Agenda item

County Councillor C Wyatt-Lowe and Ian MacBeath, Director of Adult Care, HCC, to provide members with presentation.

Cllr Guest introduced County Cllr C Wyatt-Lowe (Executive Member for Adult Care Services) and I MacBeath (Director of Adult Care Services). She also noted that Helen Brown (WHHT) would be able to offer a perspective on this item from the view of a Trust. 

I MacBeath introduced the report; he explained that the terms ‘delayed discharges’ referred to people in hospital that were medically fit to be discharged, but could not go home – he also said that these individuals tended to be mainly older, frail people. I MacBeath went on to explain in detail the contents of the report contained in the agenda pack (specifically points 1-6 at pg 12-13 of the agenda pack), setting out the circumstances that led to delayed discharges.

I MacBeath went on to refer to two graphs set out in pg 14 of the agenda pack. He confirmed that the purpose of these graphs was to show the Committee that delayed discharges in Herts were decreasing, albeit not as quickly as they would like. He highlighted that that NHS England had set a target for Watford hospital that no more than 24 beds of 600+ be occupied by delayed discharges, and confirmed that at the end of August, they had nearly achieved this target with only 26 beds being occupied. I MacBeath confirmed that on the day of the meeting, this figure was 36, however noted that at the end of March 2017, this figure had been 100, and so said that the situation had significantly improved.

I MacBeath went on to highlight the new monies received from the Chancellor (detail set out in full at pg 15 of the agenda pack) of £13million for Hertfordshire in 2017/2018. He confirmed that an investment of £3m in new schemes to reduced delayed discharges (set out in full at point 2–4 of pg 15 of agenda pack). I MacBeath acknowledged there were challenges with money in relation to pay rises for Home Care workers, as it would not be available in year four. Despite this, he said that Herts County had taken the decision to raise care workers wages above the minimum wage.

County Cllr C Wyatt-Lowe endorsed I MacBeath’s presentation as an accurate representation of the situation, and said that the programme of work being undertaken by health partners was fully supported by the County Council. County Cllr C Wyatt-Lowe re-iterated the comments made by I MacBeath about the pay of Home Care workers, and the resulting challenges of recruitment and retention. County Cllr C Wyatt-Lowe said that she was very proud of Herts Care Standard; she confirmed that they were one of the first local authorities to give an enhanced living wage to care workers, as well as one of the very few to pay holiday, travel and training time to care workers. This was because they recognised the value of these individuals. Both I MacBeath and County Cllr C Wyatt-Lowe confirmed that they were happy to take questions on this subject.

At the request of the Chairman, K Magson then added the perspective from HVCCG’s point of view; She confirmed that this issue was the subject of an integrated discussion between WHHT, HCC, AND HVCG. She said that a three way document had been produced between herself, I MacBeath and another stakeholder around the target for the whole of the year for the Better Care Fund, and had just been submitted for consideration. She said that all parts of the system were working together to reduce delays; she added that although they were pleased with the progress, this needed to be maintained. K Magson referred to the documents provided by HCVGG as part of their presentation (pg 6 - 8 of agenda pack), noting that this gave a breakdown of the various reasons for delayed discharges. She added that as numbers reduced, it enabled the HVCCG to identify which processes still needed to be improved. She also highlighted a number of matters that impacted on discharges that were being considered, including the flow of community beds (and how best to maximise this) as this significantly impacted on hospital beds; finally she also said that failed discharges (e.g. lack of transportation) were also being monitored to see how these could be prevented.

H Brown said that she recognised that how hard all parties had been working to improve patient journeys. She asked F Gertler to provide some more information from a hospital perspective.

F Gertler told the Committee of the efforts being undertaken to ensure that patients discharge planning was correctly actioned. This was to try and prevent and prevent the risk of becoming delayed. She said that they were using a number of tools, including SAFER, which she outlined as follows:

The SAFER patient flow bundle

S - Senior Review. All patients will have a senior review before midday by a clinician able to make

management and discharge decisions.

A – All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal recovery and assuming no unnecessary waiting.

F - Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure the first patient arrives on the ward by 10am.

E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday.

R – Review. A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (over 7 days – also known as ‘stranded patients’) with a clear ‘home first’ mind set.

F Gertler said as well as this, they were also always using Red and Green Days, which she explained was a simple approach; when any patient was waiting for something to happen, this was a Red Day, e.g. a diagnostic test that does not take place.  However, Green Days were where actions had been progressed, and steps had been taken to enable discharge. F Gertler confirmed that this was represented as a visual above a patient’s bed board.

F Gertler said that they had also commissioned HCT to provide discharge facilities; currently they were providing 60 patients with care at home, who would otherwise have been in hospital. She said that there were some issues about how subsequent social care was being provided, however the big difference was that this delay to social care took place at home, rather than in hospital.

F Gertler said that they had also implemented an aftercare project, focusing on patients who had left hospital. She said that as well as improving the patient journey, the purpose of this was also to try and prevent any unnecessary readmissions.

Cllr Guest invited the Committee to ask any questions in relation to this matter. Cllr Taylor wished to extend his thanks, on behalf of DBC, to all the Health professionals that regularly attended the Committee to provide full and frank updates on what was happening in the community. He said he was very grateful for all the support that they gave.

Cllr W Wyatt-Lowe said that despite his efforts, when looking at all the figure surrounding the Delayed Transfers of Care (DToC), he had been unable to find what is the ratio of the DToC’s to the total number of patients going through the hospital path. He said that this figure would aid much easier comparison of performance. In respect of the issues surrounding DToC’s, he thought it was essential to look at the particular areas that patients were being discharged into. He also noted there was a huge ratio of difference between DToC’s for NHS reasons, or social care reasons, in West Herts; he asked why this was.

I MacBeath began by saying that he received a report containing all the social care delays and which area the patient was due to go back to – he said that this delay tended to be where there were Home Care waiting areas. He said the highest areas were Hertsmere and St Albans; areas which he said had full employment. He noted that Home Care was easier to source in Watford and Dacorum. He confirmed to the Committee that although he had not brought this information with him, it was available to him. Cllr Guest asked I MacBeath to provide R Twidle with a copy of this information following the meeting so that it could be fowarded onto the Committee.

Action Point: I MacBeath to send R Twidle a copy of the report outlining DToC due to social care and the patient’s home area.

I MacBeath said that the percentage of patient choice was lower in Watford Hospital in comparison to L&D. He said that there were miniscule delays at the latter, which was linked to the fact that there were no recruitment issues with Home Care workers; he added that he actually bused in Home Care staff from Luton to ensure Home Care cover was provided. In additional to this, I MacBeath added that there were similar issues with Social Care at Watford Hospital in comparison to L&D.

K Magson re-iterated her invite to Cllr W Wyatt-Lowe to spend some time with HVCCG to understand how these figures are calculated.

Cllr Timmis began her questions by noting the report’s statement “Some hospitals are better than others at preventing admission to hospital altogether when people present at A&E”, and observed that this responsibility was as much for the community as the hospital; She asked the following questions (that related to point 2 – 4 of pg 12-13 of the agenda pack)

• For clarification of the term “cohort”.
• She queried the link between patients staying one night and this being deemed that they should not have been admitted; surely, she said, this decision would have been made on good medical grounds, and asked if it was right to query this.
• She also set out the issues surrounding an elderly person falling over in the home, which often resulted in them being admitted to hospital, regardless of whether it was necessary, and asked what could be done to address this.

I MacBeath clarified that the term cohort” referred to patients that may be frail or older, with long term health conditions, or other individuals that were considered vulnerable.

He also said that because social care, Home Care and NHS IT systems were not interlinked, it could be difficult to establish if the was a care package or agency in place for a patient, therefore there may be a need for the patient to stay overnight to ensure their safety. I MacBeath said that a scheme was currently being trialled in East Herts where an Occupational Therapist (OT) was attending as many ambulances that had been called out for falls as possible; The OT then stays with the individual for up to two hours to assess them throughout this time, and decide whether the individual required further care in hospital. I MacBeath said that so far, only 20% of the callouts had resulted in these individuals being conveyed to hospital. H Brown added that the clinical decision to admit was a complex one, affected by a multitude of factors, particularly if an individual was frail & elderly, coupled with the time of day.

Cllr Birnie asked for some clarification regarding the assessment and social care package; specifically why this would be completed at home, once a patient had been discharged. I MacBeath said that they were currently trialling a new process, where a patient would be assessed as fit to go home and a short term care package put place (this, he said, was often cheaper than a stay in hospital); once they were home a full assessment was then carried out. He said that this appeared to be a significantly better assessment; in terms of both how the discharged patient presented themselves, as patients tended to be much happier in their own surroundings, as well as allowing professionals to accurately assess the home. In parallel to this, a performance indicator had also been created and was being closely monitored, assessing where the patient was 3 days after the original discharge

Cllr Maddern asked for clarity of the figures contained in pg 7 of the agenda pack; she said it appeared as though some patients had been discharged without being assessed. I MacBeath apologised and said that there appeared to be an error. He confirmed that it should have stated “Assessed within 48 hours”, instead of “Assessed within 72 hours”. At the request of Cllr Maddern, K Magson then gave some greater detail surrounding the graphs in the agenda pack.

Cllr Guest said that there was currently an Overview and Scrutiny panel at County Council about delayed discharges and why they differ from East to West Herts; this was due to take place in the autumn. Cllr Guest invited I MacBeath and County Cllr C Wyatt-Lowe to the February/March meeting, to inform the Committee of the outcome of this OSC panel, as well as what had been implemented as a result.

Action Point: I MacBeath and County Cllr C Wyatt-Loweto provide Committee with Delayed Discharges update in light of County Council OSC at meeting of 7 March 2018.

In conclusion, Cllr Guest thanked all the health professionals for their contribution to the Committee, as well as their enlightening presentations.