Agenda item

To consider information from the North Tees and Hartlepool NHS Foundation Trust (NTHFT) in relation to this scrutiny topic.

The third evidence-gathering session for the Committee’s ongoing review of Reablement Service considered information from the North Tees and Hartlepool NHS Foundation Trust (NTHFT).  Led by the NTHFT Head of Community Services (who had worked within reablement provision for many years) and supported by the NTHFT Care Group Director – Healthy Lives, a presentation was given which covered the following:

·       NTHFT current role working alongside Stockton Reablement Service: With a focus on ‘Home First’ principles, the Trust’s priority was to get patients home from hospital as soon as it was clinically safe to do so.  Avoiding hospital admittance in the first place was also central to its thinking.

To facilitate this approach, NTHFT was a key partner within local integrated services, working alongside Stockton-on-Tees Borough Council (SBC) to provide an Integrated Single Point of Access (ISPA).  There was also a well-established Integrated Discharge Team (contributing to the Trust having one of the top performing Emergency Departments in England – a reflection of the strength of pathways in place to get people home), as well as a Community Integrated Assessment Team (CIAT) which worked in collaboration with the Reablement Service (30 clients on average per month, involving 80 contacts).

A change in delivery of the local Reablement Service from autumn 2024 had seen SBC bring the offer in-house.  From a NTHFT perspective, recent operational challenges had led to patients staying in hospital longer, though the Trust had worked with SBC for additional support to get individuals home for Christmas.

·       Case study – Support in the Community: A case study resulting in a referral to the Reablement Service was included as an example of the rising demand for this type of care.  Increasing frailty and complexity of cases across the general population was leading to greater challenges in providing support for those needing these services.  This example also involved a referral to the Virtual Frailty Ward (also known as the ‘hospital at home’ service) for further clinical assessments, treatment and observation.

·       Emerging system frailty model: Whilst there was estimated to be around 140,000 people aged over 65 within the Tees Valley footprint (15,500 of which had moderate or severe frailty and 5,500 of whom were residing in care homes), these numbers were expected to increase by over 20% in the next 10 years.  In order to meet this rising demand, NTHFT was developing a system frailty model which involved interventions ranging from emergency care within the hospital environment to self-care (including carer support).  Its aim was to help reduce hospital admissions and Accident and Emergency (A&E) attendance for those over 65 years-old, as well as reduce care home admissions.  The final model still needed to be approved by the Trust’s governance structure.

·       NHSE Frailty Strategy: The wider NHS England Frailty Strategy included a pathway to receiving reablement in the community.  This may or may not follow a period of care within a hospital setting, and the delivery of the strategy would require the support of a range of partners, including primary care services and the voluntary sector.

·       Future possibilities: Reablement provision was a key element in delivering more care in the community, and the Trust (with its partners) was trying to push the boundaries regarding what could be done outside of the hospital environment.  Investment in technology to aid in the move from analogue to digital (NTHFT was already working with the existing Reablement Service in relation to telecare) and focusing on preventing people from reaching crisis point (requiring collaboration between partners) were also future considerations.

From a service structure perspective, a move to facilitating 24/7 access should be central in developing the current offer as it was not appropriate to stop provision at 5.00pm.  Continuing with the ‘Discharge to Assess’ principles so as many assessments as possible were undertaken outside the hospital setting was important, particularly since individuals may be more independent within their own home and not require a significant care package identified whilst in hospital.  Developing understanding and management of complex cases, and the use of OPTICA (a secure cloud application, built by North of England Care System Support (NECS) in collaboration with NHS Trusts and Local Authorities, which tracked all admitted patients and the tasks relating to their discharge in real-time through their hospital journey) within the community was also highlighted.

Regarding the questions put to NTHFT in advance of this meeting, Trust representatives added that, in terms of measuring the success of the existing Reablement Service, this was difficult to comment on given NTHFT did not have access to relevant data.  However, it was recognised that the Borough’s reablement provision played a key role in the ongoing strong local performance around hospital discharge, much of which reflected the established partnership between NTHFT and SBC.  It was also noted that the Trust had received no feedback (either positive or negative) from the public about the Reablement Service – any compliments / complaints would likely be submitted to the Council.

Thanking NTHFT for its presentation, the Committee asked how the provision of 24/7 reablement care might impact upon the recruitment and retention of staff.  The Trust stated that it was aware of pockets of its workforce who would prefer to undertake their duties more flexibly (including nightshifts), though acknowledged that it would need to make specific approaches / adverts to identify interested individuals (whilst not the same type of offer, the ISPA had been operating on a 24/7 basis for around 18 months now).  Demand for support within the community would continue to increase, and this would have ramifications for workforce planning.

In response to a Committee question on the numbers being cared for as part of the ‘hospital at home’ (Virtual Frailty Ward) initiative, NTHFT confirmed that it currently provided 110 beds across a range of pathways, 30 of which were offered for frailty (as of today, these were all full).  In related matters, it was stated that any required assessments of an individual potentially in need of care should be done as early in the day as possible so requirements could be put in place on the same day.

Members queried if there were any established links between reablement provision and end-of-life care.  NTHFT noted its work with both Butterwick Hospice (Stockton-on-Tees) and Alice House (Hartlepool) and that individuals can be admitted into these settings from the community.

AGREED that the information presented by the North Tees and Hartlepool NHS Foundation Trust be noted.