The panel will hear from Mike Quinn, the Managing Director of Medicine for the Clinical Services Centre at QA Hospital and Marie Edwards, Senior Manager, Hospital & Health Services, Adult Social Care.
Minutes:
Mr Mike Quinn, the Managing Director of Medicine for the Clinical Services Centre at QA Hospital
Mr Mike Quinn explained that there are 105,000 discharges a year which are managed through the hospital. 80% of these discharges are classed as 'simple', with the remainder being categorised as 'complex'. There is a cohort in the middle which requires more focus and attention. An example of a simple discharge would be a patient who has an arranged procedure and is in hospital for a few hours for that procedure. An example of a complex discharge is when a patient is admitted following 'an event' and has more than likely come through the emergency department.
Prior to the pressure period before Christmas the Integrated Discharge Bureau ('IDB') used to meet twice a week, now it meets daily. Mr Quinn chairs these meetings which community partners from Hampshire and Portsmouth also attend. The IDB discuss the discharge and care package of the more complex cases, which tend to have a complicated discharge planner. Often social services recommend a referral whilst the patient is on the ward. It is at the IDB that the patients other needs often become identified. For example, whilst admitted a patient could become homeless. A delayed discharge is often non-health related and these cases are discussed daily at the IDB meetings. The bed stock needs to be utilised for 'acute' care. The hospital look to discharge a patient once the healthcare plan is complete and a safe discharge is ensured. The hospital does not want to leave any patient feeling vulnerable. Working with partners is key and the hospital's relationship with Portsmouth City council is very positive.
The following information was given in response to questions from members of the panel:
· When a patient is in hospital, this offers a period of respite for the carer and it is often at this point that the carer feels they cannot cope. This is not recognised prior to the patient admission and so is not planned for. Families/carers feel that they cannot cope when the patient is discharged. The hospital would identify this as 'potentially complex' and would involve social services.
Mrs Marie Edwards gave an example of this where social services have recommended a patient be discharged to Grove House as an interim arrangement but the family are adamant that the best place for the patient is here in hospital. A whole care package is available for the patient at Grove House but the family are blocking the discharge. The acute care has finished and the family want the patient to go home but not via another route. The family have been advised that this is a step down opportunity to give the family more time to look at the next care step.
· Families do not see that they are 'bed blocking' and feel that it is their right to say no to a discharge. It is about managing expectation, first at ward level by nurses and doctors, and then this being enforced by other partners of the 'managing discharge team' ('MDT').
Mr Quinn reiterated that it is important that all of the clinical groups work towards one document plan within the patients' notes. This is managed by the MDT on their white board rounds, at ward level, who look at the whole care package. All patients have a named consultant and any decision made by that consultant can be challenged as to its reasonableness.
· Mr Quinn said he would be horrified to know that patients have been discharged unsafely. Hospital transport is available up to 2100 hours and the family is consulted regarding the most appropriate time of the day for a patient discharge. 60% of discharges occur after 3pm and this is mainly due to family need.
· Mrs Edwards explained that patient care providers should know how to feed information back to the hospital. If agencies have a wasted visit or an agency goes out to see a patient recently discharged, the health and hospitals team need to know. The health and hospitals team have met with PHT to look at moving these processes in alignment. There is now a much more co-ordinated approach for all.
· Mr Quinn explained that there is currently a big focus on patient experience and PHT has appointed a role of Corporate Nurse (CN) who will lead on this issue. Friends, family and patients, are encouraged to provide feedback on the website, through PALS. PHT meets with nursing home managers on a regular basis, where patient experience feedback is encouraged. Mrs Edwards mentioned that she has met, and will continue to meet with the CN to look at sharing the issues logs and to look at any recurring themes. She felt that there is now a real sense that things are moving forward.
· Mrs Edwards explained that if a particular nursing home cannot accommodate a discharged patient, options would be provided for a suitable alternative vacancy. However it is often the case that the family will insist on waiting for the home of their choice to become available. The health and hospital services team then try to encourage an interim move but again this often takes a lot of persuasion. It is appreciated that this is often a difficult decision for the family to make but there is an expectation from families, which needs to be managed. Often homes will not accept patients if they cannot accommodate their particular needs even if there is room available. Nursing Home staff will come to assess the patient whilst in hospital but quite often the patient is not told the reasons why they have not been accepted at the particular home of their choice. Mr Quinn added that if there are staff shortages at the nursing homes, then they are unable to turn up to assess a patient. This non-assessment has a knock-on effect and means the patient has to stay another night in hospital when it is not necessary. There are arrangements in place where groups of home care staff come out to make an assessment. The question has been raised as to why the PHT cannot make assessments, particularly when the patient has been agreed ready for discharge. However the Care Quality Commission must undertake the assessment of care.
Mr Quinn reiterated that the weekly IDB meetings has improved the flow of patients through the hospital and the relationship between Portsmouth adult social care and the PHT has hugely improved. There is room for improvement but the healthy relationship means there is an appetite for improving, to iron out 'the niggles' and to strive for perfection.
Mr Quinn gave an example of a patient who lived in a raised apartment, who was admitted to hospital and following treatment needed a wheelchair. He was assessed as physically fit to leave the hospital but needed ground floor accommodation. During the patients stay in hospital, his accommodation had been let out by his father and therefore was deemed to be homeless. Eventually the patient took himself to Portsmouth City Council housing office.
Mrs Edwards explained that the city council do need to have a couple of adapted disabled properties, preferably ground floor, available for incidents like this. The city council does have Grove House and Longdean Lodge for interim care but more independent interim accommodation is needed.
· Mr Quinn explained that patients can be transferred directly to St James' Hospital. However, patients are often in beds here at QA with mental health issues who need to be assessed. Security is often required as they are unpredictable. Medically they have been addressed but mentally they are 'not fit' to be discharged.
· The PHT are satisfied that Portsmouth Rehabilitation and Reablement Team work well and the community nurses attend the daily meetings. The CN team then assess the number of visits required.
· Mr Quinn explained that patient needs are identified as early on as possible regarding the equipment which would be of benefit to the patient on discharge. The PHT discharge patients to Longdean House and Grove House if patients are waiting for equipment or adaptions.
· Mr Quinn explained that PHT would never assume patients who are discharged to a local authority sheltered home are fully supported as PHTs aim is for a 'safe' discharge. If a weekend discharge were planned PHT would look at the support available to the patient.
· Mr Quinn explained that patients receive on-going support and care. Patients are monitored through re-admittance. PHT have failed if the patient is re-admitted within 28 days. PHT do not receive any payment for a re-admittance.
· Mr Quinn explained that the Red Cross are situated within the hospital and supply equipment. Mrs Edwards also explained that an initiative started four months ago, day after discharge workers ('DAD'). DAD follow patients who have come through the social care route to see if all has gone well with the discharge, checking milk etc and support is in place. The workload for a DAD worker is roughly 4-5 patients a day. Social care workers are based in the hospital until 2000 hours daily now. Mr Quinn also added that the hospital now has a supply of tracksuits for patients who are admitted during the night in their nightwear so that when they are ready for discharge the following day, we can get them out of the bed and into the discharge lounge. PHT is working towards 24-7, 7 day working and now employs a registrar for three hours on a Saturday and Sunday. The registrar is able to discharge patients. Weekends are often the ideal time for patient discharge as the family are around and able to offer support.