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The Public Engagement Agency™
Improving discharge pathways in East Kent
Report of engagement sessions held in June 2018
The Public Engagement Agency™
1. Introduction
The NHS in East Kent is reviewing current practices around discharge from hospital in order to
improve patient outcomes, experience and efficiency. New models of discharge, which use home as
a default option, need to be in place by the end of August in preparation for winter pressures and in
line with stretching national targets.
Three workshops were held in June 2018 - one for clinicians, one for people responsible for the
delivery and commissioning of care and one for patients. These were designed to:
Explore the issues around delayed transfer of care (DTOC) and their impact on patients and
services
Consider how systems and processes could be redesigned– in line with local care models
being developed in east Kent - to improve patient outcomes
Ensure smoother, more effective transitions across services and reduce the significant level
of inappropriate bed occupancy
The Public Engagement Agency (PEA™) was commissioned to support this phase of engagement. This report provides an overview of the feedback from the three events.
2. Key themes
The themes that emerged from the discussions were similar across all three participant groups.
These themes were entirely consistent with previous work that had been undertaken by
Healthwatch Kent in relation to the west Kent health economy.
Key perceived problems/challenges in the current system included:
Cultural issues: lack of trust, in and across organisations, risk aversion - fear of blame, leading to
multiple assessments/duplication
Clinical behaviour: unnecessary interventions – ‘just in case’ – delaying discharge; people having
things done for/to them, reducing independence (‘PJ paralysis’)
Demand issues: pressures in each part of the system; needing to move the patient on from A&E but
no beds, then from the ward but nowhere to go, causing inappropriate transfers to other hospitals;
operational pressures versus clinical decisions
Information/IT systems: information not accessible to all; different methods of recording and
sharing information
Communication issues: lack of communication between services, organisations and with the
patient/family; lack of handovers; poor documentation
Hospital systems: pressure to achieve targets outweighing care and clinical decisions
Lack of clinical leadership in some areas
Lack of knowledge of what’s available - the alternatives to admission or services that could support
earlier discharge
Late referrals, causing people to go into crisis
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Not person-centred: patients and carers not listened to; patient choice not taken into account;
carer’s needs not considered
Unrealistic expectations of how the patient should perform after discharge; not taking previous
ability and living environment into account
Hospital systems that can be over-complicated and block discharge
Lack of resources in discharge teams, in community; insufficient support for particular needs,
overnight care, 24-hour care
Funding disputes between health and social care, causing discharge delays; lack of joint working
Medicines management: not taking into account the patient’s previous medicines/history or
potential post-operative needs, post-discharge;
Discharge planning taking place too late in the day for home support/medicines/transport to be
arranged
Lack of tailored discharge information or contact person, causing anxiety when home
Too many home visits from too many different people/services; duplication
Care homes unwilling to take the person back, no longer able to meet their needs
Mental capacity issues: mental capacity act not always followed or decisions recorded
Suggested potential solutions/improvements included:
Change the culture: empower and build confidence in staff to follow one agreed care plan and
assessment, take appropriate risks; create a shared vision and culture; reduce blame culture; build
trust
Change clinical behaviour to stop over-investigating/over-medicalising and actively promote patient
independence as soon as possible; increase and allow clinical ownership and accountability
Skilled, competent clinicians along each part of the patient pathway; triaging by someone with the
right level of competency; rotation between acute and community; cross-boundary working; dual
trained roles in the community
Strong clinical leadership: to change culture/behaviours; lead by example, promote adherence to
one assessment/care plan, and respond to patient’s wishes
Create one shared IT system and strategy, to standardise and share patient information across all
services and organisations
Early intervention, before crisis, to avoid admission where possible
Clear and timely communication across services: between acute, community, primary care and
other decision-makers, particularly those who know the patient best, particularly the GP
Open, honest communication with patients and families so they have enough information to make
their own choices and decisions
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Person-centred: keep the patient at the centre of care: ‘no decision about me without me’; looking
at person’s entire needs, as well as carers’
Have realistic expectations of the patient: use pre-admission assessment and plan as the baseline
Timely discharge planning: early on, once admitted; early in the day to make sure all discharge
requirements can be carried out by the afternoon
A named link person to engage with the patient and family in hospital and follow through to home
An advocacy scheme for those less able to speak for themselves or with no family
Written, tailored discharge information to address any concerns/questions that may arise after
discharge
More resources to avoid admission, in discharge-related teams, in the community and in the home –
support people in crisis to stay at home; more rehabilitation and prevention
Increase access to services: 24/7 and 7/7
Change funding streams between health and social care; joint commissioning to promote better
joint working
Develop systematic, simplified patient pathways
Safeguard vulnerable patients, with a full, recorded assessment and plan
Share learning from tests/pilot sites; build on what’s known
Better medicines management: review pre and post hospital prescriptions; use exiting medications;
increase length of hospital supply
People information/education to understand how to use services and have more control over
decisions made about their care
3. Detailed findings
3.1. Clinical Event
Clinicians from East Kent Hospitals University NHS Foundation Trust (EKHUFT), Kent Community
Health Foundation Trust (KCHFT) and primary care attended an event held in Canterbury on 6th June.
East Kent’s DTOC Lead set the background and context (presentation is at Appendix A). This was
followed by a facilitated conversation with three clinicians, to gain their views of the presenting
DTOC problems.
Key issues, from the GP perspective:
GPs are creating care plans but these aren’t uniform across practices. All have escalation plans but
these are rarely followed in an emergency. Most people want to stay at home but when they’re in
crisis: services are not accessing their care plan, the person in crisis doesn’t think about their plan
and care homes don’t necessarily follow them.
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GPs have a lot of information about the care someone received at home, so there needs to be a
more coordinated approach, with greater communication between services and better use of
existing information.
There are some good discharge plans for the frail elderly but GPs don’t always get copies of results
and have to chase and results sometimes arrive too late.
Key issues, from the Community Geriatrician perspective:
Patients in care homes are asked what they want, care plans/advance care plans are created, but
then they can’t be found.
Community hospitals have the same problems/pressures as acute hospitals and there’s a real
problem regarding assessment and reassessment.
People in their own homes are much more empowered and their rights should be respected -
community hubs are really supportive in that.
Key issues from the EKHUFT Consultant Geriatrician perspective:
Patients feel lost in the system. When asked, they don’t want loads of procedures and questions,
they just want to go home. Clinicians not always responsive to that and there may be further
complications like hospital infections and being immobile that worsen the situation. At each point of
the journey there’s some “clinical aversion” to taking a risk.
Consultants would buy into a care plan that identified the patient’s involvement and wishes but
services all communicate and document in different ways. The clinician can conduct a
comprehensive assessment of the patient’s needs but can’t action those decisions, so the next
team reassess and so on, at each handover/transfer.
Key issues from group discussions
Participants were then asked to consider what the challenging issues and potential solutions were,
from their perspective.
Key challenges included:
Culture: multiple assessments, within/across organisations; lack of trust; not all clinicians bought
into this; complex decision-making, at each stage of the patient’s journey; risk averse; fear of getting
into trouble/being held to account for things going wrong
IT systems: don’t talk to each other; interface problems
Communication: families can be challenging but, in most cases, want to know what’s happening
Unrealistic expectations: people expected to perform better at discharge than before admission
Resources: the rapid response team is too small to cope with demand; IDT is under-resourced
Hospital system: getting out of hospital can be really complicated; discharge resistant
Funding: disputes between health and social care; big delays and battles between services and with
patients/families.
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Potential solutions included:
Culture change: empower staff to have confidence in following the agreed care plan and be able to
take appropriate risks; reduce assessments; develop relationships and build trust across Trusts, GPs,
community services/hubs; greater cross boundary working; rotational roles
Clinical behaviour change: stop teams from “over-investigating” – should be the patient not the
medical agenda; understand what’s realistic; give people a better quality of life
Shared IT system and strategy: share a common portal; standardise patient information; one
assessment/shared care record/plan, followed by all; use patient tracking lists
Communication with patients and families: hold informed, honest conversations with patient and
relatives about risks, pros and cons of going into hospital; build relationships
Realistic expectations of the patient: work to the patient’s pre-admission baseline;
understand/work with what they can do at home
More home/community resources to support the person in their own home, in crisis and at end of
life; expand the rapid response team/IDT
Shared discharge planning: full discharge summary with information from all consultants and ward
Change funding streams: better joint working between health and social care
Systematic, simplified patient pathways: cross boundary working; rotational roles; clarity of roles
Strong leadership: reinforce adherence to care plans and patient wishes; lead by example; prevent
over-investigating; bring all clinicians need to the same level of understanding/permissiveness
Access to services: review delivery of services 24/7 and 7/7
Safeguard vulnerable patients
Shared learning: share findings from and mainstream related tests/pilots
Medicines management: increase hospital supply; use medicines patient brought into hospital;
review pre and post hospital prescriptions
Greater home support: resources/systems to allow people in crisis to stay at home
Creative/innovative approaches (e.g. care plan on phone)
3.2. Staff event
This event, held on 7th June, was attended by nearly 70 people responsible for the delivery of care
and current discharge arrangements.
Participants were asked to:
a) identify and cluster the problems/issues with the current system/process at three key
stages: before arriving at and in A&E; on the ward; at discharge
b) suggest possible solutions, in an ideal world, at each of the three key stages
Key problems/issues identified with the current system
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PROBLEMS PRE-A&E/AT A&E
Culture: lack of trust between services, leading to multiple assessments throughout the
pathway; care plans not shared/referred to; risk averse
Information not accessible: services don’t know what’s already been done/known about
the patient, can’t see/get access to the information
Communication issues: difficult to understand the systems; people unaware of alternatives
to A&E; lack of handovers; poor documentation; silo working
Not person-centred: patients/carers not heard; pre-hospital ability not taken into account
Flow and demand: being treated/left unattended in corridors; bed pressures; over-
crowding; may be ready to be transferred to ward but nowhere for them to go
Lack of knowledge of alternatives: a range of support in community - that hospital staff
may not be aware of - that could prevent admission/support earlier discharge
Hospital systems; bureaucratic issues, such as A&E PTL; scoring systems; slow decision-
making
Medicines management: not recognising medications the patient already has, reissuing, not
recognising any problems patient may have had with particular medicines; wastage
Care homes: care plans in care homes not followed; unable/unwilling to have person back
Transport: limited/not available at time of discharge
Demographic differences: different needs of different patient groups (e.g. generational)
PROBLEMS ON THE WARD
Culture : multiple assessments, duplication, lack of trust; A&E busy so reassessment on the ward, in
case A&E has not assessed fully
Different IT systems: no one centralised system
Communication issues: poor communication between A&E and ward; poor documentation; limited
access to computers on ward
Patient choice/decision-making: patient may want to go home rather than to another hospital, but
depends on how able patient is/how vocal relative is
Hospital systems: pressure to perform outweighs care; pressure to achieve targets; different
definitions/understanding/use of red and green bed days
Clinical behaviour: unnecessary interventions - ‘just in case’ tests, delay discharge; “PJ paralysis”;
kept in bed too long; having things done for them; losing independence
Leadership: no consultant leadership in some areas
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Inappropriate transfers: pressure to move patients on because of demand in A&E, potentially
creating greater problems; staff feel disempowered and reluctant to discuss with patient and family;
decisions taken away from clinicians; operational pressures versus clinical decisions
Discharge planning: decisions made too late in the day to organise; decisions out of hours, or late in
the week, rather than from admission
Lack of resources: not enough non-weight-bearing support in community/home (rather than beds)
Equipment: not available/not being delivered on time
Fast track: lack of access to appropriate placements; needs to be given adequate time
Transport: delays, particularly out of area; limited access; not always the best option
PROBLEMS ON DISCHARGE/POST-DISCHARGE
Culture: risk aversion – not challenged; fear of blame; too caught up in ‘the doing’; trust issues; lack
of teamwork
Information/IT: existing patient information not used/taken into account; not used appropriately;
some out of date; recorded through different methods (manual/electronic)
Communication issues between acute and community services/services and patient and family;
aversion to difficult conversations
Not person-centred: treating people as statistics rather than individuals; not acknowledging the
person’s ability to cope at home before hospital or ability to make judgements; assessment when
acutely unwell is not the baseline
Carer’s needs not considered enough – what they can do, what they might need
Lack of knowledge of what’s available; who/how to access; care home criteria
Lack of resources/services alongside insufficient IDT capacity to support hospital discharge plans;
some services no longer commissioned; insufficient provision for people with particular needs, e.g.
dementia, 24 hour/ overnight care; not enough non-weight bearing services; pressure on community
beds - strict criteria
Lack of joint collaborative working: social care versus health care responsibilities/budget; people
staying in hospital for weeks, as no access to a care package; systems not joined up
Care homes can’t meet the patient’s needs so don’t accept them back; lack of staff/skills; difficulties
trying to get patient into hospital; only manager has the ability to assess patient’s ability; fear re CQC
Discharge delays: waiting for information/results, prescriptions etc.; equipment not provided in
timely enough manner; making simple discharges complex
Mental capacity issues: patients not being allowed to make their own decisions; mental capacity act
not followed in its entirety; often not clear enough about the decision
Housing issues: not being considered
Fast track assessment: continuing healthcare assessment done in home but not followed through
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Home adaptations not done in a timely manner
Medicines management: post-discharge checks not carried out
Transport not booked early enough
Out of area beds and repatriation to/from rest of county/country – different care/health
commissioning processes
Whilst there were concerns again about multiple assessments one clinician commented that
assessment was an important part of engaging and building a relationship with the patient.
What the system and process would look like in an ideal world: ‘the art of the impossible’:
PRE-A&E/IN A&E
Single assessment throughout the care pathway
One shared IT system: shared access to patient information, assessment, care plan, advanced care
plan, used by all organisations
Standardised information in the most appropriate media – e.g. Red Bag scheme
Clear communication between acute, community, primary care and other decision-makers,
particularly those who know the patient best, including voluntary sector
Patient focused: ‘no decision about me without me’; not financially or clinician focused; looking at
the person’s entire needs, not just health; supporting the patient to make informed decisions
Resources to support admission avoidance; more therapists; 7 day services, for the whole MDT (for
both physical and mental health issues); multiskilled team at A&E front door, including voluntary
sector; ART team in all areas; larger teams in community across all CCGs; SECAmb accessing step up
and emergency respite; therapists on ambulances; easier GP access
Joint health and social care budget: identify specific pathways to begin with
Clear pathway: reduction of time between stages; consistency; adherence to care plans/actions;
direct streaming to the right place/person; knowledge of all services and what each service provides
Use walk-in/minor injuries criteria in A&E
Educate the public, to reduce walk in; recognise A&E isn’t minor injuries; clear signposting of what’s
available and how to navigate
Triaging at the front door, by someone with the right level of competency to reduce the number of
admissions, get to the right service quickly; clearly defined threshold for managing risk
Local care coordinated around the patient
Hospital at home: acute frailty assessment in patient’s home; virtual wards in the community
Discharge planning at front door, engaging with community
Rotation of roles across acute and community
ON THE WARD
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Early discharge planning from admission onwards; early referral/discharge arrangements;
communicate with local care (example given of QE discharge form)
Information systems: shared, to avoid duplication; greater use of technology - iPad or iPhone with
app showing live discharge information/alerts; link into PTLs (being developed for bed management)
Registered practitioner competency led discharge: senior decision-making; engaging with wider
clinical team
Patient ownership: allow patient to make their own decisions; keep patient at the centre of care;
communicate early with patient and relatives and identify what they want/need; use existing home
care plan as a baseline; mobilise/promote independence as soon as possible, with volunteer support
(to avoid ‘PJ paralysis’)
Discharge to where patient lives rather than another hospital
Clinical leadership to change culture/behaviours; stop unnecessary tests/procedures
Invest in staff development
Clearly defined roles to ensure clinicians can focus on giving high quality care; others to carry out
discharge procedures/ensure actions ae followed (for example, Band 4 discharge
coordinator/named nurse per shift)
More integrated approach: better communication between ward and other services, e.g. social
services; more holistic approach
Discharge planned and carried out early in the day
AT DISHCARGE/POST-DISCHARGE
Culture change: MDT working together; reduce blame culture; build trust in each other; one trusted
assessment that follows patient all way through; create a shared vision and culture
Clinical ownership and accountability for safe and effective discharge: ‘everybody’s business’; know
about other services in community for full package of support; robust decision-making, no delays
Agree systems to manage risk: care homes as part of whole system; clinical risk management (GPs
manage risk in different way to other clinicians in the system)
Review and revise whole system/ process: all services joined up/talking to each other, breaking
down service/organisation barriers; reduce ‘hand-offs’; work as one organisation
Change staff expectations: need to understand and work with people’s baseline before admission;
change expectation of person’s ability to cope when discharged
Person-centred decision-making/choice: need to build trust, be honest, allow patients to choose;
patients and families/carers key to discharge planning; support self-management, self-referral if
have long term condition
Staff development and competency: right skill mix; rotation between acute and community; dual
trained roles in the community; cross-sector working; shared learning
Increase community resources to ensure the right support when home, including rehabilitation and
prevention; increased care in the home (e.g. dementia care, home treatment team); 7-day service;
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longer hours, including night care; more senior management, out of hours; better use of technology,
such as telehealth
Review number/use of community beds (“more”, “less”, “no more” community beds); reduce bed
base, move resource into community
Joint commissioning; integrated placements without prejudice; ensure fit for purpose
Post discharge package to stop attendance at A&E or, in acute episode, link to future attendances at
A&E, not start the whole assessment/planning process again.
3.3. Patient and Public Event
An event was held in Herne Bay on 15th July, attended by patients, carers and representatives from
local charitable organisations and the council (presentation is at Appendix 2).
Key challenges/issues from the discussions were:
Late referrals: causing people to go into crisis
Lack of GP appointments: so people don’t go, get unwell and are then admitted to hospital
Inappropriate hospital admission: ‘just in case’
Trained staff doing administrative work
Discharge takes too long: from being informed in the morning to actual discharge late evening
Lack of information on discharge: generic discharge booklets not informative enough; lots of
unanswered questions/anxieties
No named link person for aftercare: to answer post-discharge concerns/questions
Access: some patients offered care but don’t want it at the point it’s offered however, they change
their mind when home but then can’t access the care needed
Lack of knowledge of local services, what’s available in the community
Services not joined up between organisations; between health and social care
Medicines management: people with dementia/confused take medicines wrongly; medications to
take home don’t take into account common post-operative problems, risking readmission; many
people experiencing delusions from prescriptions; not routinely reviewed once home
Too many interventions in the home: too many people involved; too many separate visits;
duplication
Under-resourced services: e.g. enablement service; Hilton nursing – only paid for 3 days support
Patient centred caring versus rigorous performance management; focus on managing targets
rather than the needs of the person
“My husband was told he was going to be discharged at 10 in the morning. Finally got
home 8pm”
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‘I’m amazed there isn’t the tie up between health and social care. that should be the
major thrust’
“If I wasn’t there my husband wouldn’t know what to ask – simple questions like can he
shower, what do I do about pads?”
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Suggested improvements/changes included:
Review and redesign along the whole pathway, from early intervention/prevention through to
post-discharge support, including:
Early intervention, before crisis, referrals to/from right services to prevent admission (Reference:
weekly MDT meetings in hubs)
Early planning/communication once in hospital, to ensure transport/equipment/care
package/clinical support post-discharge is arranged in advance
Timely and organised discharge, so the person leaves hospital early in the day and supporting
services are still open/accessible
A named link person throughout the hospital experience and after – to give tailored response to
concerns and anxieties; ensure appropriate follow-up (reference: Bromley ‘Coordinate My Care’
plan)
Advocacy scheme for those less able to speak for themselves/people with no family
Communication with patient and family throughout: informed, involved in decisions made
Written, tailored discharge information for patient and family
Better coordination, communication and less duplication: reduce people/contacts post-discharge
Recognise, value and support the carer, including paid leave from work
One care plan, shared with/owned by all, including the patient and carer
Joint working/shared budgets across health and social care: integrated working at senior and
operational level
Medicines management: ensure patient leaves with the right medicines needed post-discharge;
review impact of medicines; patient fully informed about how to use/possible side effects
Tailored home support for elderly, confused: including short visit to give medication, to longer-
term/night time care
Greater community resources to support the person in the home to prevent admission/readmission
Person-centred: caring versus rigorous performance management/targets; treat the whole person
(mental and physical health needs)
Patient risk versus organisational risk: need shared organisational and clinical risk, working with
patient’s wishes
Communication between GP and hospital: GPs know what the patient can do and what can be done
for the patient in their own home
Expert clinical assessment in the home: right knowledge/skills to avoid unnecessary
transfer/admission to hospital; more see and treat
Patient education to understand how to use services; stay more in control
Greater non-hospital care in the home (reference: high intensity nursing in London: IV antibiotics)
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4. Conclusion & Recommendations
There was without doubt, consensus across stakeholder groups that the delayed transfers of care in
east Kent had reached unacceptable levels and immediate action was required to address the
problem. All participant groups welcomed the initiative currently underway to address the problem
but were often concerned that the programme would not gain traction as soon as necessary to avoid
winter pressures.
Whilst there was recognition that there were many examples of good practice in both hospital and
community services, there was agreement that a number of critical success factors need to be
addressed in the next stage of planning. These factors included;
1. Organisational culture(s);
2. Clinical leadership and behaviour;
3. Information and IT systems;
4. Joint working across health and social care;
5. Medicines management;
6. Person-centred care.
There were a number of practical recommendations that emerged during this initial engagement
phase that can be summarised as follows:
1. Clinical and staff participants suggested that there should be a planned series of events to
support continued discussions and keep people up-to-date with actions, particularly as
changes have to be in place within the next few months.
2. Recommendation 1 above would need to be supported buy a comprehensive
communications strategy that ensured all staff and patients understood the plan
3. Clinical sponsors, who had volunteered during the sessions, should be supported to build the
new model of care and pathways and champion changes.
4. A patient and citizen panel is created to share plans and act as a point of reference at each
stage of development, to ensure the patient perspective feeds into the new models of
discharge.
Public Engagement Agency (PEA™)
June 2018
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