Agenda item

Collaborative presentation between WHHT, HVCCG and HCC

The Chair advised that delayed transfers of care is the term that the health world use these days for what the media call bed blocking.  I personally think bed blocking is an unfortunate term because it’s not the poor patient’s choice or fault they’re stuck in hospital. It’s because there’s things happening preventing them going home when they’re fit to.  The chair asked HBrown to say where West Herts Hospitals Trust is at from the health world’s point of view?

HBrown advised that EGlasser is looking at the information that Ian circulated, the Herts County Council overview, HBrown added that she herself is not an expert in delayed discharge, and says that particularly because the devil is in the detail and the rules are quite esoteric and complicated about how people get counted, so unless you’re really immersed in it, it’s easy to lose track.  Patients’ journeys through hospitals vary and actually it is a relatively small number of patients who need formal ongoing care following discharge, either from social care or from health.  Delayed discharges generally relate to patients who require an ongoing package of care, either health or social care but they are only counted after a particular number of days and after a particular number of steps and processes have been triggered, so they only present a small bit of the picture.

HBrown referred to and guided Members through data in an information provided in a pack she has put together.

The Chair thanked HBrown and firstly extended a welcome to Committee to Cllr Howard, advising that as she is attending as a non-member of the Committee, she will not be able to take part in any votes, but advised she is more than welcome to ask questions.

The Chair continued that, as has already been mentioned, there is a disparity of delayed transfers between East and North Herts, The Lister Hospital in Stevenage and the West Herts Hospitals Trust in Watford.  Basically there’s a far lower percentage of delayed discharges at The Lister than there are at Watford and the County Council’s Health Scrutiny Committee is going to be having a topic group that’s going to be looking at the reasons for that in April or May this year.  County is carrying out scrutiny on it.

KMinierasked if it was possible to see wards sometimes open up at Hemel to take up some of the excess, to alleviate some of the problems at Watford to actually have these people that are delayed for whatever reason, as long as it’s not a clinical reason.

HBrown responded that Herts Community Trust have got two wards at Hemel that provide post-acute care.  We would love to, HCT increase the number of beds that they were able to provide, the funding wasn’t available so if David was here, I’d be looking at David, but the CCG wasn’t able to make funding available to enable the Community Trust to do that.  From our point of view our biggest challenge currently is workforce, so we are really stretched from a nursing and medical workforce point of view and now it’s easier for us to staff additional beds on the Watford site because we can share staff in between wards that can cross cover, we can manage on the night, so if three nurses don’t turn up on Croxley Ward and they do on Langley Ward, we can cross cover.  It is much, much more difficult to do that with remote sites.  Over, this winter we have converted two wards at St Albans that are surgical wards.  We’ve converted one of those to be medically fit for discharge wards so patients that are ready to go home from a medical point of view but neither the Community Trust nor anybody else is able to take them, so we are running some of those beds at St Albans and the reason we decided to do it at St Albans not at Hemel is because we’ve got an established presence there at the moment in surgical wards but also we’ve converted them from surgery to medicine so we’ve got a staff group who already work at St Albans and are established to cover those patients.  We talked about it but we just didn’t think we could staff it safely.

KMinier sought clarification, asking, so if I’m right, what you’re saying there is basically because they won’t fund somebody to do it, you are having to stretch all your resources to cover it?

HBrown confirmed that’s the Hospital’s perspective, I don’t want to get too detailed, It’s a system challenge so we are under an enormous amount of pressure and I don’t want to drown you in the detail of how we get paid but under payment by results, we get a payment for every person who attends A & E and every person who gets admitted and that is partly determined by the case and its complexities so there’s all coding that says how much you get paid but there is something called the emergency admissions threshold which was set a long time ago which means for any admissions over a set number you only get paid a third of the tariff price, so obviously we’ve got a large financial deficit so actually we lose money on every patient anyway.  It’s very financially challenging because we don’t get the income to cover the cost of the number of patients that we admit and we particularly don’t get the income when the length of stay is longer.  As I was just saying, that’s not all about other people.  Some of that’s about us and our own processes and some of it’s about the difficulty there is in arranging onward care for patients who need something following hospital.  I think the general challenges, the more beds you open, actually, sometimes the worse the system operates

Cllr Maddern commented about the differences between here and The Lister, and the fact that it is a so much bigger problem here.  Looking at a map of Hertfordshire, this has got to be more of a problem than Watford and I just wonder how it’s improved.  We’re so close to the boundary, to the border with the London Borough of Hillingdon and with Buckinghamshire County Council, and when I did the topic group before, there was a very clear issue between dialogue between the hospital staff (this wasn’t criticism of the hospital, this was criticism of the social care in the other two areas), where they weren’t communicating properly with each other and people were sitting in beds in Watford hospital because Buckinghamshire County Council couldn’t get their act together and get their home care sorted out when they got home. 

HB confirmed that potentially with patients who are out of area, sometimes it can take longer to resolve their problems.  Actually, we’ve changed the way we operate to a degree in that firstly we have some people who come from outside Herts Valley to Watford and it is appropriate because we are the nearest hospital, so we have a small number of patients that we discharge back out to North London, actually historically, and I hate to say this but I haven’t got County Council colleagues here to put their side to the story, but historically Hertfordshire has had a reputation for having long delays.  I think it will be interesting what the Scrutiny review manages to determine as it works through this.  It’s quite complicated but I don’t think that’s the issue.

Cllr Hicks asked, if you had the sixteen step down beds that were in Berkhamsted, how would that have affected the bed blocking issues in Watford?

HBrown responded that the issue is how many patients would have been treated there, so if it had been sixteen patients admitted and every two weeks and then you admitted another sixteen patients, it might potentially have had a reasonable impact.  If it’s one lot of sixteen patients that get admitted and then because it’s a small site, remote, not the top of anybody’s list then the length of stay go out, it makes relatively little impact.  In the end it comes back to the workforce argument.  Small, sixteen bedded units are incredibly difficult to staff.  Just really, really difficult to staff, so you need to have a minimum of two qualified nurses, two unqualified nurses and on one night one of them doesn’t show up, that’s it, they’re unwell, you’re unsafe, it’s just the critical mass issue.

KMinier referred to his nursing associates and asked, how do you think that’s going to help Watford deal with all its issues and are we going to get them?

HBrown responded it is probably best that she draw a line here because she does not  work for HVCCG so I’ll better not update for them.

HBrown continued by offering David’s apologies, he’s very sorry, he does normally come and he just didn’t have it in his diary.

The Chair thanked HBrown for her contribution and advised that the meeting would now return to Item 5 of the agenda, the Action Points, a lot of which have now been addressed anyway.