This chapter provides information to help establish what actions may need to be taken when a patient with no recourse to public funds who is experiencing homelessness is in hospital. Planning for a safe discharge should be started as early as possible after a hospital admission.

9.1 Discharge process

NHS bodies and local authorities exercising health and adult social care functions in England will need to refer to the Department of Health and Social Care guidance: Hospital Discharge and Community Support Guidance to inform local service planning and delivery when adults are discharged from acute hospitals and community rehabilitation units (excluding maternity patients). Mental health trusts are encouraged to embed some of the principles set out in the guidance and adapt these for mental health care pathways. The NHS and local authorities can jointly fund and commission services through the Better Care Fund to support multi-disciplinary practice.

The Hospital Discharge and Community Support Guidance reflects the changes to hospital discharge processes that are due to be implemented by the Health and Care Act 2022. The changes provide more flexibility for local authorities and the NHS to implement different types of discharge plans, including a ‘Discharge to Assess, Home First’ model. The Health and Care Act will amend section 74 and repeal Schedule 3 of the Care Act 2014 (assessment notices and delayed discharge).

The Hospital Discharge and Community Support Guidance states:

From 1 April 2022, [NHS bodies and local authorities] should adopt discharge processes that best meet the needs of the local population. This could include the Discharge to Assess, Home First approach. Systems should work together across health and social care to jointly plan, commission, and deliver discharge services that are affordable within existing budgets available to NHS commissioners and local authorities, pooling resources where appropriate.

With regards to patients who are homeless, the guidance states:

Where there are ongoing health, housing or social care needs after discharge with different care options available, individuals (and, where relevant, their family, unpaid carers or advocates) should be empowered and supported to make the best choice for their individual circumstances.

Transfer of care hubs should incorporate appropriate safeguards for individuals who require this. For example, people who are homeless, at risk of homelessness or living in poor or unsuitable housing should be determined on admission to hospital…

Health and social care professionals should follow an ongoing commitment to reducing health disparities and inequalities and consider the needs of groups that might need specialised support. This includes, but is not limited to, understanding issues relevant to people from black, Asian and minority ethnic groups, LGBTQI, faith or cultural needs, people living with disabilities, autistic people, older people, unpaid carers, people who do not speak English, and those with specific communication needs. (Chapter 14)

Further information relating to hospital discharge processes can be found in the guidance: Managing transfers of care – A High Impact Change Model, which has been developed by government, the NHS, and local government partners.

9.2 Discharge planning when a patient has no recourse to public funds

Section 6 of the Care Act 2014 requires local authorities and NHS bodies to cooperate when exercising their functions relating to adults with needs for care and support. Section 82 of the National Health Service Act 2006 requires local authorities and NHS bodies to cooperate when exercising their respective functions, in order to secure and advance the health and welfare of their local population.

The Hospital Discharge and Community Support Guidance states:

Local areas should develop and implement the hospital discharge model that best meets the needs of their local population that are affordable within existing budgets available to NHS commissioners and local authorities. Discharging an individual onto the right care pathway when they no longer need to remain in hospital requires a whole system approach. NHS organisations should work closely with adult social care, children’s social care, care providers, housing, the voluntary sector and others to ensure people’s care and treatment is timely, optimal and coordinated, while also minimising delays when they are ready to be discharged. (Chapter 4)

Any discharge model should address the needs of patients who are experiencing homelessness, including those with no recourse to public funds, and will require health, social care, and housing practitioners to work closely together to ensure that the right pathways for an individual are identified and followed. When a patient with no recourse to public funds is experiencing homelessness, the local authority will need to demonstrate that it has considered all legal duties and powers that may enable accommodation to be provided.

It will be important to identify whether a patient has (or may have) no recourse to public funds and whether they are experiencing homelessness as soon as possible after their admission. As well as ensuring that any relevant assessments of need are undertaken, it will be necessary to clarify who will be responsible for assisting the patient to access immigration advice or any other non-health/ social care services that they may require, and for establishing what alternative housing options may apply, should the person not qualify for care and support or continuing healthcare.

Some hospitals will be operating a Discharge to Assess, Home First model, where an assessment for care and support or continuing healthcare is carried out after the person has been discharged to their home, rather than whilst they are in hospital. The Hospital Discharge and Community Support Guidance states that it is best practice for a needs assessment to be undertaken in a person’s home to determine their long-term care needs. Depending on a patient’s care needs, they may be discharged to a ‘step-down’ bed to receive ongoing healthcare. Under this model, patients with no recourse to public funds who are experiencing homelessness could be placed in a step-down bed or provided with alternative temporary accommodation whilst the needs assessment is completed.

9.2.1 Assessing need under the Care Act 2014

When a patient. who has no recourse to public funds, is experiencing homelessness and is recovering from a condition that has been treated by the NHS, the Care Act needs assessment will be the first step in determining the support options that are available to them. Where a person with no recourse to public funds has care and support needs arising from a physical or mental impairment or illness, accommodation and financial support can be provided under the Care Act.

The Hospital Discharge and Community Support Guidance states:

Local authorities have duties to assess and meet people’s eligible care needs in relevant circumstances and these assessments should be conducted in a timely manner, in accordance with their Care Act 2014 duties. (Section 7)

Adult social care must therefore determine whether the person has ‘an appearance of need’ and can refer to information provided by NHS colleagues to inform its decision to undertake a needs assessment. Where a person has ongoing health needs, it is highly unlikely that they will fail to meet this threshold. For more information about the duty to assess, see section 3.1.

Healthcare professionals will play an important role supporting Care Act assessments undertaken by adult social care by providing any medical and/or therapist reports that are relevant. Such medical reports will highlight how a patient’s health is impacting on their ability to manage activities of daily living and also how homelessness could impact on the person’s recovery or ongoing treatment plan. The input of NHS staff will therefore help to inform adult social care’s analysis of whether the person has eligible care and support needs under section 18 of the Care Act, or whether the power to meet non-eligible care and support needs should be engaged under section 19(1). For more information about assessing need, see chapter 4.

When a person is being discharged from hospital, or is exiting a step-down placement, it may be necessary for adult social care to provide emergency accommodation under section 19(3) of the Care Act whilst the needs assessment is being completed. For more information about meeting urgent needs pending the outcome of the care assessment, see section 3.3.

9.2.2 Step-down accommodation

Where a Discharge to Assess, Home First model is being followed, a person with no recourse to public funds may be provided with step-down accommodation following their discharge from acute care.

The Hospital Discharge and Community Support Guidance states:

People who are homeless or at risk of homelessness should not be excluded from short-term post-discharge recovery and support because of their housing status. (Section 14)

Whilst a person with no recourse to public funds is in a step-down placement and their needs assessments are being undertaken, responsibility must be undertaken for effective step-down planning. This may involve assisting the patient to access immigration advice or any other non-health/ social care services that they may require, and establishing what alternative housing options may apply, should the person not qualify for care and support or continuing healthcare. A multi-disciplinary approach will ensure best use of step-down placement funding, so that alternatives to homelessness are found.