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The legislation that made it mandatory for hospitals to notify local authorities that someone is ready to be discharged came in to place in 2003; I remember it well as I was working in King’s College Hospital in London in my first NHS job, and the arrangements we now know intimately as delayed transfer of care reporting were created. The concept of organisations giving each other notice and time to plan for a good discharge was sound, but what has materialised has in too many cases led to conflict rather than collaboration in organising care and support for the individual to be ready at the right time.
Since 2003 more complexity has been added, including the introduction of a 3.5% maximum target for delays and specific focus on patients whose length of stay are over 21 days. While all of these policies have the right focus, they have created a cluttered and confusing space for professionals to operate within, and potentially made it harder to focus on getting the very best care and support for local residents following an acute hospital admission.
It has therefore been quite extraordinary to see the seismic changes that have happened during the COVID-19 pandemic, underpinned by the Hospital discharge service requirements publication. Professionals and leaders have described the approach as “liberating; a game changer; the right push to make things happen; good common sense!”. The largest impact of the changes appears to be on two fronts. Firstly, on those patients whose discharge has routinely been challenging to organise and their length of stay in acute care being over 21 days. Secondly, on the strengthening of the relationships between health and social care organisations and leaders. The foundations of the discharge to assess model are trust, collaboration and flexibility, and provide the opportunity to benefit local residents as they have the time to recover/rehabilitate in their own home, before any decisions are made with them about their long-term health and social care needs.
While the pressure on hospitals from COVID-19 cases has decreased substantially from the peak, now is not the time to lose the progress we have made. The Hospital discharge service requirements guidance and covering letter were clear that the approach, and the NHS COVID-19 funding, would last until the end of the pandemic. Therefore, all systems should continue to use the discharge to assess model and the full approach described in the publication. We are working with government to ensure the arrangements for maintaining this ethos and approach continue; a written update to local systems to reiterate this approach will be published soon.
While there has been incredible support for operating in a different way, we also know that improvements need to be made. Successful acute units have fully implemented the daily medically-led review of all patients, ensuring that individuals who no longer need to reside in acute care are able leave the ward on the same day, with the right package of post-acute care in place. The recording of these decisions in the daily return has become part of their normal practice, yet many acute units have separated out the daily collection of data from the daily patient reviews and report the returns to be onerous. Social care colleagues in some systems remain concerned that the ‘home first’ approach and mentality is not being sustained and that rates of bedded care discharges (short term or permanently) are higher than they would like to see. All these points, and many more, are areas of improvement that the Emergency Care Improvement Support team will be working on with systems over the coming weeks and months as we mainstream and embed a discharge to assess model in every part of England.
Thank you to health and social care and to voluntary sector partners and volunteers for the herculean efforts that have been made over the past weeks to support a new way of working, maintaining a high quality and safe discharge service throughout the country. I am in awe of the work that has been done and the positive outcomes achieved for local residents. Please do continue to mature the local integrated arrangements for discharge, where assessments for long-term care always take place outside of hospital. We will be publishing the practical experiences and case studies from across England which will be useful to learn from and will allow you to adopt and adapt them with pride into your local systems. I encourage you to register with the Better Care Exchange for more support and resources.