Tensions around hospital discharge

Hospital discharge arrangements are often a cause for tension or dispute. This won’t be a surprise to anyone who has had to get involved in these cases.

And it’s understandable that this will occur, there are a lot of competing interests involved. For example, pressure on hospital beds are a big driver on NHS Trust decision-making. Generally speaking, once someone is fit for discharge, the NHS Trust wants the bed cleared ASAP. Local authorities would generally be supportive in this, partly because co-operation is paramount, and partly because they can be required to pay the NHS l if lack of social care is delaying discharge. But local authorities need to carry out assessments of need, and commission necessary support for that person. They need to consider choice of accommodation, and the person’s wishes. Support planning in accordance with the Care Act 2014 can be a lengthy and detailed process.

Sometimes the CCG will also be involved, if s117 aftercare is required, or if there is question about continuing healthcare. Arguments about whether the person should be assessed whilst in hospital or before hand are common. The CHC Framework encourages assessment after discharge whenever possible, but sometimes the local authority won’t have access to the type of placement that the person needs, and assessment will be required before discharge can’t be supported until a CHC decision has been made. Also, the local authority can’t be required to pay for delayed discharge until a CHC assessment has been conducted.

And all of that gets even more complicated if the person lacks capacity, and capacity and best interests assessments need to be carried out thoroughly and in compliance with the Mental Capacity Act 2005. The temptation for rushed assessments based on assumptions and without proper consideration to how the person could be supported to make that decision is high. That temptation should be resisted at all costs. The Mental Capacity Act 2005 is not something we follow only when it is convenient, it must be embedded in practice, so that the question of whether someone has the capacity to make the relevant decision is one the first questions asked, not the last.

Those often competing interests are just between the professionals, the person and their family will have their own views and their own motivations which can create further issues that need to be resolved before discharge.

In some cases, court involvement might be needed if, for example, the person refuses to leave hospital and so their licence needs to be terminated. Where the person lacks capacity and a dispute arises as to the discharge arrangements, a Court of Protection order might be needed.

Does that sound nice and straightforward?

Well it gets worse in the current circumstances. You will likely be aware of the hospital discharge guidance, but just in case you haven’t read it, it’s here:


This, for understandable reasons, tries to compress the timescale for discharge to a matter of hours. This is undoubtedly posing a challenge. It increases the already considerable pressure to get people out of hospital, and in doing so, increases the risk that assessments will be rushed, that capacity won’t be explored and that best interests consultation will be limited. That isn’t good news for anyone.

But I attended a webinar today, where we were discussing the conflict between the guidance, which says that individuals’ preferences shouldn’t delay discharge (i.e. they can’t wait in hospital to their preferred placement is ready to take them) and the Care and Support and Aftercare (Choice of Accommodation) Regulations 2014. And my initial reaction was concern, but on reflection, I think these 2 provisions can be rectified.

Because the choice of accommodation regulations never have required the local authority to make placements available, and there was never a blanket requirement to keep people in hospital or supported at home until the preferred placement was available. This was a decision to be taken on an individual basis, considering the views of the person, and the risks of remaining where they are. Choice of Accommodation only applies to available accommodation, and the national bed tracker should make it much easier to identify which beds are available in, and out of county, and so the local authority checking this, and enabling the patient to choose from what is available will be in compliance with the regulations and the guidance.

What a relief.

In case it isn’t obvious from the fact I still haven’t identified the authority I work for, the views expressed on this blog are my own opinion and not the opinion of that local authority

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