NHSE plans 24-hour target for new hospital discharge service

Slides presented to an NHS England webinar reveal it is seeking to pilot “one single intermediate care step-down service [organised] at place through one lead commissioner”.

It would include a target, or standard, requiring that when patients no longer meet the “criteria to reside in hospital”, they enter the new community recovery service within 24 hours. NHSE’s “vision” is that this 24-hour standard is met for all acute hospital patients within five years, the slides seen by HSJ reveal. The documents do not specify whether they would also be discharged within 24 hours.

Delayed discharges have been a problem for many years, but have caused particularly huge difficulties in the past 18 months, leading to emergency department overcrowding and ambulance handover delays. In August, one in seven patients in acute hospitals were medically ready to be discharged, NHSE figures suggest. 

According to the documents seen by HSJ, key objectives for the new service also include reducing long-term care costs “by decreasing demand and acuity”, and ”increasing people’s functional outcomes” by giving more people better rehab care on discharge. This appears to be a recognition that at present many people discharged receive inadequate rehab, which can exacerbate their condition, requiring more care.

The presentation acknowledges there are major outstanding questions about staffing, designing, funding and commissioning the service. It will need to solve difficult questions about the split in responsibility between the NHS and local government social care commissioning.

The NHSE presentation says the organisation is “working with systems to increase overall capacity of community services”, and that it is “imperative” that post-discharge short-term health and care services “increase in capacity, improve in quality and effectiveness and can support system flow for both urgent and emergency care and elective recovery.”

The new community recovery service would initially focus on post-discharge “step-down” care, but there is an “expectation” that the service could expand to “step-up” care to prevent hospital admission “in later years”.

Jenny Keane, NHSE’s national director for intermediate care and rehabilitation, told the webinar on 23 September that the new service would aim to address the “siloed working” of many current rehabilitation services.

She said: “It’s not that intermediate care doesn’t exist out there, but they have been built upon in a very ad-hoc way, very often with non-recurrent, intermittent type funding. They are funded through social care and the NHS, which adds to the complexity.

“We know there are a lot of patients who are not getting the appropriate input in this service that has a really strong focus on rehabilitation and recovery, with the right individuals leading that.”

Systems will be asked to test commissioning models, “ensuring an agreed lead agency providing a single commissioner function”, consider the effectiveness of services for people with cognitive impairment “or other excluded health populations”, and facilitate “flexible staffing across organisational boundaries.”

Commissioning models for the new service will “respond to known challenges in systems that often rely on rigid approaches and a lack of join-up between organisations”, the presentation says.

“We know we need to respond to challenges in systems,” Ms Keane told the webinar. “We know there’s a lack of joined-upness across organisations. And we know it’s not as simple as commissioning these services, we need to map the gaps we need to understand the current landscape.”

The cost of the new service is “untested and requires substantial economic modelling to show return on investment,” but “it is likely that services will require more investment due to the need to increase capacity, increased intensity and increased demand”, the slides say.

“National modelling” will be undertaken to understand anticipated costs for the new service, and “the resulting savings on long-term care and support needs”. Modelling will also be done to understand workforce demands.

The presentation said there “is a need to agree” who should be accountable for the new community recovery service, and who should be responsible for funding all recovery and rehabilitation services.

Matthew Winn, NHSE’s director of community health, told the same webinar: “We have to move away from siloed services that all have separate criteria and then we hand patients across both health and social care into those things according to our definitions.

“We have to move to a service, both bedded care or at home, that flexes, and the intensity of the support wraps around the person. It’s our job to get the right people with the right skills and the right intensity to support someone, but we pull it from a bigger team.”

NHSE told HSJ  the proposal for community recovery services is “in its initial stages” and is being developed with key partners. 

A spokesman added: “We are exploring how to enable more patients to leave hospital and receive the care and treatment they need closer to home, ideally in their own home, to boost recovery times and increase capacity in hospitals. NHSE will be further testing and evaluating this proposal over the next 12 months.”