Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Liz Griffiths, Royal Pharmaceutical Society (DD 21)

  Delayed discharges have an impact upon many people throughout the country every day. They affect and upset patients who have already been given a discharge date and time. They inconvenience the relatives, who, in light of the expected discharge, are often obliged to re-arrange prior commitments. They generate unwanted pressure upon primary and secondary health care workers who have to work within the constraints that are imposed upon the health service by the delays.

  Additionally, it is important to remember that every delayed discharge equates to a delayed admission. This in turn represents a person who has already had to wait to be admitted into hospital—possibly for tests, for treatment or perhaps for an operation. Given the constraints of the NHS—waiting lists are inevitable, but they are not desirable, and they generally have a negative effect on prospective patients. Those waiting to go into hospital prepare themselves emotionally and practically for the date of admission. It can be profoundly distressing to such a person to be told at very short notice that the admission is to be cancelled and re-scheduled.

  The media has done much to draw the public's attention to the unacceptable waiting times that are often experienced by patients in Accident and Emergency departments. An A&E trolley is designed to be used only briefly by a patient. However, it is no longer uncommon for a patient to lie on one for many hours, whilst waiting for admission to a ward. Delayed discharges thus impact upon A&E patients awaiting admission—which in turn impact upon the time other patients have to wait to be examined on a trolley by a doctor.

  There are many factors that influence the original date and time of the proposed discharge. The current situation cannot be improved or indeed resolved until these factors are identified and remedied.

  The Society will attempt to identify some of the major factors that impact upon discharges and will propose some solutions for consideration by the Health Committee.


  1.  The Audit Commission's recent report entitled "A Spoonful of Sugar" has acknowledged that the complexity of patient treatment often results in a considerable delay to the "supply chain" process.

  The most recent audit undertaken at the Addenbrooke's Hospital NHS Trust reveals that 7 per cent of discharge prescriptions give rise to queries by the dispensing pharmacists—resulting in junior doctors being corrected at the point of discharge.

  2.  Completion of the discharge paperwork is often delayed due to increased patient turnover. The delay is compounded by the reduction in junior doctor working hours. At Addenbrooke's Hospital NHS Trust, the workload generally reaches its peak at approximately 3pm—when other demands upon the pharmacy department result in fewer pharmacists being available at this time.

  3.  There is an acknowledged national shortage of pharmacy staff—and this compounds the problem referred to in point 2 above.

  4.  Many re-admissions to hospital are due to problems associated with medication. Scottish data suggests that (excluding deliberate self-poisoners) 30 per cent of patients are re-admitted with medication problems within 28 days of discharge. This issue was also highlighted in the Audit Commission's report, which observed that patients leaving hospital were unsure how best to manage their medication.

  5.  Acute hospitals are under considerable pressure to achieve greater efficiency—which is often judged to be a fast turnover of patients. This results in ever decreasing lengths of patient stay. There are many anecdotes of hospitals rationalising the patient's therapy, by discontinuing medication and re-introducing only the medication perceived to be essential. At this point, the patient is often discharged. What seems to be overlooked, is that despite the fact that medications might have been discontinued, often the patient continues to have therapeutically active drug levels in his circulation. It is when these drug levels become therapeutically inactive, that the patient visits the GP, only to have his medication re-instated and to be re-admitted to hospital.

  6.  Community hospital beds are often used as convalescent beds by acute hospitals. The difficulty community hospitals experience when attempting to discharge patients back into the community has a knock on effect on the discharge process within acute hospitals.

  7.  In general terms, the existence of the extended family has all but vanished. This in turn has impacted upon the amount of time and care that can be given by relatives to a patient discharged to the home.

  It should be noted that the families that are able to care for relatives within the home save the State a significant amount of money.

  8.  Care home registration units have noted a reduction in the number of available care home beds in the private sector. There is also evidence to suggest that the number of nursing home beds are on the decrease, whilst there is a general increase in the number of residential home beds. The reason for this is likely to be associated with the funding levels imposed by social services commissioning. For example, Leicestershire comprises 5 residential home bands (ie funding levels) and 3 nursing home bands. The difference between residential home band 5 and nursing home band 1 is £20 per month—a difference that can be wiped out by just a single visit from a district nurse.


  1.  Pro-active intervention by pharmacists working in the primary care field would be able to support patient medication compliance and concordance. This is likely to result in fewer people requiring hospitalisation in the first place.

  2.  Consideration should be given to reviewing hospital pharmacists' current grading structure and pay scales, which have fallen behind those of the community pharmacy sector. This would encourage more pharmacists to enter the hospital pharmacy environment, thereby improving the current recruitment problem.

  3.  Transferring all hospital outpatient work to the community would increase the hospital pharmacist resource available to deal with the discharge prescriptions.

  4.  The future rationalisation of drug therapy should continue to be controlled by the hospital, whilst the therapy and appropriate monitoring could be transferred to the pharmacist working in the primary care environment. Transferring pharmaceutical care into the patient's home situation and the development of new partnerships between hospital and community pharmacists could significantly improve the current problem of patient re-admission and delayed discharges.

  5.  Intermediate care is an effective alternative to convalescing the patient within the secondary care environment—and would release an abundance of hospital beds. However, in order to ensure effective intermediate care, increased funding and an increased resource of primary health care workers to support the convalescing patient within the home situation would be essential.

  6.  There is a great need for frequent and planned respite care, if families are to continue to care for elderly relatives. Care homes should be encouraged to designate one bed per home for respite purposes. However, as demand for respite will mirror peak holiday periods, care home owners will need financial encouragement to maintain bed availability.

  7.  There should be greater collaboration between the funding relationships of social services commissioning and health care provision. The Primary Care Trust, with its ability to view these two fundings as a single budget, should be encouraged. Early discharge would inevitably require additional funding.

  In terms of domiciliary care, the Society suggests that the following guidelines be observed:

  1.  Comprehensive medication assessment is necessary, together with good communication and collaboration between primary and secondary care agencies and professionals. Compliance aids should only be used following appropriate assessment and contingency monitoring.

  2.  Pharmacists contributing to multi-professional and inter-agency team planning should be encouraged to manage any issues relating to medicines.

  3.  Pharmacists should be involved in intermediate and domiciliary care—to advise and support issues relating to medicines management—thus reducing re-admission rates attributed to mismanagement of medicines.

  4.  Pharmacists should be advised to take drug histories from all patients upon admission into domiciliary care—thus encouraging a reduction in medication errors and the subsequent delays.

  The Society also wishes to draw the attention of the Inquiry Panel to a one stop dispensing project, which is currently operating on one ward at North Tyneside Hospital. The project has shown to improve discharge times and subsequently helped to reduce the problems associated with delayed discharges.

  In conclusion, the Society wishes to submit evidence to support its claim that collaborative care can indeed reduce the number of delayed discharges. The Society would be grateful if consideration could be given to a report (which will follow with the hard copy) produced specifically for this Inquiry.

  Thank you again for the opportunity to respond in writing to this consultation, and please do not hesitate to contact me should you require the Society to attend an oral evidence hearing.

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Prepared 29 July 2002