How is the NHS improving hospital discharge arrangements to cope with winter pressures?

In October, when health secretary Frank Dobson announced a pounds300m winter cash boost for the NHS, he promised it would provide 'a catalyst for developing innovative and imaginative ways of working which will serve the NHS well in future years'. When health authorities began to earmark this cash, it became clear much of it was to be used to improve hospital discharge arrangements.

Wakefield HA, for example, has given pounds38,000 to the adaptations and disability unit of Wakefield council 'to respond to referrals from hospital and social services to allow early discharge, where appropriate'.

Bradford social services department has been guaranteed pounds50,000 for 12 nursing home beds to provide earlier discharge from hospital, plus a further pounds30,000 to fund additional medical, nursing and therapy staff to support people discharged to the nursing homes.

Salisbury General Hospital intends to open a discharge lounge so that beds can be made available within an hour of patients being assessed ready for discharge, while community hospitals in Dorset are to be used more widely to transfer patients from district general hospital beds when they no longer need acute care but are not yet ready to go home.

But the NHS accreditation unit, Health Services Accreditation, has warned in a report that reductions in lengths of stay can threaten patients' health. It has outlined a series of standards which it believes all hospitals should meet when managing patient discharges.1

By streamlining discharge procedures, hospitals can ensure patients are discharged with the right continuity of care, reducing current high levels of readmission, says the report, Service Standards for Discharge Care.

'Meeting these new standards will help ensure patients are discharged on time, with the right levels of support and the right medication,' says Jean Bailey, chair of the working group which devised the standards. 'This will free beds and other services for patients and will release considerable resources for the NHS.'

The Audit Commission has also urged health and social services staff to agree who is responsible for the different stages of the discharge process, and to monitor whether these responsibilities are being met.2

In its recent report, The Coming of Age, the Audit Commission highlighted three 'key parts' of the discharge process which results in 'blocked beds'. First, the failure to agree responsibilities between hospital and social services staff; second, a failure to set reasonable time standards which left people 'languishing in hospital for long periods unnecessarily'; and, finally, inconsistent assessment procedures leading to poor-quality assessments. 'Assessments must be accurate,' says the report, 'since in many cases it affects where people spend the rest of their lives.'

But many health service organisations are getting to grips with the thorny problem of discharge.

South Manchester intermediate care team

This six-month pilot early-discharge scheme for all adult clinical departments of South Manchester University Hospitals trust, developed by local GPs in collaboration with the hospital trust, Mancunian Community Health trust, Manchester social services and Manchester HA, has been running since July.

The scheme has created a community-based team of nurses, therapists and social care workers which, supported by a patient's own primary healthcare team, can offer a similar quality and intensity of care to patients as the hospital-based team, says local GP Peter Fink, director of the project. 'We have also improved the level of communication between hospital clinicians and GPs so that patients can be discharged as soon as they are medically fit, with the hospital doctors having confidence that recovery/rehabilitation will be managed according to their preferred route.'

The scheme has been financed with pounds240,000 from the Continuing Care Challenge Fund, following a bid to the NHS Executive. A further pounds720,000 will be provided next year so that the scheme can be rolled out across the whole city.

At present, the scheme involves 22 general practices, two-thirds of the practices in south Manchester. The intermediate care team is made up of a community liaison sister, physiotherapist, occupational therapist, care manager, project manager and project director. Initially, nursing homes were used for the discharged patients, but now, increasingly, patients are being returned to their own homes, where they receive care from the team and their own GP.

Patients get as many visits as they need from the nurse and relevant therapists, Dr Fink explains.

A patient who has had a hip replacement, for instance, may come out of hospital on day five and then spend 10-14 days in the intermediate care scheme. Initially, patients receive daily visits from nurses and physiotherapists, and these are reduced as mobility increases and pain diminishes.

The extra burden on GPs is minimal, says Dr Fink. 'No practice is likely to have more than two patients on the scheme at any one time and most patients only require the one initial visit from their GP, 24 hours after discharge. Most of the workload is carried by the nursing and therapy staff.'

GPs are given control over whether a patient is discharged to the scheme and get paid for their extra work, he adds. GPs are paid on a piece-rate basis - only when they have a patient on the scheme. They receive pounds17.50 for a visit and pounds5 for a telephone call or other contact. The scheme guarantees that a patient will receive a visit from their GP within 24 hours, he points out. 'So far, only one patient and two GPs have refused to opt for early discharge.' Some 40 patients have been successfully discharged from hospital early, with conditions ranging from cardiac failure to chest infections.

'All of them were medically fit at discharge but were weak and poorly mobile and most needed regular oral analgesia,' says Dr Fink. 'They were all fit for discharge to the primary healthcare team after a further five to 14 days, and there have only been three readmissions due to unexpected illness.'

Royal Cornwall Hospitals trust

Four discharge co-ordinators who link with social services, two discharge liaison nurses who link into primary care, and a discharge nurse trainer, make up the trust's discharge team which has provided, according to Denise Samuels, the trust's patient services director, 'an absolute boost to the whole organisation'. The scheme has been operating since 1995.

The team makes patient discharge happen smoothly and, as the only acute trust serving the county of Cornwall, this is essential, says Ms Samuels. 'We can never close our doors. The nearest hospital is 70 miles away, so we have to take everyone who comes in and we are often chock-a-block. If we can't move people on, we can't cope. We face that constant pressure so, perhaps, this has made us concentrate on discharge more than other units.'

The discharge co-ordinators visit each ward every day and work very closely with social services, as well as with patients' carers and relatives, to ensure the right package of care is in place before the patient is discharged. Ward staff still have ultimate responsibility for referring cases to social services and completing the necessary form, but the discharge co-ordinators take on much of the time-consuming work, such as chasing up the information needed for the form. Most cases are fairly straightforward, although around a third of the workload can be dealing with complex cases, and these are picked up by the discharge liaison nurses.

The bulk of the work is with elderly people, but other cases are also dealt with by the

discharge team. 'The team may have to organise arrangements for someone in their 50s who has had a stroke, or for a young disabled person,' says Ms Samuels. 'But I can now say, with confidence, that we have very few bed-blockers.'

Pentland Medical Centre, Edinburgh

Community nurses, social workers and GPs are 'steadily dismantling the Berlin Wall between health and social care' in the Currie district of Edinburgh, according to Ian Kerr, a GP at the Pentland Medical Centre. The Currie care management team was set up by Dr Kerr, Lothian health board, Lothian social services and Edinburgh Healthcare trust. It has been in operation since 1993. The team works with three acute hospitals and one psychiatric hospital in Lothian. It covers 18,000 patients, and sees about 150, mainly elderly, people a year.

The team comprises a full-time social worker, half-time district nurse and half-time health visitor, both of whom are trained in assessment and care management, supported by GPs.

Patients can be referred to the team by themselves, or their carer, before discharge from hospital and by a GP, district nurse, or other health professional. Most referrals are made by health professionals.

Patients are referred to the team for assessment. The social worker, district nurse and health visitor cross each other's boundaries and can set up packages of care, including referrals to nursing homes and residential care. The Currie management team can assess and process a patient within two weeks, freeing hospital beds quickly. But the team can only place people in long-term care if the funding is available, Dr Kerr points out.

It has a 'one-door approach' to addressing and providing for the needs of patients in the community, says Dr Kerr. 'This provides seamless care for those discharged from hospital and a faster, more targeted approach for vulnerable patients, their carers and families. Referrals are made earlier, cutting the nail-biting time that patients and their carers wait for assessment.

'Patients also deal with one named person, so there are no problems about whose responsibility the patient is. Multiple visits by professionals are also avoided as the care package is co-ordinated by a manager who maintains an overview and liaises with all the professionals involved.

'It makes discharge much quicker and smoother, and it can also prevent unnecessary hospital admissions. As well as winning patient approval, hospitals like the scheme, too. Staff prefer to deal with one person who organises care to meet the discharged patient's needs back in the community.'

Queen's Medical Centre University Hospital trust, Nottingham

A co-ordinator is to be appointed next month to launch a two-year pilot project aimed at speeding up discharge to the community. The scheme, to be known as 'healthcare of the elderly community services', will involve day hospitals.

So far, three groups of patients have been identified as suitable for the scheme: stroke patients, patients with fractured neck of femur and elderly, frail people who are medically stable but have rehabilitation goals and increased social care needs. GPs and social services will be involved and care workers, with a nursing auxiliary background and some therapy training, will visit patients at home, probably daily, until they are no longer needed, or care is handed over to social services.

'It is still a vision, not yet up and running, but we plan to use some of the winter pressures money to develop the service,' says John Morrant, healthcare for the elderly director at Queen's Medical Centre University Hospital trust. 'It is being set up to improve hospital discharge but, no doubt, services will be able to be accessed by people in the community, potentially avoiding some hospital admissions.'

The objective is to 'make a dramatic difference' to patients' length of stay in hospital, he adds. 'For example, at the moment, a severely disabled stroke patient will have a very long stay in hospital. We aim to cut that stay by a massive three to four weeks.'

Dudley social services

A recuperative care scheme is being piloted by Dudley social services with support from Dudley HA. The scheme is designed for people who have been through their acute hospital inpatient stage but need a 'halfway house' in which to convalesce before going home.

Dudley social services is starting the scheme with six beds in a residential home. 'If it works,' says Keith Leatham, acting assistant director for adult care, 'our intention is to use a new home, which has only recently been opened, to provide a dedicated unit of 18 beds.

'We think this will work better, as the motivation of staff in a normal residential home is to make the patient comfortable and encourage them to feel at home there, whereas the emphasis we want is on rehabilitation and then returning home.'

Social services will provide an occupational therapist, and other care staff will be linked into the new unit. 'It is not a short-term measure for the winter,' adds Mr Leatham. 'If the pilot is successful we will carry on the scheme throughout the year.'

Barnsley District General Hospital

A 'discharge lounge' will be in operation from this month at Barnsley District General Hospital in order to make beds available much earlier on the day of a patient's discharge.

The dedicated area will provide a high standard of comfort and facilities, such as hot drinks, newspapers and music, says Brenda Howard, operations director, surgical services. 'It will create a much nicer environment for patients waiting to leave, rather than their waiting on the wards.'

Nurses, a pharmacist and porters will be attached to the unit, and patients will be brought to the lounge in the morning to wait for their transport. 'It will free beds many hours earlier in the day and avoid the situation where patients are having to wait in A&E for a bed,' says Ms Howard.

'At the moment, patients hang around the ward until an ambulance or their private transport arrives to pick them up. The lounge will streamline the discharge process and also give patients a quality service while they wait to leave.'

North Staffordshire health authority

Seven-day working has been introduced at North Staffordshire Hospital trust for all support services, pharmacy and physiotherapy so that discharge can take place at weekends. 'Many patients have their discharges delayed because they are waiting for drugs or for test results from pathology,' says HA commissioning director Tracey Baldwin. 'Making sure the hospital support services work seven days, rather than five, can eliminate many of these unnecessarily long waits.'

Discharge chasers have also been employed by both North Staffordshire Hospital trust and North Staffordshire Combined Healthcare trust. 'These are senior nurses whose job is to go onto every ward, look at the discharge arrangements for each patient, and see what they can do to speed the process as much as possible,' Ms Baldwin explains. Since they were introduced five weeks ago, the average length of stay for elderly patients has been reduced from two weeks to five days, she adds.

Both trusts, together with social services, have also agreed to collect their discharge information in the same way, on the same day, using the same form 'so that any 'funnies' around delayed discharge are ironed out early', says Ms Baldwin. 'We have standardised all discharge information, so that everyone has exactly the same information at the same time and all parties meet weekly to discuss the situation. This has created the net result of moving patients through the system much more quickly.'

The Royal Hospitals trust, London

A new role of care co-ordinator has been introduced at the Royal Hospitals trust in a bid to keep track of patients from the day they are admitted. Unlike a discharge co-ordinator, the care co-ordinator follows the patient from admission through to discharge, says Debra Davidson, the trust's operations manager for general and emergency medicine.

'There was a clear need for someone to be responsible for co-ordinating a patient's treatment in order to facilitate a rapid and efficient hospital stay,' she explains. 'A care co-ordinator accompanies the consultant on the admissions ward each morning. If a patient needs an investigation, the co-ordinator will make the appointment themselves, rather than using the post. If they think the patient has to wait too long for this appointment, they have the power to challenge it. They also chase up test results, to make sure they come back as quickly as possible.'

Care co-ordinators liaise with GPs, other hospitals to get notes or medical histories, and social services. Meetings are held with social services once a week 'to nip problems in the bud as they arise', says Ms Davidson. 'The role of the care co-ordinator is to push past normal boundaries and use their initiative to ensure patients are not held up in the system.'

The trust has also changed the way in which beds are managed in the medical directorate. A lead nurse now has responsibility for bed-management issues, and consultants have become ward-based, with every effort made to group together patients who come under the same consultant. Wards automatically ring the lead nurse when they have spare beds, and patients waiting in the admissions ward can be matched to an up-to-date list of beds.

Despite these initiatives, general and emergency medicine still averages 20 patients a week who are able to leave hospital but who are still filling beds, Ms Davidson admits. 'In the past, all of these delays would have been blamed on social services, but we now know that only around one-third of

our delays occur because social services are resolving particular problems. The rest are due to delays in moving patients on to other establishments, such as rehab units, and a whole host of other miscellaneous reasons.'

South West London total purchasing pilot

A hospital discharge project, funded by the South West London TPP, is having an impact both on speeding up discharges and on preventing unnecessary admissions to the St Helier trust in Carshalton. The project is run by representatives of the HA, trust, social services and community health council.

At present, there are three routes of access to the scheme. GPs can refer patients directly from the community; doctors and nurses in the trust's A&E department can refer patients who present there; and patients can be discharged from hospital to the scheme. Up to 15 patients a month - 10 per cent of the TPP's emergency activity - are currently being referred to the scheme, reducing the pressure on inpatient beds, says Heather Maughan, discharge planning co-ordinator.

The TPP has purchased eight beds from the existing hospital-at-home scheme and six inpatient beds in local nursing homes and the Carshalton War Memorial Hospital. Most hospital inpatients to be referred to the scheme have come from orthopaedics, although patients with other conditions, including pneumonia and end-stage chronic renal failure, have been referred, as have a number who needed palliative care.

Whether patients are allocated a hospital-at-home bed or a nursing home/War Memorial Hospital bed depends on their level of dependency, patient choice and where beds are available at the time, says Ms Maughan. Target lengths of stay are 10 days for hospital-at-home patients and 14 days for others, and the average length of stay is currently working out at 13 days.

The discharge planning team - made up of the co-ordinator, two discharge planning nurses and an administrator - is also able to carry out screening and prevention work with elderly people in the community. 'The best way of facilitating hospital discharge is to keep patients out of hospital in the first place, and that is what we are trying to do,' says Ms Maughan.