Winter is here. Well, OK so the weather is bizarrely warm for November, and it has felt like winter pressures never really went away this year. But, technically, it is now winter. All of the NHS and all ICSs are struggling with financial, quality and performance metrics this year. So, we are focusing on five areas that will help address the most pressing issues affecting our system. As I’ve mentioned before, our “winter workplan” priorities are primary care (resilience and support), urgent and emergency care, mental health, elective recovery and money – our budget as a system.

The main focus of my blog this month will be on urgent and emergency care and primary care and then I’ll move on to workforce: the pending industrial action and some amazing work and resources available to support staff wellbeing. When times are so tough, it’s more important than ever for us to look after ourselves and each other.

Urgent and Emergency Care

Everyone knows that our urgent and emergency care pathways continue to be extremely busy. But I thought it would be helpful to share some of the big pieces of work we have been doing whilst we have been in critical incident.

Ambulance offloads – we’re adding additional vehicles at our acute hospitals when delays occur, to allow “cohorting” of patients there, to release ambulances and crews back on the road as quickly as possible. We’re also implementing various schemes to provide additional staff so that we don’t keep asking the same people – ambulance and emergency department staff – to do even more. We’ve used the learning from what worked well during the pandemic to bring in reservists, bank staff and medical students to help. We’ve developed and approved a new employment framework, simplified training and competency requirements, and agreed the governance for bringing in new staff in advance, and we’re using a unified process across all of our sites.

Reducing conveyance and admission and the community falls service – An MDT virtual room has been trialled, where patients who have called 999, and been categorised into one of the slightly less urgent categories (3 or 4) in the ambulance “stack,” are reviewed by the MDT to see if we could help them in another way. For example, an Advanced Care Practitioner (ACP) could go to assess them, take bloods, prescribe analgesia or antibiotics, and arrange additional care at home – a much better experience for the patient, and one less ambulance request. We’re currently looking at different options to expand this team, extend their hours and bring in more senior people to join it, and we’re planning to implement a digital tool to identify suitable patients more quickly this month too. In line with the NHS England winter falls web page, we also want to introduce an additional falls vehicle and team. We know that if an Occupational Therapist and paramedic go to see someone after a fall, having a hoist, and the most commonly required equipment with them can make all the difference, preventing the harm associated with a long wait, and preventing the need for an ambulance, hospital attendance and admission too.

COVID-19 – numbers are thankfully falling in our hospitals, but we continue to push both the flu and COVID-19 vaccination programmes. More than 320,000 COVID-19 vaccination boosters have been given to eligible patients across Norfolk this autumn, nearly 30% of our total population. We also continue with the COVID medicine delivery units (CMDUs) for those most at risk of serious complications, and hospital admission, and we are hopeful that patients will be able to get their oral antivirals direct from some community pharmacies rather than through the CMDUs over the next couple of months.

Care home support – as a system, we are also looking at what else we can do to support care homes, in particular those which most frequently call 999 or convey patients to hospital. Communications – We’ve also stepped up our communications and public health advice. We want people to think 111 not 999 unless it’s a true emergency, so that they can get the most appropriate support, and to reduce the pressure on our emergency services. The winter campaign will last until at least February 2023. This has been designed with and for the whole system, so includes both health and social care elements. Please do share these messages with people you come into contact with, and on social media if you can.

Continued focus on discharge – as you know, discharge is a very complex issue. At the start of this month, we still had nearly 600 patients across our acute, community and mental health trusts who didn’t meet the ‘criteria to reside’ across Norfolk and Waveney. Around a third are pathway zero so fairly straightforward to discharge, another third were waiting for other health support, such as P1 and P2 – transfer for rehabilitation or long-term nursing care. The final third, around 200 people needed support from social services; largely domiciliary care in their own home with around one in three needing permanent placements.

The main reason why we can’t discharge many of these patients is a lack of capacity: we just don’t have enough nursing and residential beds, and domiciliary care hours available across our system.

So – how are we supporting discharge? We are looking at every step of the discharge pathway to make as many gains as we can together led by our Director of Nursing at the ICB. We have opened an additional 64 residential beds, in a mixture of long-term providers, care home, nursing home and palliative care beds, as well reablement and rehabilitation beds. We have created an additional 104 bed equivalents so far. This includes elements such as extra staff or funding to support care at home, expanding the virtual wards, additional Home First staff, intensive home support, and improving staffing in our discharge hubs.

The councils have also opened an extra 20 extra flats, or homes with care, and expanded the care hours available by bringing in additional ‘non-framework suppliers to provide care at home. Domiciliary care isn’t something that the NHS usually provides, but as we are so affected by this, we are also exploring a few different ways to expand our capacity in all areas of our patch.

Primary Care

Despite local and national challenges, our latest appointment data for appointments in primary care is amazing. People in Norfolk are able to access primary care when they need it, and where they need it in the vast majority of cases.

• In September, there were 160k more appointments in primary care compared to the same month pre-pandemic (not including all of those vaccinations too)
• We delivered 575,611 appointments in total (equivalent to one for every two members of our population in one month alone)
• 73.4% were face-to-face, compared to 68.1% as the national average
• 38.2% of appointments were provided on the day and 45% by the day after the request was made.

Unfortunately, a staggering 23,124, or 4.1% of all primary care appointments were not attended though, which is so frustrating and feels like such a waste. So, we have also stepped up our public communications in this area. We are sharing this figure in the hope that it will encourage people who don’t need or can’t make their appointment, to cancel it instead, so we can book someone else in more quickly.

Future Care records technically went live on the 1 November, and though it’s not live in every practice, please assume that patients can now access all of their GP records including all MDT outcomes and correspondence.

I’d like to take this opportunity to thank all our GP staff for their hard work, commitment, and determination to ensure our patients have the care and support they need.

Industrial action

You will have seen that the outcome of the Royal College of Nursing ballot is recommending industrial action. This will affect many but not all of our providers. Planning is being led by our Workforce and Director of Nursing teams. A set of system-wide Frequently Asked Questions is available giving more detail on this, but If there is anything specific you need, please contact Emma, our Associate Director of Workforce Transformation; emma.wakelin1@nhs.net.

Staff wellbeing

We have strengthened our health and wellbeing resources available to colleagues across primary care, including Community Pharmacy, Dentistry, and Opticians, as well as General Practice. There’s no shortage of health and wellbeing resources out there – just a lack of time to work out what’s good and where to find it. Our #WeCareTogether website is a single point of access to 200 of the best NHS HWB resources; free for all staff, as well as to all the health and wellbeing resources provided by professional bodies nationally.

The resources included 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 out more about SHAPES by viewing these one-minute videos or simply joining one of the lunchtime health and wellbeing webinars starting with ‘Take control of your time and workload’ at 12.30 on 5 December 2022.

The Resilient Team Academy is for busy healthcare professionals and anyone in a leadership role or looking after a team in primary care. You don’t need ‘manager’ in your title. It offers bite-sized videos and activities, as well as downloadable monthly workshops to help you create a resilient and healthy team without burning out yourself.

To find out more about how we are trying to help improve health and wellbeing in primary care, please contact Martin Pettifor by email at m.pettifor@nhs.net.

Finally, in case you haven’t seen it, a new survey was launched last month for all clinical and care professionals across Norfolk and Waveney. Please fill this in, it only took me 5 minutes, but it will help us understand what people want and how we can better support you and each other. The closing date has been extended to Monday 21 November so we can ensure we get as many of our staff views as possible.

A new web page has also been published, which will include information relating to the Clinical and Care Staff Leadership Programme; please take a look at this too.

Thank you as always, for all your continued determination, hard work, and support.

Frankie