Improving health and social care service resilience over public holidays: report

4 Health and Social Care Services

4.1 Primary and Community Care

The aim of the Primary and Community Care Working Group was to develop a set of recommendations to improve community based services, over public holiday periods.

Enhancing the interface between Primary Care OOH services and in-hours general practice is essential to support continuity of care. This has been recognised in the draft Memorandum of Understanding (MoU), ^[13] underpinning the delivery of the 2018 General Medical Services ( GMS) Contract, which promotes the development of expanded primary care teams and general medical practitioners ( GPs) as expert medical generalists. This MoU, supported by Chief Officers of Integration Authorities and Chief Executives of NHS Boards, sets out the development of local Primary Care Improvement Plans, promoting effective health and social care collaboration. Going forward, these Primary Care Improvement Plans embrace the role of GP Clusters in quality improvement, facilitating information exchange both in-hours and out-of-hours periods.

The volume of work in the community increases markedly over public holidays, over and above normal weekend demand.

Some of the significant issues impacting on primary and community care services over public holiday periods include:

Staffing

• Workforce planning and management of staffing over public holidays
• Availability of sufficient staff – and in particular general practitioners ( GPs), community nursing and Advanced nurse practitioners, staff working for NHS 24 and the Scottish Ambulance Service ( SAS)

Services

• Lack of availability of routine services during public holiday periods exerts significant pressures on all OOH services. This includes Primary Care OOH services, community pharmacies, NHS 24, SAS, social care community services and nursing homes

Communication

• Fragmentary/unreliable communication across and between services
• Access to and consistency of, anticipatory care plans ( ACPs)
• Awareness and availability of Urgent Care Patient Group Directives ( PGDs) and the Pharmacy First initiative for access to medicines

Recommendations 1-11 cover primary care and community services (see Section 7 and Appendix 2).

During public holiday periods, a large number of contacts with NHS 24 and Primary Care OOH services are about accessing previously prescribed medicines. We believe that there should be a stronger focus on enhancing the role of community pharmacies to support self-care, provide better access to medicines and also to promote better use of the Minor Ailment Service ( MAS). ^[14]

Across Scotland, more ready access to community pharmacy services is already underway in OOH periods. This includes novel models of care being developed by NHS Greater Glasgow and Clyde, NHS Lothian and NHS Tayside.

Increasing the numbers of trained independent (non-medical) prescribers in the community should also contribute to the timely supply and administration of medicines over public holiday periods. This requires further evaluation.

NHS 24 provides specific palliative care support and advice via their NHS Inform website service. ^[15] Developing, updating and sharing of individual anticipatory care plans ( ACPs) is imperative - particularly in advance of extended holiday periods. Timely and secure record access is essential for sharing of electronic care information (Emergency Care Summary ECS/Key Information Summary KIS). This is particularly pressing for individuals who have service accessibility issues, including: cancer care, frailty, mental health, palliative care and end of life care needs.

Workforce planning and development of extended professional roles within primary care was recommended by the Primary Care OOH Review and is presently underway. More Advanced Nurse Practitioners ( ANPs), District Nurses, Community Pharmacists and Allied Health Professionals ( AHPs) including paramedics, will be required to meet the evolving needs of individual communities and localities. This is in keeping with the National Clinical Strategy ^[16] and national workforce planning. ^[17]

in addition to its traditional 999 and transport roles, the Scottish Ambulance Service ( SAS), is also now focused on taking care to people, helping them to remain in their own homes and to avoid unnecessary attendance and admission to hospital. ^[18]

Some Health Boards, in collaboration with Integration Authorities, presently deliver a locality based single point of contact service, from where combined health and social care input can be coordinated. This function was originally recommended in the Primary Care OOH Review, described as an Urgent Care Resource Hub. ^[19] Where this is not available or not yet developed, we recommend that NHS 24 should support Board areas to provide safe and timely access to optimal clinical decision support, including anticipatory care plans. This is particularly important for the optimal care and support of care for palliative/end of life care needs.

4.2 Acute/Hospital Care

The aim of the Acute/Hospital Care working group was to develop a set of recommendations to optimise service accessibility and to improve hospital ‘patient flow’ over public holiday periods.

A number of issues consistently impact on acute services over public holiday periods, including: an imbalance of demand and capacity, reduction in discharge rates and increased length of stay in hospital. Individuals admitted for acute hospital care over the Christmas and New Year festive period are likely to have a prolonged length of stay of one day extra, or more.

Available evidence shows that while bed occupancy rate reduces in the immediate run up to Christmas, it then rapidly increases by the end of the festive period. Across Scotland there were ~1200 more hospital discharges than admissions in the lead up to Christmas 2016, followed by ~2000 more admissions than discharges over the festive holiday period. This then impacts on the delivery of optimal care for a number of weeks into the new year. It may take up to eight weeks for some acute hospitals to ‘recover’ from the effects of festive holiday periods.

There are a number of initiatives presently underway, as part of the Six Essential Actions for Unscheduled Care Improvement Programme. ^[20] These initiatives should help to improve systematic hospital discharges on a continuous (365 day) basis.

There is also a drive to increase the timeliness of hospital discharge each day by shifting the daily discharge curve. A collaborative programme to support the roll out of Daily Dynamic Discharge ( DDD) ^[21] is underway across acute and community hospitals in Scotland. This approach should improve quality of the patient journey of care - linked to a timely site-based patient (bed) management system. Planning and synchronising clinical and therapeutic pathways helps to ensure that patients are appropriately discharged as soon as they are fit and ready.

Some of the significant issues identified as impacting on acute hospital services that lead to unnecessary admission and/or delays in discharging patients over public holiday periods include:

Staffing

• Workforce planning, ensuring the right availability of multidisciplinary staffing and skills mix, including AHPs (physiotherapy an occupational therapy)
• Systematic rostering, accessibility and visibility of senior decision makers aligned with prevailing demand

Support Services

• Proactive discharge prescribing and availability of prescribed medicines
• Ready access to aids and equipment
• Availability of diagnostic, laboratory and imaging services
• Timely transport availability
• Accessibility of relevant patient information to assist optimal decision making

Communication

• Greater awareness / accessibility of community services and care provision

Data/Intelligence

• Better use of local intelligence to understand and anticipate demand over public holidays
• More systematic use of demand prediction tools (System Watch), ^[22] to support advance planning of demand and capacity

Acute/Hospital Care Recommendations

Recommendations 12-16 suggest measures to improve care and to mitigate pressures on hospital services over public holiday periods (see Section 7 and Appendix 2).

Proactive discharge planning should be in place prior to public holiday periods, following the principles of the Six Essential Actions for Unscheduled Care. ^[23] This includes timely preparation of Immediate Discharge Letters ( IDLs) and medicines availability – including near patient dispensing, for example: One-Stop dispensing. ^[24]

On-going, reliable availability of support services within hospitals is equally crucial for the timely discharge of patients.

Analysis suggests that many patients admitted to hospital during week days - either as an acute medical or surgical emergency - will have recovered sufficiently and could be discharged over the following weekend. These are typically patients admitted on a Wednesday, Thursday or Friday who would normally have a length of stay of two to three days, but who have their length of stay extended over the weekend. If these recovered patients were discharged over weekend periods this would free up many beds for earlier admission of new urgent/emergency cases in the following week and would contribute to shorter lengths of stay. These findings also apply to public holiday periods (see Section 3).

4.3 Mental Health

NHS 24 continues to support increased numbers of contacts from individuals with mental health needs. In turn, this has resulted in a raised number of people referred to partner agencies in the OOH period. This also leads to an increase of in hours referrals, particularly to child or adult protection services.

The recently published Mental Health Strategy ^[25] aims to improve Adult, Child and Adolescent Mental Health services and to bring together other providers of mental health services for children, young people, adults and families/carers to receive optimal and timely support.

Presently there is no national standard specification of OOH care and support for those individuals accessing services for mental distress/illness. Additionally, evidence suggests that individuals maybe more likely to directly seek help from the Scottish Ambulance Service ( SAS) or self-present in crisis or distress at acute/A&E services (Emergency Departments/Minor Injury Units) than to access traditional primary care services. Through the work being undertaken by NHS Health Improvement Scotland as part of the Urgent Care Portfolio, initial data analysis by the Patient Journey Group (mental Health) established that these individuals are three times more likely to directly present to A&E services in acute mental crisis/distress and five times more likely to be admitted in OOH periods.

Relevant recommendations outlined in the Mental Health Strategy have been taken account of in the Public Holiday Review, in order to improve service access and availability during public holiday periods.

Hospital mental health services operate continuously across Scotland, 24 hours a day, 365 days a year. Some areas have OOH crisis services to try to prevent admission or to support early discharge or to support people at home – this varies across Scotland. Inpatients admitted just before or at a public holiday may experience delayed discharge.

Recommendations 9 and 10 are specific to improve urgent care arrangements, take account of the needs of people with mental health problems or distress and seek to promote shorter waiting times. Many of the other recommendations also apply to individuals with mental health issues (see Section 7 and Appendix 2).

Closer working is required between mental health and primary care OOH services with enhanced access to mental health services in ‘front door’ hospital sites and for referrals in community settings during public holiday and OOH periods.

Distress Brief Interventions ( DBI) ^[26] support people in distress and were supported in the Suicide Prevention ^[27] and Mental Health strategies. ^[28] The need to improve the response to people presenting in distress has been strongly advocated by service users and front-line service providers. The overarching aim of the DBI programme is to provide a framework for improved inter-agency coordination, collaboration and cooperation across a wide range of care, settings, interventions and community support. By intervening early, DBIs seek to better engage and equip people in managing their own health, offering a structured approach for medium to long-term reduction in distress.

4.4 Social Care

The main aim of the Social Care Working Group was to assess and make recommendations about the key function of timely social care support around acute and community hospitals. Core social care services need to be reliably put into place to prevent people being admitted unnecessarily to hospital and to speed up discharge when appropriate, on a continuous basis including public holidays and weekend periods.

Social care OOH services have primarily been developed to provide public protection functions and to respond to the urgent needs of vulnerable people. Integration Authorities have begun to commission new arrangements either as an adjunct to their main OOH services or as a separate service provided around acute hospitals.

The recommendations from this Review provide a timely opportunity to implement the principles underpinning Health and Social Care Integration for improving urgent care throughout Scotland The ethos of Health and Social Care Integration recognises the move away from individual care sectors acting autonomously - towards increasingly aligned (‘joined up’) health and social care service. This also includes third and independent sector provision.

Delegated functions to Integration Authorities include: Adult Social Care, NHS Community Services, Primary Care and certain hospital functions associated with unscheduled care. Some Authorities have additional delegated functions including children’s services, with differing patterns across Scotland.

Integration Authorities have the statutory role for strategic planning and setting priorities for changing services including how resources are used for delegated functions. These are central to achieving change through NHS Boards and Local Authorities. As noted before, Chief Officers of Integration Authorities have been engaged in the work of the Public Holiday Review and are committed to work within their localities to ensure that jointly planned services are implemented according to local needs and circumstance, including public holiday provision.

Over public holiday periods the Review has identified challenges for all OOH services including better integration of these services.

Significant issues identified by the Social Care Working Group were:

Staffing

• There is a pressing need for effective and continuous leadership and decision making during OOH and public holidays periods
• Social work activities may be limited over OOH and public holiday periods, due to limited staffing availability

Services

• There are variable levels of access to social care services provided during OOH and public holiday periods throughout Scotland
• New admissions to care homes are lower at weekends and during the first three days of an extended public holiday period

Communication

• Effective cross-system communication is key - including with the third and independent care sectors
• A flexible and pragmatic approach is required for optimal care decision making over weekends and public holiday periods

Social care OOH services in Scotland have been developed around the core functions of keeping individuals, families and communities safe and responding to urgent situations, according to need. Much of the current social care activity in the OOH period relates to child protection, adult protection and monitoring of high risk offenders.

Social Care Recommendations

Recommendations 17-20 cover what we suggest can be done to enhance social care services during public holiday periods (see Section 7 and Appendix 2). The thrust of winter planning over recent years has been shifting away from a hospital focus to a whole system focus across the whole calendar year. This will support the implementation of the recommendations in the Review and should promote better links between all health and social care partners

Innovative models of care have already been developed, for example, in Grampian and Lothian, where Integration Authorities have led winter planning across the whole care system. This has resulted in novel ideas being tested, for example: improving flu vaccination uptake for housebound patients.

In order to support best care, we recommend that the Scottish Government should work with Integration Authorities and other partners to develop good practice and shared learning on the prevention of unnecessary admission to hospital and timely discharge from hospital during OOH and public holiday periods.

Integration Authorities should commission OOH services that provide resilient integrated health and social care over public holiday periods. This includes effective communication and clarity about where authority lies to set up and alter individual social care support arrangements, whenever required, including public holidays.

In keeping with the recommendations in the Primary Care OOH Review, ^[29] we also recommend that a model service specification should be developed to assist with the redesign of integrated OOH arrangements.