Agenda item

Report of the Interim Strategic Director, Care, Wellbeing and Learning

The Committee received a report providing progress to date to reduce delayed transfers of care from hospital, and to improve the system and experience for people who require a multi-agency approach at the point of leaving hospital.

In conjunction with the report the Committee received presentations from Steph Downey, Service Director, Adult Social Care and Independent Living, Michael Laing, Associate Director, Community Services, Gateshead Care Partnership and Jean Kielty, Service Manager, Assessment and Support, Adult Social Care and Independent Living.

This OSC received a case study in respect of delayed transfers of care in 2012. The OSC agreed to include an updated case study on this issue in its 2016-17 work programmes as this had been identified as an area where performance needed to improve.  The focus of the case study has been the pressure on the health and social care system in respect of timely and safe transfers of care, and the work being undertaken jointly by the Local Authority, CCG and QE Trust to address the issue.

A delayed transfer of care occurs when a patient is ready for transfer from acute care but is still occupying a bed for such care.  To achieve a safe discharge that the patient is ready to be discharged. These are not separate or sequential stages; all three should be addressed at the same time whenever possible. They are:-

·         A clinical decision has been made that the patient is medically fit for discharge/transfer AND,

·         A Multi-Disciplinary Team (MDT) decision has been made that the patient is ready for discharge/transfer AND,

·         The patient is safe to discharge/transfer

Delays are measured in key areas, and reflect delays between NHS to NHS service, and NHS to Local Authority Services.

Another two key factors are the increasingly older population which is projected to increase a further 20% over the decade to 2024 and system pressures and the associated costs with delayed transfers of care.

The support for people who require support at the point of discharge from hospital are as unique as the needs of the people themselves. However, they broadly fall into the following categories:

·         Equipment and adaptations

·         Housing

·         Reablement/intermediate care (bed based and community based)

·         Planned packages of support (home care)

·         District nursing interventions

·         Residential or nursing care

Best practice is that where possible people should be supported to return home directly from hospital, and one of the areas most frequently identified as a pressure, in terms of arranging safe discharge from hospital, is the provision of packages of home care.

Therefore the CCG, the QE Hospital Trust and the Local Authority have worked with the independent sector providers to develop a new and innovative approach to facilitating hospital discharges for those people who require a planned package of care. These ‘bridging’ packages, which commenced in January 2017, have enabled independent home care providers to employ home care assistants on a salaried basis, thereby enabling them to provide a rapid response service, to facilitate timely discharge from hospital. Whilst the data for January 2017 has not yet been reported by NHS England, the feeling from colleagues working within the system is that the approach has been successful, to such an extent that the original pilot period has been extended further.

Building on a model developed in other areas, weekly “surge” meetings have been introduced, which provides the opportunity to bring together a range of health and social care professionals, to discuss more complex discharge issues, provide support to “unblock” problems, and enable system learning for future scenarios. These meetings are stepped up daily if and when required e.g. when the system is reporting significant pressures.

The transfer of community health services from South of Tyne Foundation Trust to the Gateshead Care Partnership (a joint approach led by Gateshead CBC, QE Trust and the Council), took place in October 2016. This Partnership bid was based on the intention to develop a new model of integration between the different sectors of the health service, and between health and social care.

Whilst the work over the winter period has rightly focused on the safe transfer and mobilisation of the workforce and service, going forward, all partners are committed to developing integrated ways of working, which will seek to reduce duplication and therefore improve the experience of people/patients. Even within the short timescale that the service has been delivered via the Partnership, there have been some positive examples which have demonstrated how the removal of organisational boundaries has improved the delivery of care.

The pilot of the “bridging packages” of care model is being evaluated, and as noted, data from NHS England should shortly be available, which should help to establish whether there is an improvement in delays reported to be associated with community packages of support. Officers are also aware of other areas piloting similar approaches, and some shared learning will be undertaken to identify whether there is a financial justification for the continuation of a longer term solution.

The surge meetings are now an established and successful process, and the intention is to continue with this approach. However, there is also the opportunity to review the other meetings and groups across health and social care, to be clear that the arrangements are lean, and do not lead to duplication of discussion.

Other areas for development planned include the role of “trusted assessor” and “discharge to assess” models, both of which seek to streamline the assessment process, and the provision of pharmacy and patient transport support, which are both crucial to the safe discharge of people with complex health needs, whilst by their very nature, more complicated to arrange for people with complex needs.

Across the system officers have taken the opportunity to explore models and ways of working in other areas, especially those that were identified as integration Vanguards. This has led to joint visits to Stockport and Sunderland with a plan to visit Salford as well. Whilst such visits cannot provide a “blue print” for integration, it is helpful to understand what has worked well, and what has worked less well in other areas.

A review of Intermediate Care has been undertaken in Gateshead, and the outcomes from this review are feeding into a combined scoping paper, looking at the potential future model of Intermediate Care in Gateshead.

A crucial element of integration across health and social care is the ability for professionals from different sectors to be able to access and read information across electronic systems, on a system of role based access. Across the North East the Great North Care Record and Connected Health Cities are working on solutions which will facilitate this access, in a way which is embedded within existing IT and data base solutions.