Leeds Health and Care Partnership is made up of health and care organisations from across Leeds and is part of the wider West Yorkshire integrated care system (ICS). The partnership currently covers a population of around 800,000 people. Leeds has a diverse and growing population with wide health inequalities and challenges around economic inactivity and deprivation in parts of the city.

Addressing challenges with patient flow in Leeds

Significant operational pressure across the health and care system has encouraged leaders to consider how they can address challenges around patient flow. Over the past 18 months, Leeds Health and Care Partnership has been carrying out a review into why people present at hospital, why they stay for long periods, and the costs associated with delivering long term care in the community.

Although lots of work was already underway across the partnership to improve system flow, the programme formally commenced in March 2022 with a desktop review of intermediate care services in Leeds. The review concluded with a clear definition of intermediate care services in Leeds, and a set of collective problem statements the partnership needed to resolve. To take forward the work, the partnership agreed to secure the support of an external partner to undertake a more detailed diagnosis of the issues in intermediate care services. This diagnostic process undertaken in autumn 2022 helped the partnership to identify and quantify opportunities for improvement and transformation, and created a shared view of the current position.

The role of intermediate care in supporting patient flow

The findings of this review highlighted a range of opportunities across intermediate care services in Leeds. Over winter 2022/23, the partnership decided to focus on short-term interventions which would benefit patients and staff immediately. This included providing targeted support to discharge people from community care beds to reduce length of stay, reviewing the trusted assessor model and developing a 'system visibility tool' to create a live dashboard for system partners to understand patient flow across Leeds.

The tool includes data feeds from the hospital, community care beds, neighbourhood teams, reablement, and adult social care services. It has created a 'single version of the truth' for Leeds Health and Care Partners and allowed the impact of improvement projects to be tracked and understood in real time. Developing this shared dataset was a complex piece of work given the issues around data quality and information governance, but has brought a number of benefits, including by providing system partners with a clear, shared view of the challenges with patient flow across Leeds.

Key enablers

The system visibility tool, which allows cross-organisational access to a single dataset, is an enabler to more integrated working across system partners and allows for better distribution of resources to support patient flow.

The chief executive of Leeds Teaching Hospitals NHS Trust, Professor Phil Wood, is the senior responsible officer for the Home First programme on behalf of the Leeds Health and Care Partnership. A programme board of senior leaders provides oversight and support. This level of engagement from senior leaders across the partnership, is very beneficial in supporting the Home First programme to land in a positive way across the partnership and ensuring organisational engagement.

Engagement of staff from across intermediate care services in designing, testing and delivering solutions is also key.

Key barriers

Information governance was a key barrier in developing a 'system visibility' tool. This is now in operation but was delayed due to the complexities of sharing data across organisations. Leeds Health and Care Partnership has highlighted the scale of the challenge to national policy makers and is clear that achieving national community targets, such as ensuring patients have access to intermediate care within 24-hours of being discharged from hospital, will be reliant on system partners being able to share data in real time.

Benefits for staff, patients and system flow

Leeds Health and Care Partnership have already seen tangible benefits from their work on intermediate care, particularly through their Active Recovery offer.

Active Recovery was launched in October 2022 and brings together Leeds City Council's SkILs Reablement team and Leeds Community Healthcare NHS Trust's neighbourhood teams to support people at home through rehabilitation and reablement services. Delivering these services through a dedicated team aims to reduce dependency on long term services and keep people well in the community for longer, delaying possible admission into long term care. It can also help improve access to short term community rehabilitation at home.

Through several different interventions, the acute trust saw reduced numbers of delayed discharges over winter 2022/23, with more people receiving ongoing care in their own homes. The partnership saw an increase in the number of people discharged in under 27 days from 21%-38% in the pilot community care bed site. No reason to reside numbers in Leeds Teaching Hospitals NHS Trust have reduced and queue across pathways 1 to 3 have either stabilised, or reduced – counter to the national picture, or where Leeds was a year previous.

The opportunities presented by investing time and resource in transforming intermediate care are clear in Leeds, and there is hope that as the programme continues to develop, the evidence for change will become even stronger.

Looking to the future

Having delivered key short-term measures to support patient flow last winter, Leeds Health and Care Partnership are now delivering the more transformational work for the future. As part of this, the partnership is changing the model of intermediate care in the area to include step-up and step-down care, with a clear focus on admission avoidance. They see this as being an 18-month programme of work with the aim of redesigning intermediate care services.

The programme of work will be broken down into a number of key initiatives, one being Active Recovery at Home. Other areas of work will focus on: 

  • enhanced care at home
  • transfers of care
  • rehab and recovery beds  
  • system visibility and active leadership.