Supporting hospital discharge: Discharge to Assess part 2

So a while ago, I said I would do another post on the Discharge to Assess operating model, focussing on the detail, after my last post looked at the broad principles. It has taken me some time to do for a few reasons. Firstly, because I am expecting revised guidance as the emergency covid funding ceases and I’ve been trying to wait for that. Secondly, because ‘detail’ might be an over-estimation for what is a very ‘broad brush’ document.

That being said, let’s start.

Discharge to Assess is a great idea, getting people out of hospital and back home as quickly as possible. It allows for more accurate assessments too, when people are (hopefully) in environments where they are settled and comfortable.

It sets out 4 pathways numbered 0-3 based on ongoing needs. Pathway 0 is for those who can be discharged without any need for support (beyond follow up outpatient appointments for dressing changes etc). Those people are to be discharged in a matter of hours under the operating model. Most of the time this is a perfectly sensible approach, and as long as the people deciding what pathway a person should be on are obtaining all the relevant information at the time then this should be entirely appropriate.

The potential difficulty comes if pressure to free up beds impacts on the time taken to make that decision. There are rare but real cases where pride or confusion can lead someone to mask the difficulties at home resulting in them being discharged to an untenable situation. Most professionals are good at spotting that though.

When I think about this, I am reminded of a lady who was on the orthopedic ward with me in hospital a number of years ago. She was adamant she would be absolutely fine at home and could be discharged right away without weight bearing on her affected leg. She said this confidently, and I’d have believed her. But during the course of the conversation the occupational therapist was able to discern that this lady lived alone, with a small dog that liked to run around her feet and there were multiple steps into and out of her house. I’ve no idea what happened to my ward mate, because I went home before she did.

So pathway 0 can, and I believe does, work effectively in most cases.

Pathway 1 is where it can get a bit more complicated. This is for people with some ongoing need for social or health care services, but that can be delivered at home. These people are to be discharged once those arrangements have been made. But those arrangements are made quickly. Very quickly. So there isn’t always a lot of scrutiny given to a) what support is needed, and b) whether that is health or social care support (or both). In my area, this has led to under and over provision of services. It has also resulted in very limited information being given to customers, who have often been given an unrealistic expectation of what their support will look like in the longer term. It’s also led to information not been given about the fact that assessments will be conducted in the community, and the potential for services to be charged for after the first 6 weeks/after assessments are completed.

And this is one of the places where I found the operating model to be a bit unhelpful, because it doesn’t really set out what information should be given to customers and by whom. So healthcare co-ordinators will often see this as outside of their role, which was to facilitate discharge, but social care professionals aren’t getting involved until a later stage. Now you would think that would be an easy enough thing to resolve with an agreed information leaflet or similar. But that’s not something that many local authorities and CCGs have as a high priority piece of work just now. Some fallout can, therefore, result.

Pathway 2 is for those who require short-term support in a 24 hour setting, and pathway 3 is for those who will need this support in the long-term. In my locality, finding available beds for both of these pathways has been difficult. There is a limited market, and covid precautions have made new admissions… complicated.

Another area there is a lack of clarity on is precisely how organisations are to ‘co-operate’ when implementing the guidance. Without clearly defined roles, there is scope for a lot of to-ing and fro-ing because demand on all parties is so high. And I mentioned in my last post on this topic the difficulty of agreeing arrangements and don’t even get me started on the local authority role in terms of ‘commissioning’ without giving thought to the power to do that, which I wrote about last time and will continue to wind me up.

Roles are referred to, such as ‘case manager’, ‘joint coordinator’ and ‘single point of access’ but responsibility isn’t given to any particular organisation. Whilst allowing flexibility has its advantages, it can also lead to disagreements between organisations, and thus, delays. But maybe I’m just being a cynic.

The same can be said of the funding arrangements. Whilst the guidance sets out an approach, it is a suggested approach only and local arrangements can be agreed that differ. I am not aware of many authorities where different general approaches have been agreed. But I am aware of local variations to timescales, notifications being given etc. The CCG would usually fund until assessments have been completed, but in many areas staff have varying understanding of what an assessment is, and what the reasonable timescales for other organisations to carry out their functions and implement longer-term arrangements might be.

What the guidance says, very clearly is that the Mental Capacity Act 2005 continues to apply. The short timescales given do not preclude capacity and best interests assessments being undertaken, but I do think it is a lot to expect from staff with an awful lot on their plates. Anecdotally, I am told that a lot of the assessments under the MCA taking place in these circumstances are, well, less than robust.

Expecting a lot is something of a theme in the guidance though. What jumped out at me is that ward staff are expected to have continuing contact with patients, when needed. Now it is a few years since I spent any time on a hospital ward. But at that point staff were so busy I was waiting 30 minutes for support to get to the loo, so I doubt that many ward staff members have time to answer questions from discharged patients on top of everything else. But hopefully staffing arrangements have improved since then.

The same goes with community services. Occupational therapy and physiotherapy are expected to be available 7 days a week. Providers of domiciliary support are expected to be able to react quickly to step in when needed. I can’t even imagine how difficult it must be to maintain staffing rotas in these circumstances. I wrote last time about the difficulty of accessing appropriate staff in the numbers required during the pandemic.

For what it is worth, my view is that discharge to assess is here to stay, given the broad scope of the integration agenda. However, I am hoping that lessons will be learnt from the last year, and that when long-term arrangements are made, a lot of these issues will be dealt with in thorough and detailed joint working agreements.

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.