We must not treat patients as accounting units
Nick Kempe discusses the Scottish Governments proposals for health and care reform, raising concerns that the focus on “delayed discharge” risks seeing patients as lines on a spreadsheet rather than people.
Tackling “delayed discharge” plays a central role in the Scottish Government’s proposals to reform health and social care announced in their Programme for Government (PfG) last week.
Faced with “increasing demographic challenges” and “growing financial pressures on health and social care”, the Scottish Government is committed to making do with existing resources. Hence the emphasis in the PfG on ‘improving”, i.e. speeding up, “patient flow” through hospitals as a key means of delivering “financial sustainability”. (At the same time government needs to give people some hope so the PfG claims the Scottish Government is still committed to improving outcomes for people with health and social care needs).
Unless, however, the Scottish Government can deliver on its commitment to “ensure sustained reductions in delayed discharge”, NHS staff will be left treating people in urgent need of medical attention in corridors and public pressure to expand the capacity of the NHS will grow. Much of the rationale behind the proposed structural reforms in the PfG appears to be that the Scottish Government believes it could manage “patient flow” better than existing bodies. Hence the proposals to reduce the numbers of health boards to two and for transferring responsibility for social care services from councils to a more centralised NHS.
This programme is based on a fundamental misunderstanding of people’s health and social care needs and what services are required to meet those needs and improve outcomes. A good illustration is the proposal that discharge planning should begin “on day one of a hospital stay, through the Discharge Without Delay approach, to ensure people are supported to get home quickly and safely”. While that approach is reasonable for people who are admitted to hospital for problems which are easily diagnosed and treated, it is unworkable for people who are very sick or seriously injured, for example, someone who is in a coma after a serious accident.
Requiring frontline hospital staff to start discharge planning on day one in such circumstances simply distracts those staff from giving their full attention to the treatment and care that person needs. At best staff can pluck dates out of thin air but they then face the prospect of having to explain to managers why those discharge dates have not been met. More bureaucracy, less care and a failure to trust staff, most of whom are in their jobs because they wish to help people and that includes helping those who can to get home.
It is also completely unfair to families, serving to raise hopes in such cases when a significant proportion of people admitted to hospital never return home. Imagine how it would have sounded if the Scottish Government had announced it was asking hospital staff to predict a person’s date of death as part of plans to “improve patient flow”? It is little wonder so many organisations representing people with disabilities and most doctors are against Voluntary Assisted Dying: they rightly fear it could be mis-used to put pressure on people to end their own lives to reduce demand on resources, including NHS beds, and meet targets.
“At present people are classed as bed blockers and enormous pressure is put on their families to move them into care homes”
The wider issue is the PfG fails to distinguish between circumstances where ‘patient flow’ can be improved and those where it is not in the interests of patients or their families to do so. On the one hand throughput in certain areas, most notably for planned treatments such as hip or knee replacements, has speeded up considerably in the last few decades and there is potential to do more for some interventions. On the other hand, there are growing numbers of people who are admitted to hospital because they are medically sick at and who have social as well as medical needs.
While many such people want to get home as soon as possible and have the supports to do so, the PfG fails to recognise that a significant proportion will need time to recover from illness and their circumstances are such that an early return home is not possible. At present such people are classed as bed blockers and enormous pressure is put on their families to move them into care homes, many of which charge exorbitant fees and where they risk losing their inheritance.
Successive Scottish Governments have been trying to address this problem of ‘delayed discharges’ for the last 20 years. The only time, however that management measures adopted to address the ‘issue’ have made a significant difference was at the start of the Covid crisis when existing protocols were discarded and thousands of older people cleared out of hospital to free up beds.
Three months later Health and Social Care Scotland produced a paper celebrating that ‘success’. This failed to mention the human costs, which evidence showed were horrific, with non-infected people being placed in care homes with Covid and dying as a consequence, while infected people helped the spread of Covid-19 into Care Homes which were not designed or staffed to manage the illness.
That lived experience should serve as a warning of the risk to people if the Scottish Government and unaccountable civil servants are allowed to centralise control over patient flow within the NHS.
The PfG is slightly better when it comes to acknowledging that more resources should be devoted to preventing people being admitted to hospital in the first place, as Common Weal argued in Caring for All, our blueprint for a National Care Service.
The actual proposals in the PfG are however vague and framed in the usual management jargon: a ‘new Community First approach’ intended ‘to shift more care into communities’; ‘New Integrated Navigation Centres’ to provide ‘coordinated triage and advice’ between NHS 24 and the Scottish Ambulance Service; ‘Delivering frailty services………..to help more vulnerable patients receive care in the right place’; and ‘Increasing units designed to deliver the same day care without admission to hospital’.
They also appear based on a medical model of health and are solely concerned with developing or moving new NHS services into communities. In many cases that is likely to cost as much or more than providing such services in hospital. Community clinics still require buildings while NHS professionals can see three times as many people than they can at home or other institutional settings.
From a wider perspective the proposals fail to recognise that health prevention starts well before people start to need NHS services. Real prevention requires investment in infrastructure that local councils are best placed to provide or support, such as housing, community spaces or neighbourhood support networks. Nor does the PfG recognise that one of the main reasons for inappropriate hospital admissions is that social care service provision has been cut to such an extent that NHS Accident and Emergency has become the main service of last resort.
It is for these reasons that Common Weal believes a radically different approach is needed to delayed discharge. Instead of starting from a management accountancy perspective, in which people are treated as units which “flow” from one column of an NHS spreadsheet to another, any reform must start with people and their needs in all their complexity. Common Weal is currently working on a more detailed policy paper to submit to the Scottish Government explaining why its proposals to address delayed discharge will fail and how the underlying issues could be addressed.