Rollout of the Discharge to Assess (D2A) model in England

On 21 August 2020, NHS England released its updated guidance on hospital discharge.

The new Hospital Discharge Service Operating Model introduces Discharge to Assess (D2A) for all providers of NHS commissioned acute, community beds, community health services and social care staff in England. 

What is D2A?

  • D2A is a process designed to rapidly discharge 95% people from hospital once it is medically optimal and safe for them to return home.
  • With this model, there is limited assessment of rehabilitation within the acute hospital. Once someone has returned home, detailed functional assessments take place and ongoing care and equipment are organised.
  • It anticipates that half of this group need simple discharge and no more formal NHS or social care support on returning home and that 45% require a package of support including rehabilitation.
  • A package of out-of-hospital assessment, rehabilitation and re-enablement as part of this model is provided for a period of up to six weeks.

Why is it coming in now?

  • The D2A model is not new. Many local services have been working to deliver a rapid hospital discharge approach for years.
  • During the current pandemic, many acute hospitals introduced D2A on a temporary basis because of the urgency of getting people out of hospital as quick as possible to reduce the spread of Covid-19 and free up capacity to treat very sick patients.
  • The decision to keep this as a permanent model is driven by planning for potential further outbreaks and implementation of the NHS Long Term Plan in developing capacity in out-of-hospital services.

When is it coming in?

  • Implementation of the new model as a permanent feature is expected to start immediately, in line with the restarting of Continuing Healthcare and social care needs assessments on 1 September 2020.

What is the CSP's view?

  • The CSP supports D2A as the right model for hospital discharge to best support individuals’ recovery process and provide timely rehabilitation.
  • Successful implementation of D2A is dependent on sufficient staffing in acute, intermediate and longer-term community rehabilitation teams.
  • Staff in acute and bedded rehabilitation teams need the capacity to provide rapid discharge decision-making and work flexibly where needed in the community to provide trusted assessments there. This can only be achieved through an increase in their numbers or via different ways of working. Without this adjustment, core rehabilitation time for inpatients who need it to expedite recovery and meet their clinical criteria for discharge will be reduced, which undermines the model.
  • Intermediate rehabilitation teams providing the six-week rehab packages identified through assessments at home will need to be fully staffed to meet this.
  • Community rehabilitation provision for patients who require rehabilitation beyond the first six weeks needs to be accessed quickly and at the intensity and frequency needed. Without this, there is a risk patients will deteriorate and re-present in primary and secondary care and long-term social care needs will rise.
  • While rehabilitation teams across the pathway will need to work closely together and to work flexibly, it is essential that the staffing required for D2A does not come at the expense of already understaffed community rehabilitation teams.
  • This is a major change in working for many staff, and as such there must be early and meaningful consultation and engagement with staff to shape implementation.
  • All CSP members in acute, intermediate care and community services in England have an important role to play in shaping how implementation happens.

Is D2A already established anywhere

What does it mean for physiotherapy staff working in acute hospitals?

D2A will significantly affect the way physiotherapy staff are expected to work in acute care settings in England, including:

  • Prioritising MDT discharge decision-making over other work.
  • Providing limited functional assessments for discharge in acute hospital settings – detailed assessments will be undertaken in the community.
  • No longer ordering equipment for discharge.
  • Acute hospital staff working flexibly in the community to deliver assessment and rehabilitation support.
  • Physiotherapy staff acting as coordinators or case managers where needed and appropriate to their role.
  • Implementing seven-day therapy working and extended hours in some services.
  • The undertaking of one ‘trusted assessment’ of care and equipment needs which is a universally agreed document and accepted across acute and community settings – with the trusted assessment taking place in the home environment.
  • Contributing to the collection of data on patient flow.

See the NHS England in actions cards for more details.


What does it mean for physiotherapy staff working in bedded community units?

  • Liaising with a single case manager in the acute setting to expedite admission to the unit.
  • Prioritising MDT discharge decision-making and MDT clinical reviews over other work.
  • Undertaking ‘trusted assessments’ for onward referrals.
  • Limiting the extent of assessment required to determine care and equipment needs – detailed assessments will be undertaken in the home environment.
  • Contributing to the collection of data on patient flow.

See the NHS England in actions cards for more details.


What does it mean for physiotherapy staff working in intermediate care and community and social care settings?

  • Physiotherapy staff in intermediate care teams will be providing the six-week packages of rehabilitation for people assessed as having this need and the new system will likely bring with it new processes and working arrangements.
  • Physiotherapy staff in longer-term community rehabilitation teams may be asked to contribute to D2A pathways (see ‘What is the CSP's view?' above).
  • Contributing to the collection of data on patient flow.

What does it mean for physiotherapy managers?

Physiotherapy managers have a critical role to play in shaping how D2A is implemented. Some of the important actions will be:

  • Making the case for D2A funding to provide adequate staffing levels to deliver rapid discharge decision-making and support trusted assessments in the community and six-week rehab packages.
  • Making the case for access to IT training and facilities for physiotherapy staff in order to support access to shared records systems and new ways of working.
  • Where acute, community and social care record systems are not shared, ensuring there is a mechanism by which staff can appropriately access information.
  • Putting in place clear governance and reporting structures.
  • Undertaking community lone working risk assessments for staff and ensuring necessary actions are taken.
  • Creating good communication and engagement systems and links between acute and community teams to support effective working and shared learning.
  • Ensuring access to suitable shared training and development to support new ways of working as well as addressing individuals’ learning needs.
  • Contributing to the collection of data on patient flow.

See the NHS England in actions cards for more details.


What does it mean for patients?

  • There is strong evidence that people recover and recuperate more successfully outside a hospital environment and when rehabilitation is continuous from hospital to home. D2A can help to deliver this.
  • Lengthy waits in hospital for equipment and access to appropriate community care support should stop.
  • People should gain greater certainty about the report they will receive on discharge from hospital, for the first six weeks and beyond six weeks.

Is there extra resource for rolling out D2A?

  • The government has provided funding, via the NHS, to help cover the cost of post-discharge recovery and support services, rehabilitation and reablement care for up to six weeks following discharge from hospital.
  • New funding is available from 1 September 2020.
  • Further information about funding is in the hospital discharge guidance and in the NHS England document Who Pays?

What do I do if I don’t agree with how D2A is being implemented?

  • You should raise any issues and concerns with your line manager in the first instance.
  • Contact your CSP steward, health and safety or workplace rep if you need further support to escalate your concerns
  • You can also contact the CSP to speak to one of our professional advisers or an employment relations and trade union team member on 020 7306 6666. Or email enquiries@csp.org.uk.

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