Health and social care services have joined forces in Portsmouth to ensure that patients experience minimal delay before being rehabilitated outside hospital. Jeremy Dunning reports (pic credit Alamy)
The Christmas cold weather and the winter flu bug revived attention in the problem of bed-blocking and triggered a blame game between health and social care.A survey found that half of doctors believed the problem had become worse. Many blamed social services cuts, which meant support services to enable patients to be discharged from hospital had disappeared. The Association of Directors of Adult Social Services retorted that most delays were the fault of the NHS. Yet official figures indicate a fall in rates.
What is clear is that joint working between health and social care has been key in those areas that have had most success in ensuring that support packages are in place for people ready to leave hospital.
One such area is Portsmouth, where the council, the primary care trust and the Portsmouth Hospitals NHS Trust, which runs the Queen Alexandra Hospital, believe that a good joint working relationship has helped in reducing delays.
From 1 April last year to 18 January 2011, the city council has been at fault for just 54 delayed bed days, despite the hospital social work team receiving 103 referrals during this time. Since August last year, the council has been responsible for just one week’s worth of delays.
Talks on how to improve the discharge pathway took place about two years ago involving hospital, community health and social care staff.
Out of this came two key changes. The first was the establishment of an integrated discharge bureau involving health and social care, which has helped to foster a better understanding between them.
The bureau sees senior hospital social workers meet clinicians and discharge planners from the Queen Alexandra (QA) to discuss patients who are medically fit but have complex needs.
Angela Dryer, the council’s assistant head of social care, says there is a consistency about who attends those meetings within social care. If it is not the manager of the hospital social work team, it will be one of the senior practitioners.
“That’s meant staff from both sides have got to know each other,” she says. “There’s relationship-building at an operational level, and at a strategic level we are looking at how we can get a system that works across the city economy.”
Nicola Martin, senior nurse for discharge services, says: “The integrated discharge bureau has been positive. We try to think a bit differently. It’s not about process, it’s about the patient and how we can get them out of hospital and into the right environment. That is at the hub of trying to move all the things forward.”
This bureau also helps ensure that patients with support needs who are brought down into the discharge lounge should not be kept waiting for longer than six hours.
This lounge aids the QA in matching admissions and discharges.
Gillian Gould, the QA’s head of nursing in medicine for older people, rehabilitation and stroke, says: “By using the discharge lounge we can move the patients leaving the ward earlier in the day so we have the beds available for those new patients coming in.”
A second key aspect to the low levels has been the streamlining of some social work processes.
Previously, the hospital social work team worked on discharges and picked up reviews of people in the community 28 days after their discharge; at the same time, community social workers also dealt with their clients when in hospital. The drawback was that, if the community social worker was under extreme pressure, someone in a hospital bed did not jump to the top of their priorities, leading to delayed discharges.
Now the hospital social work team focuses solely on discharges. Community teams no longer deal with hospital cases, but resume responsibility for their clients when they leave the wards.
Underlying all this has been an emphasis by the council, the primary care trust and the hospital trust on rehabilitation and care in the community.
So in Portsmouth, once people have been discharged but assessed as having a care need, they will often go to a social rehabilitation centre called the Victory Unit, a residential home in the Paulsgrove area of Portsmouth that provides care for older people. Here, free rehabilitation is offered for up to six weeks, in line with government guidance. Some people may then move on to one of five rehabilitation flats in council sheltered housing schemes in the city.
Such rehabilitation services are also largely where the council and the PCT are spending their slice of the £162m announced by health secretary Andrew Lansley on speeding hospital discharge between January and the end of March.
The city has had a multi-disciplinary rehabilitation-focused team in place for three years. Longitudinal studies suggest it has led to a reduction in care packages. About 40% of those undertaking a course of rehabilitation have no care needs when the course is over and a year later 30% of the total still have no ongoing needs.
The Lansley money has been used to pull together a second team and to put 16 extra beds into nursing and residential homes and more investment in domiciliary care.
It is also accepted that some delays are due to reasons that have nothing to do with health or social care. These include the patient wanting family involvement when the family lives far away or is on holiday; the home environment not being suitable for return and requiring adaptations; the person being on holiday in Portsmouth and not having a home nearby to return to, or not feeling ready to leave.
Understandably, the council and the hospital trust are proud of their efforts because outcomes for patients are vastly improved, though they acknowledge more can always be done.
Dryer says: “What we are most proud of in Portsmouth, with the hospital discharges and reablement generally, is the joint working we’ve got with our partners in health.
“We work hard with each other to try to understand roles and responsibilities and, although that does prove challenging at times, we have good links at all levels in getting across our views and concerns that are listened to.”
The nature of joint working will have to change because of the government’s health reforms. The PCT will be scrapped by 2013 and GP consortia will take over responsibility for health commissioning; meanwhile, the council will take overall responsibility for health and social care strategy through a new health and well-being board.
Gould sees this as positive: “The change in terms of the local authority being more involved in overseeing health provision and quality within health services may have an impact in terms of strengthening joint working because if you are part of that body it’s even more in your interests to make sure what’s happening is positive for patients.”
Sharon Hollins: “If people are in their own homes, they can relearn skills”
The hospital social worker’s view
Sharon Hollins has been a senior practitioner in Portsmouth Council’s hospital social work team for four-and-a-half-years.
Before qualifying as a social worker in 1994, Hollins was an occupational therapy assistant at the Queen Alexandra Hospital so she understands it well. She says delayed discharges have declined over the past six months as a result of changes in the process and the development of strong personal relationships.
“It’s the leadership, it’s the fact we talk more with our health colleagues about how we can get the right referrals at the right time,” she says.
“It’s also the fact that people are meeting each other, doing updates. It’s also having the enabling services out there. People do well in their own homes.
“The environment is false in hospitals but, if people are in their own homes, they can relearn their skills.”
Day-to-day contact is crucial with the clinical staff, she adds. “We will be phoning the ward, monitoring the situation, talking to ward doctors, staff nurses daily, ringing different wards discussing where we are at. Also, we work very closely with discharge planners.”
Working so closely together also helps to foster an understanding among health colleagues about what social workers do and what procedures and legislation they work under. However, there are differences in professional outlooks, which can lead to delays, particularly with regards to mental capacity.
“Ward staff are worried about risk and don’t realise that, if a person has capacity, they can choose to leave when they like,” she adds.
Roy Brown: Victory Unit helped to restore his confidence to live independently
The patient’s view
Roy Brown, 73, was in hospital twice last year, the second time as a result of a liver infection in May.
He had come to the notice of social services at the start of last year after a referral from his sister who had become concerned about his welfare.
On the second occasion, he was in hospital for three weeks. When he came out, he went to the Victory Unit rehabilitation centre for seven weeks to help regain his independence.
Before his discharge, an occupational therapist from the Victory Unit visited him at the hospital to assess his needs.
He went there because he felt he needed to regain his confidence as a result of being at the QA.
Now he is at home and has recovered so well that his file has been closed but, without that initial help, Brown does not believe he would have been able to look after himself.
“Social workers used to visit once a week, then once a fortnight and then once a month and then at Christmas they said they would be closing the case,” he says.
“Obviously it was helpful because we [my social worker and I] used to have chats about things and she made sure I wasn’t running out of food.”
Gillian Gould (left) and Nicola Martin believe less bureaucracy will speed the discharge process
The nurses’ view
“The people on the ground are there for the patients, however differing the priorities and the political tensions. That’s the most important thing and we try to cut through the who’s paying for what, which often is at the root of it,” says Gillian Gould, head of nursing in medicine for older people, rehabilitation and stroke at the Queen Alexandra Hospital, Portsmouth.
Despite this positive outlook, Gould and her colleague, Nicola Martin, senior nurse for discharge services, admit problems can arise, particularly when trying to join services together for complex cases.
The answer is to cut out more bureaucracy and to make the discharge process slicker, which is something the hospital is considering.
Gould recalls a male dementia patient who was admitted to the Queen Alexandra in the middle of the flu outbreak after Christmas.
He was medically fit to leave but both social care and health care felt he was eligible for continuing care funding, which can take a week to be agreed.
“Everybody agreed that in this man’s case it was detrimental to him to stay in the hospital,” says Gould. “What we were able to do was work with social care, the hospital, community staff and the PCT, which co-ordinate continuing care funding, to agree that he could go to an appropriate care home where his needs could be assessed in a more appropriate environment, and that happened within 24 hours.
“That wasn’t a one-off. I know over that winter period that was happening quite regularly.”
This article is published in the 10 February 2011 edition of Community Care under the headline “A cure for bed blocking”
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