Discharge guidance could lead to increased death and disability, warn senior clinicians

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Senior geriatricians David Oliver and Martin Vernon issue warning over guidance
Charities say guidance promotes rushing patients home before they are ready
NHSE says “importance of timely discharge has been heightened by covid-19” and guidance was developed by clinicians

Serious patient safety and wellbeing concerns about the latest hospital discharge guidance have been raised to HSJ by senior clinicians and charities.

Senior geriatricians warned that the guidance could prompt an increase in “urgent readmissions”, “permanent disability” and “excess mortality”, while charities said families could be left with “unsustainable caring responsibilities” because of the new rules.

The government guidance, Hospital Discharge Service: policy and operating model, published in August, said clinicians should consider discharging patients when they were “medically optimised” rather than “medically fit”. It said 95 per cent of these patients would return straight home with additional social care and rehabilitation support if needed.

Many of the concerns raised surround the retention of the “criteria to reside”. This was originally agreed in March when there was a push from NHS England to free up acute beds over fears hospitals would become overwhelmed with covid admissions as the pandemic hit the UK. The criteria has, however, been maintained in the new guidance, despite a significant fall in infections and deaths from the virus.

Rachel Power, chief executive of The Patients Association charity, warned: “This guidance makes it clear that the NHS is still having to take drastic emergency action in the face of covid-19, that will continue to take a heavy toll on patients. It is clear that many patients will be rushed home who would normally have had a longer period of hospital care.”

The document said: “Active consideration for discharge to a less acute setting must be made” if patients do not fit at least one of the criteria listed which includes “requiring ITU care; oxygen; undergone lower limb surgery within 48 hours; [or] thorax-abdominal/pelvic surgery within 72 hours.”

Former Department of Health national clinical director for older people, David Oliver, told HSJ: “The criteria raises the potential for badly planned and unsafe discharges from hospital, and the consequences from that is urgent readmissions, and may lead to some people who had the chance to recover and rehabilitate not having that and ending up with permanent disability.”

Professor Oliver, a consultant in geriatrics and acute general medicine at the Royal Berkshire Foundation Trust, added that the guidance does not take into account “human factors” such as carer stress or a patient not feeling ready to go home. He also raised concerns about the wording in a guidance leaflet for patients.

The patient leaflet said: “Once you no longer need care in hospital, as decided by the healthcare team looking after you, you will be discharged. You will not be able to remain in hospital if you choose not to accept the care that is being offered to you.”

Professor Oliver said: “[That] effectively says ‘if you don’t accept what we are offering, we are going to throw you out’. That is very adversarial.”

Martin Vernon, consultant geriatrician and clinical director at Tameside and Glossop Integrated Foundation Trust, said: “[The guidance is] extraordinarily narrow. A number of things could occur following implementation this winter. We could see larger numbers of older people leave hospital without adequate assessment and/or adequate support to recover safely in their own home.

”Should this occur, perversely we may see hospital readmissions or premature care homes admissions going up for people whose care needs cannot be met at home as a result of falls related injuries or unresolved cognitive problems including delirium. One crucially important factor to keep a close eye on this winter will be excess non-covid related mortality.”

The professor, who was national clinical director for older people at NHS England in 2016, also warned the guidance would most affect “older people with complex needs… yet it is presently not clear that the community health service capacity exists to safely meet their needs”. He said research shows up to two-thirds of acute bed occupants are aged over 65 and often have frailty, long-term conditions or cognitive problems.

Charities warn of new carers’ burden

The document asks family members to help people who have just been discharged with “washing, eating and dressing” among other tasks. It said school children should let their school know “so they can help with managing your studies” and employers may be able to ”arrange flexible working”.

The leaflet signposted people to Carers UK’s website for more advice.

Helen Walker, chief executive of Carers UK, said: “[The guidance and leaflet] demonstrate an alarming lack of recognition of carers’ roles, making no mention whatsoever of their right to a carer’s assessment. It does not consider family members’ ability or willingness to provide care, nor does it mention the need for staff to have the right discussions with family members about taking on care.

“Failing to address family members’ caring roles runs the risk that they will be left with unsustainable caring responsibilities. We urge the government to update the guidance immediately so that unpaid carers are made aware of their right to an assessment by staff.”

Ms Power, from The Patients Association, added: “Shifting the burden of care to family members and friends seems to acknowledge that the health and care system can no longer meet all its responsibilities to patients – which may well be true, but it feels like something of a landmark to see it set out so starkly.”

Clifford Mann, NHS national clinical lead for urgent and emergency care, said: “There has long been consensus that helping people to get home or to a more appropriate place in the community as soon as medically appropriate improves outcomes and should be a priority for all staff. The importance of this has been heightened by covid-19, and these criteria, published by the government, have been developed and discussed with clinicians and system leaders.”

The document said the discharge guidance was supported by the Academy of Medical Royal Colleges. An academy spokesman said: “It is important to recognise that this is a general guidance document, not mandatory requirements. It is for clinicians to use their clinical judgement as to the most appropriate care and treatment for individual patients.”

A Department of Health and Social Care spokeswoman added: “People will only be discharged from hospital when they are clinically ready and support will be provided to return to their place of residence, where an assessment of longer-term needs takes place.”

Updated 9 September 1.30pm: Updated a job title.