National Institute for Health and Clinical Excellence (NICE)
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Supporting people who need social care, as they move between hospital and home: NICE consults on draft guidance

The National Institute for Health and Care Excellence (NICE) has published a draft health and social care guideline to help manage the complicated needs of adults being admitted to and discharged from hospital who are receiving or need support from social care.

The focus of the guideline is on adults with health and social care needs – and who have or will need support from a range of practitioners such as family doctors, social workers, physiotherapists, or community nurses.

The draft NICE social care guideline places people at the heart of decisions as they move between hospital and their own home, a care home or other living arrangements.

The draft guideline recommends ways to integrate effectively social care with medical support during transition to and from hospital. It addresses how services should work together and with the person, their family and carers, to make sure they are admitted for medical treatment in a timely way and spend no longer in hospital than is necessary.

Professor Gillian Leng, deputy chief executive and director for health and social care at NICE, said: “Going into or being discharged from hospital is a worrying and uncertain time for many people – especially if they are vulnerable or need extra support. This draft guideline puts people at the heart of plans for their transition between where they live and the hospital. Ensuring proper support following discharge will help reduce readmissions and improve outcomes for patients.

“Focusing on the needs and wishes of people in decisions about their care benefits everyone – the person, their carers, social workers, social and primary care providers and hospital staff. Carefully planning the complicated moves between social care and hospital, which can involve lots of different health, social care and other services, improves outcomes and potentially reduces costs significantly for the NHS and social care providers. It’s a win-win.”


  • From April 2014 to March      2015, hospitals lost thousands of bed-days as people waited for care to be      put in place:
  • 174,138 days waiting for a place in a residential home
  • 215,662 days waiting for a nursing home place to become available
  • 206,053 days for help from social care workers or district nurses to enable people to return to their own home
  • 41,389 days for home adaptations ranging from grab rails to ramps and stairlifts.
  • A monthly snaphot (from figures collected on the last Thursday of each month) shows an increase of 19.3% in the number of people needing social care who were delayed in hospital between 2013/14 and 2014/15.
  • NHS England says hospitals lost 2,442,014 bed days between June 2010 and March 2015 as people waited for social care.
  • According to Age UK, an NHS bed costs on average £1925 a week compared to about £558 for a week in residential care or £356.58 for home care based on three hours of care per day over the course of one week.²

Being prepared

The guideline states that from admission, or earlier if possible, hospital-based and community-based multidisciplinary teams should work together to identify and address factors that could prevent a safe, timely transfer of care from hospital. The factors could include homelessness, safeguarding issues, or finding a place in a suitable care home if their own home is no longer appropriate.

The draft guideline explains the importance of making sure the right supporting infrastructure is in place, as Professor Leng explains: “To support person-centred care, it’s essential that local health commissioners, hospital trusts and local authorities offer a coordinated range of services in their area: this might include practical support for carers, helping people to re-learn skills needed for day-to-day living that they may have lost, as well as other services that will help people when they have left hospital. We are actively working with NHS England and the new vanguard sites to show how better joined up health, care and rehabilitation services can be provided in the future.”

The guideline says that local health commissioners should keep all care providers, including GPs and out-of-hours services, up-to-date on the availability of local health and social care services. 

Person-centred care

The draft NICE guideline recommends that everyone receiving care should be seen as an individual and an equal partner who can make choices about their own care.

The draft guideline says that people who have less access to services (such as people with communication difficulties or if they misuse drugs or alcohol) should be identified and supported. 

It recommends that families and carers should be involved in discussions about the care being given or proposed (if the patient consents)³.

The guideline gives details of ways to ensure that care is coordinated and information shared before admission (either planned or from Accident and Emergency departments), during a hospital stay, and on discharge.

It says that one health or social care practitioner should be responsible for coordinating the person’s discharge from hospital. They should be selected according to the person’s care and support needs and will be a central point of contact for health and social care practitioners, the person and their family.

The guideline makes clear that the person being cared for should be able to contact their community-based health and social care team after they have left hospital.  In addition, the team should maintain contact – for instance through regular phone calls and home visits.

Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission, said: “Our inspections do identify some really good examples of joined up care, but we only have to look at our Cracks in the Pathway review – exploring the experiences of people living with dementia as they moved from care home to hospital and back again – to know that transitions between services need to be improved so that safe, compassionate, effective and high-quality care becomes the norm for everyone.

“Information that isn’t shared properly, poor planning, lack of communication and inconsistent monitoring around a person’s quality of care as they move around the health and social care system are some of the everyday problems we see in our inspection work.

“I welcome the draft guidance from NICE which reinforces the importance of services focusing on the needs of the person, not the organisation.”

Anna Bradley, Chair of Healthwatch England, said: "Taking the time to ask people about how they are going to cope when they return home from hospital and ensuring everyone has the support they need sounds simple, but all too often fails to happen. Sadly, it's when people fall through the gaps between different bits of the health service or between health and social care that serious problems occur, leading to unnecessary suffering for those involved and costing the taxpayer billions in additional care costs.

"Over the last year Healthwatch have been investigating this issue speaking to more than 3,000 people who have experienced the effects of the current lack of coordination first hand. This guidance is a step in the right direction, but what we really need is for this guidance to be implemented and applied consistently across the system; there are too many bits of good practice and advice already that are being ignored by commissioners and providers.”

The draft NICE guideline has now been published for consultation. Local authorities, clinical commissioning groups, home care organisations and other social care groups are encouraged to comment on the draft recommendations before the consultation ends on 6 August 2015 to contribute to the further development of the recommendations.

The final guideline is expected to be published later this year.

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Contact: John Davidson 0207 045 2179


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