David Oliver: Guidance tools won’t solve long hospital staysBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5870 (Published 09 October 2019) Cite this as: BMJ 2019;367:l5870
- David Oliver, consultant in geriatrics and acute general medicine
Follow David on Twitter: @mancunianmedic
NHS England and NHS Improvement have launched “Where Best Next?”—a campaign to reduce the number of patients staying in hospital for three weeks or longer.1 Announcing the campaign, NHS England reported that 350 000 hospital patients had stayed for over 21 days in the past year.2 Getting 140 000 of them home sooner could free up 7000 beds, or “the equivalent of 15 large hospitals.” I have some big reservations about this claim.
Preventing avoidably long stays for older patients is a worthy ambition. Such stays put these patients at risk of physical and psychological harm3 and add to considerable pressure on a hospital system that already has the fewest beds per 1000 people among developed countries.4
I also endorse the principles of care behind the campaign. We know that older people with frailty, multimorbidity, or functional or cognitive impairment generally have the highest risk of being marooned in hospital.5 So, if these are the right messages to promote, with a good rationale behind them, why am I still concerned?
First, in terms of official campaigns or recommendations, we’ve been here before. The National Audit Office reported on hospital discharge and delayed transfers in 2016.6 NHS Benchmarking has produced two rounds of detailed audits of hospital processes.5 Healthwatch England has published key reports on discharging and avoidably long stays.7 NHS Improvement issued Safer Faster, Better guidance and then a major patient flow resource,89 listing key actions. And NHS England has an internal team and national targets to cut the number of “super stranded” patients staying longer than 21 days.10
Yet recent research by CHS Healthcare and official figures from NHS Digital show that we’re miles off achieving the levels of ambition set out by government officials.11
Second, the guidance and actions focus almost exclusively on what happens in hospital. Hospital staff need to play their part. But we have half the capacity we currently need in intermediate care services out of hospital, and waiting times are worsening.12 Government cuts over the past decade have drastically reduced the availability of social care.13 NHS continuing care funding is also heavily rationed,14 and we’ve seen sustained falls in community nursing capacity.15
For long hospital stays, solutions often lie in wider systems outside hospitals’ direct control. But it’s far easier to issue edicts to hospitals than to the wider health and care systems.
Third, the ambition around reducing long stays seems to focus on the results national NHS bodies want to see, rather than any realism about what’s possible.
Finally, such changes are generally implemented and sustained by the actions of local, multidisciplinary clinical and operational management teams in supportive organisational cultures.16 Unless the government offers big funding and support for local improvement, guidance will take us only so far.
Hospital staff are already very aware of long stays, bed shortages, and worsening wait time performance. They take no pleasure in looking after stranded patients who no longer need to be there. And they know that the kinds of actions recommended in “Where Best Next?” are important: it’s their daily reality as they try to free up bed capacity. Cards and posters won’t solve this, however laudable their aim.
Competing interests: See www.bmj.com/about-bmj/freelance-contributors.
Provenance and peer review: Commissioned; not externally peer reviewed.