CQC We and I Statements
Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions
We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.
When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.
I feel safe and supported to understand and manage any risks.
- most people should be discharged to their home
- discharge planning should begin at the point of admission
- discharge planning should be person centred and involve a range of partner agencies, and the adult, their family, and carers (including unpaid carers) and independent advocates
- an initial safety and welfare check should take place on the day of discharge.
- 1. Introduction
- 2. NHS and Local Authorities Working Together
- 3. Structure, roles and responsibilities
- 4. Joint Accountability across Health and Social Care Leads to Better Outcomes
- 5. Safe and Timely Discharges
- 6. Assessing for Long-Term Needs
- 7. Active Risk Management
- 8. Specific Needs
- 9. Case Studies
- 10. Further Reading
The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) came into effect from 1 April 2022. It sets out how NHS bodies (including commissioning bodies, NHS trusts and NHS foundation trusts) and local authorities can plan and deliver hospital discharge and recovery services from acute and community hospital settings.
According to the guidance, local areas should adopt discharge processes that best meet the needs of the local population. This could include the ‘discharge to assess, home first’ approach. Systems should work together across health and social care to jointly plan, commission, and deliver discharge services that are affordable within existing budgets available to NHS commissioners and local authorities, pooling resources where appropriate.
Under Discharge to Assess, Home First approach to hospital discharge, most people will be expected to return home (to their usual place of residence) following discharge. The Discharge to Assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs.
Multi-disciplinary hospital discharge teams and transfer of care hubs, comprising professionals from all relevant services – including health, social care, housing and the voluntary sector – should work together so that, other than in exceptional circumstances, no one should transfer permanently into a care home for the first time directly following an acute hospital admission. Everyone should have the opportunity to recover and rehabilitate at home, wherever possible, before their long-term health and care needs and options are assessed and agreed.
This approach reduces exposure to risks such as hospital-acquired infections, falls and loss of physical and cognitive function by reducing a person’s time in hospital, and enables people to regain or achieve maximum independence as soon as possible. It also supports hospital ‘flow’, maximising the availability of hospital beds for people requiring this level of inpatient care and elective surgery, such as hip replacements.
Local areas should work together to develop the model within existing resources. This should include agreeing any investment to reshape provision towards more home-based, strengths-based care and support, and with less reliance and expenditure on bed-based provision.
The principles in the guidance should form the foundation for local planning of arrangements for discharge from acute hospitals and community rehabilitation units. This can best be achieved by providing choice for individuals, who should be supported to make fully informed decisions, with input from their wider family or unpaid carers (where appropriate, and where the individual consents) or their independent advocate. This process should be person-centred, strengths based, and driven by choice, dignity and respect.
2. NHS and Local Authorities Working Together
2.1 The care journey
The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) aims to support local partners to jointly agree how to use their existing resources to best effect, to deliver the best possible outcomes for their population.
The local NHS body and local authority should agree the discharge models that best meet local needs and that are affordable within existing budgets available to NHS commissioners and local authorities.
This could include the discharge to assess, home first approach. Funding to support discharge can be pooled across health and social care via an agreement under section 75 of the NHS Act 2006 to minimise delays, ensure effective use of available resources and ensure the decisions about an individual’s care needs are made in their own environment.
Local areas can choose the appropriate funding mechanisms to enable these processes, such as the Better Care Fund (BCF), or other means that are affordable within existing budgets available to NHS commissioners and local authorities. For example, the BCF can, subject to local agreement, continue to be used to fund services at the interface of the health and social care system, such as intermediate care and hospital discharge planning, as well as core adult social care services and breaks for unpaid carers.
Care, when delivered at home, not only leads to better outcomes for the individual, but is also a better use of resources.
NHS bodies and local authorities should ensure that local funding arrangements are agreed by all partners and are aligned with existing duties, including those under the Care Act 2014 and the Mental Health Act 1983. These arrangements should also include clear information for self-funders of adult social care, so they can make informed choices about any onward care needs that do not fall under locally funded eligible costs.
Where local areas agree to fund a period of care (pending a long-term needs assessment being carried out), agreements should be in place to ensure no one is left without care or – if needed – an assessment of long-term needs prior to the end of this period. This should also ensure that no carers are left without adequate support or an assessment of their longer-term needs (if needed) at the end of this period.
Regardless of the hospital discharge, community support and funding model that is adopted locally, people and, where relevant, their families, unpaid carers, and independent advocates, should expect to receive personalised support that meets their needs and maximises the person’s independence. People should not be routinely discharged to a community step-down bed simply to free a hospital bed, nor should they routinely be discharged to a community bed simply because home-based care is not available. Where relevant, the decision about when to discharge a person, and any support they might need before an assessment of their long-term needs, should take into account the views and circumstances of any unpaid carers as well as those of the individual. Hospital discharge teams should also consider unpaid carers’ preferences and involve them to ascertain whether they are both willing and able to provide care and support post-discharge, before an assessment of longer-term needs. This should include an offer to refer to local carers’ support services.
If a person’s preferred placement or package is not available once they are clinically ready for discharge, they should be offered a suitable alternative while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they do not need acute care, including to wait for their preferred option to become available.
While NHS organisations should seek to offer choice to patients where such choice exists, in practice, there may be limited situations where an NHS organisation may decide to reduce the choice of services offered to people on discharge. Such situations include times of extreme operational pressures, for example, the UK COVID-19 Level 4 National Incident. A record should be produced of the considerations of the relevant discharging body in deciding to offer that patient a reduced choice, setting out all of the material considerations for and against doing so, and the balancing exercise between the patient choice duty in the NHS Act 2006, and relevant competing duties and countervailing factors.
2.2 Planning for discharge
Planning for discharge from hospital should begin on admission. Where people are undergoing elective procedures, the planning should start pre-admission, with plans reviewed before discharge. This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs. Further detail on the four discharge to assess pathways is set out in Annex 3 of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care).
From the outset people should be asked who they wish to be involved and / or informed in discussions and decisions about their hospital discharge, and appropriate consent received. This may include a person’s family members, friends or neighbours, some of whom would be considered unpaid carers. Paid care workers and personal assistants may also be included. The person or people identified at this stage may be wider than a person’s next of kin. A person who does not have family or friends to help, or who may find it difficult to understand, communicate or speak up, should be informed of their right to an independent advocate (see Independent Advocacy chapter).
Multi-disciplinary teams (see Section 4, Joint Accountability across Health and Social Care Leads to Better Outcomes) should work across hospital and community settings – including with services provided by community health, adult social care and social care providers – to plan post-discharge care, long-term needs assessments and, where appropriate, end of life care (see End of Life Care chapter). Social workers, including children’s social workers of young carers and young adult carers, should be involved at an early stage of the discharge planning process where appropriate, including where that planning takes place in a hospital setting. The multi-disciplinary team should also ensure that any mental capacity and safeguarding concerns have been considered alongside other support needs post-discharge (see Mental Capacity chapter and Adult Safeguarding chapter).
Discharge planning should include information about post-hospital care, such as advice and information about community and voluntary sector organisations, housing options (such as home adaptations and possible alternative housing) and NHS or social care crisis response teams that can be contacted post-discharge.
Family members and unpaid carers providing care for the individual should be offered support where appropriate. For example, all unpaid carers may benefit from signposting to local carers’ support services, and they should be made aware of their right to an assessment for their own needs by their local authority. This includes young carers under the age of 18.
2.3 Discharge timing, location and support
Health and care professionals who are enabling hospital discharges to take place should work together with people and – where relevant – families and unpaid carers, to discharge them to the setting that best meets their needs. This process should be person-centred, strengths-based, and driven by choice, dignity and respect.
Most people being discharged go home without the need for ongoing support. Of those that remain, most people requiring supported discharges should be going home, with only a small proportion needing short-term bed-based intermediate care. Only in exceptional circumstances should someone be considered to need long-term care at the point of discharge. See Annex 3 of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care) for further details about discharge pathways.
Support should extend beyond discharge itself. Local areas should have agreed protocols for collaborating with onward care providers about the individual’s hospital discharge through the transfer of care hub. Community health and care services, including GPs and social care providers, should:
- communicate with the person and, where relevant, their unpaid carers to track and manage their recovery;
- ensure that any change in the support needs of the person (or their carer) happens at an appropriate time.
People should be discharged to a familiar setting where possible, as they often respond well to the familiarity of their home environment when it is appropriate for supporting their needs. If required, they should receive rehabilitation or reablement support from NHS or social care services to enable them to regain their independence as far as possible. This can lead to a more accurate assessment of their future needs, once they have reached an improved point of recovery. Practitioners within acute and community health and local authorities should consider a range of factors when supporting the person and their family, unpaid carers or independent advocate to decide their care pathway and post-discharge support. This includes their preferences, existing provision of care, and whether unpaid carers are willing and able to support their recovery. Practitioners should be aware of young carers or young adult carers involved in unpaid support, working with them respectfully and appropriately and ensuring they have necessary support in place.
Discharging people to the most appropriate place to meet their needs requires active risk management across organisations to reach a reasonable balance between safety at all times, and independence (see Section 8, Specific Needs). Anyone requiring formal care and support to help them recover following hospital discharge should receive an initial safety and welfare check on the day of discharge to ensure basic safety and care needs are met and allow time for fuller assessments to take place as the person settles in their environment. This should be coordinated via the transfer of care hub. People should not have to make decisions about long-term care while they are in crisis or in an acute hospital bed.
Local areas should draw upon a range of short and medium-term interim care services, depending on the severity of a person’s needs. For example, some people may benefit from voluntary sector support, or very short term ‘hospital to home’ services to get them settled back home. Short-term (72-hour) reablement or live-in care services may also be useful to ensure people have care available while they settle at home, rather than being discharged to a community or care home bed, but these should be organised and agreed as affordable within existing budgets available to NHS commissioners and local authorities.
People with ongoing mental health needs, a learning disability, dementia, those in the last few months of life, and a range of other factors and conditions may require specialised support in the community to ensure their needs continue to be met. Children and young people facing the loss of a family member, and anyone facing the loss of a loved one due to suicide, should be informed about how they can access specialist bereavement support. The needs of homeless people will also need to be considered (see Section 8.5, Tailoring support to specific needs and circumstances). Local commissioning plans should include the provision of specialised support that meets the local population’s needs.
3. Structure, roles and responsibilities
3.1 Developing a discharge infrastructure
Discharging a person onto the right care pathway when they no longer need to remain in hospital requires a whole system approach. NHS organisations should work closely with adult social care, children’s social care, care providers, housing, the voluntary sector and others to ensure people’s care and treatment is timely, optimal and coordinated, while also minimising delays when they are ready to be discharged.
Senior level support from the NHS provider and the local authority should provide strategic leadership and oversight of the discharge process to monitor and eliminate the causes of unnecessary discharge delays, and ensure that the agreed hospital discharge procedures are being followed consistently.
NHS bodies, the local authority and other relevant partners should develop local protocols. These should set out each organisation’s role and how responsibilities should be exercised to ensure appropriate discussions and planning concerning a person’s short and long-term care options happen at the appropriate time in their recovery.
To ensure hospital discharge processes are effective, NHS bodies and the local authority should also ensure local recovery, rehabilitation and reablement services are commissioned effectively and sustainably, and meet the needs of their local population in the short and long term and are affordable within existing budgets available to NHS commissioners and local authorities. This may be provided as part of intermediate care services, and should be done in collaboration with relevant organisations, including the voluntary and community sector and care providers.
The support needs of specific populations should be considered when commissioning local services. This includes determining the type of specialist rehabilitation services needed for people with complex conditions, and ensuring appropriate social work provision and other specialist support is in place for people in complex, abusive or neglectful relationships. The involvement of advocacy should also be a key consideration where appropriate (see Independent Advocacy chapter). Local areas should also determine the best working arrangements for multi-disciplinary health and care teams who manage discharge from acute and community hospital settings, whether they choose to co-locate their staff, work together using virtual systems, or find other means of effective collaboration.
Commissioners should work with local voluntary and community sector organisations to develop and maintain capacity in the community to support people, including those who do not need specific reablement or rehabilitation, to retain links into the community and maintain their wellbeing.
3.2 Strategic planning
Health and social care systems based around a hospital should have an identified executive lead, employed by any partner in the system, to provide strategic oversight of the discharge process. They should ensure that appropriate procedures are followed, including the inclusion and support of carers, and that there are no avoidable delays to discharge.
Every local health and social care system should have a single coordinator who acts on behalf of the system to secure safe and timely discharge on the appropriate pathway for all individuals. This system leadership role can be employed by any partner in the system. Their primary function is to develop a shared system view of discharge, hold all parts of the system to account and drive the actions that should be taken as a system to address shared challenges. The single coordinator is accountable to the executive lead.
Every local health and social care system based around an acute hospital footprint should have a transfer of care hub whereby (physically and/or virtually) all relevant services across sectors (such as health, social care, housing and voluntary sector) are linked together. The transfer of care hub should coordinate care for people who require formal care and support after discharge from hospital, and any support for unpaid carers providing care. Hubs should be staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support (if needed). Staff based in the transfer of care hub may also be the care givers and rehabilitation professionals for an individual. Decisions about what long-term support package is needed should not be taken on the hospital ward.
Case managers in transfer of care hubs should link relevant services to coordinate care and support the person. The case manager can be from any discipline (such as social care, primary care or therapies) depending on the needs of the person. They should also make arrangements for everyone leaving hospital with ongoing health and care needs to have an initial safety and welfare check on the day of discharge to ensure basic safety and care needs are met and allow time for fuller assessments to take place as the person settles.
Hospital multidisciplinary teams should describe – with input from the person and their unpaid carer, advocate, or relevant community-based professionals – the needs that require support after discharge before an assessment of their long-term needs. This could include non-clinical factors like their physical, social, psychological, financial and practical needs, including home adaptations and equipment. This could determine whether the person’s home is suitable for their needs upon discharge.
Multidisciplinary teams may include social workers, clinicians, therapists, mental health practitioners, pharmacists, care workers, dietitians, housing representatives, volunteer and community services and any other specialists needed to coordinate care for the individual. They should adopt strengths-based and person-centred planning, working together to plan care and carry out joint assessments. These teams should be aware of carers’ rights, and ensure carers are willing and able to care and that they have sufficient support to care safely. This helps to facilitate an integrated transition from hospital to the person’s usual place of residence. Safety should be ensured from the day of discharge. They should refer those requiring support to the transfer of care hub.
Hospital-based social workers have a vital role as members of a multi-disciplinary team, ensuring a person-centred and strengths-based approach is adopted during pre-admission, hospital stays and planned safe discharge. Their role in hospital and assessment settings is essential for people whose social circumstances are complex. These social workers should be experienced in supporting people to make informed choices, weighing up the risks and benefits of options. They should be familiar with mental health, mental capacity and safeguarding issues. They should also be knowledgeable about carers’ rights. They should understand the full options available to people in community settings in order to offer people the best choice and understanding of their recovery pathway.
It is critical that general practice and other primary care providers are directly linked into all discharge planning to ensure that health recovery support is available to the individual throughout their care journey.
Detailed guidance on accountability and roles can be found in Hospital Discharge Service: Action Cards.
4. Joint Accountability across Health and Social Care Leads to Better Outcomes
4.1 Cooperation duties
Section 82 of the NHS Act 2006 requires NHS bodies and local authorities to cooperate with one another to secure and advance the health and welfare of their local population. NHS bodies and local authorities must also comply with duties in the Care Act 2014, which requires them to co-operate with each other in the exercise of their respective care and support functions, including those relating to carers and young carers.
See Structure, Roles and Responsibilities, Hospital Discharge and Community Support Guidance (Department of Health and Social Care), planning, delivery and monitoring of discharge services, legal duties on health and social care bodies,
Health and social care systems should have escalation mechanisms for people with concerns about care and support that are clearly communicated to people using services, their families, their unpaid carers and advocates, and service providers. These should clearly set out who is responsible for what and at which step of the process they should be engaged.
Concerns should be escalated via the locally agreed escalation mechanism, overseen by the single coordinator reporting to the executive lead. Areas will have flexibility over how this is implemented locally, but they should ensure mechanisms are agreed with all partners, and that there is a clearly identified responsible person at each stage of the discharge process.
Where a complaint needs to be raised against an NHS body, it should be made to them directly in the first instance. This can be done through the relevant body’s complaints department, or its Patient Advice and Liaison Service (PALS).
Where a complaint needs to be raised against a local authority or care provider, it should be made to them in the first instance. If this does not yield satisfactory results, or the complaint is not answered within a reasonable time, a complaint can be raised through the Local Government and Social Care Ombudsman.
People can also provide information to local Healthwatch organisations and the CQC, which may carry out a range of actions including inspecting the relevant body if it has the powers to do so.
5. Safe and Timely Discharges
Health and social care professionals should support and involve the person to be discharged in a safe and timely way to ensure they are only hospitalised for as long as they require hospital care. Discharging people once they no longer need acute care improves their outcomes and reduces the risk of medical complications such as deep-vein thrombosis, hospital acquired infections, and loss of independence.
No person should be discharged until it is safe to do so. This should include ensuring that, where relevant, any unpaid carers have been consulted on whether they are willing and able to provide care and support. Young carers should be offered independent advocacy support if they want it, to support them to consider how they will be impacted.
See also – the criteria to reside tool (see Annex D of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care) supports clinical teams to have discussions and make decisions whether a person needs to stay in an acute bed to receive care.
6. Assessing for Long-Term Needs
People should be assessed for their long-term care needs following a period of recovery, rehabilitation and reablement (where required) when they are back in a familiar environment. The assessments should take place at a point of recovery when their long-term care needs are clearer.
Local authorities have duties to assess and meet people’s eligible care needs in relevant circumstances and these assessments should be conducted in a timely manner, in accordance with their Care Act 2014 duties. Best practice is for these assessments to be undertaken in a person’s home to determine long-term care needs.
If care, treatment or support is needed, the person should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options that are available. This includes, if they require, consultation with family members and any carers who are willing and able to provide care and support. If they do not have any friends or family members to consult, an independent advocate should be consulted (see Independent Advocacy chapter).
Social care expertise is a central part of the process to determine people’s long-term care needs following a period of recovery and rehabilitation. It can maximise their independence, meet their needs and wishes and ensure they are fully aware of their options and the implications of each choice.
For people leaving the acute hospital environment it is best practice to screen for NHS Continuing Healthcare at the right time and in the right place for that individual (see NHS Continuing Healthcare chapter). In most cases this will be following discharge and after a period of recovery at home.
People with end of life needs will have additional considerations, which are set out in Section 8.1, Palliative and end of life care needs.
7. Active Risk Management
Multi-disciplinary discharge teams should work together when discharging people to manage risk carefully with the person and their unpaid carer, representative or advocate, as there can be negative consequences from decisions that are either too risk averse, or do not sufficiently identify the level of risk.
At one end of the scale, people may be discharged onto pathways which result in care being over-prescribed; and at the other end, individuals may not receive the care and support they need to recover. Any onward care providers should be included early in the person’s discharge planning. This allows more time for local capacity to be managed and for suitable support to be put in place. People’s care needs may also change, and there should be processes in place to ensure these needs are continuously reviewed and that the person is receiving appropriate support (see Section 4, Joint Accountability across Health and Social Care Leads to Better Outcomes).
Individuals and local factors will determine how best to manage risk. For example, in areas covering a broad geography, a virtual transfer of care hub may be one model that can facilitate multidisciplinary working to ensure information about individuals and any family or friends caring for them is shared effectively across organisations with their consent. Other areas may choose to co-locate key staff members from relevant organisations at a physical transfer of care hub, such as in a local acute hospital.
Alongside ensuring integrated working across health, housing, social care and other key organisations, assigning a single point of contact ensures that the individual or the family can communicate with professionals in a timely manner. Unpaid carers, in particular young carers and young adult carers, should be told how to communicate their concerns to professionals. This could be particularly crucial if there were a change in the person’s care needs post-discharge, such as their condition worsening. Supporting multidisciplinary working is also key to developing a shared approach to risk to support discharge. Huddles, trusted assessment, shadowing, and peer learning can all support this.
Health and social care professionals working in NHS bodies and local authorities should ensure that ‘safety netting’ is provided whereby the individual is provided with advice on discharge. The person should be given the contact details of their discharge team at the point of discharge and advised to make contact if they are concerned about anything. People should not be asked to see their GP or go to the emergency department following discharge, and they should only be followed up by a new team when the person’s relevant information has been handed over to the new team. Where appropriate, information provided to the person on discharge should be shared with their family, any unpaid carers and providers of onward care services. Where a young carer is identified, or any professionals responsible for care planning have concerns about this, the local authority has a duty to conduct a needs assessment, where it appears that the young person may need support.
8. Specific Needs
8.1 Palliative and end of life care needs
Consideration should also be given to people who have palliative care needs, including those who are nearing the end of their life (see End of Life chapter). Health and social care partners should work together to provide appropriate rehabilitation and reablement support from palliative and end of life specialist services and voluntary organisations. This may include support to maximise the individual’s independence or meet other personal goals.
People receiving palliative or end of life care should be supported to, where possible, recover from the incident that resulted in them being admitted to the acute hospital. They should receive appropriate and compassionate support from specialist organisations post-discharge to continue living the remainder of their time with dignity and as fully as possible. People who are recognised as likely to be in their last year of life may also benefit from further support such as benefits advice and equipment.
Systems should have regard to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care for people where an appropriate clinician has decided that they have a primary health need arising from a rapidly deteriorating condition and the condition may be entering a terminal phase (see Continuing Healthcare NHS chapter).
Health and care providers should collaborate to minimise common issues that may disrupt end of life care during the interim care period. This includes access to medication and support, or trained professionals to administer them where necessary, and access to 24-hour nursing care and support to talk through the person’s wishes and preferences. Each person’s care journey should be anticipated and mapped out, including advanced care planning, to ensure they can move through a seamless pathway to end of life care, without unnecessary disruption.
8.2 Information sharing
One of the purposes of integrating health and social care is to ensure smoother care pathways with care joined up around a person’s life, needs and wishes, including an individual’s information and data being shared between relevant organisations with their consent. Relevant care information should be discussed and communicated in a timely manner to the individual and the people who will provide ongoing support, such as domiciliary care teams, GPs, unpaid carers, advocates and family members.
Health and care professionals (such as clinicians, social workers and therapists) should share appropriate information early to support a safe and timely discharge – for example about medication (including whether medication has changed since hospital admission) and immediate support needs, including transport and equipment required.
Local areas should work to establish information sharing protocols and mechanisms to enable data about the discharge process to be shared in a timely and effective manner to facilitate safe and timely discharges.
8.3. Planning and implementation of discharge
On discharge from hospital people who have new or additional needs should be offered choices of onward care and support to aid their recovery before any out of hospital assessment and arrangement of ongoing care and support (if needed). The choices offered should be suitable for their short-term recovery needs and available at the time of discharge.
Key to enabling choice while preventing delays is early and ongoing discharge planning conversations between healthcare professionals and people and their families and unpaid carers, following the principles of personalised care (see Personalisation chapter).
People in hospital should be supported to participate actively in making informed choices about their care, including, for people who fund their own care, the potential longer-term financial impact of different care options after discharge. These conversations should begin early in a hospital stay, and not when a person is ready to be discharged. This should also include, where appropriate, information about housing options (adaptation of the existing home and possible alternative housing, for example supported living).
Where there is disagreement between a person and their unpaid carers or family members, and the person is deemed by the appropriate professional to have capacity to make decisions relevant to their discharge, the person’s right to make these decisions should be respected.
Where a person wishes to return home and their family member or unpaid carer is unwilling or unable to provide the care needed, NHS bodies, local authorities and care providers should work together to assess and provide the appropriate health and care provision required to facilitate the individual’s choice, where possible, and enable a safe discharge.
If a person’s preferred care placement or package is not available once they are clinically ready for discharge, an available alternative or alternatives appropriate for their short-term recovery needs should be offered, while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they no longer require acute care, including to wait for their preferred option to become available.
8.4. Involving unpaid carers and family members in discharge decisions
Family members, friends and other unpaid carers play a vital role in the care of people who are discharged from hospital.
A determination should be made as early as possible in discharge planning – or following a period of recovery – about the status and views of any carers who provide care, including that they are willing and able to do so. This will need to be age appropriate if this is a young carer under the age of 18.
In delivering sound discharge planning, NHS bodies and local authorities will need robust systems to identify carers, including young carers, early in the process.
A carer’s assessment can be completed as soon as practicable after discharge (see Assessment chapter, Section 7, Carer’s assessment), but should be undertaken before caring responsibilities begin if this is a new caring duty or if there are increased care needs. If the assessment needs to take place prior to discharge it should be organised in a timely manner so as not to delay discharge from hospital. Under the Care Act 2014 the local authority must carry out an assessment where it appears that an adult carer may have needs for support at that time, or in the future, and to draw up a support plan for how these needs will be met. Should carers have substantial difficulty engaging in their own assessment, they should be referred for independent advocacy support (see Independent Advocacy chapter). Young carers in particular may benefit from independent advocacy support.
Recording carers’ details in electronic patient records can be one way to facilitate the identification and recognition of carers, particularly in cases where the person they are caring for has experienced repeat admissions. There is also the opportunity to identify the carer on their own patient record.
Practitioners should note that not all individuals who are (or will be) providing ongoing care will identify as a ‘carer’. If the person is nevertheless acting in the role of a ‘carer’, they should be regarded as one and involved in key conversations about the care needs of an individual after their discharge from hospital, or in having their own needs assessed. In other cases, the person being discharged may themselves have caring duties, such as a parent of child with a disability. Parents in this situation should be made aware of their right to an assessment of their needs and any additional services the local authority may need to put in place to support them in fulfilling their caring role for their child. This could include, for example, the provision of a short break or respite care to support the family (see Carers’ Breaks chapter).
Consideration should be given to identifying any children or young people in the household who have caring responsibilities, or may have new responsibilities at the point of discharge. This may include children or young people taking on a greater caring role in relation to a disabled sibling or other child in the family, as well as providing care to a parent following discharge.
Where a young carer is identified, or any professionals responsible for care planning have concerns that the person will be discharged into the care of a person under the age of 18, the local authority should be notified of this information. Upon notification, the local authority must carry out an assessment where it appears that the young person may need support or on request from the young carer or their parent. Any assessment should take into account the young carer’s age, understanding and family circumstances. Local authority assessments must also consider whether it is appropriate or excessive for the young carer to provide care for the person in question, in light of the young carer’s needs and wishes. The NHS has a duty to cooperate with local authorities in exercising these responsibilities.
There are instances where relationships are abusive: the individual or their carer may be abused, may abuse or be neglectful, or may have key information about abusive others. The Local Multi-Agency Safeguarding Adult Procedures should be followed where abuse, or risk of abuse, is identified, or staff members have concerns about abuse.
8.4 Mental capacity and advocacy
Mental capacity should be assessed on a decision-specific basis. If there is a reason to believe a person may lack the mental capacity to make relevant decisions about their discharge arrangements at the time the decisions need to be made, a capacity assessment should be carried out as part of the discharge planning process. Where the person is assessed to lack the relevant mental capacity to make a decision about discharge, a best interests decision must be made in line with the Mental Capacity Act 2005 and usual processes. No one should be discharged to somewhere assessed to be unsafe, and the decision maker must make the best interests decision.
Onward care and support options which are not suitable (for example, those not considered clinically appropriate) or available (for example, placements which are not available) at the time of hospital discharge should not be considered in either mental capacity assessments or ‘best interests’ decision making. Just as a person with capacity does not have a right to remain in a hospital bed if they no longer require acute care, neither is this an option for a person who lacks the mental capacity to make the discharge decision.
During discharge planning, health and care providers should continue to meet their responsibilities regarding Deprivation of Liberty Safeguards, where appropriate (see Deprivation of Liberty Safeguards chapter). This is especially the case for, but not limited to, people with a learning disability, dementia, acquired brain injury or people currently lacking capacity to make decisions about their mental health treatment. This includes carrying out a capacity assessment before a decision about discharge is made if there is reason to believe a person may lack the mental capacity to consent to their discharge arrangements which amount to a deprivation of liberty.
It may be appropriate for an independent advocate to support an individual during the discharge planning process, and in some cases this may be a legal requirement (see Independent Advocacy chapter). Referrals to independent advocacy services should be made as soon as discharge planning begins and ideally upon admission.
8.5. Tailoring support to specific needs and circumstances
Where there are ongoing health, housing or social care needs after discharge with different care options available, individuals (and, where relevant, their family, unpaid carers or advocates) should be empowered and supported to make the best choice for their individual circumstances.
Transfer of care hubs should incorporate appropriate safeguards for individuals who require this. For example, people who are homeless, at risk of homelessness or living in poor or unsuitable housing should be identified on admission to hospital. Individuals with a physical or learning disability and mental health needs have an increased probability of needing to use the social care system in their lifetime. Local areas should ensure that all legal responsibilities are met in relation to After-care in section 117 of the Mental Health Act 1983.
Health and social care professionals should follow an ongoing commitment to reducing health disparities and inequalities and consider the needs of groups that might need specialised support. This includes, but is not limited to, understanding issues relevant to people from black, Asian and minority ethnic groups, LGBTQI, faith or cultural needs, people living with disabilities, autistic people, older people, unpaid carers, people who do not speak English, and those with specific communication needs.
Any local changes to discharge arrangements should ensure that care providers are continuing to meet their responsibilities regarding Deprivation of Liberty Safeguards. This is especially the case for, but not limited to, people with a learning disability, dementia, acquired brain injury or people currently lacking capacity to make decisions about their mental health treatment.
For people where new mental health concerns have arisen, psychiatric liaison teams should be contacted by case managers in the first instance to review and assess as appropriate. A care co-ordinator or relevant mental health clinician should be involved in the discharge planning for people with a pre-existing mental health concern who are known to mental health services, to ensure their mental health needs are considered. They should ensure that the proposed onward care provider, if relevant, is fully aware of the person’s support needs. For those who are being discharged from an acute hospital following an episode of self-harm, the provider should consult NICE guidance on Self-Harm to ensure appropriate processes are being followed. Where individuals present with mental distress but do not meet the criteria for secondary mental health services, a preventative mental health offer should be available.
All people who are homeless or threatened with homelessness (see Homelessness chapter) should be identified on admission to hospital. During the hospital stay, the person should be referred by acute hospital staff to local authority homelessness or housing options teams, under the requirements of the Homelessness Reduction Act 2017, if the person consents. This duty to refer ensures services are working together effectively to prevent homelessness by ensuring peoples’ housing needs are considered when they come into contact with public authorities. People who are homeless or at risk of homelessness should not be excluded from short-term post-discharge recovery and support because of their housing status. Further guidance on supporting people who are homeless when being discharged from hospital can be found in the LGA and ADASS high impact change model for managing transfers of care and the accompanying support tool (see Managing Transfers of Care – A High Impact Change Model (LGA et al).
For people living in poor or unsuitable housing the local housing authority has a duty to provide any necessary adaptations (as determined by legislation and regulations underpinning the Disabled Facilities Grant System) and assess housing needs. The local authority also has the power to implement fast track and integrated systems for such provision.
Many people admitted to acute medical units have a condition which makes them frail (see Working with People Living with Frailty chapter). This is characterised as:
- multiple physical, cognitive and functional impairments resulting in longer stay in hospital;
- higher rates of hospital acquired harms such as deconditioning, falls, infection, delirium and adverse drug events.
Research suggests that the average 30-day readmission rates are around 20% in this group, but many can be prevented by comprehensive geriatric assessment and discharge planning that includes a specific focus on:
- medicines reconciliation and optimisation;
- patient and carer information, advice and support;
- falls interventions (see Preventing Falls chapter);
- provision of assistive technology to mitigate risk at home (see Technology Enabled Care chapter).
The default pathway for people with frailty should be home first, with intermediate care at home to regain functional ability after discharge. However, some people with more severe frailty may require a period of step-down bed-based care to support them to regain confidence and independence in a homelike environment. For those individuals, care should adopt a reablement approach, supported by the community intermediate care team in order to maximise recovery and delay progression to long term residential care.
9. Case Studies
The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) provides two case studies about how two local areas have agreed funding to support best practice for their local hospital discharge services.