Across the country, thousands of people are delayed every day in their discharge from hospital. For some of these people, this is the start of their journey towards using long-term bed-based care for the rest of their lives. Senior Research and Data Analyst for the Better Care Fund Support Programme, David Maguire, sets out in this blog the learning from supporting health and care systems to embed discharge to assess.
In the BCF Support Programme team, we’ve been providing support to health and care systems across the country, to diagnose their strengths and weaknesses locally around how they discharge people from hospital and provide intermediate care and identify the actions their staff recommend they take to improve.
The discharge to assess (D2A) support offer comprises of four modules: a review of recent cases by multi-disciplinary teams, a survey of the conditions for change with staff across the local system, facilitated interviews to hear the experience of people who were discharged through the system recently and an analytical exercise to see how data use can be improved locally.
So far we’ve supported six systems and have seen a number of similarities between them.
Overuse of bed-based intermediate and long-term care
Across all the places we’ve worked with, there was an over-reliance on bed-based care, with between 33 and 63 per cent of the cases in our case reviews receiving bed-based care where they should have had a home-based offer or no intermediate care.
In many of these cases, people were being moved into 'interim placement' intermediate care beds. These placements typically have no, or very limited, therapy input and are more likely to result in deconditioning among people over 65 years old than other forms of intermediate care.
Between 33 and 63 per cent of the cases in our case reviews were receiving bed-based care; where they should have had a home-based offer or no intermediate care.
The most common reasons people received bed-based care when they shouldn’t have was due to family or friends’ concerns, patient concerns or risk aversion in clinical decision-making.
Respondents to our Environment for Change survey in each area disagreed that D2A principles were being consistently applied locally and disagreed that their work was maximising independence for those receiving inpatient care.
In the areas we worked with, only between 24 per cent and 31 per cent of staff responded to the question “Is there a focus on maximising independence for all individuals during their hospital stay?” with “Strongly agree” or “Agree”.
No more than a third of staff agreed with the statement “Those going through the D2A process locally understand what is happening to them and the plan going forward.”
Communication between services and with people and their wider circle
This theme of communicating effectively with people and their wider circle, as well as between organisations was one that came through in each area we worked with. This was leading to confusion about which services were being offered in different parts of each place, as well as delays in communication leading to delays in discharge. In some places, a 'D2A bed' was any bed that allowed the person to move on from hospital, even if it was inappropriate for their needs.
A common theme in the places we worked with was that when staff were unclear on what intermediate offers were available locally, they were more likely to recommend bedded care, even where that might not have been the best option for that person.
A breakdown of multi-disciplinary working
One of the main causes of both of these issues was a loss of integrated working across health and social care services. Participants often talked about how the integrated team working they had done previous to the pandemic had been lost in the move to remote working at the onset of social distancing.
Social workers can be a key part of multi-disciplinary teams in advocating for someone’s potential for independence. They are also brokers in often complex care markets, helping ensure value for money and optimising placements for people in intermediate care. Without their skills in negotiation, therapy and having difficult conversations with people and their wider circle, health staff are left to pick up these responsibilities in the places we’ve worked with, while they balance their normal roles.
This results in more of a short-term focus, with health staff thinking about the person’s next step, rather than their long-term future. In our case reviews, participants recognised an underlying perspective of “the council will pick them up later”, in particular when people were discharged into interim placements. Because there was no social care input into these decisions, the council weren’t able to assess or support the person until after discharge, invalidating the “Home First” principle.
A lack of high-quality data to support commissioning
In each of the places we worked with, there were significant gaps in systems’ ability to draw together useful information on discharge performance, outcomes and activity to support their strategic commissioning. Without the ability to reflect on the effectiveness of their services, senior leaders were less able to make informed decisions about what services they required or the quality of what they were providing.
This was usually the result of the analytical function in these areas, especially in the local government sector, being almost entirely dedicated to national reporting, with little time left over for data quality or quality improvement work. There were often cultural issues between organisations (linked to the trust issues described earlier) which prevented closer partnerships on data use. As a result of this D2A support offer, systems were more able to identify their greatest opportunities for improving discharge outcomes, and to take first steps in making these changes.
Many of the things we’ve explored here require significant investment or change to improve. We’ve already examined good practice in discharge in our High Impact Change Model on discharge from hospital.
If you’d like to speak to us about what we might be able to do to support integrated working in your area, please email the BCF Support Programme Team at [email protected].