As part of making sure people receive the right care in the right place at the right time, we want to ensure people are supported to live as independently as possible. We are committed to ensuring people are supported at home and within their communities whenever possible, and are admitted to and stay in hospital only when clinically necessary. Central to our thinking is working towards the provision of care tailored to the individual, in a place which best provides this care and as close as possible to when it is required.

Supporting Carers

Carers remain vital partners in supporting the most vulnerable people in society and while society emerges from the pandemic, carers continue to feel its effects daily.

Despite its challenges, in 2021 contracted provision under the Edinburgh Joint Carer’s Strategy (EJCS) 2019-22 was rolled out to support carers across the six priority areas:

• Identifying carers
• Information and advice
• Carer health and wellbeing
• Short breaks
• Young carers
• Personalising support for carers

Short breaks and developments around Adult Carer Support Plans were affected by pandemic restrictions, however, resulting in a portion of funds being re-invested to benefit carers. Importantly, where provision was affected, carers continued to be supported in creative and dynamic ways, making the first year of the contracted provision a great success.

The Edinburgh Joint Carer’s Strategy is being refreshed in 2022 and will align with the National Carer Strategy, which is currently under consultation. This shall allow recent challenges to be addressed and will ensure the six priorities continue to be delivered upon. A working group has been established and the Carers Strategic Partnership Group shall have oversight as this work progresses.

Home First

Home First is developing services to better support people to remain at home or in a homely setting, preventing hospital admission and providing alternatives to hospital where it is clinically safe to do so. Significant progress was made in several workstreams during the year.

To support the prevention of admissions, we implemented a Single Point of Access through the Flow Centre for all urgent health and social care/therapy pathways requiring a 4-hour response. From March 2021 – February 2022, 357 referrals were received and 53% of admissions were avoided. We also expanded the social work hospital team to include Home First Navigators in Home Based Complex Clinical Care and intermediate care, and additional social workers to support the front door at the Royal Infirmary and Western General Hospital. Our Hospital@Home service also prevents admissions. Referrals to this service have increased by 40%, with the introduction of different referral routes and virtual clinics which accept Emergency Department referrals out of hours for visits next day.

Our Home First approach also works to support timely discharge from hospital. In 2021/22, Edinburgh became the first Lothian partnership to test Planned Date of Discharge (PDD), as part of the pan-Lothian pathfinder site for the national Discharge without Delay initiative.  We also enhanced our Discharge to Assess (D2A) service, which enables more people to be assessed at home, supporting 2,173 discharges or referrals since June 2021. Additionally, the Community Respiratory Team built on the success of the test of change done at the Royal Infirmary in 2021 to support the discharge of COVID-19 patients. In 2021/22 there were 20 referrals with 60 hospital bed days saved.