• Huge number of patients harmed by spending too long in hospital, warns senior medic who advised NHS England
  • Ian Sturgess says there may be a risk of the patients suing the NHS in large numbers for the damage 
  • Doctors failing to give patients a planned discharge date is a driver of length of stay, he says (see box)

Harm done to NHS patients who deteriorate from spending too long in hospital has hit “epidemic” levels which “dwarf the damage done by hospital acquired infections”, a senior national adviser to the NHS has warned.

Leading geriatrician Ian Sturgess told HSJ potentially in excess of tens of thousands of patients, largely older people, had been harmed by what he termed “hospital acquired functional decline” in the NHS over the last decade.

The NHS must “wake up [to] the hidden epidemic of harm”, which he said was troubling all developed health systems. He said an “inherent ageism” which assumes poor outcomes for older people was prevalent and raised concerns the NHS could also face legal action from patients harmed in this way.

Dr Sturgess, who developed the stranded patient measure NHS England is now using to cut patients’ length of stay, also raised fundamental concerns about the approach taken by both senior policy makers and clinicians. He said NHS England’s current drive to free up beds, which he is advising on, risked “perverse incentives”.

The former senior clinical leader in the NHS national emergency care improvement programme is now an independent adviser who has worked with more than 150 hospitals worldwide, including many in Australia and New Zealand.

The harm done by deconditioning was comparable to the impact of hospital acquired infections C difficile and MRSA had on the health service 20 years ago, he said, but stressed deconditioning harm was far more widespread.

“Many of our care services are full of people who have suffered from avoidable deconditioning.” Between 50 and 90 per cent of delayed transfers of care patients have suffered deconditioning, he estimated. “Delayed discharges are the surrogate marker for avoidable deconditioning. I’m not saying every single one, but a significant amount are.”

He supported NHSE’s decision to focus on cutting super stranded patients – those who have spent more than 20 days in hospital to free up 4,000 beds – but said a more holistic approach was required.

”It has to be done in the right way,” he said. “The [stranded patient metric] is a measure for improvement – not a measure for judgement. As soon as you use it as a measure for judgement, then you create perverse behaviours.

“There is a risk that the current approach could lead to perverse incentives. It could lead to the opening of community beds and people being parked there.

“When measuring the stranded and super stranded metric, you need to measure three other key metrics: quality, readmission rates, and post-discharge community and social care costs. You have to measure them all together, in what is described as a virtuous cycle of metrics.”

He also described having medically fit for discharge wards – something many hospitals have adopted –  as “the worst thing you can do”. 

He added: “Firstly, they are full of patients which are deconditioning. And secondly, what message does that give to the staff who discharged them? ‘I don’t have to sort out the discharge, do I? I can pass it onto somebody else.’”

A leading clinical negligence lawyer told HSJ there was a theoretical legal risk, but that a large number of claims against the NHS because of deconditioning was unlikely.

Bevan Brittan senior partner Joanne Easterbrook said: “You can see the potential for a claim if there has been a personal injury in theory. But there are many factors in play both in terms of whether people pursue legal action and in terms of the legal process.

“There could also be scope for a public law challenge via a judicial review arguing there are systemic problems with the way the NHS is looking after patients. But, again, I am not convinced this would succeed either as the NHS could argue that it had reasonable processes and governance in place and was doing its best within its resource constraints.”

Sturgess: Doctors’ failure on “basic competency” is driving up length of stay

Dr Sturgess said patients’ length of stay was being needlessly extended because a large number of NHS consultants could not produce case management plans or proposed discharge dates.

He said: “My challenge to Health Education England, the General Medical Council and the [medical royal] colleges is that we are producing consultants who are unable to construct a case management plan [which should be] a basic competency.

“How can you do operational management if you do not have a definitive plan with a discharge date?

“I know I am being tough on the medical profession, but I do worry when they say it’s everyone else’s fault [social care and other services]. If they have not set a plan, then they have the responsibility.

“The Royal College of Physicians has been pretty clear that a patient should have an expected date for discharge and clinical criteria for discharge… But far too often I go out and see patients without a definitive plan.”

Setting a discharge date helped to “flush constraints out of the system”. It does not matter if these dates are not always hit – providing the reason is explained to the patient as early as possible, he added.