Agenda item

(Indicative timing 2:05 – 3:00pm)

The Cabinet Member with Responsibility (CMR) for Adult Social Care and Senior Officers from the People Directorate were welcomed to the meeting.  Panel Members were reminded of the main points within the Agenda, including:

·         all of Worcestershire’s health and social care partners were committed to delivering good quality person centred care

·         an Intermediate Care Service had been in development for 12 months, on an interim basis.  Partners collectively challenged what ‘good’ looked like, reasons for delays and what barriers were stopping progress.  It was clear that System pressure was year round, not just during the winter months and the interim model would continue whilst long term plans were developed

·         the Onward Care Team (OCT) model was due for review after being in place for 12 months.  Although a vital service, sitting on the front door of urgent care, it was important to challenge whether any further improvements to the OCT could be made.  The hospital based Team covered both health and social work staff and was responsible for short term discharge planning, supporting individuals and signposting to consider all discharge options  

·         the Reablement Service supported people leaving hospital to recover at home (Pathway 1) and had an element of admission avoidance as a ‘service of last resort’ on occurrences of existing care provider failure.  Although very successful, there were challenges around recruitment, especially as front line roles were attractive to those already employed in other areas of the care market.  Of 100 new posts created through additional funding, 60% had been filled within 6 months.  This success had earned national recognition and other local authorities were keen to learn how it had been achieved

·         further challenges related to increased demand, the requirement for additional domiciliary care hours, the need for staff to double up for some patients and the logistics of a large, mainly rural County

·         ‘Right to Reside’ was when a patient no longer met the national criteria to reside in a community hospital and had replaced ‘Delayed Transfers of Care (DTOC), which Panel Members would have heard previously.  If barriers to community hospital discharge (Pathway 2) were identified, such as equipment needs, family circumstances or agreeing eligibility for NHS Continuing Healthcare (CHC), System partners would work with individuals and families to devise discharge plans.  It was noted however that delays could also occur if resource was shifted to promote Pathway 1 discharges from acute settings

·         Intensive Assessment and Rehabilitation (IAR), Pathway 3, was provided at Worcester City Inpatient Unit, where up to 21 beds could be used for patients who were assessed in acute hospitals as being unable to have their care and support needs met in their own environment and had no rehabilitation goals identified at that point in their recovery.  Patient flow could be an issue due to the complex nature of rehabilitation needs.  The chance of long term care was much higher, but those conversations did not take place in an acute setting.  In addition, a small number of Discharge to Assess (DTA) beds, also Pathway 3, were sourced in Care Homes for up to 4 weeks if no IAR bed was available.  This option would not have any therapy attached and was therefore not desirable

·         a Wrap Around Care provision was commissioned as a pilot project in April 2022 to deliver live in care between 48 and 72 hours minimum to support positive risk taking and provide an opportunity for individuals to make decisions about their long term care needs whilst in their home environment.  The success of the pilot project had resulted in an extension to August 2023 and it was hoped that the provision would be looked at long term

·         a Worcestershire System Escalation Management Plan (EMP) was in place and all System partners had a role to play.  It was noted that organisational boundaries were diminishing and partners were working effectively with the resources available.

The Chairman invited questions and in the ensuing discussion, key areas included:

·         Recruitment was a challenge, not only in Worcestershire, but nationally across health and social care.  By working with partners, collective action had been taken to mitigate shortfalls, such as a recent System wide recruitment event

·         The recording of reasons for failed hospital discharges could be problematic as the terminology used was not consistent throughout the System.  The 46% recorded as ‘not medically fit for discharge’ occurred when the status of a patient had changed since the discharge had been agreed, or the care needs had changed and hospital remained the safest place.  It was recognised that clarity of the categories of the remaining 54% could be improved, however, the CMR reminded Members that it was an NHS system which recorded the information

·         A Member, who was also a Member of the Health Overview and Scrutiny Committee (HOSC), referred to the 15% of failed discharges due to Hospital Delays and asked whether this would include pharmacy delays.  It was confirmed that the figure included all delays in the control of the hospital, including pharmacy

·         The System had a target to discharge 700 Pathway 0 patients, i.e. those which would not require any health or social need.  These simple discharges made up about 80% of hospital discharges and 20% of discharges would require some onward health or social need.  Worcestershire’s performance was the best in the region for Pathway 1 (where a patient was discharged home, with support).  The System had invested heavily in Pathway 1 and results were positive

·         Delays were more likely from a community hospital when an individual was going on to long term care as often, the patients were frail elderly and had to make a choice on where they would spend the rest of their life.  These life changing decisions were not something anyone would wish to be rushed

·         With reference to length of stay in IAR or DTA beds, it was explained that a goal of up to 4 weeks was in place.  On occasion, extensions were required as choices may need to be made, such as onward location or determining any CHC eligibility

·         The OCT was fully staffed with social workers, however, the Reablement Service had 50 vacant posts.  These were not full time positions, with over 50% advertised as evenings only.  A review of the recruitment process was in place; however the Panel was assured that the current staff were dedicated and flexible and they were able to mitigate vacancies.  Officers recognised that goodwill was not a solution.  Members questioned whether the Job Title ‘Promoting Independence Worker’ was a barrier to applications, to be informed that recent adverts were more generic, which had made a difference to the volume of applications.  Frontline posts were paid at a slightly higher rate recognising the intermediate care skills profile     

·         The decision to escalate the Worcestershire System Escalation Management Plan was prescribed nationally and implemented locally by the Integrated Care Board Membership.  When asked how often Level 4 was reached, it was explained that levels could change during a day.  For assurance, once level 3 was triggered, the Strategic Director or Assistant Director would be directly involved.  Members asked for data to further understand the scale of the changes, which the Strategic Director agreed to look into

·         The Panel was informed that the level of scrutiny of the Worcestershire System was huge, with the expectation that hourly reports to the NHS national team would be made     

·         When asked whether the 21 IAR beds was sufficient, the Panel was informed that there were in excess of 250 community hospital beds which were utilised, but the 21 were for time limited, very intensive rehabilitation as a step down from an acute hospital where long term care was likely but those decisions were not taken in an acute setting

·         When asked the extent of working with District Councils, in relation to Disabled Facilities Grants (DFG), the Panel learned that the Government funding formula meant significant funding was allocated to district councils and the Council did not have a role in how it was distributed other than discussions about adaptations.  It was noted that the Health and Wellbeing Board was to discuss the subject soon

·         In response to a query as to whether social care had a role in Accident and Emergency (A&E) Departments, it was clarified that that the OCT was based at the acute hospitals and did have a role, alongside clinical staff, in working with patients on arrival, mindful that clinical needs were prioritised.  If social care input was likely, plans were initiated quickly to enable a discharge.  It was further explained that on arrival at A&E, patient streaming was in place, with support from General Practice, to try to better signpost those who did not require A&E.  Furthermore, a Social Worker in the OCT supported the homeless pathway, to ensure that discharge was not delayed due to circumstances

·         Intermediate Care was focused on step down, however, the Strategic Director believed more could be done to ensure the service was a true intermediate service

·         It was clarified that decisions on whether a patient required long term care were taken outside of an acute hospital setting and all System partners had agreed that approach.  It was clear that there were sometimes challenges, especially when best value was required, however, ultimately patient choice was always a consideration.  An interim placement was always a possibility, however, only if safe to do so

·         At the requirement of the NHS national team, the Worcestershire Acute hospitals had implemented the Bristol ‘Push’ Model, whereby patients were moved to a ward every hour whether a bed is available or not.  This ‘boarded on the ward’ approach was to encourage patient flow; however, it was explained that patients may arrive on a trolley bed and the expectation was that Ward staff would take on patient care

·         Leaflets were given on admission to explain what would happen once a patient was medically fit for discharge, however, families did not always understand the process 

·         When asked about the state of the care market, it was explained that it was buoyant.  Occupancy levels had dropped during the COVID-19 pandemic and had not yet fully recovered

·         The Council would offset vacancies in a number of ways, including working with Neighbourhood Teams to investigate joint working opportunities.  People in other roles could also step in and extra shifts were offered to existing staff.  There was a strong team ethic, however, Managers were mindful that there was also a lot of goodwill.  Some visits would have to be re-arranged and some be undertaken remotely

·         When asked whether the Council offered work experience, it was reported that there was no formal arrangement in place, however, there was good relationships with the University.  Furthermore, 2 new recruits would be working and training to a degree level qualification. A Member advocated the need to work with young people early

·         At a recent HOSC meeting, it was reported that arranging packages of care was not as responsive as it could be.  The Strategic Director suggested that language was used interchangeably and not always correctly and reiterated that Pathway 1 discharges were extremely successful.  Furthermore, not all packages of care may refer to adult social care, for example arranging CHC.   If the reference had been in relation to domiciliary care, it was acknowledged that at one point, around 80 people were waiting, but at present it was 19, which was the lowest in some time.  It was further reported that there would always be some people whose care was more challenging to arrange, such as time specific care for medicine reasons

·         The Strategic Director was keen to stress that if the patients waiting for something to happen one day were different to the following day, that proved there was patient flow

·         When reviewed, if Wrap Around Care was considered successful, it was hoped it would be discussed by the System for plans beyond the extension to August 2023

·         Crisis response included the response of social care to work at pace to keep someone safe at home and make an admission avoidance

·         A Member asked how the Strategic Director was supporting the CMR to ensure he was aware of what was needed to provide a good service in Worcestershire.  A ‘no surprises’ approach was taken through regular dialogue alongside being aware of national developments and doing everything to influence national decisions

·         The predicted overspend at the end of the year was likely to be over £8m, a picture seen across other local authorities. 

John Taylor, a Director of Healthwatch Worcestershire was invited to comment on the discussion and asked about the level of involvement of carers in the processes outlined.

In response, it was reported that as a result of a Healthwatch survey on hospital and out of hospital services, practice had been changed to work with carers and improve earlier communication on discharge planning.  The Council, and partners, welcomed feedback and learning from experiences was ongoing.