[…] This report draws attention to people who were not receiving the most appropriate support to get them back home. This impacted on their health and wellbeing not just in terms of the delays to their transfer but also over the longer-term. On average, across the work programme 44% of people experiencing delayed discharges were subsequently placed in settings of care that were not the best possible for that individual. These people were identified by professionals themselves – many of whom were involved in the original decision – which further underlines that this is not about poor choices from a lack of skill or knowledge, but as a result of the system as a whole not making it simple or easy to help people achieve their best outcome.
The findings from this report show that through the efficient use of resources, more mature cross-system leadership, and joint working on the best way to manage transfers of care, more money could be released to the wider system for better prevention, ensuring that people do not end up in hospital in the first place. This report sets out some key considerations for all areas, as they progress integrated care ambitions and consider how to work together across the system, to ensure a personcentred focus on improving outcomes.