Tackling delayed transfers of care in Bradford District and Craven

Bradford District and Craven has a population of around 590,000 people. It is divided into two health and care partnership areas with distinct geographies and demographics. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

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Overview of progress

Bradford District and Craven has a population of around 590,000 people. It is divided into two health and care partnership areas with distinct geographies and demographics:

  • Airedale, Wharfedale and Craven
  • Bradford City and Districts.

Many of the strategic developments for integrating health and social care are undertaken across the whole area. However, each of the two partnership areas has distinct operational models and plans for Integrated Care Partnerships. This case study focuses on developments in Airedale, Wharfedale and Craven (AWC).

AWC has a population of around 157,000 and covers 500,000 square miles with a very diverse population. Keighley in Airedale largely has a younger population with multi-ethnic groups and is in the top 20 per cent of the deprivation index. Wharfedale has an older population and is relatively affluent. Craven in the Yorkshire Dales has a population of around 50,000 but covers 452,000 square miles, presenting issues of access to services and rural deprivation.

The main health and social care partners tackling delayed discharges in AWC are:

  • Airedale, Wharfedale and Craven CCG
  • City of Bradford Metropolitan District Council (nb Craven falls within North Yorkshire County Council)
  • Airedale NHS Foundation Trust.

AWC is an integrated care pioneer, and Airedale and partners are a vanguard for enhanced health in care homes.

Historically, Bradford Districts and Craven have low levels of delayed transfers of care (DTOCs). Bradford is ranked 7 nationally and 3 compared with statistical neighbours, with current performance at 3.6 per 100,000 population. The NHS England target is for Bradford to perform better than 3.8 per 100,000 for all delays.

Many of the elements of good practice reflected in the High Impact Change Model have been operating in AWC for several years, and have had time to embed; others are currently being worked through. A spike in social care attributable DTOCs took place around two years ago in the winter of 2016/17, as highlighted in the area’s annual system-wide review of winter. This was largely due to a decrease in the availability of domiciliary care, in part because of high demand and the introduction of a new commissioning framework. Recognising the reasons for the rise in DTOCs, Bradford Council has worked to address this (see home care market shaping below), and DTOCs have returned to low levels.

AWC’s developing Integrated Care Partnership (ICP) is intended to promote health and social care integration and make a shift to prevention away from acute services. It is based on a vision for helping people to remain ‘Happy, healthy, at home’. The ICP is regarded locally as having huge potential for sustaining low levels of DTOCs in the face of rising demand, and even making further improvements. Planning for the ICP has improved already good relationships, leading to a greater spirit of cooperation and whole-system ownership in recent months.

Key messages

  • The highest priority is to focus on the needs of people as individuals rather than trying to fit them into services.
  • It is important for each organisation to understand others’ role in tackling DTOCs, to appreciate the pressures under which they operate, and to take these into account when planning and implementing shared arrangements.
  • Joint work on an ICP has brought partners together in a ‘movement for change’ with great potential to build bottom-up solutions.
  • In a complex system it can be difficult to attribute change in performance to any particular intervention; it is more helpful to look at the overall position and keep building on it.
  • In light of demand pressures and funding cuts, the Better Care Fund has been essential to enable measures to be put in place to maintain low levels of DTOCs.

Key factors that make a difference

Streamlining discharge arrangements and a focus on discharge

Discharges from Airedale NHS Foundation Trust are organised through the multi-agency discharge team – MADT – which includes specialist nurses, discharge coordinators, social workers, intermediate care and therapists. The MADT provides a single point of referral for discharge and collective decision making. Recent developments include basing therapists with the team to increase their contribution, and additional social work capacity to accelerate assessments.

Tackling DTOCs is a top priority for the trust, with all staff encouraged to focus on safe discharge. This is supported by quality improvement methodology in ‘rapid improvement weeks’ which encourage staff to identify solutions to issues such as streamlining patient flow and DTOCs. At a recent event, staff identified that discharges were being slowed because busy ward sisters had to fill out documentation. Two wards piloted using junior staff to assist with discharge processes – this resulted in more timely discharges, and these roles have now been extended to all the adult wards.

Wrap around support – Intermediate care and reablement

As part of discharge to assess (D2A) arrangements, partners have worked to ensure a varied, flexible range of step-down arrangements.

Multi-agency support in the community is provided by Airedale and Craven Collaborative Care Team (CCT), commissioned by AWC CCG; this is a peripatetic team providing wrap-around support and assessment to prevent unnecessary hospital admission and to facilitate early discharge. It includes a range of nurses, therapists, mental health professionals, and support workers, linking with social workers, who support people both in their own homes and care homes.

Bradford Council runs Bradford Enablement Support Team (BEST) which provides intermediate care – short term support provided on a 24-hour basis for up to six weeks to help people regain/remain independent in their homes. BEST-Plus works with individuals to achieve enablement goals set and monitored by therapists.

Choice of intermediate care beds has been an ongoing problem in AWC with its large rural are – there may be an available bed but not in a place convenient to individuals and families.  Partners have worked together to increase intermediate care provision. Bradford Council operates several residential homes with 120 short term or intermediate care beds, of which 40 have been allocated for use by AWC. This includes a purpose-built intermediate care hub providing rehabilitation, assessment and respite care, supported by a GP surgery in an attached building, district nurses, physiotherapists and occupational therapists. There are also plans for a new development for extra care housing and a care home providing reablement for people with dementia which will serve Bradford and AWC.

Over the winter, measures have been taken to commission nursing home beds to provide additional short-term, step-down support, with rehabilitation provided through the CCT. Problems with staffing levels and high levels of need have meant additional discharge beds have been opened in the hospital. Outcomes for individuals are monitored, and most people return to their original place of residence. However, it is recognised that this is only a short-term solution within the D2A approach of ‘home first’.

Home care market shaping

The availability of home care has been particularly problematic in AWC, due to factors such as rurality, difficult transport, and workforce shortages. An ageing population, and high levels of need mean that home care can involve multiple-daily visits and double-staff attendance. The council has reviewed the state of the home care market, and has been working to increase provision, including using the social care precept to increase the level of fees paid. Since home care is a major factor in helping people to live safely at home, partners across Bradford District and Craven agreed that 50 per cent of the iBCF should be invested to stimulate and financially sustain the local market and develop new models to diversify the offer to local people. This includes:

  • a new approach to supporting people with late-stage dementia and their carers
  • a model of home care in hospital where care and support follows the person to enable timely and effective discharge
  • expanding out of hours support for people with complex needs
  • expanding capacity for rapid crisis response.

It has also been agreed that the BEST team will provide personal care, in partnership with the community nursing service, to people who want to be supported to die at home.

Avoiding unnecessary admission

AWC have established a number of measures to avoid unnecessary hospital admission, all of which will be developed further as part of the ICP.

  • An enhanced primary care scheme focuses on proactive care and has three main elements – frailty, ‘Physio First’ and social prescribing – to deliver better access and an alternative to GP appointments.
  • Wrap around care is provided in the community through an integrated service incorporating community nursing, therapies and intermediate care both virtual (in people’s own homes) and in community beds. This provides seven-day support focused on prevention, health promotion and retaining independence. The service is aimed at people with complex or intensive needs, including those at the end of life. The service includes community nursing, case management in health and social care and access to community matrons for clinical nursing assessments.
  • The Quality Improvement in Care Homes scheme in Craven and Wharfedale targets homes with the highest A&E call outs with proactive GP visits and an education programme for care home staff.

Airedale and Partners also ran a vanguard programme for enhanced support to care homes through digital technology. Based in Airedale Hospital’s Digital Care Hub, the programme provided 24-hour clinical support to residents in 220 homes across Lancashire and Yorkshire, as well as virtual learning programmes for staff on topics such as reducing falls and ulcer care. Initial evaluations show the vanguard has had many positive results, including good patient satisfaction, and reductions in emergency department attendance, hospital admissions and ambulance call-outs. The latest evaluation of the vanguard is due in 2018.

Ongoing scrutiny and reality checking

Partners in Bradford and Districts regularly come together to evaluate performance in DTOCs and resilience planning. The multi-agency event, Operation Frozen, considered a number of different winter scenarios and allowed participants to take on the perspective of another organisation. It became clear from the event that social care was well included in discharge arrangements, but more needed to be done to include the mental health provider.

Each year, winter planning is reviewed across the system in order to understand the drivers of demand, identify opportunities for improvement, and build on elements that worked well. Key recommendations from last year’s review informed this year’s plan. These include:

  • More focus on supporting people to stay well and avoid ill health, such as maximising the uptake of flu vaccine by eligible people and staff.
  • Exploring the role of the voluntary and community sector (VCS) in supporting admission avoidance (see below).

This year, Public Health formulated a logic model for the Winter Plan which is being used to evaluate how the system managed last winter.

Integrated care partnership

‘Happy, healthy at home’ is Bradford District and Craven’s strategic plan for integrating health and care. It stems from West Yorkshire and Harrogate Sustainability and Transformation Plan and sets out a vision for shifting the system towards prevention, and reducing reliance on acute and long-term services. It reflects other local plans including ‘Home First’, the strategic plan for the Council’s Department of Health and Wellbeing, which is based on the view that being home with family and friends is the best place to feel happy, healthy and in control of life.

‘Happy, healthy at home’ will be implemented by the two ICPs in Bradford District and Craven. The vision for Airedale, Wharfedale and Craven’s ICP is ‘3 communities 1 system.  In essence there will be one overarching integrated health and care system, but this will be implemented differently in the three communities to meet specific needs.

Partners in each of the three communities are working together on local priorities to create real movement within the communities, building on work already implemented in AWC’s transformation programme. For example, among other priorities, Airedale is looking to develop a 24/7 health and wellbeing hub, Craven is seeking to tackle social isolation/rural deprivation and poor access, and Wharfedale is looking at asset-based developments in the VCS, and social prescribing.

An Accountable Care Programme Board, with membership of senior leaders across the system, is responsible for driving the integrated system. A Provider Alliance has also been set up to help develop the ICP, which will be based on collaboration, rather than competition, between providers.

The ICP may take the form of a primary care home model in which staff from primary care, community services, social care, mental health, acute trusts and the VCS work together. It will also have a strong emphasis on mobilising community assets and resilience, and promoting health and wellbeing. Bradford Council public health is highly involved in supporting the development of the ICP.

Commissioners are looking to identify a budget and set outcomes for services currently provided through around 200 contracts, as well as developing a partnership framework and a provider memorandum of understanding. The outcomes will reflect the latest good practice, such as an increase in technological solutions and improving access to services. Examples of the types of approach that could be included are a VCS presence in the hospital’s Emergency Department to divert people with mental health problems into community options, and a ‘social care shop front’ being tested in Airedale, which could inform a single access point approach. In relation to DTOCs, the ICP is seen as a positive way of sustaining low levels, while supporting people to live independently at home, in the face of rising demand.

Next steps

Implementing the ICP while maintaining good performance and quality in existing services will be extremely challenging, but partners are very positive about the potential of the new arrangements for driving bottom-up priorities and solutions, describing this as ‘a movement for change’.

The developmental work for the ICP is having a very positive impact on relationships, and on working practices. Partners report a ‘paradigm shift’ in how they approach working together, and that things have ‘started to gel’ in the last few months. Relationships are said to have matured, with partners able to raise difficult issues with each other. People also feel more ‘supported’ and there is confidence that their colleagues will do all they can to help solve problems. As well as better relationships, partners say there is far greater appreciation of the pressures each partner is working under and an acceptance that these should be addressed by the whole system.

The Provider Alliance has also led to a better understanding of what happens in their community; for example, GPs are becoming more aware of the roles of housing, benefits advice and other social factors in supporting good health. Joint work has resulted in more cooperation across organisational borders, such as nurses in primary care and community services filling in at the hospital at times of pressure. The Provider Alliance has also been a forum for organisations to learn about and challenge working practices that may have a ‘paternalistic’ attitude – overly focused in maintaining safety rather than promoting independence. All these issues will be tackled and developed in the months to come.


Sue Pitkethly, Director of Accountable Care Airedale, Airedale, Wharfedale and Craven CCG

Stacey Hunter, Chief Operating Officer, Airedale NHS Foundation Trust

Lyn Sowray, Deputy Director, Department of Health and Wellbeing, Bradford Council

Summary of BCF and iBCF activity

Bradford District

Virtual ward; Early supported discharge; Re-ablement services; Airedale and Craven Collaborative Care; Intermediate care beds; Community equipment; Disabled Facilities Grant; Carers support; Maintaining social services; Care Act new duties; BACES – Home First; Winter pressure beds; Intermediate care reviewing team; Transformation and assistive technologies; Increased home care capacity; Protecting social care services.

Craven (specific schemes for Craven in the North Yorkshire Better Care Fund)

Quality improvement in care homes; Specialist community nursing team; Assistive technology in care homes and in individuals’ own home; Additional capacity for Craven Collaborative Care Team.

Documents and links

Happy, healthy at home

Home first

CCG strategies

Airedale NHS Foundation Trust Digital Care Hub evaluation reports

Bradford District Health and Wellbeing Board, Integration and Better Care Fund Narrative Plan 2017-19