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Hospitals: Unsafe Discharge

Volume 776: debated on Wednesday 9 November 2016

Question for Short Debate

Asked by

To ask Her Majesty’s Government what response they have made to the Parliamentary and Health Service Ombudsman’s Report of investigations into unsafe discharge from hospital, published in May.

My Lords, this very shocking report of nine deeply disturbing cases showing what happens to patients when hospital discharge goes wrong was published in May. Since then we have had a plethora of reports from the National Audit Office, the Public Accounts Committee and now, more recently, the CQC itself, which underline the wider context in which these cases cited by the health ombudsman have happened, and the increasingly desperate situation in many hospitals and in social care.

The ombudsman’s report came just over a year after Healthwatch England’s extensive Safely Home report on hospital discharges. This did not cover just nine case examples, but was the result of an extensive, in-depth inquiry led by people experiencing unsafe hospital discharge, with a particular focus on mental health and homelessness. The ombudsman’s cases all involved vulnerable, frail, elderly people, some with dementia, who were either discharged before they were clinically ready to leave hospital; were not properly assessed before discharge, with neither they nor their carers being consulted or even informed about discharge arrangements; and where no care plan was in place for how they might cope at home. Alternatively, patients were kept in hospital much longer than necessary due to poor co-ordination across services, or, in reality, no provision or support being available in the community.

Vulnerable, desperate, homeless and mentally ill people are covered in the Healthwatch inquiry. The failure to consider the full range of their needs before discharge from hospital or a care setting means for the homeless that no support housing or benefits structures are in place to enable patients to recover, leading to what the St Mungo’s charity cites as “revolving door” readmissions to hospital and huge anxiety and suffering for the individuals concerned. As regards mental healthcare, poor communication and co-ordination between different services and lack of desperately needed community support services so often resulted in patients being unnecessarily kept in hospital settings for months.

The National Audit Office report shows that overall the number of delayed hospital transfers has risen by a third in the past two years to 1.15 million, with two-thirds being a result of delays caused by the NHS and one-third caused by problems of non-availability of social care. Age UK’s estimate is that 184,000 nights are lost to the NHS on patients who cannot be cared for at home, or for whom no affordable residential care can be found, costing the NHS £820 million a year, a 70% rise in the last two years. The NAO’s comparable cost figure of care in the community for those patients is about £180 million.

Extended stays in hospitals demoralise older people, cause institutionalisation and dependency and put them at serious risk of losing mobility, muscle strength and the ability to do everyday things, such as bathing and dressing. There is also an increased risk of infection. The fact that there are almost twice as many people in hospital beds unnecessarily as a result of the NHS failing to get its act together rather than through lack of social care provision in the community is particularly striking.

Moreover, the PAC report clearly shows the huge variations and range across the country. In 2015-16, for example, there were 10 bed days lost in Northumbria and nearly 18,000 days in Lincolnshire. Many areas are getting it right under difficult and challenging circumstances. The NHS itself needs to do much, much more to get its own house in order, and that is why national leadership and action are so important. In response to this situation, the PAC’s comments are very telling. It accuses the Department of Health and NHS England of relying too easily on differing local circumstances as a catch-all excuse for not securing improvement in NHS performance. The PAC says:

“Those areas which are doing best are the ones where all the local system owns all of the problem but this practice is all too rare”.

In other words, it is not enough to wring one’s hands over the variability problem.

The Healthwatch report points to guidance aplenty having been issued over the past decade including from NICE, the Department of Health and the recent transition quality standard. However, as it says with all this,

“it is not clear why further individual initiatives will make a difference without something more fundamental changing in the system”.

The crying need for national and local leadership and system-wide ownership, action and change brings us on to the strategic and transformation plans—about which we know little real detail but are told are NHS England’s only show in town. Some 44 “footprints” are to plan for a health service focused on people living with long-term conditions in the community. The Minister has underlined his optimism about the plans, most of which are “genuinely local” and are being drawn up by “collaboration” between hospital trusts, CCGs and local authorities.

The deadline for STPs is now upon us, so can Minister tell us more about how NHS England will be evaluating, assessing and analysing the plans at national level to ensure that they meet the vision set out in the NHS forward view for integrated health and social care? Is he confident that they will focus on better care rather than on just reducing finance? He said earlier this week in response to my Question on carer support that plans,

“will include radically improved out-of-hospital care through stronger integration and improved access to primary care”.—[Official Report, 7/11/16; col. 889.]

From the STPs we know about to date this looks to be funded by cuts to acute services—such as accident and emergency and maternity services—which we know will be difficult to make and will be vigorously opposed both locally and nationally. In this regard, the King’s Fund assessment is worth repeating, namely that STPs,

“will not be credible unless they demonstrate how money and staff”,

for services outside hospital will be found. Does the Minister acknowledge this? Are the Government ensuring that STP outcomes are focused on long-term sustainability rather than on short-term savings and cuts? How are the 44 footprints to be made into a coherent national forward journey?

On social care funding, the latest CQC report must surely have set alarm bells ringing right across government. Drawing on 20,000 inspections of hospitals, care homes, A&Es and mental health services, the CCQ tipping-point warning on the sustainability of adult social care is surely a game changer for the Government. The chief executive David Behan was reported as saying he was more worried than at any time in his 40-year career about council care for the elderly—200,000 more people than five years ago are being denied everyday help with basic tasks of washing and dressing and the number of care home beds is continuing to fall, with council-funded places in care homes falling by 26%. In A&E, there were 1 million more visits than five years ago, with half a million more emergency hospital admissions of people aged over 65.

The CQC is reinforcing what stakeholders, staff, campaigners, social care voluntary organisations, think tanks and patient organisations have been telling the Government at every opportunity, particularly during the passage of the Care Act, ahead of every government financial statement and Budget, and ever since they postponed the Dilnot social care funding proposals until 2019. Yesterday we saw the joint letter to the Chancellor from the Nuffield Trust, the Health Foundation and the King’s Fund pleading for urgent action in the Autumn Statement. Surely the Government must finally acknowledge the extent and the scale of the crisis in social care funding and take the action that is needed now.

We are nearly into 2017, less than two years to go until the promised action on Dilnot agreed under the Care Act is due to commence. I remind the Minister that nearly £6 billion of Government funding was committed to its implementation, the substantial part of which has never been spent on social care. Can the Minister reassure the House that the Government are not trying quietly to abandon Dilnot and most of the rest of the provisions of the Care Act that have ongoing financial costs?

I conclude with raising again the Carers UK Pressure Points report which echoed the ombudsman’s finding that growing demand on the NHS is forcing people to be discharged from hospital too early, often without proper support at home and without proper consultation or notice given to their carers. As a carer myself, and someone who speaks to a lot of other carers as a trustee of our local carer support group, the discharge process can often be the most traumatic experience you face, next to the shock of almost overnight becoming a carer of a person with long-term needs and all the uncertainty and anxiety of how you are going to cope with the huge change in your life and of course, in the person you care for. The Government’s long-awaited updated national carer strategy must surely tackle this crucial issue of improved communications between hospitals and carers head on so that carers are fully involved and get the vital support they need. I hope the Minister will be able to reassure the House that this will be so.

My Lords, I thank the noble Baroness, Lady Wheeler, for bringing this most worrying matter before your Lordships today. The Parliamentary and Health Service Ombudsman’s report and its follow-up should be acted on by everyone responsible for the NHS and, by Members of Parliament who are responsible for helping their constituents, as well as by voluntary organisations and the public. Unsafe discharge from hospital can happen throughout the country. Pressure on most hospitals throughout the country has reached a tipping point. Better communication throughout the NHS is absolutely vital.

I want to bring to your Lordships’ attention the case of Mrs F, one of the cases illustrated in the report:

“A woman in her 80s was discharged from hospital to an empty house, in a confused state with a catheter still inserted”.

She had been,

“admitted to hospital with a urinary infection. She was seen by a consultant who decided she should stay in hospital for three days so that the infection could be treated and staff could monitor her. Despite this, and for reasons that are unclear, Mrs F was discharged later the same day to an empty home and in a confused state. She had been given no medication and still had a catheter inserted”.

A neighbour,

“contacted the ward sister at the hospital who said that Mrs F should not have been discharged”.

The report concluded that:

“It was wrong to discharge Mrs F against the consultant’s instructions. There was nothing in Mrs F’s medical notes to explain why the consultant’s instructions had been changed or who had changed them. This went against recognised standards about record keeping. The hospital accepted that Mrs F’s discharge was inappropriate, and that there was no documentation about the discharge or who arranged or authorised it. However, it failed to get to the bottom of what had happened”.

Is this not a clear example of a cover-up? I wonder how many such cases across the country never come to the notice of the ombudsman.

I must mention the unsafe discharge from hospital of people apart from the elderly. A baby died after being sent home from hospital with paracetamol when he had meningitis. His mother said:

“To lose your child to an illness that is both preventable and treatable is a tragedy. By sharing our story we hope to save lives in the future as people become more aware of the symptoms and of the impact this horrible disease can have”.

Another baby was sent home from a hospital department which had a warning poster about meningitis but the mother was told the baby had gastroenteritis. A schoolgirl of 16 was sent home from A&E after being told she had a migraine. She later returned to hospital with a rash but died. Waiting for a rash can be fatal. I wonder how many people have died in the past year from meningitis and sepsis due to misdiagnosis.

I have a friend whose son became mentally ill at the age of 18. He went berserk one afternoon, brandishing an air gun. As the situation was out of control, the police were called. They took him to Northallerton, where it was realised that he was seriously mentally ill. He was admitted to the local hospital’s one ward for mentally ill patients and was later transferred to a more secure ward at Middlesbrough, where he remained for six months. The consultant then told his parents that he could be discharged home. They said that they would not be able to cope, and they feared for his safety and that of the community. He was then sent to the first hospital, where the consultant told the parents that it would have been a disaster if he had been sent straight home. How many unsafe discharges of mentally ill patients will there be when the pressure on beds becomes insurmountable, with no slack in the system?

With the elderly population increasing and with complex conditions, the local population in North Yorkshire are dismayed at the closure of the Lambert Memorial Hospital in Thirsk. This hospital has taken the pressure off the local district hospital when people need 24-hour care but not acute surgery. Too much pressure on hospitals means too many unsafe discharges.

I am pleased to see that Healthwatch England has been involved in the safe discharge of patients. In 2014-15 it conducted its “safely home” inquiry, highlighting the impact on patients and their families when discharge goes wrong and identifying good practice where things go right. It also welcomed the publication of the Parliamentary and Health Service Ombudsman’s report and its role in highlighting the continued importance of ensuring that discharge is undertaken safely, effectively and respectfully.

The purpose of Healthwatch England and the 152 local Healthwatch organisations is to understand the needs, experiences and concerns of those who use health and social care services, and they were granted the statutory powers to speak out on their behalf. Healthwatch needs to stand up and be counted by helping uncover cover-ups, supporting patients and promoting good practice in both NHS and social care. The combination of services is important.

The Royal College of Nursing stresses the vital contribution of the community nursing workforce in relieving pressure on the system and delivering care in the community. The RCN is clear that any poor care is unacceptable and that action must be taken where breaches of the Nursing and Midwifery Council code occur. It is important—so that solutions can be found—that these cases are viewed within the wider context of the pressures facing the health and care systems.

I am pleased that the BMA supports the conclusions of the ombudsman’s report and welcomes the committee’s follow-up inquiry. It states that it is of paramount importance for patients, as well as their families and carers, that they are discharged from hospital in a safe, appropriate and timely manner that is co-ordinated and centred on their needs. There are extra needs for people with dementia and their carers. I hope that the Government, too, will do their very best to make the discharge of patients safer and better. This is not only a local matter; it is a matter of national concern.

My Lords, I congratulate the noble Baroness, Lady Wheeler, on submitting the same Question for Short Debate as the one that I submitted myself, but clearly she was in front of me in the queue.

This is a very important topic, impacting, as it does, both on the health of individual patients and their families and on the sustainability of the health and social care services. As usual, we see in the PHSO report evidence that we will never achieve sustainability in the health service until we address the shortfalls in budgets and provision in the social care service. Only recently we heard about more social care providers handing back local authority contracts because they are unable to make a reasonable profit while providing an adequate standard of care. One of my colleagues, who is a local councillor, told me that, in fulfilling its statutory duties relating to social care, her council now has to spend 33%—and rising—of its budget and that, if this carries on, the council will soon run out of money.

Care providers are not fat cats who do not think that they are making enough money; on the whole they are caring companies which have reluctantly had to admit that they cannot go on as they have recently been forced to do and deliver the standard of care they want to give. We have also had media stories about the fact that those who are self-funding in care homes are paying a premium of up to £400 per week to subsidise the home’s budget and compensate for the shortfall in local authority payments for publicly funded patients in the setting. From every point of view, this is an unsatisfactory state of affairs, which threatens to get worse, and it backs up the call by my right honourable friend Norman Lamb MP for an independent or cross-party commission on how the health and care systems can be sustainably funded.

I turn to the detail of the report. When I asked an Oral Question about this on 15 June, the Minister’s first Answer was to the effect that the sustainability and transformation plans would integrate health and social care, fill the black hole in funding and solve all our problems. So my first question to him today is to ask him to follow up on that Answer. We have heard in the news recently that STP boards must delay making their draft plans public for two weeks because of the concerns of some Conservative MPs that the plans may involve controversial hospital closures. Is that the case?

That is not the only concern I have heard. I am told that the development of the plans has been very top down and has been led by the acute hospitals, despite the fact that one of their main purposes is to plan how patients can be treated in primary and community care rather than in expensive hospitals. I have also heard that local authorities and community groups have not been involved in developing the plans but have been told that they can comment after the plans are complete. Once the ink is dry on the paper, people can do no more than tweak the plans. Given that these plans need to fundamentally reform the way that care is delivered, and given that the most successful change is bottom up, this is no way to go about it. It will produce the “not invented here” syndrome. I have found that health and care professionals will engage enthusiastically with change that they know will work because they have recommended it, but not when change is imposed on them. Every manager knows that the best changes, and those that are easiest to implement, come from the staff suggestion box.

Also, I have heard that “sustainability”, not “transformation”, has become the over-riding objective. In other words, boards have been told that the books must be balanced, and this has resulted in outrageously unrealistic plans. The Government were wise to call these plans “sustainability and transformation” because, through transforming how services are delivered, we might achieve savings. However, it cannot be the other way round. I also heard a health economist make the very valid point last week that in mental health there has been a transformation from in-patient care to care in the community, but this has taken 20 years. The point he was making was that the timescale for the Government’s STPs is quite unrealistic.

If ever there was a demonstration that this process needs to be carried out properly, it is to be found in the PHSO report on unsafe discharge. The point that I made in my supplementary Oral Question in June, quoting examples from the report, was that there are problems on both sides of the discharge cliff edge: problems in the hospital and problems with the care to which the patient should be discharged. The Minister answered:

“My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO's report. In particular, it states:

‘We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight. …health and social care ... have historically operated in silos’”.—[Official Report, 15/6/16; col. 1216.]

I agree with the Minister that there are millions of satisfactory—nay, exemplary—interactions every day, but the report quoted specific examples only where the ombudsman felt that they did demonstrate systemic issues. That was made very clear in the report. But common sense tells us that mistakes are more liable to be made when people are under great pressure. The Minister also acknowledged that these historic barriers to safe discharge cannot be fixed overnight. So why are the STPs expected to fix them in the health service equivalent of overnight, which is in three or four years?

No doctor or nurse wishes to discharge a patient into unsafe circumstances, but mistakes will be made when the pressure on the service is so great and there is such a shortage of hospital beds, according to the briefing from the BMA. In its submission to the Public Accounts Committee inquiry on this very same subject, the Royal College of Physicians revealed that 40% of advertised consultant vacancies remain unfilled, mostly due to the lack of suitably qualified candidates. At the same time, the Government are telling us that they do not want to bring in doctors from abroad. This is quite unrealistic in the timescale quoted. The RCP says that the,

“staffing crisis is impacting on physicians’ ability to swiftly assess patients… to tailor their care plans and to work across disciplines to achieve safe and timely transfers of care”.

The RCP also emphasises that more needs to be done to prevent unnecessary admissions, and quotes examples where early access to multidisciplinary assessment led to a reduction of up to 24% in hospital admissions. Patients were given care in more appropriate settings and pressure on hospitals was reduced. That is what we should be seeing across the board.

It also makes the point that better integration between hospital and community settings is fundamental in preventing patient readmission to hospital. That was one of the regrettable consequences of unsafe discharge, according to the report. To be fair, this integration is one of the major objectives of the STPs. Why, therefore, in too many cases, is one partner producing the plan and then showing it to the other for comment?

The Royal College of Nursing, in its briefing for this debate, accepts that poor care is unacceptable, and agrees with many of the findings of the report. It mentions the problems with recruiting and retaining nurses in the NHS and shows a link between shortages and poor patient experience. Can the Minister tell us what impact the Government expect the change in funding for student nurses to have on this situation and what effect this will have on the availability of nursing homes?

The RCN also points out that discharge targets mean little if the resources in social care are not there to meet them. What do the Government plan to do about this? They must surely accept that the small precept for social care which has been allowed to local councils to cover the cost of the increase in the national minimum wage will not do so—and by the way, I refuse to call it the national living wage because no one could live on it. We also know that in the areas where most is needed for social care, because of the predominance of publicly funded patients, the ability to raise extra cash from the precept is the lowest. This is a topsy-turvy policy that the Government are labelling a legitimate solution to the problem.

I ask the Minister what plans the Government have to address the shortfall in funding for social care and the shortage of doctors and nurses, the main causes of unsafe discharge? There are problems with communications and poor interoperability of IT systems, but—although they should be addressed—they are not the great big elephant in the room. We all know what that is. When will the Government address it and stop burying their head in the sand? Even Simon Stevens and a Select Committee in another place have questioned the Government’s claim that they have given the NHS all it asked for. They have not, and the five-year forward view remains an aspiration and not a plan.

Without a properly funded plan, the crisis in health and social care, of which unsafe discharge is very sad evidence, will continue as demand continues to rise. Instead of picking fights with junior doctors and community pharmacists, the Secretary of State would be better advised to tackle this with his usual energy. If he did so, his name would go down in history as the best Secretary of State for Health we have ever had. I await that day with bated breath.

My Lords, I thank the noble Baroness, Lady Wheeler, for initiating this debate on a hugely important issue. I hope the noble Baronesses, Lady Wheeler and Lady Walmsley, will not think I am being churlish when I say that we covered a very wide range of issues today and at times strayed somewhat beyond the health ombudsman’s report, which is the substance of this debate.

The noble Baroness, Lady Wheeler, raised the issue of homelessness. That illustrates the complexity of the discharge process. I have seen a homeless person at UCLH in London who has nowhere to go. The issue is finding somewhere for that person to go—otherwise, as the noble Baroness said, he ends up back under the arches, then back in A&E, and the whole revolving door syndrome goes on. The noble Baroness, Lady Masham, mentioned the situation with someone who is mentally ill. Such discharges are very complex, so we should be careful not to oversimplify how difficult some of them are.

There has been a lot of talk in this debate about STPs. I will come to them, but I say to the noble Baroness, Lady Walmsley, that they are bottom up and are done locally. Of course, the acute hospital is going to have a major impact on the local STP: it would be strange if it did not. Some STPs, however, are run by the local authority and others by the chief executive of the local acute trust. That varies around the country, depending on the local leadership. They are not top down: these are bottom-up organisations, and they are increasingly in the public domain for discussion locally. One of the issues is that the NHS and the care system are so complex and so difficult that exceptional leadership is required to get lots of people together in the same room and come up with a plan that can be executed. Somehow, we have to move to a system in which you do not have to be exceptional to achieve results, in which average people can make progress. It is very difficult.

The noble Baroness, Lady Masham, mentioned Northumbria, where there is good local leadership that has worked in a consensual way with other partners in the system for many years. That way, you can get progress. The noble Baroness, Lady Walmsley, said it took 20 years to make the changes in mental health from the old, big, acute asylums to much greater community provision. It does take time, and you have to put the resource into the community before you can take it out of the acute sector. She talked about the difference between transformation and sustainability. Transformation means change, and change is difficult. It means people changing the way they have delivered care for many years. It does mean closing some acute activities in order to put resources into the community—there is no getting away from that. The Five Year Forward View was a view, not a plan. The STPs are, in a sense, transforming the view into a plan. We should not be surprised if there are some difficult messages in that. If we run away from those difficult messages, we will not put the Five Year Forward View into practice. I think everyone in this House feels that at least the direction of travel in the Five Year Forward View is the right one.

I do not want to sound in any way complacent because, as we heard in the story of Mrs F, when these discharge processes go wrong they are catastrophic for the individual concerned and their families. To put it in context, however, reported incidents of discharges going wrong account for less than 0.1% of the 15 million discharges made every year from hospital. Of that 0.1%, 96% are categorised as “no harm” or “low harm”. It is important to have that context. In fact, the PHSO makes it clear that the cases set out in its report should not be considered as representative of practices across the NHS and social care. However, it says:

“We are aware that structural and systemic barriers to effective discharge planning are long standing … these include the need for better integration and joint working of health and social care services, which have historically operated in silos”.

That was also acknowledged by the Public Administration and Constitutional Affairs Committee, which said that,

“discharge failures identified by the PHSO report are not isolated incidents but rather examples of problems”,

experienced “more widely”.

It, too, draws attention to the lack of integration between health and social care. It is therefore right that in this debate we have focused largely on these structural problems, which are not just between health and social care but within the health service itself.

The experience of these patients supports the strong case that this Government have made—and indeed the past Government—for closer working between health and social care and between different organisations and the NHS. We have to resist resorting to yet another major structural change in the NHS. Just as this last lot is settling down, there is a temptation to say that we should radically look at the whole structure of health and social care again, in which case the whole thing will be pushed up in the air for another few years. We therefore need to be careful before we resort to that.

I will repeat the figures that were given by the noble Baroness, Lady Wheeler. In August of this year about 60% of delays were attributable to the NHS—so it is not just the interface between the NHS and social care—33% to social care, and the remaining 10% or so to both social care and healthcare.

In December, 44 health and care systems across England were asked to come together to create their own local blueprints, called sustainability and transformation plans. STPs are designed precisely to tackle the barriers to improved patient care—the silos that were mentioned—by better alignment across organisations. This could have been done on a statutory basis, but we would have been here discussing that until kingdom come. The STPs have evolved; they are local and not top-down. They were not put out there by Jeremy Hunt: this has been done by the NHS and by social care on a local basis.

To some extent this builds on the Government’s £5.3 billion better care fund and upon the vanguard schemes—the various models of care that were described in the NHS Five Year Forward View. This is a logical evolution of those two developments. If I had more time, I could give examples of a number of the new care models in the NHS Five Year Forward View that are getting some considerable traction.

We are clear that in some areas, rising delayed transfers of care are placing considerable financial and operational strain on the NHS. However, we are equally clear that delays in themselves can prove particularly dangerous to older patients. There is a growing body of evidence on the harms associated with long hospital stays for older people. A pretty staggering statistic is that 10 days lying in a hospital bed can lead to the equivalent of 10 years of ageing in the muscles of people over 80. Therefore, delayed discharges are not fundamentally about saving money, although of course they would save money. They are about how we provide better care for vulnerable, usually elderly people with comorbidities.

NHS England and NHS Improvement have taken action to establish a number of work streams across community services and acute hospitals, because that is often where the delays occur. This will identify and deliver a series of interventions to help deliver system-wide transformation of community services, supporting timely discharge from hospital.

The decision to discharge remains a clinical one, but ensuring all discharges are safe and timely requires a multidisciplinary effort from clinical and nursing staff, allied health professionals, and community and social care workers. The imperative to discharge as quickly as possible must be balanced against the needs of each patient. I acknowledge fully that when a hospital is full and there are ambulances queueing outside in the car park to get people to A&E, the pressure to discharge patients is huge. We can pick out examples where it has gone wrong, but if you put yourself in the place of the nurse on the ward, who is told, “We’ve got to find three beds by 8 o’clock because we’ve got people in A&E who are about to breach the four-hour target”, you can understand the pressure there sometimes is in hospitals to make discharges earlier than they should be.

When the NHS was founded in 1948, 48% of people died before they reached the age of 65. In 2016, this figure is only 12%, and the fastest-growing age group is the over 85s, for whom the discharge process is inevitably the most difficult. Some 80% of this group will suffer from two or more chronic conditions, which adds to the complexity in discharging patients today.

I want to dwell on two issues related to safe discharge. First, the whole thrust of the seven-day NHS is to ensure that urgent and emergency care patients have access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions, whatever the day of the week. The problems of discharge are the same on a Saturday or Sunday as they are on a Monday, Tuesday or Wednesday. Other work includes the new discharge planning guidelines published by NICE, which cover transitions between care settings for adults with social care needs.

There is absolutely no doubt that the structural difficulties of the NHS are quite profound and exceptional people are required to overcome those barriers. We are bound to see considerable variability in some of the STP plans when they are published over the next couple of weeks. However, we can also improve operational issues within hospitals: making sure that the drugs and transport are ready; that there are multi-disciplinary teams, including social workers as well as care workers; and that everyone who comes into hospital gets an estimated date of discharge, so that everything can be brought together around that discharge process.

I end by paying tribute to NHS staff, who are working under huge pressure and with people with complex conditions. I think we all recognise that the structure of the NHS means that things are not as easy for them as they might be.

I will certainly do that. I should just say that the theme that comes out of the carers strategy is better communication. When half of carers say that they feel that a hospital admission could have been avoided or that the discharge could have been easier if only there had been better communication, that is clearly a critical area.

Sitting suspended.