By Dr Richard Newland
A very significant organisational challenge has recently been moved from the “good to have” to the “must do” list. Discharge to assess has been cited as the model of best practice for some time, both in terms of reducing delays in patients moving out of hospital and in terms of outcomes for those patients. The rationale is clear: ideally, people should not be assessed in an acute setting, where we know they are likely to perform tasks less ably than in their own home or a community setting. Equally, there is an obvious flaw in having patients in acute beds beyond the point when they need acute care, simply because they are waiting for an assessment to take place.
Yet only an estimated 35 per cent of hospitals across England currently have any form of discharge to assess service (sometimes also described as Home First, Safely Home and Step Down). Recent guidance from NHS England has firmly shifted the goalposts: by the end of September, all trusts must have decided best model and agreed funding for discharge to assess (D2A). By October, trusts must ensure everything is in place to support the integrated working essential for this new pathway to work and a pilot of the model must commence by November.
How are trusts responding? We have worked in D2A for six years and currently run services in Birmingham, Gloucester and in the south-east and we speak to several trusts every week about this model. Although the principle behind it seems straightforward, it challenges services to integrate in a new way. One issue that repeatedly emerges is that of trust: the guidance places the concept of a trusted assessor at the centre of the new model. Traditionally, before moving out of hospital, the patient needs to be assessed by a social worker, a hospital based nurse and if moving to a care home, a nurse from that care home. Inevitably, this leads to delays and a three-way duplication of process. The D2A model set out by NHS England is based on a single assessment to decide whether the patient is able to move out of hospital and which D2A pathway they should go through. This single assessment needs to be jointly accepted by both continuing healthcare and social work teams and also by the care home admitting the individual. Will single trusted assessments work in reality? Care homes are extremely reluctant to accept any individual who they haven’t seen and assessed themselves and social care and health teams are challenged to move out of their work silos, agree who will do the single assessment and timeframes for it to take place.
There is the challenge of capacity: while a proportion of patients can return to their own home with support, D2A usually relies on capacity within the care home sector. Care homes can provide a good ‘step down’ for patients who do not require an acute level of care, where they can benefit from reablement services and a period of rehabilitation. However we know that in some parts of the country, care home resources are extremely limited, particularly in nursing homes. Our own survey of nursing home capacity in the south coast of England found some vacancy rates of just 2-3 per cent in some counties. Where this is the case, skilled bed brokerage is required to make the most of available community capacity or an available hospital ward may need to become a D2A unit.
Another problem we frequently see is when D2A models are not well managed, delays are simply displaced from acute and out into the community. We have seen systems where patients spend many months in D2A despite a length of stay set at four or six weeks. This occurs when the different services have not sufficiently committed to the new pathway and old patterns prevail, with delays building up as different professionals “wait for reports” from each other. A single database for D2A helps to address this issue, but a change of working ethos is also key. Robust management of all processes on the D2A pathway by focused, accountable co-ordinators is essential. With all these elements in place, D2A is an excellent model, but the changes in working practices it requires should not be under-estimated.