Why the revolving door of hospital discharge is likely to keep on spinning

One of the saddest things about Healthwatch England’s report into the inadequate care and support endured by thousands of patients undergoing hospital discharge is that the “shocking stories” it contains come as no great surprise.

The “revolving door” experiences of those affected bear near-inevitable testimony to a broken system that’s increasingly being denied any meaningful chance of repair. Patients find themselves being transferred into the community only to find inadequate support or care, leading to further need for hospital care. Often the problems that led to admission become complicated by other, unanticipated healthcare concerns.

Some months ago, in collaboration with my colleagues at Nottingham University Business School, I published a study into knowledge-sharing in the hospital discharge process. Many of the findings have uncomfortable echoes in Healthwatch England’s revelations.

At their bluntest, the problems can probably be summed up in two points: the various individuals and agencies involved in hospital discharge routinely fail to communicate with each other effectively – and the issue is unlikely to be resolved anytime soon, as the staff best placed to make the process work are most likely to lose their jobs to funding cuts.

This may well sound alarming and depressing in equal measure – and it is. Not least when viewed through the prism of the public sector’s steady annihilation, it’s hard to see how things might improve in certain settings. So is there any hope?

Routine failure to communicate

Most patients see hospital discharge as a landmark in the rehabilitation process. Given that they’re going home, this is perfectly understandable. For them it’s the end of one phase of their “journey” and the start of the next.

Teddy still waiting.Kate Hiscock, CC BY

But hospital discharge isn’t a one-off, isolated event. It’s a complicated and vulnerable stage in the patient pathway, contingent on an intricate series of activities and situations such as the planning of on-going rehabilitation, arranging medicines to take home, dealing with changes in patient medication, organising social care, scheduling transportation, and informing the patient’s GP. In many ways it exemplifies the threats that lurk “between” care processes and organisations. As such, it demands knowledge sharing.

To understand the benefits of knowledge sharing, it’s vital to appreciate the difference between “know about” and “know-how”. A simple illustration: you might know what my job is, but you don’t know what my job entails, or you don’t know what I actually do. Mere facts are seldom sufficient, because facts are of genuine worth only if we know what they really mean, how they should be applied and how they might link and combine to create new facts.

Our study, carried out for the National Institute for Health Research, suggested a number of ways in which knowledge sharing might be enhanced to improve the discharge process. At the heart of our recommendations was the need to identify and exploit opportunities to bridge the gaps between acute care (delivered in hospital settings) and community care.

Encouragingly, we found that different interested groups agree that it’s everyone’s business – including the patient’s – to support and contribute to the discharge process. That this doesn’t always happen isn’t due to a lack of willingness: it’s due to a basic absence of communication and coordination.

This is characteristic of one of the great paradoxes of our age. With the world more “connected” than ever before and the “death of distance” practically complete, we’re losing the art of conveying messages at the most fundamental levels. It takes seconds to collaborate with people thousands of miles away, but we might spend years not really knowing what some of our closest colleagues do and why they do it.

Importantly, there are individuals involved in the discharge process who habitually work across occupational and organisational boundaries. We found that discharge liaison nurses, community nurses and Early Supported Discharge teams excel at getting the right information to the right people at the right time. They’re central to making colleagues recognise and make use of the distinct facets of experience and expertise that each brings to the overall procedure.

Others fulfil similar functions, albeit less conspicuously. Ward clerks, porters, voluntary workers, domestic staff, ambulance drivers – all help to facilitate routine information exchange, whether through retrieving records, passing on memos or chasing up referrals. Being more “backstage”, their contributions are too easily taken for granted.

The key, then, is to highlight, build on and learn from the success of those who are able to span boundaries. But there’s a potentially significant hurdle to overcome – and this brings us to the problem of staff lay-offs.

Losing good staff

At present it appears knowledge sharing is more likely to be further eroded than enhanced. We uncovered evidence that roles identified as conducive to patient safety once patients are back in the community are being scaled back – or even discontinued – as funding constraints intensify. The very talents and abilities we need to nurture are the ones we’re in danger of losing.

This trend should be resisted and reversed, which is why we recommended introducing designated discharge coordinators or similar internal/outreach teams to foster more effective information exchange and, as a result, best practice. It’s imperative to have in place people who take an “architectural” view and fully appreciate how the wider system works and fits together – as opposed to those who might have only a “component” interpretation focused exclusively on their own contribution.

Of course, this kind of joined-up approach is desirable in every area of modern-day healthcare. In large part, because of its misperceived simplicity, what the everyday act of hospital discharge illustrates especially well is that the one-dimensional notion of drawing a line in the sand and declaring “my work is done” is increasingly unsustainable.

“Our work continues” is a much better mantra for modern-day healthcare. Whether those who hold the purse strings have any interest in pursuing this or any other ideal, though, is another matter altogether.

Justin Waring receives funding from NIHR HS&DR.