Agenda item

Karen Fuller (Director, Adult Social Care) and Ian Bottomley (Lead Commissioner, Age Well); have been invited to present a report on the Oxfordshire Way and the support provided to people leaving hospital.

The Committee is invited to consider the report, raise any questions and AGREE any recommendations arising it may wish to make.

Karen Fuller (Director, Adult Social Care) and Ian Bottomley (Lead Commissioner, Age Well); have been invited to present a report on the Oxfordshire Way and the support provided to people leaving hospital.

The Chair highlighted that the purpose of this item was to receive an update on the support for people leaving Hospital and the Oxfordshire Way. It was emphasised that upon commissioning the paper for this item, the Committee sought an outline as to the kind of support that residents could receive upon being discharged from hospital, and to look at this in the context of the Discharge to Assess (D2A) Process and the Oxfordshire Way.

The Chair also specified that key attention should be placed on the rationale behind prioritising care at home, and any National Directives and Nationally set Targets around this; and that it was also important for the Committee to understand how effectively the D2A process was working, and how it met people’s healthcare needs.

The Lead Commissioner for Age-Well informed the Committee that Oxfordshire was on a journey to improve how the system helped people leaving hospital. Oxfordshire needed to ensure that 95% of people leaving hospital returned to their usual place of residence. Oxfordshire was focused on getting people home and had rolled out a Home First D2A to achieve this. It was more possible to move to this approach due to operational and commissioning improvements that had been made, and the Home First D2A was better for Oxfordshire’s residents.

The Committee were informed that Oxfordshire also utilised short-term bed options each winter to increase flow out of hospital and to keep A&E moving, leading to the short stay hub model. Short-term beds created a further step in the onward journey, and they needed social work, therapy and medical cover to each bed. Most of the people in those beds eventually went home (over 70% of people in short stay hub beds). Oxfordshire was required to get 95% of people directly home from hospital; however the current achievement was 91-92%. There had been an improvement to the flow home through reablement, where 78% of people were now discharged without requiring any further care. In order to get to the 95% target, there was a need to support 15-20 people from bed-based to home-based pathways. The learning from the discharge to assess pilots indicates that only 33% of people waiting in beds for long-term care actually required that care. Getting people home first was therefore in line with national policy; the right thing to do for residents in line with the Oxfordshire Way; and was now possible because of changes that had been made in the Oxfordshire system.

The Committee were also informed about the Transfer of Care Hub in the hospital; which allocated patients to the appropriate discharge pathway, anticipated and pre-empted any barriers to discharge, and promoted a discharge to assess approach.

In regards to the Home First D2A model, there had been extended reablement through national Additional Discharge Funding to extend the reablement model to include:

1.    Short-term live-in reablement care and/or

2.    Short-term waking nights to support reablement

3.    Discharge to assess pick-ups

It was also explained to the Committee that there had been increases in capacity to enable people to be supported at home including:

1.    Short-term additional support from local providers to deliver the Home First D2A model funded from Additional Discharge Funding.

2.    Increases in care hours delivered at home under the Live Well at Home framework from 27,888 to 31,095 per week from December 2022 to December 2023, an increase of 7.65%.

Additionally, the Director of Adult Social Care outlined a resident’s story which demonstrated the impact of Home First D2A. The experiences of the resident (Beth) with the D2A process had been indicative of the effectiveness of this model. It was explained that through adequate support, Beth was able to make a recovery in just 19 days and had fully regained her independent lifestyle. The Director of Adult Social Care also reiterated that it was important that the support for people leaving hospital is looked at as a system. Historically, Oxfordshire had not performed well with regards to Delayed Transfer of Care, and therefore, something had to be done differently. Oxfordshire was, in comparison to other areas, ahead of the curve in terms of the Transfer of Care Hub. The Adult Social Care Director emphasised that the Transfer of Care Hub was genuinely a multidisciplinary team, with input from Adult Social Care also.

The BOB ICB Place Director added that Oxfordshire was working well as a system, and that the NHS and the local authority should be congratulated for this. There was a commitment to continue to work toward building the Partnership between the NHS and the County Council, as well as to support people to live well independently in their homes.

In response to a query from the Committee regarding the level of public or stakeholder engagement around prioritising support for people in their homes and the decisions made in this context, the BOB ICB Place Director explained that the engagement could have been better, and that lessons will be learned from the public engagements undertaken in Wantage as part of determining the future of Wantage Community Hospital. The Director of Place outlined that the system needed to find ways of communicating with the public and stakeholders regarding some of the ensuing changes as well as some of the positive developments and activities undertaken by the system; including around the Transfer of Care team, the D2A, the Urgent Community Response, the Virtual Wards, and the Hospital at Home. All of the improvements in these aforementioned areas were enabling the system to provide better support for people in their own homes and giving people the independence that they want.

The Committee asked the following three questions in relation to the withdrawal of Short Stay Hub Beds (SSHBs) in Henley:

1.    Who was responsible for commissioning these beds?

2.    What engagement had there been around the withdrawal of these beds, and when specifically did any engagements occur?

3.    What would the potential consequences be of delaying the closure of these beds?

The Director of Adult Social Care responded that the County Council had commissioned these beds on behalf of the system. SSHBs were initially put in place in Oxfordshire at a time when the system did not have the capacity to enable flow. It was emphasised to the Committee that these were not statutorily required beds, and were established at a point in time to help with system flow. These beds had previously been flexed, particularly during the winter months when demand for these beds may had been higher. Another important consideration was how the Oxfordshire Pound was maximised to ensure that people received the best benefits. Therefore, the system would flex beds up and down as required. The Director of Adult Social Care also explained that 17 SSHBs were already closed in the North of the County, and that the flexing of SSHBs was an indication of business as usual. The Committee were informed that initially, the hub beds were commissioned by Oxford University Hospitals NHS Foundation Trust, and that this had destabilised the market. It was decided that the County Council was the best place for these beds to be commissioned as it had the best relationship with the market.

It was also reiterated to the Committee that considerations of how to best maximise the use of the Oxfordshire pound was a factor in determining the closure of the SSHBs in Henley, which had cost £11000 a week in totality to remain in place. However, the Adult Social Care Director emphasised that the withdrawal of the beds was not driven purely by financial considerations, but was also a crucial element of supporting people at home and helping them to regain independence.

The Director of Adult Social Care also explained that it is difficult to determine what people need when they were in a hospital bed. Therefore, if people were enabled to go home with the necessary wraparound care, including with Occupational Therapy, Social Workers, as well as Urgent Care at home, this would also make decisions regarding people’s long-term care needs much more effective. 

The Committee urged for there to be more effective communication with the public and key stakeholders around the broader context in which the withdrawal of SSHBs were taking place. This would allow for both a greater understanding as to why such withdrawals were occurring as well as a reassurance to residents as to the alternative services that would be provided to them in the absence of these beds.

The Committee enquired as to whether there was adequate support for people being discharged from hospital whilst they were at home within the 72 hours? It was queried as to who the assessor would be upon arriving home from hospital, and as to how soon after arriving home would the assessment take place. The Deputy Director of Adult Social Care responded that the Transfer of Care Hub, which operated in the hospital, would review all the referrals that came in when a patient was ready for discharge. As part of this process, a multidisciplinary team in the Hub would determine whether there were concerns with a patient’s home environment. If any concerns were identified, such as equipment needing to be provided or furniture needing to be moved, efforts would be made to put things in place in preparation for the patient’s return home. However, in circumstances when concerns had been identified subsequent to a patient already being discharged and arriving home,  social care teams (including Occupational Therapy, social workers, and coordinators), were able to respond very rapidly to resolve the concerns or to ensure same day equipment was provided. In cases where patients already had a relative at home who was able to help support them upon arrival, a mutual agreement may be made that the patient is discharged initially but that the domiciliary provider would arrive as soon as possible to set up the care and understand what was required.

The Committee referred to how the report referred to the importance of getting people discharged and assessed at home wherever possible, and enquired as to the extent to which the suitability of a patients home was taken into account prior to discharge. The Director of Adult Social Care explained that there may also be requirements for shower or bathroom adaptations, but that was not a significant risk in the short term, as support could be provided for discharged people to wash alternatively pending the completion of the adaptation work for instance.

The Committee emphasised that some patients who were discharged may require ongoing support in taking their medications appropriately, and queried as to whether this was being taken into account, and the measures that would be taken to provide support in this regard. It was responded that support for patients and their medications is undertaken as part of the original setup with the domiciliary provider, who are certainly experienced in being able to support people with their medication needs. The Home First team was also looking at a range of technologies that could support with medication reminders and in helping people to be able to take charge of their own recovery journey and their ongoing needs when it was appropriate to do so. However, for individuals who had a broader package of care, support with medication was incorporated into their ongoing care plan.

The Committee referred to the live well at home providers, and enquired as to how many organisations were being worked with that provided this care, how flexible they were, and whether there was an appropriate level of workforce in this area. The Lead Commissioner for Age Well responded that there was a need for flexibility in their teams, and that things were improving in that regard. A lot of work was undertaken with the providers, and that providers had been expected to be much more sophisticated in their ability to recycle the right staff. Providers had also been encouraged to think about how they organise the right people to the right space so that they could work 7 days a week. There had also been an advantage from the additional discharge funding, which had been used to fund some short-term arrangements with other providers.

The Committee enquired as to whether a hierarchy existed for the purposes of monitoring providers, particularly if something were to go wrong in the services that were supposed to be provided. It was also queried as to whether there was a clear and accessible complaints process for discharged patients to be able to access if they were not satisfied with the services they were receiving. The Deputy Director of Adult Social Care explained that it was crucial to take into account that all the relevant teams were working across the board providing many care hours every week. All providers worked to a quality assurance framework that ensured that mechanisms were in place to escalate with health professionals if there were any concerns. Having multiple teams working collaboratively provided the advantage of identifying any issues or challenges with a discharged patient early on. Work was also undertaken with providers to look at incidents and to determine whether the right escalations were made at the right time and whether the right health professional was contacted. It was also highlighted to the Committee that the Adult Social Care team were not medical professionals, although they were competent in being able to recognise the changes in an individual’s circumstances and in being able to send up the signal to relevant providers who will help them to resolve such issues. There were adult social care link workers working alongside domiciliary providers, and therefore there were a number of individuals who had eyes on a discharged person, and they could make escalations as appropriate.

The Committee queried as to whether patients who were being discharged were provided with written information or a leaflet with details on the services they would receive, and whether this included information on who to contact if they had any concerns. It was explained to the Committee that a Home First leaflet was being updated, and that there was a leaflet in development which covered all the discharge pathways and was going to be ready imminently.

The Committee enquired that given the system’s commitment to ongoing learning and evaluation, would there be considerations to take into account the outcomes and feedback of the recent Public Engagement Exercise held in Wantage around the future of the Wantage Community Hospital. The ICB Director of Place responded that the Wantage engagement exercise was discussed at the ICB’s executive management committee, and the case of Wantage was being utilised across the BOB footprint as an example.

The Committee enquired as to how effective the communication and coordination was between the NHS and Care Providers. It was explained to the Committee that system meetings were held daily, where points of escalation or concern are raised. Therefore, there were daily escalations within the system that were being heard and addressed.

The Committee queried that despite the positive factor of most people having a preference for being at home as opposed to in a bed, were there any potentially negative consequences if Oxfordshire was not meeting nationally set discharge targets, such as reductions in funding, and whether this might have been a vital context for the closure of beds. It was responded that the system had to demonstrate how effectively the money had been invested to make a difference to the residents of Oxfordshire. The case for having additional discharge funding was dependent on meeting discharge targets, and it would be difficult for Oxfordshire to argue the need for further funding if such targets were not being met. In response to a query by the Chair as to how this would influence the public or stakeholder engagements that took place, the BOB ICB Director of Place explained that at times decisions had to be made in an agile a manner as possible and that some of the system’s capacity had to be flexed in some occasions. The Director of Place also specified that the system needed to find ways to have conversations with communities in regards to some of the changes that the system would need to make. But this would require bandwidth, capacity, and immense time and effort on the part of senior officers to be able to reach out and talk to all communities. 

The Committee queried whether there were any indications to suggest that the use of D2A had actually resulted in an improvement of hospital flow within Oxfordshire. It was outlined to the Committee that the D2A process was slowing the growth in the demand for hospital services, and was also reducing delays to discharging.

The Committee enquired as to whether there was a consistent criteria that was utilised to determine which patients would be more suited to the D2A process. The Deputy Director of Adult Social Care responded that the Transfer of Care team were charged with looking at the initial referrals and making a pathway decision. The system was working hard collectively to make such discussions around a patient’s discharging arrangements as robust as possible. People working in the Transfer of Care team had access to a whole range of health and social care systems to help understand what was most appropriate for each patient.

Related to the above point, the Committee also enquired as to what would occur in the event of a patient refusing to leave hospital due to concerns regarding the care they will receive upon being discharged. The Director of Adult Social Care explained that there were processes around how to deal with such circumstances in the rare occasions when they do arise, and that there were also choice protocols across all hospitals in Oxfordshire. In such circumstances, patients would also be advised on what the consequences of them remaining in hospital may be on other patients who may urgently require hospital admission.

The Committee queried as to how long the system had tracked outcomes for people discharged home, and how long subsequent trips to hospital were observed. It was responded that the system worked collectively to track individuals who have had made frequent subsequent trips to hospital. Data was also looked at by the system to monitor if a particular individual has had regular trips to hospital subsequent to being discharged, and decisions could be made as to how to provide an alternative service to such individuals that may be more suited to their needs.

The Committee emphasised that there were existing pressures within primary care, and queried how well-resourced neighbourhood teams were in the context of such pressures, and whether there was further funding for these teams or if it was a case of joining up existing provision. The BOB ICB Director of Place specified that there was some funding that was secured for integrated neighbourhood teams. However, part of this would also include utilising resources that had already existed in the system, as well as attempts to secure further avenues of funding.

The Committee AGREED to issue the following recommendations:

1.    That a process of learning and evaluation is reviewed and developed. It is recommended that input from Healthwatch Oxfordshire and service users is also enabled inasmuch as possible so as to improve the process of learning and evaluation.

2.    For the establishment of clear KPIs for the purposes of measuring the performance of services delivered under Discharge to Assess and the Oxfordshire Way. It is recommended that there is clear transparency around this, alongside the inclusion of lived experience (including the learnings from the data in the Wantage area co-production work) and the evaluation of long-term outcomes.

3.    For communications and regular public engagement to be adopted so as to provide reassurances to the public as to the quality of the services they could expect to receive upon being discharged from hospital; and for any additional feedback from the public or stakeholders to be heard.

4.    For patients to be clearly communicated with in relation to the services they will receive upon being discharged from hospital. It is also recommended that leaflets for patients include an outline of the complaints processes in place.

5.    To ensure that staff who provide support for discharged patients at home receive adequate and ongoing training.

6.    To ensure that integrated neighbourhood teams are sufficiently resourced and geographically spread in as appropriate a way possible so as to meet demand across both rural and urban areas. It is recommended that any available resources are maximised to meet demand for support at home.

It was also AGREED that site visits would be arranged to provide the Committee with insights into how the Discharge-to-Assess process functioned in practice.