Agenda item

To provide an update on the work that Adult Social Care and the Integrated Care Board have undertaken to support hospital discharge in Haringey.

Rachel Lissaeur, Director of Integration for Haringey at the North Central London Integrated Care Board (NCL ICB), introduced the report on this item and highlighted the context heading into winter 2022/23. Within primary care, GPs were seeing more people than they had at the same time the previous year and the proportion of face-to-face appointments had also increased while the proportion of people being seen on the same day was around 50% of those presenting to primary care. There was also an increase in Emergency Department attendances, particularly at North Middlesex Hospital, but this was mainly for minor illnesses and there was not an increase in people being admitted to hospital. Staff sickness levels were also up across the country. Emergency Departments were therefore extraordinarily stretched and this was the context for the increased ambulance waiting times. The additional funding provided through the Winter Access fund has been focused on increasing the number of primary care appointments and increasing the primary care presence within the Emergency Department at North Middlesex Hospital.

Rachel Lissaeur went on to explain that the adult social discharge fund was distributed to both local authorities and ICBs with the aim of taking more people through the system, expediting discharges and reducing the length of hospital stays. Additional funding had been put in place to support GPs to see more children face-to-face, to add nursing capacity and acute respiratory infection hubs.

Another initiative was to put two GPs at the Emergency Department at North Middlesex from 8am to 8pm in recognition that there were high numbers of people attending with minor illnesses in need of medication or advice. Over 80% of the available appointment slots had been used, enabling around 200 additional patients to be seen each week.

Rachel Lissaeur, Vicky Murphy, Service Director for Adult Social Services and Cllr Lucia das Neves, Cabinet Member for Health, Social Care & Well-being, then responded to questions from the Panel:

• Asked by Helena Kania how the GP services at the Emergency Department was being publicised, Rachel Lissaeur explained that this wasn’t being advertised as such but that patients were triaged with nurses deciding whether someone was suitable to see a GP.
• Asked by Helena Kania about the situation at the Whittington Emergency Department, Rachel Lissaeur said that they also had seen increases in attendances, though not at the same levels as North Middlesex. There were GPs at the front door of the Whittington but they had not received the Winter Access funding. The mix of cases at North Middlesex leant itself better to seeing GPs with a higher proportion of working-age adults and young people. Helena Kania queried whether additional funding was required at the Whittington. Rachel Lissaeur responded that they had a very substantial ambulatory care service that worked efficiently and they didn’t have the same level of pressure on their Emergency Department as at North Middlesex, which is why the additional capacity had been added at the North Middlesex. However, the real challenge over the winter in the Whittington had been in freeing up beds.
• Cllr Abela asked whether the promotion of self-care by the Council could help to reduce the pressures on primary care services. Rachel Lissaeur said that GPs tended to be appreciative of the significant support that could be offered by social prescribing, peer support and local area co-ordinators particularly when this relates to chronic conditions. The appointment structure of a GP surgery was not conducive to provide the support that people with chronic conditions needed, which could often be better provided with a holistic approach by a team of different professionals. Most GP surgeries now had a social prescriber at the practice. Cllr das Neves reported on a visit to the new West Green practice where there was a specialist space used for convening groups of people looking at self-management and sharing their experiences, for example around diabetes. It was culturally appropriate because they were coming together as a group and talking about the challenges that they face. She agreed that it was a good question to consider how more support could be provided by having the right spaces to enable people to do this at home or in person.
• Cllr Mason observed that a problem with social prescribing was in building relationships with people who found it more difficult to access services. She suggested selecting other spaces such as food banks and community rooms on estates to connect social prescribing services with more people. She also suggested that interpreters may be needed in some circumstances. Rachel Lissaeur agreed that a lesson from the Covid-19 pandemic was to go to where people were already accessing support. She noted that more people were now back at the places that people traditionally access such as GP practices and emergency departments and that targeted outreach elsewhere was sometimes more resource intensive to organise but agreed that it was important to consider where this could be beneficial.
• Cllr Connor asked how much additional funding was received through the Winter Access Fund and whether this would also be received in subsequent years. Vicky Murphy explained that the winter pressures funding emerged from government initiatives. The details of the amounts provided often came at the last minute which could make it challenging to utilise. The Council had worked closely with the Department of Health and the ICB on the plans for staffing and implementation of this funding.
• Cllr Connor requested further explanation about the deterioration of ambulance response times highlighted on page 18 of the agenda pack and whether ‘cohorting’ was being carried out to free up more ambulances. Rachel Lissaeur confirmed that there was some cohorting at the North Middlesex and Whittington hospitals but agreed to look into the levels of this and respond in writing to the Panel. (ACTION)

Carl Brownsill, the mid-term financial strategy lead for Adult Social Care, presented further slides, explaining that the aim of the Adult Social Care Discharge Funding, as set out on pages 23 & 24 of the agenda pack, was to reduce the delays in discharging people from hospitals. The funding was split between the Council and the ICB. The Council used this for staffing initiatives to strengthen the workforce and to cover the cost of additional care purchasing to help deal with the additional cases from November onwards. The approach was to free up beds with additional support in health and social care settings, including from mental health inpatient settings.

It was noted that the definitions of the various discharge pathways from hospital had been circulated to the Panel Members and were as follows:

Pathway 0 – Simple discharge with no Health / Social Care input.

Pathway 1 – Support to recover at home, able to return home with support from Health and/or Social Care.

Pathway 2 - Rehabilitation in a bedded setting.

Pathway 3 - Life changing event, home is not an option at point of discharge (require 24-hour bedded care on an ongoing basis following an assessment of their long-term care needs).

Referring to the slides, Carl Brownsill highlighted the significant increase in Pathway 1 cases in December and said that this additional pressure had continued in January and February.

Setting out the figures for the Discharge Funding, Vicky Murphy said that the Council had received £957k this year, while the ICB had received just over £1m. This had been invested in various projects across the system enabling further work in individuals with complex needs such as 24-hour care or those with homelessness issues. Two sets of accommodation had been secured – the Ruby Ward which was an intermediate care base shared across NCL as well as five ‘step-down’ flats in Haringey utilised for people who may be homeless or not quite ready to go home. Some wrap-around care was also being provided and additional capacity had been secured in reablement services. She added that, according to the national data set published six weeks previously, Haringey had been ranked 7^th best in the country for discharges and throughput. In addition, an organisation called Empower had been to brought in to work with the Council and the ICB to support next steps for discharges, with a particular focus on Pathway 1. Additional physio and therapy support in the community would be needed to support this.

Vicky Murphy and Rachel Lissaeur then responded to questions from the Panel:

• Cllr Peacock expressed concerns about people recovering at home and asked how often they were visited and contacted. She added that some had care needs and often required help with essential tasks such as food shopping. Vicky Murphy explained that community services were provided at a level based on the individual person’s needs. Sometimes an individual may have needs that are outside of Pathway 1 that it was important to be mindful of and to step in at an early stage to provide support. She added that wrap-around care, including tasks such as shopping, could be provided where required and suggested that Cllr Peacock speak to her outside the meeting regarding any individual cases that she was concerned about. Asked by Cllr Connor about the funding for wrap-around services, Vicky Murphy said that services had developed and improved significantly in recent years and could provide personal care, meals and medication, while Age UK had a presence in hospitals and offered additional support with a variety of tasks.
• Asked by Cllr Peacock whether the step-down flats were located within sheltered housing schemes, Vicky Murphy said that there was a large portfolio across NCL and all could be accessed by Haringey residents. Rachel Lissaeur added that the first port of call for Haringey residents was usually at Priscilla Wakefield House which was set up for short stays with multi-agency input. There was also Canterbury Ward and Cape Town Ward on the Chase Farm site in Enfield, and also beds at Kings Cross and Mildmay. Where a resident required a step-down bed, there were a range of options across NCL where they could be placed.
• Asked by Cllr Opoku how the levels of Discharge Funding received compared with other boroughs in NCL, Vicky Murphy explained that the funding was provided based on population and throughput so there were slight differences between Boroughs. However, she added that the Council was in conversations about obtaining extra funding for Haringey due to the enormity of the challenge faced this year. Cllr Connor commented that this ought to weighted according to levels of deprivation and welcomed the challenge that the Council was making in this area. The Panel recommended that deprivation levels should be considered as part of the NCL calculations for Discharge Funding. (ACTION)
• Asked by Cllr Connor how the funding levels compared with previous years, Rachel Lissaeur said that around £1m was received but this was focused on increasing health capacity rather than being split between the Council and the ICB. There had been slightly more funding available this year through the integrated approach but there was still the challenge of managing the cliff-edge in April without the additional funding.
• Helena Kania expressed concerns about the lag between discharge and assessment. Vicky Murphy acknowledged that this had been a challenging area this winter and that, due to the higher levels of demand and acuity, some people had been on reablement for longer than they usually would. In terms of demand, the numbers of people coming through the system was as high as 298 in one particular month compared to a normal level of 226. In terms of acuity, the proportion of reablement patients requiring long-term care had increased from 27% to 49%. At present there were two residents that had been there for longer than six weeks. However, there had been some recent workforce changes and so her ambition was that, by the end of March, everyone would be reviewed within 2-3 weeks and then reviewed again at the 6-week stage should they require ongoing reablement.
• Cllr Mason said that, from her experience of working with a local food bank, she was aware of some residents being discharged without access to their benefits or being placed somewhere without basic utilities and expressed concern about a small number of people slipping through the net of support. Vicky Murphy responded that there was a discharge to assess process for Pathway 0, run by a specialist person, but people could be referred back to Connected Communities services if required. She suggested a further conversation outside of the meeting to pick up on the concerns relating to the specific individuals.
• Cllr Brennan referred to cases of very vulnerable individuals that she was aware of and asked how quickly people would be assessed where there was urgent need. Vicky Murphy explained that individuals with complex needs would be discharged with appropriate care/support and wrap-around services so the assessment should take place before they leave hospital. However, if their level of need subsequently increased, then there was a rapid response service that can provide additional wrap-around care or a resident could be ‘stepped-up’ if their home is no longer safe for them. Cllr Brennan commented that some cases that she was aware of were done on a ‘discharge to assess’ basis. Rachel Lissaeur commented that people were discharged quickly because of the huge pressure on beds, but also that the ethos of ‘discharge to assess’ was that an assessment was more accurately carried out in someone’s normal residence. She added that the issues raised highlighted the importance of communication and reassurance with patients at discharge and assessment.
• Cllr Connor suggested that a card, including the key information points and contact details, could be provided to patients upon discharge. Vicky Murphy agreed to check on the documentation that was given to the patient and to provide this information to the Panel. (ACTION)