Memorandum by Liz Griffiths, Royal Pharmaceutical
Society (DD 21)
Delayed discharges have an impact upon many
people throughout the country every day. They affect and upset
patients who have already been given a discharge date and time.
They inconvenience the relatives, who, in light of the expected
discharge, are often obliged to re-arrange prior commitments.
They generate unwanted pressure upon primary and secondary health
care workers who have to work within the constraints that are
imposed upon the health service by the delays.
Additionally, it is important to remember that
every delayed discharge equates to a delayed admission. This in
turn represents a person who has already had to wait to be admitted
into hospitalpossibly for tests, for treatment or perhaps
for an operation. Given the constraints of the NHSwaiting
lists are inevitable, but they are not desirable, and they generally
have a negative effect on prospective patients. Those waiting
to go into hospital prepare themselves emotionally and practically
for the date of admission. It can be profoundly distressing to
such a person to be told at very short notice that the admission
is to be cancelled and re-scheduled.
The media has done much to draw the public's
attention to the unacceptable waiting times that are often experienced
by patients in Accident and Emergency departments. An A&E
trolley is designed to be used only briefly by a patient. However,
it is no longer uncommon for a patient to lie on one for many
hours, whilst waiting for admission to a ward. Delayed discharges
thus impact upon A&E patients awaiting admissionwhich
in turn impact upon the time other patients have to wait to be
examined on a trolley by a doctor.
There are many factors that influence the original
date and time of the proposed discharge. The current situation
cannot be improved or indeed resolved until these factors are
identified and remedied.
The Society will attempt to identify some of
the major factors that impact upon discharges and will propose
some solutions for consideration by the Health Committee.
1. The Audit Commission's recent report
entitled "A Spoonful of Sugar" has acknowledged
that the complexity of patient treatment often results in a considerable
delay to the "supply chain" process.
The most recent audit undertaken at the Addenbrooke's
Hospital NHS Trust reveals that 7 per cent of discharge prescriptions
give rise to queries by the dispensing pharmacistsresulting
in junior doctors being corrected at the point of discharge.
2. Completion of the discharge paperwork
is often delayed due to increased patient turnover. The delay
is compounded by the reduction in junior doctor working hours.
At Addenbrooke's Hospital NHS Trust, the workload generally reaches
its peak at approximately 3pmwhen other demands upon the
pharmacy department result in fewer pharmacists being available
at this time.
3. There is an acknowledged national shortage
of pharmacy staffand this compounds the problem referred
to in point 2 above.
4. Many re-admissions to hospital are due
to problems associated with medication. Scottish data suggests
that (excluding deliberate self-poisoners) 30 per cent of patients
are re-admitted with medication problems within 28 days of discharge.
This issue was also highlighted in the Audit Commission's report,
which observed that patients leaving hospital were unsure how
best to manage their medication.
5. Acute hospitals are under considerable
pressure to achieve greater efficiencywhich is often judged
to be a fast turnover of patients. This results in ever decreasing
lengths of patient stay. There are many anecdotes of hospitals
rationalising the patient's therapy, by discontinuing medication
and re-introducing only the medication perceived to be essential.
At this point, the patient is often discharged. What seems to
be overlooked, is that despite the fact that medications might
have been discontinued, often the patient continues to have therapeutically
active drug levels in his circulation. It is when these drug levels
become therapeutically inactive, that the patient visits the GP,
only to have his medication re-instated and to be re-admitted
6. Community hospital beds are often used
as convalescent beds by acute hospitals. The difficulty community
hospitals experience when attempting to discharge patients back
into the community has a knock on effect on the discharge process
within acute hospitals.
7. In general terms, the existence of the
extended family has all but vanished. This in turn has impacted
upon the amount of time and care that can be given by relatives
to a patient discharged to the home.
It should be noted that the families that are
able to care for relatives within the home save the State a significant
amount of money.
8. Care home registration units have noted
a reduction in the number of available care home beds in the private
sector. There is also evidence to suggest that the number of nursing
home beds are on the decrease, whilst there is a general increase
in the number of residential home beds. The reason for this is
likely to be associated with the funding levels imposed by social
services commissioning. For example, Leicestershire comprises
5 residential home bands (ie funding levels) and 3 nursing home
bands. The difference between residential home band 5 and nursing
home band 1 is £20 per montha difference that can
be wiped out by just a single visit from a district nurse.
1. Pro-active intervention by pharmacists
working in the primary care field would be able to support patient
medication compliance and concordance. This is likely to result
in fewer people requiring hospitalisation in the first place.
2. Consideration should be given to reviewing
hospital pharmacists' current grading structure and pay scales,
which have fallen behind those of the community pharmacy sector.
This would encourage more pharmacists to enter the hospital pharmacy
environment, thereby improving the current recruitment problem.
3. Transferring all hospital outpatient
work to the community would increase the hospital pharmacist resource
available to deal with the discharge prescriptions.
4. The future rationalisation of drug therapy
should continue to be controlled by the hospital, whilst the therapy
and appropriate monitoring could be transferred to the pharmacist
working in the primary care environment. Transferring pharmaceutical
care into the patient's home situation and the development of
new partnerships between hospital and community pharmacists could
significantly improve the current problem of patient re-admission
and delayed discharges.
5. Intermediate care is an effective alternative
to convalescing the patient within the secondary care environmentand
would release an abundance of hospital beds. However, in order
to ensure effective intermediate care, increased funding and an
increased resource of primary health care workers to support the
convalescing patient within the home situation would be essential.
6. There is a great need for frequent and
planned respite care, if families are to continue to care for
elderly relatives. Care homes should be encouraged to designate
one bed per home for respite purposes. However, as demand for
respite will mirror peak holiday periods, care home owners will
need financial encouragement to maintain bed availability.
7. There should be greater collaboration
between the funding relationships of social services commissioning
and health care provision. The Primary Care Trust, with its ability
to view these two fundings as a single budget, should be encouraged.
Early discharge would inevitably require additional funding.
In terms of domiciliary care, the Society suggests
that the following guidelines be observed:
1. Comprehensive medication assessment is
necessary, together with good communication and collaboration
between primary and secondary care agencies and professionals.
Compliance aids should only be used following appropriate assessment
and contingency monitoring.
2. Pharmacists contributing to multi-professional
and inter-agency team planning should be encouraged to manage
any issues relating to medicines.
3. Pharmacists should be involved in intermediate
and domiciliary careto advise and support issues relating
to medicines managementthus reducing re-admission rates
attributed to mismanagement of medicines.
4. Pharmacists should be advised to take
drug histories from all patients upon admission into domiciliary
carethus encouraging a reduction in medication errors and
the subsequent delays.
The Society also wishes to draw the attention
of the Inquiry Panel to a one stop dispensing project, which is
currently operating on one ward at North Tyneside Hospital. The
project has shown to improve discharge times and subsequently
helped to reduce the problems associated with delayed discharges.
In conclusion, the Society wishes to submit
evidence to support its claim that collaborative care can indeed
reduce the number of delayed discharges. The Society would be
grateful if consideration could be given to a report (which will
follow with the hard copy) produced specifically for this Inquiry.
Thank you again for the opportunity to respond
in writing to this consultation, and please do not hesitate to
contact me should you require the Society to attend an oral evidence