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Evidence-Based Healthcare & Public Health (2004) 8, 323–324

1744-2249/$ - sdoi:10.1016/j.e

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EDITORIAL

The benefits of joined up care: coordinated dischargeprocedures in the elderly

Does joined-up working through coordinated dis-charge of elderly patients from hospital improvecare and prevent the necessity of hospital re-admission? Our systematic review in this issue ofthe Journal suggests that it does. Although theevidence is patchy in places, randomised controlledtrial results consistently suggest that coordinateddischarge by primary and secondary care facilities,acting in tandem, reduces hospital re-admission byabout 17%, and is at least as safe.

The evidence, however, is based almost entirelyon trials conducted in North America and Europe. Ifit is to be implemented, policy makers need toprovide incentives for effective joint workingbetween hospital and community services andbetween health and social care. The nature ofthese incentives depends on the structure andorganisation of local health and social care ar-rangements.

For example, policy initiatives in England haveemphasised joined-up working between health andsocial care.1 Primary care organisations, which arenow responsible for commissioning health care, areencouraged to partner with social services. Jointworking between health care and local governmentorganisations is encouraged and supported byfinancial flexibilities introduced in the Health Act1999. In some areas, this has led to the formation ofCare Trusts, which manage both health and socialcare services in a locality.

British policy makers have also set new standardsfor health and social care arrangements for olderpeople in a recent ‘National Service Framework.’2

The framework identifies the range of community-based services (collectively known as intermediatecare) that should be used to prevent hospitaladmission where possible and to provide activerehabilitation in the community following dischargefrom hospital.

ee front matter & 2004 Elsevier Ltd. All rights reservhbc.2004.09.036

These policy objectives have been reinforcedwith incentives. For example, time spent inthe accident and emergency department is nowa performance indicator in the National HealthService and a target of no more than four hourshas been set. The Community Care (delayeddischarges, etc.) Act introduced a system ofreimbursement for delayed transfers of care, toencourage coordination between acute healthand community social care and so to reducedelayed transfers of care from hospital into thecommunity.

Such incentives can, however, have per-verse consequences. For example, if communityservices are unable to support early dischargefrom the accident and emergency department,then unnecessary hospital admission may bearranged to avoid a ‘‘breach’’ of the 4-hourlimit. Introducing financial incentives to reducedelayed discharges can also place health andsocial care organisations in conflict over thoseresources and local mechanisms for triggeringpayment.

These issues emphasise the need for carefulconsideration of local conditions before introducingspecific changes in working arrangements. Happily,in Britain, the most recent National Health Servicehealth and social care planning framework3 hasaddressed some of these issues, thus moving us atleast in part towards improved local plans, sensibletargets, and whole-system working across healthand social care.

References

1. The NHS Plan: a plan for investment, a plan for reform.London: Department of Health; 2000.

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EDITORIAL324

2. National Service Framework for Older People. London:

Department of Health; 2001.

3. National Standards. Local Action: Health and Social Care

Standards and Planning Framework 2005/06–2007/08.

London: Department of Health; 2004.

S.G. Parker, MD FRCP, S.D. Lee, MBBS MRCP,R. Fadayevatan, MD MPH

Sheffield Institute for Studies on Ageing,University of Sheffield and Barnsley District

General Hospital United Kingdom