Ensuring recovery, rehab and reablement are commissioned within 'existing budgets'.
Amongst the raft of changes brought about by the pandemic, hospital discharge and community support may have slipped under the radar of many. But for community care practitioners and people in need of care and support, hospital discharge funding has been a vital source of additional money which has now dried up.
Prior to the pandemic hospital discharge to community settings were organised at local level. Integrated approaches to manage delayed transfers of care were largely coordinated via the Better Care Fund. The onset of the pandemic triggered huge pressure on NHS resources, with access to inpatient facilities for acute and chronically ill patients in high demand. A joined up approach was needed to free up scarce beds and the government responded by developing the hospital discharge service and operating model.
Summarised as discharge to assess (D2A), the model identified four discharge pathways people were expected to fall into, with the vast majority (50%) only requiring a straightforward discharge with no ongoing support. For the remainder, the priority was to discharge as early as clinically indicated to the person's home – D2A. Under this arrangement, assessment for longer term needs were not carried out in an acute care setting. Most importantly, any care required by the person to enable them to go home would be funded from a central pot for up to 6 weeks or until assessments were concluded, whichever was the soonest. For those individuals with a pre-existing care package, only the increase in care needs (i.e. the person used to have 2 calls per day and now needs 4) would be paid.
Clinical commissioning groups (CCGs) and Local Authorities were incentivised to complete assessments in a timely way as care costs would have to be met by local budgets once the 6 weeks expired (NB the latest version of the model published 21/9/2020 reduced the period to 4 weeks).
From 1 April all of this changed and we went back to the pre-pandemic position. What does this mean for some of our more vulnerable clients?
The government has issued guidance clarifying that CCGs and Local Authorities are expected to commission effective discharge procedures from within existing budgets. NHS and LA must work together to develop effective working practices and protocols "to ensure people's care and treatment is timely, optimal and coordinated, while also minimising delays when they are ready to be discharged".
Whether this will lead to delays in discharge remains to be seen. The change does, however, feed into the government's overarching policy of a more integrated healthcare system, with guidance promoting the use of pooled budgets to manage discharge procedures across localities.
Currently, section 82 NHS Act 2006 "requires NHS bodies and local authorities to cooperate with one another to secure and advance the health and welfare of their local population. NHS bodies and local authorities must also comply with duties in the Care Act 2014, which requires them to co-operate with each other in the exercise of their respective care and support functions, including those relating to carers and young carers (section 6 and 7)". Governance structures should be put in place to support this.
All of the above is paving the way for statutory integration between NHS bodies and Local Authorities by means of the Health and Care Bill. The Bill envisages a new NHS architecture of integrated care systems and integrated care boards that will replace CCGs. The legislative programme had anticipated passage of the Bill this April, but at the time of writing it remains subject to ongoing debate in both Houses.
In the meantime, vulnerable clients should continue to make use of intermediate care or 'step down' support and reablement services wherever appropriate, as this can be a source of additional support for up to 6 weeks that is provided free of charge. Carers and concerned family members should also be aware that "decisions about what long term support package is needed should not be taken on the hospital ward." This approach should hopefully ensure that what is already a difficult and challenging time is not made even more so, by long term decisions being made whilst the person is still being treated for the acute episode.
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