Agenda item

To provide details to the Panel on:

a)    The hospital discharge arrangements currently in place across North Central London to support Haringey residents to return home, including those who have additional care needs out of hospital.

b)    The NHS Continuing Health Care (CHC) arrangements in North Central London and how this is joined up with social care services.

Hospital Discharge Arrangements

Paul Allen, Head of Integrated Commissioning (Integrated Care & Frailty) at NCL CCG and Haringey Council, introduced the report stressing that there was a multi-agency effort to discharge people from hospital to help them to recover in a safe and timely way, ideally to their own home. Paul Allen added some brief comments on key points in the report:

• There was a process called Discharge to Assess which involved discharging patients out-of-hospital to recover as much as possible and then assessing their long-term needs afterwards. The Covid-19 pandemic had both reinforced the importance of this approach and accelerated the plans for this model to be used.
• Another important area was the establishment of acute-based and multi-agency Integrated Discharge Teams (IDT) including at Whittington Hospital and North Middlesex University Hospital.
• Reporting requirements had changed following the suspension of statutory monitoring of delayed transfers of care in April 2020. Alternative measures on length of stay in hospital were now being used as set out in paragraph 3.8 of the report.
• The report had been written just before the recent government announcement to extend the funding for the additional costs of out-of-hospital placements beyond September.

Alison Kett, Director of Operations for Adult Services at Whittington Health NHS Trust, added that pressures on services the previous winter had been unprecedented. While this had plateaued since then, the Trust was anticipating the coming winter to be challenging with Covid patients in the hospital in addition to the existing caseload, but were now in a much better place to deal with this. From a community perspective, additional funds had been provided to support the prevention of hospital admissions, including through the Rapid Response service.

NnennaOsuji, Chief Executive of the North Middlesex University Hospital NHS Trust, commended the intra-agency working that had developed during the pandemic and emphasised the importance of having the right discharge arrangements noting that this impacted all the way through to the emergency department. They chaired a joint A&E Delivery Board which looks at inflow, throughflow and outflow. She added that the funding announcement from the government had been welcome ahead of what was likely to be a difficult winter and recognised that a system-wide effort would be required to minimise admissions where possible, optimising patient time in hospital and maximising discharge.

Cllr Gideon Bull asked about the issue of delays in offloading patients from ambulances to A&E. Alison Kett acknowledged the pressures in this area and the knock-on effect on the rest of the system, noting that this was closely scrutinised. Nnenna Osuji added that the Trust aimed to offload 95% of ambulances within 15 minutes. Offload times that exceeded 30 minutes or 60 minutes were also closely monitored with the latter measure regarded as a significant breach. This was regionally and nationally monitored so there was an intense degree of scrutiny involved.

Cllr Bull asked about the assessments carried out on patients prior to discharge. Nnenna Osuji said that the Trust worked hard to ensure that discharge arrangement were safe for patients, both in terms of their clinical safety and also from a therapies point of view. This reflected the importance of working systematically and in partnership to address non-health related considerations and so the Trust was working closely with Connected Communities to pick up on the other aspects of people’s quality of life. The Trust had also been piloting a ward at Chase Farm hospital which aimed to focus on these aspects of care before a patient leaves the hospital.

Cllr Peacock asked what measures were in place to ensure that the details of a patient’s hospital stay were provided promptly to their GP. Kiran Sanger, Associate Director and Borough Lead for Haringey at Whittington Health NHS Trust, noted that recent changes had enabled the uploading of notes onto a digital system that could be accessed by patients and their GP. Nnenna Osuji also recognised the importance of digital innovations in this area including the OneLondon system which would enable information about a patient’s health and care to be accessed by clinicians in different parts of the NHS. She added that, at the point of discharge, a letter is created which should reach the GP within 48 hours and that she would be happy to look into any individual cases raised by Panel Members where this had not happened. Rachel Lissauer, Director of Integration, Haringey Borough at NCL CCG, added that clinical interface meetings were held which were an opportunity for GPs to communicate directly with the senior clinicians and others.

Asked by Cllr Connor how further feedback was obtained by GPs and clinicians after discharge, Kiran Sanger said that Discharge Alerts could be raised if there were any particular issues raised following a discharge. This enabled patterns to be identified from a governance level. Nnenna Osuji added that active monitoring of existing commitments, such as letters to GPs within 48 hours, and dealing with any exceptions was a proactive step that was taken. Outcome measures looked at what had happened 28 days after discharge as well as at the hospital stay itself. There were also individual feedback mechanisms such as the complaints process. Alison Kett said that the benefits of an Integrated Care System across the NCL area included the standardisation of the Discharge Alert process. Beverley Tarka, Director of Adults & Health at Haringey Council, emphasised the integrated nature of the discharge team including the role of social workers and the reablement and rehabilitation teams which enabled integrated after-care for patients.

Cllr Bull highlighted the importance of discharge arrangements for people with severe mental health issues and suggested that this be considered at a future meeting. Cllr Connor confirmed that mental health was included in the Panel’s current work plan.

NHS Continuing Healthcare

Cllr Connor asked about the funding arrangements for NHS Continuing Healthcare (CHC) and how excess demand for this funding was managed. Marisa Rose, Director of Continuing Healthcare for NCL CCG, explained that there was a national framework for CHC which was administered at a local level with scrutiny from NHS England through benchmarking of how many people were assessed and how many qualified for funding. NCL CCG was currently in the middle of the pack for this benchmarking. In terms of the process, as people were identified for CHC a checklist was reviewed before they were progressed to a full assessment. CHC was assessed on needs rather than diagnosis.

Asked by Cllr Connor about the qualifications of the person carrying out the checklist stage and how advocates for the patients were included in this process, Alison Kett explained that Whittington Health provided assessors so there was separation between the clinical assessment and where the money sits. The assessors were experienced, trained, there was national guidance to meet and every assessment had to be quality checked so this provided consistency. The recommendation had to be based not just on the decision of the assessor but also had to be agreed in conjunction with the social worker and then the CCG would consider whether the evidence supported the recommendation. An appeal process was also available to individuals who were not satisfied with the recommendation. Marisa Rose said that if an advocate was identified by the individual or a medical professional then everything possible would be done to ensure that the advocate was included as part of the process. Cllr Connor said that not everyone would know how to request an advocate and suggested that advice on this should be provided to patients and their families at the outset. (ACTION)

Asked by Cllr Mahir Demir how people know that this service exists, Marisa Rose said that information was readily available on the NHS website but that, as people go through a clinical process, the clinicians and social workers involved would outline the next stages. CHC was technically a funding mechanism to meet people’s ongoing needs so that was no need to specifically promote this. Assessments now tended to be carried out in the community post-discharge rather than in hospital as used to be the case and this was generally more suitable.

Asked whether there was any analysis about which part of the borough people going through CHC assessments came from, Marisa Rose said that the number of people assessed for CHC was relatively small. Across Haringey, as of June 2021, 376 people were on CHC so as the numbers were relatively small this was not typically broken down by ward level. She said that she could check whether it would be possible to provide this information. (ACTION)