Thanks to a winter of unprecedented pressure, the OPEL framework is becoming increasingly familiar, both within the NHS and beyond.

Published last October, the Operational Pressures Escalation Levels Framework was developed to establish a nationally consistent system for defining pressure on health and social care systems.

The idea is to have agreed criteria for interpreting pressure and clear mitigating actions to address that pressure at each stage.

Inevitably, media headlines have focused on individual trusts declaring OPEL level four, the highest state of pressure and escalation.

However, lesser publicised detail of the framework, particularly the mitigating factors for each level of escalation, provides a very valuable insight into what can be done when a health and social care system comes under pressure.

For example, when a system moves from OPEL 1 to OPEL 2, across all the mitigating actions, these themes stand out: prioritising discharge in clinical processes plus better co-ordination and communication between acute and community.

The guidance states: the acute trust must maximise rapid discharge of patients. At the same time, commissioners should expedite additional capacity in the community and independent sector, while community care should also maximise use of reablement/intermediate care beds.

This is precisely the interface where we work; we recognise the impact which can be achieved here, despite all the well-known challenges. For example, where we are commissioned to maximise discharge of patients by providing care co-ordination and family support, we are typically reducing DTOC (Delayed transfers of care) by 50 to 80 per cent, depending on trust’s benchmark before our service commenced.

Working effectively with the community health and social care sector, we reduce delays (for example, by supporting care homes to speed up hospital based assessments) and through our close and individual links with care providers, we do find capacity even in the most challenging areas.

Moving up from OPEL level two to three, again, there is a consistent emphasis in all parts of the system to expedite discharge by discharge. Again, the need to ensure care packages are arranged to facilitate discharge is described in the guidance several times. The guidance also states that domiciliary care packages should be increased for individuals in their own home to reduce the risk of those individuals needing an emergency hospital admission.

We work in 25 different hospitals across the country and frequently hear “there is no domiciliary care” resource in certain areas, or where an individual has very complex needs. In some areas, services are working with an automated system of care brokerage, while others are heavily reliant upon email based communications. Our teams speak with home care agencies on a daily basis; through these relationships, we build willingness to meet challenges and the ability to find solutions.

We would not seek to underestimate the challenge of domiciliary care capacity, particularly in some parts of the country. However we have shown, in many areas, that better communication and co-ordination does have a real impact in terms of finding capacity and solutions.

Even on the highest OPEL level four, where the overall emphasis is upon emergency measures, there remains a focus on discharge and community capacity. Community services are tasked with ensuring all available capacity is identified and board rounds are recommended to achieve “quick wins” and better flow. We have been involved in board rounds, tasked specifically with expediting discharge and recognise how this step can have a very significant impact.

In other words – there are factors in an escalation in pressure which are very difficult to control. But there are mitigating factors at each level; there are things which health and social care systems CAN do. And the same theme appears in the mitigating factors in all four escalation levels: expedite hospital discharges by a number of measures applied across the whole health and social system – use board rounds, prioritise discharge, good communication with community providers, consistent and rigorously seek capacity, even in challenging areas. These are all interfaces where we work: we can support patient flow and we do so on a daily basis in NHS hospitals from the south coast to the north of England.

By Dr Richard Newland, CHS Healthcare chief executive

It is recognised that a myriad of medical, individual and organisational factors produce delays in hospital discharge. The problem is precisely recorded. Statistics released in the NHS Monthly Situation Report tell us, for example, that in July 2015, there were 4,881 patients delayed in an acute care bed. This amounts to 147,005 delayed bed days, representing the total figure for acute care being provided beyond the stage when it is clinically needed, in a single month.

The report drills down further into reasons for these delays. NHS delays are the most common cause of delays, where patients are waiting for further non-acute NHS care such as rehabilitation services or an intermediate bed. This accounts for 17 per cent of the total delays. The second largest factor is waiting for an assessment, producing 11 per cent of delays. Patient or family choice produces the third highest numbers of discharge delays, at 9 per cent of the total. This is not an insignificant proportion – choice was responsible for 11,911 delayed bed days across England in July 2015 alone.

What is the scenario behind a delayed discharge due to patient or family choice? This is something we repeatedly see and discuss with our NHS partners. When patients need to choose a care home in order to leave hospital, ward staff often do not have time to do more than provide a directory listing hundreds of care homes. Many patients and families, understandably, find this overwhelming. Choosing a care home for a parent or relative is commonly a difficult, emotional challenge and left without support and guidance, families will flounder and delay. Family choice can be particularly challenging if next of kin live far from the elderly relative, if there is a lack of transport to view homes and disputes between family members can occur, causing complex delays.

Self-funding patients are a growing proportion of home of choice patients; across the south-east, accounting for more than 70 per cent of patients who need to choose a care home in order to leave hospital. Without the support which comes with social services funding for long term care, self-funders are widely recognised as being at a high risk of delayed discharge.
Our work is founded on the recognition that when patients and families need to choose a care home, this should be a supported process. Left to do this alone, people frequently feel daunted and poorly equipped. Our advisers have the experience and local knowledge to help families focus on the care homes most appropriate for them, supporting them through visits and each step. In this way, they are making an informed, supported choice.

We regularly carry out evaluations with the families we have worked with and ask – how would you have managed to choose a care home without our service? The most common answer is: we would have got there in the end, but it would have far more challenging, stressful and would have taken a lot more time.

From a health and social care systems perspective, there is a simple message: some of the causes of delays to discharge are not easily addressed or changed. Organisational factors such as patients transferring to other parts of the NHS or assessments taking place are critical challenges to address, but may take time as they involve a complex health and social care system.

On the other hand, patient and family choice as a significant cause of delays is something that can be quickly and effectively addressed. Our dedicated, personalised support for families choosing a care home is proven to reduce delayed bed days by at least 50 per cent and equally, to enhance the experience for service users.