An Australian’s perspective on NHS discharges

Two months have passed since the Dazi Report found that “too many people end up in hospital, because too little is spent in the community”. Since then, there has been significant conversation on the funding of acute vs community care. However, the barriers to shifting care out of hospitals are broader than just the misaligned funding models – England’s complex network of siloed organisations creates additional complexity for so many patients.  

Having recently joined IMPOWER as a healthcare consultant from Australia I was initially surprised by England’s fragmented care delivery and its impact on discharge delays. In New South Wales (NSW) where I am from, all healthcare, and the majority of social worker support falls under the single organisation of NSW Health. A patient journey may involve multiple clinical handovers of responsibility as they pass through teams within the NSW Health system, but the patient rarely needs to cross to a new organisation. 

At IMPOWER we have supported a significant number of health and care systems in their transfer of care across organisational interfaces through our Valuing Home approach. In a recent project I observed how in England a single patient journey could involve: 

1. Funding, governance and support from an Integrated Care Board 
2. Acute care from an NHS Trust 
3. Care at home from a community health trust 
4. Social care support provided by a local authority 
5. Additional support from voluntary community and social enterprise 

Each interface adds a further layer of complexity to discharge through communication barriers, different IT systems, misaligned or conflicting priorities, policy and regulatory differences, unique workforce challenges, challenging care navigation, reduced continuity of care, and diffused leadership and accountability. IMPOWER has examined this in detail including in our recent report ‘The future is out there’ with the Academy of Royal Medical Colleges, and our co-produced reports with the Association of Directors of Adult Social Services; Age of Intermediate Care and Intermediate Care – The Reset. 

One solution to this is to create more vertical integration, aligning the model more with how care is provided in Australia. There are examples of this occurring across England already for example, Manchester Local Care Organisation and trusts like Cheshire and Merseyside, Coventry and Warwickshire, and Kingston, who are rolling community health trusts into their local acute trusts. However, there are risks in fully integrated care organisations. Concerns include community care developing services that are overly focused on patient flow out of the acute setting, rather than services being designed to meet the health and care needs of the community.  

At IMPOWER I have worked on the alternative solution, investing in partnership planning for our care interfaces. This approach needs to be underpinned by an inclusive ambition which sets out the desired future state with accompanying aligned short and long–term goals. To deliver the vision, partnerships require collaborative leadership and governance models that include ways of working and escalation pathways. At the front line, a culture of trust and an understanding of the role they play in the broader system will support practitioners to collaborate effectively. 

Our IMPOWER theory of change helps systems to break down complex interface challenges; starting with an inclusive ambition and then building the right behaviours, at scale, to create a new set of outcomes.