Today’s research by The Times finds an alarming number of patients being discharged by hospitals at night (defined as being between 11pm-6am). The NHS Medical Director has said that he will look into the issue, but what can be realistically done to address it?
There is little doubt that, in many cases, discharging patients between the hours of 11pm-6am is not ideal for the patient, their family or carer. Such practice raises concerns about safety and also throws up a number of logistical challenges for those affected.
Hospitals may well discharge patients during these hours for clinical reasons and because it would be in the best interest of the patient to spend the night in their own home rather than in hospital. However feedback indicates that managers and clinicians may well have other motives, such as freeing up beds and saving resources.
Solving this issue is, however, far from straightforward. Some of the levers and incentives in the new system could well provide a useful framework to begin to eradicate such practice. Our recent report looking at the use of quality payments through the Commissioning for Quality and Innovation (CQUIN) scheme, Paying for Quality found that all hospitals in London were being incentivised to improve the quality of their discharge processes. This included being paid a quality premium for:
· Increasing the number of patients going home on an agreed date
· Increasing the percentage of discharges that occur between 6am and 12 Noon
· Increasing the percentage of weekend discharges on relevant wards
Yet the findings from our research reflect the problems identified by The Times in relation to hospital discharge practices. Only four (22%) of the eighteen providers who supplied data achieved the full payment available to them through the CQUIN. Indeed of the seven regional CQUIN payments agreed in London in 2010/11, this was the measure that hospitals were least likely to achieve. Two – St George’s Healthcare NHS Trust and Ealing Hospital NHS Trust – received no payment at all, Croydon Health Services NHS Trust and Newham University NHS Trust only received 16.7% of the available payment, and Epsom and St Helier University Hospital NHS Trust achieved just 25%.
Whilst the use of CQUINs remains in its relative infancy in the NHS, where they have been introduced and maintained there is evidence that they have been effective in supporting the delivery of sustained improvements in clinical practice. For example Paying for Quality found that trusts that were able to perform well against the national Venous Thromboembolism (VTE) CQUIN for 2010/11 risk assessed a higher proportion of patients for VTE in quarter 1 2011/12.
With the Government planning to extend the use of CQUINs, this is one measure which could be introduced more broadly to help drive up discharge standards and improve the experience of care for patients, their families and carers. If implemented it could help to stop things going bump in the NHS night.