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My opinion on planning for timely discharge has previously been posted (ref 1), in response to an article by Dr Oliver.
In the latest opinion piece, Dr Oliver is correct when he acknowledged "we should focus on alternatives to hospital admission—from ambulatory emergency care to rapid community response teams, from medical support for care home residents to better support and planning for people living or dying with long term conditions outside hospital."
Unfortunately the legacy of the misguided and ultimately failed 4 hour target program, which waned almost a decade ago and almost certainly at its end in 2020 (ref 2), meant a golden opportunity to address acute conditions that can be appropriately managed in the community is lost, and a huge amount of time, money and effort is spent on hospital processes to improve admission time without considering the impact of high numbers of emergency hospital admission, some of which would have been either avoidable or unneccessary if thoughtful and well supported clinical processes are put in place to manage people with inadequate home support and services in place.
It took a pandemic to normalise hospital-in-the-home or virtual ward care across the country, albeit many of the changes are largely directed at people with COVID-19 infection.
While I agree there are some circumstances when the discharge may appear "rushed", in my opinion, more often patients are held back for investigation which often does not significantly change their fitness for discharge, or a chronic stable condition best managed by those who know the patient better, ie primary care physicians. Many a times, blood tests or body imaging scan are ordered and done in the morning, the results available by midday, and yet they are only reviewed by those who ordered the tests the next day; it is as if they are moving one chess piece once a day. Often these clinicians are trainees or junior consultants, hence I totally agree with Dr Oliver about "proactive senior decision making in hospitals, with more prompt assessment, investigation, and treatment". Similarly I have personally found that orthopaedic patients being looked after by student allied health professionals achieve their goals slower than those being looked after by qualified professionals, and sometimes discharge is even inappropriately delayed by trying to attain unrealistic or unnecessary goals that will not materially improve the patient's ability to function at home.
Sure, junior doctors and allied health professionals need to learn, but not through "trial and error" at the cost of the patient, or "one-step-at-a-time" at the cost of the NHS. Although students may be "supervised", being a training system should not affect the care and services for the patients.
There is no doubt resistance to timely discharge due to patient's lack of confidence in ability to cope, or the carer's poor confidence or unavailability to support the patient, but no amount of preparation in the alien hospital environment can ready the patient for the impact of transition into their home environment.
Hence the key is not getting the patient ready for home by being in the hospital, but getting the home ready (with additional support) for the patient.
Granted there are times where the discharge indicators may suggest the patient is ready for discharge whereby the clinician needs to overrule this on behalf of patients clinically unfit to do so, but in my experience, by and large discharges are more likely to be delayed due to social reasons than not.
The cult of overzealous early discharge may not be as significant as the social road blocks for patients to return home
Dear Editors
My opinion on planning for timely discharge has previously been posted (ref 1), in response to an article by Dr Oliver.
In the latest opinion piece, Dr Oliver is correct when he acknowledged "we should focus on alternatives to hospital admission—from ambulatory emergency care to rapid community response teams, from medical support for care home residents to better support and planning for people living or dying with long term conditions outside hospital."
Unfortunately the legacy of the misguided and ultimately failed 4 hour target program, which waned almost a decade ago and almost certainly at its end in 2020 (ref 2), meant a golden opportunity to address acute conditions that can be appropriately managed in the community is lost, and a huge amount of time, money and effort is spent on hospital processes to improve admission time without considering the impact of high numbers of emergency hospital admission, some of which would have been either avoidable or unneccessary if thoughtful and well supported clinical processes are put in place to manage people with inadequate home support and services in place.
It took a pandemic to normalise hospital-in-the-home or virtual ward care across the country, albeit many of the changes are largely directed at people with COVID-19 infection.
While I agree there are some circumstances when the discharge may appear "rushed", in my opinion, more often patients are held back for investigation which often does not significantly change their fitness for discharge, or a chronic stable condition best managed by those who know the patient better, ie primary care physicians. Many a times, blood tests or body imaging scan are ordered and done in the morning, the results available by midday, and yet they are only reviewed by those who ordered the tests the next day; it is as if they are moving one chess piece once a day. Often these clinicians are trainees or junior consultants, hence I totally agree with Dr Oliver about "proactive senior decision making in hospitals, with more prompt assessment, investigation, and treatment". Similarly I have personally found that orthopaedic patients being looked after by student allied health professionals achieve their goals slower than those being looked after by qualified professionals, and sometimes discharge is even inappropriately delayed by trying to attain unrealistic or unnecessary goals that will not materially improve the patient's ability to function at home.
Sure, junior doctors and allied health professionals need to learn, but not through "trial and error" at the cost of the patient, or "one-step-at-a-time" at the cost of the NHS. Although students may be "supervised", being a training system should not affect the care and services for the patients.
There is no doubt resistance to timely discharge due to patient's lack of confidence in ability to cope, or the carer's poor confidence or unavailability to support the patient, but no amount of preparation in the alien hospital environment can ready the patient for the impact of transition into their home environment.
Hence the key is not getting the patient ready for home by being in the hospital, but getting the home ready (with additional support) for the patient.
Granted there are times where the discharge indicators may suggest the patient is ready for discharge whereby the clinician needs to overrule this on behalf of patients clinically unfit to do so, but in my experience, by and large discharges are more likely to be delayed due to social reasons than not.
References
1. https://www.bmj.com/content/351/bmj.h5225/rr
2. https://www.nuffieldtrust.org.uk/news-item/a-new-era-for-a-e-targets-wha...
Competing interests: No competing interests