Health and Social Care Committee evidence on hospital discharge

Cwm Taf Morgannwg University Health Board – Summary briefing submission

Current CTM UHB Situation regarding delayed transfer of care

· There are currently 136 patients in our hospital inpatient beds that could be transferred into a social care setting.

o 66 of these patients are awaiting care home placements

o 70 are waiting for packages of care to be established.

· A joint spot audit of delayed transfer of care (DTOC) patients across CTM was carried out in early December by health and social care staff. This identified 82 patients that could be appropriately placed in a residential or nursing home while waiting for packages of care or care home placements to be confirmed and organised.

Background

· Despite various schemes, incl. short term funding designed to support discharge, discharge rates have remained fairly static. One of our Local Authorities discharges between 14-25 patients per week and the staywell@home team accept 16-28 patients per week (data Oct 2021 to 9/12 2021). It has been observed that there has been an increase in the complexity of care packages required.

· Funding for community teams in health and social care has historically come via different funding routes with different timescales. An example of this is that health has been allocated non-recurrent winter funds via NHS Wales and social care have submitted winter funding requests via the Regional Partnership Board (RLB).

· Specifically, over the past 18 months the table below shows patients waiting for packages of care have steadily increase within CTM and across Wales.

Key issues

· There has been an increase in patients waiting for packages of care due to the unavailability of these packages from Local Authority providers. This information is provided by Local authorities to our “silver command” weekly operational meetings to manage covid and winter pressures.

· There has been a large increase in patients waiting for a social worker allocation due to social worker vacancies and recruitment issues.

· Local Authorities are experiencing an increase in demand and case complexity from outside health referrals combined with the challenges in securing the required number of staff for the service.

· The number of patients discharged into social care settings has remained constant, however the complexity of the patients have increased and there are more requests and assessments for a higher intensity level of care required.

· The concept of a single point of access has been replaced with individual patient referrals who meet a set criteria referred to specific teams.

· The Health Board is committed to working closer with Local Authorities to ensure we are consistently aligned on the numbers of patients who are medically fit to be discharged. There are examples where understandings can differ between organisations on whether patients are truly ready to be discharged or whether they require additional needs before they can leave (e.g. awaiting prescriptions etc).

The table below identifies patients waiting to be transferred to a ‘discharge to assess’ pathway:

Impact

· The most readily observed impact is on the flow of patients through our acute hospital sites. This ultimately results in patients spending longer waiting in our Emergency Departments, Medical Assessment Units as well as waiting in ambulances on hospital forecourts before they are able to be admitted into the hospital. This causes knock-on delays for the Ambulance Service who then struggle to respond to urgent calls within the community, putting lives at risk.  

· As the table below sets out, the Health Board’s 4 hour compliance is lower in 2021 compared to 2020 along with the performance of the 15 minute ambulance handover target. This is an accepted symptom / result of lack of patient flow causes by an inability to discharge patients consistently.

Health Board Overall	01 Nov 20 - 30 Nov 20	01 Nov 21 - 30 Nov 21
4 Hour Compliance	76.89%	65.25%
Attendances	11388	14272
12 Hour Breaches	1095 (90.4%)	1463 (89.7%)

Health Board Overall	01 Nov 20 - 30 Nov 20	01 Nov 21 - 30 Nov 21
15 Minute Handover	49.86%	33.48%
1 Hour Handover	81.3% (467)	65.4% (799)
Total Handovers	2501	2312

· As an example of this, our data shows that one of our acute hospitals admits 1-2 patients per day more than it is able to consistently discharge. This means the hospital steadily fills up and eventually operates beyond its capacity requiring further short term measures to bring it back into its operating capacity. This can have a knock on impact for elective surgery if elective beds have to be utilised for unscheduled care patients.

Possible solutions

· The social care system requires support for recruitment and retention. A suggestion could be for social care staff to be employed on parity with the health ‘agenda for change’ terms and conditions.

· Funding should be allocated to both health and social care as an integrated system, involving key incentives to encourage a closer working relationship.

· A holistic review of all the health and social care teams at Regional Partnership Board level and a follow on recommendation of how these teams can fall under a single point of access for the benefit of patients.

· The Health Board is in the process of trying to work with Local Authorities to ‘block book’ care home beds to be able to increase the amount of medically-fit patients being discharged from our acute hospitals. This follows from the Swansea Bay UHB initiative in an attempt to improve patient flow.