Further supplementary written evidence submitted by The Royal Pharmaceutical Society (PHA0070)

Key Point

• Given current pressures in the NHS, delays in discharge have received increased political and media attention scrutiny, with an estimated cost in 2022/3 of at least £1.7 billion[1]. 

• There is a perception that the pharmacy team is a significant cause for discharge delays, but as described in research from Countess of Chester Hospital “discharge delays relating to availability of medicines at discharge result from a combination of events, not solely and not primarily within Pharmacy[2].”

• Research shows that biggest contributors to delay at discharge[3] are need for further assessments, delays in writing discharge summaries and gaining agreements on further needs. These needs could include waiting for care packages from community health and social care services or access to a short-term bed for rehabilitation or a permanent bed in a care or nursing home. Indeed, just under half of patients that were deemed medically fit to leave were discharged on the same day, indicating a systemic issue[4].

• Patients and staff may have experienced the speed and efficiency of community pharmacy supply systems, and therefore often have expectations that this will be the same in an acute hospital. Comparison between pharmacy systems in community settings and hospital fails to grasp the complexity of medicines supply as part of the discharge process. Processing discharge prescriptions is only one of many activities undertaken by pharmacists and the pharmacy team to support safe and effective medicines use across a hospital.

• There are many innovations that pharmacists and pharmacy teams have introduced to improve efficiency and safety of discharge medication in hospital settings, including electronic prescribing, automation, use of skill mix, and utilising pharmacist prescribers.

• Greater investment and support in hospital pharmacy teams and systems can further improve efficiency, whilst ensuring safety and accuracy of these processes for patients.

• While there are financial and operational steps for investment, behind these numbers are the stories of patients who have experienced frustration, disruption and discomfort waiting to be discharged from a hospital setting.
  

Introduction

and Background

Discharge from hospital is a complex, multidisciplinary process that requires many people and teams to ensure it is timely, safe, and accurate. Discharge delays create frustration for patients and their carers. Healthcare professionals are frequently confronted with complaints regarding such delays. A disorganised and dysfunctional discharge process leads to long wait times, a lack of bed space availability, and restricted patient flow through the hospital, as well as poor patient satisfaction.

Discharge from hospital is known to be ridden with issues and is considered a time-consuming process. Patients commonly feel that discharge from hospital took too long and lacked patient involvement[5]. The demographic change in the population, with more comorbidities has further increased the complexity of the discharge process[6], further constraining patient flow through the hospital.

Economically, the cost of patients, that are medically suitable for discharge not being discharged is estimated to be at least £1.7 billion in 2022/31. As a result, releasing hospital beds by speeding up the discharge process is therefore a priority for many hospitals.

Given current pressures in the NHS, delays in discharge have received increased political and media scrutiny. Delays or failures in the discharge process can result in an increased length of stay and high rates of readmission, which accrue additional costs and stifle flow through the hospital. The number of patients remaining in hospital who no longer meet the criteria to reside increased through 20221. While many delays are outside of the direct control of the acute hospital trust, such as access to nursing or care home beds and community support packages, there are many factors that can delay or postpone a patient deemed medically fit for discharge.

The pharmacy team is a key part of the process, ensuring patients receive their medication at discharge[7]. However, there is a widely cited belief that access to medicines is the main reason for discharge delay[8], and while on occasion medicines supply can contribute to the length of a discharge process, the data and evidence points to other factors in the hospital. In the vast majority of cases hospital dispensaries are able to dispense and supply medication for discharge within 2 hours of receipt of the discharge notification, commonly referred to as ‘To Take Out’ or ‘To Take Away’ (TTO/TTA)8.

It is vitally important that this process is safe and accurate. Medication discrepancies at discharge are common and contribute to unnecessary harm to patients and can result in readmission to hospital. When discharge goes wrong, it comes at significant cost[9], both to individuals and to the health and social care system[10].

The role of pharmacists and pharmacy teams were highlighted in a recent evidence session to the Health and Social Care Select Committee Inquiry into Pharmacy[11], where questions were raised about the speed and efficiency of the discharge process.

This short summary review from the Royal Pharmaceutical Society outlines where medicines supply sits in the discharge process and provides evidence of the vital role that pharmacy teams play in supporting the safe and timely discharge of patients. A complete description of all aspects of the discharge process is beyond the scope of this paper. Instead, this focuses on challenges surrounding the process of medication supply at discharge and during transfer of care to the community as well as describing many of the innovations that pharmacy teams have implemented to improve the discharge process.

Case Study Example from a Patient Audit at the Countess of Chester Hospital

Understanding the Discharge Process

Discharging patients from acute care is a complex process. It involves multiple teams, departments, and coordinated efforts to ensure it is safe and timely. The pharmacy team are one part of this process. 

The discharge process typically commences when a decision is made as part of the morning ward round led by the consultant with the multi-disciplinary team. At this point the patient is considered medically fit for discharge.

It is vital that the expectations of departure from the hospital are clearly shared with the patient. Patients are often informed that they are medically fit to leave, but the complexity of the administrative processes associated with discharge often aren’t well understood.

The supply of medication at discharge begins with the creation of a discharge prescription which is commonly referred to as ‘To Take Out’ (TTO) list[12], and a GP Letter or Electronic Discharge Notification (eDN). The TTO is a complete and accurate list of all medication the patient should take after discharge from hospital, also referred to as ‘To Take Away’ (TTA) medicines. In a typical discharge process, a junior doctor will traditionally take responsibility for writing the discharge notification (TTO). Although increasingly other members of the multi-disciplinary team may be involved including Pharmacists, Physician Assistants and Advanced Nurse Practitioners.

Many Trust policies suggest this discharge notification, with the list of TTA medicines, should be prepared at least 24 hours in advance of discharge. As described later, some innovations consider using other staff, such as pharmacists to expedite this process.

Depending on the Trust, this discharge notification may be physically written on paper, often using stationery developed for that purpose, or increasingly entered digitally using an electronic patient record (EPR) as a summary for discharge. The extent of digital maturity varies greatly across each NHS Trust in England, leading to local differences in this TTO generation process.

It is commonly only once the TTO is created that the pharmacy team become involved. The TTO will be checked by the pharmacy team, in some cases this is screened by a pharmacist based on the ward (where available) or sent directly to the hospital dispensary. This process ensures that the TTO is safe, accurate and does not have any omissions or errors at this early stage. In the case of physical documents this requires staff to transport the documentation from the ward or clinical area to the pharmacy. This may be dedicated portering staff, health care assistants, nurses, pharmacists, or pharmacy technicians depending on the protocols in place within the trust.

Discharge prescriptions are often incomplete[13], amendments and updates may be made, and checks put in place to ensure the accuracy and safety of the medicines supplied. This may include checking the patient’s own drugs (PODs) to understand if additional medication supplies are required. The patient will be informed of any changes to their medicines and has the opportunity to ask any questions.  There is a reconciliation process between the medicines at admission and those at discharge to ensure accurate discharge information for onward care settings. Where all the medication is already available on the ward, the pharmacy team and nursing staff support the patient being discharged directly from the ward.

Any medication that is not either the patient’s own medication or already labelled and appropriately packaged on the ward is requested from the hospital pharmacy, where it is dispensed based on the TTO, and supplied back to the ward. The hospital pharmacy will check, individually label, and prepare each medication to ensure that it is safe for supply as part of the dispensing process. For more complex medications, such as controlled drugs, the pharmacy team will complete the additional legal and regulatory requirements for supply. The pharmacy team are unable to release the medication until there are confident that appropriate safety and clinical issues have been addressed. For example, follow up appointments for managing high risk medicines, which can involve coordination with specialist teams. Some patients may also require their medication to be dispensed into a multi-compartment compliance aid or dosette box, which often require advanced notice due to their complex nature.  Typically this can be 24-48 hours prior to discharge.

Most Trusts have standard turnaround time targets for the dispensing process, which are typically less than 120 minutes from receipt of the TTO to availability of the medication for transport to the ward.  A recent benchmarking exercise of Trusts in 2023, showed that 83.9% met this target including at weekends [14].

These medications must then be supplied back to the patient, who may still be on the ward or in a part of the hospital for patients who are medically fit to leave, often known as a Discharge Lounge. This transfer of the physical products may require staff, such as porters, or pneumatic tube systems to physically move the products around. Some organisations use dedicated discharge porters for this purpose, others rely on the general portering team.

Typically, the nursing team looking after the patient will re-check the medications supplied back to the ward against the TTO before giving them to the patient along with the discharge summary, and re-iterating advice provided by the pharmacy team.

Separation is often made between a “minimal” or “simple” discharge which can be executed at ward level and a “complex discharge” where patients have enhanced care needs and may need placement or specialist funding or social care which are more likely to be subject to further delays. In some cases, funding arrangements may be related to high-cost medication and its ongoing supply.

Waiting for pharmacy to supply discharge medicines is commonly perceived by hospital staff and patients as the main delay to discharge2. However, as this explanation shows, there are other factors outside of the pharmacy teams’ control that may contribute to discharge delays. 

FIGURE 1 - TYPICAL DISCHARGE PROCESS

MEDICALLY FIT FOR DISCHARGE (MFFD)

Patients cannot leave the hospital until they are deemed medically fit for discharge. This discussion may occur at a morning “board round” but documentation usually occurs on a ward round with a consultant to provide senior medical review and approval for the discharge process to start. Ideally, the discharge documentation should be completed prior to the ward round.

-          Consultant / Senior Staff Availability - This requires a senior member of the medical team to provide a review and sign off. This is dependent on consultant availability, which may be limited due to competing demands, outpatient clinics or other ward round delays.

-          Investigation results – The team may often be waiting for confirmatory results before being willing to declare a patient fit for discharge. Examples may be imaging results or confirmation that a blood level is within acceptable range. Patients may wait several hours until all the necessary procedures are completed and then for the results to be received[15].

-          Speciality review – The discharge process is complicated and can be delayed due to poor interdepartmental communication. A review may be required from a specialist team, such as a mental health team, or a physiotherapy assessment which may not be immediately available at the point of the ward round, contributing to a delay in the discharge process.

TTO/GP LETTER/ DISCHARGE NOTIFICATION

The next stage of the process requires the completion of the documentation and the discharge summary. Delay in the completion at this stage is attributed to about 6% of discharge delays for patients that have been in hospital more than 7 days[16].

-          Competing Clinical Priorities – The creation of the TTO or Discharge notification is typically reliant on a junior doctor who may have other competing priorities. While a patient may be declared fit for discharge during the morning ward round the discharge summary and TTO are often not commenced until after the ward round and once other urgent clinical tasks are addressed.  An audit at the Countess of Chester Hospital demonstrated that a quarter of patients waited almost three hours to have their discharge prescription written, and half waited just over an hour from the time they were told they could go home.  One of the contributory factors was the traditional ward round process and prioritisation of clinical workload2. A recent Quality Improvement project of 2000 discharge prescriptions written in one month at Maidstone and Tunbridge Wells Hospital Trust explored the times that TTOs are written in more detail. The data on TTO writing times shows clustering across a hospital and infers that very few TTOs are written until the morning ward rounds are finished. The Trust identified that the workload in the dispensary peaked at 12pm and 3pm.  Despite Trust initiatives 94% of discharge prescriptions are not written in advance and are required for the same day[17].

-          Adequate information and Complexity on the Discharge/GP Letter – The creation of the GP letter for discharge includes more than just the medication and provides a summary of the patient’s diagnosis in hospital, the treatment provided and the ongoing care to be received. With increasingly complex patients, who may have been in hospital for extended periods of time, this can be a time-consuming process and may, in some cases, take hours to write.

-          Number of Medications – The number of medications the patient requires affects how quicky the discharge documentation can be completed and written.

-          Medicines Reconciliation – The process of reconciling the medication the patient was taking on admission and matching that to discharge can be a complex and lengthy process especially when multiple teams have been involved in the patient’s care. 

-          Access to IT Hardware– Where the Trust uses a digital approach to creation of the discharge letter and records, the team need access to physical computers and keyboards to enter the information. Digital maturity often presents a challenge, where hardware may not always be freely available and can be limited by multiple staff seeking to access this at the same time (often at the end of ward rounds)[18].

TTO SCREENING

The TTO, once generated, needs to be a screened by a pharmacist to ensure that the listed medication is safe and accurate. This process helps to identify discrepancies and address errors in the discharge documentation.

-          Ward based Pharmacist availability – Where a ward-based pharmacist is available and physically on the ward, they can expedite this process quickly, with the relevant clinical team on the ward. Under current workforce challenges that exist in some Trusts, there may be reduced availability of pharmacists on wards.  The Long-Term Workforce Plan[19] for the NHS has pointed to increasing pharmacy workforce numbers across the NHS, but shortages in workforce persist[20] in pharmacy[21]. Whilst there may be multiple patients being discharged from different teams, there may not be enough pharmacists to review these multiple TTOs at once. Where there isn’t a ward pharmacist available the TTO will need to be sent to the pharmacist in the dispensary for screening with the patient’s drug chart.

-          Complexity of the Discharge – Depending on the number of medications, the length of stay and the number of changes that have been made to the medication, this will influence how long it takes to perform a safety and accuracy check of a TTO prescription.

-          Communication with the patient – The pharmacy team will discuss changes and establish which medicines a patient may require for discharge.  Patients are encouraged to bring their own medicines into hospital to facilitate discharge and the reconciliation process.  Where patients do not bring their own medicines, or where new medicines are prescribed, most pharmacy teams pre order medication labelled ready for discharge (one-stop dispensing/OSD) to expedite this process.

-          Medication Availability – The pharmacy team may be aware that a medication prescribed is unavailable for supply due to a shortage. This requires further dialogue to provide a suitable alternative.

-          Change in Patient Status – In situation where the discharge information is prepared in advance there can be cases where the patient becomes acutely unwell or destabilised warranting a further change in the discharge prescription. This can occur, for example, in elderly patients where the blood pressure has dropped, and medications need to be amended.

TTO TO PHARMACY

Once a discharge summary and TTO have been generated it may need to be transferred to the pharmacy for the supply of any additional medication that may be required for discharge.

-          Availability to transfer TTO to pharmacy – In paper-based hospitals the physical TTO documentation will need to be transferred to the pharmacy for dispensing and supply. This transfer is reliant on the physical movement around the hospital. This may be via pneumatic tubes or could rely on portering staff, healthcare assistants, pharmacists, nurses, or pharmacy technicians to ensure that the paperwork travels from the ward to the dispensary. Depending on the time of day, some services may not be available to help with this transfer.

TTA MEDICATION

The medication required is processed through the hospital pharmacy which is managing the supply of medicines across the hospital both for inpatient and for discharge. Most hospitals have a target of completing this within 2 hours of the receipt of the TTO. Nearly 90% of TTOs were ready within 2 hours of the prescription being written. The average dispensing time per patient was 1.2 hours[22].

-          Pre-screening Completed - If the TTO has not been screened on the ward any questions or clarifications that are needed are dependent on availability of the ward pharmacist or the junior doctor that created the TTO. This can be challenging when these staff have other competing clinical priorities or may be in clinic. In some cases, the junior doctor may need to contact the consultant for further clarity.

-          Pharmacy workload & Flow – The time at which the TTO arrives in the pharmacy will influence how quickly the TTA medications can be prepared. There are peaks within the day where many TTO arrive at the same time. Where this influx arrives at the pharmacy the TTO joins the queue, which can significantly vary across the day. Pharmacy teams have attempted to rota staff to address and manage the workflow, and worked with prescribers to try to smooth the peaks - however peaks in the day can significantly influence turnaround times.

-          Dispensary Staff Availability – The speed of the dispensing process is heavily influenced by the staff that are available to process the prescriptions and prepare the medication. In the current workforce challenges, there may be occasions where the pharmacy is unable to operate at sufficient capacity to meet demand, which can slow down the speed of processing. This can also be influenced by the time of day, such as the TTO arriving out of hours where they may not be staff available, or at weekends, where the pharmacy team operates with fewer staff.

DELIVERY TO WARD / DISCHARGE LOUNGE

Once the medication is physically prepared and safe to be given to the patient it needs to be transported to the patient.

-          Porters and Delivery - The transfer of the medication from the pharmacy often relies on porters, pharmacy technicians or nursing staff from the ward coming to collect medication. The availability and speed of the round may be influenced by factors such as completing cases, other ward activities or their availability at the time of day.

-          Location of the patient – It is vital that medication makes it to where the patient is located, which may no longer be on the ward and may be in a discharge lounge. Ensuring the medication is transferred to the correct place can help to prevent delays.

PATIENT DISCHARGED

The final completion of the discharge process requires receipt of the medication and a discussion with the patient.

-          Counselling and Supply - Staff will counsel the patient, check the medication list and hand over medications. This may be completed by nursing staff on the ward, who can be delayed with other competing clinical priorities. In some cases, ward pharmacists or pharmacy technicians are available to help expedite the counselling process and provide expertise to the patients at discharge.

-          Supportive Advice – Pharmacists and pharmacy team that support the final supply of the medication use this opportunity to provide wider public health advice, such as smoking cessation information, alcohol use support and healthy living advice to support recovery.

-          Discharge Medicines Service[23]  - Through the Discharge Medicines service NHS Trusts can refer patients who would benefit from extra guidance around prescribed medicines to their community pharmacy. At least one new medication is prescribed to 79% of patients after being discharged from hospital. New prescriptions can sometimes cause side effects, or interact with existing treatments, potentially leading to readmission. Research shows that people over 65 are less likely to be readmitted to hospital if they are given help with their medication after discharge. This service aims to contribute to the safety of patients at this transition of care and help reduce readmissions to hospital.  The community pharmacy will contact the patient to discuss their medicines and any questions they have and can complete a reconciliation of their updated medication list.

Given the number of steps in the supply of medicines at the discharge process, the Pharmacy team specific elements accounted for less than half the time patients were waiting for TTOs8.

The Complexity in Hospital Pharmacy

Due consideration should also be given to the other processes and functions that the pharmacy team provide across the hospital. These clinically important elements are a competing priority to expediting discharge medication. Patients have experienced the speed and efficiency of community pharmacy services, where prescription dispensing and supply is typically measured in minutes, rather than hours.  Therefore, the public often have expectations that this will be the same.

Comparison between pharmacy systems in primary care settings and hospitals fails to grasp the complexity of medicines supply as part of the discharge process. These are often medications that are new for the patient, require a far higher level of clinical intervention and include medications that typically have a higher clinical risk. In addition, patients are more likely to be prescribed controlled drugs (often opioid based painkillers) on discharge. The supply of controlled drugs adds additional time to the supply process. Some of the unlicensed and hospital-only medications that may be supplied also require additional paperwork or records to support their supply. In addition, some patients require their medicines to be dispensed into a multi-compartment compliance aid or dosette box before they are discharged, which take longer to prepare.

It is worth bearing in mind that pharmacy teams in hospitals are not solely focussed on discharge medication, providing a wide range of activities to support safe and effective medicines use across a hospital. They ensure that inpatients can access the medication that they require, completing medicines reconciliation when new patients are admitted to hospital and ordering essential items.  They procure and distribute medication stock to wards and out-patient settings as well as supporting the running and operation of clinical trials across the organisation. Hospital pharmacy teams also prepare complex parenteral medicines such as chemotherapy, nutrition, and antibiotics in an aseptic dispensing unit in controlled environments. 

Pharmacy teams work alongside medical teams as members of the ward multi-disciplinary team (MDT). As such they are available for ad-hoc clinical or medicines-related queries, and many participate in ward rounds and MDT meetings.

Innovations in the Discharge Process

There are many innovations that pharmacy teams have introduced to improve the efficiency and safety of discharge medication in hospital settings:

• Discharge Planning on Admission - Many Trusts have implemented processes to begin considering the discharge process at the point of admission. For those with elective admissions this involves clarifying their medications prior to admission or reconciliation of the patients’ medication in the admissions areas to ensure that their medication lists are accurate and up to date. Nottingham University Hospitals NHS Trust implemented a change to shift working from 8am to 8pm, which led to 100% medicines reconciliation for patients admitted to the Medicines Assessment Unit (MAU)[24]. The addition of pharmacists into A&E and urgent care settings can help to clarify medication use early in an admission[25].

• One Stop Dispensing (OSD) and Patient’s Own Drugs (PODs) - As outlined in guidance published by the Royal Pharmaceutical Society[26], patients are encouraged on admission to bring in their medicines, which are assessed by pharmacy staff for suitability for use for the patient during their hospital stay. Patients’ own medication (also known as Patient’s Own Drugs) is used in hospital and the patients self-administer their medication when it is assessed to be safe. Patients are continuously informed and trained in how to manage their own medications during hospitalisation and at discharge[27], [28]. OSD refers to the practice of combining inpatient and discharge dispensing into a single supply labelled for discharge[29]. Patients are dispensed new medicines on admission and during their inpatient stay. In general, a 28-day supply is prepared and all medicines for the patient are then stored in the patient’s bedside medicine locker for the duration of the hospital stay. Research has demonstrated the mean waiting time between the patient being informed of discharge and actual discharge was reduced from five hours 40 minutes to one hour after the implementation of a ‘re-engineered’ process, including OSD and bedside medication lockers[30]. Using patients’ own drugs reduced the requirement to issue further supplies at discharge, and this in turn reduces TTO requirements, speeding up the medication supply demands at discharge. Data provided by Maidstone and Tunbridge Wells NHS Trust demonstrated 44% of items are already dispensed and available on the ward when the Electronic Discharge Note (EDN) is generated[31].

• Technicians discharge prescribing service[32] - Using skill mix within the pharmacy team, research demonstrates that involving pharmacy technicians early in the process to transcribe the information from medication charts to discharge summaries and TTOs can improve the speed of the supply process. While this approach is still relevant in some hospitals, it has increasingly been replaced by Electronic Prescribing Systems that reduce the need for transcription between different documents.

• TTO in Advance – One area of delay that is identified is the time taken from the patient being medically declared fit and the required paperwork to be completed to allow the pharmacy team to begin the medication supply process. Many Trust polices require TTOs to be written 24 hours in advance of anticipated discharge. Encouraging the medical team to write the TTO in advance can help to provide further time to support timely discharge.

• Pharmacist Prescribing and Transcribing - Options are being explored to encourage earlier writing times such as including TTO-transcribing pharmacists on consultants’ rounds8. In these cases the pharmacists on the ward round can prioritise the timely writing of the TTO summary for discharge. The increase in the number of pharmacists who are prescribers, and therefore able to legally make the clinical decisions regarding the discharge medication have been shown to help expedite the discharge process.  Calderdale and Huddersfield NHS Foundation Trust introduced a dedicated discharge team led by a pharmacist prescriber with support from a pharmacy technician and physician’s associate.  This approach demonstrated an average time saving of 5 hours 15 minutes per patient, which equated to 8.6 bed days per week and a reduction in prescribing error rate. There were unintended benefits revealed in the pilot, including increased confidence and competence of staff, improved job satisfaction and positive feedback from primary care teams on receipt of the discharge letters[33].

• Near Patient Dispensing – One of the challenges associated with the medication supply process can be the physical movement of the medication across a hospital site. Transporting a medication from the main dispensary to a ward where the patient Is ready for discharge, can, in some Trusts be a distance measured in miles. As a result, some Trusts have adopted an approach where the medication is dispensed on the ward or close to the point of discharge, such as in a discharge lounge area. For example, In Bristol Royal Infirmary, a near-patient dispensing service reduced the discharge turnaround time by 58%[34]. At Lancashire Teaching Hospitals NHS Foundation Trust, they introduced pharmacist prescribing and near patient dispensing on acute medical wards which reduced prescribing errors on TTOs from 22% (doctors) to 0.7% (prescribing pharmacists). Patients with medicine changes accurately captured in TTOs increased from 46% (medics) to 99% (pharmacists). Average time from patient told they can go home to leaving ward reduced from 8.5 hours to 5 hours (time to accurate prescription reduced from 4 hours to under 1 hour), and time to discharge medicines ready on ward reduced from 3 hours to 20 minutes[35].

• Information at Discharge - Providing patients with the necessary information when being discharged from hospital is a crucial part of their recovery. NICE guidance[36] states that patients should be fully informed about any medicines they need to take, including information about the purpose of the medicine, the expected outcome, the potential side effects, and how to take the medicine. Ensuring patients continue to take medication correctly after being discharged can improve health outcomes by reducing hospital re-admissions and antibiotic resistance. Pharmacists and pharmacy technicians on the wards supporting the hand over and supply of the medication can help to improve patient understanding and limit readmissions23.

• Electronic Prescribing Systems - Despite investment by some Trusts in health care technology, this hasn’t yet been universally adopted. The integration of software that functions in collaboration with electronic health records can help to improve communication between staff and departments, helping to track the movement of a discharge through the hospital. The implementation of electronic prescribing systems, which have the ability to remove the need to physically move drug charts and TTO documents around a hospital, improve discharge flow. These also allow clinical interventions to be made by staff providing clinical care to the patient who aren’t physically present. For example, a clinician working in a clinic can access records to support the discharge of a patient remotely. Evidence presented to the Health and Social Care Select Committee by the Department of Health[37] demonstrates that the target to eliminate paper prescribing in hospitals is on track for completion by 2026. The government’s response to the Health Select Committee acknowledged the variation in digital maturity across NHS Trusts but suggests that 80% of providers have some form of electronic prescribing system. Indeed, there is significant variation in the implementation of ePMA systems in NHS Trusts. This includes some parts of services not using ePMA (e.g., specialist units) and for some groups of medicines (e.g., IV fluids) due to technical functionality limitations of the systems for more complex prescribing requirements. Digital Maturity assessments indicate that 20% of providers are yet to implement ePMA36. 

Future Opportunities

Pharmacists and pharmacy teams play a vital role in supporting the timely discharge of patients from hospitals, ensuring that the supply of medication at discharge is efficient, safe, and accurate. There are both real and perceived pharmacy-related delays. Real, for example, if pharmacists are unavailable to check discharge prescriptions, or discharge medicines take a long time to arrive from pharmacy. Perceived pharmacy-related delays could be through misinformation supplied by ward staff, or because the discharge process and its expected duration are not explained to patients. However, as previously suggested, discharge delays are a much wider issue and pharmacy is not the only cause2,12.

Pharmacy teams are not complacent, and many innovations have been tried and implemented to help speed up the medication supply process as part of a patient’s discharge journey alongside the wide range of supportive activities that pharmacists contribute to effective medicines use across a hospital. Pharmacy teams continue to innovate to help tackle some of the challenges we see in the discharge process through use of the patients’ own medications, near patient dispensing, use of digital integrations, using pharmacist prescribers, and maximising the skill mix of the pharmacy team through process mapping and quality improvement. These have been implemented in many Trusts, but the level of maturity of implementation and transformation hasn’t been uniformly implemented across the entire NHS.

Regardless of where delays are attributed, the entire discharge process continues to require attention and investment.  To support timely discharge there needs to be continued investment in the pharmacy organisation, the pharmacy workforce, and the digital infrastructures to support electronic prescribing to ensure that the innovations seen in a few Trusts are shared to all wards in all trusts and settings.

While there are financial and operational challenges to further this investment, behind these numbers are the stories of patients who have experienced frustration, disruption and discomfort awaiting discharge from hospital.

References