Clinical Case for Change

Quality of Care

Patient Flow

Maternity

General Information

Financial Case for Change

Travel

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CLINICAL CASE FOR CHANGE

QUALITY OF CARE

CCG Quality Governance arrangements

The CCG is committed to improving the quality of care for our patients and therefore assessing,
measuring and benchmarking quality is a key focus. We continue to strengthen, refresh and adapt
our quality assurance processes, including learning from others.
We recognise that quality is everyones business and our quality assurance processes is a
partnership with Providers and other commissioners
QUALITY Governance
The quality framework describes our approach to monitoring and assuring quality in all our
commissioned services. The process describes a structured approach to the steps taken in
response to increasing risk and reducing assurance. However, where a significant event or serious
failing is identified a Risk Summit should be called immediately.
The three domains of quality: patient safety, clinical effectiveness and patient experience are
monitored through routine internal contractual processes and quality governance structures and
external sources such as CQC, Monitor, peer reviews, national surveys etc. Providers are required
to have their own quality monitoring processes in place and through the duty of candour and the
contractual relationship with commissioners they have to provide information and assurance to
commissioners and engage in system wide approaches to improving quality.
Stage 1) Routine Quality Assurance Monitoring
Routine Monitoring includes, but not limited to, the following quality metrics:
Patient Safety Indicators include: monitoring of Health Care associated Infections, safeguarding
vulnerable children and adults, patient safety incidents, never events, complaints, mortality rates,
and workforce numbers, skills and training.
Clinical Effectiveness Indicators include: The implementation of the National Institute of Clinical
Excellence guidance, delivery of Commissioning for Quality and Innovation (CQUINS), key
performance indicator monitoring, learning from audit and peer reviews.
Patient Experience Indicators include: Patient reported outcomes measures, Friends and Family
test, patient survey results, respecting privacy and dignity, eliminating mixed sex accommodation
monitoring, complaints monitoring, CQC inspection results, access to services, patient advisory and
liaison service, health watch etc.
Stage 2) Routine Quality Assurance Meetings
Commissioners and providers are involved in a number of meetings where quality is the key priority
and focus of those meetings. We operate a Clinical Quality Board as part of contract governance
arrangements with CHFT this gives opportunities for quality monitoring to take place and assurance
to be gained. This Board is attended by the CCG Quality Committee Chairs (GPs), the CCG Head
of Quality and Director of Nursing and Medical Director from CHFT, this meeting take place bi
monthly. This meeting has an agreed workplan, and has the opportunity to review indicators
described in this paper as well as areas of concern.
Other meetings include focussed meetings around specific areas such as Infection, Prevention and
Control, Safeguarding Board and local contract groups.
Adapted from NHSE guidance on Quality Assurance
3

Stage 3) Enhanced Quality Surveillance Measures

Commissioners works closely with providers in ensuring processes are transparent in how we gain
quality assurance. This may involve being invited to join provider governance and patient safety
meetings, e.g. the CCG is a member of the recently established Mortaility review group. Clinician to
Clinician meetings, Commissioning joining PLACE inspection visits, patient safety walk rounds and
targeted quality assurance visits. The duty of candour placed on all providers should support this
process as they will be required to be open and transparent.
Stage 4) Enhanced Quality Review
The Enhanced Quality Review Process is enacted when risk is increasing and assurance reducing
and it may result in a number of stages dependent on the providers ability to provide assurance that
any quality issues can be resolved quickly, these are supported by NHS England and follow a
process described by the National Quality Board. This process can involve the following:

Quality Review meetings

Single Item Quality Surveillance Group meetings

Rapid Response Reviews

Risk Summits
Where there are quality concerns identified or the level of assurance is insufficient a Local Quality
Review meeting is held with commissioners, regulators and other agencies i.e. Health watch to
share intelligence and determine if the proposed actions by the provider give the appropriate level of
assurance.
Where assurance is not gained then a Single Item Quality Surveillance Group meeting will be called
involving the commissioners, regulators and the provider to enable the provider to present their
actions to address the quality concerns in a timely manner. This stage will be followed by a rapid
review visit or a risk summit if there are significant risks that the provider is unable to deal with
effectively.
NB The escalation to a rapid response review or risk summit could be instigated at any point in
the process if patient safety concerns require urgent action
CCG Quality Governance arrangements
Each CCG has a Quality Committee, chaired by a GP Governing Body member, included in its
membership is a CCG Lay member. They meet monthly, have and agreed work plan. Agendas
focus on the three domains of Quality, Patient experience, Patient Safety and Clinical effectiveness.
The focus of the Committees is both Quality Assurance and Quality improvement.
The Governing Bodies receive bi monthly reports including Quality and Safety.
Penny Woodhead
Head of Quality
Calderdale and Greater Huddersfield CCGs

Adapted from NHSE guidance on Quality Assurance

4

Adapted from NHSE guidance on Quality Assurance

5

Adapted from NHSE guidance

Quality Governance

Routine Quality Monitoring

CQC minimum standards

NHS Constitution/Mandate
Patient experience indicators i.e.
Complaints/Friends and Family test
Safety indicators i.e. mortality,
harm free care, incidents
Safeguarding

Serious incidents/Never events

Safe staffing levels
Infections control
Clinical effectiveness indicators, NICE
compliance, clinical audit performance

Persistent and/or Increasing Quality Concerns Identified

Develop Provider Risk

Profile

Step up to Enhanced Quality

Assurance Process

Arrange Quality Review

meeting with
commissioners and
regulators to determine
next steps

Targeted Quality
Assurance Visits

Was assurance gained?

No
Single Item QSG Triggers

Lack of confidence in the providers ability to

improve
Serious patient safety concerns
Serious contract breaches/Contractual
notices
Issues outside of providers control
Persistent failure to meet CQC standards
CQC Special Measures

Was evidence gained that

concerns would be resolved
within a reasonable
timeframe?

Yes

Maintain Enhanced
surveillance for a
minimum 3 months

Yes

No
Single Item QSG

Risk Summit Triggers

serious failings within a provider
a need to act rapidly to protect patients and

/ or staff
a single, material event

Increasing assurance /
Reducing Risk

RRR/Risk Summit

No
7

Yes

Surge and Escalation

Resilience Response Plan
2015/2016
Contents

Calderdale & Greater Huddersfield

System Resilience Group

To be developed when final version agreed

Calderdale and Greater

Version 12
Final Version

December 2015

1.0

Purpose

The Surge and Escalation plan describes the agreed local processes for ensuring a
co-ordinated and planned response to circumstances where pressure in one or more
parts of the system is impacting on the systems ability to ensure services are safe
and of high quality. This plan has been developed through the Calderdale and
Greater Huddersfield System Resilience Group (SRG) structure by the following
organisations, all of whom have made a commitment to use the processes to
support the system:
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Calderdale CCG
Greater Huddersfield CCG
Calderdale & Huddersfield NHS Foun0dation Trust
Calderdale Council
Kirklees Council
Locala CIC
Spire Hospital Elland
BMI Hospital, Huddersfield
Local Care Direct
Yorkshire Ambulance Service
South West Yorkshire Partnership Foundation Trust
Community Pharmacy West Yorkshire
Voluntary Action Calderdale
NHS England

2.0

Objectives

The objectives of the plan are to ensure there is clarity on:

The local approach and the commitment of organisations to the approach which

builds on current on-call arrangements and strengthens what currently exists.

The need for organisations to work together pragmatically and maturely.
The need for organisations to use their own individual Service/Business Continuity
Plans to deal with situations which can be managed operationally within their own
organisation.
The triggers identified by individual organisations that signify that; either a
circumstance has arisen which may impact negatively on other organisations,
and/or that the organisation requires support from the system to help it mitigate
risk.
The new system command and control processes which responds to system
triggers and delivers a prudent and proportionate response.
The REAP (Resource Escalation Action Plan) framework and its alignment to
system level command and control approaches.
The links to surge and escalation approaches led by NHS England.
The need for SRG to hold organisations to account for delivery of the agreed
approach.

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3.0 Local Context

Further to discussions at Calderdale and Greater Huddersfield Urgent Care Board,
Planned Care Board and System Resilience Group (SRG), the system has been
engaged in a process to update and strengthen its Surge & Escalation Plan.
Feedback concluded that last years approach based on daily telecoms and an
organisational rather than system approach did not usefully support system
resilience. Also that the approach to teleconferencing simply provided a vehicle to
share information and concern rather than one where organisations came away with
confidence that actions were actually being taken to improve patient care. Partners
identified the need for a more radical refresh that focuses more on; system triggers,
control and command structures and mutual aid. As a result, the Surge & Escalation
Group, made up of SRG partners, was mandated to develop a new plan.
Using national good practice we have developed a Command and Control structure
linked to; organisational triggers, escalation/REAP (Resource Escalation Action Plan)
levels and arrangements for local teleconferences. The approach is supported by
Emergency Planning leads within local councils. The approach builds on the on-call
arrangements already in place in individual partner organisations, to create a system
on-call structure.
The SRG will hold organisations to account for delivery of the commitments made in
this Plan, and will oversee learning and agree ways in which the Plan can be
continuously strengthened in order to make the system as resilient as possible.

4.0 Learning from 2014/15

As a starting point we have reviewed the information documented in daily telecoms
undertaken last year and identified the main issues faced by organisations. They are
ranked in order of frequency within each care setting. It is very likely that these are
the scenarios that will emerge this year;
Acute Care
Sustained high levels of demand, with increasing acuity and subsequent Length
of Stay (LoS)
Sustained Out of Hours peaks in demand combined with reduced Out of Hours
discharges
Limited or no acute bed capacity
High numbers of Delayed Transfers of Care (DToC) patients affecting bed
capacity and flow
A&E Streaming Service rotas not filled which is affecting A&E performance
Hospital Medical Assessment Unit/Wards closed due to infection
Staff sickness impacting on patient care

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Community Services
Limited capacity in Intermediate Care beds and other community beds
Community beds/home(s) closed due to infection or CQC measures
Staff sickness impacting on patient care
Social care
Limited or no capacity in Elderly Mentally Ill (EMI) beds
Limited or no capacity in Home Care Services
Limited or no capacity in Transitional beds
Beds closed due to infection or CQC safeguarding issues
Limited capacity or sickness in social care teams and Gateway to Care /
Re-ablement to support flow out of hospital
Ambulance Services
Demand or reduced capacity impacting on the delivery of services
Demand for ambulances reduces capacity for hospital transfers and A&E returns
WYUC
111 - high demand and abandonment rates cause pressure in A&E and Primary
Care
Primary Care
Demand affecting General Practice access patients access hospital or other
services which could have been avoided
Business continuity issues in individual practice mean that the practice is
struggling to meet demand
Staff sickness impacting on patient care
Using these scenarios, we have worked through our local SRG structures to identify
potential actions which can be used to try to mitigate risk as it occurs and ensure
that services remain safe and are delivering high quality care.

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5.0 Local Approach

The agreed local approach has the following four elements:
1. Data
Through SRG structures we are developing a new system dashboard, building on
the current Urgent Care Board Dashboard which allows the system to see at an
early stage pressure building across a range of settings. This will provide an
opportunity for us to better predict where the pressure will land and the focus of
mitigating actions needed to reduce pressure.
The NHS England daily (Monday to Friday) reporting arrangements have
commenced and the following information is provided to colleagues in the North
and National teams.

No. Ambulance handover delays +60 mins

Bed Occupancy General & Acute
Urgent Operations Cancelled
Elective Operations Cancelled
Beds closed to norovirus as % of beds
DTOC as % of beds
A&E diverts (ambulance diverts)
A&E Performance
12 hour trolley waits

The majority of this date is available to NHS England through the UNIFY2 SitRep
submitted by Acute Trusts daily.
2. Bronze Level - Service/Business Continuity
We have agreed with partners the need to refresh their internal Service/Business
Continuity Plans in line with best practice. Whilst there are contractual
requirements around the need for Continuity Plans to be in place, we have
agreed that partners will ensure their plans are; strengthened, fit for purpose and
aligned to this Surge & Escalation Plan. This approach has included the
strengthening of plans in local GP practices.
As part of their approach to business as usual, at a Bronze (Operational)
level, organisations will use their own Continuity Plans to ensure their services
are operationally resilient. Using their internal command and control structures
they will maximise operations to enable them to manage periods of pressures
due to capacity/demand. Organisations are expected to use data to enable them
to predict usual patterns of demand and capacity due to seasonal trends and
mitigate predictable risk wherever possible, and to learn lessons from previous
years.

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Bronze level activity is generally expected to mitigate risk associated with

internal REAP levels:

1 (Green): Normal business as usual,

2 (Yellow): Concern where there is some concern related to
capacity/demand which is affecting service provision and waiting times within
a single service area,
3 (Amber): Moderate Pressure - where demand/capacity is causing
moderate pressures which are affecting service provision and waiting times
within multiple service areas.

3. Silver Command Triggers

We have agreed with partners where particular circumstances in their own
organisation is likely to result in pressure being felt in other parts of the system
these triggers are identified within this Plan (Appendix A). These triggers will
initiate a Silverteleconference. The aim of the call is to both share the situation,
but all so seek support from others as necessary.
Silver Command activity is usually expected to mitigate risk associated with
REAP levels:

4 (Red): Severe Pressure - where demand or capacity issues are causing

severe pressure impacting on service provision and waiting times within
multiple service areas, one or more service area may be lost entirely and
cancellation of appointments may be occurring, and
5 (Purple): Critical Situation - where multiple service areas are failing to
provide a service and there is widespread cancellation of appointments.
6 (Black):
Potential Service Failure(s) where one or more
organisation cannot deliver its critical functions.

It is expected that organisations will take a pragmatic approach and ensure that
the call is initiated as quickly as possible, before it has reached a critical state.
However, it is recognised that there may be instances where a critical state may
develop which could not have been predicted.
Using their own triggers as a guide, any organisation can request a Silver
Command telecom using the CCGs On-Call structures 24/7. The CCGs On-Call
Manager should be contacted via CHFT Switchboard (01484 342000). The way
in which calls will be initiated will differ dependent upon whether a call is needed
in or out of hours:

In Hours (9am 5pm Mon-Fri) - The Silver Command representatives

from each organisation have been identified in advance, are of a Senior
Manager level and have the authority to make decisions and agree courses of
action at a tactical and strategic level.

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The CCGs On-Call Manager will contact the Sliver Command members by
using a pre-populated email. These individuals are detailed in the Silver
Command Contact List (Appendix B). Each organisation will be

responsible for ensuring that the email is automatically directed to

the relevant deputy to ensure that all organisations are effectively
represented.

Out of Hours (Weekends, Bank Holidays, Weekdays (5pm 9am).

The CCG On-Call Manager will contact the relevant organisation(s) by phone
(dependent upon the nature of the trigger) using the out-of-hours numbers
listed on the Silver Command Contact List (Appendix B).

A standard agenda for the Silver Command teleconference is attached as

Appendix C. Action notes will be taken and circulated. The CCG On-Call
Manager will chair the call using the set agenda. The aim of the call will be to:

Seek clarification from the organisation(s) triggering the call about the
current situation
Confirm what actions need to be taken including communication out
Agree the support required from other organisations
Agree next steps and whether another call is needed
Agree of any issues or messages which may require escalation to Executive
leaders in partner organisations
Consider de-escalation arrangements.

Silver Command will expect assurance from individual organisations that they
have exhausted all the actions set out within their individual Service Continuity
Plans and that organisation(s) have worked pragmatically and maturely together
in order to deliver all possible mitigating actions. In addition, it will have the
ability to agree courses of action which are outside those normally available to
individual organisations. This would take the form of:

Agreeing to extend the hours or strengthening capacity of individual

organisations(s) in order to provide support to the system.
Facilitating support from one partner organisations to another partner to
provide mutual aid
Agreeing to escalate communications to inform the system of the risk and
issues being faced, including public facing communications where needed.
Providing a mandate to enable a provider to take an action to improve
patient care without being penalised for failure of a performance target.

Also included within this document for reference are; triggers associated with
weather and triggers associated with the delivery of critical care (Appendices D
& E). This will enable organisations to understand how scenarios associated
with limited critical care capacity in other trusts or bad weather locally or
nationally may affect the actions that need to be taken.

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4. Further Escalation and Communication

(a)

Locally

Members of Silver Command will be expected to take a prudent and

proportionate view about how they escalate issues and information through their
own organisations into executive level forums or other internal structures.
It is expected that, as a matter of course, Chief Officers across the system (and
where appropriate NHS England see (b) below), will be informed by email
regarding circumstances where an organisation(s) in the system moves to REAP
levels 5 (Purple), or 6 (Black). They should also be informed when deescalation has taken place.
Routine calls are in place between CCGs and CHFT at 8.30 on Monday mornings
in order to ensure that all relevant information about the weekend is available.
The CCG Manager On-Call will also ensure that any relevant information is fed to
the appropriate CCG representatives in advance of the 12.00 pm call with NHSE.
Existing Emergency Planning arrangements will not be affected by this Plan, and
each organisation will continue its commitment should a Major Accident alert be
initiated.
(b)

NHS England

Based on the daily information supplied to NHS England (set out in 1.0 above),
NHS England will need to be informed where there is a combination of; higher
than normal ambulance handover delays, high bed occupancy levels or bed
closures, a large number of short notice operations cancelled, sustained failure
of the Emergency Care Standard or higher than normal delayed transfers of
care. For the purposes of this plan these will be regarded as circumstances
where an organisation(s) in the system moves to REAP levels 5 (Purple), or 6
(Black).
The EPRR Framework1 also identifies the following situations which should be
escalated to NHS England (Yorkshire and the Humber):

Capacity and demand reaches, or threatens to surpass, a level that requires

wider resources that cannot be accessed by a provider
A business continuity incident that threatens the delivery of patient services
Responding to a declared major incident or major incident standby
A media or public confidence issue that may result in local, regional or
national interest
A significant operational issue that may have wider implications that a
provider (e.g. public health outbreak, suspected Ebola, security incident,
HazMat / CBRN incident.

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A daily update, by 11.00 am to england.yorkshire-oncall@nhs.net is then

required until the situation de-escalates.
In addition, a weekly call between NHS England and CCGs across the region will
take place weekly (Monday at 12.00 pm). The aims of this call are to;
(a) Understand any impact on the local system as a consequence of pressures in
other systems
(b) Understand the impact on the local system of pressure being faced by
providers whose footprints sit across more than one SRG, for example Yorkshire
Ambulance Service
(c) Ensure that we are able to learn from other systems.
5. Overview of Process
The full process is set out below
1. Data flows provide a temperature check of system
performance

3. Silver - an organisation(s)
reach their system trigger
and ask for a Silver
Command to be called
(REAP levels 4,5,6)

2. Bronze organisations use

their Business Continuity
Plans to guide actions
during period of pressure
(REAP levels 1,2,3)

4. Communication and escalation of issues to executive leads

/internal structures in individual organisations and NHS England as
necessary (dependent upon the nature and severity of the trigger)

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APPENDIX A - Organisational Triggers by REAP level

Level

Trigger

Normal - Bronze

Level 1

Capacity available to meet expected demand; no issues with reduced staffing

Good patient flow through A&E and other access points
ECS consistently being met
Ambulance turnaround within 15 minutes
999 call volumes within expected levels and 999 standards consistently being
met
111 call volume within expected levels and standards consistently being met
Community capacity available across system
GP out of hours demand within expected levels
GP attendances within expected levels with appointment availability sufficient to
meet demand
No expected events or circumstances likely to impact on services
Cold weather / heatwave plan level 0 or 1
Gateway to Care call volumes at normal levels
Intermediate Care occupancy below 95%
Transitional Occupancy occupancy below 95%
Hospital Social Work Social Workers able to facilitate placements, care
packages and discharges from acute care and other hospital and community
based settings
Infection Control no issues in care homes
Home Care Provision no waiting list in brokerage for new home care
packages; patient flow is not affected
Re-ablement capacity to receive new referrals and timely discharges are in
place
Care Home Provision provision available, no concerns
Safeguarding 0 providers subject to whole service safeguarding
Mental Capacity Act (Deprivation of Liberty Safeguards in hospital) 2 or less
live cases
Mental Health Services bed occupancy below 85% and capacity available
across the system

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Level

Trigger

Concern - Bronze

Level 2

Capacity some unexpected reduction in staffing due to sickness or weather

Individual organisation declaring level 2 (locally determined)
Beds available, but short of beds in 1 specialty area* (for 24hrs)
Missed ECS at single site for 48hrs
Single 12 hour trolley wait
Single department Business Continuity Plan invoked
Anticipated or actual pressure in facilitating ambulance handovers (over 60
minutes)
Loss of single service (GP practice, community team, mental health support or
professional group within an organisation)
Anticipated event or circumstances likely to impact on services
On day cancellation of non-urgent elective activity
Cold weather / heatwave plan level 2
Gateway to Care call volumes 10% above normal levels
Intermediate Care 100% occupancy and a waiting list of fewer than 3 people
Transitional Occupancy 100% occupancy and a waiting list of fewer than 3
people
Hospital Social Work waiting up to the maximum assessment notice and
discharge notice timescales
Infection Control issues in 1 care home
Home Care Provision rising 3-5 people who have been referred for brokerage
who are waiting for a package of home care start up with new packaged due to
commence within 24 hours where patient flow is affected
Re-ablement capacity in re-ablement but unable to discharge existing cases
due to rising waiting list for ongoing care.
Care Home Provision more than 95% occupancy
Safeguarding 1-2 providers subject to whole service safeguarding
Mental Capacity Act (Deprivation of Liberty Safeguards in hospital) 3-4 live
cases
Mental Health Service no acute beds available in local area; beds available in
other parts of Trust

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Level

Trigger

Moderate Pressure - Bronze

Level 3

Capacity significant unexpected reduction in staffing due to sickness or

weather
Individual organisation declaring level 3 (locally determined)
Shortage of beds across more than one specialty area* or for more than 24hrs
Actual or forecast missed ECS for single site for more than 48hrs
GP demand unable to be met by ordinary increase in appointment availability
for 48hrs
Predicted discharges below expected admissions
Actual or forecast loss of more than one service for 24hrs
Cold weather / heatwave plan level 3
Gateway to Care call volumes 20% above normal levels
Intermediate Care 100% occupancy and waiting list of 3 or more people
Transitional Occupancy 100% occupancy and a waiting list of 3 or more
people
Hospital Social Work assessment capacity at 70% or less
Infection Control in 2 or more care home settings and causing significant
impact of service provision
Home Care Provision rising 5-8 people who have been referred for brokerage
who are waiting for a package of home care start up with new packaged due to
commence within 48 hours where patient flow is affected
Re-ablement waiting list with more than 5 cases waiting in any locality
Care Home Provision no residential or nursing care home capacity
Safeguarding 3-4 providers subject to whole service safeguarding
Mental Capacity Act (Deprivation of Liberty Safeguards in hospital) 4-6 live
cases
Mental Health Service occupancy above 100% (including patients on leave);
less than 2 useable beds across the Trust; community capacity unable to meet
demand leading to delayed discharges

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Level

Trigger

Severe Pressure - Silver

Level 4

Critical - Silver
Potential Service
Failure - Silver

Level 6

Level 5

Capacity significant unexpected reduction in staffing due to sickness or

weather
Individual organisation declaring level 3 (locally determined)
Shortage of beds across more than one speciality area* or for more than 96hrs
Actual or forecast missed ECS for single site for more than 96hrs
GP demand unable to be met by ordinary increase in appointment availability
for 96hrs
Actual or forecast loss of more than one service
Cold weather / heatwave plan level 3
Gateway to Care call volumes 30% above normal levels
Intermediate Care 100% occupancy and waiting list of 4 or more people
Transitional Occupancy 100% occupancy and a waiting list of 4 or more
people
Hospital Social Work assessment capacity at 50% or less
Infection Control major issues in care home settings causing severe impact of
service provision
Home Care Provision no capacity and waiting list of 5 or more people referred
for brokerage with no planned package of care start-ups within 48 hours
Re-ablement formally no longer accepting new cases in any locality
Care Home Provision no residential or nursing care home capacity and waiting
list of 5 or more at panel
Safeguarding 5 providers subject to whole service safeguarding
Mental Capacity Act (Deprivation of Liberty Safeguards in hospital) 6-10 live
cases
Mental Health Service no beds available across the Trust and local out of area
provision; patient flow restricted; unable to complete urgent assessments due
to staffing levels or high demand
Continued severe pressure >96 hours in existing health economies
Additional escalation in other health economies
Gateway to Care closure of council social care assessment service
Intermediate Care major incident confirmed
Mental Capacity Act (Deprivation of Liberty Safeguards in hospital) 10 or
more live cases
Mental Health Service - no beds available within Trust or Out of Area; unable to
admit from General Hospital or urgent MHA assessments
Potential for multiple full service closures
Staffing levels fully inadequate to delivery safe care
Sustained and long-term heavy snowfall level 4
Major incident called

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APPENDIX B Silver Command Contact list

Personal Identifiable information - removed

(To be initiated through a call to the CCG Manager On-Call via CHFT switchboard
Organisation

Silver Command

Telephone Number

Calderdale CCG
Greater
Huddersfield CCG
CHFT
Calderdale Council
Kirklees Council
Locala
SWYPFT
YAS
NHS England
Spire
BMI
Third Sector

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APPENDIX C Silver Command Standard Agenda

Calderdale and Greater Huddersfield SRG

Surge and Escalation Silver Command Agenda

Dial in details:
Date and Time:
1. Attendance and apologies
2. Issues/summary to date
3. Actions being taken and their progress
4. Challenges that are ongoing
5. Assistance needed from other services/organisations
6. Membership for next meeting
7. Agenda items for next meeting
8. Actions before for next meeting including communications and escalation
9. Date, time, location of next telecom if needed

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APPENDIX D - Cold weather/Heatwave Plan Triggers

Cold weather

Heatwave

Level 0

Long-term planning

Long-term planning

Level 1

Winter preparedness and action

programme

Heatwave and Summer preparedness

programme

Severe Winter weather is forecast

Alert and readiness

Heatwave is forecast Alert and

readiness

Response to severe Winter weather

Severe weather action

Heatwave Action

Major incident Emergency response

Major incident Emergency response

All year

All year

1 November to 31 March
Level 2

1 June 15 September

Mean temperature of 2C and/or

widespread ice and heavy snow are
predicted within 48 hours, with 60%
confidence.
Level 3

Severe Winter weather is now occurring:

mean temperature of 2C or less and/or
widespread ice and heavy snow.
Level 4

Central Government will declare a

Level 4 alert in the event of severe or
prolonged cold weather affecting
sectors other than health

60% risk of heatwave in the next 23

days

Temperature reached in one or

more Met Office National Severe
Weather Warning Service regions
Central Government will declare a
Level 4 alert in the event of severe
or prolonged heatwave affecting
sectors other than health

Calderdale and Greater Huddersfield Surge & Escalation Plan v12

23

Page 16

APPENDIX E - Critical Care Triggers

Level

Summary

Trigger

Normal

Business as usual - more than 4 beds available in each network

Concern

Low bed alert (LBA) activated - less than 4 beds available for 24 hours
across one or more network

Moderate All beds open in Unique Transfer Group (UTG see appendix A) but
Pressure none available for 48 hours and all level 1 delayed transfers
discharged out of units
Severe
All beds across 3 WY networks open but none available for 24 hours
Pressure and patients ventilated out of units

Critical

Potential
Service
Failure

All beds across 3 WY networks open but none available for 48 hours
Major incident involving large number of casualties requiring intensive
care
100% additional capacity achieved but level 5 triggers remain for 24
hours
Regional or national pressure

Specialty areas: medicine, surgery, trauma, orthopaedics, paediatrics, maternity,

adult or paediatric critical care, rehabilitation, nursing

Calderdale and Greater Huddersfield Surge & Escalation Plan v12

24

Page 17

25

Summary of the Trusts Patient Experience Improvement Projects

Inpatients: Themes from inpatient feedback highlighted 5 key projects that have formed the
patient experience improvement programme.
Comments received through the various feedback systems in the Trust, along with some
comments from staff submitted as part of the staff friends & family initiative, were used to describe
what patients / staff see as a good experience and also what they would like us to improve.
Five improvement projects were agreed:
Theme
1. Reducing patient anxiety
2. Keeping patients informed
3. Treating patients as an individual
4. Making patients feel safe
5. Make the patients stay / visit as
pleasant as possible:

Project
Ward orientation
Regular information round
Hello my Name Is campaign
How can I help - supporting staff to work in an enabling culture
Reducing noise at night

Outpatients: A similar approach was taken in order to develop the plan for outpatients, the 5
themes identified for improvement were:
1. Waiting: Start/finish times of clinic, waiting rooms
2. Access: Signage / direction / patient check-in
3. Communication: Patient letters, Hello my name is..
4. Patient Focus: Staff on stage, sharing the short film standing in someone elses shoes
5. Next Steps: What happens next, supporting patients with information about tests and investigations

Accident and Emergency: Improvement priorities have been identified by the departments with
the following priorities:
1. Waiting times:
- Extending the Emergency Nurse Practitioner service to support a quicker process through the minor
injury stream
- Introduced electronic waiting room screens to provide accurate patient information for patients on
number of patients in the department, waiting times for assessment and waiting times to be seen by
a clinician.
2. Staff engagement:
- Bi-monthly patient experience meetings
- Opportunity for complainants to attend and tell their story in person
- You said we did work

26

Further data analysis of CHFT Mortality

Details of mortality rates for each site over at least a 3 year period to help assess if there are any
trends.

2.50%

Crude Mortality
Rates by
Site
CRH
HRI

2.00%
1.50%
1.00%
0.50%
0.00%

Crude mortality rates for CRH and HRI individually are plotted monthly for the past three years. In
this case the data is presented as a %mortality, although it is also possible to express the data as
deaths per 1000 bed days, for example. The trends, however, are seen equally using any of these
methods.
As can easily be seen, there is a consistent difference, with crude mortality higher at HRI. It should
be borne in mind that the service configuration currently split between the hospital sites has HRI as
the acute surgical, trauma and oncology base.
Mortality rates are subject to a marked seasonal variation, which is very visible. In common with the
rest of England and Wales, there was a higher winter mortality peak in 14-15 than in previous years.
There has been a lot of national academic debate as to the causes, one of which may be the less
effective influenza vaccine that year.
This past winter has not seen as sustained a peak in mortality, although a late national surge in
influenza reports may affect this.

27

The number of deaths following discharge.

For this measure, we have selected 30 days as the post discharge period, as it is the period
incorporated in the Summary Hospital Mortality Index (SHMI), and the data is therefore tracked
regularly. It is presented monthly for 12 months, although other periods can be supplied on request.

Deaths within 30 days post discharge

60

CRH

HRI

50

40

30

20

10

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

In isolation, this is a difficult statistic to interpret, as there is no ideal figure. On the one hand a
high figure might indicate a tendency to discharge too early or poor discharge planning or
community support. On the other hand it might equally indicate good end of life care with
appropriate discharge to home or hospice care at the end of life. Again the HRI oncology service is
likely to result in a higher figure.

Clarification of the reasons why there has been a deterioration in the mortality rates (HSMR) since
2011/12 (which were within the expected/acceptable range).
Standardised mortality ratios (HSMR and SHMI) at CHFT have been the subject of intense analysis for
many years, dating back to our participation in the Safer Patients Initiative in 2006-7. The data has
varied, but it is true that there has been a deterioration in both of these measures since 2011-12.
Our responses to this have been outlined in detail previously, but include a programme of mortality
case review, based on diagnoses that appear to have higher than expected SMRs, groups of patients
of special interest, and latterly working towards 100% coverage of inpatient deaths. We have
undertaken wholesale coding reviews, commissioned external reviews of specific services, and
sought expert advice from Professor Mohammed Mohammed of Bradford University. Despite this,
we have not been able to identify any consistent reason why the HSMR and SHMI at CHFT are both

28

higher than expected. It should be noted that SHMI is rebased so that the average is consistently
100, it is therefore possible that the Trusts position relative to other organisations has deteriorated
due to a failure to improve at the same pace as other organisations rather than an absolute increase
in mortality rates.
Meantime there is an increasing body of academic evidence that there is a poor correlation if any,
between SMRs and other measures of care quality and measurements of avoidable death. The most
recent and highest profile study is that of Professor Black and his team at the London School of
Hygiene and Tropical Medicine, the PRISM2 study (Hogan et al BMJ 2015;351:h3239). In their paper,
the authors conclude: hospital-wide SMRs do not provide a useful indication of the proportion of
avoidable deaths in a trust.
Increasingly, therefore, attention in the NHS is turning to the assessment of avoidability and
opportunities for learning from death through standardised mortality case record review, and CHFT
is participating in work of the Yorkshire and Humber Improvement Academy that has achieved
national recognition.
We continue to focus on care quality through our Care of the Acutely Ill Patient plan, which, along
with other work picks up themes that emerge from out mortality review work.
The proposals contained within the current Consultation will facilitate the delivery of Consultant led
care, 7 days a week, focussing the sickest patients and the Doctors to care for them on a single site,
reducing delays in care and the need to transfer patients between sites, and therefore improving the
quality of in hospital care. Furthermore the delivery of care closer to home will result in fewer
patients being admitted into hospital for end of life care. These actions may impact positively on
reducing the SHMI.
Alex Hamilton
11/4/16

29

30

Actions at CHFT to reduce hospital mortality and improve patient

outcomes.
Calderdale and Kirklees JHSC Question
What work is currently being done to reduce and improve mortality rates in the Trust
and an explanation of how the new model would help to further improve rates?
Response
At CHFT we work continuously to improve patient outcomes and reduce inpatient mortality.
1. The centrepiece of this work is the Care of the Acutely Ill Patient plan, which addresses
the following areas of work in 6 themes:
Retrospective mortality case reviews and learning
o Mortality case note reviews aim for 100% coverage of in-hospital adult
deaths, with more in-depth review for selected cases, or concern raised via
complaints, incidents, inquest etc. October deaths. 3% of reviewed cases
have avoidable elements, in keeping with national average. We have
recruited specialist reviewers for deeper reviews with more consistency.
Monthly learning reports from reviews with recommendations are written.
Themes include: lack of senior reviews, failure to recognise deterioration,
failure to deliver reliable care.
o CHFT is also a participating pilot site in the academic work on mortality
reviews through the Yorkshire and Humber Improvement Academy.
Reliability of care and reducing unnecessary variation
o The focus here is on the use of care bundles, as a tool to reduce unnecessary
variation in care. We have recently redesigned bundles for Chronic
Obstructive Pulmonary Disease, Pneumonia, Sepsis, and Acute Kidney Injury
integrated into standard documentation. A care bundle for the management
of Heart failure is in the preparation stage.
o There is also other design work underway to reduce variation in Obstetric
and Upper GI Surgery outcomes.
Recognition of, and response to the deteriorating patient.
o CHFT has implemented Nervecentre, a system for electronic recording of
nursing observations using mobile devices. This system automatically alerts
staff to remind that observations are due, and alerts senior staff if any
patients observations are deteriorating. This then allows for review and
earlier intervention.
o Using this system, our improvement target of a 10% reduction in cardiac
arrests was met for latest data July Oct 2015.
Improving the quality of end of life care.

31

o We have seen significant improvement in the documentation of discussions

with patients and family members about the appropriateness or otherwise of
cardiopulmonary resuscitation in their case. Our hope is that this will avoid
futile and distressing resuscitative efforts at the natural end of someones
life.
Coordinating services to address the frail patient
o We are at the early stages of a project to coordinate care for frail patients.
Accurate clinical coding to capture activity.
o This of course has no effect on mortality per se, but means that we have
accurate data on which to base improvement efforts.

2. In addition to this work programme, we are working on the design of a coordinated

team to improve the management of, and response to, patients across the hospital
overnight and at weekends. This work links to, and builds upon the Nervecentre work,
and involves the development of a senior coordinator role in the hospital who monitors
the status of patients and allocates tasks to the available staff. There is good evidence
from elsewhere that this approach improves the timeliness of response to unwell
patients if some staff are busy elsewhere.
We are a Yorkshire pilot site for the NHS 7 day Services project, working with NHS
England to design ways of delivering enhanced services to our patients across seven
days of the week. Historically at CHFT we have not seen the markedly poorer outcomes
for patients admitted at weekends that have been reported across the wider NHS, but
we regard it as an important area for development.
The standards we are working towards as part of this project are:

All emergency admissions must be seen and have a thorough clinical assessment
by a suitable consultant as soon as possible but at the latest within 14 hours of
arrival at hospital.

Hospital inpatients must have scheduled seven-day access to diagnostic services

such as x-ray, ultrasound, computerised tomography (CT), etc

Hospital inpatients must have timely 24 hour access, seven days a week, to
consultant-directed interventions such as critical care, Interventional radiology,
interventional endoscopy, emergency general surgery.

All patients on the AMU, SAU, ICU and other high dependency areas must be
seen and reviewed by a consultant twice daily, including all acutely ill patients
directly transferred, or others who deteriorate. To maximise continuity of care
consultants should be working multiple day blocks.

We are working to improve the transfer of information during shift handover against
using Nerve centre as an electronic hand over tool.
The Trust is currently preparing to implement an electronic patient record, which will
aid a number of quality initiatives, reduce errors, and improve the availability of

32

information across the health care economy, the preparation of this system is
ongoing and is planned to be implemented on the 8th October 2016.
There is ongoing improvement work in the following areas

Clinical documentation

Management of Pressure Sores

Infection Control and the use of antibiotics.

Venous Thromboembolism prophylaxis

Patient Falls

Improving management of fractured neck of the femur.

Improving diabetic care

Improving the management of stroke patients

Improving medicines management

WHO checklists

Improving staffing levels e.g 1.5 million extra investment in nursing.

Additional funding for Consultant medical staff including Emergency care,
Stroke, Renal Medicine.

3. Right Care, Right Time, Right Place

From a clinical perspective, there is no doubt that early and regular review by the
appropriate senior clinical staff is central to good quality care and achieving the best
outcomes possible. This cannot be achieved by fragmentation of acute services and
spreading staff thinly. Difficulties in achieving regular consultant review of
inpatients, particularly at weekends, is often highlighted as a theme in our mortality
case note reviews. Centralising our specialist workforce to concentrate on the care
of the sickest patients can have a significant benefit on outcomes.
The aims of the seven day project, for example, can only be achieved by the
consolidation of on call rotas to achieve sufficient senior expertise in the right place
at the right time, rather than leaving clinical decision making in the hands of junior
doctors.
Focussing Emergency care on a single site will allow our most senior and experienced
clinicians to be present for more of the time, we will meet the emergency care
standard of Consultant presence 14 hour per day 7 days per week. It is not possible
to meet this standard with the current duplicated emergency service. Furthermore
patients will have the necessary support from expert clinicians and improved
facilities within the acute hospital site, so that delays of care that currently occur due
to the necessity to transfer patients from site to site within the current configuration
will be avoided.

33

We have data to show that surgical outcomes improved after acute surgical services
were centralised at HRI a few years ago, reducing mortality associated with
gastrointestinal perforation and obstruction from approximately 12% to 6%. Across
the wider NHS we know that outcomes for Acute Myocardial Infarction (heart
attack), with modern interventions, have significantly improved with centralised
specialist care in our local case, in Leeds.
The same dramatic result has been achieved with acute stroke care in London by
centralising care in a few hyperacute stroke centres, not in every local hospital as
used to be the case. A reduction in mortality up to 3 months after the stroke of 25%
was seen. There is no reason to think that these potentially improved outcomes
from concentration of specialist care are limited to these specific conditions.
There is good data across the NHS to show that acutely ill patients who, as a result of
bed pressures are admitted to wards who usually manage patients under other
specialities (outliers) have poorer outcomes. Moving to a redesigned system in the
future of dedicated emergency and planned provision will help to minimise this and
have a positive impact on outcomes of care.
The Trust is experiencing significant difficulties in recruiting and retaining Senior
Doctors and has significant vacancies both in Emergency Medicine and our medical
specialities. As these services are largely duplicated on both of our current acute
hospitals these jobs require onerous on-call rotas and are therefore unpopular when
compared to positions available in surrounding trusts. Furthermore we are unable to
develop specialist rotas which would be both more popular and potentially deliver
safer care. The centralisation of acute services along with the provision of modern
facilities would substantially improve our ability to recruit and retain staff. It should
be noted that a number of Consultant staff have left the organisation over the last
year citing workforce pressures and the current models of care as contributory
factors in their decision.
Another feature of our hospital mortality work is the sad observation that frail
people or people at the end of their life are sometimes admitted to hospital when
there might have been other ways of caring for them and supporting their family.
The development of non-hospital services, with care closer to home will help avoid
unnecessary hospital admission and help to support care at home. Most people, if
asked, state an advance preference to die at home. We cannot avoid death; but we
can design services that can help people to receive support in their final days in the
right setting.
Alex Hamilton
Associate Medical Director
17/03/2016

34

A & E ACTIVITY 2012/13 2015/16

Activity data for the last three years for A&E is as follows. Note 15-16 is not a full year yet.
Hospital
CRH
CRH
CRH
CRH
HRI
HRI
HRI
HRI

Year Fiscal
2015-16
2014-15
2013-14
2012-13
2015-16
2014-15
2013-14
2012-13

Cases
68,048
72,530
71,475
72,048
66,199
69,775
67,776
69,089

All data is full years except 2015-16 which is April 2015 to February 2016

35

36

PATIENT FLOW

37

Patient move between sites

Data provided w/c 13.03.16
Movement Between Wards:

FnYr 13-14

FnYr 14-15

FnYr 15-16

Grand Total

CRH to HRI

1,156

1,091

951

3,198

HRI to CRH
Grand total

1,113
2,269

1,008
2,099

921
1,872

3,042

Movement from A/E to other site

Attended Site
CRH

CRH Total
HRI

Transferred to/Admitted to
ADMITTED TO HUDDERSFIELD
TRANSFER TO HUDDERSFIELD
A/E
ADMITTED TO CALDERDALE
TRANSFER TO CALDERDALE A/E

HRI Total
Grand Total

Financial Year
FnYr 13FnYr 14FnYr 1514
15
16
564
570
472
8
572
504
16
520
1,092

7
577
499
21
520
1,097

18
490
930
42
972
1,462

The data shows an increase of 430 patient moves from HRI A/E to CRH.
Reasons are:

Paediatric medical admissions are all now at CRH. This has increased admissions by 250.
180 adults transferring to CRH for specialist assessment in areas such as stroke,
cardiology and gynaecology.

Dr Ashwin Verma has reviewed the data on hospital ward to hospital ward transfers
(roughly 1,000 in each direction each year). Ashwin has advised there is really little
meaningful themes from data. The reasons we transfer patients include:
Transfers from CRH to Surgical Assessment Unit or Surgical wards will be because of GI
bleeds and Surgical condition found/developed.

Transfers to Endoscopy from CRH for ERCPs (Endoscopic retrograde

cholangiopancreatography, used for both diagnosis and treatment) and Stents in cancer or
jaundiced patients.
Transfers from HRI to CRH will be for ERCPs and stents as previously.
Transfers from CRH Clinical Decision Unit to Surgical beds will be as surgical need
identified.

38

MATERNITY

39

CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST

Home Births Paper for Joint Overview and Scrutiny Committee
18 March 2016
Purpose
The purpose of this briefing is to advise the Overview and Scrutiny Committee on:
the number of homebirths that were predicted as a consequence of the previous
changes to maternity services;
the actual number of homebirths that have taken place;
actions being taken to improve the rates of homebirths.
Predicted home birth rates post reconfiguration
This data is to be confirmed
Home birth rates
In 2013, approximately 2.3% of women in England gave birth at home (planned and
unplanned). This figure was unchanged from 2012. The South West had the highest
percentage of women giving birth at home in 2013 (3.2%) while the North East had the
lowest (1.1%) (Office for National Statistics 2014).
Table 1: CHFT Homebirth Rates 2010- Year to Date (YTD) 2016
Year
15/16 YTD
14-15
13-14
12-13
11-12
10-11

Number of Home
Births
73
101
84
126
118
141

Total Number of
Births
5104
5630
5746
6031
5966
5950

Rate
1.4%
1.8%
1.5%
2.1%
2.0%
2.4%

Actions being taken to improve rates of homebirth

Women birthing at CHFT can choose to birth at:

Home
Freestanding midwife led birth centre
Midwife led birth centre on the same site as the medically led Obstetric Unit
Obstetric Unit

Home birth is offered as standard option to all women who are at low risk of complication.
Our Consultant Midwife works with women who are at high risk of complication but choose
homebirth and their named community midwives to ensure women make an informed choice
about place of birth.

40

Our home birth service is delivered by the on call community midwifery team and is available
24/7. Womens satisfaction with the service is generally high. A community based home birth
champion team was established in October 2014. The team currently has 3.2wte midwives.
As the number of women choosing home birth increases, the home birth team numbers will
increase.
Actions the home birth team are doing to increase homebirth rates include:

Networking with Trusts with higher home birth rates

Planning and promoting a programme of meet the homebirth team coffee morning
events
Supporting community midwives in terms of discussing home birth as a positive
option at booking clinics
Developing a standard operating procedure for lease of CHFT owned home water
birth pools
Providing support at home births for less experienced community midwives
Leading on a refreshed training plan for community midwives about home birth

This work is being led by the Matron for Community Midwifery Services
Audit
Between October 2014 and July 2015, 135 women expressed a wish to birth at home. 58
women achieved this (43%). Reasons for women not achieving home birth are provided in
Table 2; all are appropriate. Despite extensive searching, it was not possible to obtain
national data against which to benchmark this data. The plan is to rerun the audit Q4 20152016
Table 2: Planned homebirth outcomes
Outcome

n=

Birthed at home as planned

Born before arrival of midwife rapid birth
Transferred care antenatally

49
9

Transferred into hospital in 1st

stage of labour

20

Reasons

45

41

n=

High risk fetal factors

High risk maternal factors
Post Maturity
Prelabour SROM
Maternal choice
Preterm labour
Malposition
Not recorded
Slow progress

22
3
6
5
5
1
1
2
5

Meconium liquor
APH
Malposition
Pain relief
Maternal choice
Increased maternal risk factors
Increased fetal risk factors

4
3
2
1
1
1
1

Transferred into hospital in 2nd

stage of labour

Not recorded
Malposition

2
1

Transferred into hospital in 3rd

stage of labour

Fetal heart concern

Meconium observations

2
4

Significant perineal tear

Retained placenta
Concern about maternal wellbeing

3
1
1

TOTAL

135

References
National Institute for Health and Clinical Excellence. 2014. Intrapartum care: care of healthy
women and their babies during childbirth [online]. [Accessed: 15.08.15]. Available from:
http://www.nice.org.uk/guidance/cg190/chapter/1-recommendations#/place-of-birth
Office for National Statistics. 2014. Characteristics of Birth-England-and-Wales [online].
[Accessed: 15.08.15]. Available from: http://www.ons.gov.uk/ons/rel/vsob1/characteristics-ofbirth-2--england-and-wales/2013/sb-characteristics-of-birth-2.html

42

GENERAL INFORMATION

Response to Information Requested by Calderdale and Kirklees Joint

Overview and Scrutiny Committee following the Meeting held on 22nd
March 2016
Questions Asked:
1.

More information on the modelling work/analysis that was undertaken that

shows the impact on the flow of patients (into Urgent Care and the
Emergency Centre) on each site based on CRH being the unplanned site
and the same analysis based on HRI being the unplanned site.

2.

Details of the information that has been used to support the assumptions on
the expected reductions in demand in the numbers of admissions to hospital
(bed capacity).

3.

Details of the breakdown of the assumptions used to support the modelling

work that has been undertaken on the predicted emergency centre/urgent
care activity for : CRH as the unplanned site and HRI as the unplanned site
(This may get covered under bullet point 1).

4.

Details of the plans for expanding the intensive care/high dependency units
on the CRH site to include details of current and expected demand on the
CRH site.
44

Question 1 - More information on the modelling work/analysis that was undertaken that shows
the impact on the flow of patients (into Urgent Care and the Emergency Centre) on each site
based on CRH being the unplanned site and the same analysis based on HRI being the
unplanned site.

Page 131 of the Five Year Strategic Plan for Calderdale and Huddersfield Foundation Trust provides
the output of the modelling of patient flows to the urgent care centres (UCC) and the Emergency Care
Centre (ECC) on each site (this is shown for both CRH being the unplanned site and HRI being the
unplanned site).
The key planning assumptions that were used to develop this are described below.

All modelling has used forecast activity for 2015/16 (as at month 6) as the baseline. Year 1 of the
model is 2016/17.

Demographic growth has then been modelled across the years as below:

It has been assumed the planned care site will not have an Emergency Care Centre but will have
an Urgent Care Centre.

It has been assumed that all ambulance journeys will be diverted to the nearest Emergency Care
Centre based on travel time.
45

Urgent Care Centre Assumptions

The Clinical Director for Emergency Services agreed a list of treatment codes to identify patients
who were suitable for management in an urgent care centre (UCC). These are:
Adults with minor injuries and / or minor illnesses
Children over the age of 5 years with minor injuries
The categories of minor injuries and minor illnesses are highlighted below. All A&E diagnosis fields
that matched the below criteria were used for modelling purposes.
Walk in patients who met the UCC criteria are assumed to be treated at the site they present at.
Walk ins who do not meet the UCC criteria are assumed to firstly attend the current site at which
they are treated, but then are moved to the future unplanned care site (if they need to be moved)
and hence they would appear as 2 attendances in the modelling work. In other words, these
people attend the UCC and then attend the ECC.
Minor injuries
Bites/stings
Burns and scalds
Contusion/abrasion
Diagnosis not classifiable
Dislocation/fracture/joint injury/amputation
Electric shock
Facio-maxillary conditions
Foreign body
Head injury
Laceration
Muscle/tendon injury
Nerve injury
Sprain/ligament injury

Minor illnesses
Allergy (including anaphylaxis)
Dermatological conditions
ENT conditions
Infectious disease
Local infection
Ophthalmological conditions
Psychiatric conditions
Social problem (includes chronic alcoholism and
homelessness)
Soft tissue inflammation

46

Emergency Care Centre Assumptions

The urgent care centres will absorb some of the activity that would otherwise go to the Emergency
Care Centre.

Patient travel times were calculated using MapInfo and the postcode field within the FY15/16 data.

Based on travel times, the nearest Emergency Care Provider was determined for those patients
who were seen at the future planned care site and arrived by an ambulance.

If this is another Trust, the inpatient stay related to this ECC attendance will also be assumed to
have moved to the new provider.

Walk ins who do not meet the UCC criteria or are admitted are assumed to firstly attend the
current site at which they are treated, but then are moved to the future unplanned site (if they
need to be moved) and hence they would appear as 2 attendances in the modelling work.

47

Divert rules

The principles applied to diverting patients to another provider (if they require treatment at an
Emergency Department) are outlined below.

Scenario

Arrival mode at
ED

Principle applied

Attendance at UCC does not

meet UCC criteria

Ambulance

Ambulance is redirected at source to next nearest provider (based on

travel time from patient postcode). ED attendance and associated
admissions are moved to new site.

Attendance at UCC does not

meet UCC criteria

Walk in/Other*

Patients are redirected to the nearest ED

Non-elective Inpatient spell

does not meet the inpatient
criteria

Ambulance

Ambulance is redirected at source to next nearest provider (based on

travel time from patient postcode). ED attendance and associated
admissions are moved to new site.

Non- elective Inpatient spell

does not meet the Inpatient
criteria

Walk in/Other*

Patients are redirected to the unplanned care site

Elective Inpatient spell does

not meet the inpatient criteria

N/A

Spell moved to planned care site (assumed that all elective transfers
stay within the organisation)

48

Activity Diverted to other Trusts

The providers included in the travel time analysis are shown below. The impact of activity shifts to
these other providers is included in the Five Year Strategic Plan for Calderdale and Huddersfield
Foundation on page 134.

Nearest Provider
Royal Blackburn Hospital
Fairfield General Hospital
Leeds General Infirmary
Trafford General Hospital
Bradford Royal Infirmary
Pontefract General Infirmary
Pinderfields General Hospital
St James's University Hospital
Manchester Royal Infirmary
North Manchester
The Royal Oldham Hospital

49

Question 2 - Details of the information that has been used to support the assumptions on
the expected reductions in demand in the numbers of admissions to hospital (bed capacity).

The plan assumes a 6% year on year reduction in non-elective admissions to hospital.

This is based on nationally benchmarked information that shows current rates of non-elective
admission for some conditions (e.g. heart failure, angina, gastroenteritis, pneumonia, respiratory
conditions and cellulitis) is above national average.

The development of Care Closer to Home and delivery of new models of care will reduce the
need for hospital non-elective admissions.

These assumptions are described on pages 107 110 of the Pre-Consultation Business Case.

The bed model includes the assumed 6% reduction in non-elective admissions per annum (from
2017/18 onwards). This reduction in admissions has been converted into an associated reduction
in beds over the 5 year period.

The full bed modelling impact (that takes into account the impact of a number of factors such as
demographic growth, reduction in length of stay as well as reduction in non elective admissions)
is shown on page 126 of the Trusts Five Year Strategic Plan. A summary of this is shown on the
next slide.

50

Bed Modelling Over 5 Years

1,200

Number of beds

1,000
800
600
400
200
-

51

Question 3 - Details of the breakdown of the assumptions used to support the modelling
work that has been undertaken on the predicted emergency centre/urgent care activity for
: CRH as the unplanned site and HRI as the unplanned site (This may get covered under
bullet point 1).

This has been answered at question1

52

Question 4 - Details of the plans for expanding the intensive care/high dependency units
on the CRH site to include details of current and expected demand on the CRH site.

The Trust currently has a total of 13 intensive care beds.

8 Intensive care beds are located at HRI and 5 intensive care beds at CRH.

The plan proposes an expansion of critical care beds to provide a total capacity of
18 critical care beds with all the beds provided on the unplanned / emergency site
at CRH.

Occupancy of intensive care beds during 15/16 at HRI was 82% and at CRH it was
65% (this is midnight occupancy).

53

54

FINANCIAL CASE FOR CHANGE

55

Calderdale and Kirklees JHOSC Meeting - 9 March,

Response to Financial Data Request
A request has been received following the Joint Health Overview and Scrutiny Committee for a paper
to be provided that outlines the correct financial data that members should be considering when
reviewing the financial case for change to include:
1. Details of the financial analysis and economic assumptions;
2. The external funding required to include a breakdown of the various elements such as:
capital requirement, revenue costs, deficit support, costs of the new build (Acre Mill) and
the extensions/adaptions to CRH.
In order to address these queries in an open and transparent way the following details of the
financial analysis have been extracted and referenced from the document, 5 Year Strategic Plan for
Calderdale and Huddersfield NHS Foundation Trust version 1.2 completed in January 2016
(referenced below as the 5 Year Strategic Plan).
1. Details of the financial analysis and economic assumptions
Details of the financial analysis are provided at section 8.2, page 138 of the 5 Year Strategic Plan
document. The economic assumptions are specifically stated at section 8.2.2.4, page 142 of the
same document.
2. The external funding required to include a breakdown of the various elements such as: capital
requirement, revenue costs, deficit support, costs of the new build (Acre Mill) and the
extensions/adaptions to CRH.
External funding requirement
The following details are extracted from Table 88: Funding requirement under CRH as the site for
unplanned care option, section 10.2.3, page 216 of the 5 Year Strategic Plan document.
Under the option with CRH as the unplanned care site, the total capital requirement is as follows:

Existing capital programme (Medical equipment / IT)

Investment in Pharmacy Manufacturing Unit
PFI capital funding
Sub total
Reconfiguration capital
Total capital investment

m
52.8
1.2
9.6
63.6
291.2
354.8

The funding for this capital investment would be required at 354.8m through loan funding from the
Independent Trust Financing Facility (ITFF).

56

The revenue costs across the planning period will require external funding support as follows:
m
115.0
9.1
124.1

Liquidity support funding (excluding depreciation)

Revenue reconfiguration costs
Total revenue support

Of the above, the 9.1m revenue reconfiguration costs are expected to be funded by Commissioners
/ NHS England.
In totality the cash support required would be:
m
354.8
124.1
478.9

Total capital investment

Total revenue support
Total cash support

It should be noted that of the 478.9m total funding requirement, 9.1m would come from
Commissioners / NHS England and the balance; 469.9m would require Treasury support through
the ITFF.

Capital funding
The following details are extracted from Table 72: Capital expenditure for CRH as the site for
unplanned care option, section 8.3.1.6.3, page 181 of the 5 Year Strategic Plan document.
The capital expenditure is broken down as follows:
m
63.6
15.5
275.7
354.8

Non reconfiguration capital expenditure

Backlog maintenance at HRI (pre-reconfiguration)
New build / Upgrade (Reconfiguration)
Total capital investment

The reconfiguration element of the capital expenditure at 275.7m is analysed by:

m
55.5
220.2
275.7

Acre Mill
CRH and all other site costs
Total New build / Upgrade (Reconfiguration)

57

PFI
Facts
Signed in 1998 original term 60 years, break clause 30, 40, 50
Agreement can only be terminated by mutual agreement of all parties and approval of the
lenders - NHS cannot exit the contract unilaterally.
Annual revenue cost 22m, two components:

11m - domestics, catering, porters and security these would be ongoing costs for
the Trust regardless of the PFI, i.e. even if we employed the staff ourselves. The
contract permits regular benchmarking/market testing of these ancillary costs to
ensure we can demonstrate value for money. The provisions for this within the
contract were reviewed by DWF Lawyers in September 2014.
11m - mortgage and capital financing costs (if the site was not financed by PFI the
Trust would still incur estate financing costs as per the rates that apply to NHS
owned estate).

Review of contract
Over the years the contract has been reviewed by accounting and legal teams from:

Deloittes
KPMG
Monitor

These have all confirmed the Trust cannot exit the contract unilaterally
It is not in the interests of the financial lenders to agree to early termination despite the
break clauses.
Summary
We have a responsibility to ensure we deliver the best value for money out of the PFI,
within the conditions of the signed contract equally. If CRH was not part of a PFI
arrangement, significant costs would still be needed by the NHS to pay for patient services
and finance what would then be NHS owned estate.

58

TRAVEL

59

Calderdale and Kirklees Joint Health Scrutiny Committee

Meeting on 19 April 2016
The outline programme for the above committee lists the following actions from both Kirklees
and Calderdale Councils
1. It will help the discussion on transport if the local authorities have prepared a brief
contribution about their involvement to date and any projects that relate to transport
to and from the hospitals.
2. Members will be interested in hearing from the local authorities:
i. What involvement have the local authorities had in the development of
the PCBC in relation to transportation etc
ii. The impact of improvements to the A629 on transport flows,
ambulance journey times, bus times etc?
------------------------------------------------------------------------------------This paper provides brief responses to these actions for potential use at the Committee:

1. On behalf of Kirklees Council, Kirklees Transportation has had no contact from,

or involvement with, this process to date.
Kirklees Transportation is part of the Councils Strategic Investment Service and
concerns itself with the policies and transport system itself, as well as with its
impacts in and relationships with other aspects of the social, economic and
physical environment.
2. As part of the City Deal between West Yorkshire, York and central government,
a new Transport Fund in excess of 1bn targeted specifically to increasing
housing, employment and economic growth across the region has been created.
The West Yorkshire (Plus) Transport Fund (WY+TF) identified a Core 10-year Package
of measures that would enable change and deliver economic growth, measured by
(amongst other things) a growth in GVA and the release of development land, whilst
accommodating the traffic impact of future housing and employment growth. This paper
however deals with the journey time and reliability benefits associated with the
measures to be implemented.
The A629 Halifax to Huddersfield Corridor is part of this Core Package. The corridor
is divided into a number of phases for delivery. Each phase comprises a number of
transport schemes that seek to improve accessibility for all road users, reduce bidirectional journey times and enhance journey time reliability between Huddersfield and
Halifax (and vice versa) by targeting known points of delay and congestion along the
A629 and increasing provision for sustainable modes. Kirklees Council and Calderdale
Council are jointly developing the range of interventions proposed along the corridor.

60

The table overleaf shows the current status and the anticipated benefits in terms of
journey time savings associated with the following phases:

Phase 1: Southern Section (Elland Bypass to Free School Lane);

Phases 2 and 3 combined: Halifax Town Centre and Free School Lane into
Halifax;
Phase 4: Ainley Top (M62 Junction 24) and Wider Strategic Interventions;
Phase 5: Ainley Top to Huddersfield.

Whilst the table focuses on journey time benefits of the interventions because that it was
has been asked from this paper, it is important to note that there are other benefits that
the Fund seeks realise. Good local and regional transport links underpin the
development of business and the creation of new jobs. By helping create around 18,000
new jobs over the next 10 years, unlocking potential development land and increasing
economic output by 1bn per year, the Fund will be key to increasing economic
prosperity and sustainability of the West Yorkshire region as a whole.
As important as journey time savings is journey time reliability. Analysis of journey times
between Halifax and Huddersfield has shown that they can be between 60% and 70%
longer in the am and pm peaks than they are in the middle of the day with high levels of
variability. The interventions proposed or being worked up in the phases will seek to
reduce the variability and the difference between peak and off peak travel times. Clearly
the levels of traffic present in the both the morning and evening peaks means that
journey times will not be the same as the off-peak, but the key point to note is that they
will be substantially more reliable..

61

West Yorkshire Transport Fund

A629 Phases 1 to 5 Details
1

Phase
Elland Bypass to Free
School Lane
(Calderdale Lead)

2
3

Halifax Town Centre and

Free School Lane into
Halifax
(Calderdale Lead)

Ainley Top (M62 Junction

24) and Wider Strategic
Interventions
(Calderdale Lead in
partnership with Kirklees)
Ainley Top to Huddersfield
Kirklees Lead

Schemes Description
Jubilee Road to Dudwell
Lane- Widening to form two
lanes inbound and outbound
on Salterhebble Hill
Capacity improvements at
Dudwell Lane and Dry Clough
Lane junctions
Major junction improvements
at the A629 / A6026 Calder &
Hebble junction
Improvements to the strategic
accessibility and public realm
within Halifax Town Centre to
deliver regeneration and growth
aspirations, including unlocking
land for development;

To be determined, within the next

12 months

Status
A successful case
has been made for
funding to be
allocated for the
schemes and their
implementation is
being progressed

A successful case
has been made for
funding to be
allocated for the
schemes

Schemes to be
developed

Schemes are currently being developed.

62

Potential Journey Time savings

2021

2031

NB

SB

Average

0800-0900

03:51

00:49

02:20

1000-1600

01:40

00:39

01:10

1700-1800

03:47

01:50

02:48

0800-0900

03:29

01:43

02:36

1000-1600

01:52

00:52

01:22

1700-1800

04:45

02:12

03:29

Reliability Improvements on the A629 and A58

approaches to and round the western side of Halifax
Town Centre
Reliability Improvements on the eastern route round
Halifax Town Centre (Charlestown Road/Church
Street/Shaw Lane)
Improved bus and pedestrian accessibility, reducing
journey times
This phase will concentrate on bus benefits which
may include consideration of Park and Ride and/or
express bus options depending on viability and
commercial deliverability.
Expected to be in the region of 1 minute to 1:30
minutes between 0800 and 0900 and 1700 to 1800 in
2021 and 2031 although this remains to be detailed.

West Yorkshire Transport Fund

A629 Phases 1, 2 and 3 and 5 Potential Improvments

Reliability and Journey

Time Improvements
2021

2031

NB

SB

Average

AM

03:51

00:49

02:20

IP

01:40

00:39

01:10

PM

03:47

01:50

02:48

AM

03:29

01:43

02:36

IP

01:52

00:52

01:22

PM

04:45

02:12

03:29

Potential journey time improvements

of between 1 and 1:30 minutes up to
2031

63

64