Discharge to assess – we must not lose progress

The history of public policy is littered with disappointed expectations. The NHS is facing multiple threats and social care is grappling with the lack of a sustainable funding model. So, when an initiative succeeds, and when it does so in the tricky area of health and social care integration, surely we would want to keep it? Sadly, the government seems on the verge of doing the reverse.

A conspicuous success in the pandemic response

The issue in question here is the discharge to assess approach. This has been one of the conspicuous successes of the NHS response to the pandemic. It has enabled thousands of medically fit patients to be discharged, ensuring they are not kept in a hospital bed any longer than needed. 

Before the pandemic, between 20 and 30 per cent of NHS acute beds were consistently occupied by patients who were ready to leave hospital, but were waiting for confirmation of a care package or transfer to a community or care home bed. 

The new approach - discharge to assess - guarantees four weeks of care support for each discharged patient, funded centrally. Patients can leave hospital as soon as they are medically ready, freeing up vital capacity. The NHS, social care and patients and their families then have a full four weeks to finalise longer-term care arrangements. 

Discharge to assess has worked on many levels. 

It’s worked for the NHS, freeing up 30,000 beds during the first COVID-19 wave with a 28 per cent reduction in patients staying more than 21 days between winter 2019/20 and winter 2020/21. 

"Discharge to assess has driven much greater integrated working between health and care."

It’s worked for social care, providing vital, stable, funding to fragile social care providers and supporting more people to live well at home. With better use of short-term recovery services, there has been reduced need for formal care and support packages. And discharge to assess has driven much greater integrated working between health and care. 

It’s worked for the public purse as NHS England and NHS Improvement data shows discharge to assess has delivered £450 million of hospital bed savings and freed up over 6,000 staff, including almost 4,000 nurses.  

Above all, it’s worked for patients by cutting recuperation time and avoiding the increased likelihood of physical and mental deterioration and lost independence associated with longer hospital stays. It’s helped reduce the risk of hospital-acquired infections including COVID-19. It’s also meant a lower level of care need post discharge as patients are usually assessed in their place of residence, better calibrating the care package to actual patient need. 

At one hospital in the Midlands, average waits for patient discharge with a care package reduced from 17 weeks to less than half a day. Increased therapeutic support has meant four in five patients were discharged with no immediate support, up from just over half of patients, and the average length of hospital stay was cut by a week. 

In Birmingham and Solihull, the numbers of people medically ready to leave has reduced from around 650 to a much more sustainable 250-275. In Sussex, the average length of stay has fallen by 37 per cent. 

Success is now at risk

But all this is now at risk, in less than 60 days.  

Given the uncertainties of COVID-19, the government only set NHS budgets for the first half of the year. And, despite repeated requests, it has refused to confirm extension of the dedicated £600 million April to September discharge-to-assess funding for the rest of the financial year. 

Frontline leaders are deeply concerned that failing to extend this funding will bring huge risk for the NHS, social care and patients. 

The NHS is currently under huge pressure. Growing waiting lists, record levels of urgent care demand in emergency departments and ambulance services, and the loss of around 15,000 of the NHS’s normal 100,000 beds due to COVID-19 infection control are translating into very worrying, high levels of hospital bed occupancy. These pressures will only increase as we head into the traditionally intense winter months.  

Failure to extend discharge to assess into the second half of the year will give the NHS a dangerous capacity squeeze just as we come into winter when NHS bed capacity is at its tightest. Inevitably, the NHS will have to slow down care backlog recovery. Waiting times for urgent and emergency care will lengthen. Ambulance handover delays will grow. These will all, inevitably, compromise patient care. 

Time is of the essence

Failing to extend will also increase pressure on an already hard-pressed social care system. And it would seem bizarre to axe a successful policy initiative that supports social care just as the government unveils the comprehensive social reform package it has promised in the autumn.  

Timing is of the essence here. Trusts and local authorities are already having to make major decisions at risk and many are reporting that, as a result, discharge flow is starting to slow down. Given the four-week funding envelope it is vital that the government makes a decision on the future of discharge-to-assess funding by mid-August. 

"Frontline health and care leaders are desperate not to lose the progress they’ve made."

There are few positives to come out of the pandemic but speeding up the safe discharge of medically fit hospital patients has been one of them. It feels very odd having to publicly persuade the government to continue a highly successful policy it’s introduced. But frontline health and care leaders are desperate not to lose the progress they’ve made here. The ball is now firmly in the government’s court.

Matthew Taylor is chief executive of the NHS Confederation

Chris Hopson is chief executive of NHS Providers

You can follow Matthew and Chris on Twitter:
@FRSAMatthew
@ChrisCEOHopson

This blog was first published in the HSJ