Engage: Addressing delays in discharge – a case of integrated care in action?

A report by the National Audit Office (NAO) published earlier this year estimated that delays in discharging medically fit patients from hospital were costing £820m a year. In spite of many organisations across the country introducing various measures to reduce delays in discharges, the NAO reports that the number of delays has risen by a third in the past two years equating to more than 1.1 million days.

Subsequently, MPs on the Public Accounts Committee have produced their own report which is critical of the narrative that cost cutting in social care services is to blame and called on NHS England to help spread good practice being pioneered by those organisations that are managing to reduce delays. Sheffield Teaching Hospital might be one of those organisations at the top of the list – its Big Room initiative is an example of professionals from health and social care coming together to discuss individual patients on a weekly basis and to find solutions to problems preventing discharge. Meanwhile the Trust’s discharge to assess model provides access to active recovery (AR) – a community-based team of nurses, occupational therapists, physiotherapists and rehabilitation assistants. Patients receive an initial hospital-based assessment of their fitness for discharge and their immediate needs, while any ongoing needs are assessed on the day of discharge at home by the AR team. 

NHS England might also be interested in another example from the Midlands, where a partnership between the local CCG and acute Trust has seen the recent introduction of a frailty service to help avoid admissions in the first place and to manage discharge more effectively. Daily multi-disciplinary case conferences, which include the Third Sector, consider the right package of care for patients seen in A&E, or medically fit inpatients.  Immediate actions can be taken to put into effect services and support in the community.

What is common to both organisations is the multi-professional work across organisational boundaries. This has helped to remove previous barriers to timely discharge and has allowed the establishment of closer links with community colleagues, and those in social care, establishing a greater understanding of roles among professionals and between organisations, and increased trust.

These initiatives have not happened overnight and while good examples of integration in action there will undoubtedly have been challenges along the way in their implementation. Indeed last year’s report from the Nuffield Trust on an evaluation of the North West London Whole Systems Integrated Care Programme highlights just how hard delivering integrated services is with much time and energy spent on planning and design and not enough spent on implementation.

It is widely acknowledged that in spite of a wealth of research into the integration of services and the provision of integrated care, how best to achieve it is still a ‘mystery’ for many. The literature continues to highlight the lack of clarity as to whether integration makes a difference and provides meaningful outcomes over and above non-integrated services, or non-integrated care.  

This picture might be about to be redrawn however with more certainty as to what works and when, at least within the NHS in England. A recent announcement by the NAO advises that the organisation is about to embark on a study examining the progress of the range of integration initiatives that currently exist in the NHS, including the Better Care Fund. The study will highlight where and how integration of health and social care is working, what the Department of Health and other organisations are doing to support it, in order to provide some assessment as to whether the Government is on target to achieve full integration by 2020. Other evaluations are also underway, including the national evaluation of Integrated Care Pioneers, led by the London School of Tropical medicine and Hygiene and the Policy Innovation Research Unit, and of which the Health Services Management Centre is part. 

It is possible that the NAO study and other evaluations can provide the evidence to satisfy the Public Accounts Committee that good work is happening when it comes to integrated care in general and integrating services to discharge medically fit patients specifically but it just hasn’t been particularly well documented and shared. With the NAO calling for evidence to be submitted for the study, this is a perfect opportunity for organisations to bring their lights out from under their bushels.

About The author

Hilary Brown is a Senior Fellow and Director of Policy at The Health Services Management Centre, University of Birmingham, and co-author of Integrated Care in Action: A Practical Guide for Health, Social Care and Housing Support.