Ensuring that people have good physical and mental health and wellbeing through provision of high quality integrated care services
A strong and well-functioning integrated system will ensure that people can be supported in the community where clinically possible.
Enhanced winter measures:
Health and Social Care Partnerships must build on the Home First approach that has been successful in many parts of Scotland and widely adopted during the pandemic. Strong multi-disciplinary working across health and social care is needed to support a Home First approach, with the NHS supporting a range of Intermediate Care services as well as Hospital at Home. Healthcare Improvement Scotland (HIS) are developing a national learning system to help share knowledge and good practice on Hospital at Home. Resources include:
- Online learning sessions, case studies and podcasts
- Twinning areas developing Hospital at Home to provide peer support and mentoring
- Development of a toolkit to support areas to assess their readiness to adopt Hospital at Home
- Development of standard protocols and templates to help standardise services across Scotland.
Local authorities must balance the COVID transmission risk of restarting some supports and services with ensuring that social care packages allow people to live fulfilling lives. The priority is to ensure that eligible care and support needs are being met, in the right way for people and unpaid carers, to ensure safety, dignity and human rights. This includes where care and support needs have changed. We will work with COSLA, Integration Authorities and providers on the scope and mechanisms of additional funding for financial sustainability throughout the winter period to protect social care services In addition, work with Health Boards and Integration Authorities will continue over the coming months to review and further revise financial assessments, and as part of this we intend to make a further substantive funding allocation in January.
Significant work has also been undertaken to ensure that the NHS ‘wraps around’ social care during the pandemic. This has worked well in addressing direct harm from Covid-19 and ensure that non-Covid-19 health harm is addressed. We need to maintain and extend this ‘wrap around’ more widely for people using adult social care provision. The Clinical and Professional Advisory Group is leading on the development of the care model and this must now be supported into the delivery phase.
There are two aspects to this:
- Ensuring that people stay well for as long as they can; and
- When hospital admission is required, suitable provision is available for people to return to their home with the right support in place, supporting the Home First approach.
It will be important to support the acute hospital sector by ensuring no-one is unnecessarily delayed in their discharge from hospital. We must ensure that the approach of planning for safe discharge as soon as people are admitted to hospital is adopted across the country. This approach, already shown to be person centred and effective makes sure that when a patient is clinically able to leave hospital they can be safely discharged home or to a homely setting. Packages of care must be appropriate and in place rapidly. Unpaid carers must be involved in the hospital discharge of those they are caring for, ensuring they are able to provide the care required. This approach provides a better outcome for individuals, as well as ensuring hospital capacity is used appropriately.
Public Health Scotland were commissioned to undertake an analysis of discharges from hospital to care homes and their report was published on 28 October. The independent report, produced in partnership with senior clinical and data experts from the Universities of Edinburgh and Glasgow, showed that whilst discharge from hospital, when other factors were considered, did not contribute to a significantly higher risk of a COVID outbreak, discharge along with other factors requires continued improvement and focus. It found the strongest association with outbreaks of COVID was care home size. To ensure that hospital discharge is both safe and effective across the country, in line with the findings of the independent report, Health Boards must ensure that the national testing requirements for people are followed:
Admission of COVID-19 recovered patients from hospital
Patients should always be isolated for a minimum of 14 days from symptom onset (or first positive test if symptoms onset undetermined) and absence of fever for 48 hours (without use of antipyretics). They also require 2 negative tests before discharge from hospital (testing can be commenced on day 8). Tests should have been taken at least 24 hours apart and preferably within 48 hours of discharge.
Where testing is not possible (e.g. patient doesn’t consent or it would cause distress) and if discharged to care home within the 14 day isolation period, then there must be an agreed care plan for the remaining period of isolation up to 14 days.
Admission of non-COVID-19 patients from hospital
Testing should be done within 48 hours prior to discharge from hospital. A single test is sufficient. The patient may be discharged to the care home prior to the test result being available. The patient should be isolated for 14 days from the date of discharge from hospital. Risk assessment prior to discharge from hospital should be undertaken in conjunction with the care home.
Note: an admission to hospital is considered to include only those patients who are admitted to a ward. An attendance at A&E that didn’t result in an admission would not constitute an admission.
The way we provide primary care has already changed during the pandemic, with increased use of telephone and Near Me assessments to minimise potential transmission of infection through face to face contact. There are still times when a face to face consultation is clinically necessary, and health and care professionals will continue to enter settings such as people’s homes and care homes to provide ongoing care and support when required, with appropriate safety measures. District Nurses, Advance Nurse/AHP Practitioners, specialist nurses and AHP’s and community mental health teams have continued to provide essential care during this pandemic and will continue to do so over winter months.
Heath and Social Care Partnerships will continue to work closely with community pharmacists, AHPs and community nursing teams to co-ordinate support for care homes and other care settings to ensure good pathways of care and support during any outbreaks. GPs and multi-disciplinary teams lead delivery of care to patients at home with multiple co-morbidity, general frailty associated with age, and those with requirements for complex care. Ensuring the deployment of sufficient resources across the multidisciplinary teams to support compliance is crucial. Health care pathways and more care within the community setting, including urgent care and support for palliative and end of life care over the winter period must be supported. In addition, where possible GPs may wish to consider aligning with a care home local to their practice to offer strategic support to the care home management over the winter months, whilst respecting the individual choice of residents on GP registration.
Oral and Eye Health care underpin the wellbeing of people living in care homes or other at risk groups. During winter 2020/21 the focus will be to continue the safe provision of urgent and essential oral and eye health services, including remote consultations where it is appropriate. Patients will continue to be risk stratified with ongoing support to those in care homes and with additional needs. Service remobilisation also involves availability of key services such as new spectacle prescriptions for failing eyesight, the replacement or repair of dentures and spectacles, and the detection of oral cancer and sight-threatening conditions.
The Community Pathway has been in place since 23 March 2020 with symptomatic patients being directed (via NHS24 111) to local Community Hubs for further triage and assessment. As announced in the Programme for Government, the existing Covid Community Pathway will be enhanced to support people over the winter period, as patients present with symptoms similar to COVID-19 symptoms, such as cold and flu. Significant engagement has taken place, and will continue, with key stakeholders – across Primary and Secondary Care – to agree how this model will be delivered at a local level. Public Health Scotland data reports that between 23 March and 8 October a total of nearly 180,000 consultations were carried out with patients being triaged to Community Hubs and Assessment Centres. This includes telephone advice, face-to-face consultations at assessment centres and a small number of other recorded consultation types.
People who may be approaching end of life will get the care and support that is right for them. We will support medical professionals to have sensitive and timely conversations with individuals and their loved ones (where appropriate) about their care wishes should there be a risk of them becoming seriously ill. These can be challenging conversations and can reflect the variety of anxieties and concerns people can have during what remains a difficult time for us all. That is why we want to learn from our experiences earlier in the pandemic and adopt a more person centred and sensitive approach to anticipatory care planning (ACP) discussions.
It is important to recognise that in some cases of overwhelming illness, particularly in individuals with significant or multiple pre-existing conditions, some treatments such as Cardiopulmonary Resuscitation (CPR) may not be effective. This can often be a difficult subject to discuss, however it is important for medical professionals to be open and realistic with people and their loved ones, about whether this treatment is likely to be successful given the specific medical circumstances of the individual. However, there is no specific requirement to have a discussion on CPR as part of an anticipatory care planning (ACP) conversation, unless the individual raises this and wishes to discuss it, or the clinician feels strongly that they need to discuss it for the individual’s wellbeing.
Our healthcare professionals are trained to have these conversations and will help people, and those closest to them, to make an informed choice about the treatment and care that is right for them. However, we want to build on our learning from earlier in the year and have a range of tools to support clinicians in taking a more person centred and sensitive approach when having these discussions. To aid them in this work, on 30 September 2020, the GMC launched updated guidance on Decision making and consent. The updated guidance focuses on person centred care and aligns with the Realistic Medicine agenda in Scotland. It promotes shared decision making as the key to ensuring people receive the treatment and care that they need, based on what matters to them, and ensuring they have all the information they need to give informed consent.
Additionally, resources have been developed to support clinical colleagues in having these conversations in a more person centred, sensitive and holistic way. These are available on the Healthcare Improvement Scotland website https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/
We will also continue to work with health and social care colleagues to ensure that information and guidance to support care planning conversations are easily accessible to the public, medical professionals, and care providers to help ensure that people get the advice they need, when they need it.Our overarching Cardiopulmonary resuscitation decisions – integrated adult policy guidance makes clear that these discussions and decisions should be consistent with relevant legislation and guidance, such as the Human Rights Act (1998), and the Adults with Incapacity (Scotland) Act 2000.