The impact of changes made to free up hospital beds at the start of the Covid-19 pandemic has been widely scrutinised, from the implications of cancelled operations on patients with other illnesses to the scale of discharges to care homes.
In this blog, we look in more detail at hospital data from March this year and compare it to March last year. By examining the number of discharges for adults (only) and how they differ by key characteristics across both years, we can provide a better understanding of what happened in March and the implications for the NHS – whether or not there is a second wave of Covid-19 this winter.
What happened to discharges in March?
Our analysis shows that discharges fell in March in comparison to the same period last year, with 267,432 fewer discharges. Numbers began falling below last year’s figures in early March and continued to drop throughout the second half of the month.
The fall in discharges therefore pre-dates the letter from the NHS chief executive Simon Stevens on 17 March, which called for all NHS bodies to radically modify health services to expand capacity for coronavirus patients. By the official start of lockdown on 23 March, discharges were nearly half the previous level.
The majority of patients are discharged from hospital on the same day they are admitted. The big fall in discharges that we saw in March this year reflects a big drop in admissions. Discharges following planned care fell by 22% as hospitals cancelled operations and investigations. But emergency admissions also fell – by 15% – suggesting that patients avoided going to hospital, and more emergency cases were managed outside hospital by ambulance services and 111.
While the total number of discharges in March this year was considerably lower than in 2019, this was not the case for patients with hospital stays longer than 11 days. In March 2020 there were 6,780 more discharges for this group of patients, which is above average for this period. More people who had a long hospital stay were therefore discharged in March this year than last.
Where did patients go at discharge?
As in 2019, the majority of patients – over 1.1 million people – were discharged to their usual place of residence, either their own home or elsewhere (such as a care home).
But it is revealing to examine the remaining 81,476 who were recorded as not returning to their usual residence. The chart shows high numbers of discharges to care homes, as well as high numbers of people dying, in March 2020 compared to 2019. In particular there were more discharges to care homes for patients who had been in hospital for more than 10 days. It is also evident that there were considerably fewer transfers in March 2020 to other hospital providers, particularly among patients staying at hospital for under 11 days.
Analysis of where people went upon discharge indicates that care homes received around 2,500 new residents who had been in hospital for 11 or more days.
It should be noted that this data does not include patients who were discharged to a care home that is recorded as their usual place of residence. How hospitals record place of discharge is variable, but the usual place of residence is more likely to be used where the patient was in a care or residential home before admission.
In contrast, analysis from NHS England that uses a different method to identify care home residents, also including people already living in care homes, found a drop in discharges to care homes in March. This reflects the overall drop in both admissions and discharges. The widely reported 25,000 discharges to care homes comes from this NHS England data.
The combination of the NHS England analysis and our own indicates that, while hospital discharges of care home residents fell, this was largely driven by a drop in admissions from care homes. Over the same period, there was actually a small increase in the number of longer-stay hospital patients discharged to care homes.
What are the future implications?
The vast majority of patients stay under a week in hospital, indicating that hospitals can make rapid changes in activity by reducing admissions.
From what we saw in March, it is clear that decisions were made locally about reducing activity, even prior to national guidance. The rapid cancellation of treatment and investigations has left patients waiting longer, and difficult decisions on priorities will need to be made. Local flexibility will be key for the NHS in recovering from the impact of the first wave, and in responding to any future local outbreaks. It will be unfortunate if national targets limit the service responses available locally.
Our analysis found that despite the overall drop in discharges in 2020 – below the usual levels for March, which was a result of fewer admissions – hospital discharges did increase among patients with a hospital stay of 11 days and above. There are likely to be wider lessons to be learnt about how the financial and service support to patients and families enabled them to leave hospital. This will be important for managing hospital capacity if there is a second wave, as well as to support long-term aims to reduce the number of medically fit patients in acute inpatient beds.
More urgently, further investigation is needed to determine the impact of discharges into care homes on the very high death rates of care home residents. For example, it is not clear to what extent outbreaks in care homes are related to levels of transmission in the wider community, but we already know that staff working across multiple homes is a factor.
While it is likely that the number of new placements in care homes is far less than the widely quoted 25,000, it has become clear that too little consideration was given to the care home sector, which was in a fragile state going into the crisis with severe staff shortages and historic underfunding.
At a local level, health and social care organisations, including the private and voluntary sectors, need to examine their own discharge data to understand the impact on patients. This will enable them to identify gaps in provision, as well as to find what worked well and what didn’t, so they can learn and put the systems on a stronger footing for any future surge.
As the fallout of Covid-19 continues, reflecting upon the extent to which each sector is prepared and can cope is particularly pressing ahead of a possible second wave of the virus.
Hospital Episode Statistics data (year range 2019/03 and 2020/03) Copyright © (2020), NHS Digital. Re-used with the permission of NHS Digital. All rights reserved.
Elias L and Scobie S (2020) “How did the NHS free up hospital capacity at the start of the pandemic?”, Nuffield Trust comment.