Paper 21 NHS Ayrshire & Arran Meeting: NHS Board Meeting date: Monday 29 March 2021 Title: Performance Report Responsible Director: Kirstin Dickson Report Author(s): Donna Mikolajczak (Performance Manager), Paul Dunlop (Senior Performance Officer), Steven Fowler (Senior Performance Officer) 1. Purpose This is presented to the NHS Board members for: • Discussion This paper relates to: • Government policy/Directive This aligns to the following NHS Scotland quality ambitions: • Safe • Effective • Person Centred 2. Report summary 2.1 Situation The health and social care system as a whole across Ayrshire and Arran has been continuously adapting throughout the COVID-19 pandemic to effectively and safely respond to the ongoing challenges and presence of COVID-19. Re-mobilisation commenced in the summer months to restart as many of its normal services as possible, and as safely as possible. However, the resurgence of COVID-19 in the autumn and winter months placed considerable pressure on services and resulted in a decision to again pause the majority of planned care. This report provides an overview of Unscheduled Care (2.3.1) and Planned Care (2.3.2) performance to ensure that NHS Board members are sighted on the corresponding impact of COVID-19 across the system as a whole. All NHS Boards across Scotland are required to develop the next iteration of their Re-mobilisation Plans, to cover the period from April 2021 to March 2022. This will be considered as our Re-mobilisation Plan 3 (RMP3), a one year plan setting out key priorities and actions for 2021/22. Whilst being clear about our plans in the next year, RMP3 will continue to be adapted and modified as we move forward through 2021/22. 1 of 38 The first draft of RMP3 was submitted to Scottish Government at the end of February 2021. Once this has been finalised and approved by the Scottish Government, this Performance Report will report on progress against the RMP3. 2.2 Background Emergency Departments (EDs) at both University Hospital Ayr (UHA) and University Hospital Crosshouse (UHC) initially experienced a significant reduction in attendances following the lockdown restrictions at the end of March 2020. Attendances then steadily increased month on month, and by August 2020 had returned to levels similar to that experienced in the pre- COVID-19 period. However from September 2020 onwards, attendances have again been reducing. The new Redesigning Urgent Care (RUC) pathway was launched on 3 November 2020, with the aim of routing all unscheduled care attendances via NHS24 to be triaged and directed to the most appropriate care service, which in many cases would be alternatives to attending the Emergency Department. Although we have seen a decrease in both ED attendances and emergency admissions, rising COVID-19 positive patients in hospital over the winter months presented a significant challenge in terms of Unscheduled Care. A re-mobilisation process over the summer months supported the re-introduction of some planned care patient activity and prioritised this on the basis of clinical urgency rather than length of wait. However, the increasing prevalence of COVID-19 during the autumn months resulted in a decision to again pause the majority of acute planned care. Cancellation of appointments was a necessary step to ensure the safety of the population, therefore on this basis compliance against key National Waiting Times Service Access targets remains at a lower level. This means that current performance is not truly comparable to system performance prior to the start of the period of the COVID-19 pandemic. Some measures have remained stable or indeed improved throughout the initial response and through into the recovery stages. These include services that have largely been able to be delivered remotely through telephone and NearMe technology such as Child and Adolescent Mental Health Services (CAMHS), Psychological Therapies, Drug and Alcohol Treatment and Musculoskeletal Services. We continue to monitor the effect of the pandemic across all areas of Performance routinely reported to Board members. 2.3 Performance Sections 2.3.1 and 2.3.2 include the most up to date data using local management information in relation to unscheduled and planned care. A separate Appendix (1) includes trends in performance; Appendix (2) compares NHS Ayrshire & Arran to NHS Scotland performance; and to provide additional context, Appendix (3) highlights trends in the number of COVID-19 positive patients in our hospitals. 2.3.1 Unscheduled Care NHS Ayrshire & Arran was an Early Implementer Test of Change Board for the National Redesign of Urgent Care (RUC) Programme. The new Redesigning Urgent Care (RUC) pathway was launched locally on 3 November 2020, with the aim of routing all unscheduled care attendances via NHS24 to be triaged and directed to the most appropriate care service, which in many cases would be via alternatives to attending the Emergency Department. The Programme was further rolled out nationally from 1 December 2020. The Redesign of 2 of 38 Urgent Care National programme aims to reduce ED attendances and prevent overcrowding in ED waiting rooms. The intention of the redesign of urgent care services across Ayrshire and Arran has been to provide safe, person centred urgent care over a 24/7 period to support General Practice and Primary Care out of hours services as well as our Emergency Department and Combined Assessment Units (CAUs). As part of this programme, NHS Ayrshire & Arran introduced a Flow Navigation Centre that offers rapid access to a senior clinical decision maker who has the ability to advise self-care, and direct patients to available local services such as: • Primary care (in and out of hours) • Mental Health Teams • Minor Injury Units • Same Day Emergency Care (Acute) If a face to face consultation is required, this will be a scheduled appointment with the right person, at the right time in the right place based on clinical need and to ensure the safety of patients and staff. Overall attendances at our ED departments fell to the 2nd lowest level ever recorded in January 2021. It is likely that the new pathway, combined with Tier 4 restrictions implemented in November 2020 and continued throughout December 2020 and January 2021, have contributed to the reduction in ED attendances. Although overall attendances at our ED departments reduced in January 2021, the numbers of COVID-19 confirmed cases in hospital started to increase from a baseline of near zero in early October 2020, accelerating rapidly towards the end of December 2020, and by 25 January 2021 had reached 240 (Appendix 3). This placed considerable pressure on our services and presented a significant challenge in terms of appropriate space for these patients to be reviewed within the ED and CAU. Ward and room closures due to COVID-19 infected patients also had a significant impact on patient flow through both acute hospitals. COVID-19 positive cases in hospital peaked on 1 February 2021 and have been steadily decreasing since. 3 of 38 Emergency Department NHS Ayrshire & Number of ED Number of ED ED Compliance Arran Attendances 12 Hour (%) Breaches Jan-20 8,820 514 77.4% Feb-20 8,006 447 77.0% Mar-20 6,915 191 86.7% Apr-20 5,314 0 96.3% May-20 7,213 0 96.1% Jun-20 7,717 0 96.4% Jul-20 8,397 2 95.4% Aug-20 8,805 3 93.5% Sep-20 7,866 88 90.5% Oct-20 7,143 110 85.6% Nov-20 6,248 117 82.0% Dec-20 6,136 274 79.2% Jan-21 5,624 312 79.1% Difference (Jan- 20 and -3,196 -202 +1.7 Jan- 21) Source: Local monthly management reports, Information Team ED Attendances across NHS Ayrshire & Arran decreased to a low of 5,314 in April 2020 following the outbreak of COVID-19, before returning to pre-COVID levels by the summer. Attendances have since reduced each month from August 2020, falling to 5,624 in January 2021 (a decrease of 36% compared to January 2020). The numbers of ED 12 Hour Breaches at Board level have been increasing significantly, rising from 0 in June 2020 to 312 by January 2021. Despite this, numbers remain lower than for the same period of the previous year. The ED 4-Hour Wait compliance at NHS Board level reduced to 79.1% in January 2021, falling below the 95% target for the sixth consecutive month having previously exceeded the target in each of the calendar months between April 2020 and July 2020. Throughout January 2021, the pandemic continued to severely impact on waiting times in our EDs, both for 4 hour and 12 hour waits. Long waits in ED due to bed shortages were driven by the steep increase in COVID-19 positive inpatients in December 2020 and January 2021. Bed occupancy within Medical specialities was at 100% at times, with high acuity reported within the clinical areas. This meant that there were challenges with flow moving patients to downstream beds. Ward and room closures due to COVID-19 infected patients also had a significant impact on patient flow through both hospitals and this in turn has meant the 4 hour standard has been more difficult to achieve. A comparison of ED attendances, 12 hour breaches and compliance against the 4 hour ED standard for both UHA and UHC is outlined in the infographic below. 4 of 38 Comparing January 2021 against January 2020, there were 1,046 fewer ED attendances at UHA, representing a 34.4% decrease. Similarly at UHC, there were 2,150 fewer ED attendances in January 2021 than in January 2020, representing a decrease of 37.2%. The decrease at both sites was predominantly in relation to Flow 1 (Minor Injury) and Flow 2 (Acute Assessment, including Major Injury) attendances.