David Oliver: Discharging patients from overcrowded hospitals—fewer “progress chasers” and more “doers” please

david_oliverThis year, urgent activity in English NHS hospitals has reportedly hit a record high. Officially reported “delayed transfers of care” (inpatients medically fit to leave, but awaiting community health and care services) have also peaked. These figures routinely underestimate the real number of people in beds whose needs no longer require the full facilities of the general hospital.

Hospitals are routinely declaring “Red” and “Black” status alerts and their executives are coming under increasing pressure from politicians, regulators, and NHS England over declining performance against the four hour standard for emergency department assessment and treatment (a target almost unique to the NHS). Emergency readmissions to hospital within 30 days are running at around 15% for patients aged 65 or over.

All this has happened against a background of: an ageing population; the increasing medical and social complexity of acute hospital patients; drastic cuts in funding to social care services, which might otherwise support people to remain at home or leave hospital sooner; and inadequate capacity and responsiveness in intermediate care services outside of the hospital.

We have also lost around one third of hospital beds over the past two decades, and now have fewer beds per head of the population than all but one country in the Organisation for Economic Cooperation and Development. Furthermore, the “flat funding” settlement for the English NHS has created unprecedented efficiency challenges in the face of rising demand and activity.

There is huge pressure and publicity around (increasingly undeliverable) performance targets, and performance in acute admissions can impact on hospitals’ ability to meet their targets for planned surgery or urgent outpatient work. So it isn’t surprising that hospital managers with operational roles are tempted to create battalions of “progress chasers,” “patient flow teams,” “discharge coordinators,” and “bed managers” to ensure clinical teams get as many patients out of hospital as early in the day as possible, seven days a week.

Matrons often join in the fun, and hospitals in crisis hold regular bed meetings or even quasi “star chambers,” where clinical staff have to justify patient by patient why they are still in a bed. By the miracle of technology, they also use cascades of texts, pager messages, emails, and screensavers just in case any clinical staff didn’t realise the hospital was full and pressurised and that beds were needed. Consultancy firms are hired at great expense to point out the obvious through bed occupancy audits, which clinical teams could do themselves on the back of an envelope.

An almost macho culture can develop in which doctors or ward teams that send large numbers of patients home—especially at times of pressure—are seen as outstanding “performers,” without any regard to how pressurised, fearful, or unsupported individual patients or their families may feel, or how likely mistaken discharges or readmissions may be. It isn’t managers who then have to deal with complaints, coroners’ inquests, or bereavement meetings when things go wrong. Nor it is managers speaking to the public every day on the wards, telling them that beds are scarce and that they have to play their part by leaving as quickly as possible.

Staff in acute medical specialities have a daily ethical, legal, and professional tightrope to walk between duty of care to individual patients and their families (who may sometimes value an extra day or two in hospital to regain confidence, or who have suffered readmissions before after hasty discharge, or who may feel unsettled by a move to community services), and to a whole load of incoming acute patients who need those beds even more. It’s a hard place to be, day in day out.

Of course, we know that there are still far too many people in hospital beds who no longer technically would need to be there if the right alternatives existed; and that being in hospital has harms and risks all of its own; and that there is big, unwarranted variation in bed occupancy and length of stay between some hospitals and others.

We also know that a key factor in cracking these problems lies outside the hospital’s direct control—through more capacity and responsiveness in primary, community, and social care services; more investment in preventative approaches; and in the help seeking behaviour of the public. Many acutely admitted patients have bypassed alternatives altogether and presented directly to ambulance or emergency departments. Adequate, timely transport home also counts and isn’t always there.

We also know what does deliver within hospitals. For instance, senior clinicians at the front door of the hospital seven days a week until well into the evening. Chair based hot clinics instead of beds. Rapidly responsive community services providing “in reach,” or “discharge to assess,” or early supported discharge. Ensuring that patients are admitted to the right ward first time under the right team and not moved. Adequate therapies and rehabilitation so that people don’t lose function in hospital. Minimising the harms of hospitalisation, which lead to a longer stay. Frequent senior review and structured decision making on discharge planning every day. Minimising internal delays—for instance, waiting for investigations or second opinions. Embedding all these approaches systematically can deliver the goods.

Whose job is it to deliver all these elements? First and foremost it is core business for doctors, nurses, and therapists in the acute medical unit and on the wards—and any in reach teams from community and social care services working with them—to expedite discharge. In hospitals where they are already reviewing people regularly and already focussing as a team on good discharge planning, an endless cascade of people and pilots badgering them to do what they are already doing is the definition of unhelpful and shows no professional trust. It actually distracts them from the job.

Senior managers should focus on negotiating good collaboration, pathways, and capacity for those services outside of hospital, and on moving away from a “them and us” blame culture between sectors all focussed on organisational interests. They should support the coalface staff to do a very difficult job. This might include taking some of the flack from the public when full hospitals increasingly prioritise discharge above all else.

When it comes to those armies of “progress chasers,” my suggestion is where possible just have one team—otherwise it’s too confusing and annoying for everyone else. Make sure that their job involves practical help and doing some of the work, and not just hassling staff to do what they are already trying to do or collecting endless performance data required by the commissioners as some kind of contract incentive.

If they personally phone anxious daughters and care home managers, personally fill out social work referral forms, personally ensure care packages haven’t been cancelled or that community hospitals can take someone before their prescription is quite ready, and personally help the ward staff get discharge letters and prescriptions ready, then bravo. But it isn’t always what happens.

Considering that many of the people employed in these teams are registered nurses, healthcare assistants, administrators, or allied health professionals by background, the most use they could often be in busy hospitals is in uniform back on the ward, doing the job they were trained to do, and giving hands on help to ward teams—rather than putting even more pressure on them. Do what works, not what reassures executives, regulators, and commissioners that “something is being done.”

David Oliver is the president of the British Geriatrics Society and a senior visiting fellow at the King’s Fund.

Competing interests: None declared.