Agenda item

Purpose of the item:

1.1 To inform Surrey County Council’s Health Select Committee of the current Discharge to Assess arrangements in Surrey and to set out challenges and work underway to enable improved outcomes for people who are being discharged from hospital.

1.2 The Committee is asked to note the important part that Discharge to Assess plays as a contributor to resident/patient flow in discharge, as well as the commitment given to Discharge to Assess by Surrey Heartlands Integrated Care System.

 

HEALTHWATCH SURREY PRESENTATION

Witnesses:

Katharine Newman, Intelligence Officer Healthwatch Surrey

Key points made during the discussion:

 

1. Healthwatch Surrey provided a presentation on Discharge to Assess insights and reflections.

 

2. The Chairman asked where people could find the hospital guide for carers. The Healthwatch Surrey Intelligence Officer explained that the carers’ hospital guide could be found on the Action for Carers Surrey Website, and it was practical guide on the support carers were entitled to when the person they cared for were being discharged from hospital.

 

3. A Member raised that there did not always seem to be a continuity in communication between the hospitals and carers. The Healthwatch Surrey Intelligence Officer explained that the discharge team should be communicating with the carer and managing people’s expectations on what would be available to them.

 

4. The Executive Director for Adults Health and Wellbeing Partnerships (AW&HP) provided the committee with Surrey-related data. Based on a survey in 2022/23, 69.5% of carers felt included in discussions on discharge, against a national average of 64%. The re-launched jointly produced Surrey Carers Strategy was prioritising carers with significant co-production work to ensure that the position would be improved.

 

5. A Member asked if Healthwatch Surrey had received any feedback from the cloud telephony system in GP surgeries. The Healthwatch Surrey Intelligence Officer explained that where it was working it was working well but there were still some areas where people were having difficulty.

 

Recommendations:

1. To ensure that language used for automatic responses reflects a friendlier approach.

 

 

SURREY HEARTLANDS & SURREY COUNTY COUNCIL DISCHARGE TO ASSESS REPORT [Item 7]

Witnesses:

Mark Nuti, Cabinet Member for Health, Wellbeing and Public Health

Helen Coombes, Executive Director for Adults, Wellbeing and Health Partnerships (AW&HP)

Paul Morgan, Head of Continuing Care

Lorna Hart, ICS Development Director- Surrey Heartlands Health and Care Partnership

Gareth Howells, Director of Delivery (East Surrey Place)

Malin Farnsworth, Consultant- Surrey Downs Health & Care Partnership

Christopher Sin Chan, Frailty Consultant- Epsom and St Helier University Hospitals NHS Trust

Sue Tresman, Independent Carers Lead

 

Key points raised during the discussion:

 

1. A Member asked how Surrey Heartlands ICS had made improvements to streamlining access to care and advice for frail and elderly residents, providing more proactive and personalised care. The ICS Development Director explained that each of Surrey Heartlands ICS places had a model of care that encompassed discharge to assess, which included access to information, communication, and engagement with communities. Surrey County Council (SCC) had been forthright in bringing together information for all carers. The carers partnership forum, chaired by the Surrey Independent Carers Lead for Surrey Heartlands ICS, was bringing together carers from across Surrey Heartlands ICS and promoting their voice, and the voice of patients.

 

2. The Director of Delivery (East Surrey Place) explained that a lot of work had been completed in the past year around Surrey and Sussex Healthcare NHS Trust’s ‘let’s get you home’ campaign. This campaign would start with providing consistent information to patients and carers on what to expect during hospital stays and after. There was discrepancy in the way some information was given, such as the needs of patients not being described to the teams delivering the care, resulting in patients being missed. There was work to address this and to build on the campaign and the transfer of care hubs. The places were working across different sectors to ensure this work would be done correctly.

 

3. The Executive Director of Adults, Wellbeing and Health Partnerships (AW&HP) explained that in busier times staff were not all in the right place and the pressure increased. There had been increased involvement in daily calls in the last few months reviewing, for example, how many people would be discharged on a particular day, and who would need to be involved in this. Extra staff capacity, particularly on weekends, had been ensured by the Council, along with flexibility for staff, making it easier to contact families. In terms of operational processes, AW&HP were trying to work closely with acute colleagues. There was a monthly Chief Operating Officer call, attended by all acute hospitals, to hear the different perspectives. AW&HP had an information advice strategy until 2026, which had done effective work and needed to be refreshed post-Covid. Feedback conveyed was that there was too much information, which might need to be simplified. The carers strategy would also help address some issues. The Head of Continuing Care added that The Care Act 2014 assessments would involve people with a caring role where possible. Due to a fast-paced hospital discharge environment this had sometimes not occurred. The Discharge to Assess Task Force had found information sharing to be an issue, resulting in a workstream to ensure information was consistent, related it to where people lived and what hospitals a person would attend. The Connect to Support Surrey website had a section on preparing for leaving hospital, which was being related back to each hospital.

 

4. The ICS Development Director referred to the review completed by Healthwatch Surrey and Action for Carers for Surrey Heartlands ICS. The recommendations that came out of this were being followed up on as part of the Discharge to Assess Task Force and the carers toolkit, that was being implemented throughout NHS England. It was recognised that there were problems with communication and engagement with carers, which Surrey Heartlands ICS was striving to improve, with the good measures that were already in place to support it.

 

5. The Chairman asked what processes were in place to ensure there was effective and streamlined co-operation between different organisations, which were also within the budgets available. The Executive Director of AW&HP explained the need to be clear on the role of the Discharge to Assess Task Force to ensure there was joined-up evidence. Regarding finance, the NHS planning guidance or confirmation of the financial envelope for some elements of the better care fund was not yet visible. Both the NHS and local authorities were facing pressures on budgets but ensured its delivery under the duties of The Health and Social Care Act 2012 and The Care Act 2014. The Task Force was ensuring that available resources were used effectively, and the utilisation of blocked beds had been improved. The Head of Continuing Care explained there was a monthly finance and activity performance report which was reviewed co-operatively with healthcare colleagues as a learning tool. Finance was discussed at these meetings to ensure that the £14.4 million financial envelope would arrive at the end of the year. The main issues related to the discharge to assess time period being set at four weeks, which had resulted in overrunning. Work was being done to tackle this throughout the year. Block contracts were also an issue. The usage of them would need to be maximised, and removal action had been taken during the year to ensure there was an upward trend on the usage of block contracts, currently at 89%.

 

6. The ICS Development Director explained there was a good governance structure which supported good decision-making. Commissioners in the NHS and the local authority were working closely together, and there was a good relationship at every level. Co-operation was already in a good place.

 

7. The Director of Delivery (East Surrey Place) explained monthly meetings occurred where the activity and cost dashboard were reviewed with the local area directors for social care. There were daily and weekly calls with operational social workers to ensure that joint working was filtered down to the patient level.

 

8. A Substitute Member referred to the importance of innovation. The Executive Director of AW&HP explained that despite the work that was being done, there was more to do.

 

9. The ICS Development Director added that there was innovation going on, such as population health management, data, and risk stratification.

 

 

10. The Chairman raised a question around proactive and preventative measures that had been taken for people coping with frailty. A Surrey Downs Frailty Consultant explained that recognition and education was a big step towards a more preventive approach, by recognising frailty as a long-term health condition, and knowing there was an evidence-based treatment and intervention, such as with the Rockwood Frailty Scale. More locally, there was work with local primary care networks and multidisciplinary team meetings (MDTs), where patients living with frailty could be proactively given an assessment. This was the evidence-based treatment for frailty and was done with health and social care colleagues, voluntary services and in a neighbourhood setting where patients were known. This resulted in personalised care plans, which were centralised around what mattered most to the patient, which were shared with General Practitioners (GPs) and community teams. There could be a variety of recommendations from these assessments such as medication rationalisation and proactive social care engagement. The data showed that personalised care plans resulted in a significant reduction in the need for emergency services. There were education and self-management opportunities for those living with a lower degree of frailty to try and prevent progression.

 

11. A Member referred to Surrey Heartlands ICS and Frimley Health’s implementation of services such as Urgent Community Response, Virtual Wards, urgent care, and walk-in centres as well as proactive and preventative community models.  The Member asked what services were the most effective and why, and what actions were being taken to ensure that carers and patients were aware of all the options available. From an ICS perspective, the ICS Development Director noted there was strong joint governance in Surrey Heartlands ICS, where all evidence was appraised, evaluations were completed, and learnings were shared. There was a good governance structure at the place level and Integrated Care Boards (ICB) would also appraise all the local models and services that were put in place, which would be fed back into the ICB system governance.

 

12. The Director of Delivery (East Surrey Place) explained that the proactive care hubs, worked best, which used the Rockwood Frailty Scale, and the risk stratification tools to highlight the patients most at risk of hospitalization. There was an MDT based in general practice led by GPs, with community services and acute geriatricians. Virtual Wards had struggled to get to the desired level, due to clinical/consultant availability which was being addressed. Linking the proactive care hubs with urgent community response, community services, providers, and virtual wards together was having a significant impact on in-patient flow. There were still unprecedented demands and a significant number of patients being redirected which was being linked into the work around the development of neighbourhoods, ensuring best use of non-health-based community assets such as the voluntary sector.

 

13. The Executive Director of AW&HP acknowledged the challenges in implementing services and that local place had to be looked at, to understand what impacts for towns, villages, and some work in local place. This would be important whilst developing community support.

 

14. A Member referred to reablement needing to be better focused on. The Executive Director for AW&HP explained that reablement was effective and reasonably cheap and the satisfaction rates were high. The issues were that it was too small and lacked sufficient capacity. An ambition was to significantly increase the capacity in reablement and consider how resources could be moved around to achieve that. Reablement would reduce the cost of care packages and the amount of hospital admissions.

 

15.  A Member asked about what could be done to better support carers and if there was adequate training available to allow for the skills and empathy required in the role. The Independent Carers Lead explained that one of the difficulties in supporting carers adequately was identifying where they were. In the 2021 census, more than 100,000 people had acknowledged themselves to be carers across Surrey, but the GP patient survey indicated that it was closer to 18% or 20% of the Surrey population. There were a variety of initiatives in place across Surrey Heartlands ICS to support identifying carers, such as projects which used Better Care Funded services and carer actions groups within neighbourhoods and places helping to hear the voice of carers and allow Surrey Heartlands ICS to understand what was needed. Remembering and including carers was important to help support them, with progress being made with this at Surrey Heartlands ICS, as well as acknowledging carer’s expertise and supporting carers in various initiatives such as training and contingency planning. Voluntary sector partners were also involved through the Better Care Fund. The role of the Independent Carer Lead was a way to hear the voice of carers, such as through membership of the Health and Wellbeing Board and the Integrated Care Partnership. Other carers were also used such as Luminous, who were commissioned to give carers a voice so Surrey Heartlands ICS could understand and involve carers in the co-production of training and other services.

 

16. The Member asked what the data portrayed about re-admissions with care providers, and if there were any concerns regarding quality or resource needs. The Executive Director of AW&HP explained that Surrey had a good market of care providers, with a large percentage having good and outstanding CQC ratings. Care providers were represented by Surrey Care Association and the NHS. During the Covid experience, care providers struggled and there was still a legacy of that. The Head of Continuing Care added that there was a quality assurance team within AW&HP that monitored care providers. The readmission rate for discharge to assess was 11%, compared to a national readmission rate for older people within 28 days of 15%. There were some cases where care providers struggled to meet the needs of patients. This was due to issues around what had been communicated to the carers on what the patients’ needs were. Commissioners were aware of this and were working with providers and Trusts to ensure the needs of patients could be met.

 

17. A Member asked about the mental health support available for carers and how it was being managed in relation to NHS industrial action and the impact of Covid-19. The Executive Director of AW&HP explained the directorate was trying to lead compassionately by recognising when people were tired, when there was a need for flexibility in working hours and being visible as leaders and feeding back appreciation. The Cabinet Member for Health, Wellbeing and Public Health noted the importance of the transformation work in producing benefits for staff and improving their working environment.

 

18. The Independent Carers Lead explained that the latest census conveyed more carers were providing more hours. The voice of carers was needed to understand how carers could be supported going forward. One example of how Surrey Heartlands ICS had responded were through emergency plans provided to carers, and in the instance of such an emergency could potentially prevent hospital admissions. The Innovation Fund as part of the Better Care Fund was also in place which looked at carer and partner ideas into where there may be gaps. There were some mental health support pilots that were funded through the Innovation Fund, based on what carers had said was needed. There was a new carers partnership group which had representatives from SCC, the NHS, and carers themselves. This group would hear the outcomes of the Innovation Fund and services that supported mental health. If it was felt services were not meeting strategic requirements it could be escalated through Surrey Heartlands ICS.

 

19. The Head of Continuing Care referred to the tools offered to carers, such as the ‘looking after family or friends’ section on the Connect to Support Surrey website, Care Act assessments, and carers prescriptions.

 

20.  A Member asked about how the vetting of care providers was undertaken, ensuring that carers had the skills and training required for the role. The Executive Director of AW&HP explained that due to some changes made around visas and international recruitment, AW&HP had to undertake more activity in vetting care providers. The association of directors of adult social care worked closely with the Home Office and Department of Health and Social Care. There was an information flow that went into Southeast region association of directors of adult social care highlighting any concerns around agencies, and in turn alerting the AW&HP Directorate. A further piece of work would also be undertaken with the provider. Care providers must had undertaken several checks and sit on the Council’s Dynamic Purchasing System (DPS). To get onto the DPS, AW&HP reviewed the provider’s quality, financial sustainability, and pricing. Some of the requirements within this system are that providers must be regulated by the Care Quality Commission (CQC). AW&HP occasionally had to utilise the provider intervention protocol. Healthcare colleagues and the local authority worked closely where joint intervention was required.

 

21. The ICS Development Director explained that the NHS did not do things separately to AW&HP in terms of its commissioning. It was recognised that the Council had a strong commissioning team and a dynamic purchasing framework, which the NHS partnered in.

 

22. Regarding the NHS Anchor programme and other programmes that aimed to generate work opportunities in disadvantaged priority areas, a Member asked what actions were being taken to foster skills and recruitment in priority areas and whether adequate sources of provision were being enforced. The ICS Development Director explained that Surrey Heartlands ICS had launched The Health and Social Care Academy, which was set up jointly with the Council and rolled out an education programme in care homes and home care providers, offering 500 places in year one. There were trainee nursing associates in the social care and community settings and 41 of these places were being offered by 2025. Two team leader training qualifications, funded by Nescot College, had been rolled out. Joint bids were underway with the Council to support volunteering and the ‘working well programme’, which was helping to support people who were long-term sick back into work. On 15 March 2024 Surrey Heartlands was going to a career day, which would include 130 schools and colleges. In terms of cohorts that required engagement, there was a roll-out of in Surrey, for Surrey, by Surrey, which was offering employment to local people, helping to address a skilled workforce with the Employee Disability and Neurodivergent Advice Service. Oliver McGowan training was also mandatory to all NHS staff.

 

23. A Member suggested it would be helpful to understand what was meant by the term complex. The Executive Director of AW&HP explained that when The Care Act 2014 was established, it set a national framework for assessing eligibility, and the term complex had become more important. Since Covid, more people who had activities of daily living and personal care were seen to be struggling, but people’s home environment and interaction with the wider community seemed to be different with an increase in people that were self-neglecting, hoarding and more isolated.

 

24. A Surrey Downs Frailty Consultant explained that from a healthcare perspective the term complex was sometimes referred to people living with multi-morbidities or frailty. Frailty tended to be the term used in a clinical setting to identify a group of older people who would have the highest risk of adverse outcomes, such as disability, hospital admissions and the need for long-term care. Frailty was like a long-term health condition, and recovery for those patients could be unpredictable. Frailty would generally go unrecognised until a person went to hospital with a crisis, which could result in more significant harm.

 

25. The Chair asked how the differences across organisational boundaries were being managed and how the issues found in rural areas were being managed, compared to urban areas to ensure there was consistent experiences and outcomes for people, irrespective of where people lived. The Head of Continuing Care said the Council wanted to ensure that people’s experiences and the service offer would be broadly similar irrespective of where people lived. All places were brought together to get them to explain their discharge to assess offer and what the variation was. Aspects concerning what was going on in the hospital, whether there were criteria in place, and what information was provided to people around discharge from hospital was reviewed. Several areas of information were collected as part of the Discharge to Assess Task Force, which was being brought into action in a programme plan. As well as this, there was now a discharge co-ordinator lead in each hospital that communicate to share learning. Practical things such as a housing protocol for mental health in hospital discharge which was not being applied to general hospitals, only mental health hospitals, was being reviewed to ensure consistent approaches across the county. AW&HP had reviewed people’s experiences of living with a learning disability or Autism within a hospital setting, for example, the length of stay, and if there was a discharge to assess offer like anybody else. AW&HP would get places to map out their local services to compare, having also mapped out discharge pathways from each acute hospital to improve consistency by highlighting differences and collecting learning together in a coordinated way.

 

26. The ICS Development Director explained that The Discharge to Assess Task Force was maintaining consistency, which also enabled places get together with partners, to articulate the differences and respect that places and neighbourhoods needed to be different, effectively working together and learning from each other.

 

27. The Director of Delivery (East Surrey Place) acknowledged that the work being done around the transfer of care hubs was important. East Surrey Place had a specific challenge with 50% of the activity going to the East Surrey hospital coming from Sussex. East Surrey was working in partnership with Sussex partners around how to ensure consistency for all patients going through the Surrey and Sussex Healthcare NHS Trust locality. There were some more challenges in rural areas around accessing some services, but East Surrey Place was working closely with partners to resolve this.

 

28. In relation to the impact of the cost-of-living crisis on residents and those living with more complex needs, a Member asked what work was being undertaken in supporting community digital needs. Regarding the cost of living, the Executive Director of AW&HP explained it was important that people were reminded of the right to claim attendance allowance. In AW&HP, a lot of assisted technology was already provided, such as pendant alarms. The Council was ensuring there was access to things like broadband and ensuring that people who needed to use this would understand how to. The Council would like to increase the Technology Enabled Care (TEC), because it could support a better quality of life for people. There is work being undertaken into addressing digital inclusion, and what the impacts would be for those who were digitally excluded.

 

29. A Member asked what steps were being taken to ensure technical measures such as monitoring services, were being used in a timely manner ensuring it could be understood and accepted, particularly when dealing with ethnic minority communities, those with dementia, mental health issues or related. The ICS Development Director explained that there was some technical monitoring available in care homes such as WHZAN Blue Boxes, and monitoring for patients at home. The monitoring services came into the multidisciplinary transfer hub process, where community matrons and other clinicians reviewed the data and acted upon it accordingly.

 

30. The Director of Delivery (East Surrey Place) noted there was an aspiration to increase the amount of assisted technology and telemedicine that was used to support frail and complex patients in their homes. The WHZAN Blue Boxes, in care homes, reported vital measures such as blood pressure readings back to GPs, allowing the proactive management of patients.

 

31. A Surrey Downs Frailty Consultant explained that there was a place for technology and remote monitoring through virtual hospital provision. It could be helpful to allow patients to return home sooner and have ongoing treatment at home. Technology should be utilised in a tailored way to the patient and their circumstances while also recognising the importance of face-to-face clinical assessments which could provide more information.

 

32. The Executive Director of AW&HP explained that there had been a recent meeting with several partner organisations, such as the Surrey Minority Ethnic Forum. There was evidence that some communities were more likely to end up in crisis and not be able to access some carer support. There was a piece of work in relation to this that needed to be worked on. It was agreed to meet with the Surrey Minority Ethnic Forum again to review if the Council had the pathways accessible and were sensitive to different cultural differences, to help ensure people were getting access to services before a crisis hit and that people felt able to ask for carer support.

 

33. The Chairman suggested more needed to be done with communication, both for people/carers entering the system and for those being discharged, and to ensure there was coherent and accessible information, that also considered minority groups. The Chairman asked what was being done in this area. From an SCC perspective, the Executive Director of AW&HP explained that there was a lot of resource that sat at local place, which would be good to build on. Some community services had recently been welcomed into the council, such as local area coordinators and community link officers. There was a need to ensure that the different community services were able to provide the support at a local place. The Cabinet Member for Health, Wellbeing and Public Health added that communication and education was important and tied into the Council’s goal of prevention.

Actions:

1. The Executive Director - Adults, Wellbeing and Health Partnerships, to provide a written response on how the organisations providing care are vetted, to ensure they have the right skills in place to do their job correctly.

 

2. The ICS Development Director (Surrey Heartlands) to provide a written response on the data that was referred to, concerning the NHS Anchor programme and other programmes, which aim to generate work opportunities within disadvantaged priority areas. To also provide an update on what actions are being undertaken to foster skills and recruitment in our priority areas ensuring adequate sources of provision are in place.

 

3. The Executive Director - Adults, Wellbeing and Health Partnerships, to provide a further written response concerning the availability of Internet and Broadband technology.

Recommendations:

1. We think it would be beneficial for Adult Social Care to produce a simple information booklet and ensure it is properly distributed amongst residents.

 

2. To ensure that you are managing the demand of acute beds required and provide an update on what is being done to deal with the demand in acute capacity and the management of it.

 

3. To provide information on the vetting of care organisations, including what training is being provided for carers.
4. To provide an update on what changes are being implemented to the transformation work in response to the report from Healthwatch Surrey on Discharge to Assess processes, and of how that is that being reflected within the transformation work.