Lothian Delayed Discharge Action Plan 2006 - 2008

Summary of the Lothian Partnership's performance and targets established for 2006 to 2008:

The final results of the April 2006 census of patients awaiting discharge in Lothian confirmed Lothian's performance against the 2005 to 2006 targets. The table below outlines the Lothian performance at the time of April 2006 ISD Census and the targets we have agreed for 2006 to 2008.

April 2006 Census figures

This table shows that for April 2006 the Lothian Delayed Discharge Partnership met and exceeded its agreed target of 178, showing an overall reduction of 88 patients (38%) from the position in April 2005. The bottom line figure of 142 delayed discharges across the Lothian Partnership area compares well with the agreed Scottish Executive target of 178. Thus the Partnership has out-performed the Scottish Executive target by a total of 36.

Across Lothian, the number of patients delayed for over 12 months was reduced to zero in April 2005, as per our agreement with the Minister. This position has been sustained up to the present time.

Lothian also met and exceeded its target of reducing the number of acute beds occupied by patients whose discharge was delayed. We have agreed with the national guidance to use the target figure (56) as our baseline for the coming years.

Working in partnership, NHS and Local Authority staff in each Lothian Local Authority area has successfully delivered the Scottish Executive target reduction in delayed discharge, thereby fully contributing to the overall Lothian target achievement.

Lothian Delayed Discharge Partnership Quarterly Targets 2006-08

NHS Lothian are pleased to submit the 4 sets of local partnership targets (table below) for the Lothian Partnership. The 5 Partners are currently in discussion to agree these targets which, when agreed, will be confirmed to the Executive.

Local Targets

The Lothian Partnership progress report

Overarching framework for the Lothian Joint Action Plan in 2006/2008

Background

In devising the 2006/08 Action Plan, the partners in Lothian have agreed to give equal priority to continuing to shift the balance of care to individuals' own homes, and to stabilise and grow the supply of care home places.

After additional care places and packages, our second priority was to target additional therapeutic services on individuals for whom a better clinical outcome could be achieved.

The third priority was to make more effective use of the community care capacity that already existed in Lothian by making placements more quickly.

The fourth priority group of projects consisted of further developments of current schemes, many of which were tried and tested in hospitals and communities within Lothian.

Managing the market

Lothian's most significant difficulty in terms of reducing the number of patients whose discharge from hospital is delayed is the capacity of the care home market. The Partnership's long-term plan is to invest in new, purpose built long-term facilities to address this gap.

During 2005/06, considerable work and negotiation has continued with care home owners across Lothian to avert closure, particularly those whose care homes, because of size or layout, will not meet the new care standards on space or facilities. It is crucial that as many homes as possible are kept in business until new build developments and additional community based services can be brought on stream.

We have opened 106 interim care home beds and all of these will be running throughout 2006/07. However, we anticipate further care home closures and will need to ensure access to further alternatives to care home beds if we are to manage the position until the new facilities commissioned in Edinburgh(240 beds) and Midlothian(60 Beds) open (currently planned to commence in Spring 2007) and come on stream on a phased basis through to 2008/09.

It appears that the closure of many private care homes in Lothian is a business decision where a combination of factors such as low profit margins, staff recruitment and retention difficulties and the high cost of modernisation to meet new Care Standards are weighed against the option of liquidating what are often high value capital assets. The Edinburgh Partnership in particular continues to finding it challenging to find affordable care home beds within the current pricing policy. Additional care home capacity is being purchased wherever possible, often outwith Edinburgh.

In the interim period, we also fully intend to continue to identify and implement opportunities to improve our bed management and discharge processes. Many process improvements have been made to date and we intend to build on these during the life of this plan.

Long term care home provision

The Craigmair Interim Care Facility 30 bedded unit at Craigshill in West Lothian is now an established feature of the range of services effecting very speedy discharges from St. John's Hospital in Howden.

Arrangements for the commissioning of the 240 new care home beds in Edinburgh are underway, and the City of Edinburgh Council has allocated substantial additional capital funding to contribute to these building costs. Both Partners, NHS Lothian and City of Edinburgh plan to share the cost of obtaining the sites for the care homes. Two homes are now being built with plans for the third and fourth well advanced.

Lochend Care Home is currently being built and due to be completed and operational by April/May 2007. Work will commence by the end of July this year at the second care home sited in Craigmillar. It is anticipated that Craigmillar Care Home will be completed in November 2007. Discussions are still taking place between Health and the City of Edinburgh Council regarding the Merchiston site proposed to be operational by May/June of 2008. The old Eastern General Hospital site at Seafield is the planned location for the fourth care home anticipated to be completed by early 2009.

Care at home / home care packages

Action by the 4 Lothian Local Authorities to provide and purchase additional care packages to support those who can go home is considered to have been very effective. However, all 4 Local Authorities are currently reporting over commitments in their care at home budgets, despite significant additional mainstream funds (i.e. additional to the funds already committed by the Local Authorities to the Delayed Discharge Action Plan) being added to these budgets by each council. At the present time each council continues to prioritise patients delayed in hospital for funding where packages of care at home are required.

Summary Table

The Summary table lists the measures we will put in place between April 2006 and April 2008 to:

1. Reduce delays over 6 weeks to zero by April 2008

2. Reduce the number of delays in short-stay beds to zero by April 2008

3. Prevent unnecessary emergency admissions

4. Speed up assessment process and discharge planning

5. Ensure resources are available to fund care home and domiciliary care

6. Ensure quarterly sustainable reductions are made

Funding The Action Plan

In 2006/07, following a reconfiguration of the resources and their distribution, the Joint Lothian Delayed Discharge Action Plan will be funded by two primary income streams namely, £6.2 million from the four Councils and £3.9 million (at 2005/06 prices) from the NHS budget via the Scottish Executive Health Department Delayed Discharge Fund.

The total cost of the four local joint plans, which comprise the overall Lothian Plan, is £10.1 million.

NHS Lothian continues to fund related core services and actions in the NHS Divisions and CHPs, together with NHS Winter Services strengthening, but these have all been separated off from the joint delayed discharge plans.

Patients delayed in short stay settings

This is a new measure and so we have some difficulty comparing in full how we have performed in this area retrospectively. However the management and consultant teams at Lothian University Hospitals Division have asked CHP and Council partners to consider adopting a more challenging local definition of "short stay" specialties, to include all specialties in the Royal Infirmary of Edinburgh and the Western General Hospital. This is currently under active consideration.

Patients delayed for more than 6 weeks

Past performance against this measure leads us to believe that we can deliver this target largely through sustaining and further focussing our previous actions and initiatives, some of which have vastly improved the process of moving patients through Lothian Hospitals.

Reducing delays over 12 months to zero.

As indicated in previous section, Lothian are pleased to have no patients delayed for over 12 months since April 2005 and we fully intend to sustain this performance from now on.

Other Additional Measures

A short-term secondment is planned for the latter half of 2006 working across the whole health and social care system in Edinburgh. The purpose of this modernisation manager post is to review the delayed discharge actions in Edinburgh in the light of the new national targets and to make recommendations for any service configuration changes deemed necessary for the full delivery of the targets.

For example, actions were instituted to ensure that the number of health care delays in the system was brought to an absolute minimum, by the date of the April 2005 and 2006 ISD censuses. This was achieved through a combination of additional therapeutic inputs delivered closer to the beginning of patients journeys through the Orthopaedic system, and analysis of the best use of the Continuing Health Care beds across the whole of Lothian. There may be long-term developments we can now put in place to build on this success.

We will also be considering whether other parts of Lothian can and should implement the use of Intermediate beds as has been done in West Lothian at Craigsmair.

What data do we collect and how often do we monitor it?

Monthly performance data is collected across the Lothian Partnership to the same quality standard as the quarterly delayed discharge census.

Financial Activity monitoring data is collected and collated into an Excel Spreadsheet.

The plan is on an Excel spreadsheet; with each agency involved in the plan receive their own extracted project details, with the agreed allocation of funding for each project shown.

On a monthly basis, these extracts are sent to each agency, requesting completion of projected out-turn costs against each project.

This should be based on current spend to date, with a prediction of the future monthly spend, by month, giving a total predicted spend against each project for the financial year to which the plan relates.

These are then collated, to see whether there are additional pressures on the funding, or whether there are possible areas for slippage.

Concerns within Lothian.

The Lothian Partnership faces very specific difficulties in relation to the care home market, relating to the buoyant economy in the Capital City and its surrounding area, and the linked factors of high property values and almost full employment. A detailed property search commissioned from a private sector agency confirmed the dearth of buildings in or near to Edinburgh, which could be used appropriately for the provision of care to older individuals. We believe that we have now exhausted the supply.

Recruitment and retention issues affect all care staff groups in Lothian.

Conclusion:

A range of intensive actions has brought about a further step change reduction in the number of patients delayed in Lothian Hospitals. All 4 local partnerships exceeded their targets for 2005-06.

Key initiatives to offer rehabilitation to orthopaedic patients earlier in their patient journey, to improve the joint management of placement processes in Midlothian and East Lothian, and to improve the discharge of patients to their own homes in Edinburgh have brought sustainable benefits to the Lothian health and social care system. These will be sustained and built on during 2006/08.

It is clear that joint work focussed on shared objectives has brought very significant gains for Lothian since 2003-04. This forms a firm foundation for the delivery of the challenging national targets agreed for 2006-08 and we are keen to move Lothian's performance forward through the agreement and delivery of this joint action plan and enhanced partnership working during 2006-08.

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Lothian 2006/ 2008 joint action plan: detailed list of funded projects

Edinburgh Partnership / LUHD / PCO

Delayed Discharge/winter Services to be provided 2006/07

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Midlothian Partnership delayed discharge/winter services to be provided 2006/07

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West Lothian Partnership delayed discharge/winter services to be provided 2006/07

East Lothian Partnership / LUHD / PCO

Delayed Discharge Services to be provided 2006/07