The Overview and Scrutiny Committee will receive a joint presentation from the Integrated Care Board and the County Council on system pressures in Warwickshire.
Minutes:
The Committee received a joint presentation on system pressures in Warwickshire from Rachael Danter of the Coventry and Warwickshire Integrated Care Board (C&WICB) and Pete Sidgwick for the County Council.
The presentation covered the following areas:
Questions and comments were invited with responses provided as indicated:
· Several members recorded their thanks for the presentation.
· Councillor Holland noted the data provided on the low numbers of people awaiting care packages to be able to leave hospital, which showed this was an efficient service. The data on discharges he received as a hospital governor showed this to be a major concern for the Trust. He asked what could be done to align the figures to give a common understanding.
· Pete Sidgwick replied that operationally there was a good understanding. The challenges may relate to NHS England metric requirements around medical fitness for discharge. He had discussed the same issue with the Portfolio Holder, Councillor Bell. In broad terms the data reported by hospital trusts and the County Council were similar. Another contributor was where patients lived. Some patients at George Eliot Hospital lived in neighbouring areas and were included on social care data for Leicestershire or Coventry.
· Reference was made to the Discharge Integration Frontrunner Initiative. This sought to streamline acute hospital discharges, the ask being to discharge patients within 24 hours of when they were deemed to be medically fit to do so. This could be very challenging both from a commissioning and operational perspective and an outline was given of the many facets which needed to be considered. That said, there was always room to improve.
· Rachael Danter spoke about perceptions and what was actually required to enable patients to return safely to their place of residence. Sometimes acute services may feel the process took longer than necessary, especially when those trusts were under pressure. The frontrunner initiative provided the way forward and whilst its target was challenging, it was believed it could be achieved.
· Councillor Holland sought more information about NHS continuing care and onward treatment for people in their home, referring to recent announcements from the Secretary of State for Health and Social Care. This should assist earlier hospital discharge and an example was given for elective surgery procedures which may only require patients to be in hospital for a single day. He asked if there were perceived problems with delivering such care at home for both the NHS and Social Care.
· In response, Officers advised this was known as ‘virtual wards’ with continued treatment in the home. Social Care was precluded from providing healthcare. However, when it came to delivery there would likely be a partnership approach, given the links between WCC and the provider market. The financial support aspects of continuing healthcare were explained. There were ongoing discussions about virtual wards across the local system.
· Councillor Matecki asked if there was a real understanding of the root causes of system pressures and whether the actions being taken were an immediate response, or permanent corrective actions. He asked if the approach taken would lead to future capacity challenges.
· Rachael Danter provided context on the pressures faced every year and those experienced for the last two winters, mentioning flu rates, respiratory issues and Covid. The local system looked at the baseline issues it faced, approaching them in partnership and made best use of any additional funding allocations. It reviewed what was working well. Then for unusual issues or where extremes were identified, short term measures were used, based on previous experience. Services ‘looked back’ post winter to take learning for the future. In effect it was a hybrid model.
· Pete Sidgwick added that today’s presentation had included how to assist discharge, and a future aspect would be avoiding unnecessary admission to hospital and managing hospital throughput. This was a complex and national issue more about how people used the NHS. The approach was to make the supported discharge as effective as possible, helping people to return to their residence with as much independence as possible.
· Rachael Danter confirmed the commitment to the preventative agenda, referring to the Integrated Care Partnership Strategy, improving population health and wellbeing, also addressing health inequalities. This was a longer-term aspect.
· It was questioned if the NHS used external consultants to identify potential solutions. Such consultants were used where feasible, whilst being mindful of the costs to public funds. The frontrunner work was an example where some consultant support had been used, but much of this process had been undertaken internally. The expertise rested with the clinicians and practitioners who needed the space and environment to focus on such projects. Data and benchmarking to others were also used.
· Councillor Drew congratulated officers for the achievements made on providing domiciliary care packages efficiently. She referred to graphs in the presentation on the reductions in hospital stay data, asking if there were lessons that could be learned from the data for these periods to assist, either now or in the future.
· Rachael Danter responded that the graph corresponded to a spike in the Covid pandemic where hospitals reduced admissions and sought to get people out of hospital as soon as possible. There had been a lot of learning from the pandemic and examples were given around stepping down non-critical services when the system was under significant pressure. Where possible the way care was delivered would not revert to that pre-pandemic. At the same time restoring services and increasing public confidence in the NHS were important. Councillor Drew clarified that her question was more about lessons learned for discharge processes. Pete Sidgwick added that at the time referred to, there were less people in hospital, which in turn assisted the discharge process. This was coupled with the pandemic providing even more impetus to get people out of hospital.
· Councillor Drew questioned the 0% data on people being discharged to nursing or residential care. Pete Sidgwick clarified that this concerned pathway three, which was NHS led and for cases involving continuing healthcare. The majority of social care cases were under pathways one and two, for which data was provided.
· On discharge to assess, Councillor Drew sought more information about how the beds were commissioned and whether this may cause the beds to be under-utilised or lead to hospital discharge delays if there was not sufficient capacity. These beds were ‘block’ purchased, with periodic assessment of the numbers required in each location. If they were ‘spot’ purchased there may be a shortage of capacity at times. There were measures to utilise these beds efficiently but were times when some beds were empty.
· Councillor Drew sought clarity on the term ‘people living independently’ as this may be doing so with or without support. This was confirmed and people discharged under pathway one may require ongoing support. After a period of time, if ongoing support was required, the Care Act Team became involved.
· Councillor O’Donnell spoke from personal experience of the significant improvements made in the discharge pathways. The process had been smooth, removing stress for the family and enabling them to plan for the discharge. It showed the joined-up approach between teams. The family member was now being supported at home and the difference in the service was phenomenal. She gave thanks for these improvements, recalling the frustrations experienced previously. There was also recognition of the improvements in care in hospital. An area for further improvement was patient information transfer to the ambulance service supporting the patient to travel home, in this case about mobility issues. Officers were asked to pass on these thanks to the staff.
· Chris Bain explained that Healthwatch looked at the pressures on patients and carers. Feedback over the last couple of years showed a decline in trust and confidence in the system. Patients were presenting later and with more complex conditions, with more anxiety, frustration and some anger being seen by HWW staff. Such studies showed where capacity met demand, and where perception met expectation. There was known misunderstanding and frustration. HWW received feedback about GP access, and the services being better at some practices than others. There were delays in assessment, diagnostic services and treatment. Further points about access to mental health services, dentistry, and pharmacy. These had not been reflected in the system pressures despite the known staffing challenges in these areas. Over the last five years, HWW had asked people about what would make things better. Chris quoted four key areas raised:
o Remove assumptions and bias about the patient.
o Communication and good administration – do what you say you will and at that time; communicate what I can expect – this will improve trust and confidence.
o Create a safe space for those who are anxious, concerned, lonely or isolated. A safe space and trusted relationship will transform the patient’s experience.
o Simple acts of kindness – the actions of one person could change significantly the views of a patient.
· In summary, there was a need to think from a patient perspective. The Chair agreed the patient / person was key.
· Rachael Danter was aware of these points and HWW’s input of the patient view was valuable, an example being on the new ICP Strategy.
· Councillor Humphreys referred to the challenges for patients with dementia. When the pandemic restrictions were in place, many nurses had a lack of awareness of the dementia protocol. This enabled dementia patients to be accompanied so they had support, for example with food and hydration. Refusing such access caused stress for the family member/carer providing the support, as well as impacting on the patient’s condition. It was important to cascade information about the dementia protocol. The point was acknowledged and would be taken back. Officers reminded of the challenges from the pandemic, the constant changes in guidance and the impact for the staff delivering the care.
· Councillor Humphreys stated the need for a facility in the north of the County to provide bedded rehabilitation services. She spoke of the closure of the former premises at Bramcote and sought a breakdown of the costs of sending patients out of county for rehabilitation. Previously there had been such provision within Warwickshire to provide step-up/step-down care and it should be reinstated.
· Pete Sidgwick responded, being mindful of the questions Councillor Humphreys had submitted ahead of the meeting. There was a known challenge in capacity for community services and it was hard to recruit to people in some areas of Warwickshire. This meant that staff had to move around.
· In terms of step-down care Rachael Danter noted the points, which would be taken back. The aim was to get people home not require more beds. A capacity and demand exercise was being undertaken. This was linked to a change in approach to get people home and with the support they needed to enable them to be as independent as possible.
· The Chair reiterated that there were no rehabilitation beds in the north of Warwickshire. She made a comparison to the current services provided in the south, the review of those services and the previous request that this review be undertaken county-wide to give a ‘One Warwickshire’ approach.
· Councillor Bell sought more information about the respiratory hubs. These were provided in partnership between primary and secondary care as a ‘virtual’ ward. For patients with respiratory issues, it looked at the support required in the acute phase of treatment and the treatment afterwards at home or to avoid the need for readmission to hospital. Rachael Danter outlined the clinical support arrangements in place, the referral pathways and the extensive use of the service, which had now been in place since the second wave of Covid. An offer was made to provide further information on the locations and usage numbers.
· Councillor Bell sought clarity on the difference between NHS and local authority discharges from hospital. Pete Sidgwick explained that currently, a supported discharge from hospital was provided for all, irrespective of whether this was from health or social care. Previously the challenge was around people paying for or contributing to their support costs. There was additional one-off funding which met these costs. Technically all hospital discharges were currently health led, but some were facilitated by social care staff. He gave an example to demonstrate this, spoke of the multiple pathways involved currently from a practitioner perspective and how this would be a single pathway under the frontrunner initiative. At a future date when people transferred back to social care support, an assessment of need and contribution costs would take place. Related points discussed were discharge numbers, the national guidance on discharges, the discharge to assess pathway and the administration of this health pathway by the local authority.
· A discussion about contributions to social care costs. Pete Sidgwick explained that staff held conversations with service users to explain the requirements. Those with capacity may elect not to receive the care. As context the contributions towards care costs in Warwickshire amounted to £52m per year.
· The Chair picked up the earlier points about soft skills to interact with patients with courtesy and respect. Managing patient expectations was also important. She spoke about infrastructure too and the challenges in providing services such as domiciliary care if the travel route was congested as it impeded effective service delivery.
· Pete Sidgwick reflected on the points from Chris Bain and the value in hearing lived experiences. On the points about making things better and the four areas identified, he spoke of the Council’s team principles which did cover these areas. As an organisation the Council could seek to influence colleagues in the local NHS too. He agreed that patient perceptions were often based on experiences and contact with front facing staff such as porters.
Resolved
That the Committee notes the presentation.