Jade Griffiths-Jones

Dear Miss Brown

Inquest Relating to the Death of Mrs Griffiths-Jones on 04/06/23 - Response to Regulation 28 Report to Prevent Future Deaths

I write in response to the Regulation 28 Report made by you following the inquest into the death of Mrs Griffiths-Jones.

Firstly, on behalf of NHS Birmingham and Solihull, we extend our sincere condolences to the family and friends of Mrs Griffiths-Jones.

NHS Birmingham and Solihull (BSOL ICB) has carefully considered the concerns raised within your report to prevent future deaths, specifically relating to your concern that:

• Death was due to natural causes in combination with a delay in ambulance attendance arising from increased demand for ambulances and significant hospital delays.

• Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.

• The availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.

All partners acknowledge the risk posed for citizens awaiting an ambulance response for longer than deemed safe within a community setting. As you outline, this can be caused by various factors including an increase in demand, the number of crews on duty within the ambulance trust and the productivity of these crews. This latter factor is influenced by how much time the crews spend outside of hospitals awaiting handover of their patient, although other factors also contribute. It is also acknowledged that, although there are significant mitigations in place to prevent harm for those cared for in the back of an ambulance on a hospital site, remaining in the back of an ambulance at a hospital site is not without clinical risk, and is also a poor experience of care for the individual affected.

This letter summarises the way that partners across NHS BSOL are working together to reduce delays in handover at hospitals and thus to reduce any potential harm to those awaiting an ambulance response within our community.

It should be noted that the current performance metric specified by NHS England is that category 2 response times should be an average of 30 minutes and this has been included in our 2024/25 operational plan for the NHS locally and by West Midlands Ambulance Service (WMAS). The average monthly category 2 response time for BSOL across 2023/24 was 37 minutes and 56 seconds which is above the national standard of 30 minutes. This has continued to improve over the last few months as illustrated in the graph below.

On a day-to-day operational level, partners within BSOL providing emergency care, work closely with colleagues at WMAS to ensure that care provided as a whole emergency partnership is as safe as possible. The BSOL System Co-ordination Centre (SCC) co-ordinates interactions with a ‘battle rhythm’ of partner meetings, but individual partners, especially University Hospital Birmingham NHS Trust (UHB) and WMAS colleagues are in frequent and regular contact to enable best working together. Although at times all parties can be managing significant risks within their own provider footprint, there is a well-developed understanding of the concept of risk equalisation, where one provider will need to take on extra risk associated with a greater risk within another provider. The number and length of category 2 waits are a well understood marker of such community risk with professional and respectful co-operation to reduce wherever possible.

Measures to reduce ambulance handover delays are multifaceted and are distributed across the patient pathway. They fall into the categories described below:

• Reducing health care demand by enabling self-care.

• Provision of effective alternatives for public access to prevent Emergency Department (ED) attendance with signposting.

• Provision of effective alternatives for health care professional access to prevent ED attendance.

• Effective management within UHB to reduce ED overcrowding.

• Prompt and effective discharge processes from all providers to final destination. In addition, measures for the ICS to implement are summarised within NHS England » Delivery plan for recovering urgent and emergency care services.

Each provider oversees the pathways that they deliver within their own governance frameworks. However, to function effectively the urgent and emergency care pathways have to work as a whole system. Changes in capacity in any part of this complex programme can have effects elsewhere, and as discussed, there are occasions where risk sharing has to occur to ensure that the risk of harm is equalised, where possible, across all pathways.

For this reason, oversight is via a UEC Delivery and Improvement Board which is chaired by the ICB Chief Delivery Officer with senior representation from all system partners. This Board provides integrated system leadership to set and deliver the Urgent and Emergency Care Strategy, with a focus on equity of access and system efficiency.

Where provider performance metrics are a cause for concern these are reviewed weekly within the ICB System Oversight Group, along with appropriate change programmes with trajectories for improvement. Quality concerns associated with UEC pathways are again reviewed via individual provider governance arrangements with ICB agreed metrics. These are discussed monthly within an escalation pathway to the System Quality Group and Quality Committee, where all long ambulance waits and excessive ED stays are discussed and escalated to the ICB Board along with mitigations to prevent harm and improvement plans. Operationally, individual providers have in place a daily rhythm that oversees the efficient, effective and safe delivery of care within their provision. This continues into out-of-hours with senior managerial input. The ICB hosts the SCC, which holds full accreditation status from NHS England in compliance with the national SCC specification. The team are responsible for co-ordinating the system-wide response to pressure points, such as ambulance handovers and increases of activity in EDs, and supporting interventions in all pathways. They have access to a wide range of data to enable their role and bring system partners together throughout the day, and into the out-of-hours period, to ensure joined up problem solving, effective flow and maintenance of safety.

WMAS is not directly commissioned by BSOL, but by the Black Country ICB on behalf of the West Midlands ICBs, with BSOL as associate commissioners. As such BSOL contributes to discussion on performance and quality via established routes with Black Country colleagues. Operationally, however, WMAS colleagues are very integrated into BSOL provision and daily oversight rhythm. This not only includes the paramedic crews themselves, but presence of a senior co-ordinating role, the Hospital Ambulance Liaison Officer (HALO), and until recently provision within UHB with Ambulance Decision Areas (as below). The overall objective of the HALO service is to facilitate the handover of patients presenting at ED by ambulance, in a clinically safe, effective and efficient manner, thus enabling crews to turnaround ambulances in readiness to respond to other emergency calls. This provision reduces the build-up of ambulance downtime at ED sites.

Senior operational colleagues are also involved in SCC calls to ensure that the ambulance resource is deployed as effectively as possible.

Reducing health care demand by enabling self-care

We routinely share important messages with our local communities and general public, encouraging them to make the best possible choices when it comes to seeking care. This aims to reduce pressure on emergency departments and other urgent care services. These messages are delivered through channels including social media, the media and advertising spaces in high footfall areas, all created and pushed out in partnership with system partners. Messages include:

• Use of NHS 111 online and over the phone.

• Signposting to pharmacies and self-care options in the event of minor health concerns.

• Directing patients to Urgent Treatment Centres (UTC) where appropriate.

• Bank Holiday messages, ensuring patients are aware of available services.

• Emphasising the importance of vaccination as a preventative measure, both for winter illnesses and childhood diseases.

• Sharing national campaign messaging provided by NHS England.

Provision of effective alternatives for public access to prevent Emergency Department (ED) attendance with signposting

Access to general practice has been a significant improvement focus for the ICB. A system wide improvement programme has supported practices in making it easier for patients to access care – including improved telephony systems. There are now approximately 15% more GP appointments available than in 2019, with some appointments routinely offered at weekends and evenings. Practices have also been working together to provide additional care in trials of ‘locality hubs’.

NHS 111 is the main portal for access of NHS services out-of-hours, but can also be accessed in-hours if required. There have been an average of 1,310 calls per day over the last 12 months, with 535 of these calls being ‘in-hours’ and 775 calls being classed as ‘out-of-hours’. 22% of the calls to 111 are referred onto integrated urgent care/ED, 17% of calls are referred to primary care, 15% to a UTC and 13% require an ambulance to be arranged. Just over 18% of these calls require no onward referral. Call answering time is on average 60 seconds with 6.98% of calls abandoned. In a similar manner to WMAS services, BSOL ICB do not directly commission NHS111 services, but work closely as associate commissioners with Black Country ICB who commission this service on behalf of the West Midlands with Derby and Derbyshire ICB for the Midlands Region.

BSOL has six UTCs across the footprint; these can be accessed either by walking-in or via direction from NHS 111. They provide an alternative pathway away from ED for those patients who require swift medical attention with urgent but non-life-threatening conditions. The UTCs can also offer clinical telephone advice to ambulance crews on the scene and can accept conveyances when and where agreed. On average, 714 patients have been treated daily within UTCs over the last 12 months. A full review of UTC provision was instigated in May 2024 to ensure it meets the needs of both our local population and new national guidance published in October 2023.

The ‘Pharmacy First’ Service commenced on the 31st January 2024 and enables community pharmacists to complete episodes of care for patients without the need for the patient to visit their GP. Across BSOL 93% of pharmacies have registered to provide the service which includes referrals to community pharmacy for minor illnesses, previously commissioned as Community Pharmacist Consultation Service (CPCS), and seven new clinical pathways which include uncomplicated urinary tract infection, shingles, impetigo, infected insect bites, sinusitis, sore throat and acute otitis media.

Provision of effective alternatives for health care professional access to prevent ED attendance

The Urgent Community Response (UCR) team, provided by Birmingham Community Health Care Trust (BCHC) and UHB community provision, provides urgent care for people in their homes, helping to avoid hospital attendance. Referrals can be made directly by GPs and there are regular contacts with WMAS

each day to divert patients to this pathway if appropriate. There are in the region of 60 referrals a day for UCR. We are currently reviewing the service offered to ensure that as many patients as possible can be treated safely by the team. Patients can also be admitted to the frailty virtual ward, here a patient can receive close monitoring in their own home with consultant oversight if required.

‘Call before you convey’ is a direct service available to WMAS colleagues whilst with the patient in their own home, offering different pathways to use where appropriate, other than hospital attendance. This service is primarily aimed to support patients over the age of 75 years, offering diversion into the UCR or wider community services. Since the commencement of this service in December 2023 there have been an average of just over 65 calls per week equating to nearly 10 patients per day.

For those with mental health needs, where there is no physical health need to address, discussion is facilitated directly with mental health provision to determine the best way to address the care required, with ED avoidance where at all possible.

Effective management within UHB to reduce ED overcrowding

Whilst a number of initiatives are being undertaken across the NHS to assist in reducing delays and congestion within EDs, we have set out below an example of a number of initiatives that have been implemented at UHB with the aim to reduce congestion in the ED.

The Rapid Assessment and Treatment (RAT) team assess patients arriving by ambulance on arrival, organise diagnostic tests and initiate treatment. In the event that there is a lack of flow out of the assessment area, the team undertake the same process on the ambulance in order to reduce delays. Those patients who are sufficiently mobile and fit to wait in the main seated waiting area are directed there to reduce demand for majors cubicles and thus rapidly release the paramedic crew back into the community.

An escalation process operates which makes use of defined areas within ED to accommodate patients at times of surge in demand. Staff are assigned to the area to maintain safety and the area is stood down once sufficient capacity has been released.

The ED have a range of services they can refer into at the point of triage. The most frequently utilised of these are the on-site primary care service and the Same Day Emergency Care (SDEC) service. The primary care service has capacity for around 250 patients a day (66 at QEH) across the three UHB ED sites, typically presenting with a minor illness. The SDEC service treats ambulant patients on an emergency day case basis in order to rapidly diagnose and commence treatment for a wide range of presentations. Typically 39% of admitted patients are cared for in this manner at the QEH. The Frailty SDEC and Emergency Observation Units are also available to the triage team.

A clinical site integrity team co-ordinates the clinical movement of patients across each site at UHB. Key tasks include the allocation of patients to available capacity to ensure optimal utilisation and the management of the ‘medical push’ model whereby patients waiting admission are transferred to the allocated ward in advance of planned discharges leaving the ward, thus reducing the occupancy of the ED. The team are in frequent dialogue with all clinical specialities to co-ordinate discharges, prevent the spread of infections and ensure site safety is optimised at all times. This team also chair regular site integrity meetings with all clinical areas to ensure any operational issues are allocated to the appropriate team for timely resolution.

A key priority for all clinical specialities is the reduction of length of stay within the acute setting. A range of improvement activities are in train to ensure all specialities achieve or surpass benchmarked

performance levels. With emergency demand increasing each year, this activity is essential to ensure all patients can be accommodated in an appropriate timescale.

Prompt and effective discharge processes from all providers to final destination

A single transfer of care hub approach was implemented by UHB, BCHC, Birmingham City Council and Solihull Metropolitan Borough Council in May 2024 to improve the flow of patients out of the acute hospital and into community services. The new process enables fewer handoffs between teams and will enable hospitals to ‘free up’ beds earlier, and therefore, admit patients from ED in a more timely way.

The package of measures set out above demonstrate the focus of the NHS and wider partners locally in addressing issues across the urgent and emergency care pathway within the resources that are available. The is important as nationally NHS England also provided WMAS with additional resources in last financial year (£24m) on a recurrent basis to support additional ambulance crew hours on the road and the best use of resources required for ambulance handover delays to be minimised.