The drive to rapidly clear hospital beds at the start of the pandemic left some of those discharged unsupported with unmet care needs, research has found.
More than four in five of those discharged between March and August 2020 (82%) did not receive a follow-up visit and assessment at home, with 18% of this group reporting an unmet care need, found a survey of 352 patients and 177 carers of people discharged during this time.
Almost half (45%) of disabled respondents to the survey by Healthwatch and the British Red Cross reported unmet needs following their discharge, as did 20% of those with long-term conditions. Issues reported by those with unmet needs included problems accessing aids and equipment, a lack of consideration of their home situation and being unsure how to manage their conditions.
Contrary to government guidance
The findings come despite government guidance published in March saying that patients with no or minimal support needs should have access to support from voluntary organisations if necessary within 48 hours, while those with care needs receiving an assessment from a lead professional on the day of discharge.
Healthwatch and the British Red Cross said their findings, which were also based on 47 in-depth interviews with health and care professionals involved in the discharge process, indicated “a real gap in the provision of post-discharge community health and social care services for those who are likely to need additional help”.
The organisations’ research examined the “discharge to assess” policy introduced in March to quickly free up 15,000 beds to provide capacity to tackle Covid-19, by assessing people’s ongoing support needs post-discharge, usually in the person’s home. To enable this, the government provided the NHS with £1.3bn to fund post-discharge support from March to August.
The report praised health and social care professionals’ efforts in rapidly discharging so many patients so quickly, highlighted the value of national policy and funding in reducing bureaucracy in the discharge process, and said there was evidence of better joint working between health and social care services as a result.
Lack of post-discharge support
However, the research found one-fifth of people felt unprepared for their discharge, while 35% did not receive the contact details of a health professional they could get in touch with if they needed further support or advice, again contrary to the government guidance.
Also, 30% of those tested for Covid-19 did not receive their results before they left hospital, creating barriers to managing people’s conditions post-discharge, which was particularly the case in care homes.
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The research also found that 53% of unpaid carers felt that their caring responsibilities were not considered when they should have been, which included not being kept informed, being unclear about the patient’s transport arrangements and a lack of information about how to support their loved one after discharge. In addition, 54% of paid and unpaid carers felt they did not receive enough information to support their friend, relative or client after discharge.
The report also raised concerns about the government guidance allocating specific proportions of patients to each of four discharge pathways, with 50% able to go home with minimal or no additional support, 45% able to do so with a care package, 4% requiring rehabilitation and 1% nursing home care.
“We are concerned that the use of a single number as a national assumption might result in local systems using this as an informal “target” rather than developing their own assumptions,” said the report. “This appears counter-productive to ensuring that post-discharge support services are responsive to local needs.”
Social workers unable to assess capacity
The discharge to assess policy resulted in many hospital social workers being removed from wards so that they could assess and support people post-discharge. However, the report identified issues with there being a lack of social workers available to assess people’s mental capacity in hospital.
“Instead, some hospital staff had to conduct these assessments, when they reported lacking confidence in doing them or were not adequately trained to deliver them,” said the report. “This has been challenging for staff and caused delays for patients’ discharge.”
The British Association for Social Workers (BASW) said the report’s findings mirrored those of its own recent survey of social workers and people involved in hospital discharges, which also highlighted a lack of follow-up visits post-discharge and issues regarding capacity assessments.
‘Rush to discharge driving decisions’
Liz Howard, professional officer at BASW England, said a rush to get people out of hospital was driving decisions, with social workers no longer involved in the initial decision making about discharge arrangements.
“Moreover, without access to care and health settings, social workers are struggling to comply with the Mental Capacity Act to obtain the person’s views and wishes, carry out mental capacity assessments, or advocate what is in a person’s best interests,” she said.
Association of Directors of Adult Social Services (ADASS) immediate past president Julie Ogley said directors were particularly concerned that follow-up calls and assessments had not always happened, and that good information and advice were not readily available post discharge.
“At times, it required greater staffing support across social and community services that were simply not available,” she said. “If we are going to avoid repeating those mistakes this winter, we must learn the lessons of this report.”
From September, the government amended its policy to limit NHS-funded care to six weeks post-discharge, backed by £588m to last until March 2021, though has continued with the discharge to assess approach.
Ogley said more funding was needed to “allow us to properly remunerate and expand our committed and valued workforce, and to make effective post-discharge care a reality”
Her call for extra investment in post-discharge services was echoed by Healthwatch and British Red Cross, who said it should be a medium-term objective to improve the discharge process, amid a resurgence in coronavirus cases and anticipated winter pressures across the health and social care system. This should include ensuring community services can operate seven days a week and tackling workforce shortages, it said.
The report added that, immediately, everyone leaving hospital should be given a follow-up contact for further support, with carers and family members also given this information. In the short-term, the Department of Health and Social Care and NHS England should assess and tackle the low level of follow-up visits post-discharge, which should then be monitored locally and nationally, by local leaders and the Care Quality Commission respectively.
It also said policy should be amended to ensure everyone is given a follow-up visit, even if they are anticipated not to need post-discharge support, and that the allocation of national proportions to each post-discharge pathway should be reconsidered.