July 162 101 62.35% 2,619 1,623 61.97% 2,781 2,479 89.14% August 164 99 60.37% 2,855 1,824 63.89% 3,018 2,726 90.32% September 175 112 64.00% 2,660 1,684 63.31% 2,835 2,562 90.37% YTD Total 1,010 664 65.74% 16,051 10,204 63.57% 17,058 15,344 89.95%

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Gloucestershire monthly activity/performance 2015-16 – by unitary authority

Cheltenham Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 35 28 80.00% 504 397 78.77% 539 520 96.47% May 44 34 77.27% 563 432 76.73% 607 583 96.05% June 31 22 70.97% 515 403 78.25% 546 536 98.17% July 38 32 84.21% 506 381 75.30% 544 526 96.69% August 32 21 65.63% 540 425 78.70% 572 561 98.08% September 38 27 71.05% 507 389 76.73% 545 530 97.25% YTD Total 218 164 75.23% 3,135 2,427 77.42% 3,353 3,256 97.11%

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Cotswold Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 19 8 42.11% 323 157 48.61% 342 242 70.76% May 16 9 56.25% 341 159 46.63% 357 258 72.27% June 10 6 60.00% 272 150 55.15% 281 201 71.53% July 12 8 66.67% 357 178 49.86% 369 261 70.73% August 23 7 30.43% 399 199 49.87% 422 326 77.25% September 13 5 38.46% 324 175 54.01% 337 257 76.26% YTD Total 93 43 46.24% 2016 1,018 50.50% 2,108 1,545 73.29%

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Forest of Dean Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 18 14 77.78% 335 170 50.75% 353 300 84.99% May 17 10 58.82% 379 187 49.34% 396 326 82.32% June 16 8 50.00% 330 178 53.94% 346 276 79.77% July 22 9 40.91% 343 157 45.77% 365 300 82.19% August 22 8 36.36% 363 186 51.24% 385 313 81.30% September 29 16 55.17% 366 197 53.83% 395 335 84.81% YTD Total 124 65 52.42% 2,116 1,075 50.80% 2,240 1,850 82.59%

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Gloucester Red1 Red2 Red19T Total Total Total Ac hieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 57 48 84.21% 657 517 78.69% 714 693 97.06% May 50 43 86.00% 727 532 73.18% 777 756 97.30% June 50 34 68.00% 635 478 75.28% 684 668 97.66% July 50 35 70.00% 669 488 72.94% 719 698 97.08% August 39 32 82.05% 754 560 74.27% 793 768 96.85% September 54 43 79.63% 669 496 74.14% 723 706 97.65% YTD Total 300 235 78.33% 4,111 3,071 74.70% 4,410 4,289 97.26%

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Stroud Red1 Red2 Red19T Total Total Total Achieved Achieved Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 28 16 57.14% 450 234 52.00% 478 415 86.82% May 33 17 51.52% 466 237 50.86% 499 427 85.57% June 26 16 61.54% 460 239 51.96% 486 405 83.33% July 27 9 33.33% 456 258 56.58% 483 412 85.30% August 27 17 62.96% 453 245 54.08% 479 409 85.39% September 23 11 47.83% 465 227 48.82% 488 406 83.20% YTD Total 164 86 52.44% 2,750 1,440 52.36% 2,913 2,474 84.93%

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Tewkesbury Red1 Red2 Red19T Total Total Total Achieved Achiev ed Achieved Incidents Incidents Incidents Month within Performance within Performance within Performance with a with a with a Target Target Target Response Response Response April 15 11 73.33% 326 206 63.19% 341 326 95.60% May 23 14 60.87% 318 193 60.69% 341 324 95.01% June 21 14 66.67% 325 207 63.69% 346 329 95.09% July 13 8 61.54% 286 159 55.59% 299 280 93.65% August 22 14 63.64% 349 210 60.17% 371 352 94.88% September 18 10 55.56% 330 201 60.91% 348 329 94.54% YTD Total 112 71 63.39% 1,934 1,176 60.81% 2,046 1,940 94.82%

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RED1 AND RED2 75 TH PERCENTILE: 1 APRIL – 30 SEPTEMBER 2015 How long it takes for an ambulance resource to arrive at Red1 and Red2 calls, 75% of the time (target is 8 minutes)

LOCAL AUTHORITY Red combined Red1 Red2 Cheltenham 7.72 7.92 7.67 Cotswold 15.02 13.27 15.17 Forest of Dean 12.65 11.82 12.68 Page 33 Gloucester 8.03 7.68 8.03 Stroud 12.65 11.32 12.73 Tewkesbury 10.58 9.87 10.60

16 14 12 10 Red1 8 Red2 6 Target 4 2 0 Cheltenham Cotswold Forest of Dean Gloucester Stroud Tewkesbury

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Gloucestershire – Red1 hits and misses August 2015 Page 35

Red1 incident where an ambulance resource did arrive within eight minutes

Red1 incident where an ambulance resource did not arrive within eight minutes

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Gloucestershire – Red1 hits and misses September 2015

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Red1 incident where an ambulance resource did arrive within eight minutes

Red1 incident where an ambulance resource did not arrive within eight minutes

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NHS 111 National Weekly Sitrep Data – week ending 18/10/2015

NHS 111 Dispositions

Percentage of triage calls which:

Recommended to Recommended to Did not recommend Led to ambulance Recommended to Region Service Area Name Provider attend primary and attend other to attend other dispatches attend A&E community care service service

- England 11.4% 8.3% 61.5% 3.7% 15.1%

North North East England NHS 111 North East Ambulance Service 16.3% 8.8% 54.9% 6.7% 13.3% North North West NHS 111 North West Ambulance Service 12.9% 9.9% 59.7% 1.6% 15.9% Yorkshire And Humber NHS 111 Yorkshire Ambulance Service Page 37 North 9.1% 7.4% 62.6% 4.0% 16.9% Midlands & East Lincolnshire NHS 111 Care UK 13.9% 9.8% 64.1% 2.5% 9.7% Midlands & East Luton NHS 111 South Central Ambulance Service 10.8% 8.3% 66.4% 2.5% 12.0% Midlands & East Nottinghamshire NHS 111 Derbyshire Health United 11.5% 8.3% 56.6% 2.4% 21.2% Midlands & East Derbyshire NHS 11 Derbyshire Health United 11.2% 7.2% 53.3% 4.9% 23.4% Midlands & East Hertfordshire NHS 111 Herts Urgent Care 8.7% 7.5% 63.9% 6.8% 13.1% Midlands & East Great Yarmouth And Waveney NHS 111 IC24 13.4% 5.7% 57.0% 6.1% 17.8% Midlands & East Norfolk NHS 111 IC24 11.7% 7.1% 55.8% 6.0% 19.4% Midlands & East Suffolk NHS 111 Care UK 11.8% 8.1% 64.6% 4.0% 11.5% Midlands & East North Essex NHS 111 IC24 7.7% 7.9% 61.3% 5.5% 17.6% Midlands & East South Essex NHS 111 IC24 8.1% 7.8% 59.4% 7.5% 17.1% Midlands & East Cambridgeshire & Peterborough NHS 111 Herts Urgent Care 11.5% 7.6% 69.2% 1.6% 10.1% Midlands & East Northamptonshire NHS 111 Derbyshire Health United 11.0% 9.4% 58.9% 2.2% 18.4% Midlands & East Milton Keynes NHS 111 Care UK 9.7% 9.7% 64.8% 2.2% 13.5% Midlands & East Leicestershire & Rutland NHS 111 Derbyshire Health United 11.2% 7.9% 51.5% 2.5% 26.9% Midlands & East Bedfordshire NHS 111 South Central Ambulance Service 12.0% 11.3% 61.7% 2.5% 12.4% Midlands & East Staffordshire NHS 111 Staffordshire Doctors Urgent Care 12.7% 8.1% 61.3% 6.2% 11.6% Midlands & East West Midlands NHS 111 Vocare 10.4% 8.0% 61.9% 4.5% 15.2% London Inner North West London NHS 111 LCW 11.8% 6.7% 44.3% 3.4% 33.7% London Hillingdon London NHS 111 Care UK 11.6% 9.3% 61.3% 2.4% 15.4% London Croydon NHS 111 Care UK 12.6% 10.5% 63.5% 2.9% 10.5% London Wandsworth NHS 111 Care UK 10.7% 11.3% 59.3% 3.5% 15.2% London Sutton & Merton NHS 111 Care UK 10.1% 8.4% 65.0% 2.2% 14.3% London Kingston & Richmond NHS 111 Care UK 10.4% 9.4% 60.1% 2.9% 17.2% London North West London NHS 111 Care UK 12.0% 8.9% 61.6% 3.1% 14.5% London North Central London NHS 111 LCW 12.5% 9.5% 56.4% 4.3% 17.3%

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Recommended to Recommended to Did not recommend Led to ambulance Recommended to Region Service Area Name Provider attend primary and attend other to attend other dispatches attend A&E community care service service London East London & City NHS 111 Partnership of East London Co-operatives 10.4% 11.7% 60.1% 2.4% 15.3% South Isle Of Wight NHS 111 Isle of Wight NHS Trust 11.1% 7.3% 67.7% 6.1% 7.8% South Oxfordshire NHS 111 South Central Ambulance Service 10.9% 8.7% 64.4% 6.9% 9.2% South Mainland Ship NHS 111 South Central Ambulance Service 11.9% 7.7% 65.0% 7.4% 8.0% South Buckinghamshire NHS 111 South Central Ambulance Service 12.4% 8.8% 63.6% 6.1% 9.1% South Berkshire NHS 111 South Central Ambulance Service 10.6% 8.0% 67.2% 4.5% 9.8% South South East Coast NHS 111 South East Coast Ambulance Service 10.9% 7.7% 67.6% 0.4% 13.4% South Banes & Wiltshire NHS 111 Care UK 11.8% 8.9% 66.1% 1.3% 12.0% Bristol, North Somerset & South South Gloucestershire NHS 111 Care UK 12.9% 9.2% 65.7% 0.8% 11.5% South Gloucestershire & Swindon NHS 111 Care UK 12.8% 9.8% 63.4% 1.2% 12.8% South Somerset NHS 111 Somerset Doctors Urgent Care 12.5% 7.0% 60.3% 8.9% 11.3% South Dorset NHS 111 South Western Ambulance Service 13.3% 6.8% 61.6% 2.7% 15.6% South Cornwall NHS 111 South Western Ambulance Service 13.4% 5.5% 62.3% 3.8% 15.0% South Devon NHS 111 South Western Ambulance Service 11.9% 6.0% 66.9% 1.6% 13.6% Page 38 NORTH REGION 12.0% 8.6% 59.9% 3.7% 15.8% MIDLANDS AND EAST REGION 10.8% 8.0% 60.2% 4.4% 16.6% LONDON REGION 10.8% 9.9% 58.3% 3.4% 17.6% SOUTH REGION 11.7% 7.7% 65.7% 3.0% 11.8%

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Ambulance Quality Indicator data

Since April 2011, ambulance services have been measured on a range of clinical and process quality indicators, providing a more realistic picture of their performance beyond solely speed of response.

Page 39 The following tables show how all ambulance services are performing against these indicators. The first table, for process indicators, covers the 2015-16 financial year to August 2015, which is the latest data available.

The second table, for clinical indicators, covers the 2015-16 financial year to May 2015 – again, the latest data available given that reporting times for some indicators are longer as they involve patient outcomes.

Following both tables are explanations of what each indicator is measuring.

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Ambulance Quality Indicator data – Process Indicator data, 2015-16 (to August 2015)

Quality Units East East of Isle of London North North South South East South West Yorkshire All Indicator Midlands England Wight East West Central Coast Western Midlands

Time to answer - 50% mm:ss 0:02 0:01 0:01 0:00 0:01 0:01 0:03 0:03 0:02 0:01 0:01 n/a - 95% mm:ss 0:09 0:0 4 0:01 0: 02 0:44 0:03 0:10 0:31 0:15 0:03 0:19 n/a - 99% mm:ss 0:41 0:23 0:11 0:39 1:32 0:30 1:16 1:19 1:00 0:29 0:48 n/a Abandoned calls % 0.27 0.45 1.30 0.28 1.15 0.39 0.90 0.73 0.68 0.53 0.77 0.55

Cat A8 - Red 1 % 74.5 76.8 71.4 67.2 74.9 77.9 72.9 73.7 76.1 79.8 71.5 75.1 - Red 2 % 71.4 66.2 74.0 65.5 74.9 76.2 73.9 74.6 67.2 76.2 71.3 71 .4 Page 40

Cat A19 % 92.4 92.8 94.3 93.8 95.1 95.0 94.5 95.1 91.5 97.5 95.6 94.4

Time to treat - 50% mm:ss 8:41 6:55 4:55 6:50 6:25 6:1 3 6:04 5:57 7:13 5:55 6:04 n/a - 95% mm:ss 17:13 21:23 16:5 0 18 :41 20:33 21:39 19:28 19:14 24:07 15:32 15:46 n/a - 99% mm:ss 27:28 32:43 23:24 33:46 34:01 45:58 32:32 28:53 39:12 23:39 24:11 n/a Frequent caller % 0.26 0.31 1.09 1.23 0.23 0.74 2.17 0.00 0.00 0.00 1.67 0.67

Resolved by % 8.5 6.2 10.7 13.9 6.4 10.5 7.3 11.2 12.1 5.0 9.0 9.6 phone Re-contact 24hrs % 6.7 11.3 7.1 2.6 14.6 4.7 11.1 8.3 13.5 12.2 1.7 7.1 phone Non-A&E % 30.4 40.9 49.5 34.4 31.0 30.6 42.1 43.8 52.7 37.7 31.9 37.3

Re-contact 24hrs % 4.8 5.9 3.2 8.2 5.0 4.4 5.1 4.2 5.8 5.9 3.2 5.3 on -scene

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Ambulance Clinical Quality Indicators – Clinical Indicator data, 2015-16 (to May 2015)

Clinical Quality Units East East of Isle of London North North South South South West Yorkshire All Indicator Midlands England Wight East West Central East Western Midlands Coast

STEMI care % 71.6 80.2 75.0 71.7 92.8 87.6 55.4 65.0 87.3 67.5 85.4 77.7

STEMI 150 % 92.8 90.4 0.0 85.2 82.2 85.8 84.8 90.1 73.3 83.2 80.0 84.3

Stroke care % 98.2 97.3 100.0 97.0 98.3 99.5 99.1 97.1 97.7 96.9 97.8 97.7

Stroke 60 % 57.2 57.3 67.6 63.7 70.2 77.9 55.1 64.0 51.1 43.8 58.5 59.4 Page 41

ROSC % 24.0 25.1 33.3 30.6 22.3 32.3 30.6 24.4 25.4 32.1 27.6 27.7

ROSC Utstein % 55.6 39.4 66.7 57.1 64.0 56.9 56.7 41.9 47.9 51.3 62.1 52.8

Cardiac STD % 6.1 5.8 4.2 7.8 6.0 9.5 13.4 5.8 8.9 9.9 9.6 8.2

Cardiac STD Utstein % 26.7 21.0 16.7 30.5 40.9 24.4 34.9 14.5 23.3 30.3 39.3 28.0

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National Ambulance Clinical Quality Indicators

Process Indicators

Indicator Description What does this mean?

Call Answering Average time (in seconds) to answer 999 calls presented The time until a call is answered represents a period to the Trust switchboard. of clinical risk to the patient prior to assessment from trained ambulance service staff.

Page 42 Many adverse events are related to initial delays in care and many emergency conditions are time sensitive. Reducing delays in treatment can improve health outcomes and the patient experience. Call Abandonment Rate The percentage of emergency calls presented to the Call abandonment rate is a marker of patient Trust switchboard that are abandoned before being experienc e. A high call abandoned rate may not answered. indicate safe practice and could reflect a high level of clinical risk for patients. Category A (Red 1) 8- Category A (Red 1) incidents (immediately life- For patients with immediately life-threatening Minute Response Rate threatening conditions) should receive an emergency condition, faster response times may improve health response within 8 minutes irrespective of location in 75% outcomes and the patient experience. of cases. Category A (Red 2) Category A (Red 2) incidents (may be life-threatening For patients with immediately life-threatening 8 Minute Response Time conditions but less time -critical) incidents should receive conditions, faster response times may improve health an emergency response within 8 minutes irrespective of outcomes and the patient experience. location in 75% of cases. Category A 19 Minute Category A (immediately life-threatening) incidents Ability to transport patients with immediately life- Transportation Time should receive an ambulance response at scene within threatening conditions in a clinically safe manner 19 minutes irrespective of locat ion in 95% of cases. may improve their health outcomes and patient experience.

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Time to Treatment Average time (in minutes) for a qualified health The period of time before a patient is seen by a profes sional dispatched by the ambulance service to health professional represents a period of clinical risk arrive at the scene of a Category A call. and anxiety for the patient. By encouraging earlier definitive care and reducing delays in treatment this indicator will improve the health outcomes and patient experience for all patients with life-threatening conditions. Calls Closed with Number and percentage of calls that are appropriately Providing clinically appropriate pre-hospital care Telephone Advice managed through telephone advice without the need for through clinical telephone advice may result in better an ambulance resource arriving on scene. outcomes for patients and a more efficient use of ambulance resources. This can include advice from Nurses within our Clinical Hubs and advice about other NHS facilities the patient could attend themselves (Minor Injury Units etc). Re-Contact Rate Following Volume and percentage of calls where the initial call was Patients may re-contact the ambulance service

Page 43 Discharge of Care by resolved through telephone advice only, which then because their condition has worsened. However in Telephone Advice result in a further emergency call to the Trust within 24 some cases there may be further contact due to an hours. incorrect initial telephone diagnosis or poor explanation by clinical staff. Unplanned re -contact is a marker of the accuracy of the initial telephone assessment in identifying the needs of the patient a nd those requiring an escalation of care or who may be likely to experience deterioration. It should be noted that this Indicator also includes Frequent Callers who call the Trust many times a month because of mental health issues or clinical conditions they are unable to manage. Calls Closed without the Number and percentage of calls that are appropriately Providing effective pre-hospital care allows for better need for Transport to A&E managed without the need for and ambulance response care for the patient; such as care being delivered (Emergency Department) at scene, or onward transport to major A&E departments. closer to home. A reduction in avoidable emergency patient journeys and admissions to hospitals whilst responding to and conveying those patie nts who would not be suitable for treatment at the scene or through clinical telephone advice.

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Re-Contact Rate Following Volume and percentage of calls where the initial call was Ambulance staff will always use the most appropriate Discharge of Care from resolved through treatment by a clinician on scene, which treatment pathways based on their clinical Treatment at the Scene then result in a further emergency call to the Trust within assessment of the patient on scene. 24 hours. However patients may re -contact the ambulance service because their condition has worsened or they have received a poor explanation of their condition by the staff who attended them on scene. It should be noted that this Indicator also includes Frequent Callers who call the Trust many times a month because of mental health issues or clinical conditions they are unable to manage.

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National Ambulance Clinical Quality Indicators

Clinical Indicators

Indicator Description What does this mean?

Outcome from Acute ST- Number and percentage of patients suffering a STEMI Early access to reperfusion (timely thrombolysis and Elevation Myocardial (type of heart attack) who receive an appropriate care primary angioplasty and/or delivery of the appropriate Infarction (STEMI) (Care bundle. care bundle) and all components of assessment and Page 45 Bundle) care interventions are associated with reductions in STEMI mortality and morbidity. Outcome from Acute ST- Number and percentage of patients suffering a STEMI This is evidenced in both NSF and CHD and National Elevation Myocardial (type of heart attack) receiving Thrombolysis within 60 Infarct Angioplasty Project Gateway 9116 (2008) and Infarction (STEMI) minutes of the call. Mendi ng Hearts and Brains (2006). (Thrombolysis)

Outcome from Acute ST- Number and percentage of patients suffering a STEMI Elevation Myocardial (type of heart attack) receiving a Primary Percutaneous Infarction (STEMI) (PPCI) Coronary Intervention (PPCI), also known as primary angioplasty, within 150 minutes of the call.

Outcome from Stroke for Number and percentage of suspected stroke patients Patients should be arriving at the hyperacute stroke Ambulance Patients (Care assessed face to face who received an appropriate care centre as soon as possible so they can be rapidly Bundle) bundle. assessed for thrombolysis, delivered following a CT Outcome from Stroke for Number and percentage of patients who were assessed scan in a short but safe time frame. This has been Ambulance Patients (FAST) face to face and provided a FAST (Face, Arms, Speech, demonstrated to reduce mortality and improve Time to Call 999) positive response and were potentially patient recovery. eligible for stroke thrombolysis who were taken to a Eligibility criteria, particularly in relation to the

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hyperacute stroke centre within 60 minutes of the call. therapeutic time window, will vary between local services, depending on the availability of local expertise e.g. intra -arterial clot lysis. This indicator supports the NICE national quality standard that indicates this is an effective measure of the ambulance service’s contribution to the stroke pathway.

Outcome from Cardiac Number and percentage of resuscitated cardiac arrest The aim of this indicator is to reduce the proportion of Arrest – Return of patients that had a Return of Spontaneous Circulation patients who die from out of hospital cardiac arrest. It Spontaneous Circulation (ROSC) at the point of handover of clinical care of the reviews patients who were in cardiac arrest but, (Overall) patient to the hospital. following resuscitation, have a pulse on arrival at Outcome from Cardiac Number and percentage of resuscitated cardiac arrest hospital. Arr est – Return of patients that had a ROSC at the point of handover of Improvement in ROSC rates informs the Spontaneous Circulation clinical care of the patient to the hospital where the arrest effectiveness of pre -hospital response and

Page 46 (Utstein) was witnessed and the initial rhythm w as VF or VT. intervention. The ROSC is calculated for two pa tient groups: The overall rate measures the overall effectiveness of the pre-hospital response and intervention for all out of hospital cardiac arrest patients; The rate for the Utstein comparator group applies to a sub-set of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival. Outcome from Cardiac Number and percentage of patients who had Survival to discharge is where a patient is able to be Arrest – Survival to resuscitation (Advanced or Basic Life Support) discharged from hospital and continue recovery after Discharge (Overall) commenced/continued by the ambulance service a cardiac arrest. following an out-of-hospital cardiac arrest. The indicator measures the effectiveness of the

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Outcome from Cardiac Number and percentage of patients who had whole urgent and emergency care system in Arr est – Survival to resuscitation (Advanced or Basic Life Support) managing out of hospital cardiac arrest . Discharge (Utstein) commenced/continued by the ambulance service Survival to discharge is calculated for two patient following an out -of-hospital cardiac arrest of presumed groups: cardiac origin, where the ar rest was bystander or The overall survival rate measures the overall emergency medical service witnessed and the initial effectiveness of the urgent and emergency care rhythm was VF or VT. system in managing care for all out of hospital cardiac arrest patients. The Utstein survival rate applies to a sub-set of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can be particularly improve survival.

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Hospital handover information: 1 April – 30 September 2015

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Health and Care Overview and Scrutiny Committee Meeting

3 November 2015

Title: Dispatch on Disposition (Ambulance Performance Review)

Presented by: Neil Le Chevalier, Director of Operations

Main aim: To update HCOSC members on the national pilot being undertaken within SWASFT

Recommendations: To note the contents of the report

1. Introduction

1.1 In February 2015 South Western Ambulance Service NHS Foundation Trust (SWASFT) was given Secretary of State approval to pilot a new way for ambulance services to respond to 999 calls. This was known as the Dispatch on Disposition trial. The pilot was closely monitored and assessed by NHS England and Monitor so that both ambulance service and system-wide impacts could be evaluated.

1.2 The new way of dispatching had a number of objectives including:  Reduction in the number of inappropriate ambulance responses by increasing the percentage of patients treated by telephone advice  Improved accuracy of triage of ambulance incidents, ensuring the most appropriate and timely response to meet the patients clinical needs  Improved response to the most critical, life-threatening ambulance incidents (Red 1 incidents)  Improvements in performance against the ambulance response time targets

1.3 Following completion of the initial trial NHS England agreed for SWASFT to continue operating Dispatch on Disposition behaviour.

2. Dispatch on Disposition process

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2.1 The changes to the dispatch process do not apply to those incidents which are identified as immediately life-threatening (Red 1 incidents), where an ambulance resource will continue to be dispatched immediately. These behaviours provide call- handlers a small amount of extra time, for non-Red 1 incidents, to triage the patient over the telephone before dispatching an ambulance. The additional telephone triage time provides an opportunity to identify the most clinically appropriate response and, in some cases, this may not be an ambulance response, patients may be better served by an immediate referral to another service (eg local GP, pharmacy or a walk-in centre).

2.2 A summary of the original Dispatch on Disposition rule-set is as follows:  The response target for Red 1 incidents remains at eight minutes from the time the call connects to the ambulance service  A number of potentially life-threatening conditions (unconscious overdose, breech/cord presentation/any part of the baby out, baby born with complications in mother or baby, gunshot wound to head) were upgraded from Red 2 to Red 1  The target time for responding to Red 2 incidents remains at eight minutes. However the clock only starts for the eight-minute response at the time a disposition is reached, on allocation of the first vehicle or a maximum of 180 seconds after the call has been connected to the service.

2.3 The overall number of incidents is not affected by Dispatch on Disposition but it is expected that the additional triage time will provide the opportunity to impact on the outcome of these incidents

3. Evaluation

3.1 A robust governance and monitoring process was agreed with NHS England as part of this change of behaviour. NHS England has strict oversight and monitoring of the results and an on-going assessment of the impact of the change. The focus is on maintaining clinical safety and quality.

3.2 It was agreed that changes would only be made nationally when the following criteria were met:  A clear clinical consensus that the proposed change will be beneficial to 999 patients as a whole, and will act to reduce overall clinical risk in the system  Evidence from the analysis of existing data and pilot implementation projects that the proposed changes will have the intended benefits, and are safe for patients  An associated increase in operational efficiency. The aim is to reduce the average number of vehicles allocated to each 999 call and the ambulance utilisation rate

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4. Outcomes

4.1 The implementation of Dispatch on Disposition quickly identified a number of benefits to the ambulance service. Based on an assessment against the 12-week period immediately prior to the implementation of Dispatch on Disposition the Trust has seen:

 Improvements to Red performance  Reductions in inappropriate resource allocations  More appropriate allocations leading to a reduction in the number of ambulance resources ‘stood down’ following mobilisation  Improvements in the proportion of incidents resolved with telephone advice or referral to a more appropriate service  A positive impact on staff experience

5. Unintended impact on performance

5.1 The benefit of Dispatch on Disposition was predominantly seen on the NHS Pathways triage system and delivered significant improvements in Red1 performance. However, the expected improvements in response time performance for Red2 incidents did not materialise.

5.2 When investigated further it was identified that the changes in the triage process were successful in improving the quality of triage but had a knock-on effect of reducing the number of incidents where ambulance resources arrive at scene before the tr iage process has been completed. These are described as “running calls”.

5.3 All running calls, as per the Ambulance Clinical Quality Indicator guidance, are automatically categorised as Red2 incidents for reporting purpose. The additional triage time as part of Dispatch on Disposition identifies the correct prioritisation of the incident, which may not be Red2, and results in more appropriate responses to meet the clinical need of the patient.

5.4 As the majority of running calls have a positive impact on Red2 performance, removing a high proportion of running calls and triaging some as Green calls, has reduced the Red2 performance percentage by approximately 5%. The 19-minute performance percentage, to a lesser extent, has also been affected.

5.5 The 5% impact was recognised by NHS England, Monitor and Commissioners in June 2015.

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6. Latest developments

6.1 The Trust has received approval of a further change to the behaviours associated with Dispatch on Disposition (now known as the Ambulance Performance Review). The change with effect from 5 October 2015, moves the clock-start position from three to four minutes meaning that overall the clock will start either:  On allocation  240 seconds (four minutes ) after call connect (T0)  When the disposition is reached (T5)

6.2 The anticipated benefits of this further change are:  Further efficiency of dispatch and a reduction in the number of dual allocations  Further reducing the number of inappropriate ambulance responses by increasing the percentage of patients treated by telephone advice  Greater utilisation on specific resources, ensuring the most appropriate and timely response is deployed to mee t the patient’s clinical needs

6.3 As with the behaviours implemented previously, it is expected that the impact on the east/west divisions of SWASFT will be more evident than the north division, due to the different dispatch systems currently in use.

6.4 This change in behavior is expected to be in place for a period of six weeks and, subject to the outcomes, will be followed by a further move in the clock-start to five minutes. This is subject to confirmation.

6.5 In addition, the Ambulance Response Programme Expert Reference Group is undertaking an exercise to review the coding of 999 calls. This is to ensure they more accurately reflect the true urgency of patient-need. This is expected to result in a trial of new ambulance response categories and associated time targets in late 2015/16. The details of the trial and where this would take place are yet to be confirmed.

6.6 Four further ambulance trusts commenced phase one in early October, with an anticipated plan of moving these trusts to phase two in the new year. The Secretary of State will complete a report on Dispatch on Disposition in late spring of 2016, which will inform the next stage of the Keogh Urgent and Emergency Care Review in the Autumn of 2016.

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Health and Care Overview and Scrutiny Committee Meeting

3 November 2015

Title: Gloucestershire community first responders and defibrillators

Presented by: Neil Le Chevalier, Director of Operations

Main aim: To update HCOSC members on the current position of CFRs and defibrillators

Recommendations: To note the contents of the report

1. Community first responders

1.1 Recruitment in Gloucestershire has historically been in conjunction with St John Ambulance (SJA). Whilst the majority of volunteers are recruited in this way, the Trust also seeks to establish its own recruited CFR groups in locations where SJA are unable to offer development.

1.2 The Trust has just trained eight new CFRs who will be responding in Lechlade, Newent, Fairford, North Cerney, Tewkesbury, Highnam, Sedbury, Upper Rissington.

1.3 A further training course is taking place in November/December with a further course planned for February 2016.

1.4 With reporting tools on activity profiles, the Trust is able to review each group and work towards matching availability to activity levels.

1.5 We currently have CFRs in 40 locations throughout Gloucestershire and South Gloucestershire:

Gloucestershire Coleford Coln St Aldwyn Dursley Dymock Fairford Frampton on Severn Gloucester Kempsford Lechlade

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Lydbrook Lydney Morton in the Marsh Nailsworth Southrop Sedbury Newent South Cerney Stone Stroud Tewkesbury Tidenham Wotton under Edge Cheltenham Abbeydale Winchcombe Longhope

South Gloucestershire Almondsbury Kingswood Bradley Stoke Puckelchurch Chipping Sodbury Stoke Lodge Coalpit Heath Thornbury Downend Warmley Emersons Green Winterbourne Frampton Cotterell Yate

1.6 The number of volunteers in each group varies from one to eight, with a total number of 93 volunteers. The locations above are grouped in to 11 areas. Support and training is delivered via these area groups:

Dymock Fairford Forest of Dean Highnam Newent North Cotswold South Cotswold Tewkesbury Winchcombe South Gloucestershire Cheltenham

2. Defibrillators

2.1 203 new defibrillators registered on our control system since January 2015.

2.2 The total defibrillators available in the community which are registered with the Trust are: Gloucestershire Static sites: 220 CPAD: 153

South Gloucestershire Static site: 46 CPAD: 32

3. Further notable developments in Gloucestershire

 Support from BBC Radio Gloucestershire  Support from local MPs and councillors

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 Working with major organisations such as Gloucester Services, Two Rivers Housing and St John Care Homes (and the installation of defibrillators has begun)  Actively seeking more defibrillators that we are unaware of through our accreditation scheme  Working with parish councils  New SWASFT assistant community responder officer (ACRO) to develop CPAD and static sites in South Gloucestershire starts on 9 November  There will be a further CFR recruitment campaign in December 2015 via NHS Jobs  There were five heart start nominations entered for SWASFT CFR groups (one being for the Fairford and Lechlade group)  The Rotary Group (in conjunction with SWASFT) received a highly commended for fundraising project of the year  Supporting many large organisations who are purchasing their own defibrillators  Working with the University of Gloucester supporting the free screening of people aged 15-35 years for cardiac abnormalities – through University fundraising supporting CRY (Cardiac Risk in the young)  Planning for 2016-17 is underway

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Page 58 Agenda Item 7

Gloucestershire Health and Care Overview and Scrutiny Committee (HCOSC)

3 November 2015

NHS Gloucestershire Clinical Commissioning Group (GCCG) Clinical Chair and Accountable Officer’ s Report

1. Section 1: National Update

These are items are for information and noting.

1.1 Department of Health Consultations Information regarding Department of Health consultations is available via the GOV.UK website https://www.gov.uk/government/publications?publication_filter_option=consultat ions This website also includes Government responses to closed consultations.

1.2 Relevant open consultations:

Public health formula for local authorities from April 2016 https://www.gov.uk/government/consultations/public-health-formula-for-local- authorities-from-april-2016 Seeks views on the public health allocation formula, which is used to allocate public health resources to local authorities. This consultation closes at 6 November 2015 11:45pm

Pricing of branded health service medicines https://www.gov.uk/government/consultations/pricing-of-branded-health-service- medicines Seeks views on proposals to change to how prices of branded NHS medicines are determined and re-align savings alongside Pharmaceutical Price Regulation Scheme (PPRS). This consultation closes at 4 December 2015 11:45pm

1.3 Department of Health Policies The following weblink provides access to Department of Health Policies: https://www.gov.uk/government/policies?keywords=&topics%5B%5D=all&depa rtments%5B%5D=department-of-health&commit=Refresh+results

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Page 59 2. Section 2a: Local NHS Commissioner Update, Gloucestershire Clinical Commissioning Group (GCCG) excluding Primary Care Commissioning (GP services)

These are items for information and noting.

2.2 GCCG Consultations Information regarding GCCG open consultations is available on the GCCG website at: http://www.gloucestershireccg.nhs.uk/feedback/engagement-and- consultation/148-2/ The CCG is currently inviting feedback on the following services. Please click on the name of the consultation to find more information.

 Wheelchair Service Review  Breastfeeding Support  Children and Young People’s Service (CYPS) – Support with emotional health and wellbeing

The GCCG website also includes information about closed consultations. http://www.gloucestershireccg.nhs.uk/feedback/engagement-and- consultation/closed-engagement-or-consultations/

2.2 Devolution bid for Gloucestershire The full “We are Gloucestershire” bid was submitted to Whitehall on 4 September 2015. This is an ambitious bid that sets out our proposals for the county and demonstrates our commitment to working with our partners to bring together experience, ambition and enthusiasm to achieve better outcomes and reduced costs. The bid follows the same format as the Statement of Intent and outlines five sections:

 Accelerating growth – infrastructure, planning, transport, business skills and employment.  Health and social care – single vision for health and social care, delivered collectively by partners, based on what local people really need.  Community safety – joined up public protection and safeguarding practice to improve outcomes for some of our most vulnerable people.  Finance and assets – getting the best out of the £3 billion public sector money spent in Gloucestershire by commissioning together and investing together to prevent demand in future.  Governance – establishing a single point of governance to remove barriers without merging organisations.

The government will now select and negotiate on bids in time for the Chancellor of the Exchequer to announce further devolution deals in his public spending review statement on 25 November 2015.

If the bid is successful, the CCG and partners will develop a business case to test how best to accelerate our progress on integration, retaining a strong focus on self- care and prevention in all our plans.

The full bid and proposals available to view online at: www.weareglos.com 2

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2.3 Winter Planning Preparations for the winter have begun in earnest, with:

 an assessment of bed modelling across the system  a review of last winter; a desktop escalation exercise  compilation of the Winter plans from across the SRG system  development of system-wide escalation measures  flu planning  review of current QIPP schemes successes and areas for development  winter “local” and national communications plans  development of the ASAP app  high impact actions  Bank Holiday assurance process  delivery of the resilience schemes

2.4 Clinical Programmes (CPG) The clinical programmes team remained very active leading on a range of collaborative service transformation work. A significant achievement has been the launch of G-Care. This on-line resource provides all Gloucestershire GPs with vital information about our local health services and support for patients. We have received very positive feedback from primary care and plans are in place for the ongoing development of the resources. Examples of recent individual clinical programme activity are summarised below.

2.4.1 Respiratory The Respiratory team held a very productive Chronic Obstructive Pulmonary Diseases (COPD) Emergency Pathways Workshop in August 2015 to agree the interface and referral criteria for pathways and services ahead of the winter period. This will ensure that the right choices are made for patients with COPD, particularly when considering alternatives to hospital admission. Key work is also being completed ready for winter on Community Acquired Pneumonia (CAP); a workshop was held in September 2015 with key partners (Emergency Department, Ambulatory Emergency Care, Rapid Response and Respiratory Physicians). We will soon be publis hing a set of “Top Tips” for primary healthcare teams and care homes to support decisions around the treatment of CAP, referral options and timely discharge to community pathways and services.

2.4.2 Muskulo Skeletal The MSK team have directed an extensive redesign programme during 2015 and a new Integrated Service Model is gaining the endorsement of key partners and decision makers. The design workshops concluded with Orthotics in July 2015 and Interface Services in August 2015. A summing up workshop was held in September 2015 to review the overall new model. For Rheumatology new annual monitoring clinics have commenced and we are gaining feedback from patients to inform the clinical team ’s decisions on service improvement. A new high level plan for Falls and Bone Health has been developed and workshop for Fractured Neck of Femur was held in October 2015.

2.4.3 Cancer The Cancer team have completed the service specification, agreed job description and designed patient education programmes for the new community based services. Based on patient research the service is to be branded ‘Gloucestershire 3

Page 61 Macmillan Next Steps ’. There was an excellent turnout for the county wide Cancer Summit at the end of September 2015 with attendees from across the health community and national speakers. The CCG’s large scale work on Cancer Diagnosis Significant Event Audits, embodied in the primary care offer, has been recognised by the Royal College of General Practitioners (RCGP) as part of a national improvement programme.

2.4.4 Strategy and Prevention Work on prevention and self-care is progressing well. The healthy individuals CPG is continuing to develop a shared work plan that will outline the key actions needed to enable individuals to better self-care. We are working on a number of key initiatives to support the partnership ’s ambitions to promote health and wellbeing. These include:

 Undertaking a series of engagement activities with patients who have a long term condition to understand how they can better self-manage. This is being supported by comprehensive a review of the evidence to inform our service model going forward.  We have started work on an obesity health needs assessments across the life course. This work will inform a co-ordinated approach to tackle obesity across the county and ensure that sufficient weight management services are in place.  A Cultural Commissioning Grant Programme has been launched inviting arts and culture organisations from the VCSE sector to develop innovative solutions to address the priorities of our clinical programme groups. The grant programme is being supported by Create Gloucestershire and VCS Alliance along with Tewkesbury Borough Council, Forest of Dean District Council and Gloucester City Council.  Florence (remote monitoring by use of text) Phase 2 was launched in September to coincide with the CCG’s AGM. The aim is to roll Florence out in primary care and look at opportunities to support other community initiatives such as weight management, telecare, specialist services and flu vaccinations.  The CCG and GCC are working with other areas across the South West to jointly submit an expression of interest to become a first wave site to join the NHS Diabetes Prevention Programme. If successful, the initiative would involve working in partnership with NHS England, and their contracted service providers, to deliver behaviour change interventions to prevent Type 2 diabetes in Gloucestershire  Working in partnership with GCC and Active Gloucestershire we have been put through to the next stage of our ‘Healthy Habits, Healthy Communities bid’ to the Big Lottery. If successful, the aim of the project will be to develop a social investment model on supporting people to become more physically active through both individual and community change programmes and creating a self-sustaining environment of permanent change to healthy living/physical activity participation.

2.5 Future in mind pilot & Gloucestershire Dementia Strategy Mental Health and Wellbeing Strategy 2.5.1 Following a consultation event earlier this year there has been a refresh of the Gloucestershire Mental Health and Wellbeing Strategy and the associated action plan. The decision has been taken to transfer many of the strategic priorities identified through the 6 strategy sub-groups into other existing strategic forums (e.g. Building Better Lives, Suicide Prevention).

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Page 62 2.5.2 Crisis Concordat Gloucestershire was the first area of the country to go live with a Concordat and associated action plan. There has been significant progress made against many of the actions within the plan but there is now a need to take stock and review the 80 plus actions across 18 different organisations. The highlights to date include:

 Remodelling of the Gloucestershire Crisis resolution and Home Treatment Team to provide faster response to a wider range of referrers (particularly police). It is intended in phase 1 that this service will have an expanded age range (16+ as opposed to current 18+) with the future intention to reduce the age further down to 12 pending the evaluation of pilots within ED mental health liaison.  ED mental health liaison is now available on a 24/7 basis.  Following a period of engagement including a series of stakeholder engagement, including workshops, the Gloucestershire Dementia Strategy will be published shortly. It is based on 5 principles and values, identifying the programmes of work supporting those themes and building on earlier National Dementia Strategy and Dementia Challenge progress, as well as aligning with Growing Older in Gloucestershire and Care Act drivers:

o Dementia is everyone’s business o People living with dementia are engaged, involved and informed o Placing the person with dementia and their carers/families at the centre o Recognising dementia as a Long Tern Conditions o Ensuring that the county workforce has the knowledge and skills to provide high quality care for people living with dementia

2.6 Locality Development Planning 2015 -2017

2.6.1 Introduction and Background In September 2015, the new two-year Locality Development Plans covering 2015 – 2017 were included in the GCCG Chair/Accountable Officer to HCOSC for Forest of Dean, North Cotswold, and Tewkesbury, Newent & Staunton localities.

This second update provides information regarding the four remaining Locality Plans for Gloucester City, Cheltenham, South Cotswold and Stroud and Berkeley Vale Localities.

2.6.2 Key achievements to date: Gloucester City Locality Choice+ – A pilot for local urgent care centres began in October 2014, with 300 appointments per week available to nine Gloucester City practices that initially opted to take part. Additional appointments at the urgent care centres in Gloucester Health Access Centre (GHAC) and Matson Lane, free up on average six hours of time in each practice every week to spend time with patients with long term conditions and continuity of care needs.

Social Prescribing – In partnership with Gloucester City Council the Locality Executive has supported the implementation of Social Prescribing for all GP practices across the City . GP’s and healthcare professionals based in practices are able to offer a ‘social prescription’. Patients are referred into the Social Prescribing hub based at the City Council’s Herbert Warehouse. A hub coordinator then meets with patients to offer signposting to a range of local, non-clinical services, which can support patients social, emotional or practical needs.

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Page 63 Pharmacy First – Promoting a new minor ailments scheme to GP practices, healthcare professionals and patients in Gloucester City to reduce GP appointments by providing medication for common ailments through local pharmacies. The scheme has been particularly successful for use by parents of younger patients, and the pilot will continue until the end of the financial year 2015/16.

2.6.3 Key achievements to date: Cheltenham Locality Care Home Zoning – All practices have continued to support care/nursing home zoning, whereby each GP practice has been aligned to a number of care/nursing home(s). This has improved the continuity of care and clinical outcomes for those patients in a care/nursing home, and enabled the practices to develop a relationship with care/nursing home staff. Due to the number of care/nursing home(s) premises within the Cheltenham locality, this has ensured visits to care/nursing homes are more manageable for GP staff.

Electronic Prescribing – Electronic prescribing has been rolled out across all practices working with local pharmacies. The deployment has gone well from the outset as practices have been pragmatic about understanding the inherent challenges posed by a change in systems and process and will now take forward Phase II of the project during 2015/16.

Greater Awareness of Suicide – An education event for GP Practice Leads focused on suicide, following advice from Public Health that this was an area the locality needed to focus on. Subsequently, the Locality Executive identified which voluntary and community sector organisations are able to provide extra support so that practices have the confidence to refer/signpost their patients appropriately.

Patient Participation Groups (PPGs) – PPGs routinely hear about patients’ experiences: perspectives of existing services and about what developments the local community feel would be useful. In the light of this, the Locality Executive sought PPG’s feedback on the priorities in the Locality Development Plan (LDP) for 2013-15, along with any issues they wished to highlight, and feedback from patients who may have benefitted from these schemes. This feedback has informed the development of plans for 2015-2017.

2.6.4 Key achievements to date: Stroud and Berkeley Vale Locality Cycling on prescription scheme – This scheme was initially commissioned for the patients of eight locality practices and has subsequently been rolled out to all 19 practices. This is a confidence building programme where individuals are supported by the Road Safety Partnership to return to cycling. The scheme is particularly for people who already own a bicycle but may not have used it for a while. In addition to confidence building sessions, the individual also receives a free bicycle maintenance check. People are then linked to local cycling clubs.

Social Prescribing – The social prescribing pilot initially ran in six GP practices. The most common reason for referral was social isolation, followed by mental health and wellbeing. The scheme was jointly sponsored by Stroud District Council and the CCG. Following an evaluation, an in practice model has been adopted and will be rolled out during the coming months.

Facts4Life – The locality commissioned the development of this programme which aims to change the attitude of children in Key Stage 1 to their health and wellbeing. The aim is to promote an understanding of illness as part of normality, helping 6

Page 64 children to understand how to keep as well as possible and how to manage ill- health effectively. The project helps children to put information in context when making decisions about their health. The pilot demonstrated positive results and the CCG has now funded the project to enable roll out to 153 schools across the county.

2.6.5 Key achievements to date: South Cotswold Locality Social Prescribing – The locality developed and successfully implemented a Social Prescribing scheme with four GP practices in the locality; in partnership with Cotswold District Council and other local voluntary and community organisations. The Hub Coordinator has worked closely with GP practices at St Peters Road, Rendcomb, Lechlade and The Park surgeries. Through the hub, patients are signposted to relevant organisations to assist with social issues a patient is facing. Over 110 patients have been seen through the Social Prescribing hub since April 2014. A majority of individuals have needs around social isolation and caring responsibilities. The scheme will be rolled out into all practices in the Locality by the end of 2015.

Cirencester Hospital has been established as an innovation test bed for community hospital service development within the county. Working together with CCG colleagues, Gloucestershire NHS Hospitals Foundation Trust and Gloucestershire Care Services, a Cirencester Hospital working group has been formed.

Dementia was a priority identified by the JSNA data for 2013-2015 in the South Cotswold Locality, as the prevalence levels were lower than expected for our population. An education event for all South Cotswold GP’s has increased awareness to support dementia diagnosis. This has led to an increase in the recording of dementia cases in the Locality and enabled the implementation of formal memory testing.

Identifying financial variation in practices – Building on an approach developed by Yorkshire and Humber Public Health Observatory (now Public Health England), the South Cotswold Locality Chair took the lead in developing an approach which allows comparison to ‘similar’ practices within taxonomy groups, enabling a comparison not only to locality practices but also to ‘practice peers.’ Based on the relative position of each practice’s regis tered list against five themes (% of older patients, deprivation, employment, health conditions and carers, lifespan and disease mortality) seven taxonomy groups were created. This approach will continue to be developed through 2015-17 as part of the newly established variation programme where the key focus will be based on what actions should take place when variance that is real, material and influential has been identified.

Complex lower limb service – With an increasing ageing population, the Locality has identified long term condition planning as imperative to the sustainability of the locality in forthcoming years. The Locality has worked towards the implementation of a holistic community based complex lower limb wound service modelled on appropriate community based care, closer to home for patients. The developed service is aligned to a social model of care and will enable efficient use of district nurse time. This scheme began in the South Cotswold locality and will then be rolled out across countywide locations.

2.7 Approach to Planning 2015/16 – Making it Happen

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Page 65 The CCG has developed a systematic approach to planning which was approved by GCCG Governing Body in July 2015. The new approach to planning covers:

 A clearly defined planning cycle representing the timings of the commissioning, business case, business planning and engagement cycles (see Figure 1) that ensures that planning activities occur in a logical order.

 An approach to engagement in the planning process which ensures that CCG plans are informed by key stakeholders.

 Arrangements to ensure that there is clear alignment between the development of Locality Plans and wider CCG planning.

 A Forward Work Plan which will ensure that the 5 year strategy Joining up Your Care is widely ‘owned’, understood, embedded, detailed, localised, coherently delivered and contemporaneous.

At Appendix 1, HCOSC Members will find a paper ‘Approach to Planning 2015/16 – Making it Happen ’, which:

 sets out the key activities and dates in the 2015/16 planning round;  clarifies the process for prioritising business cases including the principles underpinning the decision, the associated weighting and the prioritisation process; and  clarifies the governance arrangements for prioritising and approving business cases.

2.8 Seasonal Flu Vaccination

This year, the vaccination is being offered to children aged 2 to 4, children in school years 1 and 2, people 65 and over, and anyone who is living with a long term condition.

For most healthy people, flu is an unpleasant illness from which they recover within a week. However, some people are more susceptible to the effects of flu and are at increased risk of developing more serious illnesses such as bronchitis and pneumonia, or make existing conditions worse. In the worst cases, seasonal flu can result in a stay in hospital, or even death.

Individuals are likely to be particularly vulnerable if they have a chronic respiratory condition such as asthma, diabetes, heart disease or a weakened immune system. The vaccination is also advised for pregnant women because both mother and unborn baby are at particular risk from the flu. Flu is an unpredictable virus with new strains circulating each year during the winter months, so it is essential that vulnerable people take steps to protect themselves. Even people whose health conditions are well managed and who lead otherwise healthy lives should still have the flu vaccine.

A nasal spray is available for pre-school age children, and children and school years 1 and 2. This offers a quick, easy and painless way to help prevent them catching flu whilst also helping to reduce it spreading to more vulnerable people. For further information about flu and to watch a video showing how it spreads, visit www.nhsstaywell.org/health/flu/

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Page 66 2b Section 2b: Local NHS Commissioner Update, Gloucestershire Clinical Commissioning Group (GCCG) -Primary Care (GP services)

2b 1 The Springbank Surgery – Procurement Update 2b 1.1 Introduction The Springbank Surgery contract holder, Cheltenham Primary Care Services Ltd, served notice on their General Medical Services contract to NHS England at the end of February 2015. Gloucestershire CCG (GCCG) determined that a full procurement was the appropriate course of action in order to secure primary medical services for the registered population. During August 2015, GCCG undertook a successful procurement exercise, resulting in a contract award. A stand still period commenced on 9 September, finishing on 18 September 2015, with a letter sent to the successful bidder on 21 September 2015 confirming the contract award. 2b 1.2 Procurement Process The procurement exercise was designed to procure a service to meet fully the needs of the population of Springbank Surgery in accordance with our strategic direction. The service is designed to deliver the following outcomes:

 Access – The Services must be provided at the current Springbank Surgery location, meeting local client access needs;

 Capacity – to provide high quality, sustainable, Primary Medical Services for the registered patients of Springbank Surgery;

 Quality, Clinical Safety and Effectiveness – Client-centred services delivered in a safe and effective manner;

 Integration – integration with, and positive contribution to, the local healthcare community along with demonstrably effective interfacing with primary, secondary, community, social and voluntary care;

 Best Practice – an ongoing commitment to provide innovation and demonstrate compliance with the evidence base for best practice;

 Continuity of service provision through retaining a core of clinical staff throughout the term of the contract that have excellent working knowledge of Gloucestershire health and social care services. An Evaluation Panel was established by GCCG to ensure that due procurement process was adhered to and that a full technical, commercial and financial evaluation of bidder offers could be conducted in a fair and non-discriminatory manner. This included representation from two members of the Springbank Patient Participation Group (PPG), who played a formal role in the bid evaluation process, including the opportunity to question and score bidders. The evaluation methodology was designed by the Evaluation Panel to give the CCG and all bidders the assurance that the procurement approach adopted: 9

Page 67  was transparent and fair;

 had been set prior to the dispatch of Invitation to Tender documentation and could not be altered in favour of any one bid response; and

 would select the bid which best demonstrated the ability to meet the service delivery requirements and service specification in terms of quality, efficiency, professional ability and value for money. The Evaluation Panel appraised the relevant sections of the written Invitation To Tender (ITT) submissions against an established scoring matrix. 2b 1.3 Procurement Outcome Based on the total evaluation scores, the Evaluation Panel recommended one of the bidders to be selected as NHS Gloucestershire CCG’s preferred bidder , Church Street Medical Practice, and to take them forward to contract signature for contract commencement on 1 December 2015. 2b 1.4 Contract mobilisation GCCG will oversee the implementation, phase which will ensure a smooth transition from the incumbent provider to the new provider. Timely and appropriate communication will be essential in supporting the outcome of the procurement. The CCG’s Communication Team will work closely with the new provider and Cheltenham Primary Care Services Ltd in developing and sending communications over the coming months. A communication plan has been developed to cover the period September 2015 – December 2015, which includes communications to patients, local Cheltenham practices, other local stakeholders and the media. 2b 2 St Luke ’s Practice Closure 2b 2.1 Introduction and background The CCG was informed in May 2015 of the formal notice received by NHS England (NHSE) for the termination of the GMS contract for St Luke’s Medical Centre with effect from the end of September 2015. The GP partners at St Luke’s Medical Centre had offered a unique style of primary medical care. While offering all services within their core contract, the practice emphasised a holistic approach to patient care and anthroposophic medicine was used to aid this approach. The main reason given for termination of contract related to the inability to appoint new GP partners to replace the two GP Partners due to retire in September 2015. It was clear that much effort had been given to the recruitment process and although they had successfully recruited twice, the appointments had failed. The practice explored options for merging, initially with a local practice and later with another Gloucestershire practice. Unfortunately this too proved unsuccessful and therefore alternative options had to be considered for provision of primary medical care. GCCG would normally not consider patient dispersal to other practices and therefore has invested significant time in trying to support the practice to continue

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Page 68 by other means. However, in this instance, it was the most viable option for the unique circumstances of this particular practice. The patients’ addresses were distributed over a wide geographical area, meaning not only that patients would continue to have a surgery close to home, but also that they would continue to have choice of where to register. This distribution helped reduce the impact of the practice closure. The map below demonstrates the spread of those patients and the GP practices within that area:

The practice operated from two locations:

 Main surgery site in Stroud at 53 Cainscross Road:

 Branch Surgery in Tuffley, Gloucester City at 10 Tuffley Lane: The practice registered list size as at March 2015 was 3,983 patients. The list size had been steadily reducing since December 2011 (4,233). While all registered patients were free to attend either site, approximately 700 patients live closer to the branch surgery at 10 Tuffley Lane than the main branch surgery site. Throughout this process, the practice and GCCG took the opportunity to engage with patients registered with St Luke’s. A media statement was published in the local press explaining the challenges but also emphasising the support that we were giving to get a local solution. In addition, with support from the CCG, the practice wrote to all patients explaining the challenges. The Practice’s Patient Participation Group (PPG) were kept fully informed and involved throughout, with several meetings held throughout the process. With regards to local practices in Stroud and Tuffley, GCCG worked with the Local Medical Committee (LMC) to ensure all affected practices in Stroud and Gloucester were consulted in order that all implications are were considered and no destabilisation of existing services occurs. 2b 2.2 Preparation for practice closure

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Page 69 Dispersal of patients is not an easy task and we were mindful of the need to ensure there was a robust process over a sufficient period of time for patients to re-register where they would like to be. Getting this right ensured patients had a smooth transition from one practice to another and can start building relationships with their new GP. With this in mind, GCCG established a ‘St Luke’s Advice Line’ for patients to call, free of charge, or email. This service supported patients with the process of registering with a new local NHS GP Practice. In excess of 70 GCCG staff received training in handling calls in the period running up to the Advice Line going live. While working on the Advice Line (up to five staff at any one time) all staff were able to continue with their own work during times when they were not responding to patient calls. The Advice Line went live on 9am Tuesday 28 July, and was open Monday to Friday 9am-5pm, with extended hours to 7pm on Wednesdays. A messaging service was available when the Advice Line was closed. The Advice Line stayed open until the end of first week in October 2015. GCCG Patient Advice and Liaison Service (PALS) team responded to more complex calls, when patients required a greater degree of support to register with a new practice or who had more complex queries. However, few callers required a referral to PALS. A personalised letter from the practice, together with information from Gloucestershire CCG (GCCG) regarding registration with a new GP practice, was sent to all patients on Monday 27 July informing them of the intention of the practice to close at the end of September 2015. A second letter was sent to patients on 14 August 2015 reminding them of the importance of registering with another GP surgery soon. This was followed up on 1 September by a text from St Luke’s Medical Centre to those patients for whom it had a mobile phone contact number. A third letter was sent to patients on 9 September 2015 urging them to take urgent action, followed by a further text from St Luke’s. A final letter was sent on 25 September 2015. 2b 2.3 Progress As at 20 October approximately 3,300 patients have so far registered with another practice. St Luke’s Practice identified all vulnerable patients and offer ed support and worked collaboratively with other agencies to ensure this group of patients were registered with another practice. The overall spread of practices the patients choose is relatively even across Stroud and Gloucester, with patients advised both in the letter, and by the staff working on the Advice Line, that they must live within a GP Practice’s boundary to be eligible to register with a particular practice. Feedback from pat ients received by the St Luke’s Practice Manager has been that the Advice Line was very helpful, and other practices have also indicated that the Advice Line was useful in managing practice administrative workload. Media coverage was on the whole been balanced, with print media and local radio covering the story. 12

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3. Section 3: Local Providers’ updates This Section includes updates from Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT), 2gether NHS Foundation Trust (2GNHSFT) and Gloucestershire Care Services NHS Trust (GCSNHST).

These items are for information and noting.

3.1 Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT)

3.1.1 New Academy launched GHNHSFT now has a dedicated academy to coordinate safety and quality improvement training. This will enable staff to access a range of training opportunities to help them to build the skills necessary to identify hazards, measure and manage risks and test and implement quality improvement initiatives.

The Gloucestershire Safety and Quality Improvement Academy will provide education to staff and support in the transition from learning to implementation. The Academy launched the dedicated Quality Improvement education programme in October 2015, initially as a series of pilot courses.

3.1.2 100,000 Genomes GHNHSFT will be playing a role in helping to develop a new genomics medical service for the NHS and transforming the way people are cared for. The Trust has signed up to the West of England Genomics Partnership, an ambitious programme aimed at developing the genomics capability in the West of England with the view to becoming a Genomics Medical Centre (GMC).

The Prime Minister announced the 100,000 Genomes Project in December 2012. Under the project 100,000 genomes from around 70,000 people will be sequenced by 2017. The aim is to create a new genomic medicine service for the NHS – transforming the way people are cared for. Patients may be offered a diagnosis where there wasn’t one before. In time, there is the potential of new and more effective treatments.

The project will also enable new medical research. Combining genomic sequence data with medical records is a ground-breaking resource. Researchers will study how best to use genomics in healthcare and how best to interpret the data to help patients. The causes, diagnosis and treatment of disease will also be investigated. For more information visit Genomics England’s website: www.genomicsengland.co.uk/the-100000-genomes-project .

3.1.3 New passports for catheter patients The Countywide Urinary Tract Infection Group has developed a Urinary Catheter Passport for adults with long-term urinary catheters in Gloucestershire. The aim of this is to reduce the number of unnecessary urinary catheters in the county and reduce the number of calls to the out of hours service due to problems with catheters.

3.1.4 Safeguarding our patients

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Page 71 The Trust has staged a number of events/exhibition stands across its hospitals throughout September and October 2015 to raise awareness of safeguarding. In Home Safety Week, from 28 September - 4 October 2015, the Trust focused on fire safety and flu, particularly for older people. The Trust was supported by Gloucestershire Fire & Rescue who promoted their services including their home safety checks. The Fire Service also carried out Home Safety Checks (on request). The aim of these checks was to ensure that individual households were safe from the dangers of fire and that residents were taking the necessary precautions. In conjunction with this, the Trust also promoted the flu jab and how important it is for older people to get the vaccination. Other safeguarding awareness events staged in October included domestic abuse, adults at risk and safeguarding children.

3.1.5 HRH Princess Royal launched new Mobile Chemo Unit HRH Princess Royal officially opened the next generation Mobile Chemotherapy Unit, provided by the charity Hope for Tomorrow, at Cheltenham General Hospital in September 2015. The new unit incorporates features and improvements that reflect feedback received from patients, carers and the staff who run the service. The mobile unit has helped many cancer patients receive chemotherapy treatment closer to their homes since it was first launched in 2007.

3.1.6 Board meetings to be held across our sites Our public Board meetings, which have traditionally been held at Trust Headquarters in Cheltenham, are now being staged across all three sites (Cheltenham, Gloucester and Stroud). The initiative is aimed at enabling more staff and members of the public to attend. The September 2015 Board meeting was held in the Gallery Room in Gloucestershire Royal Hospital. The Board monitors the performance of the Trust and work undertaken by Board Sub- Committees.

3.1.7 Walk for Wards (Cirencester Park) The Cheltenham and Gloucester Hospitals Charity staged a ‘Walk for Wards’ fundraising event at Cirencester Park on Sunday 11 October 2015. More than 80 people took part in the family friendly walk (3k or 10k). The Cheltenham and Gloucester Hospitals Charity raises funds to make a real difference for our patients, their families and the staff who treat them and work at Gloucestershire Royal and Cheltenham General Hospitals as well as Stroud Maternity Unit.

3.1.8 Charity recipe book on sale soon Our charity has been chosen by Cheltenham Sainsbury’s on Tewkesbury Road, following a public vote, to be their charity of the year. The Cheltenham & Gloucester Hospitals Charity will be working with our staff and the store to develop a recipe book that will be on sale in time for Christmas. More information will be available on our website shortly.

3.1.9 NHS thanksgiving service A service of Thanksgiving recognising the enormous contribution that staff have made to patient care in Gloucestershire was held on 21 October 2015.

3.1.10 Inspiring exhibition Fifty portraits of women who have had breast cancer surgery and reconstruction have been exhibited at Gloucestershire Royal Hospital during Breast Cancer Awareness Month (October). The Keeping Abreast Portrait 14

Page 72 Exhibition , ‘Femininity Comes From Within’ was part of a national tour funded by The National Lottery.

3.1.11 Annual luncheons Every day Trust hospitals benefit from the hard work and commitment of our army o f volunteers who give up their time to help patients. To say ‘thank you’ annual reception and volunteers’ long service awards take place at both Gloucester (King’s School in October) and Cheltenham (Cheltenham College in December). These events are extremely well received among volunteers.

3.1.12 Research paper of the year Specialists at GHNHSFT were part of a team of researchers which won a Research Paper of the Year Category Award from the Royal College of General Practitioners (RCGP). Prof Peter Scanlon, Consultant Ophthalmologist at the Trust and Visiting Professor at the University of Gloucestershire, led a team of researchers who worked on a study which explored the factors which contribute to a high or low uptake of retinopathy screening among patients in primary care.

The RCGP award recognises an individual or group of researchers who have undertaken and published an exceptional piece of research relating to general practice or primary care and they invited the paper’s lead author Dr Antje Lindemeyer to present the results at the RCGP annual conference.

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes in England by allowing quick diagnosis of sight-threatening retinopathy. However, the rate of screening uptake between GP practices can vary from 55% to 95%. The paper looked at the factors contributing to this variance in uptake including service and staff interaction. It concluded by recommending a range of measures to improve patients’ attendance at screening as well as more research.

3.2 2gether NHS Foundation Trust (2GNHSFT)

3.2.1 World Mental Health Day A global awareness day held annually on 10 October. This year the theme was Dignity and focused on tackling the stigma and discrimination surrounding mental illness which can prevent people from seeking the help and support they need. 2gether’s Social Inclusion Team hosted information stands and events in a range of locations across the county to help to raise awareness of emotional wellbeing and access to local services. The Trust’s Managing Memory Team also took part in a health and wellbeing drop in session in Cheltenham.

3.2.2 Park House and Weaver’s Croft, Stroud Following extensive structural work at 2gether’s Park House in Stroud, work has commenced to provide fit for purpose accommodation at the site for Children and Young Peoples Services, Memory Advisory Service and Intermediate Care. Together with subsequent work to the adjacent Weavers Croft, and the construction of a larger car park, the work will create a high quality, modern and easily accessible centre from which the Trust will deliver all of the Stroud based services. The project will be completed in January 2016 and is supported by the Friends of Weavers Croft.

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Page 73 3.2.3 Recovery College The achievements of students who have completed courses through 2gether’s Severn & Wye Recovery College were celebrated at a graduation ceremony at Shire Hall, Gloucester in September 2015. The college provides courses and educational workshops which teach people to become experts in their own recovery and self-care. Attending graduates represented both the adult Recovery College and students of the Discovery College, which has been established specifically for young people aged 16 to 25. 2gether are holding taster days for the next set of courses on 7 and 14 December 2015 in Cheltenham. For more information, please visit www.swrecovery.org.uk/

3.2.4 ROSCAs Nominations are now being received for 2gether’s 2015 Recognising Outstanding Service and Contribution Awards (ROSCAs). Among the 10 awards, three are nominated by users of Trust services and their carers including Service User and Carer Choice, Clinical Team of the Year and Non Clinical Team of the Year. The closing date for nominations for ROSCAs 2015 is 5pm on Friday 6 November. For more information, please click on the ROSCA link found on the Trust’s homepage at www.2gether.nhs.uk.

3.2.5 Care Quality Commission (CQC) The CQC is making a f ull inspection of 2gether’s services during the week commencing 26 October 2015 . This is part of the Commission’s national programme of inspections.

3.3 Gloucestershire Care Services NHS Trust (GCSNHST)* * Gloucestershire Care Services NHS Trust also contributes to the joint GCC/GCSNHST report.

3.3.1 Gloucestershire Care Services NHS Trust (GCS) performance remains good overall and the Trust continues with a wide range of its service development and improvement programmes.

3.3.2 Care Quality Commission (CQC) Inspection As previously reported the inspection took place June 2015 and the outcomes from this were published 22nd September 2015. The Trust was awarded a rating of “Requires Improvement”.

The CQC is the independent regulator of health and social care in England. They are responsible for ensuring health and social care services provided to people are safe, effective, and compassionate, high-quality care and they encourage care services to improve. For GCS, 66% of areas across the Trust were rated as ‘Good’ or ‘Outstanding’. The CQC also identified areas of Outstanding Practice which included:

 A multi-disciplinary approach embedded in community hospitals  A strong, visible person-centred culture in community hospitals  The seven day service provide d by the Trusts children’s community team  The integrated, collaborative approach in the Trusts sexual health services  A detailed, innovative approach to falls management / prevention within the Community Hospitals  The Trusts dental service response to the complex needs of service users 16

Page 74  The Trusts involvement of volunteer groups within our community hospitals

The overall rating for the Trusts according to the CQC domains can be seen below:

Actions to mitigate the risks identified within the inadequate rating for urgent care – the 7 Minor Injury and Illness Units (MIIU) have either been addressed or are being addressed. However, the Trust remains concerned about a number of issues within its MIIUs and these include:

1. Rising levels of patient attendances across the GCS MIIU units some of which can be attributed to the changes in the medical OOHs provision that came into place April 2015 – the Trust is keen to work with the GCCG to manage this more effectively so that the expert resources within the units are deployed and resources according to demand and; that the commissioning arrangements for this service become more robust.

2. Challenges in the recruitment of emergency care practitioners and particularly Emergency Nurse Practitioners (ENPs) - although GCS has progressed with some innovative activities to mitigate these risks the Trust is aware that this is a wider health care risk both locally and nationally.

3. Ensuring that the Trust ’s MIi Us continue to be an integral part of the Gloucestershire wider urgent care services. MIiUs are ideally placed to support people locally but there is a continued need to raise awareness with members of the public about what can be delivered from an MIiU and “myth bust” the perception that they operate along the lines of an Emergency Department.

As a Trust, there remains a commitment to improve continuously and GCS has already completed actions which required an urgent focus. For the remaining areas, GCS has action plans in place to ensure that the recognition of all the good practice is maintained as well as seeking to make this outstanding. The Trust will submit its Quality Improvement Plan to the CQC in November 2015 and it is this

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Page 75 that will form the formal response to the areas for improvement identified by the CQC. The Trust is not aware of when the CQC will visit to re-inspect services.

3.3.3 Community Hospital Developments Over and above what was presented at the September 2015 HCOSC meeting, the GCS Community Hospitals teams continue to work on service and clinical developments which include:

 Cirencester Community Hospital – the Minor Injuries and Illness Unit (MIIU) became a nurse-led unit on 1 October 2015. This now aligns to the other six MIiUs across the county and will continue to be run using the expertise of emergency nurse practitioners (ENPs).

 GCS continues its roll-out of its clinical record IT system across its Community Hospitals. Since the last HCOSC meeting, its Forest of Dean and North Cotswold hospitals have s uccessfully gone ‘live’ and Tewkesbury Community Hospital will transfer to SystmOne by November 2015.

 Safe Staffing – In response to recent national guidance the Trust is progressing with its work to ensure that patient care is provided in a more flexible and responsive way rather than be tied to a national numbers approach, such as the 1:8 staffing ratios. It is very much recognised that other staff groups can positively influence the delivery of care time such as allied health professionals, housekeepers and ward clerks. In addition to this, a proposal to amend the safe staffing principles in community hospitals is being presented within the Trust during October 2015. This is in light of the Trust Development Authority (TDA) confirming that NICE guidance around the 1:8 ratios cannot be benchmarked in a similar way to acute trust beds for community hospital beds.

3.3.4 System-wide Capacity and Managing Patient Flows GCS continues to support the health and care system to ensure daily reporting of service capacity via the System-wide Escalation Call (daily), previously known as the ‘Alamac’ call .

GCS continues to focus on work associated with reducing the numbers of those Multi-Disciplinary Team (MDT) stable patients in Community Hospitals who are waiting for discharge so that any increased throughput across the community hospitals increase the number of beds available on a daily basis. The Trusts Single Point of Clinical Access (SPCA) is also reviewing how they allocate beds working towards a proactive pl anned approach rather than an “on the day” allocation of community beds where possible. This will also support the aim of ensuring that people are as close to home as possible rather than in the next available bed.

3.3.5 Performance of Reablement Services GCS continues with its work to manage the Countywide Reablement service, an integral part of the Integrated Community Teams (ICTs). There has been continued success with progressing cases onto alternative services after six weeks of reablement, with 35 patients continuing to receive input after this time frame.

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The average length of stay in the reablement service is 2.9 weeks.Sickness continues to be a challenge in the Reablement service; this is being actively addressed by GCS Team Managers.

The “deep dive” into the service has now been completed. The commissioners have a face to face service user contact time target of 60% but it is acknowledged that GCS should be aspiring to a 70% target as commissioners believe this would make the reference costs into the service competitive within the current market. To achieve this, it would require scheduling of visits in a way that ensures that at least 5 hours 15 minutes are in patient homes, and no more than 2 hours 15 minutes are used for all non-face to face activities including travel, follow up, supervision and multi-disciplinary team meetings. Modelling of the number of available reablement visits and length of visits is required to understand the impact on capacity and wider health and care system implications, particularly related to hospital discharge.

3.3.6 Transfer of Health Visiting Commissioning to Gloucestershire County Council (GCC) As per national policy from 1 October 2015, the GCS Health Visitor service is now commissioned by Gloucestershire County Council (GCC). With this change the cohort of children who are now eligible for health visiting service (children who are ordinary resident in Gloucestershire regardless of which GP practice they are registered with) is different to the cohort of children who are eligible for immunisation (those children registered with a Gloucestershire GP Practice regardless where they reside).

This change creates a risk that some children will be missed from services GCS provides or that the change will result in additional work to the current Health Visiting and Child Health Information Service, who monitor and record immunisations. This risk has been added to the Trusts corporate risk register and to mitigate this risk, a working group has been set up, and a meeting will be progressed with NHS England and the providers of children’s services on adjacent borders.

An agreed protocol for transfer of service users and new registrants across providers is in place, and commissioners have agreed to non-recurrent administrative resources to support the transfers in and out of existing children open to our services.

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Page 77 3.3.7 Community Nursing As previously reported, the Trust continues its activities within both service development and risk management within its Community Nursing workforce; one of which is the recruitment of nurses with the district nurse qualification, which remains a local and national challenge.

As reported at the last HCOSC meeting GCS continue with the implementation of its District Nurse Action plan to address the challenges in terms of district nurse recruitment. The position as at 25 September 2015 was 13.19 WTE vacancies for District Nurses, which equates to 22.9% of the funded establishment for Band 6 salaried posts. For Community staff nurses the vacancy was 10.50 WTE, which included the additional posts required to backfill those colleagues who have started the SPQ (Specialist Qualification) education programme to become District Nurses. This equates to 6.8% vacancy of the funded establishment for Band 5 posts.

As HCOSC will be aware, the ongoing shortage of nurses nationwide has made recruiting to full establishment an ongoing challenge. In collaboration with the GCCG, a number of areas of service redesign are underway to release community and district nurses from carrying out interventions that could be done in a different way, thus releasing nursing capacity to focus on the more complex cases such as end of life.

The service areas under redesign include:  Business case for Community phlebotomy service - under consideration by GCCG.  Development of a Community continence service - agreed by the GCCG and GCS, now commencing implementation under the leadership of the GCS and GCCG Directors of Nursing.  Management of complex leg wounds - in implementation stage by GCS.  Identification and shift of work to ambulatory care settings - in testing stage by GCS, starting in Cirencester

3.3.8 Community Nurse Shift Pattern Changes In response to feedback from its nursing colleagues, GPs and a review of planned care activity in community nursing, the current shift pattern was changed across GCS as from 5 October 2015.

The shift pattern was:

Time Service

7.30am to 10.30pm Early, core and late (three community nurse shifts)

10.30pm to 7.30am Evening and night service

The new shift pattern for community nursing is now:

Time Service Shifts

8am-8pm Day service 8am-4pm

12pm -8pm

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Page 78 8pm-8am Evening and night service 8pm-12am

12am -8am

Nurse colleagues are expected to work a full shift and will be rostered accordingly. This provides greater visibility for primary care on which nurses are working each day and allows for greater continuity in patient care. As part of this change, a review of flexible working arrangements did occur and there has been an agreement for some nurses to work different hours, in exceptional circumstances where required, to meet family commitments.

3.3.9 Dental Out of Hours Service Provision

The changes to how the Trust ’s Dental out of hours service will be provided has now been completed. The changes are intended to ensure the service provides better access to urgent care appointments for emergency pain relief, as well as ensuring the service is delivered within the current financial allocation provided by NHS England.

The new service has been designed to reflect and respond to the sharp decline in demand for an urgent care evening service and substantial increase in demand for access to urgent care at the weekend and will offer:

Dental Urgent Care Advice Service: Evenings 17:00- 20:00 hours  Nurse triage advice only (no dental appointments offered)  Patients will be:  offered self-help advice and pain relief advice  Signposted to pharmacies for advice on further pain relief if required o Given advice on General Dental Practitioners who are currently taking on NHS patients o Urgent pain patients will be given an appointment within 24 hrs as per Emergency Dental Care Clinical Guidance o Emergency patients with severe systemic infection, severe swelling likely to compromise the airway, uncontrolled bleeding, and severe trauma will be signposted to the their nearest Emergency Department

Dental Urgent Care Appointment Service: Weekends and Bank Holidays, 9:00 - 14:30 hours  Triage begins at 09:00am, with additional phone line availability  Appointments will be available from 10:00 until 14:30 (previously finished at 13:00).

4. Recommendations This report is provided for information and HCOSC Members are invited to note the contents.

Dr Helen Miller Mary Hutton Clinical Chair Accountable Officer NHS Gloucestershire CCG NHS Gloucestershire CCG

October 2015

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Page 80

An Approach to Planning 2015/16

Making It Happen

1

Page 81 Contents

Contents 2

1. Overview 3

2. The Planning Cycle 3

3. Key Dates in the 2015/16 Planning Round 5

4. Business Case Approval Process 6

5. Prioritisation of Business Cases 9

6. Key Recommendations 11

2

Page 82 1. Overview

The paper An Approach to Planning was approved by Governing Body on the 30 th July 2015. This paper outlined a new approach to planning covering:

 A clearly defined planning cycle representing the timings of the commissioning, business case, business planning and engagement cycles (see Figure 1 ) that ensures that planning activities occur in a logical order.

 An approach to engagement in the planning process which ensures that CCG plans are informed by key stakeholders.

 Arrangements to ensure that there is clear alignment between the development of Locality Plans and wider CCG planning.

 A Forward Work Plan which will ensure that the 5 year strategy Joining up Your Care is widely ‘owned’, understood, embedded, detailed, localised, coherently delivered and contemporaneous.

Having approved this broad approach to planning and engagement this paper has the following aims:

i) To list the key activities and dates in the 2015/16 planning round.

ii) To clarify the process for prioritising business cases including the principles underpinning the decision, the associated weighting and the prioritisation process.

iii) To clarify the governance arrangements for prioritising and approving business cases.

2. The Planning Cycle

The CCG follows a relatively standard cycle of planning activities. It is proposed that this is formalised into the cycle described by the diagram shown at Figure 1 , to allow for ease of communication with a wide range of stakeholders. The Planning Cycle describes the required planning activities during each month of the year. Each circle represents a different type of planning activity, namely:

 The commissioning cycle  The business case prioritisation cycle  The business planning cycle including writing and refreshing our strategic plan JUYC, and the Operational Plan  The engagement cycle

3

Page 83

Figure 1: The Planning Cycle

Page 84

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3. Key Dates in the 2015/16 Planning Round

Shown in Tables 1-3 are the key dates in the 2015/16 planning round, based around the Planning Cycle. Events are categorised as engagement , business planning/contracting or business case prioritisation and QIPP definition .

Table 1: Engagement Month Date Event Sept ‘15 3rd AGM Oct ‘15 22 nd South Cotswolds Locality Executive Group 22 nd Engagement Event with key stakeholders – Joining Up Your Care, Our Five Year Forward View (Continuation until Jan ’16) Nov ‘15 2nd Cheltenham Locality Executive Group 3rd Tewkesbury, Newent & Staunton Locality Executive Group 10 th Gloucester Locality Executive Group 11 th Stroud & Berkeley Vale Locality Executive Group 18 th Forest of Dean locality Executive Group 23 rd North Cotswolds Locality Executive Group 18 th VCS Alliance Provider Forum Dec ‘15 1st Healthwatch Gloucestershire Forum

Table 2: Planning and Contracting Month Date Event Sept’15 30th Write to our providers with contract intentions Oct ‘15 19 th Outline Commissioning Intentions

Nov ‘15 26 th Finalise Commissioning Intentions and Governing Body sign-off Dec ‘15 21 st * NHSE Publishes Planning Guidance 31st Outline activity plan Jan ‘16 15th Updated contract intentions sent to providers April ‘16 4th * Contracts signed 4th * Completion of Operational Plan June ‘16 30th Refresh JUYC to respond to 5YFV Table 3: Business Case Prioritisation & QIPP Definition Month Date Event Sept ‘15 TBC QIPP Development and Monitoring Group Oct ‘15 7th Priorities Committee TBC QIPP Development and Monitoring Group 30th High level benchmarking for programme groups Nov ‘15 TBC QIPP Development and Monitoring Group 30th Directorates, clinical programmes and localities submit outline business cases Dec 15 TBC QIPP Development and Monitoring Group Jan ‘16 TBC QIPP Development and Monitoring Group 21 st Priorities Committee 29th Directorates, clinical programmes, localities sign off draft QIPP schedules Feb ‘16 TBC QIPP Development and Monitoring Group Mar ‘16 TNC QIPP Development and Monitoring Group 3rd Priorities Committee

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Page 85 Apr ‘16 TBC QIPP Development and Monitoring Group May ‘16 TBC QIPP Development and Monitoring Group 19 th Priorities Committee *Estimated dates subject to change by NHS England

The Priorities Committee is scheduled throughout the year, although it is intended that that the majority of business cases will be reviewed in January 2016. Additional Priorities Committees are primarily to review ad-hoc business cases that either could not be anticipated or where it is infeasible that they can be developed in January. The QIPP Development & Monitoring Group is a proposed new group (terms of reference to be defined but likely to involve colleagues in the Transformation, Finance, Information and Commissioning Directorates) to define the 2016/17 QIPP schedule, ensure alignment with emerging Commissioning Intentions and provide advice during the development of new business cases to be reviewed by the Priorities Committee. In this way delivery of the 2016/17 QIPP schedule will be maximised and the QIPP Development Group could then assist in the development of QIPP delivery and development of new business cases.

Consultations events are scheduled in order to receive early input into the Commissioning Intentions and well in advance of the production of the Operational Plan or refresh of the clinical strategy. Particular emphasis is placed on localities in order to improve alignment between the Locality Development Plans and wider CCG planning. The proposed engagement activities will involve the following stakeholders:

GP member practices District Councils County Council Gloucestershire Hospitals NHS Foundation Trust Gloucestershire Care Services NHS Trust 2Gether NHS Foundation Trust South Western Ambulance Services NHS Foundation Trust GDoc Ltd Gloucestershire VCS Alliance HealthWatch GFirst LEP Police and Crime Commission Fire and Rescue Service

4. Business Case Approval Process

Figure 2 below shows the governance arrangements for the approval of new, and ratification of existing, business cases (including QIPP schemes). Table 4 outlines, in broad terms, the role of each group in this process.

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Page 86

Figure 2: Business Case Approval Process

New idea for a programme, project or other change initiative (a “scheme”) proposed by a programme , locality or other CCG group and given Director sign-off to proceed

QIPP Development & Monitoring Group reviews new proposals on a monthly basis to test viability and potential benefits

Core Team receives Outline Plan and agrees business cases to be put forward to Priorities Committee . Checks business case preparation and scoring is complete.

Outline business cases reviewed at Priorities Committee according to agreed principles*

Scheme not Scheme

prioritised prioritised

Scheme not Scheme submitted to approved Governing Body for final approval

*Full business cases will subsequently be reviewed on a monthly basis by the QIPP Development & Monitoring Group following approval of the outline business case by Governing Body to ensure that the detailed proposals are realistic and will deliver the intended benefits.

Page 7 of 11

Page 87 Table 4: Roles of Groups

Group Role Governing Body as Priorities Committee Prioritises Outline Business Cases for new scheme s according to the Prioritisation Matrix (see section 6 below).

Reviews existing schemes and recommends whether they should proceed into following year.

Core Team Approves the Outline Plan of schemes to be put forward to Priorities Committee.

Assures business case preparation and scoring is complete prior to submission to Priorities Committee.

Governing Body Provides final approval for Outline Business Cases .

QIPP Development & Monitoring Group Reviews new proposals arising from CPGs, localities, Programme Boards or elsewhere to test viability prior to developing Outline Plan for Core Team .

Defines 2016/17 QIPP schedule through liaison with other departments in CCG and linked to emerging Commissioning Intentions.

Review s full business cases that are developed subsequent to the approval of outline business cases to ensure they are consistent with the aims of the approved outline business case.

Monitors QIPP delivery in 2016/17.

Localities, Programme Boards and CPGs Conceive of new projects and schemes in order to meet CCG objectives

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Page 88 5. Prioritisation of Business Cases

The role of the Priorities Committee , as described above, is to review and prioritise outline business cases to determine which should be supported to proceed. Table 5 below shows the Prioritisation Matrix which forms the basis of this process and the aspects of each outline business case that should be reviewed.

The detailed process to be followed by the Priorities Committee is as follows:

i) Outline Business Cases for new 2016/17 schemes sent to Priorities Committee members in advance of January 2016 meeting.

ii) Members read and score each Outline Business Case and submit scores electronically to PMO.

iii) Priorities Committee meets on 21 st January 2016 and reviews collated scores for each business case. Any amendments are made to scores based on any further information received or misunderstandings.

iv) Schemes are prioritised and a proposal made for those that should go forward.

v) Priorities Committee reviews existing schemes and, based on feedback regarding effectiveness to date, make a proposal as to whether these schemes should continue.

vi) The recommendations of the Priorities Committee are sent to Governing Body for final approval.

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Page 89

Table 5: Prioritisation Matrix Factor Scale Score Weight Mark Mandatory (Core to confirm status) DO NOT SCORE FURTHER Detail Low (0-3) Mid (4-7) High (8-10)

Partially addresses one or more of the Fully supports one Does not address objectives set out or more of the Supports delivery of the objectives of in Joining Up Your objectives set out in Gloucestershire priorities, Joining Up Your Care or Joining Up Your Care Joining Up Your Care, national Care or meet national/local or national/local policy, managing access (care national/local priorities. Makes priorities. closer to home/reduced priorities. Does some contribution Significant waiting times and LOS) and not improve to improving improvement to reducing variation, access or reduce access or reducing access or significant reputational or other variation. No risk variation. Some reduction in imperative (e.g. to reputation or risk if not variation. High risk Strategic Fit procurement) other imperative. delivered. if not delivered. 1 Little contribution Significant towards reducing Some contribution contribution health towards reducing towards reducing inequalities or health inequalities health inequalities needs identified or needs identified or needs identified Reduces identified health in JSNA / Health in JSNA / Health in JSNA / Health Addressing Health inequalities, proportionate Inequalities Inequalities Inequalities Inequalities universalism delivery plan delivery plan delivery plan 1 Clinical evidence base, patient experience, measurable impact on health and wellbeing outcomes and/or life expectancy, Limited benefit Significant and Quality and negative impact on care if not to patients is Some Benefits measurable Outcomes delivered demonstrated demonstrated benefits to patients 1 Significant Some questions of questions of deliverability, Clear evidence of deliverability, resourcing or deliverability, resourcing or sustainability, resourcing or sustainability, neutral or sustainability. Do-ability, Workforce, adverse evidence of some Significant positive Sustainability, Environmental environmental positive impact on impact on the Deliverability Impact impact environment environment 1 Limited evidence Return on Investment of return on Some evidence of expected (supporting investment, return on Clear evidence of schedule - can be quantified investment vs investment, return on or qualitative assessment), benefits and investment vs investment, investment vs benefits significant benefits, some investment vs delivered, use of resources questions about questions about benefits and clear Cost Effectiveness and Value for Money value for money value for money value for money 1 0 TOTAL Maximum 50 Cost (£) £0.00 Cost (£) per point £0.00

Weighting

The development of a new prioritisation matrix requires careful consideration of the relative impact of the individual criterion. This new framework has initially been set with all criteria offering equal weight. The approach will be tested through an exercise applied to existing approved business cases Page 10 of 11

Page 90 to determine if relative weights need to be adjusted for future application. This process will be led by the QIPP Development and Monitoring Group and the results will be shared with the Governing Body for approval at the November session.

6. Key Recommendations

The key recommendations for consideration are as follows:

No: Recommendation:

1 To note the key planning dates (Tables 1-3)

2 To approve the business case approval process (Figure 2)

3 To approve role of groups in the planning process (Table 4)

4 To approve the Prioritisation Matrix (Table 5) in principle, pending a review of the weighting

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Page 92 Agenda Item 8

Director of Public Health Report for the Gloucestershire Health and Care Overview and Scrutiny Committee

November 2015

This is my first report to the Health and Care Overview and Scrutiny Committee (HCOSC) since being appointed to the role of Director of Public Health. It has been over two and half years since this post was filled substantively so I wanted to take this opportunity to provide an overview of the role and briefly discuss the public health offer going forward.

The Director of Public Health is a statutory chief officer of Gloucestershire County Council (GCC) and the principal adviser on all health matters to Members and officers, with a leadership role spanning the three areas of public health stated below:

1. Health improvement • Tackling inequalities in health • Developing and commissioning services to support healthy lifestyles • Developing healthy, sustainable and cohesive communities through the Health and Wellbeing Board and the wider Council and partners

2. Health protection • Working with Public Health England to deal with infectious disease and environmental threats • Preparing for emergencies including pandemic influenza (in conjunction with Stewart Edgar, Chief Fire Officer)

3. Health services public health • Population health care, including oversight and promoting population coverage of immunisation and screening programmes • Supporting the commissioning of appropriate, effective and equitable health care from the NHS locally • Contribute to the integration of health and social care services

As well as being a County Council officer I have a leadership role in driving forward the public health agenda across the county. The public health agenda is much wider than the services commissioned by the public health team in GCC using the public health ring fenced grant. A large part of my role will involve influencing, shaping and supporting the public health agenda in other organisations for example the Clinical Commissioning Group (CCG), local health providers, District Councils, the voluntary and community sector and with the public. I will continue to build upon existing good working relationships to take this work forward.

A recent example of working across the system is the Keeping Well in Winter conference that took place on 21 October. In order to support health and social care resilience across

Page 93 Gloucestershire I have been working with the Directors of Nursing from the CCG, Gloucestershire NHS Foundation Trust and Gloucestershire Care Services. We ran a conference for care home staff to promote the management of Norovirus within the patient’s home and to encourage staff to take up the offer of a seasonal flu vaccination. The conference increased levels of awareness around best practice in managing and preventing Norovirus and the health services available to support patients in their own homes, for example the rapid response. It also focused on challenging preconceived ideas about the seasonal flu vaccination in an effort to increase uptake amongst front line staff. The event highlighted a number of areas for improvement and I am working with colleagues from the organisations above to take these forward.

I will continue to work with Councillor Andrew Gravells as Cabinet Member for Public Health and Communities and the public health team to further refine the public health offer to the system. This will include how we use the public health budget to commission services that have the greatest effect on tackling health inequalities and improving health and wellbeing and supporting and influencing the public health agenda in other organisations. Finally the public health offer will include how we use our public health skills, for example in epidemiology, statistics, health economics and evidence based practice to support colleagues in GCC and partners to commission services that contribute to the public health agenda.

Page 94 Agenda Item 9

Health and Care Scrutiny Committee – Report from Commissioning Director: Adults and DASS ______

Meeting the Challenge 2, Single Programme – Older People

The Single Programme is a collective of linked projects whose aim is to change the way we provide care and support for older people. It recognises Gloucestershire’s Strategy for Older People and the ability to meet the needs of a growing population of older people within available resources, and to bring about the necessary changes in practice and performance which will make this possible. We anticipate that this changed model of care will enable greater independence for older people and deliver more personalised services.

Key activities include:

Recommissioning Domiciliary Care

Retendering the contract for provision on home-based care and support, to deliver better integration with health services and with a greater emphasis on supporting independence. The tender for both rural and urban areas will be published by the end of October.

Recommissioning Community Meals

Introducing a new Community Support Model and retendering the contractual element for the provision of subsidised hot meals to vulnerable older people. The tender has been published.

The Single Programme has also widened its scope so that it now includes projects to address Reassessments, Care Home Admissions, Reablement, Referral Centres and other areas of process management. Bringing these areas of work, which were previously managed by Gloucestershire Care Services, into one programme will enable us to better influence whole system change and to co-ordinate multiple projects more effectively.

GIS (Healthcare) – Integrated Community Equipment Service

GIS Healthcare has recently been accredited with CECOPS Award (Community Equipment Code of Practice Scheme). This was an audit on how GIS Healthcare manages the delivery of the “Integrated Community Equipment Service in Gloucestershire”.

This award follows a recent annual audit by Bureau Veritas for the national award ISO 9001 2008 which GIS Healthcare passed with flying colours.

Page 95 In recognition of GIS Healthcare being the only organisation delivering a 1 day community equipment delivery service in the UK, CECOPS Chief Executive Brian Donnelly MSc wants to do a feature on GIS Healthcare in a national care magazine to celebrate this achievement.

GIS (Healthcare) as a business continues to seek improvement to the operating processes and procedures to create greater levels of efficiency and effectiveness.

Physical Disabilities

Needs Analysis

Work is underway to develop a Physical Disabilities Needs Analysis which will be co- produced with Physical Inclusion Network Gloucestershire (PING) a user led organisation. This will help Gloucestershire County Council (GCC) and the Clinical Commissioning Group (CCG) to gain a better understanding of current services for people with physical disabilities and their families and help to shape future services.

Physical Disabilities Partnership Board

We are setting up a Physical Disabilities Partnership Board which will be independently chaired. This will include representation of people with physical disabilities and key stakeholders such as PING, Disabled Responsive Organised People (DROP), Gloucestershire Deaf Association, Insight and STAR College etc. The Board will meet bi-monthly initially and quarterly after the first year. The focus of the Board will be to oversee the development of the Needs Analysis and develop some commissioning priorities and an outcomes framework which will help to implement Building Better Lives and ensure that our future contracts are delivering the right outcomes for individuals. The Board will operate as a federated model reporting to the Building Better Lives Board.

Quality of Service Provision

We are establishing Physical Disabilities as a distinct part of the regular Quality meetings (managed by Learning Disabilities Quality Team). We will hold a Physical Disabilities planning workshop with the Quality Team, Commissioning Placements for Adults and Children Team, Safeguarding, Care Quality Commission (CQC), User- Led Organisations and colleagues in operational services to prioritise and plan for quality visits and quality compass. The planning workshop will also clarify roles and responsibilities, establish how we will escalate issues and work with providers to improve their performance.

Care Act Update

Despite speculation, there is unlikely to be news either about next year's ongoing Care Act funding or what will happen to funding this year relating to Care Act Part 2 until after the spending the review and settlement in December 2015. Consequently some elements of project planning are extremely difficult.

Page 96 The next Care Act Stocktake has been released and a final submission is due on 4 November . Many of the questions relate to volumes of activity resulting from the implementation of Part 1. It is considered that the answers will be used to inform decisions about future and current funding. It is therefore extremely important to give very careful consideration to the answers given. Officers are aware of this and are working to ensure that accurate returns are made. A meeting has been arranged within the South West Region to ensure that there is consistency in Stocktake responses across the Region.

Notwithstanding the above, steady and good progress is being made across the Programme and there is real sight now of projects coming together.

Initial Contact

A Workshop was held on 17 September, this was well attended with delegates from GCC, GCS and the CCG. Significant progress was made towards agreeing a new model. There was a clear understanding that the existing system does not fit with the current or future “integrated landscape”. The view held by most is that the single point of clinical access should remain as is and not be part of the revised model. Next steps have yet to be determined but before moving on there is a need to better understand the volume of calls to the Help Desk and what happens to them. A meeting has been arranged with the CCG Joint Commissioning officer with a view to establishing a project working group to develop the model further.

Support Planning

The new specialist Direct Payment team is now in place and has started to review existing cases. Recruitment of the Support Planning team for service users with a physical disability is well under way.

Resource Allocation System (FACE)

September saw the first meetings of both Carers RAS Implementation Group and the Disability RAS implementation group. Progress on both is challenging but steady. It is difficult to predict when this work will be complete as there are various stages to go through, including extensive testing. The carers RAS in some regards is more straightforward but the value of costs that can be attributed to the RAS will not be known until after the spending review and settlement in December. There may also be a requirement to go to consultation as the outcome from the RAS is likely to result in different (albeit more rational and equitable) outcomes for carers. The implementation of this RAS will focus on carers assessment, needs and cost and what assessment work is being undertaken within mainstream operations and whether there is any double funding or not. Consequently this project will have a major impact on improving the overall processes and practice alongside achieving significantly improved Care Act compliance.

FACE is on the verge of launching a new analysis tool called “Imolytics”. This is reported to be a very sophisticated tool that will give us the ability to analyse assessment detail in a way that has not been possible before. For example, we would be able to tell how much we are spending within particular domains on the

Page 97 RAS by area, team and individual. We could determine the differences between Indicative Budgets and Personal Budgets and what had led to the differences i.e., did it result from some of the new duties under the Care Act or was it down to other factors. Imolytics will be available for other applications and early thoughts are that it may well prove very useful in interrogating the new finance module when it is implemented. The tool is free to use within FACE but if used in other applications there would be a cost.

New Finance Module

Final evaluation of the two tenders received is nearing completion. A decision on the preferred supplier will be made before the end of October.

Information, Advice and Advocacy

The Your Circle refresh was purchased at the end of September. This is expected to be in place by the end of December 2015. This will see a significant improvement in the look and feel of the website and will include seamless links into corporate and other websites in a way that has not been previously possible.

ADL Smartcare self service website and Smartcare Clinics

Care Act Project Resources have now been deployed to introduce a revised ADL Smartcare self service web offer. This is coincident with the imminent production of an improved version from ADL Smartcare. The new version is fresher and cleaner and although the questions and algorithm will be largely unchanged, the result will be a vast improvement on what we currently offer. Early talks are taking place on whether Gloucestershire may become a test bed involving service users prior to the official launch of the new product.

A meeting has taken place with GCS and CCG partners regarding the implementation of this project. There is considerable interest in this not least because there is an opportunity to implement a joint solution that includes not only OT services but could involve community nurses.

Gloucestershire Care Services

Referral Centres

Referral Centres continue to thrive and develop during 2015-16. Referral numbers for community health and social care are rising significantly, with referrals going up 22.4% in the first quarter of 2015-16, compared to the same period last year. As a result, it is critical that the centres continue to develop and work differently to help manage this extra demand. A countywide workshop led by Commissioners was held on 17 September 2015 1 which indicated widespread support to increase the role of referral centres in each

1 “Reviewing initial contact points for community health and social care services (adults) workshop”

Page 98 patch, becoming the main receiving point for initial contacts in the community. Currently, referral centres focus on:

• Responding quickly to cases that require timely intervention to make safe or stabilise a situation. • Linking referrals to community based support/services when appropriate • Resolving simple cases that can be closed quickly and easily by the referral centre. • Managing cases where it is more efficient (and with a better experience for the service user) to retain within the referral centre rather than transferring to another team. • Using a positive risk taking approach, seek to maintain people’s independence with the minimum short or long term statutory support.

Work will continue with commissioners to develop the role of the referral centres and to ensure that the model is consistent across the county.

Further training has taken place with both frontline and management colleagues to embed strengths-based approaches and solution-focused training. This is helping colleagues to transform the way they ask questions, gather information and then support and plan with service users to help keep them in control of the situation and their lives. The training has been very well-received by colleagues and over 130 have taken part so far. The training continues until February 2016 with more staff taking part in the New Year.

The referral centres continue to resolve as many queries as they can to give a swift but safe response to peoples’ needs, with a real focus on keeping people in control of their lives, putting them in contact with their communities and accessing preventative support such as reablement and telecare services. The latest figures show that 69% of referrals were resolved in the referral centre in August.

Telecare

Linked to the Care Act and the Single Programme plan a review of telecare provision has been completed, and areas for focused work identified. A successful pilot, in partnership with the Fire and Rescue Service, is being rolled out across the county. The scheme enables vulnerable older people to name the Fire and Rescue Service as a responder to a telecare alert. During the first six weeks of its trial period, telecare equipment was issued to 24 people who would otherwise have been unable to use the service.

This extension of the service forms part of an overall growth in the number of service users receiving telecare by almost 200 since March 2015 with the percentage of community service users receiving telecare having grown from 23% to 26% in total.

The Telecare Team are also working with GFRS to train selected staff on telecare equipment as part of a government pilot which goes live in November and have been working with the CCG to pilot “Florence” a text messaging prompt service to support telecare which is being piloted for 3 months.

Page 99 Based on the telecare review findings, training continued through the summer, supporting the Integrated Discharge Teams at both Gloucester Royal Hospital and Cheltenham General Hospital. Referrals from the hospitals are increasing and accordingly the team are refocusing their resources to ensure they can support this demand.

Finally, the team are reviewing the equipment they use to make sure they make the best use of equipment funding so that it can support as many people as possible.

Reablement

An improvement plan for reablement continues to be actioned, with work focusing on reducing sickness within the teams, increasing the amount of face to face time (contact time) that reablement workers spend with service users and making sure that the majority of service users receive their service within the expected time of six weeks.

Contact time has reduced slightly but significant work is underway to make sure that this is being recorded properly (this is shown at figure 4). The numbers of people receiving a service for longer than 6 weeks is reducing steadily. This allows the teams to provide more capacity, particularly with new service users who often need additional support in their first few days and weeks of receiving reablement. In August 2015, 84% of people had a reassessment and were progressed into being independent or supported to move into new services. Unfortunately, sickness increased again in August to 7.7% and the teams are working hard to manage this.

The focus in the coming weeks is preparation for winter, to make sure that the reablement service is supporting people to come out of hospital, but also helping to prevent them being admitted where possible. The reablement service works closely with all hospitals in Gloucestershire and plays an active role in helping people get home from hospital and back to their optimum levels of independence.

Feedback is very positive from service users receiving the service and work is now underway to review how the impact of reablement is shown – for example, in the way the service measures how independent people are following reablement and the impact on their quality of life. The aim is to conclude this work soon, so that a fuller picture of the impact of reablement can be shown.

Learning Disabilities

User-led organisations negotiating a merger

Three user-led organisations in Gloucestershire are in the process of negotiating a merger. The Physical Inclusion Network for Gloucestershire (PING), Gloucestershire Voices and Disabled, Responsible, Organised People (DROP) are three user groups of varying sizes and remits. PING focus on people with physical disabilities, Gloucestershire Voices on people with learning disabilities and DROP is a multi- impairment group.

Page 100 The organisations plan to merge to achieve two important aims:

• to align themselves better with the all age and all disability direction set by Building Better Lives • to continue to grow and develop as a robust and ambitious organisation, capable of winning contracts and bringing in business on an equal footing to other providers.

The organisations expect to have completed the merger by 1 April 2016.

Black and Minority Ethnic project commencing for people with Learning Disabilities

Through the Big Plan, work was started to build up connections and relationships with BAME communities. This was due to the recognition that there were not strong enough connections with BAME and newly arrived community groups. These initiatives which are under way to engage closely with the BAME community will start coming together through the Building Better Lives BAME reference group. This group (consisting of the existing Building Better Lives reference group membership and the BAME project led by GL Communities) will take an all age and all disability remit. The group will deliver a range of initiatives for the BAME community, as well as providing an advisory role to the wider workstreams of the Building Better Lives programme to ensure that the needs of disabled people from the BAME community are recognised and catered for appropriately.

User committees developing in drop-in services

There are six drop-in services for people with disabilities in the county. The drop-ins used to be for people with learning disabilities and now are all-disability. The drop- ins have an important function to provide community support to people about issues such as finances, safety, benefits, being aware of social opportunities and getting a job. Over the next couple of years it is anticipated that the drop-ins will be commissioned out to local disability groups. This is a significant change and requires a shift in culture and some prior planning. In preparation for this, user committees are being set-up in all the drop-ins. The drop-ins in the Forest, Tewkesbury and Gloucester are the first to develop this committee approach. The remit of the committees is to form a management function in the drop-ins.

Hate Crime strategy commencing

Gloucestershire County Council is working closely with the police to start the work on an ambitious and coordinated hate crime prevention strategy. The Building Better Lives programme is involved in the work and particularly in the initiatives to tackle disability hate crime. A conference was held over the summer with over a hundred attendees to discuss people’s experiences of disability hate crime and the contributions that statutory services and the voluntary sector currently make to the agenda. Further planning and coproduction is anticipated during national hate crime week.

Page 101 Electronic Call Monitoring

The roll out of Electronic Call Monitoring has now been implemented across the learning disability sector. This means that the county knows exactly what care has been delivered, what times it was delivered and who delivered it. These quality measures will be incorporated into other quality initiatives. As a by-product of this GCC will now only pay for care that it can verify has been delivered. Progressive work with this system has allowed for the on line verification and payment of invoices and thereby reducing back office costs.

Brandon Trust

Work with Brandon Trust to turn a block bed contract into personal budgets and wrap around services is continuing in line with the Cabinet approved plan. The work involves a widespread move to supported community living and a refurbishment of housing which was either not fit for purpose or was in a poor location to meet the community inclusion needs of its service users.

Mental Health

Crisis Care Concordat

Gloucestershire is in the process of reviewing its Crisis Care Concordat action plan after 1 year of operation. There has been significant development with 2gNHSFT in remodelling the existing Crisis Resolution and Home Treatment Service into the new Mental Health Acute Response Service. This service will have two functions:

• Urgent Response Team • Rapid Assessment and Home Treatment

The intention is that the new service will provide faster access to initial triage, assessment, signposting and treatment to a broader range of people. It is intended that the service will develop close working relationships with both Police and Ambulance services. We are working towards certain functions being co-located with the Police at Waterwells.

External Care Budget

Colleagues in 2gNHSFT are working closely with colleagues from GCC finance/commissioning to:

• Seek to reduce the level of spend to match the available budget. • Gain assurance that the service provided by 2gether provides good value for money. • Gain assurance that working processes are robust. • Consider how to build upon the cost reductions achieved during 2014/15, and forecast potential levels of expenditure for 2015/16 and 2016/17. • Consider the form of contract that should be in place between the commissioners and 2gether to deliver this service.

Page 102 This work should be completed by December and a paper will be shared with senior managers/executives across GCC/CCG/2gNHSFT.

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