Milton Keynes Council: Getting people home

The objective of the project was to eliminate the barriers above and to implement the ethos of Home First due to recognising the importance and value of people being more likely to improve, adapt and recover in their own homes. This example of a local initiative forms part of our managing transfers of care resource.

Prior to September 2018 there was no representation from adult social care based within the acute hospital making timely and safe discharges incredibly difficult to facilitate.  This caused the following barriers:  

  • ability to have effective partnership working with all professionals which impacted on holistically meeting individuals needs 
  • created a blame culture between all services across the health and social care system.  
  • high delays in transfer of care and increased length of stays  
  • individuals being assessed multiple times by different professionals for the same reason, discharge destination 
  • individuals being discharged on inappropriate pathways not suitable for needs and increasing dependency on long term care and placements.  

The plan

The objective of the project was to eliminate the barriers above and to implement the ethos of Home First due to recognising the importance and value of people being more likely to improve, adapt and recover in their own homes.  From a social care perspective there was a need to minimise long term decisions regarding care and support being made in an acute setting where an individual is most unstable.   

As part of the Getting People Home project which had both financial and supportive input from the clinicial commissioning group, Central and North West London NHS Foundation Trust (CNWL), the acute hospital, voluntary services and social care the following was set up to enable early discharge planning.   

A team of social workers are now based in the hospital. The social workers attend daily board rounds and actively seek out individuals who will require reablement or social work input.  

This early identification means that discharge planning can commence earlier in the discharge pathway enabling timely discharges minimising delays.  We have also developed good and effective working partnerships with all professionals across the system. 

Although the social work team currently only work Monday-Friday we have piloted seven day working over the Christmas period. We will continue to do this, where possible, during peak periods, to enable us to evaluate the benefits and cost efficiency of social work support over weekend and bank holidays. 

We do however now provide a seven day service through Home First Reablement (social care) offering daily support to the wards and supporting discharges every day of the week. This also includes supporting the Emergency Department (ED) and where possible preventing people being admitted into hospital. 

To reduce the amount of continuing healthcare (CHC) assessments that were taking place in Milton Keynes Hospital we reached an agreement with our CHC team that we would simplify the process and agreed a gateway tool. Those patients clearly identified as unlikely to receive CHC funding have their discharge arranged by adult social care. For those clearly identified at likely to receive CHC funding have their discharge arranged by the CHC team. This usually involved a step-down bed so the assessment can take place outside of the hospital. Using the IBCF monies we were able to implement two recuperation pathways. recuperation at home and recuperation in a bedded unit. For those people that are not well enough to engage in reablement or not safe to return home this gives the person longer to recover whilst their assessment takes place out of the hospital.  

  • Home First Service:The merging of the community services including therapy, social care (reablement), nurses and psychology input to provide a holistic joined up approach to getting people home.  This includes working with voluntary services like Age UK to make discharge home as smooth as possible.   
  • We now have a multi-disciplinary front door team based in the ED. The team is made up of occupational therapists, physiotherapists, rehab assistants, team leaders and a social worker. This is a seven day service whose priority is to work with ED colleagues to prevent admission to hospital and utilise community resources to get people home (seven day services – established). 


The Getting People Home Project was initially piloted in 2015 but has evolved significantly over the last 18 months. The starting point was getting all key stakeholders including frontline staff to understand and work towards the common goal of getting people home. Once this shared goal was agreed planning commenced with key stakeholders agreeing the different discharge pathways and admission avoidance.   Pathways 1, 2 and 3 were developed and it was agreed who would take the lead on each pathway (Early discharge planning – mature) 

Communication was a key aspect in overcoming barriers and one aspect that has helped with this is the daily teleconference. There is a representative from the clinical commissioning group, CHC, mental health, social care, Home First and the hospital where individual cases are discussed and agreements made on discharge pathway. This enables a whole system approach to trouble shoot issues that can hinder early discharge. It has minimised a blame culture and evidences a collaborative approach to supporting discharges utilising all resources and achieving positive outcomes for the individuals being discharged. 


Reduction in delays: 

  • Delayed transfers of care (DToC) have improved significantly over the last 18 months. As of February 2019 Milton Keynes ranked joint first with Nottinghamshire in terms of social care delays. DToC attributable to Hospital and Social Care rate per 100,000 (rolling average 18/19) is 0.1.  DToC attributable to Social Care rate per 100,000 (rolling average 18/19) is 1.3.  

Improved patient outcomes: 

  • ASCOF2B(1) Proportion of Older people (65 and over) who were still at home 91 days from hospital into reablement/rehabilitation services. 
  • Our performance indicator for 2018/2019 is 80 per cent. At the end of February our outturn was 85.83 per cent.  
  • ASCOF2B(2) The number of people offered reablement on discharge from hospital. 
  • Our performance indicator for 2018/2019 was 3.5 per cent. At the end of February our outturn was 4.8 per cent. 
  • In December 2018 we received 85 referrals into our reablement team and 71 per cent of these individuals left with no ongoing care needs. In January 2019 we received 137 referrals into our reablement team and 73% left with no ongoing needs. This is a substantial improvement which previously has seen the team averaging at 48 per cent.   
  • Due to the team now based in A&E within the acute hospital less people are being admitted that could be cared for at home reducing the impact on the hospital and more importantly improving outcomes for people we are supporting.  

Next steps

Embedding of the Trusted Assessor role: It has been identified that one of the barriers to effective discharges is the trust between professionals and non-professionals in relation to the right professional being trusted to complete assessment at the right time for the individual. This has caused individual’s being assessed multiple times which is time consuming for the individual as well as the professionals.  The development of a shared assessment tool and implementing ways for this to be shared across the system is currently being piloted (Trusted assessment – Established) 

Whilst we recognise there is a benefit to social workers being based within the hospital weekends and bank holidays we still need to measure the actual demand and cost effectiveness of this. For this to be successful we would need to have the reassurance that there are care providers within the community willing to accept new referrals during these periods. In addition the acute hospital would need to be able to guarantee that there will be Consultants available to make a clinical decision that the patient is fit for transfer and that there is timely access to To Take Outs (TTOs) and transport. 

Individual case study

Mr A was admitted to hospital in December 2018 following a stroke.  Whilst in hospital it was identified that there was safeguarding concerns regarding him being subjected to physical and emotional abuse from a close family member.  Mr A’s clear goal was to return home despite the safeguarding concerns and he had the mental capacity to make this decision. Mr A’s physical abilities had deteriorated and despite therapy input on the ward he needed assistance of one with all daily living tasks and mobility/transfers. There were concerns regarding Mr A’s ability to safely use the stairs but he was determined he could achieve this and agreed that a home visit with the hospital therapists, social worker and Home FirstTherapy team would enable him to show that it was safe for him to return home. 

It took several weeks for access to be gained to Mr A’s property as his family member was not engaging or wanting him to return home. The home visit was completed and Mr A attempted the stairs but was unable to safely manage this. This, alongside the realisation that his family member, had removed all of his belongings from the home made Mr A identify that he could not return home at this time.   

Adult social care in partnership with housing identified that a contributing factor to extended length of stays in hospital and delays in discharge was the issue in having appropriate accommodation to be discharged to. Therefore 18 months ago, two extra sheltered flats were provided to support discharges from hospital. These flats have been used for individuals like Mr A to enable them to be assessed in supported living to determine their long term housing and social care needs. It was agreed that Mr A could use one of these flats.   

Mr A was discharged on a Friday afternoon and the warden of the sheltered housing accommodation contacted adult social care to raise issues in relation to the discharge in that Mr A was unable to safely use the toilet or armchair in the flat due to them being too low for his height. 

There were concerns for his safety and inability to be supported by the carers to remain at home. Contact was made with the occupational therapist on the ward who had left for the day. The hospital advised that they would arrange for him to be readmitted to the hospital.  To avoid  readmission, adult social care worked closely with an occupational therapist in Home First therapy who knew Mr A’s needs and was able to order the necessary equipment. 

Contact was made with the equipment store to agree for them to extend their collection hours so there was time to pick this up. A social work assistant who has had low level equipment training and whose background is in reablement then collected the equipment and installed it whilst assessing that Mr A was safe to use it, which he was and also provided him with increased independence. Mr A was able to remain in the sheltered housing flat and a readmission to hospital was avoided. 


Yvette Chicharro
Team Manager, Reablement and Hospital Discharge Team

This case study is an example of the High Impact Change Model (Change 5): Flexible working patterns.