Emergency hospital admissions - the revolving door
The headlines tell us it's a scandal. A new study from Healthwatch England says patients are being put at risk because they're discharged without the necessary checks being undertaken to ensure that everything they need is in place.
They collected data from individual patient cases, surveys from patients and Freedom of Information requests - and the results do not make comfortable reading. In all, 120 trusts responded to Freedom of Information requests, and of these, half weren't recording details on the patients' home circumstances before discharge and one in three weren't recording whether the GP had been informed about changes to medications.
Of course, failing to record whether something is done isn't the same as not doing it - in fact, in the 25 years I've been in practice I have seen a revolution in communications between hospitals and the patient's GP. These days, I'll usually get details of my patients' discharge (including lists of all medication changes and planned follow-up) within a day of them arriving home. In fact, I'm more likely to get two copies of their discharge summary than none.
What's more, while the area where I work has more than its share of problems, my patients' care has been hugely improved by innovations which keep patients where they want to be (at home) with high-quality care. In my area, we have a 'virtual ward' with a separate staff of doctors and nurses who can provide intensive follow-up in the patient's home. They can take blood, give medication and monitor patients almost as frequently as they would be seen in hospital - at a greatly reduced cost compared to an inpatient admission.
But I do see examples of hospital doctors bowing to ever-growing pressure to free up hospital beds, and that can be a very expensive false economy. We don't need to go back to the days where patients stayed in hospital for 10 days after having their appendix out (the vast majority of patients discharged these days one day after an appendicectomy don't come to any harm). But we do need to be more thoughtful about the knock-on effect of a headlong rush to free up precious bed space.
The fact is, 54% of the cost of the NHS comes from inpatient admissions. The average A&E attendance costs £114; the average 'non-elective' (unplanned) hospital admission costs £1,489, with every day over the average costing £273 - and elderly patients who catapult back into hospital take a lot longer than average to get better.
Older patients, and those with mental illness, are at particularly high risk - 80% of emergency admissions which result in a hospital stay of over two weeks are in the over-65s . The average length of an emergency hospital admission dropped by 20% between 2004 and 2009 - but in the last decade, emergency readmissions among the over-75s have increased by 88%. It's not likely that these two figures are unconnected.
One of the examples in the report was an 81-year-old patient discharged in a cab at 10.30 at night following a stroke - he was back in hospital within days. It's dreadful for the patient and expensive for the NHS, whilst also having a knock-on effect on a GP service already stretched to breaking point. These days, elderly patients are almost always discharged with several outstanding medical issues that haven't been dealt with while they're in hospital. In a hospital, it's easy to get repeated blood tests or daily chest assessment - in general practice it's a logistical nightmare. And often super-specialised hospital teams only look at their little bit of the patient, sending reams of investigations for the GP to follow up on because it isn't that hospital team's 'job'.
There are two major issues that need to be addressed. Firstly, we need to make sure that all patients have a full assessment of their home situation before they're discharged. Secondly, once that situation has been assessed, we need to make sure that the services they need are in place before they go. Often it's as much about social as medical services. Time after time I have seen patients not needing hospital admission even though they have multiple medical problems, because we can offer a combination of nursing, doctor and social services to make sure all their needs are catered for. But I've also seen many patients admitted for hospital not because they have an acute medical emergency but because they just can't cope.
If patients have district nurse visits, home help for shopping, meals at home (meals on wheels) for food and carers for bathing or dressing ready to swing into action as soon as they arrive home, this distressing and expensive 'revolving door' situation can often be avoided. Let's not pretend that there's a limitless pot of money for the NHS - there isn't. But making it a requirement for all hospitals to set a plan in place before discharge could save a fortune in readmissions. We've done it with assessment for clots on the leg and the lung - every discharge summary now carries a note about whether the patient was at high risk of deep vein thrombosis (DVT). 'Prevention is better than emergency readmission' may not be as catchy as 'prevention is better than cure' - but it's every bit as true.