Theme no. 2: Options for integration of health and social work inputs, in the context of hospital discharge

‘Discharge to Assess’ policy and practice differs around the country but is all part of a determined push towards integration of health and social care thinking tasks, to ensure people get out of hospital beds as soon as possible.

The benefits of a fully mature, integrated system that has the right capacity in the right place are outlined below:

  • People’s health outcomes improve as more people will be able to live at home for longer if services are designed for discharge to home to be the default.
  • People’s length of stay in a hospital bed decreases due to longer-term assessments taking place in a more appropriate situation and place. Evidence suggests this should reduce deconditioning and improve outcomes significantly since 10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 .
  • Encourages NHS and Adult Social Care leaders to work together for the best outcomes and experiences for people through joint approaches to discharge to assess. This may include joint commissioning or funding.
  • Improves system flow by enabling patients to access urgent care at the time they need it.
  • Reduces duplication and unnecessary time spent by people in the wrong place.
  • Enhances working relationships between the health, social care and housing sectors and increases development opportunities for their staff.
  • Sharing responsibility, risks and skills across partners leads to innovative and creative solutions that deliver safe, effective care and support.

The practicalities

Many local health systems have introduced ‘trusted assessment’ or ‘generic assessment’ where one person/team appointed to undertake health and social care assessments on behalf of multiple teams, using agreed criteria and protocols.

  • Sheffield Teaching Hospitals and Sheffield Hallam University have developed a 2 day generic assessor course.
  • South Warwickshire’s trusted assessment form has enabled direct referral to reablement without the hospital social work team’s involvement.
  • East and North Hertfordshire Care Home Vanguard is piloting a trusted assessor model and has developed the Complex Care Premium which is paid to the care home, for residents who have ‘complex needs’.

The following exhortations are taken from the PCA’s report in 2016 into unsafe hospital discharge:

Best practice guidance has been consistent over the past decade in stating that ‘discharge is a process and not an isolated event at the end of the patient’s stay’. The key steps and principles identified to enable appropriate discharge include:

  • Starting discharge and transfer planning before or on admission to hospital, to anticipate problems, to put appropriate support in place and agree an expected discharge date.
  • Involving patients and carers in all stages of the planning, providing good information and helping them to make care planning decisions and choices.
  • Effective team working within and between health and social care services to manage all aspects of the discharge process, including assessments for social care, continuing health care and, where necessary, assessments of mental capacity.
  • Community-based health and social care practitioners should maintain contact with the person after they are discharged, and make sure the person knows how to contact them when they need to.


Guidelines published by the National Institute for Health and Care Excellence in December 2015, on transition from inpatient hospital settings for adults with social care needs, also recommend that a single health or social care professional should be made responsible for co-ordinating a person’s discharge .

The discharge co-ordinator should be the central point of contact for other health and social care professionals, the person and their family during discharge.

But here at CASCAIDr we think that some limited sort of social services skill with regard to social care needs is desirable for informing the Checklist. We are not saying that a discharge co-ordinator cannot supply that skill but that she or he will need a broader competency basis than just nursing and writing up what is needed to meet unmet clinical needs.

The domains on the checklist include domains from the DST that have been transparently suppressed in terms of scoring so that they can never lead to eligibility on their own: they are the tradition social care needs domains and yet the systems now coming to the fore allow for no social work consideration of those domains.

Whilst social workers may not understand what makes someone’s breathing or states of consciousness problematic, or why a pressure sore isn’t healing, they can see the facts as well as anyone else; and the same must go for discharge co-ordinators, regarding the traditional social care domains

But do discharge co-ordinators get trained in social work values or know much about what the MCA says must be the response to cognitive impairment before anyone lays hands on the patient and moves them out of the hospital?

Top tips from the D2A quick guide:

  • Use a trusted assessor model – this is about responsible staff understanding the dual legal frameworks that operate here, in our view.
  • The cultural and behavioural challenges associated with new ways of working, can be overcome through the weekly multi-agency and multidisciplinary ‘Big Room’ meetings, which are seen as an open place in which people are supported to contribute and share – this is about stopping hierarchical turf wars and ‘we know better than you lot do’ cultures undermining progress or becoming further entrenched, to our mind.
  • Do not underestimate the significant engagement and communications which need to take place to enable systematic changes. (ditto!)
  • Explore using existing staff structures and re-align teams (again, only if trained in the legal framework)

CASCAIDr’s view of what law can contribute:

Integration can be enhanced by polite appropriate use of the s6 and s7 reciprocal duties of co-operation under the Care Act. Health bodies (the CCG and the Hospital Trust) are relevant partners, and must have a good reason for not doing what is asked of them, but that’s true for social services as well.

Fines for the council not doing its job in a timely way are no longer a mandatory piece of the jigsaw, but that hasn’t translated into any more clarity about whose job is whose, and why the NHS may be letting patients down too.

If discharge co-ordinators were skilled and legally literate in Care Act functions, they could discharge both health and social care thinking tasks in one go.

The same goes for any CCG’s roving band of nurse assessors – legal literacy entitles either organisation to delegate its statutory functions or tasks under Guidance to the other agency, to save time and human resources.

If social work staff stepped up to checklisting on the basis of a social care quick look and a nursing needs assessment identifying any needs for registered nurse nursing at one’s next stage, the nurses could be freed up for what they excel at, which is meeting clinical needs, and not doing paperwork.

Where hospitals and local authorities are already operating joint discharge teams, which are often co-located in the same office with access to a shared database, an update to the database may be all that is required to get good workflow going…

While reimbursement is a potential way of exposing local difficulties in the relationship between the NHS body and the local authority, NHS bodies should not use reimbursement as the first approach to address any local difficulties around delayed transfers of care.

Please see our overview of the legal provisions for why we think that not enough focus is placed in the training for hospital discharge on the legal framework. It’s an attachment to this post, here: Summary of the law relating to hospital discharge notices