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4th April 2024
Every hospital trust will be required to have ‘a designated lead for the primary-secondary care interface’ and integrated care boards asked to ‘regularly review progress’, according to NHS England’s newly published ‘2024/25 priorities and operational planning guidance’.
Delayed since December due to funding discussions, the guidance sets an overall priority for the NHS in England over the next 12 months as the ‘recovery of core services and productivity following the Covid-19 pandemic’ continues.
According to the guidance, streamlining the patient pathway by improving the interface between primary and secondary care is ‘an important part of recovery and efficiency across healthcare systems’.
By introducing a designated lead for the primary-secondary care interface, it is hoped that trusts will deliver on the four key areas set out in the access to primary care recovery plan and endorsed by the Academy of Medical Royal Colleges: onward referrals, complete care (fit notes and discharge letters), call and recall and clear points of contact.
Commenting on this interface, David Wiliams, head of policy and strategy at NHS Providers, said his organisation is already ‘seeing the advantages’ of leaders of NHS trusts and local health systems ‘working closely with primary care partners to improve how they cooperate to benefit patients’.
And he said this was ‘playing out in a variety of ways as system working matures and care pathways are being transformed, often at a very local level’.
He added: ‘Designated primary care leads will be welcome support in the drive to achieve closer working, but given the pressure of day-to-day operations, trusts and primary care providers will need national support to focus on the long-term to deliver further improvements.’
Improving emergency department waiting times compared to 2023/24 is another core focus of the planning guidance, with a target for A&E staff of a minimum of 78% of patients being seen within four hours in March 2025.
The Royal College of Emergency Medicine (RCEM) had described a previous target of 76% of patients being seen within four hours as ‘unambitious’. On the latest target, RCEM president Dr Adrian Boyle said the ‘small percentage improvements in four-hour access performance are difficult to endorse when there are so many people waiting for 12 hours or longer’.
He also highlighted the incentive scheme for major emergency departments that ‘achieve the greatest level of improvement’ and/or are able to see 80% of patients within four hours outlined in the planning guidance as being ‘potentially divisive’ and uneconomical.
‘We would prefer a quarterly approach to incentivise improved performance, perhaps using the Commissioning Quality Incentive payment system,’ he said.
Dr Boyle did, however, welcome the planning guidance focus on bed occupancy, saying: ‘It is critically important to reduce the dangerous occupancy levels we are currently seeing.’
Dr Boyle noted NHS England data showing that total bed occupancy levels in hospitals across the country reached 95.1% on 20 March 2024.
He said: ‘Overcrowding and patients who are technically ready to go home but haven’t got the right care provision in place, is really adding to the delay problems faced by ambulance staff and we need to ensure that staff in Emergency Departments are able to offer patients the care that they deserve.
“Bed occupancy is still too high and seems to be increasing which is not a good sign that any improvement in that area is forthcoming.’
Nevertheless, the planning guidance outlines an ambition to reduce the number of patients who are still in hospital beyond their discharge-ready date, as well as the length of delay.
It is hoped that continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, admissions avoidance and hospital discharge will also be of benefit, the guidance said.
Other priorities outlined in the planning guidance include reaching a 77% faster diagnosis standard (FDS) target for cancer this year as an interim step toward meeting the target of 80% by March 2026, reducing Category 2 ambulance response times to an average of 30 minutes across 2024/25, as well as improving the working lives of all staff and increasing staff retention and attendance through systematic implementation of all actions and best practice made available through the NHS retention hub.
Acknowledging that many of these ambitions will be ‘stretching’ and require ‘a relentless focus on improvement, fewer delays and unnecessary processes’, NHS chief executive Amanda Pritchard said the guidance ‘should be seen as the floor, rather than the ceiling, of our collective ambition to be a better and more responsive employer’.
Royal Colleges and NHS partner organisations have expressed concerns about how this will work in practice.
Looking at the guidance as a whole, Matthew Taylor, chief executive of the NHS Confederation, called the ambitions ‘very challenging for the health service’.
‘We are concerned that the NHS is entering the new financial year in a worse underlying position, with the risk of further strike action over the next six months… compounded by the financial crisis facing many local councils.’
He also criticised the timing of the publication, saying that while the Confederation understood the impact the wider political context is having on long term decision making, ‘we need to get back to a position where the planning guidance is released months and not days ahead of the new financial year’, and that ‘this short-term approach risks holding back the NHS and with it, the wider health and care system’.
Also picking up on the strikes, Sally Warren, director of policy at The King’s Fund, warned that the plan is ‘built upon an assumption that there will be no industrial action throughout the year despite the fact negotiations are still ongoing’.
She added: ’This means it’s quite possible the Government will need to step in to find additional funding if industrial action continues or new pay deals are agreed, assuming it wants the NHS to deliver on the expectations and targets that have been set out.’
12th January 2024
Over 80% of asthma patients hospitalised following an asthma attack are not getting appropriate follow-up care, a new study has found.
Data collected by the University of Birmingham, and published in the British Journal of General Practice, shows that only 18% of hospitalised asthma patients had a GP appointment within the recommended 48-hour period post-discharge.
The findings were worse for black patients, and the researchers suggest there are ‘serious inequalities’ in the follow-up care received.
Using electronic healthcare records collected between 2017 and 2019, the researchers analysed data from more than 17,000 patients over the age of five.
The findings show that the current recommendations for follow-up care of asthma patients are not being met, and primary care appointments after hospitalisation are falling far outside the 48-hour window for most asthma patients, with many waiting months for a review.
While 82% did not receive the recommended follow-up care within 48 hours, only 60% of patients had a primary care follow-up within 28 days post-hospitalisation.
Further evidence suggests that while just over half of patients received medication following an appointment, only 13% of patients were offered asthma reviews, and just 8% were offered management plans.
Senior author of the study, Dr Shamil Haroon, clinical epidemiologist and associate clinical professor of public health at the University of Birmingham‘s Institute of Applied Health Research, said: ‘Not only are most patients not getting care in the recommended time frame of 48 hours, but patients are being left for months and more before being reviewed.
‘We recommend that robust plans be put in place to ensure that these recommendations are being followed more closely, and greater scrutiny where they are not.’
The inequalities highlighted in the study also showed that black patients receive less care associated with their asthma management. The researchers estimate that depending on their age, black patients were between 27% and 54% less likely to receive the level of care that their white peers were provided.
Dr Prasad Nagakumar, paediatric respiratory consultant at Birmingham Children’s Hospital and senior author, added: ‘Our study highlights significant shortfalls in implementing the recommendations of the 2014 national review of asthma deaths for follow-up of hospitalised asthma patients.
‘It is time for policy makers to review the recommendations to reduce the health inequalities experienced by black and ethnic minority groups who also have a high risk of fatal and near fatal asthma attacks.’
A version of this article was originally published by our sister publication Nursing in Practice.
18th December 2023
Patients given transitional care before and during discharge from hospital are less likely to be readmitted, according to new research from the University of Manchester.
The systematic review and network meta-analysis was published in the journal JAMA Network Open considered data from 126 trials with 97,408 participants.
It showed that interventions were associated with significant reductions in readmissions at 180 days post-discharge.
While the types of changes implemented differed across the studies, common changes included improved discharge planning, medication review, case management, multi-agency team meetings, psychological support, home visits and peer support.
Low complexity interventions comprised of one to three changes to usual care applied together and were associated with a 55% reduction in readmissions at 180 days post-discharge.
The medium complexity interventions, with four to seven changes to usual care, were associated with a 42% reduction during the same time period.
Even at 30 days, the low complexity interventions were associated with a 22% decrease in the odds of readmission and the medium complexity interventions were associated with a 18% decrease.
For high complexity interventions, which included eight or more changes to usual practice applied together, were associated with a 24% reduction in readmissions at 180 days post-discharge.
Principle investigator Maria Panagioti, senior lecturer from The University of Manchester, said: ‘This study shows that more changes to usual practice are not always better to reduce health care needs and prevent emergency department visits for patients transitioning from hospital to the community.
‘We need to think about what changes to the usual care are truly meaningful for patients, whether professionals can implement those changes and how those changes can work together as a coherent bundle of care.
‘We strongly recommend that the NHS develops of a set of patient and staff-reported outcomes to better capture the full range of benefits and impacts of transitional care interventions especially those of high complexity.’
Natasha Tyler, research fellow from the University of Manchester and lead author of the study, added: ‘This study shows that transitional care arrangements are a powerful way to avoid readmission to hospital because patients feel more involved in decisions and supported during a particularly vulnerable stage in the care pathway.
‘It is well known that an increased demand for urgent hospital care has created pressure to discharge patients to the community. We know some of those patients are discharged too early or without necessary support to recover in the community.
‘There is also evidence that one in five patients may experience suboptimal or unsafe care around the time of discharge from hospital mainly because of the prompt reduction in continuity of care and co-ordination challenges of multiple independent professionals and agencies.
‘This is why it is important to understand the value of intermediate care and how best that is delivered.’
15th December 2023
One-off payments to reduce delayed hospital discharge ‘come with insufficient advance notice for effective planning’, forcing providers to resort to short-notice residential care rather than supporting patients at home, a new King’s Fund report has found.
The report, ’Hospital discharge funds: experiences of winter 2022-23’, looked in-depth at six health and care systems. The authors spoke to local authorities, integrated care system leads, acute trusts, Healthwatch and local care provider associations.
Commissioners and providers across each area ‘strongly criticised burdensome monitoring requirements’ and said funding was rarely available to prevent hospital admissions.
Areas did manage to use the funding to put services in place and support social care, but ‘were not confident they were spending funding as effectively as possible’.
The funding in question was provided in two tranches: the Adult Social Care Discharge Fund of £500m from the Department of Health and Social Care, and a further hospital discharge fund of £250m from NHS England. Each had different conditions, which were not known in advance, authors pointed out.
The report found that the six sites ‘did not all have a shared understanding of local causes of delayed discharges’ or ‘priorities for action’. Authors heard of more than 20 reasons for delayed discharge, although lack of staffing was a consistent theme.
The report also highlighted NHS England data which found that although many more patients were discharged home simply – seen in 85% of cases – compared with the predicted 50%. In addition, three times more patients needed 24-hour bed-based care on discharge (3%) compared with the predicted 1%.
Simon Bottery, a senior fellow at the King’s Fund and co-author on the report, said: ’Delayed hospital discharge is a widespread and longstanding problem that affects thousands of patients, their families and loved ones. The underlying reasons for delays are often complex and vary between local systems, though workforce issues are often at the root of them.’
He added: ’Our analysis makes clear that the Department of Health and Social Care should only use short-term, ring-fenced funding on an exceptional basis and should ensure sufficient notice to sites so that they can plan for it. It’s welcome that this has been largely done for 2023/24 and 2024/25.
’It’s also clear that places should invest effort in developing shared understanding of discharge performance, the causes of delays and the priorities for action to tackle them, as we found that these were often lacking between system partners.’
2nd October 2023
Tailoring opioid prescriptions for patients discharged from an emergency department (ED) with acute pain can support recovery and help to avoid the risk of drug misuse, according to a study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.
The study found half of patients discharged from an ED with acute pain required five tablets or fewer of morphine 5 mg or an equivalent opioid painkiller to help manage their pain and recover from their injury or condition at home.
By tailoring the number of opioid painkillers prescribed for each patient, ED clinicians can ensure the right balance between sufficient pain relief and avoiding the over-prescribing of these drugs, which can lead to dependence and abuse in some cases.
Professor Raoul Daoust, from the University of Montreal, Canada, who presented the research, said: ‘Opioids such as morphine can be very beneficial for patients suffering acute pain, for example when they have injured their neck or broken a bone. However, patients are often prescribed too many opioid tablets and that means unused tablets are available for misuse. On the other hand, since the opioid crisis, the tendency in the USA is to not prescribe opioids at all, leaving some patient in agonising pain.
‘With this research I wanted to provide a tailored approach to prescribing opioids so that patients have enough to manage their pain but almost no unused tablets available for misuse.‘
Some 2,240 adult patients were recruited for the study, all of whom were treated at one of six hospital EDs in Canada for a condition that causes acute pain. They were each discharged with an opioid prescription and were asked to complete a pain medication diary for the following two weeks.
While half of patients took five 5 mg morphine tablets or fewer, the researchers noted that the number of tablets each patient required during the two-week period varied greatly according to the patient’s painful condition. For example, patients suffering from renal colic or abdominal pain needed only eight tablets and patient with broken bones needed 24 tablets.
Professor Daoust added: ‘Our findings make it possible to adapt the quantity of opioids we prescribe according to patient need. We could ask the pharmacist to also provide opioids in small portions, such as five tablets initially, because for half of patients that would be enough to last them for two weeks.’
Also commenting on the results, Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘It’s estimated that millions of people around the world are struggling with opioid addiction and more than 100,000 people die of opioid overdose every year. These drugs play an important role in emergency medicine, but we need to ensure they are prescribed wisely.
‘This study shows how opioid prescriptions could be adapted to specific acute pain conditions, and how they could be dispensed in relatively small numbers at the pharmacy to lower the chance of misuse. This research could provide a safer way to prescribe opioids that could be applied in emergency departments anywhere in the world.‘
Although widely prescribed in an emergency setting, a recent study has found that using opioids for patients with acute low back or neck pain offers no significant pain relief advantage compared to placebo.
25th September 2023
NHS England has confirmed it is developing a ‘national standard for rapid discharge’ from hospitals in its new guidance for ICBs on ‘intermediate care’.
Concerns have been raised that it does not sufficiently take into account the impact on general practice, with GPs inevitably picking up a larger share of the workload if patients are discharged sooner.
The framework recommends a number of actions for system commissioners to consider to improve short-term health and social care to adults who need support after discharge from acute settings.
Earlier this year, in its urgent and emergency care recovery plan, NHSE committed to developing a new planning framework and national standard for rapid discharge ‘by autumn 2023’.
The new guidance confirmed that this national standard is in development, however it emphasised that ‘improved data’ is needed to ‘inform the approach’.
It said data on discharge ‘are not standardised, consistent and are often collected at a local level in multiple formats’.
‘This limits the understanding of the timescales and processes that support optimum discharge into intermediate care,’ it added.
The framework therefore sets out actions for ICBs to improve ‘data quality, coverage and completeness at system, regional and national-level’.
NHS England’s guidance also aims to improve workforce mapping, increase therapist input by releasing their capacity and implementing ‘care transfer hubs’.
The hubs are intended to be a ‘focal point for coordinating discharge’, particularly complex discharges, and are made up of a multidisciplinary team of health, social care, housing and voluntary sector partners.
Walsall Healthcare NHS Trust, one of the so-called frontrunner sites that has been trialling new approaches to step-down care, has a care transfer hub which currently includes only social care, mental health, acute and community health, but is working towards primary care inclusion.
Aside from this case study, there is no direct reference to general practice or primary care involvement in the action plan.
Professor Azeem Majeed, professor of primary care and public health at Imperial College London, said the guidance aims to ‘improve patient outcomes and reduce hospital readmissions’ which will ultimately result in a better use of resources and improved patient experience.
‘But successful implementation will require support from general practices and this is not discussed in any detail in the plans (e.g. in sharing of patient data),’ he said.
The guidance said: ‘Implementation of step-down intermediate care as outlined here is expected to result in improved outcomes, experiences and independence of people discharged, reduced avoidable hospital readmissions, and reduced avoidable/premature long-term care provision.
‘Further expected benefits include improved flow and discharge from acute and community hospitals, freeing-up NHS hospital capacity for those who need it most.’
A recent study showed that medication errors when people go into or are discharged from hospital in England could be reduced by nearly 40% with the introduction of this standard which makes it easier to share information across hospital and GP systems.
Over the summer, NHS England announced plans to speed up patients’ discharge this winter, including additional ambulance hours, extra beds, and new ‘care traffic control centres’ to act as ‘one stop’ for staff to coordinate discharges.
This article was originally published by our sister publication Pulse.
28th July 2023
Medication errors when people go into or are discharged from hospital in England could be reduced by nearly 40% with the introduction of new digital information standards being rolled out this year, say researchers.
Analysis by a team at the University of Manchester found that medication errors would be cut from 1.8 million to 1.1 million (39%) by the easier sharing of information across hospital and GP systems.
They also calculated that there could be around 12,000 fewer people experiencing harm from their medicines, with 14,000 fewer days spent in hospital at a saving to the NHS of £6.6m.
But they stressed, there still needs to be a healthcare professional, usually a pharmacist, doing medicines reconciliation.
The standards, which first came into effect in October 2021 with NHS organisations having to show compliance by this year, should make that work easier and quicker so more patients can have their medicines checked properly, they added.
A report commissioned by NHS England looked at published research on medication errors in the UK as well as evidence from other countries where similar changes to digital information standards have been made.
Overall, they estimated that around 31,000 people experience harm from a transition medication error, with over half of these happening to mistakes made at hospital admission.
They also estimated that such errors lead to 45 deaths a year, 20 of which could be prevented when the standards are introduced.
This is not just a UK issue, the researchers said. Errors relating to medicines missed off the list, extra ones added, or wrong doses written down are common worldwide, and the World Health Organization has made it a priority for health services to find ways to reduce them, they added.
Speaking to Hospital Pharmacy Europe‘s sister publication Pulse, study lead Professor Rachel Elliott, professor of health economics, said the standards were being rolled out this year but it was a very complex process with lots of different stakeholders.
She added: ‘Medicines reconciliation done at admission and discharge has been shown to reduce medication errors. This is not about replacing that process but it is about making it easier to access the information which at the moment is all over the place and all the different systems can’t talk to each other. It is enabling the human element to be done more quickly.’
This article was originally published by our sister publication Pulse.
NHS England has announced plans to help speed up patients’ discharge this winter, including additional ambulance hours, extra beds and new ‘care traffic control centres’, to ‘boost capacity and resilience’ across the NHS.
A nationwide rollout of ‘care traffic control centres’ will provide ‘one stop’ for staff to locate and co-ordinate the best and quickest discharge options for patients, according to NHS England.
The centres are expected to bring together teams from across NHS, social care, housing and voluntary services in one place to help ‘make live decisions and offer patients everything they need in one place’.
Around a quarter of local areas currently offer this service 12 hours a day, seven days a week, and this is set to expand to every area of the country by winter, NHS England said.
The commissioner expects a third of patients to be discharged using this model by December, drawing information from electronic patient records to track patients and link up with housing services.
Chelsea and Westminster Hospital NHS Foundation Trust has been able to speed up and improve staff rounds and discharge patients more easily using the Timely Care Hub, where staff can track tasks and patient statuses live, and check information like anticipated discharge date and pathways. In future, the Trust will also be able to use the Timely Care Hub to check outstanding risk assessments for things like falls, infection control and pain assessment.
North Tees and Hartlepool NHS Foundation Trust also has a new system which operates in a dedicated control room and tracks patients from admission through their hospital journey, highlighting in real-time any issues that could delay their discharge once they are medically ready to leave. Following a successful pilot, this system is now being rolled out around the country by NHS England.
The NHS will also be announcing a new scheme to encourage local teams to ‘overachieve’ on performance measures with financial incentives provided for these areas.
Winter preparations have been well underway since the publication of the NHS Urgent and Emergency Care Recovery Plan, NHS England said.
The NHS has also outlined how it is bracing for another winter facing the possibility of higher than usual levels of respiratory illness including Covid, flu and respiratory syncytial virus.
The use of Acute Respiratory Hubs, for urgent, same-day face-to-face assessment for conditions like Covid, flu and RSV, will also be expanded to be available in every part of the country.
Australia, whose activity often predicts what the NHS in England is likely to see in winter, is experiencing one of the biggest flu seasons on record with children particularly affected, making up four in five of flu-related hospital admissions, NHS England said.
Hospitals are putting more beds in place for patients and are on track to hit 5,000 additional ‘core’ permanent general and acute beds.
Plans will also be put in place to ‘strengthen ambulance response to mental health calls, to raise the profile of all-age 24/7 urgent mental health helplines’ and to avoid long lengths of stay in mental health inpatient settings.
Sarah-Jane Marsh, NHS national director of urgent and emergency care, said: ‘Ahead of winter we will not only have more ambulances and beds in place, but we will also be continuing to work more closely as an entire NHS and social care system, increasing the capacity of community services that help keep patients safe at home.
‘We will continue to build on this progress and do everything we can to put the NHS on the front foot ahead of what has the potential to be another challenging winter with covid and flu.’
Dr Vin Diwakar, NHS medical director for transformation, said: ‘The rapid expansion of ‘care traffic control centres‘, means patients can be more easily discharged with the right support when medically fit to leave hospital with the latest information available to staff in one spot – this is both better for patients and for the NHS.’
A version of this article was originally published by our sister publication Pulse.
8th February 2023
A randomised trial of a patient-centred deprescribing intervention in older adults led to a significant reduction in medicine use compared to a control group who did not receive the intervention according to a study by US researchers based in Tennessee.
Polypharmacy is defined by the use of five or more medicines and one US study found that in 2010, among elderly patients (65 years and older), polypharmacy was present in 39% of cases. Polypharmacy increases the risk of adverse drug reactions and somewhat alarmingly in one analysis of 2,105 older adults discharged from hospital, 74% were prescribed a polypharmacy regimen.
Consequently, deprescribing interventions to reduce medication burden are likely to decrease the risk subsequent adverse events associated with the use of multiple treatments. In the current study, the US team examined the effectiveness of a deprescribing framework at reducing medication burden. The intervention had been previously piloted in one centre and was found to be effective, leading to US to undertake randomised, controlled trial of the intervention.
The intervention itself involved nurses or pharmacists reviewing the medicines of older adults prior to hospital discharge to a post-acute care (PAC) facility and the outcomes compared with the usual hospital discharge care.
The primary outcome was the total medication count at hospital and PAC discharge and participants were followed-up for assessment, 90 days after being discharged from the PAC facility. Secondary outcomes included the total number of potentially inappropriate medications (PIMs) as well as the drug burden index (DBI) which measured sedative and anticholinergic burden.
Deprescribing intervention and total medication burden
A total of 284 participants (142 per group) with a mean age of 76.2 years (62% female) were included in the final analysis and the median length of PAC facility stay was 22 days. Overall, the median number of prehospital medications per patient was 16.
As a result of the intervention, participants were taking a mean of 14% fewer medications upon discharge from the PAC facility (mean ratio, MR = 0.86, 95% CI 0.80 – 0.93, p < 0.001). In addition, at the 90-day assessment, those previously assigned to the intervention were taking 15% fewer medicines (MR = 0.85, 95% CI 0.78 – 0.92, p < 0.001) compared to the control group.
The intervention group were also prescribed fewer PIMs and had a lower DBI after 90 days yet the incidence of adverse drug events was similar between the intervention and control groups (hazard ratio, HR = 0.83, 95% CI 0.52 – 1.30).
The authors concluded that their deprescribing intervention was both safe and effective at reducing overall medication burden and called for future studies to examine the impact of the intervention on both patient-reported and long-term clinical outcomes.
Citation
Vasilevskis EE et al. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute CareA Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023.
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