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Discharging older people from acute hospitals

문서에서 Treasury Minutes Progress Report (페이지 139-143)

2: Committee of Public Accounts conclusion:

There is unacceptable variation in local performance on discharging older patients.

Recommendation:

There are several contributory factors behind the variations in local performance. The Committee expects the Department, NHS England and NHS Improvement to understand the reasons for the variations and address the further recommendations made below.

2.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

2.2 The Government is committed to addressing variations in local performance in delayed transfers of care. A clear deliverable for improved delayed transfers of care performance has been set through the Government’s mandate to NHS for 2017-18, which support this recommendation by requiring NHS England to work with NHS Improvement and local government partners to reduce NHS-related delayed transfers of care in support of a total reduction to 3.5% by September 2017 (recognising existing variation between areas).

2.3 In July 2017, a further package of measures was introduced to support both the NHS and Local Government to reduce delays. This included a performance dashboard showing how local areas in England are performing against metrics across the NHS-social care interface including delayed discharges. The package also included plans for Local Government to deliver an equal share to the NHS of the expectation to free up 2,500 hospital beds, including a breakdown of delayed days per 100,000 of the population and the indicative reduction levels required by each Local Authority and local NHS, which can be shared out differently at local level if agreed by both organisations.

2.4 In seeking to reduce variation in local performance the Government will consider a review, in November, of 2018/19 allocations of the social care funding provided at Spring Budget 2017 for areas that are poorly performing. This funding will all remain with local government, to be used for adult social care.

2.5 In addition, the Care Quality Commission will undertake 12 reviews of local areas to consider how well they are working at the health and social care boundary. A further 8 reviews will be commissioned based on the performance dashboard and informed by Local Authority returns due in July. The majority of the reviews will be complete by the end of November, with a view to identifying issues and driving rapid improvement.

2.6 As part of a comprehensive sector-led support offer, NHS England, NHS Improvement, Local Government Association, Association of Directors of Adult Social Services and the Better Care Support Team will publish the definitive national offer to support reductions in delayed transfers of care to all areas.

3: Committee of Public Accounts conclusion:

The fragility of the adult social care provider market is clearly exacerbating the difficulties in discharging older patients from hospital.

Recommendation:

The Committee’s report on personal budgets in adult social care recommended that the Department clarify its position as national steward of the social care market in its National Market Position Statement. Given the effect that serious funding pressures and market fragility are having on discharging patients, the Committee re-iterate this recommendation. The Department should report back to the Committee by January 2017 on progress in implementing the key elements of the Position Statement and what impact this is having.

3.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

3.2 The Department continues to have an important stewardship role for the adult social care market.

This involves oversight of the system and continued engagement with local authorities and providers to ensure the market overall is sustainable and delivers improving outcomes and quality.

Introduction from the Committee

Discharging older people from hospital involves not only hospitals, but also community health and social care services as many older people need some support in the short or longer term to allow them to live in their own homes or to take up a place in a care home. The number of older people (aged 65 and over) in England is increasing rapidly, by around a fifth every 10 years. Emergency admissions of older patients have gone up at an even faster rate—by 18% between 2010–11 and 2014–15. This rising demand for services, combined with restricted or reduced funding, is putting pressure on the capacity of local health and social care systems. Official figures show the number of delayed transfers for older people—that is where a patient remains in hospital after the clinicians and professionals involved in their care decide they are ready to leave—increased by 31% to 1.15 million bed days between 2013 and 2015.

Background resources

• NAO report: Discharging older patients from hospital - Session 2016-17 (HC 18)

• PAC report: Discharging older people from acute hospitals - Session 2016-17 (HC 76)

• Treasury Minute: November 2016 (Cm 9351) Updated Government response to the Committee

There were 8 recommendations in this report. As of the last Treasury Minute (Cm 9351), 8 recommendations remained work in progress, of which 7 have now been implemented, as set out below.

1: Committee of Public Accounts conclusion:

There is a poor understanding of both the scale and cost of the problem of delays in discharging older patients from hospital.

Recommendation:

NHS England should develop measures that fully capture the number of older people who are no longer benefiting from acute hospital care. Also, building on the initial work set out in the NAO report, NHS England should coordinate work to fully understand the cost to hospitals of delayed discharges and the costs, where these fall on the public purse, of caring for these people in the community.

1.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

1.2 NHS England, NHS Improvement and the Department of Health believe that the first priority is to reduce the number of DTOC patients. In July 2017, the Department of Health and DCLG published indicative expectations for DTOC reduction by local authorities and the local NHS, with associated planning requirements.

1.3 As set out in the Department’s letter to the Committee in January 2017, the clinical advice received has suggested there is limited benefit in beginning a new collection based on patients that are medically fit for discharge (MFFD). We will, however, commence analysis of Secondary Users Service (SUS) data to create a measure of ‘stranded patients’ as part of obtaining the wider view of delays that the Committee was seeking.

1.4 NHS England will also work with NHS Improvement and NHS Digital to explore how to best utilise SUS data collections that will capture the date on which an inpatient was confirmed by their medical team as ready to be transferred from acute care. The data burden on trusts will be taken into account but it would be expected that Local Accident and Emergency Delivery Boards and Sustainability and Transformation Plans review this data alongside metrics captured within the Discharge Dashboard.

Twelfth Report of Session 2016-17 Department of Health

Discharging older people from acute hospitals

2: Committee of Public Accounts conclusion:

There is unacceptable variation in local performance on discharging older patients.

Recommendation:

There are several contributory factors behind the variations in local performance. The Committee expects the Department, NHS England and NHS Improvement to understand the reasons for the variations and address the further recommendations made below.

2.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

2.2 The Government is committed to addressing variations in local performance in delayed transfers of care. A clear deliverable for improved delayed transfers of care performance has been set through the Government’s mandate to NHS for 2017-18, which support this recommendation by requiring NHS England to work with NHS Improvement and local government partners to reduce NHS-related delayed transfers of care in support of a total reduction to 3.5% by September 2017 (recognising existing variation between areas).

2.3 In July 2017, a further package of measures was introduced to support both the NHS and Local Government to reduce delays. This included a performance dashboard showing how local areas in England are performing against metrics across the NHS-social care interface including delayed discharges. The package also included plans for Local Government to deliver an equal share to the NHS of the expectation to free up 2,500 hospital beds, including a breakdown of delayed days per 100,000 of the population and the indicative reduction levels required by each Local Authority and local NHS, which can be shared out differently at local level if agreed by both organisations.

2.4 In seeking to reduce variation in local performance the Government will consider a review, in November, of 2018/19 allocations of the social care funding provided at Spring Budget 2017 for areas that are poorly performing. This funding will all remain with local government, to be used for adult social care.

2.5 In addition, the Care Quality Commission will undertake 12 reviews of local areas to consider how well they are working at the health and social care boundary. A further 8 reviews will be commissioned based on the performance dashboard and informed by Local Authority returns due in July. The majority of the reviews will be complete by the end of November, with a view to identifying issues and driving rapid improvement.

2.6 As part of a comprehensive sector-led support offer, NHS England, NHS Improvement, Local Government Association, Association of Directors of Adult Social Services and the Better Care Support Team will publish the definitive national offer to support reductions in delayed transfers of care to all areas.

3: Committee of Public Accounts conclusion:

The fragility of the adult social care provider market is clearly exacerbating the difficulties in discharging older patients from hospital.

Recommendation:

The Committee’s report on personal budgets in adult social care recommended that the Department clarify its position as national steward of the social care market in its National Market Position Statement. Given the effect that serious funding pressures and market fragility are having on discharging patients, the Committee re-iterate this recommendation. The Department should report back to the Committee by January 2017 on progress in implementing the key elements of the Position Statement and what impact this is having.

3.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

3.2 The Department continues to have an important stewardship role for the adult social care market.

This involves oversight of the system and continued engagement with local authorities and providers to ensure the market overall is sustainable and delivers improving outcomes and quality.

3.3 The Department had initially proposed developing a National Market Position Statement.

Following discussions with stakeholders it agreed to develop an on-line Markets Hub primarily focussed on drawing together good local practice examples of commissioning, market shaping and contingency planning as well as links to data sources. The aim is to provide a resource to help local commissioners improve practice and therefore improve people’s wellbeing.

3.4 The Markets Hub has been available through GOV.UK since November 2016 and is being kept under review. More broadly, the Department continues to work with the sector to promote guidance to encourage quality services, smart commissioning and protection for people with care needs.

3.5 As the Department has completely refreshed its approach, it will measure the impact of the Hub through a wider evaluation of the Care Act, including a research on market shaping due to be complete in 2019. Interim outputs will be available from mid-2018.

4: Committee of Public Accounts conclusion:

While good practice on discharging patients from hospital is well understood, implementation is patchy across local areas.

Recommendation:

NHS England and NHS Improvement should report back to the Committee by January 2017 on what steps they have taken to increase the pace of good practice adoption.

4.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

4.2 The Government’s mandate to NHS England for 2017-18, the Next Steps on the NHS Five Year Forward View, and the Better Care Fund Policy Framework for 2017-18 – 2018-19 all state that areas must implement the 8 High Impact Change Model. This Model is made up of 8 key models that are known to improve transfers of care, including trusted assessor and discharge to assess. Joint NHS England, NHS Improvement, Local Government Association and Association of Directors of Adult Social Services guidance on implementing trusted assessors was announced in July 2017. All local systems have been asked for milestone delivery plans and resource has been provided regionally and locally to help with transformation.

4.3 England and NHS Improvement have come together to form a joint programme to support delivery of Urgent and Emergency Care including these measures. They are developing their improvement offer working closely with the Local Government Association and Association of Directors of Adult Social Services to ensure there is a coherent, joined-up approach for local systems. This builds on the work of the Emergency Care Improvement Programme (ECIP), an integrated team which works across health and social care and delivers intensive on-site support for challenged systems using a number of approaches targeted at improving flow and discharge such as Multi Agency Discharge Events and implementing best practice guidance.

4.4 To incentivise areas to work together to implement good practice on discharging patients, NHS England developed, with partners, a Commissioning for Quality and Innovation (CQUIN) incentive for 2017-18 – 2018-19 on safe and proactive discharge that incentivises areas to work across local health systems to enable patients to get back to their usual place of residence in a timely and safe way. This CQUIN builds upon the Urgent and Emergency Care (UEC) Delivery Plan discharge-specific activity to support systems to streamline discharge pathways, embed and strengthen the Discharge to Assess pathway and to understand capacity within community services to support improved discharge.

5: Committee of Public Accounts conclusion:

The absence of widespread and effective sharing of patient information remains a significant barrier to the effective discharge of older patients.

Recommendation:

NHS England, working with local government partners, should identify early lessons from the ongoing work on information sharing, so that health and social care providers can get a clear idea of what will work best in their local area. It should report back to the Committee by January 2017 on what progress has been made on information sharing in local areas.

5.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

5.2 Localities around the country have made significant progress in enabling effective information sharing across care settings and transfers of care in a way which supports hospital discharge processes, and are undertaking work to join up health and care records. In Northumbria, they are providing a single view of a patient for those providing direct care to individuals.

5.3 A particular focus has also been on sharing of transfer of care information - such as assessment and discharge notifications. This is a critical part of the discharge process. Work in Islington has enabled the electronic exchange of Care Act compliant discharge information so that social care is notified of assessment requirements and discharge dates from hospital accurately and timely.

5.4 Work between Hertfordshire and NHS Digital is enabling benefits in relation to efficiencies and prevention from enhanced information sharing to be captured. This is the key evidence base being used to support the wider national adoption of this information sharing.

5.5 NHS England, working in conjunction with national bodies and localities, are currently commissioning the development of a series of case studies which will outline areas of excellence. These will be made available to all organisations to ensure that best practice is spread as widely as possible.

6: Committee of Public Accounts conclusion:

Current structures do not have an effective line of accountability, either nationally or locally, for what is at root a shared problem for health and social care systems of discharging older patients.

Recommendation:

As steward of the system, the Department of Health should set out in its accountability system statement how local health and social care systems will be held to account for areas of care that require a whole system approach, such as discharging older patients. This could, for example, involve strengthening the remit of the national Discharge Programme Board and local system resilience groups to hold the whole system to account.

6.1 The Government agrees with the Committee’s recommendation.

Recommendation implemented.

6.2 Managing Public Money advises that accountability system statements must be clear on the core data and information flows that the system will rely on. The Treasury included this requirement in the revised guidance for all departments to report on their accountability systems.

6.3 This included an expectation that Departments will identify how accountability systems align with the financial data set out in their Annual Report and Accounts (ARA), and the performance indicators set out in Single Departmental Plans (SDPs). Permanent Secretaries’ objectives are also aligned with SDPs.

Departments are not expected to repeat the detail of performance metrics and financial data used to oversee systems within their accountability system statements, but they should indicate how they are aligned. In some cases, this might require departments to make clearer in their SDP or ARA where arm’s length bodies are responsible for delivery, and what performance and financial data is expected and how it will be used.

6.4 The Treasury issued guidance in time for Departments to prepare these statements alongside their ARAs for 2016-17. The Department’s ARA was published in July 2017. The ARAs show how information and accountability flows through the whole health and social care system.

7: Committee of Public Accounts conclusion:

Local health and social care organisations are too often not working together effectively, with organisational boundaries getting in the way of what should be a smooth and seamless process for the patient.

Recommendation:

NHS England, working with local government partners, should clearly set out good practice models for integrated and closer working that they expect to be adopted by local health and social care systems, and report back to the Committee by January 2017 on what steps they have taken to increase the pace of adoption of such models.

3.3 The Department had initially proposed developing a National Market Position Statement.

Following discussions with stakeholders it agreed to develop an on-line Markets Hub primarily focussed on drawing together good local practice examples of commissioning, market shaping and contingency planning as well as links to data sources. The aim is to provide a resource to help local commissioners improve practice and therefore improve people’s wellbeing.

3.4 The Markets Hub has been available through GOV.UK since November 2016 and is being kept under review. More broadly, the Department continues to work with the sector to promote guidance to encourage quality services, smart commissioning and protection for people with care needs.

3.5 As the Department has completely refreshed its approach, it will measure the impact of the Hub through a wider evaluation of the Care Act, including a research on market shaping due to be complete in 2019. Interim outputs will be available from mid-2018.

4: Committee of Public Accounts conclusion:

While good practice on discharging patients from hospital is well understood, implementation is patchy across local areas.

Recommendation:

NHS England and NHS Improvement should report back to the Committee by January 2017 on what steps they have taken to increase the pace of good practice adoption.

4.1 The Government agreed with the Committee’s recommendation.

Recommendation implemented.

4.2 The Government’s mandate to NHS England for 2017-18, the Next Steps on the NHS Five Year Forward View, and the Better Care Fund Policy Framework for 2017-18 – 2018-19 all state that areas must implement the 8 High Impact Change Model. This Model is made up of 8 key models that are known to improve transfers of care, including trusted assessor and discharge to assess. Joint NHS

4.2 The Government’s mandate to NHS England for 2017-18, the Next Steps on the NHS Five Year Forward View, and the Better Care Fund Policy Framework for 2017-18 – 2018-19 all state that areas must implement the 8 High Impact Change Model. This Model is made up of 8 key models that are known to improve transfers of care, including trusted assessor and discharge to assess. Joint NHS

문서에서 Treasury Minutes Progress Report (페이지 139-143)