Maintaining high quality integrated health and social care services across care settings
Maintaining good physical and mental health and wellbeing through the provision of high quality care services and a strong and well-functioning integrated system will ensure that people can be supported where clinically possible.
A balanced system - mutually supportive
- Primary and social care
£62 million for 2021/22 has been allocated for building capacity in care at home community-based services. This additional recurring funding should help to fulfill unmet need, and deal with the current surge in demand and complexity of individual needs, also helping to ease pressures on unpaid carers.
This funding should be spent on:
i. Expanding existing services, by recruiting internal staff; providing long-term security to existing staff; enabling additional resources for social work to support complex assessments, reviews and rehabilitation; commissioning additional hours of care; commissioning other necessary supports depending on assessed need; enabling unpaid carers to have breaks.
ii. Funding a range of approaches to preventing care needs from escalating, such as intermediate care, rehabilitation or re‑enablement and enhanced MDT support to people who have both health and social care needs living in their own homes or in a care home.
iii. Technology-Enabled Care (TEC), equipment and adaptations, which can contribute significantly to the streamlining of service responses and pathways, and support wider agendas.
Funding of £40 million for 2021/22, has also been provided to enable patients currently in hospital to move into care homes and other community settings, on an interim basis, to ensure they can complete their recovery in an appropriate setting. This is likely to be for a period of up to six weeks through an expedited process. Local teams will work with people and their families to explore options, maintaining choice and control.
Multi-disciplinary teams will provide support to people in these interim settings to ensure they receive high quality, responsive healthcare and rehabilitation. Consent will, of course, be sought before discharge from hospital and safe clinical pathways, aligned with public health advice and guidance must be adhered to. Any placement is expected to be in their immediate locality or other suitable location. There will be no financial liability for the individual or their family towards the costs of the care home.
The offer of an interim placement should be made when the HSCP is unable to provide an appropriate care at home package immediately, or when the first choice care home is temporarily unavailable. A clear care plan for this period of interim care needs to be in place, with an agreed date for the placement to end, set out before the placement begins.
We will also build on the Home First approach through the launch of an improvement programme (in collaboration with the Centre for Sustainable Delivery). The Discharge without Delay Programme will engage teams across the whole patient journey, aiming to ensure all delay is prevented where possible and placing a strong focus on discharge to assess.
This approach will ensure local teams engage patients and their unpaid carers from the point of admission in the planning and preparation of safe and timely discharge, ensuring that strengths can be properly identified, goals discussed and expectations properly managed. We will use a 'Planned Date of Discharge' approach and link with the wider multi-disciplinary team across seven days. We will put systems and processes in place to protect time for planning and joint decision making and to ensure we do not inadvertently cause or contribute to delay. This will also allow us to improve our understanding of where pressures and blockages are in the system. We will promote discharge to assess for the ongoing assessment of care needs in a more homely setting, ensuring in-patient stays are only as long as is clinically and functionally essential. Funding of £40 Million has been allocated to make provision for moving patients currently in hospital into care homes on an interim basis.
An additional £2.6 million has been shared between ten health boards so they can continue to develop Hospital at Home services to avoid admissions to hospital and we will work with Health Improvement Scotland (HIS) colleagues to monitor the progress of this work.
Day and Respite Services continue to have an important role in supporting adults with additional support needs and their families. Guidance remains that these services can re-open, and decisions regarding the re-opening of services should be made at a local level. These services provide a number of essential functions such as enabling those who attend to reconnect with friends and networks. In doing so they provide vital support to allow unpaid carers to continue in their role.
For primary and community health care support, a National Healthcare Framework for Adults and Older People Living in Care Homes Working Group has been established, which will focus on: Prevention; Anticipation and Supported Self-Management; Early Intervention; Urgent and Emergency Care; and Palliative and End of Life Care. A priority for the winter will be to ensure that there are good communication channels between care homes and primary care and the Working Group is developing an engagement strategy which will be used to share information to enable good healthcare for people living in care homes. As HSCPs develop the breadth of professionals working within their extended MDTs (e.g. District nurses, Care Home Liaison Nurses, AHPs and advanced practitioners), it is important that care homes understand who to contact and how to access both planned and urgent healthcare.
Keeping Anticipatory Care Plans up to date with details of what matters most to the resident within the care home, and if possible with information on how the person within the care home would like to be cared for if there was a sudden serious deterioration in their health (e.g. following an infection not responding to oral antibiotics) remains important in ensuring that the right care is provided. There should be a clear mechanism for sharing this information through the Key Information Summary.
The oral health sector continues to remobilise, despite dentistry not yet being back to business as usual. The sector is currently delivering around 50% of pre-pandemic activity due to the risks associated with aerosol generating procedures and associated infection prevention and control requirements. Recently announced Scottish Government funding to provide drills which do not create the fine aerosols and also to support more sophisticated ventilation systems in practices, in addition to revised IPC guidelines for dentistry, will provide further capacity in the system. During winter 2021/22, dentists will continue to optimize provision of a full suite of GDS services within the capacity available, providing urgent and essential care according to clinical priority. The Caring for Smiles Health Improvement Programme will consolidate its pre-pandemic support and Boards will continue to methodically re-engage with all their Care Homes to identify the backlog of care.
The community eye care sector has fully remobilised. Activity has returned to pre-pandemic levels and is available to all patients who require care. Practitioners who provide care in care homes and to patients in their own home are fully up to date with current protocols for isolation, the use of PPE and how to react to a COVID-19 outbreak within a care home, and will deliver services accordingly.
Audiology services are currently at around 80% of pre-covid levels of activity and that is set to increase following the recent changes to IPC guidance. A postal repair service will remain in place with turnaround times of 7 days, typically. Our plans to improve services will include training for care home staff and support from the third sector.
We continue to work closely with Boards around community pathways, including local Covid hub and assessment centre pathways. They have adapted to support local population needs and circumstances, and as we continue to respond to different phases in the pandemic, we have developed a number of supports including:
- a remote monitoring pathway to support people to self-manage Covid symptoms at home, helping to detect early signs of deterioration;
- support for GP practices to enable them to manage people with respiratory symptoms, including practice guidance around infection prevention and control measures;
- a national respiratory guidance document, which is currently out for consultation.
Scotland is already widely recognised for providing high-quality palliative and end of life care. The new Palliative and End of Life Care strategy recently announced in the Programme for Government will build upon and improve our services for palliative and end of life care by taking a whole system, public health approach. To support the development of the strategy, a new national clinical lead for palliative care will be appointed and engagement with key stakeholders and partners will continue throughout autumn/winter 2021-22.
The COVID-19 pandemic has had a significant effect on those in receipt of care, in addition to the social care workforce and unpaid carers. Our Mental Health Transition and Recovery Plan sets out our response to the mental health effects of the COVID-19 pandemic, containing over 100 actions which will continue into autumn/winter 2021-22, including:
- − Working with local authorities to maintain community mental health and wellbeing services, with over 200 new services and supports having been established to date.
- − Continuing to support the roll-out of Computerised Cognitive Behavioural Therapy – 16 CBT treatments are now available to all territorial Health Boards.
- − Rolling out our Distress Brief Intervention (DBI) programme on a national basis (via its NHS24 pathway), with over 3,200 people having already benefited from support.
- − Continuing to support the Clear Your Head campaign across radio, digital and TV, offering tips for people to look after their mental wellbeing.
- − Supporting the expansion of the NHS 24 Mental Health Hub to be available to the public 24 hours a day, 7 days a week.
Further measures to address wellbeing concerns within the social care workforce are discussed at pp 7-8.
Links to training, funding and guidance in relation to maintaining high quality integrated services
- Keeping a record of care – 1
- Keeping a record of care – 2
- COVID-19: Advice for people at highest risk
- COVID-19 Highest Risk List Survey Report July 2021
- Practice in the community setting
- Mouth care
- Palliative and end of Life Care
- Mental Health & Wellbeing
- Death and Bereavement
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