Hospitals: Unsafe Discharge

Lord Prior of Brampton Excerpts

Wednesday 9th November 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I thank the noble Baroness, Lady Wheeler, for initiating this debate on a hugely important issue. I hope the noble Baronesses, Lady Wheeler and Lady Walmsley, will not think I am being churlish when I say that we covered a very wide range of issues today and at times strayed somewhat beyond the health ombudsman’s report, which is the substance of this debate.

The noble Baroness, Lady Wheeler, raised the issue of homelessness. That illustrates the complexity of the discharge process. I have seen a homeless person at UCLH in London who has nowhere to go. The issue is finding somewhere for that person to go—otherwise, as the noble Baroness said, he ends up back under the arches, then back in A&E, and the whole revolving door syndrome goes on. The noble Baroness, Lady Masham, mentioned the situation with someone who is mentally ill. Such discharges are very complex, so we should be careful not to oversimplify how difficult some of them are.

There has been a lot of talk in this debate about STPs. I will come to them, but I say to the noble Baroness, Lady Walmsley, that they are bottom up and are done locally. Of course, the acute hospital is going to have a major impact on the local STP: it would be strange if it did not. Some STPs, however, are run by the local authority and others by the chief executive of the local acute trust. That varies around the country, depending on the local leadership. They are not top down: these are bottom-up organisations, and they are increasingly in the public domain for discussion locally. One of the issues is that the NHS and the care system are so complex and so difficult that exceptional leadership is required to get lots of people together in the same room and come up with a plan that can be executed. Somehow, we have to move to a system in which you do not have to be exceptional to achieve results, in which average people can make progress. It is very difficult.

The noble Baroness, Lady Masham, mentioned Northumbria, where there is good local leadership that has worked in a consensual way with other partners in the system for many years. That way, you can get progress. The noble Baroness, Lady Walmsley, said it took 20 years to make the changes in mental health from the old, big, acute asylums to much greater community provision. It does take time, and you have to put the resource into the community before you can take it out of the acute sector. She talked about the difference between transformation and sustainability. Transformation means change, and change is difficult. It means people changing the way they have delivered care for many years. It does mean closing some acute activities in order to put resources into the community—there is no getting away from that. The Five Year Forward View was a view, not a plan. The STPs are, in a sense, transforming the view into a plan. We should not be surprised if there are some difficult messages in that. If we run away from those difficult messages, we will not put the Five Year Forward View into practice. I think everyone in this House feels that at least the direction of travel in the Five Year Forward View is the right one.

I do not want to sound in any way complacent because, as we heard in the story of Mrs F, when these discharge processes go wrong they are catastrophic for the individual concerned and their families. To put it in context, however, reported incidents of discharges going wrong account for less than 0.1% of the 15 million discharges made every year from hospital. Of that 0.1%, 96% are categorised as “no harm” or “low harm”. It is important to have that context. In fact, the PHSO makes it clear that the cases set out in its report should not be considered as representative of practices across the NHS and social care. However, it says:

“We are aware that structural and systemic barriers to effective discharge planning are long standing … these include the need for better integration and joint working of health and social care services, which have historically operated in silos”.

That was also acknowledged by the Public Administration and Constitutional Affairs Committee, which said that,

“discharge failures identified by the PHSO report are not isolated incidents but rather examples of problems”,

experienced “more widely”.

It, too, draws attention to the lack of integration between health and social care. It is therefore right that in this debate we have focused largely on these structural problems, which are not just between health and social care but within the health service itself.

The experience of these patients supports the strong case that this Government have made—and indeed the past Government—for closer working between health and social care and between different organisations and the NHS. We have to resist resorting to yet another major structural change in the NHS. Just as this last lot is settling down, there is a temptation to say that we should radically look at the whole structure of health and social care again, in which case the whole thing will be pushed up in the air for another few years. We therefore need to be careful before we resort to that.

I will repeat the figures that were given by the noble Baroness, Lady Wheeler. In August of this year about 60% of delays were attributable to the NHS—so it is not just the interface between the NHS and social care—33% to social care, and the remaining 10% or so to both social care and healthcare.

In December, 44 health and care systems across England were asked to come together to create their own local blueprints, called sustainability and transformation plans. STPs are designed precisely to tackle the barriers to improved patient care—the silos that were mentioned—by better alignment across organisations. This could have been done on a statutory basis, but we would have been here discussing that until kingdom come. The STPs have evolved; they are local and not top-down. They were not put out there by Jeremy Hunt: this has been done by the NHS and by social care on a local basis.

To some extent this builds on the Government’s £5.3 billion better care fund and upon the vanguard schemes—the various models of care that were described in the NHS Five Year Forward View. This is a logical evolution of those two developments. If I had more time, I could give examples of a number of the new care models in the NHS Five Year Forward View that are getting some considerable traction.

We are clear that in some areas, rising delayed transfers of care are placing considerable financial and operational strain on the NHS. However, we are equally clear that delays in themselves can prove particularly dangerous to older patients. There is a growing body of evidence on the harms associated with long hospital stays for older people. A pretty staggering statistic is that 10 days lying in a hospital bed can lead to the equivalent of 10 years of ageing in the muscles of people over 80. Therefore, delayed discharges are not fundamentally about saving money, although of course they would save money. They are about how we provide better care for vulnerable, usually elderly people with comorbidities.

NHS England and NHS Improvement have taken action to establish a number of work streams across community services and acute hospitals, because that is often where the delays occur. This will identify and deliver a series of interventions to help deliver system-wide transformation of community services, supporting timely discharge from hospital.

The decision to discharge remains a clinical one, but ensuring all discharges are safe and timely requires a multidisciplinary effort from clinical and nursing staff, allied health professionals, and community and social care workers. The imperative to discharge as quickly as possible must be balanced against the needs of each patient. I acknowledge fully that when a hospital is full and there are ambulances queueing outside in the car park to get people to A&E, the pressure to discharge patients is huge. We can pick out examples where it has gone wrong, but if you put yourself in the place of the nurse on the ward, who is told, “We’ve got to find three beds by 8 o’clock because we’ve got people in A&E who are about to breach the four-hour target”, you can understand the pressure there sometimes is in hospitals to make discharges earlier than they should be.

When the NHS was founded in 1948, 48% of people died before they reached the age of 65. In 2016, this figure is only 12%, and the fastest-growing age group is the over 85s, for whom the discharge process is inevitably the most difficult. Some 80% of this group will suffer from two or more chronic conditions, which adds to the complexity in discharging patients today.

I want to dwell on two issues related to safe discharge. First, the whole thrust of the seven-day NHS is to ensure that urgent and emergency care patients have access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions, whatever the day of the week. The problems of discharge are the same on a Saturday or Sunday as they are on a Monday, Tuesday or Wednesday. Other work includes the new discharge planning guidelines published by NICE, which cover transitions between care settings for adults with social care needs.

There is absolutely no doubt that the structural difficulties of the NHS are quite profound and exceptional people are required to overcome those barriers. We are bound to see considerable variability in some of the STP plans when they are published over the next couple of weeks. However, we can also improve operational issues within hospitals: making sure that the drugs and transport are ready; that there are multi-disciplinary teams, including social workers as well as care workers; and that everyone who comes into hospital gets an estimated date of discharge, so that everything can be brought together around that discharge process.

I end by paying tribute to NHS staff, who are working under huge pressure and with people with complex conditions. I think we all recognise that the structure of the NHS means that things are not as easy for them as they might be.

[Baroness Wheeler]

I asked the Minister about the national carers strategy. Could he please write to me on that?

[Lord Prior of Brampton]

I will certainly do that. I should just say that the theme that comes out of the carers strategy is better communication. When half of carers say that they feel that a hospital admission could have been avoided or that the discharge could have been easier if only there had been better communication, that is clearly a critical area.