Getting the fundamentals right: how to better prepare for discharge pressures next winter

Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England last winter. In this long read, Camille Oung highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.

Long read

Published: 24/07/2023

It may be the heart of summer but, for health and social care system leaders, winter is already looming. And the last few winters have been particularly difficult for health and care services, with long waits for patients to get in and out of hospital. Last December, one in six patients in England were waiting in hospital to be discharged to care homes, short-term intermediate care, or to their own home.

People not able to access the support they need in a timely manner are more likely to require more long-term support in the future. For this reason, the National Care Forum, the membership organisation for not-for-profit organisations in the care and support sector, last month brought together leaders from across the health and social care system: leaders of integrated care boards, national NHS leads, local authority commissioners, social care providers, and carer representatives. The roundtable, chaired by the Health Service Journal, sought to identify concrete solutions that system leaders can put in place now to be better prepared for discharge pressures next winter.

In this long read, we highlight what needs to stop, continue and start to help to make next winter better than the last. We focus especially on the role of social care, even if successful discharge involves a much broader range of community health, social care and voluntary providers.

A system better prepared to support people who leave hospital

Over the last three years, the government has provided multiple rounds of emergency short-term funding to support local areas to better manage issues arising from discharge. Last winter (2022/23), this included the £500 million adult social care discharge fund allocated to local authorities and integrated care systems (ICSs) via the Better Care Fund, and £250 million to NHS leaders to purchase step-down care to speed up hospital discharge.

The good news is that most ICS areas have made strides over recent years towards putting in place initiatives to better handle winter pressures. These include the development of transfer of care hubs that bring together system partners to better coordinate services to better support timely discharge, and virtual wards that allow people to receive hospital-level care in their own home. Social care has also seen some slight positive development in its ability to hire staff, with an additional 60,000 staff recruited internationally into the sector since last year.

But we should not get ahead of ourselves. We heard caution from health and care leaders about “sleepwalking” into winter without thinking now about what is needed to make meaningful improvements to discharge in the long run. While funding has helped support the system and alleviated some of the pressures in adult social care, delayed discharges remain high. As of April this year, more than 12,000 people were waiting to be discharged from hospital.

Two things to stop

1. Stop allocating funding to support discharge via short-term emergency pots that make planning impossible

A common feature of government funding to support discharge has been its stop-start nature. Providers gave the example of how discharge funding has been allocated over recent years, with packages automatically funded for six weeks by the NHS. But when that initial package ends, the local authority is left needing to meet these costs – with funding that often doesn’t match the long-term costs of complex care.  

This also hampers long-term thinking. ICS leaders and local authorities are reluctant to commit to commissioning new approaches that are not backed by a clear funding source when national funding drops off. One example of this is commissioners asking providers to increase wages for certain groups of social care staff temporarily to cover winter pressures, but without assurances that funding will be available to make wage increases sustainable in the long term.

Discharge funding should move from short-term emergency funding to a more systematic year-round approach, allocated in advance to support with long-term planning.

2. Commissioners and providers should move away from sticking too closely to categories of care

Discharge from hospital for people who require additional support involves a complex number of service types spanning health and social care. These services fit under three broad categories: support to recover at home; short-term rehabilitation and recovery; and long-term care and support for people no longer able to go home.

But a person leaving hospital may need a package of services that spans some or all of these categories of care throughout their recovery. Requiring services and staff to slot people neatly into detached boxes can lead to siloed thinking. Our attendees were clear that improving discharge would require moving away from silos to develop a whole view of need, capacity and provision across the entire system – with the person and family at the centre.

Two things to continue

1. Improvements made since the inception of ICSs should continue, but these are not felt by everyone across the country

One year on from the formal inception of ICSs, they do seem to have led to some progress around collaborative working. ICSs and local authorities have collaborated around building specific capacity for discharge pathways, increasing the number of people who can benefit from remote monitoring, developing discharge and hospital avoidance schemes, or co-commissioning intermediate home-first schemes. However, social care providers felt that improvements to joint working have not been universal, and have seen only minor improvements where relationships were not already strong.

Despite often being expected to take on more complex caring responsibilities to support discharge, providers and unpaid carers also frequently report not being involved in early conversations, and can feel like they are not always trusted as equal partners by their ICS counterparts. Improving discharge so that people can benefit from better care is a challenge that unites ICS leaders, local authorities, social care providers and carer representatives – it’s essential to have good communication with (and early involvement of) all relevant parties.

Social care providers are diverse and often perceived by commissioners to be fragmented. There is perhaps an opportunity to support local care provider representative organisations to bring together different provider voices and to streamline communication, being mindful to ensure that people’s voices are also heard. Likewise, ICS and local authority leaders should make more effort to consistently ensure that it’s clear who within their teams can be approached by care providers should they have offers for help or concerns.

2. Data can support a more transparent and shared understanding of system needs, but efforts to build up data infrastructure will need to continue

Care Data Matters (the government’s data roadmap for adult social care) has created opportunities to improve streamlining and collecting data that can support discharge planning. ICS leaders have pointed to positive developments in their local area, such as expanding shared care records to include social care providers or developing common dashboards.

Better data can be a resource for shared understanding, and support more transparent decision-making. But collecting, submitting and analysing data is not always straightforward – social care providers are at varying starting points in their ability to collect data. We have learnt that mandatory data collections such as the Capacity Tracker during the pandemic could be excessively burdensome on providers, particularly for the many small organisations with limited back-office capacity. There is potential for ICSs and local authorities to play a much greater role in understanding and building up the digital capability of their local providers, and sharing key data and intelligence across the system.  

But improvements in data collection and flows are not going to happen without investment. The potential of good data relies on good data infrastructure to ensure all stakeholders can feed in information in an useable way. Fully understanding the impact of approaches to discharge will also require stakeholders to collect data on the impact of these on people and family carers.

Two things to start

1. People are presenting with increasingly complex needs, and system leaders need to harness the expertise of their local care providers to ensure the right care and support is available

People drawing on care and support have increasingly complex needs. Social care providers told us they were providing more reablement hours per person than in 2019. Since the pandemic, a fifth to a quarter more people are dying at home, which impacts on home services and the wellbeing of staff who must manage significantly more complex activity.

This shift in complexity must be better recognised as care providers adapt their services to provide the appropriate care and support. Conversations about discharge are often too overly focused on getting people out of hospital now, and are not often enough about the long-term planning for how people and their carers will need care and support in the future.

This singular focus can have unintended consequences. Some social care providers told us that they have found recruiting nursing staff who could support people with dementia more difficult due to these staff being focused on the national discharge priority. It is essential that improvements such as enhanced care in care homes and delegating health care activities are not hampered in their scope by too narrow a focus on supporting discharge, and are adequately funded to ensure sustainability.

2. Long-term sustainable approaches need to be rooted in prevention

More long-term thinking will also require system leaders to be more bold, and reframe prevention as a precursor to good care for people rather than a part of the step-up/step-down discharge pathway. Unpaid carers often feel that an emergency admission of their loved one could be prevented with more access to and better support from social care in the first place.

The call is clear for more proactive chronic care and reablement that can foster greater inclusion and reduce isolation.

How to make a sustainable difference to winter pressures

The announcement of discharge funding over the next two years via the Better Care Fund (provided this materialises in 2024/25) allows some level of opportunity to overcome short-term thinking and improve collaboration. However, collaboration across the system cannot focus solely on discharge for next winter. Ultimately, local systems must ensure people can access good care and support whenever they need it, throughout the year.  

In a complex system with competing priorities, ‘success’ often looks different to different people, and recognising this gap is crucial to finding common ground. Care providers are not all convinced they have seen meaningful improvement. There is a huge potential for ICSs, local authorities, care providers, and people who draw on care and support and carers to align around a shared vision of what good care and support looks like. This requires all stakeholders to have shared trust and an equal voice, and for each to be clear about what they have to offer, what they need from counterparts, and who to speak to when they need support.

Building up the evidence base for different approaches is key to understanding their impact on different parts of the system, but more importantly on their impact on people and their family carers. Some improvements to the system, such as virtual wards, can be beneficial, but shift the majority of caring into people’s own homes in unprecedented ways. We don’t always see the impact on people, and their carers, who are faced with the consequences of new caring responsibilities. System leaders will need to ensure that adequate support and information on how to care safely are in place, alongside necessary funding flows, if we are to rely on these approaches more systematically in the future.

Those searching for silver bullets are likely to be disappointed. We need to make sure we get the fundamentals right: shared trust, shared vision and shared purpose. System leaders have to ensure that social care providers are involved in decision-making, alongside the other strategic leaders, and together can bring positive and long-term change that really makes a difference to people who draw on care and support whenever they need it, not just at the point of hospital discharge.

*This long read is in association with the National Care Forum.