When it comes to discharge, timing is everything

Professor Martin J Vernon discusses the importance of NHS England’s Quick Guide: Discharge to Assess and benefits for older, vulnerable people.

I am really pleased to be writing about the publication of NHS England’s Quick Guide: Discharge to Assess which comes at a critical time for NHS hospitals. This new resource provides us with pragmatic approaches to reducing delays in hospital. This will lead to improved experiences for some of the most vulnerable people we care for.

Put simply, discharge to assess (D2A) is about funding and supporting people to leave hospital, when safe and appropriate to do so, and continuing their care and assessment out of hospital. They can then be assessed for their longer-term needs in the right place.

Why is it so important for us to get on with this now?

In May 2016 the National Audit office (NAO) reported its findings on discharging older patients from hospital. It reported nearly two thirds of hospital bed days being occupied by people over 65 with an 18% rise in emergency admission for older people in the last four years. The NAO also reported 1.75 million hospital bed days being lost due to delays in transfer of care in 2015, with an estimated 4.2 million bed days occupied by people no longer in need of acute hospital care.

The NAO described older people stranded in hospital when they no longer need to be there. It has been estimated that 10 days of bed rest for healthy older people can equate to 10 years of muscle ageing with attendant loss of function. This is something we really have to avoid.

There are many complex reasons why older people are delayed leaving hospital to continue their recovery. Not least it relates to the sheer numbers of older people requiring NHS acute care. The older population is expanding which will accelerate over the next twenty years. The number of people in the UK aged over 75 will rise by 90% to nearly 10 million over the next 25 years. The number of people aged 85 and above will more than double.

However increased longevity can come at the expense of living with multiple long-term conditions (LTCs). Half of older people have three or more LTCs making them the single largest group of NHS service users. This is because loss of physiological reserve as a result of multiple LTCs makes older people especially vulnerable to sudden decompensation after a stressor event such as an acute illness or injury.

We can now recognise this vulnerability as frailty, a condition, which for those affected places them at almost double the risk of needing hospital care or acquiring new disability. For those with severe frailty these risks more than quadruple. More than 1 in 10 people over 65 live with frailty in England today.

Time is everything to people with frailty. We need to find them before, or soon after, a crisis and look after them differently to give them the best chances of getting the best outcome after illness.

People with frailty do not bounce back quickly from illness or accidents. They need time and support in the right place to enable them to recover. The last thing a person with frailty needs is to be kept waiting unnecessarily in hospital for an assessment to get access to care and support.  And because of their vulnerability they need to be fully involved, wherever possible, in making the right choices to suit their individual circumstances and preferences.

Imagine leaving your home abruptly and never returning to it again…imagine being told that you are moving house tomorrow and you have no control over where you are moving to and how much it will cost. The quick guide aims to address these scenarios by supporting local health and social care systems to reduce the time people spend in hospital once their acute care has come to an end.

This means we have to be quick, slick and effective if we are to achieve the best results for everyone. To do this the guide rightly emphasises the importance of challenging current practice and changing mind-sets.

The good news is that there are many ways to address the problems that we face in working together to achieve a ‘complex adaptive system’. The guide sets this out for us and provides many links to connect us to successful systems around the country from which we can learn. Most importantly, simple evidence based rules, which everyone can understand and work to, are much more effective than rigid and inflexible criteria. It’s the person being cared for who matters most.

D2A works from the principle that, in the main, people should be supported to go home from hospital. D2A services are free at point of delivery, prompt, rapidly deployed and time limited normally to six weeks. The service should always try to say ‘yes’ and be inclusive, even if end of life is expected. People and their families are central to decisions about their care and D2A can only work if information is shared properly.

To get us started the guide urges us to keep it simple, start small and build the service up. Keep checking how it’s going, talk to each other, measure and celebrate your successes. If it’s working well, keep going! If something is not working as well as it might, take stock and adjust to get you back on track. This way you will build confidence in yourselves, the system you work in, and most importantly those who use it.

D2A is a cornerstone of modern care for older, vulnerable people. Be sure to check out everything the quick guide offers to help you improve your services.  Finally don’t forget to use the Better Care Exchange to share or discover more examples of best practice!

Martin Vernon

Professor Martin Vernon was appointed National Clinical Director for Older People and Person Centred Integrated Care at NHS England in 2016.

He qualified in 1988 in Manchester and following training in the North West he moved to East London to train in Geriatric Medicine where he also acquired an MA in Medical Ethics and Law from King’s College. He returned to Manchester in 1999 to take up post as Consultant Geriatrician building community geriatrics services in South Manchester.

Martin was Associate Medical Director for NHS Manchester in 2010 and more recently Clinical Champion for frail older people and integrated care In Greater Manchester. He has been the British Geriatrics Society Champion for End of Life Care for five years and was a standing member of the NICE Indicators Committee.

In 2015 Martin moved to Central Manchester where he is Consultant Geriatrician and Associate Head of Division for Medicine and Community Services. He also holds Honorary Academic Posts at Manchester and Salford Universities and was appointed as Visiting Professor at the University of Chester in 2016.

In 2017 he became Chair of the NHS England Hospital to Home Programme Board and is working on National Frailty Care with NHS Improvement.