South Ayrshire Health and Social Care Partnership

REPORT

Meeting of South Integration Joint Board Ayrshire Health and Social Care Partnership

Held on 15 November 2017

Agenda Item 9

Title Biggart Community Hospital Redesign and Reconfiguration Update

Summary:

This paper provides an update on the progress made towards implementing the new model of care and associated reconfiguration of beds at Biggart Hospital.

Key Messages:

1) The team at the Biggart Hospital have redesigned and reconfigured services in line with the New Models of Care for Older People in South Ayrshire. 2) Our vision for Biggart Hospital is that it will become a centre of excellence providing focussed, tailored, rehabilitation and end of life care for those who do not require acute hospital care, but need more support than can be safely provided at home. 3) Management, Staff and Partnership/Trade Unions have worked together to successfully delivery the reconfiguration which was completed on 25th October 2017. 4) Improvement and performance measures have been agreed and will be monitored closely over the coming months and years.

Presented by Tim Eltringham, Director of Health & Social Care

Action required:

The Integration Joint Board is asked to note the progress made in redesigning and reconfiguring Biggart Hospital during the period 2015-17.

1 Implications checklist – check box if applicable and include detail in report

Financi HR Legal Equaliti Sustainability al es

Policy ICT

Directions required to NHS Ayrshire 1. No Direction Required

& Arran, South Ayrshire Council, or both 2. Direction to NHS Ayrshire and Arran

3. Direction to South Ayrshire Council

4. Direction to NHS Ayrshire and Arran and South Ayrshire Council

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SOUTH AYRSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP INTEGRATION JOINT BOARD 15 November 2017 Report by Director of Health & Social Care

Biggart Community Hospital Redesign and Reconfiguration Update

1. PURPOSE OF REPORT

1.1. The purpose of this report is to update the IJB on the progress made towards implementing the new model of care and associated reconfiguration of beds at Biggart Community Hospital.

2. RECOMMENDATION

2.1. That the Integration Joint Board notes the progress made in redesigning and reconfiguring Biggart Community Hospital during the period 2015- 17.

3. BACKGROUND INFORMATION

3.1. This progress update specifically relates to the reconfiguration of rehabilitation and end of life care beds at Biggart Community Hospital set out in proposals approved by the NHS Scrutiny Panel in April 2017. The proposals form part of the South HSCP response to the New Models of Care for Older People and People with Complex Needs.

3.2. Our vision is that people receive services that are important to them to achieve the best outcomes possible enabling them to live longer, healthier and happier lives closer to home.

3.3. Over the past two to three years there has been significant investment and redesign of community and acute services with the aim of supporting people to live as independently and as close to home as possible. These include the newly established Intermediate Care Team, Combined Assessment Unit, Acute Care of the Elderly Practitioners, Care at Home Team and the appointment of a Nurse/Allied Health Consultant in Older People’s Services.

3.4. Biggart Hospital has benefitted from some of that investment (more Physiotherapists and Occupational Therapists) and redesign with the testing of a new rehabilitation pathway. Our vision for Biggart Community Hospital is that it will become a centre of excellence providing focussed, tailored, rehabilitation and end of life care for those who do not require acute hospital care, but need more support than can be safely provided at home.

3.5. The wards have been reconfigured to ensure the best use of the space available and to ensure that Biggart Community Hospital builds on its success as a centre for health and wellbeing, supported by the community for the

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community. This includes developments in partnership with volunteers and the local community such as the community garden and cafe area.

3.6. The first stage of this reconfiguration has seen rehabilitation concentrated in Lindsay and Urquart Wards with end of life care being moved to McMillan Ward. The move was successfully completed on 25th October 2017.

4. REPORT

4.1. Bed Model and Activity The previous bed model consisted of 113 beds spread across 4 wards with a throughput of 607 patients per year (392 rehabilitation, 30 palliative care, and 185 accommodated whilst awaiting care).

The new model will concentrate resources over 83 beds, in 3 wards (23x Palliative Care, 30x Ortho-geriatric Rehabilitation and 30x General Rehabilitation). The expected throughput of the new model is 635 patients per year (470 rehabilitation, 27 palliative care and 138 accommodated whilst awaiting care.)

4.2. Clinical Model Four consultants provide geriatrician cover for all patients in Biggart Community Hospital. They provide one formal ward round each per week but are available to support decision making as required. A test during 2015-16 demonstrated that a multidisciplinary goal setting, discharge planning and criteria led discharge model is appropriate for some patients. The clinical team continue to explore and test the optimum clinical model to support the home first approach and to free up consultant time to spend in University Hospital Ayr.

4.3. Clinical Redesign for the Model for Rehabilitation and End of Life Care Proposals in the original business case set out a number of changes necessary to achieve the new model. The table below provides an update on progress against each of the proposed changes:

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Aim Progress 4.3.1 Home First Investment received Home first principle aims for those £0 who are safe to receive their Future investment rehabilitation and care at home to £139k return home rather than being Impact transferred to Biggart or a care home. The opening of the CAU, The model relies on the Intermediate appointment of ACE practitioners Care, Rehabilitation, Home Care and and investment in and District Nursing Teams having the reconfiguration of ICT have meant necessary capacity and skill to that more people are returning home provide a quality service. This without being admitted. However, requires investment in community anecdotally, there remain a nursing and community rehabilitation significant number of people who are (originally estimated at £246k but identified as requiring a bed at reduced to £139k due to funding Biggart who could return home if additional in patient nursing posts – community support was more robust. see 4.2) to enhance capacity. A key Access to care at home remains the aim of this model is to reduce the primary reason for this. number of people requiring a care home and to take South Ayrshire from the upper quartile of care home occupancy in Scotland to the average and then the lowest quartile. 4.3.2 Enhanced In Patient Investment received Rehabilitation Nursing = £562k For those unable to receive their Physio = £57k rehabilitation at home, requiring Occupational Therapy = £33k rehabilitation in a hospital or more Future investment specialist clinical setting, there will be £0 access to community step up and Impact step down rehabilitation beds on Improved outcomes for people, Lindsay and Urquart Wards. The reduced need for care, reduced reconfiguration will concentrate our length of stay. resources over fewer wards enabling our clinical teams to provide a more focussed approach. This requires re- investment of some of the savings into in-patient nursing (originally anticipated to be £455k but now expected to be £562k) and investment into rehabilitation staffing through Integrated Care Funding. 4.3.3 End of Life Care No investment required End of life care will be provided on a Impact home first basis. Working closely in When the model is fully realised partnership with The Ayrshire throughput may exceed the Hospice, specialist end of life care will conservative improvement of 10%. be provided at home or in a homely With one of the highest rates of

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setting reducing throughput by an acute admission within the last estimated 10% (3 people per year). 6months of life, South Ayrshire will In cases where it is not possible to give greater focus to this as an area provide suitable care at home, for improvement. specialist end of life care will be provided on McMillan Ward with single bedded rooms being offered where possible. Stays on the ward should be short (3-6months). 4.3.4 Community Assessment for Investment received Care Home Care Home = £300k The “home first” model will ensure Care at Home = £150k that where possible, in cases where a Future investment care home is being considered this £0 will be determined from the Impact community where home based Although there has been investment options will be tested first. The in both care at home and care home purpose of this approach is to places capacity is limited due to diminish the number of people recruitment and retention of staff and discharged direct from acute care to a the number of places available in care home without first trying a period care homes. There are now 50 at home and to move from the upper (approx.) delays across UHA and quartile of care home places per head Biggart. of population in Scotland to the lower quartile. The model will require access to appropriate care when needed and will only be achieved with investment in more care home (15 places = £300k) and care at home (15 places = £150k) capacity.

4.3.5 Recruitment and Retention Saving realised The new model is predicated on £200k agency cost avoidance staffing levels that are safe and Future saving appropriate. Team members will £300k agency cost avoidance work to the top of their professional Impact competence and coordinate their There has been no use of agency efforts to improve outcomes for staff at Biggart since March 2017 people. A Compassionate although use of bank remains high Connections Programme interviewed meaning that the full cost avoidance staff at the Biggart and identified has not yet been realised. This is “implementing a clear vision for the expected to improve further following Biggart” and “ensuring safe staffing completion of the reconfiguration. levels” as critical actions. This staff Staff morale at present remains very feedback suggests that the intended low due to the immediate impact of improvements are likely to have a the changes however, staff are positive impact on staff moral in the committed to the new vision and are long term and patient safety, working to refocus as newly improving recruitment and retention. established teams. Improvements have already reduced

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the reliance on agency nursing and significantly reduced the £500k annual overspend. 4.3.6 Bed Model Progress The new model will enable a greater There were 113 beds in Biggart throughput (635 compared to 607 Community Hospital. 16 of the 113 people per year) with a need for beds were out of use throughout the fewer beds (82.3 compared to 97.7 winter 2016-17. It was planned to beds at 85% occupancy levels). complete the configuration by end There will be 30 general rehabilitation August 2017, however there were beds on Urquart Ward, 30 delays as a result of the General Orthopaedic rehabilitation beds on Election, unanticipated adverse Lindsay Ward and 23 Palliative beds publicity and associated disruption on McMillan Ward. 30 beds on and the organisational change Drummond will be left vacant. process. Reconfiguration was completed on 25th October 2017. 4.3.7 Delays in Accessing Care at Progress Home and Care Home Places Between January and June 2017 In January 2016 there were 60 beds delays fell from 60 to 20 resulting in across University Hospital Ayr and no waits for a bed at Biggart despite Biggart, lost to delayed discharges over 20beds having been closed. whilst people waited for care However, since July 2017 delays packages or care homes. It was have risen again to over 50 and as a proposed that reducing delayed result 5-10 patients are waiting for a discharges by 25% would create bed at Biggart. capacity equivalent to 10 beds.

4.4. Performance and Improvement Measures. The performance and improvement measures set out below will enable the team to ensure that the aims of the improvement work are delivered and that there are no unintended consequences.

4.4.1 Outcome Measures

Day of Care Audit Day of care audit results will be used to compare against the benchmark data. Aim: The proportion of patients meeting day of care audit criteria within Biggart Community Hospital will rise from 33% to 80% by December 2017.

Throughput Throughput will be monitored to ensure that it at least remains as high as current levels. However, if community services become more effective at maintaining people safely at home throughput may fall whilst the overall system continues to improve. Aim: An average of 36 patients per month will move through the rehabilitation wards by March 2018.

4.4.2 Patient Experience

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Patient experience will be measured to ensure that the changes do not negatively impact on patient experience and will hopefully improve staff experience.

Staff Experience Staff experience will be measured to ensure that the changes do not negatively impact on patient experience and will hopefully improve staff experience.

Patient Outcomes Patient outcomes will be measured using “Talking Points” to ensure that patients are achieving the goals that are important to them.

4.4.3 Balance Measures

Length Of Stay Length of stay will be monitored for both rehabilitation and end of life care patients. Aim: The average length of stay for rehabilitation patients will fall from 42weeks to less than 30weeks by December 2017.

Re-admission Rate The re-admission rate to University Hospital Ayr and Biggart Community Hospital will be monitored to ensure that the new model does not cause people to return home more quickly only to be readmitted soon afterwards. Aim: Re-admission rate will not rise by March 2018.

Delayed Discharges The efficiency and effectiveness of the system relies on those requiring a care home place or care at home being able to access one. Aim: Delayed discharges will reduce from 60 to 20 by June 2017 and reduce to 5 or less by December 2017.

5. STRATEGIC CONTEXT

5.1 The redesign and reconfiguration of Biggart Hospital will contribute to the following South Ayrshire HSCP strategic objectives:

(A) We will work to reduce the inequality gradient and in particular address health inequality. (D) We will support people to live independently and healthily in local communities. (E) We will prioritise preventative, anticipatory and early intervention approaches. (G) We will develop local responses to local needs. (I) We will support and develop our staff and local people.

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(J) We will operate sound strategic and operational management systems and processes. (K) We will communicate in a clear, open and transparent way.

6. RESOURCE IMPLICATIONS

6.1 Financial Implications

6.1.1 The reconfiguration has reduced a recurring £500k overspend related to nursing agency and bank by £200k and is expected to eliminate it by the end of the financial year. £1.56m has been released as Cash Releasing Efficiency Savings or has been reinvested as detailed below:  £413k of Cash Releasing Efficiency Savings within support services.  £300k reinvested into 15 additional care home places.  £150k reinvested into 15 additional home care packages.  £562k reinvested into additional nursing at Biggart Hospital (to be reviewed in 6months)  £139k to be reinvested into community AHP services.

6.2 Human Resource Implications

6.2.1 Managers worked in partnership with Human Resource and Partnership/Trade Union colleagues to reconfigure the staffing using the NHS Organisational Change Process.

6.3 Legal Implications

6.3.1 None

7. CONSULTATION AND PARTNERSHIP WORKING

7.1. There was wide multidisciplinary and service user engagement and consultation in the redesign of services at the Biggart with changes being aligned to the New Model of Care for Older People in South Ayrshire. There continues to be ongoing engagement of the workforce and service users in the planning and implementation of the improvements detailed in this paper.

7.2. The Chair and Vice Chair of the IJB have been consulted on the contents of this report.

8. EQUALITIES IMPLICATIONS

8.1. Poor access due to high numbers of delayed discharges result in increased risk to those who are most vulnerable. Those who are most able to navigate the system or can afford private care are able to limit their wait meaning others are left waiting even longer. The proposed improvements aim to limit these effects.

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9. SUSTAINABILITY IMPLICATIONS

9.1 There are no environmental sustainability issues arising from the proposals contained in this report.

10. CONCLUSIONS

10.1. There were a number of delays in realising the proposed changes set out in the original business case. However, the reconfiguration was successfully delivered on 25.10.17 with resulting financial and clinical improvements having been realised. Staff morale remains a challenge and work is ongoing to support staff to refine the clinical model to ensure that the Biggart fulfils its role within the new model of care as a centre of excellence for rehabilitation and end of life care.

REPORT AUTHOR AND PERSON TO CONTACT

Name: Billy McClean, Associate Director for AHPs Phone number: 01292 559860 Email address: [email protected]

BACKGROUND PAPERS

Report to IJB on 13th September, 2017 on Service Review Programme:

https://www.south-ayrshire.gov.uk/health-social-care-partnership/documents/item%2011%20- %20service%20reviews%20ijb%202017%2009%2013.pdf

07.11.17

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