Agenda Item 8 - Delayed Discharge Performance
North Ayrshire Council · 22 August 2024
Back to Integration Joint Board — 22 August 2024 and its agenda
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Integration Joint Board 22 August 2024 Subject: Delayed Discharge Performance Purpose: To update the IJB on performance in relation to Delayed Discharge and the Improvement Plans for North Ayrshire. Recommendation: The IJB are asked to: a) Note the wider system performance as highlighted in the report for the Unscheduled Care system in Ayrshire and Arran. b) Note the performance for Delayed Discharges in North Ayrshire and associated improvement plans. c) Note the national mission to reduce Delayed Discharges across Scotland and the associated governance arrangements put in place to achieve this. d) Endorse the North Ayrshire response to COSLA re the resources required to deliver the performance improvement requested of the HSCP. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required √ 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms NHS AA NHS Ayrshire and Arran LOS Length of Stay MHO Mental Health Officer CFSD Centre for Sustainable Delivery COSLA Convention of Scottish Local Authorities DWD Discharge Without Delay CRAG Collaborative Response and Assurance Group PDD Planned Date of Discharge CFSD Centre for Sustainable Delivery 1. EXECUTIVE SUMMARY 1.1 The Integration Joint Boards have delegated responsibility for elements of Urgent and Unscheduled Care activity in large hospitals. Previous report(s) have been presented to the IJB in June 2022, October 2023 and March 2024 setting out those arrangements, the programme(s) of work in place to improve performance and the areas where focused action was required to improve services for the people of Ayrshire and Arran. These reports have provided a comprehensive update on performance across the whole pathway for unscheduled care, this follow up report to the IJB focuses on Delayed Discharge
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performance, plans to improve performance and highlights the national mission to reduce Delayed Discharges across Scotland back down to pre-pandemic levels. 2. BACKGROUND 2.1 Health and Social Care services across Scotland continue to face real pressures, with delayed discharge performance utilised as one of the key indicators to measure the efficiency and effectiveness of our health and care system. Overall, levels of delayed discharges in Ayrshire and Arran have improved in 2024 when compared to levels in 2023, however remain higher than pre-pandemic levels. Whilst it is the case that generally 94-96% of people are discharged from hospital without delay, hospital occupancy levels remain high with significant pressure on a range of health and care services. Furthermore, Ayrshire and Arran remains an outlier in some areas of urgent and Unscheduled Care performance when compared nationally with other Health Boards. 2.2 The Partnership’s Health and Community Care teams, alongside Mental Health colleagues, developed a local winter preparedness and delayed discharge improvement plan in response to service performance levels and community unmet need in late 2023. The implementation of the plan continued through early 2024 with a focus on enhancing Care at Home Capacity, Discharge to Assess and Adults with Incapacity. 2.3 This report describes the elements of Unscheduled Care performance which interface with the HSCP, for example core discharge planning including Discharge without Delay and provides an update on the national mission to reduce Delayed Discharges, the improvement targets set for North Ayrshire and the HSCP assessment of resources and capacity required to deliver on that ambition. 3.1 National Mission to Reduce Delayed Discharges 3.1.1 COSLA and Local Government have agreed to support the First Minister’s mission to reduce Delayed Discharges across Scotland. This is in recognition of the impact on both patients and also the acute hospital system which is under immense pressure, with a view to supporting the decongestion of the hospital sites in advance of the next winter period which inevitably adds more pressures to the health and care system. There is a Collaborative Response and Assurance Group (CRAG) chaired by the Cabinet Secretary which was established to address system pressures. This group has stepped up to now meet weekly and is now co-chaired by the COSLA Health and Social Care Spokesperson, the focus has shifted to delayed discharge performance and variation across the country. The Group will drive the joint mission and oversee intensive and focussed activity to achieve a material and sustained reduction in levels of delayed discharge, assessing how the system is performing against outlined national and local trajectories, and agreeing improvement actions and support, where needed. Chief Officers are also invited to join weekly CRAG meetings. Scottish Government aim to have delays across Scotland reduce back to pre-pandemic levels (circa 1,400 delays) by October 2024, currently the delays are over 1,900. Each Local Authority/HSCP area has been given a target level of performance based on current performance against a target of less than 34.6 per 100,000: • remain low – maintain performance • moderate – some improvement required, a reduction of up to 35% • major – a reduction of more than 35% is required North Ayrshire is currently in the Major improvement category based on reported delays of 67 at 5th August and a target reduction of 43% to 38 delays.
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To support the national mission, the CRAG commenced meeting on a weekly basis to gain updates and assurance and to provide regular updates to the First Minister and COSLA leaders. Furthermore, the CRAG has developed a Rapid Peer Review and Support Team resource to augment improvement activity and has stepped up the development of several workstreams. The Rapid Peer Review and Support Team have been described as a complementary resource, consisting of Scottish Government personnel and COSLA Officers, to deploy additional support to engage with local systems to support them in their response and provide practical help and capacity to those systems that are experiencing the most challenge in sustaining reductions in delays. An additional 3 workstreams have been established to focus on: 1. Targeted improvement and performance support 2. National Improvement support 3. Mental Health, Learning Disability and AWI. 3.1.2 In June 2024, COSLA and SOLACE invited Health and Social Care Partnership’s to provide input on the action and support required in local areas to remove barriers to progress on achieving a material and sustained reduction in the number of people delayed in transfers of care from hospital. The North Ayrshire HSCP provided a detailed submission outlining a summary of the current position, key challenges and specific actions and investment required for North Ayrshire to sustain and improved delayed discharge performance. A copy of this submission is included as Appendix 1. This submission confirms that financial constraints remain the single biggest barrier to achieving performance and service improvement, with detail of a requirement of investment totaling £8.7 million in key areas as follows: • Community capacity • Complex and Non-Complex Care Home Beds • Out of Area Placements • Mental Health Officer Capacity • Power of Attorney Campaign • Front Door Re-Direction • Hospital Assessment Team Capacity • Capacity for 7 Day Working • Interim Bed Capacity • Care at Home Capacity • Support for Island Services • Technology In addition to financial investment, the submission also detailed requirements linked to guidance and policy change. The requirement is for additional resources to not only sustain our current performance but to deliver any further improvement in delayed discharge performance. The current financial context and constraints we are operating within will not enable us to deliver any meaningful improvement without this, and in fact our performance is more likely to deteriorate further as we strive to meet financial balance. The HSCP were requested by NHS Ayrshire and Arran to set out improvement trajectories for delays as part of the Board’s Annual Delivery Plan and set out targets to maintain performance rather than being in a position to delivery any improvement.
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From our unscheduled care report at IJB in March 2024 and the more recently shared detail from the CfSD data we are aware of the opportunities for improvement in other parts of the hospital journey for delayed and non-delayed patients where there should be equal focus on driving forward improvement. 3.1.3 In May 2024, COSLA and the Scottish Government issued a communication describing a renewed local and national focus on embedding Discharge without Delay. Specific areas of focus highlighted include a national approach to interventions such as Planned Date of Discharge (PDD), weekend discharge, discharge before noon and referrals to social work. Ensuring these practices are embedded in service delivery will be captured as part of the new Delayed Discharge and Hospital Occupancy Plan for 2024-25 and delivered through the national DwD working group, building on the actions and outcomes of the previous action plan. The Scottish Government have reiterated that effective discharge planning for all patients is essential and having the right, basic principles in the acute hospitals will improve flow, reduce long waits due to exit block and benefit performance, the basic principles include: • Increased senior decision makers at front door • Fully adopting planned date of discharge processes • Fully adopting Discharge without Delay • Daily / twice daily ward-rounds with senior-decision-makers • Whole-system MDT reviews of long-stay patients Currently these elements are not fully embedded consistently across all acute areas in Ayrshire and Arran, for example planned date of discharge is not operating on an MDT basis in acute wards. 3.2 Centre for Sustainable Delivery – Ayrshire and Arran Discovery Debrief 3.2.1 The Centre for Sustainable Delivery (CFSD) has developed a Discovery Analysis Approach which was designed to support Health Boards to generate evidence-based planning assumptions upon which to base whole system improvement plans and improvement trajectories. The Discovery Debrief concluded that the most significant cause of NHS Ayrshire and Arran’s full capacity issues are exceptionally high numbers of long stay patients (i.e. those discharged after a length of stay greater than 14 days). In common with 9 out of 11 of mainland Health Boards, NHS Ayrshire and Arran has seen a significant increase in the number of long stay patients in hospital since 2019. The scale of this increase, however, has been greater in NHS Ayrshire and Arran than in most other Health Boards and has significantly affected flow in the acute hospital sites. Further analysis provided from the exercise undertaken by SG colleagues into patients with LoS longer than 14 days, illustrated that in Crosshouse for all patients over 14 day stay, 36% were a delay on discharge, and of those patients the greatest proportion of their duration of stay was before they became a delay with 68.9% of their bed stay LoS being before they were recorded as delays. Indicating the maximum opportunity and gain in LoS improvement being the pre-delay/referral part of a stay or those long stay patients who do not need care to be discharged home. This also results in deconditioning amongst an older and frailer population and when care is required upon discharge undoubtedly results in a higher level of care to support. NHS Ayrshire and Arran have a significant number of additional acute beds open in UHC and UHA hospitals. Length of stay is a significant driver of occupancy, previous modelling suggested that if the LoS in Ayrshire and Arran could be reduced in the two acute hospitals to the Scottish average that there would be a reduced bed requirement from the existing
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funded acute baseline. Delayed discharges and particularly AWI delays are high and do contribute towards this but the majority of the long-stay patient population are never recorded as a delay. Therefore, the greatest opportunity to release significant bed capacity is likely to be in reducing non-delayed long-stay patient numbers. The table below illustrates the average LoS for emergency admissions for NHS Ayrshire and Arran and illustrates that no overall sustained improvement has been achieved. 3.2.2 The discovery analysis for Ayrshire and Arran highlighted 4 areas for focus which they believed presented the greatest opportunity for improved performance: • Scheduling next-day returns to and from RAAC each evening • Increasing the number of patients managed on short-stay admitted pathways • Reducing the number of long-stay patients in hospital (particularly non-delayed patients but also standard and AWI delays) • Bringing forwards admission times from CAU into hospital wards 3.2.3 The CFSD have also produced a report setting out the baseline and benchmarking references for NHS A&A against other Boards across a key set of indicators. The evidence also sets out the areas where there is variation and areas of focus for improvement. Health Boards were required to submit improvement plans based on key leverage points which had been shown to statistically correlate with performance where there was significant variance to other mainland Boards. These leverage points were accompanied by a set of suggested aims to illustrate the level of change that would be required for the system, to close the gap and reduce variation. The leverage points described by the CFSD are detailed below: • Reduce the number of patients in Acute & Community hospital beds with a LOS >14 days • Reduce the number of non-delayed patients in Acute & Community hospital beds with a LOS >14 days • Reduce the number of patients in acute and community hospital beds affected by standard delays • Reduce the number of patients in acute and community hospital beds affected by AWI delays • Reduce the average LOS in the Emergency Department for patients that get admitted to hospital after arriving between the hours of 5pm to 5am (Overnight)
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• Reduce the average LOS in the Emergency Department for patients that get admitted to hospital after arriving between the hours of 5am to 5pm (Day time) 3.2.4 Ayrshire and Arran have produced an improvement plan and further developed a set of aims, targets and trajectories designed to provide oversight to the level of change required and performance against this. The improvements aims set out by Ayrshire and Arran are detailed below: • To increase performance against the 4hr Emergency Access Standard from 58% to 71.3% by March 2025 • To reduce 12hr delays in the emergency department from 30 to 10 by March 2025 • To increase the proportion of patients handed over within 60 minutes of arrival to the emergency department from 50% to 77.1% by March 2025 • To increase the number of patients aged over 65years old discharged within 72hours of admission by an average of 4 patients per day by March 2025. • To increase the number of patients under the age of 65 discharged within 48hours of admission by an average of 2 patient per day by March 2025. • To reduce average length of stay for emergency admissions to acute hospitals from an average of 8.1 days to 6.7 days by March 2025. • To reduce the number of non-delayed patients in hospital with a LOS >14 days from an average of 241 to 220 (minus 21) by end of June 2024 and then further to 185 (minus an additional 56) by March 2025. • To reduce the number of patients in hospital with AWI delays by an average of 2 per day by March 2025 (Aim provided for East Ayrshire only) • To reduce the occupancy of acute hospital sites from an average of 126.8% in March 2024 to an average of 99.8% in March 2025. 3.2.5 For 2024-25 an acute plan, covering both Urgent and Unscheduled Care, has recently been established incorporating an Urgent and Unscheduled Care Programme which has resulted from a commissioning request from the Ayrshire and Arran Board Leadership Triumvirate. The plan mirrors the outcomes of Ayrshire and Arran’s Delivery Plan for 2024/25, with the Programme goal to deliver sustained improvements in managing front door overcrowding, which includes enhancing the quality of care and ensuring patient and staff safety through a structured Programme of work. The Unscheduled Care section of the plan incorporates outputs from the Centre for Sustainable Delivery (CFSD) Discovery Analysis Approach which was designed to support Health Boards to develop evidence-based planning assumptions upon which to base whole system improvement plans and improvement trajectories as detailed in section 3.5. Alongside the plan, there has been the development of an Urgent and Unscheduled Care Programme Board which will oversee and monitor the progress of identified workstreams within the Urgent and Unscheduled Care Plan against agreed trajectories with the aim of providing assurance to the Acute Services Programme Oversight Group and the Strategic Planning and Operational Group. The Urgent and Unscheduled Care Programme Board will be chaired by the Site Director (UHC) and includes membership from both acute hospitals, and the Health and Social Care Partnerships. Delivery groups will be established and require to provide monthly highlight reports to the Urgent and Unscheduled Care Programme Board detailing monthly performance and progress updates against plans, risks and issues. Delivery groups have been established in the following areas – Front Door, Length of Stay, Urgent Care Alternatives, Surgery, Diagnostics, Women and Children, AHP’s, Site safety, Discharge Oversight and Improvement and Communication and Engagement.
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3.3 Delayed Discharge Context and Discharge Without Delay 3.3.1 There are many factors which impact upon levels of delayed discharges within any Health and Social Care Partnership including capacity for onward care provision and Adults with Incapacity legislation. The process for supporting individuals to be discharged when their health and care needs have changed can be very complex. Limitations of community capacity in Care at Home, Care Homes and for complex care services remain the main challenge to further reducing delayed discharges, plans are impacted by staff absence, vacancies and ongoing fragility in the provider market. Adults with Incapacity Adults with Incapacity delays refer to hospital inpatients who are considered to be a delayed discharge due to the adult lacking capacity to make informed decisions regarding their future care and where a need has been identified for a proxy decision make to be formally appointed under the Adults with Incapacity (Scotland) Act 2000 (hereafter AWI Act). This allows for a nominated person to make some or all decisions on the adult’s behalf and ensure that their best interests, views and the least restrictive options are considered. For many adults this results in the application of a Guardianship Order to safeguard their welfare and manage their financial or property affairs. Applying for a Guardianship Order under the AWI Act requires the involvement of several agencies ranging from social work staff, Mental Health Officer’s (MHO), Independent Advocacy workers, Local Authority and private solicitors, Scottish Legal Aid Board, Scottish Courts and the Office of the Public Guardian. Unfortunately, there can be delays at any point in this process at these various stages and a number of challenges have been recognised nationally in progressing. Delays linked to AWI across Ayrshire remain high. Of the 172 delays reported across Ayrshire and Arran at 29 July 2024, 24% relate to AWI reasons. The people delayed for the longest periods of time in hospital sites are usually associated with AWI processes therefore this has a significant impact on the individual people delayed. Accessing Care and Support Limitations of community capacity for care and support services continue to be the main challenge to reducing delayed discharges. This includes access to Care at Home services, Care Home placements including interim care beds and long term placements, and support for adults with complex needs. There are limited resources for delivery of care across all of these service areas for both services that are delivered directly by the Health and Social Care Partnership and those commissioned via third sector and independent providers. This is typically impacted by the significant workforce and financial challenges facing the Health and Social Care sector and continues to limit the success of plans to expand and enhance service delivery. Discharge without Delay: NHS A&A and the three Ayrshire HSCPs were part of a national pathfinder programme in relation to Discharge without Delay (DwD), which has now been rolled out across Scotland. This is supported by the Scottish Government DwD steering group and improvement teams. One of the aims of the programme is to deliver Discharge without Delay within both community and acute settings, working in close partnership with hospital and community teams to agree the most effective and efficient process to ensure positive outcomes for patients. A significant number of patients are discharged without delay, currently sitting at 93.8% of patients across A&A. The overall proportion of patients discharged without delay has remained fairly constant between 93% and 96% since January 2022.
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3.4 Delayed Discharge – Performance – Ayrshire and Arran 3.4.1 Timely discharge from hospital is an important indicator of quality and is a marker for person- centered, effective, integrated and harm-free care. The term delayed discharge is used to describe a situation whereby a patient in hospital has been assessed as clinically ready for discharge from inpatient hospital care and continues to occupy a hospital bed beyond the date they are ready for discharge. The graph below shows the number of delayed transfers of care for each HSCP, this data captures all delays across all NHS A&A hospital sites including community and mental health settings. The total number of people delayed in their discharge from hospital has reduced from a peak of 251 in July 2023 to 175 in June 2024. The graph below shows the number of occupied bed days due to delayed transfers of care for each HSCP, this data captures all delays across all NHS A&A hospital sites including community and mental health settings. The total number of bed days occupied due to delayed transfers of care has reduced from 6,988 in July 2023 to 5,333 in June 2024. The graph below shows the total number of delayed transfers of care for across Ayrshire and Arran, this data captures all delays across all NHS A&A hospital sites including community and mental health settings per delay category – Code 9 (Non AWI), Code 9 (AWI) and Standard.
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The formal measure of performance for Delayed Discharges applies to the number of delays over two weeks. The graph below shows the number of delayed transfers of care of over 2 weeks (excluding code 9 delays) for each HSCP, this data captures all delays across all NHS A&A hospital sites including community and mental health settings. The total number of people delayed in their discharge from hospital by more than 2 weeks has reduced from a peak of 104 in July 2023 to 48 in June 2024. 3.5 Delayed Discharge – Performance – North Ayrshire 3.5.1 The graph below shows the number of delayed transfers of care for North Ayrshire Health and Social Care Partnership. This data captures all delays across all NHS A&A hospital sites including community and mental health settings for all delay reasons. The total number of people delayed in their discharge from hospital peaked at 81 in July 2023 and continued at a higher level through to December 2023. January 2024 saw the lowest levels of delayed transfers of care in North Ayrshire in the previous 2 years however the number of delays has steadily risen since then, to 58 in June 2024.
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The graph below shows the number of occupied bed days due to delayed transfers of care for North Ayrshire Health and Social Care Partnership. This data captures all delays across all NHS A&A hospital sites including community and mental health settings for all delay reasons. The total number of bed days occupied due to delayed transfers of care has reduced from a peak of 2,269 in September 2023 to 1,665 in June 2024. 3.5.2 As noted as part of the national mission to reduce Delays, North Ayrshire is currently in the Major improvement category based on reported delays of 67 at 5th August and a target reduction of 43% to 38 delays. Based on previous performance levels and the level of demands placed on services to support both hospital and community packages of care, and with no expectation that this level of demand is likely to reduce, there is no possible way for this level of sustained improvement to be delivered without additional resources and capacity. This is described more fully in Appendix 1. 3.5.3 The Partnership’s Health and Community Care teams, alongside Mental Health colleagues, developed a local winter preparedness and delayed discharge improvement plan in response to service performance levels and community unmet need to ensure resilience across the health and care system in North Ayrshire. This plan was shared with the IJB in October 2023 and an update brought to IJB in March 2024. The plan is in the process of being refreshed, with a workshop for key teams scheduled for September 2024 to design a refreshed plan, aligned to the updated Delayed Discharge and Hospital Occupancy Action Plan 2024/2025. 3.6 North Ayrshire HSCP Operating Context 3.6.1 Care at Home Demand for Care at Home services has been consistently high for a period of time with an approximate increase in demand of over 30% since pre pandemic levels. Referrals to Care at Home services in North Ayrshire are made from a number of sources – community referrals such as family, self-referral, GP/nurse etc, referrals made from the Enhanced Intermediate Care Team and referrals to support people on discharge from hospital. There is an eligibility criteria with formal Care at Home supports only provided to those who have been assessed as having critical and/or substantial care needs. There can often be high turnover across the Care at Home service due to constant changes in people’s assessed needs, planned short term support via Reablement services and service change due to admission to settings such as Hospitals and Care Homes. In addition to the high volume of demand for services, it is also recognised that there has been an ever increasing complexity in the needs of people in our communities as people live at home for longer with a range of complex health and care needs. This is further impacted by the local demographic challenges our communities face and the result this has on the
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health of the population. Being the second highest area for Child Poverty, the second highest for proportion of the population with Long Term Conditions and a growing older population with now the lowest healthy life expectancy in Scotland. The Care at Home service undertook a formal review of the Care at Home Assistant role in 2022, resulting in a regrading for this workforce in 2023, and this took into consideration the change in the complexity of needs of people that are being supported in the community. The development of the Care at Home role incorporates a range of skills including supporting people with administration of medication and a range of extended complex moving and handling and personal care supports. Across 2023, the Care at Home service received an average of 296 referrals per month, with around 51% of all new referrals to support hospital discharge. The level of community referrals had been fairly static with referrals via the hospital experiencing high peaks in demand. However in recent months community referral activity has experienced several peaks with a notable high level of increase referrals for existing care packages. In July 2024 the Care at Home team received 448 referrals for Care at Home over a 4 week period. This is inclusive of new and increase referrals from all referral sources. The Care at Home Service continues to support around 2,000 people in North Ayrshire on a weekly basis. Following a recent review of Care at Home provision, a decision was taken in March 2023 by the IJB that all Care at Home provision via Self Directed Support Option 3 should be provided by the Partnership’s in-house Care at Home Team. Following the implementation of this decision in North Ayrshire around 95% of Care at Home provision is delivered in-house. The decision that was made has required a significant financial investment and reflects the Partnership’s commitment to delivering safe and high quality care through this critical frontline service. The move provides a fairer approach to care provision across North Ayrshire and will allow the Partnership to provide greater long-term stability and quality of care provision for all Care at Home service users in North Ayrshire. In addition to this, there are also over 4,000 people who receive supports via the Care at Home’s Community Alarm and Telecare service. With over 35,000 Care at Home visits on a weekly basis, this goes some way to illustrate the size and scale of current Care at Home provision across North Ayrshire. During 2024-25, and as part of the HSCPs Transformation Plan, the service role, function and pathways will continue to be reviewed alongside the review of Community Rehab Models to maximise the impact of the Care at Home Service. This will ensure that the model and service configuration, including the management structure and pathways of support, are as efficient as possible. This will complement the work underway to reduce and manage levels of unmet need for Care at Home services. 3.6.2 Care Homes There are 17 older people’s care homes in North Ayrshire which provide a mix of both residential and nursing level care. Concerns regarding the fragility of the older people’s care home market in Scotland are well documented and in North Ayrshire there has been a continued trend of reducing care home bed availability. There have also been concerns regarding the quality and sustainability of care home provision in North Ayrshire with the permanent closure of 2 care homes in recent years. Throughout 2023 capacity for care home placements had been a challenge, with a continued decline in bed availability having an impact on the choice(s) of placement available to people in North Ayrshire. Despite this, the North Health and Social Care Partnership had continued to ensure that there were no waits in either the community or in a hospital setting for funding for a long-term care home placement for older people and this had consistently been the position since 2020 with a downward trend in the level of care home requirements. For 2024-25 the budget for care home placements includes provision for a total of 765 care
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home placements for older people, with further budget provision for around 40 placements for adults with a Physical Disability. This is a reduction from the 2023-2024 budget and as a result of this reduced level has required there to be a waiting list for funding for care home places due to high and sustained levels of demand. The waiting list is managed through a funding resource group, and to date has only impacted on community referrals with hospital referrals for care home placements continuing to be approved without delay. It is, however, unlikely that this will be able to continue if the level of demand continues due to the projected financial position. In addition to this the Partnership has also continued to utilise interim beds in Care Homes for people who are delayed in their discharge from hospital and can move to a more homely setting as part of the discharge to assess process. 3.6.3 Unmet Need The HSCPs provide weekly data returns to the Scottish Government to illustrate unmet need across the system. This focusses particularly on waits for Care at Home Services, Statutory Social Care Assessments and Social Care Reviews. The below table provides a snapshot of this data return from June 2022 to July 2024: Over time there had been no demonstrable improvement in the position in terms of unmet need throughout 2023. It was evident that the Partnership’s inhouse Care at Home service has continued in its growth month on month, however the benefit of this has been negated from 2022 to date by both ongoing demand for services and the previous reduction in capacity via independent care providers. There has, however, been some improvement in terms of levels of unmet need both in the community in comparison from July 2023 to July 2024, with hospital levels of unmet need having improved earlier in 2024 but subsequently deteriorating by July 2024. The number of people in the community awaiting a new package of care has also reduced from 205 in July 2023 to 180 people at the end of July 2024. Care at Home services, to support people on discharge from hospital, remains a significant demand with considerable resources allocated on a daily basis to support these processes. On a weekly basis, since April 2024, the Care at Home service received an average of between 25-35 referrals to support hospital discharges. In July 2024 this peaked to an average of 44 referrals weekly. Whilst the size and scale of Care at Home supports are based on individual assessment, it is recognised that care packages to support hospital discharge are often larger and more complex than referred community supports. Many of those waiting the longest for Care at Home supports to facilitate discharge from hospital are requiring double handling supports of up to 4 visits daily, often to support very specific and complex health needs. For the month of July 2024, the average weekly hours required by those delayed in hospital awaiting Care at Home supports is 13.5, compared to the average weekly hours of those awaiting in the community for a new package at 5 hours weekly.
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There continues to be a significant difference in the level of unmet need between individuals awaiting care in hospital compared to in the community, with 75% of the hours of unmet need at the end of July 2024 being for individuals on the community waiting list and a significant number of individuals in the community awaiting assessment and review. This is reflective of the continued focus on prioritising packages of care for individuals in hospital to support with wider hospital pressures. However, the impact of this is the continued risk posed to those individuals in the community who have been assessed as requiring support and this is not in place which is not in line with the early intervention approach to keeping people safe, fit and well. The Partnership has undertaken a number of initiatives linked to the management of demand for services and unmet need, including a programme of reviews, reablement initiatives and the introduction of a weekly unmet need oversight group. 3.6.4 Adults With Incapacity Adults with Incapacity delays refer to hospital inpatients who are considered to be a delayed discharge due to the adult lacking capacity to make informed decisions regarding their future care and where a need has been identified for a proxy decision maker to be formally appointed under the Adults with Incapacity (Scotland) Act 2000 (hereafter AWI Act). The AWI Act provides a legal framework to safeguard the welfare and financial affairs of individuals who lack capacity and allows for a nominated person to make some or all decisions on the adult’s behalf and to ensure that their best interests, views and the least restrictive options for their care and support are considered. For many adults this results in the application of a Guardianship Order to safeguard their welfare and manage their financial or property affairs. Applying for a Guardianship Order under the AWI Act requires the involvement of multiple agencies ranging from Social Work staff, MHO’s, Independent Advocacy workers, Local Authority and private solicitors, Scottish Legal Aid Board, Scottish Courts and the Office of the Public Guardian. Unfortunately, the process can be lengthy and there can be delays at any point in this at various stages many of these often out with the Partnership’s control such as capacity assessments and family disputes. A number of these challenges have been recognised nationally. North Ayrshire Health and Social Care Partnership has experienced high levels of delays linked to AWI processes and currently has the highest per 100,000 adult population rate in Scotland. To date a number of measures have already been implemented including additional MHO capacity and dedicated MHO support within the Partnership’s Hospital Social Work Assessment team. Despite this, delays linked to AWI in North Ayrshire remain high, and whilst this can account for around one third of all delays across the Partnership at any one time, people delayed for the longest time in terms of delays are usually associated with AWI processes therefore this has a significant impact on the individual people delayed. The longest AWI delays are also associated with individuals where no powers exist before their hospital admission and no one has legal authority to make decisions on their behalf. There can be delays even where a POA arrangement is in place as there is follow up required regarding the nature of the POA powers and legal agreement, complexities of capacity assessment and family views and wishes. Therefore it is key that priority is given to prevention and early intervention. In the 10 years between 2000-2010 around 175,000 people registered a POA with the Office of the Public Guardian in Scotland – an average of 17,500 per year. In 2013, the annual OPG registrations across Scotland had increased to 45,004. In 2018 there were 58,848 and in 2023 these had increased to 70,409 representing a 56% increase over the decade and 20% increase since 2018. In North Ayrshire the percentage increase in the previous decade has been 73%, therefore above the national position, however whilst this is positive and a clear indication of the success of recent National Power of Attorney campaigns, to ensure continued impact in North Ayrshire this requires further attention.
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Evidence indicates the negative impact of an extended delayed discharge and prolonged hospital stay on individuals physical and emotional wellbeing therefore it is a priority for the North Partnership to continue to develop practice and procedures to improve performance associated with AWI delays. This was a key component of the local Winter Preparedness and Delayed Discharge Improvement Plan and to ensure clear understanding of the current North Ayrshire position a self-assessment was undertaken using the Scottish Government’s AWI Good Practice Guidance. The self-assessment identified a number of positive areas of practice and recent developments within North Ayrshire including: • Power of Attorney campaigns (national and local) • Guardianship activity oversight • 13ZA application including recent Practice Enhancement Notice • Development of Practitioners Guidance for Requesting Capacity Assessments • Hospital Based Locality Social Work Team • Dedicated Hospital MHO including specialist support for discharge planning • Interim bed capacity and discharge to assess models of care • Good MDT working • Hospital Co-ordinator and link to community wards • Arran Unscheduled Care response plan including intermediate care and step down • Local and robust Senior Management oversight of Delayed Discharge performance Further areas for improvement were identified as an outcome of the self-assessment and many of these have been progressed as part of the Delayed Discharge Improvement Plan: • Local and Targeted Power of Attorney campaign • Implementation of Guardianship activity tracker with exemplar timescales • Review of demand, current MHO capacity and development of linked performance dashboard • Implementation of Supported Decision Making training to complement current AWI training There had been some early indicators in late 2023 and into early 2024 of a positive movement in terms of a reduction for people delayed in their discharge from hospital (linked to social work assessment/requirement for long term care needs) and in particular for adults with incapacity however this was over a short period of time and is influenced by fluctuations in referral activity and demand. This reduction was not sustained and there has been a steady increase in AWI delays since May 2024 as is detailed in the table below. It is also important to emphasise that there are limits to the control that the Partnership can exert in influencing the desired reduction in AWI delays as has been previously described this can often be due to a variety of factors that are out with the Partnership’s control, including the demographic composition of our communities and the restrictions of the AWI legislation which is designed to uphold an individual’s Human Rights.
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3.7 Mental Health Unscheduled Care 3.7.1 Mental Health assessment wards in Ayrshire and Arran have been operating in excess of 100% capacity with significant bed pressures for a sustained period of time, with the implications of the highest threshold for admission and the impact this has for community services, Psychiatric Liaison services and Acute Hospitals. This is compounded by ongoing significant challenges associated with delayed discharges in Mental Health Wards and also with providing robust alternatives to admission. A review of both Health and Community Care older adult and Elderly Mental health inpatient wards at Woodland view will be undertaken and will follow on from previous whole system review work that has taken place. The review will focus on models of care, workforce and environmental factors the outcomes of which may also inform learning regarding delayed discharges. 3.7.2 The new Mental Health Unscheduled Care Assessment Hub is a specialist in-patient care provision in Woodland View, is nurse-led and provides intensive assessment by highly qualified clinicians for a period of up to 72 hours. The referral criteria includes patients presenting to Adult Mental Health Unscheduled Care teams with acute mental illness and/or associated risk profile who would be eligible to access an adult acute mental health bed, to facilitate a period of ongoing assessment to determine the most appropriate plan of treatment. The Hub was due to formally launch in 2023 however due to delays in estates works this was delayed. The Mental Health Unscheduled Care Service undertook a soft launch of the Hub early in 2024. This allowed the Hub to open with reduced capacity to test out pathways, policies and procedures. Referrals were received from a variety of different teams from within the Mental Health Unscheduled Care Service with the pilot period delivering a range of positive outcomes for people who accessed the service and it is evident from the success of the pilot the significant benefit this service will provide as the front door for acute Mental Health admissions, which will lead to more assertive and re-direction of patients from requiring a hospital admission. The Mental Health Assessment Hub is planned to partially reopen in mid-August 2024 on completion of a programme of works to make this important new facility fully fit for purpose, with 3 beds opening initially and stepping up to a full bed compliment of 5 beds by October 2024. The impact for Adult Mental Health assessment beds has been evident with increased
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bed pressures and comparative data is being collated/analysed to evidence the benefit of this new provision. The service has continued throughout this pause of ‘inpatient’ provision through outreach to ED, CAU and the community. 4. CONCLUSION 4.1 In summary, whilst it is evident that there have been significant efforts made in the planning and implementation of programme(s) of work to address ongoing performance linked to both Unscheduled Care across NHS Ayrshire and Arran and in North Ayrshire, unfortunately the desired improvements have not been achieved across the whole system. Delayed discharges in North Ayrshire fluctuated throughout 2023, reducing to lower levels in mid-2023 and then peaking in early December 2023 to the highest levels seen all year. In late December 2023 delayed discharge levels began to reduce and stabilised throughout January and February 2024 at a lower level than had been seen through most of 2023. Delays are rising again, with a steady increase in AWI delays. There remain a number of risks to this position and performance in this area is dependent on volume and demand for supports which are currently demonstrating an upward trend. There will be ongoing and increased scrutiny of levels of delayed discharge levels due to targets set as part of the national mission. Levels of community unmet need also fluctuated throughout 2023. This position had worsened over the 2022-23 winter period then experienced a period of stability and improvement however levels of unmet need, similarly to levels of delayed discharge, increased to the highest levels throughout the year in December 2023. Similarly, to the performance relating to delayed discharge, there has been an improved picture since the beginning of 2024 when compared to levels in 2023. Despite this improvement in performance and access to Care at Home supports for people both in the community and to support discharge, there remains a significant level of risk being held in the system and in our communities. The CRAG is now providing weekly oversight, scrutiny and challenge to delayed discharge performance. The North HSCP has provided a summary of current performance and challenges linked to improvement, clearly setting out the financial requirement to sustain and improve current performance levels. The current challenging financial position is having a detrimental impact on people across our community, particularly in relation to unmet need. This position is likely to deteriorate given financial projections and the actions required to achieve financial balance. North Ayrshire HSCP continues to proactively respond to these demands and adapt services as necessary, with workforce, provider sustainably and financial resource challenges being the limiting factor to the pace of improvement. There remains an urgency for Partners across NHS Ayrshire and Arran and the three Health and Social Care Partnership’s to continue to prioritise efforts and subsequently improve performance linked to Unscheduled Care, community unmet need and levels of delayed discharges to ensure resilience and continued delivery of critical services. 4.2 Anticipated Outcomes Improved awareness for the IJB of current performance and challenges and the work underway to improve services for the citizens of Ayrshire and Arran and our local communities. This will ensure that the IJB will be in an informed position and national focus on Delayed Discharge performance at a local level. 4.3 Measuring Impact
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Urgent and Unscheduled Care measures are tracked through the NHS Pentana Performance Framework and through the established governance arrangements. Performance linked to community unmet need, demand and planned transformational change projects will be tracked through existing Partnership oversight arrangements. The IJB will receive updates on progress. 5. IMPLICATIONS Financial: North Ayrshire IJB reported a projected overspend 2023- 24 and are projecting a significant overspend for 2024-25 with recovery actions in progress, therefore there is no further resource available. Savings required as part of recovery plans are likely to impact current levels of performance and for people awaiting services. Acute services in Ayrshire and Arran are projecting additional costs due to unfunded beds which remain open across both sites, the closure of these unfunded beds will be an ambition for NHS AA during 2024-25. Human Resources: Workforce across the system remains a challenge, plans are in place to proactively value and retain our health and care workforce and to support staff to respond to the growing demands placed on services. Legal: The Public Bodies (Joint Working) (Scotland) Act 2014 sets out the IJBs responsibilities for Unscheduled Care services delivered from large hospitals, this is further detailed in the Integration Scheme. Equality: Addressing whole system pressures on acute services, Unscheduled Care and levels of unmet need will improve timely and appropriate access to services for the whole population of Ayrshire and Arran. Children and Young People Addressing whole system pressures on acute services, Unscheduled Care and levels of unmet need will improve timely and appropriate access to services for the whole population of Ayrshire and Arran. Environmental & Sustainability: N/A Key Priorities: The reshaping of Unscheduled Care activity, access to services and whole system planning to support seasonal service demands and improve health outcomes aligns with the vision and values of the IJB. Risk Implications: Risks are noted in the report, the most important risk being the risk of harm being posed to patients in hospital and people in the community as a result of the current lack of whole system performance improvements. Community Benefits: N/A Caroline Cameron, Director For further information please contact Kerry Logan, Head of Service Health and Community Care, klogan@north- ayrshire.gov.uk.
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NORTH AYRSHIRE Health and Social Care Partnership Delayed Discharge Performance Improvement – CRAG Current Position Levels of delayed discharge in North Ayrshire are detailed for a 12 month period, from March 2023 to March 2024 in the table below. Delayed Discharges to date in 2024 have been generally at a lower level for most of 2024 than seen throughout 2023, with a sustained reduction in AWI Delays. However there have been indicators of a steady rise in delayed discharge levels in recent months. The Partnership’s Health and Community Care teams, alongside Mental Health colleagues, developed a local winter preparedness and delayed discharge improvement plan in response to service performance levels and community unmet need in late 2023. This was in anticipation of seasonal demands to ensure resilience across the health and care system in North Ayrshire. This was anticipated to be a short-term plan however has developed to become a longer-term improvement plan and is being developed alongside the service’s Transformation Plan. The Plan continues to focus on enhancing Care at Home Capacity, Discharge to Assess and Adults with Incapacity. A comprehensive update on unscheduled care performance and progress with the plan was presented to the IJB in IJB in March 2024. In North Ayrshire the delayed discharge performance has stabilised back to pre-pandemic levels, despite the significant service pressures and rising demands. The proposed approach to reduce delays nationally to a maximum of 34.6 delays per 100,000 adults across Scotland will require a further 30% improvement from current levels. The financial context is extremely challenging. The IJB received the final outturn for the 2023-24 financial year last week where an overall overspend of £7.5million was reported, this position has virtually eliminated the remaining IJB free general fund reserves. The overspend includes additional capacity in a number of areas which have supported the whole system and created capacity to minimise delays as far as possible. Many of these areas of financial pressure continue into the new financial year with an initial estimate of a projected overspend of £4.9million for 2024-25, this includes an overspend of £3.4million in care at home services which is reflective of the growth in capacity to meet the level of demand for services in the community and to support hospital discharge, which has enabled our community waiting list to positively reduce. Unfortunately, this level of service is not able to be financially sustained moving into the new financial year, and as such we have set out a number of areas of immediate focus for financial recovery. This includes strengthening the governance and oversight of our financial position, review of all expenditure plans and commitments and regrettably reductions in care delivery. Appendix 1
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North Ayrshire Challenges: Summarised below are the key challenges in meeting the needs of our local population and in sustaining and further improving performance in relation to delayed discharges: • High levels of demand for Care at Home services – circa 30% higher than pre-pandemic levels - with an increase in the complexity and size of care packages • Complexity of care and increased acuity of need – recent reviews suggest a number of people being admitted to hospital are requiring significantly increased care packages to support discharge often caused by reduced mobility and function upon discharge • Increased Length of stay within acute sites, the recently shared CfSD data for Ayrshire and Arran clearly outlines A&A as an outlier for length of stay with the summary findings outlining that The most significant cause of NHS Ayrshire & Arran’s exit block issue is an exceptionally high number of long stay patients (i.e. those discharged after a length of stay greater than 14 days), with the majority of long stay patient population never recorded as a delay. Further local deep dive analysis showed that for those 36% of patients who are delayed on discharge that 69% of their LoS was before they became a delay. This is reflective of the overall functioning of the acute hospitals and also results in a high number of failed discharges, the increased LoS has a significant impact on the level of care needs and support required upon discharge. • North Ayrshire has a high number of out of area placements, predicated by a number of community providers establishing services to deliver residential services for complex care needs for adults, this capacity is not aligned to nor in response to our local need. This has a significant financial and operational impact across Social Work, Mental Health Services, Learning Disabilities, commissioning, leadership capacity and MDT support for care providers. The risks around placement breakdown are ongoing and have resulted in a direct impact on inpatient services in LD and MH services leading to additional staff costs, bed capacity challenges and difficulties in timely discharge of patients. • Whilst we have steadily reduced the numbers of people awaiting in the community for support, we still have significant levels of unmet need for care at home services in the community, currently around 80% of waits for CAH are for individuals in the community. As we require to pull back on capacity these waits will increase, with a greater level of risk being held within the community and furthermore the ongoing risk of a hospital admission or more costly intervention for these individuals. We also have a waiting list for care home admissions from the community as we manage placements in line with resource constraints, we have not had any community care home waits since 2020. • Demographic challenges are evident in North Ayrshire, with chronic need evidenced across population health indicators. We have the lowest healthy life expectancy in Scotland with huge inequalities across our population localities, this has a demonstrable impact on demand across all services including mental health, primary care, addictions, older people, children’s services including our child protection activity and care experienced population. • Care Home bed availability remains challenging, choice and availability in North Ayrshire is very limited with the closure of 3 care homes in recent years and little growth in the market, furthermore we have no local care homes that support older people with more complex needs. • AWI Legislation and MHO capacity for adults who lack capacity and require formal powers, we are currently 5th highest in Scotland for AWI delays per 100,000, and across Ayrshire and Arran the numbers are high. • Capacity and demand in remote and rural localities – North Coast (Largs, Skelmorlie, Cumbrae) and Arran in particular with critical recruitment and retention difficulties across all areas of the workforce, the workforce availability is not aligned to the population need and demographic in those areas. • Mental Health and Learning Disabilities – lack of care provision via third and independent sector, all services for adults in the community are commissioned through a provider framework which remains stagnant with a lack of any capacity to respond to urgent or emergency requests for support, including to facilitate hospital discharge. In North Ayrshire currently, financial constraints remain the single biggest barrier to achieving performance and service improvement.
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North Ayrshire - action and support required to reduce delayed discharges Our improvement plan as set out describes the actions and resource requirements, firstly to sustain our current level of delayed discharge performance and thereafter to further create capacity for delivering targeted improvement. The resources required to sustain our current performance is £4.7million, and with a further £4million of investment, £8.7million in total. We are confident if the resources were made available in full that not only would the target improvement level be met but that in North Ayrshire we could deliver further improvement. For this to be sustained all resources would require to be invested recurringly, as the plans would be predicated on recruitment and capacity building. This requires to be considered in the context of the cost of delayed discharges to the whole system, based on a conservative bed day rate estimate and for current delayed discharge levels for North Ayrshire there is a cost of £9.7miillion already within the health and care system. The investment would not only improve performance but mitigate the impact of future demands and most importantly improve outcomes for the patients and their families for whom any delay in hospital when ready to leave will be distressing. Whilst recruitment and retention is a challenge across a number of service areas, in North Ayrshire we have evidenced good progress in a number of service areas through different approaches to recruitment and skill mix, therefore would be confident of the ability to recruit if resources were made available. Annex 1 attached outlines the specific actions and investment required for North Ayrshire to firstly sustain and thereafter improve delayed discharge performance and we welcome the opportunity and request from COSLA and SOLACE to set out what we would require at a local level to deliver tangible improvement to our position. This outline targeted plan is aligned only to delayed discharge pressures and improvement and whilst includes some areas of prevention, it is not a true reflection of the totality of resources and investment required across the local system and services to fully embed and support early intervention and prevention approaches. In addition to those areas specially for North Ayrshire we would also request that there is a review of the existing guidance in relation to delayed discharges, including the criteria, coding and classification. The guidance is out of date and doesn’t reflect the new approaches to discharge planning including PDD and there remain many areas of the guidance open to interpretation. With the ongoing scrutiny and challenge for improvement across areas, COSLA and the Scottish Government should be satisfied that each area is recording and reporting delays consistently. CAROLINE CAMERON DIRECTOR – NORTH AYRSHIRE HSCP 20th JUNE 2024
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Annex 1 - North Ayrshire - action and support required to reduce delayed discharges Sustain Performance Deliver Targeted Improvement Area Detail £000 £000 Mental Health and Learning Disabilities Community Capacity Resource to fund complex care packages/recruit bespoke specialist in-house service to facilitate discharge - similar to IST in place for LD to replicate for MH. The provider market for MH care packages is not functioning. The LD Intensive support team is funded from the Community Living Change Fund which ends in March 2025. Additional funding could support a move to 7 day working. 250 500 Complex Care Home beds There are no available care home placements for EMH patients with more complex needs in North Ayrshire. We are in the process of trying to re-provide HBCCC beds, with a current care home provider able to step up 8 complex needs beds alongside HBCCC which would allow for our complex EMH delays to leave hospital but there are no resources to fund the block booking arrangement with the care home. - 861 Guidance Refresh of delayed discharge guidance in relation to MH and LD delays, to ensure all areas are recording consistently for individuals with more complex needs, also ensuring all Out of Area delays are accounted for and monitored. - - Policy/Guidance Ordinary residence rules for health and social care/social work responsibilities are not aligned leading to extreme difficulties upon Out of Area placement breakdown. the ability to repatriate and arrange discharge cross boundary. Agreed SOP and rules of engagement are required to ensure patients don't fall between health and social care services across organisations. This will allow areas providing health care or inpatient services to more quickly repatriate and plan discharges for patients. - - Out of area placements Recharges to other areas for in-patient dedicated staffing to support admissions. Invoices have been issued which are unpaid at this point. If unable to recover costs will further impact on HSCP financial position. 930 MDT capacity to facilitate the social care and clinical oversight of community-based care providers where individuals are placed out with their area of ordinary residence, impact of guardianship transfer, care management/sustaining placements, advice support and staffing for complex care providers, commissioning/contract management. 500
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Adults with Incapacity MHO Capacity Resource to fund the MHO capacity provided by previous dedicated MHO funding (removed 23/24) plus additional MHO capacity which is critical for timely allocation to support hospital discharge for AWI. There has been a 47% increase in Mental Health Legislative work from the beginning of this year to May, in comparison with 2023. This includes a 61% Mental Health Act work and 33% increase in Adults with Incapacity Act. This would allow us to keep the dedicated MHO in the hospital team and add another and additional capacity for community-based MHO work to manage increase in demand and further impact on admission avoidance. 91 170 Support for POA Learn from the Glasgow pilot re legal support in a targeted way around POA arrangements, funding would facilitate cost of legal support and as a catalyst for proactive arrangements to be put in place. - 60 Front door re-direction Ensure clinical leadership and front door re--direction/diversion for patients on discharge to assess basis, avoiding capacity assessment at frailest point of patient experience. - 57 POA campaign More intensive national POA campaign which reaches into communities and across communities of interest in a targeted way to change culture, make it the norm for all adults to have arrangements in place. - - Standard Delays HSCP Hospital Ax Team Capacity To further embed Homefirst, support an integrated discharge team, facilitate true early referral and increase the efficiency of the assessment process, support PDD implementation in ward areas and extend the assessment team to community hospital areas. This is inclusive of a service manager, social workers, OT, OT assistant, discharge facilitator. 458 HSCP Hospital Ax Team - 7 day working To expand the hospital assessment team to operate across 7 days to facilitate both assessment and discharge 7 days a week. 250 Interim Bed Capacity Resource to fund interim bed capacity to a support discharge to assess model of care for up to 5 block booked placements on a weekly basis, non-recurring interim bed funding has been fully spent. 296 Care home beds There are currently 789 funded care home placements for older people with budget aligned to 765 placements leading to in-year overspend. The service will require to incrementally reduce funded placements leading to increased waits in community and hospital. Additional capacity beyond this for complex care home beds is included above under MH/LD delays. 713 Care at Home Capacity Reflects current CAH overspend and increase in capacity in the service. From July 2024 95% of CAH services in NA will be in-house which means further efficiencies in service delivery would support increasing care delivery capacity from within existing resources. 2,400 1,000 Arran Disproportionate cost of delivering and sustaining island services, with a population of less than 5,000 and 1/3 of those on the island over 65. The HSCP cannot compete with other island hospitality employers with social care. Arran doesn’t attract any remote or rural pay enhancements for social care. tbc
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Technology Free Community Alarm and Telecare service offered for all SUs on the care at home waiting list in the community, as a safeguard and gateway while awaiting formal services. Avoid risk of community incidents leading to hospital admissions. 100 Recurring Funding Requirement 4,680 3,956 8,636