Agenda item

To consider a report by the Principal Manager (copy attached) to provide information about partnership arrangements within community health and social care services to monitor and address delays in arranging transfer of care, in particular from hospital.

9.40 a.m. – 10.15 a.m.

 

The Chair welcomed the Lead Member for Social Care, Adult and Children’s Services, Councillor Bobby Feeley, Phil Gilroy, Head of Community Support Services, Cathy Curtis-Nelson, Principal Manager, Operational Services and Alison Kemp, Assistant Area Director of Community Services – Central (Betsi Cadwaladr University Health Board) to the meeting

 

The Lead Member for Social Care, Adult and Children’s Services, introduced the report (previously circulated) to provide information to Members regarding partnership arrangements within community health and social care services to monitor and address delays in arranging transfer of care, in particular from hospital.

 

The Lead Member advised that delayed transfer of care (DTOC) was a subject that had received extensive media coverage for some time and was a complex, multi-agency issue.  In a bid to find a sustainable solution to one of the factors that contributed to this problem representatives from Denbighshire and Conwy Councils together with Betsi Cadwaladr University Health Board had held a three day summit in December, to which independent care providers had been invited, to scope out the extent of the problems which health and social care services were likely to face going forward.  Each individual authority would need to devise sustainable solutions to some of the pressures identified, other solutions would require two or more partner organisations to work together to resolve.  The Head of Community Support Services  advised that pressures identified at the summit included:

·       A shortage of nursing home beds and domiciliary carers in certain geographical areas;

·       A shortage of care providers who could provide complex care packages e.g. ‘double-handed’ care, particularly in the south of Denbighshire;

·       A lack of trained nurses to work in a health care setting;

·       A shortage of people who wanted to work in care services

 

The outcomes of the above event were due to be reported to all North Wales Chief Executives in due course.  It was evident that a multi-faceted approach would be required in order to deliver sustainable solutions and the Welsh Government (WG) required to resolve the issue of cost sharing for health and social care services.  The Locality Teams already included cluster teams within hospitals which worked intensively with patients with less complex needs, to aid their recovery and safe discharge from hospital.

 

Betsi Cadwaladr University Health Board’s (BCUHB) Assistant Area Director of Community Services – Central advised that:

·       The development of Extra-Care housing facilities would help ease pressures;

·       recruitment in all sectors of health and social care had, and continued, to be a problem;

·       There was a need to better manage people’s expectations and consequently improve outcomes for individuals;

·       As people now lived longer there was a need to have adequate support to help them live independently for longer, as this improved their quality of life.  To facilitate this, health and social care services required to work far better with the independent sector to commission support services from them;

·       From April 2018 Health and Social Care Services would be required to pool care budgets.  For this to work effectively and efficiently to improve outcomes for the individual, it would require the local authority and the Health Service to adopt a robust cohesive strategic approach;

·       The ‘What Matters’ conversation approach would be key to delivering health and social care services in future.  There also needed to be a cultural change in the approach taken by health and social care staff to move away from delivering ‘dependency’ services to delivering services that promote and support the individual’s independence.  It was acknowledged that this was difficult as both health and social care workers were instinctively ‘carers’ and therefore wanted to care for the service-user.

 

Responding to members’ questions the Lead Member, Local Authority and Health Board officers informed the Committee:

·       That the number of training places for nursing students had been increased in recent years in order to address the shortage of trained nurses across the country.  However, there was some concern at present that the NHS nursing bursary reform, due to come into force on 1 August 2017, could have an adverse effect on the potential number of people applying for nursing courses in the future;

·       An equivalent qualification to the former State Enrolled Nurse (SEN) qualification was due to be introduced, known as Assistant Practitioners.  It was anticipated that this would help ease pressures in the Health Service in due course;

·       That the Health Board was currently examining re-admissions to hospital to establish whether any patterns or trends were emerging i.e. had patients been discharged home too soon, or without adequate care and support packages etc.;

·       That it was widely acknowledged lengthy hospital stays were not always conducive with improving outcomes, as there were risks associated with being  a hospital in-patient i.e. disorientation, falls, infections etc.;

·       Staff shortages within the health and social care sectors was a complex issue.  Despite the introduction of the national living wage, more agency staff were being hired to cover shortages.  In an attempt to attract younger people into the sector, develop career pathways, and ensure that the public sector did not ‘poach’ staff from the independent sector or vice-versa etc., a regional workforce development programme had been established to address all aspects of staff shortages.  The programme would also look at developing training and preventative services as well as working with HR to develop an attractive recruitment campaign;

·       that both Health and the Council employed Occupational Therapists and confirmed that their terms and conditions would be in accordance with their employer’s terms of employment;

·       that both Health and Social Services used a number of IT systems,  which were not compatible with each other.  Nevertheless, staff working in the Single Point of Access Service (SPoA) had access to all systems required to deliver a seamless service.  SPoA also had its own overarching IT system on which all enquiries were registered and relevant Health and Social Care information was recorded;

·       that it was encouraging that in Denbighshire the DTOC numbers were reducing.  There were a number of reasons for this, including step-down services and the work facilitated by SPoA.  It was vital, therefore, that the funding for SPoA was secured for the future;

·       the availability of assistive equipment and adaptations to the service-user’s home were also key considerations when discharging people from hospital to a safe home environment.  Generally, required equipment was readily available, unless more complex equipment was needed.  Care and Repair undertook home adaptations, these were undertaken promptly in the majority of cases, however if more complex adaptations were required every effort would be made to put temporary measures in place to aid timely and safe discharge;

·       ‘pressure mattresses’ were the responsibility of the Health Board to provide for individuals who required them.  However, Health and Social Services worked together in relation to supplying and issuing these mattresses;

·       Care packages were now designed and commissioned based on ‘What Matters’  to each individual, whilst the period for their delivery was based on each service-user’s needs;

·       That the Council had robust contract monitoring arrangements in place to manage and monitor all contracts it had with outside providers from whom it commissioned care services.  In April of 2017 all domiciliary care packages were due to be subject of a new tendering exercise.  Due to the pressures placed on the independent sector from directives such as the national living wage etc., the Council had increased its budget for commissioned care services by 5% to accommodate these pressures.  It was estimated that the local authority would be spending an additional £1.5m this year on services commissioned from independent care providers.  Work was currently underway with independent care providers across North Wales in a bid to develop services that would improve outcomes for individual services users;

·       A liaison nurse was employed within each hospital.  They would meet on a weekly basis to discuss DTOC and report back to the relevant authorities;

·       That BCUHB had procured a community information system which would eventually replace PARIS and Health IT systems over a three year period.  The Health Service already possessed a system which alerted Community Nurses when a patient had been admitted to hospital. The local authority’s contract for the PARIS system was in place until 2019.  To date it had not committed itself to the CSSI Patient Documentation System, it would be keeping a watching brief on its development and implementation, prior to deciding which system to procure for the future;

·       That work was already underway in relation to the creation of ‘pooled-budgets’;

·       That work was also currently underway on how the Health Board could best utilise the skills of all staff and maximise its use of those skills;

·       That across Conwy and Denbighshire (including Holywell Community Hospital) BCUHB had 228 community beds, all of which were used to maximum capacity;

·       That the Health Board was currently considering how to develop the ‘hospital at home’ approach across the region with a view to keeping people as hospital in-patients for as short a period of time as necessary.  Patient safety would be paramount and the Board was aware that there would be obstacles to overcome during the development of this concept, not least in relation to family tensions and anxieties in relation to very short term hospital stays;

·       That a regional Health and Social Care Partnership Board had been established in a bid to develop pooled budgets, compatible policies and practices, and cohesive working practices etc.  The Board’s work to date indicated that there did not seem to be any benefits for one local authority to be working on the ground in other county areas and that regional working did not always lead to a reduction in costs.  It would depend on the type of service provided;

·       That both Health and Local Authority officials were well aware of the fact that moving a resident out of their ‘own’ community area to another area for the purpose of receiving the necessary care had the potential to have an adverse effect on an individual’s health and well-being;

·       That no actual figures were available for ‘untimely discharges’, neither was there a clear definition available for the term ‘untimely discharge’.  However, it was felt that wider availability of prevention services could potentially reduce the number of people who presented themselves to Accident and Emergency (A&E) departments i.e. patients who could have utilised community services.  A study had recently been undertaken to identify patterns or trends in relation to patients presenting themselves to A&E.  There was also a need to develop support for end of life care at home rather than admitting people into hospital for their final days;

·       That although DTOC were reducing, where there was a delay, there was a valid reason behind it.  It was usually due to a shortage of community beds at a particular time in a community hospital or due to the shortage of nursing care beds available in the independent sector.  As the majority of independent nursing homes in North Wales were small family run businesses, with very few large company group providers operating in the region, there was very little resilience in the sector if one or more homes closed;

·       The long-term goal of providing more Extra Care facilities across the county should ease pressures on the Health Service two-fold, through the delivery of prevention services to avoid unnecessary hospital admissions and through the provision of care/nursing services at the Extra Care establishment which would aid timely discharges from hospitals;

·       That the outcomes for individual service-users in future would be covered by a suite of Performance Indicators (PIs) all of which would have to conform with the well-being goals of the Well-being of Future Generations (Wales) Act 2015;

·       That information on outcomes for individual patient/service-users were shared between Health and Social Services.  The Reablement Service had comprehensive records on the outcomes for users of its services;

·       that there was a team based within A&E Departments that assessed patients on admission on the care they presently received to enable that information to be recorded to inform the Discharge Team to aid their planning of what would be required when the patient would be ready to return home;

·       that clear communication by all services and individuals involved with the patient/service user was key if services were to be effective.

 

At the conclusion of the discussion the Lead Member emphasised that every individual had a responsibility for their own health and that the health and social care services where there to be used at a time of need.

 

The Chair thanked everyone, including the members of the public in attendance, for contributing to the discussion and debate, and the Committee:

 

Resolved subject to the above observations:

 

(i)              to receive the report and request that a progress report be submitted to it in the autumn of 2017 on ‘Timely Hospital Discharges’; and

(ii)             that a report be submitted for its consideration at its April 2017 meeting on the ‘Development of Health and Social Care Pooled Budgets’.