Tag Archives: Media

Discharges in the dead of night

NHS Hospital discharges: thousands claimed to occur overnight

The news this week has been full of horror stories of patients being discharged from hospital in the dead of night. “Where is the compassion?” they cried, “How could they, the supposed caring profession?”  The stories began after The Times discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 11pm and 6am

The immediate response of the press was to paint a picture of an army of ambulance drivers booting out frail 90 year olds; dumping them at their front doors, alone in the dead of night. This dramatic depiction fuelled discussions on various forums and news programmes. The callers on Radio 4s “Any answers” actually made me turn the radio off.

My major concern is that this data was released without proper analysis. As usual in the reporting of science news, and particularly health-related news, the headlines were more important than the content. It took me two minutes to think of a list of possible contributing factors which may have led to these numbers of supposed patient discharges overnight:

  • Deaths are often coded as discharges. These may happen overnight.
  • Sometimes patients self-discharge, especially those admitted due to intoxication. On sobering up they may decide that at 5am they’d rather sleep off the rest of their hangover in their own bed. Good for them.
  • Many patients are offered the chance of discharge after a period of observation in a short-stay ward. Such patients are not really “admitted” in the traditional sense, merely held somewhere outside A+E due to the constraints of the 4hour rule, often awaiting test results.
  • Patients may leave the hospital hours before the discharge is “declared” by the ward. Sometimes this is due to the ward staff prioritising patient care over paperwork, and only getting around to logging the event later. Sometimes this is a more overt tactic to prevent more ward admissions when ward staff are under pressure. This may not be best practice, or good for patient flow, but is better than what has been imagined by reporters.

It is disappointing that those at The Times didn’t construct a similar list, and is part of a worrying trend of negative NHS stories despite high patient satisfaction. In my more cynical moments I wonder about influences on reporters and editors and links between media execs, politicians and those with interests in private healthcare.

“Patients should only be discharged when it’s clinically appropriate, safe and convenient for them and their families.” says Sir Bruce Keogh. Absolutely. I know no-one working in the NHS who does not “believe in the principles of holistic care – thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital.”

There may be a very small number of cases which fit the picture painted by The Times, and each of these is a failing of the system, which requires investigation and action. But please can we stop the media driven NHS-bashing? Those of us who work in public service endure long hours in difficult circumstances, but do so because we care. Nurses, doctors, occupational therapists, physiotherapists, pharmacists, discharge co-ordinators and matrons spend our working lives assessing patients to ensure that at the end of their medical investigations and treatment they are safe for home. When they are not we engage social services to put in place care to achieve a safe discharge. I worry that the profit motive, competition and privatisation will bring pressure to change this, but for now compassion remains at the heart of what we do, and no-one vulnerable and alone is going home at 3am on my watch.

BBC article: Overnight discharges from NHS hospitals to be examined

Sensible analysis by FullFact.org

My health, my choice?

I spent this Christmas, as I’m sure many others did, over-indulging in rich foods and alcohol, and barely moving from the sofa. I made choices that were far from healthy, and take full responsibility for the resulting lethargy, bad skin and headache.

But on a larger scale, to what degree is an individual responsible for their health? It is all too easy to label the smoker with lung cancer, the alcoholic with liver failure or the obese patient with heart disease as culpable and look no further. And of course it is true that no-one held a gun to their head and made them smoke, drink, or eat to excess. But this view is dangerously narrow and simplistic. The actions of individuals and their health-related actions must be viewed within a broader social context. We act as individuals but we do not live in a vacuum.

There is a huge body of literature on the social determinants of health, encompassing the  effects of the physical, social and cultural environment. To hold people responsible they must have true choice and control. But to what degree does an individual make a true choice, influenced as they are by their sex, race, socioeconomic status, education level, peer group, and cultural identity in addition to being bombarded by manipulative and exploitative advertising? Focusing too strongly on individual responsibility in relation to health is particularly unfair in relation to poverty. Poverty itself has a negative impact on health, even when individual factors such as smoking and poor diet are controlled for. It is no longer a radical concept that people at progressively lower socioeconomic status levels have correspondingly less opportunity to control the circumstances and events that affect their lives, and that control is imperative to well-being.

Class as a factor must not be ignored. Not only does class have a huge impact on an individual’s beliefs and expectations of health, but the debate on personal vs societal responsibility for health is often conducted in a class-influenced framework. Most of the discussion is led by the privileged middle-classes – politicians, academics and physicians who are wealthy, highly educated, with the freedom to consume and act on the information on “healthful choices.” Those that are castigated for making “poor choices” in relation to their health are often the working class; seen as stubborn, short-sighted and a drain on the country’s constrained health resources.

Putting politics and morality aside, on a practical note, to make real population changes a population approach is required. A huge burden of disease can be directly attributed to a combination of smoking, obesity and a lack of exercise. This costs, and will continue to cost the country vast sums in healthcare, social care and lost work days. As a public health strategy, targeting individuals to take more responsibility is unlikely to have a significant impact on these large-scale health problems. Society-wide initiatives work – banning smoking in public places has had a much greater impact on quit rates than years of poster campaigns and a “nudge” approach.

We need healthy public policies and health-promoting environments, that support individuals in making choices conducive to good health. We can still safeguard autonomy and acknowledge that different individuals within the same context make different decisions. But we must avoid victim-blaming, which helps no-one.