It calls on the government of each country in the UK to develop and publish a robust workforce plan for community nursing which reverses the decline in staffing and transforms the workforce to meet current and future healthcare challenges.

Patients, in some cases, were provided with very low levels of care but needed much more. This questions whether they should have been placed on a higher pathway and given an adequate level of support.

• Carers were not consulted about or involved in discharge.
• Consideration was not always given to a patient’s ability to remember or recall important information putting the patient’s and, at times, the carer’s health at risk.
• Some carers were given no or little information on a person’s condition and yet were expected to provide significant amounts of care. Carers were left to care without sufficient support, placing them at risk.
• Carers were left without contacts if there was a problem.
• Patients were clearly not safe to be discharged and their health was put at risk, with insufficient support. • Carers’ expert knowledge about complex conditions was not respected or utilised.
• Carers were not considered partners in care.
• Carers’ stories suggested that nutritional needs were not always being met.

When it comes to the discharging of a patient from hospital, it should be a time of relief – perhaps a long-term condition or illness is under control or an operation completed successfully. However for many thousands of carers this is not often the case.

In more normal times, a period in hospital would have provided an opportunity for the close family friends and carers of a patient to become familiar with treatment plans, clinical staff and plans for discharge, as well as whatever rehabilitation and after care is needed.

Being able to visit the patient in hospital would have also provided opportunities to alert clinical staff to changes in a patient which only a close family member or carer would recognise. Even if that’s as a result of a sneaky look at the patients notes at the end of the bed! Although not always perfect, the carer was able to be a partner in the triangle of care between patient, clinician and carer.

In these times, and with the necessary Covid policies put in place, it has meant those relationships have not been developed; the ability to notice changes and ask and receive answers to questions has gone and even being able to make contact with the patient has been made more difficult.

The person who knows the patient best has in many ways been cut out of the conversation. This is even more problematic if the main carer is not the next of kin and if consents and permissions are not agreed ahead of admission.

This has then resulted in poor quality discharges from hospital, putting patients at risk and even more pressure on carers who then take the reins of providing physical and emotional care for the person they care for. The impact of this could be readmission, a worsening of the patient’s health and a negative impact on the health and wellbeing of the carer.

Nobody knows a patient better than the person who is caring for them, who often has been their carer for many years but may have also known them well long before they became their carer. Carers are all different, of any age and many are in education or work as well as often having other responsibilities – children, parents, as well as their own health needs. Many are not financially well off and and continue to provide care themselves often for 24 hours a day. Carers need to be resilient and problem solvers but caring is tough and everyone involved in a hospital discharge needs to recognise the carer as an equal partner so that a discharge is positive and doesn’t result in further harm to the patient or the carer.

In a recent Carers UK report on experiences of hospital discharges, only a third of respondents said they had been involved in the decisions about discharge and what care and treatment the person they care for needed. Only 21% agreed that they had been asked about either willingness or ability to care at discharge and only 20% were given enough information and advice to care safely and well.[1]

Imagine how this would feel if it were you?

We have heard first hand from carers about their experiences, the challenges they face and what support they need. An example is James’ story as a young carer. This highlights the challenges and frustrations experienced by James when it came to caring for his mother and reinforces the need for the main carer of an individual to be recognised as an equal partner in the discharge process regardless of whether they are the next of kin or not.

If you are involved in hospital discharge this is how you can help the carer:

• Ensure that carers are involved in all discharge planning conversations because they know the person they care for best.
• As well as being considered an expert partner, the needs of carers themselves also need to be considered before a patient is discharged.
• Provide carer awareness training for all health professionals to help them better identify and know how to ensure carers they come into contact with are supported.

Reference

1. Carers UK. Carers’ experiences of hospital discharge: Discharge to Assess model. 7 September 2021.

It identifies the negative impact of inadequate community rehabilitation services, including:

• reduced quality of life and independence for people with long term conditions.
• increased risk of death for cardiovascular disease patients.
• increased emergency hospital admissions for falls.
• increased overall costs for the NHS (for example, in treating traumatic brain injury).
• increased healthcare inequalities.

The manifesto argues that community rehabilitation must be radically reformed to:

• be fully accessible, helping people overcome any barriers they face.
• be truly person-centred, tailored to meet individuals’ multiple physical and psychological needs.
• be seen as an equal priority to domiciliary care, nursing and residential care in local authority adult social care planning and provision.
• embrace social prescribing.
• harness new technology and innovation seen in the response to the pandemic to provide a wider menu of options.

• The strong associations between organizational readiness to change and safety climate in nursing homes have the following implications for practice and research:
• Safety climate interventions should first assess and address staff and system readiness to change.
• Readiness to change assessments and safety climate interventions may also need repeating as staff turnover brings in new staff and may change these dynamics.
• Whether staff skills and knowledge moderate the association of readiness to change and safety climate should also be examined in future research. Staff members willing to change need adequate skills/knowledge to make safety-related change. For example, senior managers making walk rounds may need training in active listening for these rounds to be effective while new direct care personnel may lack knowledge of warning signs related to resident safety. 

1. Nursing, care and residential homes: Allow normal family interactions by stopping restrictions and instead continue to inform and support families on the steps to take for safe contact in a spirit of trust and cooperation. Be confident that restricting visits should not be used as a replacement or shortcut for inadequate infection prevention and control measures – address gaps in safe practices where they exist. Commit to using infection prevention and control as an enabler that will protect staff, residents and families.
2. Government, local authorities/public health departments: Remove any statements that may be seen to justify “blanket bans” on visiting. Instead actively vocalize the need for local decision makers to facilitate safe, normal interaction, appropriate to the local situation. Even where an outbreak occurs and some restrictions may be warranted, make it clear that safe, compassionate exemptions must still prevail and be actively facilitated. Continue to address gaps in safe practices and lack of resources, in order to facilitate infection prevention and control.
3. Infection prevention and control community: Speak up in support of safe family interactions now and apply infection prevention and control with compassion. Actively facilitate safe family interactions and support planning to ensure adequate infection prevention and control supplies, and the implementation of training and communication activities/materials.
4. Healthcare leaders: Speak up and support infection prevention and control with compassion, respect infection prevention and control expertise but help apply it in support of the ethos of this letter.
5. Families: Understand, respect and adhere to the infection prevention and control recommendations requested of you to support the safety of yourself, your loved ones and care home staff.
6. Campaigning groups: Use this letter to support your efforts.

1.Further academic research should be conducted to clinically establish the extent to which care home residents in England are at an increased risk of preventable blood clots, and what the appropriate threshold for thromboprophylaxis should be.

2. The CQC should develop national guidance on prevention and management of VTE in the care home setting, closely informed by the latest academic research on the risk of VTE in care homes in England.

3. All hospitals should include a mandatory section on VTE risk in their discharge summaries, indicating instructions on the steps that should be taken to manage the patient’s risk.

4. CCGs should work with local secondary, primary and social care providers to develop local transfer of care protocols to facilitate smooth transfer of care between hospitals and care homes and clarify procedures for managing patients’ VTE risk post-discharge.

5. CCGs should develop community-based VTE treatment pathways for occurrences and recurrences of VTE in the care home setting to relieve capacity pressure on hospitals and ensure timely treatment.