By Becky Sharp, Implementation Lead, Health Innovation Kent Surrey and Sussex and NIHR Applied Research Collaboration Kent, Surrey and Sussex

In January 2024 the statutory guidance for hospital discharge and community support was updated.  It outlines how NHS bodies and local authorities have a statutory duty to come together and agree the discharge models that best meet local needs.  The guidance goes on to say how discharge planning must involve professionals from all relevant services; whether that’s health, social care, housing or the voluntary and community sector.  More importantly, it also acknowledges that carers and family members should be involved in decisions concerning a person’s discharge from hospital. 

We already know that prolonged stays in hospital are bad for patients, particularly frail or elderly people.  It presents increasing falls risk, an increased likelihood of catching infections and deterioration of mental and physical health.  Coupled with this, the pressure on our hospitals to free up beds for others, exacerbated through COVID-19 and beyond, just highlights the need for continual improvement of discharge pathways; and also of course admission avoidance.      

Late last year, Health Innovation Kent Surrey and Sussex and the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Kent Surrey Sussex (ARC KSS) ran a series of briefing sessions across Kent, Surrey & Sussex, to share the findings of our evaluation of discharge to assess (D2A) pathways across Kent Surrey and Sussex.  This work was funded through the NHS Insights Prioritisation Programme (NIPP).   D2A aims to reduce length of stay in an acute hospital by moving the point of assessment for ongoing care from the acute hospital into the community, with full assessment undertaken 4-6 weeks post discharge.  This allows for a period of active rehabilitation to promote independence within a more suitable environment, whether that’s a community bedded rehabilitation unit or a person’s own home.    

The briefing sessions we ran attracted more than 250 people from across all sectors, and our findings reassuringly endorse this latest statutory guidance.  You can read more about our findings here.     

As part of the project, we developed a simple and interactive Service Improvement Tool which prompts those involved in the pathway to come together and work through a series of questions that help identify what issues enhance or detract from a smooth and successful pathway; and implement the necessary pathway improvements.  These all fall under three key themes:  

1. Commissioning - How the service is financed, the structure and culture of the service, and what outcomes are services working towards.

2. Multidisciplinary working - How the services in the pathway connected, the skills and knowledge of the teams, how care is coordinated along the pathway.

3. Information and knowledge exchange - How service users and carers are assessed and communicated with, how the information is managed and flows between teams, how the path is overseen.

What was clear from our study was the complexity of the pathway.  Certainly, following a D2A pathway is not suitable for all patients and the statutory guidance mentioned above also provides information on good practice and the use of care transfer hubs to manage discharges for people with complex needs.

However, for those who will benefit, the D2A programme has successfully provided a mechanism to reduce hospital stay, provide rehabilitation, and improve the assessment of a person’s long-term care needs. However, our study identified that in all sites, there were obstacles and blocks in the pathway that impacted on the experience of patients, their carers, and the workforce, and the Service Improvement Tool was developed to help identify and resolve these challenges. With the additional duties on NHS bodies and local authorities to collaborate and agree the discharge models that best meet local needs, Health Innovation KSS can help bring together all relevant stakeholders across our Integrated Care Partnerships (ICPs) to help facilitate and deliver on improving care and outcomes for patients who are discharged on a D2A pathway; and importantly their carers and family members.

If you would like more information on the study findings, the Service Improvement Tool, and discuss how Health Innovation Kent Surrey Sussex can support the implementation of improvements to your D2A pathways, please contact This email address is being protected from spambots. You need JavaScript enabled to view it..

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