Agenda item

The following report provides an update on progress made by the Community Independence Service, which helps to support residents in their own homes or community.

Councillor Vaughan welcomed Helen Poole (H&F CCG), Susan McCabe (WLMHT) and Katherine Murray (Central North-West London NHS Foundation Trust), who jointly presented this item.  The report provided an overview of how the service had been operating since being implemented on 1^st November 2016.  Helen Poole explained that the main element of the process ensured that there was a single point of referral, strengthening the process, with the introduction of an integrated patient record.  Referring to a case study, set out in section 4.2 to 5 of the report, it was reported that 85% of patients referred to the Community Independence Service avoided re-admission and that there had been improvements to the triage service.

It was noted that the clinical priority was to improve the patient pathway, prescribing the optimum patient journey.  This was an on-going area of work, to ensure a seamless transition and integration of care between health and ASC.  Looking ahead to 2018, the current contract with the provider was under review.

Jim Grealy referred to section 1.3 of the reports, point 4, Reduce readmission rates, observing that the Hammersmith and Fulham service, serves residents with complex needs, and, the number of residents appear to be much higher in number compared to other boroughs.  It was noted that this was a separate piece of work that was currently being undertaken by the CCG and that the data would be shared at a later date.

Bryan Naylor sought clarification regarding the difference between a failed discharge and a premature discharge.   Part of the process of identifying if there had been a failure of treatment or if a person’s condition had deteriorated, dependent on the information available.  Katherine Murray referred to the case study in the report, and explained that they had access to a diagnostic tool at Imperial which could help with diagnosis. 

Councillor Carlebach enquired about the large number of residents who were based outside of the borough.  Katherine Murray responded that the figures were maintained across the three boroughs and that WLMHT made provision for placements in Ealing and that reciprocal arrangements across Brent, Harrow and Hounslow were in place. 

In response to a query from Councillor Brown regarding the friends and families test, Katherine Murray explained the Trust was keen to communicate as widely as possible, utilising tools such as friends and families. 

Councillor Vaughan enquired about the data and information sharing that might come from the deep dive, to indicate for example, if a clinical decision led to a reaction in a complex illness, and whether this was feasible.  Vanessa Andreae clarified that a failed discharge was not the focus of the CIS and that this would not necessarily be happening to patients that were not under the care of the service.  Katherine Murray explained that CIS was a multi-disciplinary team consisting of GPs, nurses, occupational therapists, pharmacists and social workers.  She added there was an enhanced provision of community based services within the borough, a model of care which was being widely replicated and developed in other areas.

Councillor Vaughan referred to paragraph 5.3 of the report, which reported that a performance survey undertaken during April-July 2017 indicated that 96% of Hammersmith and Fulham residents that responded would recommend the service to a friend or family.  92% felt they were treated with dignity and respect and 82% indicated that they felt involved in decisions about them.  Katherine Murray explained that a rapid response intervention was a “fast” service, with patients being seen over 5 days, and might be seen by different members of the multi-disciplinary team, depending on the range of complexity that was presented, so less complex cases would receive input from an external partner.  The rehabilitation unit would see patients within a 24 hour to two-week window. Some patients might begin by being seen by the rapid response team, move onto the rehabilitation unit and then onto the reablement pathway.

A member of the public commented with reference to section 7 of the report that the number of beds should not be reduced.  Helen Poole responded that this was about demand not keeping pace with resources, but added that this had not been the primary focus of the paper. 

In summarising the main points of the discussion, Councillor Vaughan commended the report which had covered a six-month operating period.  A further request for data on discharges would be followed up with the CCG separately and the CCG confirmed that they will be able to share monthly statistics in future. 

ACTION: CCG

RESOLVED

That the report be noted.