David Oliver: Who is to blame for older people's readmission?

In July Healthwatch England published Safely Home, a report describing the problems facing older people and their families when they leave hospital.Disturbing personal stories highlight poor coordination between services. Patients often feel stigmatised for problems they don’t control—for instance, viewing themselves as “bed blockers,” which is a dreadful term—and they are not always properly involved in very personal decisions. Despite considerable efforts to plan hospital discharges well, about 15% of patients aged over 65 in England are readmitted within 28 days. Charities including Age UK and the Royal Voluntary Service have highlighted this distressing statistic and have publicised that support at home is often inadequate. Simplistic media coverage may suggest a scandal, in which acute hospital staff are to blame—but the problem is far more complex.Many patients are readmitted not because the discharge was poorly planned or because they went home while still acutely unwell, but rather because of relapse of a long term condition or because of a new illness or injury. Intermediate care teams outside hospital have inadequate capacity to respond to crises or support discharge, and access to such care is too slow. Cuts to social care funding have left even people with “substantial” needs unsupported, as well as their carers. Older people with frailty or complexity and age related conditions receive generally less attention in primary care than those who are younger, and they often find poor coordination and continuity of care. Only a quarter of over 75s admitted to hospital with conditions sensitive to management in primary care are referred by their GP; the rest present to emergency care. Mentally competent older people who have expressed a clear wish to go home are often readmitted. But clinical staff who support their right to go home, however risky, are practising person centred care; to tell them “I told you so” misses this point. The idea that hospital is “safe” while home is “unsafe” is false. Rather, prolonged hospital stays expose older people to considerable harms, often leading to a loss of function and independence—and a shorter length of stay is not correlated with readmission. Delayed transfers of care are becoming more common, and lengthy wrangling over NHS versus social care funding is a polar opposite to the idea of “putting patients first” that clinical commissioners and local authorities talk of in their “value statements.” Furthermore, peer reviewed evidence on interventions to prevent readmissions is patchy. England has relatively few hospital beds and has lost them rapidly, and the unavailability of beds impairs the care of new acute patients. So, hospital staff are encouraged year round to discharge patients early to clear the beds; along with pressure from national performance targets, such as four hour waits, these are dominant daily priorities. Well planned and well supported discharge matters greatly, of course, but the public needs to know the whole story about what acute hospital beds are for.