Item 5 is evidence from Scottish Government officials on winter resilience. We have Geoff Huggins, acting director for health and social care integration; Alan Hunter, deputy director for performance management and national programme director for the unscheduled care programme; Shirley Rogers, deputy director for the health workforce; and Dr Daniel Beckett, consultant physician, NHS Forth Valley. I thank you all for your attendance. Does anyone have any brief comments to make?
I will ask members of the team to say a wee bit more about their experience, but we will not make extensive opening remarks.
Okay. After that, we will move to questions.
My particular interests are in delayed discharge, health and social care integration and primary care.
I have responsibility for the health workforce and the quality and efficiency support team—QuEST. I have a particular interest as the chair of the task force on sustainability and seven-day services.
I have been with the Scottish Government for almost a year. I came on secondment from Greater Glasgow and Clyde NHS Board, where I was a general manager in the acute sector for about 14 years. Prior to that, I had experience in hospitals in Scotland and England.
I am the chief medical officer’s specialty adviser for acute and general medicine. I am also the national clinical lead for the whole-system patient flow improvement programme. I am the associate director of standards at the Royal College of Physicians of Edinburgh and a consultant physician in acute medicine in NHS Forth Valley, which is where I spend most of my time.
We have been fortunate for the past few years in having relatively mild winters and I hope that we may be fortunate again. However, I am concerned about delayed discharge numbers. The figures had been dropping since delayed discharge was defined as involving a delay of more than six weeks. In 2002 to 2003, when the programme came in, the figure was 3,000. The Labour Government reduced the numbers considerably and the Scottish National Party Government, to give it credit, had reduced the number to zero by March 2008. However, in the past three years, the numbers have risen.
The latest report says that 450,000 bed days have been occupied, which is the equivalent of 1,100 beds occupied in our acute sector every day of the year. Given that problem and the fact that local authorities are cash strapped, how will you ensure that, if the winter is even moderately bad, our health service can manage the situation and continue elective surgery? I hear that a number of boards are predicting that cancellations of operations will increase significantly over the winter, which means that the Scottish Government’s targets will not be met for even more Scots than the 10,000 a year for whom the legal guarantee is not met.
11:30
I will talk about where we are on delayed discharge and then bring in Alan Hunter to talk about the work on elective surgery. First, I refer to the statement and comments that the new First Minister has made on the programme for government. The Government is clearly committed to tackling delayed discharge and it will take action to do so. In her speech, the First Minister set out the additional £15 million that would be spent across the winter to take additional steps in individual partnerships to reduce the number of delayed discharges.
I can say a bit about that work to illustrate what is happening in practice. NHS Fife is doing work to increase the number of step-down beds, which enable staff to move people on appropriately when they are ready for discharge from hospital into a location in the community. That is part of the process of—ideally—returning people home. Through the work that it has commenced, NHS Fife expects to take about 60 people relatively quickly out of its current number of delayed discharges.
In Glasgow, we have a system where the health board and the council are working towards a process of discharge for assessment. When appropriate, patients would not sit in a hospital bed waiting for an assessment but would return home quickly to be assessed and then move on.
The £5 million that the Scottish Government has offered—together with the contributions that health boards and local authorities are making, the national unscheduled care action plan money from earlier in the year and the £5 million that we allocated in the summer—is being used in targeted ways to address the short-term challenge and look beyond it to build systems that do not simply transfer the problem elsewhere. The intention of integration and the work on delayed discharges is to release the pressure on the NHS by ensuring that the whole system works effectively. That means that we need to take more evidence-based approaches in hospitals that enable us to work across the hospital-care boundary.
We are doing some work nationally. We have engaged with the Care Inspectorate on work that it can do to assist us to ensure that care homes can take people and that the quality that care homes offer does not mean that councils or the inspectorate must block people going out to them. Targeted support is being offered in the City of Edinburgh Council area, where access to care homes has been a particular issue. The approach is also being taken into other areas where a lack of access to care homes might cause a delay.
Through the work of the residential task force, we are thinking carefully about how we want to use care homes in the future. We are beginning to move increasingly to seeing them as part of a system of care whose objective is to enable people to stay at home for as long as possible. We see care homes in many cases not as long-term residences. Home is the appropriate long-term residence for people—that is what they tell us. We are thinking about care homes having a different function in the system from the one that they might have had before. We are taking that work forward in collaboration with COSLA and other colleagues.
To build on the work that we have done in Fife, we are working directly with partnerships to anticipate how things might operate under integration. In that context, we have worked directly with the chief officer as well as both partners—health and social care—to talk through the different solutions that they might adopt during 2015-16, when the integration partnerships come on stream. We have asked them to do that now because there is no reason to wait to do sensible things. As partnerships, they are stepping up to the mark to do that.
Internally in the Scottish Government, we have established a programme board to actively manage delayed discharge across the winter. That will meet weekly and will look at what I would describe as the grey data—the unvalidated data that we get weekly, which we do not publish. It will also identify across the period whether there are challenges or blockages that we might want to become involved in.
Delayed discharge is an area where local systems are best placed to design and develop local solutions, although there needs to be strong engagement between the centre and the localities. Our objective is to move the dial on delayed discharge across the winter.
Thank you for that comprehensive answer. I should declare that I have two interests in relation to the issue. First, I am the director of a nursing home, although I am glad to say that, as it is based in England, it is not relevant to the Scottish situation. However, it gives me experience of what is happening in delayed discharge in the nursing home area. Secondly, my wife is the head of social care for a council, which is relevant to my second question.
Some local authorities, such as Stirling Council and Clackmannanshire Council, have no delayed discharges because they have reintroduced social workers in hospitals to ensure that there is early assessment on admission, rather than when people are ready for discharge. How will you ensure that you do not simply reward areas that have not been successful, which do not have step-down beds, which have not used care homes for short-term provision before people go home and which do not have—as there is in Edinburgh, under Peter Gabbitas—good integrated nursing and social care, which picks people up for 10 weeks and assesses what they need? In the long term, such a perverse incentive would be self-defeating.
I agree. Our intention is that the approaches that we are working on with particular partnerships should apply across the system. The challenges of chronicity, multimorbidity and more people living longer have become pronounced in particular areas, such as Edinburgh and the Lothians, where we have challenges in accessing particular services. The situation is similar in Grampian and Aberdeen city.
If we do not see reform across the system, the challenges that are faced here will be faced elsewhere. We need to take a long-term strategic view of the whole social care system. The fact that a particular area is not challenged at this stage does not mean that it will not be challenged next year. We are entirely conscious of that.
Do you want us to say something about elective care or is that for a later question?
Someone else might come back on that important area.
If a hospital already has step-down beds, it will not be rewarded with funding to increase its number of step-down beds. If an area is running a cost-effective hospital-at-home scheme, it will not be rewarded for introducing that.
Will areas such as Stirling and Clackmannanshire, which have no delayed discharges, have made a big effort and have step-down assessment and so on, be rewarded? They are in deficit, as are all local authorities. Every single social care budget is in deficit. All local authorities are struggling enormously. How can they produce £5 million to match Government funding? If they already have such measures in place, should that be counted as their contribution towards the £5 million that you are producing?
It is important to say that, in addition to the work that the additional money is funding, partnerships are taking other actions. Some of the work that is going on in Fife, where we have been directly involved, is being funded directly by the health board. The health board has looked at the sums and the structure and has identified that it makes more sense for it to spend the next £100,000 in a community location than in a hospital location. That will offer a better quality of care and be more financially efficient and, importantly, it responds directly to what people are looking for, which is to go home.
We are seeing a flexible use of resource. When the then Deputy First Minister introduced the proposals on integration back in December 2010, she talked about the need for us to think about how we apply money and effort across the system, to think from the perspective of the individual who is receiving care and no longer to think purely in organisational terms—between NHS this or council that. We are getting into that space, and our sense is that that is where the solution lies to the challenge that you have put down.
I conclude simply by pointing out that the integrated resource framework programme was introduced in 2009, but I hear from my local authority colleagues that many of them do not even know about the integrated resource framework spreadsheet. Even though it is fundamental to the integration budget, it has not been published, and we do not know what it is. We are within six months of allocating the first budget for the groups, and they still have no access to the spreadsheet, which I know they have asked for.
I can certainly take those comments away with me. I know that, as part of the process that is being taken forward, colleagues who work for me and colleagues outside the Scottish Government are routinely using that information on the ground.
Indeed. I know that that is happening in Perth and Kinross.
I can think of five partnerships where that is happening, because a very tall pile of data from those partnerships recently arrived on my desk. The granularity and understanding that we took from that information was really good. If there is a genuine challenge, I am happy to follow it up.
That would be helpful.
Our objective is to ensure that the process is underpinned with data.
I have a supplementary about council nursing homes. Over the years, councils have closed such homes because they had no en-suite facilities. What action have you taken and what discussions have you had with councils to ensure that they are signing up to the provision of the new step-up, step-down facilities?
Over the next couple of months, we will carry out targeted work in areas where we will benefit from having more nursing home places. Although a number of nursing home places are unoccupied, they are not necessarily in the locations where we would benefit most from them.
Another challenge that we face is how much it takes to bring a home back into use, but the City of Edinburgh Council is working with NHS Lothian to bring Pentland Hill nursing home back into use, and a similar approach to other properties in the Lothians—one of which is a council location—could be considered. The issue is on our agenda and we have clearly identified it as an area for further work.
So you are working to ensure that councils do not shut nursing homes that we might need over the next period.
We are concerned to ensure that any service that is provided is of a high quality and meets people’s expectations. Within that, there are small flexibilities—say, four inches here or six inches there—that the Care Inspectorate can apply, but bringing homes back into use or maintaining them in use is more straightforward in some cases than in others. We are looking for a proportionate approach but, as I said, we have clearly identified that we can do more partnership working on the issue. That reflects the engagement process between us and partnerships.
That was only a supplementary question, convener. I have another question that I will ask later.
That is why I let you in, Richard. I wanted to get some clarity about the step-down facilities and the flow-through that have been mentioned in recent Scottish Government announcements and press releases.
When I listened to your earlier responses, I looked at NHS Greater Glasgow and Clyde’s winter resilience plans and noticed that it seems to have identified step-down facilities not just as a winter provision but as part of its forward planning. We need some clarity about that. Although the publicity has said that these step-down facilities are going to be put in place, a scant look at the plans suggests that they are not yet there. Are they? How much additional provision is now available across Scotland for winter resilience, and what is the longer-term view of step-down facilities? After all, as Richard Simpson has pointed out, high bed occupancy and delayed discharge are, unfortunately, things that happen not only in winter. There seem to be a couple of things going on here.
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I will talk a bit more about that. Step-up and step-down facilities are 365-days-a-year facilities and they are the future; they are a key future component of care in Scotland. They are already in use across Scotland, although not in a consistent way in all local authority areas. Our objective is for them increasingly to be seen as the first step for either assessment or reablement, on the basis that there is an understanding that many people, having had a period of time in hospital, require some additional support to get back to the full level of functioning that will enable them to return home.
About six years ago, my aunt—this is a personal story—went through such a facility in Northern Ireland, where she is resident. She had four weeks there and then a further two weeks, and then she went home. She is now about 90 and she has been living at home for the six years since she went through that process, having had a period of about eight weeks in hospital during which she picked up a hospital-acquired infection.
That is the future. People tell us that they do not want to go to a care home or a residential setting where they will lose their autonomy. They want to take every step that will enable them to go back to their own home. It is a strategic approach that will be taken right across the system. We are accelerating it in the run-up to this winter; we are offering support to some partnerships, and some are using it for that purpose. It is core to how the business will be delivered.
What does that acceleration mean for step-up and step-down facilities? If we consider the issue in the context of resilience planning, what additional capacity are we creating in NHS Greater Glasgow and Clyde? I may be reading its plan wrongly, but it seems to suggest that it is doing this not for winter resilience planning but in a long-term, strategic way. What extra capacity is there in the various health boards?
In Glasgow, the board’s intention is to produce 90 beds for assessment. They will be a continuing component of its system with the objective that it will discharge people within three days of their being ready to discharge, which is also clinically indicated—
Is that additional?
That is additional to what it had previously.
In Fife, the board is looking at having two 30-bed units. That is how some of the £5 million that has been allocated is being used across the current period. It is being used in one or two other areas in the same way. In other areas, because of either the current structure of the service or the unavailability of a location where boards could offer such a facility, it is not part of the current use of the resource that has been offered over this period, but in our strategic engagement with partnerships we are looking to have it as a component of all systems and services.
I am not sure that we have an audit that enables us to make the distinction between different types of beds and to show change over time, but we could begin to look at how we might capture that.
I am perfectly happy with your answer. Additional capacity is being made available. I was not clear about that from what had been said.
Some more clarity on the finance would be helpful. A number of figures have been bandied about in the past couple of days, including £15 million, £18 million and £1 million that was allocated in August, approximately half of which has already been allocated. There seem to be various pockets of money that have been brought together once or twice.
If we make a comparison with the amount of money that was made available last year for winter resilience planning, which was set out in a letter to the committee from the cabinet secretary at the time, Alex Neil, what is the increase on last year? What is the new money this year?
There have been three relevant allocations during 2014-15. First, £5 million was allocated in the summer. Was that in June?
It was in August.
Secondly, £8 million was allocated through the NUCAP. That was part of the larger amount that would have been included in the letter last year, which covered a three-year period. Then there is the £5 million that is currently being issued, which is being supplemented by contributions from NHS boards and local authorities. That means that £18 million is coming from central Government across the period. We also recognise the contributions that are being made by local partners—NHS boards and local authorities.
How does that compare with last year?
We invested £9 million from the NUCAP funding last year. The extra £10 million that has been focused on relates to delayed discharges and additional sums. We have more than doubled the money that went in last year.
You have more than doubled it.
Yes—the central allocation.
Did that money flow through over the years, or is it new money?
It is new money this year. The first £5 million tranche of the NUCAP money went out in August; the second £5 million went out in November.
As part of the process of encouraging partnerships to think of themselves within the integration framework, we are beginning to receive their proposals to spend the £100 million integration fund. We will be ascertaining the degree to which the use of that resource supports our objectives around delayed discharge.
That is being used to buy up beds.
That money will appear in 2015-16, so it is looking forward to next year. As people make decisions over this winter, they may do so with the understanding that there will be resource support during the coming year.
You mentioned NHS Lothian and the fact that it has managed to get hold of the old Pentland Hill care home. What kind of numbers are we talking about? What will it be used for, and what dent will that make in the problem area of delayed discharge? What kind of help will it be? How has the board managed to fund that?
The board has used some of the allocation that we have offered, but that allocation clearly will not be sufficient for the work over the period for which it will be running the service, so money has been found between the health board and the council.
In the short term, the board’s intention is to bring into use 60 beds for step-down care. It expects to have 60 beds available from the middle of January. That will take a significant bite out of the Lothian figure. That is the basis on which the board is doing that. Historically, the home had 120 beds. The 60 beds that are being brought in relatively quickly are the ones for which the process is more straightforward. The board will of course wish to be confident about being able to staff the new service and to operate the premises effectively as a step-down facility, having historically been run as a residential care home. The board is looking to a different service model. That facility will take a big bite out of the problem for NHS Lothian.
For 365 days a year, the out-of-hours service and NHS 24 cope when doctors’ surgeries are closed. What plan do we have in place for this year, bearing in mind that, this Christmas, doctors’ surgeries may close on the Wednesday and then not open until the following Monday? Out-of-hours services will have to cope from 6 pm on the Wednesday, all day Thursday, Friday, Saturday and Sunday until 8 am on the Monday, and the same again at new year, over and above what they already do. What planning is in place to ensure that we have sufficient cars and doctors, and that we can cope with any possible snowy weather that we might have on the horizon?
I will cover the initial part of the question, on the resilience that NHS 24 is building in. I will then bring in Shirley Rogers to speak about workforce and ensuring that we have enough people, which was the second part of your question.
The NHS 24 winter plan is on its website—we have asked all boards to place their winter plans on the web. That plan sets out exactly what it expects to happen at this stage.
NHS 24 is predicting that 2 January will be the busiest day that it has ever had. There are a couple of reasons for that, one of which is where new year falls in the week. Another is that, since the introduction of the new 111 number in the summer, there has been roughly a 20 per cent increase in calls generally. The service is being used more by the public anyway and this is a time when it would expect to be busier. It is basing its expectations on what it will need to do across the two four-day weekends, with a particular focus on a couple of spikes, which are probably the Saturdays. It is ensuring that it has the establishment on deck on those days so that it can respond to more calls than it has ever had before. It has recruited an additional 65 call handlers for the period, so more people will be available.
That gives you the story of what NHS 24 will do if what it expects to happen happens. Beyond that, it has looked at resilience, continuity and contingency should what happens be different from what is anticipated. That has been a wee bit of the NHS 24 story during 2014 already. Call rates to the 111 number have been less predictable than they were to the previous number, so there has been more day-to-day and week-to-week volatility. NHS 24 has already had to be more fleet of foot throughout the year in its responses to different pressures. It will take that learning in.
The plan that NHS 24 has laid out, which is on the website, deals with the different methodologies that it will use to address different challenges, particularly spikes in call volume, and the processes by which it will prioritise clinically significant calls, bring people back to their desks, extend shifts and bring people in, should it be required.
NHS 24 takes this work extremely seriously, so it sat down last week and considered its plan again, after having submitted it and put it on the web. The board spent a significant chunk of its time considering other things that it could do to address other contingencies. It is now considering whether there are other steps that it might build in so that it becomes more robust.
An interesting little nugget out of what we have seen in the recent period is the suggestion that, over weekends and in current out-of-hours periods—we run 52 out-of-hours periods every year, because every weekend is an out-of-hours period—people are choosing to contact NHS 24, which might be having an impact on accident and emergency attendances at weekends. That is suggested in some of the data, but I would be cautious about suggesting that there is a big behavioural shift, although that is clearly the sort of shift that we look for. The data is beginning to suggest that people are thinking about NHS 24 in a different way, and perhaps the 111 number has contributed to that.
Shirley Rogers might want to say something about the workforce and having enough people.
Geoff Huggins has given the picture for community services, so I will touch on the acute sector’s response. Our expectation is that boards will adopt the Scottish Government winter planning protocols, which specifically ask them to look at rotas during festive holidays and disruptions from whatever source, whether it be norovirus or increased activity for whatever other reason, such as travel or slips and falls caused by icy weather. We particularly asked for a focus on four specialties that relate to those, one being emergency medicine, for obvious reasons. The others are gastroenterology, geriatric medicine and respiratory medicine, which will allow us to deal with respiratory conditions arising from flu and so on.
We have a specific, targeted piece of work around those four-day periods. It is not the first time that we have had four-day periods but, nonetheless, they always make us thoughtful about service provision, so we spend a bit of time focusing on that. The committee will have seen some of the data that ISD Scotland produced at the beginning of December, which suggests that NHS boards properly using the methodologies that we talked about earlier when we were talking about rosters should have sufficient staff.
Over the past couple of years, we have moved into risk-based workforce planning across staffing borders and have tried to ensure that boards anticipate any areas of concern. At this stage, boards are not alerting us to any specific areas of huge concern for that four-day period.
12:00
I welcome the point that Mr Huggins made. I have had previous experience of driving with the out-of-hours service. If you phone NHS 24 and immediately get an appointment, you do not have to wait in accident and emergency; you can go straight in and get your appointment to see the doctor, or indeed the nurse, because in some cases a nurse can cope with the situation without a doctor. That relieves pressure on A and E, so I encourage people to do that. Having worked in hospitals on Christmas day, new year’s day and 2 January, I have seen the pressures on A and E and on the service. Thank you for your comments.
There has been a bit of publicity about GP practices not being available. I notice that one of our old friends, Dr Buist, was on television last night saying that GP practices are available over that four-day period. Do we know which GP practices will be available?
I return to my opening comment, which was that we deliver an out-of-hours service 52 weekends of the year. Our general approach is that, during weekends and holiday periods, we will offer an out-of-hours service, which is a combination of GP out-of-hours provision and NHS 24. We have already had one four-day weekend this year; the Easter weekend was also a four-day weekend. At this stage, we are going through the process of ensuring that boards are able to fill their rotas to deliver the four-day weekend in the same way that they would deliver any weekend. We are staying in contact with boards and, as we did with the Easter weekend, we will take the opportunity when we talk to chief executives and chairs of health boards to get a sense of where they are on filling rotas.
Some areas are beginning to think about additional opening days for normal GP surgeries.
That is what I meant.
That is effectively an experiment that a board is engaged in. At this stage, we do not know whether that is a service that will be taken up by the public. We do not know whether they will choose to use it, and we do not know whether it will be a more effective way of delivering the service than the current methodology, which is to go through NHS 24 and receive an out-of-hours appointment.
We are interested in the fact that a board has decided to take that approach, but we will want to see the implications and consequences before we decide whether it is a benefit. At the same time, we will ensure that boards are delivering a robust out-of-hours service, as they will this coming weekend.
You operate on the reality, which is that normal GPs’ surgeries are closed.
Yes. That is the case every weekend.
What was the effect on A and E figures at Easter?
I do not have the A and E figures.
I do not have specific figures for the four-day Easter period, but we can get them for you.
They were up quite significantly last Christmas, were they not? I think that they were up by something like 22 per cent.
The overall activity last year was up compared with the previous year, but our performance on waiting time was significantly better than in the previous year. It is not just a matter of attendances at A and E that can influence the figures; it is a mixture of attendances and the admission ratio that comes from those attendances, so there is not a direct correlation between the two.
There is an element of risk, then.
Yes.
What is different about the holiday that is coming up is that, out of 11 days, GP practices will be open for three days rather than for five or seven, so we are looking at quite a long period with little cover. That obviously affects the number of people going to A and E, which you have tried to deal with. It would be useful to know how many additional beds are put in to deal with pressure on A and E departments.
I have figures on that from each of the boards. As Geoff Huggins said, and as we have discussed, the issue is not just about beds. Particularly with elderly patients, it is not always best just to house them in hospital. That is why we are looking at step-down facilities and the different capacities and processes that we can put in place.
Having said that, I can give figures on extra winter surge beds. NHS Ayrshire and Arran has plans to put in 14 more acute beds this winter compared with last winter, with a potential to increase that by approximately 10 surge beds at the weekend. The board has also increased capacity in receiving wards by converting other beds, and it is introducing frail elderly pathways to support such people at the front door and get them back into their home with appropriate care.
NHS Borders is building on an ambulatory care assessment unit concept, and it is purchasing extra nursing home beds over the period. The board has a surge capacity of 25 beds, which increases to 35 beds at the weekend.
Another example is NHS Lanarkshire, which is also introducing ambulatory care units in Wishaw and Monklands hospitals, with capacity for 35 patients per day in those units. The board also has 30 additional beds at Udston and 14 additional beds in Monklands, which will be available from January.
There is a similar range of responses in the other boards.
The figures for last year’s winter show that slightly over 5 per cent additional staffed beds were available over the period. During the previous winter—the 2012 winter—there were 7 per cent more beds than the norm. As part of the planning process, boards are looking to ensure that they can staff more beds and that more beds are available to respond to the sort of challenge that we expect.
What is the percentage increase this year? You said that it was 7 per cent two years ago and then 5 per cent last year.
Alan Hunter has outlined the capability in the system to open beds—those are beds that could be opened. We will know what percentage are actually opened only when we get to the post-Christmas period. However, from what we have seen, the scale will be similar to that in previous years.
I want to ask about people with chronic conditions. One issue is that people who become unwell then wait and become very unwell in the interim period of four days—indeed, people might have to wait 11 days if they do not get an appointment in the three intervening days between the closures. What steps are being taken to encourage people to contact NHS 24 and to keep emergency appointments available for those three days?
We certainly encourage people with chronic conditions who might require care to approach NHS 24. There is a clear commitment that they will see somebody appropriate and will receive care and treatment. As part of the winter message, we are clear that people who require treatment should come forward and seek it.
More generally, we ask people to think ahead if they know that, over the winter period, they will require a prescription or some other form of activity that does not need to be done on a particular day and is not for an issue that arises. It is clear that the message is not that people should not seek out help. We are clear at every stage that people should look for help.
You say that you encourage people to get in touch, but how are you getting that message across?
That was included in the be health-wise this winter campaign. People are told to attend their GP in advance and approach their pharmacy early to ensure that they are well stocked for any escalation problems that they might have. Also, the winter planning guidance that went out specifically on respiratory disease encouraged boards, hospitals and GP practices to look at anticipatory care needs over the period, particularly for chronic disease patients. We have built that in, and boards are building it in to their winter planning arrangements.
There is a flu vaccination campaign for folk under the age of 65 with comorbidities, much as Rhoda Grant describes, such as people with respiratory or cardiovascular disease. Last year, just over 60 per cent of those people were vaccinated and 77 per cent of over-65s were vaccinated. It was the sixth year in a row that our figures have been above the World Health Organization’s flu vaccination target.
In recent years we have seen a smoothing out across the year. Activity has been less pronounced in winter than it would have been historically, and we are seeing more activity across the year. There is a pattern of activity in which people are busier for more of the time, but there are fewer spikes in the system.
That is reflected in the winter death figures, which have shown an on-going downward trend. For example, last year’s figure was 17 per cent down on the figures for recent years.
Winter is clearly very significant, but some of the challenges now appear to be spread out. That can be attributed to things such as better work on vaccination and chronic care management. We are now seeing morbidities spread across the year rather than being concentrated in winter, although we plan on the basis that there will be some concentration.
I note from the Government’s briefing that, last winter, far fewer wards were closed due to norovirus being either suspected or confirmed. Was that due to any specific measures? Can you enlighten us as to why that was the case?
Yes, some specific action was taken. Evonne Curran, who is the senior person in charge at Health Protection Scotland, introduced bay closures. Hospitals closed down bays rather than waiting and enclosing a whole ward, and kept the ward operating with stricter controlled infection measures. They also reduced visiting in those wards, for obvious reasons. After reviewing its action, Health Protection Scotland believes that that was the right thing to do, so it is building it into the plans for this year.
Health Protection Scotland will also look at better on-call services for domestic teams so that we can get them in earlier to clean facilities rapidly. It is trialling the use of hypochlorite fluid in four hospitals to see whether that kills the norovirus earlier and quicker. The organisation believes that the stay at home campaign has also had some impact, and we are trying to get the message out to relatives and people who are ill that it is better to stay at home.
So if that action is repeated this year, we can hope to see better figures next year.
We hope so.
An interesting point is that the experience last year partly reflected the fact that the 2013 norovirus strain was the same as the 2012 strain. At present, we are seeing similar levels of norovirus to those that we saw last year—again, those are below the levels that we have historically seen.
In the post-winter period, there has been an evaluation of what worked. When something goes well, it is quite good to know why, and a number of the elements that Alan Hunter has mentioned are part of that. We are now looking at norovirus management and recording not just in whole wards but in bays.
One key factor is that there is now more of a common understanding among the public that, if they are ill, they should not go to hospital. That has been cited by a number of staff in response to the surveys. People understand that people not only get well in hospital but also get ill, and that if they are ill they should not take their illness into hospital. It is really interesting: we cannot know yet what the story for this Christmas will be, but again it is looking like we will be in a good place.
12:15
Is there any predictability about how a strain of norovirus changes?
There is advice provided by, I think, the centre for disease control.
HPS advice so far is that there is no way of predicting how bad the norovirus season is going to be, based on current data.
The literature for the be health-wise this winter campaign makes for interesting reading. Indeed, what struck me was its point that winter resilience is a joint responsibility between the NHS and the individual and that we as individuals all have our part to play in our communities.
In that respect, some of the things that have come up in our conversation include knowing when to stay at home instead of going to a GP surgery or accident and emergency; ensuring that you have cold and flu remedies at home, should you need them, and that you have enough prescriptions; knowing when your GP surgery is open over the Christmas period; and knowing where your local pharmacy is, when it is open and when you should go there.
I am going to continue, convener, because my point is an important one. Other things include knowing when to go to a minor injuries unit instead of A and E—and, indeed, finding out whether you have such a unit—and when to use out-of-hours services or NHS 24.
When tied together, all of those things represent a pretty comprehensive package of healthcare provision over the winter period, but there is a lot of information for individuals to take in. We all have a responsibility to digest and be aware of it all and to take certain steps, but whose job is to put everything set out in the be health-wise this winter campaign on the one piece of paper or portal and get it out to individuals so that we can play our part and take on our responsibilities as individuals in the community? I stay in Maryhill in Glasgow. Who do I contact if I want all of that information for my local area?
NHS 24 is the lead health board for the campaign, but each health board was asked as part of the winter plan to carry out local initiatives. Boards have done so; for example, I know that there have been articles in papers in Stirling and that a lot of work has been done in Lanarkshire, the Borders, and Dumfries and Galloway. Each board has a responsibility for getting the information across to the general public through the local media.
Yesterday, the cabinet secretary did the NHS Ayrshire and Arran annual review, and after the event she talked to the media about the winter message. The challenge is for us, directly, and the health boards to ensure that people get that message.
I am aware of advertising campaigns on the television and the like, but I wanted you to tell me about the methods you are using to ensure that the message permeates across Scotland.
Before my final question, I want to make a general point. Time and again, we hear that that general practices should act as hubs at the centre of communities. At this time when we most need people to use the other approaches in order to take the strain off the system, could a single concise message go out to each household registered with a GP, setting out not only the practice’s opening times over the winter period but where the minor injuries unit can be found and when to use it, the use of repeat prescriptions, where and when to go to the local chemist and a variety of other messages?
The publicity campaign is great, but I am looking for a kind of one-stop-shop message to my constituents. Have you given any thought to how that might be captured? I realise that my idea will incur postage costs, but the cost savings could be huge. After I get some reflections on that, I will ask a final brief but related and, I think, important question.
Your idea is really interesting. Indeed, with new technology and new approaches, it is probably more straightforward to do what you have suggested this year than it might have been five years ago.
The fact is that information about, for example, minor injuries is valid all year round, and the other challenge, which comes back to us, is whether the behaviours can be built in across the year. You mentioned pharmacies; with prescription for excellence, pharmacists are increasingly being seen as front-line primary care service providers. Pharmacies, too, might be locations where such information can be found, but we can certainly take away your idea about customised local information.
Okay. I appreciate that.
Many GPs send out a letter on flu immunisation. Mentioning the winter plan for over the Christmas period in that letter and saying when the practice or a pharmacy will or will not be open will give local information. Bob Doris has made an excellent suggestion. It would not cost a lot to say that that should be done regularly.
We have a meeting lined up early in January with the directors of communication from each of the health boards. That is a good idea, and we will build it into that meeting.
GPs repeatedly tell us that they should be the centre of a community health hub. That certainly gives them a key responsibility to take that message forward, perhaps for next winter.
My final question was going to be: how will we monitor the effectiveness of all those things? I would, of course, like you to answer that question, but we have not really spoken about the preparedness for at-home care packages over the winter period.
I think that we all know from family members that it is not just a matter of having prescriptions and medications and knowing when A and E, the chemist and the GP are open, for example. Given the nature of leave and the inconsistencies in staffing in local authority areas or agencies, how much work has been done to ensure that, if a person has a care-at-home package, that continues seamlessly throughout the winter period? I can think of constituents of mine who require four visits a day for fundamental primary care assistance. If we do not get that right, aside from affecting the dignity of the individual, it leaves them open to family members having to take them to A and E and the like. Obviously, very vulnerable and frail individuals would be involved.
That is a really important point. Home is probably the location of care where more people will receive care over this winter. In the work that we did in 2009 when we had significant issues around access and the availability of travel with the snow, ice and everything, we liaised directly with local government systems to ensure that they had appropriate arrangements in place to provide continuity of care and that they knew who was receiving care and what the nature and structure of the care was, and to be assured that that was continuing. We would look to our local government colleagues. We do not monitor that in quite the same way in which we monitor the NHS, but that is part of the overall resilience work that we will do.
A key component of how we have changed the guidance on winter for 2014-15 from previous years is that we are now bringing in the interim chief officers of the integration bodies that will have responsibility for social care in the expectation that they will increasingly play a part in the interaction between health and social care. However, the current arrangement is the resilience approach to ensuring that we have appropriate liaison in place should winter become challenging. We do not have the same degree of granularity in terms of individual services or authorities as we would for hospitals or health boards.
I do not have a follow-up question, but I make the observation that it appears that we need further work on that area across Scotland. I hope that integration will help, but one issue is who a person should call if their care visitor does not turn up on Christmas eve or Christmas day. How do they resolve that?
We have been working with human resources directors from health boards and directors of personnel from local authorities for probably the past nine or 10 months, and one of the key priorities that we have asked them to focus on is joint workforce planning across the organisations for the delivery of integrated health and social care.
Okay. Thank you.
There are about 20 bullet points in and around all that for the health boards, such as Greater Glasgow and Clyde NHS Board, but what is missing is the evaluation. I give a plug for the joint initiative with the British Red Cross—it is involved as well—to provide transport services that support the discharge of elderly patients. That is interesting and there is the added benefit that it can take people from A and E and receiving wards. The initiative is particularly well received because the British Red Cross not only transports the patients home but settles them and ensures that they have basic essentials. If necessary, it can also wait for relatives and carers.
A great deal of planning is going on. However, Bob Doris is correct that it is not obvious whether the analysis of what works that is applied in the health service is being applied in other areas. Certainly, the components seem to be there.
It is coming together. In preparation for the integrated joint boards we are having much closer contact through COSLA and directly with the shadow chief officers. David Williams, the chief officer of the Glasgow city health and social care partnership, is on the national unscheduled care steering group. He is advising and working with us.
The Red Cross initiative is a really good one. It works.
I want to ask about the work that is being done to improve the flow of patients in hospitals in winter time, particularly with regard to time of discharge. As I understand it, one of the biggest challenges in getting people who are able to leave hospital out of hospital timeously is the ability to access prescription medicines that the in-hospital pharmacy dispenses. It strikes me that if a way of cracking that problem for the wintertime could be found, we would have won a watch for 365 days of the year.
What work is going on there? Have you found a way to tackle the pharmacy issue?
We are working on that. A key message of our unscheduled care programme and our winter guidance is that the focus must be on time of day and weekend discharge rates. We have had a significant reduction in weekend discharges and the time of day makes a big difference, so we need to get a balance.
Have we cracked that specific problem? No, not yet, but we are working with the Royal College of Surgeons, the Royal College of Physicians and the Royal College of Nursing to focus on that. We believe that we will be able to make the cultural and behavioural changes that we need to make.
Getting the scripts out quicker involves the way in which ward rounds take place. Sometimes it boils down to the most junior doctor writing the script. We are looking at the way the ward rounds change and we are introducing things such as board rounds: instead of a full ward round taking place, a board round can quickly identify which patients can go home and prioritise their discharge. We are working on that.
We are also looking at delegated discharge, which the Victoria infirmary in Glasgow has introduced. In the wards where that has been introduced, the pre-noon discharge rate has gone from 13 per cent to around 35 per cent. We are holding learning events and we are rolling that out. At our unscheduled care six-monthly learning event in September, which we used to launch the winter campaign, we had a session on delegated discharge and we are developing improvement programmes on it.
I echo Alan Hunter’s points. The pharmacy script problem is a difficult one to crack, but there are things that can be done, such as pre-emptive discharging the night before. If a patient has a care package starting the following day, the discharge script can be ready the night before, to go home with the patient.
We are starting to better understand the reasons why people are not going home in the morning. Work has been done on the day of care survey, which we have been looking at in conjunction with the Royal College of Physicians. It looked at what proportion of patients in hospital at any one time no longer need acute care. It depends where you look, although it is broadly the same in Scotland, England or Australia, but between about 20 and 25 per cent of patients do not need to be in hospital. Those patients could be waiting for various things: it could be pharmacy, as Graeme Dey said, consultant ward rounds, consultant decisions or multidisciplinary team decisions. Having a better understanding of why people are delayed in hospital allows us to structure how the hospital works to deal with those specific things.
12:30
We are nearly on schedule now, but I want to raise a couple more points. Delegating the power to discharge will speed up the process, but does that mean that the ward sister or allied health professional can discharge patients?
Yes.
How has that been received by patients and families? I know that delays can happen because people have to wait for the consultant to do his rounds, but is there not a certain reassurance for vulnerable or older people in not being rushed out of the hospital?
There will be agreement against set criteria, so that if the patient’s bloods or X-ray come back and everything is okay and if they do not have a temperature, they will be discharged. Those set criteria should reassure people about the points that you have raised.
Communication with the patient is absolutely key. When I see patients on my ward round, I make it clear to them that I think that, say, they will get better tomorrow, and that if their temperature and blood tests look better, my junior doctor Dr Smith will get them home. Therefore, the patient knows that we are planning to get them home; of course, we are thinking about discharge when they first come in, but the patient and their family, the junior doctor and the nursing staff are made fully aware of and know what needs to happen before they can be discharged.
Perhaps you can tell me whether I am right, but it is my understanding that for someone to be discharged early in the day their script needs to be in the robotics centre in Glasgow the night before.
That is right.
If it is not there, is there not an automatic delay? It is not that it would be nice for the script to be there the night before; is it not that is has to be done the day before?
Scripts can be expedited for certain patients, but the standard practice is to get the script down before a set time. As the ward gets busier, the junior doctor might not get the script done and things will be delayed overnight. There are reasons for such delays in the system.
Is there any way of circumventing that during the busy winter period by, say, working with local pharmacies?
What your question is probably drawing out more strongly is the need to think about discharge, and throughcare, at the point of admission to ensure that discharge is contemplated on, say, Sunday afternoon and does not come as a surprise on the Tuesday morning and that the required steps, even if they are not carried out directly by the treating clinician, are being taken. As a result, people will understand it as part of a system in which they interact with other health professionals to ensure that the individual meets their own objective of getting home as quickly as possible. It is probably as much about mindset as it is about putting in place fixes when the thinking has not been done properly. That is the objective.
Are there any other questions?
In Glasgow, a centralised robotic system dispensed medicines to local dispensaries in hospitals, but patients also kept their medicines in a defined area in the ward, and they were kept topped up and ready for discharge. That combination of centralised robotics for the whole of Glasgow and localised dispensing seemed very sensible, and NHS Forth Valley has a variation of that that works very well.
I have a final question about patient flow within rather than out of hospital. Clearly the boarding out issue is quite a vexed one; although we supposedly have a recording system, boarding out still has to be defined. I know that Dr Beckett has done some work on the matter—indeed, he and I have had conversations about it—and I wonder whether he wants to put anything on the record.
We have certainly traded emails on the issue. In fact, it is surprisingly difficult to define what a boarded-out patient is; nevertheless, we have managed to redefine it, and we are asking boards to report on a weekly basis the number of boarders that they have.
It is important to recognise that patients being boarded out is a symptom of poor flow rather than the problem itself. There are multiple manifestations of poor flow—boarding patients is one; others are crowding in emergency departments and higher readmission rates. If we tackled one of those in isolation, we would risk causing problems elsewhere in the system. Clearly, we need to improve patient flow across the whole system, and we are considering carefully how to do that. We will measure boarding as one outcome measure, while another marker will be performance against the four-hour standard in emergency departments, which we will measure. That work is being progressed through the unscheduled care steering group and the unscheduled care programme board.
As an aside, you will know that Scotland is really the only country that has done any research on the outcomes for patients who are boarded. I hesitate to put a date on when that research will be published, but within the next six months would be nice.
Another issue that I have been pressing in a number of forums is the linkage of cognitive assessment to boarding out, because of the dangers of that. I do not know where we have got to on that. If patients with cognitive impairment have to be boarded out, that creates a problem downstream of how to get them home and how they can be managed. If such people are institutionalised further, they will have particular difficulties when they are moved around. I wonder where we are on linking those two systems.
I am not aware of any direct linkage between the two, although a couple of health boards are looking to gather data on the proportion of patients with cognitive impairment who are boarded out at any one time. The message that I am keen to get across is that all boarding is bad and we should seek to eliminate it by improving flow. Clearly, a significant proportion of patients who come into hospital are elderly and have cognitive impairment, so we should seek to ensure that those patients get to the right ward the first time, by improving flow and looking at variation in the system. As I said, we are taking forward that work.
The unscheduled care steering group is doing work on eliminating boarding wherever possible. During the older people and acute healthcare audits of hospitals, the importance of not boarding people with cognitive impairment is emphasised.
We have done some work on people with dementia, who are a sub-group of people with cognitive impairment. I could certainly put together what we have on that, if that would be of help.
Thank you.
We would appreciate that.
Bob Doris has one final question.
It is a brief one. It is more of a mopping-up exercise so that the witnesses have the opportunity to put something on the record. Right at the start of our evidence session, we heard that the number of planned elective procedures will be downsized over the festive period. There will be less of them and then, depending on other pinch-points, some may fall by the wayside. Frankly, that has been routine for many years in the management of winter stresses and strains. However, the committee would be concerned if that included urgent elective procedures or emergency treatments, such as cancer treatments. Will you say a few words on that to get something on the record?
I will offer a couple of comments and will then bring in Alan Hunter. That is certainly one area in which we expect NHS boards to be on the ball in their winter planning. The term “elective” indicates that the procedures are planned work, so the boards should look at the winter period and particularly the two weeks that are likely to be the busiest and think about smoothing work so that they do not rely on beds being available that might not be available. Some boards have worked in a way that involves a nine-week rather than a 12-week planning presumption, which means that they are more likely to be more robust. Work is already in place on that.
This year’s winter guidance makes a particular reference to cancer. The guidance draws boards’ attention to the need to meet the 31 and 62-day standards and to think about that as part of their planning process across the winter period. Because 31 days and 62 days are longer than the 10 or so days of Christmas, with robust planning, boards have the opportunity to perform effectively in that area. That particular issue is therefore now drawn out in the checklist that they are offered.
Alan Hunter will say a bit more about elective procedures.
That is part of the winter planning process, and there is an escalation process. The last treatments to be cancelled would be urgent ones and all the systems are geared towards ensuring that that does not happen. As Geoff Huggins said, the chief medical officer wrote on 30 October reminding boards about the importance of planning for maintaining the cancer multidisciplinary teams over the festive period and putting in place extra diagnostic support to maintain them if required. We have tried and tested systems, which I have witnessed, and it would not be urgent treatments or cancer treatments that would be cancelled. Wherever possible, the objective is not to board patients in surgical beds—the first thing is to avoid that.
That brings this interesting session to a close. I thank all our witnesses for attending. Extensive measures are being taken—I found lots just looking over the issues in the past couple of days. It was interesting to hear your evidence, because we are talking about significant planning measures. We wish you a happy Christmas and hope that all of your planning is rewarded and that the service copes with all the stresses and strains over the Christmas and new year period.
12:41 Meeting continued in private until 12:56.Previous
Health Inequalities: Early Years