GWH's Home to Assess leaders: (l to r) Emily Hussey, Alison Koster & Jill KickNo one can keep admitting sick people to a hospital if those whose treatment is complete and are ready to go home are not leaving the wards.
Blocked beds - also known as 'delayed transfers of care' (DTOCS for short) - cost the NHS dearly and cause longer queues in the hospital's emergency (or A&E) department.
At Great Western Hospital they have started a pilot of a system called Home to Assess and it is already having an impact on the number of empty beds GWH has available on any one day.
At present it - as Chief Executive Nerissa Vaughan told the GWH Board - '"Small stuff'. But the results in terms of freed-up beds were, she said, good: "It's the first time ever we've had positive information about DTOCs"
When I went to meet the leaders of the Home to Assess team, GWH was on a high state of alert - that means the hospital was FULL. During October GWH was running with bed occupancy at 104 per cent - with extra beds brought into use. The level of bed occupancy for safe and efficient treatment of patients is considered to be 85 per cent.
For those fit enough after medical treatment, Home to Assess moves the assessment process for the care they will need, from hospital to home.
To explain how it works I met the three people leading the scheme: Senior Occupational Therapist Emily Hussey, Jill Kick working in Discharge Services and Alison Koster, with a nursing background and now GWH's Associate Director of Patient Flow.
And sustained flow through the hospital is what this is all about: it is crucial not just to free up beds for those who need to be admitted from the emergency department, but also for the safety of frail and vulnerable patients.
These three health professionals know well that staying in hospital too long can be bad news. The old can very quickly become institutionalised so losing independence, they can pick up infections and they can have falls: "Family members," says Emily, "really came on board - once they had it explained that hospital is not the best place for their relative."
The Home to Assess (H2A) scheme turns the usual process upside down: instead of waiting in hospital while they are assessed for the type of care they need and an appropriate care package is assembled, some patients who are deemed fit enough will go home and be assessed in their homes. But no one is sent home who will not be able to manage between care calls.
"Hospital", Alison Koster told Marlborough.News, "is quite a false environment for assessment for what care and help they need at home." It is one thing to ask a patient while they are lying in a hospital bed and hoping to leave if they can make themselves a cup of tea at home - and tick the box. It is so much better to see them making a cup of tea in their own home.
If, after medical treatment, a patient needs a wheeled Zimmer frame, they may find it easy and safe to use on the hospital's flat and uncarpeted floors. Get them home and they may well fall as they try to negotiate carpets, rugs, narrow doors and hearths.
Patients are chosen for H2A with reference to the NHS' exacting codes of fitness and they are discussed with the clinical specialists treating the patients and at daily multi-disciplinary meetings. Individual needs and the wishes of relatives are taken into account.
When each H2A patient arrives home they will have someone there to make sure they are all right for the night. Next morning the assessment starts - with a "burst of support" to complete their assessment within their first 72 hours at home. It is a staff intensive scheme.
They will be seen first by an occupational therapist, followed by nurses and sometimes a physiotherapist. The occupational therapists do the functional assessment - making sure a patient can cope with personal care, is safely mobile and can carry out domestic tasks. This is the key element in determining a patient's care needs.
The H2A team at GWH is small at present - two occupational therapists, a physiotherapist and intermediary care nurses from the community team. The current pilot scheme only concerns patients from Swindon.
Emily Hussey and Jill Kick are new members of GWH's staff. In October they transferred to GWH from the social enterprise organisation SEQOL when GWH became caretaker for Swindon's community healthcare services. GWH takes over the full SEQOL contract in February.
Emily and Jill's close involvement with this scheme shows the advantages that more integrated community healthcare services will bring to GWH and its patients.
This team have many plans for the future - more use of tele-care and tele-health (remote monitoring of vital signs) and the introduction of single-handed equipment - aids for the old and disabled which only need one person to handle patients safely.
This H2A scheme is not unique - it has been used by a hospital in Aintree and a similar scheme is used by Salisbury Hospital. At GWH the scheme was set-up as part of the hospital's plans to combat 'winter pressures' and was funded by the Swindon Clinical Commissioning Group.
It started on November 14 and has so far involved 32 patients - all but one of them continue to function well at home (one needed 'reablement support'.) In the new year, the team's aim is to use the scheme for five patients a day five days a week.
Delayed discharges are at crisis point. In October GWH lost the equivalent of 805 bed days due to delayed discharges. This was less than the September figure but was a 42 per cent increase on October 2015. The November figures are expected to be more sertious still.
Beds are in demand: GWH had to cope with 165 more emergency admissions in October than in September - and that was an 8.7 per cent increase on October 2015.
The hospital's plan to reach required government target for number of people coming to their emergency department and being seen, treated, admitted or discharged in under four hours, relies on the number of DTOCs being halved. So the success of H2A is very important.
It is forecast to be 'fairly uncontroversial', but the Sustainability and Transformation Plan (STP) for the area that includes Wiltshire dominated the AGM of the Wiltshire Clinical Commissioning Group in Salisbury on Tuesday (November 22.)
We have already had a published summary of the plan, which mainly spelled out the intentions for the NHS across Bath and North-East Somerset (BANES), Swindon and Wiltshire - an area known as BSW. It remains to be seen how detailed the version to be published on December 14 will be.
The leader of the BSW planning, James Scott (Chief Exec of the RUH in Bath), told a recent meeting of Wiltshire councillors that details will not become clear for six months. Tuesday's meeting of the CCG was told that BSW is "...at the early stages as regards the maturity of our plan."
The basis of the plan was spelled out to the meeting under the heading: "Time for Change".
Tracey Cox (Accountable Officer for BANES CCG and at present for Wiltshire CCG too) was quite open about the problems the STP team faced: "In an extended period of financial austerity, the resources are not enough for the needs and demands we are facing." But she described the BSW plan as 'fairly uncontroversial': "If anything our plan isn't radical enough - to be honest."
Tracey Cox gave an outline of work being done on the four main areas of health care the plan addresses: primary care, urgent care, planned care and preventative care. She leads the work on this last area and explained work planned to combat diabetes.
A member of the public asked why there was no mention in the STP summary of mental health. The answer was that each area has mental health components within it - and further plans for mental health care in Wiltshire will be announced by the end of next month.
And Dr Chet Sheth, of the CCG's Sarum locality, said that mental health 'is all our concern': "It's not just about the STP working downwards, but about all of us working upwards."
One of the difficulties with the STP policy is finding a balance between what is good for the wider STP area (or 'footprint') and the more locally identified needs and decision making which have been the mainstay to date of Wiltshire CCG's policy making and programmes for community based health care.
This difficulty was acknowledged at the meeting. It may become more of an issue as procurement of services is going to be done on a 'footprint' wide basis.
Another main topic for the AGM was the unreliability of the Arriva non-emergency ambulance service. A member of the public said there had been no sign of improvement.
He had canvassed nurses who were 'unanimous' that it had not improved and that ordering an ambulance by phone sometimes took half-an-hour. He stressed that the drivers were being put under unreasonable pressure: "Drivers come out of it well - it's the management."
There were reports of patients being kept in hospital for an extra night because an ambulance was not available to take them home.
For the CCG it was said that the contractual process that was underway to ensure improvements could end in the cancellation of the contract. However: "We can't terminate the contract immediately."
If a new contractor has to be found for this Wiltshire service will it be drafted purely to suit the county’s rural geography or, if it is an STP-wide procurement, will one contract cap have to fit Wiltshire, BNES and Swindon?
Keeping an eye on forthcoming NHS changes that may also affect or influence plans for our area:
A neighbouring Sustainability and Transformation Plan (STP) area - or 'footprint' - has declared its intention to cut its workforce costs by £34,200,000.
The Buckingham, Oxfordshire and Berkshire STP area's newly published document states that the three counties are going to introduce more 'generic support workers' across health and social care and employ fewer registered nurses. The document calls for "...skill mix changes to support a more flexible workforce".
A report in the Health Service Journal says that a projected workforce growth for the footprint of 4,526 full-time equivalent staff will be reduced to an increase of just 978 - despite admitting staff will face "...approximately fifteen per cent more patients".
Among those 'generic support workers' will be healthcare assistants and physicians associates. They also hope to save a further £17,800,000 in their spend on agency staff by setting up an STP-wide staff bank - these are generally nurses who do not want full-time jobs but need to work fill-in shifts at hospitals.
We are constantly being told that the STP project teams will not be a permanent part of the NHS' organisation. But this neighbouring STP footprint - known, apparently, as BOB - is planning to set up a board that will meet monthly to 'hold the three health economies to account' as they try and implement the new plans.
Statutory responsibilities will remain with the clinical commissioning groups and with the hospital trusts and, presumably, with the local authorities - but there will be an executive for the all three counties that will be commissioning health provision. One of their targets will be a saving of £60,200,000 by preventing an expected three per cent growth in commissioning specialised treatment services - see below.
This is beginning to look more and more like a major restructuring of the NHS organisational model set-up by the Lansley reforms during the coalition government. Inserting an extra layer into the organisational hierarchy will get very close to reintroducing the Strategic health Authorities that the Lansley restructuring abolished.
These plans came in the same week as research published in the British Medical Journal Quality and Safety Journal found that diluting the nursing skill mix increases the risk of patient death. The study revealed that for every 25 patients, substituting one registered nurse with a non-nurse increased the possibility of the patient dying by 21 per cent on an average ward.
One anonymous comment published on the Health Service Journal website says: "Mid Staffs anyone? It beggars belief that despite all of the evidence demonstrating the value of [registered nurse] time and the improved safety and quality of care - when faced with austerity they all cave in."
FAQ: What are specialist services? They are treatments centralised in relatively few hospitals serving a large enough area with enough patients enough patients with rare disorders so that expert teams can be recruited and can develop their skills. They include services from renal dialysis to treatments for rare cancers and life threatening genetic disorders. NHS England spends £15.6 billion on funding specialised services.