Delayed discharge is a multifactorial, multidisciplinary and multiservice area. It is fair to say that there is considerable variation in delayed discharge figures across the piece, both in the mainstream of delayed discharges and in what are referred to as code 9s and the more specialist areas of guardianship. Our figures show that we have had some deterioration, but it is not a consistent deterioration. When you look over the past one to two years, you can see general downward trends in most areas.
We have peak periods and we work to anticipate those peak periods, both through winter planning and through day-to-day planning. We are doing a great deal of work. For example, we have done work across Clackmannanshire and Stirling on guardianships, because we have quite a high level of guardianship in our area. We have carried out reviews of all the guardianships, we have taken advice from the Mental Welfare Commission for Scotland, and we have worked with Greater Glasgow and Clyde NHS Board, which has some specialist input, on retraining and refocusing our mental health officers on how to handle guardianships, given that the legislation and practice tend to move a bit. MHOs had been using quite a traditional method rather than using section 13ZA of the Social Work (Scotland) Act 1968, which is to be used in cases where somebody is unable to consent but where there is a clear impetus because of a pre-existing statement of the person’s desires and a clear agreement with both clinicians and family about moving to alternative placements. We had not been using those powers as well as we should have been doing, but we are now seeing the number of cases declining and cases being managed tightly.
Allow me to give you some assurance about the work that is being done on a day-to-day basis. We have weekly calls in place that are supported by the chief executive, and that involves all senior members of staff, including most of the panel members who are here today. We review our activity and discuss any issues that have arisen and anything that we need to go in and sort very quickly. That is supported by senior management team steering groups, which meet every single week to review and flag up issues. I check our delayed discharges on a daily basis, and if you talk to any of my staff they will tell you that I am on the phone the minute I see any kind of variation, if I do not like the look of something or if I have a query. We are working hard to keep up with all of that.
We have multidisciplinary daily huddles in place, so social care staff, third-sector providers and clinical staff are on the ground in the hospitals every day reviewing not just who is delayed in discharge but who is coming through the system. We need to do a little more work on that, but we are getting a lot better at understanding which people are likely to be delayed. They tend to be the people who are pretty complex. If you look at the delayed discharge figures, both in Falkirk and in Clackmannanshire and Stirling, you will see that the people who are delayed are those who have a degree of complexity. It is not straightforward. There are family issues, there are sometimes accommodation issues, and there are frequently mental capacity issues or other things that cause the delay, but that is worked on very heavily. We are also working on our frailty pathway, which is one of the areas where the board knows that we can do some improvement work. The improvement support service—ihub—is involved in that.
Both integration authorities have looked at commissioning and we have recommissioned some of the care-at-home services. Some of them are currently under contract, so Stirling’s will not be due for renewal until later this year, but in Falkirk we have jointly commissioned a new provider with a focus on discharge to assess, which has made a huge difference to the Falkirk services. In Clackmannanshire and Stirling, we have rebadged our services as a quick step, to make it clear to staff and providers that we expect a quick one-hour or two-hour response, not a one or two-day response, and that has made a huge difference.
We have initiated a home-first approach. When we talk to families, clinicians and others, the focus is on people going home and not remaining in hospital or moving to another hospital or long-term care—unless they absolutely need to do so. Patients will tell you that what most people want is to go home, in a supported way.
Over the past year or year and a half, we have worked much more strongly with providers. We established provider forums, and the multi-agency strategic planning group, which includes patients, carers, service users and so on, monitors our performance on discharges and supports us by providing direct feedback about service user and carer experience. There is a clear feedback loop in the system.