This should really have been the first in my hospital discharge series, this being the most far-reaching of the policies I have explored. But its taken me a while to order my thoughts on this, and I’ve ended up breaking this into two posts. In this one, I’m going to talk ‘broad brush’ principles and in part 2 we’ll drill down into some detail.
If you haven’t already seen it, the current push for Discharge to Assess comes from the government’s guidance here.
I will begin by saying that discharge to assess, as a principle makes a lot of sense to me. No one is at their best after any stay in hospital. I have had the misfortune of twice having to spend 3 to 5 days in hospital and a combination of lack of sleep, heat and unappetising food had me almost unrecognisable.
And we all know the system is over-stretched. So being able to discharge individuals from hospital without waiting for a social care assessment seems desirable.
After all, greater integration is very much on the policy agenda at the moment. A shared pot of money would certainly seem to stop some of the disputes that health and social care professionals get involved in.
The biggest issue I have with the policy guidance, as a principle is that it is policy guidance. It’s not even statutory guidance.
For me, that creates something of a headache, because the guidance says what we should be doing, but has very little about how that can be done within existing powers, duties and legal frameworks. As I have said before, local authorities can only do what statute gives them the power to do. They are also specifically prohibited for providing health services that should be provided under the National Health Service Act 2006.
And the separation of legal powers and duties does not have to be an issue. There are legal mechanisms by which both organisations can work together, with delegations of powers to each other to enable a an appearingly seamless system.
But those mechanisms take time to put in place. Each organisation will need assurance that its powers will be used appropriately, that funds will be duly approportioned and that legal protections will be afforded. And that takes time to implement even when there isn’t a national emergency.
Now in many areas there will be existing arrangements for co-operation. I very much doubt any of those arrangements will have been designed to cover this precise scenario, but it’s likely that some could be adapted to suit these purposes. And adapting existing arrangements is often (but not always) an easier and simpler process than starting from scratch.
But if adaptable arrangements are not already in place, then they are very unlikely to be created during the middle of a pandemic when no one really has time to set their minds to irritating things like paperwork.
Which puts both organisations in a difficult position. The NHS, at least, has broad powers but social care powers are more limited. And if the local authority is carrying out any social care services, it needs to be sure it is acting within the frameworks set out in the Care Act 2014. But since the whole point of discharge to assess is to delay detailed assessment until after they have been discharged, section 18 powers aren’t being used.
That means that any support the local authority is relying on either its prevention powers, or its powers to meet urgent needs pending assessment under section 19. These are of limited scope, and are, frankly, difficult to justify prioritising when more forceful duties under the Care Act also require resourcing.
So many local authorities are having difficulty trying to work out how to implement this guidance, which could have been removed with more thought through guidance, or appropriate provision within the Coronavirus Act 2020.
The other issue that can come up where frameworks aren’t clear, is that if can lead to disagreements about who is responsible for what within a process. These things are rarely well resolved in an emergency, and often important things like patient involvement and the Mental Capacity Act 2005 can get lost in the mix. They shouldn’t. These things are vital to the whole process.
The final issue of principle that continues to present to me, is whether this deals with the fundamental issue of the limited market for care and support services that is an important factor in the delays of discharges in the first place. There are, after all, a finite number of health and care providers, and a finite workforce. It is possible that in some cases there will be ‘hospital at home’ type services available that can pick up cases under Discharge to Assess, where they wouldn’t under other models of operation. But I am unconvinced that this applies in a sufficient number of cases to make this worthwhile, without further support for the system.
Certainly, what I am finding is that Discharge to Assess is being supported by moving staff away from other services. And I am not sure that this was really thought about when the policy was produced.
That being said, we’ll look at some of the detail next time.
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