As the pandemic approached England in early 2020, government policy decisions ensured most people stayed at home and NHS hospitals were largely protected. Yet some lives were not saved that should have been and England subsequently experienced the highest levels of excess mortality in Europe. Now as we head towards a winter living with covid-19, a new hospital discharge policy suggests the English NHS has not learned from early mistakes and may be putting the lives of vulnerable people at risk.
Getting health policy right is difficult and things can easily go wrong. Government and its agencies use policy levers to get individuals and groups to behave differently. By careful positioning of key tipping points, people and behaviours can be shifted with relative ease. The trick is positioning the right lever for greatest benefit without expending too much effort or causing harm.
In March 2020, this played out spectacularly when NHS England leveraged public and Government concern for inadequate hospital bed capacity to deal with the hitherto stubbornly resistant problem of care transfer delays. Within days hospitals became eerily quiet.
The exodus was achieved using a well chosen tipping point comprising removal of care assessment barriers while freeing resource to move patients rapidly out of hospital beds. Emergency legislation ensured that care eligibility assessments did not delay discharge, while new government funding for community care was suddenly made available. These plans were not new, having originated in Lord Carter’s NHS hospital productivity review, but led, according to NHS England CEO Simon Stevens, to the “fastest and most far reaching repurposing of NHS services ever seen.”
But who felt the greatest impact? The National Audit Office (NAO) previously estimated around 3 million hospital bed days (62% of NHS capacity) costing almost £1 billion per year were occupied by mainly older people no longer needing to be there. Though delays for older people waiting for care had been slowly decreasing through sustained effort, by 2020 they were again rising. Immediately before the pandemic hit, 5,370 people per day were delayed in hospital. The March covid-19 discharge plan fixed this problem in just days.
Subsequently there have been over 30 000 more deaths among care home residents than we would normally expect, and 4,500 excess deaths among people receiving social care at home. This suggests that in the haste to discharge people needing care home or care at home, the NHS also failed to meet some care needs.
Undaunted, on 21 August the Government and NHS England published its Hospital Discharge Service Guidance placing continued emphasis on rapid discharge and displacement of assessment for care needs into communities after, not prior to discharge. New “Criteria to Reside” are heavily skewed towards critical and procedural care to justify keeping a person in hospital, yet as the NAO found in 2016, those needing longer stays in hospital are older with frailty where things are much less straightforward.
Rigid enforcement and performance management of the criteria could drive older people with complex conditions into their communities without adequate assessment or care. NHS services and local authorities will be under considerable and sustained pressure when they are least equipped to deal with such a shift in policy. Despite funding for care being available for up to six weeks, the end of free care may mean the end of care: many older people simply cannot pay.
The six week cut off in communities subtly moves a critical point of failure in system flow into communities while agreements are reached about who pays for ongoing care needs. This is a historic battle ground of dispute and delay, especially for continuing healthcare, for which commissioners must now catch up following paused assessments in March and a burgeoning backlog pre-pandemic. All of this will not improve system performance this winter and risks unintentionally worsening it. I suggest we need to look out carefully for rising NHS readmissions and continued excess community deaths among older people including those with dementia.
The pandemic has already left the NHS and care system stretched beyond its limits. The money for discharge has stopped flowing freely and obstacles have been reinstated, albeit six weeks from discharge and away from the hospital glare. Pandemic policy levers have started to weaken and fragment. Shifting the tipping point through blunt instruments such as the hospital discharge guidance without more counter balancing, risks NHS failure on a grand scale. Regardless of political fallout, the immediate costs will be staff wellbeing and patient safety.
Martin J Vernon is a Consultant Geriatrician, NHS Leader and Clinical Advisor in Greater Manchester and London. He was National Clinical Director for Older People at NHS England for three years until 2019.
Competing interests: I am a member of the British Medical Association, British Geriatric Society and Action on Elder Abuse. I am a Fellow of the Royal College of Physicians (London) and Member of the Royal College of Physicians (Edinburgh). I am a Trustee of Research in Specialist and Elderly Care (RESEC).