Published: 12/08/2004, Volume II4, No. 5918 Page 22 23

The introduction of delayed discharge fines has inspired trusts to dream up numerous plans in a bid to avoid incurring penalties. Here, some of those on the front-line explain how they dealt with the challenge

Birmingham Heartlands and Solihull trust

The introduction of delayed discharge fines earlier this year should make us all focus on the reasons why, on any particular day, a patient remains in hospital.

The key to the change at Birmingham Heartlands and Solihull trust was a pilot study to test using an estimated discharge date (EDD). This revealed a widely held view that the reimbursement process has been the main catalyst for action on discharge management. It was considered to have no clinical input and instead be focused solely on the responsibility of the local authority.

The pilot also raised concerns about EDD involving staff in 'more form-filling'. Furthermore, it found that some clinical staff delegated social services notifications to clerical staff, which could erode the quality of clinical information (and means that a process to flag key timepoints in discharge is handled by staff not directly involved in the patient's clinical care).

As a result of what we learned, senior trust staff and social services worked hard on the reimbursement process to ensure patient data is accurately recorded at the right stages during the hospital stay. Local guidelines (produced with the strategic health authority) aim to translate the act into operational best practice.

Accurate EDD remains a core responsibility of clinical teams, requiring two main steps: a clinical process to estimate and document a date of predicted medical fitness followed by a communication process to document the EDD.Without these, there will be little real multidisciplinary professional working within an acute team, let alone between social services and health.

But conventional patient review on ward rounds is too rigid to allow other multidisciplinary team members to attend and contribute. Allied health professionals may feel their contributions would be undervalued, or they may fear their existing workload would make it more difficult to hit the delivery date.

The first 24 hours as an inpatient are likely to be the most intensive in terms of assessment, investigation and treatment.Nurses, let alone doctors, will naturally shy away from predicting estimates of a discharge date in what is seen to be the period of most medical instability.

Accident and emergency departments are under extreme pressure to achieve the four-hour maximum episode time target. This erodes the time available for nurses to obtain a social history from patients and carers, which in turn will have an impact on discharge planning, often through inadequate and duplicated assessments or fragmented information.

The advent of admission wards means that patients who remain in hospital for more than 24 hours increasingly have their inpatient stay divided across at least two wards, disrupting continuity of care. Nurses may not realise the importance of social information they collect after the patient has moved to another clinical area.

Planning the discharge date should be used to lever the exchange of relevant information between team members in health and social services.

This would make the outcome - the estimated discharge date - credible and constructive. Any perception that the process leads to patients being offered unsuitable, temporary places of care at a considerable distance from their family will lead to cynicism.

Agreeing an EDD will not necessarily address problems with transfers of care. Good discharge planning requires recognition of the importance of a host of factors, often unrelated to the patient's presenting illness (problems with mobility, cognition, hospital-acquired infection, pressure sore care or family relationships).

Much also has to be done outside hospital to ensure that district nurses, care packages, intermediate care and respite care are able to respond promptly and in a co-ordinated way.

Liz Lees is a consultant nurse and Dr Mark Temple is a consultant physician at Birmingham Heartlands and Solihull trust.

Southwark council

A co-ordinated approach across the south London councils of Southwark and neighbouring Lambeth maximise the benefit of the discharges grant funding and ensures fines paid by social services are reinvested in solutions. Southwark's blocked beds have fallen from 35 to three in the year to June 2004. It is investing the reimbursement grant in a pooled budget with King's College and Guy's and St Thomas'Hospital trusts.

Schemes funded this year include:

A community-based urgent care team, trialled to prevent older people attending A&E and being admitted when they could be supported at home. The multidisciplinary team will receive most referrals from GPs, district nurses and social workers, but will also support those being discharged from A&E.

Additionally people who have fallen at home, called an ambulance, and been assessed but not conveyed to A&E (around 20 people per month) will be referred and supported.

Step-down housing flats, six sheltered and two mainstream housing flats commissioned from Southwark housing department and housing association the Peabody Trust for patients whose housing situations have not yet been finalised or whose adaptations/equipment have not been delivered.A social work assistant supports the transferred patients.

Extra occupational therapy capacity at King's College Hospital. Two extra occupational therapy posts and an assistant post have been employed to minimise delays within the hospital and help with the smooth movement of patients into intermediate care options.

Councillor Denise Capstick is Southwark council's executive member for health and adult care, and a modern matron.

East Kent Hospitals trust

A key action for the trust was to integrate the secondary and intermediate health and social care teams. The intermediate care team provides a service to the emergency care centres, assessing patients presenting at the hospital with hospital-based multidisciplinary teams.

Staff awareness and the use of intermediate care resources have been improved.

We are piloting discharge home visits with intermediate care support at William Harvey Hospital, Ashford. For example, an elderly woman living alone was referred to the hospital following a fall at home.

She was confused and required treatment for a chest infection. The intermediate care team identified her as someone who would benefit from their services, and monitored her progress in hospital for three days.

The woman's mobility had slightly worsened during her illness, but rather than refer the patient to a rehabilitation bed with a prolonged inpatient stay, the occupational therapist paid a home visit to establish that she could be safely managed downstairs pending rehabilitation at home.An intermediate care team member accompanied the OT and assumed responsibility for her, negating the need for her to return to hospital for more planning.

Sarah Maycock is rehabilitation and intermediate care manager, East Kent Hospitals trust;

Lynette Frost is team leader, social services, for Mid Kent council.

Key points

Delayed discharge fines increase pressure on trusts to prevent delays.

The loss of vital information between health and social services undermines discharges' credibility.

Pooled budgets between the two sectors are a powerful means of fostering innovation.