Agenda item

The Committee will receive an update on urgent care in Wiltshire’s rural communities, which includes the availability of services and response times. 

The Chairman welcomed Heather Cooper (Urgent Care and Flow Director – BaNES, Swindon and Wiltshire Integrated Care Board) (BSW ICB), Helen Wilkinson (ICS Community Pharmacy Clinical Lead, BSW ICB), Jo Cullen (Director of Primary Care, BSW ICB) and Paul Birkett-Wendes (Head of Operations, BSW, SWAST) who were in attendance to give an update on urgent care in Wiltshire’s rural communities.

Summarising the more detailed presentation included in the agenda pack, the following was highlighted:

·            An overview of the urgent and emergency care (UEC) approach across the BSW ICB included the focus and priority to ensure that safe services are provided with a system wide approach.  There were a number of key objectives to improve response times, A&E waiting times and maintain acute bed and ambulance service capacity.  Providers were to deliver key performance outcomes and partners had worked collaboratively to develop the system operational plan for 2024-25;

·            There were four focus areas in the BSW Urgent Care and Flow 2024-25 plan which included Virtual Wards, System Care Coordination, Process Improvement and Locality Plans;

·            There had been an increase in non-elective demand.  Details were shown of the areas where there had been an increase in activity and the actions being taken to address the challenges.  Prevention would play a significant role in the future management of the UEC demand and would be through the delivery groups that relate to Primary Care and Community, THRIVE (mental health) and Children and Young People;

·            Details were given of locality funded schemes to support patients to stay at home and receive the right care from the right clinician at the right time;

·            The BSW primary care services are a vital part of the system serving a combined population of 940,000 which is made up of 84 GP practices and 28 Primary Care Networks.  The map shared in the agenda pack showed where these services were located.  The ICB spend around £175 million a year on primary care services including around £12 million on locally commissioned services;

·            The demand on services was in increasing challenge – 500,000 appointments requested a month across BSW, a mixture of phone calls, online consultations and some face to face appointments.  There was monitoring around this at practice level and they were trying to do what they could to support additional access with the increasing demand.

·            The Pharmacy First scheme had been launched nationally and individual pharmacies could choose whether to participate or not. All Wiltshire pharmacies had signed up to help with seven common health conditions without needing a GP appointment which included sinusitis, sore throat, earache, infected insect bite, impetigo, shingles and urinary tract infections.  This was to enable GPs to have more time to deal with patients who needed to be seen;

·            Local specific data dashboards were in development and the Wiltshire data could be shared at a future meeting.  There was an average of 6000 Pharmacy First consultations a month across 139 BSW pharmacies which can be broken down by clinical condition (e.g. sore throat, UTI) of what consultations are going to the pharmacy first.  The vast majority of those are dealt with by the pharmacy and when a referral is needed then most patients are referred back to the general practice;

·            Ambulance mean response times by local authority area for 2023 and 2024 were shown for category 1 responses (life-threatening injuries and illnesses, specifically cardiac arrest) and category 2 responses (for emergency calls such as stroke patients).  Response times across the Southwest had been under increasing pressure over the last two years, linked both to increases in activity volumes and hospital handover times at acute hospitals.  For BSW, the average hospital handover times during this period is around a 69 minute delay per patient compared to the 15 minute national standard; and

·            The Trust currently manages a high proportion of activity without conveying the patient to an Emergency Department (ED) which helps avoid unnecessary attendances.  The percentage of incidents conveyed to an ED was around the mid thirties.  Only 3 or 4 patients go on to an ED as there was an increased focus on treating at the scheme with the care being directed throughout the Care Coordination Hub which had a number of experts based in Chippenham.  Calls can be made to them to get further expert advice to take to an alternative destination rather than an ED so as to avoid handover delays at Eds and the ability for ambulances to respond in a timely manner. 

The Committee asked the following questions which included but were not

limited to:

·            Did the planned growth in the system to benefit the community come with any money from government to improve emergency and urgent care - has there been an increase to the number of beds available, particularly in the winter, are there more ambulances available, has the number of clinicians been expanded particularly in NHS 111 to ensure that people are directed to the right place. What help has the Government given you to rise up to meet some of these challenges?  It was noted that there had been in increase in funding which had helped increase the number of and hours ambulance resource that they had been able to provide.  An extra £33 million had been received across the Southwest which had been used to increase operational cover and to increase the number of clinicians in call take centre to give advice to patients directly.  It was further noted that in previous years they had been told that there were no more winter monies and they have to work within their allocated finances.  There had been work into looking at demand and bed capacity and what is needed at acute hospitals.  This was factored into planning so that the capacity can increase as the demand increases.  The workforce is a critical issue which was a well known issue particularly for the Southwest.  They were fortunate to have an integrated urgent care provision that was provided by Medvivo and there were senior clinicians that support that service. It was recognised that demand had and continues to increase and they would continue to work on that in line with the national drive so that people are seen by the right clinician at the right place and at the right time. Overall, there had been no significant financial increases apart from for the ambulance service and would not be for this winter coming.  There had been additional funding for primary care services or winter care funding.

·            Feel that the scales on the Pharmacy First graphs are not clear and not sure what the actual pattern is showing – could they be made clearer going forward?  It was noted that these graphs were a work in progress and they could try to make these clearer going forward.  There had been a dip in GP practices referring patients to pharmacy over the summer and as it was still quite new they would continue to work hard with the practices and PCN’s get them to refer to pharmacy.  They were working on the digital barriers and it was hoped that it would come back up when the autumn data was received and they could continue to monitor carefully.  It was hope that they would be able to see the GP referrals dropping with patients knowing that they can now use pharmacies for the 7 identified conditions and there was a further public communications campaign around this starting this week. 

·            Comment that a committee member would have liked to have seen the range across the ambulance mean response times as to what the lowest and highest times are and what they are for rural communities.

·            Are the numbers of consultations undertaken broadly what was expected since the service launched in January 2024?  It was noted that the ICB benchmark well nationally as prior to Pharmacy First they had a locally commissioned service in place which looked quite similar and the pharmacists were quite experienced with this.  However, they would like there to be more use of the service as it suits their skills, helps their income stream and makes a community pharmacy a more attractive pace to work, and takes the pressure off GP practices.   

·            Is there any follow up / tracking for the 96% of pharmacy First consultations that are not referred onward to ensure that this was the appropriate course of action?  It was noted that there was not a lot of data available at this time but for some patients it would be appropriate for them to go back to the GP’s.  There were tight conditions on the 7 illnesses and for those that fall outside of those criteria will need to go back and be seen by their GP.

·            Had there been a reduction in consultations in other areas since the launch of Pharmacy First – was there any data on that?  It was noted that there was no data for that, and it was likely that those appointments would be filled up with others that needed to be seen. 

·            How available is the pharmacy service overall but especially out of hours 100-hour pharmacies?  It was noted that all Wiltshire pharmacies had signed up to provide this so it should be available for the hours that they pharmacy is open.  There had been some challenges with the locum population that were not quite on board at the beginning, but this was now a core part of community pharmacy.  There were some pharmacies that had reduced their opening hours – they have to supply core hours, and they can they do optional supplementary hours but some had cut these back for financial and business reasons.  There was not complete coverage in Wiltshire but if it could be used where it can it should help to take the pressure of GP surgeries.  

·            What are the plans to bolster the 100 hours a week pharmacy?  It was noted that some pharmacy businesses had made the decisions about their opening hours down to their profitability.  Whist they have a core set of contractual hours anything above that is supplementary and optional.  Whilst they could not make them open for 100 hours a week they could have a conversation around that.  An update could be brought to a future meeting around this.

·            Could we explore the reasons for the long handover times as presumably the ambulance staff are not working during those handover times as the NHS staff have not got the capacity to onboard the patients and what needs to happen in ambulance service or A&E service to reduce those times and who is leading on improving that?  It was noted that when ambulance crews are waiting for a handover they are still caring for the patient and remain responsible for them but are obviously not able to respond to other calls.  The handover delay dues are a symptom of capacity and demand across the whole system.  There was work being undertaken to look at having capacity at the right times of the day and how there can be flow through the hospitals with patients being able be discharged timely to home or other suitable settings.  Heather Cooper was leading on this work.

·            Are we still using First Responders and if not, why?  It was noted that absolutely First Responders are still being used and they are trying to expand how they can help us.  They had also developed a scheme called Hospital Helpers who would be working alongside crews who are outside of the ED.  It was confirmed that there were lively community responder schemes which were used and felt to be extremely valuable and an essential part of the team.

·            Noted that Wiltshire is higher than Swindon or BaNES in the mean response time across 2023 and so far in 2024 for category 1 responses – is there any analysis on this presuming is has something to do with rurality and is there anything that can be done to improve it?  It was noted that generally now ambulances are released to responses from hospitals (as opposed to standby points or bases) and of course can take longer to reach a patient.  The intent is that when there is capacity they are at standby points so that they are in the right position to respond to calls in a timelier manner.

·            We seem to be doing better for category 2 responses but note that we still rank 2^nd or 3^rd behind Swindon and BaNES – is this for similar reasons?  It was noted that this was the case and when there is an improvement in handover times they usually see an improvement in category 2 response times.

Resolved:

That the Health Select Committee:

1.          Undertake a Rapid Scrutiny to understand the data collected with regards to Urgent Care (to include range of response time and hospital handover).  The aim would be to develop a report for the Committee on Urgent Care, having reviewed what data is available.

2.          Following this the Committee receive an annual report on Urgent Care based on the findings of the Rapid Scrutiny which should include a specific update on 100 hours pharmacies (availability and viability).