Agenda item

Karen Fuller (Director of Adult Social Care) has been invited to present a report with an update on the support for 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 (Oxfordshire County Council Director of Adult Social Care); Ansaf Azhar (Oxfordshire County Council Director of Public Health); Dan Leveson (BOB ICB Director of Place and Communities); Hannah Berry (Home First System Lead); Sally Steele (Head of Service – Hospitals); Tasmin Cater, Head of Transfer of Care [TOC] Hub); and Isabel Rockingham (Commissioning Manager Age Well - Improve and Enable); were invited to present a report with an update on the support for people leaving hospital, and to answer questions from the Committee.

The Director of Adult Social Care introduced the report on hospital discharge support, noting the collaborative approach and ongoing improvements in performance and reablement outcomes. They also mentioned the positive work done in partnership with Healthwatch.

The Commissioning Manager described that since January 2024, Oxfordshire's Home First Discharge to Assess (D2A) service had significantly improved hospital discharge performance, reducing the average length of stay and increasing patient support. Despite higher demand and funding challenges, many patients were gaining independence through reablement pathways, with more referrals from community settings. Joint health and social care training sessions were ongoing, and efforts to support unpaid carers continue through a quarterly leads group. Nationally recognised for its approach, Oxfordshire had welcomed visits from NHS England and presented on national webinars. The next goal was to reduce non-elective admissions and prevent hospitalisations with proactive community care.

The Committee expressed concerns over a five-day hospital wait after medical optimisation, pointing out that it seemed lengthy and could lead to unsuitable discharges due to delayed patient accommodation assessments. The Director of Adult Social Care responded by explaining that the five-day average included complex cases, while patients on the discharge-to-assess pathway typically returned home within 24-48 hours. This timeframe also accounted for patients moving to residential placements or dealing with housing issues.

The Director of Adult Social Care further clarified that during the 72-hour assessment delay, known home environment issues were discussed prior to discharge, and a care provider assessed the home on the day of discharge to flag any rehabilitation challenges. It was emphasised that the discharge-to-assess model employed a trusted assessor approach to collaboratively evaluate the patient's environment and support needs. Any arising issues were promptly escalated and resolved, with specific cases being addressed directly if needed.

Members also raised concerns about the difficulty in accessing information related to the Disabilities Facilities Grant and other support options for self-funding individuals. Despite multiple assessments, many patients were not informed about their entitlements or how to apply for the grant. They also criticised the leaflet's suggestion to contact a GP, considering the limited availability of GPs, and questioned whether patients and carers were involved in creating the leaflet.

The Head of Transfer of Care (TOC) Hub acknowledged the challenge of including all relevant information in the leaflet, given that it was distributed to all hospital admissions. The leaflet aimed to provide general information and direct people to other organisations for further details. The Head of Transfer of Care (TOC) Hub also mentioned that the acute trust had prioritised improving discharge quality for the upcoming year, partly based on Healthwatch feedback. Healthwatch had reviewed the leaflet and gathered feedback from patients. Various patient services and individuals involved at different stages of the discharge process were consulted to ensure the leaflet met the overall requirements. Regarding accessibility, it was mentioned that the communications team provided accessible copies of the leaflet and would check its availability in different languages.

The Committee inquired about the sustainability of funding for additional discharge services given the financial pressures, and how the system planned to manage this in the future. The Director of Adult Social Care and the Commissioning Manager explained that the success of the discharge services had increased the need for more funding in community services. They were discussing fund allocation within the system to support these services and were utilising the Better Care Fund (BCF) planning process to align different funding streams to maximise resources. They noted they did not expect an increase in BCF funding and would need to decide on the optimal use of available resources, focusing on preventing non-elective admissions to manage costs effectively. 

The Committee sought information on the equality of the rollout of services across Oxfordshire, focusing on staffing levels in urban and rural areas. The Head of Service – Hospitals explained that the rollout had been planned using demand and capacity modelling, which considered the geography and specific needs of different areas. Although they observed higher demand in the Western Vale than initially modelled, adjustments were made to staff allocation accordingly. The care provision was coordinated through collaboration with commissioners and the quality improvement team, which allowed for the engagement of additional providers as needed to ensure consistent service across the county.

The effectiveness of reablement support, its measurement, and the importance and availability of occupational therapists (OTs) and physiotherapists in supporting individuals discharged from the hospital were key topics for the Committee. The Head of Service and The Head of Transfer of Care (TOC) Hub, explained that the reablement service had significantly expanded, achieving a 75% independence rate, with an additional 15% of individuals requiring reduced long-term care post-reablement. They emphasised the significance of a therapy-led approach, converting some social work positions into OT roles to enhance support.

They noted the challenge presented by having only three physiotherapists for the entire county but addressed this by employing physiotherapists through Oxford Health NHS Foundation Trust and utilising non-registered professionals and care providers for lower-level activities. Additionally, they highlighted the integration of housing support and the involvement of district councils in the discharge process.

The Committee examined the integration of GPs into the system for identifying and supporting unpaid carers. The Director of Adult Social Care stated that this was part of Oxfordshire's broader carers strategy, which included an action plan. The plan aimed to improve the identification of carers by GPs and ensure GP systems could flag and share this information. An audit had determined how many GP surgeries provided information about carers on their websites, and ongoing efforts were being made with the GP lead on the place-based partnership to enhance this.

The recognition of carers who were not formally registered but available to assume full care responsibilities, particularly in hospital settings, was discussed. The Committee inquired about the adequacy of carers to support individuals being discharged and the impact of National Insurance increases on care providers.

The Director of Adult Social care explained that the carers' strategy included the introduction of a carers identification card, which was notably supported by Oxford University Hospitals (OUH). This card helped identify carers when they visited the hospital, ensuring appropriate measures could be taken from a community perspective if the primary carer became unwell. Additionally, during social work and community assessments, contingency plans were discussed with individuals, especially those with learning disabilities and elderly parents serving as carers.

The Director of Adult Social care and the Home First System Lead elaborated that home care provision in the community had increased by 33% since 2021, with approximately 34,000 hours of care delivered weekly in Oxfordshire.

Regarding the impact of National Insurance increases, the Director of Adult Social Care mentioned ongoing dialogues with providers to understand the consequences and potential unintended outcomes. A survey was being conducted to collect feedback from providers. Challenging discussions about financial sustainability were anticipated as part of understanding the broader implications of National Insurance changes on care provision.

Steps were discussed to investigate and understand the causes behind hospital readmissions and the measures implemented to reduce this. The Director of Adult Social Care and the Head of Service explained that reducing readmissions was a priority, focusing on providing comprehensive care for individuals with long-term conditions to prevent acute flare-ups and hospital readmissions. They utilised integrated neighbourhood teams and primary care resources to understand individual needs and baselines, noting that some individuals chose to go home despite potential risks. Data on readmissions was tracked, and patterns were analysed to identify areas for improvement, with the 72-hour assessment outcome and 90-day measure being key performance indicators.

The Director of Public Health highlighted the importance of addressing the root causes of readmissions, with integrated neighbourhood teams examining specific issues such as respiratory illnesses and optimising medication for conditions like asthma. Projects like the alcohol care teams managed alcohol-related admissions, and initiatives like "Move Together" aimed to prevent falls. The broader strategy included lifestyle services and healthy place shaping to maintain health and reduce hospital admissions.

In response to a follow-up question about the role of vaccines, the Director of Public Health emphasised the importance of vaccinations in preventing respiratory illnesses. While the Joint Committee on Vaccination and Immunisation (JCVI) evaluated the evidence for vaccines, the focus remained on encouraging eligible individuals to get vaccinated for flu and COVID-19 to reduce respiratory-related hospital admissions.

The Committee explored the role of the BCF and its role in reducing non-elective admissions. The Commissioning Manager stated that the BCF aimed to reduce non-elective admissions by improving discharge processes and system flow. It was noted that the increase in admissions was due to an ageing population with complex conditions and delayed project starts caused by recruitment issues. Additionally, the introduction of the single point of access had unexpected consequences, which would be addressed in the next planning cycle. 

The BOB ICB Director of Place and Communities emphasised the importance of avoiding unnecessary admissions. Mentioning several initiatives such as the "call before you dispatch" programme with ambulances and the development of integrated neighbourhood teams. These measures were intended to manage acute cases and prevent readmissions, thereby enhancing community care.

Officers highlighted the need for strategic planning and collaborative efforts to improve patient outcomes and system efficiency. The BCF sought to address these challenges by focusing on innovative solutions and coordinated care delivery. The goal was to create a more resilient healthcare system capable of meeting the needs of an increasingly complex patient population.

The Committee AGREED to issue the following recommendations to system partners involved in providing services to support patients leaving hospital:

1. To support data sharing across the whole system to help to understand the causes of non-elective admissions into hospital. It is recommended that there is good relationship building across the system to support this.

2. To continue to support sufficient funding and resource for integrated neighbourhood teams.

3. To take measures to ensure workforce availability to maximise support to discharged patients in both urban and rural areas across Oxfordshire.