South Norfolk Council: District Direct social prescriber

The project

The project was initiated in response to ongoing problem of Delayed Transfers of Care (DTOC) of patients and following discussions with the Norfolk and Norwich University Hospital. It was obvious that there was an absence of identifiable funding to ease the issue and an urgent need to act. South Norfolk Council initiated the District Direct project at its own expense and risk with just one officer covering the catchment area of the hospital (five district council areas). The aim was to prove the concept that making connections initially between patients who are fit for discharge and delays caused by housing related issues (either frailty or homelessness) with the aim of resolving these issues and speeding up discharge.

The concept was proved, and saw the project rolled out to other acute hospitals in Norfolk and the number of officers was increased to 2.6 FTE. Although the service was demonstrably expediting discharges there remained an identified problem, namely the delay between identifying impediments to discharge (cluttered and unhygienic housing, the need for minor works, removal of furniture etc.) and accessing the funding through Adult Social Services to address these issues.

The advent of COVID-19 exacerbated difficulties and the council used recovery monies (Contain Outbreak Management Fund) to enhance the service by providing funds (£80,000 per annum), enabling officers to pay directly for work required in patients’ homes and thus eradicating the delay caused in requesting funding through Adult Social Services. This reduced DTOC in cases referred to District Direct by between 10 and 14 days.

The benefits

The service, in addition to providing staff to engage with patients at the earliest opportunity to assess their needs on discharge, also has funding (£100,000) that enables officers to make appropriate provision on the same day rather than awaiting decisions through local adult social services departments. The Norfolk and Norwich University Hospital believes that a referral to District Direct saves, on average, ten bed days. 84% of all referrals require a spend to expedite discharge.

District Direct officers have the capacity to visit patients’ homes to make an assessment of need and to liaise with families and neighbours as necessary to ensure robust discharge planning. The service was extended to the Emergency Department in late October 2022 and, in the first month of operation, was able to make provision for twenty patients who had been transported there for social reasons, avoiding the need for admission.

Paramedics are aware of this service and are now calling it to make an assessment of a patient’s home circumstances on the same day, where there are welfare/ safeguarding concerns. This provides an alternative to an ambulance being used to take the patient to the Emergency Department for social reasons.

District Direct officers in the Emergency Department also deal with all the patients who present as homeless, link them into appropriate support provision and instigate referral to the relevant housing authorities. This provides for rapid throughput of patients presenting in these circumstances without encroaching on the time of clinical staff.