Executive Medical Director Blog: April 2023 – Dr Frankie Swords

6th April 2023

Well, it’s almost Easter – and for many of us a nice long weekend.  So, I would like to start my blog this month by saying a massive thank you to those who will be foregoing time with their own families and loved ones to work or be on call supporting the Norfolk and Waveney health and care system and keeping people safe. Thank you so much for everything you are doing.

As I outlined last month, we have now set our system priorities as part of our Joint Forward Plan and a reminder of these is listed below.

  • Transforming Mental Health services
  • Improving Urgent and Emergency Care
  • Improving Elective Care
  • Developing a resilient and integrated model of Primary Care
  • Improving Productivity and Efficiency
  • Population Health Management, Reducing Inequalities and Supporting Prevention
  • Improving services for Babies, Children and Young People and developing our Local Maternity and Neonatal System (LMNS)
  • Transforming care for older people

    I’ve picked out just a few of these to focus on this month – urgent and emergency care, elective care, primary care and productivity and efficiency as well as giving an update on the forthcoming round of industrial action. 

    Industrial action update

    Local NHS services will be very busy this coming Easter weekend and during the industrial action planned for the four days afterwards. The British Medical Association, Hospital Consultants and Specialists Association and British Dental Association have announced further strike action, with Junior Doctors’ and Dental Core Trainees taking industrial action to run from 7am on Tuesday 11 April to 7am on Saturday 15 April. This will involve a stoppage of all work including nights, on-call shifts and non-residential work.

    So, we have looked at our key learning from last time to inform our planning this time:

    Firstly, we think that increased public messaging would have been beneficial. So, we are doing a really big push in advance of this latest round of industrial action stressing that: Our services will be busy and under more pressure than ever so to choose wisely, think NHS 111 first, use alternative means where appropriate and plan ahead. We are also stressing that we will need to reschedule elective work in order to keep our emergency and inpatient services safe, but for people to please still attend appointments unless contacted to say they have been cancelled. You can read more in our press release here.

    Discharges were also later than usual and flow was challenged particularly for the first 24 hours. So, we have run Multi Agency Discharge Events (MADE) this week to try to create capacity in advance, we have plenty of transport available to support discharge, and we have internal transfer teams to support with flow. IC24 will again have additional staff to redirect as many patients as possible away from EDs if clinically appropriate. There will be additional clinical assessment service (CAS) capacity to support NHS 111 and additional vehicles for home visits.

    Planning ahead was very effective last time so we’ve built on that too. Staff at the acute trusts were fantastic and we were able to fill emergency and inpatient rotas well including amazing support from pharmacy, digital, operational and nursing teams as well as consultants and other senior medical staff. The trusts also did well to maintain the highest priority elective activity minimising the number of urgent or cancer patients affected, and they also managed the rescheduling of patients well with very few on the day cancellations.

    Finally though, the aftermath of the IA was actually a little worse than expected. We had a very tired workforce who needed compensatory rest and some time off in lieu (TOIL) which further affected the elective recovery challenge. There were also challenges with the huge amount of time to contact and reschedule very large volumes of patients.

    Please take a look on the dedicated workforce section of the ICS website including the latest industrial action information, along with a dedicated frequently asked questions section. This provides the most up to date source of information for our system.

    And please use our #WeCareTogether website as your single point of access for free health and well-being resources, free for all staff. We need to look after ourselves and each other so we can look after our patients.

    Urgent and Emergency Care

    This has been a very challenging winter. The ‘twindemic’ of COVID-19 and flu, and the resurgence of other illnesses, has affected patients and staff (and therefore services too). This pressure has been felt right across the system.

    Demand for urgent and emergency care services has been higher than last winter.  ED attendances have fallen over the last year, but were 3.3% higher this winter compared to the last. (Between November and February there were 2,884 more attendances compared to the same period the previous year, which is 24 extra attendances per day.)

    Emergency admissions have also increased over the last year, and were 4% higher this winter compared to the last. (Between November and February there were 1,148 more admissions compared to the same period the previous year, which is 9.6 extra admissions per day.)  

    Looking on the bright side, the number of inpatients with COVID-19 in our hospitals is still falling slowly. At the time of writing (Tuesday 4 April 2022), this figure currently stands at 84 across all providers and only 1 inpatient with flu.

    At year end, we had nearly 500 more beds (or bed equivalents) open across the community compared to September, as well as a large number of escalation or surge beds across our hospitals. So, there is detailed work ongoing to gradually phase out some of these, convert others to reablement capacity and some we hope to have available permanently.  We are also determined to get out of those escalation areas in a planned fashion as soon as it is safe to do so.

    We have been working with Newton Europe to really focus on complex discharge and have found a lot of areas where we could do better, to avoid overprescribing and overcomplicating the care we think people need before they can go home, which makes arranging their discharge so much harder and more time consuming and which in turn can make deconditioning worse. We have also identified the need for a lot more reablement capacity to support this.

    We are also working with NHS England national Intensive Support Team to build on our pre-hospital and ED work. Schemes such as “call before convey” and access to the stack are reducing the number of people being conveyed to hospital. We also have a massive focus on what happens at our front doors to offload ambulances and provide care for people much more quickly, and to provide alternatives to admission for more people, in particular those with multiple attendances, the largest group of whom tend to be older adults and those with mental health needs in our system.   

    Elective recovery

    I highlighted in February that we were still hoping to clear all patients who have been waiting more than 78 weeks (18 months) by the end of March. The final figures haven’t been confirmed yet, but it appears that we will have less than 200 patients waiting over 78 weeks in our final reporting. This is an amazing achievement and in line with our system target to get below 700 by April. This is down to massive hard work and cooperation across all sites, balancing this ambition to clear our longest waiting patients at the same time that we also address the needs of emergency, urgent and cancer patients. Thank you to all who have been involved in this mammoth task.

    Primary Care

    The latest data published shows that for February 2023, the overall trend of demand for general practice services isn’t letting up.

    Overall appointment activity continues to exceed pre-pandemic levels, with almost 55,000 more appointments in February 2023 compared to February 2020 – an 11% increase.

    Face to face appointments as a proportion of overall activity have gone up to 77.4%, an increase from January (76.4%) and 7.6% higher than national average.

    40% of patients are able to get a Same Day appointment, and that rises to 64% of patients who are able to be seen within 7 days and 79% within 14 days. And more Same Day appointments are offered now than before the pandemic, 223,516 same day appointments in February compared to 200,702 in February 2020, another 11% increase.

    Hidden within all this activity is a growing number of Did Not Attend appointments, which worryingly continues to rise compared to pre-pandemic levels. This February there were over 21,000 missed appointments, a 7% jump in numbers compared to February 2020.

    Delegation of primary care services

    As you many know, Primary Care is made up of four different services: General Practice, Pharmaceutical (which includes dispensing and distance selling), Ophthalmic, and Dental services.

    The ICB (and previously the CCG) has had delegated responsibility from NHS England for general practice services since 2017. And now, as of 1 April, we have also taken on delegated responsibility for the other three services as well. Previously, those commissioning decisions had sat with NHS England – East of England. Having delegated responsibility means that we are responsible for the commissioning decisions for these services at a local level.

    We welcome this new commissioning responsibility, which will enable us to design primary care services and pathways of care that better meet our local priorities and needs. It presents opportunities for us to commission services differently where we’re able to, and opportunities to improve outcomes for patients. But we recognise that this opportunity also comes with its challenges. Our primary care team has been busy working to prepare for this transition, with the NHS East of England team, representative bodies of the different primary care services, and organisations like Healthwatch and Health Education England, to improve our understanding of the landscape of services and the challenges ahead. Working together is going to be essential to our planning and progress in developing and making improvements to these services locally, and we’ll be sharing more information on these plans in the weeks and months ahead.

    Improving productivity and efficiency

    Nationally the NHS faces one of its toughest ever periods financially. In order to meet increasing demand from a once in a generation pandemic, a growing ageing population and drive-up quality and respond to rising patient expectations, we need to think and work differently and I hope that our focus on prevention and on improving care for older people will support that.

    On Thursday 2 March 2023, NHS England published a national letter confirming that integrated care boards (ICBs) will need to make a real terms running cost reduction of 30% by 2025-26, with at least 20% to be delivered in 2024-25. The financial challenge for Norfolk and Waveney is significant and so we and all other ICBs across England are being asked to review their organisations to see how best we can meet this challenge.

    Also in the news this week, an independent review of integrated care systems (ICSs), led by our Chair The Rt Hon Patricia Hewitt, published its final report on Tuesday.

    The review considered how the oversight and governance of ICSs can best enable them to succeed. The review covered ICSs in England and the NHS targets and priorities for which integrated care boards (ICBs) are accountable, including those set out in the government’s mandate to NHS England. The government is now considering the recommendations made by the review. The full report can be found here.

    Clinical and Care Professional leadership

    Finally, I am delighted to share that we had a large number of excellent applicants for our various new roles. We have successfully appointed to the planned care, population health management, inequality, place leads, mental health, primary care lead and deputy medical director roles. A few more interviews are still underway around maternity, learning disability and autism and children and young people – but I am absolutely delighted with the number, breadth and calibre of the applicants.

    Please do have a look at the CCP landing page which carries our manifesto, rolling leadership programme and lots more details of how to get involved.

    Talking of leadership – the Medical Director of QEH and deputy Medical Director of JPUH roles are currently out to advert, please spread the word and consider applying.

    As always, thank you for everything you continue to do.

    With best wishes,