Agenda item

The Health & Social Care Sub-Committee is presented with a report on the Discharge Integration Frontrunner programme, which aims to bring together transformation efforts from across Croydon to develop an effective, integrated system across hospital, social and community care.

The Sub-Committee is recommended to:

1.            Note the strategic direction on the Integrated Discharge Frontrunner programme.

2.            Comment on the highlighted risks and challenges from the presentation; identifying topics the Committee wish future reports to focus on.

The Sub-Committee considered a report set out on pages 13 to 40 of the agenda which provided an overview of the Discharge Integration Frontrunner programme. The aim of the programme was to transform the delivery of the hospital discharge process by bringing together partners from across Croydon to deliver an effective, integrated system across hospital, social and community care. The report had been included on the agenda to update the Sub-Committee on the strategic direction of the programme and to provide the opportunity to comment on the potential risks and challenges.

The Chief Executive of the Croydon Health Service NHS Trust (CHS) and Croydon’s Place Based Leader for Health, Matthew Kershaw, the Council’s Corporate Director for Adult Social Care & Health, Annette McPartland, Rachel Flowers, Director of Public Health and the Programme Manager for One Croydon, Laura Jenner attended the meeting for this item, to introduce the report and answer questions arising.

During the introduction, it was noted that Croydon had been selected as one of only six pilot sites across the UK for the Integrated Discharge Frontrunner programme. Participating in the pilot programme provided the opportunity for health and social care partners to build upon the existing integration in the borough delivered through the One Croydon Alliance. The pilot would allow different options to be tested across the system, with the aim of improving the discharge process.

The starting point for the process was a deep dive across services to gather as much data as possible on the whole system, in order to identify the key pressure points. The data confirmed that the delays within the hospital discharge process had increased since the pandemic and although there was existing integration between teams, this could be improved. For instance, several areas of duplication had been identified, which through smarter working would deliver a better, more efficient service.

After the data gathering and analysis process, a series of workshops were arranged, with over 200 participants from across the health, social care and voluntary sectors to shape the plan going forward. It was highlighted that the voluntary sector would be a key partner in the delivery of the programme to improve hospital discharge. Healthwatch Croydon had been engaged to gather feedback from residents on their experience of the hospital discharge process, which would also be used to inform the delivery of the programme.

Following the introduction of the report, the Sub-Committee had the opportunity to ask questions on the information provided. The first question highlighted the importance of staff being able to access a patient’s medical history and questioned whether the current system was able to provide sufficient access to data sharing. It was acknowledged that the system was not as good as it should be and part of the programme would be looking at the integration of IT systems to ensure there was an improved flow of data. This workstream would also look to reduce the amount of manual data entry required and the number of times patients were asked the same questions. In response to a follow-up question, it was confirmed that access to patient data held by GPs was limited due to patient confidentiality requirements.

It was confirmed that the diagnostic and data gathering process had been completed, which had resulted in the identification of a model of care the partners wanted to implement and the creation of workstreams to deliver this model. The next milestone was to have this model set up within the hospital and across the borough by October 2023. It was highlighted that this deadline was ambitious, but it had been concluded that the system should be in place ahead of the winter period. As it was an 18 month programme, there would be continued opportunity for testing and adjusting the new system as it was worked through.

It was confirmed that best practice was to start planning for a patients discharge from the point they entered hospital care, with the support required for discharge refined as they passed through the system. As part of the Frontrunner Programme, there would be a multi-agency team established to oversee the discharge process, who would be able to cross check patient data with each other to identify what support was needed following discharge.

Given recruitment within the health and social care sectors was a challenge nationally, it was questioned whether there was sufficient existing resource in place to deliver the programme. Although recruitment of health and social care staff was challenging, it was highlighted that the data gathering exercise had indicated that the current discharge service was not working as effectively as it could, with fragmented patient pathways and inefficiency identified. The aim of the programme was to deliver a multi-agency discharge process that ensured patients were supported by the right professionals for their needs during the different stages of the discharge process. As part of the data gathering process there had been demand and capacity analysis, which indicated that the capacity needed to deliver the Frontrunner programme could be created within the service through addressing the identified inefficiencies.

Although capacity had been identified within the system, it was also recognised that staff should not be expected to deliver the programme without any additional resource, which had been allocated within the budget for the programme. Different options for bringing in additional resources were being considered, although given the aforementioned challenges in health and social care recruitment it was likely any solution would take time to be delivered.

As the model included provision for patients to receive an initial visit within 24 hours of their hospital discharge, it was questioned whether the person visiting would be medically trained and continue to oversee the patient’s recovery going forward. In response, it was advised that healthcare would have primary responsibility for a patient’s ongoing recovery in the first 72 hours following discharge, after which responsibility would pass to either social care or another service as required. It was likely that person undertaking the initial visit would not be medically trained, but they would be trained to identify medical issues and have access to nurses and geriatricians to provide support as needed. It was clarified that patients would only be discharged from hospital once they were considered to be medically fit and an assessment made of their needs by the multi-agency team. In some circumstances, there was also the option to use the virtual ward system to support patients in their own homes. It was agreed that it would be helpful for the Sub-Committee to visit the virtual ward service to learn more about how it worked.

It was confirmed that weekly conversations held with the five other pilot areas to share learning. As Croydon already had a history of integration between health and social care through the One Croydon Alliance, the other pilot areas were keen to learn from this experience. As would be expected from a pilot programme, each of the six areas participating were taking slightly different approaches, which would help to inform the overall outcomes from the programme.

A reference to ‘overprovision’ in the report was questioned, with further information requested to explain what this meant. It was advised that this was a reference to some patients leaving hospital and receiving a service that overprovided for their needs. There was caution within the system which needed to keep people safe, but in doing so it meant that support could be over provided, or support provided when an individual may have family support at home and as such did not need the full package of support provided. From the deep dive on the discharge process, it was found that 25% of patient were receiving an extended package of care, when they could have been supported in another way.

Given the importance of the role of the community and voluntary sector in supporting the delivery of the programme, it was questioned how the sector would be supported to fulfil this role. It was advised that for the work would be allocated on a contractual basis, with organisations able to bid to deliver services. This would provide a greater level of certainty on what services were available and the level of service those contracted were expected to deliver. It was highlighted that the Social Care service already commissioned the voluntary sector to deliver services and the new approach would include joint health and social care commissioning to ensure that the aims of the Frontrunner programme were being achieved.

Regarding how the allocation of support would be managed, it was confirmed that there would be a multi-agency meeting prior to discharge to agree what support a patient needed in the first 72 hours after discharge. The level of support would then be reviewed as needed during the first 24-hour visit.

The reference in the report to ‘one version of the truth’ in relation to the data analysis was questioned, including whether it would be possible to achieve ‘one version of the truth’. It was advised that this referred to a consistent approach being used across services to identify the pressures with the system. The data used to inform the process had been gathered over the course of a year and from a variety of sources to provide the best possible understanding of the system. The data was also compared to data collected in other areas to identify any Croydon specific issues.

Further information was requested on the demographics of people going through the hospital discharge process and whether this information would be collected throughout the pilot. It was highlighted that Croydon had the biggest areas of health inequality in South West London and as such collection of data on ethnicity was essential to ensuring that there was equal access to services and that people were not being missed. There were complex needs within the borough, and as such it was important for the pilot to support the system to provide holistic support, including linking into other services such as mental health provision.

It was acknowledged that prevention was another really important area of work, which would connect into the pilot through the Integrated Community Networks (ICN). The ICNs worked to identify people whose condition was likely to deteriorate unless supported, which was provided through work with GPs and locality teams. There had also been investment into the Accident & Emergency service to help with patient frailty. Another programme set up to look at how well people were being mobilised in hospital, with a view to freeing up the time of the therapy team.

It was confirmed that the time between people being considered medically fit and then being discharged would be monitored. A full key performance indicator dashboard would be used to monitor the pilot, which would also be reviewed by NHS England throughout the process.

Reassurance was given that negative feedback would be listened to as well as the positive, to better inform the outcome of the pilot. There was a need to facilitate the system to gather patient feedback on their experience and that of their carers as well. It was confirmed by Healthwatch Croydon co-optee, Gordon Kay, that he would be able to provide an update on the patient feedback sessions at the next meeting of the sub-committee.

At the conclusion of the item, the Chair thanked the Cabinet Member, officers and representatives from partner organisations for their attendance at the meeting.

Actions

1.    A request was made for the diagnostic data gathered through the deep dive on the discharge process to be shared with the Sub-Committee, and where possible provided in terms of the number of patients involved as well as percentages.

2.    A request was made for further information on the individuals and groups who had taken part in the consultation process to design the Front Runner programme to be shared with the Sub-Committee.

3.    It was agreed that a request would be made to the Croydon Health Service NHS Trust for the Sub-Committee to be provided with data on the time between patients being determined to be ‘medically optimised’ to being discharged from the hospital.

4.    It was agreed that a request would be made to Croydon Health Service NHS Trust for the Sub-Committee to be provided with further information on what data was gathered from patients about their experience following a stay in the hospital.

5.    The Sub-Committee agreed that it would be beneficial to their understanding of the service for a visit to the Virtual Ward service to be arranged.

Conclusions

1.      Although reassurance was given that, due to identified inefficiency with the current system for hospital discharge, there was staffing capacity to deliver the pilot, the Sub-Committee agreed that staffing was a key area of risk to be managed and that a deep dive on this would be requested as part of an update on the delivery of the Frontrunner pilot.

2.      The Sub-Committee welcomed the co-ordinated multi-agency approach to delivering the programme, which built upon a history of partnership working in the borough. It was concluded that there needed to be robust oversight over all areas of the coordinated delivery to ensure the potential benefits of the programme were maximised.

3.      The Sub-Committee welcomed the commitment given to gathering data on protected characteristics, which would provide reassurance on the equality of service and indicate whether any specific group required additional support.

4.      The Sub-Committee welcomed the reassurance given that patient feedback would be used inform the programme and the commitment given to ensuring the timely review of this feedback.

5.      It was agreed that given the importance of the Integrated Discharge Frontrunner Programme to health and social care in the borough, an update on the delivery of the programme would be requested for another meeting of the Sub-Committee later in the year.