Themes
- Strengthening community teams
- Working with external partners
- Tackling recruitment challenges
Background
East Lancashire Hospitals NHS Trust (ELHT) provides acute and community healthcare for people of East Lancashire and Blackburn with Darwen. ELHT also provides some general practice and primary care services to a segment of its population.
The trust covers a wide geographical patch with big variations in levels of deprivation. Employing 10,000 staff and treating over 700,000 patients a year, healthcare services are offered across five hospitals and various community sites. In July 2024, Blackburn with Darwen adult physical health community services, previously part of the mental health trust, completed a transfer across to ELHT to ensure equitable and more resilient provision for their communities.
The trust has experienced increased demand in A&E, with a 23% rise in attendances over the past 12 months. This has been driven by more presentations of people over 65 with increased frailty, as well as patients coming from local care homes or receiving palliative care. The trust borders Manchester, Preston and Yorkshire, and receives patients from each of these areas. The area has the lowest number of GPs per head across the system which has resulted in disparities in access to primary care, leading to further pressure on urgent and emergency services.
To manage demand and ensure all patients receive the care they need in the most appropriate setting, the trust, together with place partners, has developed an urgent and emergency care improvement plan centring around three pillars (East Lancashire Hospitals NHS Trust, 2024):
- Community response focused on step-up pathways and care home improvements.
- Crisis response and wrapping care around the individual.
- Improving care in hospitals and same day emergency care.
Some of the initiatives to bring these pillars to life are set out below. The trust's approach aligns with its overall commitment to providing preventative, proactive and holistic care for patients in their own home.
Taking a 'home first' approach
Over the last few years, the trust has been strengthening its community teams and focusing efforts on supporting patients in their own homes, easing pressure on urgent and emergency settings and ambulance conveyances.
The 'home first' approach is at the heart of a coordinated response to stop unnecessary admissions and support the earliest possible discharge of every patient, which focuses on ensuring everyone receives the right care and has the right to return to their own home post-discharge. Central to this is the Intensive Home Support Service (IHSS), which provides a 24/7, year-round service and is accessed through a direct phone line.
The IHSS team assesses the patient's individual needs to determine the care they require and agree a care plan. The IHSS also oversees the trust's urgent community response service and provides access to health and social care support to their communities within two hours across East Lancashire and Blackburn with Darwen. In total, the IHSS had 15,508 referrals across several workstreams in the last year. Since its inception the 'home first' service has had 18,488 successful discharges, with the number growing year on year.
In 2022, the IHSS initiated a 'front door' service in its emergency pathways which allows staff to identify patients who are well enough to receive care at home and avoid further waiting in the emergency department. Typical presentations include falls and breathing difficulties including shortness of breath. Interventions include advanced assessments, monitoring, support, and therapy, delivered through a multi-disciplinary team with access to a GP and hospital doctor. They can also commission crisis care packages via their intermediate care allocation team.
Between October 2022 and August 2024, the IHSS has assessed around 3,000 patients through the extended front door model. In that time, the team has prevented 816 confirmed admissions and discharged 2,291 (82%) patients. Compared to the rest of the trust, which has a readmission rate of 13%, this model has meant that only 6.3% of patients are readmitted within 28 days with the same presentation.
Also supporting the IHSS is 'hospital at home', the virtual ward service launched in September 2022, through which the trust has accepted over 23,000 referrals and allowed 90.6% of patients referred to the scheme to remain in their usual place of residence. ELHT has the highest capacity and highest utilisation rate of virtual wards among providers across Lancashire and South Cumbria.
Working with partners and building confidence
Developing strong relationships and gaining confidence from partner organisations has been crucial in making improvements in urgent and emergency care – including social care, mental health and voluntary, community and social enterprise (VCSE) organisations. The trust has an open-door policy which encompasses care home partners, who are encouraged to seek support through the IHSS. In addition, Age UK has worked in collaboration with the trust to provide a range of support services. This includes providing essential support with assisting patients returning home and settling in, particularly for those living alone or experiencing anxiety.
Overcoming challenges
Nevertheless, as with any new initiative, the IHSS service has faced challenges, primarily related to recruitment. Now the service is established and has gained a positive reputation, these have eased. In addition, specific strategies, such as running targeted recruitment events and offering conditional job offers on the day, have accelerated hiring processes.
While financial challenges for the service remain a concern, the trust continues to demonstrate the positive impacts on patients, staff, and the wider community and highlight the value of integrated services in easing demand elsewhere in the trust. Ken was supported at home by the IHSS after a stay in hospital. He said:
“You feel better just thinking you are going home. I had only been home two hours, and a nurse came round. It was brilliant, one to one support – that’s what I liked. You are in your own environment; you have your family around you and I always feel safer at home. Having the IV drip at home, I couldn’t fault it. You are being treated at home, the nurses know what they are doing, and they were superb. I’d recommend it to anyone. The IHSS is a brilliant idea. It stops people going into hospital and you get as good a treatment at home.”
Expansion and replication
The trust is hoping to build on the success of the IHSS service and its wider community offer to expand its work to move care upstream, alleviating pressure on emergency departments and urgent care – an approach it says could be replicated across the region. For example, the trust is currently collaborating with North West Ambulance Service NHS Trust to reduce unnecessary hospital admissions. Their new initiative ‘call before convey’ involves paramedics contacting the integrated community hub before transporting patients to the hospital, facilitating a more timely and appropriate response from the IHSS team. They are already seeing positive results, with fewer attendances among individuals over 65 and a decrease in overall hospital admissions.