What was it like at the back end of 2014 going into 2015 coping with the huge professional and management pressures caused by large additional numbers of older people being admitted into hospital – the so-called winter pressures? And how did adult social care services prove their indispensability? Andrew Milroy takes us through those months step by step as a local authority is seen stepping up to a very difficult plate…

DERBYSHIRE COUNTY COUNCIL’S preparations during the latter part of 2014 for our work with the NHS to manage collectively winter pressures turned out to be particularly important. By December we were making it clear to all our local leadership teams that measures to prevent avoidable hospital admissions and limit delayed discharges and transfers of care would be given absolute priority. At our meeting with all our service managers on Friday December 20 we made it clear that everything else would take second place and that we needed to be prepared to escalate our work at any time.

Adult social workers are used to the Christmas and New Year being a very busy time - especially those colleagues working with any of the 12 acute care hospitals serving Derbyshire. However the extent of the increased demand on hospitals that hit us (as it did everywhere in the country) during the first week of the New Year, was unprecedented and tipped a stressed system into crisis.
 

Since October 2013 to Feb 2014 the adult care department received 1347 referrals from the acute trusts in the north of the county. In the same period Oct 2014 to Feb 2015 this rose to 1668 referrals - a 23 per cent increase in referrals for the period. During January 2015 there was a 29 per cent increase in activity on the previous year. There was particularly high demand across urgent care services from mid-December until mid-January 2014-15 with particular pressure on acute medical beds, community hospital beds, NHS111, GP Out of Hours and ambulance services. 

The language used to describe the problem is inherently dehumanising – bed blockers are always people with families and commonly frail older people with multiple difficulties to deal with. Delivering social care support to people who are at risk of admission to hospital and where it might be - and if at all possible should be - avoided, is sometimes straightforward as well as often complicated.

Helping people who have been staying in hospital after treatment for an exacerbation of multiple long-term conditions can be simple. More often it isn’t and the pressure on our hospitals leaves NHS teams with very little time or space to explore the personal dilemmas or implications frail older people face. Too often we aren’t able to hear what the person wants for themselves and how they would choose to manage the risks they face.
 

So too easily we can slip into needlessly removing people from perceived risks to their health and wellbeing by prescribing residential or nursing home care, or needlessly intrusive home care support.

Hospitals and their patients under the sort of pressure we have been seeing need the support of skilled, confident and respected social workers and adult social care teams. This has been the foundation of our winter plan and effective collaboration. Success depends on doing the right thing for the right person at the right time. This depends on the quality of the relationship we can establish with each person, their family/key people in their lives and the network of key services they need – those they have already and those that need to be added because of what may have happened. Poorly people, many frail and elderly, will have to make important decisions about the help, care and support they need next. For some people these will be major life-changing decisions about where they live and where they die.
 

Our operating principle is dignity in care – getting it right for people means getting it right for the system. For Derbyshire Adult Care, it is as important to make sure someone leaves hospital as soon as they are medically stable to transfer and wherever possible this should be back home, wherever home is. Half a day spent in hospital longer than is necessary is an affront to the dignity of anyone and especially for older people nearing the end of the lives. Nobody who is the responsibility of Derbyshire County Council stays in hospital because of a delay in allocating funding for care. Even though the council has had to cut £13 million from the adult care 2014/15 budget and has to cut a further £25 million in the next financial year. 

Derbyshire County Council has given priority to the provision of adult social care services. With the provision of additional funding from North Derbyshire and Hardwick Clinical Commissioning Groups and Chesterfield Royal Hospital NHS Foundation Trust (CRHFT) contributing to the additional costs, and the £230,000 additional grant funding announced by Government early in 2015, the council has invested strongly to enhance social care services and support the winter plan. We have:
 
  • Increased the number of social workers and social care professionals in the team based at CRHFT to ensure we are able to respond to the increased number of people, many frail elderly people, and people with more complex care needs who require social care help to avoid hospital admission or leave hospital safely following a period of inpatient care. The increase in the number of elderly people in our community is a huge success of our generation. This success brings with it an increase in the number of people living with long-term conditions as well as more people where their continued independence depends on the careful assessed management of clinical, social and personal risks and the availability of more networked care and support. Organising safe and sustainable community care and support for and people is more complicated and demanding and can’t simply be switched on and off!  
 
  • Extended access to social worker support at weekends to 9 -5 Saturday and Sunday and increased the number of social workers deployed, flexing this to reflect the pressures on the hospital encountered during the week. This investment means that we can discharge more people during the weekend as well as take forward care and support planning for people who are then able to leave earlier during the week. Social workers working at the hospital during the weekend also deal with people attending the Emergency Department or transferred to the assessment units. Priority is given to preventing admission wherever possible. Social workers will assess care and support needs and mobilise family, community and care service support to help people get home again rather than spend the weekend in the hospital.
  • Provided dedicated support to the new Acute Frailty Unit (AFU) that provides intensive care and support for people over the age of 75 by a multi-disciplinary team led by a specialist consultant in the care of elderly people. The AFU is `joined up care in action’ and aims to assess, treat and manage the elderly person’s medical condition and get them home. If that isn’t possible, they can be transferred to a suitable community care facility within 48-72 hours. There is plenty of evidence that the longer frail elderly people stay in hospital the more likely they are to lose functional abilities and their independence.

  • Enhanced the capacity of the specialist re-ablement and home care services provided directly by the council. This involved increasing home care worker capacity, facilitating extra hours for current staff (around 700 per week) since November and ongoing. The availability of a network of local home care services and the capability to provide intensive help to aid recovery and avoid or reduce the need for long-term funded care and support has been a crucial capability during the period of exceptional demands.

  • Streamlined access to the specialist residential and community care Centre and residential care homes provided directly by the council – providing scope for the rapid transfer of people who, while medically stable, still need more intensive care and support to assist recovery. This significant capability as a result of the council’s investing in a directly provided residential care service that many other councils have discontinued or significantly reduced, has helped to reduce the number of older people being admitted to permanent residential care.

  • Supported timely hospital discharge and admission avoidance.

  • Provided daily bed availability data to assist care planning and discharge planning.

  • Flexed our out of hours (weekend in particular) domiciliary services organiser cover to support and enhance usual arrangements for our directly provided home care services as and when required.

The success of the investment made for the winter 2014/15, sustaining our resilience as the pressures continue on our hospitals into March and leading to a reduction in the number of people avoidably delayed in hospital, has built on a long-standing partnership with the NHS and community health services. This long standing relationship is really important. We work closely with Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Community Healthcare NHS Foundation Trust and all our GPs and primary care teams. Avoiding delayed transfers of care in hospitals depends on planning and well co-ordinated community health care services working with and supporting adult social care teams.

Our community social work teams and direct care services are closely aligned with GPs and primary and community healthcare teams and work continues to strengthen integrated care services across the county. Effective community care also depends on a network of voluntary and community sector services and the Council working with the Clinical Commissioning Groups has maintained investment to support the VCS groups, despite enormous financial pressures.
 

Andrew Milroy
Assistant Director Adult Care
Derbyshire County Council