Delayed Transfer of Care Roadshow

Delayed Transfer of Care Roadshow Learning from Winter LondonADASS in partnership with the Better Care Support Team (BCST)

Contents Item Understanding DToC Performance in London Speakers Grainne Siggins (Newham CCG) Learning from Experiences in the North Matt Baker (Newton Europe) Sharing Good Practice: Enhanced Health in Care Homes Sharing Good Practice: Trusted Assessors Keynote: National CHC Framework Review Supporting Discharge Multi-agency Discharge Events (MADE) Mark Brooker (PPL) Hannah Nickson (Cordis Bright) Lesley Bainbridge (NHS Newcastle Gateshead) John Woods (NHSI) Melanie Weatherly (Walnut Care) Jim Ledwidge (independent) Chris Rose (OLM) Ruth Davey (London Purchased Healthcare) Vin Diwakar (NHS England)

Welcome, introductions and context setting Grainne Siggins Executive Director - Strategic Commissioning (Statutory Director of Adult and Children's Services) ADASS National Policy Lead London Borough of Newham

Understanding DToC Performance in London Grainne Siggins Executive Director - Strategic Commissioning (Statutory Director of Adult and Children's Services) ADASS National Policy Lead London Borough of Newham

Care Closer to Home Strategic Impact on DToC 8.0% 7.0% 6.0% 6.3% DToC performance over the last 12 months Top Tips finalised Regular Pan-London Mental Health sessions 5.5% England: 4.2% 5.0% 4.0% National target: 3.5% Mental Health: 3.4% 3.0% 3.2% London: 2.5% 2.0% 1.0% 0.0% 2.3% Quarterly Improvement Collaborative Events Acute: 2.0% Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 MADE Significant 7 Training England London London Acute Trusts London Mental Health Trusts National Target London as a whole is performing better than the national average and has done so over the past 12 months. Since the start of the CC2H programme in April 2017, London s performance has gradually improved to meet the target. The positive improvement is particularly visible in the performance of mental health trusts in London, whose DToC rates have seen a dramatic decrease over the year

London DToC performance compared to National London Trusts DToC position has consistently been below the National target of 3.5%. In February 2018, London DToC was 2.5%. 7.0% A comparison of trust DToC rates nationally and in London (data shown is % of beds occupied by delayed patients compared to total number of occupied beds) 6.0% 5.0% 4.0% 3.0% National Target 3.5% 2.0% 1.0% 0.0% Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 England all providers London all providers National Target 6

Daily Bed Days 7 Acute / Non-acute Over the past year, there have been more days lost to Acute DToC, compared to non-acute DToC. In February 2018, NHS was responsible for 59% of all DToC and ASC was responsible for 35% of it. 600 London Trust DToC Performance Trend (Bed Days) 500 400 300 200 100 0 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Acute DToC Non-Acute DToC Total Sum of London DToC - Per Day 300 Acute / Non-acute split details 250 200 150 100 50 0 76 172 64 85 20 Sum of NHS DToC - Per Day Sum of ASC DToC - Per Day Sum of Joint DToC - Per Day 2 Acute Non-acute

Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 STP level performance The diagram below shows an overview of DToC performance across the 5 London STPs as of February 2018. SEL levels of DToC have been exceeding their targets since October 2017. NCL met their target for the second consecutive month since January 2018. NWL has been meeting their target since December 2017, although February figures show an increase. NEL and SWL met their target in January 2018, but did not in February 2018. DToC performance overview 140 129 120 100 80 60 99 97 89 74 89 79 71 66 77 75 116 95 105 125 95 93 82 83 80 70 70 62 61 52 40 20 0 NCL NEL NWL SEL SWL Sum of NHS DToC - Per Day Sum of ASC DToC - Per Day Sum of Joint DToC - Per Day 8

Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 STP level performance: Acute Overall, there were more acute than non-acute reasons for delays. SEL had the smallest number of acute delays between November 2017 and February 2018. DToC performance overview - Acute 80 70 60 57 56 55 73 61 55 68 63 55 56 58 50 40 41 42 46 47 36 36 44 34 39 30 20 10 0 NCL NEL NWL SEL SWL Sum of NHS DToC - Per Day Sum of ASC DToC - Per Day Sum of Joint DToC - Per Day 9

Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 Nov-17 Dec-17 Jan-18 Feb-18 STP level performance: Acute The majority of non-acute delays were recorded in SEL and NWL. NEL had the smallest number of non-acute delays between November 2017 and February 2018. 80 DToC performance overview Non-acute 70 60 50 40 42 41 34 33 67 62 54 49 49 45 46 47 30 20 10 7 10 12 9 18 18 21 22 0 NCL NEL NWL SEL SWL Sum of NHS DToC - Per Day Sum of ASC DToC - Per Day Sum of Joint DToC - Per Day 10

11 Mental health and community providers have higher DToC rates than acute providers In February 2018, mental health providers had a DToC rate of 3.4% whereas acute providers had a rate of 2.0%. This distribution remains relatively consistent over time. Both rates are below the national target of 3.5%, but mental health providers are above the London target of 2.4%. 4.5% London DToC February 2018 4.0% 3.5% 3.4% 3.6% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 2.0% London target 2.4% 2.0% 0.0% Feb-18 London Acute Trusts London Mental Health Trusts Community Trust Care Trust Provider

12 The reasons for DTOC remain fairly consistent over the course of a year Awaiting nursing home placements and further non-acute NHS care account for 17% of delays respectively. Availability of residential home placements is responsible for a further 14% of delays. 700 Reason for delays overall 600 500 400 300 200 100 0 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Care Package in home Community Equipment Adapt Completion Assessment Disputes Further NonAcute NHS Housing Nursing Home Other Patient Family Choice Public Funding Residential Home

The most common acute reason for delays in the past year was further non-acute NHS (23%), followed by finding placements in nursing homes (21%). 400 Acute reasons for delays 350 300 250 200 150 100 50 0 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Care Package in home Community Equipment Adapt Completion Assessment Disputes Further NonAcute NHS Housing Nursing Home Patient Family Choice Public Funding Residential Home 13

The most common non-acute reason for delays was finding placements in residential homes (20%), followed by the completion of assessment (15%). 350 Non-acute reasons for delay 300 250 200 150 100 50 0 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Care Package in home Community Equipment Adapt Completion Assessment Disputes Further NonAcute NHS Housing Nursing Home Other Patient Family Choice Public Funding Residential Home 14

Sharing Good Practice Learning from Experiences in the North Matt Baker (Partner, Newton Europe)

REDUCE THE NUMBER OF PEOPLE STUCK IN HOSPITALS.

GET THE RIGHT DATA

TRUST THE DATA

USE THE DATA

INTERMEDIARY ASSESSMENT CARE ACTIVITY PACKAGE OF CARE OR DOMICILLARY CARE

BUILD THE FOUNDATIONS

INFORMATION FOUNDATIONS

CONTROL INFORMATION FOUNDATIONS

PATIENT SERVICE ESCALATION

HOW WILL YOU CREATE A TRUSTED VIEW OF THE INFORMATION? HOW WILL YOU GET THE THREE LEVELS OF CONTROL WORKING AS EFFECTIVELY AS POSSIBLE?

Sharing Good Practice Enhanced Health in Care Homes Mark Brooker (Senior Consultant, PPL) Hannah Nickson (Consultant, Cordis Bright) Lesley Bainbridge (Lead Nurse Frailty and Integration, NHS Newcastle Gateshead)

Enhanced Health in Care Homes: learning from the Vanguards and other local areas Hannah Nickson, Mark Brooker and Lesley Bainbridge 24 th April 2018 29

Introduction The Enhanced Health in Care Homes model and its relationship to secondary care service use, including DToC. Programmes of work developed and delivered by local areas to enhance healthcare in their care homes. Key learning and principles for success. 30

EHCH aims: Improving quality of care and reducing pressures on the system Provision of high quality care within care homes Improved resident experience. Improved health and wellbeing outcomes for residents. High-quality end of life and dementia care. Delivery of right care and health services in place of resident s choosing Best use of resources by avoiding unnecessary secondary care use Enhanced primary care support. Increased MDT support and care coordination. Emphasis on reablement/rehabilitation. Workforce development. Avoidance of unnecessary non-elective admissions. Reduction in DToC. Joined up commissioning across health and social care. Better use of data, IT and technology. Source: NHS England (2016) The framework for enhanced health in care homes. See: https://www.england.nhs.uk/wpcontent/uploads/2016/09/ehch-framework-v2.pdf 31

Interventions and programmes Nurse-led case management in care homes Increased MDT input into care homes Rapid response and treatment service GP alignment to care homes or specialist GP practices Telemedicine in care homes Red Bag scheme for hospital transfers Specialist clinical pharmacy reviews 32

What do we know about impact? Emerging evidence Qualitative individual programmes/interventions help to improve quality of care, resident choice and person-centred care, and delivering improved outcomes for residents as a consequence. Qualitative and quantitative some programmes/interventions may contribute to efficiencies across the system, and therefore reduced pressures on secondary care. But No single programme/intervention emerges as most impactful. Local context and fit is key. National and local challenges in developing appropriate metrics and collating data to support the evaluation of system-wide outcomes. Attribution is a challenge. 33

Key components in implementation Understand & develop care homes skills base Strong leadership & strategic planning Co-produce with key local stakeholders Use & develop evidence base 34

Top tips for implementation 1. Strategic needs assessment. 2. Shared strategic plan. 3. Robust value proposition and logic model. 4. Clear responsibility for leading change. 5. Base interventions on existing evidence base. 6. Robust outcomes monitoring. 7. Early and ongoing engagement of key partners. 8. Audit skills in care homes. 9. Balance direct delivery by health professionals with upskilling staff. 10. Build in sustainability planning at the start. 35

https://vimeo.com/252146915

Model Link practice Lead GP Nurse Specialist Home [ward] rounds Virtual ward Shared records Care home staff engagement

Evidence Comprehensive geriatric assessment problem solving and care planning Multidisciplinary working complex needs, responsive Nutrition and hydration improved health and wellbeing, system benefits Exercise meaningful activities

Learning It take time to make sustainable change There is an evidence base; listen Bottom up works Good things happen in care homes Workforce development needed across the system for system benefits to be realised

Metrics 8.8% decrease 999 calls resulting in conveyance to hospital with overall decrease in number of 999 calls 3% decrease A&E attendances 34.7% decrease in non-elective admissions for care home residents with a urine infection 16.6% decrease in non-elective admissions for care home residents with a chest infection 26% decrease in oral nutritional supplement prescribing (15,000 less prescriptions) 41k less spending on low dose antipsychotics 11% more dying in place of choice, improved recording means we now have a baseline to further increase this

Thank you! Hannah Nickson Cordis Bright hannahnickson@cordisbright.co.uk Mark Brooker PPL mark.brooker@pplconsulting.co.uk Lesley Bainbridge NHS Newcastle Gateshead Lesley.bainbridge@nhs.net 41

Sharing Good Practice Trusted Assessor John Woods (Social Care Lead Emergency Care Improvement Programme) Melanie Weatherly (Chair, Lincolnshire Care Association)

Trusted Assessments 24 th April 2018 John Woods Improvement Manager (Social Care)

Trusted Assessor or Trusted Assessment? Why Have a Trusted Assessor? Agenda. How do you know if you need one? How might you get going? Myth Busting 44 Presentation title

What is A Trusted Assessor One profession or service trusting the assessment of another profession or service and acting upon it. 1. A person working for & employed by the Independent Care Sector (ICS) who s primary role is carrying out assessments to allow for prompt discharge to care and support in the community inc at home 2. A person employed by the Health or Social Care who s primary role is carrying out assessments to allow for prompt discharge to care and support in the community inc at home 3. A person employed by Health or Social Care who s primary role is associated with managing discharges from hospital and in addition can carry out assessments to allow for prompt discharge to care and support in the community inc at home. A Trusted Assessor completes a bespoke and agreed assessment for a specific purpose. 45 Presentation title

What is A Trusted Assessment One profession or service trusting the assessment of another profession or service and acting upon it. A assessment carried out during the course of someone's treatment in hospital that is subsequently accepted and used for a different purpose e.g. A physiotherapist or Occupational therapist assessment used to support acceptance, upon referral of someone into a discharge support service e.g. discharge to assess A ward nurse assessment being used to commission and start a community health package. A Dr s report being used to start an interim support package from Adult Social Care A Trusted Assessment is completed for one purpose but also used for a second purpose with the agreement of both parties. 46 Presentation title

Its number 6 in the 8 High Impact Changes. Why have a Trusted Assessor NHS England, NHS Improvement, The Department of Health and Jeremy say you should. They will count towards performance targets. The lack of them could effect your budget. Because it s flavour of the month and everyone else is doing them. None of the above even if they are true. 47 Presentation title

48 Presentation title

How Do you Know a TA is what you need? Do you have DTOC due to delays in getting assessments completed. NO, pat yourself on the back and carry on doing what your doing Yes then go to next question. Why is there a delay? Is it because the process is complicated and drawn out e.g. requires sign offs from managers off site. If so, consider a process redesign workshop perhaps using process mapping. Is it because the assessment tool itself is cumbersome and unwieldy? If so hold a redesign workshop. Is it because the assessor s situation or workload is such they cannot carry out the assessment when required. If so, then you should consider a trusted assessment/assessor. 49 Presentation title

How Might you set it up? Map the stakeholders Invite stakeholders to a co-design meeting n.b. if your assessments are for the independent care sector they must be included, and it may be best to go to them e.g. the local care forum. Explain the problem and seek consensus on a solution. The members of the group feel changes other than TA could improve matters. Explore these options first The members of the group want to explore TA. 50 Presentation title

Can you access funding to develop a scheme. No then look to see what existing posts might lend themselves to the role. Yes consider whether you have enough need to justify a paid position(s) Look at the TA guidance and draw up a set of agreed principles. These will form the framework for your design team. The stakeholders nominate a small design team to come up with a workable solution to bring back to the larger group. 51 Presentation title

Myth busting trusted assessment is: Not about forcing trusted assessment on systems If your system does not have delays in discharge caused by delays in assessment you may not need to develop a trusted assessor approach. Not about forcing trusted assessment on providers A provider cannot be forced to take a trusted assessment and in any event, they should be part of its development or it will not work. Not about costing more In fact, trusted assessment could be free if you use existing resources, or relatively inexpensive if you share the costs between several organisations Not about moving costs from health to social care or vice versa Trusted assessment is not meant to change the outcome, just to speed it up. Not about denying people a full assessment The assessment should be as detailed as is necessary to reach the next stage. 52

Myth busting trusted assessment is: Not about slowing up the process Trusted assessment is meant to speed up the process. If it does not, it is being done wrong. Not about moving people home from hospital without the right support and without their consent or a best interest s decision The laws and guidance still apply as they did before. Not about transfer of responsibility If a trusted assessment is carried out on an organisation s behalf, that organisation is still responsible for both the assessment and the outcome. Not about discharging people from hospital before they are clinically ready A trusted assessment comes in when the system needs speeding up, but not sooner than is appropriate. 53

Myth busting trusted assessment is: Not illegal Trusted assessment is referenced in The Care Act 2014 Supported by The Care Quality Commission. Not only for hospital discharges It can be used in lots of areas including making eligibility determinations. Not really that hard If the wills there it s doable and you can put in safeguards. Not going to change the world It s good but not that good. 54

Further Information / Help john.woods2@nhs.net / john.woods.consulting@gmail.com https://improvement.nhs.uk/resources/rapidimprovement-guide-trusted-assessors/ https://improvement.nhs.uk/resources/developingtrusted-assessment-schemes-essential-elements/ https://www.nhs.uk/nhsengland/keoghreview/pages/quick-guides.aspx https://future.nhs.uk/connect.ti/system/login?nexturl =%2Fconnect%2Eti%2Fbettercareexchange%2Fview %3FobjectId%3D9820976#9820976 55 Presentation title

The Real World 56 Presentation title

Care home trusted assessor (CHTA) Working together to improve transfers from hospital to care homes Melanie Weatherley Chair, Lincolnshire Care Association (LinCA) melanie@walnutcare.co.uk

What does a Care Home Trusted Assessor do? Support for busy Care Home Managers An independent, experienced individual who is there to support the Care Home Manager to facilitate timely discharge Ask the questions and gather the information needed Make sure the check lists have been done Report back in an agreed format Available at the hospital when the resident needs them Support for the Discharge Team Able to respond as soon as a placement is agreed Liaison between hospital and care home on an equal footing Support for the Health and Social Care System Reduced cost of delays human and financial

Who can be a Care Home Trusted Assessor? Experience of Managing Residential Care must have done pre-admission assessments Preferably with nursing experience Able to interpret hospital notes Able to work with the discharge team, But stay independent Excellent Communicator Professionally Curious Able to build trust integrity is essential Part time or full time

Why have a Care Home Trusted Assessor? People need to be home as soon as they are ready, Delayed transfers of care cost money Lack of trust and understanding between partners Getting to hospital can be challenging for busy managers CHTA can be a way of working together to speed up the process

Developing the Care Home Trusted Assessor Role Key factors of our success to date OWNERSHIP brings TRUST Assessor is answerable to (ideally employed by) the Care Home Sector Service is available to all, but not mandatory Care Home documentation is used where appropriate CHTA must not place individuals Independence from all parties individual care homes can be challenged if appropriate Recognising the importance of the information collected Granular level information about delays Trends spotted in a timely manner (end of the week not the quarter)

Statistics in first full year 439 referrals 340 Assessments Completed 304 discharges Total days saved 735 Total Savings 400K (Net)

Panel Discussion Matt Baker (Partner, Newton Europe) Mark Brooker (Senior Consultant, PPL) Lesley Bainbridge (Lead Nurse Frailty and Integration, NHS Newcastle Gateshead) Hannah Nickson (Consultant, Cordis Bright) John Woods (Social Care Lead Emergency Care Improvement Programme) Melanie Weatherly (Chair, Lincolnshire Care Association)

2018 National CHC Framework Review Jim Ledwidge

Strategic Context Care for vulnerable individuals Improving the individual experience Making the best use of our health and social care staff Ensuring consistency of assessment and decision-making 65

Process and Parameters Long structured engagement process NHSE, CCGs, NHS Clinical Commissioners, LAs, patient representative groups, ADASS & LGA, etc. Mandate not to change underlying principles or criteria for CHC - very limited scope for regulatory change Policy area where change has not been possible: o Checklist threshold Co-production of updated Framework and Tools The new Framework is different, and we all need to read it with fresh eyes and decide what we need to do differently in order to implement it

Key changes in the revised National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care 1. No change in eligibility criteria for, or access to, NHS Continuing Healthcare (CHC) 2. A new structure and style to provide greater clarity to individuals and staff 3. Changes to reflect introduction of Care Act 2014, and other legislative/policy developments since 2012 4. Additional clarity to a number of policy areas 67

New Structure and Style The overall layout has been amended to provide greater clarity to individuals and staff. The revision has taken the flow of the process into account so that the contents are in clearer sections Key policy parts of previous Practice Guidance moved into main Framework Structure of Practice Guidance revised to fit with structure of Framework as have the annexes, and associated tools (Checklist, Decision Support Tool (DST) and Fast Track Pathway Tool) 68

Legislative Changes The National Framework has been revised in 2018 to reflect legislative changes since the publication of the 2012 version; primarily to reflect the implementation of the Care Act 2014, e.g. in relation to: what counts as care and support (social care) the limits of LA responsibility the duties of local authorities and NHS bodies 69

Key areas of Policy clarification When and where to assess eligibility for NHS CHC When not to screen/checklist Purpose and frequency of 3 and 12 month reviews Principles for Local Resolution Provision of dedicated sections for: o Primary Health Need o Roles of CCGs, NHSE and Local Authorities o NHS-funded Nursing Care (NHS FNC) o Inter-agency Disputes o Well-managed Needs o The Fast Track Pathway 70

71 When and where to assess eligibility for CHC Clearer messages about assessing for CHC at right time and in right place. (consistent with QP measure, that CCGs must ensure that less than 15% of all full CHC assessments take place in an acute hospital setting) Additional guidance relating to the interaction between CHC and hospital discharge. CCGs and their partner organisations are clearly advised to ensure they have appropriate processes and pathways in place for individuals who may have a need for CHC. Some examples of these processes and pathways are given which should support more accurate assessment of need and reduce unnecessary stays in hospital.

When not to screen/checklist In addition to the section on when and where to assess eligibility for CHC, further clarity is given on when it is not necessary to complete a checklist. This section is intended to encourage screening at the right time and location in order to reduce unnecessary assessment processes. 72

Situations where it is not necessary to complete a Checklist include where: a) It is clear, and practitioners agree, that there is no need for NHS Continuing Healthcare at this point in time. b) The individual has short-term health care needs or is recovering from a temporary condition and has not yet reached their optimum potential c) It has been agreed by the CCG that the individual should be referred directly for full assessment of eligibility for NHS Continuing Healthcare. d) The individual has a rapidly deteriorating condition and may be entering a terminal phase in these situations the Fast Track Pathway Tool should be used instead of the Checklist. e) An individual is receiving services under Section 117 of the Mental Health Act that are meeting all of their assessed needs. f) It has previously been decided that the individual is not eligible for NHS Continuing Healthcare and it is clear that there has been no change in needs. See para 91 of 2018 Framework 73 When not to screen

Purpose and frequency of 3 and 12 month reviews An initial 3 month review is required followed by further reviews taking place on at least an annual basis. The primary focus of reviews is clarified as checking whether the care plan or arrangements remain appropriate to meet the individual s needs. Reassessment of eligibility is only to take place where there is clear evidence of a change in needs to such an extent that it may impact upon the individual s eligibility for CHC. The intention is to reduce unnecessary reassessments and details on the responsibilities are set out in a flow chart. 74

Principles for Local Resolution Where an individual or their representative asks the CCG to review the eligibility decision, this should be addressed through the local resolution procedure, which is normally expected to resolve the matter. Introducing a new set of principles for local resolution is intended to resolve situations earlier and more consistently. 75

a) informal two-way meaningful discussion between the CCG representative and the individual and/or their representative. b) Where a formal meeting involving the individual and/or their representative is required, this should involve someone with the authority to decide next steps on behalf of the CCG. c) Following the formal meeting and the CCG will either uphold or change the original eligibility decision. 76 Principles for Local Resolution (1 of 2)

Principles for Local Resolution (2 of 2) d) If the CCG does not change the original decision, the individual or their representative has had a clear and comprehensive explanation of the rationale for the CCG decision. e) Where individuals wish to move straight to a formal meeting this should be considered. f) CCGs may choose to prioritise cases for individuals currently in receipt of care. 77

Provision of Dedicated Sections for: Primary Health Need - bringing together the definition and explanation of PHN into one section early in the Framework Roles of CCGs, NHSE and Local Authorities whilst recognising strong system leadership is required for the delivery of NHS CHC, this section clearly outlines organisational roles and responsibilities NHS-funded Nursing Care (NHS FNC) clearer detail is provided about what this incorporates including how it is funded and reviewed Inter-agency Disputes greater clarity is given about duties of CCGs and Local Authorities within their agreed local dispute resolution process. This covers principles required and what sort of issues it should address. Well-managed Needs this brings all the information together to support consistency of understanding The Fast Track Pathway - this brings all the information together to support consistency of understanding; it clarifies how the tool should be completed, CCG responsibilities on receipt of a completed Fast Track tool and the review process 78

The Associated Tools The Associated Tools have been reviewed to align with the revised National Framework Re-ordering of domains in Checklist and DST Minor changes to some wording in the descriptors Slightly different layout for Checklist, with inclusion of when not to screen Better alignment of Tool user notes with Framework wording Fast Track responsibilities 79

Role of NHS England a) Strategic leadership in relation to CHC, including organisational and workforce development b) Holding CCGs accountable for CHC delivery - engaging with them to ensure that they discharge their functions. c) Ensuring that local systems operate effectively and deliver improved performance. d) Appointing persons to act as chairs of independent review panels (IRPs) and establishing a list of IRP members drawn from local authorities and CCGs, in accordance with Standing Rules. e) In some limited circumstances, NHS England may also have commissioning responsibility for some individuals who are either prisoners, or serving military personnel and their families.

Role of CCGs (1 of 2) CCGs are responsible and accountable for system leadership for NHS Continuing Healthcare within their local health and social care economy, including: a) ensuring delivery of, and compliance with, the National Framework for NHS Continuing Healthcare; b) promoting awareness of NHS Continuing Healthcare; c) establishing and maintaining governance arrangements for NHS Continuing Healthcare eligibility processes and commissioning NHS Continuing Healthcare packages; d) ensuring that assessment mechanisms are in place for NHS Continuing Healthcare across relevant care pathways, in partnership with the local authority as appropriate; e) making decisions on eligibility for NHS Continuing Healthcare; 81

f) identifying and acting on issues arising in the provision of NHS Continuing Healthcare; g) commissioning arrangements, both on a strategic and an individual basis; h) having a system in place to record assessments undertaken and their outcomes, and the costs of NHS Continuing Healthcare packages.; i) Implementing and maintaining good practice; j) ensuring that quality standards are met and sustained; k) nominating and making available suitably skilled professionals to be members of Independent review panels (in accordance with Standing Rules); l) ensuring training and development opportunities are available for practitioners, in partnership with the local authority; and m)having clear arrangements in place with other NHS organisations (e.g. Foundation Trusts) and independent or voluntary sector partners to ensure effective operation of the National Framework. 82 Role of CCGs (2 of 2)

Role of LAs (1 of 2) Roles and responsibilities of the local authority include: a) Where it appears that a person may be eligible for NHS Continuing Healthcare, the local authority must refer the individual to the relevant CCG. b) There are specific requirements for local authorities to cooperate and work in partnership with CCGs in a number of key areas. c) Local authorities must, as far as is reasonably practicable, provide advice and assistance when consulted by the CCG in relation to an assessment of eligibility for NHS Continuing Healthcare. d) A local authority must, when requested to do so by the CCG, co-operate with the CCG in arranging for a person or persons to participate in a multidisciplinary team. Local authorities should: respond within a reasonable timeframe when consulted by a CCG prior to an eligibility decision being made respond within a reasonable timeframe to requests for information when the CCG has received a referral for NHS Continuing Healthcare. 83

Role of LAs (2 of 2) e) It is also good practice for local authorities to work jointly with CCGs in the planning and commissioning of care or support for individuals found eligible for NHS Continuing Healthcare wherever appropriate, sharing expertise and local knowledge (whilst recognising that CCGs retain formal commissioning and care planning responsibility for those eligible for NHS Continuing Healthcare). f) Regulations state that local authorities must nominate individuals to be appointed as local authority members of independent review panels where requested to do so by NHS England. This duty includes both nominating such individuals as soon as is reasonably practicable and ensuring that they are, so far as is reasonably practicable, available to participate in independent review panels. 84

Questions

Supporting Discharge BedFinder Chris Rose (Chief Commercial Officer, OLM)

Supporting Discharge CarePulse: London s Bed Vacancy Solution Ruth Davey (London Purchased Healthcare Team)

CarePulse London s bed vacancy solution 24 April 2018 Ruth Davey ruth.davey1@nhs.net

Search over 1,500 care homes by postcode, service type and local authority area View bed vacancies, service information, contact details and CQC ratings Access monthly quality monitoring reports

Quality dashboards London Use r

Willow Tree Nursing Home Care Providers Ltd Vacancies updated: 24 April 2018 1 Church Street, Barnet, EN4 8AN Service Types: Nursing homes Goo Services: Caring for adults over 65 yrs. d Jane Smith Registered Manager Contact information Jane Smith Registered Manager 02081234567 jane.smith@willowtree.co.uk CQC overall rating: Good Prompt home to update vacancies

AQP placements 72.4% 21 out of 29 AQP homes 42.3% 11 out of 26 AQP median 845 Non-AQP median 979

NHS 111 *6 service x When dealing with an urgent situation, the NHS 111 *6 service will provide you with fast access to a GP 24/7. You will be able to get the advice and medical input you need to care for residents without transferring them to an Emergency Department. To remind staff of the NHS 111 *6 service, please print this poster and put it by your telephones and nursing stations: View NHS 111 poster

Hospitals & hospices 300 CCGs Local Authorities Hospitals Hospices Commissioning support services

Enf 376 Active care homes 27% Hrw Brn Hgy Wth 21% 26% 7% 16% Hdn Elg Brt Cmd Isl Hck Rdb Hvg 1,137 Vacancy updates in last 7 days 50% 62% 39% 35% 11% 31% 27% 52% Hns Hms Kns Wst Cty Tow Nwm Bar 65% 70% 50% 66% N/A 24% 76% 64% Rch Wns Lam Swr Lsh Grn Bxl 70% London nursing home beds 38% 74% 49% 69% 29% 45% 26% Kng Mrt Crd Brm 39% 65% 49% 20% Stn 48%

I use CarePulse on daily basis. I am able to give a wider choice to families. Able to complete out of borough placements quickly. I use CarePulse to search for homes in particular geographical locations. Selecting options such as over 65 and dementia makes the placement process easier. Easy to use, very user friendly. I like that I can filter by location. I find it a very useful tool in finding/making placements. Informs my quarterly monitoring meetings with homes. Reduces time contacting nursing homes. Quick access to vacancies without having to rely on emails. Provides up to date quality information.

Ruth Davey ruth.davey1@nhs.net Register: Commissioners: https://www.carepulse.co.uk/registration/ Providers: https://www.carepulse.co.uk/care_home_registration/

Lunch 12.30 13.00 After Lunch: table top discussions within A&E delivery boards

Barnet & Enfield A&E Delivery Board Royal Free London NHS Foundation Trust Barnet Table 1 Enfield Camden A&E Delivery Board University College London Hospitals NHS Foundation Trust Camden Table 2 Haringey local A&E Delivery Board North Middlesex University Hospital NHS Trust Haringey Table 3 Islington A&E Delivery Board Whittington Health NHS Trust Islington Table 4 City & Hackney Health and Social Care Transformation Board Homerton University Hospital NHS Foundation Trust City and Hackney Table 5 BHR A&E Delivery Board WEL local A&E Delivery Board ChelWest A&E Delivery Board Barking, Havering and Redbridge University Hospitals NHS Trust Barts Health NHS Trust Chelsea & Westminster Barking & Dagenham Havering Redbridge Newham Tower Hamlets Waltham Forest West London Hounslow Hillingdon A&E Delivery Board The Hillingdon Hospitals NHS Foundation Trust Hillingdon Table 9 ICHT A&E Delivery Board LNWHT A&E Delivery Board Bexley, Lewisham and Greenwich A&E Delivery Board Imperial College Healthcare NHS Trust London North West Healthcare NHS Trust Lewisham & Greenwich Hospitals NHS Trust Table 6 Table 7 Table 8 Hammersmith & Fulham Table 10 Central London Ealing Brent Table 11 Harrow Bexley Lewisham Table 12 Greenwich Bromley A&E Delivery Board King's College Hospital NHS Foundation Trust Bromley Table 13 Southwark and Lambeth A&E Delivery Board King's College Hospital NHS Foundation Trust Southwark Guy's & St Thomas' NHS Foundation Trust Lambeth Table 14 Croydon A+E Delivery Board Croydon Health Services NHS Trust Croydon Table 15 Epsom & St Helier A&E Delivery Board Epsom & St Helier Hospital NHS Trust Sutton Table 16 Kingston & Richmond A&E Delivery Board Kingston Hospital NHS Foundation Trust Kingston Richmond Table 17 Wandsworth and Merton Emergency Care Delivery Board St George's Healthcare NHS Foundation Trust Merton Wandsworth Table 18

Learning from Winter: Multiagency discharge events Vin Diwakar Medical Director NHS England (London)

Learning from Winter: Multiagency discharge events Vin Diwakar Medical Director NHS England (London) Supported by and delivering for: London s NHS organisations include all of London s CCGs, NHS England and Health Education England

1. What s to be covered 1. Multi Agency Discharge Events (MADE) reflecting on what we saw in acute hospitals over the Easter 2. Rethinking approaches to flow while still counting what matters! 3. Some reflections WORKING TOGETHER FOR THE NHS

Delayed transfers of care (monthly) in England, 2007 to 2015-164. The numbers of patients in a hospital bed but ready to be discharged fell between 2007 and 2010, and then stayed relatively steady from 2010 to about 2013. However, in the past two to three years the number of patients delayed has risen by about 50% John Appleby BMJ 2016;353:bmj.i3585 2016 by British Medical Journal Publishing Group

1. Multi Agency Discharge Events (MADE) Multi Agency Discharge Events (MADE) were held over Easter worked with eight challenged trusts plus a community hospital to: improve discharge patients from acute settings, in particular those with a length of stay over seven day understand improvement since the January 2018 programme help bring increased focus on barriers to discharge from hospitals in health and care systems Large investment in staff time from many organisations WORKING TOGETHER FOR THE NHS

2a. MADE What did we find? Leadership The support to MADE events by external agencies improves flow and discharge Senior leadership from all system partners is required for sustainable change and improvement Discharge planning was rarely seen as the whole site s responsibility, especially where patients were more complex WORKING TOGETHER FOR THE NHS

2b. MADE What did we find? Processes, systems and resources MADE and Stranded patient reviews were not fully embedded as business as usual Understanding and role of discharge planning with multi agency teams appears to be an area for improvement across most sites Discharge to Assess (D2A) policies were often not aligned to processes and the understanding of the pathway within the community Repatriation of patients remains an issue in most sites and there was limited evidence to suggest escalation actions were having an impact WORKING TOGETHER FOR THE NHS

2c. MADE What did we find? Culture, beliefs and behaviours There was very limited evidence of trusted assessor principles being applied. The lack of medical leadership on some sites reinforced the impression that the site saw the event as taking them away from patients and were unsure about how clinicians could add value Limited ownership of recommendations and evidence that lessons from the New Year MADE events had been widely adopted WORKING TOGETHER FOR THE NHS

2. Programme review: Findings Metrics Site 1 Site 2 Data from the events does not enable us to conclude that the programme had a significant positive impact. However, though simplistic, another approach of evaluating the impact of the Easter programme is to compare sites where MADEs were considered to have been run effectively (for example at site 1) compared to sites where they weren t (for example site 2). This provides a clearer indication that running effective MADEs can have a positive impact on the numbers. WORKING TOGETHER FOR THE NHS

3. Some Initial Thoughts on Next Steps KEEP GOING Continue programme of Made events over 2018 with focus on same trusts to identify leaning and improvement NOT IN ISOLATION MADE events are part of basket of on-going improvement tools trusts should be applying EDUCATE and LEARN Raise aware of MADE events across system partners QUID QUO PRO Trusts being supported need to commit to programme through senior management leaders and clinical leaders Although not part of the MADE approach, prior to delivery of MADE events are review of discharge policies, procedures and performance should be undertaken by system partners to identify issues WORKING TOGETHER FOR THE NHS

Rethinking approaches to flow The best bed is your own bed Supported by and delivering for: London s NHS organisations include all of London s CCGs, NHS England and Health Education England

Proposed areas of focus for 2018/19 Stay Becoming stable at home Treat and go Prevent admissions Treat Optimise flow in hospital Go Supporting discharge Stay Remain stable at home Enhanced rapid response services act effectively at time of crisis to prevent unnecessary admissions Care homes use NHS 111 *5 and *6 lines, to access GP advice and avoid a 999 call Train the Trainer Significant 7 enables staff to identify deterioration earlier, resulting in residents receiving care at home rather than in acute Care home professionals use NHS Mail, to improve speed and accuracy of information People access the best service to respond to their needs Review existing patient flow models and develop new ones Use digital technologies to re-direct walk-in patients from the UCC to more appropriate health services Rapid response services, AHPs and Frailty Units assess people at the front door of the hospital People spend the right amount of time in hospital and receive high-quality care London systems are aware of #PJParalysis and implement effective discharge pathways Implementation of plan for discharge on admission processes Development of service standards for board rounds and MDTs Focused work with patients and families around patient choice, in partnership with the third sector (Red Cross) Focused work with mental health systems to identify the root cause of the problems and their solutions. People return to their residences as soon as it is safe for them Discharge to Assess and Trusted Assessor models Common nurse referral across London Enhanced community service offer, to ensure community services have the capacity to treat people Care Pulse App enables professionals to see in real time which beds are available in care homes Mental health discharge Top Tips support honest discussions between professionals, in order to create a joint plan for improvement. People have the right support to remain well at home after an acute episode Implementation of Clinical Hubs Increased use of Rapid Response, reablement and rehabilitation services The Medicines Optimisation programme ensures that people living in care homes get the right medication, to reduce the risk of harm from medicines Images from: House icon by Xinh Studio for Noun Project; Hospital icon by Mikicon for Noun Project; Person by asiansondesign for Noun Project *line data Feb 2107 to March 2018 114