Used as a descriptor for inefficiencies in hospitals – delays in getting a patient back home causing delays in getting new patients seen – one could have scarcely come up with a word that inherently accuses patients of the failures of the care system. Yet the true cause behind preventable “bed blocking” has very little to do with the patients themselves, and a lot more to do with logistical planning. At its essence the root problem is usually a communication failure, usually between hospitals, patients, their families, and social care.
In order to understand this better, let’s explore the fictitious but all-too-familiar example of Alison, an 82-year old woman who is treated for a hip fracture. Let us consider an ideal-case scenario from a communications perspective. When is seen initially, before the operation, the clinician who sees her will give her a rough idea of what she should expect her recovery to look like and how long this will take. This will depend from person-to-person, but in her case it involves being let out of the hospital conditional on her being able to walk a short distance and be able to go to the toilet unaided.
Jean, her eldest daughter, is also present when the hip fracture is diagnosed and the same clinician establishes that Jean is happy to take care of Alison. Jean is told what kind of condition Alison will be in when discharged, and gets her own house ready for Alison’s return. This is because Alison’s house has a flight of stairs with the toilet on the top floor and the clinician points out that this will cause Alison a lot of difficutlies. The operation is thankfully a success, and, having reviewed Alison’s now stabilising condition, Alison’s care team helps her get her confidence and physical fitness back over the course of two weeks. When Alison is deemed medically fit to go back home, Jean is informed with a lot of notice, so that she can take the time off work to greet her in.
At the pre-established time and date, a car is arranged to help bring Alison to Jean’s home as neither have their own car. In the weeks that follow, Jean does the shopping for her and goes on short walks with her. At the same time, community therapists, who have been fully informed of Alison’s progress in hospital, her incentives and objectives, help bring Alison back to a physical condition close to that prior to the fall. She is taught a series of exercises for her balance and gait that will help prevent her from falling again, and having to go through this very long and painful process.
In the meantime, the local authorities have been informed that Alison’s house is not suitable for her condition, and help advise what kind of modifications could help her live in it and prevent further falls. Depending on Alison’s financial position they may also help pay for these and install them in Alison’s house. Within two months of the fall, Alison is happily back in the house she has lived in for 52 years and is able to do most of her day-to-day shopping herself, although Jean often comes over to go for walks with her.
This story of Alison’s recovery is a highly simplified version of what is actually meant to happen by national guidelines, and that thankfully does happen many times. Unfortunately, it is easy to see how a break-down in any of the dialogues between the actors involved would lead to a completely different outcome, and this is where the crux of the problem lies. Lack of communication because of time pressure or forgetfulness, miscommunications, misunderstandings – these all lead to those horrendous real life-stories that are unfortunately not rare enough. Like the story of the lady who got dropped off by an ambulance after she was discharged to an empty house and her room at the top of the stairs but the toilet below and slept in her kitchen, with no way of getting food for herself. Or that of the gentleman who did not leave the hospital bed for a week even after having been declared fit simply because he had given his family the pre-operative estimate of when he would be back from hospital and he was then discharged early – but his family were on holiday. Too many stories that point to a system that is too prone to failures and warped incentives that reward hospitals that led to the former case over physicians who would not allow it to happen in the latter.
A lot is being changed – the right objectives are already in place, and all across the country novel initiatives are being tested. In Oxfordshire, the NHS Trust has bought a series of out-of-hospital beds to continue the treatment of patients with lower care needs without slowing the care delivery to others. There’s a bright space for innovation and new digital systems to facilitate communication – just as long as it doesn’t become yet another standard.