DELAYED DISCHARGES IN SCOTLAND REPORT TO THE MINISTER FOR HEALTH AND COMMUNITY CARE

DELAYED DISCHARGES IN SCOTLAND REPORT TO THE MINISTER FOR HEALTH AND COMMUNITY CARE BY TREVOR JONES, HEAD OF DEPARTMENT, SCOTTISH EXECUTIVE HEALTH DEPARTMENT, AND CHIEF EXECUTIVE NHSSCOTLAND 5 MARCH 2002 1

1. INTRODUCTION In August 2001, the Minister for Health and Community Care asked The Head of The Scottish Executive Health Department to consider the problem of delayed discharges in Scotland and to report on both the short and longer term actions needed to resolve this problem. A group of senior experts in this field, was convened to assist with this task. It comprised Local Authority and NHS Chief Executives, Directors of Social Work, NHS and Social Work service managers and SEHD staff, and offered a wide range of views on the extent of the problem and the solutions required. Discussions with that group of experts have heavily informed this report. A project team was also commissioned to take forward some more detailed work, part of which was to see what the situation was in other UK Healthcare systems and whether other countries had achieved significantly better performance. From this, it is clear that Scotland is not unique in having this problem. Similar problems exist in the other UK countries, and international research undertaken by the Department of Health in England suggests that every developed healthcare system has a significant problem with delayed discharges. It is also clear from this work that the problem of delayed discharge is not new, and it has always been with the NHS. However, with the transfer of resources for community care from the NHS to Local Authorities under the Resources Transfer arrangements, and the consequential reduction in the number of NHS continuing care beds throughout the 1990s, coupled with the move towards increasing throughputs and shorter stays in hospitals, the problem is becoming more acute. 2. DELAYED DISCHARGES The NHS provides treatment in hospitals for people who need medical care. When the clinical team led by the doctor in charge, with the appropriate involvement of social work staff, assess a patient as no longer needing treatment in hospital they are regarded as ready for discharge, and arrangements are made for them to go home. In most cases the patient s GP and primary care team provides the follow up care. However, for some people most often older people some other form of home support or care provided by Local Authority social work staff is needed to enable them to continue to live at home. For many older people, there will already be a package of care and support in place to help them live as independently as possible in the community. Following a hospital admission, this has to be reviewed and adjusted. For a few who need more intensive care and are no longer able to live at home, care and support in a care home or other specialist resources such as frail elderly sheltered housing is necessary. 2

For most people, following a multi agency assessment, the necessary care, support and accommodation arrangements are put in place in the community in time for the patient s discharge from hospital. Delayed discharges occur when the patient ready for discharge cannot leave hospital because the other necessary care, support or accommodation for them is not available. Nationally, Local Authorities, NHS Boards and the Scottish Executive have agreed that a reasonable period to assess, make plans for and then arrange the discharge of someone who needs community support or nursing home care after leaving hospital is 6 weeks. 3. THE SCALE OF THE SCOTTISH PROBLEM. For over a year, a quarterly census of all patients ready for discharge in NHS Hospitals in Scotland has been undertaken. It is analysed, statistically validated, and published quarterly by the Information and Statistics Division of the Common Services Agency. The last available census information on this subject was published in January 2002 and showed the position at 15 October 2001 as:! 3,138 patients waiting for discharge, an increase of 6.2% over the previous quarter. About 40% of these are in the Acute Sector. The table below shows the top 5 reasons for their delay Reason for Delay All cases No. of % of Total cases Cases 1 Awaiting commencement/completion of 681 21.7 post hospital social care assessment 2 Non-availability of public funding for 546 17.4 nursing home place 3 Awaiting place availability in nursing home (not NHS funded) 398 12.7 4 Awaiting bed availability in other NHS Hospital/speciality/facility 249 7.9 5 Patient exercising statutory right of choice 158 5.0 Table 1 reasons for delay all cases.! 2,191 were waiting over the agreed 6-week assessment and discharge-planning period, an increase of 8.5%. About one third of these were in the Acute Sector, and the table below shows the top 5 reasons for their delay 3

Reason for Delay 6 weeks and over No. of % of Total cases Cases 1 Non availability of public funding for 481 22.0 nursing home place 2 Awaiting commencement/completion of 342 15.6 post hospital social care assessment 3 Awaiting place availability in nursing 333 15.2 home (not NHS funded) 4 Patient exercising statutory right of choice 140 6.4 5 Awaiting place in specialist residential facility for younger age groups (<65) 85 3.9 Table 2. Reasons for delay 6 weeks and over! At any one time, almost 10% of all NHS beds are occupied by a patient whose discharge is delayed. The table below shows the position for each NHS Board NHS Board Area of Treatment % of NHS Board s beds occupied by patients ready for discharge Argyll & Clyde 13.9 Ayrshire & Arran 13.1 Western Isles 12.4 Lothian 11.6 Highland 11.3 Grampian 9.9 Orkney 9.8 Forth Valley 9.2 Fife 9.1 Tayside 8.5 Borders 7.9 Lanarkshire 6.2 Greater Glasgow 5.3 Dumfries & Galloway 4.5 Shetland 0 All Scotland Average 9.0 Table 3 Percentage NHS beds occupied by patients waiting for discharge 4

! 300 patients had been waiting for discharge for 1 year or more. The table below shows their NHS Board area of treatment. NHS Board Area of Treatment No of patients waiting for discharge for 1 year or more % of NHS Board s total patients waiting for discharge Argyll & Clyde 74 16.3 Ayrshire & Arran 18 6.3 Borders 2 3.6 Dumfries & Galloway 1 3.1 Fife 19 10.5 Forth Valley 13 7.6 Grampian 42 11.8 Greater Glasgow 14 3.7 Highland 32 19.9 Lanarkshire 25 11.2 Lothian 28 5.3 Orkney 0 0 Shetland 0 0 Tayside 12 4.5 Western Isles 19 6.1 All Scotland Total 300 9.6 Table 4 Patients waiting for 1 year or more by NHS Board area The table below shows the total number of patients waiting for discharge for each Local Authority area, and the numbers with Local Authority involvement both in total and outwith the agreed 6 week discharge planning period. Local Authority Total patients ready for discharge Number considered to have Local Authority involvement Number outwith the 6 week discharge planning period with Local Authority involvement Argyll & Bute Council 72 51 51 West Dunbartonshire Council 41 37 34 Inverclyde Council 109 104 98 Renfrewshire Council 235 221 187 Scottish Borders Council 55 49 38 East Ayrshire Council 128 113 87 North Ayrshire Council 100 81 64 South Ayrshire Council 62 55 39 Dumfries & Galloway Council 42 28 15 Fife Council 192 179 140 Clackmannanshire Council 15 12 4 Falkirk Council 102 90 78 Stirling Council 51 38 26 Aberdeen City Council 195 170 137 Aberdeenshire Council 91 74 48 5

Moray Council 67 61 48 East Dunbartonshire Council 11 11 8 Glasgow City Council 285 240 167 East Renfrewshire Council 31 21 11 Highland Council 160 158 136 North Lanarkshire Council 133 120 79 South Lanarkshire Council 119 95 56 City of Edinburgh Council 362 270 159 East Lothian Council 38 28 17 Midlothian Council 68 57 41 West Lothian Council 44 42 26 Orkney Council 11 11 7 Shetland Council 0 0 0 Angus Council 34 28 15 Dundee City Council 126 101 66 Perth & Kinross Council 94 93 77 Comhairle nan Eilean Siar 33 30 30 Local Authority not identified 32 23 20 All Scotland 3138 2699 2009 Table 5 patients waiting for discharge by Local Authority area The chart below shows the numbers of patients ready for discharge for each Local Authority and NHS partnership by each NHS Board area of treatment. NHS Board Area of Treatment No of patients ready for discharge % of all Scotland patients ready for discharge NHS Board % of Scotland s population % of NHS Board s beds occupied by patients ready for discharge Argyll & Clyde 454 14.5 8.3 13.9 Ayrshire & Arran 283 9.0 7.3 13.1 Borders 55 1.7 2.0 7.9 Dumfries & Galloway 44 1.4 2.8 4.5 Fife 181 5.7 6.8 9.1 Forth Valley 172 5.8 5.4 9.2 Grampian 356 11.3 10.3 9.9 Greater Glasgow 376 12.0 17.7 5.3 Highland 161 5.1 4.1 11.3 Lanarkshire 223 7.1 11.0 6.2 Lothian 527 16.8 15.2 11.6 Orkney 10 0.4 0.4 9.8 Shetland 0 0 0.4 0 Tayside 265 8.4 7.7 8.5 Western Isles 31 1.0 0.5 12.4 All Scotland Total 3,138 100 100 9.0 Table 6 patients ready for discharge by NHS Board 6

# Action: Support needs to be given to those partnerships with a disproportionate share of all Scotland s patients waiting for discharge. 3. OLDER PEOPLE AND DELAYED DISCHARGE Patients whose discharge is delayed are mainly older people. Nearly three quarters of all delayed discharges are patients over the age of 75. Often, these people are forced to wait unacceptable periods of time in hospital wards, without access to rehabilitation or diversional therapy, and sometimes far from their own homes. This can undermine their confidence and independence and can help encourage an unnecessary dependency, which can ultimately reduce their ability to care for themselves or be cared for at home or in a place in their own community. Over the next 15 years the number of older people is set to increase both proportionally and in real terms, with a projected rise of 16.9% in the over 65s 17.5% in the over 75s 29.4% in the over 85s In addition, there has been a sharp rise in the number of emergency admissions of people over 75. This is forecast to accelerate over the next 20 years as the graph below shows. Very clearly, without effective action, the present problem will increase significantly. As the older population grows the problem of delayed discharges will worsen unless the wider health and social care systems gear themselves up much more than at present to provide appropriate high quality care for older people who no longer need treatment in hospital. 7

4. THE HUMAN DIMENSION It is vital that the problem is not just seen as one of beds, budgets and statistics. It is the human dimension to this that must be at the forefront of action, and that must drive Local Authorities and NHS Boards to find creative solutions. People are involved - usually older people - more often than not admitted to hospital as an emergency because of a sudden illness or injury, with all the trauma and anxiety that brings. Then, when they are well and able enough to leave, they cannot. They are stuck in hospital waiting too long to be discharged to a more appropriate setting. Losing their independence, at risk of other infections, and in a hospital ward, which does not offer the comfort, privacy or quality of life that all of us, want and need. And, they are unable to do much about it. There are other people affected too. Those who are waiting to go into hospital for much needed medical treatment and who cannot be admitted because people who do not need to be there occupy beds. Sometimes their treatment is delayed, and sometimes the date they already have for treatment or operation is cancelled. 5. THE PROBLEMS TO BE TACKLED The group of experts who provided assistance all agreed that there were five main components to the current problem. These are: the demand and admissions to hospital for emergency care the available supply of the full range of care packages needed to support hospital discharge the choice exercised by and available to individuals for the appropriate care home the resources available to develop appropriate care, and the organisation and management of care services between the NHS and Local Authorities. A brief synopsis of each of these is outlined below. Demand and admissions to hospital for emergency care The number of hospital admissions of older people for emergency care has broadly doubled in the last 20 years and is set to continue to rise. Many of these admissions could be avoided if there were a better range of options known and available to doctors responding to emergencies. The NHS emergency services through the General Practitioners are normally the first point of call for older people who have become unwell or have been injured as a result of a fall. If, in the judgement of the attending GP, the older person cannot 8

immediately be treated and continue to care for themselves at home, or in the case of a fall, the GP feels that some further investigation is needed in hospital, then the attending emergency doctor will arrange for the patient to be taken to the local Hospital Accident and Emergency Department by ambulance for assessment and treatment. When the older person is assessed at hospital, a key factor the doctor in charge takes into account when considering admission, is whether or not the patient can look after themselves at home given their condition. If it seems they cannot, and if they do not have appropriate support at home, then the doctor will admit the patient until this can be arranged. This means that often people are admitted, not because they need treatment in hospital, but because they need some support at home, which is not available. Often, the doctor in charge has limited information about an individual s social care details and history, and may be forced into admitting the individual into hospital as a precautionary measure. 17 of the 32 Local Authorities in Scotland have developed Rapid Response Teams for the whole of their council areas to work with the NHS and help head off avoidable hospital admissions. Through the winter period of 2001/02, Local Authorities estimate that the intervention of their Rapid Response Teams avoided on average 269 hospital admissions each week. Nonetheless, the social work out of hours emergency teams are not always seen by GPs as being able to respond quickly enough to allow GPs to take alternative actions when dealing with emergencies. While Lothian have developed support from social work staff in Accident and Emergency units to arrange home support to prevent avoidable admissions, this is not routinely available in all local authority areas. Despite the localised successes of some rapid response teams, much more still needs to be done by the NHS and Local Authorities in partnership to prevent avoidable hospital admissions. Well integrated services for older people in crisis in their homes are needed, along with improved links between social work and NHS emergency services to support GPs in their out of hours service, and in Accident and Emergency departments. # Action: Local Authority/NHS partnerships need to develop more support at preadmission and admission stages, and stronger liaison between NHS and social work emergency services for older people to head off avoidable hospital admissions Supply Both NHS and Local Authority care patterns and models of care have been changing and will continue to change. With advances in medical treatment, the NHS has been moving towards shorter periods of treatment and shorter lengths of stay in hospital. With a more intensive use of beds and more rapid turnover, more people are being treated in hospital, but for shorter periods of time. In addition, there has been a reduction in the number of continuing care beds and a move to care in the community. 9

Local Authority models of community care have also been changing with a move away from institutional care in residential and nursing homes to more support for people in the community to help them live as independent a life as possible in their own homes for as long as possible. However, there are concerns that these changes in the pattern of care have developed unevenly and have resulted in a gap in provision for some people between NHS hospital care and care at home or in a nursing home. There is a need for new models of care to be developed to recognise this with more intermediate rehabilitation taking place to maximise the independence of the older people involved. There is increasing evidence to suggest that, because of this gap, there is a tendency for older people to move directly into nursing homes where, otherwise, with a more developed intermediate care provision in place, they would be able to move back into their own homes. Nor are the necessary rehabilitation services available to those who go into care homes. The care home market has largely been left to the private sector to develop with the result that provision is patchy across the country. In some places it is very near its limit, while in other places it is as yet undeveloped. In Edinburgh, for example, there is a lack of affordable care home places. More recently, the ready availability of care home provision has been further threatened by the dispute over care home fees. # Action: Local Authority/NHS Partnerships need to develop more co-ordinated rehabilitation encompassing hospital, community and care home based services. # Action: Building on the work of the Care Development Group, a review of the range and capacity of Community Care services for older people over the next 5, 10 and 15 years needs to be commissioned. # Action: A strategic review of care home provision needs to be commissioned to identify the most effective way of developing and managing the market to meet future needs Choice. All agree that choice of care home placement is essential for those people who are going to move to live and be looked after in a care home. Some significant problems have been caused by different approaches to how issues of choice are handled around the country although guidance is available to Local Authorities and the NHS on this issue. People moving to a care home and their families naturally wish to have a place in the home of their choice but the variable nature of the care home sector - both in numbers and character - often means that problems arise when that first choice place is not immediately available. 10

Some areas operate a system which allows individuals to exercise their right of choice, but requires them to make an interim move to an available care home place if their first choice is unavailable. Others have interpreted the directions as allowing the individual to continue to occupy a NHS bed until a place in their first choice care home becomes available, even though in some cases that may be a very long time. This can cause major difficulties, because while a person continues to occupy a NHS bed, in an environment which is not matched to their needs, people who are ill and in urgent need of treatment cannot be admitted for the treatment they need. In cases where the current directions on choice are interpreted in this way, the NHS Board and the Local authority can do no more than wait until the place of choice becomes available. # Action: Interpretation of the directions on choice needs clarified urgently to introduce a consistent national approach Resources - Funding Under the present funding regime, Local Authorities are responsible for funding services in the community including nursing home places for older people who are ready to be discharged from hospital. The NHS funds the care and treatment of people in hospital until they are discharged irrespective of how long their discharge is delayed. Local Authorities funding from the Scottish Executive accounts for about 80% of their expenditure. The other 20% is raised locally through Council Tax. It is for Local Authorities to identify and agree their spending priorities and service levels locally, and there is no ring fencing of funds for older people s services by the Executive. However local outcome agreements are being developed between the Scottish Executive and Local Authorities in relation to some new funding. Some Local Authorities have decided to invest resources in other services, which they have given a higher local priority than services for older people. They have also chosen to invest some ear marked additional funds for older people in other services such as children or leisure services. NHS Boards receive all their funding from the Scottish Executive in the form of a weighted capitation allocation that takes account of demographic and other factors. There is no central direction to NHS Boards about where they should spend their allocation, and it is for NHS Boards to agree their local investment and service priorities. Some NHS Boards have decided to invest their funds in other services, which have been given a higher local priority than services for the elderly. One of the principles underpinning the care in the community policy was that NHS Boards would transfer resources saved by the closure of inappropriate continuing care beds to Local Authorities to enable them to develop and provide services in the community for older people. Local Authorities have felt that there has not been an open and transparent formula consistently applied to the transfer of resources from NHS Boards as beds have closed. NHS Boards for their part have argued that real cost savings only come with ward closures and staff reductions and have therefore 11

operated their resource transfer rather later than Local Authorities would have liked. There is some evidence that not all the resources saved have been transferred to Local Authorities for investment in community services for the elderly. The Joint Future agenda is progressing with Single Shared Assessments and Joint Resourcing and Management due to be in place from April 2002. Indications are that only 1 Local Authority and NHS partnership will have pooled budgets, and that others will align resources initially. The present funding regime and the way Resource Transfer has been handled have not supported the development of innovative joint solutions to reduce the number of patients waiting to be discharged from hospital. There is wide dissatisfaction in the NHS and Local Authorities around Resource Transfer arrangements, which have not provided sufficient financial incentive to encourage patients to be transferred to more appropriate care. # Action: A review of the funding regime between Local Authorities and NHS Boards around the care of older people needs undertaken to consolidate and accelerate the Joint Future agenda Resources - Staffing As well as difficulties around the financial resources, both Local Government and the NHS report that there are also some shortages of key staff in Local Authorities, Care Homes and the NHS which slows down assessments and makes it impossible to make full use of vacant care home places. In some parts of Scotland there are new employment opportunities and some essential care jobs are no longer seen as attractive as they once were. As some staff are opting for employment elsewhere, it is becoming increasingly difficult to recruit and retain suitable replacement staff, both within the NHS and Local Authorities. There was generally felt to be a need for more integrated workforce planning across the spectrum of care for older people to avoid publicly funded agencies competing with each other for the same group of potential staff. # Action: Greater integration of workforce planning needs to take place in Local Authority/NHS partnerships across the health and social care sectors to ensure an adequate supply and the retention of properly skilled staff. Organisation and management To meet the needs of older people in these situations, a number of different organisations across Local Government, the NHS and voluntary sectors must work together with the needs of the patient at the centre of what they do. However, there is acceptance that organisational boundaries, with different cultures, priorities, funding and budgeting arrangements, at times get in the way and inhibit the delivery of seamless, and appropriate care for individuals, as the responsibility for their care moves from one organisation to another. However, while there are some difficulties 12

between local Government and NHSScotland, there are also difficulties between the NHS Acute sector and all the other organisations. Both Local Authorities and the NHS are suspicious of each other s commitment, priorities and funding decisions around the care of this group of people. For example, there is a view held by Local Authorities that the NHS siphons off money for care of older people to support the overspending acute sector, while in the NHS there is a view that Local Authorities siphon off money to leisure and children s services. There is some truth in both views, as explained earlier. While some good progress has been made with the Joint Future agenda and closer partnership between Local Authorities, these views reinforce the need to continue to support the development of the Joint Future principles, by developing more robust mechanisms for effective partnership between the two agencies. While there is a lot of good practice around the country this is not routinely shared and little in the way of benchmarking of services is undertaken. Joint agreed discharge policies and protocols are not in place in all NHS/Local Authority partnerships, and there is no national model agreement or framework, although there is central guidance on the need for such protocols to be in place. The proposed Delayed Discharge Learning Network, which was produced by a NHS/Local Authority working group, chaired by John Ross, Chair of Dumfries and Galloway Primary Care Trust, needs to be implemented across Scotland in Local Authority/NHS partnerships. There is also no single accountability in the system for delayed discharges, and few levers for either Local authorities or NHS Boards to enable the Executive to ensure the two systems align their priorities and resources around care of older people. This has meant that the two systems have not synchronised their developments and investment in the past to match emerging needs, and they now need to align their resources and priorities around this issue. Even now, there is not sufficient consensus between Local Government and NHSScotland about the high priority that needs to be given to this issue if it is to be resolved, and both services do not share the Scottish Executive s view of its importance. # Action: Action needs to be taken in Local Authority/NHS partnerships to ensure the alignment of Social Work/Acute sector/nhs priorities and organisations, and to accelerate consolidation of the Joint Future agenda. # Action: A delayed discharge learning network, and a good practice resource and network must be established urgently. # Action: Joint Discharge policies and protocols and a model national framework must be developed, implemented and audited urgently. # Action: Local Government and NHSscotland need to reach top level agreement about the high priority to be afforded to patients ready for discharge. 13

6. THE WAY AHEAD Sustainable improvements need to be made to the existing situation, and the Scottish Executive needs to take action to ensure that Local Authority and NHS funding, planning and priorities in bed blocking are aligned so that all are working together, in the interests of the individual, to resolve the problem. This needs to be done in a way that encourages and reinforces joint working between Local Authorities, the wider NHS and in particular, the NHS Acute Sector. It also needs to ensure any ear-marked additional funds for the care of older people are used for that purpose and that any existing funding is not diverted into other areas. Because of the current scale of the problem, immediate action needs to be taken to reduce the number of beds blocked by people being cared for in inappropriate settings. The Scottish Executive has announced an additional 20M funding specifically for this purpose. Patients waiting for discharge in the acute sector need to be given the highest priority because of the much greater impact on the ability of the NHS to treat acutely ill people and because this is a wholly inappropriate environment in which to maintain people who need long term care. # Action: This 20M needs to be allocated to the joint Local Authority /NHS partnerships through NHS Boards, ring fenced for delayed discharges only, and targeted as first priority to freeing up beds in the acute sector. There is also an issue is about how this issue is performance managed. It has become clear during the review of action needed to resolve the problem of people waiting to be discharged, that there could be improvements in the way the Scottish Executive, Local Authorities and the NHS monitors and manages performance of this issue. # Action: The performance management of delayed discharges across the health and social care fields needs to be strengthened. 7. IMPLEMENTING ACTION The actions identified in this report will have both short and long term impact on the numbers of people waiting to be discharged from hospitals. The short term actions to be implemented are summarised here as follows: # The additional 20M announced for delayed discharge should be allocated to NHS Boards under the Arbuthnott formula, ring fenced for the Local Authority/NHS partnership for initiatives to reduce the number of people waiting for discharge from hospital. The funding will be released by the Scottish Executive against joint Local Authority/ NHS Board action plans, which will include NHS and local Authority targets, to reduce the number of patients waiting for discharge and to deliver their share of transferring 1,000 extra patients across Scotland to more appropriate care. 14

The plans must target reductions in the acute sector and in patients waiting for 1 year or more Each partnership will require to bring forward innovative solutions that: help develop more community care services and support utilise extra care home places where appropriate bring into use extra NHS continuing care beds where the capacity of the care home market is limited increase the rate of assessments by social work staff provide more support at the pre-admission and admission stages develop stronger liaison between social work and NHS emergency services for older people to head off avoidable hospital admissions, and begin rehabilitation earlier. In these joint action plans, where services will be provided by Local Authorities, NHS Boards will transfer the appropriate amount of finance to the Local Authority partner concerned. Because urgent action is needed, 25% of the funding will be made available from 1 April, in advance of the action Plans being submitted, but only for these initiatives. Funding will not be provided where a NHS Board or Local Authority reduces its present level of funding, or diverts funds into other areas of activity. The Scottish Executive will monitor performance closely, and where partnerships fail to deliver will not release further funds until the Support Team has helped the partnership resolve their difficulties. These arrangements will ensure any additional funds are used for the resolving delayed discharges. Guidance to Local Authorities and NHS Boards will be issued in March, and the action plans of the Local Authority/NHS Board partnerships will be submitted to the Scottish Executive by early May 2002. # Local Authority/NHS partnerships need to develop more support at preadmission and admission stages, and stronger liaison between NHS and social work emergency services for older people to head off avoidable hospital admissions. # Local Authority/NHS Partnerships need to develop more co-ordinated rehabilitation encompassing hospital, community and care home based services. Local Authority/NHS partnerships will be required to cover these areas in their joint action plans to help minimise the number of people whose admission to hospital could be avoided and to speed up the discharge process. Further detailed guidance will be issues to Local Authority/NHS Board partnerships on these issues. # Interpretation of the directions on choice should be clarified urgently to introduce a consistent national approach. Consultation with all interested parties will take place with a view to the clarified national approach and protocols being introduced at the end of July. 15

# A delayed discharge learning network and a good practice resource and network will be established urgently: # Joint Discharge policies and protocols and a model national framework will be developed, implemented and audited. A small team of seconded staff from Local Authorities and the NHS will be established to implement these two action points. # Support will be given to partnerships with the most disproportionate problems to be tackled in relation to patients waiting for discharge. This will be in the form of top level support from a team comprising a Local Authority Chief Executive and a NHS Chair from partnerships achieving success in minimising the number of people waiting to be discharged from hospital. They will work with the wider partnership to assist them in developing and implementing good practice. # Action needs to be taken in Local Authority/NHS partnerships to ensure the alignment of Social Work/Acute sector/nhs priorities and organisations, and to accelerate consolidation of the Joint Future agenda. # While progress is being made in implementing the Joint Future agenda, this work will help ensure that the priorities, organisation and delivery of services to older people of all organisations involved are aligned, and that organisational boundaries do not inhibit the delivery of good quality care. # The performance management of delayed discharges in the Scottish Executive, Local Authorities and the NHS across the health and social care fields will be strengthened. The Health Department has introduced a revised structure with an integrated Performance Management Directorate from 1 February 2002. It will take further action to strengthen performance management of this issue in local Authorities and the NHS by summer 2002. # The Scottish Executive, Local Government and NHSScotland need to reach top level agreement about the high priority to be afforded to patients ready for discharge. Ministers will meet with Local Authority and NHS leaders and the Scottish Executive will work with COSLA, Local Authorities, NHS Boards and others at all levels to build consensus and agreement about the importance of this issue. # Greater integration of workforce planning needs to take place in Local Authority/NHS partnerships across the health and social care sectors to ensure an adequate supply and the retention of properly skilled staff. This will ensure that the right numbers of appropriately skilled staff are able to be recruited and retained across the sectors in the future and will avoid publicly 16

funded agencies competing with each other for the same diminishing pool of staff. This work should be completed by the end of this year. Long term actions. There are two long term pieces of work that the Scottish Executive should commission, which will impact in the longer term in supporting the development of more responsive services to minimise the number of people waiting to be discharged from hospital. These are: # A review of the range and capacity of Community care services for older people over the next 5, 10 and 15 years, including a strategic review of care home provision to identify the most effective way of developing and managing the market to meet future needs. This will build on the work already undertaken by the Care Development Group and will provide a clear view of the nature and range of services that need to be provided to meet the needs of the growing population of older people so as to minimise the numbers waiting to be discharged in the future. It will form the basis of longer term national and local planning of future developments. The Scottish Executive should take this forward in partnership with Local Authorities and the NHS, with a view to completing the work by September 2002. It will also enable the long term planning and development of the care home sector to managed and implemented to ensure an adequate supply of appropriate homes in the right locations. The work should be complete by the end of this year. # A review of the funding regime between Local Authorities and NHS Boards around the care of older people needs undertaken to consolidate and accelerate the Joint Future agenda This will help ensure that funding arrangements support rather than inhibit a customer focused approach that is able to meet evolving needs of individuals irrespective of organisational boundaries. This work should be complete in the summer. 9. CONCLUSION The key to improving services for older people, and at the same time speeding up admissions to hospitals for those who need medical treatment, is for the two agencies that serve the public in the health and social care fields to align properly their planning, resources and priorities around this group of vulnerable and needy people. The short and long term actions laid out here provide the framework to enable more productive partnership and improved services to the public. The extra 20M funding coupled with the actions set out here will make a difference to the problem of delayed discharge. Most importantly, they will make a difference for our older people. They will stop so many of our older people remaining unnecessarily in hospital because they cannot get the care they need elsewhere, through no fault of their own. 17

With more effective partnership between the Scottish Executive, Local Government and NHSScotland, 1,000 fewer people will have their discharge from hospital delayed by April next year. At least 300 of these will be from the Acute Hospital sector. This will free up beds for ill people who need medical treatment. TREVOR JONES Head of Scottish Executive Health Department, and Chief Executive, NHSScotland 5 March 2002 18