improving discharge pathways in east kent · improving discharge pathways in east kent report of...

The Public Engagement Agency™

Improving discharge pathways in East Kent

Report of engagement sessions held in June 2018


1. Introduction

The NHS in East Kent is reviewing current practices around discharge from hospital in order to

improve patient outcomes, experience and efficiency. New models of discharge, which use home as

a default option, need to be in place by the end of August in preparation for winter pressures and in

line with stretching national targets.

Three workshops were held in June 2018 - one for clinicians, one for people responsible for the

delivery and commissioning of care and one for patients. These were designed to:

Explore the issues around delayed transfer of care (DTOC) and their impact on patients and

services

Consider how systems and processes could be redesigned– in line with local care models

being developed in east Kent - to improve patient outcomes

Ensure smoother, more effective transitions across services and reduce the significant level

of inappropriate bed occupancy

The Public Engagement Agency (PEA™) was commissioned to support this phase of engagement. This report provides an overview of the feedback from the three events.

2. Key themes

The themes that emerged from the discussions were similar across all three participant groups.

These themes were entirely consistent with previous work that had been undertaken by

Healthwatch Kent in relation to the west Kent health economy.

Key perceived problems/challenges in the current system included:

Cultural issues: lack of trust, in and across organisations, risk aversion - fear of blame, leading to

multiple assessments/duplication

Clinical behaviour: unnecessary interventions – ‘just in case’ – delaying discharge; people having

things done for/to them, reducing independence (‘PJ paralysis’)

Demand issues: pressures in each part of the system; needing to move the patient on from A&E but

no beds, then from the ward but nowhere to go, causing inappropriate transfers to other hospitals;

operational pressures versus clinical decisions

Information/IT systems: information not accessible to all; different methods of recording and

sharing information

Communication issues: lack of communication between services, organisations and with the

patient/family; lack of handovers; poor documentation

Hospital systems: pressure to achieve targets outweighing care and clinical decisions

Lack of clinical leadership in some areas

Lack of knowledge of what’s available - the alternatives to admission or services that could support

earlier discharge

Late referrals, causing people to go into crisis


Not person-centred: patients and carers not listened to; patient choice not taken into account;

carer’s needs not considered

Unrealistic expectations of how the patient should perform after discharge; not taking previous

ability and living environment into account

Hospital systems that can be over-complicated and block discharge

Lack of resources in discharge teams, in community; insufficient support for particular needs,

overnight care, 24-hour care

Funding disputes between health and social care, causing discharge delays; lack of joint working

Medicines management: not taking into account the patient’s previous medicines/history or

potential post-operative needs, post-discharge;

Discharge planning taking place too late in the day for home support/medicines/transport to be

arranged

Lack of tailored discharge information or contact person, causing anxiety when home

Too many home visits from too many different people/services; duplication

Care homes unwilling to take the person back, no longer able to meet their needs

Mental capacity issues: mental capacity act not always followed or decisions recorded

Suggested potential solutions/improvements included:

Change the culture: empower and build confidence in staff to follow one agreed care plan and

assessment, take appropriate risks; create a shared vision and culture; reduce blame culture; build

trust

Change clinical behaviour to stop over-investigating/over-medicalising and actively promote patient

independence as soon as possible; increase and allow clinical ownership and accountability

Skilled, competent clinicians along each part of the patient pathway; triaging by someone with the

right level of competency; rotation between acute and community; cross-boundary working; dual

trained roles in the community

Strong clinical leadership: to change culture/behaviours; lead by example, promote adherence to

one assessment/care plan, and respond to patient’s wishes

Create one shared IT system and strategy, to standardise and share patient information across all

services and organisations

Early intervention, before crisis, to avoid admission where possible

Clear and timely communication across services: between acute, community, primary care and

other decision-makers, particularly those who know the patient best, particularly the GP

Open, honest communication with patients and families so they have enough information to make

their own choices and decisions


Person-centred: keep the patient at the centre of care: ‘no decision about me without me’; looking

at person’s entire needs, as well as carers’

Have realistic expectations of the patient: use pre-admission assessment and plan as the baseline

Timely discharge planning: early on, once admitted; early in the day to make sure all discharge

requirements can be carried out by the afternoon

A named link person to engage with the patient and family in hospital and follow through to home

An advocacy scheme for those less able to speak for themselves or with no family

Written, tailored discharge information to address any concerns/questions that may arise after

discharge

More resources to avoid admission, in discharge-related teams, in the community and in the home –

support people in crisis to stay at home; more rehabilitation and prevention

Increase access to services: 24/7 and 7/7

Change funding streams between health and social care; joint commissioning to promote better

joint working

Develop systematic, simplified patient pathways

Safeguard vulnerable patients, with a full, recorded assessment and plan

Share learning from tests/pilot sites; build on what’s known

Better medicines management: review pre and post hospital prescriptions; use exiting medications;

increase length of hospital supply

People information/education to understand how to use services and have more control over

decisions made about their care

3. Detailed findings

3.1. Clinical Event

Clinicians from East Kent Hospitals University NHS Foundation Trust (EKHUFT), Kent Community

Health Foundation Trust (KCHFT) and primary care attended an event held in Canterbury on 6th June.

East Kent’s DTOC Lead set the background and context (presentation is at Appendix A). This was

followed by a facilitated conversation with three clinicians, to gain their views of the presenting

DTOC problems.

Key issues, from the GP perspective:

GPs are creating care plans but these aren’t uniform across practices. All have escalation plans but

these are rarely followed in an emergency. Most people want to stay at home but when they’re in

crisis: services are not accessing their care plan, the person in crisis doesn’t think about their plan

and care homes don’t necessarily follow them.


GPs have a lot of information about the care someone received at home, so there needs to be a

more coordinated approach, with greater communication between services and better use of

existing information.

There are some good discharge plans for the frail elderly but GPs don’t always get copies of results

and have to chase and results sometimes arrive too late.

Key issues, from the Community Geriatrician perspective:

Patients in care homes are asked what they want, care plans/advance care plans are created, but

then they can’t be found.

Community hospitals have the same problems/pressures as acute hospitals and there’s a real

problem regarding assessment and reassessment.

People in their own homes are much more empowered and their rights should be respected -

community hubs are really supportive in that.

Key issues from the EKHUFT Consultant Geriatrician perspective:

Patients feel lost in the system. When asked, they don’t want loads of procedures and questions,

they just want to go home. Clinicians not always responsive to that and there may be further

complications like hospital infections and being immobile that worsen the situation. At each point of

the journey there’s some “clinical aversion” to taking a risk.

Consultants would buy into a care plan that identified the patient’s involvement and wishes but

services all communicate and document in different ways. The clinician can conduct a

comprehensive assessment of the patient’s needs but can’t action those decisions, so the next

team reassess and so on, at each handover/transfer.

Key issues from group discussions

Participants were then asked to consider what the challenging issues and potential solutions were,

from their perspective.

Key challenges included:

Culture: multiple assessments, within/across organisations; lack of trust; not all clinicians bought

into this; complex decision-making, at each stage of the patient’s journey; risk averse; fear of getting

into trouble/being held to account for things going wrong

IT systems: don’t talk to each other; interface problems

Communication: families can be challenging but, in most cases, want to know what’s happening

Unrealistic expectations: people expected to perform better at discharge than before admission

Resources: the rapid response team is too small to cope with demand; IDT is under-resourced

Hospital system: getting out of hospital can be really complicated; discharge resistant

Funding: disputes between health and social care; big delays and battles between services and with

patients/families.


Potential solutions included:

Culture change: empower staff to have confidence in following the agreed care plan and be able to

take appropriate risks; reduce assessments; develop relationships and build trust across Trusts, GPs,

community services/hubs; greater cross boundary working; rotational roles

Clinical behaviour change: stop teams from “over-investigating” – should be the patient not the

medical agenda; understand what’s realistic; give people a better quality of life

Shared IT system and strategy: share a common portal; standardise patient information; one

assessment/shared care record/plan, followed by all; use patient tracking lists

Communication with patients and families: hold informed, honest conversations with patient and

relatives about risks, pros and cons of going into hospital; build relationships

Realistic expectations of the patient: work to the patient’s pre-admission baseline;

understand/work with what they can do at home

More home/community resources to support the person in their own home, in crisis and at end of

life; expand the rapid response team/IDT

Shared discharge planning: full discharge summary with information from all consultants and ward

Change funding streams: better joint working between health and social care

Systematic, simplified patient pathways: cross boundary working; rotational roles; clarity of roles

Strong leadership: reinforce adherence to care plans and patient wishes; lead by example; prevent

over-investigating; bring all clinicians need to the same level of understanding/permissiveness

Access to services: review delivery of services 24/7 and 7/7

Safeguard vulnerable patients

Shared learning: share findings from and mainstream related tests/pilots

Medicines management: increase hospital supply; use medicines patient brought into hospital;

review pre and post hospital prescriptions

Greater home support: resources/systems to allow people in crisis to stay at home

Creative/innovative approaches (e.g. care plan on phone)

3.2. Staff event

This event, held on 7th June, was attended by nearly 70 people responsible for the delivery of care

and current discharge arrangements.

Participants were asked to:

a) identify and cluster the problems/issues with the current system/process at three key

stages: before arriving at and in A&E; on the ward; at discharge

b) suggest possible solutions, in an ideal world, at each of the three key stages

Key problems/issues identified with the current system


PROBLEMS PRE-A&E/AT A&E

Culture: lack of trust between services, leading to multiple assessments throughout the

pathway; care plans not shared/referred to; risk averse

Information not accessible: services don’t know what’s already been done/known about

the patient, can’t see/get access to the information

Communication issues: difficult to understand the systems; people unaware of alternatives

to A&E; lack of handovers; poor documentation; silo working

Not person-centred: patients/carers not heard; pre-hospital ability not taken into account

Flow and demand: being treated/left unattended in corridors; bed pressures; over-

crowding; may be ready to be transferred to ward but nowhere for them to go

Lack of knowledge of alternatives: a range of support in community - that hospital staff

may not be aware of - that could prevent admission/support earlier discharge

Hospital systems; bureaucratic issues, such as A&E PTL; scoring systems; slow decision-

making

Medicines management: not recognising medications the patient already has, reissuing, not

recognising any problems patient may have had with particular medicines; wastage

Care homes: care plans in care homes not followed; unable/unwilling to have person back

Transport: limited/not available at time of discharge

Demographic differences: different needs of different patient groups (e.g. generational)

PROBLEMS ON THE WARD

Culture : multiple assessments, duplication, lack of trust; A&E busy so reassessment on the ward, in

case A&E has not assessed fully

Different IT systems: no one centralised system

Communication issues: poor communication between A&E and ward; poor documentation; limited

access to computers on ward

Patient choice/decision-making: patient may want to go home rather than to another hospital, but

depends on how able patient is/how vocal relative is

Hospital systems: pressure to perform outweighs care; pressure to achieve targets; different

definitions/understanding/use of red and green bed days

Clinical behaviour: unnecessary interventions - ‘just in case’ tests, delay discharge; “PJ paralysis”;

kept in bed too long; having things done for them; losing independence

Leadership: no consultant leadership in some areas


Inappropriate transfers: pressure to move patients on because of demand in A&E, potentially

creating greater problems; staff feel disempowered and reluctant to discuss with patient and family;

decisions taken away from clinicians; operational pressures versus clinical decisions

Discharge planning: decisions made too late in the day to organise; decisions out of hours, or late in

the week, rather than from admission

Lack of resources: not enough non-weight-bearing support in community/home (rather than beds)

Equipment: not available/not being delivered on time

Fast track: lack of access to appropriate placements; needs to be given adequate time

Transport: delays, particularly out of area; limited access; not always the best option

PROBLEMS ON DISCHARGE/POST-DISCHARGE

Culture: risk aversion – not challenged; fear of blame; too caught up in ‘the doing’; trust issues; lack

of teamwork

Information/IT: existing patient information not used/taken into account; not used appropriately;

some out of date; recorded through different methods (manual/electronic)

Communication issues between acute and community services/services and patient and family;

aversion to difficult conversations

Not person-centred: treating people as statistics rather than individuals; not acknowledging the

person’s ability to cope at home before hospital or ability to make judgements; assessment when

acutely unwell is not the baseline

Carer’s needs not considered enough – what they can do, what they might need

Lack of knowledge of what’s available; who/how to access; care home criteria

Lack of resources/services alongside insufficient IDT capacity to support hospital discharge plans;

some services no longer commissioned; insufficient provision for people with particular needs, e.g.

dementia, 24 hour/ overnight care; not enough non-weight bearing services; pressure on community

beds - strict criteria

Lack of joint collaborative working: social care versus health care responsibilities/budget; people

staying in hospital for weeks, as no access to a care package; systems not joined up

Care homes can’t meet the patient’s needs so don’t accept them back; lack of staff/skills; difficulties

trying to get patient into hospital; only manager has the ability to assess patient’s ability; fear re CQC

Discharge delays: waiting for information/results, prescriptions etc.; equipment not provided in

timely enough manner; making simple discharges complex

Mental capacity issues: patients not being allowed to make their own decisions; mental capacity act

not followed in its entirety; often not clear enough about the decision

Housing issues: not being considered

Fast track assessment: continuing healthcare assessment done in home but not followed through


Home adaptations not done in a timely manner

Medicines management: post-discharge checks not carried out

Transport not booked early enough

Out of area beds and repatriation to/from rest of county/country – different care/health

commissioning processes

Whilst there were concerns again about multiple assessments one clinician commented that

assessment was an important part of engaging and building a relationship with the patient.

What the system and process would look like in an ideal world: ‘the art of the impossible’:

PRE-A&E/IN A&E

Single assessment throughout the care pathway

One shared IT system: shared access to patient information, assessment, care plan, advanced care

plan, used by all organisations

Standardised information in the most appropriate media – e.g. Red Bag scheme

Clear communication between acute, community, primary care and other decision-makers,

particularly those who know the patient best, including voluntary sector

Patient focused: ‘no decision about me without me’; not financially or clinician focused; looking at

the person’s entire needs, not just health; supporting the patient to make informed decisions

Resources to support admission avoidance; more therapists; 7 day services, for the whole MDT (for

both physical and mental health issues); multiskilled team at A&E front door, including voluntary

sector; ART team in all areas; larger teams in community across all CCGs; SECAmb accessing step up

and emergency respite; therapists on ambulances; easier GP access

Joint health and social care budget: identify specific pathways to begin with

Clear pathway: reduction of time between stages; consistency; adherence to care plans/actions;

direct streaming to the right place/person; knowledge of all services and what each service provides

Use walk-in/minor injuries criteria in A&E

Educate the public, to reduce walk in; recognise A&E isn’t minor injuries; clear signposting of what’s

available and how to navigate

Triaging at the front door, by someone with the right level of competency to reduce the number of

admissions, get to the right service quickly; clearly defined threshold for managing risk

Local care coordinated around the patient

Hospital at home: acute frailty assessment in patient’s home; virtual wards in the community

Discharge planning at front door, engaging with community

Rotation of roles across acute and community

ON THE WARD


Early discharge planning from admission onwards; early referral/discharge arrangements;

communicate with local care (example given of QE discharge form)

Information systems: shared, to avoid duplication; greater use of technology - iPad or iPhone with

app showing live discharge information/alerts; link into PTLs (being developed for bed management)

Registered practitioner competency led discharge: senior decision-making; engaging with wider

clinical team

Patient ownership: allow patient to make their own decisions; keep patient at the centre of care;

communicate early with patient and relatives and identify what they want/need; use existing home

care plan as a baseline; mobilise/promote independence as soon as possible, with volunteer support

(to avoid ‘PJ paralysis’)

Discharge to where patient lives rather than another hospital

Clinical leadership to change culture/behaviours; stop unnecessary tests/procedures

Invest in staff development

Clearly defined roles to ensure clinicians can focus on giving high quality care; others to carry out

discharge procedures/ensure actions ae followed (for example, Band 4 discharge

coordinator/named nurse per shift)

More integrated approach: better communication between ward and other services, e.g. social

services; more holistic approach

Discharge planned and carried out early in the day

AT DISHCARGE/POST-DISCHARGE

Culture change: MDT working together; reduce blame culture; build trust in each other; one trusted

assessment that follows patient all way through; create a shared vision and culture

Clinical ownership and accountability for safe and effective discharge: ‘everybody’s business’; know

about other services in community for full package of support; robust decision-making, no delays

Agree systems to manage risk: care homes as part of whole system; clinical risk management (GPs

manage risk in different way to other clinicians in the system)

Review and revise whole system/ process: all services joined up/talking to each other, breaking

down service/organisation barriers; reduce ‘hand-offs’; work as one organisation

Change staff expectations: need to understand and work with people’s baseline before admission;

change expectation of person’s ability to cope when discharged

Person-centred decision-making/choice: need to build trust, be honest, allow patients to choose;

patients and families/carers key to discharge planning; support self-management, self-referral if

have long term condition

Staff development and competency: right skill mix; rotation between acute and community; dual

trained roles in the community; cross-sector working; shared learning

Increase community resources to ensure the right support when home, including rehabilitation and

prevention; increased care in the home (e.g. dementia care, home treatment team); 7-day service;


longer hours, including night care; more senior management, out of hours; better use of technology,

such as telehealth

Review number/use of community beds (“more”, “less”, “no more” community beds); reduce bed

base, move resource into community

Joint commissioning; integrated placements without prejudice; ensure fit for purpose

Post discharge package to stop attendance at A&E or, in acute episode, link to future attendances at

A&E, not start the whole assessment/planning process again.

3.3. Patient and Public Event

An event was held in Herne Bay on 15th July, attended by patients, carers and representatives from

local charitable organisations and the council (presentation is at Appendix 2).

Key challenges/issues from the discussions were:

Late referrals: causing people to go into crisis

Lack of GP appointments: so people don’t go, get unwell and are then admitted to hospital

Inappropriate hospital admission: ‘just in case’

Trained staff doing administrative work

Discharge takes too long: from being informed in the morning to actual discharge late evening

Lack of information on discharge: generic discharge booklets not informative enough; lots of

unanswered questions/anxieties

No named link person for aftercare: to answer post-discharge concerns/questions

Access: some patients offered care but don’t want it at the point it’s offered however, they change

their mind when home but then can’t access the care needed

Lack of knowledge of local services, what’s available in the community

Services not joined up between organisations; between health and social care

Medicines management: people with dementia/confused take medicines wrongly; medications to

take home don’t take into account common post-operative problems, risking readmission; many

people experiencing delusions from prescriptions; not routinely reviewed once home

Too many interventions in the home: too many people involved; too many separate visits;

duplication

Under-resourced services: e.g. enablement service; Hilton nursing – only paid for 3 days support

Patient centred caring versus rigorous performance management; focus on managing targets

rather than the needs of the person

“My husband was told he was going to be discharged at 10 in the morning. Finally got

home 8pm”


‘I’m amazed there isn’t the tie up between health and social care. that should be the

major thrust’

“If I wasn’t there my husband wouldn’t know what to ask – simple questions like can he

shower, what do I do about pads?”


Suggested improvements/changes included:

Review and redesign along the whole pathway, from early intervention/prevention through to

post-discharge support, including:

Early intervention, before crisis, referrals to/from right services to prevent admission (Reference:

weekly MDT meetings in hubs)

Early planning/communication once in hospital, to ensure transport/equipment/care

package/clinical support post-discharge is arranged in advance

Timely and organised discharge, so the person leaves hospital early in the day and supporting

services are still open/accessible

A named link person throughout the hospital experience and after – to give tailored response to

concerns and anxieties; ensure appropriate follow-up (reference: Bromley ‘Coordinate My Care’

plan)

Advocacy scheme for those less able to speak for themselves/people with no family

Communication with patient and family throughout: informed, involved in decisions made

Written, tailored discharge information for patient and family

Better coordination, communication and less duplication: reduce people/contacts post-discharge

Recognise, value and support the carer, including paid leave from work

One care plan, shared with/owned by all, including the patient and carer

Joint working/shared budgets across health and social care: integrated working at senior and

operational level

Medicines management: ensure patient leaves with the right medicines needed post-discharge;

review impact of medicines; patient fully informed about how to use/possible side effects

Tailored home support for elderly, confused: including short visit to give medication, to longer-

term/night time care

Greater community resources to support the person in the home to prevent admission/readmission

Person-centred: caring versus rigorous performance management/targets; treat the whole person

(mental and physical health needs)

Patient risk versus organisational risk: need shared organisational and clinical risk, working with

patient’s wishes

Communication between GP and hospital: GPs know what the patient can do and what can be done

for the patient in their own home

Expert clinical assessment in the home: right knowledge/skills to avoid unnecessary

transfer/admission to hospital; more see and treat

Patient education to understand how to use services; stay more in control

Greater non-hospital care in the home (reference: high intensity nursing in London: IV antibiotics)


4. Conclusion & Recommendations

There was without doubt, consensus across stakeholder groups that the delayed transfers of care in

east Kent had reached unacceptable levels and immediate action was required to address the

problem. All participant groups welcomed the initiative currently underway to address the problem

but were often concerned that the programme would not gain traction as soon as necessary to avoid

winter pressures.

Whilst there was recognition that there were many examples of good practice in both hospital and

community services, there was agreement that a number of critical success factors need to be

addressed in the next stage of planning. These factors included;

1. Organisational culture(s);

2. Clinical leadership and behaviour;

3. Information and IT systems;

4. Joint working across health and social care;

5. Medicines management;

6. Person-centred care.

There were a number of practical recommendations that emerged during this initial engagement

phase that can be summarised as follows:

1. Clinical and staff participants suggested that there should be a planned series of events to

support continued discussions and keep people up-to-date with actions, particularly as

changes have to be in place within the next few months.

2. Recommendation 1 above would need to be supported buy a comprehensive

communications strategy that ensured all staff and patients understood the plan

3. Clinical sponsors, who had volunteered during the sessions, should be supported to build the

new model of care and pathways and champion changes.

4. A patient and citizen panel is created to share plans and act as a point of reference at each

stage of development, to ensure the patient perspective feeds into the new models of

discharge.

Public Engagement Agency (PEA™)

June 2018

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