Internal reviews detail litany of failings at NHS Highland over adult social care services and complex care packages including a lack of leadership and clarity
Two internal reviews have detailed a litany of failings that effectively crippled the ability of NHS Highland to fully deliver on its adult social care services and younger adults’ complex care packages objectives.
Leadership and accountability shortcomings in introducing the new Discharge Without Delay model for adult social care services were such that there was “no documentation or scrutiny of the whole discharge planning process”.
Younger adults’ complex care packages problems ranged from a lack of oversight that saw packages promised but go undelivered while some lacked regular reviews, which incurred costs and did not address how needs change over time.
Over both services a total of 12 so-called grade three problems were identified that “represented high risk to the organisation” due to issues in leadership, accountability, delivery and whether sufficient time and resources were dedicated to delivery.
The reviews were discussed at the NHS board audit committee on June 18 but the information only came to light in the minutes to tomorrow’s full board meeting at Assynt House.
Together they paint a dire picture of organisational problems as the board attempts to deal with some of its most intractable problems, namely the delivery of social care in the Highlands.
Delayed discharge and adult social care
Delayed discharge, sometimes called bed blocking, is when patients are unable to leave hospital because the care they need outside is unavailable. A year ago we reported that this is estimated to cost NHS Highland £10.7 million annually.
Delayed discharges are currently running at 186 a month but the target of 95 is not being met though the board says there has been an “improved performance” in the last three months – in January delayed discharges 213.
It is a major issue for the health board that routinely struggles to balance its books while adding to the pressures on the availability of beds in places like Raigmore not to mention keeping well people in hospital.
The first of the damning reports covers the delivery of the new “multi-disciplinary discharge model across community and acute services” where Stephanie Hume, the internal audit found eight points that were “grade three which represented high risk to the organisation.”
Essentially DWD aims to reduce hospital stays and bed blocking by planning for discharge from when a patient is admitted, prioritising a home first ethos. The new ‘Discharge Without Delay’ (DWD) planning model suffered serious issues.
A short-term working group implementing the new process suffered from “a lack of clarity” on – leadership and accountability, if key individuals were involved in the process design and whether sufficient time and resources had been allocated.
The DWD delivery group was disbanded and then the senior official responsible retired and there was no replacement.
The audit highlighted how there was “no documentation or scrutiny of the whole discharge planning process” – a clear handicap when that is what is trying to be managed more efficiently.
The new DWD process also lacked a clear escalation policy or process regarding patient discharge from hospital and treatment. The audit found that with different structures in place “it was fundamentally unclear who held overarching oversight and management”.
There were similar issues with Care at Home as the accuracy of Care at Home data was not robust nor easily accessible and management could “not confirm the accuracy of the information with different information across different systems”.
Reporting on care package reviews was very limited and while the costs were reported within financial reporting there was little information presented to district and area managers and the adult social care team.
And there was no documented process while staff demonstrated inconsistencies in levels of understanding of care package processes and reviews.
Younger adults’ complex care packages
The audit committee also received an internal review of younger adults’ complex care packages and governance arrangements where again the significant “grade three” issues persisted.
Despite “clear scrutiny of individual packages the audit could not provide assurance on how they were seen within the context of wider system delivery”, which appears to have lay at the heart of the issue.
That “explained” why some care packages were confirmed but could subsequently not be fulfilled “due to other factors” – in short someone was promised a care package but did not get one.
Some “high impact and value care packages” did not appear to “include recommendations and did not address wider considerations such as resources availability and sustainability of the service.”
The audit also suggested that there should be periodic reviews of packages because those that did not have set times for reassessment carried “significant cost impacts” while care needs may change over time.
The audit saw that as some packages were “hampered” there was a need for the service to be more aware of what that means “not just from an individual perspective” but also within the system.
