WP 17
Ymchwiliad i barodrwydd ar gyfer y gaeaf 2016
Inquiry into winter preparedness 2016/17
Ymateb gan: Cymdeithas Llywodraeth Leol Cymru a Cymdeithas Cyfarwyddwyr Gwasanaethau Cymdeithasol
Response from: Welsh Local Government Association and Association of Directors of Social Services
Inquiry into Winter Preparedness 2016/17
1. The Welsh Local Government Association (WLGA) represents the 22 local authorities in Wales, and the three national park authorities and three fire and rescue authorities are associate members.
2. It seeks to provide representation to local authorities within an emerging policy framework that satisfies the key priorities of our members and delivers a broad range of services that add value to Welsh Local Government and the communities they serve.
3. The Association of Directors of Social Services Cymru (ADSS Cymru) is the professional and strategic leadership organisation for social services in Wales and is composed of statutory Directors of Social Services, and the Heads of Service who support them in delivering social services responsibilitiesand accountabilities; a group of more than 80 social services leaders across the 22 local authorities in Wales.
4. Much like other parts of the UK, urgent and emergency care services in Wales have experienced periods of significant pressure and demand. There has been a sharp rise in the number of people seeking treatment and care at emergency departments and a peak in ambulance arrivals at hospitals throughout Wales. Over recent years the NHS across Wales has seen an increased number of people being admitted with a complex range of medical conditions and consequently greater degrees of frailty. Because of the nature of their conditions, these people take longer to assess, diagnose and treat and may have ended up staying in hospital longer for their treatment; they often need more support arrangements to be put in place to enable them to eventually be discharged.
5. Current plans to cope with higher demand over the winter period are aimed at cutting hospital admissions and discharging patients more quickly. Winter plans include:
· Identifying how extra hospital beds can be made available to respond to any surge in demand
· Using minor injury units and working with GPs and out-of-hours services to reduce hospital admissions
· Better support for people at home to help them be discharged from hospital as early as possible
· Better coverage by health services at weekends and evenings
6. A recent Together for Health paper, published by the Welsh Government, demonstrates the pressure being put on services for the critically ill. It has reported that critical care units have been over capacity at periods of high demand. In January 2015, bed occupancy was as high as 107% - significantly above the recommended levels of 65 - 70% set out by the Intensive Care Society. The report also notes that serious staff shortages means "the current workforce is beginning to experience added stresses and uncertainty". The report also warned of too many delays in discharging patients from critical care units, with two thirds (66%) of all critical care patients delayed for more than four hours, affecting almost 4,000 patients.
7. The report also warns that with an ageing population, "demand for critical care services will outstrip current supply levels" and recommends that more is done to make efficient use of critical bed capacity across Wales in order to best meet the demands on services.
8. The pressures on acute hospitals in winter come from many sources and are a symptom of wider issues in the local health and social care system, suggesting that a more sustainable response will be developed by looking at the whole system. In addition, we are now finding that problems that were usually confined to the winter months are now increasingly being experienced at other times of the year as well. Whilst there is a mixed picture across the Welsh authorities and regions there are a number of trends reported by local authorities in relation to unscheduled pressures. These include:
· The fragility in domiciliary care and reablement services, exacerbated by volatility in demand and short-term problems, associated with sickness or leave at times of public holiday.
· Responsiveness and complexity of service required are significant issues, with recruitment and retention said to be challenging, particularly, though not exclusively, in rural communities.
· Capacity in traditional residential care has been relatively resilient, but many areas have reported a scarcity of specialist EMI and nursing care capacity (in part as a result of workforce issues and with a particular challenge with recruitment of nurses)
· Pressures on the hospital system, in particular increased admissions and people presenting with higher levels of acuity
9. Delayed transfers of Care (DToC) are seen as the main reporting mechanism and are the benchmark used by Welsh Government to determine how well a Health Board and Local Authority are performing. Over the years there has been a great deal of work to both understand the issues and causes of DToC along with tools and resources to address these. A number of actions have been identified that could be taken to improve performance in relation to DToC, these include:
· Implementation of existing guidance - such as ‘Passing the Baton’ and the Ten High Impact Changes for Complex Care.
· Avoiding unnecessary hospital admissions – working with GPs to identify key people at risk to target early intervention, use of specialist staff at the “front door”, providing support and advice to care homes, use of third sector organisations in the provision of preventative services and support.
· Choice – ensure implementation of existing guidance, ensure staff are “on message” i.e. hospital is not accommodation and need early discussions to plan discharge, use of intermediate care beds, step down beds, interim placements etc.
However, whilst there has been work to help improve performance challenges still remain.
10. The Social Services Improvement Agency (SSIA) will shortly be publishing a report, ‘Delayed Transfers of Care: Informal Review to Identify Good Practice’, which reviewed existing practice and identified actions aimed at enabling sustainable improvement. Capacity was identified as the major factor impacting upon effective flow and contributing to delayed transfers of care. The research found there has been a conscious move towards rebalancing provision towards primary and community led healthcare service. The move towards a more community driven NHS response has led to significant investments in community services, including the establishment of Community Resource Teams (CRTs). Local authorities in partnership with Health Boards have developed the CRTs and have also provided a shared approach to reablement, in addition to the longer term domiciliary care provision. This reinforces the need for all responses to take a whole system approach.
11. Local authorities have been working closely with local health boards, Welsh Government and other partners to plan for these unscheduled pressures and design services to meet needs. Local authorities have utilised the funding streams available to support much of their work in helping to lessen the impact of winter pressures. For example, previously funding from the Regional Collaborative Fund (RCF) was used to support the development of new services across regions with a focus on priority areas, including winter pressures for social care and health services. The Intermediate Care Fund (ICF) has also provided opportunities to achieve a further step change in the way services work collaboratively at both strategic and operational levels.
12. The ICF was introduced in 2014/15 with a focus to improve outcomes for older people and reduce pressures on the unscheduled care system by supporting people to remain at home, avoiding unnecessary hospital admissions and also preventing delayed discharges. Managed through regional arrangements, the funding has been used for:
· Additional domiciliary care packages (including high end packages).
· Residential and nursing home care.
· Extra care nursing and social work capacity.
· Community equipment.
· Fast tracking adaptations.
· 7 day discharge liaison nursing services.
· Reablement services.
· Single point of access.
· Additional step up/step down beds.
· Respite placements.
13. We have seen significant progress being made on reducing the levels of DToC in Wales in recent years, whilst at the same time it has been reported that the numbers of delays in England are rising. This demonstrates the importance of protecting funding provided to local authorities and the need to continue to invest in preventative services, through schemes such as the Intermediate Care Fund, to improve outcomes for people and reduce pressures on the unscheduled care system. More recently we have seen this reduction in DToC level off and in response a specific element of the ICF grant for 2015/16 was allocated to regions to support them to reduce the number of people who were delayed due to community care assessments, community care arrangements, selection of care home and waiting for availability of care home. This funding has been used by regions to focus on areas where there are known capacity issues, such as domiciliary and residential care. The funding has enabled regions to secure additional capacity to provide more care and support within the community. It has also demonstrated more effective partnership working and more integrated systems of care and support, as well as a greater emphasis on prevention and early intervention. Whilst the data does not demonstrate a reduction in the number of delayed discharges as a result of this work, there is evidence of additional capacity and an increasing number of people that have been supported, along with better outcomes being delivered for individuals. It is clear that without this investment the DToC position would be higher due to the pressures being placed on the system.
14. Other work local authorities have been involved with include the development of unscheduled care plans and pilot projects, aimed at managing winter pressures. This has included elements such as:
· An exploration of opportunities to jointly fund interim placements with the aim of improving the discharge process and reducing the number of delayed transfers of care
· Improving GP access during core hours
· Closer working with regard to escalation procedures at times of increased demand
· Development of step up / down beds.
· Expanding Intermediate Care Service (Social Workers, Therapists, District Nurses and generic workers) available over the weekend in order to increase the number of safe discharges during the Winter pressures period
· Having social work presence within hospitals to help prevent avoidable hospital admissions and facilitate earlier discharge.
15. There are also examples of innovative approaches that have been developed, for example, Healthy Prestatyn/Healthy Rhuddlan Iach, an integrated model of primary care delivery. This aims to treat patients as full and equal partners in their health journey, applying an integrated Multi-Disciplinary Team (MDT) approach to primary care which makes maximum use of community assets to fully address patient need. The new primary care service is based on four elements - Same Day, for minor ailments and injuries; Elective Centre, for planned care including chronic conditions; Domiciliary and Care Home Support; and an Academy providing training for professionals and patients. This represents a more holistic approach, recognising that the way to avoid delayed discharges is to identify how people end up in hospital and tackling the problem at its source.
16. Whilst there are examples of good practice and much progress has been made, a clear and real challenge in addressing the challenges presented by Winter pressures and unscheduled care is the capacity of the organisations and resources available. Given the ever growing pressure on services and continued cuts, particularly to local authority budgets this will continue to be an issue.
17. The chair of Care Forum Wales recently spoke of the need for urgent action to deal with the "triple whammy" hitting care homes and domiciliary care companies (http://www.bbc.co.uk/news/uk-wales-politics-37157515) – with a lack of funding and resources and a major recruitment problem meaning that the care sector was facing a "crisis". As highlighted earlier, one of the challenges facing local authorities is the fragility of the domiciliary care market and challenges around recruitment and retention. These services are vital to support both the NHS and social services to meet the needs of people, but they are being placed under increasing pressure. We believe there is a need to seriously look at the future funding of social care in Wales and invest new monies into the sector, to ensure the future sustainability of the social care sector.
18. There is a need to get things right for people and their carers/families, ensuring good communication to enable effective decision making. Partners need to work together across the statutory and third sector to ensure best use of scarce resources in a time of austerity. There is a need to inform and involve the public, manage expectations and plan for increasing demographic pressures to ensure the system is fit for purpose going forward, with the development of preventative services.
19. The Social Services and Well-being (Wales) Act provides opportunities to support integrated working with the creation of Regional Partnership Boards and requirements to undertake joint population assessments. We believe that we need to take a more radical approach to integration, with local government at its heart. This is critical if we are to shift focus and resources towards prevention and early intervention, rather than treatment or resolving crises. The Intermediate Care Fund has provided us with opportunities to develop new models of service delivery that have involved the integration of health, housing and social care, along with the essential contribution of third and private sector agencies. We need to learn from this, as well as from the approaches in other countries, in order to be able to accelerate this agenda in Wales, making better use of all available resources to both health and social services, to drive this forward towards more meaningful integration and improved outcomes.
20. Given the pressures facing the health and social care workforce it will also be important to make links between this inquiry and the inquiry looking into the sustainability of the health and social care workforce.