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Select committee inquiry

Follow-up to PHSO report on unsafe discharge from hospital inquiry

Closed

Public Administration and Constitutional Affairs Committee · Opened 12 May 2016 · Closed 25 October 2017

3 recommendations · 11 conclusions
Inquiry on parliament.uk ↗

What the inquiry looked at

“The report looks at the work already carried out by the PHSO (Parliamentary and Health Service Ombudsman) which highlighted harrowing cases that illustrated the human costs of poor discharge, causing suffering and distress for patients, and anguish for their carers and relatives. Poor patient discharge can take the form of both delayed transfers of care, where patients are kept in hospital longer than is necessary, and premature or early discharge, where patients are discharged before it is clinically safe to do so, or without appropriate support in place.”

The committee's words, from the inquiry page on parliament.uk ↗.

What it found

In the committee's words, from the summary of 5th Report - Follow-up to PHSO report on unsafe discharge from hospital ↗

PACAC received a report of investigations into unsafe discharge from hospital by the Parliamentary and Health Service Ombudsman (PHSO). This highlighted nine harrowing experiences that illustrate the human costs of poor discharge, causing suffering and distress for patients, and anguish for their carers and relatives.

Our inquiry found that the discharge failures identified by the PHSO report are not isolated incidents but rather examples of problems that patients, relatives and carers are experiencing more widely. Despite increased attention to the issue, it remains a persistent problem. We identified a need for more data to be gathered on the scale and impact of these discharge failures.

We heard that, whilst excellent guidance on best discharge practice is available, the extent to which good practice is implemented varies across the country. Barriers to the implementation of best practice are prevalent both within hospitals and at the interface between health and social care. We heard that pressures on resources and capacity within hospitals are leading to worrying and unsafe discharge practices. We call upon health and social care leaders to ensure that staff are operating in a culture where person-centred care is the undisputed priority.

A lack of integration between health and social care is preventing seamless discharge processes, coordinated around the patient’s needs. The NHS must support local areas to adopt the best models of integration.

At a structural level, the historic split between health and social care means that interdependent services are being managed and funded separately. We consider this to be political maladministration. The Government has accepted the recommendations of our predecessor Committee to merge the Local Government Ombudsman with PHSO as part of a new and comprehensive Ombudsman Service, and this will mean that it will be able to investigate the administration of health and social care together more effectively. The Government has developed promising plans to tackle this structural disconnect between health and social care, from the Discharge Programme Board to the Better Care Fund and long-term integration policy, but they are far from implemented.

The Government must ensure that these plans are set out clearly and supported by sustainable funding arrangements, so that they may be effectively delivered.

Fundamentally, the problem of unsafe discharge requires high levels of trust and openness between leadership and staff, to ensure that staff are empowered to make the decisions that put patients, their relatives and carers first. We expect the Healthcare Safety Investigation Branch (HSIB) to play a major role in investigating serious incidents of unsafe discharge and to ensure that learning is disseminated and implemented throughout the NHS.

What the government said

The government responded on 14 February 2017.

Summary written by Accountability Index from the government's response.

The government recognises the importance of the issues raised and says it is "not complacent", pointing to local transformation plans, integration of health and social care and a range of actions "underway" to improve discharge.

  • On night discharges, the government says it "would not appropriate, or practical for Government to interfere" in local arrangements, but expects patients with Alzheimer's or dementia not to be discharged between 11pm and 6am until appropriate arrangements are in place.
  • On data, it says NHS England and NHS Improvement have recognised the need for more data on discharge flows, and a new work stream will explore "new metrics". A minimum community dataset is to be embedded "from autumn 2017".
  • On the Discharge Programme Board, the response does not set out the objectives, success measures and timelines requested. It says the Board "will now focus on maintaining strategic oversight of delayed discharge issues".
  • On social care funding, it says local government has "access to the funding it needs" to increase social care spending in real terms by the end of the Parliament, and that it is "for local authorities to decide how to prioritise their spending".

Read the government's response ↗ Read the report ↗ Report an error

How the inquiry ran

Each dot is a dated item listed on this page, from the inquiry's opening on 12 May 2016 to its close on 25 October 2017.

  1. Oral evidence 12 Jul 2016
  2. Report 28 Sep 2016
  3. Government response 14 Feb 2017
  4. Correspondence 25 Apr 2017

What it recommended 3 recommendations · 11 conclusions

1early discharge and readmission.
Concluded (the committee's words)
early discharge and readmission. The Secretary of State for Health and the NHS must set out, as part of the Government response to this report, how they will improve understanding of the scale of early discharge and its impact in terms of unplanned readmission. (Paragraph 20) We agree with the Alzheimer’s Society that night discharges are potentially dangerous for patients, and detrimental to their carers and relatives. Whilst we are aware than
2an outright ban on night discharges might have unintended consequences, the Secretary of State for...
Concluded (the committee's words)
an outright ban on night discharges might have unintended consequences, the Secretary of State for Health must set out, in the Government’s response to this report, how he intends to ensure that only those who want to be are discharged between 11pm and 6am. (Paragraph 22) The PAC, in its July 2016 report, concludes that there is a poor understanding of “both the scale and cost of the problem of delays in discharging older patients from
3hospital”.
Concluded (the committee's words)
hospital”. The PAC recommends that NHS England develop measures for improving its understanding of these issues. We strongly agree with their recommendation. (Paragraph 25) We regard the failure of hospitals to involve carers and relatives in decisions to discharge patients, and even to inform them of these decisions, as maladministration
4and unacceptable.
Concluded (the committee's words)
and unacceptable. The Secretary of State for Health and NHS England must set out, in the Government’s response to this report, how this issue will be analysed and assessed and what steps will be taken to promote improved communication with relatives and carers by hospital staff. (Paragraph 30) It is clear from the evidence presented to this Committee, and from the findings of the PAC’s inquiry into delayed transfers of care, that best practice guidance on patient
5discharge is not consistently implemented across healthcare providers.
Concluded (the committee's words)
discharge is not consistently implemented across healthcare providers. Tackling this variation in discharge processes is key to producing greater consistency in outcomes. We welcome and strongly support the recommendation of the PAC that NHS England and NHS Improvement report back to that committee by January 2017 on the steps they have taken to increase the pace of good practice adoption. (Paragraph 34) Barriers to best practice implementation We agree with the Local Government Association that strong leadership and engagement with staff is needed to support staff who are operating under significant
6organisational constraints.
Concluded (the committee's words)
organisational constraints. We are deeply concerned that hospital staff may be put in positions where they feel pressured to discharge patients before it is safe or appropriate to do so. We believe that it is the responsibility of hospital leadership to communicate to staff that organisational pressures should never take priority over person-centred care. Leaders should also ensure there are clear mechanisms 20 Follow-up to PHSO report on unsafe discharge from hospital for staff to raise concerns about unsafe discharge with hospital leadership. This can only be achieved with high levels of trust and openness between leadership and staff and this must be understood not just by the leadership of hospitals and social services, but by NHS Improvement too. (Paragraph 39) A lack of integrated working between health and social care presents a long-standing, persistent barrier to coordinated, safe and timely patient discharge. We fully endorse
7the recommendation of the PAC, aimed at establishing good practice models for improving integrated working...
Concluded (the committee's words)
the recommendation of the PAC, aimed at establishing good practice models for improving integrated working across local health and social care systems. We look forward to NHS England’s response to the PAC on what steps have been taken to increase the pace of adoption of such care models. (Paragraph 43) National responsibilities for improving discharge practice We welcome the establishment of the Discharge Programme Board, which will bring together national health and social care organisations to improve patient
8discharge.
Concluded (the committee's words)
discharge. The Secretary of State for Health must establish by March 2017 a clear set of objectives for the Discharge Programme Board, together with success measures and timelines against which the progress of the Board in improving patient discharge can be measured. (Paragraph 46) We are concerned to learn that a significant proportion of the Better Care Fund’s current funding is reliant on savings from the New Homes Bonus. This seems to
9PACAC to be an extraordinary way to fund essential public services.
Recommended (the committee's words)
PACAC to be an extraordinary way to fund essential public services. The Government must explain what is happening in parts of the country where these funds do not materialise. (Paragraph 49) We are clear that pressures on funding and overall resources in health and social care do not excuse the egregious examples of poor discharge that we have heard
10about.
Concluded (the committee's words)
about. However, it is clear from the evidence we received that pressures on social care funding have made it increasingly difficult for hospitals to discharge patients in a timely and appropriate manner. (Paragraph 52) We are concerned that the current funding plans for adult social care will not adequately tackle the long-standing social care funding gap. We ask the Government
11to bring forward a comprehensive solution to health and social care funding that reflects a...
Recommended (the committee's words)
to bring forward a comprehensive solution to health and social care funding that reflects a long-term, sufficient, sustainable, integrated approach to adult social care funding. Recognising that change will take time, but that the status quo is not adequate, the Government should set out a route map for how the new funding arrangements will be implemented, by March 2017. (Paragraph 53) We welcome the Government’s clear policy statement and vision for comprehensively integrated health and social care spending. We note however, that HM Treasury
12has yet to fully articulate how this vision will be achieved.
Recommended (the committee's words)
has yet to fully articulate how this vision will be achieved. We recommend that the Government sets out a clear plan for implementing this policy without delay, taking into consideration ongoing funding pressures in social care, which are yet to be adequately addressed. (Paragraph 55) Follow-up to PHSO report on unsafe discharge from hospital 21 Concluding remarks The incidence of unsafe discharge from NHS hospitals is much too high and this is unacceptable. Spending constraints and demand pressures can only make matters
13worse, but these in themselves are not an excuse for poor practice or failure to...
Concluded (the committee's words)
worse, but these in themselves are not an excuse for poor practice or failure to communicate, leading to unacceptable risk to patients. This is a challenge that can only be met by empowering staff and ensuring that their attitudes and procedures can guarantee that clinical judgement and humane common sense are not marginalised by the pressure to provide bed space to other patients. These pressures add to the challenge, and PACAC pays tribute to all those on the front line of care who face this challenge. (Paragraph 56) Our predecessor committee’s sixth report of the 2014–15 session, ‘Investigating clinical incidents in the NHS’, has resulted in the government establishing the
14Healthcare Safety Investigation Branch (HSIB).
Concluded (the committee's words)
Healthcare Safety Investigation Branch (HSIB). We expect this emerging body to play a major role in investigating serious incidents of unsafe discharge, to learn lessons from each case, and to ensure that learning is disseminated and implemented throughout the NHS. (Paragraph 57) 22 Follow-up to PHSO report on unsafe discharge from hospital

Evidence

Oral evidence sessions 1

Correspondence 1 letter