The Health and Adult Social Care Scrutiny Commission met to discuss hospital discharge and reablement, and to receive an update on the Barnsley Street Neighbourhood Mental Health Centre pilot. The commission was also scheduled to review and confirm their work programme for the next meeting.

Close to Home - Part 2: Hospital Discharge and Reablement

The commission was scheduled to continue its 'Close to Home' series, focusing on how the local system supports residents after hospital discharge, including access to reablement¹ and post-hospital care. The report pack included submissions from:

• Newham Hospital (Barts Health NHS Trust)
• East London Foundation Trust (ELFT)
• London Borough of Newham Adults and Health Directorate
• NHS North East London Integrated Care Board (ICB)
• Healthwatch Newham
• Age UK East London
• One Newham & Sustainable Newham

The submissions covered integration between services, current system pressures, inequalities in access or outcomes, and opportunities for improvement.

ELFT Community Health Services

East London NHS Foundation Trust (ELFT) Community Health Services (CHS) provides a range of services to local residents across Newham and Tower Hamlets. The core function has a strong emphasis on providing care closer to home, preventing admission to hospital through professional and clinical intervention and judgement.

ELFT's submission noted that while they are fully committed to person-centred care, it needs to be considered in the context of increasing patient caseloads and growing demand for community services, which has historically not been matched with equivalent funding of resources.

The Integrated Discharge Hub (IDH) was formed by ELFT in March 2000 to support optimal flow and maximum bed capacity at the Newham General Hospital.

A number of posts are non-recurrently funded raising sustainability concerns and the commissioning constraint limits community stepdown impacting discharge flow from hospital and long term recovery planning.

ELFT is implementing a consistent outcomes framework across all community teams using the following tools:

• Rockwood Clinical Frailty Scale (CFS): to assess frailty level and progression over time.
• EQ-5D-L: to capture health-related quality of life and functional recovery.

ELFT noted that population-level data relating to age, disability, ethnicity, and housing status is not systematically captured within their outcome tools, which means inequalities are not yet routinely measured or reported.

Feedback, Datix/Inphase reports, and staff experience suggest that certain groups are less likely to engage fully with discharge or follow-up care. These groups include:

• People with dementia or cognitive impairment
• Individuals who are socially isolated or have insecure housing
• Working-age adults with long-term conditions
• Some ethnic minority communities

London Borough of Newham Adults & Health Directorate

The London Borough of Newham Adults & Health Directorate provided a presentation covering ASCOF data on discharge, the statutory framework for hospital discharge, local arrangements, discharge pathways, short term investments, deconditioning prevention, barriers to integration and service delivery, getting people home, what reablement is, a case study, improvements to reablement, benefits of increased referrals, long term increase in reablement for residents, long term packages of care, bedded intermediate care/pathway 2, care homes and pathway 2, and ongoing challenges and opportunities.

The presentation noted that Newham operates the NHS's Discharge to Assess (D2A) model, which determines the right support for patients leaving the hospital.

The presentation also noted that hospital deconditioning can lead to a loss of up to 10% of muscle strength in just one week due to inactivity.

The presentation stated that partners have differing local priorities and pressures, and that each organisation will have different information technology systems that either do not communicate with each other or information governance issues occur.

The presentation included a case study of DY, a 78-year-old lady who lives with her husband in their council property. DY was admitted to hospital following a fall, and was discharged home with a package of Care of 31½ hours per week, four calls per day, and a referral was made to the reablement service.

The presentation stated that over the last few years reablement pathways and the service itself has been redesigned and delivered significant improvements.

The presentation stated that there are five main Adult Social Care options to support people home:

1. To ensure the person is safe at home, where necessary, the Age UK Home & Settle support service is available to ensure the person is settled at home and that basic amenities are in place
2. Home Care providers are communicated direct from the hospital to ensure care starts as soon as people get home.
3. Within a week the Reablement and assessment service based in Adult Social Care will visit the person at home and again assess needs at home and look to reable the person where possible
4. Equipment is provided that allows people to return home. In Newham this is provided through Enabled Living
5. Sometimes people home require adaptations or specialist cleaning services to allow them to return home

The presentation stated that there will always be a need for intermediate care beds, and that there are c50 people in Temporary P2 beds at any one time.

The presentation included an audit of LBN commissioned P2 beds, which found that the needs of people coming out of the hospital were diverse, and that where there was purposeful therapeutic input, residents were able to return home.

The presentation included a discussion of Fothergill Ward, stating that the audit found that 37% of residents could have returned home if optimal community resource were available.

Newham Hospital

Newham Hospital's submission noted that repeat admissions are concentrated in older people and those with frailty/multimorbidity, but a large and important share also comes from younger adults with specific long-term conditions, people with mental-health or alcohol/drug problems, and from socially disadvantaged groups.

The submission stated that the hospital regularly runs at 98-100% bed occupancy, of which around 10-15% of these patients are deemed 'medically optimised' i.e. medically fit to be discharged, but awaiting for nursing and care home placements, or specialist adaptations/equipment needed in their homes.

The Newham Integrated Discharge Hub (IDH) is a good example of where the hospital already supports the discharge of patients from hospital to home or community care, thanks to an integrated and coordinated discharge process.

The submission noted that there are opportunities to improve post discharge support in Newham particularly focusing on community service provision and better integration of services like re-ablement.

The submission stated that Early Supported Discharge (ESD) services play an important role in helping patients return home sooner, but current provision is not yet fully developed to meet the needs of some more complex patients who currently require fixed-term inpatient care.

The submission included the hospital's perspective on the recent Fothergill Ward audit, noting some limitations, namely, that the scope only covered those patients currently in inpatient beds and admitted under their previous criteria.

NHS North East London

The NHS North East London submission stated that given the nature of reporting all submissions of community services data is provider-based, not at an ICB level, which therefore doesn't allow comparison between Newham and other boroughs.

The submission outlined some of the key areas that support residents to leave hospital safely, access reablement and reduce the risk of unplanned readmissions, including neighbourhood priorities, people with complex needs, community services end of life service improvement and in-reach to care homes, and enabled living equipment mutual aid work across North East London.

Age UK East London

Age UK East London's submission stated that for over ten years their Home and Settle (H&S) and handyperson service has supported Newham University Hospital's (NUH) discharge process and reduced the need for Newham Adult Social Care (ASC) support.

The submission stated that their team find it easier to be trusted, and build trust, than statutory colleagues, and that they are flexible and connected.

The submission noted opportunities not being utilised, including better strategic involvement, service expansion, emergency department presence, developing ward relationships, and economies of scale.

The submission noted difficulties and challenges in patient experience, including referral awareness, patient updates and next steps, and the use of blocked numbers.

Healthwatch

The Healthwatch submission stated that following the 2022 Healthwatch Newham Hospital Discharge Project, the Scrutiny Commission requested ongoing monitoring of patient experience around hospital discharge and reablement pathways at Newham University Hospital (NUH).

The submission included a summary of evidence, including 2022 findings, and 2023 – 2025 observations.

The submission stated that improvements have been observed in discharge communication, family and carer inclusion, and structural links between hospital and community have strengthened.

The submission stated that continuing challenges include pharmacy delays and transport waits remain common, some patients still feel unprepared or unclear about aftercare, reablement referrals are inconsistent, and there is no systematic capture of discharge-specific feedback.

The submission recommended introducing discharge-specific feedback mechanisms, expanding qualitative monitoring with VCSE partners, addressing persistent operational delays in pharmacy and transport, strengthening reablement linkage to community services, and sustaining carer engagement and communication initiatives.

One Newham & Sustainable Newham

One Newham & Sustainable Newham's submission stated that VCFS organisations in Newham play a vital role in supporting residents through hospital discharge and reablement.

The submission stated that VCFS organisations offer trust and cultural competence, flexibility and responsiveness, and holistic support.

The submission noted opportunities for expansion, including formal inclusion of VCFS representatives in discharge planning teams, commissioning VCFS-led reablement programmes tailored to specific communities, and investment in digital tools to enable better data sharing and referral pathways between hospitals and community groups.

The submission stated that VCFS organisations have identified several recurring issues, including delayed or poorly coordinated discharges, lack of follow-up, barriers to accessing reablement, and unplanned readmissions.

Barnsley Street Neighbourhood Mental Health Centre - Pilot Update

The commission was scheduled to receive an update on the Barnsley Street 24/7 Mental Health Pilot, to support wider consideration of community-based mental health provision and potential future delivery models in Newham.

The report pack included a report from Bailey Mitchell, Newham Borough Director ELFT, and Michael Jones, Joint Head of Strategic Planning & Programmes, and a report on the HASC Tower Hamlets Community Mental Health Pilot Site Visit.

The report from Bailey Mitchell and Michael Jones stated that the Barnsley Street Neighbourhood Mental Health Centre held a launch event on Thursday 17 July 2025, and that the Tower Hamlets service was the first out of the six pilots across England to open.

The report stated that the Centre is available for local residents registered at any of the following five GP practices: Bethnal Green Health Centre, The Mission Practice, Sutton's Wharf Health Centre, Strouts Place Medical Centre, XX Place Health Centre, and that the service partners with a number of local Voluntary, Community and Faith Sector organisations in direct delivery of care and to support outreach and engagement with the local community.

The report stated that the national pilot funding for the Tower Hamlets service ends on the 31/03/2026, and that at the time of writing there was no information from NHS England as to whether further expressions of interests to apply for funding will be available for others areas to bid for, including Newham.

The report stated that Newham is developing plans to align our current Community mental health services (CMHTs) along the agreed Newham system Neighbourhood lines (North East, North West, South East and South West).

The report on the HASC Tower Hamlets Community Mental Health Pilot Site Visit stated that the visit provided Members with an opportunity to observe the model in operation and hear directly from staff and partners, as part of wider scrutiny of community-based mental health approaches.

The report stated that the pilot in Tower Hamlets is one of 6 English pilots offering different interpretations of the 'Trieste' model of walk-in community mental health facilities which are believed to have greatly reduced the need for acute beds within that region of Italy.

The report stated that the facility is open access to patients registered with the one primary care network covered by the pilot, and that although GPs can refer instantly, those seeking support can equally walk in off the street.

The report stated that the site has replaced the pre-existing Community Mental Health support for the Primary Care Network (PCN) and presents as an alternative to hospitalisation with 6 beds available.

The report stated that the site's colours have been chosen to look like a community space rather than a medical setting and deliberately offer amenities usually absent from facilities used by those in mental health crisis owing to perceived risk.

The report stated that the pilot is overseen by the Tower Hamlets Mental Health Partnership Board which comprises various key community stakeholders and is essential to trust-building and partnership working.

The report stated that performance impact to date includes a 23% reduction in length of stay compared to acute wards, and new admissions reduced by about 45% in the pilot PCN (Jan–Sept year-on-year).

The report stated that key takeaways and reflections from staff include that the support is not restricted to those who are actively in crisis, and that the Pilot has been co-produced from the outset of working on the NHS bid.

The report stated that challenges and risks include that short-term pilot funding currently runs to April, and that workforce stability is difficult given current short-term nature of pilot.

The report included lessons for Newham to consider, including to start small (one PCN or neighbourhood) to learn and iterate before scaling, to put third sector in true partnership across governance and budgets from day one, and to fund and protect a small number of short-stay community beds to avoid admissions to wards where community option would be better suited.

Work Programme

The commission was scheduled to review and confirm the work programme for the next meeting. The report pack included the Health and Adult Social Care Scrutiny Commission Work Plan 2025-2026.