Assessing the implications of the new hospital discharge workbook

The government has recently implemented measures to better manage the hospital discharge of older people. Such policy has, however, seemed largely concerned with the problem of bed blocking rather than optimum care practice, and the rights and choices of older people have often been ignored in an effort to speed up the process. Stephen Lowe, a community care (services) policy officer at Age Concern England, assesses how far the publication of the workbook, Discharge from Hospital: Pathway, Process and Practice, might help remedy the problems and establish good-practice guidelines in discharge care.

The discharge of older people from hospital has been the subject of a great deal of recent attention from the government. Intermediate care, fines for local authorities who delay the provision of care services, and performance indicators intended to promote the faster provision of social care services are all aimed at ensuring that older people are not unnecessarily detained in hospital. In some cases, however, this concern seems to stem primarily from a preoccupation with freeing up hospital beds.

Measures to ensure that disputes are resolved and that older people move on to receive the most appropriate services, and that they are able to exercise choice, have often been lacking. This absence has been conspicuous during the passage of the Community Care Services (Delayed Discharge) Bill, which initially failed to even mention the rights of older people, let alone take account of them. Former statutory guidance (HSG(95)8:LAC(95)5) governing hospital discharge was cancelled by the continuing care guidance (HAS 2001/015: LAC(2001)18), and there are no plans to replace it. It is, therefore, of increasing importance that statutory authorities follow good-practice guidance.

The publication of the new workbook, Discharge from Hospital: Pathway, Process and Practice is, therefore, of particular importance

Structure of the workbook

The new workbook is described as building on the previous (1994) hospital discharge workbook. It sets out good practice, which is intended to apply to all adult-client groups. It begins by taking a broad view of key themes and principles, along with the policy and legislative context. A section on background information usefully lists and describes existing policies, guidance and legislation that relate both to hospital discharge and to avoidance of unnecessary admissions. The workbook then moves on to sections on specific aspects of discharge planning. These are:

Developing a whole-system approach;
Involving patients and carers;
Co-ordinating the patient journey;
Intermediate care, transitional care and sheltered housing;
Continuing health and social care.

Each of these sections includes practical checklists of steps that agencies should take to develop appropriate policies and practice. To assist in developing an inter-agency discharge policy, for example, the workbook sets out the steps needed to establish the aims of the policy and to establish the outcomes it should seek to achieve. Agencies should then look at the joint agreements or protocols that will be required, and at guidance for specific professional groups about their responsibilities. A joint review of existing policies and of information-exchange practices should take place, and a timetabled action plan should then address the findings of the review.

The workbook is described as building on a whole-system approach. Patients, “with expertise and understanding of their own needs and ability to influence how the discharge process works”, are included as an integral part of the system. Benefits to the patient of a good discharge process should include their believing that they have been supported and have made the right decision about their future care. This includes understanding and signing up to their care plan and feeling an active partner in the process. References to involving patients and carers in decision making are, therefore, liberally sprinkled through the workbook. These references reveal a marked difference, however, between the approach to patients and carers. Carers should be provided with information about their rights, including their right to assessment. A checklist identifies information that should be provided to carers. This includes the discharge plan, information about the medical condition of the patient, how to challenge decisions and other sources of help and support. A carers’ assessment checklist is included, and carers training needs must be identified. Clinics should be held where relatives and carers can book an appointment with a social worker, consultant or ward-based consultant.

Specific requirements to involve and empower the patient are far more limited. An information/ communication strategy must involve both patients and carers, and they must be provided with a folder or booklet in which to keep and record information to take home. Both patients and carers should be provided with independent/informal support at meetings with professionals, and both should be provided with advice and training regarding administration of medication and use of equipment. The workbook does at least state, however, that: “Patient-centred care must be much more than just keeping the patient informed and up to date with decisions about their care as passive players in the process.”

A section on rights and responsibilities makes only one explicit reference to the rights of patients, pointing out that patients do not have the right to indefinitely occupy an NHS bed. They do, however, have the right to refuse discharge from NHS care into a care home. This paragraph goes on to note that the current Direction on Choice of Accommodation (LAC (92)27 and LAC(93)18 – which is sometimes seen as a cause of delayed discharge due to patients awaiting the home of their choice – is currently under review.

The workbook deals with issues of partnership working by looking at the “patient journey” from proactive early intervention, which may avoid the need for acute care, through to hospital and discharge. Effective inter-agency working should involve identification of possible continuing health or social care needs at the earliest opportunity, with the help of pre-admission and admission-assessment processes, which are described in detail, with a “pre-admission checklist” included. Inter-agency agreements should ensure effective and flexible discharge pathways, and there should be effective communications and referral processes. Discharge planning should take place over seven days a week.

A named person at ward level should be responsible for proactively co-ordinating the patient journey. This “ward-based care co-ordinator” will usually be a nurse but could, in a rehabilitation setting, be a therapist or social worker. The workbook sets out their key tasks, which include discussing a potential discharge or transfer date as soon as possible after admission, keeping the patient and family informed of progress and ensuring that carers are engaged and their needs assessed if appropriate. The care co-ordinator is responsible for such tasks as liaising between services, ensuring referrals are made and followed up, and keeping documentation up to date.

On the day of discharge, the care co-ordinator should check that the patient’s condition is as expected and confirm follow-up arrangements. Appendices to this section deal with a number of specific issues such as medicine management and discharge of people who are homeless.

One of the most significant sections of the workbook is the guidance on interim or transitional placements following hospital discharge. A definition of transitional care describes it as care provided to a person who is not able to be placed in their home or the permanent setting of their choice but who still requires a supported and appropriately-staffed environment to live in. Transitional care can be provided by the NHS and by the independent sector. Community hospitals can be used for transitional care but only when agreement has been reached regarding a long-term placement. Transitional care may include rehabilitation, support, confidence building and time for recovery.

The workbook states that if a transitional placement is used while the person waits for the home of their choice, it must meet the assessed care needs of the patient, who must receive, “active help to move on to the home of his/her choice when a place is available”. Trusts should have agreed policies and procedures to address situations where patients and their families refuse to move from an acute bed. Patients and carers faced with important decisions about their future – including those funding their own care – should have access to support such as an independent advisory service.

Discussion

There is a degree of overlap between the definitions of transitional care and intermediate care, which is likely to be a source of contention, primarily because intermediate care services will be free, whereas social services will be able to charge for transitional care that they provide or arrange. Current guidance (HSC 2001/01: LAC (2001) 1) sets five criteria, which services must meet to be defined as intermediate care. These criteria refer to time-limited services with planned outcomes that have been decided on following comprehensive assessment. Intermediate care services must involve cross-professional working and must be targeted at people who might otherwise be unnecessarily delayed in hospital or forced to enter hospital, long-term residential care or continuing care (at the time of writing, new regulations are expected, which may amend this definition).

The safeguards set out for people placed in transitional settings should provide some defence for older people who feel that they are being pressurised and given little choice regarding what, for many, will be a major life transition. This is an area where the abolition of statutory guidance has particularly weakened the rights of patients. However, regulations will be issued under the Community Care (Delayed Discharges etc.) Act 2003, which should give patients limited rights. Draft regulations were published prior to the bill completing its passage through Parliament, but they will require some modification in order to comply with commitments made by the government during the passage of the bill. Assuming these modifications are as expected, several of the regulations will have an impact on the implementation of the new workbook:

Guidance will be issued stating that a check will be made within two weeks of discharge to ensure that post-discharge care has been adequate and is working;
Patients who receive mental health care will not initially be included under the new system of fines for delayed discharge. While in many respects welcome, there must be concerns that this exclusion, while intended to safeguard the interests of such patients, may also result in their being excluded from some of the measures being applied to other patients, such as the checks on after-care referred to above. The definition of a mental health patient proposed – this being a patient under the care of a consultant psychiatrist – is also likely to prove contentious;
Regulations will specify that the patient will receive a continuing-care assessment, the results will be recorded, and patients will be told they have a right to have the decision reviewed;
Further consultation will take place on how dispute-resolution procedures should take account of the rights of patients to challenge decisions that will affect them.

Reform of the NHS complaints procedure is also planned. Details of the proposed reforms are set out in a Department of Health publication: NHS Complaints Reform - Making Things Right. Implementation of these proposals is dependent on the passage of the Health and Social Care (Community Health and Standards) Bill, which is currently before Parliament and which contains provision for the Secretary of State to issue regulations regarding complaints about both health and social-care provision.

Other information

Additional information on discharge planning and on avoiding unnecessary hospital admission, will be placed on the Department of Health Change Agent website at www.doh.gov.uk/jointunit/changeagents.htm. A learning and improvement network is also being set up, details of which are available on this site.

Stephen Lowe is a community care (services) policy officer at Age Concern, England. He can be contacted at: lowes@ace.org.uk.