NHS + Clinical Guidance, Discharge and Commissioning

On this tab we have information about NHS and clinical guidance, discharge procedures and commissioning.

Key links

A PDF version can be found here.

Background

As the new variant of the Coronavirus is driving up cases of COVID across the country, social care services are now the focus of the NHS once again, as they are being asked to accept people being discharged from hospital as a matter of urgency.

Back in April 2020, we issued advice for NCF members in relation to safe hospital discharge. Ten months on, with all that we have now learnt during the pandemic, and with the rapidly increasing pressures that we are seeing across the hospital system and which will inevitably move to social care, we are updating that advice, with a refreshed blueprint for hospital discharge. This blueprint includes key considerations for social care providers and key recommendations for how local systems need to respond collectively to make sure that we focus on protecting the most vulnerable.

The Government’s policy has moved on since April 2020 and now includes the creation of designated settings specifically for COVID positive (and potentially COVID infectious) people. This note also includes key considerations in relation to designated settings – see below.

NCF position summary

It would be a grave mistake to make at this point to discharge large numbers of COVID positive people to care and nursing homes, particularly with the new variant of the vaccine being so virulent.

Any discharge of a person from hospital into care homes should have the following safeguards in place, including:

  • only the care home can decide if the person can be safely admitted into the care home from hospital
  • clarity and evidence on their COVID status with full details of their most recent COVID test, when it was taken and what the results are
  • comprehensive discharge notes with clear clinical history. If the patient has at some point been COVID positive, then this history must clarify that it was at least 14 days since the first positive test was taken, the current situation in relation to symptoms, clarity about their current level of likely infectiousness and any exposure to new COVID risk while in hospital
  • guarantees about local community health support post discharge
  • vaccination of individuals pre-hospital discharge wherever possible as well across the care home community, including residents and staff
  • agreed fixed fee for discharge, eliminating the unnecessary and time-consuming local negotiations on a patient-by-patient basis

The crisis and pressure in the hospital sector is mirrored in the care and nursing home sector where we are already seeing testing and widespread community transmission causing rapid and unpredictable staffing shortfalls, adding phenomenal pressure to an exhausted and stretched workforce. Calls to protect the NHS must not ignore the massive potential impact on those living and working within care and pressure in hospitals must not result in pressure on care homes to allow unsafe discharge.

Key conditions for hospital discharge into care homes

  • Only the care home can decide if the person can be safely admitted into the care home from hospital: The decision to admit a new resident from hospital can only be taken by the care home at the relevant point in time. Care homes that are not in a position to take people being discharged from hospital must not be pressured into taking them. Considerations that homes must take into account include the frailty and needs of the person involved, the position in relation to existing residents, whether current staffing levels will allow admissions and any other considerations about the situation in the care home, including strict infection prevention and control measures, at the time of requested admission.
  • People must be tested prior to discharge and their COVID status clearly stated to the care home: Care homes must be given full information about the person’s COVID status, details of their most recent COVID test, when it was taken and what the results are. The current guidance references a test within 48-hours prior to discharge.
  • Comprehensive discharge notes with clear clinical history: A clear clinical history must be provided in the discharge notes. If the patient has at some point been COVID positive, then this history must clarify that it is at least 14 days since the first positive test was taken, the current situation in relation to symptoms, clarity about their current level of likely infectiousness and any exposure to new COVID risk while in hospital.
  • Guarantees about local community health support post discharge: Many of the people being discharged from hospital are likely to need ongoing, timely access to and support from community health services. For those who have been COVID positive the risk of long COVID is also very real and while we are still learning how best to treat it, we know that there will be much more health care and support needed for those people. There must be a mechanism in place for the local CCG to prioritise the provision of community health services and pharmacy services to ensure ongoing support for the resident.
  • COVID Vaccination and time for it to take effect: care home residents and staff are a priority for vaccination, as the vaccine has maximum lifesaving impact on these individuals. There must be ongoing vigilance at a local level to ensure that all residents and staff in care homes are vaccinated as quickly as possible so that the vaccine can provide additional protection to enable them to take an active part in supporting discharge. Where possible, people should also be vaccinated prior to discharge from hospital.
  • Insurance: we have long advocated to DHSC for specific indemnity insurance for the social care sector. In the absence of this, care providers do need to check the position with their insurers in terms of new admissions.
  • Clear communications with existing residents and families: care providers must be open and transparent with their existing residents and their families about their position in relation to accepting new residents and the COVID specific arrangements and safeguards they have in place – these should include robust risk assessments and IPC measures to minimise risk of transmission and outbreaks.

Recommendation for local health and care systems to support care providers

There are a number of key considerations for wider local health and care systems who have a clear role and responsibility here to support social care as well as the NHS:

  • Indemnity insurance must be in place for the care sector: finding collaborative and supportive solutions to the failure of the insurance market will be essential
  • Local plans with clear understanding of discharge requirements: these plans must be developed with social care providers, not just with local authority and local health voices at the table. This must include ensuring a recognition that care homes must always be able to choose whether or not they can accept individual people from hospital depending on a whole range of factors; ensuring costs are fully met (see below); supporting vaccination locally; providing community health support, developed plans to respond to staffing pressures and exploring how to increase – if needed – the number of designated settings in the area
  • Fixed fee for hospital discharge: we recommend that an enhanced standard fixed fee is agreed at a local level with care providers to cover the costs of taking the person from hospital which covers all the additional operating costs and care costs but eliminates the time delays built in for negotiation.

Designated settings

Background

The DHSC outlined the intent to create designated settings in the Social Care winter plan in September 2020. It was developed to ensure people who were COVID positive were not discharged from hospital straight back into care homes.

The guidance

Despite many schemes becoming operational in November and December, the guidance on designated settings was not issued until 16 December 2020. By that stage it was clear that running these schemes was complex and care providers needed extra resources to support the additional staffing needed to meet a range of specialist and diverse needs, the challenge of insurance to cover such a scheme and the logistical challenges of running such a service, along with the support expected from community health services and specialist rehabilitation services.

Every effort within the local health and care system must be available to support those organisations who are able to respond to this ask, so that they can manage the risks involved effectively for all involved – the people they will be caring for and their families and the staff they employ.

Key principles for designated services

There are some key principles that need to be observed in relation to designated services:

  • Designated services can only be negotiated when care providers give their full agreement to the local authority in becoming a designated setting
  • The decision to accept or decline an admission lies with the registered manager of the designated service
  • The choice of the individual must also be considered in their discharge decision
  • Parity with the NHS in terms of financial support and insurance indemnity, so the full costs of running a designated service must be met and insurance indemnity must be provided
  • Additional expert support with IPC and PPE, especially in relation to the new variant of the virus
  • Guaranteed clinical and community health support for residents during their stay, which can follow them when they move
  • Clear communications with existing residents and families about offering to become a designated setting and what that means