A leading charity is calling for improvements to the hospital discharge system – and for people’s holistic needs to be placed at the heart of services in Wales – after a new report found the current process is not consistently meeting the needs of patients and carers.
Common sense change is needed, according to the British Red Cross, as too many people are experiencing delays, leaving hospital without the key information they need, receiving no transport support, not having their wider needs considered, and returning home feeling unprepared.
The Red Cross report – Listening to what matters: Placing people’s needs at the centre of hospital discharge practice and policy in Wales – details the experiences of 100 patients who left hospital after May 2020 and, while it shows they are very positive about healthcare staff, some patients feel let down at the point of going home.
The report explores how well the hospital discharge process is working for patients and their carers in Wales, providing unique insight into people’s real experiences of leaving hospital alongside the perspectives of those who work in health and social care.
The British Red Cross found:
- All of the professionals involved in this research were in support of the D2RA model with a collective agreement that patient outcomes tend to be better when they are able to recover at home.
- Many patients are not receiving information leaflets about the discharge process, or follow-up contact information.
- Many family members and carers reported not being involved in the hospital discharge process despite expressing a wish to be included.
- Pre and post discharge assessments are not being carried out where patients felt they had support needs.
- There is a lack of resources in the community. This includes the availability of social care, services in the community not having capacity to run a “seven days” service, and barriers to the voluntary and community sector (VCS) being able to provide support in the community.
The Red Cross research was conducted against the backdrop of the Covid-19 pandemic and after new hospital discharge guidance was issued in Wales in April 2020 to help free up hospital beds.
That guidance sought to implement the nationwide roll-out of the Discharge to Recover then Assess model, which aims to allow patients to be sent home from hospital more quickly and to have their ongoing needs assessed where they live.
The challenges facing hardworking NHS staff throughout the pandemic were obvious, placing additional strain on hospital discharge teams, and the Red Cross report shows that, while many people said they were keen to go home, leaving hospital during the pandemic felt daunting for them and many felt apprehensive about doing so at such an uncertain time.
The Red Cross now wants to see improvements, starting with having patients subject to holistic hospital discharge checks – so that they can be more confident about a successful return home – and a dedicated point of contact for people leaving hospital.
The survey of 100 patients leaving hospitals or their carers found:
- All those interviewed had experienced some level of delay in leaving the hospital, with patients commonly reporting waits of four or five hours to be discharged.
- Only 52 per cent of respondents (42 of 81) said they, or the person they care for, were asked if they needed support with transport to the place they were being discharged to.
- It is not uncommon for people to feel unprepared for discharge, with only two fifths (42 per cent / 34 of 81) saying they felt “completely” prepared.
- Around two fifths (41 per cent / 33 of 80) reported that they, or the person they were caring for, were not given information about who to contact if they needed further health advice or support after leaving hospital.
- Some people are still falling through the gaps, with around one in six survey respondents reporting unmet needs.
The British Red Cross recommends:
- Consistent implementation of Covid-19 Hospital Discharge Service Requirements in Wales.
- Updated guidance to include holistic welfare checks so that everyone leaving hospital will receive a holistic welfare check to determine the level of support, including non-clinical factors, such as their physical, practical, social, psychological and financial needs.
- Discharge teams follow the Covid-19 Hospital Discharge Requirements to provide a point of contact for all patients leaving hospital within the discharge choice leaflets.
- The Department for Health and Social Services clarify the hospital discharge policy to health and social care staff in Wales through training on the discharge pathways.
- Further investment in community-based support to better meet the increased workload. This should include further investment in making community services “seven-day services” to meet the needs of patients and carers being discharged from acute hospitals.
Kate Griffiths, British Red Cross Director for Wales, said:
“The Covid-19 pandemic has only highlighted what we already knew about the value of leaving hospital at the right time and with suitable support in place. We hope the Welsh Government will reflect and act upon the common sense, low cost, recommendations in our report as these small steps could make a huge difference to people’s lives.
“The Red Cross in Wales has a proud history of working in partnership with the NHS and social care staff – placing people’s needs at the centre of our support – and we know and can see from this report just how valued those brilliant professionals are.
“But everyone agrees we still need to get hospital discharge right and that starts with asking what patients need to recover safely, comfortably, and hopefully swiftly at home and to ensure those things are in place when they leave the hospital ward.”
Darren Hughes, Director of the Welsh NHS Confederation, said:
“We welcome the British Red Cross report and its findings. Delays in hospital discharge has an impact on individual patients, on staff and on the flow of patients through hospitals, affecting the care available for others. It also has a knock-on effect on other services, including the Welsh Ambulance Services NHS Trust’s ability to provide effective and rapid responses and interventions, and on elective capacity and services.
“While there are significant challenges across the health and care system, the NHS is working with local authorities and voluntary and community sector at a local level to develop partnerships and initiatives to assist in reducing the current extreme pressures on the system in Wales.”
The health professionals’ view
The British Red Cross report shows there was widespread agreement among the patients and professionals involved in the research that good communication is key to successful discharge. However, most expressed concern that this is lacking throughout the health and social care sector.
While patients tended to highlight issues within the hospital as causing delays, professionals placed greater emphasis on factors outside the hospital – the key issues being availability of transport and domiciliary care.
Some health and care professionals felt that while they tried to work in a person-centred way, pressures within the system made it difficult for them and their colleagues to do so, with staffing issues and extra resources required to communicate with families who were unable to visit the hospital due to Covid-19, being a significant challenge.
Health and social care professionals reported that, often, patients want to leave hospital but families do not feel able to support them at home, making it difficult to balance what patients want and what their families can support them with.
Shortages in care packages can result in professionals being unable to balance the wishes of both the patient and their family, which can lead to readmission.
Being ready to leave hospital
The Red Cross research found a distinction between being medically ready and emotionally prepared for discharge. Around two fifths of survey respondents (39 per cent / 28 of 71) said that they, or the person they care for, did not have a conversation with someone at the hospital about what matters to them when it came to them going home.
Feedback from patients with more complex needs and from professionals in the Voluntary and Community Sector was that “what matters” to patients is often overlooked during the discharge process, with priority given to addressing medical needs.
John’s story – a case study
John Evans, 63, is a retired firefighter from Cwmbran.
He was admitted into hospital just before Easter last year.
Thinking back on his experience with hospital discharge, he said:
“To be perfectly truthful, I didn’t know any better but, looking back at it, when I was discharged, we didn’t have any information on what to expect, what I should be doing – just some notes would have been really useful.
“The doctors do their rounds, and the nurses do what is written on your notes. The notes said I was to be discharged so that’s what happened.
“I just had to wait around for the tablets before being able to leave. I was wheeled out of the ward by a porter, he stayed with me until my wife came to get me, and then we drove off and that was pretty much it.
“I was grateful to be leaving hospital, but there was a mix-up with the discharge papers, which luckily my wife spotted.
“That was my experience; we didn’t have any medical notes or additional information, just given the medicines to take home and that was it.
“I’m not really someone to complain, we know that everyone in the NHS is doing their best in often difficult circumstances, it’s not really about the individuals, but we really could have done with more information and more support when I came out of hospital.
“A bit of information about what was happening and what to expect, a contact number, someone to call if we had questions, someone just to come in and check we’re on track, that could have made a huge difference.
“One of the nursing staff phoned me 3-4 weeks after, and the diabetic nurse called me, so I had some information from them, but it was a bit disjointed.
“I go to a support group for people who have been through ICU and that’s been very good. I realise how lucky I am. I go there once a month and, while I was there, the ICU nurses put together a diary for me, that was nice to have.”
The Red Cross and hospital discharge in Wales
The British Red Cross helps around 84,000 people a year to live independently at home in the UK.
We have a long history of working with the NHS in Wales to deliver home from hospital services.
In 2021 we delivered eight such services across Wales and accepted 2,737 new referrals for support.
Through this work, we have seen the positive impact support at home can have, both on individuals and the healthcare system.