Abstract
Discharge to Assess (D2A) models of care have been developed to expedite the process of discharging hospital patients as soon as they are medically fit to leave, thereby improving the efficiency and effectiveness of the healthcare system. This article focuses on the implementation of a D2A model in Kent, England, which formed a case study for a European research programme of improvements in integrated care for older people. It uses the Critical Systems Heuristics framework to examine the implementation process and focuses in particular on why this improvement project proved to be so difficult to implement and why the anticipated outcomes were so elusive. The analysis highlights the value in using critical systems thinking to better evaluate integrated care initiatives, in particular by identifying more explicitly different stakeholder perspectives and power relationships within the system and its decision environment.
Highlights
Delayed discharges of older inpatients occur in most countries and have significant associated costs for healthcare systems and for patients (Landeiro et al, 2019; Rojas-García et al, 2018)
In the UK, a Discharge to Assess (D2A) model was developed whereby patients who are clinically optimised and do not require an acute hospital bed, but may still require care services, are provided with short term, funded support to be discharged to their own home or another community setting (NHSE et al, 2016)
This article presented a systemic analysis of findings from the evaluation of Swale Home First, using the Critical Systems Heuristics (CSH) framework, to understand why achievements were less positive than expected, especially given adoption of a national good practice model (D2A) and an improvement plan co-produced within the SUSTAIN programme
Summary
Delayed discharges of older inpatients occur in most countries and have significant associated costs for healthcare systems and for patients (Landeiro et al, 2019; Rojas-García et al, 2018). Hospital discharge in England involves the safe and timely transfer of patients between settings and services based on different organisational principles; it requires coordination between different branches of the NHS, local authorities, private providers and the voluntary sector. The NHS in England is organisationally fragmented between and within hospital, primary care, community health and regulatory bodies, but is accountable to Parliament and the Secretary of State for Health and Social Care. It has a powerful national identity and strong public allegiance. It enjoys considerably less status than the NHS and is often perceived to be its unequal partner (Wistow, 2001)
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