Agenda item

Care pathways for the frail elderly

[Andrea Smith CCG, Head of Integrated Commissioning, WCCG and David Watts (or delegate), Director of Adult Social Care, to on the work being undertaken by CCG/RWT/BCPFT/CWC on addressing delayed transfers of care]



David Watts, Director of Adult Social Care, City of Wolverhampton Council, and Andrea Smith, Head of Integrated Commissioning, Wolverhampton CCG, presented the report on care pathways for the frail elderly and highlighted the key points.


David Watts referred to the importance of ensuring that care pathways were good in the city.  There were several different drivers for health and social care, a key document being the NHS Five Year Forward View which stated that areas should have a plan for integrating health and social care by 2020.  He referred to the Better Care Fund (BCF) Programme which was the primary way to implement change through the more efficient use of resources.  The programme was currently being refreshed and had yet to be signed off.  That delay had primarily been caused by the delay in published guidance from the Department of Health, which had become available on 4 July 2017. Once finalised, the Leader of City of Wolverhampton Council would be asked to sign it off.


He referred to several projects underway which aimed to avoid emergency admission to hospital and Delayed Transfers of Care (DTOCs) and he asked Andrea Smith, Head of Integrated Commissioning, to highlight several them.


Andrea Smith referred to the following projects:


People Living with Frailty Programme.  This was in the BCF Programme, with several work streams to support primary and secondary care.  GPs were taking part in a pilot scheme looking at patients using a Frailty Index to identify those most in need.  By using Care Management Plans, it was hoped to allow the elderly to remain at home for longer.


Review and Redesign of Community Services Programme.  This was in the BCF Programme, with all services being provided to ensure the right services in the community setting and the right support.


Admission Avoidance Programme.  This was both proactive and reactive; community nurses worked proactively with GPs to look at high risk patients and those frequently using services.  The Rapid Intervention Team worked reactively with nurse based teams in the community supported by Social Care teams.


David Watts referred to the following projects:


Discharge to Assess Programme.  As from the beginning of 2017 it had become part of the BCF Programme as it was considered that it covered the whole system.  A pilot scheme using Discharge Hubs and improved initial assessments had been introduced on four wards at the Royal Wolverhampton Trust.


  • Six-month extension of Home Assisted Reablement Programme (HARP).
  • Additional Stepdown/Very Sheltered Housing or Extra Care.
  • Hospital Discharge Demand Management Implementation.
  • Hospital Discharge Voluntary Sector Service.


The above projects were part of additional Adult Social Care.  £6.4million would be available this year if three conditions were met. Firstly, stabilising the local care sector, secondly relieving press on the NHS locally by getting more people home safely and quickly,and thirdly helping to deliver the challenges for health.  Spending was controlled by the BCF Programme Board and the A & E Delivery Board.


In response to questions from Panel members, officers stated the following:

  • Improvements had been made to the assessment process already.  The issue related to where an assessment was taking place, given that assessments would often require several visits it was better to do an initial assessment in the hospital and then further assessments when the person had returned home.
  • It would depend on the type of adaptation required as to whether this would or could be done before a person left hospital.  Under the Small Adaptations Grant stair lifts and other minor adaptations could be completed quickly and it was hoped to pilot the scheme in other areas.  If a person was unable to return home as adaptations were still required alternative accommodation would be found.
  • Efforts were being made to work with other authorities; however, it was not proving straightforward. 
  • The NHS was made aware that delays occurred when Wolverhampton was dealing with people transferred from other hospitals.  Based on the performance indicators used, the service was in an extremely challenging position.  However, improvements had been made during the past year, for example in the number of delayed days during the month, which had fallen from 600 to 400.  Other indicators in the dashboard required assistance from other bodies, including GPs and the ambulance service working together better.
  • It was important to ensure transparency and have efficient methods of data collection to avoid replication.
  • It was important to remember that outside events could influence figures, for example when ambulances were diverted to Wolverhampton from other areas.
  • It was unclear why there had been a spike in the figures for the number of delayed days last November 2017; however, NHS delays were more pronounced than social care delays as perhaps more people were unwell.
  • One project related to hospital discharge and would bring together data and information from health and social care to ensure that a care package was in place.  Also, to ensure the correct support to GP practices, services were now aligned to the CCG footprint based around GP clusters.
  • To help the sick and vulnerable to be prepared if they required hospital care a Red Bag Scheme had been successfully piloted in residential and nursing care homes and had seen a huge reduction in discharge times  as important patient information is available when a person is admitted which will help reduce delays in diagnosis and treatment. It was hoped that the scheme could be introduced in Wolverhampton and extended to include vulnerable people in their own homes and it was hoped to have that in place by October 2017.
  • The Adults Budget Working Group looked at the Transformation Programmes.  The Secretary of State has recently announced that a penalty of up to 10% of the budget (£640,000) would be imposed if targets were not reached.  That would require Wolverhampton achieving a 36% improvement against performance measures by September which would be very difficult to achieve.  Seven of the West Midlands authorities would require an improvement of more than 60% which showed the scale of the task. 
  • Wolverhampton had a good health and social care system and it was difficult to be required to have those discussions on trying to meet this trajectory even though the system was working well and the NHS and DCLG would receive feedback that it had proved disruptive.
  • The link to the BCF guidance was available to be circulated to the Panel.  The information including the dashboard  which provides information about six  key performance measures  - for example, the proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services. The information is used to track if current performance is on target for reducing the number of delayed hospital attributable to social care. There was concern the table does not capture all the complexity of the factors beyond the control of the local authority which can affect its performance against the published indicators.
  • Wolverhampton had been ranked 117 out of 150 but  based on current evidence the situation is improving


Members of the Panel welcomed the comments and responses from officers and stated that the main priority should be to ensure patient welfare rather than trying to achieve unrealistic Department of Health targets


David Watts suggested that as the Department of Health would be reviewing the current progress of the dashboard in October 2017, if there were any areas of concern they could be considered at the Panel’s meeting on 25 January 2017.



  1. That a link to the Government guidance on the BCF be circulated to the Panel.
  2. That an update report on the performance of Wolverhampton against six performance measures detailed in the Local Performance Measure performance dashboard is be submitted to the meeting on 25 January 2018.  

Supporting documents: