Delayed Discharge into Care Homes

– in the Scottish Parliament on 25th August 2020.

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Photo of Emma Harper Emma Harper Scottish National Party

2. To ask the Scottish Government whether it will provide an update on delayed discharge into care homes. (S5T-02346)

Photo of Jeane Freeman Jeane Freeman Scottish National Party

The latest published information from Public Health Scotland indicates that 357 patients who encountered delay in their discharge were discharged to care homes during June 2020, which is 32 per cent of the total discharges that month. The remaining 68 per cent were discharged back to their own homes. That compares with 33 per cent of delayed discharges going to a care home in June 2019.

Hospitals and care homes are taking three key steps whenever a patient is discharged from hospital. First, a patient should be tested 48 hours before discharge. Secondly, they should be isolated for 14 days on arrival in the care home, regardless of the test result. Finally, at all times a thorough risk assessment should be undertaken prior to discharge, to ensure that the care home is able to provide the care required, including having suitable physical space for isolating individuals and having staff available for the delivery of care and support to the resident.

Last week, as members might recall, I commissioned Public Health Scotland to produce validated statistics on patients who were tested prior to discharge, and on the outcome and date of the test. That information will include how many were discharged while still considered to be infectious and the rationale for that decision.

Photo of Emma Harper Emma Harper Scottish National Party

How does the number of delayed discharges compare to the number prior to the pandemic?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

The number of delayed discharges has reduced significantly over the past few months. The June census, which is the latest published, validated census, showed 808 delayed discharges for any reason or duration, compared with 1,627 in February 2020 and 1,442 in June 2019. Nearly a third of all those that were delayed this June were complex cases, including people who lacked capacity and were awaiting a court-appointed guardian.

Photo of Emma Harper Emma Harper Scottish National Party

The cabinet secretary will be well aware that the winter season always sees an increase in hospital admissions, and I know that work is currently being undertaken to strengthen the resilience of our Scottish health service. What forecasting work is being done to balance the transfer of care and mitigate the impact of that on our health and social care sectors?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

A number of steps are being undertaken as part of what would be normal winter planning but are this year increased in their significance because we are still in the middle of a pandemic. They include the significant expansion of the flu vaccination programme.

With regard to our health boards’ work, another step is health board mobilisation plans, which the boards were asked to produce to take us through to the end of March 2021. Those plans have to have been developed in consultation with the local health and social care partnerships, which include our local authorities, so that we can also see what additional capacity either needs to continue, particularly in terms of care at home, or needs to be brought in, as we make those estimates. The overall objective is to treat people as close to home as possible, so part of that effort also includes scaling up—where it is clinically safe to do so—the hospital at home initiative, which has been so successfully undertaken by NHS Lanarkshire over many years.

Photo of Neil Findlay Neil Findlay Labour

To follow up on the revelations by the

Sunday Post and

The

Courier at the weekend, if the decisions that were made in March and April to discharge all those hundreds of patients who were untested or Covid positive were based on the clinical needs of patients, why were those same patients not discharged in February or December or January, when they were likely to have become delayed discharge cases?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I will make two points in answer to Mr Findlay’s question.

First, the point of commissioning Public Health Scotland to do the work that I have just outlined is to make the data that it produces, which will cover all our health boards, really clear. As Mr Findlay knows, the

Sunday Post article was able to deal with only some returns from some of our health boards. Part of the objective of the Public Health Scotland work is to identify not only patients who were discharged who had had a positive Covid test, but the date on which they had that test. That information determines whether they were infectious at the point of discharge. When we have those numbers, which I hope that we will have by the end of next month, that data will of course be published, and then we can have further discussions with colleagues on the issues that they want to raise.

On Mr Findlay’s other point, I remind members that, on 17 March, I said in the chamber:

“We are also working closely with the Convention of Scottish Local Authorities, health and social care partnerships and chief officers to get a rapid reduction in delayed discharges. I have set a goal of reducing those by at least 400 by the end of this month.”—[

Official Report

, 17 March 2020; c 7.]

That was part of a statement to the Parliament that outlined our understanding and expectation at the time of the number of potential hospital cases that would have to be dealt with because of Covid-19. Our modelling said that we needed to create space in our hospitals and additional intensive care space to deal with the demand. That was all part of that work.

It has long been a policy of the Government to reduce delayed discharges, and colleagues from across the chamber have agreed with that. In the period that we are talking about, the health and social care partnerships, supported by the health boards, put additional focus on working through the obstacles that were in the way of discharge. However, that does not contradict the fact that it is always a clinical decision that determines whether someone is ready to be discharged and that a multidisciplinary risk assessment is carried out to agree where they should be discharged to.

Photo of Colin Beattie Colin Beattie Scottish National Party

Following the reports on the issue from the Queen’s Nursing Institute, is the cabinet secretary aware of whether there have been issues related to delayed discharge early in the pandemic in other parts of the United Kingdom?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

Yes, there have been. In the regular four-nations calls that I take part in with my colleague health ministers in Wales and Northern Ireland and the Secretary of State for Health and Social Care, Matt Hancock, we regularly discuss the common challenges to us all in responding to the pandemic. Those challenges have included ensuring that our NHS was prepared, introducing additional resources—in Scotland, that was done through the NHS Louisa Jordan hospital—the issues around personal protective equipment, which have been rehearsed in the chamber many times, and of course the situation with delayed discharges. We discussed the care and support that were needed to ensure that we had the right care-at-home services, as well as the approach that was taken in care homes. In common with those three other countries, we have developed our understanding as the understanding of the virus has developed, and we have developed our guidance and actions accordingly.

Photo of Alison Johnstone Alison Johnstone Green

On Sunday, a letter was published from the cabinet secretary and COSLA’s health spokesman to Scotland’s health and social care partnerships. The letter revealed that the director general of health and social care set a target to reduce delayed discharges by 900 by the end of April. Does the cabinet secretary consider that that letter constitutes an intervention by Government in decisions that would otherwise have been taken purely by clinicians in consultation with social work colleagues? What consideration was given to the impact that urging the partnerships to meet the target might have?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

No, I do not think that there is any contradiction whatsoever in our approach. I mentioned what I said in the chamber on 17 March. On 1 April, I said that we had

“reduced the numbers of delayed discharges in our hospitals by 500.”

I went on:

“We will continue to work towards a further reduction of 500 over the month of April.”—[

Official Report

, 1 April 2020; c 85.]

There is no contradiction in the Government or indeed any Opposition party having a policy to reduce delayed discharges on the ground that we all know about and accept—that it is positively harmful for people, particularly older people, to stay in hospital for longer than is clinically required—and saying that the final decision about whether someone is ready to be discharged is a clinical decision that is to be taken patient by patient, as it should be, or that the decision about where they will be discharged to and the care and support that they require involves a multidisciplinary risk assessment that is undertaken by social work, the clinicians and the resident or their family, or both.

There is no contradiction in that at all, so that letter is not some blinding revelation; it is simply the Government enacting a policy decision. The decisions about who is discharged, when, and to where remain clinical and multidisciplinary decisions, as they have always been.

Photo of Willie Rennie Willie Rennie Liberal Democrat

Big questions are still outstanding, on: the advice on asymptomatic transmission; the value of testing all the way through the pandemic; the number of positive patients who were sent or moved to care homes; and the isolation arrangements in care homes. All of those are big questions. Do they not lead the health secretary to the conclusion that we need an early public inquiry?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

Mr Rennie is right that all those issues require big decisions and need to be scrutinised thoroughly. As the First Minister and I have said more than once, we know that there will need to be a public inquiry into the entire handling of the pandemic in Scotland—I expect that there will be inquiries elsewhere, too. When the time is right, we will say what we believe the remit of the public inquiry should be, and it will get under way.

Right now, we are still in the middle of a pandemic. We have outbreaks, clusters of cases, testing challenges and a flu vaccine expansion programme, and we still have to remobilise the NHS while it does all that additional work. This is not the point for us to take our focus away from that job—which, at the end of the day, is about saving lives—in order to set up a public inquiry and direct all officials into that area of work.

The work that we do now is important. The public inquiry will also be important. When the time is right, we will have that public inquiry.

Photo of Monica Lennon Monica Lennon Labour

It is unfair to let social workers and clinicians take the blame for what happened. We have all seen the letter, so I give the cabinet secretary another opportunity to now admit that it was the Government’s policy that led to so many untested and infectious patients being cleared out of hospitals and placed into Scotland’s care homes. Will she admit that?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

Nobody—not me, the First Minister or any other member of the Government—is suggesting that clinicians, care home workers, social workers or even patients themselves are somehow to blame for what happened. [

Interruption

.] No, I am explaining to Ms Lennon how delayed discharge works in any circumstances, including in a pandemic.

First of all, the lead clinician for a patient—any patient—determines that the patient is ready to be discharged, because they need no more treatment in the hospital setting. A multidisciplinary assessment is then undertaken to determine the best place for the individual to be discharged to. One of the great improvements that we have seen during the pandemic is the widespread adoption across our health and social care partnerships of work on such assessment beginning much earlier than the point at which the clinician decides that a patient should be discharged.

I am not in the business of blaming anyone at all. I have always been clear that I am accountable for the decisions that I have taken. I believe that it is right to hold a public inquiry at the right time. Right now, I am focused on doing the best possible job that I can to ensure that citizens, patients, residents and our staff across the NHS are given the resources that they need and are kept as safe as possible.

Photo of Brian Whittle Brian Whittle Conservative

I keep hearing the phrase “clinical decision”. The reality is that a clinical decision is about the health of the patient and the patient’s ability to leave hospital; it is not about the impact of Covid on a care home. We heard today that the Care Inspectorate was not involved in the decision-making process, so who was looking after the care homes when the legislation was brought to the Parliament?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

The care home looks after the care home in relation to—let me be very clear—deciding whether it wishes to take a person. That is the care home’s decision. Some care homes closed their doors to new admissions, and some still do. We ask them to do so if they have a positive case but, in those early days, care homes did that themselves, because they are independent providers. As Mr Whittle knows, some care homes are run by the private sector, some are run by the third sector and some are run by local authorities.

They make those decisions. However, the work of determining whether the care home in question has the right nursing and physical capacity to keep a new admission isolated from day 1, as the guidance specifies, is undertaken by the multidisciplinary team, which will of course talk to that care home about whether it can meet the resident’s requirements.

I tell Mr Whittle that that is how it works. It is not rocket science—it is really straightforward. I know that he knows that, so I am not quite sure what point he is trying to make. He knows as well as I do the process that is gone through—there are many care homes in the constituency that I represent and which he covers as part of his responsibilities, so he knows exactly how the system works with East Ayrshire Council and the local health and social care partnership.

We know how the system works: it continues to work as it always has done. The idea that there was some secret target is nonsense; I have just read out from the record—twice—what I previously said we were going to do.