Medical Director blog: January 2023 – Dr Frankie Swords

16th January 2023

Firstly, Happy New Year!

I hope that you have all been able to get a bit of downtime over the festive season. It’s not been the easiest way to start the year, we remain in Critical Incident as a system and demand for health and care services remains at an all-time high. But, I continue to be amazed by the determination and commitment from all health and care staff across the system. We’re all in this together and I know everyone is doing all they can to care for those who need our help. Thank you for all that you do.

Our five system priorities remain the same:

  • urgent and emergency care,
  • primary care resilience and support,
  • mental health,
  • elective recovery and
  • financial recovery.

I’ll focus on the first two this month, and I will also talk a little about the industrial action, set to take place on the 18 and 19 January 2023 as well as reminding you about the support available for staff at the end of this blog.

Urgent and emergency care

Before we de-escalate from Critical Incident, there are four key clinical risks to our patients as per last month’s blog.

  • Our highest risk is of patients waiting longer than they should do for an ambulance response
  • The next risk relates to patients delayed in ambulances awaiting hand over at acute hospitals.
  • The next risk is to patients being cared for in non-standard settings (for example extra beds in emergency departments, wards, community, mental health and multiple other sectors).
  • Last is our ability to respond to any concurrent EPRR issues.

Thank you for all your hard work and focus, we are making progress and we are doing all we can to provide safe and high-quality care in order of clinical priority and as quickly as possible.

Flu and COVID-19 numbers were still rising across Norfolk and Waveney last week, but we do seem to have turned a corner in the last few days. Respiratory syncytial virus (RSV) and Group A streptococcal disease are also plateauing which is good news but I’ve included links to relevant guidance here too.

NHS England issued interim clinical guidance in response to an increase in infections, which can be found here.

Additional clinical guidance can be found from UKSA at Group A streptococcal infections: guidance and data, and the NICE guidelines for management of Scarlet Fever.

We are sharing this UKHSA advice on social media, along with a dedicated page on the Norfolk and Waveney ICS websiten and a lot of advice and information on the CYP website for parents who may be worried.

Over the Christmas period, we also saw logistical challenges with oxygen cylinders. There was no shortage of oxygen and no issues with flow at hospitals as we saw at times during covid, but we did see large numbers of people needing to use oxygen from cylinders – not just at our acute hospitals, but also at GP surgeries and on ambulances. Thank you to all those who helped with the logistics needed to address this, which was a national problem, but again this does seem to be settling for us now.

Demand across the system remains high but not exceptional. Our main challenge is that our hospitals remain too full due to challenges discharging patients. So, the financial announcement last weekend of additional funds to support hospital discharge are very welcome.

We are working at pace to do all we can to bolster the number of community beds and the care available to support more people at home across our system. When you look at the number of beds we have available in our community care settings compared with our population demographics, the numbers are quite staggering.

As a health and care system, we have a high proportion of older people, but the number of beds in our community settings just doesn’t match up. So, we are continuing to work with NHS England, Local Authority partners and other partners to try to address this.

Primary Care

The latest data again show an incredible month for primary care across Norfolk and Waveney – still way above pre-pandemic levels:

  • A staggering 660,161 appointments, as well as more than 40,000 COVID-19 vaccinations led by primary care were delivered in November
  • 74% of appointments were face to face, (national average of 69%)
  • 19% of appointments were by telephone, (national average of 26%)
  • And a whopping 242,691 appointments took place on the same day (37%), 33,617 more than took place on the day in November 2019, pre-COVID.

Primary care resilience update

At this time of year, the main public focus tends to be on ambulance and emergency department delays. But, we are absolutely aware of the impact current pressures are having on primary care too, and how much they are doing to mitigate and share the clinical risks to support the rest of the system.

We are incredibly grateful for how hard general practice is working to keep patients and staff safe. We regularly highlight this at system level executive meetings, in particular stressing how reliant we are on general practice for providing the vast majority of our urgent patient contacts, and this has helped us to agree various measures below:

Practise and Capital Funding

  • We have committed to supporting practices to target capacity at those most at risk of complications and/ or admissions. This support is through a Quality Support and Stability Payment (QSSP) and will apply should practices and PCNs not meet established targets for QOF and IIF this year as a result of using their clinical judgement to clinically prioritise their services. This offer of a QSSP is available to all practices and PCNs and we hope that this decision will enable practices to continue to use their clinical judgement to provide the right care to their patients.  We very much welcome the close working relationship we have with our LMC to work through the detail of this

Significant funding to fund additional primary care capacity

  • We recently had confirmation of a successful system bid against winter funding which should see £150k per locality invested in general practice support, which will need to be spent by the end of March. This is in addition to the circa £750k access and support PCN IIF flexibilities already nationally announced for winter capacity. We hope that together this funding will support practices with much needed additional capacity which can come online very quickly. For example use of LIVI to provide additional appointments or to use locum and other extra staff.

Community-based schemes

  • In addition, there has also been a further £150k per locality awarded for community-based schemes. Exactly what this money is spent on, will be decided through the existing locality-based meetings, supported by the ICB locality-based primary care teams in response to local needs.

Acute respiratory infection hubs

  • You will also be aware of very recently announced national funding for Norfolk and Waveney to implement acute respiratory infection (ARI) hubs in response to the massive increase in demand for children and adults with respiratory conditions this winter.  We received £779k late December, and this has been allocated to localities on a capitation basis (this funding is only available to the end of March).  This should provide additional capacity for triaged patients who don’t need admission, but who do need to be seen for a face-to-face assessment for their respiratory symptoms, with access to point of care tests,.  These should stand up within the next 2 weeks and we hope to use the learning from this short-term funding to determine our future approach to ARI hubs.

Locally Commissioned Services (LCS)

  • As well as this, we will be reviewing the LCS costing model for 2023/24 as part of our formal consultation with the LMC, to consider how we can continue to reflect the true cost of service delivery, in line with the LCS principles we previously agreed.  We are also reviewing our Inclusion Health LCS following feedback from practices and the increasing numbers of asylum seekers being dispersed into our system.

Patient demand, media and patient abuse

  • We take every opportunity to remind the wider public and our stakeholders about our zero tolerance of inappropriate behaviours towards our health and care teams.  We are working to refresh and implement a sustained communications and engagement plan to raise awareness of clinical triage and the different roles in general practice, following feedback from local practices. 
  • We are also working to try to recalibrate public expectation and behaviours, in response to the massive increase in demand for primary care services. Our communications and engagement team are helping to push this message of support to primary care as well as to help reduce demand where we can, with our winter campaign in full swing, including advice on choosing wisely, and to remind people to attend or cancel their booked appointment. Our GP practices are continuing to see unprecedented demand as well, which is captured in this latest article.

Elective recovery

On Tuesday, we were visited by the national NHS England and Getting it Right First Time team to see what else we can do to expand our capacity to support patients on our waiting lists. There’s a range of projects and programmes in place across the system already, and we are taking every opportunity to bid for funding, for extra diagnostic capacity, not just for imaging, but for blood tests, ECG, spirometry, foot checks, extra operating theatres, elective wards and much more.

Mental Health

The Norfolk and Waveney Mental Health Transformation Programme is also starting to pick up speed with lots in the pipeline for 2023. Jossy Pike is leading this for our system, working with NSFT, NHS Suffolk and North East Essex and of course, organisations and key stakeholders across our ICS.

Last week, we launched a new survey which builds on the 2019 strategies launched in 2019 for both Adult Mental Health and Children and Young People’s Mental Health in Norfolk and Waveney. Since then, we’ve all lived through a pandemic which has led to a significant increase in demand for mental health support alongside increased severity of cases. Considering these changes, we want to make sure that the plans we put in place in 2019 based on what people told us still meet the needs of the people of Norfolk and Waveney and we want to hear your views.

Please have a look at the new web page published on the ICS website which includes a summary of some of the work that has been done since 2019 to improve mental health services, with a focus on support in primary care, improving access to services, working better together, support in a crisis and prevention and wellbeing. At the end of this page, there is a survey which we are asking all staff, people and communities to complete – if you have a few moments, please do take a look.

Digital developments

In other news, I’m pleased to share that today, the ICS Digital Transformation Strategy and Roadmap has been published which aims to help improve the lives of people and communities across Norfolk and Waveney.

Highlighting the need to invest more in technology, the strategy will help enhance peoples’ experiences of delivering and receiving care using innovative tools and processes.

The strategy forms part of a bigger digital improvement programme, called Connect-NoW, which will see the rollout of more digital tools to help staff and patients have better experiences of services. You can find out more on the ICS website – it’s great to see our digital journey expanding and developing.

Workforce Support and Industrial Action

The Royal College of Nursing (RCN) ballot outcome did indeed recommend industrial action and in the next round on 18 and 19 January, we will see four organisations across our patch taking part:

  • Norfolk and Norwich University Hospital NHS Foundation Trust
  • Norfolk and Suffolk NHS Foundation Trust
  • Norfolk Community Health and Care NHS Trust
  • NHS Norfolk and Waveney Integrated Care Board.

A dedicated section of the ICS website is available including the latest information, along with a dedicated frequently asked questions section – please do take a look. Further information will be added as soon as it becomes available.

We are working together, as a system to plan for this Industrial Action and will be communicating directly with our people and communities to do all we can to encourage them to come forward for appointments as planned, unless they have been contacted in advance.

Finally, at our clinical risk panel this week, we also considered the issue of moral injury to our staff. Working in such a pressured environment and for such an extended period of time is hard. Many of us are struggling as we feel that we are not always able to give the quality of care that we would like for our patients. This is compounded by other pressures, such as the cost of living crisis and widespread industrial action.

So, please look after yourself and your colleagues. Please do take your breaks, they are important. Why not book your annual leave now, it’s good to have something to look forward to, and please do talk to someone if you need extra support.

In my November blog, I shared a lot of information on wellbeing, so I’ve included the links to these again this month.

Our #WeCareTogether website is a single point of access to 200 of the best NHS HWB resources; free for all staff.  The resources include the SHAPES toolkit, practical tools developed by a Cambridgeshire GP and proven in General Practice to help improve your health and work-life balance. You can find more about SHAPES by viewing these one-minute videos.

The Resilient Team Academy also offers bite-sized videos and activities, and downloadable monthly workshops to help you create a resilient and healthy team without burning out yourself.

Thank you for everything you continue to do.

With best wishes,