ITEM 6 Hospital At Home
North Lanarkshire Council · 21 February 2024
Back to IJB Performance, Finance and Audit Committee — 21 February 2024 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: 6 SUBJECT: Hospital at Home TO: Integration Joint Board Performance, Finance & Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer, NL HSCP Author(s) of Report Hazel Mitchell, Service Manager, AHSU DATE: 21 st February 2024 1. PURPOSE OF REPORT This paper is coming to the IJB PFA for noting of the current Hospital at Home service provision, the service expansion updates, and the strategic risks to the longevity of maintaining increased performance. For Approval: ☐ For Endorsement: ☐ To Note: ☒ 2. ROUTE TO THE BOARD This paper has been prepared by Hazel Mitchell, Service Manager to update the Board on the current H@H service performance, and to update on on-going expansion plans. The paper has been reviewed by Jamie Quin, General Manager, AHSU Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐
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2 3. RECOMMENDATIONS The IJB PFA are asked to approve the following recommendations: (1) In line with the Scottish Government initiative to implement a Hospital at Home service in every Board in Scotland, that NHS Lanarkshire shall expand their service provision to the Clydesdale locality within South Lanarkshire. (2) In line with the Board’s Unscheduled Care strategy, that Hospital at Home should seek to expand their operating hours to increase virtual bed capacity. (3) To ensure that the service is achieving maximum efficiency and operating in line with the Boards strategic objectives, a Rapid Strategic Review would be undertaken. 4. VARIATIONS TO DIRECTIONS? This section outlines if the report requires a direction to be issued to the Local Authority, the Health Board, to both, or that no direction is required Yes ☐ No ☒ N/A ☐ 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1) The Health Board are trying to increase virtual beds and reduce hospital attendances in line with their Unscheduled Care & Winter Planning programmes 5.1) The Scottish Government has a National Objective to double virtual bed capacity by 2025 6. CONCLUSIONS 6.1) Hospital At Home service in NHSL has continuously increased virtual bed capacity every year since 2019 via its expansion programmes and pilots. 6.2) KPIs including increased capacity and reduced LOS have all been achieved (data embedded) 6.3) Risk factors to future expansions include non-recurring finding streams
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3 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☐ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☐ 7.2 ASSOCIATED MEASURE(S) 7.3 FINANCIAL Substantive Budget £2.79m (inc Clydesdale & Stepdown) = 96 virtual beds One year non-recurring pledge of £1.25m for additional 60 beds (48 H@H & 12 Cardiology) from SG/Unscheduled care. Risk in confirmed recurring funding has made achievement of additional 60 beds challenging and will only be mitigated by permanent funding. This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT Non confirmation of recurring funding to substantiate current expansion plans will reduce virtual bed capacity back to 96 substantive virtual beds.
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4 Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICIPATION . Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details on the engagement and participation that was undertaken. Objectives Further details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes All staff and relevant management have been involved in service changes and expansion plans ☒ Provide stakeholders with information on how to get involved All staff and community colleagues have been informed on how to engage and onward refer to H@H ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs Various working groups and patient forums are on-going ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services Community stakeholders are involved in active working groups including patient representation where appropriate □ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings Always supported and encouraged □ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☒ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership
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5 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes No N/A EQIA added to website: Yes No N/A 8. BACKGROUND PAPERS None. 9. APPENDICES Please include a glossary of terms if not already included. Appendix 1– H@H update January 2024, author Hazel Mitchell Appendix 2– H@H Rapid Strategic Review Recommendations, authors Claire Rae & Maggs Thomson (Head of Health for South & North HSCPS respectively) Appendix 3– H@H Data 2023, author Hazel Mitchell Appendix 4– H@H Funding Application update as at January 2024, author Hazel Mitchell CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Hazel Mitchell, Service Manager, AHSU Hazel.Mitchell@lanarkshire.scot.nhs.uk Jamie Quin General manager, AHSU Jamie.Quin@lanarkshire.scot.nhs.uk
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6 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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7 Appendix 1 TITLE & PURPOSE OF PAPER: NHS Lanarkshire Hospital at Home Service; Update for IJB DIRECTORATE: Adult Health Services Unit DATE: 15 January 2023 AUTHOR: Hazel Mitchell 1) BACKGROUND Hospital at Home (H@H) was initially set up as an Admission Avoidance service by NL H&SCP in 2011. The service covers all areas of North Lanarkshire and areas of South Lanarkshire (excluding Camglen) With prior endorsement from the (then recently retired) Cabinet Secretary for Health, all areas of Scotland were to introduce a H@H service. Having created the first H@H Service in 2011, the task for Lanarkshire was to provide full geographical coverage by the service, and expand our virtual bed capacity in already existing localities In 2022 the H@H service undertook a large scale project to introduce the service and provide 12 virtual beds in the Clydesdale locality within South Lanarkshire, and to extend the operating hours of the whole service. In February 2022 the service participated in the organisation’s “Firebreak” process and use the opportunity to test the value in extending their operating hours to later in the evening and weekends. This was evaluated with the learning and outcomes used to inform future decision making and service changes. 2) GENERAL OVERVIEW H@H Operates a service model that consists of 4 Hubs/Teams, 3 located within the Acute Hospitals across Lanarkshire, with the Monklands and Wishaw Hubs covering North Lanarkshire and the Hairmyres Hub covering the Hamilton & EK localities of South Lanarkshire. A new hub has been opened in Carluke Health Centre to cover the Clydesdale locality. The substantive operating budget is £2.1 million for the 3 teams within Acute sites, each team has a staffing structure incorporating: Band 7 Team Leader Band 6 Nurse Practitioners Band 4 APR’s Band 3 Administration Staff The service is currently Medically (Consultant) led and each Hub is supported by Consultant Geriatricians from the associated Acute Hospital Site, for which NL H&SCP meet the funding. The teams above each provide 24 virtual Admission Avoidance beds, 72 in total. While successful, the original operating model described above provided challenges to growth & expansion. The lack of available Consultant Geriatricians within the recruitment market meant a replication of the Consultant led model was not possible, and alternative would need to be devised. In response to this plans to introduce Advanced Practitioners into the H@H model were
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8 : ANP (B7) 1.00 wte £61,118 RGN (B5) 3.00 wte £123,279 APR (B4) 1.00 wte £33,686 TOTAL Recurring Annual Cost £218,083 initiated. In principle, qualified and experienced Advanced Practitioners could work autonomously as clinical decision makers. It was proposed to implement this role into the service to work in collaboration with the Consultant Geriatricians. HIS under the direction of the Scottish Government have supported expansion plans in NHSL H@H by providing non‐recurring funding to help us implement expansion proposals Over the course of 2022 & 2023 the following expansions were implemented: Confirmed substantive implementation of Stepdown ‐ 12 virtual beds Service coverage into Clydesdale locality – 12 virtual beds Service coverage for identified Cardiology Heat Failure patients requiring infusion – 3 beds Extended hours working via Firebreak programme 3) EXPANSION PROGRAMMES STEPDOWN: Model: Stepdown model was introduced in 2020 as a response to the Covid pandemic. This allowed 12 ring‐fenced virtual beds to assist with hospital flow. Inpatients within the COTE wards who were still acutely ill and met the H@H clinical criteria could be discharged home and vacate an inpatient bed, with the remainder of their care being delivered by H@H. Clinical criteria & referral pathways were developed using the Trakcare Workbench function to accurately record the patient’s movement and transfer the care record. Funding: In 2022/23 the Board permanently funded the Stepdown facility within and the following funding was received: Service Provision: By 2022/23 the Stepdown function were managing over 36 referrals per month, with an average LOS of 5.5 days. By end September 2023 this service had increased capacity to an average of 46 referrals per month and reduced LOS to 3.81 days. The addition of this facility also allowed for the introduction of Band 5 RGN posts into the service, which provides attraction and career progression into the service. Since establishment in 2020, 2 Band 5 RGNs have progressed into Band 6 Nurse Practitioner posts. CLYDESDALE Model: The expansion into Clydesdale was anticipated to increase virtual bed capacity by 12 beds Due to the lack of additional Consultant availability and the rural nature of the region it was agreed to implement an ANP model to this locality. In contrast to the existing H@H model, patients would be reviewed by a Band 7 ANP and discussed virtually with the Consultant to
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9 confirm the clinical plan. The framework for the ANP roles was established in collaboration with Practice Development. The project was commenced late 2021 with the first actions being to: Confirm funding Recruit Project Manager Recruit clinical staff Compose patient pathways into service Compose SOPs to govern the ANP model Define Patient cohort and demand Establish working relationship with Clydesdale locality Senior management and ICST teams Identify accommodation Plan & endorse electronic patient record keeping Plan & endorse POCT Funding: In 2022/23 the Board provided funding as per below to fund a 12 virtual bedded service: ANP (B7) 2.28 wte £139,349 NP (B6) 1.77 wte £89,790 APR (B4) 1.77 wte £59,736 Admin (B3) 0.50 wte £14,699 Supplies & Equipment £20,500 TOTAL Recurring Annual Cost £324,074 £27,006 TOTAL Recurring Monthly Cost Aim of Service Provision: To ensure the service was providing care to the most appropriate patient cohort, (and not to reroute patients from existing appropriate community services) a demand profile was established as per below using the criteria: patients admitted to hospital via ED Over 65 years of age Registered to a Clydesdale postcode Admitted between 8am and 4pm, Monday‐Friday (H@H operational service hours) This data showed: 1438 hospital admissions during H@H working hours (8am‐4pm, Mon‐Fri) 710 of those were clinically suitable for H@H referral Potential for 13.6 referrals per week. The service therefore aimed to safely prevent 13.6 hospital admissions per week. Process for implementation: A working group was set up to ensure collaborative working between Clydesdale locality teams and H@H. Accommodation was identified within Carluke Health Centre and the team are located with ICST to ensure good communication, collaborative working, and safe and effective patient care.
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10 Staff recruitment was commenced and concluded. All staff were in post by summer 2023. The Band 7 ANPs were all recruited on an Annex 21 Trainee basis. New patient pathways and SOPs were devised and ratified to ensure patients are referred and managed safely The use of electronic patient records on patient Trak were tested, ratified and implemented to allow for virtual working between ANP/Practitioners and Consultants. POCT and CRP machines were purchased to maximise efficiency in diagnostics and treatment plan initiation. Trainee ANPS were supported by Practice Development and a Senior ANP to ensure their compliance with the ANP framework and academic programme. Robust Communications programme to ensure all GPs and community teams were aware of service, service provision, criteria and referral process. Also patient engagement events were attended by the team. A Band 6 Project manager was recruited and funded by HIS on non‐recurring funding. Achievements to date: The Clydesdale hub began accepting “test” patients in a planned manner in May 2023, with multi‐ disciplinary reviews after each case to assess success and explore any issues. By August 2023 the hub was fully functional in its intended manner and operation from its new base in Carluke Health Centre. The team have increased their live capacity each month, and by December had an average of 10 patients per week and an average LOS of 7.2 days. This is referral rate is expected to have reach a weekly average of 14 patients by end of March 2024, as set out in the main aims of the programme. Associated Risks: ANPs are currently still in Training Programme, and are therefore not fully qualified autonomous practitioners, but are receiving enhanced Consultant support to allow the service to function as expected. It is anticipated that 3 of the 4 Trainee ANPs will be fully signed off by June 2024. CARDIOLOGY HEART FAILURE: Model: As part of HIS non‐recurring funding programmes, they financially supported the recruitment of 2 Band 5 RGNs to administer the infusion of IV Furosemide to identified Heart Failure patients. This was with the intent that these patients, as identified by Heart Failure nurses as being clinically safe to remain at home for infusion, would no longer need to occupy an inpatient bed for up to 5 consecutive days for infusion only purposes. These patients are still clinically responsible to the Heart Failure service and H@H are responsible for the infusion only. Funding: His Funded £105,000 = 2 x band 5 RGN, non‐recurring for 1 year only Service Provision: Due to the fixed term nature of this post, only 1 staff member was successfully recruited. The pilot is live. We have been unable to manage all patients at home as the Heart Failure pathways do not currently allow for management of other medical issues (such as Acute urinary retention). Therefore to develop this more robustly new clinical pathways would need to be developed. A
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11 0.0 1 separate bid to the Government for an enhanced Cardiology H@H service has been submitted by the Cardiology team which may address this. Risks: Not fully adapted to keep all patients at home as yet Non‐recurring funding made recruitment unsuccessful EXTENDED HOURS VIA FIREBREAK PROGRAMME: In February 2023, the H@H participated in the NHSL Firebreak programme. Aim of Service Provision: To increase virtual bed capacity within the service, and reduce hospital attendances and admissions by extending operating hours to include evenings and weekends. Process for Implementation: Amend opening hours to accept new patient referrals up to 8pm Monday‐Friday (9pm for Care homes), and from 8am until 4pm at weekends (5pm for care homes). Implementing a temporary organisation change to amend shift patterns and off duties for Practitioner and support staff Creating a virtual process for Consultants to review patients Enhanced Communications programmes to GPs, SAS, ERC, Care homes and OOHs to ensure they were aware of our new operating schedule. Recruitment of Locum junior doctors and redeployment of Nursing staff from other services within AHSU Achievements: The service increased the active caseload by 77% over the 9 day period, with referrals totalling 129 compared to the average 73 (compared to an average 9 day period pre firebreak). 14 120.0 H@H FIREBREAK REFERRAL ACTIVITY OVER 9 DAY ROLLING PERIOD 29 100.0 80.0 60.0 40.0 42 45 35 66 31.2 80 41.6 95 52.0 113 62.4 72.8 20.0 20.8 21 21 0.0 Fri 24/02/23 Sat 25/02/23 Sun 26/02/23 Mon 27/02/23 Tue 28/02/23 Wed 01/03/23 Thu 02/03/23 Fri 03/03/23 DURATION OF FIREBREAK Rolling Average of Referrals pre Firebreak Actual Number of Referrals during Firebreak NUMBER OF REFERRALS
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12 4) ON‐GOING WORKSTREAMS RAPID STRATEGIC REVIEW In 2023, The organisation requested a Rapid Strategic Review be undertaken. This was jointly chaired by the Head of Health from both North & South HSCPs. It was supported by the Planning department. The outcome is shown in appendix 2. UNSCHEDULED CARE/WINTER EXPANSION The Organisation requested via the Unscheduled Care Board that H@H expand their service capacity in response to winter pressures. The initial plan was to replicate the Firebreak programme with the intention of introducing an additional 48 virtual beds to the service. Thus far recruitment has been unsuccessful as the non0recurring budget for 6 months has made the posts unattractive to candidates. The Band 7 ANP posts were funded permanently and they have been filled with candidates taken up post between January & February 2024. The lack of additional staff meant that the service could not sustainably replicate the firebreak programme for a 6 month period, as it was not sustainable with the staffing resource in post. Current achievements include increasing virtual bed capacity by 12 beds by extending operational hours to 6pm instead of 4pm. Future Aims: To substantively provide a 7 day/12 hour operational service to increase capacity permanently Risks: Lack of substantive funding as non‐recurring budget does not allow tests of change or pilots to be tested and proven effectively. Current ANPs are Trainees and will have a year before all are qualified and signed off Lack of new Consultants in recruitment market 5) CURRENT SERVICE DATA Information is included under appendix 3 and 4.
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13 Appendix 2 HOSPITAL AT HOME RAPID STRATEGIC REVIEW RECOMMENDATIONS 1. Recommendations Over the past 8 months, the Rapid Strategic Review Group have met to review the current service, the immediate plans for expansion and the future vision for Hospital at Home in line with Scotland’s national strategy and the following recommendations are proposed: Horizon 1 – timescale 6 months (as part of Winter funding proposal) Extend operating hours to include evening and weekend working Enhance interfaces between community nursing, hospital based specialities and more understanding of capabilities across the system. Increased reporting of agreed KPIs Increased professional to professional advice via consultant connect Capture learning from Heart Failure Test of Change to inform speciality developments across the service Explore Flow Navigation Centre being the single point of access for escalation and de- escalation Horizon 2 (learning from Winter proposal) – implemented by March 2024 Refocus on service to admission avoidance Clearly define step down criteria for complex cases Move from medical delivered model to a medical oversight model Rapid access to diagnostics Develop and implement recommendations from Heart Failure learning Horizon 3 – implement March 2025 Finalise workforce mode for service Connect Hospital at Home to locality teams (urgent response and nursing) Agree model for multiple Responsible Medical Officers when the service expands into other specialties Clarify system wide governance arrangements Ensure a de-escalation and escalation framework is in place ANPs undertaking differential diagnosis A structure to support the implementation of the recommendations is required and a group will be established to oversee these strategic developments. The work will also continue to be connected into the Operation Flow programme. An MDT approach will be essential to support the implementation of the new model, incorporating disciplines such as pharmacy, physio, mental health and social work.
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14 Appendix 3 REFERRAL DATA REFERRALS TAKEN TO DATE 2023 = 1590 AVERAGE REFERRALS TAKEN PER MONTH 2023 = 265 Hub Apr May Jun Jul Aug Sep Total Hairmyres 61 70 68 63 67 66 395 Monklands 75 84 94 70 96 90 509 Stepdown 47 54 48 43 43 38 273 Wishaw 69 63 70 73 69 69 413 Grand Total 252 271 280 249 275 263 1590 2022 VS 2023 Patient Increase % Increase 6 10% 8 11% 10 28% 20 40% 44 20% AVERAGE REFERRALS SITE 2022/23 2023/24 Hairmyres 60 66 Monklands 77 85 Stepdown 36 46 Wishaw 49 69 Grand Total 221 265 H@H Referral per Hub, 2023/24 120 100 80 60 40 20 0 Hairmyres Monklands Stepdown Wishaw Apr 61 75 47 69 May 70 84 54 63 Jun 68 94 48 70 Jul 63 70 43 73 Aug 67 96 43 69 Sep 66 90 38 69 NO REFERRALS
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15 LOS 2023/24 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 AVERAGE LENGTH OF STAY 2023 AVERAGE LOS = 5.99 DAYS 0.00 April May June July August September Grand Total Hairmyres 8.38 5.71 7.79 7.67 8.42 7.18 7.50 Monklands 3.95 3.96 4.51 5.19 4.83 4.87 4.55 Stepdown 4.06 3.37 3.75 3.58 3.40 4.89 3.81 Wishaw 8.83 7.17 8.16 7.01 8.17 7.28 7.77 Grand Total 6.38 5.04 6.09 6.07 6.32 6.08 5.99 AVERAGE LOS PER SITE 2021/22 2022/23 2023/24 Hairmyres 8.02 7.4 7.50 Monklands 6.01 5.7 4.55 Stepdown 5.77 5.5 3.81 Wishaw 10.48 9.3 7.77 Grand Total 7.44 6.91 5.99 2021 VS 2023 Reduction in days % Reduction 0.52 7% 1.46 24% 1.96 34% 2.71 26% 1.45 19% 2022 VS 2023 Reduction in days % Reduction -0.11 -1% 1.10 19% 1.71 31% 1.50 16% 0.91 13% 2021 VS 2022 Reduction in days % Reduction 0.63 8% 0.36 6% 0.25 4% 1.21 12% 0.54 7% DAYS
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16 REFERRAL SOURCE 2023 Referral Source Apr May Jun Jul Aug Sep Total A&E 32 31 19 21 13 24 140 Clinic 1 1 2 1 5 ConsultantConnect 1 2 1 2 1 3 10 DN 2 1 3 ECU 1 2 1 2 2 1 9 GP 162 166 200 157 191 170 1046 Nurse 1 1 SAS 8 12 7 17 17 23 84 Ward 47 56 50 48 50 41 292 Grand Total 252 271 280 249 275 263 1590 CAREHOME PATIENTS Carehome Patients Apr May Jun Jul Aug Sep Total Hairmyres 12 12 9 11 11 12 67 Monklands 2 4 2 5 8 4 25 Stepdown 2 6 2 10 Wishaw 1 3 2 1 1 6 14 Grand Total 15 19 13 19 26 24 116 BED COMPLEMENT Bed Complement Apr May Jun Jul Aug Sep Hairmyres 24 24 24 24 24 24 Cardiology 3 3 Monklands 24 24 24 24 24 24 Stepdown 12 12 12 12 12 12 Clydesdale 12 Wishaw 24 24 24 24 24 24 Grand Total 84 84 84 84 87 99
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17 WORKFORCE DATA 2023 Month FE In Post Vacancy Rate Vacancy (WTE) Employee Headcount Total Leaver s WTE Total Leavers 12Mths Rolling 12 Mths Turnover Sick Leave % September 42.44 45.21 (6.53%) (2.77) 48 0.0 0 0.00% 4.79% August 42.44 40.65 4.22% 1.79 43 0.0 0 0.00% 7.29% July 37.93 39.26 (3.51%) (1.33) 42 0.0 0 0.00% 15.88% June 37.93 39.26 (3.51%) (1.33) 42 0.0 0 0.00% 7.80% May 37.93 38.26 (0.87%) (.33) 41 0.0 0 0.00% 7.63% April 37.93 37.26 1.77% .67 40 0.0 0 0.00% 9.62% 2023 39.43 39.98 (1.40%) (.55) 42.67 0.0 0 0.00% 8.83% Average The team have been fully established for the entirety of 2023, with no staff having left the service and a turnover rate of zero. The only vacancy being for the newly developed Cardiology team in August while we awaited a start date. All recruitment campaigns have been highly successful The Clydesdale was formed and began operational activity on 28th August, this data will follow Sickness Absence is managed well within the policy
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18 Appendix 4 Chief Operating Officer, NHS Scotland Directorate Deputy Chief Operating Officer: Performance and Delivery Division To: Chief Executives IJB Chief Officers CC: COO NHS Scotland 14th November 2023 Dear Jann, ADDITIONAL FUNDING TO SUPPORT HOSPITAL AT HOME EXPANSION 2023-24 Thank you for recent work to identify your Health Board’s ability to mobilise additional virtual capacity to support resilience over winter. This letter sets out additional funding which should be utilised to develop the services set out in your submission with a focus on reducing hospital admissions and maximising capacity. I am pleased to tell you that Scottish Ministers have approved the allocation below which is based on your return which set out the additional capacity which could be created by the end of this financial year. Board Additional beds Indicative Funding 23/24 NHS Lanarkshire 60+ £ 1,274 ,685 Funding will be released at the end of this financial year based on delivery and monthly evidence of the impact it is having to ease system pressures and improve the experience of services users. This funding is provided for the current financial year only. If an underspend is expected to arise as compared to the costs outlined above, this must be notified to us as soon as possible. The funds should be used entirely for the purpose outlined in your submission and should not be top sliced or used for any other purpose. Considering current service pressures NHS Boards, particularly those facing the greatest challenges, should continue to consider what additional initiatives, within the hospital at home programme, can be evidenced and rapidly stood up if support was available. You should notify the Unscheduled Care Policy team where this is the case. Future Arrangements For Hospital at Home to be effective and to ensure Boards progress at pace, we recognise that funding must be provided on a recurring basis at full year costs. This will help ensure the ongoing sustainability of new services in pressurised boards and to reduce the risks of services
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19 folding or failing to start due to ongoing funding concerns. We will work with you over the coming months to understand the recurring element of your funding. Until the 2024-25 Budget is approved we cannot confirm future year or recurring funding. The biggest risk to expansion of hospital at home services is whether sustainable workforce models can be developed. Mitigation of this risk requires a concurrent focus on developing a sustainable workforce model across all disciplines. The Scottish Government will work organisations including NES and HIS to ensure effective governance and oversight is in place and based on best practice. Governance Expansion of virtual capacity so far has been overseen by the Hospital at Home Expert Working Group chaired by Graham Ellis, Deputy Chief Medical Officer. This group will now cease and will be replaced by a Programme Delivery Board within Scottish Government, supported by operational support within the Centre for Sustainable Delivery (CfSD) as lead agency and in close collaboration with other National and territorial boards. This group will support the delivery of the wider Hospital at Home expansion across a range of specialties, supporting shared learning and collaborative working across Health Boards. As confirmation of receipt and acceptance of this funding envelope, please provide us with the name of the nominated representative for your board to attend the Programme Delivery Board. You may wish to name 2 people to ensure operational and clinical representation. Performance monitoring and Reporting It is essential that early evaluation is in place to assess how well the virtual capacity is delivering and to ensure the funding delivers value for money and services are safe, consistent, efficient, and person-centred. NHS Boards are asked to consider what local service evaluation can be put in place to support this. Reporting will be requested on the first Monday of every month from 4 December and should be sent to the Unscheduled Care Team UnscheduledCareTeam@gov.scot A template has been provided in Annex A. Please contact the Unscheduled Care team if you require any further information. Yours sincerely, The Unscheduled Care Policy Team MONTHLY HOSPITAL AT HOME SUBMISSION HB Named Representative: Submitted by (if different to above): Contact: Hazel Mitchell Board: Lanarkshire Date: 04/12/2023 ANNEX A
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20 Complete and return by 1st Monday of every month. Trajectory of additional bed numbers by March (as provided to Scottish Government) Hospital at Home pathway Nov Dec Jan Feb Mar Older People 12 24 36 48 48 Heart Failure 12 12 OPAT / / / / / Paeds tbc tbc tbc tbc tbc Other (please specify) / / / / / Total 60+ 60+ Current actual number of additional beds Hospital at Home pathway Nov* Dec* Jan Feb Mar Older People 0 12 12 Heart Failure OPAT Paeds Other (please specify) Total 0 12 12 *Please note November & December has been amended to accurately reflect the additional beds as opposed to total beds previously reported. What progress has been made in the last month in increasing virtual capacity? Include details on whether you remain on trajectory and any issues impacting on agreed deliverables and whether you remain on track to spend funding. Active recruitment process has been on-going since September to help enable us to fulfil this expansion plan. The temporary funding of the posts has deterred candidates from taking up these roles and this has made the expansion challenging. We have failed to recruit the Band 6 Practitioners and Band 4 Assistant Practitioners due to the temporary posts not being an attractive option. Successful recruitment does includes3wte Band 7 Trainee ANPs and a Band 8a Senior ANP.
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21 This cohort of staff are due to take up post mid-January so will hopefully help bolster capacity into February once the induction programme has been followed. Notwithstanding the issue of not having any additional Practitioner staff in post, utilising additional excess and bank hours for the past 2 months have allowed us to increase capacity by 12 beds. Additional Senior medical staff have been utilised on a sessional basis, although this arrangement is temporary and not a long term sustainable plan. In terms of Junior doctors, 3 locums have been recruited on short term contracts via Agency. How are you ensuring virtual beds are being fully utilised? Please include data that evidences how beds are being utilised? Increased capacity is evidenced below by number of referrals accepted by team: *Please note October & November data has been revised and accurately recorded above, previous submission was inaccurately reported As the table above shows patient referrals accepted by the team have increased since October. The table below shows that December saw a 13% increase in patients accepted into the service. Also as December had less working days due to Public Holidays, this is actually a 25% increase in true terms of daily referrals. The additionality of the Junior Doctors in place to support the Senior clinical decision maker has allowed the service to accept additional patients, and enabled more virtual working, hence allowing the Wishaw & Clydesdale hubs to accept more referrals than previous months. The Acuity of the patients we have managed has increased with patients presenting as much sicker and frailer than the months prior, however this is consistent with the expectation of what we would expect in winter months, when frailty and co- morbidities make patients more vulnerable. Team October* November* December Hairmyres 63 82 70 Monklands 95 100 99 Wishaw 66 58 69 Clydesdale 11 18 30 Stepdown 40 47 44 Total Referrals 275 305 312 Analysis October November December Increase in referrals since expansion ‐ 30 37 Increase in referrals since expansion (%) ‐ 11% 13% Average referrals per day 12.50 13.86 15.60 % Increase daily referrals ‐ 11% 25%
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22 What impact are you seeing on acute capacity, e.g., admissions, length of stay, occupancy? Increased admission rates have helped support the Acute sites winter plan and helped minimise their challenges wth patient flow and reduce delayed discharges by keeping patients with POC in their own homes. The average LOS in 23/24 for NHSL H@H patients was 6.08 days prior to expansion. As mentioned above the acuity of patients in November/December has increased and this has a consequential impact on the LOS, which has risen to an average of 7.02 days for December 2023. Without additional funding and the additional medical staff and excess/bank nursing hours it would not have been possible to manage these sick patients and increase referral rates. December referrals of 312 x average LOS of 7.02 days = 2190 Acute bed days saved Any further information (please note any further information around concerns or impact such as patient and staff feedback / experience) Patient feedback has been very positive as is the expectation in our service as we strive to give excellent patient centred care at all times.