The DHSC’s August 21 guidance to hospital trusts goes further than previous such guidance in spelling out the need for additional government funding of “post discharge recovery and support services” to cease after the maximum six week period after patients have been hurried out of hospital.
The whole focus is on speeding the process and minimising the numbers of patients deemed eligible to remain in a hospital bed by strict implementation, in twice-daily ward rounds, of a draconian checklist of “criteria to reside in hospital,” asking whether each patient:
- Requires ITU or HDU care
- Requires oxygen therapy/NIV?
- Requires intravenous fluids
- Has a National Early Warning Score of 3 or more
- Has a diminished level of consciousness where recovery realistic
- Has acute functional impairment “in excess of home/community care provision”
- Is in the “Last hours of life”
- Requires intravenous medication (including analgesia) more than twice daily
- Has undergone lower limb surgery within 48hrs or thorax-abdominal/pelvic surgery with 72 hours
If the patient does not fit at least one of these categories, and regardless of their social circumstances, the policy states they must be discharged “as soon as they are clinically safe to do so” to a “designated discharge area” – within an hour, or at most on the same day, and where possible discharged from the discharge area as soon as possible, “often within two hours”. (p4)
Hospitals are required to give reasons for any delays to this whistle-stop discharge process. “The default assumption will be discharge home today.” (p25)
Since the peak of the Covid-19 response, this policy, which emptied tens of thousands of NHS beds, has been linked with a suspension of data collection on Delayed Transfers of Care, and to additional government funding to cover up to six weeks of recovery and support services (p5).
The funding could also be used “for urgent community response provided within 2 hours to prevent an acute admission” – although how many areas have been able to offer such a rapid response, and how many did so has not been revealed.
The “discharge to assess” policy is based on the assumption that 65% of people will require no further care (p10), and the other 35% will require an ongoing package of care, although these numbers to not correspond with the “pathways” analysis a few pages earlier in the document.
That states (with no supporting evidence) that 50% of people can simply be discharged home from hospital, with relatives or neighbours taking the strain and no further support from NHS or social care; 45% will need some support from health and/or social care to recover at home, while 4% will need rehabilitation of short term care in a 24-hour bed based setting and just 1% will need ongoing 24-hour nursing care. (p6)
For the 5% of patients over 65 with needs too great to be returned to their own homes: “rehabilitation/short term care in a 24 hour bedded care facility will be arranged through the case manager. For people being discharged to a care home bed (short term or permanently) for the first time, this provision will be provided in a care home, at rates which have been agreed locally by the health and care system and will be free to the individual for up to six weeks” (p15-16)
However there are complications over Covid screening: “DHSC/PHE policy is that people being discharged from hospital to care homes are tested for COVID-19 in a timely manner ahead of being discharged …. Where a test result is still awaited, the person will be discharged if the care home states that it is able to safely isolate the patient ….
“If this is not possible then alternative accommodation and care … needs to be provided by the local authority, funded by the discharge funding.” (p16).
It’s not at all clear what “alternative accommodation” might be available or appropriate for patients who might potentially arrive with Covid-19, and are also likely to require complex care – or how local authorities whose budgets and staffing for social care have been cut to the bare bones over the last ten years are expected to be able to spring into instant action and procure sufficient suitable alternatives on the immensely tight timetable set by NHS England.
The expectation is that a “lead professional or multidisciplinary team … suitable for the level of care and support needs”, will visit people at home on the day of discharge or the day after “to co-ordinate what support is needed in the home environment” (p15). It’s not clear what options if any there are for patients and their families if this does not occur.
However what is clear is that any apparent generosity in the system and provision of ongoing care and support with no charge to the patient comes to an abrupt halt after six weeks, when the central support ceases and local health and care systems are left to their own devices:
“Whatever arrangements are agreed costs from week 7 cannot be charged to the discharge support fund and must be met from existing budgets. CCGs and local authorities should agree an approach to funding of care from the seventh week.” (p16)
The discharge policy expects that an assessment for ongoing health and care needs takes place within six weeks of discharge, and that a decision will have been made by this date about how this care will be funded.
However it seems clear from NHS England’s July 31 Phase 3 Letter that this has not been the case with many of those patients discharged from hospital between 19 March 2020 and 31 August 2020, who now form a hefty backlog of cases to be urgently assessed by hard-pressed local teams: in many area the capacity to assess on the scale required is just not available.
The policy is clear on one thing: from six weeks after discharge from hospital the local NHS and social services are left to carry the can: “CCGs will not be able to draw down funding from the discharge support arrangements after the end of the sixth week to fund any care package beyond this date. …
“On the rare occasion that a decision is not reached within this timeframe the parties paying for the care should continue to do so until the relevant ongoing care assessments are complete. Whatever arrangements are agreed, costs from week seven cannot be charged to the discharge support fund and must be met from existing budgets. CCGs and local authorities should agree an approach to funding of care from the seventh week.” (p27).
Around the country staff in community health and social care will be grappling now with the fall-out from these policy statements without the necessary means to cope. The social care funding gap remains unresolved, as do the financial problems of hundreds of privately run care homes. The buck-passing guidance may have been published, but the implementation is far from a done deal.
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