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.