Agendas, Meetings and Minutes - Agenda item

Agenda item

Delayed Transfers of Care

Minutes:

Attending for this Item were:

 

Worcestershire County Council (WCC)

Richard Keble, Assistant Director of Adult Services

 

Worcestershire Clinical Commissioning Groups (CCGs)

Chris Cashmore, Urgent Care Lead

 

Worcestershire Health and Care NHS Trust (WHCT)

Jan Austin, Associate Director of Countywide Community Services

Sharon Buckley, Urgent Care Strategic Lead

 

Members were informed that unfortunately Representatives from Worcestershire Acute Hospitals NHS Trust could not be present, however, any questions which could not be answered at the meeting would be taken away for action.

 

The Panel had requested an overview on Delayed Transfers of Care (DTOC), in order to understand more about the subject and appreciate the respective roles of the Council and Health partners. Members of the Health Overview and Scrutiny Committee (HOSC) had also been invited to attend and participate, due to the relevance of the HOSC’s scrutiny of health services.

 

The Panel received a presentation, which would be circulated to Members following the meeting. During the presentation, the Assistant Director highlighted that:

 

·         A DTOC was the period of time it took someone to leave or be transferred from a hospital (Acute, Community or Mental Health) to an alternative setting after they had been deemed Medically Fit for Discharge (MFD)

·         The time period was measured in whole days

·         A delay meant that beds were unnecessarily occupied, which slowed down flow through the hospital and impacted on A&E, both in relation to wait times and ambulance handovers

·         For patients, delays impacted on fully recovering independence

·         Delays were assigned into one of ten categories and responsibility for delays were either classed as NHS, Social Care or Joint.  Weekly meetings were held with all parties to ensure that the reason and responsibility were agreed

·         Data was reported in a number of different ways; however, the Department of Health required the number of delays per day per 100,000 population.  For Worcestershire, the 2018-19 target was 12.5 and in February 2019, performance was at 12.9 delays per day per 100,000 across all providers

·         For the period January to March 2019, Worcestershire Health and Care NHS Trust reported around 10.5% of delayed patients occupying beds, in comparison to 3% for Worcestershire Acute Hospitals NHS Trust.  This was a positive reflection on the work undertaken to focus resources on keeping patients flowing through the acute hospitals

·         Although patient numbers were small, out of area delays were often lengthier as the process was more difficult to manage at a distance

·         It was felt that delays due to patient choice and housing issues could be reduced

 

In the ensuing discussion, the following main points were raised:

 

·         The Clinical Commissioning Groups had a role in managing and challenging DTOC across the system and was very clear that resources were focussed on assisting the flow through the acute hospitals.  This had resulted in positive results, whereby reported figures were following the national trajectory

·         Worcestershire Health and Care NHS Trust was responsible for community hospitals and as the focus was on acute services, the challenge had shifted.  It was stressed that discharge from a community setting was more complex due to external factors such as family circumstances, patient choice or adaptations required to the home. Invariably, patients were frail elderly, where recovery took longer or they were unable to return to their existing living arrangements

·         In response to a query about when discharge was first discussed and what reasons there were for delays, WHCT reported that discussions about discharge took place in their settings very early on, and on a regular basis, with the approach that ‘own bed is best’.  In relation to reasons for delay, it was clarified that the decision could be made that a patient was medically well, but was frail and therefore other factors could be the explanation, such as:

·         the requirement for a package of care on discharge

·         equipment or adaptations required

·         residential accommodation needing to be organised

·         patient choice (location/funding/assessment)

 

·         It was stressed that the reasons for delay from a community setting were different to those from an acute setting.  The majority of cases tended to be complex as patients often elderly frail. It was suggested that less than 50% of discharges from WHCT were simple discharges

·         In terms of learning from others/best practice, the Panel was advised that there had been a huge amount of support for the Acute Trust from National Health Service England (NHSE) and National Health Service Improvement (NHSI) and learning was also taken from other local authorities.  In addition, the new Chief Executive brought a wealth of experience

·         In response to the suggestion that acute DTOC were due to a lack of availability of doctors to sign prescriptions, it was reported that delays for this reason were common but the Acute were supported by an Emergency Care Improvement Team to address these types of issues and the Urgent Care Recovery Plan drilled down into these issues too 

·         In addition, a Member asked about delays due to pharmacy procedures and it was clarified that this would only apply to Acute Hospitals.  Officers were asked to request a response from the Acute Trust

·         National guidance stated that a plan for discharge should be commenced within 16 hours of admission to hospital and it was accepted that it was easier for a patient to be discharged into a community setting rather than home.  The Acute Trust was developing a criteria led discharge programme, which would hopefully lead to further improvements

·         Members were reminded that if a patient was in an acute hospital setting, they were in crisis and the planning which took place would be for their next appropriate setting which was not necessarily home (although it could be) 

·         If a patient was discharged incorrectly and readmitted later, it would be classed as a new admittance, however, the patient would be marked as a repeat attender and the reasons why would be investigated

·         In relation to discharges at night, the Health and Care Trust reported that they do not discharge after 8pm, regardless of the time of year and generally do not accept admissions after 8pm either, however, in exceptional circumstances would do so.  Information from the Acute Trust was requested

·         The Panel queried whether Care Home capacity was a cause for concern and whether it was a reason for DTOC.  Generally, it was not an issue, however, specialist placements (such as high level of dementia, older adult mental health or eating disorders), may be a challenge.  Additional bed space could be purchased; however, assessments would need to be carried out by the Care Home staff and are not undertaken at weekends

·         Data on the number of patients delayed in a community setting was discussed each week, with the most recent figure being 25 people.  Figures from the Acute Trust were requested

·         Partners wanted to work together to find a whole system approach of providing the appropriate flow through the system, from ambulance handovers through to discharge

·         Care Homes carried out their own assessments, however, hospital based Social Workers carried out assessments for step down placements.  It was noted that as Care Homes were independently regulated, they were responsible for ensuring the safety of all of their patients

·         Worcestershire had received additional winter care funding, which had been fully allocated to the Acute Trust

·         Patients who were already in receipt of a package of care, were generally easier to discharge. However, those patients who were independent when admitted to hospital but required support on discharge usually took longer to arrange.  As previously stated, discussions about discharge would commence within 16 hours of admission

·         In relation to monitoring arrangements after discharge, it was noted that if a package of care had been introduced, there would be a review within six weeks

·         DTOC due to families was discussed as being one of the most challenging.  A 2017 report by the Worcestershire Association of Carers cited that 50% of families weren’t told about their relatives discharge until the day of discharge.  It was now hoped that the patient and their family were at the centre of discharge and plans were discussed at the earliest opportunity

·         When asked where resources should be focussed to reduce delays, it was suggested that assessments not being able to take place on day of discharge and family/patient choice conversations were perhaps the ones which would benefit most.  Equipment and housing demands were also mentioned as priority areas

·         The Panel was pleased to note that the number of delays was reducing, and further action was being taken to improve the situation further.  It also appreciated that it would take time for new systems to bed in.

 

The following information would be requested from Worcestershire Acute Hospitals NHS Trust:

 

·         Further information around pharmacy being a reason for DTOC and the on-going to support this

·         Clarity on timings of discharge (i.e. evenings, month dependent) and whether there was any guidance

·         An update on the Emergency Care review, the Long Length of Stay review and the Urgent Care Recovery Plan

 

In addition, Worcestershire Health and Care NHS Trust would provide further information about numbers of patients affected by delays in discharge. 

Supporting documents: