Agenda item

Nathan Atkinson,  Ian Atkinson and Claire Smith to present

Ian Atkinson, Rotherham CCG introduced an update on progress with regard to reducing Delayed Transfer of Care (DTOC) at TRFT. As with the other workstreams discussed this was again very much a partnership approach.

NHS England defined patients as ready to transfer out of the hospital setting when:

a)           A clinical decision had been made that the patient was ready for transfer

AND

b)           A multi-disciplinary team decision had been made that the patient was ready for transfer

AND

c)            The patient was safe to discharge/transfer.

Delays in discharge could be linked to a number of different reasons; common areas of delay related to patients waiting for assessment and decision regarding Continuing Care, patients waiting for care packages to be established in the community or awaiting a care home package. 

One of the four national conditions set out in the 2017 Better Care Fund planning guidance required health and social care systems to work jointly to reduce DTOC to a level of no more than 3.5% of patients at any one time being classified as DTOC within the hospital setting (equates to an average 15 patients at any one time).

Historically Rotherham health and care community had performed well on DTOC, consistently delivering below the 3.5% target. However throughout 2017 (although comparable to many other areas of the country) TRFT had reported a more challenged position.

In terms of numbers, on average the hospital had 400 beds for patients daily.  83 people per day were discharged from Acute Care, so 3.5% meant around 10 patients being delayed and 5.5%-6% was approximately 24/25 patients classed as being delayed for discharge. 

DTOC had had a raised national profile recently and although Rotherham was not a significant outlier; it was a key performance indicator and was at the heart of three main indicators in the Improved Better Care Fund that needed to improve upon.  In response partners commissioned an external review undertaken by the Local Government Association and a peer NHS Foundation Trust. This provided an objective view of how flows of patients, assessment processes were managed and the capacity going forward. 

Flow back end of patients out of hospital and bed availability also impacted on A&E performance. Therefore the multi-agency A&E Delivery Board had agreed and was overseeing the Rotherham DTOC action plan based on the recommendations from the review. Key points that partners wanted to challenge themselves on before the onset of winter pressures were highlighted in red in the action plan.

Key issues in the improvement challenge were:-

·                    integration of the discharge teams (Health and Hospital based Social Work Team) in terms of teams going and providing support around the patient and the family to expedite care out of the hospital

·                    data and information joined up by using similar data sets e.g. for the stop/start time for the assessment process

·                    discharging patients home first when it was medically safe to do so then the full assessment

Integrated Better Care Fund (IBCF) funding would help with these issues and the winter pressures, to assist with winter capacity and winter planning, with a good amount of transformation money to work across the system. A report on the IBCF was discussed at Health and Wellbeing Board on 20th September outlining the extra initiatives. The key was bringing those people involved in discharge together in a more coherent way in what was a high pressure environment.  The intention was to bring in some jointly funded posts (TRFT and RMBC) to project manage the DTOC pathway and to look at different initiatives to improve practice.  Rotherham could also benefit from sharing the learning from colleagues in Sheffield who had really struggled with DTOC so had invested in workforce and organisational development which partners were looking to do in Rotherham.

For patients DTOC was an emotive subject and the CCG had worked with Patient Participation Groups (PPGs) who raised other issues for consideration such as patient flow in the hospital and prescribing on discharge.

Re-ablement capacity was also being looked at as if people quickly accessed rehabilitative services there were benefits in terms of people’s independence and moving through the system faster in addition to financial benefits.

The importance of the voluntary and community sector in the plan was emphasised, with £90,000 to be invested in Age UK’s really successful Back to Home pilot which was limited to a small number of wards at present.

The following issues and questions were raised by Members:-

·         Was there a time limit to get professionals together in order to move patients out more quickly and free up beds? – No target at this juncture but a commitment at multi-disciplinary team meetings to support discharge. As yet more co-ordination was needed.

·         Reasons for the spike in March? – Although overall it was still small numbers it did have a ripple effect in the hospital and following winter there had been real reduction in system pressures.

·         Information from care homes on their services and bed capacity to help people move out of hospital – The empty beds register was updated weekly.  Patient choice of care home could lead to delay if there was no current availability or not until a specific week. In terms of specialisms of care homes a range was in place, including for intermediate care, such as Lord Hardy or Davies Court and health partners also used Ackroyd House.

Rotherham had an allocation but across the system there was too much reliance on the care home bed base; the wish was to increase care at home where possible and not in residential settings. As highlighted previously a shortage of nursing beds existed in the Borough compared with over supply of residential beds which could be a potential challenge in the future.

·         Was a weekly update sufficient given the pressures last winter and with some care homes having vacancies? – The ultimate driver was to keep people at home and it was always a challenge with homes with vacancies, quality and individual preferences.  Initiatives were coming through the NHS on bed availability, with some councils having automated systems where care homes could log on and input availability.  This would be looked at as at present it was a manual system, hence weekly.

Within TRFT the award winning SEPIA interactive portal allowed staff to see the live bed base in the community and in hospital.  Within the IBCF around £100,000 had been earmarked for IT development to try to get to grips with real time information across the whole system.  This would assist with strategic planning and for staff on the ground to access to real time data facilitating discussion with individuals and families on bed/care package availability.

·         Delays due to medication not being available did not count towards the DTOC measure but could be an issue and impacted on patient experience, affecting both discharges and transfers of care.

·         How quickly was discharge planning initiated when a patient came into hospital and was it linked to an overarching view of capacity? – It was a mixed picture but moving forward on development of the discharge process there was a role for the wards to plan for discharge dates as soon as someone was admitted.  There was also a role for the Integrated Discharge Team (IDT) to expedite discharge where the patient needed more complex care, plus set legal guidelines to comply with, which were part of the process.

It was worth noting that in terms of length of stay TRFT was in the top quartile and doing well on the amount of time people spent in hospital but there were still improvements, as had been mentioned with prescribing.  An internal pharmacy resource was needed.

In terms of care homes, the focus in the TRFT had been on preventing admissions but providing more support to people transferring from hospital to a care home through the Care Home Liaison Service could be looked at.  The service had been working more on supporting people who were already there.  The IDT would also provide a more streamlined process.

Coming into winter a significant increase in influenza was anticipated which had not occurred last year but still experienced pressures so the IBCF was very important to help to address this.

·         To help reduce delays could patients be discharged with a generic prescription that could be used at any chemist rather than having to go to the hospital pharmacy? Response to follow.

Resolved:-

That the Health Select Commission note the content of the report, including Appendix 1 the Delayed Transfers of Care Action Plan.