EHSSB Patient Choice Related Discharge Delays – Protocol

AUGUST 2004

Question 1  - Is the overall aim of the protocol clear?

The overall aim appears to be reducing delayed discharges from hospital and is clear. However, the document appears to assume that discharge will normally be to residential / nursing home care rather than back into a community setting. The protocol needs some re-working to make it clearer that it is covering both options on discharge.

Question 2 – Does the protocol as described find the correct balance between the immediate health needs of patients requiring access to inpatient services and the needs of patients who require time to make choices about their long term social care needs?

The acknowledgement, at paragraph 2.1, of the problems facing those trying to access affordable, good quality care either at home or in another location is welcome. This should be moved up to sit along side paragraph 1.2. Leading with paragraph 1.2 and not immediately acknowledging why many people might be waiting in an acute setting for a particular placement may hint that most people who are considered to be delayed due to ‘patient choice’ are somehow to ‘blame’ for the resultant difficulties caused.

Investment in ‘step down’ options is a positive way forward and is essential to achieving the aim of prompt discharge from acute hospitals. There may need to be some consideration of how the impact of a number of moves on patients can be best managed.

The introduction of step down options would help all delays, not just those strictly due to there being a waiting list for a room in a particular care home, but also those where workers are not available, e.g. night sitters, or where funding is delayed from a particular budget. It would be helpful if the protocol could set out the options of initial intensive support to remain in the community followed by support being reduced in appropriate cases where a person’s condition improves. This would help to delineate between people needing an intense level of support in perpetuity from those who need such support for an initial period followed by a reduced level of care.

It would be useful for the protocol to give examples of ‘appropriate settings’ that will be considered as step-down/rehabilitation options.

The protocol acknowledges the needs of both groups and the balance will be appropriate if the effective non-acute options are made available.

Question 3 – Are the principles outlined for the protocol clear and appropriate?

Yes, the principles are clear and appropriate.  Paragraphs 4.5 and 4.6 are particularly welcome.

Question 4 – Are the processes outlined in the protocol clear and appropriate?

The process section might benefit from more clarity on the patient role and the carer /relative role in discussions about needs and choice. This would be particularly important in the case of a person who has difficulty communicating or who has a low level of capacity. The DHSSPS Guide to Good Practice on Consent might be a relevant reference.

It would be useful if the protocol suggested a way forward where there is a dispute. How a dispute might be tackled would depend on whether it related to a difference of opinion between the patient and the Trust or between members of a family and the Trust, and in the latter situation, to what extent the process would depend on the capacity of the patient.

At paragraph 5.2, the assessment of care needs is triggered by a ‘clinical indication’. It would be helpful if this could be clarified. Should a care needs assessment be triggered by a clinician only, if that is what is intended? Departmental Circular ECCU 1/98 states that people should receive appropriate comprehensive assessment of their health and social care needs including rehabilitation.

In ascertaining the source of funding to support care outside hospital, in line with paragraph 5.3, will the Care Manager/Discharge Facilitator be considering continuing care, which would allow funding of care as health care in locations other than hospital. A person may be medically fit for discharge from acute hospital but have primarily ongoing health care needs, which should be funded from a health budget.

It would also be helpful if the protocol set out that a person will normally receive written details of any assessment conducted into his or her needs.

At paragraph 5.4, it would be useful to highlight examples of when a step-down/rehabilitation option is not appropriate, given paragraph 2.5 which foresees it as the norm for care managed patients.

Paragraph 5.5 involves the Trust advising how much it will contribute towards the cost of a placement, having confirmed the gross cost. At this stage, it would be useful for Trusts to also advise of the implications for social security benefits of moving to the care home on a temporary or permanent basis.

The checklist to be made available to patients and family members will be useful.

Question 5 – Are the responsibilities of the patient and their family or representative adequately described in the protocol? 

As noted above, the roles need to be clarified and there needs to be more clarity on what happens if agreement cannot be reached.

Question 6 – Do you agree with the outcome of the initial screening form attached? Please provide any comments.

The initial screening indicates that there may be an impact on people with a physical disability due to less provision in the community. If this is case then these people are less likely to be delayed through ‘choice’ but through a lack of ability to meet their needs. It would be contrary to guidance and this proposed protocol to discharge without an appropriate care package being in place in order to free up an acute bed. The operation of this protocol would not impact adversely on this group therefore. The increased focus on community options would be helpful for those people with a physical disability who are ready to leave hospital.

Question 7 – Are there any other ways in which you believe we could better promote equality or human rights in regard to this issue?

There should be a consistent approach to continuing care both across Northern Ireland and within the UK.

A stronger emphasis on the need to work with patients to get their informed consent to care options where the person has capacity or communication difficulties would help promote equality and human rights.

Other comments

The screening form lists associated policies but does not mention the main guidance on hospital discharge which is Departmental Circular ECCU 1/98. The protocol should be measured against this guidance. One aspect of the guidance which could be more emphasised in the protocol is that it states a principle of people being enabled to return to their own homes whenever possible.

It would be useful for the protocol to recognise that top up fees and third party agreements should be an exception rather than a rule and be clearly related to a payment for a home which offers more than is necessary to meet a person’s needs. Given that these top up fees are now commonplace, the protocol should highlight the need for Trusts to continue to work towards ways of reaching a scale of reasonable fees agreed by both the statutory and independent sector.

Law Centre (NI), 26 August 2004