In the first of a series of blogs looking at the campaign to support NHS staff reduce long hospital stays, called Where best next?, the National Clinical Director Older People and Person Centred Integrated Care discusses caring for someone in hospital with complex needs:

“I’m sure I’ve met you somewhere?..” The lady with her shopping trolley looked at me quizzically as I wrote my assessment in her medical notes.

“We just met a few minutes ago, I’m one of your doctors?” my voice trailed off as she grabbed my ID badge to check my name. “No..no..that’s not it. Any way must go, or I’ll miss my bus and I want to get home”. Off she trundled down the corridor.

I had only minutes before explained to Clara (not her real name) that she was getting over a bad chest infection and, that following prolonged delirium, her vascular dementia, diagnosed two years previously, may have worsened slightly and during recovery she had fallen a few times on the ward getting lost on her way to the toilet.

It now seemed everyone but Clara was worried about her returning home, but I was more worried about her staying in hospital.

Avoiding excessive hospital stays for people like Clara requires a sustained and focused approach on planning for discharge from the outset. For everyone caring for a person with complex needs in hospital this means keeping focused on five things:

• Planning for discharge from the start;
• Involving patients and their families in discharge decisions;
• Establishing systems and processes specifically to support people with complex conditions – such as frailty and dementia – and their families;
• Embedding multidisciplinary care approaches for people at risk of delay;
• Maintaining a supported ‘home first’ mindset.

Clara’s circumstances were complicated but not insurmountable and her risks on leaving hospital had largely been identified by her team and the correctable things managed: pneumonia treated, medicines optimised, shopping trolley provided for stability and confidence following which she had no further falls.

Adopting the five principles for an effective discharge means the team caring for Clara must keep in touch with her daughter to plan ahead and anticipate her care needs as she recovers, with the mindset that she will return home as soon as her condition permits. Gaining access to her home to assess and manage her environmental risks in good time for discharge completes the process. This means proactively working with family, carers, community and social care services well ahead of the discharge date.

Newton Europe in their excellent report Why not home? Why not today? note that a patient delayed in their transfer from hospital is symptomatic of a whole care system not working, not simply the failure of a single organisation or person.

The ramification is that for people whose hospital care is complete and their discharge delayed, prevention of delay is achievable but requires four key ingredients.

Firstly, there must be shared understanding and ownership of the entire patient journey by the people and their organisations responsible for ensuring the person gets what they need. Critical to this is a requirement to measure and identify delays consistently when they occur. You cannot easily improve what you do not measure.

Secondly, system behaviours must be directed towards achieving optimal outcomes for patients, through shared planning, a common mind set, mutual accountability and avoiding poor behaviours-such as moving people around wards for non-clinical reasons in times of system stress, tempting though that may be.

Thirdly, discharging a patient requires multiple decisions to be made. Rather like a pre-flight checklist these are all critical to success, so throughout the care journey decisions must be consistent, reasoned and their impact across the pathway understood to ensure poor decisions are avoided and there is positive deviance towards making the right decisions all the time. For a successful care system, embedded processes are vital.

Finally, none of this will work without system level leadership to create the right support for everyone to do the right thing. This is arguably the most important and most difficult thing to get right.

Those in the front line of health and care services must be supported to develop risk appetite through shared accountability. This means paying close attention to a patient’s choices and preferences and working with families and carers to solve problems.

To help with this the NHS Long Term Plan now sets out greater focus on primary and community health services backed by new government investment. The new national Ageing Well programme has been designed to support older people in their communities both to prevent unwarranted admission and to expedite timely discharge from hospital at the conclusion of care.

For Clara, and people like her across the country, these services are designed and funded to work across health and care sectors to ensure that the outcomes of care are optimal wherever possible.

We all have a role to play in making this work by understanding the needs and circumstances of patients, communicating consistently, understanding the impact of our decisions (or indecisions) and always looking for the keys (sometimes literally) to unlock complex problems.

For more background information, see:

• Why not home? Why not today?’ report
• NHS Long Term Plan
• NHS England: Ageing well and supporting people living with fraility