Robert Francis: Keeping hospital beds free in a second peak

Back in March this year the NHS received orders to free up 15,000 beds and prepared itself for a surge of patients unlike any seen before. Thankfully, due to the hard work of everyone in the health and care sector, and the broader population as a whole, not all these beds were needed.

This success was in part down to the way the NHS and social care sector managed to keep people flowing through the system. To achieve this, new national guidance introduced some big and rapid changes to the way people were discharged from hospital. 

While we know these measures kept beds free, we know far less about what impact they had on patients and how they affected staff. As we prepare for potentially even tougher demands for hospital beds in a second wave, it’s vital we understand what worked and what didn’t.

Healthwatch and the British Red Cross have been investigating precisely this. During the summer we spoke with 590 patients, family and staff to find out about their experiences, a summary of which is published today. 

Discharge to Assess is the way to go

In short, we found that when it’s implemented in full the “Discharge to Assess” model is likely to be the right approach. Not only does it get people home faster, but it ensures they have a more holistic assessment of their rehab and ongoing care needs. This is what people have been telling us for many years makes for a positive experience when leaving hospital.

One of the perennial issues with hospital discharge has been the variation in approaches and the plethora of guidance. With the new national guidance, for the first time hospitals and their partners in the community were all given the same model to follow. The dedicated funding for this also help cut through some of the bureaucratic barriers that exist in more normal times. This should continue.

The redeployment of staff to community-based, multi-disciplinary teams helped in a number of ways. In particular it brought new skills and mindsets together, and it gave health and care staff a shared common purpose. This was vital in a crisis. 

All this meant that when we asked people to tell us about their care, they continued to be glowing in their praise of the hard-pressed doctors, nurses and care workers (and all other staff and volunteers) and their ability to deliver compassionate care under immense pressure. 

Consistent implementation

But the successful implementation of “Discharge to Assess” needs follow-up visits and phone check-ins to take place consistently. This in turn needs community services to be resourced to meet demand. Too often we found that visits were not taking place, leaving people with unmet needs struggling to cope in the community. 

This was compounded by people not being given a point of contact they could approach with any issues post discharge. 

We saw 8% of respondents discharged between 8pm and 8am. What’s more troubling is that many of these patients weren’t offered transport home. Other concerns were raised about access to ongoing support not being made available immediately because of the time they were discharged. This can be an incredibly distressing experience for anyone, let alone a frail or confused patient. 

Testing also emerged as an area for attention. Policy now dictates that those being discharged to a care home must know their results before leaving hospital. For those going back to their own homes the picture is patchier, creating potential situations where family and carers are left ill-equipped to manage any infection risk.

Simple solutions

As we ramp up for a tough winter, I urge anyone reading our report to focus on the simple solutions we put forward. For example:

  • Guaranteeing everyone a point of contact after discharge should they need help (it’s in the guidance but needs to be standard practice)
  • Avoiding discharging patients at night 
  • Always asking patients about their transport arrangements home
  • And if they have to be discharged without knowing their covid status, carrying out a proper risk assessment to help families and carers prevent any infection.

Some of this can be fixed and fixed right away.

There were of course some bigger and more systemic issues highlighted. In particular the lack of resourcing in community services and social care.  We will continue to raise these with the government as they develop their thinking on reform. 

In the meantime, if the NHS and care services use the feedback patients and staff have provided, we can make small changes that will get people home safe, keep avoidable readmissions low and beds free for those who need them this winter. 

See also:

Robert Francis QC is Chair of Healthwatch England. He has chaired several health-related inquiries, including two inquiries into the care provided by Mid Staffordshire Foundation Trust and the Freedom to Speak Up Review into the treatment of NHS staff who raise concerns. He is the honorary President of the Patients Association, a trustee of the Point of Care Foundation and the Prostate Cancer Research Centre and Honorary Fellow of the Royal College of Anaesthetists.

Competing interests: None declared.