Discharge to assess is the model that decides what happens the moment a hospital doctor says a patient is medically fit to leave. Instead of keeping that patient on a ward while a full care assessment is completed, the assessment itself moves into the community — a person’s own home, a short-term bed, or a care setting — and the hospital bed is freed up. It sounds like a scheduling fix. In practice it is one of the clearest examples of what integration of health and social care actually requires: an NHS trust and a local authority agreeing, case by case, who does what and who pays for it.
What Discharge to Assess Changes
Before this approach became standard, the default was to complete a full needs assessment before a patient left hospital — often meaning days of extra bed occupancy while social workers, occupational therapists, and family members worked out a long-term plan. The discharge to assess model, sometimes called "Home First," separates those two decisions. Medical fitness for discharge is judged first, on clinical grounds. The assessment of ongoing care needs happens afterwards, in a setting that resembles the person’s actual life rather than a hospital ward. NHS England’s national guidance on hospital discharge and community support has set this out as the default approach for most adult inpatients, on the basis that assessments made at home tend to produce more accurate, less institutional care plans than ones made under a consultant’s discharge deadline.
The Four Pathways
Discharge to assess is not one route but four, graded by how much support a patient needs on leaving hospital. The pathway a patient is placed on determines which organisation leads the next stage of their care, and how quickly.
| Pathway | Who it’s for | What happens next |
|---|---|---|
| Pathway 0 | No new health or social care needs | Discharged home with no further support arranged |
| Pathway 1 | New or additional support needed at home | Reablement, domiciliary care, or voluntary-sector support arranged in the community |
| Pathway 2 | Needs a period of recovery before a full needs assessment | Short-term placement in a community bed for rehabilitation and reablement |
| Pathway 3 | Likely to need ongoing 24-hour care | Assessment for long-term bedded care, used only once other options are ruled out |
The design logic runs through all four: even patients heading toward long-term residential care are not meant to move straight from a hospital bed into a permanent placement. A period of recovery and reablement comes first, on the evidence that people assessed too early, and in the wrong environment, are more likely to be assessed as needing more support than they actually do.
Where the NHS Ends and the Council Begins
This is the part that makes discharge to assess a genuine integration mechanism rather than just a hospital process. The NHS trust manages the clinical discharge decision, but the moment a patient is likely to need ongoing social care, the relevant local authority is meant to be notified early, so that a council social worker — not a hospital-based one — can pick up the case. Under the Care Act 2014, councils retain a duty to cooperate with health services and to help ensure care and support provision is genuinely joined up with what the NHS is doing, even though the earlier requirement to complete a full needs assessment before discharge has been removed. Reablement services, which help someone regain the ability to manage daily tasks after a hospital stay, are typically commissioned and delivered by the council or its contracted providers, not the NHS trust that treated the patient.
In a city with 32 boroughs plus the City of London, each running its own adult social care service, this handover point is where care-closer-to-home policy either works smoothly or breaks down. A patient discharged from a hospital in one borough may live in another, meaning two different council social care teams, two different sets of local provider capacity, and two different waiting lists for home care packages — all before the NHS side of the case is even closed.
The Funding Mechanics Behind the Handover
None of this works without a way to pay for it that does not depend on litigating, case by case, whether a cost is a "health" cost or a "social care" cost. NHS bodies and local authorities are expected to pool resources for discharge services, commonly through Section 75 agreements under the NHS Act 2006, which allow an NHS body and a council to combine budgets and delegate functions to each other, or through the Better Care Fund, a long-standing joint pot that both sides contribute to and draw on for exactly this kind of joined-up care. These are not minor administrative details. They are the practical answer to the question that sits at the centre of every integration debate: when a service sits between health and social care, whose budget does it come out of, and who is accountable if it fails.
Why It Matters for London’s Integration Agenda
Discharge to assess is a small, procedural-sounding policy that nonetheless tests the exact proposition that the integration agenda depends on: that an NHS trust and a local authority can treat a single patient’s transition as one continuous piece of work rather than two separate systems handing a case back and forth. When it functions well, a patient leaves hospital promptly, recovers in a familiar setting, and is assessed for long-term needs without the distortion of a hospital bed pressing on the timeline. When the handover between trust and council stalls — through a missed notification, a funding dispute, or a lack of reablement capacity in that borough — the result is either a delayed discharge that ties up an acute bed, or a rushed one that under-assesses what the patient actually needs. Either outcome is a failure of the same structural question: whether health and social care are, in practice, integrated enough to share a single patient’s discharge as one job rather than two.