Agenda item

To receive an update on winter pressures.

Paul Sinden, CCG Chief Operating Officer, Alex Faulkes, Head of Urgent and Emergency Care, and Darren Farmer, Director of Operations: Ambulance Delivery and Emergency Operations Centres Transformation, introduced the report which provided an update on winter pressures.

Paul Sinden noted that the priorities for winter were to reduce ambulance handover delays, to maintain elective recovery, and to maintain the rollout of the vaccination programmes for Covid-19 and the flu.

It was explained that there had been increases in primary care and urgent presentations, as well as low acuity appearances at A&E. It was noted that 6% of general and acute beds and 20% of critical care beds were currently occupied by Covid positive patients. It was commented that approximately 80% of these patients were unvaccinated which underlined the importance of maintaining the vaccination programme. It was added that there were high levels of bed occupancy with an average of 96% across North Central London (NCL) compared to the London average of 92%. It was explained that the pandemic had exponentially increased how trusts provided mutual aid and that escalation triggers were in place and had been strengthened for winter.

In relation to primary care, it was explained that situation reports were being undertaken by practices every two weeks. There were some concerns about a very small number of practices, approximately seven of 200, being closed and work was underway with these practices to ensure continuous provision. It was noted that about 20% of practices were reporting constraints on administrative capacity and that a number of staff were experiencing abuse from patients.

It was noted that the Winter Access Fund had provided approximately £7 million to extend primary care capacity over the winter period. This would be supporting practices to extend same day access and would be channelled into the areas with the highest levels of deprivation. It was noted that there would be some extended remote monitoring for people with long term conditions and extended links between practices and community pharmacies. It was added that many practices had raised administration capacity concerns and that work was underway with NHS bank partners to allow practices to access administration support.

In relation to e-consult, it was noted that this was introduced at the start of the Covid-19 pandemic in order to maintain access to healthcare. It was explained that, in general, the number of GP appointments had increased by 15%, not including e-consult. It was noted that e-consult flagged patients based on the severity of responses and that about 5% of people were diverted to 999 for emergencies and 111 for urgent issues. It was added that mechanisms were being developed to understand patient experiences of e-consult and that work was underway with the provider and 111 to refine the service offer.

Darren Farmer noted that the London Ambulance Service (LAS) had experienced a large increase in demand of approximately 15-20%. It was explained that, as a result of the Covid-19 pandemic, a number of people were using private transport which was impacting the road networks and journey times. In relation to hospital breaches in October 2021, it was reported that there had been 450 over an hour at North Middlesex Hospital, 459 at Barnet, 333 at the Royal Free, 159 at Whittington, and 48 at University College London Hospital. It was highlighted that, since October, the LAS had been developing a new process with colleagues across the system which had been trialled over a two week period and had been reducing delays.

Alex Faulkes noted that the non-emergency NHS number, 111, had seen significant activity over the pandemic with a 30% increase in calls which was approximately 610,000 calls per year. It was explained that additional call volumes were anticipated over the winter and that suitable resources should be in place, although it was acknowledged that there were staff retention issues across the country.

In response to questions, the following responses were provided:

·         Some members shared their experience of e-consult. It was noted that there was a lengthy form to fill out, that some of the questions asked were quite personal but irrelevant to a patient’s situation, and that it was not useful for urgent requests. It was added that some GPs were using e-consult and were not booking appointments over the phone which was difficult for some patients. Jo Sauvage, NCL CCG Chair and Primary Care Lead, noted that staff were available on the phones and that it would be important to ensure that e-consult was not a barrier to access. It was explained that e-consult may not be appropriate for all patients but that it was an important option to cater for diverse populations. It was added that it was useful to hear about the relevance of the questions asked by e-consult and to consider whether this required refinement.

·         John McGrath, GP & Clinical Responsible Officer (CRO), explained that e-consult was designed to provide online consultations rather than to book appointments. It was noted that the questions asked were based on a clinical algorithm that had been checked and that many of the questions would have been asked by a GP if the consultation was in person. It was accepted that e-consult was not useful in all situations, such as for under fives, and that it should be used as an addition to normal GP arrangements rather than a replacement.

·         Some members noted that there had been issues with cycling schemes that had affected attendance times at hospitals for the LAS and it was enquired whether the LAS was included in the consultation process for new schemes affecting roads. Darren Farmer explained that contact differed by borough but that more focus was placed in areas where there had been more incidents. It was highlighted that there were two elements: Low Traffic Neighbourhoods (LTNs) which were organised by councils and cycle lanes which were organised by Transport for London (TfL). It was noted that the LAS continued to work with councils and TfL to ensure that patients could be reached in a timely manner. It was added that the LAS was a stakeholder and was routinely consulted but that engaging with this process was not always possible with increased workloads.

·         It was noted that the LAS had been implementing some new measures to tackle delays and it was enquired what this involved. Darren Farmer explained that work had been undertaken to identify which trusts were under the most pressure and which had capacity and, in response, boundary areas had been adapted to redirect some activity to trusts with capacity. It was highlighted that this was done in relation to patients who were least likely to require admission.

·         It was noted that a number of LAS sites across London had been reconfigured in response to the Covid-19 pandemic but had now been deconsolidated to increase capacity. It was explained that there was a long term ambition for the LAS to move to a more centralised model but that no further changes were anticipated in NCL at present. It was added that it had been difficult to identify direct links between changes and impacts due to the number of developments that had taken place.

·         In relation to mental health, Sarah Mansuralli, Director of Strategic Commissioning, acknowledged the significant impact of the pandemic on mental health. It was noted that A&E was not an appropriate place for those experiencing a mental health crisis but that many patients experienced a long length of stay where out of hospital pathways were not well-established. It was explained that there was some additional funding for mental health winter pressures and that it was aimed, working alongside colleagues in social care and housing, to establish better pathways. It was noted that it was aimed to support multi-disciplinary work around discharges to ensure that people would have the right care and support in the community. It was added that there had been developments in community transformation, including additional roles within primary care to support mental health need. It was noted that primary care had become more integrated with mental health and that lower level crisis provision had significantly improved. For example, it was highlighted that it was now possible for patients to access support lines directly rather than having to go through crisis services.

·         The Chair enquired whether there were any areas of particular concern for the LAS. Darren Farmer explained that the LAS was in a solid position to cope with winter pressures and that, with new systems, was hoping to halve waiting numbers. It was noted that there had been significant, increased demand on the system, and particularly on staff, which could not be sustained and he urged everyone to use the system wisely, including the 111 telephone number and pharmacies.

The Chair noted that the Committee appreciated all of the work of the LAS in keeping the public safe and well and fully supported the request for extra staffing and wellbeing support. It was noted that it was useful to hear the actions that had been undertaken to reduce waiting times outside hospitals. The Committee requested a future update on the results of the proposed actions to improve LAS waiting times. In relation to e-consult, the Committee asked to receive additional information on how it was being used and whether it was an appropriate platform. In relation to workforce pressures, the Committee requested a future update to ensure that GPs and staff were appropriately supported.

It was noted that the deputation on primary care and winter pressures had raised a number of questions and it was requested that the CCG sent a written response to the deputation after the meeting.

RESOLVED

1.    To note the update.

2.    To request a future update in relation to e-consult, including additional information on how it was being used and whether it was an appropriate platform.

3.    To request a future update on the results of the proposed actions to improve the London Ambulance Service waiting times.

4.    To request an update in relation to workforce pressures to ensure that GPs and staff were appropriately supported.

5.    To request a written response to the deputation from NCL NHS Watch and Keep Our NHS Public on primary care and winter pressures for the Committee to consider.