Service user experiences of CNWL services: part 1: discharge to assess

Camden Clinical Commissioning Group asked Healthwatch Camden to conduct service user research around two newly commissioned services. The first, referred to by the title “Discharge to Assess”, aims to replace the practice of assessing patients in hospital to determine home support needs (equipment and services) and instead to conduct this assessment at home very soon after discharge. Evidence suggests that assessment at home is likely to be more accurate and ensure a better match between patient needs and the prescription of both equipment and other support.

The majority of interviews did not identify a consistent or distinct service that matched the CCGs description of “Discharge to Assess” (patient discharged and then assessed at home with consequent prescription of suitable equipment or services). Instead, the interviews produced evidence on what seems to be a highly varied set of support measures provided in a highly varied way. The ways in which individual patients experience or perceive the services is also highly varied and individualised. 

Where the range of different support is well coordinated the patient experience is more positive.  Cases where the support is well coordinated and works smoothly seem to correlate with cases where the patient is cooperative and dependent. 

For patients who draw on other resources (family support or personal problem solving), or express a greater desire to exercise control over the support offered, the patient experience is less positive. 

Overall, the level of satisfaction with the services being provided at home is high for most patients interviewed. Many patients offered high praise for care staff. Most patients were very grateful for the support and several expressed feelings of guilt. This suggests patients did not feel a sense of entitlement to services. 

Most patients did not feel in command or control of the services they were receiving. Most did not express a strong sense of being able to shape whether or not those services met their expectations or needs. 

 Only one patient out of 14 interviewed expressed anxiety at the fact they were discharged home and none said they would have preferred to stay in hospital. The link between hospital and community services appears to be mostly but not always clearly explained to patients before they leave hospital.

Some patients reported a lack of clarity about what people visiting home were briefed to do or how they linked up but this was not a cause of concern for most patients. Reporting on whether patients felt confident they knew who to contact if things went wrong are mixed. Some were clear that they had a name and phone number while others talked about contacting their GP or thinking there was something on a letter somewhere.

 In some cases, patients have showed paperwork to the interviewer. Often the paperwork is unclear with several services listed, care plan incomplete, no discharge date. In some cases patients do not have any paperwork as service providers had reportedly taken this away. In these cases patients appear to have been left with no details for reference including no contact details/phone numbers. 

In the majority of cases it was clear that the patients were living with multiple pre-existing conditions aside from the specific episode that had led to recent hospitalisation and discharge. This contributed to a complexity of response and varying degrees of confusion for the patient between different services and personnel with whom they were in contact. The desire for a single and well known human point of contact who could help the patient navigate between the different visitors and service offers was keenly felt by some of those interviewed. 

These findings indicate the need to ensure that services in the community are flexible and can respond to and accommodate the highly individual needs of each patient while remaining coordinated and reliable. Meeting this challenge also requires that personnel are able to adapt and accommodate the preferences and coping strategies of each patient on a case by case basis. The interview responses suggested that this flexibility and responsiveness was present in some cases but not in all.