Written evidence submitted by Healthwatch England

About Healthwatch England

Healthwatch England is the independent champion for people who use health and social care services. We exist to ensure that people are at the heart of care.

We listen to what people like about services, and what could be improved, and we share their views with those with the power to make change happen. We also help people find the information they need about services in their area.

We have the power to ensure that people’s voices are heard by the government and those running services. As well as seeking the public’s views ourselves, we also encourage services to involve people in decisions that affect them. Our sole purpose is to help make care better for people.

Role of local Healthwatch

There is a local Healthwatch in every area of England, one in each top-tier local authority area. They provide information and advice about publicly-funded health and care services. They also go out and speak to local people about what they think of local care, and share what people like and what could be improved with those running services. They share feedback with Healthwatch England so that we can spot patterns in what people are saying about care, and ensure that people’s voices are heard on a national level.

1. As the National Audit Office notes in its report, understanding emergency admissions is important because ‘some emergency admissions are clinically appropriate and unavoidable. Others could be avoided by providing alternative forms of urgent care, or by providing appropriate care and support earlier to prevent a person becoming unwell enough to require an emergency admission.’

2. Emergency readmissions within 30 days of discharge form an important part of the overall emergency admissions picture. Greater understanding of emergency readmissions would provide insight into how health and care services are working together to keep people well, given that many readmissions be avoided with the correct support in place. It was therefore encouraging to see the NAO highlight our work in this area.

3. There has been significant focus in recent years on getting people home from hospital faster, which is both better for patients and helps to free up beds. However, it is important that this is done safely, with people able to get the support they need to recover. We first explored the issue of whether delayed transfers of care were leading to unsafe discharge practices in our 2015 report, Safely home, and have long called for greater understanding of the data to make sure that welcome efforts to address delayed transfers of care are not inadvertently causing a rise in the number of emergency readmissions.

4. In October 2017 we published our report, What do the numbers tell us about emergency readmissions?. Based on information from over 80 NHS trusts, our research revealed that emergency readmissions, people returning to hospital within 30 days of being discharged, have risen by 22.8% in the last five years, compared to a 9.3% rise in overall admissions. When we dug deeper we found that more than 1 in 5 of the people affected actually had to return to hospital within just 48 hours.
5. However, we also found that the consistency of the available data collected by Trusts was variable. We were therefore encouraged to see that the National Audit Office echoed our concerns about the way in which such incidents are recorded by the NHS as part of their report on reducing the overall number of avoidable visits to hospital.    

6. In particular, it would be useful for trusts to strengthen the data they collect on emergency readmissions by:
• Applying a standard definition for what constitutes an emergency readmission, and which categories are excluded;
• Electronically recording and analysing the reasons people are readmitted;
• Including the breakdown of the demographics for emergency readmissions, identifying groups that are more at risk of an unplanned return to hospital;
• Undertaking further analysis to identify any correlation between emergency readmissions and delayed transfers of care data at a hospital trust level.

7. As part of our submission to the Government’s refresh of the NHS Mandate for 2018/19, we have reinforced our call for the better understanding of emergency readmissions to ensure the drive to get people home faster, and to free up capacity, is not having any unintended consequences.  One way of doing this at a national level would be to restart the publication of national statistics on emergency readmission data, currently under review by NHS Digital.

8. In the response to our Mandate submission, we were pleased to see the Government commit to reviewing the methodology behind the statistics, with a view to restarting publication. However, whilst we welcome the government’s intent, and recognise that getting things right will take time, we would like to see some firm timescales put in place behind the commitment.

9. Reducing emergency admission is also about prevention. This is why making sure that social care assessments are done in a timely and effective way is so important, as prioritising those in hospital over those in the community risks making the situation worse. A better understanding of social care waiting times, which we explored in our work on social care assessments, can help commissioners, providers and front line staff manage demand more effectively and reduce the risk of people being admitted in the first place.

10. Healthwatch has not been the only organisation making this point. The Care Quality Commission has done some interesting work as part of its local system reviews in order to understand patient flow by looking at how people move between health and social care, including delayed transfers of care, with a particular focus on people over 65 years old. As part of the reviews, they have followed a small number of patients from treatment to recovery. These case studies, part of larger ‘data profiles’, provide unique insight into experiences that statistics alone might overlook, and supports our call for greater understanding of individual patient journeys as a way of measuring integration between health and care services. These steps are positive, but more remains to be done to fully understand people’s experiences of leaving hospital.

11. Previous parliamentary committee inquiries, such as the Public Administration and Constitutional Affairs Committee’s 2016 inquiry into the PHSO’s Unsafe discharge from hospital report, have recognised the need for a greater understanding of the relationship between early discharge and readmission. In the Government’s response, it committed to exploring ‘the development of new metrics to understand the true impact of delays to discharge and patient flow, and to allow regular monitoring of and action in response to national trends in performance.’ It is now imperative that this is not only explored, but given a clear timeframe for implementation.

Healthwatch England

March 2018