Agenda item

A report outlining the importance of intermediate care in achieving Haringey’s vision for integrated person-centred services, as well as the findings from a local review of intermediate care provision in Haringey was included as part of the agenda pack (pages 17-21). A copy of the presentation was also included in the agenda pack (pages 23-46).  Dr Will Maimaris, Public Health Consultant introduced the report. Other contributors to the presentation were: Lynn Carrington Designated Nurse Children in Care Nurse – Whittington Health; A slightly updated version of the presentation slides was distributed as hard copies to the Board. Following the presentation the Board discussed its findings.

Dr Maimaris advised the board that an aging population, where the majority of older patients had at least one long term condition, placed huge demand on hospital services and residential care placements. Furthermore, a significant proportion of older patients were being admitted to hospital when they did not necessarily need to be admitted, intervention at an earlier stage could have prevented those admissions or services could have been provided which meant that the person was supported in their own home. Integrated or person-centred care could improve quality of care for residents and also save money. 

In the vision for the Better Care Fund (BCF) submission 2016/17, the Council set out it’s ambition to improve health and care through a reorientation of the way health and social care was provided in the borough, moving away from the model of reactive hospital-based care to a more proactive and integrated care in the community model.  The Board noted clear synergies with Priority 2 in the Haringey Health and Wellbeing Strategy (increasing healthy life expectancy) and objective 1 of Haringey Council’s Corporate Plan 2015-18; ‘enable all adults to live healthy, long and fulfilling lives’.

Dr Maimaris advised the Board that intermediate care was an extra layer of support in between low level GP-based community care services and long term care provided by hospitals. This extra support was ideally community based and was needed in response to when a patient had an escalation of need, such having had as a fall. The aim of which was to either keep that person out of hospital all together or to reduce the amount of time spent in hospital, whilst still receiving the required care. Other parts of the country had succeeded in boosting Intermediate care and had seen success in terms of reducing hospital admissions. The Board were advised that LB Waltham Forest had a very large rapid response service with over 20 nurses and it also had the lowest rate of hospital admissions across London. Evidence was starting to emerge from a number of authorities around the effectiveness and cost-effectiveness of intermediate care. 

Dr Maimaris introduced Sue Gibbs, who managed the Rapid Response and the Ambulatory Care services at Whittington Hospital. Ms Gibbs outlined a number of examples of good practice in relation to intermediate care currently being undertaken in Haringey. The Board were advised that these were two stand alone teams, however they did work collectively. The Rapid Response service was a seven day service which provided health and social care to patients in their own homes, with the aim of reducing unnecessary hospital admission. The Service was staffed with community matrons who oversaw the recovery process and also provided short-term case management. The service normally provided care for a maximum of 5 days and could respond almost immediately with a visit by a matron who could initiate the nursing care management. As part of the service, Haringey Council could provide experienced care assistants; including over night carers for up to two nights and a carer visiting during the day for up to 4 visits. Ms Gibbs advised that the admission criteria were that the person had to live in the borough of Haringey and they had to be cleared as medically stable and by a GP or an A&E department. The referral to the Rapid Response service was via a phone call made from the GP, the A&E department or the Acute Admissions Unit.         

Dr Maimaris introduced Marcelle Van-Tull, from BRT Home from Hospitals which also provided intermediate care services in Haringey. The Board were advised that the service looked after patients who were 50 and over and had been discharged from hospital and were also a resident in Haringey. The service provided practical support including; shopping, assisting with GP/outpatient appointments, a ‘Check and chat service’providing friendly telephone calls to check everything is alright and signposting patients so that they did not have to return to hospital. There was a 91% non-readmission rate to hospital within 4 weeks for medical reasons. 

Haringey currently invested 35% less than the national average in intermediate care services. Dr Maimaris gave the Board a summary position on the gaps within intermediate care within Haringey:

•      Current services were small scale

•      No integrated intermediate care pathway

•      Multiple organisations involved in intermediate care

–     Often not joined up

–     Different access points to different services

–     Communication to patients and GPs about what is available is patchy

•      Limited bed-based intermediate care provision at present

•      Hospital teams not fully linked to community teams in the hospital discharge process.

Dr Maimaris identified a number of next steps identified from the review of intermediate care in Haringey being taken forward by the Health and Care Integration Board:

•      Increasing capacity and scope of our Rapid Response service

•      Commissioning dedicated rehabilitation and re-ablement beds for step-down from hospital and step-up from the community

•      Increasing re-ablement capacity

•      Bringing together existing services into an integrated intermediate care pathway with clear links to the hospital discharge process. Linking to Safer, Faster, Better improvement programme at North Middlesex Hospital.

The Cabinet Member for Finance and Health enquired what would be needed to adopt a transformational approach as opposed to the proposed transitional approach and how long a transformational approach would take to implement. The Cabinet Member for Finance and Health also enquired how much funding from the Council would likely be required, in addition to the funding applied for from the BCF submission. In response, Dr Maimaris advised that in order to work at a faster pace, changes would be required of the whole system such as looking at how resources were spent across the whole system including hospitals to determine the best pathway. Dr Maimaris suggested that the next agenda items of the NCL Sustainability Transformation Programme and the Haringey and Islington Wellbeing Partnership could contribute to a transformation shift.

Sharon Grant, Chair Healthwatch Haringey, applauded the idea of developing an integrated intermediate care pathway in Haringey but enquired whether the plans were sufficiently ambitious and gave her support to investing in sufficient scale to produce the transformational shift required, particularly given the potential savings involved. Ms Grant also commented that there seemed to be a policy around intermediate care without a strategy behind it.

Zina Etheridge, Deputy Chief Executive commented that in terms of funding; in order to invest in the development of an intermediate care pathway, partners would need to disinvest in other aspects of service provision as there was only a limited amount of funding available. The Board were advised that because this resulted in a slow process, there was an unavoidable impact on the ability to effect a transformational change. Any transformational change would require the whole system to shift how it operated and this would create inevitable barriers to achieving that shift and the pace at which it was implemented. Sarah Price, Chief Officer Haringey CCG echoed the comments of the Deputy Chief Executive, acknowledging that the Board would have to look very carefully of what was already being funded. Furthermore, any scaling up of services would need to be properly evaluated to ascertain what services were perhaps not delivering in the same way as for example the Rapid Response service and where the funding for that upscaling of services would come from. It would also be important to bring the patient and wider public along with us on any transformational shift to ensure that any shift was viable. It was proposed that the next step should include dialogue with patients to ascertain what services they would value most, as well as being part of a wider goal to measure outcomes instead of inputs.

Geoffrey Ocen, Chief Executive BRT, suggested that the Board should look at how other organisations had achieved the change required whilst still operating under comparable financial restrictions. Mr Ocen also enquired how well the different pockets of intermediate care were integrated and questioned whether signposting of patients involved links to community and wellbeing services. Dr Maimaris commented that attempting to integrate those services was an ongoing process and that there were clear links between this and say the social prescribing model discussed at the previous meeting of the Board.

Jon Abbey, Director of Children’s Services commented that the non-readmission rate given in the presentation in relation to the Home from Hospital service was compelling. The Director of Children’s Services also asked what LB Waltham Forest had done in order to create that shift in intermediate care. Dr Maimaris responded that they had been working on an integrated footprint in that part of London for the last four or five years and in order to achieve that transformative shift, there would have to have been some engagement with other services such as hospitals.

Cathy Herman, Lay Member Haringey CCG, commented that there seemed to be big pluses to be achieved from an integrated approach and from looking at the pathway as a whole. Ms Herman advised that in terms of looking at the transformation, the Board would need to consider this in the context of the whole North Central London area and the application for transformational funding due to the clear synergies involved. The Board were also cautioned that the challenge would be finding the upfront investment required to implement these changes and the clear savings involved.

Beverley Tarka, Director of Adult Social Services advised that she attended a recent finance and performance meeting around the Better Care Fund and that there had been an agreement in principle to increase investment based on an evidence based assessment of the intermediate care pathways. Enabling people to remain at home after discharge from hospital was a key outcome for Adult Social Services and the Board was advised that performance around this had risen from 76% to 91% in the last year, which was considered to be directly attributable to the intermediate work that had been undertaken. The Board were advised that a lot of detailed business case work and evidence base had been undertaken by Dr Maimaris and his team and this had enabled the Council to invest in additional funding for pathways for intermediate care. The Director of Adult Social Services advocated that further development of intermediate care services should be a key outcome for the Council and partners but acknowledged the critical element of being able to release money from the system in order to invest money more effectively.

Carol Gillen, Chief Operating Officer Whittington Health NHS Trust

advised that often hurried decisions were made in acute care about people going into long term care because beds were at a premium. Ms Gillen advocated that intermediate care allowed patients to get home quickly and to maintain their independence. Ms Gillan also advised that she worked at Waltham Forest throughout the development of their intermediate care programme and that the present arrangements were a result of a lot of joint working that was initiated around 2003. The Board were informed that it took a long time to build those relationships in order to for the system to work.  Richard Gourlay, Director of Strategic Development North Middlesex University Hospital NHS Trust, echoed the comments of Ms Gillen and emphasised the need to make decisions about long term patient care and ensuring that this was done in a joined up fashion, involving the families and in the most appropriate setting.

Dr Maimaris was asked to consider how the development of an integrated intermediate care pathway could be best monitored by the Board going forwards, particularly in terms of the Board playing a key role in ensuring a step change in intermediate care provision. Dr Maimaris stated that there was an existing project sitting within the CCGs governance structure and agreed to bring back an update on intermediate care to either September or December Board. (Action: Will Maimaris). 

In regards to the development of a strategy, officers advised that there was an intermediate care strategy developed as part of the Better Care Fund and that this along with the recommendations from the review, formulated a strategic approach to developing and scaling-up an integrated intermediate care pathway in Haringey.

The Chair thanked those present for their contributions.

RESOLVED:

I). That the HWB supports the approach being taken by Haringey Council and Haringey CCG to develop and scale up an integrated intermediate care pathway in Haringey.

II). That the Board members were asked to consider how their organisations could contribute to the development of an integrated intermediate care pathway in Haringey.