At a meeting of Oxfordshire Joint Health Overview Scrutiny Committee on Thursday (30 January), senior leaders in the county’s health and social care system have reported a positive picture. The region’s discharge figures show that 150 people were supported to return home with additional care in the week of new year, thanks to Oxfordshire County Council’s discharge to assess programme.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “While most of us take some time off towards the end of the year, our hard working colleagues in health and social care are supporting people in hospital and community settings, enabling people to live well and as independently as possible.

“The last year has seen a positive shift in how the entire system is working, with more people being supported to head home after a hospital admission, reducing pressure on the hospitals and improving people’s chances of regaining their independence.

“To see this continuing to take effect over Christmas and new year is great news for health and social care partners and even better news for families who are able to start 2025 together.”

Significant changes have been taking place in Oxfordshire’s health and social care system during the last 12 months, with increased partnership working and a greater emphasis on supporting people to access services, and live more independently, at home.

This includes the council’s discharge to assess programme, which supports people home more quickly after a stay in hospital, by providing additional home care support before care and financial assessments have taken place. Prior to the launch of the programme, this was done on a hospital ward, adding to a person’s length of stay.

Oxfordshire County Council is now working with home care organisations through a dedicated framework to provide more than 34,000 hours of care in people’s homes each week, compared to 24,000 hours per week, five years ago.

Coupled with the Transfer of Care Hub, which has been embedded into Oxfordshire’s hospitals to help identify a person’s route out of hospital and back home at a much earlier stage, discharge to assess has enabled more than 7,000 people to be moved safely out of hospital with additional support during 2024. An increase of 23 per cent compared to the previous year.

Felicity Taylor-Drewe, Chief Operating Officer at Oxford University Hospitals, said: “This achievement is testament to the excellent partnership work across the health and social care system to get people home from hospital as quickly and safely as possible – not least at a time like Christmas, when so many people want to be in familiar surroundings or with their loved ones.

“Initiatives like our Transfer of Care Hub are a really important part of this. Since the hub was set up in January 2023, the number of people in hospital beds waiting to go home or into community care has reduced to less than 90 a day, from a peak of 135 in 2022, including a recent low of 59.

“We know that being at home can really help patients with their recovery and wellbeing. Not only that, but by getting those patients who are well enough to leave us back home, we are freeing up beds for those people who need urgent or emergency care.”

However, people are still advised to choose their healthcare services wisely, ensuring that urgent and emergency care is kept for those who genuinely need it.

Felicity added: “While we are working hard on getting people home from hospital, we also need people to be mindful and careful of their healthcare choices before coming to hospital.

“Emergency departments should be for genuine emergencies only. If you need medical care that isn’t urgent but are unsure of where to go, NHS 111 can help. They can point you in the right direction in terms of a local service, whether that be a minor injury unit, your local pharmacy, or your GP, making sure that you get the right care, in the right place, at the right time.”

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At a meeting of Oxfordshire County Council’s cabinet on Tuesday 17 December, councillors noted the improved experiences of patients since the roll-out of the health and social care system’s Discharge to Assess programme, by reducing hospital discharge delays and increasing chances of regaining independence once people are back home.

Discussions were also held around how these improvements have led to a reduction in need for short stay hub beds, which were previously used as a stop gap for patients between staying in hospital and going home, with a commitment to remodelling the service to support residents with the most complex needs.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “Our Oxfordshire Way vision shows the importance we place on supporting people to live well and independently, within their own communities for as long as possible.

“This is particularly important after a hospital stay as people’s chances of regaining their independence are much higher if they return home more quickly.

“Our joint-system Discharge to Assess programme is reducing hospital stays and we are seeing 73 per cent of people regaining the levels of independence they had before being admitted.”

The policy was discussed after a motion passed at November’s full council, asking cabinet to fully consider the reasoning behind the reduction of short stay hub beds in Oxfordshire, specifically in Henley, where seven beds in a care home were repurposed for alternative use in December last year.

The motion also asked cabinet to clarify if there was any need for an official consultation to take place prior to the decision being made.

Cabinet heard that the decision to reduce short stay hub beds followed national guidance to support people home from hospital safely and quickly, but members acknowledged that while formal consultation was not required, better engagement should have taken place with Henley stakeholders and residents ahead of the decision.

They noted the work that council and NHS leaders have since undertaken to better communicate the decision this year.

Comments were also considered from the Minister of State for Health, Karin Smyth MP, who in response to a letter from Henley and Thame MP Freddie van Mierlo,  said: “local joint commissioners, the NHS Buckinghamshire Oxfordshire and Berkshire West Integrated Care Board and Oxfordshire County Council are best placed to determine the needs of their local population,” and that the decision to repurpose the beds did not meet the threshold for further intervention.

Councillor Bearder continued: "Following a written question from the Henley and Thame MP Freddie van Mierlo, it is good that we have some clarity from the Minister of State for Health, Karin Symth.

“We were grateful for the opportunity to fully and publicly discuss our approach to supporting people to return home from hospital quickly and safely through Discharge to Assess and offer reassurance that the partnership programme is producing good outcomes for residents.

“While it is understandable that people would like to retain access to as many local services as possible, our need for short stay hub beds is reducing and as contracts begin to expire, we need to make sure we make the best use of the Oxfordshire pound to support residents, where possible, in the comfort of their own homes.

“This inevitably means fewer short stay hub beds are required, but for those people who ultimately need the facility, they will continue to be available in Oxfordshire.”

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Funded through Oxfordshire County Council, discharge support workers are an important part of Oxfordshire’s Discharge to Assess programme, supporting people to leave hospital more quickly to continue their recovery with additional care at home. 

“The great thing for us is there’s no time pressure. We can sit and talk with people for as long as needed”, said Rachel, who is based at the John Radcliffe Hospital in Oxford.

“That first conversation can uncover any concerns a patient may have, which aren’t necessary medical, but can potentially be really easy to fix. This can range from people concerned that they hadn’t locked the door when they went into hospital to forgetting things like glasses and hearing aids. I’ve even gone into a person’s home to find their teeth!”

Discharge support workers are available to have bedside discussions with people who have been identified as potentially benefiting from additional support, often finding solutions to reduce people’s anxieties.

And it’s not just this practical in-patient support that’s offered by Age UK Oxfordshire that’s really making a difference. During the discharge process, they are also able to offer valuable help by ensuring patients have everything they need to go home.

Lynn explained: “For some people, they’re worried they won’t have any food in the house, so we can provide a care package of essentials for those first few days.

“Before going home, we can support people to consider how their home environment is organised to ensure a safe discharge, which can include checking the measurements of their rooms to see if equipment like a hospital bed will be able to fit. It’s often about providing that reassurance that everything will be ok once they’re home and that they won’t be forgotten about.”

This is where Lynn and Rachel’s role becomes even more crucial, as they also double up as community link workers, providing continued support to people once they’ve left hospital and returned home.

By having a face to face catch up in a person’s home, community link workers are able to tailor their support in a meaningful way, providing information about groups and activities operating in the local area, to help source more long-term support options.

This plays an important part of the county council’s Oxfordshire Way vision to support people to live well and as independently as possible in their own communities.

Rachel said: “We’re all embedded in different regions of Oxfordshire and when it’s clear a person would benefit from continued community support in their local area, we can put them in touch with groups and organisations on their doorstep.

“This could be anything from an Age UK Oxfordshire support group, all the way through to singing clubs and yoga sessions. As we can take the time to get to know people, we can really listen to what would offer them the most benefit.”

Age UK Oxfordshire’s team of support workers are an integral part of Oxfordshire’s Discharge to Assess programme, which also involves staff from Oxfordshire County Council, Oxford University Hospitals NHS Foundation Trust and Oxford Health NHS Foundation Trust, working together to identify the best way of supporting a patient to leave hospital safely and quickly.

The latest statistics show the programme has contributed to a reduced length of stay for patients in Oxfordshire, with people spending on average three fewer days in hospital than last year.

Reablement figures have also improved, with 73 per cent of people who head home through the Discharge to Assess programme regaining the levels of independence they experienced before going into hospital.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “Oxfordshire’s health and social care teams are working closely together to support people to leave hospital quickly and safely, easing hospital flow and offering the best health outcomes for residents.

“While we rightly praise the doctors, nurses and social workers, who support people to be discharged from hospital to head back home, Age UK Oxfordshire’s discharge support workers and community link workers are a crucial and often unsung hero of the team.

“People like Lynn and Rachel spend time to really get to know patients and build up important relationships to reduce anxiety and offer reassurance around what the future steps of a hospital stay might involve. This includes the crucial role around discharge which is now enabling 23 per cent more people to leave hospital compared to last year.

“Community link workers are absolutely essential to keeping our hospitals flowing and supporting people to recover at home.”

Paul Ringer, Chief Executive Officer of Age UK Oxfordshire, said: "Our community link workers play a crucial role in the hospital discharge process by ensuring that older adults receive the necessary support and resources to transition smoothly back into their homes.

“The support they provide not only helps to reduce readmission rates but also enhances the overall wellbeing of older people when returning to their home and community.”

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Discharge to Assess is a system partnership programme, involving staff from Oxfordshire County Council, Oxford University Hospitals NHS Foundation Trust, Oxford Health NHS Foundation Trust and Age UK Oxfordshire, working together to identify the best way of supporting a patient to leave hospital safely and quickly.

The latest figures demonstrate it has enabled 23 per cent more people to leave hospital compared to last year. In October, this amounted to 657 people going home from hospital through Discharge to Assess.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “Nobody wants to stay in hospital for longer than necessary. Indeed, for some of our older residents, remaining in hospital for longer than necessary can have a huge negative impact on their ability to regain their independence.

“By working closely with health partners and organisations such as Age UK Oxfordshire, we’ve developed a service that supports people to leave hospital more quickly, enabling them to continue their recovery in familiar surroundings.

“It’s an important part of our Oxfordshire Way vision, to support people to live well and independently within their own communities.

“In the first year, statistics show Discharge to Assess is having a positive effect for our residents while freeing up hospital beds for those who need them most.”

The programme is based on national guidance and came into effect in November last year. It brings together experts in health and social care in Transfer of Care Hub meetings, which take place three times a day.

The team considers a plan for a patient to leave hospital, as well as any homecare support they might require, before they are well enough to go home, speeding up the discharge process.

By working with the person and their family, plans are then put in place to support them to leave hospital and return home as quickly as possible.

Tamsin Cater, Head of the Transfer of Care Hub at Oxford University Hospitals NHS Foundation Trust, said: “This system is good news for all patients being admitted into hospital, and we’re really pleased with its progress. 

“The outcomes for people recovering in their own home are far better than staying in hospital unnecessarily, and we’ve been working hard with our health and social care partners to make this happen wherever it is safe and appropriate to do so.”

Under the Discharge to Assess programme, people are offered short-term, immediate care on the day they get home through a council arranged care provider. This can range from a short care visit to short term overnight (live in) support.

This has significantly improved hospital flow, shortening the average length of stay in an acute hospital setting from eight days to five days. It has also reduced the need for as many short stay hub beds used by the system, as personalised support is now being arranged for people within their own homes.

For people returning home through Discharge to Assess, 73 per cent of people have gone on to reach full independence following a period of reablement.

Karen Fuller, Oxfordshire County Council’s Director of Adult Social Care, said: “While it’s great to see the impact of Discharge to Assess on hospital flow, the real success is being seen in people’s homes.

“By supporting people back into a familiar environment, with all their home comforts, we can take a far more informed approach to the goals that someone wants to achieve. This enables more people than ever before to regain the levels of independence they had before going into hospital.

“It’s incredibly rewarding to see the difference the programme is making to people’s lives.”

Discharge to Assess forms part of the recently published Healthwatch Oxfordshire report, ‘People’s experiences of leaving hospital in Oxfordshire’, which praises the effective way that health and care professionals are working together to help more people to return home with the support they need.

The report identifies that many people had a positive experience of leaving hospital, and that the majority of people felt safe and happy to be home.

The document also includes some recommendations, including improvements around the continuity and quality of care experienced by patients, clearer communications for patients and carers, and better support and identification of unpaid carers.

The report goes on to recommend the continued close working relationship between health and social care partners to further improve the hospital discharge process.

Dan Leveson, Oxfordshire Place Director at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, said: “It’s relatively early days for Discharge to Assess but we’re already seeing its benefits, helping people leave hospital more quickly, offering them an even better chance to regain their independence

“We recognise that improvements still need to be made to ensure everyone has a positive experience of being discharged from hospital.

“We thank Healthwatch Oxfordshire for the valuable insights we have gained from their report and look forward to continuing to work with health and social care partners to build on our early success.”

An executive summary of the Healthwatch Oxfordshire report, including responses from health and social care partners, can be found on the Healthwatch Oxfordshire website.

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Staff from the county's hospitals, GP practices, social services, community health services, ambulance services, mental health services, and the voluntary sector are working together to provide safe, effective, and sustainable care for people across Oxfordshire.

Winter is a high pressure season for health and social care services, with the colder temperatures and harsher weather conditions leading to increased demands on GPs and emergency departments as flu season begins.

This means that health and social care staff working as 'Team Oxfordshire' is especially important.

Lisa Glynn, Interim Chief Operating Officer at Oxford University Hospitals NHS Foundation Trust (OUH), said: "Winter is the busiest season for health services – as temperatures drop, we see more respiratory illnesses like RSV and, of course, flu. After another busy year, the winter team's priority is to ensure that people who need medical treatment are able to access services to get the care they need.

"We all know that, more often than not, treatment closer to home is what’s best for patients – they can be looked after in a home setting, in familiar surroundings, and with their home comforts.

“As always, we’re working hard with our health and social care colleagues to get people safely home from hospital as quickly as possible, but also addressing the other end of the scale and preventing unnecessary hospital admissions.”

Emergency departments often see the highest demand in winter, and OUH colleagues have been working hard to improve performance this year.

Lisa added: "A variety of quality improvement initiatives in our emergency department have led to an improvement on our performance, but we still want people to remember that emergency departments are for genuine emergencies - if you need medical help but it's not urgent, then your local pharmacy, minor injuries unit, or GP will be best-placed to help you.

“If you are unsure where to go for help, contact NHS 111  who can provide advice and direct you to the best place for the care you need."

One of the best ways of keeping yourself and those around you well is to make sure you're up to date with your flu vaccination and COVID booster vaccination if you are in the groups these are recommended for.

Dr Ed Capo Bianco, an Oxfordshire GP, said: "It is important to keep yourself well this winter. Having a personal winter plan might include stocking up on the cold and flu medicines in your medicine cabinet at home, as well as thinking about other supplies that can help you manage if we have a cold snap.

“It is also important to make sure that if you do have a long-term condition like diabetes, asthma, or high blood pressure, you take your prescribed medication and attend any review appointments that are due.

“If you do fall ill, you can get helpful advice from your local pharmacy or get in touch with 111 online or by phone. And don’t forget to download the NHS App, it has lots of advice on hundreds of conditions and can help you access health services.”

GP practices will contact those patients eligible for the free flu jab and COVID-19 booster to attend vaccination clinics which are taking place over the next few months in Oxfordshire.

More information on who is eligible for a free flu vaccination is available on the NHS website.

Alongside health care, Oxfordshire County Council’s social care team play an integral role in reducing hospital admissions, and supporting those who require a stay in hospital to get home as quickly as possible.

Karen Fuller, Oxfordshire County Council’s Director of Adult Social Care, said: “Our Oxfordshire Way vision looks to support people to live well and independently within their own communities for as long as possible. This is achieved by working with partners in community and voluntary groups who, alongside us, are able to offer more personalised support closer to home.

“If a hospital admission is required, our discharge to assess model is helping to support more people to be discharged faster and safely with additional care arranged for their return home.

“This is not only good news for hospitals, reducing unnecessary stays, but crucially it’s great news for residents as people are regaining their independence faster and reducing their need for more formal long term care.”

The council’s Live Well Oxfordshire guide offers a wealth of information including details of community support groups, information for carers, and advice on staying independent and active in your local area.

Oxford Health NHS Foundation Trust provides community physical health services and mental health services, including the county's out of hours GP service and minor injury units, Oxfordshire's community hospitals, the Oxfordshire NHS 24/7 mental health helpline, and health visiting and school nurse services.

Britta Klinck, Chief Nurse at Oxford Health NHS Foundation Trust, said: "As we are moving towards the darkest and coldest part of the year, it’s important to think about preparing for winter, helping one another to support and look after our physical and mental health.

“If you, or someone you know, qualifies for vaccinations for flu or COVID it’s really important to take the opportunity. These vaccinations help to protect vulnerable people, so I am really keen as many people as possible get them.

"Oxford Health colleagues work hard to support people to stay healthy, live well, and thrive, whether that's providing clinical care at home or via our community hospitals, countywide district nursing teams, school nursing service, or help through our mental health teams.

"If you are an adult or young person struggling with your mental wellbeing, NHS help is at hand with the Oxfordshire NHS 24-hour mental health helpline via NHS 111 online. You can also look up Oxfordshire Talking Therapies online."

Last winter, South Central Ambulance Service (SCAS) attended over 216,000 emergency 999 incidents, of which just over 73 per cent were for category one or category two emergencies – the highest category of calls for the most seriously ill or injured patients.

Mark Ainsworth, Executive Director of Operations at SCAS, said: “The arrival of winter and cold weather always sees increased pressure on NHS services across the board, and the ambulance service is no different.

“Cold weather exacerbates many pre-existing health conditions and can lead to more 999 calls and more patients having to spend time in hospital. We will always focus our ambulance teams on our most seriously ill and injured patients – the category one and category two emergencies.

“Whilst we aim to get to all other patients within two to three hours, there may be times this winter when that will not be possible, and those patients may experience much longer waits at peak periods.

“That’s why we continue to urge the public to only call 999 if you, or someone you’re with, is suffering a life threatening or serious emergency that requires immediate treatment and you are unable to get yourself to hospital or other treatment centre.

“If it’s not an emergency, people should use the NHS 111 service by going online at 111.nhs.uk or by calling 111. Whether you use the online or telephone service, you just need to answer a few questions about your main symptoms to get the help and advice you need, including a call back from a doctor, nurse, or other healthcare professional if required.”

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The initiative is called Discharge to Assess (D2A) and it enables people who have had a stay in hospital to continue their recovery in the comfort of their own home, close to the communities that support them.

The national programme brings together hospital based teams from health, adult social care, therapy and reablement to plan a patient’s best route out of hospital, as well as provide a more joined up way to receive support once at home.

Karen Fuller, Oxfordshire County Council’s Director for Adult Social Care, said: “By working with NHS colleagues we have significantly changed the way we offer support when a patient with additional needs leaves hospital.

“Our social care teams have restructured, working seven days a week to support discharges over the weekend. We’ve also significantly redesigned our care provider framework, ensuring that we have capacity in the system to support people on the same day that they return home from hospital.”

The programme is based on the recognition that people have better health outcomes when they are supported to live happily and independently within their own homes. A vision known locally as The Oxfordshire Way.

The latest weekly figures, reported to the Oxfordshire Joint Health Overview and Scrutiny Committee on Tuesday, show that of the 105 people in Oxfordshire who were medically fit to be discharged from hospital but were still considered as needing additional care support, 91 were enabled to return home to continue their recovery through the D2A pathway.

How it works:

In hospital

D2A brings together experts in health and social care in a twice-daily Transfer of Care Hub meeting. The team considers which patients are medically fit to leave hospital and return home but who may need some additional social care support once they get there.

Plans are then put in place, in collaboration with the patient and their family, to enable them to leave hospital and return home as quickly as possible.

Returning home

Under the programme, instead of remaining in hospital or being moved to a short stay hub bed to wait for long-term support to be arranged, people are offered short-term, immediate care on the day they get home through a council arranged care provider. This can range from a drop in visit to overnight (live in) support.

Alongside the care provider, a patient who has been discharged home with additional support needs will also be allocated a council social worker or occupational therapist. They can make any quick modifications to a person’s home, supporting them to recover safely in a familiar environment. This can include provision of equipment, installation of assistive technology and other minor adaptations.

They will also be assigned a council link worker who will liaise with the care providers, social workers and the patient, to make sure the process is operating smoothly.

Long-term support

Within 72 hours of returning home, people then receive an assessment to make sure they get the right type of ongoing support, tailored to their individual circumstances.

Where it is thought that someone has the potential of regaining their independence, they may be invited onto the Home First reablement programme that offers non chargeable short-term support to help people find their feet.

For some people, a more long-term care package might be needed. The council link worker will be able to offer advice about this in the comfort of a patient’s home, including having discussions about any potential ongoing care costs, to enable them to make decisions that are right for them.  

Dan Leveson, Place Director for Oxfordshire at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, said: “This is a significant change in the way people are supported to leave hospital and it’s great to see the initial few weeks are working well.

“By enabling more people to recover from a stay in hospital in their own homes, rather than diverting them to a short stay hub bed or convalescing in a care home, we are supporting people in Oxfordshire to regain their independence more quickly and return to their everyday lives.

"I would like to thank the hard working staff in our local health and social care teams for their commitment to this new programme and look forward to seeing further positive results in the future.”

To support the roll out of the programme, Oxfordshire County Council has significantly increased the amount of homecare hours being provided each week by more than 7.5 per cent to 31,095 hours. This is up from 28,885 hours per week last spring and 27,888 in the autumn of 2022.

Due to the success of the programme and based on evidence from the initial pilot last summer, Oxfordshire County Council has been able to reduce the number of short stay hub beds in the region, which were originally commissioned to alleviate pressure on hospital discharges.

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A new “Discharge to Assess” programme in Oxfordshire will change the process and speed in which patients are offered social care support after a stay in hospital, helping people to leave hospital sooner and supporting them to recover safely in the place they call home.

The approach brings together teams from health, adult social care, therapy and reablement to plan a patient’s best route out of hospital as well as a more joined up way to receive support once at home.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “We work closely with health and social care partners throughout the year, supporting residents to live happily and independently within their own communities. We call it The Oxfordshire Way.

“After a stay in hospital, it’s important that we enable people to return home as soon as possible, maximising their chances of regaining their independence in a familiar environment.

“The new Discharge to Assess system will help the council’s adult social care teams to speed up this process while offering a more holistic approach to providing relevant support in the comfort of a patient’s home.” 

A pilot of the programme has been running in Oxford and north Oxfordshire since July and has already supported 116 people to leave hospital more quickly, enabling them to recover at home, supported by social workers arranged by the county council.

The system is now being rolled out across the county from Wednesday 15 November.

How it works

The plan is for patients who are fit to leave hospital to be discharged within 24 to 48 hours. In the days leading up to this, the relevant information relating to them is taken to the Transfer of Care (TOC) hub meetings, where a team of nurses, social workers and therapists will consider each person’s case individually, planning their best route out of hospital.

Discharge to Assess will support patients who will be leaving hospital and returning home but who the TOC team feel may need some additional social care support.

Under the programme, instead of remaining in hospital and waiting for long term support arrangements to be made, people will be offered immediate care to leave the hospital.

Within 72 hours of returning home, they will then receive an assessment to ensure they get the right type of ongoing support, tailored to their individual circumstances. They will also receive advice in the comfort of their own home about any potential costs of care following that assessment, enabling people to make decisions that are right for them.   

The pilot to date has shown:

• A 50% reduction in the number of days people are waiting to return home.
• 16% (19) returned to independence with no ongoing care needs.
• 11% (13) of people had reductions in their care needs once they had returned home, with relevant support offered based on what would add value to their daily lives.
• 28% (33) of people were moved onto the council’s Home First reablement pathway, supporting them to regain their independence.
• The programme also reduced the number of patients who may have been moved to a short stay hub bed, as support was immediately available for patients at home.

Dan Leveson, Place Director for Oxfordshire at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, said: “This is great news for the people of Oxfordshire. Last year we introduced our Transfer of Care Hub, run by a team of professionals, to identify the best way for people to leave hospital as soon as they are medically fit and avoid unnecessary delays. 

“Now, we are providing an increasing amount of care and support in people's homes helping them recover safely and regain as much independence where they want to be.”

The difference it’s making

Jefferson Lee is a social work coordinator for Oxfordshire County Council and now carries out care and financial assessments in people’s homes rather than in a hospital ward.

Jefferson said: “The difference I see in people is amazing. After three days of being at home, people who may have been considered as needing a long term care package have adapted so well that they can change onto the reablement pathway. Reablement offers a person the opportunity to regain their independence, so that they don’t need to access long term chargeable care services.  Very often we see that just two or three weeks of this support can make a very big difference to people’s lives.

“I am also able to see people in their usual setting, so I can make more relevant recommendations about potential adaptions, like grab rails or ramps, better supporting people to regain their independence.”

Tamsin Cater is Head of the Transfer of Care Hub and has already seen improvements to the discharge rates due to Discharge to Assess.

Tamsin said: “This system is good news for all patients being admitted into hospital. For a person medically fit to be discharged, they may notice a greater sense of urgency to leave the ward and we would greatly appreciate the support of friends and family to help with this process. But with three days of free social care support planned for when a person gets back home, the outcomes are much better for people by recovering in their own home.

“We have already seen how more than a hundred patients have been supported through the system this summer and anticipate these trends to continue as we roll out the programme more widely throughout Oxfordshire.”

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