Item 8 - Delayed Discharge and Site Occupancy Plans
North Lanarkshire Council · 17 May 2023
Back to Health and Social Care Integration Joint Board — 17 May 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 8 SUBJECT: Health and Social Care Delayed Discharge and Hospital Occupancy Action Plan TO: Integration Joint Board Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Morag Dendy, Head of Planning, Performance and Quality Assurance DATE: 17th May 2023 1. PURPOSE OF REPORT 1.1 This paper is coming to the Integration Joint Board: For approval For endorsement To note 1.2 This paper sets out Scottish Government’s action plan to improve delayed discharge and hospital occupancy. 2. ROUTE TO THE INTEGRATION JOINT BOARD 2.1 This paper has been: Prepared Reviewed Endorsed By the command structure in the Health and Social Care Partnership. 3. RECOMMENDATIONS 3.1 The IJB is asked to: (1) Note the Scottish Government action plan on delayed discharge and hospital occupancy; (2) Note that the actions contained within are being built into the phase 1 action plan for Operation Flow, to ensure a whole system approach is fully embedded in Lanarkshire; (3) Request sight of the Operation Flow phase 1 action plan and associated task and finish groups once finalised. 4. VARIATIONS TO DIRECTIONS Yes No N/A
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2 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 Winter 2022/23 was an incredibly challenging period for health and social care systems across Scotland, managing a number of complex factors including increased seasonal demand for unscheduled care and critical care due to the combined incidence of flu, Covid-19 and other respiratory infections. 5.1.2 Throughout this period, local systems have tried to manage through these competing demands with whole system actions such as Discharge Events and substantial developments such as Operation Flow within Lanarkshire. 5.1.3 This has led to a greater understanding of the issues being faced and what works, with the greatest challenge facing all systems being how to turn this into plans that can create a sustainable difference. 5.1.4 The action plan brings together 12 whole system actions across the areas of Good Practice, Data Management and Workforce, that are essential in reducing pressure on staff and the system and in ensuring people receive the right care in the right place at the right time. The Action Plan is attached in appendix 1. 5.2 Delayed Discharge and Hospital Occupancy Action Plan 5.2.1 The Action Plan places significant emphasis on ‘getting the basics right’ through consistent implementation of models such as the Discharge Without Delay programme, of which NHS Lanarkshire is a demonstrator site. This includes: Use of admission avoidance approaches such as Hospital at Home, multi-agency input at the front door, Locality rapid wrap-around models and early whole-system input within the first 48hrs of admission for those who do require acute care. The social care needs of patients are considered in every ward with social work input to wards with high frailty, providing expert advice and input to discharge planning Discharge Without Delay principles should be utilised to set jointly agreed Planned Dates of Discharge, reviewed daily and used to plan and prepare discharges Use of multi-agency teams to support senior decision making, with whole system visibility of plans and senior oversight and escalation to resolve any delay-causing issues Structured ward rounds or white board reviews 7 days per week to ensure there are priorities, plans and tasks set for the day and the parameters for criteria led discharge agreed to support early discharge Utilise Planned Dates of Discharge to commission/organise care Identify complex discharges early in their inpatient journey, including those with high frailty scores, to allow coordinated multi-agency management Ensure early engagement with families and carers to manage expectations Implement discharge to assess and intermediate care models to support discharge home and allow assessments for ongoing care to be undertaken in people’s own homes. Utilise community rehabilitation as the preferred place of recovery and intermediate care. 5.2.2 These ‘getting the basics right’ actions are included in NHS Lanarkshire’s Flow Foundation Bundle developed through Operation Flow.
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3 5.2.3 The twelve actions identified within the plan are noted below: 1 All systems to review and implement learning from their discharge event to embed improvements in an ongoing, ‘business as usual’ way Boards and IJBs to confirm this has been actioned by end March 2023 2 Put systems in place to provide the assurance necessary to confirm the measures set out in ‘Getting the Basics Right’ are consistently being applied Boards and IJBs to confirm this has been actioned by end April 2023 3 SG will continue work with NES to develop a toolkit of support and training materials to support discharge Toolkit and materials to be available by end April 2023 4 Boards and IJBs to assess their systems and processes in terms of acute discharge planning and apply the DwD toolkit in every inpatient area, community hospitals and other off-site beds Boards and IJBs to confirm this has been actioned by end April 2023 5 SG to provide a tactical social care dashboarding solution to support HSCPs and HBs to have access to a core set of indicators, predicated on existing and robust management information to enable consistent and comparable data to be available at different levels of geography Dashboard to be available by end April 2023 6 SG to provide modelling of potential future demand to support more effective local planning Modelling to be available by end April 2023 7 SG to support partners to develop forum to drive work towards more consistent and comprehensive data Forum to be established by end March 2023 8 SG/PHS/NSS to provide a strategic solution for the delivery of MI data for insights across health and social care using NSS’s Seer2 platform Solution to be agreed by end May 2023 9 SG to support local partners through NES to utilise international recruitment Ongoing 10 Continue to pursue national recruitment campaign Ongoing 11 Continue to pursue recruitment activity with DWP for Ukrainian displaced people and UK residents that are economically inactive Ongoing 12 Increase in pay to £10.90 per hour in 23/24 for adult social care sector in commissioned services. Looking at improvements to terms and conditions for adult social care in 2023/24 April 2023 and ongoing 5.2.4 A number of face to face whole-system development sessions have been held to support learning from the Operation Flow firebreak, with a weekly whole-system Operation Flow Programme in Board to develop the next stages of the local action plan. 5.2.5 Five task and finish groups have been developed to implement the local action plan, which picks up actions 1, 2 and 4 in the table above. This will conclude the first phase of Operation Flow, with the aim of having sustainable implementation of these initial actions by summer. Phase two will then commence with a view to preparing for winter, with the third phase then being the wider transformation of services in the longer-term. 5.2.6 The North Lanarkshire HSCP has been involved in the previous exercises to build a social care dashboard outlined in action 5, with work ongoing to develop this through the new
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4 national Whole System Oversight and Planning Group, of which the North Lanarkshire Chief Officer is a member. 5.2.7 The Lanarkshire system continues to engage with the Scottish Government and NES around international recruitment, with some recent success through this approach. 6. CONCLUSIONS 6.1 Through Operation Flow, the Lanarkshire system has undertaken a large-scale programme of change, which has picked up the vast majority of the actions outlined within the new national action plan. 6.2 The Operation Flow phase 1 action plan and associated task and finish groups is currently being finalised and will be shared with the NHS Board and IJBs in due course, for full implementation over the coming 3-4 months. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES This relates to all nine national outcomes. 7.2 ASSOCIATED MEASURE(S) A weekly performance framework has been developed to track progress. 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT Risk IJB 17/22 sets out the impact of unscheduled care challenges in the Lanarkshire system. 7.5 PEOPLE The Strategic Planning Group has increased in frequency to quarterly throughout the pandemic to support engagement with staff, service users and carers and staff roadshows have also recommenced on a quarterly basis. 7.6 INEQUALITY & FAIRER SCOTLAND DUTY Yes No N/A 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix 1 Health and Social Care Delayed Discharge and Hospital Occupancy Action Plan
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5 ............................................................................. CHIEF OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Ross McGuffie on telephone number 01698 752 591.
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6 Appendix 1 Health and Social Care Delayed Discharge and Hospital Occupancy Action Plan March 2023
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7 Contents Foreword 1. Context ............................................................................................................. 10 2. Delayed Discharge .......................................................................................... 11 2.1 Defining a delayed discharge ...................................................................... 11 2.2 January 2023 Discharge Events .................................................................. 11 3. Delivery Action ................................................................................................ 11 3.1 Good practice ............................................................................................ 12 3.1.1 Reduce length of stay and ensure people are discharged when they are clinically fit. ........................................................................................................ 12 3.1.2 Getting the basics right ......................................................................... 12 3.1.3 Support already provided ...................................................................... 14 3.1.4 Actions for Best Practice ....................................................................... 15 3.2 Data and Managing Variation ................................................................... 15 3.2.1 Analysis for future planning ................................................................... 15 3.2.2 Using data-driven insights to manage variation .................................... 15 3.2.3 Actions for Data and Managing Variation .............................................. 16 3.3 Workforce ................................................................................................... 16 3.3.1 Labour Shortages ................................................................................. 16 3.3.2 Actions for Workforce ............................................................................ 17 4. Sustaining Change .......................................................................................... 17 4.1 Transparency ............................................................................................... 17 4.2 Measuring Progress .................................................................................... 17 5. Conclusion and Next Steps ............................................................................ 18 ANNEX A – Context ......................................................................................... 19 Short-term pressures on the NHS ..................................................................... 19 Persistent Demand ............................................................................................ 19 Admissions into Acute ....................................................................................... 20 Ageing Population ............................................................................................. 21 Frailty and Deconditioning ................................................................................. 21 Social care vacancy levels .................................................................................... 21 ANNEX B – Delayed Discharge ...................................................................... 23 Reasons for delayed discharge ............................................................................. 23 Trends in delayed discharge ................................................................................. 24 Flow through delayed discharge ........................................................................... 25 ANNEX C – Definition of Discharge Event ........................................................ 26 ANNEX D - Improving Urgent and Unscheduled Care ..................................... 28 Increasing capacity outwith hospitals .................................................................... 28 Foreword
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8 Winter is challenging for the NHS every year, but winter 2022/23 was considerably more so for a variety of factors, not least the substantial increase in short-term seasonal demand for unscheduled and critical care due to the combined high incidence of flu, Covid-19 and other respiratory infections. This has placed exceptional pressure on an already strained system that was working hard to rebuild following the pandemic and striving to address the ‘backlog’ and meet high levels of demand for elective procedures. Additionally we have been responding to the deconditioning of those who either were waiting for care or had their care delayed due to fear of Covid-19 and/or a wish not to add to the strain on the health and social care system. In response to what we knew was going to be a challenging period, the Winter Resilience Plan set out a number of priorities in preparation for winter. Now that seasonal demand is subsiding, this Action Plan reflects on the strong evidence of what we know works and builds on the firm foundations of best practice to reduce delayed discharges and overall hospital occupancy, and reasserts the Scottish Government’s commitment to responding to the many challenges that still exist over the coming weeks and months. The Action Plan sets out the key actions which should be taken now to address the urgent issues around delayed discharge and high hospital occupancy we continue to experience and whose impacts are felt across the whole system. Immediate actions to ensure we are getting the fundamentals right consistently and in a way we can sustain can be found on pp10-11 of this plan. This Action Plan recognises the complexities of the challenges we are facing, whilst also acknowledging that the demands upon health and social care have changed significantly post-pandemic. Delayed discharge impacts on length of stay, and exit blocks cause access blocks, hence this plan emphasises the importance of a whole system response involving hospitals (acute led care), residential care (care homes) and primary/community care (including care at home). As set out in the recent NHS Delivery Plan Guidance for Board Annual Delivery Plans, the health and social care system must respond at all points along the patient journey, recognising the significant impacts interruptions to patient flow have on other parts of the system, such as the ambulance service and A&E. This plan proposes a set of immediate actions to be taken which represent good practice - and consideration should be given in delivery plans around how to embed and sustain these activities. Flow, the alignment of the discharge pattern with the admission curve, ensures patients get to the right bed at the right time and prevents unnecessary consumed capacity or increased length of stay. Working together across traditional boundaries will help us to improve flow through our acute settings, and delayed discharge as we work towards winter 2023/24. Multi-disciplinary and multi-agency teams are vital in enabling that all-important flow, and in moving the public away from the notion of doctor-led care as the default, particularly, in the context of this Action Plan, when it comes to discharge from hospital. Whilst it is impressive that around 97% of all discharges are without delay, we need to implement actions that we know are effective now to increase that figure and reduce the pressures we are experiencing across the NHS and in social care. The 3% of patients who do go on to be delayed in their care have a disproportionately poorer experience and poorer outcomes, and their delay consumes a high proportion of capacity (bed days lost). In all of our actions, we must bear the principles of realistic medicine in mind: ensuring patients, people, are involved in decisions about their own care and that we listen to their needs and wants at as early a stage as we can – particularly with regards to their wishes when it comes to leaving hospital and on into the care system. We must also recognise the ethical issues surrounding unnecessary, long-term hospital stays, and we must continue our concerted effort to reduced delayed discharge. Reducing delayed discharge is not a silver bullet to reducing hospital occupancy, but it is an important element to consider as part of the package of measures needed to improve flow. We must sustain the changes that have happened over winter 2022/23 to improve the flow of patients through urgent and unscheduled care, including, but not limited to discharge without delay.
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9 This Plan also recognises that there are challenges that will be difficult to address in the short term, such as recruitment and retention (in part itself caused by a declining supply of a working age population) and variability of capacity and demand throughout Scotland. But we know from the experience we have gained over the past months what works. This Action Plan draws together 12 actions we can take immediately under the following areas, with an over-arching aim alongside other measures of returning occupancy to pre-pandemic levels: Good practice – the evidence regarding what works is clear, and we need to adopt this consistently across both health and social care and ensure there is a continuous focus on evidence-based improvement. Data management – the data tells us the challenge and pressure the system is under, but we need to ensure that we continue to improve data and information so we move towards a whole system approach to developing intelligence that can be used to improve health and social care. Workforce – vacancy levels (particularly in social care) remain a key challenge and we must do all we can to support recruitment and retention. Whilst the immediate actions set out in this plan are essential in reducing pressure on staff and the system, assuring patient safety and addressing the ethical issues of unnecessary hospital stays, we must use these actions and learnings to support our ongoing commitment that people receive the right care in the right place at the right time. This Action Plan should be seen as a relatively short-term but important constituent part of our overall improvement agenda that gives assurance that we are as prepared as we can be for winter 2023/24 and beyond. With this longer-term objective in mind, we have commenced our annual planning cycle to help us assess current capacity against anticipated demand which will include surge activity at times when we know that the health and social care system is likely to come under increased pressure. This is set out in the NHS Delivery Plan which covers plans for both 2023/24, and for the medium term. John Burns Angie Wood NHS Scotland Chief Operating Officer Scottish Government Interim Director Social Care
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10 1. Context Winter 22/23 has seen extreme pressure across our health and social care system. But the pressures are not exclusive to the winter months alone. The average length of stay in hospital now stands at 8.4 days, which is a day longer when compared to the three years before the pandemic. This Action Plan sets out the issues facing the system and the actions we can take now to address them, with a particular focus on the bridge between hospital and care settings. There is a clear need to consider the potential social care needs of patients at an early stage in their hospital journey, and to discuss those with the patient and their family and current carers. Involving the patient in decisions about their health care and their subsequent care outwith the hospital setting is vital in both working towards our ambition of putting the patient’s needs and wishes at the heart of their care path, and in helping smooth the flow of patients as they transition into ongoing care, where necessary. 1.1 Older Population Scotland’s demographics are being shaped by an increasing older population and while we celebrate that people are living longer, this does mean that we are seeing a shift in front door presentation: we are admitting people who are older, with multi-morbidity and higher acuity than ever before. An increasing older population and the health inequalities which persist in our society mean that many people are entering their later years in poorer health, frail and with multiple morbidities. All of which is translating into longer hospital stays and a knock-on impact on the flow of patients through our hospitals and on into care after hospital. 1.2 Risks of Longer Hospital Stays People being in hospital for longer than necessary is one of the current key issues facing the system, which presents a number of ethical issues as this can be to the detriment of the patient. Spending too long in hospital can lead to: risk of deconditioning and frailty risk of healthcare associated infection, falls and delirium a sense of disconnection from family, friends and usual social networks leading to boredom, loneliness and loss of confidence distress for family and carers who have to spend time and money on regular visits to a hospital that may be some distance from home 1.3 Hospital Occupancy Hospital occupancy is an important measure as it reflects the pressure in a system and the ability of a hospital to move patients efficiently through a hospital and to a specialty bed. We know that hospital occupancy is high and this in itself is leading to an increased level of clinical risk as patient care is being delayed, which is most visible in the media coverage of long waits in Accident and Emergency (A&E) and ambulances queuing as they seek to admit patients. This is of course in spite of considerable effort being taken to divert the general public to the right place for their healthcare needs when A&E or a GP practice is not appropriate, and pausing of elective activity in some Board areas in order to generate capacity in acute settings. Pre-covid quarterly official statistics showed that acute bed occupancy was subject to seasonality, running between 85-89%. Official statistics also show that the medical group of acute beds generally run at a higher occupancy than the surgical grouping. But we know that in order to reduce occupancy levels to around these pre-covid levels, it requires a whole system response with both health and social care working together. Acknowledging that there are actions that can be taken at every point in the patient
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11 journey and implementing those actions we know work now will help relieve those pressures and set us on a path to better manage the inevitable increased demand we will see in Winter 23/24. Further context is given at Annex A. 2. Delayed Discharge 2.1 Defining a delayed discharge Put simply, a delayed discharge is when a patient remains in a clinical setting when they are deemed to be clinically fit to be discharged. Importantly around 97% of all discharges from hospital are not delayed. However, as of 24 February 2023 there are circa 1,800 patients whose discharge has been delayed, recorded via our management information systems. Whilst addressing delayed discharge is not the only solution to reduce hospital occupancy, it remains an important element, not least as these statistics represent people who are in a setting that is not appropriate for their care. It is also important to note that these figures are management information, are submitted daily, are not revised and have not been verified. Although the detail behind the overall number of patients whose discharge is delayed is often not reported, it is important to note that there are different categories of delayed discharge. These are broken down firstly by setting: acute, mental health and community hospitals. Public Health Scotland share a list of acute hospitals on their Official statistics Delayed Discharge publication and local authorities follow the same definitions as Public Health Scotland. They are further broken down by the type of delayed discharge: a standard delay or code 9 delay. Code 9 delays are when partnerships are unable, for reasons beyond their control, to secure a patient’s safe, timely and appropriate discharge from hospital. Code 9 delays can be split further into Adults With Incapacity (AWI) delays and Complex (also known as Code 9: Other delays). These are used where: the patient lacks capacity, is going through a Guardianship process, and for whom the use of S13ZA of the Social Work (Scotland) Act 1968 is being considered (AWI delay). the patient is delayed awaiting availability of a place in a specialist facility, where no facilities exist and an interim move would not be appropriate (i.e. no other suitable facility available) (Complex/Code 9: Other) patients for whom an interim move is not possible or reasonable (Complex/Code 9: Other). More detail on Delayed Discharge can be found at ANNEX B. 2.2 January 2023 Discharge Events On 17 January 2023, the Chief Executives of NHS Scotland and COSLA wrote to all Territorial Boards, IJBs and LAs to request a focused discharge event beginning in the week commencing 23 January 2023 as a means of addressing unacceptably high occupancy rates. This letter includes a clear definition of the expectations around those events, which can be found at ANNEX C. These events proved invaluable, but learnings from these must be implemented, and should now lead to sustained action, as set out in this plan. 3. Delivery Action It is important that we focus efforts on improving the way we plan, prepare for and execute the discharge process from all inpatient settings, but particularly from acute hospitals. To do that it will be important
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12 that we focus initially on delivering improvements in both discharge from delay and discharge without delay. But we also need to improve the flow through our hospital settings, not least as it is important we create the capacity to increase the volume of elective activity some of which has been paused or delayed as a result of the pressure across the system. It is also and most fundamentally about improving the safety of our acute systems and avoiding harm. The following therefore sets out the actions that are required in the short term to help address the immediate pressure being experienced, much of which has been communicated previously. 3.1 Good practice 3.1.1 Reduce length of stay and ensure people are discharged when they are clinically fit. Patient length of stay can be affected by many factors including patient complexity as already described. We also know that two patients with identical complexity and acuity can have very different lengths of stay in different settings. This can be affected by system configurations (such as same day emergency care replacing admission in some settings), system efficiencies (such as delays to access downstream beds leading to acute de-functioning or delays to treatment), clinical risk thresholds (junior staff having a more cautious approach to discharging compared to senior staff) and provision of support services such as variation in follow up, investigation delays or community supports in place. We know that for older people with frailty, access to specialist Geriatric Medicine beds reduces the risks of death or nursing home at discharge1. We also know that delays to access specialty older people’s beds directly correlates with longer lengths of stay such that every day’s delay in accessing a specialty bed adds three days onto the overall length of stay2. 3.1.2 Getting the basics right The objective of this plan is not just about reducing occupancy as a measure, but this is important in mitigating risk factors such as hospital associated infections and thus a measure of patient safety. We have work already underway through the Discharge without Delay (DwD) programme. Evidence suggests that leadership must be committed to continuous focus on good discharge processes and be relentless in the pursuit of good practice every time. The majority of NHS Board/partnerships have engaged with DwD and will shortly be provided with a DwD care bundle which supports acute wards to plan effectively with patients and carers from admission, and sets out the approach to wider-MDT planning for more complex patients. Leadership across the health and social care system should ensure that this best practice is applied reliably and consistently and monitored for effectiveness. Reducing occupancy levels is a whole-system aim, with action incumbent on each component part of the system to deliver it. In acute sites, that means optimising in day flow through early and effective discharge planning and preparation (using a planned date of discharge (PDD) approach) leading to pre-noon and weekend discharges. In community teams, a PDD approach means contributing to discharge plans, from admission, and responding to the ‘queue’ in advance of completion of treatment. There is strong 1 Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H, O'Neill D, Robinson D, Shepperd S. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub3 2 SCoOP Acute Hospitals Outcome Report 2018-2019 reduced.pdf (abdn.ac.uk)
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13 evidence of system and individual benefit from focus on whole system wraparound in the first 48 hours of admission, supporting discharge and avoiding further deconditioning of patients. The work we have undertaken over the course of the winter has led to a richer and deeper understanding of what works and much of this has been communicated out to both the NHS and Social Care systems. The discharge intervention undertaken in January 2023 in all systems with a targeted and focused approach to ensuring all patients discharge is being effectively managed has also given some critical learning. The combination of all of this has led to the creation of a package of measures that we know has an impact on reducing delayed discharge and improving flow. There is very little in this package that is necessarily new or novel, but there is extensive evidence to support that when in place and used collectively and consistently, these actions can deliver big improvements in the discharge process and flow. We would therefore ask that the following measures be continued and/or implemented, and sustained, as a matter of priority: GETTING THE BASICS RIGHT TO PREVENT DELAYED DISCHARGE AND IMPROVE FLOW Implement admission avoidance, locality rapid response wrap-around models, care management, multiagency input at the front door approaches. Whole-system input at an early point in the first 48 hours of admission to engage patient/family/carers in discharge discussions and prevent deconditioning of patients. Ensure the social care needs of patients are considered on every ward and that there is social work input into wards with high frailty and ongoing care needs. Service managers/care at home managers should attend ward rounds (this may be virtually) to understand/challenge referrals, manage and mitigate risk or perceived risk, provide expert advice and engage in planning and preparation for discharge as part of wider MDT discussions. All systems should implement Discharge without Delay principles to plan together as the patient recovers, and jointly set a Planned Date of Discharge – using the PDD bundle to aid implementation and reliable and consistent practice. Every patient must have a planned date of discharge, reviewed daily and this be used to plan and prepare in real time. Senior decision-making should happen with multi-agency teams, with regular communication and visibility of the plan. Daily senior oversight and escalation in both Health Boards and HSCPs/LAs should be in place to prevent/resolve delay-causing issues. Utilise performance data to apply continuous improvement to any emerging systemic issues. Structured ward rounds or white board assessment 7 days per week to ensure there is a plan for every day, which sets out tasks for the day and agrees the ward round priority order (sick, discharges, others) alongside parameters for criteria-led discharge to support early discharge. Commission/organise care in response to the pipeline of upcoming work (patients approaching their PDD), not just when patients are delayed. Early identification of complex discharges and appropriate referral as soon as possible. Every older person with frailty should have a clinical frailty score identified on admission to the ED or the admissions ward and appropriate referrals for specialist care made in
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14 accordance with local guidelines as well as early identification of needs (Medical, Mobility and self-care, Medicines, Mental Health, Me and Mine – family and carer support, and What Matters to Me) on admission with onward referral to appropriate professions and coordinated multi-agency team management. Earliest possible engagement with families/carers to manage expectations, recognising it is not a valid option to remain in an acute setting once clinically fit to be discharged. Implement discharge to assess models and intermediate care (bed or team) to support discharge home, wherever possible patients should not be assessed for ongoing care whilst at their most vulnerable or in an unfamiliar environment. Use community rehabilitation as the preferred place of recovery and intermediate care (and interim care home beds in the short-term) with a clear recovery plan in place. Implement discharge to assess models and intermediate care (bed or team) to support discharge. Use community rehabilitation as the preferred place of recovery and intermediate care (and interim care home beds in the short-term) with a clear recovery plan in place. Although all of these are important, perhaps one of the most critical is the need to ensure it is truly a whole system, person-centred approach based on the fundamentals of realistic medicine. It is therefore essential that social care, social workers, clinicians, families and critically the patients themselves work together in lockstep. Notwithstanding that this may require life-changing decisions to be taken – particularly following what could be a prolonged stay in hospital. 3.1.3 Support already provided A range of additional support and supporting materials have been prepared and issued to delivery partners to support the health and social care system. Additional funding of £528m was allocated directly to Health and Social Care Partnerships for 2022/23. This funding was aimed at the following social care measures: £124m to enhance care at home £144m to support the December 2021 uplift to £10.02, as well as a further £200 million to increase the minimum hourly rate of pay in adult social care to £10.50 in 2022/23. This will rise to £10.90 in 2023/24 £20m to support interim care arrangements £40m to enhance multi-disciplinary teams so that more social work assessments can be carried out, and to support joint working between health and social care This funding was designed to maximise capacity, ensuring flow through the system. Over and above this an additional £8m was made available in January 2023 to support up to 300 extra interim care home beds as there was evidence that there was capacity in the system that was unable to be used without additional funding. All of this builds on the existing investment to support activity to alleviate pressure such as the £62m to expand Care at Home and support an increase in the use of community equipment and Technology- Enabled Care (TEC) where appropriate supporting prevention and early intervention. Work has also been undertaken to support Health Boards and HSCPs to support patients and their families who have been classified as AWI as we know in those areas where best practice is implemented, it can dramatically reduce the delays for these patients
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15 A programme of meetings with all HSCPs is underway, beginning with those with the highest number of AWI delays per population. Each pinch point in the guardianship system and S.13ZA is examined with the HSCPs to see where improvements can be made and support provided. Good practice has been shared with HSCPs. Work is underway to identify emerging issues and develop a good practice paper in advance of next winter. We are considering whether it would be helpful to supplement this with a webinar where good practice can be discussed and an update given on plans to reform AWI legislation in the short to medium term. The work with HSCPs has been supplemented by joint statements on AWI practice by the Scottish Government with the Mental Welfare Commission and COSLA. 3.1.4 Actions for Best Practice 1 All systems to review and implement learning from their discharge event to embed improvements in an ongoing, ‘business as usual’ way Boards and IJBs to confirm this has been actioned by end March 2023 2 Put systems in place to provide the assurance necessary to confirm the measures set out in ‘Getting the Basics Right’ are consistently being applied Boards and IJBs to confirm this has been actioned by end April 2023 3 SG will continue work with NES to develop a toolkit of support and training materials to support discharge Toolkit and materials to be available by end April 2023 4 Boards and IJBs to assess their systems and processes in terms of acute discharge planning and apply the DwD toolkit in every inpatient area, community hospitals and other off-site beds Boards and IJBs to confirm this has been actioned by end April 2023 3.2 Data and Managing Variation 3.2.1 Analysis for future planning The work to gather and analyse data undertaken thus far has enabled a better understanding of the pressures being experienced across the health and social care system, but also provides us with a platform to consider how we can support future operational planning. Notwithstanding the IJB’s statutory strategic planning function, work is underway to provide modelled forecasting based on demography and historical demand trends to support future planning. This should also help local partners develop a good understanding of future demand based on their current capacity within both care at home and the care homes within their geographical area. 3.2.2 Using data-driven insights to manage variation Although the vast majority of local systems have detailed and granular data, we know that the quality of information is often not as robust or consistent as we would wish, given the different local systems in place and the number of different providers across the country. Within Social Care we also have not developed routine mechanisms to share information with local decision makers, but work is in hand to address this. Supported by analytical and digital colleagues within the SG, a tactical social care dashboarding solution is currently in development to support HSCPs and HBs to have access to a core set of indicators to enable consistent and comparable data to be available at different levels of geography. A cross-organisational
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16 forum will also be established to improve data collection including a review of methodology, processes and indicators. In parallel, joint SG/PHS/NSS work has now commenced looking at how to provide existing and robust MI data for insights across health and social care using NSS’s Seer2 platform alongside this faster-paced work. This work sits within the wider context of the Data Strategy for Health and Social Care Greater access, better insight, improved outcomes: a strategy for data-driven care in the digital age (www.gov.scot) and will report into the Data Board for Health and Social Care. 3.2.3 Actions for Data and Managing Variation 5 SG to provide a tactical social care dashboarding solution to support HSCPs and HBs to have access to a core set of indicators, predicated on existing and robust management information to enable consistent and comparable data to be available at different levels of geography Dashboard to be available by end April 2023 6 SG to provide modelling of potential future demand to support more effective local planning Modelling to be available by end April 2023 7 SG to support partners to develop forum to drive work towards more consistent and comprehensive data Forum to be established by end March 2023 8 SG/PHS/NSS to provide a strategic solution for the delivery of MI data for insights across health and social care using NSS’s Seer2 platform Solution to be agreed by end May 2023 3.3 Workforce 3.3.1 Labour Shortages We know there are significant recruitment challenges within Health and Social Care and particularly when compared to other sectors such as hospitality and retail. Social care in particular has been identified as an area with high levels of vacancies. A critical question is how to grow the care home workforce to accommodate higher occupancy levels. The actions set out below aim to address labour shortages across the sector. Staff demand for Healthcare and Social Care workers for the week to 13 January was 22.1% below the pre-pandemic baseline (February 2020). However, this data may obscure differences in demand between the health and social care sectors. So whilst it is important to take the action necessary to recruit additional staff, it is equally important to ensure that staff within the sector feel sufficiently valued and appreciated in order to retain this critical workforce. Staffing challenges in Social Work are also having an impact on the ability to discharge patients from hospital, given this sector’s statutory role in assessment and support planning (including the public protection role of Social Work). A workforce improvement plan is being developed jointly by COSLA and SG to address the immediate recruitment and retention issues for the Social Work workforce. This includes reserves lists, international recruitment and widening access into the profession through a fast- track route and graduate apprenticeships. There is reason to think that current pressures in social care may be a more significant contributor to delayed discharges than they were in the past, and that resolving the social care capacity crisis is vital if we are to improve discharge rates. The number of social care workers in Scotland decreased from 2020 to 2021 and there is no reason to think that it has increased significantly since then. Therefore work will
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17 continue to support Social Care Workforce capacity to undertake assessment of need and care planning required for hospital discharge. 3.3.2 Actions for Workforce 9 SG to support local partners through NES to utilise international recruitment Ongoing 10 Continue to pursue national recruitment campaign Ongoing 11 Continue to pursue recruitment activity with DWP for Ukrainian displaced people and UK residents that are economically inactive Ongoing 12 Increase in pay to £10.90 per hour in 23/24 for adult social care sector in commissioned services. Looking at improvements to terms and conditions for adult social care in 2023/24 April 2023 and ongoing 4. Sustaining Change Winter often results in both the NHS and Social Care experiencing the greatest pressure and involves many of the partners developing and implementing winter plans. But given what we know, it is essential that we mitigate against the need for crisis responses and develop Annual Delivery Plans that recognise there are peaks of demand and challenges at various points. We believe it is important to continue to focus on reducing discharges from delay as a priority, given the resultant impact on overall hospital occupancy and system flow, and indeed given the disbenefits to patients themselves of keeping them in a hospital setting unnecessarily. ADPs should, however, also focus on increasing discharges without delay once the delays pool has reduced in size. We will then, consequently, expect to see higher levels of patients being discharged without delay. This focus will support the wider whole-system approach to limiting hospital occupancy to safe and effective levels, which in turn will enable us to more quickly address the backlog of elective care exacerbated by the pandemic. Whilst not proposing to set a new target as such, we recognise stakeholder views that 85-90% generally represents a safe level of occupancy, and slightly higher (up to 92%) can perhaps be justified in certain local and short-term circumstances. As outlined earlier, reducing delayed discharge will not necessarily of itself reduce hospital occupancy to safe and effective levels, but it is an important element of the package of measures needed to improve flow. 4.1 Transparency We intend to use this data on a weekly basis and fully expect local systems such as all Integrated Joint Boards to be actively monitoring, managing and sharing delayed discharge statistics as part of their core responsibilities. We also fully expect local systems to be making the necessary resource decisions to support these responsibilities to those they are accountable to through the Integrated Joint Board. 4.2 Measuring Progress The number of people whose discharge has been delayed remains stubbornly at around 1,800 across Scotland. We would expect that as we move past peak demand and towards the quieter summer months, this will move towards pre-pandemic levels (c1,400-1,550).
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18 Hospital occupancy levels of c85-89% - also pre-pandemic levels – remain a target which Boards are working towards using the range of measures available to them, including the actions in this plan. Currently, 97% of discharges are without delay, which is very encouraging, but again, it is important to focus on increasing this number to continue to free up flow. 5. Conclusion and Next Steps As outlined earlier, this action plan is intended to both highlight the broad-ranging work that is happening to improve hospital occupancy in both the short and medium term, and to set out the clear steps we know work that we can take now and in the coming weeks to address the urgent situation regarding discharge and occupancy we have been facing over winter. We must collectively direct resource and effort to focus on these actions in the short-term, and bake them into longer-term planning via ADPs. We know Winter 2023/24 will again be demanding for the health and social care system, but with the knowledge and tools we have, we have strong evidence pointing to where we should be focusing attention to ensure we are as prepared as possible to mitigate the spikes in demand on the system. It is only in collaboration between the NHS and social care – including with patients themselves – that we will be able to meet the stretching targets we have set in this paper. But we know that for the sake of our staff and patient safety, and to begin now to mitigate future challenges, we must be ambitious and purposeful in attempting to meet and exceed these targets.
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19 ANNEX A – Context Short-term pressures on the NHS As outlined above, we also know there is short-term demand due to high incidence of flu in particular, along with Covid-19, RSV, Group A strep and other respiratory infections that have placed exceptional pressure on an already strained system. This is compounded by the indirect consequences of Covid-19 which has led to diagnosis and/or treatment being delayed. All of this has translated into increased deconditioning of patients upon admission to hospital which in turns leads to increased length of stay and the need for a more complex care package (if applicable) in place on discharge. Furthermore, early and high impact flu seasons also have a direct impact on our acute settings. The numbers of hospitalised patients who tested positive for influenza reported in weeks 51 and 52 of 2022 (1319 and 1283, respectively) were higher than those reported for any week since the start of the 2016/2017 season. Persistent Demand But beyond the short-term pressure, wider demand on the NHS is continually having an impact due to an ageing population, disease morbidity, health inequalities (potentially compounded by the pandemic). These increase the demand for health and care services. NRS report that life expectancy has fallen in 2018-20 and 2019-21 and that healthy life expectancy has also been decreasing in Scotland, resulting in a lower proportion of life being spent in good health, which may have implications for both demand and supply of social care. In 2019-21, life expectancy at birth in Scotland was 76.6 years for males and 80.8 years for females. The gap in life expectancy between the most and least deprived Scottish Index of Multiple Deprivation (SIMD) deciles was 13.7 years for males
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20 and 10.5 years for females. Meanwhile population ageing continues and the number of over 85s, who are more likely to have complex and multiple health and care needs, is projected to double in 20 years. A recent cross-sectional study which linked national health and social care data to explore multimorbidity and social care use in those aged over 65, found that 93.3% of those receiving social care had multimorbidity, and that 16.2% of those with multimorbidity had received social care, compared with 3.7% of those without. In addition to the acute pressures, the wider context is that the number of people requiring social care is steadily increasing as a result of the population pyramid and increases in the burden of disease. Population projections indicate that the proportion of older people in the population, who typically have greater care needs, is increasing. This is alongside the impact of more people living with a disability or disease. Admissions into Acute However, we are not seeing an increase in acute admissions. The following presents a summary of emergency admission data alongside A&E performance: The shift in admission levels is due to multiple factors, including significant change in clinical pathways and investment to enhance out-of-hospital based care to ensure that patients receive the most appropriate care in the right setting for their needs. We are also making significant efforts to double our hospital treatment in the home through priority pathways including Hospital at Home, Outpatient Parenteral Antimicrobial Therapy and Community Respiratory Teams. Our virtual capacity now provides acute care the equivalent to the size of a large teaching hospital, again reducing admissions.
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21 Additionally, many patients spend longer in A&E receiving care and are discharged directly from the Emergency Department, due to capacity pressures elsewhere in the hospital. There has also been an increase in pathways which provide rapid assessment and streaming out of the Emergency Department and prevent admission, such as Same Day Emergency Care. Ageing Population Social care demand is affected by the ageing population and increased prevalence of long term conditions3. Scottish Health Survey data provides evidence that the proportion of people living with limiting long-term conditions increases with age4. Population projections indicate that the proportion of older people in the population, who typically have greater care needs, is increasing. This is alongside the impact of more people living with a disability or disease.5 NRS analysis has further found that life expectancy has been stalling and healthy life expectancy has been decreasing in Scotland, resulting in a lower proportion of life being spent in good health6, which will have implications for both demand and supply of health and social care. Frailty and Deconditioning In older people deconditioning can happen really quickly – 24 hours in bed can reduce muscle power by 2- 5%, and in 7 days up to 20%, mostly in lower limbs which may be the difference between being able to walk or not. We know prevention is much more effective than treatment, and while deconditioning is, in theory, reversible, most older people do not regain their prior functionality and independence (https://thecareruk.com/deconditioning-the-warning-signs-and-how-to-prevent-it/). A survey conducted in Autumn 2022 examined reasons for increased length of stay compared to 2019/20 and highlights the impact of deconditioning. Health Boards were invited to complete the survey and 9/14 responded. Most Health Boards confirmed that they had an increase in bed days for patients with femur fractures, and frailty related conditions. High occupancy levels have been affected by COVID-19, with lockdowns impacting physical deconditioning due to reduced mobility. Social care vacancy levels Compounding this are the challenges in the social care sector, specifically in relation to staff vacancies and retention which in turn are making it more difficult for care to be provided in the community (care at home) but also to provide timely discharge from hospital. The following is an outline of reported staff vacancies within both care homes and the care at home sector, although it should be noted that this data is unpublished management information and therefore the quality and return rate is not as robust as other data sources. It is reasonable to conclude that the consistent high levels of vacancies in social care services could have a bearing on the waits for care packages as outlined above in the reasons for standard delayed discharge. 3 Demand and expenditure for adult social care in Scotland | FAI (fraserofallander.org) 4 Summary - The Scottish Health Survey 2021: summary report - gov.scot (www.gov.scot) 5 Population Projections Scotland | National Records of Scotland (nrscotland.gov.uk) Scottish Burden of Disease Forecasting Briefing (scotpho.org.uk) 6 Healthy Life Expectancy decreases | National Records of Scotland (nrscotland.gov.uk)
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22 Published figures from the Scottish Social Services Council (SSSC) show that, in 2021, the percentage of whole time equivalent (WTE) vacancies in care homes for adults was 7.9% compared to 5.4% in 2019. According to the RBS report on Jobs7 in December 2022 the strongest upturns in demand for permanent staff were seen across the Nursing/ Medical/Care and IT & Computing sectors. Nursing/Medical/Care also ranked second in strongest increase in demand for temporary staff among the eight monitored sectors. Hospitality and Retail have been identified as potential sectors that may be in competition for labour with social care. These sectors are characterised by notable proportions of jobs with low entry qualifications. In 2020, 49% of jobs in Accommodation & Food Services and 12% of jobs in Wholesale & Retail were classed as Occupation Skill Level 1, compared to a Scottish average of 9.9%.8 But even within these areas are experiencing challenges as the Business Insights Conditions Survey (BICS) indicate that 49.1% of Scottish Accommodation & Food Services businesses experienced difficulties filling vacancies in November 2022, compared with 38% of Scottish businesses overall, and 34.4% of businesses in Wholesale & Retail9. Social care providers are also very clear that they continue to lose staff to the NHS which has much better pay and conditions in comparison to social care staff, they anticipate that this will only get worse with the anticipated 23/24 NHS pay uplift. Entry level pay for adult social care in commissioned services will be a minimum of £10.90ph from 2023/24. The current Agenda for Change Band 3 minimum is £12.23ph and the expected increase for 23/24 is currently £13.03ph. This is £2.13ph above the social care minimum rate. Finally, pay is often cited as a predominant factor relating to staff vacancies in this sector as despite this workforce being certified and regulated by the minimum £10.50 hourly social care wage. For comparison supermarket and retailers hourly pay ranges from £9.75 to £11 and NHS Staff at level 1 earning around £12.23 per hour. 7 RBS report on Jobs, December 2022. Results based on responses to questionnaires sent to a panel of around 100 Scottish recruitment and employment consultancies. 8 Scotland’s Labour Market: People, Places and Regions – background tables and charts - gov.scot (www.gov.scot). Level 1 occupations are those which equate to a competence associated with a general education and may require short periods of work-related training (e.g. bar staff, cleaning). 9 Business Concerns - BICS weighted Scotland estimates: data to wave 73 - gov.scot (www.gov.scot)
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23 ANNEX B – Delayed Discharge Standard delays refer to all delays other than Code 9 delays. The following is a table breaking down delayed discharge by setting and type of delay between 23 November 2022 and 25 January 2023. The above table demonstrates the split across setting and type of delay: of the 1,764 delayed discharge (of 18/01/23) 50% were in acute, 15% were in mental health and 35% in community hospitals. These data are management information, are submitted daily, are not revised and have not been verified. However, this level of detail helps us to understand what lies behind the headline figure to manage flow. Although, standard delays have increased from about 900 in June 2021 to almost 1,300 in December 2022 (higher than a pre Covid-19 pandemic average of 1,100 delays). The following illustrates the trend of delayed discharge by category over time: Reasons for delayed discharge The majority of standard delays (about 70%) are usually waiting for suitable care arrangements in order to live at home (due to unavailability of services) or a place in a nursing home, and a post-hospital social care Standard AWI Complex Total Acute Standard AWI Complex Total Mental Health Standard AWI Complex Total Community Hospital 23/11/2022 692 191 20 903 180 32 52 264 483 182 12 677 1,844 30/11/2022 668 189 33 890 175 36 56 267 468 171 11 650 1,807 07/12/2022 681 181 41 903 168 37 56 261 471 175 18 664 1,828 14/12/2022 646 183 41 870 160 44 51 255 454 170 32 656 1,781 21/12/2022 673 186 44 872 158 41 58 288 446 169 29 644 1,804 28/12/2022 605 185 42 832 150 37 61 248 433 171 29 633 1,713 04/01/2023 624 174 46 844 143 38 62 243 463 163 26 652 1,739 11/01/2023 628 176 46 844 147 40 56 248 473 151 24 649 1,741 18/01/2023 665 176 35 877 154 42 64 260 455 158 14 627 1,764 Change -27 -15 15 -26 -26 10 12 -4 -28 -24 2 -50 -80 % Change -4% -9% 43% -3% -17% 24% 19% -2% -6% -15% 14% -8% -5% Date Acute Mental Health Community Hospital All Delays
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24 assessment as their principle reason for their delay at the monthly census point. Other reasons may include: awaiting commencement of post-hospital social care assessment non-availability of statutory funding to purchase Care Home Place non-availability of statutory funding to purchase any Other Care Package awaiting place availability in Local Authority Residential Home awaiting place availability in Independent Residential Home awaiting place availability in Specialist Residential Facility for younger age groups (<65) awaiting place availability in Specialist Residential Facility for older age groups (65+) awaiting place availability in care home (Dementia bed required) awaiting place availability in an Intermediate Care facility awaiting completion of care arrangements for care home placement awaiting completion of care arrangements in order to live in their own home – awaiting procurement/delivery of equipment/adaptations fitted awaiting completion of care arrangements - re-housing provision (including sheltered housing and homeless patients) awaiting availability of transport The following illustrates the principle reasons over time: From the above chart, we can see that waiting for care arrangements in order to live at home is the most common reason for delays at the monthly census point. Between June 2020 and December 2021 this percentage has increased to a peak of 48%. Overall, this percentage has been decreasing since December 2021, with a slight increase in November 2022 to 41%. Community demand is complex and depends too on competing demands for mental health and drug & alcohol services as well as for social care packages and social work support. Trends in delayed discharge Published data indicates the number of delayed discharges in November 2021 was 1,539, which when compared to the 1,977 seen in November 2022, equates to an average growth of eight additional delays per week in the year up to November 2022. Although this sounds like a small amount of growth, this mounts up over time. Which leads to the conclusion that the system needs to be calibrated to deal with this higher throughput.
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25 On analysing the trends in delays that were discharged from 2016 to 2022, both the average length of stay prior to delay and the average length of delay have risen higher than pre Covid-19 levels. The chart on the left hand side shows that the average length of stay prior to delay has increased since the Covid-19 pandemic (about 20 days before the pandemic) and is now higher than the pre pandemic levels (27 days in December 2022): a 35% increase. The chart on the right hand side shows that the average length of stay at the point of discharge has increased from about 7 days before the pandemic to a peak of 13 days, in August 2022, and has decreased to an average of 10 days in December 2022: a 43% increase from the pre-pandemic levels. Flow through delayed discharge It is however important to note that the total number of recorded delayed discharges is only a snapshot in time. Patients in delayed discharge can become delayed as well as resolved and discharged, resulting in a constant flow of patients. If the flow of new patients into the delayed discharges pool is greater than the flow of patients being discharged or removed through other pathways, the delayed discharges will increase. For example, 1,557 people were discharged following delay in November 2022 but the total delayed discharges still grew by 67 from October, (1,910 to 1,977). As outlined, the length of delay can also vary. For some patients their discharge can be delayed by only a few days and for others by much longer. There is therefore clear evidence that more needs to be done to both increase the number of discharges from delay and reduce the number of patients becoming delayed in the first place.
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26 ANNEX C – Definition of Discharge Event Below is an excerpt from the letter to Boards, IJBs and LAs from Chief Executives of COSLA and NHS Scotland of 17 January: Discharge intervention required It is now necessary to undertake an urgent and focused piece of work in every health board and health and social care partnership area to meticulously review all patients currently in in-patient care across acute and community hospitals. It should be noted that none of the activity proposed is new but this is a renewed and joint focus on taking forward actions appropriate for your area, reflective of your specific challenges. This review should focus on all opportunities to set Planned Dates of Discharge (PDD), discharge patients home or to a homely setting and ultimately improve patient flow across the system. The review process should engage joint clinical and community health and social care operational teams from across the whole system and ensure that feedback and intelligence is triangulated with immediate action. It is expected that this approach will be supported by identification of additional interim and permanent placements. Alongside ongoing work to support PDDs, any reason for patient delays and the patient’s discharge plan must be considered for immediate resolution. Poorer outcomes for patients who have a longer stay in hospital than necessary are well evidenced, and current pressures are increasing this risk. In all discussions with patients, their unpaid carers and families we must ensure a clear understanding of this potential for harm. Remaining in hospital is not a safe choice when clinically and therapeutically fit for discharge. It will be essential that this exercise accounts for the changed risk profile for our acute systems at this time, recognising the risk to patients whose care and treatment is delayed with best efforts being achieved to support early discharge and prevention of further delay. Initiatives and services which support Discharge to Assess, plus choice and safety must inform decisions. The skills and knowledge of the community teams should contribute to assessment of risk. The Discharge without Delay and PDD approach should continue as an organisational priority. Information and guidance can be found on the Turas website: learn.nes.nhs.scot/63373 With urgency, whole-system teams must mobilise to operationalise and deliver this review. We are asking you to use this week commencing 16 January to prepare for this and agree an implementation plan with the review to begin week commencing 23 January across all acute and community sites. This will require visible leadership from both Accountable Officers and from all Professional Leaders. It is essential that this activity translates into a sustained overall increase in all possible discharges from these settings, including those deemed in delay, to release the much needed capacity within hospital settings. In practice we are asking you to work across the system to take forward a combination of actions. The following tools are considered best practice and useful in the identification of the tasks or services which contribute to delay, and support robust evidence-based action and improvement planning: • Day of Care Audit: Used by most health boards regularly to understand delay in their systems, should form the basis of whole-system improvement planning discussions (guidance and toolkit attached to this letter); • MADE: (Multi-Agency Discharge Event) an English approach adopted by many health boards to discuss and problem-solve existing delays. The guidance can be found here: england.nhs.uk/south/wp- content/uploads/sites/6/2016/12/rig-multi-agencydischarge.pdf
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27 • Criteria To Reside: used as a snapshot or a daily process to capture delay information and find solutions. Information can be found here on the definitions: england.nhs.uk/publication/process-and-definitions- for-the-daily-situation-report/. (A ‘what why how’ poster is attached to this letter which explains the context and how this information is used locally). Each area should prepare and hold a live list of all patients with PDDs as well as those patients who are delayed. PDDs should be reviewed daily to ensure timely discharge. Patients who are delayed should have a plan which is reviewed daily as a whole system and any mitigating actions taken to resolve this as soon as possible. You should ensure the appropriate local governance is in place to actively pursue and monitor the outcomes from the review on a daily and weekly basis. Further information on the expectation of national reporting to evidence the impact of this approach will be provided in the coming days.
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28 ANNEX D - Improving Urgent and Unscheduled Care Increasing capacity outwith hospitals We know that services managing demand must include both preventing the estimated 20% of admissions that are thought to be preventable. It must also include increasing alternatives to hospital admissions where services to provide acute specialist input at home (virtual capacity) exist for acute conditions that would normally need hospital admission. We know that these services are cheaper, safe and preferred by patients. It is important to focus on the wider system that impacts on flow, capacity, demand and ultimately results in delays across the system. Key priorities are to reduce inappropriate attendances to ensure the Right Care is delivered in the Right Place at the Right Time; avoiding unnecessary admissions that keeps care as close to home as possible; reducing length of stay to ensure patients are discharged when clinically and therapeutically fit; and avoiding delay wherever possible. This is underpinned by a collaborative improvement programme that supports improvement in systems and process that reduces unwanted variation and failure demand. The redesigned Urgent Care Programme focusses on reduced unnecessary attendances by signposting and triaging to more appropriate care. Where possible attendances at A&E services can be scheduled to a more appropriate service at the right time. This process has reduced self-presentations by circa 13% with an ambition to continue to improve through initiatives such as Call before you convey, which has proven particularly successful for care homes, and for pathways such as low risk chest pain. The Virtual Capacity programme focusses on keeping care as close to home as possible. Increasing out-of- hospital care to reduce attendances and admissions through priority pathways helps to develop a virtual hospital that improves outcomes, increases capacity and reduces risk of nosocomial infections. Current aims are to: Increase Hospital at Home services by 50% Spread successful OPAT services to all Health Boards Establish Respiratory pathways Develop case for other pathways of care such as Heart Failure Using data to monitor and drive increases in performance Supporting MDT collaboration and shared understanding of risk Embed governance & oversight strategic functions in an integrated manner Review next steps to develop urgent care – OOHs/SAS/NHS24 Improving Flow through the whole system will reduce length of stay and will be supported by consistent systems and processes that improve communication across multidisciplinary teams and multi- agency organisations to reduce variation.