Health and social care: winter preparedness plan 2023-2024

Priority Four. Maximise capacity to meet demand and maintain integrated health and social care services throughout autumn and winter.

Both COSLA and Scottish Government recognise that actions and improvements to maximise capacity are best and most sustainably delivered in an integrated and co-ordinated way across the whole system. Local Authorities, Boards and Integration Authorities together with the voluntary and independent sectors, and indeed with communities, lead the way on integration of health and social care to deliver better experiences and outcomes for the people who access services.

How we will jointly deliver this priority:

• Ensure consistent and effective discharge planning takes place over seven days and the holidays.
• Reduce the time people need to spend in hospital by promoting early and effective discharge planning deploying the basics set out in the Delayed Discharge and Hospital Occupancy Plan sent in March 2023 and robust and responsive operational management, and by recognising and meeting the challenges of unmet need in communities. The basics identified within the March Plan include:
• Admission avoidance.
• Social work input on every ward.
• Implementation of Discharge without Delay and Planned Date of Discharge.
• Early identification of complex discharges.
• Early engagement with people, families and carers.
• Implementation of discharge to assess and intermediate models of care.
• Daily multi-disciplinary reviews of all patients to ensure understanding of criteria to reside, planned date of discharge and early referrals for supported discharge ahead of clinical readiness date.
• Use of home-based assessments for all Home Support packages to ensure accurate person-centred assessments, in familiar and homely environments. This also results in more efficient use of scarce resources.
• Work intensively with HSCPs and Boards across the country to reduce delayed discharges for patients with learning disabilities and complex care needs moving from inpatient treatment to the community, including through supporting the use of the Dynamic Support Register, a consistent process for regularly reviewing and taking action to support individuals with complex needs.
• Continue to work with and support systems to ensure that suitable accommodation and support packages are in place to address delayed discharge of forensic mental health patients.
• Support telecare providers to increase the use of proactive outbound calling to support people who have been identified as being at risk or more vulnerable and directing them to community-based support earlier to keep them at home longer and prevent unnecessary admissions to hospital.
• Reduce time spent in the Emergency Department by working with Boards to deliver rapid assessment and care, enhanced triage and signposting or redirection and reduce length of stay.
• Make improvements to reporting and performance dashboards that will support visibility of capacity in social care, including levels of unmet need within the community and people awaiting community care assessments – and how this data impacts on the wider system.
• Embed use of the new dashboards to support benchmarking between systems and sharing of best practice.
• Work with Boards to ensure sufficient Dentistry and Optometry capacity to support referrals from NHS 24 and OOH/unregistered patient care and holiday cover.
• Run a mental health bed occupancy survey throughout the winter to ensure we have an understanding of service pressures and can offer support as required.
• Continue to support Boards to increase the use of Hospital at Home to enable people to be safely cared for in their own homes.
• Continue to maximise the use of Planned Day of Discharge, Discharge to Assess, Hospital to Home teams, community rehabilitation and other discharge support services.