Introduction
The stories in this report highlight the consequences of health and social care organisations failing to manage people's discharge from hospital.
In 2014-15 we investigated 221 complaints on this issue - an increase of over a third in complaints in the previous year. We upheld, or partly upheld over half of these. This was significantly higher than our average uphold rate of 37% in the same year. As we are the final tier of the complaints system, we only see a fraction of the total number of complaints made to NHS organisations - those cases that it has not been possible to resolve locally. Across the NHS there were 6,286 complaints on 'admissions, discharge and transfer arrangements' in 2014‑15, a 6.3% increase on the previous year2.
We have selected nine of our most serious cases to illustrate the gap we see between established good practice and people's actual experience of leaving hospital. We do not claim that these cases are representative of practices in all hospitals and councils across England. However, we believe that these serious cases, alongside the volume of cases coming to us, indicate that this is an area that needs attention. This means understanding why good practice is not being followed in order to make sure everyone experiences acceptable standards of care when leaving hospital.
The most serious issues we have seen are:
- Issue one: Patients being discharged before they are clinically ready to leave hospital
The most fundamental decision that clinicians need to make is whether a patient is medically fit to leave hospital. Mistakes made at this point can seriously compromise patient safety, leading to emergency readmissions and, in the most tragic cases, potentially avoidable death. - Issue two: Patients not being assessed or consulted properly before their discharge
While a person may be 'medically fit' to leave hospital, they may not be practically ready to cope at home. If a rounded picture of a patient's needs (including their mental capacity) is not established on admission to hospital and then regularly monitored, they could be sent home alone, afraid and unable to cope. - Issue three: Relatives and carers not being told that their loved one has been discharged
When a loved one is admitted to hospital it can be an extremely worrying time. But it can also be highly distressing to find out that an older and vulnerable relative has been sent home alone, without your knowledge, unable to feed and clean themselves. Many relatives are their loved one's carer, so failing to notify them can have a direct impact on the care they provide, and on their loved one's recovery and wellbeing. - Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services
Lack of integration and poor joint working between different aspects of healthcare, such as hospital and community health services can result in people being discharged without the support they need to cope at home. Equally, lack of co-ordination between health and social care services can lead to lengthy delays in finding suitable care packages for elderly people with complex needs. This means they can be stuck in hospital wards at the expense of their dignity, human rights and independence.
Discharging people when they are not clinically ready to leave hospital clearly compromises patient safety. However, the service failure we see also includes cases where people have been deemed medically ready to go home, but have not received the care they need after this, often down to poor planning, co-ordination and communication.
This causes avoidable distress for patients, their families and carers, which has a negative impact on overall patient experience. As the National Quality Board has noted, across the NHS, 'there is still some way to go before experience is viewed as equal to clinical effectiveness and safety'3. Experience is shaped by the 'relational' aspects of care: how an individual and their family are communicated with, whether they are helped to understand treatment and care pathways, and whether they feel they are treated with dignity and respect.
Failures in these areas severely undermine people's trust and confidence in the NHS. As the relative of an older woman who complained about her treatment told us:
'Surely when family members have made their concerns 100% clear and a vulnerable, virtually immobile 93-year-old is sent home alone, something is very wrong somewhere.'
There is no shortage of clear guidance on what effective discharge planning should look like (an overview is provided in the box opposite). Yet our casework shows clear examples of trusts and local authorities failing to put it into practice.
Making sure people leave hospital in a safe and timely way: what should happen?
Best practice guidance has been consistent over the past decade in stating that 'discharge is a process and not an isolated event at the end of the patient's stay'4. The key steps and principles identified to enable appropriate discharge include:
- Starting discharge and transfer planning before or on admission to hospital, to anticipate problems, to put appropriate support in place and agree an expected discharge date.
- Involving patients and carers in all stages of the planning, providing good information and helping them to make care planning decisions and choices.
- Effective team working within and between health and social care services to manage all aspects of the discharge process, including assessments for social care, continuing health care and, where necessary, assessments of mental capacity.
- Community-based health and social care practitioners should maintain contact with the person after they are discharged, and make sure the person knows how to contact them when they need to.
Guidelines published by the National Institute for Health and Care Excellence in December 2015, on transition from inpatient hospital settings for adults with social care needs, also recommend that a single health or social care professional should be made responsible for co-ordinating a person's discharge5. The discharge co-ordinator should be the central point of contact for other health and social care professionals, the person and their family during discharge.
The problems we have highlighted from our cases reflect findings from other recent reports on hospital discharge and transfers of care. Healthwatch England's Safely Home? report6 found that one in 10 trusts do not routinely notify relatives and carers that someone has been discharged, and that one in eight people did not feel they were able to cope in their own home after being discharged from hospital. Conversely Age UK estimate that older patients have spent 2.4 million days over the last five years 'stuck in hospital beds' due to a lack of appropriate social care placements and support7.
Delayed discharges from hospital are estimated to cost the NHS around £900 million per year. Tackling these delays is understandably a key target for efficiency gains for the NHS. However, there is a growing body of research that suggests hospitals may be inadvertently moving people on from hospital too quickly in order to meet efficiency targets. According to the Kings Fund 'being discharged without proper support is an invitation to relapse, a worsening of their condition and re-admission'8. While it is currently harder to capture the precise financial cost of premature discharge, the National Audit Office estimated that emergency re-admissions cost the NHS £2.4 billion in 2012-139.
We recognise there have been a range of recent initiatives to improve the discharge process. This includes specific requirements introduced under the Care Act 2014, NHS England's Patient Safety Alert on risks arising from breakdowns in communication during discharge, the new NICE guideline10, and forthcoming Quality Standard on transition between inpatient and community care or care home settings.
However, we agree with Healthwatch England that 'with all the guidance that is already available, it is not clear why further individual initiatives will make a difference without something more fundamental changing in the system'11. The cases that follow illustrate a range of serious failings across the discharge planning pathway involving a range of health and social care services. While specific guidance is useful, we believe there needs to be system wide leadership and shared ownership across health and social care services to improve transfers of care from hospital. This starts with understanding the scale and root causes of failures to follow established good practice, so that all providers can be brought up to standard.
The Department of Health's recently established national programme on improving discharge provides a vital opportunity for these problems to be addressed holistically12. The programme brings together key NHS and social care organisations to develop a vision for improvement, which should enable all health and social care professionals to put the needs of patients and their carers at the forefront of discharge planning. We set out in the conclusion key issues from our casework that should be addressed in developing this vision.
2 Health and Social Care Information Centre (2015), Data on Written Complaints in the NHS 2014‑15.
3 National Quality Board (2015), Improving experiences of care: Our shared understanding and ambition. The National Quality Board brings together the Department of Health, NHS England and key health stakeholders.
4 Department of Health (2010) Ready to go: Planning the discharge and transfer of patients from hospital and intermediate care.
5 NICE (2015) Guidelines on Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
6 Healthwatch England (2015), 'Safely home: What happens when people leave hospital and care settings?' Healthwatch England Special inquiry findings.
7 Age UK press release issued on 17 June 2015. 4m bed days lost in 5 years from social care delays.
8 David Maguire, (2015), Premature discharge: is going home early really a Christmas gift?
9 National Audit Office (2013), Emergency admissions to hospital: managing the demand.
10 NICE (2015), Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
11 Healthwatch England (2015), 'Safely home: What happens when people leave hospital and care settings?' Healthwatch England Special inquiry findings.
12 Healthwatch England (2016) A step closer to getting hospital discharge right