In a report of the Scrutiny Support Officer Members were reminded of the background to a Final Report of the Health Scrutiny Panel on Winter Pressures submitted to the Executive on 16 July 2013. At that meeting the Mayor had indicated that the Board should seek further clarification with regard to delayed discharges from hospital.
The Board was advised that subsequent to the meeting of the Executive the Health Scrutiny Panel had received an update report on winter pressures at its meeting held on 25 July 2013. The focus of attention had been on what the local health economy had or was undertaking in order to ensure that the system was prepared for such issues of high service demand and poor winter conditions as outlined in Appendices 3 and 4 of the report submitted.
The Board's attention was drawn to written evidence which had been provided from the South Tees Hospitals NHS Foundation Trust (STHFT) (Appendix 1) and from the Department of Wellbeing, Care and Learning (Appendix 2) of the report submitted.
The Chair welcomed the Deputy Director, Service Transformation, STHFT who had been given the responsibility of the discharge lead, the processes for which in partnership with Social Care had been redesigned. An overview was given of such processes together with a summary of the main reasons for delays to hospital discharge and an outline of the measures that had already been and could in the future be implemented in order to reduce delayed discharges.
From the outset it was emphasised that a significant amount of work had been undertaken to streamline processes and protocols and as part of its implementation embedded within current procedures across the Trust's 43 teams. Recognition was made of the need to sustain such measures which would be the subject of monthly audits to monitor discharge figures.
Graphical information demonstrated population changes to the demographic profile in that the number of older patients admitted as emergencies to James Cook University Hospital over the past three winters had shown that the largest cohort of patients were now over the age of 80 with an increasing number requiring a range of support services on discharge for often complex conditions.
The report detailed the prevailing legislation and national guidance in terms of hospital discharge and patient assessments.
Members were advised that a delayed discharge was recorded from the date at which a patient was medically fit to be discharged from a hospital bed but could not be discharged (DOH data standards 2007). Graphical information provided demonstrated a reduction in delayed discharges over the past six months. It was acknowledged, however, that it was not yet clear whether this was due to seasonal trends or the impact of the intensive programme of improvements undertaken over the period with partner agencies.
The report detailed the 11 codes which identified the reasons for delayed discharges. Statistical information provided showed that the two most common delays experienced within JCUH over the past 12 months were delays due to assessment and awaiting further NHS care, including intermediate care the numbers for which had also been considerably reduced in recent months. The importance of all agencies to inform others of changes in services that either increased or decreased capacity in the system was highlighted. It was vital that sufficient appropriate capacity was available to match demand as where this was not available there was a backup into acute hospital beds and an increase in delays to discharge.
Whilst the hospital social work team generally provided a very timely response to referrals it was pointed out that there had been difficulties in coping with the backlog of referrals that had accumulated over Christmas 2012 and New Year 2013 within the required statutory timeframe. Confirmation was given, however, that improved arrangements for the 2013/2014 holiday period were to be implemented.
Although the hospital social work team was very responsive to adapting to needs of the Trust with the resources available an indication was given of the desire for a greater number of social workers allocated to specific areas in hospital so that close working relationships could be established and an extension to work being undertaken regarding assessment of patients prior to an elective admission who were likely to need support from social care following discharge.
It was confirmed that over the past 12 months an intensive programme of work had been undertaken in partnership with South Tees CCG and Middlesbrough, and Redcar and Cleveland Councils via the Hospital Discharge Steering Group to redesign and streamline processes relating to hospital discharge and integrate with new services available in the community which included:-
(a) Improvements in the recording of Planned Date of Discharges and Delayed Discharges.
(b) Regular meetings and/or teleconferences to discuss delays with partner agencies, particularly during periods of peak activity.
(c) Redesign of processes relating to social care and Continuing Health Care assessments.
(d) Introduction of a single point of referral within JCUH to organise transfers of care to community hospitals and MICC.
(e) Introduction of hospital case managers, who assess patients and co-ordinate discharge arrangements for patients with complex needs.
(f) Extensive programme of discharge improvement workshops across all acute and community adult ward areas, between May and October 2013.
Graphical information was provided which demonstrated the substantial improvements made in the average length of stay, for patients who were discharged to a different location from where they were admitted, which primarily included those patients who had more complex needs on discharge.
Although the improvements outlined were acknowledged it was reported that in order to significantly reduce the length of stay of such patients, who required a significant period of rehabilitation, reablement and subsequently assessment for 24 hour care, a more radical system level redesign was required.
Members were advised of increasing evidence from other parts of the UK which had moved from an 'assess to discharge' approach to one of 'discharge to assess'. The South Tees CCG Urgent Care Group had established a task and finish group to identify what system level change was required to establish such an approach. It was also recognised that there needed to be sufficient community based services to support a patient's recovery either in their own house or other facility.
Reference was made to a scheme introduced by Sunderland Council of 'Time to Think Beds' provided by a range of private providers and commissioned by the Council. The South Tees CCG IMPROVE advisory group received an initial paper in August regarding what changes would be required to implement a similar scheme and further work was currently being undertaken to pilot such an approach over the winter months.
In the report of the Council's Interim Head of Community Care an overview was provided of hospital discharge from the Council's perspective which outlined the key legislative background and definition of a delayed discharge. The Community Care (Delayed Discharges etc.) Act 2003 established timescales, dependant on the proposed discharge date of the patient but not less than 72 hours, within which social services must assess need and effect discharge from hospital.
Members were advised that during the last winter period much work had been undertaken by staff from all related agencies in tracking delayed transfers of care on a daily basis at JCUH. A view was expressed that because of differing perceptions as to what constituted a delayed discharge and areas of responsibility for the various steps in the process had resulted in misleading and often inaccurate information being given on the outcome. It was acknowledged that considerable learning had been drawn from such an experience and the focus across partners had firmly shifted to a shared emphasis on developing joint processes more effectively.
As a result of the pressure experienced last winter by all agencies within the health and social care economy, a substantial programme of joint working had been undertaken between the hospital social work team, the acute trust and the South Tees CCG. Such work included:-
(a) Participation in the work of the hospital's Discharge Steering Group to review and streamline the hospital's discharge processes which had resulted in the updating and simplification of referral paperwork and the streamlining of referral processes.
(b) Changes to the hospital social work team's allocation system for incoming referrals to ensure that Social Workers had the maximum level of time available to plan for an individual's discharge.
(c) An increase in the Team's complement going into the winter period compared with last year.
(d) A review had been undertaken of arrangements for annual leave over the Christmas and New Year periods to ensure sufficient staff to deal with anticipated referral rates.
(e) Participation in the IMProVE Advisory Group which was co-ordinated by the South Tees CCG which one of its aims was to strive to create effective pathways for vulnerable elderly people where admissions to hospital were minimised and where individuals were successfully discharged from hospital into settings where their wellbeing could be sustained.
(f) Participation in the Urgent Care Workstream which was co-ordinated by the South Tees CCG focussing on developing local health services that allowed urgent access to the correct level of health care.
Confirmation was given of continuing work in developing the discharge processes at the hospital both in direct partnership between the Council. Redcar and Cleveland Borough Council, the hospital Trust and in the forums afforded by the CCG. Areas for consideration included the possibility of all admissions being dealt with by Social Workers from the hospital based team and whether there was merit in additional linking of Social Workers to individual wards. It was agreed that whilst it was considered beneficial the partners were mindful of current financial constraints and that careful consideration would have to be given as to the feasibility of pursuing such an initiative.
From the social care perspective it was considered that there was a much improved referral and allocation processes and a confident expectation of more effective partnership working.
Following clarification sought from Members details were given of the role of the social worker which irrespective of whether they were based in the hospital or in the community was to conduct a timely assessment of need, ensuring the contribution of other relevant professionals.
In terms of the implementation and embedding of the overall improvements the Board was advised that there had been certain links of individual social workers to specific wards in order to achieve more effective adoption of new processes.
It was noted that whilst the social worker team worked standard Council working days there had been occasions when they had worked weekends although the main areas of work during such periods had been to catch up with work from the previous week rather than on new cases. The overall concept continued to be discussed along with health professionals but it was recognised as a challenge in that the process required not just social workers but other agencies such as occupational therapists, physiotherapists and a plethora of support in developing an appropriate package of support for a patient.
Members referred to delays which had been reported in relation to the process involving cases where adaptations need to be carried out for patients with multiple requirements. The STHFT representatives acknowledged that whilst there were a comparatively small number of such patients the process took time and therefore issues around finding transitional housing in such circumstances was the subject of current discussions with Erimus Housing in identifying suitable transitional housing stock.
In commenting on improved processes specific reference was made to the benefits of capturing more accurate and documented information about delayed discharges with each ward being closely monitored. Changes and the standardisation of processes ensured that the legislative requirements were being met and planned discharges could be achieved in a more timely manner. In order to avoid delayed discharges Members supported the administrative changes and earlier involvement of social care in the overall process. It was noted that in the majority of cases referrals would be made to social care within the statutory eight day period but acknowledged that issues could arise with an increasing number of frail and elderly patients with complex conditions requiring support from a multiple agencies.
Following details of Members' personal experiences of delayed discharges the STHFT representatives reaffirmed the range of discharge improvement workshops completed across 43 teams to ensure a culture change required to embed the standardised processes for discharge. It was noted that the development and improved pharmacy processes was the subject of a major review and overall improvements. The Board was advised that recruitment and retention of staff had been an issue although a new Director of Pharmacy had recently been appointed.
Although information was provided on areas of responsibility in undertaking assessments following comments regarding an apparent lack of co-ordination between health and social care in relation to out of area patients it was pointed out that clarification was required regarding the impact of proposed legislation The Care Bill in 2016. It was also noted that further information would be required as to the impact of such legislation on the increasing demands of an ageing population with an increased cohort of patients with multiple complex conditions.
Members were advised of increased reablement resources which would involve the initial role of the hospital social work team for identifying the reablement potential and then plan a discharge based on a package of reablement support in an individual's own home.
Members considered that the feasibility of the hospital based social work team being aligned to groups of wards should be explored although recognised the financial constraints and possible practical difficulties in reducing flexibility of social workers.
In conclusion the Board acknowledged the substantial amount of work which had been undertaken since the Health Scrutiny Panel's Final Report and of ongoing work in response to last year's winter pressures. It was suggested that it would be beneficial if the Panel continued to receive an update on further developments which included initiatives such as the 'discharge to assess' approach and 'Time to Think' beds.
ORDERED as follows:-
1. That the representatives be thanked for the information provided.
2. That the recommendations of the Health Scrutiny Panel be reaffirmed and that following consultation with the Chair and Vice-Chair a report on the Board's findings be compiled and referred to the Executive.
3. That the Health Scrutiny Panel receives further updates and additional information regarding the South Tees Clinical Commissioning Group's funding priorities with particular regard to the IMProVE programme.
4. That relevant information arising from the meeting be considered for possible inclusion in the Final Report of the Social Care and Adult Services Scrutiny Panel in respect of Delayed Discharges.