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A dysfunctional care journey from hospital to home



Industry voice: Effective coordination of continuing care from hospital to home is essential if we are to stop a scandalous waste of resource and improve the quality of life for our elderly, says Simon Williams, (pictured below) director at IEG4

Lord Carter’s latest report suggests that delays in discharging patients from hospital could be costing the NHS in England £900m a year. Meanwhile, the latest NAO figures suggest that bed space lost from delays in transfer of care have risen by 31% in the past two years.

From NHS England’s latest statistics, in the last quarter of 2015-16, snapshot numbers of patients delayed in hospital averaged 5,748 – the tail end of a 17% overall rise from the start of that financial year.

That’s a lot of people stuck in hospital beds, despite being certified as medically fit for discharge. For the public sector that’s a lot of wasted time and money. For elderly people that delay can mean daily muscle wastage and longer exposure to other infections. For those waiting for a bed it means delayed treatment and care. So regardless of the financial cost to the taxpayer of this inefficiency, it’s a human story that needs to be addressed rapidly.

Lord Carter’s independent review, found that nearly one in 10 beds was taken by someone medically fit to be released, and stated this was a "major problem" causing operations to be cancelled and the NHS to pay private hospitals to see patients. Many of these patients need care and support in order to recover safely at home, but difficulties coordinating such services is causing delays.

Indeed, hospitals have a duty to provide a patient with information about how they are going to manage the discharge and identify the patient’s care needs and ability to manage when they leave hospital. In theory, the care plan should be agreed by the hospital and the patient and any relatives or carers, including social services if they are to be involved.

In reality the process does not always run smoothly. Hospital discharge is often a haphazard process administrated through paper forms and phone calls. As a result, many patients find themselves stuck in hospital for longer than necessary.

Discharging a patient requires efficient co-ordination of activities both inside the hospital and within the community. This involves working with a number of external agencies in setting up an ongoing care plan covering, for example, home care for dressing wounds, helping with the preparation of meals, and providing physio and occupational therapy to build physical independence.

Complex support needs can involve multiple organisations, such as the local authority’s social care department and charities like Age UK. Significantly, organisations’ operational boundaries rarely match, and it can be a Herculean task to achieve the seamless collaboration in the relevant processes and IT systems. Organisations are often notified only at the last minute about an individual’s return home after an illness or a fall, and have to scrabble around for resources.

This is unsurprising given the fragmented structure of NHS trusts and local authorities, and the strong resistance to adopting common processes and practices across sectors – even when it can improve service delivery. As a result, a local authority social care department may have citizens in several different hospitals and has needed to adopt different processes for each one – and vice versa – inevitably leading to inefficiency and increased costs. 

It’s hard to imagine any other organisation providing a customer service from a foundation of uncommon processes - and using different data across different geographies as a basis for improving that service. It would be too expensive and inefficient, and yet, that is what we have or had until the latest under the radar NHS restructure.

The recent announcement of 44 new Sustainability and Transformation Plan footprints is a potential game changer. The footprints aim to increase ties between local authorities and the different NHS trusts that serve their residents. But does harmonisation down to ‘just’ 44 different ways of doing things actually amount to progress?

An analysis of the figures from NHS England on delayed transfer of care (DTOC) suggests that 1.15 million DTOC days were incurred in English hospitals last year (out of 1.8m DTOC days across the entire system) The National Audit Office recently estimated that the actual number of bed days related to DTOC could be as much as 2.7 times higher than stated.  

We at IEG4 have spent a lot of time recently exploring the problems around DTOC and solutions to coordinating the pathway with colleagues in health and care. From that work I have to say I agree wholeheartedly with Ken Clemens, CEO of Age UK Cheshire, when he says:

"We have the opportunity to radically improve outcomes for older patients, and to ensure that the admission and discharge experience in hospitals is seamless and effective. The adoption of co-designed digital tools utilised by place based multiagency teams can enable hospitals to manage patient flows effectively and, more importantly, deliver the quality of holistic care that older people, their families and carers deserve."

Our analysis of the NHS England data suggests that a common approach to patient assessment and communication of discharge needs - using collaborative technology - across NHS trusts and each one’s two largest local authorities, could help improve performance in 90% of these cases.

Ken has been helping us create a solution to this problem – to effectively create a digital path for continuing care from hospital to home. You can read more about this work here

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