Improving health and social care service resilience over public holidays: report

1

Rationale: Local areas have different mixes of services, according to need. Some remain open over public holiday periods, others may be closed, for example GP services. There is potential to pull these services together either virtually or geographically into a locality clinic model.

These clinics would have multidisciplinary staffing ( MDT) including GPs, nurses, pharmacists, AHPs, paramedics, Community Rehabilitation Teams and ideally would be able to receive referrals from NHS 24 or GP OOH services. The aim would be to assess, treat and prescribe for a range of medical and social conditions and provide community based interventions to maintain optimal care at home.

Recommendation: Tests of change should be established to test the concept/viability of multidisciplinary locality clinic models during public holiday periods.

2

Rationale: There is evidence that a high number of presentations for Primary Care OOH services are to approve, sign for or replace medications during the OOH period. It is therefore important that the ability is enhanced for patients to access medications within the community without recourse to Primary Care OOH or A&E services. This would be facilitated by increasing the numbers of independent non-medical prescribers to autonomously manage urgent patient presentations.

Recommendation: The developing role of independent non-medical prescribers should be encouraged and enhanced. How appropriate educational and training support can be delivered needs to be explored.

3

Rationale: In order to add further resilience for urgent medication provision in the community, where individuals may run out or repeat medications or have lost prescriptions, Patient Group Directions ( PGDs) may assist. In Scotland the Community Pharmacy Unscheduled Care PGD has been developed to facilitate this. [A Patient Group Direction ( PGD) is a signed, written document supported by a legal framework that allows named, authorised and registered health professionals to supply and/or administer specified medicine(s). The specified medicines are supplied/administered to a pre-defined group of patients with conditions described and detailed within the PGD. An authorised PGD within a service enables named, authorised health professionals to supply and/or administer medicines without the requirement to consult a doctor or dentist].

Recommendation: Greater use should be made of Community Pharmacy Unscheduled Patient Group Directions ( PGDs) to enhance the urgent provision of medication. This would also be facilitated by immediate and secure electronic access to patient medication records.

4

Rationale: The Primary Care OOH Review recognised that greater awareness and use of community pharmacies could shift substantial demand away from both daytime/ OOH urgent care and A&E services. This is likely to be particularly important over prolonged public holiday periods.

Recommendation: Community pharmacy is an important first point of contact for patients seeking advice and treatment, this should be encouraged by:

• Promoting greater use of community pharmacy Minor Ailment Service ( MAS) for eligible individuals
• Encouraging people to make more use of community pharmacies for self-care, advice and access to medicines.
• Ensuring that sufficient community pharmacy services are open and accessible during public holiday periods.

Note: Work is currently underway with a trial partnership planning of OOH community pharmacy services in the Greater Glasgow & Clyde, Lothian and Tayside Board areas for the Christmas festive period 17/18. This aims to support improved opening times and access to community pharmacy services.

5

Rationale: The nature and availability of all OOH services may be poorly understood often resulting in people finding it difficult to know where to go with or seek assistance for urgent care requirements. This may be amplified over public holiday periods and by winter demands.

This is particularly important for people with specific needs. The Primary Care OOH Review examined and made recommendations on palliative care, mental health needs, frail and older people, the care of children, those with special access requirements and health inequality issues. These still hold good and are amplified here.

Recommendation: In order to assist the public to support self-management where appropriate and to make optimal use of available services when required, during OOH and public holiday periods:

• There should be better promotion of NHS Inform ^[35] as the reliable and trusted source of health, care and wellbeing resources (including the Self Help Guide) in Scotland.
• Particular emphasis should be placed on use of the National Services Directory ^[36] as an on-line resource for the public and for all health and social care professionals to find out what services are available locally.
• Each Board area will need to determine how best to engage its local population including use of the Know Who to Turn To resource. ^[37]
• The national winter health campaign should be enhanced to ensure the most critical messages and up to date resources are included to support the whole health and social care system. NHS 24 and local Board should support visibility of the national winter health campaign, delivered by NHS 24 on behalf of NHS Scotland.

6

Rationale: Care homes provide for the needs of frail, usually older people, often with multiple and complex conditions. As a consequence, they make frequent use of urgent care services. Work done by Healthcare Improvement Scotland, the Care Inspectorate, individual care homes and NHS 24 has shown that poor communication between care homes and NHS 24 can be a barrier to achieving fast and effective care for residents. Ensuring that care home staff receive the appropriate advice in a timely and efficient manner will aid the care of residents within care homes ensuring they are treated by the right service, the right professional, at the right time.

Recommendation: A tested handover document should be introduced to improve the care pathway of residents in care homes. This should facilitate structured communication between care homes and NHS 24 to support optimal referral of residents who need urgent care provision.

7

Rationale: People receiving palliative and end of life care and their carers require very timely access to care and assistance, when needed.

Recommendation: In the absence of direct local helpline access, the interface between NHS Board OOH services and NHS 24 should be optimised to ensure people with palliative and end of life care needs and their carers can access timely person centred-care.

8

Rationale: A significant number of Primary Care OOH and A&E services attendees who are assessed in these settings, do not have a defined medical need.

Recommendation: Individuals who attend OOH/A&E services without a defined medical need should be signposted/redirected to suitable alternative community services, including third sector provision, where available.

This will be dependent on local service provision and may include development of a “links approach” during the OOH period.

9

Rationale: In line with the Mental Health Strategy, people with mental health needs require better access to care services and support. Enhanced access should be focused to support the management and care of patients who contact in mental distress and /or with a mental health presentation, and be delivered via a stepped-model approach

Recommendation: Access to specialist services should be improved for Mental Health triage, assessment and consultation within NHS 24. A stepped model of care developed by NHS 24 will support appropriate service provision based on need, from self-help assistance to complex care.

10

Distress Brief Interventions ( DBIs) support people in distress and were supported in the Suicide Prevention ^[38] and Mental Health strategies. ^[39] The need to improve the response to people presenting in distress has been strongly advocated by service users and front-line service providers. The overarching aim of the DBI programme is to provide a framework for improved inter-agency coordination, collaboration and cooperation across a wide range of care, settings, interventions and community support

Recommendation: Further development of Distress Brief Intervention programmes should continue to better equip people managing their own health, offering a structured approach for medium to long-term reduction in distress.

11

Rationale: Significant numbers of individuals are admitted with acute respiratory disorders and exacerbations of chronic respiratory disease over public holiday periods. There is evidence from NHS Lothian and Greater Glasgow and that Community Respiratory teams have benefits including: reduced hospital admissions, increased immediate front door discharges and reduced length of stay. See also the Chronic Obstructive Pulmonary Disease ( COPD) Best Practice Guide. ^[40]

Recommendation: On the basis of local needs assessment, Board areas should consider establishing/enhancing Community Respiratory Teams over public holidays and also for other OOH periods.

Acute/Hospital Care

The rationale for the Acute/Hospital Care recommendations below (1-5) are designed to avoid unnecessary admissions, to improve patient flow within hospitals and to facilitate timely and appropriate discharge arrangements for patients. These recommendations should be regarded as a specific application of the principles of Six Essential Actions for Unscheduled Care, over public holiday periods. ^[41]

12

Recommendation: Timely and proactive discharge planning should be in place prior to public holiday periods, following the principles of the Daily Dynamic Discharge Approach. ^[42]

This approach includes:

• Prior to public holiday periods, Estimated Dates of Discharge ( EDD) should be set for all patients at the earliest opportunity.
• Senior decision-makers should identify in advance those patients who may be suitable for discharge over public holiday periods, using the principles of criteria led discharge. These include clear guidelines detailing criteria that would prevent discharge, for example: changes in National Early Warning Score ( NEWS) ^[43] or new clinical features.
• These anticipated discharges should be prepared for in advance, including proactive preparation of immediate discharge letters and timely availability of discharge medication.
• Actual discharge levels should be actively monitored against predicted activity levels throughout public holiday periods to ensure optimal use of bed resources at all times.

13

Recommendation: Acute hospital discharge teams should be reviewed and augmented, where necessary, to ensure optimal patient flows within hospitals and to ensure timely and appropriate discharge of patients over public holiday periods.

This should take account of:

• Support to the ‘front door’ of hospitals to avoid admission and facilitate early discharge where appropriate, including the availability of physiotherapy skills.
• Nursing staff, who have specific discharge experience and knowledge of available community services and access routes, should be rostered throughout public holidays.
• A directory of all available local community services on public holidays, with clear details of how to access/refer patients, should be prepared and shared with all relevant staff in advance of the public holiday period.

14

Recommendation: Effective discharge planning and processes over public holidays should be reviewed to ensure that staffing levels are optimal throughout.

This should take account of:

• Rosters with adequate levels of senior and junior medical staff, nursing staff, pharmacy staff, allied health professionals ( AHPs) and support staff.
• Timely access to equipment, social work and transport services.
• Early and proactive communication of anticipated discharge numbers to social work colleagues and SAS.
• Ready availability of medicines in A&E and front door areas when needed, for example medicines To Take Out ( TTOs), use of Hospital Based Prescriptions (HBPs) as appropriate, and 24/7 availability of advice from pharmacy colleagues.

15

Recommendation: Improved access to specialist advice from a senior clinician should be readily available to Primary Care OOH services over out of hours periods, including public holidays. Where not already in place, a dedicated clinical telephone referral line should be established enabling direct professional-to-professional consultation.

• Effective, timely and direct access to specialist professional-to-professional clinical advice is essential for optimal urgent care and in particular, over public holiday periods.

16

Recommendation: Timely use and analysis of data is required to optimise available resources, in order to meet patient needs with differing and evolving case-mix presentations. This should help to secure best care outcomes and is in keeping with the guiding principle of an intelligence-led service.

• Unscheduled care acute hospital data analysis should be regularly undertaken in order to establish which conditions are more likely to present during public holiday periods.
• This intelligence-led approach should inform better access to specialist services for advice in ‘front door’ and other hospital areas.
• A particular focus should be supporting front door staff with the management and care of patient case-mix presentations, identified as having increased presentation rates during public holidays. This includes: complex cases, frail older people, palliative care and mental health presentations. This should also take account of any prevalent infectious disease outbreaks, including seasonal flu (influenza).
• Details of current and enhanced access to specialist services available for advice should be shared within each hospital in good time prior to public holiday periods.

17

Rationale: Social care services in Scotland have developed around the core functions of keeping individuals, families and communities safe and responding to urgent and emergency situations out-with office hours in OOH periods. Much of the current social care activity in OOH periods relates to child protection, adult protection and monitoring of high risk offenders. This is particularly relevant for service continuity during public holiday periods.

Recommendation: Options should be pursued to streamline public protection services that are resilient at all times and are fit for the future. These should be explored with Police Scotland and other relevant partners, taking into account the Child Protection Register ^[44] and the Appropriate Adult Scheme. ^[45]

18

Rationale: Continuous access to social care services is imperative over public holiday periods. These services should safely sustain people at home as appropriate and include important third and independent sector contributions.

This includes:

• Support to care homes and other community based services, in order to mitigate avoidable hospital admissions.
• Clear communication, liaison and assessment provision for timely discharge from acute and community hospitals.
• Urgent initiation and change of individual social care support, as appropriate, to facilitate timely access to flexible care at home and care home placements. This must include integrated local crisis services for people with mental health difficulties.

Recommendation: Future out-of-hours social care services must be aligned with existing primary care OOH services and directly interface with acute hospitals, in order to provide integrated health and social care on a continuous basis, including public holiday periods.

19

Rationale: The integration of Health and Social Care services should improve OOH arrangements for urgent community and hospital care on a 24/7 basis, including extended public holiday periods.

Recommendation: The identification and development of good practice approaches and shared learning opportunities across all sectors in the OOH period, should be developed for:

• Prevention of unnecessary admissions to hospitals
• Appropriate and timely discharge practice from hospitals
• The timely availability of community based social care and other services to underpin hospital discharges during OOH and public holiday periods.

20

Rationale: The ability to safely and timely share information across agencies is of critical importance in order to determine optimal responses to urgent care needs.

ISD holds responsibility for the principal national data collection process for social care (including home care, care homes, self-directed support and telecare). This role builds on and enhances the Health and Social Care Data and Intelligence Project (Source), ^[46] which is designed to support Integration Authorities by making national data and specialist analyses available locally. The Source data should enhance the available intelligence about use of social care services. Through data linkage Source should offer greater understanding of care pathways for both health and social care services.

Recommendation: Future information developments in social care, including the emerging single national source of social care data, should aim to provide timely and actionable intelligence to those responsible for delivering care and support, especially to people with multiple and complex needs _.

21

Effective planning and resource allocation to secure delivery of these recommendations will require a whole system approach and leadership of a high order.

22

Developing national, social and primary care workforce plans should take account of the findings from this Review including sustainable resourcing for all professional groups.

23

Partnership and professional organisations should be fully engaged in the design and delivery of all planned changes to the workforce