East Sussex NHS Healthcare Trust has been able to restore elective services by managing its case mix, increasing day-case procedures and some limited outsourcing to the independent sector, working closely with integrated care system partners and looking to future collaboration.
What the organisation and system faced
East Sussex Healthcare NHS Trust went into the pandemic in a reasonably good position and has come out with a relatively small number of patients waiting over 52 weeks – 70 in early August 2021. The trust, which provides acute and community services, managed to continue some urgent and cancer work throughout the first wave and made the most of theatre sessions by keeping a focus on theatre utilisation within the infection control limitations.
As it emerged from the first wave last summer, the trust prioritised elective services restoration. But the arrival of the significantly higher second wave of infections in early December meant that restoration efforts were put on hold. As it restored services this summer, the trust had to do so while balancing the need for more elective work with supporting staff wellbeing, including ensuring annual leave was taken.
Once the trust was in a position to increase elective activity, post second wave, it started with a restart approach. Rather than a focus on recovery and waiting for national guidance, the East Sussex provider talked about restart, increasing capacity over a few weeks, which enabled people to take leave, rest and focus on what the trust can do, rather than full pace recovery. This ensured it had fully re-established services prior to the H2 planning round.
What the organisation and wider system are doing
While there is relatively little private provision in the area, the trust has been able to use spare capacity at the Spire Hospital which shares a site with its Conquest Hospital in Hastings. There has also been some insourcing of endoscopy to use weekend and empty sessions during the week.
“Our clinical leaders have overseen the recovery of services with a focus on maximising day case and, where possible, undertaking virtual activity in outpatients. This has enabled us to achieve over 95 per cent of day case and outpatient activity exceeding our recovery plans,” says chief executive Joe Chadwick-Bell. The trust benefited from having started an outpatient transformation programme, which included virtual outpatients and patient-initiated follow ups prior to the pandemic.
The trust has reviewed its compliance against the expected values for high volume, low complexity procedures (HVLC) and, where there is an opportunity to improve, targets are being set with clinical leaders, recognising the local demographics and potential opportunity. This is being seen through increasing day case rates.
The trust has been constrained by not having a dedicated day surgery unit and, as such capital has been allocated this year to re-establish the unit at Eastbourne DGH. This will further support recovery and maintain ringfenced ‘green’ capacity. “The opening of a dedicated unit will give confidence to our clinical teams that we can maintain electives despite bed pressures,” says Joe.
System-wide recovery group
Sussex was able to benefit from pre-existing good relationships and collaboration already existing among integrated care system (ICS) members. A recovery group for planned care across the ICS has focused on HVLC procedures, outpatient transformation and, through COVID-19, establishing a cancer hub at Queen Victoria Hospital. The leadership teams have set stretch targets, shared best practice and have looked to resolve any issues or opportunities between providers through regular, focused meetings of chief operating officers to facilitate decisions and in collaborations with ICS leaders.
A single view patient tracking list
A single view patient tracking list has been established for all specialties, enabling all trusts to see a breakdown of the waiting list. One of the more challenged specialties, ENT, is being developed as a potential single ICS service and a single PTL is being scoped at the moment. “We are going to see if we can run it as a single Sussex service, but delivered locally. It is very early days but this is our flagship specialty,” Joe says.
Results and benefits
The acute trusts in the system are working together on aligned approaches to areas such as waiting list validation, clinical prioritisation and awareness of risks and capacity. This has led to some successes, such as identifying spare capacity for urology cancer which is being used by another local provider.
“I think before COVID-19, we worked as discrete organisations that came together to discuss single issues. What has changed is the pace and intent behind collaboration – the pandemic has changed us in at least two ways,” Joe explains.
“Firstly, it showed us that an initial joint response has a greater chance of tackling all the relevant problems. Secondly – linked to this – we are now much closer as a leadership collective within the ICS.”
She cautions that although flexible movement across the county of patients and staff has played a role through the pandemic, flexible does not mean unfettered. “The geography and demography of Sussex presents a constant challenge; an ageing population, severe pockets of complex deprivation and an underdeveloped cross-county transportation infrastructure are rate-limiting factors in both our staff and patients’ ability to be flexible” she says.
As an example of a more granular issue, she also points out there are many patients who are not on 18-week pathways but who still need support, such as those with long COVID and musculoskeletal problems, as well as new diabetic patients who are presenting for the first time within our community services. These won’t be covered by the Elective Recovery Fund, but are patients for whom the care that the trust provides will be vital.
Emerging from the pandemic, finance has become a pressing issue and although the trust welcomes the recent financial settlement for the NHS, it will further need to focus on efficiency to ensure longer-term financial sustainability. “Our ‘new normal’ innovation needs to be incremental in order to live within our cost envelope.”
“The infection and prevention control measures remain essential and as such we have ringfenced elective wards, although this has resulted in opening additional capacity and running some of our day case and short stay areas as 24/7 wards”. This is in addition to the additional medical wards required to support the extra non-elective demand.
Patients who have been on the waiting list for longer than the trust would wish are in some cases presenting as more complex, which can take longer and has implications for the number of cases the trust can complete within the same theatre capacity.
Overwhelmingly workforce remains the trust’s priority. “When we are in crisis mode, particularly in wave two, people just keep going and we thank people for all the hard work, digging deep into the personal resilience reserves. We put a number of measures in place to ensure people’s wellbeing, but we recognised that at some point people will need some time to reflect and rebuild. I think that is where we are at the moment,” the trust’s chief executive explains,
The temporary workforce – such as bank staff – are “not as available as they once were” and the uptake of additional shifts has reduced, she says. “I think we have a very tired workforce. They will always care for their patients but there has been no downtime, and we need to ensure that we support them to look after themselves.”
The trust’s approach to this challenge of balancing wellbeing with service provision has been to let staff work “at their own level” for the first few weeks of the elective recovery programme and recognise that for some people they need, for example when they have returned from redeployment. However, the trust has experienced a post-Covid surge in ED attendances – up about 10 per cent on two years ago – that is difficult to absorb with staff as fatigued as they have moved from Covid response to a resurgence in non-elective activity.
- Caring for staff: The workforce has to be priority; after all, these are the people who look after patients. It’s our job to look after our people.
- Every little helps: Incremental improvements in capacity can be possible even in stretched systems – for example, switching groups of procedures to day cases. Even small amounts of capacity at neighbouring trusts can be useful in tackling waiting lists.
- System-level thinking about waiting lists: Where systems don’t yet have a shared PTL, a “single view” specialty-level PTL allows everyone to see waiting lists and can drive collaboration in new ways.
- Clinical leaders are essential to support elective planning and recovery.
Integration in Action
This case study forms part of our Integration in Action series, a collection of publications, podcasts and webinars which explores how effective partnership working is helping to address the biggest challenges facing health and care.