What’s best next? Long term focus and dedicated resource

By James Maxwell

We’re now well into autumn and looking ahead to another challenging winter for the NHS.

One thing that stands out about this winter is that by the end of it (March 2020) NHS trusts should have realised the national ambition announced by the Secretary of State in 2018 to lower bed occupancy in hospitals by reducing the number of long-stay patients (21 days or more) by 40% against a 2017/18 baseline.

As our recent research revealed, trusts are struggling to meet their targets around reducing super stranded patients with 90% of them way off the initial 25% target, let alone the 40% expected by March 2020.

Over the last month, the government has made a flurry of health-related announcements. What’s interesting about these is that many have felt slightly old fashioned and about the infrastructure rather than the patient:

  • Spending £2.7bn on building hospitals
  • Keeping bed numbers steady (and increasing bed numbers)
  • Creating an investigations Arm’s-Length Bodies (ALB)

At the same time long promised plans for social care reform remain stubbornly vague.

While the recent announcements may reassure people that the health system is in good shape and money is being spent on visible elements of the system, the picture at the back door is very different. The health system is increasingly dynamic and solving challenges like reducing the number of older people who are in hospital when they are medically fit for discharge is a team sport, which needs participation from across the sector. At its heart it’s a problem solved by focussing on the patient, especially bearing in mind the negative impact on mental and physical health of a long stay in hospital.

The ‘Where best next’ campaign from NHS England and NHS Improvement outlines five key principles for supporting patients medically ready out of hospital and into care. One of these principles is centered on involving the patient and family in decision making. This is hugely important but often overlooked – we know that dedicated family liaison including after hours and weekend support makes a direct impact on how quickly patients can be helped into care. With our support The Hillingdon Hospitals NHS Foundation Trust was able to move 20 super stranded patients into care within 7.5 days.

Making sure resources are dedicated to the backdoor is the right thing to do for patients and their families, and will help the existing capacity in hospitals to be used for patients who need those beds and care.

Are more beds really the answer?

By Gabrielle Silver

This week at NHS Providers, Simon Stevens spoke about acute hospital capacity heading into winter: “… we want to go into the winter with as many hospital beds open as we can – ideally more than last year. In June I said, looking at evidence, we should not be planning on the basis that there will be further reductions in acute hospital beds over the next five years, and [it’s] important, as people are doing their long term implementation plans locally, they are thinking carefully about that.”

But is this the right currency to focus on in terms of capacity? At first glance it seems logical that more beds should be considered a useful lever to create capacity over winter. However, when you set this against a backdrop of 350,000 patients spending more than 21 days in hospital, trusts missing targets on helping these super stranded patients out of hospital and into care, as well as many trusts already using escalation beds, it seems that the real capacity in the system is unknown. The beds that should be made available are those that are occupied by these super stranded patients – until these beds are put back into the system can we really be sure that there is a need to open and staff ‘new’ beds?

A practical and achievable intervention to release this capacity is intensive working with the family and carers of patients. We’ve been working with trusts undertaking family liaison for many years and have seen first-hand how dedicated support focussed on understanding patient needs, being available after hours and at weekends, as well as taking family members on visits to care homes can support them to make an otherwise daunting decision. With this all round approach, we discharge all patients in 10 days or less. It’s this support which could really make a difference over the coming months without the need to put more beds into a system which struggles to cope as it is.

Long Stay Wednesdays – making a huge difference at Kettering General

Long Stay Wednesdays is an initiative launched in August 2018 at Kettering General Hospital NHS Foundation Trust. The purpose of Long Stay Wednesday is to give dedicated focus to those patients who have been in hospital for more than 21 days.

Rebecca Smith, coordinator at CHS Healthcare explains how it works and what impact it’s had.

We have been commissioned by Nene CCG to support patients being discharged from Kettering General Hospital into long term care placements, Discharge to Assess (D2A) for reablement or home with a package of care since December 2016.

At Kettering General, the CHS team are located within the integrated discharge team (IDT) and we work alongside the hospital discharge teams to help people out of hospital and back to their own home with support or into care. We liaise with patients and their families to understand what help they need and what type of care home would be the right fit. We also work extremely closely with local care providers so that we know what availability they have and what facilities they have to make sure we can provide high quality referrals and they can make decisions more quickly.

How do Long Stay Wednesdays work?

Each Wednesday a team of key senior staff meet with ward teams and us and look at what needs to happen to help patients to leave hospital.

The specific focus of the long stay team is on ‘super stranded patients’ – those who have been in hospital for more than three weeks. Often these patients have been in hospital for longer than usual for complex reasons including rehabilitation and challenges to get the appropriate support arranged outside of hospital.

What do CHS do to support Long Stay Wednesdays?

Our role at is to update the team and wards on any of the patients that we are working with. We also offer advice and challenge so the team can start to really understand why a patient is unable to leave. Sometimes we might suggest a different pathway for a particular patient and because we know the local care provision so well, we might have solutions that haven’t been thought of already – for example units and hospitals that are most appropriate for specific illnesses.

We screen all patients on to the Continuing Healthcare (CHC) D2A pathway. At Long Stay Wednesdays we can ask about CHC needs and if none present, we can suggest an alternative pathway.

We also manage all the self-funding patients. We regularly received self-funders that we can’t support as they don’t have capacity or power of attorney. We also support with family and choice delays by ensuring we involved the patient and their families in discharge decisions. Long Stay Wednesdays provide an opportunity to explain the challenges and to support the ward teams and social services colleagues.

Why are Long Stay Wednesdays important?

For me, Long Stay Wednesdays is a knowledge sharing day. By getting together and talking through patients we are able to agree the best, safest and quickest route out of the hospital. This means patients avoid yo-yoing between pathways.

I also feel that being a non-clinical member of the Long Stay Wednesday team is an advantage as we can see things in its simplest form and sometimes removing the medical aspect can make things a lot clearer.  Our moto in Nene is very much “why?” which fits with Long Stay Wednesdays.

I am very pleased that the Long Stay Wednesday team has been recognised as a finalist for the HSJ Awards. Being part of the team is hugely rewarding and we have done an amazing job – in July 2018 Kettering General had an average of 195 super stranded patients on any one day – 12 months on this is 100 patients. That speaks for itself!

Unlocking the back door to get patients the care they need

By Dr Gabrielle Silver

When you think of a health service at full stretch over winter you immediately imagine a Casualty-esque scene, with ambulances queuing outside a jam-packed A&E and Charlie Fairhead running around like a headless chicken trying to manage the chaos. What you don’t visualise is elderly people no longer needing hospital care sat in beds on wards up and down the country. This is, however, the stark reality we are faced with in the NHS, which must be addressed as an urgent priority if any sustained improvements are to be made to patient flow.

This call goes largely unheard and ignored. The recent announcement by our new Prime Minister, Boris Johnson, of a £1.8 billion NHS cash injection to help improve patient care is evidence of this: while it is fantastic that patient flow improvements in Boston, Stoke and Wirral are included within a raft of upgrades outlined, these all relate to urgent and emergency care or bed capacity and unfortunately don’t tackle the critical issue at the back door.

It is not a complicated concept to understand – if we don’t fix timely discharge, we won’t be able fix some of the biggest problems affecting our hospitals such as cancelled operations and long waits in A&E and for planned surgery. If you move patients through the hospital system effectively and into appropriate care settings when they are fit to do so, there will be more beds for people who need them. This results in less pressure on frontline staff and enables them to care for more patients.

The independent research we commissioned illustrates the impact delayed discharge of super stranded patients has on patient flow through the front door. It has revealed that those hospitals missing their super stranded target between January and March 2019 could have undertaken a staggering 17,715 more operations were other contributing factors not in effect.

This isn’t even the full picture. The toll on elderly people of being in hospital for long periods of time is of great concern. NHS Improvement has recorded that 35% of 70-year-old patients experience functional decline during hospital admission in comparison with their pre-illness baseline; for people over 90, this increases to 65%.

In February this year the British Red Cross published a report into patients’ experience of discharge from hospital and their transition from hospital to home. Unsurprisingly, their research found a lack of consistent care provision and that people’s needs are still not being met.

I couldn’t agree more with their call for the implementation of a personalised approach to a person’s journey through hospital and back home or into residential care.

Such an approach is one that we at CHS Healthcare wholeheartedly believe in. We know it isn’t realistic to expect NHS frontline staff to continue to deliver against their clinical demands as well as spend intensive time liaising between families and local care services. Our purpose is to support the NHS getting to know what matters most to patients and their families. We also work closely with local care services to understand real-time availability and make sure referrals are detailed and precise to support efficient placement and reduce readmissions.

With the challenges of winter and flu season fast approaching, and with the NHS on or about at capacity all year round there are few obvious and easily actionable levers which can be used to support patient flow. Giving attention to super stranded patients now – before winter and flu hits – is the right thing to do for patients. It will also release capacity for planned activity as well as create capacity for patients who need clinical care in the future.
Return to the super stranded dashboard

Hundreds of thousands of patients are stranded in hospital and unable to leave

CHS Healthcare receives national coverage in The Telegraph, shining a light on the current state of affairs with super stranded patients in trusts.

We work closely with many hospital trusts and local authorities to help patients out of hospital and into the care they need. We know that medically fit patients are waiting too long to leave hospital, but not how big of a problem this is.

To further delve into this, we commissioned some new research using NHS England and NHS Improvement data. The data reveals that there were 330,826 super stranded patients in England from April 2018 to March 2019. The NHS defines a super stranded patient as someone who has spent 21 days or more in hospital.

Over the same period, the data shows that nearly 80,000 operations have been cancelled at the last minute for non-clinical reasons, including bed availability. This equates to more than 200 operations cancelled every single day.

With three months to go before winter and flu season – a time when the need for capacity is high – almost 90 per cent of NHS trusts in England are not meeting their target to reduce the number of super stranded patients. Between January and March this year alone, the average monthly number of these patients was 17,047.

You can see how trusts are performing against their targets on our interactive map.

The data shows the impact that lengthy discharge has on patient flow. It reveals that between January and March 2019 those hospitals missing their super stranded target could have undertaken an additional 17,715 operations were there no other contributing factors*.

Our chief executive, Dr Gabrielle Silver, said:

“Although we often hear about the challenge facing the front door of hospitals – illustrated by queuing ambulances – it’s critical to address issues at the back door. Elderly people sat needlessly in beds on wards across England is the ignored face of poor patient flow.

“The impact of an extended stay in hospital can’t be underestimated in terms of risk of further illness and physical or mental decline. NHS England made a commitment to improve patient care by cutting long stays in hospital and there are some effective schemes in place but overall not enough is being done.

“With the challenges of winter and flu season fast approaching, NHS trusts need to dedicate resource now to supporting super stranded patients into care in their own home or in the community. This will ensure operations can continue to be performed and there is maximum capacity to meet the needs of local people during winter.”

We work with Kettering General Hospital NHS Foundation Trust and are part of the team that work with super stranded patients weekly on their wards. Kettering are also one of the 13% of trusts meeting their super stranded patient targets. Fiona Lennon, Deputy Chief Operating Officer at Kettering General Hospital NHS Foundation Trust, said:

“We know how important it is for the timely discharge of patients when they are medically fit to be discharged. At our trust, we have been focusing on reducing the numbers of stranded and super stranded patients, which we’ve seen is helping to improve patient flow and most importantly, making sure that patients are getting the right care in the right place.”

Further details

NHS England and NHS Improvement data used includes:

The NHS Operational Planning and Contracting Guidance 2019/20 set a target to reduce the number of super stranded patients in hospitals by 25 per cent across all NHS trusts nationally, to release at least 4,000 beds. Once local targets are delivered, NHS England and NHS Improvement aims to reduce the proportion of beds occupied by super stranded patients by a total of 40 per cent.

NHS Improvement has recorded that 35 per cent of 70-year-old patients experience functional decline during hospital admission in comparison with their pre-illness baseline;
for people over 90, this increases to 65 per cent.

*Non-clinical reasons for cancelling operations include:

  • NO beds available on a ward
  • Staff are not available, such as the surgeon, anaesthetist or operating theatre staff
  • An emergency case had to take priority in the operating theatre
  • Some equipment is not working

Read article in The Telegraph
Return to the super stranded dashboard

Patient flow focus at national HSJ Summit

We are looking forward to chairing a broad and engaging session on patient flow at the forthcoming Health Service Journal Provider Summit.

The summit is widely recognised as a key national forum for discussion and collaboration, bringing together senior NHS leaders from across the country.

We will be leading a whole conference session entitled Optimising Patient Flow: presentation of three different case studies, executive-led discussion and learning.

Our session will feature three case studies from NHS services across the country, encompassing key issues including stranded and super stranded patients, joint commissioning and integration and discharge to assess.

We will chair a panel with senior figures from the three case studies, offering an opportunity for broad and open discussion and reflection.

The HSJ Provider Summit is taking place this year at the East Midlands Conference Centre, Nottingham on April 10 and 11. The focus of the conference is:

Revitalising the NHS of today: Reconfiguring services and processes to develop safe, efficient and patient-centred care pathways.

Dr Gabrielle Silver, chief executive of CHS Healthcare said: “This forum is designed for really open, broad discussion at an executive level of the pressing issues and challenges for NHS providers.Up to 200 people working at leadership level across the NHS are attending.

“We are focusing on patient flow from a case study perspective so there is the opportunity to drill down into different services in different regions, share experiences and reflect.

“Case studies will encompass, although are not limited to; stranded and super stranded patients, joint commissioning and integration and pathways of discharge to assess.”

Our continuing healthcare module commences in 2019: more than 500 people have now completed programme

This year’s programme of our nationally renowned Continuing Healthcare module commenced with sessions at the Royal Hospital for Neuro-disability, south-west London.

The two-day module was first launched in 2015 as the first face-to-face training in CHC, encompassing the context of the framework as well as practical sessions applying its principles to practice.

It was designed and is delivered by Art Calder, head of clinical services for CHS Healthcare, recognised as one of the leading authorities in this highly specialist field.

Mr Calder has been a registered mental health nurse for 30 years, playing a key role in the development and implementation of the national framework for CHC. He has been a member of the national consultation group via the NICE Appraisal Committee and acts as one the Royal College of Nursing’s National Advisors.

The module at the Royal Hospital for Neuro-disability on January 10 and 11 was the 32nd course to be delivered. More than 500 people have completed the module to date, with 233 participants being either CCG or local authority practitioners, who are offered the training free of charge whenever we are delivering services for their organisations. The remaining participants have been CHS Healthcare staff and associates.

Day 1 is focused on the socio-political history and development of Continuing Healthcare in England. This includes key case law, the national framework and appreciating how they have shaped the delivery of the service. In the afternoon, participants are engaged in a full screening exercise and best practices noted across regions in England.

Day 2 has a practical focus, set in the style of a case management workshop, with complementary presentations and discussions. Participants will complete a consolidation exercise to consolidate learning from Day 1. They are guided to utilise knowledge gained from Day 1, dynamically applying to practice on Day 2.

CHS Healthcare and Bath and North East Somerset Council and CCG joint entry is shortlisted for Health Service Journal Partnership Awards

Our entry Integrated management of hospital discharge pathways has been shortlisted for the prestigious Health Service Journal (HSJ) Partnership Awards.

This is a joint entry with Bath and North East Somerset Council and CCG for the hospital discharge service they commission, funded by the Better Care Fund and we deliver. It is shortlisted in the Partnership Consultancy of the Year category.

This project started as a small pilot in September 2017 and was so successful that it has been expanded to encompass all funding groups (social services funded and self-funding) and pathways, including individuals in need of Fast Track (end of life) care and a stand-alone project to safely transfer care for individuals in a care home which was closing.

We now work with up to 46 patient referrals every month, sourcing care and managing the whole discharge process and have managed, in total, more than 300 discharges to date.

This means we manage and co-ordinate the very large majority of discharges from Bath hospitals, communicating with multiple services and stakeholders in a clear, streamlined process.

Each patient and their family are allocated their own adviser coordinating every part of the process including, where requested, transport to care homes and accompanied visits and all information sourcing. This support continues through evenings and weekends as this is often the most convenient time for families and reduces delays.

Our entry highlighted a range of outcomes and strengths of the partnership:

  • Improvements in the relationship between hospitals and care homes, evidenced in care homes carrying out more prompt assessments in hospital and a more responsive approach to offering places and fees (including acceptance at local authority rates)
  • More than 95 per cent of service users rated the support as either ‘excellent’ or ‘good’
  • Audits of care three months after placement show very low hospital readmission rates
  • Reductions in delays to hospital discharge

CHS Healthcare achieves the highest level of cyber security accreditation

We have been accredited with the highest level of cyber security company assurance in a Government backed scheme.

The accreditation we have achieved is Cyber Essentials Plus, the highest level of security against the risk of a cyber-attack.

To achieve this level of accreditation, our security standards were independently verified.

The scheme was introduced by the UK Government in collaboration with industry partners, including the Information Security Forum, the Information Assurance for Small and Medium Enterprises Consortium and the British Standards Institution.  It is managed by the Government’s National Cyber Security Centre.

Recent events have shown the risk of cyber-attacks and the growing sophistication of such attacks.

“As a company, we are very conscious of our responsibilities in terms of maintaining the highest levels of cyber security,” comments Tony Wintrip, Office Manager, CHS Healthcare who has overseen the accreditation process.

“We are a major supplier of software to the NHS and as such, hold a large amount of continuing healthcare patient information. We are therefore very clear on the importance of having optimal cyber security in terms of our company processes and systems.

“The benefit of this Government backed scheme is that it gave us a very clear and robust set of standards and guidance, reflecting the latest knowledge in this area.

“We are particularly pleased to have been accredited with the highest level of assurance, Cyber Essentials Plus.”

Award for CHS team for Best Fast Track Support that is “a small nugget of brilliance” co-ordinating end-of-life care

Our Portsmouth team have been given an award for their fast track service, described as a “small nugget of brilliance” supporting patients who need end-of-life care.

The CHS Healthcare team at the Queen Alexandra Hospital provide dedicated co-ordination of care for patients with Fast Track (end-of-life) continuing healthcare funding.

Patients have high level of needs and require prompt and sensitive discharge co-ordination to ensure they spend their final days and weeks in an appropriate care setting.

The team won Best Fast Track Support category in the latest Portsmouth Hospitals NHS Trust awards. Explaining the decision to award the CHS Healthcare team, the Trust stated:

“The team is a small nugget of brilliance within the Integrated Discharge Service (IDS). They work tirelessly to deliver their tight key performance indicators to ensure prompt and suitable discharges for our most vulnerable patients.

“They communicate with all our IDS teams to make sure on a daily basis, that every opportunity for pace of discharge is explored. They are highly valued within IDS for their brokerage and their ‘hand holding’ service for patients and families” 

The CHS team in Portsmouth have been based at the Queen Alexandra Hospital supporting patients and their families since 2015. The team are commissioned to work with and support 30 self-funding/West Hampshire Clinical Commissioning Group placements, to include fast tracks, per month. The team provide a full patient discharge service working closely with families on both residential and nursing placements and packages of care at home.  

Melissa Allin, Business Manager for CHS Healthcare (south of England), commented: “We are really proud of the Portsmouth team, it is wonderful to see such commitment, skill and dedication acknowledged with this award.

“The team have worked above and beyond over the last few months, working additional hours when required, to ensure the successful implementation of a number of different processes to meet the expectations of the Trust and West Hampshire CCG.”

Care in the right placeLearn more here