Item 9 - Covid-19 Update-Resilience Response
North Lanarkshire Council · 14 February 2023
Back to IJB Performance, Finance and Audit Committee — 14 February 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: 9 SUBJECT: Covid-19 Update / Resilience Response TO: IJB Performance, Finance and Audit Subcommittee Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Ross McGuffie ,Chief Officer North HSCP DATE: 14th February 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 the actions taken to date during the pandemic response. 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 that NHS Lanarkshire stood down its Covid Live Incident down in January 2023, though command structures have been adapted to continue to focus on ongoing wider resilience challenges, specifically around service pressures (2) Note the whole-system response to ongoing health and social care pressures, as outlined in appendix 1. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 COVID-19 was declared a pandemic by the World Health Organisation on 12 March 2020, with spread of COVID-19 within all communities in the UK in the intervening period. Yes No N/A
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2 5.1.2 Command structures were immediately put in place in both North Lanarkshire Council and NHS Lanarkshire, with the Health and Social Care Partnership fully participating in both. In addition, the pan Lanarkshire Resilience Partnership has supported cross-agency developments. 5.1.3 NHS Lanarkshire stood down its Live Covid Incident in January 2023, so this will be the final Covid update report unless a new live incident is established. Further updates will continue around wider system resilience. 5.2 Update on Numbers 5.2.1 As at 26th January, the seven-day case rate within North Lanarkshire is 23.4 per 100k population, which is a further decrease to the figures last presented to the IJB from 18th November when it was 35.2 per 100k. 5.2.2 The inpatient peak of the second wave of Omicron was 322 covid positive inpatients on 28th March 2022, with a further 63 in off-site facilities. As at 31st January, there are 66 covid positive inpatients and a further 1 in offsite facilities, which in total is a slight increase from the 59 reported on 18th November. 5.2.3 On 27th July 2022, NHS Lanarkshire moved from red to black status due to escalating staff and bed shortages across the system. 5.3 Care Homes 5.3.1 As at 31st January, there are 5 outbreaks in care homes covering 29 residents and 18 members of staff cumulatively. 5.4 Delayed Discharge/System Pressures/Home Support 5.4.1 For the majority of 2022, North Lanarkshire maintained delays around the 70s and below, reaching a low under 50 delays during June. However, over December and January, delays have hovered around the 100 mark, which while significantly beyond where we wish to be, is still around the Scottish average in rate terms. 5.4.2 During peak winter pressures in 2019/20, North Lanarkshire had the highest rate of referrals for supported discharge in Scotland, averaging 77 per week. Two weeks in January 2023 have totalled 145 and 158 referrals, with the average weekly referral rate over 22/23 being in excess of 120 per week. 5.4.3 As at 30th January, the delayed discharge position is 93 delays with 41 discharges taking place. Recent data requested by Scottish Government has identified that the turnover of delays is approaching 50% per week, with many of the longer delays associated with AWI and Mental Health cases. 5.4.4 The winter business case was approved at a special meeting of the IJB on 16th February 2022, with recruitment underway to support the development of the new models proposed, including: Home Assessment Teams in each Locality to support early discharge as well as admission prevention Expanded Home Support and Reablement capacity in each Locality New resource in District Nursing teams to proactively support Care Managed patients (those identified as being at the highest risk of admission) Expanded Integrated Rehabilitation Teams to create additional rehabilitation capacity for both discharge support and admission prevention
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3 5.4.5 Home Assessment Team roll out continues, with capacity continuing to increase in Cumbernauld and Wishaw teams. Over 600 patients have now been supported home much earlier than would normally be possible, with 60% requiring no ongoing Home Support package after 2 weeks of wrap around support. 5.5 Covid Vaccination 5.5.1 The Covid vaccination programme has been very successful in Lanarkshire, with the current position noted below, following the autumn/winter programme roll out: Total doses administered 1,835,182 Individuals with at least 1 dose 560,175 Partially vaccinated 26,294 Fully vaccinated 92,277 Boosters 441,604 5.6 Ongoing Resilience Response 5.6.1 There remains significant ongoing pressure in all health and social care systems across Scotland. High demand and patient acuity, coupled with increased flu and covid numbers in recent months has placed even greater demand on the system. 5.6.2 In Lanarkshire, there is a genuine whole-system focus to our resilience response. Following a number of requests and directives from Scottish Government, a whole system letter was issued to Caroline Lamb, Director-General Health & Social Care and Chief Executive NHS Scotland and Sally Loudon, Chief Executive, COSLA to outline the positive work underway. This letter has formed the basis of a whole- system briefing prepared by the three Chief Executives and two Chief Officers (see appendix one). 5.6.3 Further resilience updates will continue to be issued to the IJB and the IJB subcommittee until balance is restored in the system. 6. CONCLUSIONS 6.1 There has been a tremendous effort across the whole system (including third and independent sectors, communities and public partners) in response to the pandemic and more recent system pressures. 6.2 The dedication, bravery and commitment of all of our frontline staff should be commended in supporting us to continue to deliver a strong service to our residents in North Lanarkshire. 6.3 A whole-system approach has been taken to respond to the current system pressures, with key actions in response to recent Scottish Government outlined in appendix 1. 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.
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4 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT Risk IJB 09/21 sets out the impact of Covid on the roll out of the IJB’s Strategic Plan and is currently rated at very high. 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: Whole system response to system pressures ............................................................................. 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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5 Appendix 1: Summary Briefing: Lanarkshire Whole System Response to System Pressures Date: 31.01.23 Prepared by: Jann Gardner - Chief Executive, NHSL Cleland Sneddon – Chief Executive, South Lanarkshire Council Des Murray - Chief Executive, North Lanarkshire Council Soumen Sengupta – Chief Officer, South Lanarkshire Integration Joint Board Ross McGuffie – Chief Officer, North Lanarkshire Integration Joint Board 1. Purpose of briefing 1.1. To provide an update on the whole Lanarkshire response to the ongoing health and social care challenges prevalent across Scotland, particularly in respect of those actions being taken in support of pressures within University Hospitals Hairmyres, Monklands and Wishaw. 2. Background 2.1. Whole system working is a defining feature of the Lanarkshire approach to the sustained and unprecedented pressures facing our health and social care system. This is manifested by both collaborative working at operational levels, and by ongoing collaborative direction and oversight at Chief Executive and Chief Officer level. The three Chief Executives work together on, are routinely sighted on and are fully engaged in addressing the significant challenges faced by our services and staff in Lanarkshire – within our hospitals, across our community health care and social care services and amongst our partners in primary care. Both Chief Officers are Executive Directors of both NHS Lanarkshire and the respective Councils – so as well as being integral members of Corporate Management Teams also provide an essential leadership bridge for the strategic collaboration that we are committed to Lanarkshire-wide. 2.2 Our staff – with the support of our partners – continue to work diligently and tirelessly. This includes the significant contribution of our leadership teams. We are hugely appreciative of everything that they all have delivered and their continuing commitment to our communities and to the difficult work ahead. 2.3. The Lanarkshire Winter Plan 2022/23 was presented to the NHS Lanarkshire Board in October 2022 and subsequently both Integration Joint Boards (IJBs) and appropriate forums of both Councils. Additionally, briefing sessions on the challenges that our communities, our staff and our system were facing and then the mitigating actions that were being taken as part of that Winter Plan were provided for members of the NHS Lanarkshire Board, both IJBs, local elected members, MPs and MSPs. 2.4 This briefing provides a high-level summary of the range of work that our teams have been progressing and developing through the festive period to now. It incorporates continuing work in relation to the above extant Winter Plan and our wider approach to unscheduled care. The contents have formed the basis of a joint letter sent to Caroline Lamb, Director-General Health & Social Care and Chief Executive NHS Scotland and Sally Loudon, Chief Executive, COSLA.
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6 3. Plan of Action 3.1. In Lanarkshire, no hospital delay is acceptable and in general, it is recognised that hospital discharges need to increase to safely and appropriately enhance the “flow” of patients through hospitals. To support this philosophy, Discharge Without Delay (DWD) has been endorsed through all management and governance routes, acknowledging that fully embedding such a significant change programme is an ongoing process. Our commitment to DWD includes our reinforcing the importance of the Home First principles and Planned Date of Discharge (PDD) across our services. It also acknowledged that circa 95% of all patients are ‘discharged without delay’ - and accordingly, ensuring effective processes internal to the hospital setting is crucial to the management of patients whose discharge is delayed for any reason so as to appropriately and safely minimise the length of stay for all patients, the vast majority of whom who do not require packages of care or care placements and whose discharges are not classed as a “delay”. Role of Professional Leads in Response to Service Pressures 3.2 Lanarkshire has a well-established Care Home Assurance Tactical Group, whose membership includes professional leads from across health care disciplines and from social work in both HSCPs. In turn, there is a dedicated Nurse-led Care Home Liaison Team that works closely with all care homes such that they can respond as flexibly as possible - recognising statutory responsibilities – and continue to provide support to the wider system pressures across Lanarkshire. 3.3 A similar multi-professional oversight group is well-established in respect of Lanarkshire care at home services under the co-chairing of both Chief Officers. As well as ensuring consistent practice, this mechanism has seen the approval of a move to retain care packages for 72 hours for anyone with a care package who is admitted to the hospital - which contributes to both our DWD programme and ‘Operation Flow’ (described in sub-sections 13 and 14 below) to maximise discharge capability. 3.4 Both Chief Social Work Officers for South and North Lanarkshire also provide close professional oversight of “in-house” HSCP care at home and residential care services so that again, those teams can be as responsive as possible whilst recognising the statutory responsibilities associated with being registered services employing registered staff. Interim Care Home Beds 3.5 Both HSCPs have commissioned interim care home beds in seeking to reduce the number of patients who remain in hospital pending the availability of their care home of choice or the necessary care at home package to support their safe discharge home. Across both HSCPs, there are approximately 80 interim/intermediate care beds being commissioned to provide additional capacity. Both HSCPs have instigated systems to promote “flow” through these placements such that the capacity can be maximised whilst ensuring patients are not “stuck” in an inappropriate setting. 3.6 We recognise that many providers have had and continue to have reservations about providing interim placements. We have also identified that that there is frequently a reporting disparity between the headline empty beds vacancy position and the actual available for use position across the care home sector, and that is a limiting factor for providers.
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7 3.7 Both South and North Lanarkshire Councils have already introduced a short term enhanced rate at 25% supplement on National Care Home Contract rates for nursing rates in support of such placements. This enhanced rate is to cover additional costs attributable to hospital discharge placements and to ensure that care homes can respond quickly to each referral. We were happy to share our work in this regard and for the methodology adopted by both Councils to have helped shape the recently announced national approach to commissioning interim care. 3.8 More fundamentally we understand that moving into a care home is a very personal decision for a person and their family, and so appreciate the importance of supporting our staff in what can be very sensitive conversations. Recognising that there is no legal framework for social workers to compel individuals to take up an interim placement, our Care Home Assurance Tactical Group guidance was developed to support staff to apply the National Choice Guidance to Patients within wards who have had their full assessment completed; have been allocated finance; and have appropriate legal framework confirmed to support moves (noting that it should not be used to support moves of any individual who is progressing through the Adults With Incapacity pathway – see 3.9). We were very happy to share this with Scottish Government colleagues to inform the national guidance subsequently circulated. Support for Carers 3.9 Extensive support for carers has been made available throughout the year as part of the respective Strategic Commissioning Plans of both IJBs and this has been enhanced in the winter period. Primarily, direct support is provided via the Lanarkshire Carer’s Centre and respective outreach services, and this is being enhanced by dedicated carers staff who support the hospital discharge processes, working with carers to seek to ensure all possible supports are in place to ensure effective and safe discharges. This includes each individual having a named worker, dates agreed for planned discharge and identified rehabilitation input to ensure an enablement focus. In January 2023, the North Lanarkshire HSCP started the offer of up to £1000 to support families and carers to support discharge, covering costs such as additional heating/food or new items required such as a bed to support downstairs living during recovery. Adults with Incapacity 3.10 The Chief Social Work Officers for South and North Lanarkshire are both committed and engaged in the whole system efforts to the significant system pressures that are being contended with. Their advice and guidance is crucial to ensure actions taken by social workers are in accordance with their powers and duties as prescribed within the legislative framework, enabling them to preserve the human rights of the individuals requiring intervention through them. This is especially important in respect to individuals made vulnerable through mental incapacity, and we are all clear about the importance of supporting the social workers involved in discharging this delicate role. 3.11 There are a variety of reasons for delay in relation to progressing guardianship application, e.g. identification of local solicitors to carry forward private applications. We understand that this might be alleviated via Scottish Government engagement with the Law Society of Scotland to consider the means by which particular concerns regarding applications can be highlighted, to encourage promotion of services at a local level. Discussion may also usefully be undertaken
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8 with the Scottish Legal Aid Board, to consider the possibility of them expediting the process of determining applications for legal aid to support families pursuing applications in the Sheriff Court. It may also be of assistance for nationally there to be discussion with the Scottish Courts Tribunal Service in an effort to identify opportunities for the prioritisation, and expeditious processing of guardianship applications to limit any delays in securing their determination and guardian appointments. 3.12 Both HSCPs utilise best practice methodology in seeking to ensure the discharge process associated with the management of AWI patients is undertaken as timeously as possible whilst still complying with legislative requirements. There is dedicated Mental Health Officer (MHO) support for these patients. Utilisation of 13za is actively pursued when appropriate and there is weekly scrutiny of the patients’ pathways. It should also be noted that both HSCPs have undertaken publicity campaigns seeking to maximise the number of people with Power of Attorney in place such that it reduces the potential number of AWI patients in the system. Confirming Arrangements for COVID-19 testing before care home discharge and follow-up communication with services and families on seasonal respiratory infections 3.13 As described above, there is a very effective Care Home Assurance Tactical Group and associated systems in place in Lanarkshire. Through the offices of this group, up to date guidance is issued upon receipt together with offer of support to any care home where they may wish some additional assistance to understand implications of same. This includes all information in relation to testing both at time of admission and discharge. It also ensures appropriate infection control advice is available for both staff and residents such that any disruption to normal working is minimised and safety maintained. Delivering a different model of care for a short period e.g. moving to critical/life saving care only 3.14 Throughout the winter, a ‘command’ meeting structure has been in operation. This has involved a three times weekly meeting supported by three (or more) times daily position statement calls. The Command Meetings are attended by NHSL Corporate Management Teams - which include both HSCP Chief Officers - and senior clinical Acute and HSCP representatives. The daily position calls are similarly attended by senior operational representatives of all parts of the system, including local social work teams and the Scottish Ambulance Service (SAS). 3.15 During the course of December and through January, the Command Meeting has agreed prioritisation of work such that, for instance, planned elective work has on occasion been stood down and priority given to unscheduled care. Similarly, there has been prioritisation of additional trauma sessions to clear backlogs/manage increased trauma during recent inclement weather. 3.16 As part of this prioritisation, it was also agreed that community nursing in both HSCPs would be moved onto a ‘red’ pathway, thereby meaning that only essential care was undertaken and releasing some staff to undertake other work to maximise hospital discharges/avoid admission.
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9 3.17 The Command Meeting has also recognised the significant pressure on primary care and is minded that in cancelling elective care and/or standing down outpatient clinics then so this increases the pressure on primary care as the patients then re-present to their GP seeking additional assistance pending access to secondary care. As such, it is only those clinics where there is real scope for the capacity released to significantly improve unscheduled care flow that have been stood down. 3.18 Work is ongoing with Scottish Government colleagues in understanding the impact of standing down some unscheduled care and the respective recovery trajectory to get services back to the original forecast for waiting times. Opening/procuring additional capacity 3.19 The ability to open additional capacity has been limited as a result of a lack of available staffing. Even where staff have been released, this primarily has been utilised to support existing staff shortfalls in mainstream areas where they are having to manage additional beds in existing wards, e.g. through the use of a ‘fifth’ bed in four-bedded bay, using day rooms, and caring for patients in beds in ‘non- bedded areas’ in A&E whilst awaiting transfer to a ward. 3.20 All efforts have been made to secure additional capacity via external providers and the Golden Jubilee National Hospital, however this has had limited impact in practice. 3.21 In addition, both HSCPs had already invested in recruiting additional health care support staff into Integrated Care and Support Teams (South Lanarkshire HSCP) and District Nurse Teams (North Lanarkshire HSCP) to support rapid response for patients who wish to be discharged from hospital to die at home. This ‘End of Life’ Care pathway work meant that patients who would otherwise be awaiting high resource care at home packages could be discharged early and means that yet another cohort of patients who may otherwise be delayed in hospital were now being managed in their own homes. These teams work closely with specialist palliative care medical and nursing staff as well as hospices if required. Typically, these teams are routinely managing around forty people who would otherwise be in hospital. Moving Staff to Areas of Pressure 3.22 As described in sub-section 7 above, appropriate staff from a number of areas were re-directed such that they could support ‘flow’ through the system in recent weeks. 3.23 Sixty-four staff from the NHSL Vaccination Service were moved to support wider hospital pressures at end of December whilst a further twenty have been moved in the last week. This follows on from the completion of the vaccination programme which also played a key role in minimising the numbers of people who may otherwise have had to be admitted to hospital either as a result of Covid-19 or flu. 3.24 In Lanarkshire, we also recognised the likely pressure on the system in winter when starting our winter planning process in July 2022. In light of this, we offered an extended LES for our GPs whereby we were asking them if they would be prepared to open on the fourth day of the four-day Public Holiday weekends, i.e. 27th December and 3rd January. Thereafter, we also asked if they would be prepared to open on each of the remaining Saturdays in January. Accordingly,
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10 around 50% of the population of Lanarkshire have been able to access their own GP as opposed to relying on A&E, Primary Care Out of Hours or NHS24. 3.25 A key part of our Winter Plan was to have additional physiotherapy and occupational therapy presence at the ‘front door’ to assist in recognising people who could be supported to rehabilitate in their own home without the need for admission. Similarly, additional allied health professional (AHP) staff were available at weekends to support ongoing assessment for weekend admissions such that the scope to maximise discharges on the Monday was achieved. 3.26 There has also been ongoing review of AHP services to recognise where any additional input could be provided to both support discharges and through additional community input, avoid admission. It is important to acknowledge that, reasonable mitigations notwithstanding, such necessary re-prioritisation of staff have inevitable implications for other areas of service delivery and performance recovery. Increased Engagement with Third Sector providers 3.27 Both HSCPs have commissioned a range of services from the third sector which support the ability of people to remain independent in their own homes as well as specifically providing ‘non-statutory’ support to those people recently discharged from hospital such that there is early warning of any issues which may otherwise result in re-admission. Additional Funding for Care Home Beds 3.28 Independent providers of social care in Scotland have highlighted the extremely difficult operating environment. Coupled to the cost-of-living-crisis and the impact of the pandemic, vacancy pressures are a significant concern for many providers in terms of service viability. 3.29 We have also identified that there is frequently a reporting disparity between the headline empty care home beds vacancy position for providers and the actual available for use position. A local review of care home information submissions identified a variety of explanations for this, including: • Care homes operating waiting lists • Care homes reserving vacancies for planned pending admissions • New admissions available but specific eligibility criteria i.e. a religious order • Fee paying private admissions • Room being used for respite • Specific bed availability e.g. frail elderly • Redecoration of rooms • Beds closed due to outbreaks • Moratoriums 3.30 As highlighted at sub-section 3 above, both Councils have already instituted a mechanism to spot purchase interim/intermediate care beds at a short term enhanced rate at 25% supplement on National Care Home Contract rates for nursing rates. Currently, there is scope to be purchasing circa eighty such beds at any time across both HSCPs, thereby moving eighty people who would otherwise be in hospital categorised as a ‘delayed discharge’. All patients requiring supported discharge with a planned date in place and those who are delayed are reviewed on a daily basis, with an individualised approach taken to explore all
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11 options to move the patients to their end destination as quickly as possible, or using an intermediate step where required. Discharge Intervention Required - Phase One 3.31 As will be appreciated from the above, there has been a huge amount of work undertaken to support the acute care sector over recent months and the associated work to try and create additional flow through the whole system. 3.32 Up to now, there has been a concerted approach to seeking to embed DWD and maximise the concept of PDD. Linked to this is work to enhance morning and weekend discharges. This is in addition to hospital transition teams (home first/home assessment teams), and investment in discharge teams A&E departments. There is a robust organisational structure where DWD improvement projects are monitored and scrutinised through a dedicated DWD Lead and DWD steering group. This group then reports to the unscheduled care board for NHS Lanarkshire. 3.33 Notable successes have been the introduction of the Home First philosophy, introduction of PDD, development and implementation of a discharge policy. In addition, there is the development of home first/ home assessment teams which are expanding across Lanarkshire and are intended to be fully embedded by March 2023. a. Home First Home First has been adopted across Lanarkshire and the message has been reinforced recently across all staff groups. Patients and families are encouraged to return and be assessed at home from hospital on the package of care they were currently on or be assessed in a care home of their choice as an alternative to a hospital bed. The Lanarkshire DWD action plan is closely aligned to the Realistic Medicine/ Health Improvement work across Lanarkshire hospitals. This work is delivered by staff on each acute site who provide a holistic approach to care and encourage the Home First principles. b) Planned Date of Discharge (PDD) PDD has been getting phased in across Lanarkshire since 2020. The approach has allowed targeted care to be delivered, reduction in referrals for care, and a multiagency approach which includes robust assessment and care management. Lanarkshire has a DWD management information dashboard which can be drilled down to hospital, HSCP, locality and ward levels. This allows for improvements to owned at the most appropriate operational level. The current percentage of PDDs recorded on the dashboard is 54% for Lanarkshire, with work ongoing to ensure this is fully embedded and being reported accurately across the system. Referrals of those without a planned date of discharge account for a high percentage of those patients whose discharge is delayed. Conversely, 90% of the patients who have a planned date leave hospital on their PDD. DWD performance is reported monthly through the NHS Corporate Management Team, and North and South Lanarkshire HSCP Senior Management Teams. A whole system gap analysis is underway in relation to DWD and PDD to understand where to focus improvements. This analysis is being developed into a
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12 heat map for Lanarkshire. Once this is complete training and tools will be put in place to ensure continuous and sustained improvements. c) Criteria Led Discharge (CLD) Criteria led discharge is a priority development within all of the Lanarkshire hospitals under the leadership of their respective site triumvirates with a clear alignment to PDD. The risk appetite for CLD across medical and nursing teams has been a component of the gap analysis and will feature in the above heat map. We have identified and sites teams within each hospital are working towards improvement in overall, pre-noon and weekend discharges. CLD has been implemented successfully in surgical areas, supporting improvements in length of stay and work is planned to expand the methodology across other areas of the system. d) Home First/ Home Assessment Teams Our Home First (South Lanarkshire) and Home Assessment (North Lanarkshire) Teams are hospital transition teams developed by South and North Lanarkshire HSCPs respectively. They are supporting ‘discharge to assess’ through an integrated approach across social work/care, allied health professional and home care staff. These teams implement PDD once the patient is admitted into the service allowing for the mainstream home care service to plan care after a period of rehabilitation and assessment. These team have prevented patients from becoming delayed, allowed for targeted care and have subsequently better patient outcomes. We have also had some early success by deploying these teams at the front door to prevent admission. Early indications suggest that around 60% of individuals supported home in this way require no ongoing home care package after two weeks of wrap around support. We are actively expanding this provision within what continues to be an extremely challenging workforce supply environment, particularly in respect of home care. e) Discharge Support in Emergency Depts. We have established discharge facilitators who support A&E departments across our Lanarkshire hospitals. These arrangements have been strengthened through collaboration with the Lanarkshire Flow Navigation Centre who will be screening patients with social care needs overnight to allow for a rapid response by social work/ care in the morning, thus allowing for more rapid restarts of care and patients to be discharged to be assessed in a care home, should long term care be indicated. In “day” hours, a combination of senior care manager, acute care of the elderly nursing, a discharge facilitator and occupational therapy staff will provide admission avoidance and rapid discharge capability. This is currently being piloted in University Hospital Hairmyres. Outcomes will be reviewed with a view of rapidly scaling up across all of our Lanarkshire hospitals. f) Hospital at Home (H@H) There is an established H@H service which covers eight of the ten localities across Lanarkshire. The service is currently expanding into the Clydesdale locality and this should be in place by March 2023. Work is currently underway to review the whole H@H service to establish how support could also be extended to the Cambuslang/Rutherglen locality.
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13 Discharge Intervention Required – Phase Two 3.34 Notwithstanding the various areas of work set out at sub-section 12 above - all of which is recognised as requiring to continue and become embedded as ‘good practice’ in supporting hospital flow – we have recognised that there is a need for an additional concerted approach to ‘de-compress’ our three acute hospitals in particular. There is also recognition that there is an imperative to consider how best to enable a similar whole system effort to “de-compress” our community health and social care services, and to work with our colleagues in general practice to do similar within primary care. 3.35 Operation FLOW was launched on 20th January 2022. This is a rapid improvement plan that will provide a focus for the work of our teams from now into spring, its key components being: • Service improvement and recovery plans that are current being enacted as part of the Winter Plan as well as the escalated measures agreed before Christmas. • A concentrated and coordinated whole-system effort – a “firebreak” - will take place from Thursday 23 February to Friday 3 March 2023, including a weekend period, to stabilise and decompress our hospital sites. • Following this “firebreak”, we will enact further measures to sustain an improved position across the whole system as we move through late winter and early spring. 3.36 In order to be successful, we are taking steps to identify for additional capacity during the firebreak period as well as working differently and flexibly over the coming weeks. It is likely that additional shifts/hours will be offered to staff in health and social care over the nine-day firebreak period to allow the necessary focus on patient assessment, treatment and discharge. Communication will be critical to the success of the “firebreak” and we are committed to ensuring we providing our staff with the information they need to carry out local briefings and discussions with staff. 3.37 This “firebreak” should release the time and energy amongst our hospital teams in particular so that they and we better progress the other elements of our overall Operation FLOW improvement plan. Active planning continues with acute site and locality teams. Each week, as we proceed with Operation FLOW, we will publish an action plan update on the NHS Lanarkshire website, including a Q&A section to provide more detail as it is confirmed. 3.38 Operation FLOW marks a different approach to addressing the pressures we are facing, but it is crucial to recognise the vast amount effort that has been and continues to be made by our staff. Additional Developments to improve flow/ release capacity Acute Front Door Model 3.39 We know that the infrastructure of A&E and Front Door Assessment Areas are limited and overcrowding persists across all acute sites. This has a substantial impact on achieving safe patient flow and ensuring staff well-being across the Acute Sites. University Hospital Wishaw is significantly vulnerable in relation to these challenges and as a consequence a priority project is underway to increase front door assessment capacity on that site. The A&E department requires to remain fully operational whilst the works progress, so an internal decant option
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14 has been identified and preparation work is underway to support a phased approach to this development. If the internal decant option can be supported, then A&E accommodation will increase by 15 bays in total once work is completed. 3.40 We know that the front door accommodation within University Hospitals Hairmyres and Monklands are also challenged, and we also acknowledge that the work outlined above to enhance the footprint of University Hospital Wishaw is a short- term solution. Therefore, we have commissioned Healthcare Planners to: • Undertake a whole system review of emergency and urgent care across acute, primary and community services. • Develop a strategy for the delivery of emergency and urgent care for Lanarkshire to inform the development of the new NHS Lanarkshire healthcare strategy, Our Health Together. • Inform NHS Lanarkshire’s infrastructure requirements for urgent and emergency care now and into the future which will influence the details of the Health Board’s Property Strategy. 3.41 We also recognise that current systems and processes within Lanarkshire A&Es may have an impact on performance and so have undertaken a gap-analysis diagnostic across all three sites. A key finding of this analysis has been the need to standardise streaming processes across the three acute sites and determine how best to ring-fence minor flow. This work is being progressed through Operation FLOW. Urgent Community Care 24/7 3.42 Urgent care in the community is that which requires a response before the next routine care service (or appointment). The over-riding principle is “right care, in the right place, at the right time”. 3.43 We know that there is increasing demand on general practice - where it is estimated 90% of urgent care is delivered – alongside workforce and sustainability challenges across general practice. The NHS Board and both IJBs have endorsed the need to look to radically change urgent care delivery to ensure sustainable services in Lanarkshire. There is significant support for a model which brings together a number of existing services together. 3.44 The current system challenges also highlight the need to consider a way to deliver urgent care during the in-hours period. Consequently, we are progressing a whole system approach to agree how we will develop a co-ordinated, sustainable in- hours community care service. We are aiming to have an outline model for this by early Spring 2023. Expansion of Flow Navigation Centre (FNC) 3.45 We also know the importance of signposting and direction of patients in terms of “right care, in the right place, at the right time”. It is a better process if this is done prior to patients presenting to A&E or Assessment Areas - the Lanarkshire FNC has an important role in this. Work has commenced with the Scottish Ambulance Service (SAS) to implement a non-conveyancing pathway for patients with chronic obstructive pulmonary disease (COPD). We are keen to expand this approach to include other conditions such as patients with frailty or those who have a non- injury fall.
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15 3.46 Given that a Senior Clinical Decision Maker (SCDM) is not always available in the FNC. we have implemented a model where the FNC teams can seek support from a SCDM in A&E via Consultant Connect (see below). 3.47 There is social work support within the FNC which is working really well in preventing presentations or admissions to the “front doors” of each of the hospitals. We are scoping the other roles that could potentially add further value to the FNC, e.g. pharmacists and other allied health professionals. We are also learning from colleagues across the wider NHS system around the form-and- functionality of their FNCs to determine opportunities for Lanarkshire. This work will also continue via Operation FLOW. Consultant Connect 3.48 Consultant Connect is a method of professional-to-professional telehealth communication which provides an opportunity for clinicians to receive specialty guidance or advice pre-referral to specialist secondary care. We anticipate that this could reduce the number of patients presenting or being referred to A&E and Assessment Areas, with project management support allocated to co-ordinate wide-scale implementation across our system. Reprioritising routine care 3.49 We recognise that the throughout the pandemic, there has been reduced capacity to provide routine care in both primary and secondary care to routine care. This has resulted in extended outpatient and diagnostic waits and impaired management of chronic illnesses. This is contributing to dysfunction within the acute care system as patient seek alternative pathways for help with their clinical conditions, and have less well controlled comorbidities which may contribute to increased length of stay. 3.50 We are exploring a Population Health Management approach to prioritising available resource, using both primary and secondary care data and following a Triple Helix model, working closely with academic and eHealth industry partners. Interface Care 3.51 The Interface Care Programme Team from the Scottish Government utilised the data from Public Health Scotland to generate relevant analysis for Ambulatory care sensitive conditions (ACSCs) codes. This analysis provided an understanding of the high volume conditions by NHS Board, both in terms of admissions and occupied beds days; and provided details of the potential reductions on occupied beds days that Interface Care aims to achieve. Respiratory conditions, and in particular COPD, was deemed as a high priority condition for NHS Lanarkshire. 3.52 In order to support the implementation of new pathways for the conditions identified, a number of enabling services were highlighted. These services were identified for further development to support the delivery of the Interface Care Programme’s aim to deliver a 20% reduction in length of stay, and provide high quality and safe care for our target population. The two enabling services identified for NHS Lanarkshire were Outpatient Parenteral Antibiotic Therapy (OPAT) and H@H (as above). A summary of the work as part of the Lanarkshire Interface Care Programme is described below. Review of COPD services
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16 3.53 We know that many of our staff have been working differently in response to the pandemic and consequently the time is now right to re-focus our service delivery approaches and models. There are three distinct areas of focus of work underway to develop a whole system respiratory pathway: COPD prevention plan – focuses on prevention and early intervention of COPD. Proactive Care – to increase the use of telehealth for symptom monitoring and management and undertaking an audit to understand the detail of patient journeys. Admission Avoidance and Supported Discharge – focuses on the implementation of the SAS non-conveyancing pathway for COPD patients; formalising the H@H response for patients with COPD; and implementation of Consultant Connect 3.54 We have established a whole system Respiratory Speciality Improvement Group and plan to use the development of the respiratory pathway as a blueprint for pathway development across Lanarkshire; and implement and embed new models or care and new ways of working as previously described. Outpatient Parenteral Antimicrobial Therapy (OPAT) Service Extension 3.55 OPAT services can release bed capacity by avoiding the need to admit patients with infections requiring daily intravenous (IV) antibiotics who are otherwise well enough not to need to be in hospital; and identifying patients who can be discharged and therefore have a shorter length of stay once they are well enough to return home and continue their daily IV treatment at home or at clinic. 3.56 The NHS Lanarkshire OPAT Service currently delivers a Lanarkshire-wide service, based at University Hospital Monklands, integrated with a community model delivered by district nurses in the East Kilbride locality. The service has capacity for 10 active patients, with flexibility to go up to 15. Additionally, an average of two patients are treated at home through the East Kilbride locality service. The number of bed days the Service saved in 2021 was 3,567, which equates to 9.8 beds at 100% occupancy. 3.57 There is an opportunity to increase the capacity of the OPAT service to treat the additional significant demand from patients currently in hospital beds unnecessarily. Nationally collected data shows that if Bed Days Saved by the current OPAT service is calculated as a rate per 100,000 of population, NHS Lanarkshire currently has the lowest rate in Scotland. If we were able to compare with the best performing Board in Scotland, this has the potential to save 19,152 bed days a year which equates to 52.5 beds. 3.58 Following consideration of a robust business case developed by staff drawn from across our system, a recruitment process is underway to develop the University Hospital Monklands OPAT Service and then develop the community based model. The scope for optimising this is limited by the non-recurrent funding available through the Interface Care Programme, and further consideration of this nationally is needed. 4. Conclusion 4.1 This has been and continues to be the most challenging period that our health and social care services have ever experienced. We recognise the impact, the distress and the frustrations that this has for patients, service users, carers and
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17 communities right across Lanarkshire – just as is the case right across Scotland. We also understand how much we continue to ask of all staff right across our services and across our partners. We are hugely grateful for their patience, resilience and adaptability, and look forward to the continuing support of Board Members, local elected members, local MSPs and local MPs – alongside Scottish Government, COSLA and other national agencies - as we collectively progress the important work ahead.