Hospital discharge disputes, delay, and distress
Healthwatch England’s Safely Home? report 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 support.
NICE had issued a guideline in 2015 – Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
NHS England issued a Patient Safety Alert on risks arising from breakdowns in communication during discharge
In May 2016 the National Audit office (NAO) reported its findings on discharging older patients from hospital. It reported nearly two thirds of hospital bed days being occupied by people over 65 with an 18% rise in emergency admission for older people in the last four years.
The NAO also reported 1.75 million hospital bed days being lost due to delays in transfer of care in 2015, with an estimated 4.2 million bed days occupied by people no longer in need of acute hospital care. Delayed discharges from hospital are estimated to cost the NHS around £900 million per year and that statistic is not up to date in any event.
Here’s a quotation taken from the Kings Fund in 2015:
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. Only one in four respondents to the survey in 2014 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.
Dame Julie Mellor the Parliamentary and Health Service Ombudsman did a report into unsafe hospital discharge in May 2016 and concluded as follows:
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.
Dame Julie’s office reported on 9 appalling cases in 2016, identifying 4 major issues.
- Discharge before one was medically fit
- Discharge without proper consultation
- Discharge without notice to relatives
- Discharge into poorly co-ordinated service profiles
The Department of Health established a national programme on improving discharge. The programme brought 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. The outcome was this:
The key message is this:
“Implementing a discharge to assess model where going home is the default pathway, with alternative pathways for people who cannot go straight home, is more than good practice, it is the right thing to do.”
Delivering on this though, requires that
“commissioners and providers within health and care systems … challenge current practice and change mind-sets. Collaboration between health and care locally is vital to ensure sufficient quality of service, demonstrable change and agreement on how best to allocate resources and funds.”
The statutory Guidance on hospital discharge in Annex G says this:
Not everyone who is admitted to hospital will need care and support after discharge. Indeed, for the majority of hospital discharges, this will not be the case and it is important within this context that NHS organisations do not issue assessment notices in a precautionary and/or routine way without having satisfied itself that there is a reasonable prospect that there may be a need for care and support for which arrangements may need to be made in order to ensure a safe discharge.
A locally agreed protocol between the NHS and local authorities which allows NHS staff to identify those likely to need care and support on discharge will provide help and advice as to when a patient should be considered to have possible care and support needs, in order to ensure the NHS issue assessment notices appropriately.
However, the relevant NHS body must issue an assessment notice where it considers that a patient may require care and support on discharge and the local authority must or may be required to meet such needs.
Before issuing any assessment notice, the NHS must consult with the patient and, where applicable, the carer. This is to avoid unnecessary assessments where, for example, the patient wishes to make private arrangements for care and support without the involvement of the local authority.
The minimum period is 2 days after the local authority has received an assessment notice or is treated as having received an assessment notice.
Any assessment notice which is given after 2pm on any day is treated as being given on the following day.
Before issuing an assessment notice, the NHS body must have also completed any assessment of the potential Continuing Health Care needs of the patient and if applicable made a decision on what services the NHS will be providing.
A balance should be struck between giving the local authority early notice of the need to undertake an assessment of the patient and the risk that the patient’s condition may change significantly such that any early planning needs to be reviewed.
A DH review has identified the following key issues with the current national framework and was planning on making decisions this month (December 2015) about changes to the Framework
Through our (the DH’s) engagement work to date we identified the following areas which points to the need for potential changes to the screening and assessment process:
- Acute hospital episode lengths of stay have dramatically reduced over the lifetime of the CHC National Framework and rehabilitation, recovery and recuperation are now expected to take place after discharge from an acute hospital;
- Recovery, recuperation and rehabilitation is required before screening and assessment for long-term care needs take place. Otherwise this leads to unnecessary assessments or needs being overstated because the person has not yet recovered;
- Discharge from acute care under the Care Act: The need to clarify pathways across the health and social care system;
- Confusion over interim funding arrangements and a lack of consistency around interim provision, which may lead to delays in hospital and act as a barrier to screening and assessment in the community;
- Raised expectations: Completing the screening process at the wrong time and/or in the wrong setting could raise the expectations of individuals and their families that they are eligible for CHC when they are actually far from eligibility, leading to appeals and complaints (some of which can last years);
- Difficult to reach decisions within 28 days, as set out as a guide in the National Framework, for example where screening is carried out in an acute setting without giving time for recovery and the need to delay assessment after discharge
Proposed Changes regarding checklisting
1) To add a statement to the National Framework that explicitly says that a Checklist does not need to be undertaken if it is clear to staff within the health and care system there is not a need for CHC.
2) To provide specific examples about the circumstances in which screening (with a checklist) is not necessary. And, where a screening (with a checklist) may be needed, providing guidance to staff to make a decision later in the individual’s recovery pathway about whether or not to screen at this point. For example:
- Where the individual is rapidly deteriorating and may be entering the end state of a terminal illness;
- Where the individual is in a post-acute phase of recovery, rehabilitation and/or recuperation, regardless of setting;
- Where the individual does not have significant long-term health care needs
- Where the individual is recovering from a temporary conditions, and their longer term needs are not clear.
Proposed Changes to review rules
1) We propose the following changes and clarifications:
- The purpose of 3 and 12 month reviews is to focus on the appropriateness of the care package and whether it is suitable for that person’s needs. The original DST will continue to be required for this review.
- Eligibility is only to be reviewed where there has been a change in the person’s health needs that could impact upon their primary health need. The decision not to review eligibility will be a professional decision, where the person’s needs are unchanged or have increased.
- Where an eligibility assessment is required, then this will involve a full MDT and a new DST, as per the normal CHC process.
2) In addition, we would like to explore if we need a 3 month review in all cases:
- Our proposition to remove the requirement for a 3 month review, while ensuring that all individuals get at least an annual review. This should give CCGs the flexibility to conduct reviews as appropriate to the case rather than focusing on trying to deliver a 3 month review target.
- Still retain the flexibility for reviews to be conducted more frequently for individuals who have needs that fluctuate or highly complex needs. This proposition is based on moving towards focusing on the quality of the care package rather than eligibility for CHC.
- Where a case is Fast Track cases, the 3 month review will remain a requirement.
Proposed changes to the training system
Our proposal is to state that for health and care professionals delivering the CHC pathway (screening. full assessments and their co-ordination, eligibility recommendations and decision-making, reviews, and challenges to individual decisions):
- Staff can only perform the CHC activities and tasks they have been trained and are competent to perform
- CCGs will retain oversight for ensuring practitioners can access and undertake formal training to enable them to perform their role within the application of the National framework, for example screening and assessments
- The National Framework should continue to encourage joint collaboration and training across the health and care system