Premature discharge: is going home early really a Christmas gift?

In the past week or so we’ve seen headlines about record delayed discharges from English hospitals and the Nuffield Trust’s considered assessment that many of the NHS’s problems last winter were caused by unsustainably high bed occupancy. We know that avoidable delays cause problems for the system, and more importantly, for patients.

However, the debate on discharge is in danger of focusing solely on delays. That’s partly because they are so obviously important, but also because delays are the most often reported-on national statistics. But what about the other side of the coin – premature discharge, or people leaving hospital too early?

There have been important and harrowing insights on this from Healthwatch England and others. Too often vulnerable people are sent home from hospital without the right equipment in their home or without a care plan or are simply discharged in inappropriate clothing without anyone to help them when they get home. These stories are not just tales of system failings that affect patient’s health directly, but also, in some cases, affect their dignity.

The King’s Fund has been fortunate to assist the Royal Voluntary Society on three projects that have looked at discharge in the round, from the perspectives of patients and their families. Together, these projects highlight the impact of poor discharge practice, both delayed and premature.

In November 2014, the Fund assisted Royal Voluntary Service with a report entitled Going home alone. This work included an in-depth survey with more than 200 older people who were asked about their experience of hospital discharge after a significant hospital stay. The chart below shows that more than a quarter of those who were re-admitted within three months said they had not felt ready to go home at the time of their first discharge, compared with only 5 per cent who were not re-admitted within three months.

Clearly part of this effect may be subjective. However, the message that early discharge is more likely to cause problems is reinforced by our most recent work with Royal Voluntary Service. The perspective of families (in this case a survey of people whose parent has experienced a significant inpatient stay) is consistent with the findings from patients themselves.

Only one in four respondents to the survey had concerns about the level of care available to their parent at discharge. But those who felt their parent was discharged prematurely were almost eight times more likely to have concerns about the level of care available after discharge than those who didn’t think their relative was sent home prematurely.

The NHS is beginning to look towards reducing delayed discharges at a time when they have reached a record high. (Look at the recent Burstow Commission report for an example of some of the effort being made in this area.) At a time when the NHS is under unprecedented financial pressure, delayed discharges will also be seen as a target for efficiency gains (see, for example, Lord Carter’s interim report).

There are warnings in other pieces of research that in the rush to solving delayed discharges we may be inadvertently moving people on too quickly from hospital. They may be clinically fit to leave (and it’s important to move people on from hospital quickly to get the most out of intermediate care and to reduce the chances of health care-acquired infection, but being discharged without proper support is an invitation to relapse, a worsening of their condition and re-admission.

The reason for most delays is not that the patient does not want to leave, but because the NHS or social care are struggling to put arrangements in place in the community or home. Furthermore, according to the survey of nurses conducted by Royal Voluntary Service this year, some of the delays we see in the NHS may come from families being worried at the prospect of their relative being discharged before support is ready.

With Christmas on the horizon, we know that most people in hospital would rather not be there, and the NHS, with its partners, works hard to get people home, so that they can spend valuable time with family and friends. But if the debate on good discharge practice is beginning in earnest in health and social care, it must balance the inefficiency of delay with the harm of rushing to move patients on.

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#545271 Chris Ward
Lay Member

There is no such thing as a 'bed blocker' only the services inability to discharge safely and appropriately. It is time we stopped thinking and referring to elderly people as 'bodies' to be moved at the will of someone else and engaged with them or their families as to what they want or would want. There is not such thing as being over 65 and becoming an 'aging population' or 'frail and elderly'. The whole population ages at the same rate and you can be frail or elderly but they are separate- its time someone took on organisations particularly the NHS for ageism!

#545272 Helen Gentles
Consultant Geriatrician
Gloucestershire Hospitals

I agree that it is the services that need to be better and react in a timely way - the individuals are not 'bed blockers'. There is a lot of work that needs to be done to improve the quality of discharges.
I work on an Acute Elderly Medicine ward. I am part of a multi-professional team and we work very hard with our patients and their families to coordinate discharges.
I also see the harm that can be done to patients when they do stay in hospital after they have got over their acute illness. As well as the hospital acquired infections described in the blog, they lose muscle strength which increases their falls risk and there may be a reduction in their cognition. When a patient of mine dies from a hospital acquired pneumonia when they should not have been in hospital, I could go home and weep. At anyone time I always have one or more patients on my ward who has landed up in hospital because of the predictable progression of their dementia. We need to develop a slicker system that can respond to these individuals needs in their own home and give them the care they deserve.

#545274 Geraldine Maguire
Assistant Director
Southern Health & Social Care Trust

Helen is right the issues surrounding hospital aquire debility, including development of incontinence, poor mobility, environmental confusion and secondary infection have long been recognised by patients, relatives and professional staff. This debility post admission is often cited by patients and families as to why they are fearful about coping post discharge. These issues can arise at any age yet as a society we seem to see the issues as age related. I have been involved in health and social care services for almost 40 years now both as a clinical nurse in acute and community settings and latterly as a manager of health and social care. I strongly feel we need to completely refocus on prevention of admission through a combined primary and social care model of acute care at home supported by outreach from hospital; rather than a focus on hastening hospital discharge for those in need of in patient care.

#545275 Jackie Walls
Health Proffesional

I agree with all that's being said, as a Health Professional in the acute emergency care setting, we need to be very aware of the importance of risk taking. Provided we have the appropriate community services to support discharge, we aim to provide the safest discharge possible in the current environment. But, and its a difficult but, there comes a point where as health professionals we have to stand up and advocate for our patients, there is a very fine balance between when we can say we've organised the safest discharge we can and when it's just not appropriate to do so. The decision to admit or discharge can sometimes result in challenging conversations, and whilst they may be challenging and uncomfortable, there are occasions when admission is unavoidable and its time all NHS organisations stop trying to force discharge and accept sometimes admission for 24 hours may make a real difference to the ultimate outcome for our patients.

#545289 Sue

Patients with swallowing problems in my experience contribute a significant number to those who are sent home too early and without support. Many acute hospitals train their nurses to screen for swallowing problems. This is because at present very few Trusts invest in adequate 7 day SLT services. Patients attend A/E , are screened and sent home with no full assessment from SLT, no adequate advice, sometimes placed on thickener by a Dr who does not know why, how thick and has not trained the pt or carers to thicken.Pts do not know if they are being followed up or why they are on modified diets and how long they should remain as such. We all agree patients should not be in hospital unneccessarily but this is not an excuse for this kind of poor care. Theses patients often return with an aspiration pneumonia or inadequately nourished. Readmission rates are important

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