Written evidence from the Royal College of Nursing[i] (UEH 12)

Public Administration and Constitutional Affairs Committee

Investigations into Unsafe Discharge from Hospital, follow-up inquiry

The Royal College of Nursing (RCN) is a professional association and trade union and the voice of nursing across the UK. We welcome the opportunity to submit written evidence to this inquiry.

1.0              The PHSO report of investigations into unsafe discharge from hospitals

1.1              The harrowing stories, outlined in the report, underline the need for systemic issues to be addressed as a matter of urgency, and for good practice to be identified and shared across the health and care system.

1.2              The RCN believes that examples included in the report of patients who are discharged unsafely are simply unacceptable. No registered nurse or staff member in a nursing support role, wants to see their patient let down or receive substandard levels of care. The RCN is clear that any poor care is unacceptable and action must be taken where breaches of the Nursing and Midwifery Council (NMC) code occur. It is important, so that solutions can be found, that these cases are viewed within the wider context of the pressures facing the health and care system.

1.3              The report recognises that many of the barriers to safe discharge within the health and care system are systemic and will not be overcome overnight. The historic separation of health and social care services, chronic underfunding of social care and the need to make substantial efficiency savings across NHS settings, are all significant factors affecting the system. These issues affect the patient experience in hospital from presentation to discharge. The RCN believes it would be remiss to disregard these factors, as there are areas where solutions are not being explored simply because they are systemic and therefore cannot be quickly fixed.

1.4              The PHSO report provides a snapshot of the most serious cases reported to the organisation and which they went on to uphold. The report rightly states that these examples are not representative of practices in all settings across England.

2.0              Removing barriers to delayed discharge

2.1              Delayed discharge of patients results from a multitude of factors, however, systemic issues play a significant part. The RCN believes that barriers to timely discharge could be improved by:

• Recruiting and retaining nurses in the NHS. There is a significant shortage of nurses across the UK, and with clear evidence to show a link between numbers of registered nurses and patient experience, increasing the number of registered nurses will improve patient care.
• Appropriately funding social care so that adequate support is available when patients are deemed medically fit to leave hospital. The RCN believes that discharge targets mean little if the resources are not available to enable them to be met.
• Investing in the district, community and social care nursing workforce to ensure that people get the right care, in the right place, to enable them to live independently either at home or in a care setting, and reduce avoidable acute admissions.
• Implementing effective discharge coordination policies for acute wards and ensuring that discharge planning is a core part of registered nurse and health care support worker education, to ensure registered nurses can assess patients and discharge them using appropriate plans.
• Recognising the evidence that the clinical decision making skills of registered nurses has a bearing on patient safety, outcomes and overall patient experience. Registered nurses, as compared to unregistered nursing staff, are able to assess patient needs and discharge appropriately, and should therefore be utilised in discharge coordinator roles. Task-based approaches can lead to delegation of discharge to inadequately trained staff and this should not happen.
• Ensuring that discharge planning starts inside the ward and takes place 24 hours a day, seven days a week, rather than only during office hours. The RCN is concerned by examples of discharge teams who work outside of the ward environment with the goal of discharging patients, and yet have no knowledge of their clinical needs and personal circumstances. These roles are best carried out by registered nurses who know the needs of their patients.
• Encouraging integration of health and social care services and sharing best practice where new models of care have been evaluated positively for discharge outcomes.

3.0              Background

3.1              In addition to the issues outlined above, the current nursing workforce crisis is a serious concern for patients. There is a shortage of nurses in England and across the UK, and we need a clear commitment and evidence-based plan to produce the numbers needed, not only to meet rising demand and deliver basic safe care, but to be able to provide the highest levels of care to patients. The RCN is warning that without a significant increase in nursing numbers and resources, there is a risk that this will not be the last time we hear of such devastating patient experiences.

3.2              The RCN is extremely concerned about the proposed changes to nurse education funding and the impact this will have on the health and care system. The shift from a centrally planned workforce to one which relies on the open market raises questions not only about numbers, but about where nurses will be placed. Patients need care at the right time in the right place. We need to see an increase in nurses in district and community nursing and social care, but as they currently stand the proposed changes fail to guarantee this. 

1.6              A recent National Audit Office (NAO) report found that delayed discharge cost the NHS £820 million last year.[1] The NHS cannot afford to waste precious funds keeping medically fit patients in hospital. The RCN strongly believes that this money would be better spent on improving patient care. 

3.3              The NAO report chimes with the findings of the PHSO, and reveals that older people are retained in hospital because of a lack of provision in the community to enable them to either return home with support to live independently, or move into a care or residential home. Keeping older people in hospital is a risk to their health and to the future sustainability of the NHS.  It not only costs the health service while they are in hospital, but also increases the likelihood of readmission and therefore further costs to the NHS in the future.

3.4              A recent survey revealed that seventy per cent of nurses across England frequently delay discharging older patients due to a lack of available support after leaving hospital. Almost all of the nurses surveyed, 95%, reported that delayed discharge is a serious problem in the hospitals they work in, with 83% of nurses reporting that they believe a good relationship between the NHS and social care is most important to a successful discharge policy.[2]

3.5              Better integration of health and social care services will go some way to help address the issue. However, the RCN believes that integration alone will not be enough to solve the problem. Social care must be adequately funded and patients must be able to access services closer to home.

4.0              The role of the district and community nursing workforce

4.1              District and community nurses are ideally placed to support patients to continue to live independently in their own homes and to keep them out of hospital.

4.2              People are living longer and many older people are living with one or more complex long term condition. The health and social care landscape must be equipped to support these needs. Long term conditions can be successfully managed through self-care and with support from nursing staff and allied health professionals working in the community. However, there needs to be the right numbers of staff in the community to enable this.  The NAO report worryingly reports that the community nursing workforce decreased by 13% from 2009 to 2014.

4.3              Figures from the RCN’s 2013 call to action on district and community nursing show there was a 44% decline in numbers over the decade. [3] Nursing numbers in primary and community settings must be rectified as a matter of urgency to ensure patients are getting the right care in the right place. To achieve this will require dedicated funding for nurses to professionally develop. The RCN is concerned about the lack of clarity related to the non-medical education and training budget in England to enable robust investment in these roles.             

4.5              Responsibilities of district and community nursing services include coordinating patients’ access to relevant services in the community and providing care for patients who would otherwise be required to return to hospital, along with the associated costs. However, their decline in numbers over the last decade means the ambitions of successive Governments to increase the community workforce have not been realised. It is likely that an increase in their numbers would positively impact on patient experience and reduce the risk of unsafe discharge from hospital.

5.0              Integration of health and social care

5.1              The RCN supports the new models of care at the centre of the NHS England Five Year Forward View which present opportunities to remove some of the systematic barriers which result from the separation between health and social care. It is too early to say whether these models are having a positive impact on discharge planning, however, the RCN is keen to understand and share best practice in this area.

5.2              Once evaluated, best practice must be shared by areas where discharge planning as a result of successful integration has been particularly effective.

6.0              Funding social care

6.1              Local government funding cuts are being felt most strongly in the social care sector, where chronic underfunding during the last Parliament led to the current shortfall. The latest figures suggest that with the introduction of the National Living Wage, the funding settlement for local authorities is insufficient to plug the social care funding gap, estimated to stand at around £2.8bn.[4]

6.2              Seventy five per cent of existing spending cuts to social care have been achieved by restricting the amount of care provided, by raising eligibility thresholds and shortening visits to service users. Without an adequate funding settlement for social care, the trend of delayed discharges is likely to get worse. [5]

7.0              Discharge coordination policies

7.1              Discharge coordination policies, and the way they are executed, affect the success of the process and the quality of patient experience in acute settings. Discharge planning roles vary and there is no single, agreed job description for a discharge coordinator. Often, discharge coordination roles are carried out by a single individual, while in other instances the responsibility is shared between nurses on duty. Some roles are carried out by registered nurses and others delegated to non-registered staff such as health care assistants.

7.2              Discharge coordination can be improved by ensuring that bachelor degree level educated registered nurses lead the implementation of discharge coordination policies. The is a wealth of evidence which shows a link between patient experience and outcomes and numbers of bachelor’s degree level educated registered nurses.[6]

7.3              The RCN believes that discharge coordination should form a core component of the workforce planning needs of local services. Effective discharge planning requires communication and leadership skills, the RCN is calling for it to form an integral part of nurse pre-registration education courses, and not just ‘on the job’ training.

7.4              The Department of Health programme to ensure that patients are discharged appropriately and safely is a welcome step in the right direction. However, the impact of years of poor workforce planning will take some time to put right.

7.5              Although each service should implement discharge planning that suits the needs of its patients, the RCN is aware of examples of effective discharge coordination on acute medical units with 24 or more beds, where there is a supernumerary registered nurse discharge coordinator. Certainly, some wards would benefit from this arrangements, however current financial and nursing workforce pressures in the NHS mean this may not be considered a viable option by Trust executives.

July 2016

5