Discharging patients

Discharge to assess

The ‘discharge to assess’ model for managing transfers of care, also known as ‘home first’ or ‘step down’, was introduced in NHS trusts in England in 2016. It aims to discharge patients from hospital as soon as they no longer need acute care but who may still need care services – providing them with short-term, funded support in their own home or another community setting during a period of recovery and reablement. Assessment for longer-term care and support needs is then carried out in the most appropriate setting and at the right time for the person.

Our 2018 report, Beyond barriers, noted that discharge to assess pathways were well established and understood by staff across health and social care, but that capacity and coordination issues could mean that people who were discharged home did not receive an assessment quickly enough, which caused distress and risk of harm.

At the start of the pandemic, in March 2020, the government’s COVID-19 Hospital Discharge Service Requirement guidance required acute and community hospitals to discharge all patients as soon as it was clinically safe to do so, expecting to free up to at least 15,000 beds.

In October 2020, Healthwatch England, working with the British Red Cross, reported their findings from a survey of more than 500 patients and carers with experience of hospital discharge between March and August 2020, as well as interviews with staff members from the health and social care sector.

There were several positive findings from this work, including how discharge to assess encouraged better collaboration and information sharing between services. The national discharge fund provided by the government helped to cover some of the cost of post-discharge recovery and support services, rehabilitation and reablement care following discharge from hospital. We have also heard that discharge to assess has given the financially vulnerable adult social care sector some more security.

However, the report highlighted some concerning factors from the first six months of the pandemic; 82% of respondents did not have their recovery and longer-term support needs assessed in the community at a follow-up visit, and nearly one in five of these (18%) reported having unmet needs. Worryingly, 45% of people with a disability and 20% of people with a long-term condition said they had support needs that were not being met following their discharge.

Healthwatch have highlighted some positive examples that have benefited patients following discharge. For example, a project was commissioned to check in with recently discharged patients to check they had the support they needed and signpost and help them where necessary. This resulting Healthwatch report showed that the project not only made the experience better for patients but could also prevent emergency re-admissions because they were able to identify problems and act earlier.

A survey carried out by Carers UK in March 2021 found that over half (56%) of carers providing significant care said they were not involved in decisions about discharge from hospital and what care and treatment the person they cared for needed.

The Department of Health and Social Care (DHSC) has recently published updated guidance that emphasises how the discharge to assess model can support more people to be discharged to their own home and improve joint working across the health and social care sectors.

Designated settings

As set out in its adult social care winter plan in Autumn 2020, the government committed to deliver with CQC a scheme for designating settings for people who were discharged from hospital with a COVID-positive test and who would be moving or going back into a care home setting.

The government asked local authorities to speak to local care providers and find suitable locations for people to be safely discharged to. Once these were identified, we assessed each location with an infection prevention and control inspection and a specific focus on a service’s ability to zone COVID-19 positive residents, and care for them with a dedicated workforce and high levels of ventilation.

In addition to these locations, some local authorities agreed with local NHS partners to make use of ‘alternative’ NHS settings to fulfil the role of a designated setting.

In the early stages of the process, some local authorities were putting services forward that did not meet the agreed criteria, which included being able to physically separate people who were discharged from hospital with a COVID-positive test and having a dedicated workforce in place. In a number of cases, the service did not know that they had been put forward. Once these issues had been addressed, the process ran well.

In December 2020, in our COVID-19 Insight report, we looked at numbers of assured settings across regions set against potential demand. This showed some variation. For example, the lowest figure of designated beds per 100 care home beds was in the South East (0.19) and the highest figure was in London (1.00).

• COVID-19 Insight 6: Designated settings and care home capacity

We followed this in the next month with an article looking at how the increase in hospital occupancy, resulting from the emergence of the alpha variant of COVID-19, which saw infection rates rise dramatically, compared with the potential capacity of beds in designated settings and alternative arrangements in each region of England.

• COVID-19 Insight 7: Hospital bed occupancy and designated settings

Again, we saw variation. For example, the South West region had the lowest rate of designated beds per 100,000 people aged 65 and over than any other region, but also the lowest regional occupancy of hospital beds by COVID-19 positive patients. In contrast, the South East had the second lowest rate of designated beds, but their COVID-19 bed occupancy level was in the top three in the country.

Conversations our inspectors had during early April 2021 with providers of designated settings gave some insights into discharge arrangements, as well as the general running of the services.

Providers spoke of effective coordination and clear procedures between different agencies to ensure smooth transition to and from the designated setting, including the clinical commissioning group, local authority, hospital teams, and social workers. However, where there were issues, these included people being discharged when they were still ill, requiring re-admission to hospital, or being discharged from hospital with the wrong or missing medicines.

Providers were generally positive about the establishment and running of the designated settings scheme. Although demand was initially high at the peak of winter, many designated settings experienced lower demand as the number of COVID-19 patients fell.

Some sites reported that they never ran at full capacity, with one provider saying that they had had no new referrals since February 2021. By the end of March 2021, designated settings were starting to switch off due to falling demand.

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