Decision details

(i)  To give approval to proceed with  the preferred future Pathway 3 Discharge to Assess option for potential Continuing Health Care (CHC) patients/clients and those with complex social care needs leaving hospital who require a period of assessment.

(ii)  To approve establishment of a fixed contribution by partner fund under S75 partnership arrangements of the Health Act with contributions of £229,183 per annum from Southampton City Council and £421,041 per annum from Southampton City Clinical Commissioning Group to fund the assessment placements required for the operation of the Discharge to Assess scheme.

1.  The consistent delivery of safe, appropriate and timely discharge from the acute hospital setting continues to challenge the majority of health and social care systems, particularly where the needs involved are complex.

2.  This report concerns the mainstreaming of Discharge to Assess (D2A) as a core part of Pathway 3 for those complex patients/clients requiring a period of assessment, following the original Discharge to Assess (D2A) pilot which commenced in November 2017 and subsequent amendments to the pilot to respond to the learning. This is a key element of Southampton's action plan to reduce delayed transfers of care (DTOC) and part of the “8 high impact change model” for improving discharge published jointly by the Local Government Association (LGA), Department of Health (DH), Monitor, NHS England and Association of Directors of Adult Social Services (ADASS) in 2015. Southampton has a significant challenge to achieve the nationally set target for reducing DTOC and is currently under national scrutiny for having one of the highest rates in the country. Ceasing this approach that the pilot has evidenced as being effective, could negatively impact DToC further.  Assessment of long term health and social care needs outside of the acute setting is better for our population and the health and care system as a whole.

3.  Alongside the nationally set target for reducing overall DTOC, there is a national target for reducing the percentage of assessments of eligibility for Continuing Healthcare (CHC) undertaken in the acute setting to 15% or less.

1.  In the report presented to JCB in February 2019, five options were considered in relation to D2A for Pathway 3 as follows:

•  Option One – Continue as is with the current Pathway 3 D2A model

•  Option Two – Abandon D2A for Pathway 3

•  Option Three – Separate D2A pathways for health and social care clients

•  Option Four – Use of Transitional Care Unit for D2A on the University Hospital Southampton (UHS) site

•  Option Five – CHC only D2A scheme

2.  A detailed options appraisal was undertaken and the preferred option in February 2019 was Option 3: Two separate D2A pathways – one for CHC patients and one for Social Care clients, with a pooled budget to cover the placement costs for the period of assessment for those clients/patients where it is difficult to predict whether they will be health or social care responsibility.  The other options were rejected for the following reasons:

•  Option One – the costs of this were considered too high and are artificially inflated above the Council’s average placement costs owing to the assessment placement attracting CHC rates, given the potential the client could meet CHC eligibility criteria.  There had also been a high rate of families refusing D2A because they are not happy for their relative to be moved twice.

•  Option Two – this would increase the DTOC rate and length of hospital stay.  It is also not in line with national policy which promotes assessment taking place outside the hospital setting and does not comply with the 8 High Impact Change Model for improving hospital discharge.

•  Option Four – this is likely to be high cost and does not comply with the general principle of assessing people in their own home or at least a setting which replicates a homely environment.

•  Option Five – this option would have little impact for the majority of patients/clients as CHC patients account for a very small proportion of Pathway 3 overall numbers (less than 2%).

3.  Since February 2019 and following further work at the request of the JCB to develop the preferred option and how it could be implemented, Option 3 has been discounted on the basis that it was found from a live audit of Pathway 3 patients/clients conducted by the Integrated Discharge Bureau (IDB) that very few are clearly CHC or social care clients prior to assessment and that the majority require a period of assessment to determine this.  In addition the tool being proposed to determine this (which other areas had adopted to determine if a client was likely to meet CHC eligibility or not without a full assessment) has been discredited nationally because it is not felt to be accurate enough to determine likely future need.

4.  Option one (Continue as is with the current model) - with some modifications to make this affordable to the Council (reflective of average council rates) and include an element of spot purchasing to enable clients to go straight to their final placement where possible - is now the preferred model.