Discharge to recover and then assess

A blog from John Bolton OBE, a former director of social services and former strategic finance director at the Department of Health. For the past decade, John has worked as an independent consultant with health and care systems across the United Kingdom on effective and efficient use of resources, including the most cost-effective way of managing the discharge of older people from hospital. He has been working with the Better Care Fund Support Programme to deliver improvement support to systems.

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In March 2020 I wrote a follow up to my first paper on hospital discharge – Commissioning out of hospital services to reduce delays, published by the Institute of Public Care – Oxford Brookes University. In this paper I introduced some new ways of looking at the process of discharging older people from hospital. 

Three new concepts emerged: the importance of understanding the capacity that systems have in order to meet the demand requirements for intermediate care services; the recognition of the different pathways in which older people’s needs might be met through intermediate care services and probably most important, the necessity to define intermediate care as services that support the recovery of patients after a period in an acute hospital prior to any assessment being undertaken on their long-term care. 

The language behind all three of these concepts is widely used in the NHS and social care though many places seem to struggle with fully implementing them. Why is this?

The concept that older people might require an intermediate care service at the point of discharge was developed and widely used in policy language in the 1990s. There have been NHS community hospitals in place from the 1960s (when the hospital wards for older people were closed). The role of therapists supporting rehabilitation of people is an even longer-term service. In the 2000s the concept of short-term reablement services became a new model in social care. 

Despite the existence of all these key elements that could define an intermediate care set of services, they have often remained distinct and different, sometimes rather disparate services. Even now, in 2024 there are many health and care systems that don’t recognise the important role their intermediate care services can have on the longer-term outcomes for older people leaving hospital.

In 2018, I worked with the NHS Development Unit in Wales where we looked to track every older person across Wales who had been discharged from hospital in 2017. The findings were not a surprise but were still astounding. 

Older people with very similar conditions ended up in very different long term care services according to the quality and level of good intermediate care services available in each region. 

In parts of Wales, where intermediate care services were either non-existent or poor a high percentage of older people leaving hospital ended up in permanent residential or nursing care. In other places that were developing good services, many older people returned to their own homes and often their recovery had been sufficient for them not to require on-going support. 

We discovered community hospitals which acted as waiting places to move on to permanent care and places where they actively encouraged recovery or rehabilitation from which people returned home. The outcome for the older person depended on what was locally available. 

Over the last decade we have learnt much more about the nature of muscle wastage and loss when a person has been bed-bound and the evolution of concepts such as pyjama paralysis. 

The more time a person spends in a bed the higher their needs will be at the point of discharge but with the right help this is reversible.

In my recent work in England, I have found a mixture of poor and good intermediate care services. Some add no value, for example, spot purchased beds procured to release a hospital bed where there is only a 20 per cent chance the person will return home; domiciliary care services that are not therapy led and where only 40 per cent of older people make any kind of recovery. This compares to some outstanding community hospitals where 70 per cent of the older people return home and domiciliary care reablement services where 85 per cent make a full or partial recovery. 

I have found that the recovery-based services that are well run not only produce much better outcomes for older people, but also manage a flow of patients through their services that is always releasing capacity for the next person. 

If a system clogs up their supply of care with people whose recovery they are not supporting, they will not have sufficient supply for those who need it, leading to longer delays in hospital, which in turn is likely to lead to poorer outcomes for the people.

Social care seems to still be pre-occupied with assessing older people for longer term care when they are in an acute hospital (despite the policy move in England to discharge to assess). 

They seem to have ignored their duties under Section 1 of the Care Act 2014 (to support the well-being of people); section 2 of the Care Act 2014 to help prevent people from needing longer term care and section 3 of the Care Act 2014 which requires the NHS and local authorities to collaborate to help achieve the best outcomes for patients. They jump straight to Section 7 of the Care Act and undertake a full assessment when other actions prior to undertaking the assessment would improve the longer-term outcomes for those people. 

I consistently hear senior staff in local authorities telling me that they are fulfilling their responsibilities under the Care Act when they blatantly have ignored those earlier important sections. The best way to support the well-being of an older person leaving hospital is to ensure that they have access to the most appropriate recovery service for them – preferably in their own home.

I still hear a debate going on about getting older people out of hospital as if that was the goal rather than a focus on the longer-term prospects for older people who have ended up in hospital. It is the constant pre-occupation with moving the person away from the acute hospital rather than on managing the person’s recovery that causes the discharge systems to clog up and the problem of delays to get worse. 

I find the best discharge systems with the lowest lengths of stay and the lowest delays in discharge are those where there is a flow of people from an acute hospital into an intermediate care service and beyond to levels of independence.

This has led to some basic rules from my work:

  • Never assess a person for longer term care when they have been in an acute hospital for more than four weeks before they have had a period of recovery. 
  • Never underestimate the potential levels of recovery a person can make when they are offered the right support.
  • Every patient leaving hospital should have a recovery plan which is a written document offering advice on the best things they can do (or require support with) to reduce the impact of their stay in hospital.
  • It’s the help on offer that makes a big difference to the long-term prospects for the person not the assessment that is made.

Why hasn’t this learning been absorbed by the NHS and social care partners? Why is intermediate care still uncoordinated and disparate in many places?

I would suggest that there are two main reasons why the old arrangements (which didn’t work) are still used. First, the currency in most places is “delayed discharges” rather than outcomes for people. Getting a person out of a hospital bed is more important than their longer-term prospects. Second, most places haven’t commissioned the right quality and quantity of intermediate care services to meet the post hospital support (recovery) needs for their population. Even though the evidence is that where the right levels of recovery are available, the longer-term costs of the services to the population are reduced.

For half a decade I have been arguing for a model called “Discharge to recover and then assess”. When I introduce this model to places, and they adopt it they produce better outcomes at a lower cost. It frees up resources for the wider population in equal measures between the NHS and the local authorities. I will continue to push the case for this being the best approach to deliver the best possible outcomes for older people leaving an acute hospital.