To consider a report from the Director of Strategy and Communications, University Hospitals of Leicester (UHL) NHS Trust that provides an overview of ‘delayed transfers of care’ (DTOC) within the UHL. The report identifies improvement actions planned with system partners to reduce the ‘delays’ that impact on the patient’s journey further.
The Commission is asked to note the significant progress that has been made across the system with reducing the number of bed delays occupied by DTOCs and support the key actions planned to further reduce the delays in the patient’s pathway.
Mark Wightman, Director of Strategy and Communications, University of Hospitals Leicester (UHL) and Mark Pierce, Strategy and Implementation Manager, Leicester City Clinical Commissioning Group (CCG) presented a report that provided an overview of delayed transfers of care (DTOC) within the UHL NHS Trust.
Members heard about the problems that arose where patients, and particularly the elderly remained in hospital longer than required. The delays arose from a wide variety of reasons and an integrated approach was needed to address the issue. The Director of Strategy and Communications commented that most of the work around DTOC was carried out by the CCG and Leicester City Council Social Care colleagues with the UHL being the beneficiaries of their work. The Strategy and Implementation Manager said that the City Council Adult Social Care service had an excellent record in helping to improve the DTOC rates. The reablement service was also doing a very good job and had received a good inspection from the Care Quality Commission.
Members heard that significant improvements had been made in DTOC performance since 2017 /18, though with a slight increase in the number of patients being delayed since July 2018. Work was ongoing to continue to reduce DTOC; one way was through Trusted Assessments. Where only a care home manager could assess whether a patient was ready to go back to the care home, a patient’s discharge from hospital could be delayed, as for example the manager might be away. However, through this system, a person appointed as a trusted assessor would carry out the assessment which the care home would accept. Mr Micheal Smith, Healthwatch Leicester and Leicestershire commented that the implementation of Trusted Assessment was a very significant achievement.
A further key action to reduce DTOC was in Patient Choice. The view of the UHL was that the best place for a patient was back at home or in a home environment. In a very small number of cases there was a significant gap between the values and expectations of families, the patient and staff and in certain circumstances a letter of notice might be issued. The letters were intended to bring a focus and clarity to the discussions. The Chair said that the Commission had heard in the past that patient choice was leading some patients to choose to remain in hospital and it appeared that the issuing of a letter of notice was helping to manage those cases. The Director said that in most cases, people wanted to be discharged from hospital but in a very few cases, people were reluctant to leave.
Members welcomed the report and the improvements that were being made to improve issues relating to DTOC. Comments and queries from Members along with responses included the following:
· A concern was expressed at the issuing of letters of notice, as it reminded a Member of an eviction letter. She queried whether there was a more suitable alternative such as a booklet setting out choices. The Strategy and Implementation Manager explained that patients and families were given a considerable amount of information at the point of admission and during a patient’s stay. The number of times that a letter of notice had been issued was very small and they were only sent when the end of a very long process had been reached.
· Members referred to two individuals who they said had wanted to return home after their discharge from hospital but had been sent against their wishes to a residential home. Members heard that there needed to be an open dialogue as to how much risk the individual was happy to take. The Strategic Director of Social Care and Education explained that where an individual was deemed to have the appropriate mental capacity, they could make the decision about where to go following discharge from hospital. With capacity the choice on discharge from hospital and at what time and to where, was solely that of the individual with advice from but not direction of supporting professionals and family. A member raised concerns that in one of those cases, the patient was assessed whilst suffering from a urinary infection and it was acknowledged that an elderly person with a water infection would get confused. It had therefore not been an appropriate time to carry out such an assessment.
· Following a concern raised by a Member, the Strategic Director of Social Care and Education said that he would be very concerned if any decision as to where an individual should go after discharge from hospital, was driven by financial considerations which influenced or overrode any formal ‘best interest’ decision making outcome as this would not be lawful.
· The Chair stated that the process should be about empowering patients and families and that patients should be kept at the heart of the decision. Members heard that the process of engagement with the patient which started at the point of admission was all about empowering the patients.
· Members heard that Age UK had an office in the Leicester Royal Infirmary (LRI) and patients, families and staff could go to them for help in navigating the system.
· The Healthwatch Manager said that Healthwatch had been going into the
Discharge lounge at the LRI and speaking to patients about their experiences. Healthwatch had heard both positive and negative experiences and these experiences should lead to a more informed discussion.
The Chair drew the discussion to a close and thanked officers for the report, and the Strategic Director of Social Care and Education for his leadership within the system and in the area of DTOCs. The Chair said that the issue was worthy of further exploration, and in particular to find out what was being done that worked so well. The Chair added however that in her view, the report lacked a degree of substance and it would have been useful to have more information about empowering patients.
that the report be noted.