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Meeting the demands of the UK's 'retirement capital'

Health Education England visit put the focus on delayed discharge in a popular seaside location where a high volume of residents are retirees.
Cliff Kilgore

Health Education England visit put the focus on delayed discharge in a popular seaside location where a high volume of residents are retirees

Dubbed the retirement capital of the UK, Christchurch in Dorset has one of the largest concentrations of older people in the country, with one in three of its 50,000 residents over 65 years old.

This demographic presents unique challenges for the county and, in recent years, it has become clear that health and social care services can no longer work optimally in isolation.

Ongoing discussions about partnership working between Dorset HealthCare University NHS Foundation Trust and Dorset County Council were given a sharper focus earlier this year when a visit by Health Education England highlighted the need to address the problem of delayed transfers of care.

It was indicated

...

Health Education England visit put the focus on delayed discharge in a popular seaside location where a high volume of residents are retirees

Dubbed the ‘retirement capital’ of the UK, Christchurch in Dorset has one of the largest concentrations of older people in the country, with one in three of its 50,000 residents over 65 years old.

This demographic presents unique challenges for the county and, in recent years, it has become clear that health and social care services can no longer work optimally in isolation.  

Cliff Kilgore
Nurse consultant Cliff Kilgore with a patient. Picture: Chris Balcombe

Ongoing discussions about partnership working between Dorset HealthCare University NHS Foundation Trust and Dorset County Council were given a sharper focus earlier this year when a visit by Health Education England highlighted the need to address the problem of delayed transfers of care.

‘It was indicated to us that our delays in transfer were quite high and there were concerns that people in Christchurch were spending an above average time in hospital than those in other parts of the country,’ says Cliff Kilgore, nurse consultant in intermediate care at Dorset HealthCare.

30%

Percentage of population in Christchurch aged 65 and over; the UK average is 16%

Source: 2011 Census

Cherry McCubbin, associate director for older person’s medicine and integrated care at The Royal Bournemouth and Christchurch Hospitals (RBCH) NHS Foundation Trust, says that delayed transfers of care are particularly acute in the seaside town because of the high numbers of people who choose to retire there. This means they may be living far from robust family support networks and matching services to demand is a struggle, especially in winter.

‘We have ongoing demand from high numbers of older people who are stuck in hospital because of limited provision of domiciliary care and care homes in the area,’ says Ms McCubbin, who is an occupational therapist.

Hospital stays of ten days or longer were commonplace, putting patients at risk of developing complications.

The situation was exacerbated by a bureaucratic system that meant the acute older people’s assessment and liaison team had to navigate through numerous support services with differing criteria depending on whether the patient lived in Bournemouth or Christchurch. ‘Discharge planning was a minefield,’ adds Ms McCubbin.

In an attempt to overcome this catch-22 situation, senior managers from RBCH, Dorset HealthCare, and Dorset County Council came together to discuss how they could better use their resources from the four services providing early supported discharge care:

  • Reablement, run by Tricuro, a private provider.
  • Interim care, and the day hospital, run by RBCH.
  • Christchurch integrated community rehabilitation team, run by Dorset HealthCare.

In addition, there are advanced practitioners and medical consultants and a GP extensivist from RBCH and Dorset HealthCare providing medical care.

The result is the Christchurch integration hub, which piloted in September.

Mr Kilgore explains that it is a system for sharing staff across community health, acute and social services. ‘We wanted to do something to represent older people looking at issues of frailty and how to bring together resources in health and social care. We couldn’t crack the issue of how to pool budgets, but we did agree that working together is the way forward,’ he says.

2.7 million

Estimate of hospital bed days occupied by older patients who no longer need acute treatment

Source: National Audit Office

At present, there is no formal service level agreement, but a letter was signed by managers from all four services setting out the terms and conditions that nursing and therapy staff would be shared to deliver early supported discharge packages. ‘It gives credibility to the scheme at chief executive level, whereas locally agreed schemes such as this have fallen down in the past when management changed,’ says Mr Kilgore.

The model is a single point of access hub that is run out of an office in a day hospital in Christchurch, which receives referrals from RBCH for early supported discharge packages. The pilot has handily coincided with the establishment of a frailty unit at the trust that bypasses the emergency department, so patients can also be directly referred from the unit, which means in some cases they will only have been in hospital a few hours, Mr Kilgore adds.

A daily clinician and an administrator review referrals and put in place care and rehabilitation packages depending on patients’ needs.

‘The idea is we can borrow staff if one team has more capacity than another,’ says Mr Kilgore, adding that the system also benefits from shared staff training.

The challenge is having to identify available capacity on a daily basis. Managers are in the process of trying to find an IT solution for the hub to share capacity data, but in the meantime this is co-ordinated by old-school telephone calls.

£820 million

Estimated gross cost to the NHS of older patients in hospital beds who no longer need acute treatment

Source: National Audit Office

‘It is using existing capacity, but more fluidly. The teams all still have to do work outside of early supported discharge,’ says Mr Kilgore.

Fluidity is at the heart of the model. ‘In the hub it should no longer matter what the name of the service is,’ adds Ms McCubbin.

‘It’s about bringing together a range of skills and expertise and blending the experience of health and social care colleagues with a rehab mind-set.’

From a nursing point of view, Mr Kilgore says the model ‘puts minds at rest as the acute teams can discharge knowing that health and social care professionals will be involved and we can monitor and intervene if necessary’.

At the moment the pilot is concentrating on early supported discharge but, if it proves a success after evaluation at three months, the aim is to extend it to admissions avoidance via GP referrals. ‘The idea of the pilot is to look at whether we can transfer resources to the hub for a better outcome for patients,’ adds Mr Kilgore.

Before and after the integrated hub pilot

Previously, patients seen by the older people’s team could end up in hospital for much longer than necessary due to hold-ups in the supported discharge system. ‘We would want to get patients home as soon as medically possible, but things can go wrong if, for example, a package of care has been re-allocated due to the pressures of providing care in the community then they could be in hospital for a couple of weeks while waiting to be reassessed,’ explains Cherry McCubbin.

Cliff Kilgore adds that previously, the community integrated discharge team, comprising nurses, therapists and support workers, would have received a referral that might have involved four visits a day to the patient, but there was often not the capacity to manage this, so patients would have to wait in hospital until capacity became available.

All the while, older patients’ risk of developing complications such as infections markedly increases the longer they stay in hospital. ‘Evidence shows that a stay of ten days or longer leads to the equivalent of ten years in muscle deterioration in people over 80. This loss of function then impacts on the level of care that’s needed,’ adds Ms McCubbin.

One of the key changes under the new system is that patients are ‘discharged to assess’ with a goal of assessment within two days of patients becoming medically stable, rather than waiting for assessment in hospital.

The approach means that early supported discharge packages can be more responsive to patients’ needs in their homes.

‘In hospital you end up over-prescribing if patients’ conditions have deteriorated,’ says Ms McCubbin. ‘We also know that if long-term services are involved then care might be given for longer than is strictly needed.’

It is early days, but Ms McCubbin says: ‘because patients are now receiving ongoing reviews by therapists, whereas previously they might only have received a domiciliary care package, their long-term care needs are reducing, which in turn is freeing up capacity.’

Mr Kilgore adds: ‘Now, the hub can source from other teams across acute and social services, so it speeds up discharge. We are hoping to see a marked decrease in discharge times.’

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