CHS has undertaken a piece of work that digs into the underlying issues causing delayed hospital discharge. Through a survey of hospital workers and social care staff, and a roundtable with expert NHS leaders, we’ve sought to pinpoint issues and discuss the solutions.

The survey* revealed hospital workers believe almost half (43%) of their patients meet the NHS’ criteria for hospital discharge. With the NHS facing unprecedented pressures almost one in five hospital workers (17%) reported patient flow as the biggest problem they face.

It is well documented that early discharge planning from admission is required to help individuals get discharged as efficiently as possible. However, the survey revealed that in 31% of cases, hospital discharge is not discussed until treatment nears completion or once the patient is medically optimised. The survey also revealed that two in five hospital workers (40%) are unaware of the government’s ‘Discharge to Assess, Home First’ guidance, which is designed to avoid delays in care discharge.

Care home staff and managers responding to the survey reported that the top three factors contributing to delays in discharge from their perspective are paperwork, admin and bureaucracy (54%), no clear discharge planning pathway (48%), and delays in agreeing funding (47%). Staff also added that better discharge planning prior to patients being medically optimised would benefit those who are transferred to additional care (75%)

So how do we fix these issues?

Speaking at the roundtable, Liz Bruce, Joint Executive Director, Adult Social Care & Integrated Commissioning, Surrey, made the point that discharge is everybody’s business, not just It’s not just a section of the staff in the hospital or the discharge team in social care. A key point, underlining the need for collaboration, starting with system design that brings together knowledge and skills from across the entire health and care sector.

The NHS must also look beyond the numbers and manage patient flow through the system, ensuring complex cases are adequately resourced and planned.

Also at the roundtable, Lesley Watts, Chief Executive Officer at Chelsea and Westminster Hospital NHS Foundation Trust, told the group of the need for strategic planning from ICBs for complex cases, such as for people with mental health or physical rehabilitation needs or need social care support, and highlighted the significant benefit for patients when systems work together.

With unrelenting pressures felt across the system, accelerating patient flow is the immediate and glaring opportunity to protect patient outcomes and create sustainably in the NHS.

Our work over the last few weeks shines a light on the issues faced by hardworking health and social care staff, and the urgent need to re-engineer processes and drive greater co-ordinated collaboration to create a system that truly meets the needs of patients and helps create much needed capacity.

A system that works for patients needs hospital teams, social care services, families and providers working and planning together. Achieving this will increase capability through resource and scale, giving everyone the tools they need to make significant change.

*CHS Healthcare Hospital Discharge Survey (May 2022)

The challenges around hospital discharge and patient flow across the public and private are well documented. Emerging guidance and initiatives set out by the Government and NHS England suggest that immediate tangible actions are required and it is extremely encouraging to see this national effort to drive improvement.

100-Day Challenge:

NHS COO Sir David Sloman set out the ambition of the challenge* in a letter to staff. An NHS taskforce, aiming to improve the outcomes for patients who no longer meet the criteria to reside, has identified 10 best practice initiatives that demonstrably improve flow and therefore, should be implemented in every trust and system:

1. Identify patients needing complex discharge support early
2. Ensure multidisciplinary engagement in early discharge plan
3. Set expected date of discharge (EDD), and discharge within 48 hours of admission
4. Ensuring consistency of process, personnel and documentation in ward rounds
5. Apply seven-day working to enable discharge of patients during weekends
6. Treat delayed discharge as a potential harm event
7. Streamline operation of transfer of care hubs
8. Develop demand/capacity modelling for local and community systems
9. Manage workforce capacity in community and social care settings to better match predicted patterns in demand for care and any surges
10. Revise intermediate care strategies to optimise recovery and rehabilitation*

(*B1782-acute-hospital-discharge-100-day-challenge.pdf (england.nhs.uk)

The 100-Day challenge calls for trusts to adopt these initiatives, with the aim of driving tangible improvements across systems.

Discharge Integration Frontrunner Sites:

NHS England has called for expressions of interest to become Discharge Integration Frontrunner Sites*. Aimed at local systems who are keen to lead      the way in developing and testing radical new approaches to discharge, these sites will focus on overcoming issues and improving discharge from hospital.

While still in development, NHS England expects Frontrunner sites will:

1. Design and test new service models, such as the delivery of a more integrated model for intermediate care across existing health and social care portfolios.

2. Design and test new enabling arrangements, which might include new funding models, more integrated workforce models, or the deployment of new technologies

We look forward to hearing more about these sites in the coming weeks.

* B1747-integration-frontrunners-letter.pdf (england.nhs.uk)

Both initiatives point to an acceptance that the current system is broken. For the challenges to be addressed, a new operating model is needed which involves active collaboration of public and private services.

Our experience of working collaboratively with the system has shown success in tackling patient flow and hospital discharge challenges. CHS Healthcare already follow best practice initiatives to ensure patients are discharged from hospital to more appropriate settings for care in a timely manner, to optimise patient outcomes. We proactively coordinate all aspects of the patient’s journey, acting as a single point of access for families, system partners and providers while being careful to set expectations and continuously keeping patients and NOK’s updated throughout the process, minimising potential family delays.

We can identify the challenges and support the system to tackle them. A new operating model based on collaborative working and a whole system approach means that hospital discharge and patient flow no longer need to be the battleground of the NHS.

Uko Umotong

Yesterday, NHS England released data revealing for the first time how many people have been on elective care waiting lists for more than 18 months and more than two years.

Up until now, the reporting timeframe of patient waiting lists only stretched to “longer than a year” but due to the impact of Covid-19 the reporting times have increased.

We now know that there are nearly 65,000 people who have been waiting for treatment for more than 18 months, including nearly 3,000 who have been waiting for more than 2 years. It is also the first time that the number of people on waiting lists in England has topped 5 million.

While record numbers waiting for elective surgery is most alarming and should certainly be a key element of focus for the NHS, a potentially bigger problem might be an issue which was raised in the Health Service Journal yesterday.

The article argues that the NHS’s most concerning waiting list problem right now may not be the total number of ‘long waiters’ but is instead the backlog of so-called ‘P2s’ – patients needing treatment within a month.

Many trusts are prioritising P2s. This is seen as the right clinical and moral approach, as these patients are at the most immediate risk of major deterioration and harm. Although these are the patients whose care is likely to become significantly more complex and costly while they wait, some are still waiting upwards of a year or more.

And it doesn’t seem that the issue of these urgent patients will be eliminated in the immediate future. King’s Fund chief analyst Siva Anadaciva said: “[A] worrying element of the issue [around P2s] is that some of the people I’m speaking to in the system are not expecting matters to be resolved any time soon. One figure I spoke to said they were looking at eliminating long waits for P2 patients only by the end of 2021.”

Thinking about patient flow this presents three different areas of focus in the conversation around elective care backlog – all concerning and requiring attention.

1. Addressing super-stranded patients

In April we highlighted that it will be impossible to manage any backlog without addressing super-stranded patients. At that point (from which the most recent data are available) there were over 10,000 beds in England being occupied by super stranded patients (patients who have been in hospital for over 21 days). Many of these will be complex patients or potentially out-of-area patients which require dedicated time and effort to pull in wider partners.

We know super-stranded patients are a manageable problem, but we are seeing more of these patients in acute beds rather than moving into community pathways. Dedicated hospital discharge services are able to efficiently manage rehabilitation needs, TTOs and support families in decision making – all critical ingredients in efficient discharge.

2. Partnership working

As we move through different phases of easing restrictions, we cannot forget that there is still a significant amount of work to get done before we return to pre-Covid waiting times. The NHS has been formidable in its response to Covid-19, but we must recognise that the battle is far from over. It will take a strategic and collaborative effort from organisations across the health and care sector working in tandem to get back to acceptable levels.

3. Focussed attention on complexity

Hospital discharge is the backbone of patient flow and a concerted and continuous effort must be applied to ensure that the backdoor is not a contributing factor to any delays for people being admitted. Complex admissions generally result in complex needs at discharge which we know has traditionally been a contributing factor to lack of available beds. These patients are easily identified on admission and often already have an element of care delivery which usually requires a high degree of engagement to ensure it remains in place for the patient to return to once treated. It may be residential care home bed, a domiciliary care provider or family carers. These existing provisions are often allowed to fail rather that exploring if it could stepped up which means a completely new provision is required to be put in place once the patient is medically optimises and ready to leave hospital.

Dedicated hospital discharge services are able to work intensively with patients, their families, clinical staff and community providers to help these patients out of hospital into long terms care as soon as they are medically optimised. Expecting NHS teams to handle these discharge cases in addition to their existing work can cause delays – often these teams are stretched and under resourced.

We’re entering the summer months when system pressures are traditionally lower, but we know this summer, like the last, will be very different from normal – we’re already seeing Covid-19 admissions climbing. Shortly we’ll be considering the collective impact of flu, the elective list activity and Covid-19. A lockdown to manage this scenario will be widely unpopular.

Following more than a year of the pandemic, we have the benefit of understanding future challenges. It’s time to acknowledge that it will take a dedicated workforce solution alongside an integrated approach between public and private healthcare organisations to reach the goals of efficient patient flow and ultimately, a reduction in waiting times for those in need.

Arthur Calder, Head of Clinical Services

At the end of March, NHS England published a report by Ipsos Mori which considered the future of the Learning Disability Mortality Review programme (LeDeR) programme. The report was removed from the website shortly after publishing and has not been republished at the time of writing this blog.

The LeDeR programme was set up in 2015 to support improvements in health and care for people with learning disabilities as well as reduce premature mortality and health inequalities for this population. It has been criticised for large backlogs in the review process and consequent delays to findings.

We have supported the LeDeR programme by undertaking reviews across North West London, South East London, Lincolnshire, Humberside and Yorkshire. We have a large and highly experienced workforce made up of reviewers as well as professional administrative support able to navigate the complex challenge of gathering evidence for reviews.

Our services have ensured that commissioners confirm compliance across all quantitative and qualitative metrics.

We have previously noted a number of challenges of the programme – many of which were reflected in the Ipsos Mori report:

• Many reviewers are undertaking reviews on top of their day job and may only be given a small number each year, which means efficiencies of scale are not realised, and neither is a consistency in approach
• Because there is no dedicated professional workforce responsible for undertaking these reviews, reviewers are unable to benefit from insight gained through considering and reflecting on a large number of cases
• The lack of dedicated workforce also means findings are not followed through to policy and implementation. The lack of challenge to recommendations suggests they are not being seen as a critical resource in design of services and care for people with learning disabilities.
• There is a lack of awareness of the programme amongst clinicians and this can result in confusion when they are asked to provide evidence into a review

It is encouraging to see alongside this report a new policy from NHS England which shapes the future of the LeDeR programme. The move for reviews and the programme to sit with each Integrated Care System (ICS), announced in the new NHS England policy, is a positive one. By commissioning this programme through ICS structures there is an opportunity to create scale for reviews both in terms of workforce and insight. ICSs have the reach and structure to follow recommendations through such that they are considered and understood in a meaningful and practical way. This has the potential to result in actionable changes which improve how health and care for people with learning disabilities is provided and further developed.

In a few months, reviews will be streamlined via a national database for all LeDeR cases. When it goes live in June, all case work will be allocated through this system. While this transfer process will result in a gap in both data and reviews between April and June, it’s critical that resources are in place to take on reviews as soon as the system is live.

Our view is that the LeDeR programme, in its current state, lacks the required partnership approach between a dedicated workforce of reviewers and specialist administrative teams, clinicians, families, experts and policy makers. There is an efficiency as well as a compassion that this relationship can bring, and it also allows for learnings to truly be implemented. These skills and expertise need to exist as a dedicated resource rather than an additional ask for staff. Positively, the move to operating under the ICS model could allow this type of capability to commissioned at scale. Ultimately, successful partnerships will improve the programme for the workforce, clinicians caring for people with learning disabilities and critically, people with learning disabilities and their families themselves.

Dr Gabrielle Silver
CEO CHS Healthcare

Recent data has shown a reducing pressure from Covid-19 on hospitals, with the total number of people in hospital with Covid-19 decreasing each day. As of 14 April, there were 1,972 people in hospitals across England with Covid-19, which is 94% fewer people than at the peak of 34,000 in January. Furthermore, deaths from Covid-19 have also fallen, with the daily average over the past week equalling 28 deaths per day. 

But while this data can be seen as relatively good news and with the vaccine rollout currently being deemed a success and major contributor to the reduction in community transmission, recent data from NHS England has raised alarm with the rise in backlog of patients awaiting elective care at unprecedented levels. 

Figures from NHS England have confirmed that approximately 4.7 million people were waiting for routine operations and procedures in England in February – the most since 2007. The number of people having to wait more than 52 weeks to start hospital treatment also stood at 387,885 in February – the highest number for any calendar month since December 2007. One year earlier, in February 2020, the number stood at just 1,613.

Additionally, as of 4 April, there are over 10,000 beds in England being occupied by super stranded patients (patients who have been in hospital for over 21 days). 

Patient flow lies at the heart of reducing waiting lists, and the government has committed £594m from April to September 2021 to support this. Prime Minister Boris Johnson has said the government would “make sure that we give the NHS all the funding that it needs…to beat the backlog”. 

Funding helps  but patient flow is complicated – if it were easy we wouldn’t be discussing it with such regularity. We need to learn lessons from winters past. To make the difference required, funding will need to be put to work in the most impactful way.  Being clear about what structures deliver results and not shoring up those which don’t, aiming to achieve better than minimums defined in guidance and investing in relationships with providers and partners will help ensure the fly-wheel of patient flow can be kick started and maintained. 

The NHS has had a dreadful time and getting patient-flow right so that elective surgery can be delivered at pace won’t be easy. Staff are exhausted and patients will become increasing high acuity as they wait.  All of this against the backdrop of a third wave and unknown variants is a worrying thought. 

The NHS is held in high regard by the public – never more so than now. Public opinion will carry a long way but these waiting lists are not comparable to anything we have seen before.  What we must avoid is a situation where this problem becomes the NHS’ alone or a problem which has to be solved by the centre. Recent news about dodgy procurement may hit headlines but in reality procurement in the NHS is highly structured and extremely well managed. Constraining trusts and CCGs from making decisions about how they utilise funding would be corrosive for the NHS itself.  An aging population and the elective backlog will continue to demand more from the NHS – it needs to be supported with appropriate funding and the support of partners.

One of the benefits of the NHS is that surrounding it there is a health sector made up of organisations of all shapes and sizes willing to support this next national challenge.  We know what’s coming and therefore we can act with foresight and thoughtfulness about what is really going to make a difference and what we know can make a difference.  What we can’t let happen is for the NHS to be left to manage this all on its own out of a misguided belief that others are seeking to take advantage. It couldn’t be further from the truth. 

 

Uko Umotong

National Discharge and Community Services Manager

On March 31 the existing schemes which have funded care for people discharged from hospital will come to an end. These schemes have covered costs for up to six weeks care in the community while patients receive rehabilitation and assessments, and long-term care is arranged. This funding had a direct impact on patient flow by removing a lot of the issues traditionally associated with delays including choice and decisions on funding. 

While patients have moved quickly out of hospital into community beds the move from temporary community beds to long term care has not been as quick in all circumstances.  There are patients who received funding in the initial phases of the pandemic who have not yet been moved into long term arrangements.   

This week marks the one-year anniversary of Boris Johnson announcing the national lockdown and the last 12 months have been a huge challenge for all organisations involved in health and care. While it’s important to acknowledge the huge efforts as well as the toll of the pandemic there is no doubt that difficult times lie ahead as well. It’s predicted elective surgery waiting lists could balloon to around 8 million people by the autumn. 

Patient flow lies at the centre of reducing these waiting lists. Last week the government committed to £594m funding from April to September 2021 to enable patients to leave hospital as quickly and as safely as possible, with the right community or at-home support. 

While it is unclear at this stage how different areas will deploy this funding. What is really important, to ensure this funding has the biggest impact, is that as patients leave hospital dedicated support is available moving them through rehabilitation and assessments so that they are able to settle into long terms care as quickly as possible. 

Schemes 1 + 2 have been a success on the whole but too often six weeks funding has been seen as a given and this slows down patient flow and reduces capacity in the community. With the right focussed support moving assessments forward, making arrangements for long term care and supporting families in decision making we can maintain flow as well as make sure people have the right care in the right place at the right time. 

Uko Umotong, Hospital Discharge & Community Services Manager

We know that efficient discharge and patient flow are especially critical at the moment given the ongoing pressures on the NHS and social care and with a “new normal” potentially on the horizon. 

To open the discussion around how this can best be managed, we recently held the fifth session in our ongoing webinar series, “How can data support better discharge management?” Here we heard from Lisa Duncan, Urgent Care and Senior Operations Manager at Staffordshire and Stoke-on-Trent CCGs, as well as Kate Tatton, Business Manager (Midlands) at CHS Healthcare. 

We discussed the ongoing challenges in discharge management, and how data can be used to overcome them. With the example of CHS’s dashboard, we were able to highlight how an integrated management system can play an important role in this process, as well as planning for the future. 

 

Overcoming challenges in discharge management

Some of the main challenges in discharge management include:

• Understanding real-time demand for services and patient status
• Having to consult multiple reporting systems for information and lack of interoperability between them
• Managing flow through Covid-designated spaces

There must be an understanding of where patients are in the system, how they are moving through it, and how this fluctuates. The best way of achieving this is through access to real-time, system-wide data. We heard from attendees that nationally, people across systems and job roles find it challenging to access the information they need when they need it. Accounting for additional Covid-19 requirements like designated spaces is incredibly difficult without this. 

Where this data is available, it allows users to look at specific areas requiring attention, as well as being able to step back and look at the system more holistically to understand the impacts that activities in specific areas have on one another.

 

Informing diverse stakeholders

The Covid-19 pandemic has undoubtedly furthered partnership working. Given the volume of patients moving through health and social care systems and the necessary pace, there is a need for a collective way to manage the data that are critical to the oversight of this process. 

Discharge processes often occur in silos, despite there being several stakeholders across health and social care involved in the patient journey. Different stakeholders will need different types of information, so we need a system that caters for this. This could include:

• Bed occupancy in acute settings and in the community, as well as insight on where fluctuations may be coming
• Where patients are at a given time, how long they have been there, where they have come from and where they are going
• Infection control in the community (such as outbreaks in care homes) and how this will impact the wider D2A system 
• Opportunities to involve other partners like mental health services 

 

CHS’s Discharge Pathway Analytics

CHS has developed a web-based dashboard that houses all of the above information, accessible in real time. The dashboard is access-led so all stakeholders only access what they need and is relevant to them. 

 

Using data and insights to plan for the future

From this information we can draw insight, which is incredibly valuable for ongoing decision making as well as evidence-informed future planning. The partnership working facilitated through a system like CHS’s dashboard allows stakeholders to move past the step of needing to collect and collate information to instead focus on what comes next given what they already know. The consequences of this are far-reaching, especially in planning and commissioning.

With the transition to Integrated Care Systems, this level of connectivity will be crucial, allowing a system to understand where gaps lie, where investment needs to be made, and how efficiencies can be enabled. At the local level this also means services can be strengthened to meet needs that will vary across and between populations and fluctuate over time. This oversight will also be key to admission avoidance and understanding if existing pathways are correct for different patients. 

 

During the session we received questions on the follow topics, both in relation to CHS’s Discharge Pathway Analytics and data supporting discharge management.

How do we balance sharing data appropriately but openly, and ensuring the right people have access to the right information? What reporting is available?

Data sharing is an ongoing issue, especially given the number of different organisations and sectors involved in hospital discharge. CHS’s dashboard provides an example of where having data housed and updated in a centralised database allows for real-time information to be extracted from the highest to the most granular level. As it is access-based, there are assurances that everyone who needs oversight has this and sees only the information that is required for their decision-making processes. 

In order to offer valuable insight, platforms need to have a reporting function that allows a user to look at discrete snapshots as well as trends, and to allow people to build their own reports based on their needs. CHS’s system shows real-time data and updates every 15 minutes. It can also be set to give you a snapshot report at a specific time, in line with any internal reporting requirements.

How can a data management system be used to account for requirements due to Covid-19, such as testing status and management of designated settings? 

Because a system like CHS’s dashboard houses its data in a central database, it can store data specific to Covid-19 such as testing status. This can be accessed on both an ad hoc and a real-time basis. Covid-designated settings are an example of where clear oversight of bed occupancy and length of stay are especially important. 

We have 3 local authorities, 1 community nursing partner, 2 acute hospitals, 3 community hospitals, 13 PCNs – would it be possible to use this tool across this entire footprint?

A system like CHS’s would be beneficial to disseminate information through this system and allow for proactive planning. 

How can we ensure as trusts that we are working in the same process?

Data held within the database will support process planning and performance metrics will allow trusts to measure consistency and alignment. Data integrity is key here – data entry is accurate and reliable ensuring output can be trusted.

A recording of the webinar is available here. 

CHS Healthcare and Acacium Group are pleased to announce that Acacium Group has completed the acquisition of CHS Healthcare. The support of Acacium Group will provide a catalyst for delivering innovative patient flow and pathway solutions across acute and community settings. Acacium Group and CHS Healthcare provide different but complementary services, and this acquisition will enable patient needs to be better served. There will be no changes to our customers’ current service delivery or our contractual terms, and we will continue supporting all our customers to the high standards we have always delivered. Dr. Gabrielle Silver, CEO, says, “CHS Healthcare is excited about joining Acacium Group. Our expert team has strong relationships across health and social care. They make a difference to the wellbeing and outcomes for patients and their families every day. The support of a healthcare solutions partner working with CHS Healthcare will provide a catalyst for delivering innovative patient flow and pathway solutions across acute and community settings. Together Acacium Group and CHS Healthcare can meet the changing needs of customers and the health and social care sectors.”

For more information, contact Ben.Hackwell@chshealthcare.co.uk.

Dr Gabrielle Silver
CEO CHS Healthcare

Hospital discharge and capacity in the community is becoming an increasingly important issue, with the pressure to keep patient flow moving out of hospital and into the community. Today (7 Jan) on Radio 4 we heard from Chris Hopson, CEO of NHS Providers: ‘Hospitals beds are full, community beds are full and community at home services are also full’. The HSJ also reported on Tuesday (5 Jan):

A spring-style policy intervention to require discharges to be arranged in hours, rather than days, with no dithering over cost, may be required. But where will the staff come from to achieve this? And where can individuals go if they are not ready for home? How do we ensure care homes are not compromised with COVID, and how to enact new policies with the independent care sector setting its own rules?

This highlights how the challenge of staffing has been drawn into sharp focus through this pandemic. I believe we need to think more laterally about how we support aspects of health and care. Hospital discharge is, at its heart, a practical process. Once a patient is medically optimised to leave hospital the clinical job to a large extent ceases. This is why I am not convinced that the issue is staffing per se. I think the issue is how hospital discharge is resourced day-to-day and a lack of effective management tools in the NHS.

Managing the discharge to assess (D2A) pathway is about having strong relationships with local care providers, working closely with families to make sure they are reassured and confident about next steps for their loved one and actively managing each individual’s care timetable to move rehabilitation along.

I see our team’s job as ‘keeping plates spinning’. On a practical level, this is making sure appointments such as occupational therapy take place on time and that any follow-up, like ordering equipment is managed. This detailed hand holding of each patient’s needs means that their care actively continues, and they are able to move quickly back home with support, or into a long-term bed with appropriate funding. And their original bed back goes into circulation for another patient who needs it.

A key element of this is the real-time tracking of patients and their care. We use a digital platform to ensure information about next steps are visible and available at any time to the team involved in their care. These tracking systems are increasingly important within acute trusts to monitor flow across multiple data feeds. We use the same logic but apply it to the discharge and rehabilitation of patients. Gone are the days when care is held up because an excel spreadsheet was not updated or someone forgot to pass a message on or record an appointment.

Technology, deployed correctly, guides staff so they are doing the exact right tasks at the right time to ensure an outcome – in this case patient flow.

As unpredictable as this pandemic has been, we know that pressure on hospital beds will continue for some time to come and that people will need to move promptly from acute services and will require substantial care in the community. The NHS has a huge amount of work to do and where we can provide support and keep things moving, we want to do so.

The workforce solution for many of the current challenges does exist. We must think beyond the NHS for solutions to non-clinical challenges. Where we look to the NHS as the only viable option, we do patients and even people waiting for vaccines a disservice. We need to be proactive and pragmatic – let the NHS get on with the complex and urgent work they need to do and are best placed to do.

When I look ahead past this pandemic and the long-term workforce challenge, I can see that there will be jobs created around health and care which have not even been considered yet. Jobs which we have seen as ‘clinical’ will be broken down and rebuilt as operational support in a whole range of new guises. This will benefit hugely not just the NHS but a completely altered labour market. Data and technology will play a huge role shaping these new job roles. In the meantime lets wrap our support around the NHS at this testing time – we all have a role to play.