Priority 6: Right care, right place, right time

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.

Amid ongoing recovery from the pandemic and a cost of living crisis, our focus was on the continuation and embedding of the contracted provision of support to carers provided mainly through our voluntary sector partners. Work was also progressed on the Edinburgh Joint Carers Strategy 2023 -2026 refresh, taking account of the national carer strategy developments, and feedback on the agreed local six priorities which remain our key focus. The refreshed strategy was developed by a short life working group which reported to the Edinburgh Carer Strategic Partnership Group, (CSPG), whose membership includes carer organisations, EHSCP and CEC managers, and the EIJB Carer representative. The refreshed strategy is the result of collaboration and wide engagement with carers, supported people and other key stakeholders. It is based on a set of Key Principles:

  • Maintain the six key priority areas and associated local outcomes
  • Align Edinburgh’s priorities with the five national themes, outcomes and proposed actions
  • Maintain the Equal Partners in Care (EPiC) approach
  • Develop a carer outcomes measuring framework
  • Indicate achievable actions/commitments to continue to enhance carers’ supports and national commitments
  • Maintain the Human Rights-based approach to commissioning

Of the 137 Key Performance Indicators associated with the contracted provision, from January 2022- March 2023: 13 exceeded the target; 102 were fully met; 7 were partially met; 14 were not met; and 1 remains under development. The contract reporting now aligns with the financial year. Of the 14 KPIs not met, 11 were related to the newly developed KPIs associated with the wider roll out of the Adult Carer Support Plans (ACSP) and associated emergency plans.

Other key achievements have seen the VOCAL carer map going live, helping carers to find information, advice and support across the city. Throughout this period, and of particular help owing to the cost of living crisis, welfare benefits and financial advice support provided has enabled carers to maximise their benefit entitlement: the Performance and Evaluation report 2022-23 indicates just over £1.6m of benefits being accessed for carer households. Across Edinburgh carers have been supported by our valued voluntary sector on a one-to-one basis; have accessed peer support and short breaks from caring (including leisure centre membership); and have been helped to access funding. Carers have also been supported through day, evening and residential short breaks. Young Carer Statements continue to be offered, to optimise support for young carers, and their transition to young adult carers.

We have been recognised by Shared Care Scotland for innovation through market facilitation to generate a variety of person-centred short break options for people with Learning Disabilities within the Short Break Hub (The Hub). The Hub supports people with planning and brokering short breaks, exploring support options which meet people’s personal outcomes, and matching people who have a short break budget to social care organisations who can provide replacement care. It also co-ordinates ongoing relationships between families and providers. Between April 2022 and March 2023, The Hub has supported 283 people to access a variety of short breaks, including daytime, evening or overnight support; social events; breaks away together for the person being cared for and the carer or other family members; and breaks with friends. 80% of respondents to a recent survey rated their experience of The Hub positively, and 85% of respondents rated the experience of the person they care for as positive.

The Hub’s relationship-based approach to brokering short breaks has led to improved support options and outcomes and has created the opportunity to consider all aspects of people’s support flexibly across a range of service models. This approach offers more consistency for users and greater sustainability for providers. The local market has grown, with 14 providers offering or engaged in conversations to not only provide short breaks but to consider all supports people need to live a good life.

Work on Adult Carer Support Plans (ACSPs), supporting an outcome-focused approach, has developed over 2022, with the template, supporting leaflets, practitioner guides and internal processes reaching completion. Delivery of training with our partners began in March 2023 and full implementation is July 2023.  This will see a rise from approximately 500 ACSPs completed each year since 2019, further optimising support for carers.

Other key developments up to March 2023 include:

  • Statement around recovery from Covid-19
  • Response to cost-of-living crisis and reinvestment of funds for replacement care
  • Carer Landscape: Edinburgh Action Research (CLEAR) getting under way to capture wider carer supports and contribution to the Carer Strategy, beyond the commissioned services
  • Developments around reporting on carer outcomes, with the co-production of the development of an outcomes framework well under way, encouraging a reflective approach in year 2 by way of preparation for year 3 reporting.

Key focus areas for development for the forthcoming year are indicated in the refreshed strategy, will form the focus for the Carer Strategic Partnership work plan going forward and are aligned with the key implementation plan of the refreshed Strategy 2023-26. This includes developments around SDS, female carers, young adult carer action plan, place based short breaks, Adult Carer Support Plan roll out, and change to reporting timeline and review of KPIs.

As part of the redesign of unscheduled care, Home First is supporting the delivery of the Lothian Strategic Development Framework with three priority areas of focus: reducing ED attendances, reducing length of stay and reducing admissions.

We have continued to work with NHS Lothian on the implementation of Discharge without Delay (DwD). Phase one of the programme identified six acute site medicine of the elderly wards at the Western General Hospital and Royal Infirmary of Edinburgh for a quality improvement approach. This introduced planned date of discharge (PDD) and embedded Home First social care staff (social workers and Home First coordinators) within the ward multi-disciplinary teams at their daily meetings. This collaboration was particularly successful on the WGH wards, with data showing a 50% reduction in bed occupancy by patients in delay over a 12-month period and when directly comparing winter periods. They also reported a 9-day reduction in median length of stay and a 35% increase in discharge rate when comparing quarter one of 2023 with the same period in 2022. The data is less indicative of improvement at the RIE and this likely reflects site progress against the agreed phase one actions. Due to the learning from pilot work at Fillieside and the success of the DwD programme, PDD has also been introduced across our other bedded units.

Over winter, we trialled a new on-site social work model in the Royal Edinburgh Hospital which provided timely and proportionate interventions to reduce social work assessment waiting times and promote a Home First approach. There has been an overall reduction in length of stay, occupied bed days, number of patients in delay and community demand for assessments. The team have improved performance, enhanced multidisciplinary team relationships and improved the patient experience.

Home First supports discharge through a range of services/teams:

  • Our Discharge To Assess service continues to be well utilised across the city with over 2500 referrals received in the last financial year. Discharge to Assess supports people in their transition home by offering assessments and rehabilitation in their familiar environment, not the hospital setting.
  • The introduction of the RESET team (third sector resilience workers) has supported people home from hospital with non-statutory services such as befriending, assistance with grocery shopping and support with welfare applications.
  • Our Hospital to Home service also provides short term support to people who are medically well to go home but who may have a gap between discharge and their care package beginning, enabling more people to be discharged without delay.
  • District nursing has introduced a home IV pathway; working with OPAT at the Western General Hospital to support patients to receive IV antibiotic therapy at home. The service is available to patients who are unable to attend OPAT on a daily basis due to their being housebound; this is supporting early discharge from hospital as well as prevention of admission.

Home First is continuing to provide and develop services to support people to remain at home or in a homely setting, preventing hospital admission and providing alternatives to hospital where it is safe to do so. The Home First coordinator located at the front door of acute sites continues to provide a dedicated focus to prevent unnecessary admission where possible by facilitating community alternatives. A single point of access was introduced via the Flow Centre to provide a professional response to requests from healthcare professionals for people who require urgent therapy and/or urgent social care interventions. This pathway has successfully prevented 80% of admissions from 456 referrals. Through the Home First navigators, the Flow Centre has developed a greater understanding of alternative urgent therapy and care pathways and is better equipped to recommend alternative options with the ability to highlight potential social admission requests.

Hospital at Home has increased its service capacity in the last year, which has enabled the service to support an additional 52 patients per month; this equates to an increase in capacity of 58%. Patients managed by the Hospital at Home team have on average a reduced length of stay of 18 days when compared with patients admitted to an acute site. The Hospital at Home service has also introduced enhanced referral pathways to include the Scottish Ambulance Service, Emergency Departments, Acute Medicine Units and other hospital wards in addition to new pathways for community teams such as the heart failure, community respiratory and IMPACT teams. A bespoke capacity planning tool has been developed by the service.

Work has been ongoing with the care home support team to undertake a test of change to prevent admission from care home settings and to identify frequent attenders from care home settings. This is progressing well and has adopted a collaborative approach across all key stakeholder groups.

Assistive Technology Enabled Care 24 (ATEC 24) offers a range of preventative and enabling supports to citizens of Edinburgh, which includes community alarms; telecare; sheltered housing support; the bathroom equipment assessment team (BEAT); children’s occupational therapy; and a Community Equipment Loan Service to Edinburgh, East and Midlothian communities.

The Community Equipment Loan Service (CELS) provides specialist daily living equipment on loan to those with an assessed need, determined by a health or social care professional. On 31 January 2023, we were awarded accreditation with CECOPS, a national quality assurance organisation. CELS is the first and only equipment service in Scotland to be accredited.

Since 2018, we have increased the number of satellite stores we support with small aids and equipment from 17 to 43, enabling equipment to be accessed locally and quickly and reducing environmental impacts, with 17,304 items delivered to satellite stores in the past year. We also supplied almost 39,000 items through our Click and Collect Service, introduced in 2020 in response to Covid-19 restrictions and now maintained as a core function. In 2022, we delivered approximately 91,000 items to people living in their own homes as part of our standard delivery schedule, with an additional 17,638 items delivered as a crisis response within a 24-hour timescale, usually supporting people coming out of hospital. This represents a 44% increase in standard deliveries over the past five years, with an almost 400% increase in crisis deliveries.

The Assistive Living Team (ALT) was formed to support early intervention with citizens who present with less complex needs through the provision of equipment, telecare and community-based support. During the last year, ALT took part in a second phase of a Scottish Government pro-active telecare / outbound calling test of change, with the external evaluation by University of West of Scotland identifying significant cost avoidance to the telecare, Scottish Ambulance Service and hospitals from this work.

The telecare service continues to develop and implement plans around the analogue to digital transition, ensuring the telecare technologies in people’s homes and the platform we are using to answer customers’ calls is compatible with the updated digital telephony network by 2025. In March 2023, 35% of our Telecare customers were in receipt of compatible technologies. Continuing to grow our telecare service is a key aspect of our Inspection Improvement Plan.

In 2022 the Innovation and Sustainability Portfolio selected Learning Disabilities Services as its primary pipeline project area to develop and improve outcomes for service users with Learning Disabilities. This has seen the collaboration of multi-agency and multi-disciplinary professionals from both the public and voluntary sectors. People with lived experience have engaged in reviewing progress and provided feedback on identified change areas. This iterative process has identified 13 key areas requiring some change and improvement work, refined from the nine outlined in the report to EIJB in September 2022. The Edinburgh Learning Disability Advisory Group, a participatory group involving individuals who have a learning disability; their support staff; learning disability third sector organisations and our staff, is engaged in ensuring that the proposals being developed are scrutinised by people with lived experience. The project is currently developing action plans to address the change proposals and still has some significant milestones ahead.

Health Improvement Scotland launched a programme in 2020 called New Models of Day Support – this programme was designed to support Partnerships to define and further develop approaches to day support that best meets the needs of individuals who have a learning disability. To take this forward the EHSCP developed a local project team with representation from third sector providers and partnership staff. There has been engagement with individuals who have learning disabilities and their carers during this project to ensure that their views are taken into consideration when developing person-centred change proposals. This project is in the final stage and the intention is to produce a menu of opportunities that reflects the aspirations of people with learning disabilities to be included in a wide range of activities including volunteering, employment, further education, and social activities.

On 29 March 2023 we held a Capacity to Collaborate event at the Edinburgh Community Rehabilitation and Support Service. This event brought together EHSCP colleagues, third sector and private organisations and people from the world of physical disability, hidden disabilities, neurological conditions and long-term conditions to promote our rehabilitation and self-management services and resources. The event highlighted the multiple avenues of support available to help people on their journey and emphasised the power of collaboration, offering marketplace stalls, a main discussion on reflective practice and collaboration, and a demo of the Smart House Tech Hub.

Case Study 4: FAIR Ltd – Welfare Rights and Financial Capability Advice

Colin lives with his wife Jeanette. Jeanette gets Personal Independence Payment (PIP) Enhanced Daily Living and Enhanced Mobility. They get full Housing Benefit and claim as a couple for Employment and Support Allowance, and Jeanette gets the Support group component. After Jeanette phoned FAIR to ask for help with a PIP review form, they were allocated an Advice Worker.

A home visit brought into focus the complexity of their case – Jeanette is house bound, she has diabetes and is very obese. She has not left the house in two years and has carers that come to the house to dress and wash her. The PIP review was completed with both Colin and Jeanette. However, from further discussion and engagement with Colin’s doctor, it emerged that Colin had a learning difficulty and receives medication for migraines but he was not in receipt of PIP and had lost his Disability Living Allowance years ago when he began to care for Jeanette despite his own limited abilities.

The couple were also needing to move house as it was not a suitable property for promoting Jeanette’s mobility or her personal care needs. FAIR ensured the appropriate housing association was contacted to address these concerns. FAIR continued to pursue Colin’s situation and referred him to the NHS Community Learning Disability Team for a learning disability assessment. They also supported him through a PIP claim, which was successful with both Colin and Jeanette being awarded PIP Enhanced Care and Enhanced Mobility claims.

Personal Outcomes:
· Personalised Support and access to a named skilled Advice Worker

· Working towards better health outcomes, including reduced isolation

· Better financial situation – Colin was able to buy a new washing machine with his PIP backdated money

Wider Impacts:
Good partnership work between agencies to get best outcome for clients. They are both less isolated and there are plans for services to help them to work towards moving to a more suitable property and to be more organised in their home.