Are Discharge to Assess services delivering on their promise?

Discharge to Assess is a health-led approach, launched by NHS England (NHSE, 2016), which aims to provide care to people at home (or elsewhere in the community) as a means of facilitating quicker discharge from acute hospital settings. The discharge to assess model has been implemented across the country, however over the period of pandemic and the increased demand on NHS resources caused by industrial action and winter pressures, services are increasingly being identified as not living up to the expectations that underpin the model. This, combined with a scarcity of available resources in adult social care services, has meant that there has been debate in relation to both the purpose and the effectiveness of the discharge to assess model across the country (National Audit Office, 2016; NHSE, 2016; Meehan, L. et al, 2018; Horton, T. & Wood, S. 2022).

In this paper the authors focus on one service and analyses the perspectives and experiences of those involved in its delivery within  systemic analysis framework. A case study approach was taken which allows for depth in the consideration of the range of variables that impact on how the service is both delivered and experienced. The study aims to exploration the motivations, values, perspectives and presumptions of the various stakeholders who are either receiving or delivering elements of the model and/or service.

Discharge to assess models have been supported by government and policy makers as a way to ease pressures on the hospital system, but is it achieving its aims?

Methods

After providing a brief overview of the discharge to assess model and setting out the policy and evidence that the approach is based upon, the authors examine one service, based in Kent, which was part of the SUSTAIN integrated care improvement programme.

For those who are not familiar with SUSTAIN, it is a European study focusing on improving integrated care for older people living in the community. This paper focuses specifically on the application of a critical systems understanding to interpret the outcomes and dynamics within one service, and consider how improvements could be made to the experience of the recipients and those delivering the service model.

To read more about the SUSTAIN project visit https://www.sustain-eu.org/

The model of analysis applied in this study is the Critical Systems Heuristics (CSH) framework (Ulrich, W. 1983), a reflective practice approach based on philosophical and systems theory. The approach asks questions about a given programme, in this case a Kent Discharge to Assess service, which includes what it is, what it ought to be, it’s purpose, legitimacy and beneficiaries. The aim being to collate multiple perspectives and explore how stakeholders (in this case professional staff, patients and their supporters) perceive and experience the service.

This study focuses on the experience of individual patients and staff by asking twelve questions across four domains, each examining a different element of the service and its operation. The domains included were:

1. Measure of success – how the service defines success and the outcome measures used by different stakeholders to determine whether the objectives of the programme are delivered.
2. Decision environment – how decisions are made in relation to the allocation of resources, workforce deployment, and identification of appropriate decision makers within both the service management and the strategic group who oversees the service.
3. Expertise – what are the range and scope of knowledge and skills available within the service, including knowledge of the organisations involved and their internal systems.
4. Underpinning rationale – what is the core focus of the model is to improve person-centred care and improve efficiency and this domain considers the extent to which the various stakeholder groups perceive this to have been achieved.

The data collected and used to develop the case study included participant observations, a series of fifteen focus groups and twenty-one interviews with service users, carers, professionals, and managers involved in the service. Notes were made of these and the perspectives used to identify enablers and barriers to the effective operation of this service.

Results

Systemic understandings have been in the background of the social care evidence-base for some time (Hardy, R, 2018), with developments in both children & families and mental health practice contexts in particular showing positive results from introducing systems thinking to practice.

What is clear in this analysis is that the anticipated outcomes underpinning the implementation of the discharge to assess programme, for example quicker discharge, more people able to return home, and the delivery of wrap-around support in the community, have not been fully realised. Issues such as the lack of leadership, difficulties in achieving professional buy-in and the availability of resources to deliver an appropriate and proportionate discharge to assess approach, were key barriers to successful implementation of the model. Other factors highlighted include some familiar difficulties and barriers such as difficulties in building relationships and challenges in making effective links with the third sector, primary care and GP partners are highlighted as the areas that require further development if the services are to support successful discharge and the discharge to assess model is to realise its aims of improving and streamlining discharge from our over crowded acute healthcare services.

Planned improvements were not realised and, in some cases, negative outcomes were identified by the researchers, for both people accessing the service and the staff working within it.

Conclusions

The analysis identifies that there has been an increasing emphasis on throughput and speedy discharges in the acute setting. The authors discuss the impact of this, particularly when it is combined with the lack of community resources and flawed assumptions about an older person’s safety and wellbeing. They conclude that the approach is not delivering on its promise to improve the effectiveness and efficiency of hospital discharge processes and point towards the lack of community and social care support options and the emphasis on what is available and affordable. This is interpreted as evidence that the objective of a comprehensive community option, i.e. to improve the discharge process, is not yet a reality in practice.

Staff and wider professional stakeholder perspectives reported in this study include an overwhelming emphasis on the delivery of discharge targets. Within this context the gains that had been achieved by the programme were sometimes lost for those involved in delivery of the service. An experience that is mirrored in anecdotal evidence across the sector.

The authors conclude the analysis with an examination of the target driven culture that has developed across acute services and identifies this theme within the case study service, however they also highlight that whilst targets and performance appear to be the central focus this does not preclude a positive experience for those involved in receiving or delivering the service.

Strengths & Limitations

This is one of a series of papers reporting the evidence base for hospital discharge to assess models, details of delivery outcomes and other pilot measures have been reported elsewhere and are not in scope of this paper although the author does provide contextual information and signposting to the wider SUSTAIN programme for further information.

For this particular paper a case study method is used, which whilst supports in-depth analysis of the perspectives of stakeholders involved, uses a very small sample size for both people who use the service and the professionals who are delivering it. The small sample size means that whilst depth is achieved in terms of evaluating the effectiveness of this particular service, generalising its findings to the service model in other areas is much more difficult.  Despite this limitation, the evidence presented, in relation to how far the objectives of the approach have been delivered provides a useful insight into current models of service delivery. Various barriers are identified by the author,  including working across boundaries and the power dynamics which exist within the microcosm of a single service, and the impact of these are helpful to consider for practitioners who work with the interface between acute healthcare and social care services.

While a small qualitative study, the barriers to delivering a coordinated and comprehensive discharge to assess service are explored.

Implications for Practice

In some ways the paper highlights what we already know about our health and social care services, that they are under pressure and under resourced, however the application of a critical systems analysis, which explores power and interrelationships to explain the outcomes of the service is a useful perspective to consider. The theoretical approach allows for the identification of systemic factors to explain why the outcomes of the service have not been as positive as originally expected and explores various aspect of the system which have contributed to these findings.

Coordination between primary and secondary care, between statutory and third-sector provisions and between health and social care are all identified as areas that impact on the delivery of intended outcomes. It is also identified that service providers are working on the assumption that every patient wishes to return home as soon as possible. This is not always reflected in feedback from participants within this study, some of who reported feeling rushed, unsupported and unsafe in their discharge, for example waiting at home, sometimes over several days, for care and support to be arranged after discharge.

The case study supports anecdotal discussions across the sector in that hospital services are under increasing pressure. and the culture of public sector services is currently focused on discharge and creation of acute capacity within our health services. Target and performance culture in health environments are discussed and the disconnect, or silo working, of different elements of health and social care services are identified as a key difficulty or barrier in achieving the aims of the discharge to assess model of service delivery.

Conflicts of Interest

None

Links

Primary Paper

Gadsby, E.W., Wistow, G. & Billings, J. (2022) “A critical systems evaluation of the introduction of a ‘discharge to assess’ service in Kent.” Critical Social Policy; 42 (4), 671 – 694. 

Other references

Hardy, R. (2018) “What is systemic practice?” Community Care, 30/09/2018. [online] Last Accessed 10/09/2023.

Horton, T. & Wood, S. (2022) Improving hospital discharge in England: the case for continued focus and support. The Health Foundation Blog, 31/03/2022. [online] Last Accessed 13/09/2023.

Meehan, L., Banarsee, R., Dunn-Toosian, V., Tejani, S. & Yazdi, A. (2018) Improving outcomes for patients discharged early using a home assessment scheme.” London Journal of Primary Care, 10 (3), 62-67.

National Audit Office (2016) Report to Department of Health. Discharging Older People from Hospital. [online] Last Accessed 10/09/2023.

NHSE (2016) Quick Guide: Discharge to Assess.[online] Last Accessed 13/09/2023.

Ulrich, W (1994) (2^nd Ed) Critical Heuristics of Social Planning: A New Approach to Practical Philosophy. Chichester: Wiley.

Ulrich, W (2000) “Reflective Practice in the Civil Society: the contribution of critically systemic thinking.” Reflective Practice; 1 (2), 247-268.

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